The Journal of the American Medical Association 1904-09-24: Vol 43 Iss 13

The Journal of the

American Medical Association

Published under the Auspices of the Board of Trustees

CHICAGO, ILLINOIS, SEPTEMBER 24.

L904 No. ie

Original Articles.

LPPENDICITIS IN CHILDREN.
\. J.. McCOSH, M.D
NEW YORK CITY.

The subject of appendicitis has, during the lasi dee-
ade, received so much attention that one might suppose
that there was but little more to learn concerning this
rather puzzling disease. ‘The term puzzling can cer-
tainly be justly employed, at least when speaking of Its
etiology, for we must frankly confess that our know lodge
of this subject is but little further advanced than when
| have, of

the disease was fitst named appendicitis. We

course, learned much about its SViInptomato1ogy, pul
even to-dav | know of no surgical disease whieh mor
often offers surprises to the operating surgeon, T|

SVinptots, O1 at feast our interpretation of the svimp

actual CONdITION ©

toms, do not alwavs indicate the
where an

append, 1 need not narrate to vou cases

in a threatening or
svinptoms have been comparatively trifling.

appendix dangerous state is found

when the
It is this uncertainty which has mainly led surgeons to
advise very early operative inter ‘erence in all cases. No
one can certainly tell at the beginning of an attack

occurred, oO;

whether perforation has or has not

cangrene of the entire organ will not result in the

eourse

t

Of course, if possib.e, it is desirable to

of a few hours.
await the subsidence of the acute attack before ren oval
of the appendix. The
often, by careful and frequent observations, safely carry
This,

can not always be done. and it is because of the

experienced surgeon Cah very

however,

the case along to the quiescent stage

excep-
tions that all surgeons are now practically agreed that
the best results, both for preservation of life as well as
of the strength of the abdominal wall, are obtamed 11

the at

}

the appendix be removed in the early hours of
tack.

Unfortunately, for many
hot invariably be carried out, and many cases are, and
will continue to be, thrust into our hands, which hav
passed bevond the early stages of the disease
cases immediate operation will not always give the best

reasons, this practice can

results. There can be no doubt, | think, but

rule of treatment should be almost absolute, provided

that the infection is contined within or to the appendix
itself. When, however, the infection has spread beyond,

whether through a perforation of its wall or through the
iransudation of nvogenic bacteria through Its inflamed

coats. the propriety of advising immediate operation in

a

every ease becomes to my mind doubtful. A few verrs

avo it was almost the universal feeling, T think. that

y
-

* Read at the Fifty-fifth Annual Session of the American Med
ical Association, in th:
proved for publication by the Executive Committee: Drs. 1
Willard

Section on Surgery and Anatomy, and ap
Morest

Charles A. Powers and J. EO Moore

the appendix should invariably be removed as soon as
possible, no luatter what the stage ol the dlsease. Per-
sonal | have alw: Vs [eit that there were I p

tions to this rule, and ior a vear or two past thi
of surgical opmion has been, | think, toward less rad

|

ical VieWs On this supyect. his drift has become still
e

more pronounced since the treatment formulate
Ochsner has apparently shown that many a life can b
saved by judicious delay. While I can not quite agre
with Dr. in his extreme position, vet I feel
very strongly that his teachings on this subject are wi

grounded, and if followed intelligently, but not blindiy.

Qehsner

will tend to lessen decidedly the morta Itvy Ol grave cases
ot appendicitis. ( ertainly mV OWD experien durn
the past year or

| feel that in some cases postponement Of the operation

two has led me to this con

lus lO, oy]

rOUTS has Pe HSeLy aided Lie recovery ot the

perforation with resultine peritoneal shock of extre

degree, the patient Is in a very condition !
and the peritoneum as well is not a

poor
serious operation.

lesistant against intection as it Will be some twelve

Nnours Or so late — In such cases, where there 1s ap lt

be mueh abdomina! distension, a weak and rapid pulse
with svinptoins oO; venera shock, the postpon ment
the operation for twelve or twenty-four hours \ Otel
result In a very decided improvement in the patien
condition, provided that starvation be absolute. The ab-
domen will generally become fess distended
pulse wil improve,
You may ask what bearing have these remarks on
tle of my paper, “Appendicitis in Children.”
mainly concerning this point of treatment. however,
Wherein [| think the treatment of this disease in
en should differ fron: that amone adults
1 do not think that it is properly appreciated, amon

|

general

practitioners at least, how frequentiy append

citis occurs in children. The operating surgeon
often encounters in the course of his operations
voung adults the history of attacks of abdominal svimp
toms dating baek to their earlier vears, whit

ediyv, arguing trom the state ot { ( ppen ‘ l
operation, were due to mild attacks of appendic ae

is often difficult to stinguish cause from
unquestionably in many of these cases the previous

dominal symptoms may have been caused not b

dieitis. but by attacks of eatarrhal enteritis. vet.
same time, there are others whose attacks of indiges

tion, which have recurred at intervals since «

hood, immediately cease after removal of an appendiy
which distinetly shows the results of vears of recurring
attacks of inflammation. Of course, I appreciate th
fact that the

intestina

surgeon encounters but ad minute prope!

tion of the cases amone eli)

of the few cases where a later manifestation of

appen-

dicitis leads him to attribute the digestive allment ol
perhaps, apt to overlook
have manifested
yet Whose appendices have never

willing to grant all

chiidhood to that cause, he is.

the millions of young patients who

similar s\ mnptoms, and

SHOWh eVIdehce OL CUisease, | al

avold tl conclusion that ap-

His. bDUL vet one can hot

COMMON Cisease.

children is not an w
SYMPTOMS.

most depend tor our dl-

Phe svinptols on which we

agnosis of appendicitis are pain, local tenderness, Mius-
‘ : ) |

Cular PIgidily. VOMITING aha avdOoMIInNAaL GIstension, Pulse

s often of value, as is also the temperature, but these

tLWo sylhptolms have more slgnilicance, perhaps, as re-

the severity, rather than the ac

ta

vards
Case.
In chi

Leet 1]

those
S\ Inptois, \W

under 10 or 12 years ol
Ith the

(ft COUT Se, the olde lr ihe

hirveh, CSPer lal \

Important exception Ol

vomiting, are apt to be masked.

chy d the nearer the (jsedse a} proaches the adult UV pe.

)
\s m\ experience Increases, 1 am becoming more ana

tore convinced that appendicitis In youne children dif-

els somewhat from the same disease 1) adults. Phe

difference consists in the obscurity of the diagnostic

symptoms. and in the more insidious progress of the
The younger the child the
The correct disease In young
hildren is often Cher
tv to locate pain, their general restlessness and fretful-

ereater is the dif-

disease.

lerence. Glagnosis of

with difficulties. Inabil-

Dese]

ness and the unreliability of the significance of tem-
perature are some of the causes of this dithiculty.
Pain.—This. especially at the beginning of the at-

probably as severe in the child as it is
n the | ; its location impairs
ts value as a diagnostic symptom A general pain in
the belly is complained of, the child not knowing ex-
pointing to the
hurts ev-

tack, Is, ads a rule,

adult, but the uncertainty of

actly where It 1s located, at one moment
upper, at another to the lower abdomen. It
: in the appendicu ar

adult is

erywhere, apparently not specially

region. This symptom, which of itself in the
of great significance, ean only help us in the case o
children by its combination with other symptoms. — In
certain phlegmatic children there seems to be at times
almost complete absence of paln. ‘Tenderness LO pres-
sure is apt to be equally doubtful. The ehild generall\
dreads any palpation of the abdomen, and complains
as much in one part as another.

Wuscular Rigidity.
most important guide in the

pendicitis in adults, is in children equally obseure.

most
This symptom, which is, per-

diagnosis of ap-

The
child is suffering pain and is prepared to ery out, and
abdominal
is touched by the

haps. our

taken unawares, to tighten its mus-

soon as or even before the skin

The dread of being hurt causes the

inless

‘xaminer’s finger. | |
point of the ab-

nuscles to act on guard at almost an\

lomen. If the utmost gentleness and patience are prac-
} attention,
.

and if
diagnosis is at once confirmed.

ticed. along with diversion of the child’s

this

mi ‘ound. the

sometimes symptom Can be elieited, cer-

Vomiting. This Is In children probably the most
symptom. It at least is thi
It, is apt to continue in spite of starvation and medica-

tion. If it does so, and persists for many hours with-

most evident.

ersistent

uit other adequate reason, and if it be accompanied by
f intestinal movement. the
Per-

twenty-four

severe paln with absence ie)

; ; Te =
suspicion of appendicitis should be
with severe abdominal

even with intestinal movements. the

very great.

sisting pain for

S11S-

hours or more

a {(PPENDICITIS IN

CHILDREN—MCOsSTI.

piclon is still considerable. "Che accompaniment of
and points more tow...
it may occur with append

arrhea is, of course, unusual.

a vastroenteritis, but st
CIUIS.

[ft the abdomen becomes more and more distended

the diagnosis ot appendicitis becomes more and mor
probable. ()t course, for a perfect picture Wwe should

either local tenderness or muscular resistance,

also have

but. as already stated, these svimptoms in children are
apt to be Walting,
The Hstor\ ot

previous attacks ot

VOoIItInNY WItho
considerable diagnostic value. ‘Thi

adequate Cause 1s Oo
surgeon is, perhaps, apt to lay too much stress on the
importance of such “billous attack,” but if he does so
it is because very frequently in the cases on which he
operates such a history is given. It is important, how-
ever, that such attacks should be separated from. those
due to indiscretions in diet or an overloaded bowel,
The diseases from which, it seems to me, appendicitis
n children is especially difficult to differentiate, are
vastroenteritis, with the gastric element most predom-
nant, diaphragmatic pleurisy and basal pneumonia. ‘To
my mind, certain of these doubtful cases are the most
puzzling which the surgeon encounters.

In certain cases
of acute indigestion or o |

gastroenteritis in its early
stages, the differentiation from appendicitis IS NOt easv
The following points may be of some yalue: The per-
sistence of vomiting with severe pain for more than
no diarrhea,
If the constipa-
tion be obstinate, the suspicion of appendicitis is gener-
sufficiently there be at the
time any one other sVinptom of this disease to warrant

twenty-four hours, especially if there be

favors the diagnosis of appendicitis.
ally should

strong. same

operation. If there be diarrhea, it generally. though not
always, means that the case is at least less urgent.
The existence of high
vastroenteritis. The blood examination may shed some
on the diagnosis. The differential count is of
more value than the mere leucocyte count, There are,
however, so many exceptions to the general rule that
personally I do not feel much confidence in blood ex-
aminations in voung children.

ever probably rather favors

light

Judging from a some-
what limited experience with the iodophilia test, it seems
to offer valuable information
than does either the leucoevte or differential count.

\s an example of the difficulties, let me ceive the fol-
owing history:
Girl, aged 4.
attacks of pain, vomiting and fever, lasting
In the
these attacks oceurred in milder degree.

Oo ie more promise of

CASE 1. During her first vear there were sey

eral a few davs

and then passing off entirely. second and third vears
The child was always
carefully dieted. In December, 1903, there occarred a sharper
attack of pain, but there was no fever, no vomiting and no lo
Since that \pril, 1904,

about once a week the child would complain of a sudden, sharp

ealization of the pain time until

abdominal pain which would last. however. but a few min
utes. It had no meals and
The diges

tion was apparently always good, and the child looked well.

apparent connection with her

might oceur when she was at play or out walking.

Phere was considerable difference of opinion as to the diagno
~is. The father, who was a physician, and myself felt, how
that the chances of the cause of the trouble was a chron
Accordingly, on April 11, 1904, it
It was found markedly diseased. with the mu
membrane the seat condition
Since the operation the
child has been entirely free from pain.

ever,
ically inflamed appendix.
was removed
cous of hemorrhages, and in a

where perforation was imminent.
To some of you it may appear foolish to dwell on the
difficulty of differentiating appendicitis from diaphrag-

matie pleurisy, but it has been my lot to eneounter sev-

SEpr. 24, 1904. APPENDICITIS IN
eral cases where it has been for a time quite impossi-
ble to distinguish between these two conditions Within
the last few years I have been called on at least half a
dozen times to either Operate or decide concerning the
propriety of operation in such cases. In these half dozen
cases time has shown that | have been as often
as right in my diagnosis, though, “ortunately, in’ the
eases that have proved to be pleurisy or pneumonia, a

Wrong

half day’s delay has in every case saved the patient from
an unnecessary operation. Let me briefly relate three
of these cases :

CASE 2.—Boy, aged 8, who had usually enjoyed good health,
was seized on November 5, in the early morning, with sever‘
abdominal pain. He was at ence given a dose of castor oil and
throughout the day this was tollowed by two doses of Rochelle

salts. Later in the day vomiting began and continued more o

less for twenty-four hours. There was some fever and a rapid

pulse. The bowels refused to move in spite of enemata, the
The family
physician called a children’s specialist in consultation from
New York (the child was in the country)

abdomen began to distend, the pain continued.

, and both were puz
zled as to the diagnosis. There was no cough, and no pain was
assigned to the chest. The vomiting continued, the abdomen
child

the child toward

was markedly distended, tender everywhere, and the

looked very ill. Prepared to operate. IT saw
midnight, twenty-two hours after the commencement of the at
tack. It was a question as to diagnosis, the vomiting, abso
lute constipation, abdominal pain and tenderness made a diag
There

sign, however, of irritation of the lower left pleu

nosis of appendicitis or intestinal obstruction probable.
Was a faint
ral surfaces, and we decided that a delay ot a few hours was
advisable. On the following morning the signs of pleurisy
with probably a basal pneumonia were well developed. The
child made a good though slow recovery.

In this case the entire absence for at least forty hours
of any abnormal chest sounds and the severity of the ab-
dominal symptoms markedly to favor intra-
peritoneal inflammation Until the abnormal chest
sounds developed, diagnosis was impossible. The case
was a most puzzling one, and the delay in awaiting the
pathognomonic symptoms would probably have caused
a fatal termination had the appendix been involved.

I do not feel that 1 can express views of much value
as to the differential points between appendicitis and
diaphragmatic pleurisy. Of course, 1 am now refer-
ring to cases where abnormal chest sounds are absent.
Perhaps in cases of pleurisy a certain fixation of the
lower ribs or stoppage of the respiratory movements at
this point may be noticeable. Perhaps also the child is
nore apt to toss about the bed than he would be apt
to de were his appendix inflamed, but even in this lat
ter condition the child is much more apt to be rest'ess
then is the adult. If the child be inclined to assum:
the adult position of rest. on the back with the thigh
or thighs drawn up, the chances are in favor of appen-
dieitis: but, as already stated, ehildren often fail to as-
sume this posture. The passive flexion and extension
hy the surgeon, of the thigh on ihe is In ap-
pendicitis, even in children, apt to be more resisted and
dreaded than it would be in diaphragmatic pleurisy.
Sometimes, but not general vy,
value,

seemed

abdomen,

this symptom is of con-
siderable

Of course, if there be a tender spot or museular rigid-
IGY;, the diagnosis is easy. If a boardlike condition of
the abdomen develops. we may be certain that the case
is a verv grave one of partial peritonitis

INSIDIOUS PROGRESS.

Another point to be considered is the progress of the
and its treatment,

diseas: The progress is often marked

CHILDREN

WCOSEH. 855
W\ insidiousness. A Gast tha Is appar ntl\ mild
will sometimes gradually drut, perhaps, without any
alarming symptoms, into a grave condition with general
septic peritonitis im spite of the most careful watching.
The pulse and temperature may remain normal. vom-
not be marked and the

bowels mav even continue to move, and vet a general

iting may cease, distension ima

peritonitis is developing. | am inelined to think that

there is not the same effort on the part of Nature to wall

off the inflamed appendix in children that

Not only is this spreading tendency of

the infection insidious, but it is often very rapid.
I have encountered dozens of cases where the

st) often OCe-

eurs in adults.

(disease

followed such a course. The following are examples:

CASE 3.—Girl, aged 13. was attacked in the early morning,

April 21, 1904, with severe, sharp pain and vomited. The tem
perature reached 9915 and the pulse 100. The bowels moved
during the day, the pain toward evening became less, and the
Whole aspect of the child seemed improving, the pulse became
slower and the night was passed comfortably. In the morning,
hours, the

boardlike,

however, of the next day, in the course of a few
whole aspect rapidly changed. The abdomen became
the countenance assumed an anxious appearance, and the pulse
There was also a ten
m. of that day, April 22,
tion revealed an appendix almost entirely

rose in frequency and was very wiry.

deney to vomit. At 11 a. an opera

gangrenous and a

veneral suppurative peritonitis. The child made a slow re
covery.

CASE 4.—Girl, aged 5, was seized on the evening of Nov. 23,
1903, with abdominal pain. She vomited, and during the night
was restless, temperature 9912, pulse 90. The night was
passed comfortably. On the next morning the child seemed

|

brighter, and asked for her breakfast: temperature 99, pulse

$5: very slight pain was complained of. When I saw the child at
11:30 of that day November 24),

three hours late

the abdomen seemed to me

rather tense, the tenseness was more marked

und the child looked more ill. Operation performed at 4 p. m.
revealed a perforated appendix and a general peritonitis. Thor-
ough irrigation and drainage was employed and resulted in
recovery.

I could narrate many other cases where the symptoms
have for davs been of the mildest degree, and apparently
all abating, when suddenly
the physician, that some change has occurred, and op-
Dr.
example of

the conviction is forced on

eration then reveals a hopeless general peritonitis.

Brannan’s' instructive another

treachery in the behavior of the appendix.
In the children there also seems to me g

Itv to rapid gangrene. Of

encounter eases where gangrene has been rapid and ex-

Case Is

reater
course, in adults we

TCNSIVe,

but this tendeney strikes me as evist he more

frequently in children. The follow Ne Case Is an
ample:
CASE 5.—Girl, aged 11. in the evening of July 2, 1902, while

nan automobile. was seized with severe abdominal pain. Dut

ing the night there was slight vomiting and some feve1 101

legrees). On the following morning the abdomen was rathei

tense, and while the pulse was not over 80 Dr. W. K. Draper
felt that immediate operation was demanded. The tenseness
of the abdominal muscles was suspicious. The operation was
done just twenty hours after the appearance of the first symp
toms, and the long appendix was found absolutely gangrenous
from its tip to its very base and even beyond.

child made

\ spreading peri

a good recover,

tonitis had begun, but the
REMARKS.

Because of this treacherous behavior of the inflamed
appendix in the child, as well as the inferior ten-
deney to limit the inflammation by adhesive
Ve} strong]

perpito-
nitis. I fee that in everv ease of appen-

1. Medical

Reeerd, Anri sO),

1904

DIAGNOSIS OF APPENDICITIS—M ‘RAE. Jour. A. M. A.

tis in clildies nediate operation shotuid be ad THk DIAGNOSIS OF APPENDICITIS.
sed. No matter what the stave of the disease may be, : = oe
-_ . . SHOULD THE APPENDIX BE REMOVED WILEN THE ABDO
1 feel it mou Vis lu operate at once, and not delay =
ll hopes that ata iter dat HW terval operation may MEN IS OPEN FOR OTHER CONDITIONS!

ve performed | s advice e 3) coord wit that o FLOYD W. McRAE, M.D

nanVy sulreconus To appendieitts { anv ave, lt, as a ATLANTA, GA
aay CX presser il Is pred pre lock hot eh \ lh alt So amuel tas eer written and said about the CUS
) ~ \\- ‘ eh) ! ses Of 4 ( t*)) |
sil : se pt ' oi O] diagnosing appenadiceal (Iscase, so little stress) ha
ria ! Lilie iss eres ( ( si ) | ] . ‘
; ten O TK eon laid on the occasional ditliculty ol MmaKING a Col
oO SD ) ) S ) Ore Vol ) rect dlagnostis, that condemnation is heaped on those
tHe Pes . pera M1 IM ' ae Who fail to appreciate the real condition. Sight is. lost
My own ey hee with operations for general sept of the fact that the best diagnosticians and abdomiuna!
nit strat yn satistaction tl urgeons are occasionally put to it to determine whether
> [s Ol the operat l l Oune aduits, They in Lhe appencdir the seat of t! trouble or not Mistakes
puddiy periorirn ire apt to b avorable, while those remade by- the very best surgeons Isach of us should
Nn patients over 00 or do are almost invariably fata protit. b Ws own inistakes and the mustakes of lis fel
| thought it mught b nterest to vive the ave sta ows, and each of us shoucd be willine to vive the whol
stics Of L000 cases of appendicitis. at the time of thei profession tis experiences, fairly and unreservediy,
Op mion Wi] en yer eC ocuses number mor than l have only removed EK Appendices Ol which | have
s, | have not included those of the last: few months. ecurate records. Tn rorty instances, multiple opera
sa ul l mbes LOO x ‘ ti) ‘ e con Llons were cone al thie Sadtne seance, and Ith TanV Ol
ment L hiave . vulate 1500 cases whi | them the diseased condition of the appendix Was hot
ve personally seen, the ages at which, as far as could detimitely diagnosed before opening the abdomen.
scertained, the tirst svmptoms of inflammation o In 71 of these cases appendiceal disease was associ
poendix manifested jtseli ited with or masked by one or more of the following
, CONCILIONS ! In r Cases DY renal ealeull: in © Gases by
>) \ ’ ‘ - } 1] .
‘i rallstones or gall-bladder adhesion; in 18 eases by
Ave i er \; i N 7 Les . | }
vears ases ent ane ie ague symptoms of indigestion, biliousness and indefi-
2 1 ox 14 nite colle; m5 eases by frequently recurring dysentery
7 6-17 24 or rectal disease: in 3 cases by acute mtestinal obstruc
£-2> in) i ba) fee | ] } } )
S19 7 thon, and in 2 cases of IV pho fever; in 12 cases by
ig - Tf 4) , , } | ]
in av Hontineg and diseased kidnevs: in dl case bv acute sept
ob 5 15-20) nephritis: mm dt case by retroperitoneal tubercular ab
6-7 a) . : : : . 5
7-8 12 20-25 176 17.6 scess > In cases by tubercular peritonitis; mm TL cases
4 * =a) -3U 1V6 17.6 yo marked menstrual disturbances: in 11 cases by dis
’ ) 11 10 3H 140 14.9 s .
»-40 go Og ease of the uterime appendages 5 my 2 cases, retrocecal
| 149-42 OD 6.5 ] a, |
15-50 “ 4 ernie were mistaken for appendicitis, the appendices
. - ’ A
+ ye 10-2 a 1.5 uly becoming involved incidentally. In 2 other cases
l - t{ ro i 1 1.1] ‘ f ‘
ioe l oot ‘ Wi no dingnoses Were made, put exploratory Operation
} 21 G5-7 Ge |
1-1 1s ieee e emonstrated appendiceal disease. In 1 case, ina
oung girl, a ruptured dermoid evst was diagnosed’ ap
~ ~ i ‘ : g ‘ |
pendicitis, and in another, a right salpingitis was diag
it ‘ ‘ » iy Ss j Loon ’ 7 :
oe De die nosed appenaieitts.
oportion Which had the firs iptoms in the first ye: ;
3 cube asenit. Ot mal ence | have done at one sitting, on the same patient, with
rst 2 year 1 out unusual shock or prolonged convalescence, the fol
I rst > vears ia : ; ;
| , Pe 17 owing operations: Dilatation of the cervix and eur
~ vears 17 | . .
It st 1h years 3] ettement of the uterus, removal of a number of en
s 20) vears tt ! | ] |
In first 25 years 54 irged cervical glands and hemorrhoids, anchoring a
a ee oe nd Noating kidney, and removal of a diseased appendix.
rst 40 years a \t another time T removed at the same sitting a dis-
rst 45 vears “4
st 50 rT ‘“ased appendix. and did a gastroenterestomy for con-
si 0 yea vs traction of the pylorus censequent on gastric ulcers
Hu gg !
rst 65 years 99.5 two ills before
TO ye 99.75 . ; '
5 100 In the process of evolution, medicine and. surgery
] ; ( reached a stave ot deyelopm Hil when such terns
| = <tatistics ) mi i] OuUunY i | 4 , : :
. , is cohe Gastraleia., acute indigestion and intestinal im
imhishes the dargest nulnber o- cases of appendicitis. , : ' ; 4
digestion con no longer be loosely used in) diagnosis
j ~ i l li prover? tion. i ewrearest nu ° coe 2 ryyy
c re thout subjecting the user to just criticism Chey are
( ( \ the msg ri) na > th ryre . : a a ong i ;
or : : ae uit symptoms of some definite chemie or mechanic
ner over = ryoy 7 Ftp " ha nr norty " " . . ‘ . ‘
ig © pe pen Miter 35 the proportion — defect in the digestive process, and careful investigation
a ) ( ? yal and WOVUTeSS aly Ssmatier. be would reyes | the underlying pathology. 1 ©. a eon-
Wand oO being but 10 per cent tracted pylorus, gallstones or appendiceal disease, or
¥ or >() he propol s YH! pel martial intestinal obstruction from old adhesions.
e the age of 15 vears, 15 per cent : befor Since Edebohls, Deaver and other leading member~ of
“ 10 vears, .0G8 per cent. The youngest eases the surgical side of the profession called attention to
; we! Iv. 1% m=? 16 an - months, | pect *Read at the Fifty-fifth Annual Session of the American Med
(ver 60 years. the proportion was near] ] per ical Association, in the Section on Surgery and Anatomy, and ap
(yy 1"] ~o)] : proved for publication by the Executive Cemmittee Drs. DeForest
( ) Cis IS 40 */e Cais Willard. Charies A. Powers and J. KE. Moors

SEPT.

24, 1904. DIAGNOSIS OF

the frequent association of appendiceal and pelvic i
flammatory disease, a vigorous discussion has been wage
pro and con, the one side claiming that inflammato1
disease of the appendix is apt to involve t uterin
appendages, and that disease of the appendages is oft
the direct cause of inflammatory appendiceal disease.
while the other side argues with equal zeal that the

;
ne

7)
il

conditions are separate and distinet and seldom = core-

|[PPENDICITIS

WRAE,

clinical experience, and is) conducive to

surgery and unsatisfactory results.

Incompielt

Kelly, m hus classical work on gynecology, gives the
opinions Of a number of the
ecologists In this country on this question.
them were the
pendix, unless markedly diseased, should not be a rou-

leading surgeons and gvn-
Most

y opinion that the removal of the a

Y=
«@)

(

tine practice, the author agreeing with these.

lated. Phey old, therefore, that th appendix shoulad he bv-no-means im requent incomplete eures fol-
not be interfered with when bound up im adhesions cue lOwlhye pelvic operations where appendices have been
to pelvic inflammatory disease, and that the freed ap- Jeft. eendemnine the yietim to chronie invalidism,. the
pendix is not likely to give future trouble. ever-present anxiety and danger of a severe and fata
I
] { ‘ rent }); Tal cl i+) }
REMOVAL OF APPENDIX DURING OTHER OPERATIONS, attack of appendicitis, have impressed me with
INCLUDED IN CLASS 1 TO 13 advisability of removing the appendix during all pelvic
S.O.. Salpingo ojphorectomy h right LD... double Operations wl h it shows the least evicde nee OL disease
(lass No Deaths 1 y “PY 1 " ; , i] a
Acute intestinal obstruction. | 1 Or When 1t Is accessible and can be remo ad Without ul-
Acute intestinal obstruction t | due prolongation of the operation or rd to the pa-
Exploratory laparotomy. 6 1 t
Exploratory laparotomy ; . 1 tient.
Dilated stomach, contracted pylorus ’ l }
Caseous deposit in R-kidney : nepher my oj 1 Had | an appenary, I would feel that an surgeon
Ia hap men =T .+8 . Ps : . .
Lubercular peritonitis ' pening mv abdomen and leavine the organ, access
Tebercular peritonitis ie > ri
Ventral hernia, post p repaired a) 1 Die d grievously sinned agaimst me. 1 entertain 1 S
ae : a) 2 —e , ; , F
P.O. sie same feeling and a similar opinion for members ol
Dermotd cysts of ovaries. D. S-O t | owl vm] Holding such an opinion, entertain
LD. pvyosalpinx, PD. S-O > 1 ; > : as é
I). pyosalpinx, D. S-O 13 1 < e for n own loved ones. cou | Ivo
Gallstones and adhesions ) 2 ] ] }
Gall bladder adhesions » Css r the toved ones of others Now ‘ .
Gall- bladder adhesions : Golden Rule mor plicable than in surge in
Nephrorrhaphy, right ) 6 . : .
Nephrorrhaphy, right 6 1 surgeon Who does more oT ess :or those who §
Ovarian cyst 6 1 } \ ] |
; 3 . t} , } } ] yes pnreserved!\ to se ¢
Cystic ovary, R. S-O. F 1 lt ealt ane V4 INreservedly ‘
Cystic ovaries, R. SO. 1 honor than he would want done for him or his, und
Cystic ovaries, ovariotomy: retro 3 ;
verted uterus: TD. ovariotomy 1 <lmilar circumstances, Is recreant to the trust repose
Sclerotis ovaries ner itué a) ae ] } + ] :
i genes sian — i 1 n him, and is unworthy the respect and confidences
Prolapsed ovary, retroversion, R. O 5 2 honest men and women.
Perineorrhaphy 1 : . ; es : : ,
Perineorrhaphy and trachelorrhaphy ) 1 CASE ] Mrs. P. W. G.. 25 vears old (yvave history of hav
Acute cholecystitis and general peri ing ovaries removed per vaginam one vear ago. Since thei
tonitis . SP ey ae 10 1 1 : : : ; ee .
Endometritis, curettement q ” has had repeated light attacks of pain in the McBurney region
yorr ari ae ‘ ‘ . e 1 ° ° . . . . ,
tetroperitoneal abscess ’ I 1 ind in right side of pelvis. Chronic indigestion for several
Acute nephritis: nephrotomy 1 1 1 : é ‘ i é
: = ears. At times has a dragging sensation over right kidney. Ad
otal 40 nitted to St. Joseph's Intirmary june 26, 1903. Has marked
APPENDICITIS (RECORD TO PATE. MAY 27, 1904 tenderness over appendix: slightly movable right kidneys
Class Cases. Deaths iterus free, it and cervix being atrophied.
1 Acute (first attack and operating during attack) .10 1 Operatic June 30. 1903. Gas-ether MeBurney gridire.
2. Interval (toperation ro one attack) 9 ; . — “ae
3 Acute (operation during attack) chronic relapsing Incision, appendix found im pelvis: Was thickened, very much
4. Acute (operation during attack) recurring a : sn 2
4 é l & atts \ g ) ar o ‘ tached bv small ac sions. Jove imputatror
5 Interval (operation during interval). chronic relaps ilarged, and attac hed by mia idhesion ] oven mpu
WOE Memon ne coe PP SE Sa eee 87 Laver closure
6. Interval (operation during interval), recurrin: 29 . : 1s
= ~ = i ~ r = 2 = a : jac i 25 re old ore . ] hist<
‘ Unclassified (belonging to above 6 headings) 18 CASE 2 Mi E.S.. » Veal Id. Negative family history
8. Abscess (operating during interval ep ; \lenstruation began at 13 vears. was regular but always pain
9 Abscess (operating during attack) 40) y , s : ’ ‘
10. Reginning general peritonitis : “49 2 ful. so a curettement was done eight vears ago. For the pa-
i Consultant (of which there is no record). ; 79 four or five vears she has suffered for five davs before an
12 Consultant surgeon (of which there is no record) .28 . ; ; » lets
13 Appendices removed during other operations ve davs after menstruation, with often severe pains over [el
Class + 1 varv \ double salpingo ojphorectomy. June. 1903, relieve
Class 3 1 i, pie: = “y
Class 5. 4 er of all pelvic pain. Dysentery from November to Februa
eS 1 nine vears ago. For vears she has had general colicky pains
Total to May 27, 1904 2g0 9 isting from a few hours to a day or so. Two years ago was
Pe in bed a month with “bilious” colic and suffered great abdon
Total deaths. 9 ises, 232 “TST nal pain. Five months after ovaries were removed she was
Deduct for *sept nephritis and septic taken with pain in epigastrium. which became localized in a
holecvstitis ? ) is ¥ : ,
3 ad few hours to appendiceal region. Since then any jolting or ex
7 220 3.43 cise Caused pain in the Jeft iliae region \ similar atta
Dedh vinning general pe ! s 2 1S . - ; 1 + t
egan ten davs ago and pain continued until admitted to St
; D 212 2 foseph’s Intirmary March 25, 1904
Deduy Ite abscess 5 10 .
Opera ph Mareh 2S. 1904. Gas-ether MeRae transver-t
¥ 172 Por neision with longitudinal opening of peritoneum, enlarged by
Cases Deaths. cent transverse cut There were thick. dense adhesions of omet
Beginning general eritonitris 1S a 16.66 : . : ly} ved
Soe Serene ” 6 tum. passing mn cecun to pelvis to stump of removed
Acute abscess (delaved cases) 0 - 125 Im, pa ing tron t ! int pe \} :
*One case belonging to class No. 1. the other to class No. 10 ovary a retrocecal appendix was dissected out of adhesions
B } j 1 hof . , ‘ hy working over and behind border of friable cecum App n
aiaqv. nm a paper read before the Sou wer Sureren - . 4 . nive2
arc. & pa} . ithern Surgica dix tore out of cecum. its lumen being closed. This umbilicea

and Gynecological Association in Atlanta, December.
1903, argued very earnestly this side of the question,
Such argument, it seems to me, is contrarv to our

+

}

1

with the best /i

knowledge of these diseases.

Variance

ion was covered over by peritoneum and adhesions, a cigarett:

rain being carried to this point. Peritoneum closed with N«
ateut. silkworm gut being used for the remainder Very
ttle disc harve follow ed. patient coing home well Anril os

DIAGNOSIS OF

CasE 3 Nii \\ L. L.. 30 vears old:

liistory of typhoid at 7.

traveling salesman

rheumatisn 10 vears of age. From

tive to two vears avo he had a diarr]

ea each spring, ending in

a dysentery, all lasting from five to eight weeks, being con
fined to bed three or four days wit the latte Kighteen

months before operation he awoke if slight pall in appen
diceal region, Which soon went to left iliac region and passed

hours. Ne
lasting six hours

all
off in about five In two months

a similar

Nausea 0}

yreness,

attack, inother in two months

months,

asting eight hours, et in attack about every
cach getting a little longei Never al nausea or soreness
after the when he was in bed

» third day, until six months ago
MeBurney

ten davs with nausea, mat pain in the

With a spasmodic pain in rectum, penis and perineun Was
sore for a week thereafter. Similar attack, lasting six days, two
months later. with daily formation of gas in cecum since
Under stomach specialist for weeks, without’ reliet

Admitted to St. Joseph’s Infirmary Aug. 14, 1902 \ppendix
could be felt with thickening of ceeun urine contained a
few casts

Operation Aug. 21, 1902. Gas-ether McBurney gridiron

\ median

transverse colon

Omentum and large intestine only found at wound

incision Was made, when stomach and came

into wound: the Jatter could not be traced to the left, but
seemed to enter pelvis on the right side \t first. no small
intestine was found: was later located matted in pelvis and
collapsed like obstruetion Tracing the bowel for a short

distance, a small

Meckel’s

thickened, rough

liverticulum was found beyond

this intestine was eranular. looked tubercu

lous, and soon became tirmlyv§ tixed it pelvis surrounded by
adhesions, so could not be brought lp

Through the McBurney wound, appendix was found in pelvis
surrounded by adhesions Doven amputation done Every
thing bled freely Abdomen flushed with saline and each
wound was closed in layers, a cigarette drain being placed in
the lower angles.

Patient very much depressed for twenty-four hours Ral
hed and. made uneventful reco, In t onths weighed
more than eve. before

CASE 4 Mrs. H. V. J.. 41 vears old Family history good
Oldest child 23 vears. Was in labor twenty-four hours: pla

centa adherent to right side and had to be removed: was very
Neve)

sensation in lower abdomen and

sick for several days following strong thereafter. hay

ing a dragging pain when
Second ehild 2]

hemorrhage after labor and was in bed five

wishing to defecate instead of normal retlex.
vears old. Had

weeks.

aborted at three wee ks:

Two vears later menses became irregular and she

Was weak and had a leucorrhea there
after, and when she walked. hemorrhage returned
after

nancy ’

Two years
beginning of

abortion was in bed three weeks. at
Three

and could not lis

preg

from weakness. months prior to labor. was

“swollen all over” down on account of diffi

cult breathing. Four years after this labor was in weakened
condition, when lacerated cervix and perineum were repaired,
she becoming very much better, but could not walk long at a
time.

Was told she had prolapsus uteri. For past seventeen

vears menses have been regular, but she always had a drag
ging in pelvis and acute, general abdominal pain, which came
on irrespective of quietude and lasted one to three hours, being
relieved by a hot douche, enema or hot applications to abdo
men g

appendix and thereafter had
region, when she rested on left side:

One year ago was in bed a day with acute pain ove
a tearing pain in appendiceal
much walking would also
cause it.

Present Illness —On April 21] was taken
the MeBurney region, which increased until relieved by morphia

six hours later.

vith acute pain in

In another six hours pain had returned and
increased until bowels acted.

Admitted to St. Joseph's Infirmary April 23, 1903
ature 100, pulse 85, nauseated, weak,

Temper
tender over right side of
abdomen. Rectal feeding until operation, May 10

Operation.—Gas-ether.
ment. Laparotomy. Appendix found adherent to right ovary
and tube; was much enlarged.

Considerable débris from curette

brawny, tearing from slightest

IPPENDICITIS

WRAE. Jour. A. M. A.

pressure \ppendix was too rotten to make euff, so a ehromi

eut ligature was tied about same, end cauterized an

cized eat
stitched over. Right tube enlarged and thickened; ovary was

a cyst, size of an orange; both were removed, the raw surta

being closed over and stump stitched to abdominal wall to sup
port the retroverted uterus. Laver closure. Uneventful recoy
ery,

“Now in better health than in twenty years.”
Mrs. D. R. W., 33 years old.

later dysentery, seventeen years ago. Eighteen years ago she

CasE 5. Bilious fever and

fell six feet and was unconscious for several hours and men
struation was delayed for six months. For twelve years atte
marriage she had a continuous leucorrhea, which was _ profus
1899 she had

followed by severe pain over left ovary

at times. During summer of abseess of both

vulvo-vaginal glands,
Which continued, at intervals, until the fall, when an applica
tion of tincture of iodin and earbolie acid was made to int ‘rior
her to bed for two

of uterus. Peritonitis resulted, confining

months, opiates beine used to relieve pain. In January, 1900
left pyosalpinx was removed, after freeing adherent ites

Was in

vhen she had la grippe, and tuber

tines, Which formed a roof to that part of the pelvis.

vood health then for a year,

culosis was suspected
Present Tllness Kou

pain in right kidney, lasting from two ti

two or three vears has had attacks otf
three day s. Fora
vear these have been frequent, with almost constant aching,
pain being relieved when she replaced the floating kidney. Has
The smallest amount of

eaten little for the past two years.

tood causes pain in right hy pochondriacal region.
Mareh 29, 1904

Ferguson incision and delivery of right kidney, whieh

Operation Curettement, and sphincter d
vulsed
was large, hard, and capsule firmly adherent. Posterior flap of
stitched to muscles and anterior flap sutured between

capsule

edges of wound, which was closed with silkworm-eut suture, a
Clvarette drain being used,
\ McBurney

eum and a long

eridiron incision was then made, when the ce
ippendix, surrounded by adhesions, were found
under the border of the liver, the colon passing to left hypo
chondrium, thence to right iliac region and into pelvis. Layen
closure and uneventful
Mrs. J. C

Since she can remember, has had a chronie laryn

recovery,

H.. 35 vears old

CASE 6
History.
gitis. Always a dysmenorrhea, which was not so bad after first

child, which is 11 vears old. Has had hemorrhoids, almost a

continuous leucorrhea and backache since birth of this child
During second pregnancy, eight vears ago, she had a violent
pain, like colic, in right side of abdomen; a mass soon developed
in the right iliae region which was pronounced a “tubal abscess,”
which later ‘discharged through uterus” while she was preg
nant! She was in bed nearly a year. At times since, has felt
this mass in side of abdomen; had frequent attacks of colic,
thought to be
Nausea, but

much for several years on account of pain, and riding was tor

ovarian, but was conscious of two distinet

kinds no vomiting. Has not been able to walk

ture. Amputation of cervix and ligation of piles one year ago
\dmitted to St. Joseph’s Infirmary Jan. 13, 1904. Had right
floating kidney and tenderness over appendix.
Operation.—January 14. Gas-ether. Ferguson incision and
delivery of right kidney; posterior flap of capsule sutured to
Silk
McBurney gridiron incision

muscles, anterior flap brought between edges of wound.
worm-gut closure, with drainage.
Appendix found in pelvis, surrounded by adhesions and stric
tured near base. Doyen invagination amputation, raw surface
closed over and wound closed in layers.

These appendices ought to have been removed when
the first operations were done, and might have been
without difficulty, and far less danger than submit-
ting to second operations necessitated. The patients

would have been cured, and the operator would have
saved himself the discredit of “successful operations
that failed to cure the patient.”

While laying more stress on removal of the appen-
dices before closing the incisions after pelvie operations,

SEPT. 24, 1904. MORTALITY OF
[ also want to put on record as holding the same view
with reference to other abdominal operations. How
often is the focus of infection that lights up gall-blad-
der disease an inflamed appendix! The frequent asso-
clation of chronic appendicitis and movable kidney is
now so well recognized as to hardly require mentioning.

Where the two pathologie conditions obtain. the cor-
one seldom cures the other. If | am not mis-
taken, I did the first combined operation for removal
of the appendix and the anchoring of a movable kid-
ney through the same incision.
before the meeting of the

ecological

rection o :

| reported two cases
Southern Surgical and Gyn-
\tlanta. Both the then
reported have been kept under observation, and both
seem to have heen perfect cures.

| have latterly, however, preferred to make separate
neisions for each operation, as it little
and the done,

Association in

cases

requires more
1

time, work ean be mueh better

FACTORS IN THE MORTALITY OF
APPENDICITIS.*

JOHN B. DEAVER,

Surgeon-in-Chief,

PHILADELPHIA,

M.D.

German Hospit:

Infectious inflammation of the vermiform appendix
has occupied the attention of the medical
inany years, has been discussed and debated
of society |

profession for
at hundreds
and has turnished a fertile theme
for thousands of good, bad and indifferent medical!
authors. Books have been written on the subject ip
France, in Germany, in and in the Unite
States describing the historic « the pathology,
the diagnosis and the treatment of the disease. |

The vermiform has been cut off, tucked in and turned
inside out; the patients have been purged, narecotized.
packed in ice or baked in poultices; they have been
starved or instructed to walk on all fours like quadru-
peds; leucocytes have been gazed on through the barr
of the microscope and tested for glycogen, and the urine
assiduously examined for indican, acetone or albu-
min, and yet, the examina-

meetings,

Kneland,

pisodes,
I

with all this study, al] of
tions, a fatal appendicitis caused by a little 8x1 em. or-
gan has doomed thousands of suffering humanity to an
early and untimely end. The lack of 1
and ordinary intelligence in eliciting the history of the
attack or the neglect of the use of the only instrument
of any service in the diagnosis of this
palpating hand of the
much of the mortality.

sense

common

disease, the
practitioner, is responsible for

ERRORS IN DIAGNOSIS,

Krrors in diagnosis are to be considered under two
headings :

|. The time that elapses between the onset of the
disease and the production of sufficient symptomatic
reaction to attract the attention of the patient.

2. The delay of the physician himself in reaching a
diagnosis.

In regard to a period of latency, it is undeniable that
in a few cases the most prompt diagnosis and early op-
eration discloses advanced pathologie changes, with a
thin, seropurulent fluid throughout the peritoneal cav-
ity. The appendix may show little macroscopic evi-
dence of disease, or may be perforated and gangrenous.

”

ical Association, in the Section on Surgery and Anatomy, and ap
proved for publication by the Executive Committee :
Willard, Charles A

Drs. DeForest

Powers and J. E. Moore

(PPENDICITIS

DEAVER.

in the latter event neither the practitioner nor the sur-
geon can be reproached for an error in judgment. ‘They
at the time of election, and were

rule.

were operated on
the few exceptions to the
habitually from colicky pain in the abdomen, due to in-
testinal fermentation and the accumulation o
women sulfer pain at the menstrual
epoch ; mianhy patients have acquired the
nabit of using laudanum

inal ache or pain, and especially when the sufferer is
dala

Some patients s fer

lial us

some abdomina
Loo ready

paregoric tor every abi
:

In such the onset ol
given warning that something unusual and more
until the has advanced
It is the duty of the practitioner to
impress on his
uncontrolled use ol Opiates,

Serious sVimptoms hay not
SUeVETE
Into Ut

Has OCCcurred disease

later stages.
tinually and persistently patients thi
danger that lies in thi

particularly in children, in whom the percentage of thi
more severe oredes ot appendicitis Is greatel than n
adults.

The failure to make an early diagnosis of acute ap-
pendicitis is responsible for most of the factors enter-
ing into the With a

unanimous avreement among experienced surgeons that

mortality of the disease. nearly
operation is indicated in the early hours of the attack,
the great importance of prompt diagnosis can be clearly)
perceived.

In ever) sudden abdomina!] pain the probability of an

appendicitis should be borne in mind, and no other di-
agnosis considered until that disease can definitely be
exeluded.

An abnormal position of the appendix may make
the diagnosis diticult at times, and in certain of

fulminating types when there is a very obscure history.
t is often difficult to locate the source of the peritoneal
perforated vastrie

obstruction,

Salpingitis, cholecystitis,
intestinal
fever,

intection.
panereatitis, mes-

enteric

uleer, acute

enteric thrombosis, basal pneumonia,
diaphragmatic pleurisy and a few other conditions are
but the history, th

sensation experienced by the

often confused with appendicitis;
onset and the
hand will usually differentiate the true condition.

paipating

The subject of the differential diagnosis is outside the
province of this paper.

In children abdominal pain is of such common occur-
rence that an appendiceal colic is very apt to be unrec-
This is especially true in the first

ognized. year 01
faney, and cases with comparatively mild local symp-
toms are certainly rarely diagnosed, If the process goes
on to abseess formation, the condition 1s more readily
discovered if the possibility of an appendicitis is not

votten.

One of the greatest fallacies which has ever been prop-
agated to account for appendiceal symptoms is rheuma-
tism. In an extensive experience with appendicitis |
have always found true appendiceal symptoms to be du
to a diseased appendix in every case, even where rheu-
matism has been held responsible for the symptom-
complex prior to operation. Without dilating further
on the diseases that may be diagnosed when-appendi-
citis is the true lesion, it may be well to consider why
such confusion continually arises.

Acute appendicitis in the great majority of cases Is
easy of perception, even in the earliest stages. The dis-
ease is so prevalent, the cases observed by every prac-
titioner of medicine so numerous, that one can but won-
der at the continuous stream of pus-bearing abdomens
that flow into a large hospital vearly. Every physician

VORTALITY OF

case Ol

has

had one severe acute appendicitis, which
caused difficulty in diagnosis, has referred
the patient to a beside the operating
table highly intlamed appendix, per-
haps gangrenous, removed. And yet this physi-
clan a lew months or years later is called to see another
patient in the throes ot appendiceal
what the disease may lead to, and

as 1] by a rattt

Inay have
surgeon,

ODst rved a

StOO0U
and

}
|
i

sale

colic, knows well
et gazes, fascimated,
snake, temporizes and dallies until the
and filled with pus.
Phe history of the onset and early |
the results of palpation of the
signboards pomting the way, and if
of peritonitis,
contuse the most
Mumford :

right iliac fossa becomes “ripe”

Hours OL

appendi-

citis and abdomen are

misinterpreted the
extent,

occurrenc even though local in
1. ]
able

=e do not coquet

may clinician,

To paraphrase
with an inteeted appen-

dix; cut it out and you will never regret it.

But 1 Li hemocytometer and IMICTOSCO pK ar used
to diagnose appendicitis to the practical exclusion of
clinical experience, then, indeed, w the mortality of
appendicitis be in the ascendency; and, furthermore,
if t iboratory is wholly relied on to determine the
time of operation, then will there be a still greater in-
crease in the mortality. J do not wish to be considered
as Opposin entific aids to practical medicine, but
rather as objecting to the exaggeration of their j re
tance in the d agnosis of acute survical diseases a \
time when operation promises a nearly absolute cu

'wenty thousand leucocytes is considered by most

hematologists to be the minimum count to diavnos

pus ertainty, but bY the time thes rures lave
been hed, the abscess is crying out to be releases
On ecently, in a French surgical journal, it) was
stated that “those who doubt the clinieal value of the

leucocyte count ar

content with
25.000

those who have been

The figure remain at
il days at least to attirm the
pus. ‘The
SCess Das a tendenc, lo spread and When the
forates into the abdominal
first,
imagine a

an occasional count. must

or above tor

presence ot

SEVeCTi. positive

leucocvtosis increases if the ab-

aAODsSCeSS Per-

l

lePucoeVtOsis sub

CAaVIT\ the
again as peritonitis
surgeon In this country

peritonitis to deve
statement

sides at but rises geve lops.

—

not Walting in

yiood tor LOD.
remarks,

lines of an editomal im a recent num-
f THe Journat of the American Medieal Associ-

} 1 te
ictiy states my “some Of the old-tramed

to which | refer in my

The concluding

views:

delicacy of observation could accomplish as much. wit]
less waste of time, as is now accomplished DV means ot
ntri mechanical appliances.”
METHOD OF TREATMENT.
Mhe next question that arises after the diagnosis of
appendicitis has been established, is that concerning

the method of

We must

not a theorv, because the issue of an at-

treatment to be pursued. face

a condition

a

tack ol] appendicitis ean not he foretold with even the

slig] test amount ot assurance, nor can the nature of

1 ] 7 ry
the pathologic lesions of the appendix be

from t}

deducted

clinica

manifestations. We are not governed
by the same reasons that influence us to perform the
radical operation for the cure of a hernia, or for the
removal ot the uterus for a fibromvoma. In anpendi-
eitis we tace the probable consequences oO] thos dread-

fu! factors in the mortality of the disease- suppura-
tion, gang and perforation of the appendix, with
Varving lesions of the peritoneum Early operation is.
therefore, a conservat ve, not a . !

To del there

rene

radical, procedure.

av oneration until s evidence of the pres

APPENDICITIS

DEAVER. Jour. A. M. A.
pus, Lo defer it also if there be any doubt as to
the pus formation, or to wait until the leucocyte count
rises or falls, is unjustifiable and nearly criminal.
Such statements, however, have become hackneyed,

ence ol

as 1 believe that every surgeon of any experience, 1
this country at least, advocates the immediate operation
if the case is seen early.

The principle may be stated: That in every case ot
appendicitis, seen carly, operation is indicated regard-

less of the mildness of the attack and regardless of thi

severity of the attack in the absence of a spreading peri
tonitis.
In stating as the

pendicitis that the diseased organ should be

the treatment of ap-
removed Lihi-

Prine lpi ol
i

mediately if the diagnosis has been made early, Loam
not unmindful of the fact that, speaking broadly, the

attending circumstances are of great significance im
many cases in determining the treatment to be adopted.

It is

Dro
A

sometimes impossible to institute early operatiy:
The patient may

he or lis

qures for ohe OL several reasons.

not live within reach of a competent surgeon 5

ino to have surgieal treatment
that the patient =
there

as advanced

not be wi

family ina)
rsued until it has become evident
only chance of recovery Is by operation ; or ma
SUCH
that

expectant or so-

underlying disease

De some SerLlLous

nephritis. diabetes, tuberculosis, ete., forbids aetiy
reuimstances

only alternative,

measures. Under such ¢

called medical treatment is the

Operation is contraindicated in those cases of ditfuse
which the abdomen is distended, the tem-
perature high, the pulse rapid and of high tension, the
patient's « most anxious and indicative of

serious intra-abdominal mfection, the bowels con-

peritonitis 1

spression
very
stipated and unable to cause the expulsion of flatus and
and tenderness is dif-
abdominal wall. The tongue 1s
and frequently delirium ts

in which vomiting is continuous,

fuse over the entire
drv and brown. the skin dry,

shortly followed by coma and death.

In another class of cases the features are pinched,

the skin cold and clammy. the temperature is normal or

subnorma!, the pulse rapid and thready, the leucocytes
are below normal 1h) number ana the abdomen hard and
In this type

of diffuse peritonitis the patient is in a state of collapse,

without much distension.

rigid throughout

and operative interference is almost always followed by

a fatal termination.

In every case of acute appendicitis the peritoneum re-

to the irritant
of which d

and secretes a serous effusion, the
epends on the amount and virulence
their hoth. Nature then
TOXIN 1a \ pe Ten-
The first and
protecting and
encireling confine

the infection to a localized area and thereby limit the

acts
bacteria or toxims, or
whieh the

offers TWo weasures 1)\

dered harmless and the patient recover.

most Common Is DI the formation of
adhesions which, for a time a least,

But sooner or later the purulent
products extend in the direction of least resistance, thus
tfering a much wider field of absorption. Nature does
in the beginning, but the aseptic scalpel of the
complete the cure by providing an exter-

amount of absorption,

(
]
}

er hest
surgeon must
nal opening for the pus.
Th

toneum reacting to th

other method [| referred to consists in the perl-

irritation by its entire effusing

surface causing the accumulation of an amount of fluid
proportionate to the irritation, diluting the toxins and
furnishing an antitoxin which endeavors to check bac-
terial invasion after perforation of the appendix (Mosz-
If the operation has been done in time, this

]
KOWICZ).

SEPT. 24, 1904. MORTALITY OF
effusion explains the rapid recovery of the peritone
from infection aiter removal of the appendix.

If operation is delayed, the swollen belly, filled with
thin serous fluid, so often encountered at the operating
table, shows that there is no tendency to form adhesions,
and that large amounts of virulent bacteria or their
toxins are invading the abdominal cavity. Failure to
remove a collection of pus in the right iliac fossa, no
matter where the locality nor what the quantity of pus.
is always a source of the greatest danger and exerts a
powerful influence on the death rate of acute appendi-
CItls.

Nearly LWo years ago | placed a number of cases of
appendicitis with abscess on the rest or starvation treat-
ment, without obtaining any results beyond an aggra-
vation of the symptoms and an increase in the mortal-
itv. It was observed that even the etherization of these
ditticult than usual, and I have fre-
quently remarked to my students that the way a patient
takes ether is often an index as to the gravity of the
intraperitoneal lesion. After opening the abdomen, it
was a serious problem how to dispose gauze pads be-
fore opening the abscess; there were so many adhesions.
not so complete as to effectually wall off the pus. but
enough to interfere with the placing of the gauze. It
intestine wer

Was more

Cases

was also found that the infected coils o
so friable that the breaking of any adhesions would
cause the serous Coat to peel off. Che latter remark
might suggest that in the presence of a walled-off ab
scess the peritoneal cavity should not be opened; but it
is often impossible to vain access to these abscesses in
any other way, situated vy are behind the cecum
and colon and well to the median line side of the flank

as they

[ do not imply that every case o peritonitis must
be operated on, but, on the contrary, as I have pre-
viousiy referred to im this paper, that operation in thi
an acute general peritonitis of
or more hours’ duration, is attended by ereat
life, and, therefore, it is often wise to defer o
In the hope that the inflammatory process will
localized. Adhesions may form |
infection, and the peritoneal effusion take
general cavity.

presence of seventy-two
risks
peratlon
becom
avout the source ol

care ol thr

Such a result is best promoted DV Yest and the re-
straint of peristalsis. When
on at the end of three or four weeks, or at a time de-
pendent on the degree of recovery trom the acute at
tack, the condition of the belly cavity in my experien
does not agree with that found by some writers. In-
stead of reducing the operation to one like the
hary interval operation for appendicitis, 1 have
it one of the most difficult. Inflammation of the per
toneal cavity of such severity as to warrant delay in op
eration must be accompanied by effusion and exudate
and the organization of such pathologie tissue is cer-
tainly one of connective tissue proliferation with tly
numerous adhesions.

these cases are operated
i

Ordal-

fount

production of

When a nearly normal peritoneum
the interval operation, with perhaps a small localized
abscess, it is quite apparent that the primary lesion could
Bowe] necrosis from pres-

is discovered at

not have been a severe one.
sure of pus, metastatic abscess of the liver, suppurative
pvlephlebitis, purulent lymphangitis and Ivmphadenitis,
septic pneumonia, parotitis and pyemia are well-known
to all of vou as occasional results of late operation.

I have referred to the fact that difficulty in etheri-
zation is in direct relation to the gravity of the abdom-
The board-like rigidity of the abdominal

“ee
esion.

inal

LPPENDICITIS

DEAVER. $6]

muscles never relaxes, the patient becomes cyanosed
the bronchi filled with mucus, and at times even respira-
tion ceases. ‘I'hese cases influence the mortality by in-
suflicient relaxation of the abdominal muscles imped-
ing the manipulations of the surgeon, making gauze
packing difficult and favoring the spread of infection.

Following operation the irritation and congestion of
the bronchi favor their infection and the production otf
an inspiratory pneumonia. For this reason it may b
argued that ether is not the best anesthesia for such
cases, but after a thorough trial of nitrous oxid gas, I
find the combination ot ether and oxygen, always fol-
lowed by oxygen, to be the most satisfactory.

‘The presence of pus is by no means necessarily fata
if the operator is experienced in dealing with this class
of cases. The salvation of the pus case lies in proper
drainage with protection of the healthy peritoneum
during and after the operation. Successful drainage
depends on a sufficient amount of gauze properly placed
with a glass tube in the pelvis if necessary. Gauze that
drain is harmful than beneficial, too
much gauze, and especially if improperly placed, only
adding to the number of adhesions and to the chances
of an intestinal obstruction shortly after
The management of the also an
| The time ana

does not more

operation

Tauze 1s lIMportant

factor in the mortality of appendicitis.

method of its removal are important points to be con-
sidered in every ease in which gauze has been emplove

The tendency is to remove the gauze entirely too soon,

and as this always requires force, adhesions are broken

mm. and infection is liable to be spread from th s

ereting eavity.

end of twenty-four or

pus
} e ms.

fortv-eight hours is, in t
jority of cases, removing the main hope of the patient
Where a large localized CO lection of pus is accom pa-
nied with what appears to be a beginning genera! peri-
tonitis with injection of the serous coat of the bowel and
considerable quantity of cloudy exudate, the ques-
general irrigation is to be considered. In the
majority of cases the entire peritoneum is not infected
can better eare of diseased

products unaided. I rarely irrigate such an abdomen.
Failure to explore the pelvis is another factor of
ittle importance. In very many instances a collection
pus may occupy the pelvis, and un

: lice red ; | . Yr drainaga rovided proves
ess aiscovered and propel aralmMage proviaed pro

tion ot

and this membrane take

no

Ol cloudy serum or
menace to the patient. Secondary collections in other
oealities must be evacuated and drained.
Acute intestinal obstruction following
terference in acute appendicitis is one of the
The gravity of the

condition depends on the fact that a second operation
is always urgently demanded. In the presence of an
infected area of the peritoneal cavity, and with the al-

operatlyve
most s

ous of the sequelae of this disease.

ready weakened resistive power of the patient to shock.
t would naturally follow that the mortality of
obstruction is high. Following the evacuation of a eir
exudate which
restricting the spread of
ts liability to organize

acute

abscess, the has served the

cumsceribed
useful purpose of
becomes a menace by into con-
tissue. Such adhesions may give rise
trous intestinal complications. By their mere adhesion
to portions of the bowel they inhibit peristalsis, and by
their contraction intestinal obstruction. Injury
to the free edges of the omentum or mesentery
sult in their adhesion to the small bowel with a conse-

to dlsas-

nective

cause
may re-

quent obstruction.

The greatest number of acute obstructions of the in-

‘ rSOLTSSTON ()\
lows yy Causes } LDS Se \
l inst op ay ( O
e rns
t) rt )
SeTO ( ( is | en
| ~ )
i i
:
~ ? ~_
“ Q Sl yy) } \ l a 1
} < \ 2pe ? y< Q
( tiscs =~ l ~|< ) \ Cl
! s ( 1} 1) ? ral 1) gs prod =
Vie] {| ippene x = 7 1 en remy (
\\ e SUC } Oo not ect : OT: nfluen
l 17 tail ratio} \ (
: ater underta repair is by no
lis ePVO | risk
7
Kit v. the great percentage of extensive drainagt
eCnses a;nre oO lowed ) hy rl } O \\ e] mechani ip
, ° 7
) inces are Of no ava Hernia requires a secondar\
yperation which is more formidable than the primar
One
In conclusion, 1 would again urge on you to advoeate the
early operation tor appendicitis. The tendency of mar
A ii .

surgeons at the present time to occupy a sort otf middle

eround should not be imitated by the rising generation

| know of successful surgeons who operate immediate)
when a case reaches the hospital, and yet who formu-
teach their \
treatment of appendicitis that a irgery\
must be earried around Furthe:
more, an expression of opinion from members of

always of interest to the

late and students so many rules for thi

text-book ot S|
in the medicine

Case.

ical association IS evenera

practitioner. Too often the discussion of a paper is lim-

ted to congratulatory remarks, surgeons whose teach-

ng is of infinite value preferring to praise or conciliate
friend rather than to boldly announce their own ideas

nd practice.
DISCUSSION

ON PAPERS BY DRS. M’COSH, M’RAE AND DEAVER

Dr. Ernest LapiLace, Philadelphia—TI believe that in every

fatal case there was a time when, if the operation had been
performed. the patient's life might have been saved; but some
body has been guilty of allowing that moment to pass by. I

deny that any one can establish the fact that there is pus in

the abdominal cavity, that there is a leveloping case of peri
tonitis, or can deny the occurrence of fulminating appendicitis.
If we

state of uncertainty as to the future of that

vecept this it follows that by delav we are in a great

patient. Taking

this for granted, it is useless to deny the necessity of operat
ing during the course of the disease. You should do the opera
tion and use common sense, according to the rules on which out

rw le lor of surgery is founded In Cver Cast whe n possi
t I believe in the dry method of operating I drain and

m and remove the rauze on tive eighth day

proble ai

W he 1 pe riton
\nother
The

local

itis occurs, one is face to face with another

isease has stepped in, and that is general septicemia

patient may die. from general septicemia although the

peritoneum has undergone improvement. A patient may die

wit! fetanus even thougt his thumb has been

amputated.

[PPENDICITIS Jour. A. M. A
Chest Ss uid uu er eX) hen | lt l Op {1
has bee rrorme | t general peritonl n the sa
oO! n principles it 1 would erysipela L watel
| wma 1 { lly l is! vith sterile
| il ( i 1 tH 1 ( ist i} i)
} hye i { inflamed pre
Tis elt thy ha ely ly
in cy I ! | |
t not 1 i iN he
i l il peracion ! 1}
l l WOW | de Vitosl
en ( Lined yperatiol
lt { tru
' ( 1 to ive 1 Vill ¥y
i ! I i tha e W) \ him then | pati
it} ind is the onlv true test of an underlying irritath
! ination Phis reveals the rigidity of the muscles
ea nh ition and points to imn
Lite ] Yiati I
med. ik. SumMers, Jr. Omaha-——Diaphragmatie pleurtss
metimes in tl] vay of diagnosing appendicitis, particular!
in children, but I believe it can be verv readilv recognized I)

a number of cases. in endeavoring to elicit the physical sign

[ have found almost complete absence of the respiratory min

lune In such a ease one

with It

mur over the lower part of the right

ean say that he has a pleurisy to deal is usually i

pleuropneumonia that the pleuritic elements largely predom

inate Dr. MeCosh did not refer to typhoid fever as a com
plicating factor in making the diagnosis; the general symp
toms are usually more severe than the local ones, but you de

eet localized svmptoms on pressure as in appendicitis, but not

MeRae’s

abdomen is ope ned is COM

so characterist 1 \s to th remarks, [ would say
that if the difficulty for which th
ippendicitis the appendix should be removed, othe
\s to In

if n the adverse

plicated by
Deaver’s paper, Tam almost too modest t
side I

appendicitis nineteen vears ago and since that time I have been

wise not
discuss did my first operation foi
on all sides of the fenee regarding the time for operation. In
that
mortality is unnecessarily

late vears I have taught Deaver is too radieal, and sta

tistics will prove that om high if

we follow his advice When the disease is progressing, and ]
am convinced of the symptoms of perforation, IT operate with
on the third, fourth or fifth day

whereas if we do not operate, but

vood results. If we

operate
we lose too many patients,
teaching of Dr. Ochsner, many more cases
that
Since we have stopped following Dr. Deaver we have obtained
results. T am glad to see that Dr. MeCosh has become

others

0 according to the

recovel Statistics in my community show this is so

hette1

conservative Perhaps will follow him im tive

more
seems foolish for us te
told us

adoption of the Ochsner treatment. It
diseuss Dr. Deaver’s paper, but maybe he has not yet
the wav to do the operation

Dre. FE. L. Hupp, Wheeling, W. Va
but ome are obliged to accept. that

fact.

all Cases of ap

It is an unfortunate
which we
pendicitis do not get well. One of the factors determining a

fatal

peritonitis antedating the

issue, where there has been a beginning diffuse, septi

interference, is a continu

of this kind that have

surgical
ance of this process Of the seven cases
recent
Practically all

a result of well-known and recognized causes :

come under mv eare in vears and been operated on.

two have died in this way other deaths in
these cases were
but within the past four weeks there has come to my notice

case of appendicitis which presents a unique feature in these
\ bov of 14
Hospital

who had been treated by his family phy

mortality factors, so far as my experience goes.
vears of age was admitted to my service in the City
of Wheeling, W. Va.,
sician for typhoid fever for a period of eleven days prior to

admission. His symptoms seemed to have been typical up un
til the tenth day, when there was discovered an induration and
localized the right On the day of

admission, May 6, under chloroform narcosis, the usual incision

tenderness in iliac region.

was made and about an ounce of very offensive pus was re-

moved from the retrocecal region In the washing there es

tubular segment of the appendix vermiformis, much

A suspiciously dark

caped a

resembling a macerated piece of macaroni.

SEPT. 2-4, 1904. DISCUSSION

ea Was detected over the cecum, but because of 1 nrofound
lapsed condition of the patient no further int
eemed advisable. Well-directed drainage was established at
e patient removed from the table Fortv-eight hours

operation the dressing was repeatedly saturated wit]

irk, offensive, coifee-eround thiid. and at times ther
be some fresh-looking blood with the exudate he
ns were removed and ther elled { , tic
ind a quantity of decomposed dark bl elot (
1 death followed three davs after the operation 1}
terest in this case centers in the autopsy. The ceeum, burik
Miass of } whe firm adhe sions vas th it of
perforation sufficiently lare ulimit two. fingers \
nant of the ippendin vas discernible \ very extens
Wasation of old decomposed blood was found istendit
eecum, ascending colon and part of the ijleun Pever's
tches exhibited the tvpical typhoid lesion and an rode
ssel in the base of one of these uleers demonstra he s t
thre hemorrhage and the cause of deat}

Dr. <A
invthing

York Citv—I have
looked like

so that T certainiv have no rig)

Jaconr, New
that

entv vears,

nol operated

appendicitis or peritvphlitis fi
T

to speak of the

peration as such. Still T have seen a great many enses of ay

endiecitis and have heen present at number of operations
\hat T have seen is a great manv cases of sudden onsets. wit]
ipid) pulse and high temperatures. which when left alone

vere better prepared for operation at the end of a week. and

there are many surgeons of the same opinion I reeall

hat T saw recently with several other physicians in whi

-ome of us desired an immediate
that if he

operation \ surgeon was

il'ed in, who stated operated on the case in its

present condition, with the high temperature and the state of

collapse, the operation might be successful, but the
would die.

patient
He operated a week afterward and the patient re
covered. I have seen a number of such cases operated on at
On the other hand, we

cases of appendicitis get well under what is ealled

the end of a week and they recovered
see many
medical treatment. That is not infrequent with children who.
still recover. and after

I do not believe that
What I
am more interested in is the diagnosis, and that. we are told by
Dr. MeCosh, is Fight
was called to see a child 4 vears old who had been ill tw

though they may have other attacks,
growing up never have another attack.
there should be for all cases one and the same rule.

sometimes very difficult. weeks ago |

davs. There was a physician in attendance and two consult
ants beside myself. There were very few symptoms. but appen
dicitis had been mentioned at first by the family physician
None of us was ready to make a diagnosis of appendicitis. The
child had vomited three or four times a day for two days and
some diarrhea.

there was The tendency among the doctors

was to call it gastroenteritis. There was very little pain and
ll that I could elicit was on the left side of the transverse
colon. It appeared to me to be a pressure pain, as it was not
fifteen

rigidity over the appendix nor any pain when pressure was

present minutes afterward. There was no muscular

suddenly discontinued. Meltzer’s symptom was absent: ther
was but little tympanites. TI saw no reason to diagnose appet
New York was
called in and also said that it was not appendicitis and that
afterward the

licitis and one of the famous surgeons of

there was no reason to operate. Two days

child died, and the postmortem showed an abscess and many

idhesions There are cases in which no diagnosis can b

made, as Dr. McCosh has told us. either by the medical or the
surgical man. TI have no particular reason for recalling this
case except that T have been conscience-stricken all the time.

and still I do not know how te avoid a mist ike when there
ire no svmptoms pointing unmistakably to appendicitis. U1
such doubtful cases do oceur.

Marcy, Boston—It

fortunately,
Dr. Henry O
since mv first operations for appendicitis

is quite eighteen vears

During this period

both in publie ind private service, my operations have heer

foo numerous to demand statistical tables. and vet not one of

t} entire series but has made im eAS\ recovery where the

ippendix had not ruptured prior to operation Experience is

now ample on which to formulate rules for surgical onidance

times diffientt te

IPPEND I ITIS. Sh.

1 ll ecauay { \ 1
Ist surgeon kes t ! l i } 3
Crols! to be rt] Lec by ttle t 1 ~ t i
be yudged oF ] ws sins =
) WinttamM H. WatTHEN Lat
raises thre rene 1 ! l
~ ol 1 ( vn ( 1
i> prin 1} ul !
l i l tev
| o1lowrst 1 } e , {
) ] es 7 i rE 1]
} \ rel S ! } n the
ry i 11) ot ‘ahi }
bile 1 ton ‘ ¢ e
Piet tures lt o raios
! mn perl Ing a fT ] l i ! ! !
" bden 1 tor \ Wel ‘ ‘ hin ! ~
roved hanism in op itin \ \
1 ions t preceeded Ii vent int ! \
WV elue in our Ameriean Gvynecolovieal Ss tv everv dis
ise in the abdominal cavity hich is treated | e general
surgeon) Phen let the vnecologvist and the eneral surgeor
nite in elforts to evolve the best methods in the diagn
herapv of diseases in the abdominal eavityv. for ther
onsensus of Opinion on many vital questions, and we hav
much to learn and much to forget. While it is genera oret

ippendix should be removed if the

that the

patient ean be opel

inflammation has extended to the adjacent

ated on eTOre t he

peritoneum, and that the operation is also indieated betw

the attacks, there is no agreement as to what should be done in

all acute cases where there is a periappendiceal septic involve

} }

nent Dr. Ochsner treats these cases by stomach lavage, and
laims results far better than he had obtained by operation,
vhile Dr. Deaver claims the reverse in his work: and as these

centlemen have had mueh experience, this difference of opin

mw?

m and practice must be carefully considered and logical con

clusions accepted. ] am sure ] have had deaths in operations

for appendicitis in acute where adhesions had formed,

CASES
and where I opened the abdomen immediately over the infected

area, because T could not intelligently separate adhesions and

successfully protect the surrounding peritoneum from infee

tion. By making the incision to the left and bevond the in

fected area. splitting the rectus muscle, or opening through the

linea alba. we mav isolate infection and intelligently treat

ithologie conditions Tn diffuse

stomach o1

suppurative perifonitis, in

appendicitis, intestinal perforation, gall-bladder

experience and observation
bet te

upture and visceral wounds. my

ive taught me that we mav expect results where we

ivoid the additional peritoneal irritation necessarily resulting
After thorough

much septic matter will remain in

from saline irrigation or extensive sponging

irrigation and sponging,
iraumatism to the perit

the cavitv. and the added

t ;

so impair its resisting powers as to encourage the more rapid

multiplication of pathogeni hacteria. The mortality will be
less if we operate on such cases quickly. Do not irrigate
but little sponging. and drain from the lowest part of

witv by a large gum tube, thus removing intraperitoneal ten

resistance to further bacterial

I believe that

sion and therebv” increasing

multiplication and invasion much of the mor

ilitv jn these cases is the result of too mueh irrigation and
sponging and insufficient drainage If the infection is viru
ntly streptocoecic, the cases ill die under anv treatment,
otherwise most of then vill recover if treated a IT have
reested, if the operatiol - nat too lenge delaved
Dr. ERNEST LAPLACI eplving to Dr. Wather stated
it where pus extends a over the peritoneut nd eT
mn ition is general e ean not thoroughl leanse the
eritoneum at the time of the operation In these ises only
o T advise repeated irrigations | the method T have } re
luced
Dr. A. J. Ocusner. Chieago—I would say that there are
o classes of cases of acute appendicitis in which it 1s some

Imit the infection to the vicinity of the ay

pendix. heecanse of e absence of a sufficiently large omentum

Si DISCUSSIGN

surround the diseased appendix Lhis condition is tre
quentiv found in young children and in greatly emaciated
adults. In these cases an early operation is consequently indi
eated, and if this can not be done for anv reason it is best to
place the patient in Fowler's position. IT have learned more
about appendicitis from Dr. Deaver than from any other
man. [ always learn when I see him operate or when I heat

his discussions on this subject Dr. Deaver and | have agreed

for years as regards the treatment of all cases of appendicitis

with the exception of one class. We have agreed on the wisdom
of removing the
still

interval

appendix so long as the infectious material is

contined to the appendix. Cases of appendicitis in the
Where

scribed abscess that abscess should be drained

should be operated on. there is a cireum

There is one

class of cases of agreed,

ippendicitis on which we have not

although To am very positive Dr. Deaver will agree with me

just as soon as he will be convinced of the facet that it is rea
sonable and that it is beneficial to the patient Within the
last month, in the preparation of another paper, IT have had

tabulated the last 1.000 eases of ippendicitis on which T have

operated in the Augustana Hospital These cases were taken

consecutively during the last thirty-three months Che follow
ing table shows the results
Pel
July 190. to Ap 1. 1904. 2 vrs. 9 mos Cases. Deaths ent
Chronic appendicitis interval operations S00 ? x4
Acute appendicitis without perforation Dest 4 19
Treated by bsolutelv prohibiting all nourish
ment and ithartiecs by mouth previous to
peration =
Oper do on withir 6 ho t
\ ‘ ippend s perfora 1 gangrenous
vith nb ©s 0
I ad \ solutely proh , ase
| )
nt d catharties by revious te
t I t4
One ted on ithin 48 hours :
Acute appendicitis. pet ited w » al s }
Treated I itely prohil ng a rish
ment and ties by mouth previo 1
eration Ts
\ yy s \ road s gel
nitis O00
(hon ge D se
Out f o40) interval operations 3 dted. all as a result of an
iddition i] operation To pyosalpinx Of weute ippendicitis
Ps |
wit he werforation there were 255 Of these T operated at
once on 200 and treated 55 bv starvation I lost 5 eases in
the 255. a mortality of 1.9 per cent The reason the ?00 were

operated on at once was because the infection seemed to he
stil] nfined to the ipp ndix Fiftv-five eases suffered from
perforated and gangrenous appendices without infection of the

veneral peritoneal cavity: of these 34 were starved previous

mw operation and the emaining 21 were operated on at

nee ecauuse it seemed clear that the infectious material was
still contined to the appendix. Gangrene had occurred, but it
iS npletely occluded from the peritoneal cavity by being
shut off bv 1) omentum Although the appendix was pen
ted still there was no infection outside of the appendix

This

and no death re

and small piece of the omentum that surrounded it.

Was removed tovethe) vith th appendix

sulte It is in the next class of cases that there would have
een a darge mortalitw had they all been operated on at once
Isston te th h spit il There vere 117 Cases OT pel

ive appendicitis in which the infectious material was not
umscribed, and of these 78 were treated by starvation It

n this elass of cases that everv surgeon who operates at

nee on making the diagnosis has a larg mortality It was
the proper treatment of these cases that reduced the mortality
to 3.4 per cent.. and it is in this class of eases that thousands
of lives are being saved all over the United States by the
treatment which changes a dangerous acute into a_ relatively
harmless chronic condition. Of the 117 there were manv in

hic hit seemed whe n thev entered the hospital that they were
peritonitis and T did not
extensive the

suffering from diffuse know abso

. ae : =
lutels how Infection was These cases corre

led to a definite type. there being a bad facial expression,

<pome
distension of the abdomen and eontraction
these 117

have heen

Hi perspiration,
of the abdominal muscles If cases had been oper-
vould a mortality like that
mentioned Nearly 40 of

once ther
Mares

ited on at

whieh Dy would

these cases

ON

APPENDICITIS. Jour. A. M. A.

have died under ordinary skill, but with Dr, Deaver’s exti

ordinary skill the mortality would, of course, have been les
but still several times as great as it was by placing them ten
porarily on this definite form of treatment, consisting in th
use of gastric lavage and the absolute prohibition of all nou
ishment and cathartics by mouth. One of the surgeons in

large Vienna hospital claims that a diffuse peritonitis will be
of the antitoxie action of thi

come cireumscribed as a result

secretion, There were 33 eases who suffered from diffuse peri

tonitis when they first entered the hospital. Some were in
such a desperate condition that they were not operated on at
all. Our mortality in this particular class of cases is large:
than it would reasonably be under ordinary circumstances, be
cause no patient suffering from appendicitis is ever refused
admission even though he may die immediately after entering
the hospital. Many patients enter in a hopeless cond...on, the
result of the administration of some form of food or eathartics
during the early portion of the attack. These patients are
usually admitted between the third and the tenth day of the
attack.

far gone that we

>

Of the 33 cases only 10 died. and 7 of these were so

eould not operate. If we had operated on

the other 26 immediately on their admission there would havi

~~»

been many more deaths. In 1,000 cases there were 22 deaths,

or 2.2 per cent. There is one point which IT wish to emphasize
in cases in which the infection had already advanced

the time of

especially
bevond the immediate vicinity of the appendix at
admission to the he spital, a definite form of non-operative
based on definite principles which 1 have frequently

rhe main features of this treatment

treatment
described’ was instituted,
consist in removing the contents of the stomach by gastric lay
age and then giving absolutely no nourishment of any form and
no cathartics by mouth, giving no large enemata, but support
ing the patient by the use of small nourishing enemata not to
foun administered through a soft rubber cath

exeeed OUNCES,

introduced from two to three inches. The nourishment is

viven every three to four hours. It consists preferably of one
ounce of some commercial predigested food dissolved in three
ounees of At first the patient is

not permitted to drink water, but may rinse the mouth with

warm normal salt solution.

cold water Later small sips of hot water and still later cold

water is given by mouth. It is well not to return to any form

of feeding by mouth too soon, and it should be begun very

cautiously,
Murpeuy. Chieago—-We are agreed that all

cases should be operated on early, that the least possible manip

Dr. Joun B

wlation should be made, and that the waiting plan and starva
tion treatment is only indicated in a few fulminating cases in
the active stage. There are a few elements in the mortality
which have not vet been mentioned, and the most important is
the tvpe of infection. There are types of infection which will

a fatal termination no matter what we do. They are

There is another ele

vo on to
rare, however, in the peritoneal cavity.
ment which affects the prognosis. “When the symptoms sub
side | and that is the fatal mistake
When the symptoms suddenly subside T am frightened. My
experience has been different from Dr. Deaver’s and Dr. Ochs

wait.’ say some men,

ner’s, Some vears ago [ stated that a large number of eases
of general peritonitis would die no matter what we did for
them, and IT now want to apologize for my error. T have had
sixteen consecutive cases of general suppurative peritonitis,
and I do not mean simply that there was a large

result

perforative:
quantity of pus in the peritoneal cavity; IT mean the

of perforations. They include perforations of the stomach,

duodenum, intestine and appendix. T operated on all sixteen
cases immediately and all recovered but one. IT have not had a
death from general septic peritonitis from any cause in over
two vears, except this one. Tt oecurred in a child with a five
day general suppurative peritonitis, from perforative appen
dicitis. The patient died from a double pneumonia six days
after operation and at a time when all peritoneal symptoms
had subsided. The operation makes the difference, and for-
merly patients had been killed on the table because too much
the abdomen at the time of severe toxemia

work was done in

O46,

1. THe JowunnaL A. M. A.. Aug. 29.

1908. p

L904, Oo\

DISCUSSION

SEPT. 24,
id severe depression. Pus retained under pressure is rapid!)
sorbed, whether it be in the peritoneal cavity or elsewhere,
nd to stop absorption all that is necessary is to relieve the

nsion. If we have an acute phlegmon of the leg we do not
ash it out, sponge it, serape it, or get our hands or feet into

we simply relieve the tension by opening 1, and we have
ist that to do in peritoneal infection and in addition close
he opening from which the infective material is leaking. There

hould be no washing, no sponging, no handling of the viscera
| advise putting a rubber drain down into the vesico-rectal
ld and placing the patient in the semi-sitting position. T an
orry to ditfer from Dr. Laplace, who gets results from wash
ng, While IT get them without washing. I do not question his
esults, but T should have to see every detail of his technic and
before 1
technic is if the

{ his treatment would consider changing. I do not

are What the results are secured. I have
iperated on every case of general suppurative peritonitis that
iis come under my charge in the period mentioned with the
ibove results.

Price,

vet In promptly and play the game.”

Dr. JOsSeri Philadel phia— Dr.

which is

Murpuy tells vou “te

just what vou

should have done in surgery many vears ago and the mortal-

itv would have been greatly lessened or nil. Dr. Ochsner’s

miper oin Saratoga has had avery bad intluence. In

Dr. Murphy's series of sixteen incised perforations he lost one

He would have saved this ease if Dr. Ochsner had not read o1

published his paper, and prebably favored the delay. I read a

pRuped some Vears ago on general suppurative Or St ptic pel itor

tis. and the Chairman left the chair in this Section and said

vo unchallenged. Dr. Deaver does not lost

he could not let it
ises that walk the streets without appendicitis. Such cases
ts Dr. Ochsner reports in his first series of 500 (borboryvgmus

loses such cases no

none should have died. Dr. Deaver neve) L
My mortality

The four deaths and the quite universal custom

loes he operate for borborvgmus. in 600 eases

Was four cases

of drainage was largely due to the very strong influence of Di
Qehsner’s paper at Saratoga on the general practitioner. The

evnecologists have taught vou all you know. If vou want t
Many of
us have lived through our period of usefulness, beyond the ave of
i) ier

know anyvching about drainage come to Philadelphia

not let the vouth of the country die in such large
wubers. A few vears ago 400 deaths from appendicitis were

ecorded in Chicago in one vear. Since then Chicago has prol
If we put the
death

population of 5.200 a veal No one

bly lost 1.600 a vear from appendicitis. mortal
the state

future of om

tv at 100 t verv light) we have a rate in

he very

should ever be permitted to die of appendicitis There is nm

herapeuties in its management. no starvation, no sweet oil, ne

clean following the diagnosis.
lv made.

eebag—only early surgery
This
strongly of the old discussions on this subjeet many vears ag

Manv of us fought the battle all over the land and

vhich is easi sharp discussion reminds me

thought

) +

he last word had been said, and rejoiced that the natural his

tory and treatment had been established for all time
Dr. Rorerr T. Morris. New York City

appendix when the abdomen is open for some other cause

Should we remove

have no ocension

hest

Our best statistics oceur among peopre whe

for any sert of surgical operation. The next statistics

ecur among people who require the least amount of surgica

deduction is that the easier we allow a sw
better will be the

ie appendix alone until it is infected, and then lose no time

’ }
oneal

il patient te escape the record Leave

+}

in having it inspected That couplet expresses mv views

Vhere are three chief objections to the plan of removing the

open tol some
Next. the

other operati n
, }

factors mav not have heen called cut te

ppendix when the abdomen, is other cause

First. it prolongs th patient's re

~Istance meet the lit

e special infection that may occur from opening the lumen of

the bowel. Third. if the precedure is taught by competent men
t will be carried out bv some
Deaver
It is better than committing taxidermy on
New York who

arrived at the

who will manage to get a death
rate out of it Dr
ige in New York.”
vour patients, but there are many operators in

agree with Dr. Deaver.

speaks about indergarten drain

Some of those who have

oint of m iking “kinde rearten drain ge have

=the h good statis

APPENDICITIS. 865

ics that thev are accused of removing normal appendices 1

Gauze packing in the peritoneal
Take

order to get such results.

cavity is a foreign body, and harmful and unnecessary
ten healthy policemen from the street to-day and put half a

vard of gauze in the abdomen of each one. and we shall preb

ably lose one or two of them. If strong, healthy men can not

bear the presence of gauze in the peritoneal cavity how cat
commit taxidermy

weak appendicitis patients bear it Do no

on appendicitis patients. Some of us do not use any gauze
picking at all in the peritoneal cavity.

Within the wa

Dr. Morpecat Price, Philadelphia

men who have seen me

room are open 100, eases of venel il

peritonitis and gangrene from appendicitis, and with therough
rt ort \N ]

ashing only two on three have cred ln the st (

sev. Probably in Dr. Ochsner’s cases his treatment is all righ
In the hands of the gentlemen throughout this country it has

been anything but satisfactory \ppendicitis has no place

in our work except for immediate removal I remember the
cease of a voung lady who was almost dead 1 could tind no
tumor but a pronounced resisting point. and IT diagnosed ap

pendicitis. TI said T should remove the appendix within the

next twenty minutes and did so. when I found it gangrenous
bevond repai [ remember another case which had been il]

Phere was a pronounced resistance over the ap
The

[ operated and

tor tive days.
pendix and [ advised immediate operation woman had‘
not had a pulse over SO nor any temperature
found a gangrenous appendix, although she had not seem

sick. Ii Jacobi When you

vet hold of a patient where vou can not tell just exactly what's

| asked about diagnosis

, Very

the matter. and there is a slight resistance over the appendix
take it out.
Dr. DEAVER

made the statement that operation should be done in all

misunderstood me I

Dr. Summers evidently

When the patient was seen earl I have advised delay in

peritomitis. LT ad
appendix in all cases Dr. MeCosh
from the attack. but I consider
certain Jacobi, like

that the

tain eases in the presence of a general x pte
not take out the

until

adv ises

that we watt recovery

this dangerous practice in cases Dr.

COuraLrs to

inv medical men, has not the decide
Many voung doctors never realize
doubt but that had the
Price or others. the

Retter take out a healthy

int belongs to the surgeon.
There is no
Ochsner. Th

the value of palpation.

Pace bi Cast been seen bv ia

iagnosis would have been made

ppendix and have the ease vet

well than leave a diseased ap
endix and let the patient dic I could never understand this
How do. thes:

The diagnosis is usually made by my in

iestion of diagnosis distinguished people

ake such errors‘
is rarely me to walk into the sw

ernes and it necessary fo

ical ward to do this. If internes can do it. surgeons shoul
lo better. In Wathen has
should then

appendicitis should readily br

ovnece lk orjsts

referred ti the
work to the pelvic cavity If see

diagnosed As to treat

Phevy confine

t iy

nent, there is a great difference of opinion I can not inter

}

et my friend Ochsner’s statistics. My cerebration may 1

little defective. I do not opel ite on cases with advan
peritonitis of several days’ duration that are practically m«
bund. as T stated in my paper. Before I came here T look

I do not like to speak aben
anvbody to

others T

on patients who had

ipo my mortality since January J

it here. heeause 5 do not expect helieve if iT

than T should expect to believe have

Operate
on 159 aeute eases sinee January 1.
evacuated

il] for from three days to four or five weeks. I have

ppendiceal pus by the gallon. The statistics of these acute

ises is 5 per cent. plus I am convinced that there is no

treatment under the heavens other than the judicious surgies)
technie that would. give vou as low a mortality as. this in
cut asses IT do not expect to lose anv in the interva "

ation. but when we do it is usually from pneumonia, and such
0 Murphy one better He had
death. while T had
The class of cases of general peritonitis that T have
had only

}
hast

exceptions will oceen IT go Wh

with one sixteen with m

~1xteen cases

been ill a few

Saturday.

recovel
case of that
the abdomen was distended, there was museular rigidity. and

imed

hours. I operated on a

kind The temperature was 104

hen T opened the abdomen T rolled out an inf! ippendin

S065 PNEUMONIA

- Ll puta gvlass drainave tube ints pel
Is i ‘ is Was e\ ited What I take exception to
yy. Oclisner’s treatment is the daneer of its being used in

st su ines as min | only solution is Don't stand
ith your hands in ur p s and dilly-dally. Don't give
ilomu ind ca n several nsultants. 1 do not agree even
so distinguished as Dr. Jaeobi Open the abdomen

Hk MORPALITY AND MANAGEMEN'

OF PNEUMONIA.

EDWARD F. WELLS, M.D
CHICAGO,

Pheunon continues, in oO country at least, the
greatest medical problem of the day. Its prevaience and
ts lata e markedly increasing, and this at a time
when there Is a grow ng, lt not as yet a distinctly ex-
essed Opinion, Within as well as Outside the profes-

slon, that this situation is needless and should not eNnist.

Under thee circumstances it may be Well tor us, at the

SOM. to

review the perti-

lent past, take stock of the presen and as carefully as
~OSs10Ie scan the Tuture Or sole rom Ise Of rel el, :
Pneumonia is ubiquitous, and in temperate regions is
the severest and deadliest of the commoner diseases, and
Is proauciive of more deaths than any other. li is re
sponsib'e for an annual morbidity of about 0.7 per cent.,
mortality rate of about 0.13 per cent... and ‘it cause
about 8.1 per cent. of all deat! s. That. it is steadily in-

creasing in preyaence | have already proved, and the
fact is graphically shown by the the wall.
Here it seen, among other showings, that in New
York an annual mortality of about 1.3 per 1.000 of pop-
LS04-1815 2.5 per
1,000 during the terminal decade of the century ; that in
Ph 1.000
f population in the vears 1861-1870 rose to 2 p
n the decade 1893-1902 - that in C] icago the rate of 0.5
1.000 of population in the decade 1851-1860 was
during the decade at the end of the half-century.
\ reasonable explanation for this increasing preva-

charts on
MAaAV Ye

} 1

’
I
In the deeade rose To about

ulation

rr 1 000

idelphia the average mortality rate of 1.2 Cal

per

(rip ed

lence of the malady may be found in a consideration of
certain facts appertaining to some of the factors which
The

in viruleney in different strains,

re especially active in bringing about this result:
Hneumococeus varies
vd any strain may be made more or Jess virulent by eul-
‘ivation. That the incre and heightened
leath-rate mav be due to the propagation, survival and

in-

re-

ised prevalence
most virulent varieties is a fair
The pneumococeus is found in the

‘piratory tract of many persons in health: and this oc-
urs in a very much larger proportion of the population
‘han the statements of most observers in this field would
ndicate. In a series of observations made:‘durine th
past few months TIT found the pneumococcus in the
tions on the tonsillor surfaces or other portions of the

lissemination of the

ference. upper

seere-

upper respiratory passages in more than 45 per cent. of
the 135 persons examined. \ remar! able. and. | believe

most important. observation was made in this
ramelyv, that in some instances the bacterium was found

]
im Svery,

SseTIes

or nearly every. member of a family, while in
ther families every member would he exempt. Further
analysis revealed the fact that in a majority of the fami-
lies in which the germ was found to be so freely dissem-
inated one or more cases of pneumonia had more or Jess
*Read at the Fiftv-fifth Annual Session of the American Med

al Association. in the Section on Practice of Medicine, and an

proved for publication by the Executive Committee: Drs. J. M
Anders. Frant: Jones and W. S. ‘I

-WELLS. Jour. A. M, A.

recently occurred, while tne histories of the other elas
free from such cases. These features
were so prominent as to make a profound impression o
my mind, a.d Ll am of the opinion that the fact,
further observation should prove it to be a fact, is o
prime importance, Inasmuch as it offers a ready explan
tion for the house epidemics and consecutive famil

Ot families were

cases which not infrequently occur; and also, and mor
important, clearly and directly points the way toward
reasonable and practicable system of prophylaxis.

Hlow is the How ca
we account for its excessive prevalence in some families

pheumococcus disseminated ¢

Why is tere, probably, an increased and inereasing dit
fusion of this germ? How does it produce pneumonia:
These fundamental and very important questions
and it is regrettable that the present state of our know]
dge does not permit a direct answer to them.
certain assumptions

are

Llowevei
may be made with the assurane
that they do not lie far from the line of truth; that the)
olfer plausible explanations for many of the know!
facts, and that they may be employed as a basis for th
propuy lactic management of pneumo, lt.

The pheumococcus Is probably disseminated yy thi
coughing, sneezing and expectorating of persons harbor
This

certadll

ing the bacterlum im their respiratory
account

pa sages,

would for its extensive prevalence in
an unatlected member be
comng infected would be greatly multiplied by living in
close contact with those aiready affected. That there is

an augmented and rapidly increasing prevalence of thi

families, i. e., the chances of

pneumococeus, with a Jarger and an increasing propo!
tion of the population acting as hosts and distributors 0
the germ scarcely admits of question; but this seems
amply accounted for by the inereased facilities for travel]
and public assembly which are demanded by the spirit ot
the times. Pneumonia is caused by pneumococc) obtain-
ing access to and developing in the pulmonary alveoli.
A paretic state of the laryngeal and bronchial reflexes,
SUK 1) as Way be produced I) undue exposure to cold. or b
exhaustion, or by profound sleep, may permit the aspira
tion of pneumococcus-laden particles of mucus or other
fluid from the upper to the deeper respiratory passages.
Another route which the infective germ may take is
through the circulation, the pneumococei entering the
blood current from the throat, attaining extraordinary
virulency by growth in a peculiarly congenial culture
medium, and making their way to the pulmonary alve-
oli. The bearing of these hypotheses on the general
pneumonia will be considered later.
The mortality of pneumonia is great, the rate
In 1892 | pub-
lished a table on the mortal'ty of pneumonia, embodving
the statistics of 223.7 This inquiry hos been
continued to the present time, and mv full table now
165.400 cases, with 94,826 deaths, a rate of
20.4 per cent. (See next page.)

Certain fallac’es are inherent to a table of this kind.
For example: As compared with private practice, the
mortality in public chariteble hospitals is very much
higher, while it is much armies in time of
peace, the eC differences depend ng directly on the differ-
ing characters of the patients. Again, the malady seems
to be more dangerous in some countries than in others.
probably due to variations in the virulency of the infect-
ing organism. Finally, manv series of cases are pub-
lished for the purpose of illustrating the advantages of
some favorite method of treatment, and in these in-
stances the reporter is prejudiced and is prone to omit

management of
very
being slightly in exce’s of 20 per cent.

9
oi) eases,

COMDLISeS

lower in

Observer

Allen and Lull
Allyn

Altschul

Anders

\nders

\rders

\nonymous
\nonymous
\ntonin

\udeoud

\ufrecht
Austro-Iung. Army
Baginsky

Daginsky

Ralfour

allard

samberger
ae

Banti & Pieraccini
tarbel

arr
Lartels
sarthez

Basel Hospital

Bauer ;
Baumgiirtner
Becquerel

Bell

Bennett

Berliner Charité
Berne, in 1762
Bertozzalo

Resnier

Bierme)

Rillings

Billings. J. S J
Bird

Bishop

bleuler

Bondi

Bormans

boston City Hosp
Bounillaud

souillaud

Boyce

Bozzolo

Dragagolo
Branders

irandes
Branthomme
Brenchley

Briquet

ritish army
British army
British army
british Med. Asso«
British Med. Jonr
British navy
Burkhard

Burt

Butry

Cabot
Cabot
Cacciunig:
Campbell
Canaliz. Werke
Canby

Cantieri

Capri
Curmichae!
Carriere
{
(

Charity Hosp... N. O
Chase

(Chase
Chatelaine
(Chatelaine
Chome}!

‘‘hurton
(hvostek
Cincinnati Bd. Health
Cincinnati Tlosp
Cochran

Cohn

Coleman

Colin

Colles
Constantineseo
Cook Co. Hosp
Cook Co. Hosp
Cooke

Couldrey
Coupland
Crandal)

( roce

Croce

Crombie

Cummins

Dagnin! & Silvani
Dalton

aaa

SHOWING

reo

PNEUMONIA

Deaths

16
0

‘)

ASI

WELLS.

MORTALITY OF PNEUMONIA

Reference.
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Am. Jour. Obst., 1901, xliii, p. 682
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Arch, f. Kinderheilk., 1891, p. 13 and 1892 p. 286
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Brit. Med. Jour., 1900, i, p. 1897

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Iemiss. du Sang. Paris, 1838

Braithwaite’s Retrospect, Jan.. 1859, p. 71
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Annalen. 1874-5, Berl., 1876-7

Smith, XX Century Practice. xv. p. 97
(raz. d. Ospedale, 1908. No. 8

Lepine’s Pneumonie, Wien, 1883
Kocher’s Pneumonie, Wiirzb.. 1866
Allbutt’s Syst. Med., 1896. i, p. 15
Johns Hopkins Hospt. Bull... v. p. 105
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Med. News. March 8. 1902. Ixxx. p. 477

Inaug. Dissert.. Ziirich. 1865

fomasini’s Mod. Cur. Pulmonite, Napoli, 1899

Gior. d. Acad. d. Med. d. Torino, July. 1901
Person. Com. Dr. Rowe (1865-1904)

Dict. de Méd., Paris, 1835

Sturges’ Pneumonia, Lond., 1876, p. 206.

Pittsb. Med. Rev., 1894, viii, p. 148.

Lambert. Jour. Am. Med. Assoc., 1900, xxxiv, p. 900
Gaz. d. Osped., 1903, xxiv, No. 89

Arch, Pediat., 1899, xvi

Virchow’s Arch., xv, p. 210

Rev. d. Méd., April, 1896.

Lancet, 1890, i, p. 1425

Ranking’s Abst. No. 28, p. 92

Personal Com. Dir. Gen. Med. Serv. (1894-98).
LaRoche, Pneumonia, Phila., 1854, p. 417.
Simpson Homeopathy. Phila., 1854. p. 117.
Collee. Invest. Ree., Lond., 1884. ii

1895, i, p. 860. and 1896, i, p. 1229.

Mercer, Med. Ree., Feb. 29, 1896, p. 295
Ranking’s Abst. No. 28, p. 92

Med. Rec., Jan. 2, 1904, Ixv. p. 14

Arch f. k. Med., xxix, p. 193.

Bost. Med. and Surg. Jour., Aug. 3. 1893, p. 117
sost. Med. and Surg. Jour.. cxxx, No. 12

Bull. d Assoc. Sanitat., Milan, i No. 9

Jour. Am. Med. Assoc., 1897, xxxix, p. 103
Bericht. fer]... 1895

Maryl. Med. Jour... March. 1900. p. 113

Clin. Med. Ital.. 1898, xxxvii, p. 689
Sieroterapia. 1898. iii, p. 41

Lancet, 1898, i. p. 1331

Rev. d. Méd., Nov., 1898

Serioterapia. 1898, iii. p. 41

Lancet, 1884, ii, p. 135
Am. Pract. and News, 1895. xix. p. 417
Osler, Tniv. Mag... Nov., 1888

Rost. Med. and Surg. Jour., 1898. exl, p. 248
Rost. Med. and Surg. Jour.. April 13, 1899
Jour. de Méd. de Brux.. 1870

Fichhorst. On. eit.. p 11

Pnenmonie. Leipzig, 1841, p. 805

Lancet, 1890. ii. p. 133

Oester, Zeitschr. f. prakt. Heilk, 1867, No. 26. p. 43

Reports. 1873 4-5

Personal Com. Registrar, 903
Med. Ree... Nov. 18. 1893. p. 664
Rankine’s Abst... No, 28, p. 92
Inaug. Dissert.. Wiirzb., 1886, p. 13
Ved. Mil Paris. 1863

1’. S. Naval Rpts., 1881, p. 414
Inang. Dessert

Renort. 1sf half. 1890, p. 36
Private Com. Asst. Warden (1903)
Brit. Med. Jour... 1899, i, p 278
Lancet, 1888

Pve-Smith. Ailbutt’s Svst. Med., vi, p. 136
Arch. Pediat.. Dee., T1898

Arch. f. klin. Med.. xxxviil, po. 554

Gaz. VOsned.. 1898, xix. p. ATH

Pract.. Apr.. 1893. n. 269

Texas Med. Jour.. Dec., 1901

Serioterapia, 1899, ill. p. 7

St. Louis Med. Rev., Mar. 30, 1889, p. 355

511

dinburg Infirmary
idinburg Infirmary
tichberg

hberg
tichhorst

ilfstrom siete
sabeth Hospital
Immerich
luglemann

Iwart and Verciva
‘anoni

ranoni

reldhausen

‘enwick

‘erguson

I
|
I
I
I
I
Elfstrom
]
|
I
}
I
{

som

iriinke!l & Reich:

(,aston

tre iSSi¢ _
(,entile
Gerbracht
Gerhard
Gerhardt
(german Army
(;erman Army
Goldsborough
(,oodhart
Graf

(;raham

(;ray

(;reen

Grisoll

‘rrund
Grundler
Grualdi
Guigeot et Deguy
Gurlt

Haedke

Hal

Ilawkins
Hegele
Helbing
Hellis

lioldheim

Holmes

Holt ste ‘ .
TIolwede u Miinich

SLLOWING

160
pF
wo

Deaths

CASK

PNEUMONIA

MORTALITY

Per
Cent

WELLS,

OF PNEUMONIA Continued

Reference

Cin. Lan. & Clin., July 15, 1890, p. 9
Lancet, 1904, i, p. 496.

Neederl, Weekb. v. Genes., Jan., 1855
Crombie, Op. cit. (1889-91)

Gaz. d. Osped., Feb. 13, i898

Rev. clin, e. Therap., 1896, xviii, p. 508
I

Policlinico, Oct. 381, 1896

Inaug. Dissert., Bonn, 1885. p. 19
Jour. Am. Med. Assoe., Nov. 20, 1890
Brit. Med, Jour., 1904, i, p. 105

Der Aderlasse in d. Lundgenentz.. Wien

Wiener med. Wochenschr., 1852

Rpt. Med, Officer, Middlesborough, 18%!
Med. Rec., Mar. 28, 1885, p. 343
Berichte, 1894.99 (Vienna)

Brit. Med. Jour... 1898, if, p. 989
Lancet, 1904, i, p. 1016

Lancet, 1896. i, p. 840

Prog. Méd., 1897, Nos. 41-42

Cin. Lan. & Obsy., Jan., 1861, p. 10
Reports, 18389 and 1865

Osler, Op. cit

Jour, Am. Med. Assoc., 1897, xxix, p
Am. Med., 1902, fil, p. 690

Spec. Path. u. Therap., Wien, 1894, i,

N. Y. Med. Jour., 18S, Ixviii, p. 556, and Sept
Brooklyn Med, Jour... 1900. xiv, p. 608

Berichte, 1894-99 (Vienna)
Arch. f. Hygien, 1884, ii, No. 1

Bost. Med. and Surg. Jour., D897. cxxxvii

Brit. Med. Jour., 1900, fi, p. 900

N. Y. Med. Jour., 1898, Ixvii, p. 646
Pediat., 1900, ix, p. 393

Inaug. Dissert., Géttingen, 1879, p. 15
Lancet, Jan. 31 and Feb. 7, 1891

Jour. Am. Med. Assoc., 1S98, xxx, p. S66

Smith, XX Cent. Prac., xv, p. 97
Wiener med. Woch., 1898, No. 39
Duodecim., Helsingfors., TSS89

Wiener med. Woch., 1893. Nos. S and 9

sericht, Wien, 1850.

Am. Jour. Med. Sci., 1901. «xxii, p. 193

Med. Ree., July 28. 1889, p 4

Arch. f. k. Med., 1873, xi, p. 391
Sturges. Op. cit., p. $29

N. Y. Med. Jour., Mar., 1875, p. 290
Prac. Med., 1868

Sem. Méd., 1891, xi, p. 440

Inaug. Dissert., Erlangen, 1847. p. 3
Med. News, 1897, Ixx, p. 28

(raz. Méd. de Strasb., LS60

Reynold’s Syst. Med.. Phila., 1880, ii, p

Berichte, 189499 (Vienna)
Lungenkrank’‘h., 1902

Zeitschr. f. k. Med., 1894, xxv
Statistik d. Pneumonie, Wiirzb.. 1855
Kichhorst, Op. cit.. p. 511

Glasgow Med. Jour Mav 19ov
Inaug, Dissert.. G6tt., 1886, p. 26
Deutsche Klinik, 1855

Inaug. Dissert., Griefswald, 1868
Med. News, 1898. Ixxii, p. 297
Pneumonie, ete.. Paris, 1877
Ranking’s Abst... No. 28. p. 92
Med. News, Aug. 5. 1898, D 142
Arch. d. Heilk.. 1861, ii. p. 115
Laennec, Dist. Chest. N. Y.. 18380, p
Inanug. Dissert., Wiirzb., 1885

Am. Jour. Med. Sei., xiv p. 328
Thiiring. Corresp.-bl., 1875, No. 11
Hermann, Lungenentz., 1880
Personal Com. Surg. Gen. (1896-1901)

Jour. Am. Med. Assoc., 1902, xxxviii. p

Osler. Prac. Med., 1899. p. 181
Inaug. Dissert., Wiirzb.. 1876
Lancet, 1903, i. p. 1031

Med. Rec., 1902, Ixi, p. 527

Med. Rec., July 20, 1889, p. 66
Traité de la Pneumonie, Paris. 1864
Pneumonie, Wiirzb.. 1891

Deutsche med. wrtzl. Zeit IST. is
Lancet. 1884. fi. p. 27

Sem. Méd., Mar. 15, 1897.

Ann. Surg., Feb... 1896

Deutsche med, Woch., 1898. p. 220
Phila. Med. Jour... 1901, viii, p. 791
Prager Zeitschr. f. Heilk., 1883, iv, p
rit. Med. Jour 1899, i. p. 1214
Lanvet. 1900. ii, p. 170

Brit. Med. Jour.. 1897, i, p. 1279

Med. News. Apr. 7, 1888

Lancet, Nov. 28, 1903,

Wiener med. BI.. 1895. p. 682
Practitioner, July, 1892. p. 19

Kissel. Pneumonie, 1852, p. 149
Canstatt’s Jahresb., 1850

Clin. Med., Paris, 1824

trit. Med. Jour.. 1895. i, p. 276
IL,Union Méd., 1847, No. 127.

Temp. in Pneumonie, Paris, 1885
Lungenentziindung, Miinch., 1880, pp
Obstetrics, 1898, p. 617.

Edinb. Med. & Surg. Jour., Apr., 1864
Therap. Monatschr.. Apr., 1892
Deutsche med. Wochenschr., 1896, xxii
Jour. Am. Med. Assoc., 1901, xxxvi. p

p. 1
1848

’

108

p O10

p

1681]

ys

SO

1544

Med. Rec.. Feb. 14, 1885, and Apr. 7, 1888

Aren. f. Kinderh., ii

iD

JOUR.

1

SEPT. 24, 1904 PNEUMONIA—WELLS S69

PARLI STPOW TENE (‘ASI ‘ie thirty Oy PNEUMONTA ‘
Per
Observe! Cases. Deaths Cent Reference
fomburger 20 9 a6. iInaug, Dissert., Strassb., LS79 71
fome for Aged. 202 123 60.9) \lauerbach (Wien), for 9 years
{lourmann et Dechambre LOd 76 70.0 Arch. Gén, de Méd., 1836. —
fHloward ; is 170 10 6.0 Osier, Op. cit., p. 131]
iluber u, Blumenthal 14 z 14.3 Berl. klin, Woch., 1897
llulava 12 i) 0.0 Deutsche med. Zeit., 1855.
llughes 14 ) 39.7 lrans, Pan-Am. Med. Cong., 18938, i, p. 324
lughes and Carte 1 V 0.0 rherap. Gaz. Oct. 15, 1892. xvi, p. 66S
I 2 375 13.9 i igenentziindung, Leipz., 1S61 U4
1 123 36.4 Jour. Am. Med. As 1902, xxxix, p. 1301
LO 45.8 Med. News, Oct. 17, 1903, p. 727 ;
Army ; 12,442 1.874 15.6 Grieco, Private Com, (1S90-1LSU9
22 0 0.0 tzyna, 1894, No. 4, p. 20.
Jackson p ; : ol S 15.0 led. Jour., Mar., 1875, p. 290
lackson 19 2 LOD

lames ; ; ; 28 5 17.9

nson LO l 10.0 Stockholm). 1S02._ 1
hus Hlopkins tlospita! 13 96 22.2 Com, Supt. Hurd (1889-190
lopes 32 10 $1.3 i Kev., Jan LS61
es 218 O7 30.7 \m. Med Assoc Aug ‘ LSS6, p. 144
30 l 3.3 de Paris, 1824, p. 17
OT 73 12.9 Pneumonie, 'Tiib., 1&8S4
I l 100.0 im. Med. Assoc., LYUU, xxxv, p. 599
nel L60 #6 28.4 l. Intelligenzb., 1SS1, xxviii, p —
501 1) 6.3 nik Kilenburg, 1852 p Ȥ 9-9]
‘y 0.0 in. Woel LS x) ll Dp. S6O
1) 0 ( med. Woenh., 1S?2, xlii » S&S
Ho 5 Q ionic Wiirzb 1S66
Kohn 32 12 37.5 Wochenschr., 1896, xxxiif, p. 1124
10 l 10.0 Med. Jou 1899, xli, p. 179
59 9 15.3 1onie, I Z LSGS
7 2 53.3 tex Ne t ri LSSO, p 2b6V
71 l 1.4 Fragmenten, Coble 1845
»S Ss 13.8 k. Med xxl, p. 364
Lacage ...... 42 1 2.5 ing’s Abst p. {
Laenne O4 18 19.1 hest, N. ¥
Laennee (A.) . er : 40 6 15.0 . So Meéd P e, 182
Lakeside Hospital ; 16 3 18.7 I 1904 (Chicago)
Lambert ; 9 I 11.1 News, Ixxvi, p bog
I 12 3 25.0 Am. Med. Assoc LYOU, xxxiv, p. DOU
0) LO 20.0 r med. Press 1S03 ) 130
et Legros 10 z 20.0 Gén. de Clin... ¢ 1901, xv, p. 785
257 52 20.2 Univ. Med. Mag Jan LSSd
10 0 0.0 r. A 1. di Med. di Torin 1S
230 16 19.5 des Armées, Paris, 1875. p. 28
SOS 135 15.0 d. Lrustkrankh
3 0 0.0 lin., 1893, p. 31
245 25 10.2 ssen, Pneumoni p. 236
40 3 7.5 Gén. de Thérap )
te 52 29 55.7 Ziemssen’s Handb.
72 0 0.0 Wiener med. Woch., May 7, 18V8, p. S85
$t) 0 0.6 Pester med.-chil Pres : 1SOG Sri. DP. iD
a7 10 17.5 Bericht d. Rud. Stift., Wien, 1867
12 0 0.0 Centralb. f. Th p.. Nov LS
235 ST 34.0 N. Y. Med. G Apr. 30, 1881, p. 154
S 78 28 32.2 Rech. sui iffets d Saigi Paris S30
75 18 24.0 Phthisis, Boston, 1840, p. 440
nev 120 2 at Med. Rec LSU6 p a)
eg $027 287 7.0 Med. Note n ¢ mea \\
eas ) 101 18 18.0 Si Méd LSO¢t Xxiv. Ne 19
s 5S 15 26.0 Mex News XXV p. llo
, ] 1 100.0 G Med. d lost Iie Suu ealh)
S 0 0.0 B ~ \léq 1. tl d. $ May 17. 1900
76 40) 92.6 \ } & News, 1S95 +]
1 392 6 14.3 I tol n Le res, Lond., 1866
farone 1 0 0.0 R Med., 1808 p. 082
fason 0 23 46.0 ( Bd. H I S S
Mass. Get los 2 486 657 26.4 S | ( ¢ \ ( \ LSS0 ]
( ~ SI 4.19
Muassalongo 10 3 30.0 I Med SUS a4
Ma n 38 LO 25.3 J le Med. de B ST: 112
Mays 209 10 2 Med © Surg ‘) 4 SOD j [
LSO7 p. 124
MeCre $84) 104 “1.2 Lor Me J 1004 x )
MeManus 62 2 3.3 Med. I Se} 8, 188s 260)
Medical N . ’ " 100.0 TSO9 xxiv. p. S8
fer 538 28 §.2 Med. Re I 29, 1896
Vl TO 9 Bull. S \! X 2iv
M Hos 492 L66 Person, ¢
Mev y 4 2 lols Oy -)
Meve 00 Q4 so \I Ss i Hos S

Co te
Aope

=

PDLELLLS

Ld

LRVBRLRSIT.

2 TLi Ta TF.

ephi
Stephens

ste phenson

easiee
elletan
ndleb
nnsy
‘pper
eppe

Schmidt

hmidt

hmidtman

chreedet

2 fe

_—

Silva
Sittma
Skod
Smith
smith
Smitt

Stephan

ierlin
ahm
tockholm

7

Mo

imie

Poli

Poph

1» eous

I

Prantois

’ril l R
Prince Bdwa
Provider If
l’rus
Putnam-Jacol
Pye Smitl
Rall

Rankl

aso

haw

Raw
Raymond

Ke »

lLieece

Reed

Reniet

Reuf
Reybur1
Ricau

Rietz

iilliet I;
Ringross
Kobinson
Robinson
Rochestet

Rox in
Rodma
Rosenow
Rooseve Lk
noth

I th
Rudolph-St
salawa
Salem Hospit
Sampson
Ssamte
Schapira
Scheef

NSchle
Schlesinge!
~

OOo

PNET

‘
245
Lf
7
0
"
a

MOT

WONTA

10.0

14.6

13.0
11.8
3.0
14.5
7.9

\l

WELLS,

(1 Niet

MIOONTA (or

inued

Referenc
(hi Med. Stand., Oect., ISSO. p. 126
Mém., de VAcad. de Méd., viii, p. 3738
Reports, Manchester, ISS1-86
Osler, Op. cit., and Kichberg,
sost. Med. & Surg. Jour., Api
Med. News, July 5, 1890

Bull. d. Thérap., exxii, p. 120
Ranking’s Abst.. No. 28, p, 92
La Méd. Mod., 1892, xiii, p. 150

Am. Med... iil

24 PSNoo

Brit. Med. Jour., Dee. 28. 1867

N. Y. Med. Jour... May 11, 1895. p. 504
Brit. Med. Jour., 1895, ii, p. 1149

Arch Gén. de Méd., 1892, pp. 274, 4452
Prager Vierteljahrschr., 1S69

Med. Rec July 13, 1889, p. 44

Reports, 3 years

Mém. de i’Acad. de Méd., 1840, viii, p. 13
N. Y. Med. Jour., June-July, IS79

Allbutt’s Syst. Med., IS9S, vi, p. 136
Inaug. Dissert., Stiitty..
Lancet, 1895, ii, p. 456
Arch. Gén. de Méd., 1S24
Lancet, 1900, i, p. 460.

ISS7, p.

Brit. Med, Jour., 1S91, ii, p. 1805

Arch. Gén. de Med... Mar., 1901, p. 99
Riv. Clin. Terap., Napoli, 1899, ii, p. 79
rit. Med. Jour., 1895, ii, p. 1314

Therap. Gaz., Apr, 15,
Wiener med. Woch.,
Ranking’s Abst., No, 28, p. 92

IS6G, p. SOS

These de Paris, 1874
Inaug. Dissert, Jena., 1868, p. 19
Mal. d. Enf Paris,

Lancet,

Lancet (Am. Ed.)

Med. Rec.. 1898, liii, p. 253

Jour. Am. Med. Assvc 1901, xxxvil, p. 1237
Cong. Int. Med. Roma, 1899, p. 3878

Am. Jour. Med. Sci., Jan., tS76

Jour. Infec. Dis.. 1904. i, p. 2S80

Miechberg, Am. Med., iii, p. 691

Statistik d. Phneumonie, Wiirzb., 1860

Lancet (N. Y. Ed
Berichte, 1865-75,
Schmidt's Jahrb.,
1877. p

(N. ¥

1855, ii, p. 36
and IS84-99
L850, IXXXVi, p. 50
Repts.,

~~
Lancet Ed.), 1851, li. p. 38

Inaug. Dissert., Breslau, 1SS1

Inaug. Dissert., Wiirzb., 1S77

Inaug. Dissert., Tiib.. 1SS2, p. 15
Inaug. Dissert., Berlin, US73, p. 23-24

Arch. f. Kinderh., 1897, xii, p. 266
Ranking’s Abst., No. 28, p. 92
l Woch., 1883, No. 28

serl. Kk y.
Hufeland’s Jour., iii, p. 441
Kiel

1890, ii, p
jost. Med. and Surg. Jou
St. Paul Med. Jour.,
Rec.,
1892, xii, p. 21
Policlinico,

Ranking’s Abst., No. 28, p. 92

Cong. Med. Intern., Roma., 1899, p. 218
Arch. f. k. Med.. lili. p. 323

Allgem. Wiener m. Zeit, 1863

Schmidt’s Jahrb... exxxii, p. 321

Brit. Med. Jour., 1895. i. p. 1029

XX Cent. Practice, xv, 1900, p. 79

Med. Ree., 1896. xlix. p. 649

Med. News, 1898. Ixxiii, p, 817

Jour. Am. Med. Assoc., i901, xxxvi. p. 1062

Marb..
July 1. 1893, p. 1

Inaug. Ji

Med. Re

ssert.. ISTO, pb. 2

Bull. Acad. Med. Roma, 1900, xxvi, p. 79
Brit. Med. Jour... Dee. 25, 1897. p. 1848
Inaug. Dissert., Leipz.. 1866. p. 14
Klinik d. Kinark.. Berl... 1865

Ohio Med. Rec., June, 1877, p. 34
Needri, Weekbl., 1888

1894-99 (Vienna)
Therap. Gaz., 1901, xxv, p. 731
Lancet, 1896, i, p. 1630

Am. Jour, Med. Nei., Oct., 1870. p. 376
terl. k. Woch., 1870, No. 26
Ranking’s Abst No. 28, p. 92
HLuss, Op. cit.. p. S6

Inaug. Dissert., Wiirzb., 1884
Brit. Med. Jour., Dec. 24. 1891
Med. Ree Mar. 16, 1889, p. 291
Pneumonia, Lond., 1876

Wien, 1850

Berichte,

Personal Com. (1895-6) (Chicago)
Personal Com. (1892-1903) (Chicago)
Report, 1870 (Quincy)

Report, 1876 (Newark

serichte, 1894-99 (Vienna)

Rpts., 1891, xix. p. 247 (London)
Trans. Luzerne Co. Med. Soc., ix, p
Med. Week, Mar, 20, 1895

147

Méd. Mod., Feb. 27 and Mar. 6, 1901. pp. GF
Cin. Lan. and Clin., 1895, xxxiv, p. 539

Med, News. 1902, Ixxxi, p. SSO

Deutsche iNlinik, 1855

Oo

PEPT. <4,

1904, PNEUMONT.AA

VABLE SHOWING CASE MORTALITY

Pei

Observer (uses Deaths Cent
rhielmann 110 12 11.0
Thomas 106 3 2.8
Thomas io 14 21.5
Thomas GS 1 14
thornton ” » GEE
fommasini 3G 14 12.1
rommasini ) 0 0.0
fownsend 12 2 0
Fregagno epidemic Loo at) SOLO
lrinidad Hospital 11 ” b.4
irousseau 2 2 $.0)
ryler . 6 1 16.7
U, S. Army OTS 224 10.8
U. S. Army {1,a00 O.116 26.1
| Ss. Army OSS L075 15.7
l. S. M. Hosp. Service G.ES5 1,108 Lave
I S: Navy tS Se | 9.3
I S. Navy rau TOS 13.5
Valleix et Vernois 28 27 99.2
Vandeboncour 17 ” 0.0
Van Zandt 1.14 vt $.9)
Verrentrap rey. 23 ] 4.3
Victoria Ry. Hospital. 7 16.7
Vienna General Hospital pi Sy | G.2iz 24.4
Voght , ne t 7.
Wagner 13 7 53.8
Waller 81 9 11.1
Waller 119 +35 27.7
Walls } » 50.0
Warbrick 7 6 S5.7
Warfwing 546 4 6.2

Wassider
Waters

Waters sf) » 24
Waters 151 11 1.2

Weber i) l 11
Weber in) 1S 90
Wiesbecke! ?1 2 9.9
Wiesmavet ) S 0.5
Wesley Hospital . So 20 Sait |
West - 1,633 apada 21.4
Whitelegge : ? 6S. 14: 20.9
Wieden Krankenh.. SOO 252 28.3
Wilbrandt 126 iz 9.5
Wilcox ae bs f) 0.0
Wilheminie Hospital. d17 110 21.3
‘ilson ; 18 $ 22.2
Wilson aS Ss 21.1
Wilson ys 0 oOo
Wilson .. Saye : 10 11 28.0
Wilson and Page . ; 1S 6 33.3
Wiison and Rosenthal 1 1 100.0
Witte NOD 25 a0
Wittiel as 3 2 0 0.0
Woman's Hospital { 0 0.0
Woodson AB) 9 10.0
Wucherer 90 1 1.1
Wunderlich 237 25 10.6
Wunderticl nO S 16.0
Ze'igelj $1) ‘) ow
Autl 1,000 243 24.5
Lo Ss oand 2\ ie : 155,400 94,826 20.4

row f11s tis
rryyyysyte
]
List ‘.
7a ct 1;]
Is Sl LILY

1. Former

mparatively
uncomplicated cases, properly tr
I on was shared by t
Hartshorn and others Trousseau says that ‘generally
there
omplicated cases “the intrinsic tendency is to recovery

nd this opini

Wood

speaking

I

deed
s Ww no
I S SAYS

iSé rhus
diseas
Te ns of
ith
es
15 p

as many of the fatal cases as can be possibly

order that his percentage of cures may be

the mortality of pneumonia appalling. b

}

increasing. This fact is conelusively proven
Ing curves constructed from the statistics

many writers considered pneumonia a disease

slight danger. Thus Bennett says that the mortality

ted, should be practically
Barthez, Joly, D’'Espine, Waters

is a tendeney to spontaneous recovery.” Flint says

is not only the rule, but the exceptions are exceed
Gerhard affirms that the death-rate in private

exceed 2 or 3 per cent To be sure these opin

hared by all the writers of the day: as for example.
at ‘‘a disease in which death occurs in one out of
uld be classed among the very fatal diseases,”’ and

are held by Copland, Watson, Drake. Sturges and

the latest editions of the textbooks on practice

the hands of the great maioritv of American medic:

very fairly the dangerous character of the dis
¢ 1]

Osler says that “pneumonia is the most fatal of all

Tyson says that it is the “most fatal of a

adults in temperate climates.’’ Anders says that the

spitals is abont 25 per cent in private practice

pt Thompson places the mortality at 30 per cent
d 8 to 15 per cen for private practice Philip
est. Pye-Smith. Fitz, Aufrecht and Eichhorst all are
doof the pneumonic attack. Striuimpell stand

inion that “pneumonia belongs to the benignant in

15.7 per cent. shown by this series, 1868-1902,
one-half greater than the 40.8 per cent. shown b

» cases occurring in this army in the vears 1840-185)

>and destructive character. or they may be of anv

Certain noticea
he introduction into the svstem of the pneumotoxin:

WELLS. Si
PNEUMONLA Continued.

Reference,
Ranking’s Abst., 1858, xxviii, p. 90
Med. Sci., Oct... ISTO, p. S76
Heilk., iv, No. 2
Richm. & Louisv. Med. Jour, US76

sour., 1804, li, p. 125.

Peripneumonie, Bologne, 1817.
Sieroterapia, 1900, iv, p. 49

Med. Assoc., Dec. 1, SSS, p. TSO
Dentsche m. Zeit., 1883, No. 41.

Op. cit. (1SS8-91)

‘s Abst., IS58, xxviii, p. 1)

Med. Assoc., xxxvi, p. 1540

Hartshorn, Op. cit. (1840-59)

Rebellion, i. pt. 1 (1860-65)

(‘om. Surg. Gen. (LS6S- 1902)
Reports Surg. Gen. 29 years
Surg. Gen. (LS7T9-SO0-S1-S2-S6-SS8. LOOT)
Person, Com. Surg. Gen. (1890-1900),
Dis. Chiid., p. 325.
Acad. Surg., Oct. 22, 1901.
.. Oct. 18, 1902, Ixii, p. 601.
Pfeiffer's Zeitschr., 1851
Com, Registrar (Montreal, 1804-1001
(1840-1891 and 1893-1899).
Bull. gén. de Thérap.. Jan., 1860
Contrastimulus, u. s. Ww serl., 1819.
Dissert., Erlangen, 1877, p. 25.

Klinik d. Brustk, p 532
Med. Assove., 1901, xxxvii, p. 560
Com.
Kichhorst, Op. cit., p. 511
Abst., 1858, xxviii, p. 99

p 87

Liverpool & Manchester Hosp. Rpts., iv
1900, i, p. 460

1901, Ix, p. 681
Jour.. 1900, vi, p. 596

Miinch. m. Woch., 1898, pp. 202, 238

k. Med., 1897, xxxil, p. 291

1901 038 (Chicago).

Organs of Resp., Lond., 1902, i, p. 503
Allbutt’s Syst. Med.. 1896, i, p. 656.
Wien, 1876, u., 1894-99.

Dissert.. Rostock, 1862.

1901, Ixxix. p. 688

1894-99 (Vienna).
Med. Assoc., 1900, xxxv, p. S95

1900. Ixxix, p. 688
Jour., 1900, v. p. 510
1901, Ixxvi, p. 915

Mon., July, 1901

Mon.. July, 1901

Dissert., Berl... 1877, p. 41
Ranking’s Abst., 1858, xxviii, p. 99
Phila., 1876. p. 12

Mar., 1870, p. 289.

Ranking’s Abst., No. 28. p. 99

Heilk., (S56, iii

Dissert., Tiib., 1858, p. 31

Satterthwaite. Med. News, Jan, 5, 1889

Med. Assoc., Jan. 9, 1892, and unpublished

Massi husetts Genera Hospital, thie Boston | it\

the Cincinnati Hospital, the Glasgow Roy:
and the Wiener Allgemeines WKrat

The statisties of the United States Army are given as

]

in example of the very uniform death rate which ma

be shown during a long term of vears by some series «

is fair to state, however. that the morta

}

‘auses of death are the direet effects of pne
activity. This fact | desire tO emphasize ha

the vast majority of cases death is due to a profoun
in which case the gross anatomic lesions ma

rsienificant. or they mav be of the most exten-

UT)
in

termediate grade: but whatever the extent and character
demonstrable lesions, the fatal result must be laid

door of the. as veg. int ingible system pneumo

intoxication.

} 0 5 } , }
hl effects follow and are agureeti (

nppie cats : aes .
in infinitestmal quantity and diluted bevons

comput ition. as. © oc. thy nrofound ehy - thy raging

» lowered arterial tension, the disturbed balanes

- {

+
yetes

Time
+ Y ~F
} ;

\ (

)
who
rym T
which }

en cons
er ( Wi
OL ( in
oto n D
Nn. pi
Was el
_ i
ristiecs o
} ~ rab
Ira
eM nt
en Sons
and t }
ent I
whnien ¢ |
+
.
eS eS ee +
tiemp: be
I
t } ry
ai i ‘
t Tt ’
{ n |
{ ,
~ (
1
CC eT)
1;
GIserse
31f et (
ot pn
n ft] Nn?
( n (
, ’ 1+ )
e
ran
I
. y
ave Tis {
there ean

PNEUMONIA--WELLS. Jour, A. M.A

tamorphosis, thi modifying influences. 1 will, therefore, content myst
waste, ete. Othe by reiterating the following conclusions:
e effects of thi 1. Pneumonia is a very prevalent disease, and
toxic leucoma:ns o prevalence is increasing.
est specially o 2. ‘This increasing prevalence is probably due to tl
rulency and speci wider diffus.on of the more vigorous strains of the pn
ind the intangible — mococeus, made possible by the increasing comminglin
ice Ofer: Ot peopie.
nfinitely in ; The pneumococcus is to be found in the upper r
son at different spiracors passages of a very large proportion of health
rge questions of — persons, and it is the migration of these ever-present
n id suscept germs into the pulmonary a'veol; whiel LUSes

phe
moni }

t

Mia iw rusetts G enera| Hospcetal.

=e {:-[o- : JJ Js] py ee J Tx
~ | O8| Sa] 8S] S| Sad on! Ret ES} es] Sa) St es) SIS 1 4%.
14 fchadaehod
| } t +
i
mm t
| hd }
+
| +
* iH +
4 | 4
|
Sal ao i °
| j rit ' * }
4 fT 7 a ;
| tt t f r* t 4 ?
s o)
i} Ih |
| $ + +4 , + +
I = } ta i d | 2
4 bs ¢
\ \ } +s + +=
i ' q 4 « 4 7 nt +
j f -
; ttt ta ae = ee a t
j y tL dt j { t
ij, e+ + 444— | 4 | } j
_—t 4 } } +
s+

WT | o4
i 0eee) ee is .

4 t +4
Be ‘
’ + ;
{
+ 4
| om
|
} 9,
} i é
'
¢ ~ 4 a
] z
| {a} 2% a
| 4 oO >
n ence of the Pneumonia is a very fatal disease Ind its morta
I imMoco ty is Increasin

pleuris The increasing mortality is probably due to the
I OU na oO rreater average virulency of the pnei OcCUs.
{ rdia What can we do to prevent and cure pneumonia? In
i 1\ opinion, we now have the foundation laid ads Out
ey n t he ined above, for a reasonable end practicabl prophy laxis
) bearin We are prepared to formulate broad rules, with insist
f n mon nce on some of the detai's, but ¢] iter will requir
vilation as a careful and prolonged study before they ean be redueed
atior t} to that clearness and simplicity which will appeal to
lification ry mind and compel aequiescciuce and compliance. |

however, that the time is now ripe for a

ard movement along thes lines, L have

PNEUM

neh

Q

failed to feel a the profess.onai and public pulse

ve have not at our hand a populace ready and willing
It o be instructed in this matter, and to heartily co-operat
vith us in every reasonable prophylactic measure which

]
|;
we may recommend. ‘This is indeed fortunate, for with
ll our efforts will go for naught.

the

ul tit

dy

such assistance a

ie following prophylactic measures re

SONS

ech of whieh are obvious, are offered for considerat.on:

1. Pneumonie sputum should be destroyed before it has be
mie dry Che sputum which clings to the teeth and lips, and
aI iat which may adhere to the fingers and bedding, should be
i \ iped up W ith moistened cotton, vauze or other cloth and these
burned \ll sputum, although not pneumonie, might well be

lestroyed. the

aT

ase of
he pneumonic, a cloth, preferably moi

In coughing, in the ¢@ healthy as well as

should be held before

the mouth in such manner as to prevent the projection into

the surrounding air of the fine, insensible, but probably pneu
mococci-bearing spray which follows ordinary coughing. The
same apphes to sneezing and blowing the nose
P
nH { ' ( y | ‘
ace T a ] aE T ] |
1 tee ee i | | }
. + +—+— + 4 t + + +44 4 $ + ¥ 4
anes | pitt | tel
Se ee ee a |
a aR | Loh |
+ + } } i \P } tat Seal |
+ +—+ iat +44 44 +44 + +44 } }
a ae ee ++ ft BeSe hi SB ee me
} bd ee! | tet tH dp tip i tet tere |
4 4 {\ ff }_if at ht py}
0 9 Jerr eri hy
deni 1 ro a am ae tet 4-444
*, } a5 4 $444 AY }
.
ei tt 4 aes ’
19 ? ry ibt i 4 {
s ° i
; 4 +} p a! { { ;
} tT iN A j
+o i? 4 | |
} aia |_| +
ane tf |
I \ J
hf \ | | |
1. | , 1 |
2 t 3
t * + +
P LJ |
!
' }
¢ rT
t
} t }
4 + + t 7
+ —
4
4
al
> =§6The ] " lih ii throat should be kept is clean as
ssible ( i spravs and washes for the nostrils
shes ( mout] ind brushing thy teeth gvargles am
lrinks for the throat. Permanent occlusions of the nostrils
ild be 1 ved, while transient ones may well be cared
r by the more or less frequent use of a spray of adrenalin
lution Honeycombed tonsils and adenoid growths should be
‘ ve Taking a drink of water after eating is a habit
hich should be formed and cultivated Every means should
iken to prevent sleeping with the outh oper
3. The room occupied by a pneumonie patient should be
A ]
fterward disinfected, as is done after diphtheria and some
ther infectious diseases Remaining long or unnecessarily in
room occupied by pneumonic patient should be avoided.
f. Respiratory ca rhs, from whatever infection, should be
wold ind if contracted should be relieved as quickly as pos
:
S1D1¢
PP n i xhausti privation; undue ex
sure to cold and inclement weather, all should be avoided as

ONIA

] 1 1 3 4 +] f
the ehill, when the bottles of hot \
moved. If perspiration should be pr
! I
; - y , : ry }
the pody shou d ay arie | ie DOW
( PELE ve ebckt dt blo
d
?
a /
+ +
:
f ”
’
.
19 bd
; a. { \
j y .
' L =
Li 4 bs |
+4 ‘i \
+ t tg be |
ail | |
B | ’
it | le bs
a 19
q
Be +--+ j
|
TT
; +
+
}
PI y
s
.
S i?
pened ) I ( ema O g ) epso ~
ne i 0 vate! ¥ ( i {hie el (
viven
Moot questions arise with surprising
first of thes Ww ] he that ot +}, YY a
dueed arterial tension, which is one of
Os 2) rsistent of t} <Vn Ytoms of me
Tyr’ } ] } {} 7 , } TIT
DrODADLV an emcee! TOVIS On ¢ n
ne mobilizin nN iT \ 0 defend ne
protecting the tieslne f the had, fy ,ry) ¢
Rey Sep fee ar eee
paral ng erects o pre ! COCCA
rh he |
theless, certain other and mos undes}
’ 7
OW, a8, 6. :2., the ay SY=tel ut
‘ . “7%. 1 ,
venous svstem is overfilled with bloo
°7 17 ’
the eapl lary w reve spender
- 7 . :
not nourish: nd waste material
heart. contract hs nsi creat] {
pecomes tired oOo] YNauUusler Wha a |

WELLS

In the treatment of pueun

lonla we
in a direct antipneumonic remed
management of the pneumonie attack
servative and symptomatic, certa
shou'd be kept in view.

Preliminarily, it may be mention
environment should be the best whic
nursing should be assiduous and o
The medical attention should be inte
servant and unremitting

At the very beg nning of the pn
patient should be placed in bed, surro
hot water and given a hypodermic in
smal! dose of morphin. e. ¢., 1/16
should be allowed to lie quietly unt

873
au ny

et 1 1
ist be con
) ect

patlieohl
able Liye

rewumestyt S s , i
¢ i " Ving ) \ Oboe \ ( LEC LY LO arise IS threat ()
7) ? =f mrt t wedi 1 1) ’ t }
I ( le arteria t pVren Sha We attempt to reduc Mien Lemperatures
’ Nictryt 7 i? ty Th } { y ] { 7
a ( avents : 2 Oo i a. oO. 2 \\ means sha | be accomplished 2 \
T oT ~ } ~ . } } } val { 1}
eas emp nder wm Gireumstanees high.
~ } ? at : , ri rey
uv ! ) ( s \ s 103 0 | ' 2) ( ) PeCruecs ‘hie mean
, ’ ’ 2 :
() > Wile ( ( } OUT 1 result pry
? } ex ) t} ? 1) Be
) ( C1 ppieation of lo to 25 drap
» , |
son
— SS ee
Wiener All gememe Krvankenha
‘ - - ? " = 7 o
» . x e 7
4} ' b 4
e i
b » j

2} Pt {
2b 9 Ie ® © }
§ * r 2 t © -
pa ¢ 4“ - ht
| a * t
= a he . ye
123 * : . .
2 y 7 >t +2 t
~ 4 abet - @ + * +
| ; Py is eo 125
i ¢ 206
li¢ eae orm
Oe ee at I H : ad
i
ot HH - +--+ t ¢
pit 4 a \ e s. oi
pis) } | 2 bt
1,4 + } 4
ee ++ ++ + + + 4
pis a \ | a) 3
1/2 \ I \ @ .
tii $+ A a 4
a }
bJO; i i ft jal s a
e | |
$< — 4+ + + + | ye
Ss “ ps 244
Sa ee | +—. — + ++ “
R : = © . P < H
yas - : = } —jo2/2 ff
; i = tatot 4 - pHi | tops ; +++ 4
Lase e vk fe + nN tt Be = 242)
Soom - i | =| oe ee Bee Bk Bae Ban es Ba a ts ee eae ae Call ae the Lae Cea sash | i 4 at Ha i ‘ bak fas bv Cali
! Royal Iufar
Lyla Cow Nheoya Wee Virary
°
e
}
¢ 1 } q 4
- ’
e o
el 4 9 t
- - oe.
. } ‘
“« vv j °
«
r ? °
s e @ 4
43
‘ 1) | ' da
* ® ° 9 ' i id 6 - :
- - &
| € # e © 1
. +f +
j a b 4 \ pt 9
ee ie Ld oe
ror * +
é !
+ 4.0 ‘
j 4
i
+
*
SS SS ee ee ee =e — ‘ 2 =
- ' } ~
\ J \ l fay ro n S hat tT riddine the syst nn Ol
Y r { roy + } ty + _ , ; ? ]
ov. ring ( - ew ho = 0} ; » drops oO OXINS x 4 accomplished b the leucoeytes md. 1
rn 4 ; , : : 7 = j . , ,
O.4 ( ! it CUCOCYTOSIS Which Is
, ay , ( ‘ n i , / ' ) . . t ] ] 4 © ryy M
la ) ; Is Or ) Cnt, and oO Whla neans F Mhis may be
+} ; | ] , :
( ( re ( 10 te i) roy ( ! MM) r ~ Howevey ) ne recourss¢ tO these
ri , } + {

(‘tT | i | 1 x ? T - ]
] ) yt fe) ~ Conts on yvnen ne ordimnar eCucocytosis falls to ap-

SEPT, 24, 1904 PNHUMONTA WELLS. S40
f
pear, Or, Hiavilly appeared, Subsequently CL les. | ory eads Us to hy lieve Lhab a SeCLu anti pne UlOCOCEL
ohne agent, howeyve ry, to which we can appe With ua ( eTULL INAay ve produced, ahd ban hopeful that this
aimty that the heavy burden ol procound toxem carly accolp!| shed
te lightened, Is VehHesSecllonl. Li, (it st ( ( 1 PELCLLLAt Lye whe putrelactiv chanves rn othe ihtes-
stances, Irom 5 to Yi ounces of biovd Withdrawn, the Lines are not rare and shotild be accorded special consid
UnOUnE OL pi UMOLONIN In the blood Vessels Is, Miitla ys Tation. Uhis Will USUALLY be prevented DbDy the ear
reduced from 1/30 to 1,10.) If at the same tim Ler catharsis Which Was recommended: however, throughout
is introduced into the system, Puplary L quantity 01 entire attack the functional activity of the gastro-
Water equivatent to the amount of blood withdrawn, th ntiestinal tract should be often and carefully investi-
remaining toxins are very appreciably aiuted his Palen An excess of sulphates or of indican in the urine;
may be done by the eMiployvyinent oO1 irge ehelnas Or V Lhe presence of a paretic state of the imtestines. witl
. LOVE: Silt Ol Prot { 1} , ]
hy podermo Lysis 4) Horie att . ll Ol. l OLOUDA (Vinkpanit ce distension ana an Wmability to puss flatus:
toxemia Olten manitests itsell by high temperatut the sudden onset of fetid diarrhea, all shouid be recog-
gradually increasing frequency o e pulse, With vi nized at ohce and proper relieving measures applied, ap
ne tension; reshiesshess ane eClrium, or a pecu lor example, regulation of the diet, the judic.ous use of
: 3 : ‘ : d .
clearness of intellect; sallowness or duskiness of the s cathartics, the employment of stimulating enemata and
faee, ete... and in these cases | can strone ecole! idministration of some ethelent intestinal antiseptic
the free sipstraction of blood, wit ormal salt solut Pulmonary edema is an oceasional event which, de-
] ] ] } ] \\ } \ t + ; + |
NV POU crMocry sts Do no 0 val Uli =) spite 1tS semous Nature, may occur early enough to per-
development OL stu sVinptoms yut imstitut Ost nit of relied knergetic stimulation of the nervous sys-
+] ‘ ’ si
ineasures ON The Vel rst Ima MIs O ( ippea el VV Strychitlia, of the Gaplitaries Dy adrenalin, ane |
INC ¢ In this connection | LO | warbicular ten- heart by a small dose of morphia, are the prop
on to the advisability of giving S ver re remedies. ‘Phe appearance of profuse, possibl 00!
throuchout tire I LLOTL LE I ( ) ae © HO ) perspiration Is an ominous, but not hopeless, syuiptom
be ee ' : ; ie . ; :
itere a prompt appeal to rational therapeul CS may be Ol
; neas ible value to the patient. The condition is prov
; } . :
DF wera age | — yk il akin to that « pulmonary edema and require 3}m-
r mahagemen
| | Ie Oxygen Inhalations meet my approva | begin then
+4 a se CO! ratively earl and ¢ mpl y them somewhat
: +-+¢ .. Ore rer | ilk is usua Oxveen wed 1D this munne!
+2 ; ‘ ,
P ' 4 = L believe to be uselul and not at all bharmtu
pal a 44h +++ + 9T3, ,
oe eee L 7y It is not my intention to consider the numerous Mino!
am ott, T | if VT NK OuY often eminentiy useful, measures which are re-
qr tr ttt ht f i y \ > . :
sano so's: “A ee et > pik tot #: mew = ari : ed to meet the various lndicatlons tor treatment
i 4 \ id ta i ae 2 Hic) \ irise during the pnheulmonic attack, Lhese
* . é i
10, Lyi NU ih i¢ ,
f bs i enumeration and must be applied to meet specta
it Hea . I
vi iv Be requirements .
-m. : 7 Whether impending death, In pneumonia, can ever b
j ‘ erted is an interesting and important question. Tha
: Ss OL great perll Inayv De It ( « Ih soll ( Cs
3 : | am firmly convinced. Among these may be mentioned
i fe : : ofound toxemia, circulatory failure, pulmona
. . , ‘ : i estinal paresis, failure of the nervous retl et
: : ; , \\ a) owever, dé th has actual \ eoun { ( ~
2 a Ca mot which Is an nereasinge sphnea, W rls
| | ‘) ( ~ 1) ? )} =< TO \\ = he o l ‘ trac Ca rh ay nopul Sjestiale . cael
{ i
. j ; Oo Olse With eac respiration, W 1 persists alte!
erstoor { eve me o Os ible |
, 9 n2), my experience Gives no 1Wstance Of recovet
pneun l ) ‘) ha ~ Oye ( ] 5 L : bys ae : 2
Ih he remarkable suddenness with which tne
Lppe ry Tlie ~ O l l 0) Cdst ,
mm" ! Ss Oc rin pneumonia is one of thie iLures wile!
This o re cca fy eo] , ee nrofont 0 is |
ry) ned s pecullal Characteristic. he patient is stricken sud 4
pop ~ ) Penh | t ~, ) - ] ] : 1] ] :
‘ f : t'] 7 < ( mproves sudden at rets worse sudcddeliu 6
Tr = T SOT fa) t ‘ ( 0) © :
eae i sa a . Ania ih, | : reason pheumonie patients should be given the
ee RE ] st cart observant, intelligent and unremitting at
YaY } ( 4) | OSes f ( > ° . 5 ° } >
; mae n¢ aii ntion. Not only should the physician’s visits be fre
7 4 4 e } 1] oe P naan lt s ¢ertain that tly presence of Tt! DHNVS1
] es ans ee ] : ‘ tan 1 thay In, Tread oO act at the moment when untavoravie ind
™T na | ct bia | OoOts. tye =H tle na '
4 : " 4 rte IS conditions aris Increases the patient es
} n } retaiy 7 s recovel and I am convineed that, in man
ses. if such medieal attention is not supplied, he is be
| ntint Yoate: < ) ( )
7 j } | na ¢ ne ce ) ived of or))} of the resourees of our int and that
7 7 1 a Q / ni 0 ree) ! are thereb direet I sened I
TY T}~< 1 ( a. ¢ ~ Cad
ayy Se : Perso} | n e sure if in few positions of pi ri can thi re
» ° . 3 Siete . Ourees yy mediemine pe more humane PIMNpPloversr {! an 1)
. ’ P neraled combat with pneumonia
wmrrtion oO = ~ ( ) =
’ ’ nis ! MWe \ 1744 Woodlawn Avenue

qo ~ {
Hosp

| ~ | ys 1)

7” Tt)

aaai {

tients broug!
) ni}
{ A iii
ood ni
T if yrie
I
non the s
roo} ( =
t yi 1 t )
Ir:
Ir 10
From 2
From 30
From 40
} ) "a
tt)
70)
Ne LO pr
I
(it) { rs Qo"
ro) ( “es
( ys
Lai - ; )
ial
nti
I
1
Rig!
Right Ip}
: ,
W i ! at ) I
,
— | ) ) ')
n ) 1) ‘
hn J
‘) ~ T t
7 ]
i (
er y ‘
ci (
? T T
)
+ y tT ~
bog
2 , 10.000
ROY OOD 1 (

Qs]
ISEPH
PHII
4 ee |
( )
I}
I)
Ortion
(
,
"
yeal
\ irs
yeal
\ irs
Ve
O
in
)
{
)
,
{
(
"
a
_ i
’ ’
(oi |
{
{
?

SAILER

nl f ! 1
lithla A ‘ \

Ovtalhed

PpheumMmonia and ai

1.2)
e \ s of the Plilade
Vast \\ I | Service al
I
Man Cases OL pheulnonia al
T>! } |
Waly W 3 1 ( Phi aU
ares porvuion Of seniles
I
s also transterred to t med
ij> ~ PLODITT n 1s)
pis il pa
nent Or at rium remens
nea obtained rom tii
delp As a result, w
( l l ~¢ { COUTS*
O re ¢ aingiy com
Tl n oO harliy obtaimed
nt I rerore
smissed briefly. Th
4 cases
‘) CAaSéE
() cases
S cases
]
o ises
} ses
~ 14 \ ‘)
| ) ~1)) ]
I | s of interest in this
~ . 3 ¢ ed by Di
y¢ ? “0 al eeetele }
~ ] (} OT ceent
( Signs ane
>
,
)
13
? ~
ne I middlk
{ { botsad
ay tire left lun :
. , t Y in ‘3 1c
if £, ill ) cit
,
! er 9] att
! nsoidated, The
nly ! the middt
iT ! ) () at
I SU iB OWeRT opes
) 17 ani
il 1
~ ( proportion yf
2 in ed Thay 1
i | Ihe Vi 1
lL;
ention was paid in |
‘ PTePrmine )
.
} be
~ } if t been gen
; i]
: 7, = the proonosis
4 . (>)
vered there wer
We] >
) ? )
, eas etween 10.000
1 9
! AGMOLEL nd OOOO in :
{ ea y C hetween
4 fw
ss ‘ } ' Ni¢
! American Med
| Med ne, and ap
mmitte Drs. J. M 1
ve 1i¢

Jot Kt \ \| \
tU,YUU and oV,V0OU in Lt eas nd dbetWeen oU VOU ane
j ) ~») " J {) {
MY U0U n «6 Gases, Phi SSlUCcatlon is alway hades
from the mMaXimum count Ot the cases that died thr
leucocytes were between LVU,OUV and 20,000 in LL cases
| ) fe
between £VU,000 and 30,000 in cases, betWeen oV,000
ind 40,000 In 1 cask men recbWween 40,000 and v0 000 11
lL case Phere LOre, allhou 1 the advantage ts slight V in
lavor Of the Cases that recove Cd, lt GO0esS NOt appear that
|
Any delinite conciusions can be drawn from the leuco
CVtic Count, and it seem adliso lmprobabl Lhiatl au
* A .
Method of treatment whi - asead merely on thie l
Crease hn the CUCOCYLES IS Cly\ > Boe: oO LY aadvantav
ln the majority of the cases the urine was examine
quantitatively lor the ¢ ) | Lhey wel entirely abd
sent Oh one or more occasions during the height of t]
11 » < . ») {
disease In 29 Gases In 23 additional cases they wet
res fT ] } | rf | } 1)
present 1) quant LICs OL less than o pel COnt..- aAnG.in: a
the remain Cases hn whic \ \\ eo Certain o (
aZLOsis OL Croupous ple monia t ry rey {
a4 | i il il Li \) l “4 i y L
aduced his subject 5 on oncerning whi there Is a
present a good deal of dis} (utrecht, in Nothnagel’s
» 4
Practice States Llial l ( Chilo Gs al’ Ol Hho provnostle
I
and ver Litt G1laLYNoOstie \ ( \L uss ry ib Cotmment
) ? | + } ¢
ng on this, quotes Hutchinson to the effect that th
L1mINUubION Is more Constant hi ple imMonia | lh ih oO Cl
( s, and therefore O SOM la@Nostlle Value
Krom a study of our cases we reached the conclusion that
the quant ty ol chiorids in the urine Is not an indication
tt SUDSeGUenHE Course oO 1] qd ~ ( re | L pro
portion Of Geaths occurrin n those eases in whieh the
HiOTiIds Were enti! SC] as Hn Loos I Which the)
Were nore oO ess moderate | On the the
} ) ~ 1) f
! ) O — gs 7m
MeumMonia ane thelr exere ( nh Ol LOUILIi¢ Onda
tT) artlicuial LVpho I l Ona! LUDeCTCU
Os ne SHOWN so Col [ I it mt latter state
the reduction is yMparative Insignificant, and il
} », and ib
nmneumol l uWavs Const ray \"( ave ( 1) to place
ne highest adiue On 1t in f wWhosis OL pneumonia
| n 9} fH
In one Case Lhe absence o ( oOrid ( to a UCCeCSST UL
agnosis 1n pneumonia in w! througho the entire
ourse Of the disease there had | hn none ot t pl sical
ens Of pneumonia. Che ¢ nosis Was only contirmed
" i } ? 7 : t |
iC autopsy, and 1n several of the cases we report the diag
1OSIS Was suspectec rom the nary « i nation petore
e physical signs v es cient ronouneed to have
A .
' } ,
nade it possibile to diagnose n Onla DY them aione
Che examinat On ot tum tor the presence ol
heunocoecl could ho ll | a 2 ) ! I 1) |
ses. In 16 cases in whit n were Po
e 14 times n ne thy \ eC Ss CW { LVpical
) Cle AK ! ! nel OS ft ealed al
verry Lr cay rroun ile None areas which
} ]
} OLOGIS regarded - Cy no 1) ona
hosts 1} 1 ~ ( = mre I Wis ryyve
>» 2 4 ]
mia complicated b rupereu ~ ( ( ( te 1"
»X.OUU. and the ehiorids Tat iTrom & tt 4 B eCn
an
ne other ease w not rea () OF pneumonia. Phi
1 l |
went had had ypneumol , bnhyre months MreVIO
rr " . ' ’
id the pl ca! sions and ft! ior OF TI reath pomtec
vanerene oO THe unY \ Cl \\ CO] red at LUTODS
ood ¢ lt res ere on | none ¢ ~ an mn
tf one no satistactol I’ { were obtamed he
nice ar 1 nh s1e9] Q ( nN veNner eh {eo}
, 1] = )
\ history of ehi vas obtain N oe ¢ In 19
2 2 ] 1 i]
history eould he obt weal n 1S us hye
use the patients when admitt ere suffern ron
. . = ]
oholism. no definite history could be ascertained.

SeEPr. 24. L904,

Of the physical signs, we were chiefly interested in
the bronchial breathing. ‘The earlier writers on plhysi-
cal signs in the lungs, followed Skoda in regarding the
indeterminate or mdelinite respiratory murmur as char-
acteristic of consolidation of the lung. Of late years,
however, this appears to have been partially forgotten,
and there is even some question as to whether, when
consolidation is complete, bronchial breathing Is ever
absent, although it is admitted by some clinicians that
in the very early stages of the disease the respiratory
murmur may be feeble or oppressed. We were able to
liscriminate between two forins of bronclial breathing,
to which we gave the name oc loud and faint. In both
forms the respiratory murmur has the hollow sound and
oth Inspiration and expiration are equally long and loud.
The ditferenee, therefore, is one of degree ; but the tat
oronchial breathing is often barely audible on the most

areful and attentive auscultation, and it is very much
fainter than the normal breath sounds. ‘This fain
yronchial breathing, although occurring more commonty

n the early stage of pneumomia, is not by any ineans
imited to the period of congestion. It was frequenti)
observed far into the
note over the affeeted lung was absolutely flat, and when

course OF the disease, Wien

both bronchophony and pectoriloquy were Gistinet lt
was noted in 21 of our cases, usual) replaced toward 1

end by loud bronchial breathing, but occasionally per-
sistent. The following case was particularly interesting :

P. R.. an Italian laborer, admitted

malaise, chills, and diarrhea which had lasted for 13 days. The

was complaining of

entire right lung was flat from the apex to the base, the

almost unaudible, but of a distinct
Voeal

were diminished; the heart and liver were not displaced; thi

bronchial sounds were

bronchial character. resonance and tactile fremitus

made on se\
Atter

the patient had been in the hospital tive days whispered pector-

ungs expanded equally; exploratory puncture

eral occasions failed to show the existence of any fluid.
iloquy appeared, of a most intense character; bronchophony
was also present, and in the course of a few days the bronchial
breathing became very pronounced. Lysis commenced on the
sixth day of the patient’s stay in the hospital, and was com
plete six days later.
heard in the lung.

the leucocytes were 7,280; the Widal reaction was repeated!)

During lysis numerous moist rales were
In this case the chlorids were 11 per cent.,

negative; tubercle bacilli were not found, but the sputum con
tained great numbers of the pneumococcus.

Of the other physical signs we shall on!y mention that
wooden tympany was only observed in 2 cases, aithough
\ufrecht regards it as fairly frequent. Herpes was ob-
served 4 times, icterus 3 times. Feeble heart action and
albuminuria were comparatively common. — Profound
cyanosis was present in 2 cases; in 1 it was temporarily
relieved by venesection, but the patient subsequent]
died. The other patient was treated with antipneu-
mococcic serum and recovered. Of the symptoms, very
severe abdominal pain was present 4 times; it was as-
sociated with tenderness in the hypochondrium on the
same side as the pneumonia. Two of these cases recoy-
ered. On one of the others no autopsy was obtained ; the
other showed chronic obliterative pleurisy and hydro-
pericardium, so that the symptoms could not be ascribed
to diaphragmatic involvement.

The complications were numerous. Chronic nephritis.
usually of advanced type, was found in 17 of 25 autop-
sies. Pleurisv. either chronic or acute, was present in ev-
In 2 there was empvema in 1 gangrene of the
Inne. in 2 acute fibrinous pericarditis, in 1 chronie ob-
literative pericarditis. in 1 acute nleerstive endocarditis,
and in 1 sente pneumocorcic meningitis. In this ease
naralvsis of the branches of the third nerve and the pres-

erv cee.

PNEUMONTA-

SATLER. S74

ence of Ixernig’s sign had been demonstrated before
death. One patient, on whom an autopsy was not ob-
tained, developed a flaccid right hemiplegia, with absent
reflexes and a positive Babinski, three hours before he
died. In 4 cases tubercular lesions were present, twic'
in the form of acute cavity, once as a healed eavity, an
once as general diffuse tuberculosis involving the adr
nals and the peritoneum. ‘The remaining cases wert
treated with another variety of serum.

CasE 1.—J. D., left upper lobe; six inje«
tions were given, each followed by a fall of one or two degree-

white, aged 47;

at intervals of about twelve hours. Crisis oceurred on the

ninth day.
2.—A. J., colored, aged 18, left
entire lung and part of right

CASI upper lobe and late:

lune; three injections were giv«
on the ninth day, and the temperature fel] about one deg

Only the middle lobe wa-

ree
Death occurred on the tenth day.
not consolidated.

Case 3.—S. N.,,

1
Vvanosed,

white, aged 45; left upper lobe,
Two injections of serum were followed by fall

of 3 and 4

‘
Geepi\
i .

Inperature devrees, Crisis oceurred on
seventh dav.

Case 4.—-C. T., white, aged 60; richt upper lobe: 5 inieetio

The I
ot temperature varied from 1 to 21% devrees. Crisis commen

of serum were given, commencing on the fifth day.

CASE 5.—H. V.,

two injections were given, the first

white, aged 33: right upper lobe: icteru-

followed by a fall ot

deerees, the second by a fall of 1 devree, Crisis occurred

the seventh day. Three days later the temperature agai

rose, became hectic; tubercle bacilli were found, and tli

patient subsequently died.
CASE 6.—J. M., white, aged 52; right upper lobe.

i arop ot. the

There wi-
temperature to normal on the third day for
tew hours. On

menced and seven were given, the antipyretic effect being «

ihe fourth day the serum injections were coi

served only on the last two days.
day.

Crisis occurred on the nint

\ltogether, there
Of the fatal cases, one was distinctly unfavorab},
another practically moribund when the serum was en
ployed, and the third died of tubereular infeetion after
ipparent recovery from the pneumonia. Of the
that recovered, 3 nay be regarded as severe—one Wit!

were three deaths and seven reco

Cases

hyperpyrexia, one with cyanosis, and one with jaundic
Both varieties of serum showed in certain cases a distin:
utipvretie action, but in other cases this was not ol)
served. Nevertheless, the general resuits may be r
varded as distinctly encouraging. }

Pseudo-crisis occurred in 2 cases; in one of these thi
temperature fell twice, with marked improvement not
only of the symptoms, but also of the physical signs
One case died suddenly of acute pulmonary edema seve1
days after the crisis.

The treatment consisted of expectant
with oceasional resort to hypodermoclysis.

were treated

stimulation

Ten
with antipneumococcie serum provided by
two firms; these cases were in part selected; two wer
distinetly unfavorable cases, and the others favorabl
subjects with not more than ordinarily severe infection

The first case, a bov, was admitted the third dav of thi
disease. In spite of repeated sponging, the temperatn
rose to 106. On the fourth dav serum was injected, anc
repeated five times on the fifth dav and once on thi
sixth. There wos no perceptible effect on the tempera-
ture, which remained ahont 104 to 105.
tions ranged hetween 40 and 55. Crisis neeurred on the
sixth dav. and the recovery was nneventful

The second. of 5&. with

Cases

The respira-

arterinselernasis

The

QA neocress

There was consolidation of the left lower lobe.

32,800; 20 cc. of

any per-

‘hlorids were absent, the leucocytes
serum were injected every six hours without
‘eptible result, and the patient died.

The third, a man of 40, had a mild attack; the serum
produced no perceptible effect, and he made an unevent-
ful recovery.

The fourth, a man of 37, was admitted with signs of
‘onsolidation at the right base. On the fourth day 100
.c, of serum were injected in the course of sixteen hours.
The temperature, which had ranged between 103 and
104, steadily fell to 100. The supply of serum was ex-
hausted, and eight hours later the temperature
igain to 103, where it remained for twenty-four hours.
\ new supply was then obtained and 120 c.c. injected in
twelve hours. The temperature promptly fell to 99 and
remained between 99 and 100 for three days, during
which time 300 ¢.c. of serum were injected. The pulse
and respirations also improved. Six days later there was
i profuse urticarial eruption, with fever and pain in th
joints, the attack lasting eight days.

TOSe

DISCUSSION

ON PAPERS BY DRS. WELLS AND SAILER.

Dr. R. C. Capor, -Dr. Wells’
meumonia at the Massachusetts General and Boston City hos

Boston tables of the eases of
pitals do not, in my opinion, show any increase in the mortal
Le Tore

what

ty from this disease during the past twenty vears.
that
ver

Dr. G. F.
factors regarding

Since 1890 we have had an epidemie of influenza which

the eases are too few to warrant any conelusions

Jk NKINS, Keokuk, lowa The re are one or two

which some information might be

‘tiologic
given.
if itself has not been particularly serious, but as an etiologic
factor in croupus pneumonia it is of great importance. Intlu

nza affects the mucous membrane, making it susceptible to

secondary infection by the pneumococcus, and that is why it is

more prevalent now than it was fifteen or more years ago.
{nother etiologic factor is the crowding together of people in
great cities. This crowding lessens the resisting power and at

the same time multiplies greatly the centers of pneumococcus
nfection. I think these will
tent the great increase in croupous pneumonia.

explain to some ex
With
to venesection, IT think we should go back and study the ques
bit. I proper use of cold

surroundings, diet and

two factors
regard
water, the

little think the

hygienic

tion a
proper fresh air, venesection
vhen indicated, is very important

Dr. DELANCEY RocuESTER, Buffalo
which ] particularly the treatment of

symptems as symptoms when the possible of the dis

There are on r two

wints in take issue,

treatment

ase as a whole would overcome the svmptoms. It would be
hest to recognize the causes producing the symptoms, and treat
them. In cases of toxemia, if you get rid of it you will cei
tainly get rid of the svmptoms. I think it is a great mistake
to add. in these cases. other poisons in the way of drugs when

the patients are already poise ned by the toxins of the disease.
| approve of bleeding early in sthenic cases, but T disapprove of
the administration of opium in the beginning. I believe in
retting rid of the poisons by the proper use of laxatives, par
ticularly calomel and salts, and by one agent which acts on the
produce sweating, namely, hot air by means of a scien
foot bath: by
in get rid of the poison of pneumonia a great deal better than
by the administration of diaphoretie medicines. Last
the New York State Medical Association T reported 210 cases

f pneumonia, with 23 deaths: this included all sorts of cases

tifically administered hot mustard sweating we

vear at

und gave about 11 per cent. mortality. This is comparatively

death rate. To relieve the pulmonary edema ocem
ring late in the result of failure of the
heart, I believe that bleeding is of the utmost value; when in
pneumonia the right heart becomes greatly dilated. as in the
vase of a boy of 16 years. whose heart apex was in the axillary

a verv low

disease, as a right

line, with consolidation of the right lung, with a liver extend

ng one inch helow the border of the ribs, and with pulsation

DISCUSSION ON PNEUMONIA.

Jour: A. M: A

in the veins of the neck, by withdrawing about 800 ¢.c. of
blood the pulse can be made to fall from 140 to 120, and the
temperature several degrees, and the respirations from 56° t
36, and impending death be thus averted, it is a procedure no!
I think it is a mistake to treat the tempera
If you treat the conditions present, the toxemia and then

to be neglected.
ture.
the special conditions as they arise, you ean get good results
The boy referred to recovered after nineteen days’ sickness.
Dr. Roper H.
struck by a statement made in the second paper that a patient

Pul

monary edema is usually supposed to be due to right heart

BaBcoock, Chicago—L have been particularly

died from pulmonary edema seven days after the crisis.

failure, and the occurrence of the edema seven days after the
crisis suggests the possibility of the explanation offered by an
Italian experimenter that pulmonary edema is due, not to heart
manifestation of infection

failure, but is a pneumococeus

acting on the pulmonary alveoli. He found in cases examined
after death evidences of this, since the pneumococel were dem
onstrable in the alveolar walls. It certainly seems in this case
that the late pulmonary edema might have been a manifestation
of a fresh infection by the pneumococeus. If [ understood what
Dr. Wells stated concerning blood pressure, he insisted that it
from the start.
at the start it is a contraindication to the administration of
veratrum viride; in fact, 1 protest against the use of cardiac

is low I believe that if blood pressure is low

depressants when the blood pressure is already low. He stated
that the low blood pressure might be an effort on the part of
that is
purely theoretical; but granting the assumption correct. 1 be

nature to resist infection by setting free leucocytes;
lieve the harm likely to be dene by veratrum offsets any bere
fit due to increased leucocytosis. If the blood pressure is low,
and

digitalis is the agent par excellence.

then as the danger
We are all inuuenced by

and grows lower lower, progresses

personal experience, but IT think it well to cite what Fraenkel
that the

tendency to low blood pressure must be combated, and is offset

from his great experience finds useful. He asserts
by the early use of digitalis. The form he employs is a fresh
infusion injected hypodermatieally, It is his rule to give fom
grams of the leaves in 106 e.c. of water, and this amount is in
jected during

twelve grams of the leaves have bee

hours for three days, unti!
He begins the

every twenty-foun

n injected.

treatment in all cases seen before the third day, excepting

those in which there is so much arteriosclerosis as to contra
indicate the use of a drue. Fraenkel believes death is the re
sult of toxemia acting on the myocardium, and that, as this

danger is enhanced by the low arterial tension, it is absolutely
necessary to counteract the tendency to increasing lowness of
blood pressure, and personally T believe this is sound reason.

Dr. S. Sorts Couen, Philadelphia—There are two periods in

the clinical history of pneumonia. in one or both of which
venesection may, in many cases, be usually employed. — First
in the beginning of the a‘tack, to reduce the toxemia. See

ondly, toward the end of the attack, to reduce the overload on
the right heart. The results obtained in any particular case by
venesection, or, indeed, by any other measure, ean not, how
ever, be applied to all cases without qualification; the keynot:
in the treatment of pneumonia, as much as in any disease, is
individualization. There are so
the constitution and habits of the patient, the environment
that it

sometimes becomes a delicate problem to decide what to do in

many factors to be considered

the preceding or concomitant complications, ete.

any special case. Whenever the indication for interference is
not clear, there should be no
justly draw conclusions from similar

interference. However, we may

features and relations.

pathologie and therapeutic, repeated in a great number of
that

removed from a patient otherwise in good condition (that is

cases. T am satisfied a goodly quantity of blood may be

infection cases, ete., but cases
of frank at the incep‘ion of the at
tack, diminishing the amount of toxemia and stimulating the
This

pendently of the mechanical relief to the obstruction of the

to sav. not senile nor terminal

pneumoccocus infection)

reproduction of healthy blood cells. is of benefit inde

circulation in the lung. Late in the disease the indication is
When

purely mechanical, blood is removed under the firs

SEpr. 24, 1904.

condition it is well to follow with saline infusion into the

vein or under the skin—not too much, not too fast; but in the

second condition saline infusion is not well given, because it

does not seem reasonable to take blood to relieve the heart and
then to add the same quantity of another fluid to embarras-
the heart as much as before. There is a qualification to this,
however, and that is in cases in which the blood is very thicix
and runs sluggishly from the open vein. Saline infusion wil!
dilute it, and the respective quantities may be adjusted wit!
skill. Temperature in itself, unless excessive or very low, of
fers no indication for treatment. IT have learned to look on
eases having temperatures of 103, 104 or even 105 degrees F.
more favorable than those cases

is being—other things equal

having a temperature of 100 to 101 degrees. The vital reac
tion is better and the temperature seems to be an indication of
this vital, reaction. Fenwick’s statistics point in this diree
tion, too, and T was recently reminded on looking over my
student DaCosta’s lectures that he had taught the

The matter is important, because many patients

notes of
same thing.
are killed by the by-effects of an ipyretic drugs, needless under
any circumstances. As to veratrum viride, it should be re
membered that many drugs are used, concerning which it may
he said that their physiologic action as laid down in the text
hooks seems to have little bearing on their effect as observed
it the bedside. T have seen some cases benefited by veratrum vi
ride, given early and stopped soon, and T know not why. Cer
tainly the benetit has not been due to depression of the heart.
Dr. Babeock has well said that chis would be a counter-indiea-
tion. Perhaps there may be some‘ hing in the complex chemis
trv of infections and drugs and body eells and fluids, of toxins
ind antitoxins, amboceptors and complements, which may here
ifter explain its action. For the present it has distinet em
judiciously-—that is, before
ind for promp' effect: using the pu'se as an index, diminishing

pirical value used consolidation
the dose as the pulse falls, and withdrawing the drug as soon
is the pulse reaches 60 or 70 beats in the minute. or otherwise
shows that the physiologic effect of veratrum has been at
tained. This, I repeat, is an index only.

Dr. Eowarp F. Wetts—In a twenty minutes’ paper on pneu
monia one ean barely indicate a few of the general principles
ind ean not go into a discussion of any of these features sys-
In answer to Dr. Cabot. T stated explicitly that
the very first effect of pneumonia on the svstem was a redue
there is no doubt about this.
onset of the pneumonie chill
If this is an effort of nature to pro

tematicallv.

tension:
minutes of the

tion of the arterial
Within a few
this reduction appears.
tect the svstem from the initial shock of a pneumococcus poi-
should not as
should do so. In

should or
believe that. early, we

son, the question arises whether we
sist nature, and IT
view of this T have taught that veratrum viride, given early in
these cases, seems to offer a further protection from the violence
of the initial shock.
ide will reduce the frequency of the pulse and this without

Empirically we know that veratrum vir-

raising the arterial tension.
ire still further dilated. I most emphatically disagree with
Dr. Cohen as to the advantage of high temperature in this dis

On the contrary. the capillaries

ease. One hundred and sixty vears ago it was stated by Cleg
medicine in the island of Min-
the temperature
in the afternoon reached 102 degrees F. with a favorable prog

horn, who practiced scientifie

oricea, that in pneumonia, in ordinary cases,

nosis, but in severe cases and with a bad prognosis it reached
104 degrees.
did in the
right regarding the use of opium. IT do

This statement applies to pneumonia to-day as it
davs of this great clinician. I wish to set myself
not think any one ap
preciates more than I the disadvantages and dangers of the
improper use of opium in pneumonia: but because it may be
improperly used is no reason why it should not be used intelli
gently, properly and beneficently. I stated that in the begin
during the course of the chill, that 1/16 o
\% of a grain of morphin, given hyperdermatically, will quiet
Also late in

ning of the attack.

and soothe the patient and be very beneficial.
the disease, similar small doses of morphin, especially in those
dangerous conditions accompanied by profuse perspiration and

pulmonary edema, small doses of morphin will stimulate the

OLD UNREDUCED DISLOCATIONS

WILLARD. 879

heart as nothing else can, and sometimes snatch victory from
With blood-letting,
from first to last, my only reason is to remove more or less
of the toxins and I am quite satisfied that this is the keynote
to the situation. Occasionally one may bleed for the relief of
an over-distended right heart, but 1 always desire to antici-
pate that event if by the exercise of foresight and discretion

apparently certain disaster. regard to

it is possible to do so,

Dr. Josep SAILER—In pneumonia | have invariably found
the blood pressure to be low. If very low I regard the prog
nosis as unfavorable. In another series of cases I hope to em
ploy the anti-pneumococcic serum intravenously, chiefly be
cause certain other serums, particularly the anti-plague serum,
seem to be more effective when introduced into the circulation
than when introduced beneath the skin.

UNREDUCED DISLOCATIONS.*
DE FOREST WILLARD

Professor Orthopedic Surgery, University of
geon Presbyterian Hospital.
PILILADELPHIA,

OLD

Pennsylvania; Sur

The term, old unreduced dislocations, is here used to
cover cases where the joint surfaces remain luxated for a
month or more after the accident. ‘The delay in effect-
ing reduction may have been due either to non-recogni-
tion of the condition or to the failure of the original
manipulative replacement efforts. The designation “ir-
reducible” is a misnomer, since a joint incapable of re-
duction by one method may be reducible by another pro-
cedure,

DIAGNOSIS.

The chief element in the prevention of this condition
lies in immediate diagnosis at a time when reduction is
easy; 0.d dislocations exist because of faulty diagnosis.
With ordinary anatomic and surgical knowledge, with
anesthesia and the Rontgen ray, primary diagnosis is
usually a simple matter. Whenever uncertainty exists
in regard to an injury near a joint, anesthesia should be
the rule, since without its employment the pain and
swelling often render accurate diagnosis impossible.
Diagnosis once established, the treatment foliows as a
natural sequence. If manipulative efforts fail, operative
measures should be at once instituted. ‘The greatest
difficulty will, of course, be encountered in dislocations
associated with neighboring fractures, especially in the
shoulder region, while the cases most likely to be over-
looked are those complicated by severe injuries of other
portions of the body.

In old dislocations of the shoulder, the body should
be stripped to the waist and examined sitting and stand-
ing. In fracture of the head of the humerus, or of the
neck of the scapula, or a Separation of an epiphysis,
the elbow can be brought easily to the side of the
and mobility is the rule instead of fixation. In all
old hip luxations the patient should be naked and ex-
amined in both the recumbent and standing posture.
By this method many errors will be avoided.
parison with its fellow, the loss of
difference in contour, altered relation of bones and _ re-
stricted motion will be noted.

Pathologie dislocations from hip disease, congenital
dislocations, coxa vara, and sliding up of the trochanter
after fracture of the neck, should be carefully differen-
tiated. Not infrequently T have been obliged in con-
sultation to restrain attempts at reduction in eases both

pod

By com-

normal movements,

* Read at the Fifty-fifth Annual Session of the American Med
ica! Association. in the Section on Surgery and Anatomy, and ap

DeForest

proved for publication by the Executive Committee: Drs
Charles A,

Willard Powers and J. E. Moore

NSO) OLD /
it hip disease and of neck fracture, which had been in-
Orrect diagnosed as luxations.

COMPLICATIONS.
Complications and obstacles preventing reduction are:
Intlam partial

lacerations of mus-

Hualory adhesions and deposits

Causiny
barrowlnye of the ho.e in the Caps i =

CS aNd LeENndONsS 5 Lillne up ol Lhe socket DY torn muscle
OF Tivrous Geposit; fracture of the rim. with bony pro-
CLO raviments o] ractured - a portiol OL Cap-
I I
Sule MUSE Ck nto thy Ol Il l ist Lhe ahil-
TO) ( ] ~ } yrsa0) " | t ) I)
| ar? i¢ wen ance I ~ COn Ih GIisiO
Cd Ol! OL ¢ ht S110 qaer ol Dp ‘a eS O I meee
ire | l hco On { l Hts ma ) oun
l OK 1 f) ! ( qd I a) oti oOod
: ;
o oO ~ to Os ) ~! \ Ch) } } < <7 |
I liter Open Ineislon SUC ah Osteo
} ~ ¢ ¢ = ( es | Haus ¢ i
\ > ] \ 11s ( ll (
iy) ~ } ‘ s}) a ) } ne
I I
! )
ii ) ) Sif Le
CCIDENTS DURIN( ILANII LATIONS
is never lore the su enness W Whit i vil
n Si) a CoO =Cqd \ ( Was assisting { I (
) t |
Protessor Agnew re than rt Ss ag i
i st © } l Olin QO] ( lt Ol ¢ } ) ( }=-
s1\ \ ~ standin as ) ) ( vr 0)
<SELCS HOUT Thre > 4 Cu ( il )
x eg pat ppl } = ] | y? ( “ear 6
{ ( ) sf ( saltyy ] ( hist a ! OllsS ai )
i s
<s 1 rig SubD¢ in a (
ut uo n parcel LU l I il if}
1) 1 ) ny) pDpiiea Ot) ) ros ) “ ( Tt
i i
A |
Sul ( i l Us l l ) ~
artery ore Ti ,
{ \\
ot t a1 eln When 1 ) ~ } t aL
Wrist e tumor Cid not pulsat
A
\ ies
In AGNEW Ss Case Ol Miahip I mo
}
rif } a6 lt }) ~ ( )
} ~ ) ~ { !
rf i —( His \ ( yn) (; rin
>
re off an entire ar [3 1 tructures
S11 nextent that lil ( 1 Ltn ! l ie 8 s-
|
~ In 0) ( ( StS VahhlY Lit ~ *¢ ree ( Wve
,
)
) ther death or amputation Gibson in 1825. in ac
' | |
COT’ at Wil Live practice ) that a irtel Vor
7 , ; F ,
rep on otf blood tetting, tartar emetic , ete., subjected
I ‘ 4 .
the man to pulley extension and counter extension tot

half an hour, then manipulations were practiced for om
more, one of the proce
ing to hang the patient 1)\ the )
As this was in preanesthetic days, and as tl

is obliged on the following morning to tie the
clavian for a pulsating tumor in the axilla, it is rather
strange that the patient lived until the eighth day, with
the arm in a state of incipient gangrene. The artery
attached to the head of

and three-quarters of an hour
iXilla over a door.

le surgeon

sub-

found to have been firmly

was

the hone and capsule,
Lister in 1873, in an old
ured the axillary artery with pulley traction by tearing
hand attached to the coraecoid and humerus. TT

forward dislocation, rup-
a fibrous
tied the arterv through an axillarv incision and resected
the head. but the patient died on the following dav.

In twenty-four eases of injurv to the axillary
) ' fifteen

vessels
luring red) etion manipulations eollected by {them

terminated fatallv: the result in
tain: the axillarv nerves were lacerated in one ease: in

two eases Was 1ncer-

1. Phi'a. Mea

VREDUCED DISLOCATIONS

OL ail tissues interfering with

WILLARD. Jour. A. M. A.
another the brachial plexus was torn from the spinal col-
umn. Michans tore off both the median nerve and the
brachial artery in reducing a luxation of the elbow, but
saved the case by amputation. In the reduction of a
posterior dislocation of the head of the femur, the sclatic
nerve has been hooked up and carried forward in front
of tl the femur, with great resultant tension
and pain, flexion of the hip and disability.

neck of
OPERATIVE METHODS.

1. Manipulation and traction. 2. Continuous exten-

3. Arthrotomy, with section

reduction. t. Resection,

Subcutancous in

hol. ana COUNLCL-CXTC@NSION,

, pPracenn

nt, when possible. ap

on of capsule or of surrounding tissues, a procedure
sually uncertain and dangerous.

if ny uidtion and Traction. In former times the r

“Ista 0 the MUSK les Was COUSIGdered to be the. chiej

wht in the prevention of reduction, consequent.y ex

( e force by pul CVs Was Cmployea, even to the tear-

nis \\ of the limb. At the present time, recognizing

t the muscles are only one of many obstacles inve!lved

it ent manipulation is considered of the first 1m-

bane \n extreme decree of foree should be avoided

rious imjyui nesthesia should be

ecured and moderate manipulative and traetion efforts

ns ted. ‘These wil vary with each joint involved, it

wcordance with the usual methods » ivsued in primar\

ses, beine varied to suit the position of the bone, thie

( OM as sl l Paipatllon, the skiagraph

L¢ Le. OVETNeCHtS re isa rule, much safer than

the shouldet

manipulative efforts at
fuction of an old dis ocation wi | Vary but lit-

tle from the ordinary ones employed in recent reductions

ave that great caution must be observed in the prelim-
Inary breaking up of adhesions. Serious aceidents. As

ly ]

already enumerated, or fractures may readily be pro-
The indications are: to fix the
traction, adduction, external rotation,

head, adduction, flexion, internal rotation

dueed D\ undue force.
scapula, apply
pressure on
The old method of upward traction was a most dan-
serous one, as it put great tension on the axillary tissues :
outward traction is less riskv, but should be emploved
with caution
rarely sueceed four

efforts

Reduction

the luxation.

months after

An old hip-joint dislocation is a most formida-
lition to eneounter, and, next to the shoulder.
is the one most liable to be involved: it is also
an injury most frequently undiagnosed. as the condition
of fracture or of dis'ocation is often

masked or over-
ooked when anesthesia has been carelessly omitted at
the time of the original injury.

| reeall a case that occurred twenty-five vears ago. in
which the man, three months after a heavy fall of earth
compressing his body, was discovered to have a dorsal
distocation of the left hip. Under ether, I readily re-
duced this and placed it in the acetabulum with a dis-
tinct thud, and with the immediate resumption of the
normal position of the leg. When comparison, however.
was made with the right leg, it was discovered that the
leg which had just been reduced was shorter than the
one of the opposite side. This condition was very puz-
zling, until it was seen that the right leg was not. only
longer, but was also slightlv everted, and that there was
a fullness in the region of the thvroid foramen, thus
showing that there had been a forward simultaneons dis-

location of the opposite hip. both legs having evidently

SEPT. 24, 1904.

been forced in the same direction. All efforts to reduce
this failed, although, with the assistance of Dr. Allis, |
applied all the then known methods of manipulation,
leverage, traction, etc. The head could be carried to the
position of dorsal dislocation, but could never be placed
in the acetabulum. The fact that the left acetabulum
had not been filled up through the three months, and
that the rent in the capsule had not united, proved that
other complications existed which prevented reduction
of the right hip. What these complications were, of
course, we could not determine, as at that time neither
Allis nor myself was bold enough to cut down on thi
joint. ‘Ten years later the man was doing hard labor-
ing work.

Allis,? who has given most thorough experimental and
practical work to hip dislocations, says that the great-
est injury to the capsule is confined to the lower two-
thirds, and that the upper thickened portion of the cap-
sule, known as the Y ligament, is rarely lacerated, which
accounts for its great service in restoration. The strong
upper rim of the acetabulum, the surrounding muscles
and the dense capsule, are all important elements in the
prevention of a luxation.

A careful consideration, therefore, is necessary as to
the probable character and direction of the force; wheth-
‘ra sudden blow or a slowly crushing power has been
‘xerted. The a-ray is here most useful in determining
the extent of the fractures and bony complications.

Allis’ fundamental law is that a dislocated joint
should be restored through steps in the reverse order of
the displacement, consequently his manipulative reduc-
tion is based on the knowledge that the lower portion of
the capsule is the one torn and that the head of the bone
in dorsal dislocation, therefore, needs to be elevated into
place. He first fastens the pelvis firmly to the floor by)
inserting into the wooden flooring three hooks—strong
opened screw eyes—one near the perineum, and one on
either side opposite the crest of the ilium. ‘To thes
hooks the pelvis is firmly bandaged over towel pads. ‘To
avoid interference in the groins from the bandage, a flat
metal cross, with its four ends curved on themselves suf-

ficiently to hold the strips of the bandage, is placed

thove the pubis. To-and-fro turns of the bandage are
then made from these hooks to the serew hooks in the
oor. The femoral head is drawn downward by trac-
tion: then the flexed knee is lifted over the flexed arm
f the surgeon until the head of the femur is brought
ypposite the acetabulum: if it catches on the rim,
surgeon steps across the opposite limb, carrying the «n

with him into extreme adduction, while traction is stil
made toward the ceiling, and an assistant’s hand ts en

nloved to lift the head into the socket. Reduction is
isually accomplished with an audible snap. Tf it does
not occur. the knee is then carried across the bodv to a
state of abduction. while steady, simultaneous upward
traction is emploved. To inerease the surceon’s tractil
power, nerforated iron bars are se urely fixed with wet
handaces to the sides of the lower half of the thigh. A
rod connecting these bars makes an excellent handle for
the surgeon in his traction and maninulation efforts
Fix pelvis. flex thigh, turn lee and heel out: lift. press
m head, turn leg in, extend.

Second. or indirect. method, emploving the Y liga-
ment of Bigelow as a fulerum. When the head has
heen lifted as already deseribed to a nosition just helow
the acetabulum, carry the knee with the lee flexed di-

2. Dislocations of the Tip (ross Prize Essay Phil 1896
Oetavo, p. 167

OLD UNREDUCED DISLOCATIONS—WILLARD. 881

rectly downward in extension; the Y ligament wil!
thus be made tense and the head will be litted into the
socket. Bigelow’s manipulations are flexion, abduction.
eversion,

For a thyroid dislocation the reverse manipulations
may be practiced, still following the law of reversed or-
der, or the head may be thrown into the dorsal! position
and then reduced. In the forward dislocation first flex.
abduct and make traction outward; then an assistant
presses on the head during adduction and traction. For-
ward dislocation, second method, utilizing the Y Jiga-
ment, flex, abduct, carrying the knee obliquely inward
and downward; then rotate outward ; not circumduction,
lest the sciatic nerve be hooked up.

Bigelow’s manipulations for thyroid dislocation a
flexion, adduction, inversion, lifting, cireumduction.

Continuous Eatension and Counter-ertension.—After
failure of reduction by manipulation, a very useful ad-
juvant, especially for the lower extremities, is the aypli-
cation of continued weight and pulley extension in bed
for a week or more, so as to relax and quiet musculat
action. At the end of this time, under thorough relaxa-
tion by ether, manipulative efforts may be successful
though failure has occurred at the first attempt.

In the upper extremity it is much more difficult to
apply continuous extension satisfactorily, even with ai
pads in the axilla and Stimson’s couch with its perfora-
tion for the arm.

Arthrotomy and Excision —When manipulations fail,
the question of open operation becomes a serious muat-

ter, especially at the hips. The tissues surrounding the
joint have not only been originally injured, but have
also been subjected to repeated traumatisms during th
several efforts at reduction. Their resistive power to in-
fection has consequently been greatly: lowered, and sep-
tie int
following ease:

J ]
I

uences easily prevail, as is well instanced in th

\ man, 28 years of age, with an eight month-old dorsal dis
location of the hip that had resisted eight attempts at redu
tion by as many different surgeons, applied to me fon relief
The hip was immovable and useless. <A earefully planned and
systematic effort at reduction was made by myself, assisted by
Dr. Allis, but without avail. At the earnest solicitation of the
man I consented to operate. An incision was made over the
trochanter, head and neck in the line of the gluteal muscles

separating the fibers; the tissues were cut away and the cap

sule opened, but the acetabulum could not be reached. An an
terior incision was then made in the triangle formed by .the
tensor vagine femoris and the sartorius The head of the s

torius and the long head of the re:tus were cut away; the psoas
was also cut from the lesser trochanter, the capsule open
strong traction applied; the acetabulum was found fill
level with fibrous tissue almost as tough as tendon. This
eut away with gonge and spud, and a large quantity of thic!
ened tissue Was cle ined Trom the hea 1. which is even t
reduced with great difficulty. The eushion in the acetabulu
still prevented the head from sinking more than one-half int
the cavitv; the bone was, therefore, redislocated and the a
tabulum absolutely cleared; at last the head remained eas
in its socket; thorough drainage with rubber and gauze
introduced and the limb fixed with plaster of paris, slight
abducted and everted, and nearly in line with the body. he
hemorrhage was considerable, but no ligatures were require
after clamp hemostasis. The man vomited persistently fron
the time of operation, and died a week later from septic end
earditis The opel w10n Was long and severe; the chances fon

rect ion were numerous.

Dr. Thomson fractured the femur in an attempt to

]
}

reduce an old disloeation of the hip.

1
( 1 r WiicAly
veTY \V l

opened the joint, reduced the dislocation and the frae-

SSz
ture, and retained silver
Dali,
Shoulder: The necessity for operative relief will de-

the latter in position with a

thereby Securing a good result.

pend largely on the amount of disability and the extent
of the pain, the latter being caused by pressure on the
nerves and vessels.

In a two-month-old
shoulder, after failure of manipulative methods, and

subeoracoid dislocation of the

ie head thoroughly fixed, | made an incision in

finding t
the pectorodeltold LYTOOVE and resected a portion ol the
As the luxation still
about the

alter

Capsule and Of the spinati muscics.
refused to yield a second incision was mad
middie Of the
thoroughly dividing the tissues the head was at last suc-
capsule
was so greatly injured that its remnants were stitched
fastened

de.told, separating the fibers, and

\ placed In the gienold cavity. The

pent)
CCs“i ul

With catgut to the acromion; the arm was

cross the chest with a plaster-of-paris bandage, and,
liter two weeks, gentie passive movements were Imstl-
tuted, with good recovery Of motion but With slight toss

vation.
that
previously through a football injury, and where the head

OL abduction and ek

In a shoulder joint was dislocated fifteen years
of the bone slid back and forth on the anterior ledge of
the glenoid, with some eighteen subsequent luxations
inflammatory swellings and great disability, | made one
incision in front of the deltoid and another through the
center of the muscle, separating its fibers. The

had evidently

outer
been torn away al
inner portion
Atter
replacing the bone the external portion of the capsule
tched to the acromion and the anterior capsule
and fastened with a chromicized catgut. ‘The
arm was held for several weeks in front of the thorax
until good union had been secured, after which forward
movements were especially encouraged, and a firm joint

portion of the capsuie

the time of the original injury, and the

had been subsequently elongated and stretched.

Was Si
J ] ]
folded

secured.
The best
and the least injury
terior to the cephalic
the deltoid and the
the head.

access to
dangerous, 1s

be obtained to this region

done by cutting just

aCCess Ia
pos-
vein, in the between
pectoral :
The
sometimes

or ve
CTOOVE

this O1VeS excellent

axillary incision, while

more when the

adhesions between the head of the bone, arteries.

necessary
veins
and nerves are dense, and is also an excellent incision for
resection, although through it the glenoid is less easily)
reached. If incision is made over the middle of the
deltoid the fibers should be separated as much as possi-
ble, not divided, so as to avoid loss of abduction and ele-
vation. The posterior incision, which starts beneath the
acromion, is most liable to injure the circumflex nerve
(which runs just below the acromial ridge), thus cut-
ting off a large portion of the innervation of ‘the del-
toid. It affords easy access to the glenoid, but not to the
head. Even with the anterior incision there will be
some atrophy of the internal fibers of the deltoid, but
this loss is partially compensated by the pectoral. The
old operation of cutting off the attachment of the del-
If the biceps tendon is torn or cut, it
should be restitched. In excisions it is better to take
away too much rather than too little. Hemorrhage is
greatly lessened by closely hugging the bone with bone
gouge or chisel. It is sometimes necessary to divide the
tendons of the infraspinatus and supraspinatus, the long
head of the biceps, subscapularis and teres minor. After
freeing the tissues about the head and neck of femur or

toid isa bad one.

3. Burrell’s operation for this condition of habitual dislocation
Asso., vol Xv, p 293

s an excellent one. Trans. Amer. Surg

OLY UNREDUCED DISLOCATIONS

WILLARD. Jour. A. M. A.

humerus, | have sometimes had the greatest difficulty in
replacement and have been obliged to divide ail the tis-
sues most freely. In some cases traction on the head
may be made through the incision by placing a curved
bone elevator or strong wire about the head, by using a
lever, or by drilling the bone and inserting strong steel
When the glenoid cavity is fied with a tough
the socket must be cleared with
gouge and knife. In the care should be
taken not to injure the epiphysis, and resection should

hooks
cicatricial fibrous mass,
young, great
not be under special circumstances
The natural accommodative mobility of the scapula must
be taken into and the
The subsequent fixation and pain depend largely on the
the head. In
tions the keyhole saw or the heavy chain saw is advisa
Owing to the liability of breakage, | have had a
chain saw When old dislo
cation and coexist, the question of manipula-
tion or arthrotomy or excision is a serious one. The
| bad

employed except

account, amount of adhesions.

original injury and the position of resee
ble.
made from an old écraseur,
fracture
broken fragment may have united to the bone in
position, or it may have become thoroughly adherent to
disconnected
»

Re-

humerus or femur, though often

surrounding tissues, or it may be entire!)
fragments mav be nailed

section of the

or wired in position.
head O
necessary in these cases, should not be undertaken as
sInce a compietely reduced Upper joint

treated the

a positive rule,
fragment can
dinary fracture and a fairly useful joint secured. — In

sometimes bi same as an or-

doubt. an exelsion deferred in old
persons until the
is. definitely ascertained, yet oa

joint, provided the museles are not too seriously injured,

eases of mav be

amount of pain and disability

resected shoulder
often gives a more useful arm than the stiff ankylosed
one so often secured by the forcible reduetion of an old
Pressure of broken fragments on the axillary
creat pain and demands

Injury.
vessels and nerves usually gives
In one of
location and fracture
advanced with locomotor ataxia that he was practically
helpless, and lived several years without any serious in-
from the presence of the head in the axilla
in others.

resection. mv eases, however, where both dis-

existed, the aged man was so far

convenience
In other eases, however, the pain is extreme ;
the inflammatory adhesions fasten the tissues in a mass
which will not only resist attempts at manipulative re-
duction, but even persist in spite of open incision — Frae-
tures of the shaft of the humerus and of the femur are
not uncommon during efforts at reduction.

It is extremely important that every aseptic preeau-
tion be taken, as disturbance of tissues already below the
normal resistive point is prone to give septic results.
Drainage either by rubber tube or gauze is necessary on
account of the severity and length of the operation.

Arthroplasty.—I have tried a number of methods to
prevent the union of joint surfaces, but nature, while
sometimes tolerating a foreign substance, usually rebels
against its continued presence. Gold or silver foil 1s less
irritating than rubber tissue. The best method is, when
possible, to turn in a flap of fascia or connective tissue.

Results.—Souchon* gives, in his admirable compila-
tion, the histories of 133 operative cases of old shoulder

dislocation, with their results, accompanied by a com-
plete bibliography. He gives the deaths immediately
following the operation as 13 per cent., with an addi-
tional 10 per cent subsequently; the chief causes being
gangrene, hemorrhage. sepsis and pneumonia. Of the

4. Operation of Irreducible Dislocation of the Shoulder Joint,

Trans. Amer. Surg. Asso., 1897; octavo, p. 138

SEptT. 24, 1904.

collected cases about 27 per cent. suppurated. Natur-
ally, sepsis was much more frequent previous to 1885. A
good result, however, has, according to statistics, been
secured in over 50 per cent of cases.

Reerink gives the fatality of shoulder excision: in 43
operative cases, 14 became infected and 8 died

reve sepsis
and other causes,

OLD UNREDUCED DISLOCATIONS

WILLARD.

element in preventing the existence of old

dislocation.

Immediate red
by manipulation or open operation should follow.

to be discovered by the surgeon,

Ke An old, unrecognized dislocation should be
examined

under the a-ray and ether to

SSO

uctiol

unreduces
With ether, the a-ray and anatomic and
surgical knowledge, a recent displacement ought alway’

t

Klbow: A dislocation of the elbow sometimes remains cover the extent of adhesions and the possibi
undiagnosed and becomes fixed in its malposition, In ty of elfecting reduction without extreme meas-
a case of four months’ standing (Fie. 1) after the first ures. The manipulations to bi practiced ar
failure at reduction [ applied extension for a week. he practically the same as those employed in- re
woman was pregnant at the time, and the method gave cent luxations, but greater caution is necessary. Failing
so much pain and annoyance that after the second un- in these, continuous extension in bed should be prae-
successful attempt at reduction L resected the condyles — ticed for a week; the sc¢ond attempt, without the apph

ion of extreme foree, shou!d then be made, the per-

the patient having been previously obtaines

of the humerus through two lateral incisions (in prefer- — eat
ence to the posterior triceps cut). brought the ulna into
position and secured a useful movable joint. A letter
received last week states that the fetus was earried to 3. Open si

Mss |

f

f deemed necessar

yf open operation,

ee : | | BS oan
should include the Qivision oO l

ction

full term, and that the elbow movements are nearly per- muscular, tendinous, capsular and bony obstacles to re
fect, although strength is impaired, duction. When the socket is filled up with dense tibrous
Head of the Radius: An old dislocation of this joint — tissue. such tissue should be excavated, and the head o

is often difficult to replace, but extension, strong press- the bone placed in situ.
ure and rotation will sometimes accomplish it. If un- |. Partial or complete excision of the head and_ of
fragments in case of fracture will frequent yume) ~-

¢ sitated.

>. In eases that have existed more than O
where the original injury has been extreme, operatior
should be avoided un‘ess pressure on nerves or bloo
vessels is seriously impairing the usefulness of the limb
or elving pain, but resection should be pr ceticed in bac

ate cases, with pain and serious nerve symptoms.

| 6. Sepsis is frequent on account of the severit ri
| length of the operation, and especially by reason of t]
| non-resistive ability of the tissues due to the original it
jury and to repeated traumatisms from manipulative
efforts
P ; n dis hI ity O med occupation i { ! st
mportant conditions in arriving at a decision eo) !
ing operation. When a limb is useful in its new pos
mn. gives no pain or difficulty, it should be Jet aon
8S. In the after-treatment, muscular evmnastics. elec-
tricity, veluntarv and involuntary muscular movements
_ and massage are very important measures and should be
Fig. 1 Lateral dislocation of elbow, four months’ duration nersistent emploved. These manipulations require
| } 7 7 ) , ° 4
successful, the joint should be opened, r placed and both patience and pluck on the part of the patier bs
stitched or resected. DISCUSSION
Clavicle: In an old dislocation of the outer of te. A. 1

JoNAs, Omaha— My

is limited almost entirely to the should

end personal experience
firmly in pl
kworm throug!

hy
Of) Cl

the clavicle, Hopkins was ab‘e to hold it
by carrying an X-shaped suture of si

two drill holes in each bone: silver

ace dislocation at the joint

joint, of which

wire would answer _ these,

two years ago [ report 1 seven cases Qt

six were operated on and one was not. One feature ot

the same purpose, or a firm nail could be used. the operative cases was common to all, and that as the Tt
Jaw: In a three-month-old dislocation of the jaw traction of the capsule. The first of the series had remaine

for three or four months. I[ b use Ke

manipulations,

unreduced gan to

Mixter applied lever extension with the
site the molars, and after forty-five minutes

—
fulcrum oppo-

ind it became reduced by this method rhe re

The

eae Oe the dislocation naining seven cases were reduced by manipulation st ru
reqguce L.©@ Uisi “ALI ‘ P . rar .
ee s . 4 — : tures which opposed reduction varied with each case. In one the
Thumb: In old dislocations of the phalanges, where
} ] } = } = ‘ ‘ oracoid process was broken off and had become adherent in ifs
the head of the bone has passed between the dons
te ea ot the on a 1) a ) — he ten ion . a alitv. Before it could be replaced it was necessat ty
these dense structures ften resist al] forte < "An ace. fig : : : é
these dense st ictures oiten resist ail errort at replac remove this broken off portion of the coracoid. In another eas
ment and open INneislon 18 Lm pe rative, the long tendon of the biceps stood in the Way of red 1@: jon. bi
AFTER-TREATMENT. the contracted capsules of the joints gave most trouble. Exti
Passive movement should be instituted vei eal pation was necessary in one of the cases. Usually the head of
, - : : ; : a : ik ay aonag panianad:. bik an moet oat thas ee Alar gs 1 thy
ifter reduction, and after operation in all old luxations the bone was replaced, but in most of the cases we in goes
= ‘ : "er : circumflex nerve, owing to the amount of manipulation We
Electric tv. massage, voluntary and involuntary muscu- a , ‘ : ,
: . ; 7 ae uld not alwavs locate it, and in most of the cases we hac
iar movements, GvmMnastics and other measures tor tne ° eh: ’
I ‘ men a4. my wi : ic _— : : ‘ ‘ atrophy of the deltoid muscle Strangely, the mobility of the
res "“ATIOT tf 1} > mus ) 1] for § ne . ‘ y
re toration ot tunecetion nust ) continued for a ong - ipula e such that all of these eases were able to perforn
Ime. the duties to which thev had been aceustomed. There were ne
CONCLUSIONS. deaths, and the recoveries were all by primary union. So far
1 Karly immediate diagnosis is the most important is adhesions to other joints are meerned, Toonly reeall one

X84

lisiocation at the

months. J]

had
the

tor
the

exisited
head of

the radius which
had to cut
idius to replace it in its normal position.
Dr. C. E. Tuomson, Scranton, Pa

lislocation of the hip. My patient, a

head of

our or five down on

I will report one Case ol

miner, Was injured last

lune by being run over by a mine ¢at The tee was lacerated
nd was amputated five weeks later four inches below the knee.
\t that time the dislocation of the remained undiscovered

He came to me last February, when I attemp'ed_ to
educe his old dislocation. Ll used the Allis method
f fixation of the hip. While Dn Allis recommended it
-o enthusiastically for experimental work on the ea
laver, he was a little chary about recommending it on
the living patient We used it most energetically, without any

After

the dis

njury to the patient further than slight excoriations
the most energetic manipulations we

failed to reduce

ocation. Hlavine failed by the Allis method, we tried the
\ocher method, with disastrous results. Notwithstanding that

a stump to manipul broke the bone between
the trochanters in oblique fracture by the Kocher method.
len days later we renewed the attack and succeeded in red

]

ng the dislocation with long, blunt hooks similar to thos«

,

used

for handling meat. We used anterior and posterior incisions simi
Th

Union has

ir to Hoffa, and the patient made a enod recovery frac

ture was held in place by a spec ially devised nail.

taken place in the fracture, and we hope he will have a useful
stump.

Dr. A. D. BEVAN, Chicago—Five years ago I 1% ported a series
t cases of old dislocations reduced by operative methods, and
n practically all of them we had a « ymplicating fracture. The

lislocations of the shoulder had no complicating fracture. If

reasonable efforts at red

fail, then
in w-ray should be taken to see if there is a complicating frac

ction by mechanical means

ture, It is impossible fo make an m in such a direction

sion

is to expose the acetabulum before vou expose the end of the

femur. The capsule should be exposed and freed before the

head is exposed. As to the importance in the work of operation

n old dislocations of the elbow of sacrificing the triceps ten

fon, if vou expose the joint vou will almost invariably find a

obtained better re
think |

ind produced resuiting paralysis,

have

iece of bone preventing reduction. |]

sults since I have paid attention to this. I do not have

njured the circumflex nerve

ut I rather think we have had an ankylosis, with an atrophy of

the deltoid from lack of us¢

I believe that where great force is
ecessary to reduce an old dislocation of the shoulder we are
more apt to obtain a satisfactory result by resection of the head
f the bone.
Dr. J. A. BLAKE, New York Cit [ have had very little ex
rience with old dislocations of the hiy but have treated sey
al of the shoulder, and I am inclined to operate rather thar

forcible attempts to reduce by

ins. I split the fibers of the deltoid as near its anterior bor
ras possible in order to avoid injuring its nerve supply. It
this does not afford sufficient access, a supplementary trans
erse incision is made just below its attachment to the acro
ion, which also preserves the integrity of its nerve supply

of the bone may be done in some cases

\fter removal of the head the functional result is often excel
ent | have recent] seen a resection of four inches of the hu
erus tor new ero th ind the result has been almost perfect
s regards function As to the elbow, lateral incisions give the
st access
Dn. 4 rT. Vauecuan, Marine-Hospital Service, Washingtor
| We are all agreed that there should be no old dislocations
f the shoulder: if one can not reduce them one should ope
ite at once. Sometimes this is not done, and the come for
itment I had one case of this kind in hich the detached

over the

tuberosity ot the hun erus was located dire tly

, me , , s
several attemp s had been made to reduce It.

nd it was thought ith success, but the patient continued to
iffer great pain for two months. I tried all the various meth
ls of manipulation before cutting I do not approve of the

uethod of placing the foot or the hand in the axilla, having ‘on

occasions fractured a rib bb n the

ising the too

axilla as

! OLD UNREDUCED DISLOCATIONS

WILLARD. Jour. A. M. A

& fulerum. tL made an incision and found the glenoid cavity

filled with bone. On Jocating the head of the humerus, | found
this bone was the detached greater tuberosity, which had to be
dissected out from its attachments over the glenoid cavity. Ex
tension and counter-extension is the best method by which té
treat these cases, as it is least likely to do harm, and if it fail
can be followed by Kovher’s or some other method.
OR. J.P: Neb.--We should take om
the recent experience of the orthopedists and adopt the sug
last

excessive

Lorp, Omaha, cue from
rather
these
recent experience that this facili
reduction of the head of

eestions voiced in vear’s orthopedic association

than resort to force in order to reduce dis

locations. It has been my

tates the the femur, and it is my be
lief that injury of the nerves and blood vessels, nerves espe
cially, is produced more by the effect of the lever action which
we produce in our manipulation than by the traction. If we
overcome this resistance by tenotomy and not exert this pres
the

evils, we will not produce these dire consequences,

sure on nerves as we do with our forced manipulation
We should
traumatism has
Dr. Willard did not
Consent to open operation should be
fail. I do

should undertake the operation until after severe manipulative

not operate immediately after severe been

produced by this bloodless reduction em

phasize that sufficiently.

obtained if manipulative methods not think we

measures have been resorted to.

Dr. CuarLes A, Powers, Denver—A number of years ago J

saw many unreduced dislocations of the shoulder at the
Chambers Street Hospital in New York, and so far as I can
remember none which had been out more than ten or twelve
weeks was replaced without operation. At that time I care

fully studied the paper of Kocher, which many of you remem
ber reading fifteen or twenty years ago and in which he stated
that old
manipulative methods. |

dislocations could be reduced by his well-known

was never quite able to understand
The ad
hesions must be thoroughly broken up before reduction by any

Kocher’s reasoning or his results in old dislocations.
method of manipulation. The breaking up of adhesions must
be done, however, with utmost caution. I am heartily in ac
cord with Dr. Willard in thinking that open operation should

be resorted to more frequently.

I would like to put on record
the of fow

months’ standing which, to my surprise, was easily replaced

1 case of intracoracoid dislocation of shoulder

This was in
Carlin of

ifter from eight or ten minutes of manipulation.
1 woman of over 60 years, a patient of Dr. P. V.
Denver. Where an old luxation can be replaced by manipula
tion it is, of course, best td do so, but we are always to bear
mind the dangers attending too forcible manipulative effort
Dr. WILLARD the unfor
tunate condition, especially for a woman, and resection of the
head
adhesions in an old dislocation is the most dangerous part of a

\nklvosis of shoulder joint is an

of the humerus is often preferable. The breaking up of

reduction. Open arthrotomy with resection of the fragments
is often the better operation.
Power of Urine; Aphrometric Test.—A

ealls attention to a means of testing the

Foam-Producing
Bienon of Lima, Peru,
urine by its power to produce a durable foam when shaken up
acid. The Boletin de la

1904, iv, Ne. 1, contains his communication

vith water and acetic {ead: mia Na-

cional de Med

cCund,

on the subje-t with detailed accounts of his tests. He estab
lishes as the standard the number of eubie centimeters of the
urine for one hour, diluted with water to 200 e.c., which will
produce a foam lasting for half an hour when shaken

100 ee. of a solution of
acid to the liter of water). In
urine

up for one minute with

wetic acid (15 ee. of acetic

normal eonditions about 1.5 e¢.ec. to 3.5 ee. of are re

quired to produce this result, but in abnormal urine a much
smaller amount is sufficient When the foam ean be induced
with less than 1 ec.c. of urine, it should be regarded as sus
picious. He is now studying the application of the test to
milk, wines, etc. He calls it the aphrometrie test, from the
Greek word aphros, foam. The term aphrodisiac is derived
from the same root. from the legend that Venus (Aphrodite
was born from the foam of the sea

Serr. 24, 1904.

L\UTOCHTHONOUS SINUS THROMBOSIS) OF
THE CEREBRAL DURA.

WITT
WILLIAM G. SPILLER, M.D.

Neuropathology and Associate Professor of
in the University of Pennsylvania,

AND

CAMP, M.D.

in the University of

A REPORT OF THREE CASES.*

l'rofessor of Neurology

CARI D.
Assistant in Neuropathology Pennsylvania
From the Wm. Pepper Laboratory of Clinical Medicine, University
of Pennsylvania (Uhabe A. Ilearst Foundation).
from the Pennsyivania Training School for Feeble-minded Children

PHILADELPHIA,

While secondary thrombosis, such as fo!lows middle-
ear disease, has elicited great interest and been carefully
studied in recent years, especially on account of its sur-
vical treatment; the primary form, the autochthonous
sinus thrombosis, because of its indefinite symptomatol-
ogy, its uncertain treatment and its comparative rar-
ity, has received much less attention

Since the year 1899 there have come under our obser-
vation three cases of autochthonous sinus thrombosis.

The first case, reported by Drs. Wadsworth and Spil-
ler.’ is as follows:

Case 1.—The patient, a boy, aged 7 years, according to his

been

mother’s account, had always been in good health and had
On March 3, 1900, at 1:30 p.

m. he became uncon

bright at school. m., he com-
plained of headache and vomited, at 3 p.
scious, and at 9:20 p. m. he was taken to the hospital. At
that time he was still unconscious, the veins of his face were
engorged, the pupils dilated and immobile, the pulse weak and
rapid, and the respirations slow and irregular (Cheyne-Stokes
type). The temperature from 99.4 to 100 degrees
Fahrenheit. Cyanosis was not present. He reacted to irrita
tion with a pin. Death occurred at 12:30 p. m. the following
day, March 4.

tutopsy.—At an autopsy
pint of clot and fluid was found in the ventriclos of the brain,
ind a clot was found partially occluding the jugular foramen
on the left Further examination showed that a clot had
formed in the united veins of Galen at their union with the
straight sinus. The thrombus was oval in shape, about three
quarters of an inch long by one-half inch wide, and consisted,

varied

held on the same day nearly a

side.

as shown by the microscope, of recently clotted blood.

The superior longitudinal sinus was entirely occluded and
‘alcified in its middle por ion. This occlusion was probably
the result of a previous thrombosis. The blood from the an
terior portion of the superior longitudinal sinus had formed a
new passageway between the lavers of the falx cerebri. This
passageway was not lined by endothelial cells, and conveyed
some of the blood from the superior longitudinal sinus to the
with the inferior longitudinal
Herophili. The

straight sinus at its junction
sinus, and

formed in the united veins of Galen had evidently caused the

some of the torenlar thrombus

hemorrhage into the lateral ventricles and death.

The second ease was reported by Dr. S. MeC. Hamil
and is included here because Dr. Hami!] gave the brain
His clinical] notes abbre \-

to us for microscopic study.

iated are as follows: ;

CaskE 2.—No history of syphilis in the mother was obtained
The patient was born normally and was not asphyxiated. The
temperature was slightly elevated from the second day afte
birth. On the seventh day after birth
veloped on the face and the temperature rose to

a papular eruption de
104 degrees.
There was no gastroin‘estinal disturbance. On the fourteenth

day marked twitching of the muscles of the right eve and ¢

* Read at the Fifty-fifth Annual Session of the American Med
ical Association, in the Section on Pathology and Physiology. and
approved for publication by the Executive Committee: Drs. V. €
Vaughan, Frank B. Wynn and Joseph McFarland

1. Proceed, of the Path. Soc. of Vhiladelphia, Oct., 1900, p. 267

2. Archives of Pediatrics,

1903. p. v64

THROMBOSIS

SPILLER-CAMP. 885
stant lateral rotation of the head were observed. General con
vulsions did not oceur. The child was somewhat cyanosed and
nursed poorly, but did not cry. The next day the child was
somewhat betier, but on the sixteenth day the temperature ros«
to 106.8 degrees and he vomited a large quantity of altered
blood and passed several tarry stools. The face became muct
eyanosed. Death occurred on the same day,

Lutopsy.—At the

were found in the umbilical arteries.

later,
The liver was

autopsy, twenty hours severa
thrombi
abnormally large. The brain showed a large mass of clotted
blood overlying the left hemisphere, more marked anteriorly
into the substance of

Chis extended the brain, causing some

lestruction of tissue, Overlying the lefi hemisphere was a less
marked hemorrhage.

The longitudinal, the left
sinus r Galen

lateral, the straight

contained

superior

and the veins of firmly organize
distended bloo

and some of the superior cerebral veins, on the left side. eon

thrombi. The veins of the brain were with

tained thrombi. Both lateral ventricles were dilated and con
tained considerable blood, especially the left.

Wicroscopic Bxamination—There was no round-celled infi
tration of the pia mater, of the medulla oblongata or cortes

ind the walls of the blood vessels were not thickened.

The pia
about the medulla oblongata was infiltrated by a great number
of red blood corpuscles, as was also the optie chiasm. The
optic chiasm did not stain well by the Weigert hematoxylin
There
was no cellular infiltration about the blood vessels of the cor
tex,
ous minute hemorrhages and intense congestion of the capil
}

method, probably because it had been kept in formalin.
Sections taken from portions of the cortex showed numer
laries of the tissue. The extensive hemorrhage had destroyed
the upper part of the cerebral hemispheres, including the par
central lobules, so that the Betz cells could not be studied.

\ third case is a reeent observation. The
notes obtained from the ease-book of the Pennsylvani:
Tr ining School for Feeble- Minded Children, of whic!
nstitution the child was an inmate, are as follows:

clinica

CASE 3.—S. M., female, 15 years of age at the time of he
leath.
peculiar and was described “as if she were walking on eggs.’

Seven years previously it was noted that her gait was
This probably means that the child was spastic. There was
Mentality was low
ind vision was imperfect. Epileptie attacks occurred and usn
lly began in the arms and face, finally involving the entire
body.

unilateral exaggeration of the knee jerk

(side from her mental condition, which steadily deteriorated
there was no change noted un‘il four months before her deat}:
was observed that while not unable to walk
liked to do so and kept her chair as much as possible. Her

when it she dis

sight had become still more defective and co-ordinate move
ments were impaired, although the grade of imbecility pre
vented accurate tes’s. No areas of anesthesia were found

rhe child was peevish and prone to ery without cause.

Her condition gradually became worse until locomotion was
In bed, her thighs were flexed on her abdomen an
ier legs on her thighs.
vreat swelling of the feet
if blebs was observed. Speech was impossible for three weeks
prior to her death, and for the last five days lifting her chin

impossible.
During the last three weeks of lif

with a tendency to the formatior

ind so permitting fluids to gravitate to the stomach was the
nethod of feeding her.
til the d lV before her death.

Rise in temperature did not occur ut
Her heart action, pulse and re-
pirations were regular and normal,

\ record of the number of epileptic attacks shows that i:
1901 she averaged eight per month, the highest number in au
month and the 1902 she

averaged the same, but the highest in one month was Sixty-five

was eigh‘een lowest was three; in
nd the lowest was two; in 1903 she had forty-three at‘acks in

January, eight in February, three in March and nineteen ir
She died May 18, 1903

lutopsy.—At the
ound to be very edematous

me Jateral

April

made brain \\

May 19, the
The superion longitudinal sinus

necropsy

sinus and the veins of Galen were thromboti

386 LHROMBOSIS
Many of the blood vessels on the superior surface of the brain
were occluded and a small collection of purulent matter was
found about one of the blood vessels of the parietal lobe. The
rain weighed 1,000 grams.

Chere were no signs of the thymus gland.

The right lung was not especially congested.
tant.

It was crepi
No distinct tubercles were found. It weighed 170 grams.
Che left lung was much more congested and appeared to be in a
state of red hepatization.

not so much as the lower.

The uppel lobe was congested, but
A piece of the lower lobe sank

when placed in water. The left lung weighed 280 grams.

\ chicken fat clot was

found in the right ventricle and one also in the left auricle.

The valves were normal. The weight of the heart was 145

vrams.

The heart was not especially fatty.

The liver was not enlarged, but moderately congested.
The kidneys and spleen were normal.

Che lower limbs were somewhat atrophied. The spinal cord,
‘xamined macroscopically, appeared normal.

Che brain and cord with their membranes were removed and
reserved for microscopic study.

Sections from the paracentral lobule from each side showed
‘onsiderable round-celled infiltration of the pia, with the blood
vessels greatly congested and their walls thickened. The cap
illaries of the cortex, especially on the left side, were unusu
illy prominent and a moderate round-celled infiltration was

found about them. The Betz cells were apparently normal.

Within a blood vessel taken from the cortex was found a
arge mass consisting chiefly of multinuclear cells; about this
plood vessel there was a slight round-celled infiltration. An
ther blood vessel showed a marked cellular infiltration about
i The

srated from the blood vessel.

cells here were multinuclear and had probably. mi
A blood vessel from the choroid
Nexus was surrounded by a very intense cellular infiltration,
he cells being chiefly multinuclear. The blood vessel in this
section was occluded by a dense mass consisting apparently of
A section from the left lateral sinus showed the sinus
endothelial lin
The optic chiasm was not degenerated, but a

tibrin.
illed with a partially organized thrombus; no
ng was found.
moderate round cell infiltration was found in the pia about the
‘hiasm.

The right and left third cranial nerves were normal.

\ moderate amount of round cell infiltration was found in
the pia mater of the medulla oblongata and the walls of the
blood vessels here were much thickened. The anterior pyra
nids were fairly well stained by the Weigert hematoxylin
method.

Sections through the cervical enlargement
inct round cell infiltration of the pia, and the nerve cells of

the anterior horns appeared normal.

showed no dis

The crossed pyramidal
racts were very distinctly, but not
Che direct tracts, by the
nethod. were not affected.

intensely, degenerated.

pyramidal Weigert hematoxylin

The mid-thoracie region showed the same degree of degener
ition of the crossed pyramidal tracts as was seen in the cer-
ical region. Cellulai

spinal cord.

infiltration was slight throughout the

The degeneration of the crossed pyramidal tracts extended
iown into the lumbar region, and disappeared upward in the
nedulla oblongata. The microscopic examination showed the
presence of lesions like those of cerebrospinal syphilis. The
lisease was probably hereditary in this case, and in all proba
ilitv had caused the thrombosis of the dural sinuses

Phese that

vhich the thrombosis is due to a general bodily eondi-

three cases belong distinctly to class in
or that form which
snot cue to direct extension ot dist ase processes ot the
head, has excited a certain amount of interest
luring many years.

Th: ¥:
f which 32 were due to gangrenous, erysipelatous or
suppurative inflammation of parts of the body whose

ion. Primary sinus thrombosis,

face or

Duseh* collected 5S cases of sinus thrombosis.

TI New Sydenham Soc., vol. xi, p. 81

-SPILLER-CAMP.

Jour. A. M, A.

vessels are in close connection with the sinuses. In 4
the thrombosis appeared to result from tumors, ete.,
causing pressure on the sinuses or internal jugular
veins. Fifteen cases were supposedly caused by lessened
circulation from debilitating diseases, especially in those
already in feeble health, as in children or the aged. In
no cause could be ascertained. One case he
added as a supplement to his paper.

Comprehensive papers on the subject of sinus throm-
bosis have also been written by Lancial* and by J. A.
Lidell,’ the latter author having collected a number of
Lancial eollected 4 from the literature.
which he considered as cachectic in origin, 1. e., as pro-
duced by a debilitated condition of the organism, ‘The
cases that he collected were those reported by Tuckwell,®
Corazza,’ Wiglesworth,® Rotch® and Grancher.’? — Rilliet
and Barthez'! reported 18 cases, and Bouchut!? 35 cases
thrombosis,

6 cases

Cases. Cascs

of cacheectic
In addition to the cases referred to above, we have
studied cases reported by Fisher,’* 'Trevithick,'* Ho6l-
scher,'’ Nonne,'® Meigs,'? Good,'® Voss,'® Ehrendorter.*"
Richardson.*! Holfman.*? Reinhold?* and Phear **
Primary sinus thrombosis is regarded by some as es-
pecially a disease of childhood and old age, the two ex-
tremes of life when the animal organism is least pre.
pared to stand the strain of debilitating influences. The
predisposing causes are variously given. Von Monakow*!

gives us the causes loneg-continued diarrhea, especially

in children, erTeat loss of blood, long-continued suppura-
tuberculosis, anemia.
According to Oppenheim,?" primary sinus thrombo-
sis is, as a rule, a result of cardiac weakness ; it is, there-
‘ore, called marasmic. He also states that in children
it is generally due to exhausting diarrhea, and in adults
may develop in the terminal stage of exhausting dis-

tion, carcinoma, chlorosis and

eases—tuberculosis or carcinoma: more rarely in the
course of the acute

infectious diseases. He mentions
Bollinger as having established the faet that chlorosis

often produces a sinus thrombosis.

Bouchut,'* in his statistics of cases oceurring in child-
ren, gives the following table of causes:

ee | al cabs é* © Cases
Measles and catarrhal pneumonia.......... 2 cases.
ret rae » cases.
ot a er : S cases,
Anasarca Without albuminuria......
{hronic albuminuria ........ ;
Pertussis and pneumonia...
Gangrene of the mouth.
SURUMRUMNOREO Wad ecw sina tole Se a oa phacae Pave 2 cases
Scrofulous cachexia, tuberculosis of bones,

lungs and intestines...

Bouchut calls attention to the fact that 23 out of the

4. “De ka thrombose des sinus de la dure-mére,” Baris, 1888
>. Amer, Jour. of the Med. Sci., January and July, 1874
6. St. Bartholomew's Hosp. Reports, 1874, p. 35.

7. Schmidt's Jahrbuch, 1866, p. 382

S. Jour. of Mental Science, 1885, vel, iii, p. 371

%. Boston Med., 1883, p. 174.

10. Grancher, unpublished, cited by Lancial (1. c.)

11. Cited by v. Dusch .

12. Cited by Lancial

13. British Medical Journal, 1900, vol. ti, p. 9

14. British Medical Journal, 1897, p. 1166

15. Weiner Klin. Rundschau, 1902, p. 561.

MittheiJungen aus den tlamburg Staatskrankenanstalten

17. Meigs: Trans. of the Coll. of Phys. of Phila sd set

vol. iii

18. Neuroclogisches Centralblatt, 1802. No. 8S. p. 340
19. Deut. Zeit. fur Nervenheilkunde, vol, xv, p. 297
20. Weiner Med. Presse, 1892.

21. Jour, of Nervous and Mental Dis.,
22. Zeit. fiir Ohrenheilkunde, vol. xxx
23. Cited by Voss
24. Ibid

25. Gehirnpathologie,

1897, p. 404

Nothnagel’s Sys. of Spee. Path. and Therap

a”

26. Lehrbuch der Nervenheilkunde, Sd edition, p. 768

Sept. 24, 1904. THROMBOSIS

35 cases he studied developed after pulmonary affee-
tions.

Fourteen of the cases that we have collected from the
literature, including our own, were in children. The
predisposing causes in these cases were pulmonary af-
fections in 3 cases; long-continued suppuration in 2,
and diarrhea, tubercular peritonitis and marasmus in
one each. In the other 6 cases there was no history of
any predisposing cause, the cerebral symptoms being
the first sign of ill health. It is possible that in two
of these six cases, namely, the case reported by Hoéleher®
and in our first case, where the blood from the superior
longitudinal sinus had formed a new passageway be-
tween the layers of the falx cerebri, which was not lined
by endothelium, that the abnormal circulation predis-
posed to thrombosis.

Murchison** is said to have been the first to eall at-
tention to the fact that sinus thrombosis is found at
autopsy when death is due to syphilitic cachexia. He
reported 2 cases, both of acquired syphilis; one in a
woman, 27 years old, who had extensive syphilitic de-
posits on the dura and whose sinuses were full of “dark
red coagulum.” In the other, a gummatous deposit
was found on the inner surface of the dura, extending
about the left lateral sinus, the lumen of which was
obliterated. Murchison himself does not attribute the
thrombosis to syphilis per se, but mentions its presence
only incidentally; as in both his cases there was exten-
sive necrosis of the eranial bones and disease of the dura,
it might be questioned whether these two cases could be
considered as instances of primary sinus thrombosis.

In our third case there were signs of cerebral syphilis,
and this disease was probably the cause of the sinus
thrombosis. It scems as though a priori, syphilis,
whether hereditary or acquired, would be a likely cause
of sinus thrombosis, though neither v. Monakow nor
Oppenheim speaks of it.

The degeneration of the pyramidal tracts in our third
ease is very uncommon in sinus thrombosis.

Childbirth sometimes causes thrombosis of the sinu-
ses, probably more often when there is copious hemor-
rhage, as in a case quoted by vy. Dusch. In this case
peritonitis also was present.

Chlorosis or anemia has been the cause in several
eases, the anemia lasting from one to six months and
followed by the sudden onset of cerebral symptoms and
death.

In a case reported by Ogle, long-continued disease of
the rectum was the only discoverable cause. <A short
time before the patient’s death the power of speech
was lost, but no other symptoms were observed. She
died of asthenia, and at the autopsy thrombosis of the
superior longitudinal and ieft lateral sinuses was found.
The inferior longitudinal sinus and the ven Galent
were found partially obstructed,

Ogle*s also reports a case of sinus thrombosis fol-
lowing pneumonia in a young man aged 26. He sud-
denly became unconscious and hemiplegic. At autopsy)
the superior longitudinal, left lateral and left petrosa!
sinuses filed with a firm, reddish-brown and
tightly adherent clot. The cerebral veins were all en-
gorged. The brain substance was softened in places,
and in the posterior and inferior part of the left mid-
dle lobe of the cerebral hemisphere was an abseess the
size of a hazelnut.

A case mentioned by y. Dusch,' in a girl aged 12, who

were

27. Trans. Path. Soc, of Lond., vol. xiii, p. 250.
vi, p. 30;

28. Trans. Path. Soe. of TLond., vol also vol. x, p. 31

-“SPILLER-CAMP.

887

developed thrombosis of the superior longitudinal sinu-
during an attack of typhoid fever, probabiy belongs also
to that class of cases where thrombosis of the cerebral!
sinuses occurs during the course, and usually near the
termination of an acute infection. In the second case
described in our paper, a baby two days old, the clinical
history pointed to a general infection, which was fol-
lowed by the sinus thrombosis.

In connection with those cases caused by anemia, a
case reported by Nonne’® is of interest. A woman had
a large uterine myoma. Probably from the metror-
rhagia caused by this, she became anemic. A little later
she suddenly developed cerebral symptoms, and died
in four days. ‘The autopsy showed thrombosis of the
superior longitudinal and lateral sinuses. ‘The cortex
was hyperemic, but there was no degeneration of the
brain substance.

In a case reported by Wiglesworth,* dementia was
present, and this condition, he thinks, may have caused
the thrombosis, but the development of severe pulmonary
symptoms before the appearance of the cerebral, and the,
presence of pulmonary lesions at the autopsy, make his
conclusion doubtful. In another case, reported by the
same author, the patient became insane for six days,
and then died suddenly. At the autopsy a sinus throm-
bosis was found which, from its appearance, might have
been several days old. A recent hemorrhage into the ven-
tricle was also found. He thinks that in this case the
acute insanity was a symptom of the thrombosis, and
that death was due to the hemorrhage. The patient had
previously been in good health, and there was no known
cause for the thrombosis.

When it comes to a consideration of the immediatt
cause of the thrombus formation in the sinuses, we are
on a very uncertain footing. Various theories have been
advanced, all of which lack definite proof. Von Mona-
kow®® thinks that sinus thrombosis gives a well-defined
symptom-complex, and yet he speaks of its resemblance
to meningitis. He makes two groups of sinus throm-
bosis—the marantic and that depending on inflamma-
tion of the cerebral veins or the pyemie form. He
says that the slowing of the circulation in the brain,
such as may occur in those afflicted with carcinoma, in
emaciated children, in the aged, ete., las been supposed
to cause thrombosis, especially if the cardiac action is
weak. ‘This view is at present far from proof.

Baumgarten has shown that blood in a vein tied at
each end so that all circulation is prevented, may not
coagulate even after weeks, provided the occlusion has
been made aseptically and the sinus wall is healthy.
The same blood, even after weeks, will coagulate if
removed from the sinus, so that, as shown by Bricke.
blood remains fluid if it is in contact with a living
healthy vessel wall, even if the vessel is tied.

Von Monakow** says that there is no doubt that
thrombosis of the cerebral sinuses and veins occurs after
long-continued diarrhea in small children, after great
loss of blood, in long-continued suppuration, in persons
with carcinoma, tuberculosis, typhoid fever ete. ‘Th
coagulation, however, does not depend on the feeble-
ness of the circulation, nor the supposed thickening of
the blood. but on changes in the walls of the vessels (loss
of endothelial lining). Zahn has shown that the endo-
thelium may be lost from chemical and thermic causes,
that are active in marasmus. He thinks, also, that the
death of certain elements of the blood, white blood cor-
puscles, or the blood plaques may cause sinus throm-
bosis, as in chlorosis. Virchow, years showed
that in a large number of cases the coagulation of the

ago,

S88 PANCREATITIS
ood precedes phlebitis, and that phlebitis followed by
coagulation rarely occurs.

liecent investigations in the coagulability of the blood
by Leo Leob** gave some important results that

certain bacteria or their toxins in blood plasma increased
the. perito-
‘There was a difference in this activity uc-

its coaguiability in test-tubes, and also in
neal Cavity.
used; for instance, the siaph-
than the

yf Lissuc

asia. oA

of muscle put into fresh-blood p.asma increases

cording to the bacteria

yiococeus pyorenes aureus Was more active

macillus cou. The absorption into the blood ¢
fluids increases the coagulability of the blood p!

H1IeCE
ts coagulabilitv. The same is true when a piece of blood

Vessel Is placed in the pI isma. ‘This action 1S, to a cer-
tain extent, specifle, tissues from the same kind of ani-
malas the one from which the plasma was obtained be-
ne more effective. .

It has not been proved that the endothelium exerts
in inhibitory effect on the coagulation of the blood, but
probably acts merely by preventing absorption of certain
onstituents from the tissues; and it also produces a
smooth surface much in the same
only much better. It seems most likely that in all these
cases the coagulability of the blood is increased either
presence of bacterial toxins or bacteria, or by
tissue products.

Virchow pointed out that the most commonly observed
seats of sinus thrombosis are the cranial sinuses and the
veins of the lower extremities and of the true pelvis,
ind that the reasons therefor are anatomic. The fact
that there are numerous fibrous bands crossing the
cranial sinuses; that the sinuses are triangular in shap¢
instead of circular, as are other blood vessels, thereby
causing increased surface and so increasing resistance ;
that the tributary veins enter the superior longitudinal
sinus at a right angle or sometimes even an obtuse angle
to the course of the blood current: that in the cranium
there is no muscular action to accelerate the current, and
that the sinuses in situ are held open by their adhesions
in spite of a diminished quantity ot blood. are all factors
that tend to produce a stasis in the blood current.

In connection with the etiology, it is well to say that

there are many cases reported which might have been
regarded as primary, except for the complete history or
postmortem examination, such as those caused by a
furuncle on the face, the removal! of a nasal polyp, an
yscess of the antrum of Highmore, ete.
In the primary form the superior longitudinal sinus
is the most frequently affected. This is in great con-
trast to those cases that are secondary to otitis media,
in which the lateral] sinus is chiefly affected. Throm-
which is secondary to nasal or facial conditions,
frequently occurs in the superior longitudinal sinus.

In the primary form, the superior longitudinal sinus
is not the only one affected. may be
very extensive, and the dural

eenerally congested

Way as parathn would,

Vv the

}
)}
at

] ’
DOSIS,

The thrombosis
involve all or nearly all
ises. The superficial veins are
vy be thrombosed, and the same is true of the veins
the choroid p!exus. In some of the
had into the ventricles,
the immediate death; in
cortical
und: in stil other cases no hemorrhage was seen any-
where.

| may
cases extensive
and

other eases

hemorr] age oceurred was
the

hemorrhages were

cause of

were free, but

re |
ventric ~

Abscess. or areas of softening, are rarely reported in

primary thrombosis.

°9. Personal communication

GERMAIN-CHRISTIAN.

bear
on this subject. ‘This author found that the presence of

clinical

Jour. A. M, A.

In the third case of our paper the endothelium of the
superior longitudinal sinus was destroyed.

The appearance of the thiombus is very variable, ac-
cording to its age. It may be a dark red coagulum, oO!
it may be completely organized so that the sinus resem

bles fibrous eord.

4 CASE OF EARLY ACUTE PANCREATITIS
WITHOUT HEMORRIDAGh.*
H. H. GERMAIN, M.D
AND

CHRISTIAN, M.D

BOSTON,

Hi. A

Of the
the literature, most present quite advanced lesions.

many cases of acute pancreatitis reported u
The
argest number are examples of hemorrhagic or of necro-
tizing pancreatitis with extensive destruction of the or-
The
study of these cases has not thrown great light on the
etiology and histogenesis of the lesions, but our present

van. A few are cases of focal suppurative lesions.

snowledge of the condition has been gained mainly fron
animal experimentation.

In animals the pancreas has been treated in a great
variety of wavs. Some of these, as injections of chrom
acid, present conditions which manifestly play no part
in the causation of the natural disease in man. Others
such as injections of digestive ferments (papain), bac-
teria, gastrie juice or bile, imitate conditions that, to say
the least. might occur in man. Of these the entrance of
bile seems to offer the most satisfactory explanation of
many of the cases of acute pancreatitis. and it has beer
civen first place in the etiology of the disease.

(Cases in man showing very early lesions are rare and
vet from these alone can the correctness of the deduc-
tions made from animal experiments to the natural dis-

PASE in man he proven. This ease is renorted hy ease it

shows an early lesion and presents certain neenliarities

not senerally fannd in other eases. Furthermore. there
is no evidenee of hile havine entered the orean, and the
inlammetory lesions are mnassoeciated with hemorrhag
The elinies]
History.—Katherine Tu... age 29,

the sur@ieal side of the Boston City

narration of the ease is as follows:
married, was admitted to
Hospital on the service of
Fam
Past history shows no severe illness o1

Dr. Gavin? with a provisional diagnosis of appendicitis.
ily history negative.
accident Last catamenia four months ago. Cons‘ipated for
past few weeks.

Present Illness Three

of moderately severe pain in left lower abdomen, becoming gen

days before entrance gradual onset
eral in a few hours
Patient

foc d

Pain extreme and most severe in epigas
Vomitus con
Chill
Last movement

trium. vomited several

sisted of

times daily.

ingested and was at times bile stained.
two days previous lasting about half an hour.
ur davs previous. No ehange in urine noted.
Well
pulse 110, of poor volume and
vith thick

hue.

of bowels fe
101.2
Tongue dry

Eeramination. developed, obese. Temperature

degrees : tension.
brownish coat. Skin pale, with a slight yellowish
Heart

Abdomen not dis

Decided pallor of mucous membranes. sounds

faint, no murmurs audible. Lunes neeative.
tended.

trie and

Slight general tenderness, which is marked in epigas
right mass to be felt
No dullness in flanks or evidence of

hv ne echondrine recions. No
General normal tvmpany.
free fluid. No edema.

eus. Tver dullness from

Moderate museular spasm above umbili
fifth rib to two inches below costa)

*Read at the Fifty fifth Annual Session of the American Med
ical Association. in the Section on Vathology and Physiology. and
innroved for publication by the Executive Committee: Drs. V. ¢
Vaughan, Frank BR. Wynn and Joseph McFarland

1. We are indebted to Dr, Gavin for the privilege of using the
history of this case

Serr. 24, 1904. PANCREATITIS

margin, Edge of liver is smooth and not tender. Spleen not
palpable. Vaginal examination shows normal vagina with a
lacerated cervix and a somewhat enlarged uterus. Urine: <A
slight trace of albumin; no sugar; sediment not examined.

Blood not examined.
Treatment and Course.
wich fair result and strychnia, gr.

scemed considerably relieved by the enema and was comfort

ible until 9:30 p. m., when she became thirsty, restless and
wih a rapid and irregular pulse. At this time she vomited

ind symptoms of collapse became more extreme. Active stimu
lation failed to give any reaction and death occurred about
$:50 a, m.

Diagnosis —As the patient was under observation only ten
hours there was little time for careful study and no definite

‘linieal diagnosis was made. Gallstones, gastric ulcer, pan
‘reatitis and appendicitis, with abscess of the liver, were con
sidered in the differential diagnosis Absence of liver tende1
ness, together with regular contour, though not excluding live
ibseess, made the possibility less Tikely. It was imp ssible to
xelude the other three conditir ns, but the rapid onset of col
apse without any evidence of hemorrhage made the dia;

rnOSIS

of acute pancreatiiis more probable than anything else

O29)
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aes "0 ’ a 7 Se o” - i
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. a wa

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) 2.2
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-
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a “395 &-* 9
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. 9
Pik) oy
ete ©

Figure 1

futopsy.—The erannnation was made twenty-three hours
after death. The body was of a well developed, well-nourished
woman, 153 em. long: abdominal panniculus, 5 cm, thick.

Peritoneal Cavity: Omentum was long, completely veiling
viscera and contained much fat, as did the mesentery. No fat
necroses were found. No fluid was present in caviiy. Mesen
teric lymph nodes not enlarged. Appendix normal, Il em
long, below cecum directed toward mid line, slightly curved
It had a mesentery for entire Jength, which except at distal
end was very short. Lesser peritoneal cavity normal. Pelvis
normal.

Pleural Cavities: Right lung slightly bound to parietes lat
erally and posteriorly by fibrous adhesions. Left normal
Pericardial cavity was normal.

Heart: Weight, 285 ems. Just beneath the epicardium ove
base of heart are numerous ecchymoses, 1 to 3 mm, in diam
eter, and of slightly irregular contour. Heart otherwise nor-
mal. Frozen section showed no fat droplets in fibers when
treated with glacial acetic acid.

Lungs: Right shows few fibrous tags. At base of both few
small eechymoses beneath pleura. Lungs otherwise normal
Bronchi and peribronchial Ivmph nodes normal.

Spleen: Weight. 75 gms. Surface slightly wrinkled and
showed numerous small irregular. slightly elevated whitish

patches. Except for this. normal

Patient was given a high enema

», every few hours. She

GERMAIN-C( HA RIS! 3 | N . sso

Gas _rointestinal Tract: In tissues about low:
esophagus there had been a slight hemorrhage The gastric
mucosa was in many places hyperemic and there were many
minute submucous ecchymoses. Duodenum more hyperemis
and along tops of mucous folds dark red. Other parts of tract

parle and contracted.

Pancreas appeared normal, though numerous parallel cuts

were made through it.

Liver: Weight, 1.690 gms. Smooth. On section, gravis}

red, with secaitered small paler areas, Markings indistinet
Consiste:ce normal. Gall bladder distended with dark bile. ne

stones. Ducts normal.

Kidneys: Weight, 510 gms. Capsule strips readily without
tearing *ki Iney substance. On section, cortex pale, oravish
with glomeruli visible as red points. Pyramids dark red with

indistinet markings. Cortex, 9 mm. thick. Frozer

shows very great numbers of small fat droplets in tubula:

i seclion

epithelium when treated with glacial acetic acid or stained
with Sudan IIL or Scharlach R. Adrenals normal Bladder

normal.
Uterus was enlarged, fundus reaching about to level of |
vic brim. Softer than normal. Uterine veins dis ended wit

blood Tubes and ovaries normal. Uterus contained

'
if

Figure 2

lving in a sac 4 cm, in diameter. Surface of sac covered with
innumerable short villi, giving it a velvety appearance

The fetus was about 1 em. long. Uterine mucosa thickened,
red and softer than normal. Over an area about 3 cm, in diam
eter the mucosa is thicker than elsewhere, placental sit
Vagina normal. Cervix slightly patulous. Aorta of small
caliber, normal. The organs of neck, tongue, uvula, tonsils and
brain were normal.

Cultures.—Heart’s blood and lung, sterile

Liver, spleen and kidney, bacillus of colon group

Microscopic Examination.—Liver: The liver cells in the cen
tral half or two-thirds of each lobule contained many laret
vacuoles. Their cytoplasm took a deeper eosin stain than that
of the cells of the periphery of the lobule. It was granulat
and many cells showed varying degrees of disintegration. Most
nuclei of liver cells stained very faintly. In the capillarie
between these cells, in the cells themselves and their remnants
were many polymorphonuclear leucocytes with deeply-staining
nuclei. Spleen negative.

Kidney: There was an occasional atrophied glomerulis and
a few hvaline casts. In tubular epithelium there were numer
ous vacuoles grouped generally in the basal portion of cell.

Sections of liver, spleen and kidney stained by the Gram
Weigert method and with eosin and methylene blue showed n

hacteria

SUO

PANCREATITIS
Uterus showed normal decidua, no other change. Fallopian
tube normal.

Pancreas shows two forms of lesion, one diffuse, the other
focal. The diffuse lesion consisted of the presence of poly-
morphonuclear leucocytes scattered between the acini of the
pancreas. These lay in the smail mount of interacinar con
nective tissue and only very rarely penetrated between the
epithelial cells of an acinus (Fig. 1). The leucocytes varied
in number in different sections, but only rarely were they
found in large numbers in any given field. On the other hand,
in only one section of a considerable number examined were
they absent. In places they were scattered similarly in the
interlobular connective tissue and between the fat
2).

The
areas of

cells (Fig.
numerous scattered
The
rule involved the

lesion consisted of not
and of
areas were generally quite small and as a
In addition a few definite fat
Into some

foeal very

necrosis cellular infiltration. necrotic

pancreatic parenchyma. necro
ses involving small groups of fat cells were found.
of the larger areas of necrotic pancreas many polymorphonu
clear leucocytes had wandered and there tissue disintegration
was quite marked. These leucocytes stained poorly. In cer
tain parts of the interlobular connective tissue polymorphonu

Figure 3.

clear leucocytes were present; in other parts, cells conside)
ably larger than a polymorphonuclear leucocyte were found.

These cells had a round or oval vesicular nucleus and a con
siderable amount of vacuolated cytoplasm. soth forms of cell
infiltrated the interstitial tissue in foci. In
places in the interstitial tissue there was a moderate amount
of fibrin. Here and there a few red blood corpuscles appeared,

but none of the lesions in the pancreas were hemorrhagic in

scattered some

character. Some sections show the capsule of the pancreas.
In it are numerous polymorphonuclear leucocytes which fre
quently appear to be in lymph channels. From the capsule the
leucocytie infiltration extended in places along interlobular
septa into the pancreas (Fig. 3).

In general the pancreas stained less well than the other or
The acinar epithelium, except in the necrotic areas,
The islands of Langerhans were

vans.
showed no lesion.
normal in appearance, The larger ducts frequently showed des-
quamation of their epithelium and in the lumen of the smaller
ducts and acini a hyaline material was generally found. The
The blood ves

however,

interstitial tissue is not increased in amount.
sels show as lesions.

Sections stained for bacteria by the Gram-Weigert method
showed groups of organisms consisting of cocci, often in short
These were

chains and a less number of fairly large bacilli.

GHRMAIN-CHRISTIAN.

Journ. A. M. A

sometimes found where there was leucoeytic infiltration of

interlobular connective tissue. Some were present in the cap

sule. Bacteria also occurred where there was no discoverabl

lesion of the and veins contained considerable

Bacteria were not present in the larger lesions with

tissue some
numbers.
definite necrosis or marked leucocytie infiltration, and they
were not found seattered in the parenchyma of the pancreas
Of the bacteria present the greater number tinctorially and
morphologically resembled streptococei,

Anatomic Diagnoses.- Karly acute pancreatitis and peripan
creatitis.
tration.

Central necroses of the liver with leucocytic infil
Marked fatty degeneration of kidneys. Subpleural
Subpericardial Submucous ecchy

Slight peri

ecchymoses. eccliymoses.
moses and congestion of stomach and duodenum.
esophageal hemorrhage. Chronic fibrous pleuritis, right side

Chronic perisplenitis. Pregnant uterus.

REMARKS.

This case is one of acute pancreatitis of less than four
days’ duration from the onset of the first symptoms
The clinical history is a fairly characteristic one. Ab-
dominal pain and tenderness most evident in the epigas-

tric region occurs ina fat woman. This is accompanied

by constipation, vomiting, fever, and finally marked col-
Autopsy shows but slight
There are seattered ecchymoses in the pleura and peri-
cardium, and congestion of the stomach and duodenum
There is a marked fatty change in the kidney and exten-
All of the findings

lapse. lesions.

MACTOSCO PIE

sive central necrosis of the liver.
point to an intense intoxication.

The source of this intoxication seems to be in the pan-
ereatie lesions already deseribed. The ir etiology is not
clear. There is no indication of any entrance of bile
into the organ. Assuming this
to he the primary lesion, extension may have taken place
to the panereas either by way of the pancreatic ducts or

There is a duodenitis.

hy direct extension possible in the close connection exist-
ing between the duodenum and head of the pancreas.
The panereatie duets show no lesion other than desqua-
mation, and this may be simply a postmortem change.
There is evidence of an inflammatory process extending
alone the interlobular connective tissue and the capsule
of the organ, eventually between the acini themselves
\ssociated with these haeteria,
<treptococe!. The method of the extension of the process
bears a resemblance to the conditions found in ervsipe-
las and has sugeested the name erysipelatoid for this
tvpe of pancreatic lesion. However, the relation of the
bacteria to the lesions is not alwavs evident, and _post-
mortem postmortem invasion,
may have taken place. So this ean not be said to be a
clear case of nanecreatitis of bacterial otiology.

The interest of the case lies in its short duration. the
extent and character of the inflammatory lesion. the
slieht degree of necrosis of the nancreas and fat tissue
and the absence of hemorrhagic lesion. Such a case
strengthens the belief in the inflammatory nature of
acute hemorrhagie pancreatitis. Seitz.? discussing the
point as to whether severe pancreatic hemorrhages are
inflammatory in origin, asks the question, “Warum sind
keine Fille vorhanden, bei dened es nicht zur Blutung
sekommen ist. wo also eine reine Entziindung so plotz-
lich tédte?” Oser? was able to find only two
those of Cavlev and Kennan, with which to answer this
Tlowever. neither of these eases is convincing.
Our case

Jesions are especially

multiplication, possibly

cases,

questions
as microsconic examinations were not made.
serves to answer the question asked by Seitz and shows

®9 PMWutung. Entziindune und brandices Absterben der Bauch
speicheldriise Zeitch. f. k'in. Med.. xx. 1892. 214.

2. Nothnagel's Spec. Path. u. Therap., xviil

Sepr. 24, 1904. X-RAY
the possibility of an inflammatory lesion of the pancreas
without hemorrhage but clinically presenting the picture
of acute hemorrhagic pancreatitis.
THERAPY IN
REPORT. WITH
LYMPHATIC LEUKEMIA,
JOSEPH A. CAPPS, M.D.
AND

JOSEPH F. SMITH,

CHICAGO,

X-RAY

4 PRELIMINARY

LEUKEMIA,

SPECIAL REFERENCE TO

M.D

he first recorded utilization of the
treatment of leukemia was by Pusey,’ who observed no
effect whatever in a case of the splenomyelogenic type,
but in one of the lymphatic type he noticed marked
diminution in the size of the glands. More recently a
fresh interest in the subject has been aroused by the
favorable reports of Senn,* Brown* and others.

In all we have seen reports of 11 cases of well-verified
leukemia treated in this way. All but f these be-
longed to the splenomyelogenie type.
the splenic tumor decreased in size, in
barely palpable The leucocytes in all cases excepting
Pusey’s diminished in number. Four
i white count under 10,000,

a-ray for the

one ol
In every instance
3 cases becoming
reporters record
with entire disappearance Oo!

+

the myelocytes. An improvement in the hemoglobin
and red corpuscles always took place, but was frequent-
ly followed by a decline. Death oceurred in
will soon result fate ally. The others were all much im-
proved at the time of their publication. It should b
emphasized, however, that none had been observed under
treatment for more than eight months.

Through the courtesy of Dr. Senn we are enabled to
report the further course and termination of his pub-
case of splenomyelogenic leukemia
hitherto unpublished. We are also indebted
and Herrick for the privilege of using pat
service at the Presbyterian apace In the accom-
pany ing table are conde nsed the salient fe:
eases that have come under our observation. The typ-
ical blood changes are graphically illustrated by two
harts : splenomyelogenic, the other of
leukemia.
Case 1

9 P
o cases; one

and one othe
to Drs. Bevan
ients in their

ished

itures of eight

one of

]
}
I

shows the inhibiting influence of t

1. Pusey: THE JouRNAU A. M. A April 12, 1902, and Tex
hook on Roentgen Ravs in Therapeutics and Diagnosis. 1095

2. Senn: N. Y. Med. Jour., April 12, 1903

3. Brown: THE JOURNAL A. M. A., March 26,

4. Other tirvant and Crane, N. Y
April 9, 1904: Weber. Am. Medicine. May 21. 1904: Guilloy and
“Spillman, Sem. Médicale, June 1 Weg: Gresh and Stone TH
JOURNAL A... M. A., July 2, 1904 Ahrens. Miineh. med. Woeh
July, 1904. No. 24: Dunn. Am. Pract. and News, July 15, 1904
August

1004
Med. Record

references are:

Chicago Med. Reeorder,

THERAPY—

CAPPS-SMITTH. So]

the leucocytes and the constant tendency for the leu
cocytes to multiply when the treatment is discontinue
The count toward the last fell to the normal, but th
myelocytes never entirely disappeared.
LYMPHATIC LEUKEMIA.

‘The only well-reported case observed
ment is the one by Pusey above referred ‘The glands
and spleen in his patient twice went down to nearly no!
mal size under the treatment, but recurrence and tinal!
death took place. He found no marked fall in the leu
cocyl s.

In our series of 6 lymphatic cases, death resulted in 4
and it will be noticed that 3 of these ran an acute or sub
acute course; the fourth showed a great shrinkage of the
vland tumors and an improvement in the blood befor
death took place. The remaining 2

teady continuous improvement in the bl lood,

during treat

eXhHibdit a

Cases

fiands ane

pi n. The blood chart of Case 6 is typical of bot!
not only does the leucocyte count become normal, but
the differential count gives no hint of the blood dim Ls

‘The spleen
enlarged.

and glands in both patients remain somewhat

SOME GENERAL DEDUCTIONS.

1. The action of the

r-ray in leukemia seems to be of

two kinds: (a) A loeal influence on the spleen an
ce ne eT eee See ee ae

}

az

| \

| \

} 4

4 Siti anal * T

= j t

- Hie Ss

| » =. ” ie ee ee

j lv 3 ‘ [ eae - as .

vlands, characterized by an
later by a bre
tissue. (b)

inflammatory reaction and
aking down and disintegration of the glans
The formation of toxins which have al
action on the manufacture of leucocytes b
marrow. It is well known that acute infections
in leukemia, such as pneumonia, septicemia or
terminal infections, tend to inhibit the
vhite corpusel s and often cause a rr

inhibitory
the bone
Occurring
production of
duction in the siz

e sple hor oland tumors Jl CP T-TaA' toxins rv be
i i om =< ‘ | * ‘ \ t i ct

oft
compared

2. In _
<p ( NHoOMmMVE

‘ such infections.
inst: ince of

la has the spleen tumor entire

to those produced ©

recorded either lymph tlc OF
logeniec Jeukem
\ disappear red,
3. With the discontinuance
fter varving periods, tends to r
{. Death may take place when the gl:
when tl

of the r-Tay, the disease
assert itself.

minds and spleer

ire smallest, and ie white count is nermal.

Fy \eute eases seem 10 reeelye no yene it ron tiie

G. The ehronie form of lvmphatie leukemia responds

to the w-ray even more promptly than the splenomye-
ogenic ye In every instance the glands r apid v solt ‘
ned and dwindled to small proportions.
+ The xr-rav holds the disease process in abevanec
ee oy

curative. Yet

early case may not give

hut probably is not it is ton soon to sar

it persistent treatment of an

a
}

<3
permanent reel -

B97 1 WINTER SEMESTER—BARKER. Journ, A. M, A

Special Article. Institute. The clinical hisvory was read by vy. Schrenck-Not

zing. ‘Lhe woman, 30 years old, had been a nervous child

me Pe ce: though actual hysterical attacks had never been noved. exam
RA ML NOT LS. A. iInalion revealed a moderate deviee of anemia, left-sided hy pet
4 WINTER SEMESTER. algesia, hysterical visual fields, and in general the psychi

LEWELLYS F. BARKER. M.D stigmata of the hysterical nature. The Parisian Mnpresaris
Was then called in and he, wich much Svengali-like nonsense

one could feel the medical men in the audience shiver—put the

(Concluded from pa S10, patient to sleep. Loewenfeld, von Schrenck-Nétzing and othe:
Municn, July 21, 1904 experienced hypuotists examined her and declared that ther
Phe unusual attractiveness of Munich as a place of residence Was no doubt as to the hypnotic condition. Professor Thiel
is, perhaps, not an unmixed advantage to the medical school, ai the piano, tested the reactions of the woman to intensity
for though it insures a large atiendance and affords unusual of tones, velocity of tone sequence, rhythm, height of tom
pportunities to the students for self-de velopment in genera scale, intervals, legato, staccato, consonance, dissonance and
uiture, for the enjoyment of art, music and the theater, it the like. The reactions were lightning-like and consistent
rings to the Universi y of Munich more than its share of the movements of the body produced were undoubtedly marvel
the lazy, loitering students who care more for ihe B ous; the con rast between the reaction to waltz music and a
ben, for which the interesting; old city gives such ample oovpor funeral march were extreme. Under the verbal suggestion of
tunity, than for the training cf their hands or the po {ine the magnetopath, further, she reacted immediately in’ corre
of their minds. In the spring and autumn the adjacent moun spondence to the most diverse human feelings and emotions
tains seduce to frequent excursions. In i@ winter the Ba \fter “waking her” with voice and various absurd move
paré, the Redoute and the delights of carnival lead to the ments, the “maenetisator’ and his charge withdrew and thre
squandering of all too many hours that should be devoted t discussion was opened. Though the chairman of the meeting
study. At all times the restaurant life and café life is ther urged that the discussion should not be made public, this was
its peculiar inducements to the sacrifice of time in the state of tension which existed in Munich at the time
lwo especial attractions appealed not only to the student: too much to hope for. The opinions expressed at the meeting
f Munich during the past winter, but to all residents an soon became public property and a résumé of the proceeding-
visitors. Both were novel forms of the dance—one the artisti Was even written by a physician for the feuilleton of thr
music interpreting dance of the American, Miss Isadora Dut Frankfurter Zeitung. The most diverse opinions were ex
an, the other the so-called sleep dance or dream dance of thi pressed, and they were not limited to the character of the case
ivpnoti red, hysterical Mme. Madelein of Paris. lhe latt presen ed, but involved, as might have been expec ed, the med
vas the more pathologic in its interest For atime ical ethtes of the whole. situation. Loewenfeld’s opinion
it seemed as if all Munich from the uppermost to th seemed to be listened to with the greatest respect. Thoug)
lowest class had been hypnotized by her; everyone you mi some of the physicians had thought the hypno‘ism simulated
spoke of her, asked if vou had seen her, and wanted to know and the hol performance a swindle, Loewenfeld felt sure
if she were really hypnotized or if it were all a swindl She that the hypnotism was genuine, but gave it as his opinion
vas “discovered” in Paris by a “magnetisator,” a quack whon that the hysterical element rather than the hypnosis was re
she had consulted regarding headaches. The “magnetisator” sponsible for the artistic attitudes, the hypnosis, perhaps
hypnotized her, and by chance, he says, while she was in the heing helpful, since in the hypnotic condition all inhibitory
hypno ie state, plaved a selection from Che pin. To his sur influences are removed, and capacities, which, possessed in the
prise, so the story goes, the patient began to react in the most waking condition, but then improperly unfolded owing to
marvelously plastic way to the musical sounds. The artisti shyness, embarrassment and distraction, ean first be fully ex
ittitudes assumed were so remarkable that she was presented hibited. The woman, it was asserted, had no especial training
in several art studios in Paris and London; the cataleptic at in art and musie, but that she, through inheritance, must be
titudes called forth by various suggestions could be main very susceptible to musie is obvious, a fact which may be ac
tained long enough for photographic reproduction, and a large counted for, some thought, through the history that her
series of pictures of her, illustrating “all phases of human mother had been a dancer in Tiflis. That no physician has
emotion unencumbered by any inhibitory influence” are on hypnotized Mme. Madeleine is a feature of the situation to
sale and used as models by artists. The “magnetopath” being which attention was more than once ealled.
a practical business man, decided to exploit her. He could From all I could see, and trying to weigh as critically as |]
have chosen no better place than Munich in which to begin could the conflicting comments made, I came away from the
operations. That city, probably, has the most mobile nervous meeting feeling that Mme. Madeleine’s performance was
system in Europe; the phenomenal success of “the Duncan” qualitatively a mixture of hypnosis, hysteria and hocus pocus.
there, as compared with her relatively cool reception in hard but as to the quantitative relations of the three ingredients 1]
headed Berlin, had sufficiently demonstrated that But how shall venture no guess.
to effect an entrance was the difficulty. Hypnotic exhibitions in The fact that public exhibitions of hypnotism are illegal.

public are prohibited by law in Germany The public had to of course, made the great public most anxious to see Mme

be smuggled in in some way under the protection of. science Madeleine. The reports of the presentations at the Psycho
The gulf between the “magnetisator”’ and the medical profes logieal Society and at the Medteal Society whetted the appe
sion was finally bridged through the intermediation of the tite further. The wavy in which the law was evaded was inter
Munich Psychological Society and of von Schrenck-Noétzing, a esting. People who desired to see the woman registered their
nerve specialist, whose offer to present “the Madeleine” as a names at one of the Munich bookstores. Invitations to attend
‘linical ease to the Aerztliche Verein was accepted. Some 400 a “private performance” in the Schauspeielhaus were then
physicians met in the amphitheater of the Medical-Clinica] sent out by the Psvechologieal Society: acceptances were to be
accompanied by a subseription of 10 or 20 marks, according to
*The previons articles in this series have been as follow the position of the seats. These difficulties helped, as T have
Travel as a Means of VDost-Graduate Medical Edueation.”’ by Th aalit ie hvpnotize the whlic The house was sold out and
Nicho'as Senr. July 22: “Is a Trip to Eurene Worth Its Cost t tg . Bs I in tity F P=
the Medical Man?’ by Dr. Lewellys F. Barker, July 80: “Spain audiences of musicians, artists, actors and the wholesale pub
ind Remon y Cajal.’ by Dr. Barker, Aug. 6: “Leprosy in the Ha lic viewed the “dream dance” unmolested. How great the
vaiian Js'an by Di Senn, Aug. 13: “Italy and _th Grea harm done to the people at large has been it is difficult to
Antimalarial Campaien.” by Dr. Barker, Ang. 20 and 27: “Pathe a . °
Damien. the Lener Hero.” by Dr. Senn. Ang. 27: “A Winter Sem ealenlate. Rumor has it that the offices of the hypnotists are
ster.” by Dr. Parker, Sent. 3 and 17: “Medical Conditions in the being more thon ever visited by women and girls, who demand
Mawailan Istands.” by Dr. Senn. Sept. 10 that they be hvpnotized in order that their slumbering or in

1. THE JouRNAT May 14. 1904. page 1327. gave an abstract

n article on thia dancer by a prominent scientist. — Fi hibited talents mav he revealed.

Sepp. 24, 1904.

New Instrument.

SALINE INFUSION AND IRRIGATING FLASK
JOHN J. SHEA, M.D.
BEVERLY, MASS.

This apparatus relates to an improvement in saline intusiot
and irrigating flasks. As illustration shows, it consists of a
chemical glass reservoir, suitably marked in cubic centimeters
up to one liter. It is provided at its base with a nipple-shaped
outlet, to which rubber tube and This
ylass reservoir is held jin place by upper and lower metal rings,

needle are attached.

between whi h and flask is interposed rubber packing to pre

vent flask from cracking. These rings are detachably con

nected, by means of metal rods going through perforated ear:

in the rings. The upper end of each rod is provided with an

wT TT

St

}

(B rn
Fig. 1 A, A’. Flask. B. Stopper. C. Rubber tubing. Db, E

Metal rings. E”. Nipple. G. Bail or handle of flask 3 |

Thermometer. I. Inlet for air. K. Coppered tin with handle

L400 ALG AM AMAIA ET

eye, to which is connected a handle. The lower end of each rod
is threaded and is secured by means of adjustable nuts. Thes«
rods pass loosely through perforated ears in upper and lowe)
rings, so as to allow new flask to be substituted if one is
broken. On lower rings are three legs serving as support
Thus it ean be seen that flask can be either hung up or set down
without interfering with the flow of the liquid.

The stopper is made of rubber, containing two perforations,
one containing a thermometer for registering temperature of
solution and the other a small glass tube, to allow air to enter
to compensate the displaced liquid.

I have also provided a coppered-tin receptacle, also having a
handle, to serve as a vessel in which to boil the solution for
purpose of sterilizing it, or for reheating the solution when in
bottle. This flask fits with rubber tubing into the coppered-tin
receptacle and the whole is placed in a box with handle.

In upper part of this box is a compartment in whieh to carry

TIC DOULOUREUA

BASTMAN. RY:

sterile needle and a concentrated sterile salt solution, an ounes

of which added to 1,000 ¢.e. of water makes a normal salt solu
tion This solution ean be pre pared and kept in the flask fo
emergencies, showing its helpfulness in ambulance calls, railway
beside its

accidents. ete onvenience to the

hospital.

physician ind the

Clinical Report.

REPORT OF A SYMPTOMATIC CURE OF
VULSIVE TIC DOULOURBUX BY IN-
JECTION OF OSMIC ACID

JOSEPH RILUS EASTMAN, M.D
INDIANAPOLIS,
History.—Mrs. H., aged 71 years, came to me on Jub

The case was one of typical intense tic douloureux in

1904

volving the right side of the face. The first paroxysm occurred

about twenty vears ago, subsequent attacks gradually becom

ing more frequent and more severe. Practically all of the many
| y ;

remedies recommended foy the relief of this cor

dition had be
benetit. \li the

tried without

teeth had been extracted in the
belief that perhaps dental caries bore some causative relation
to the pain For almost three monchs prior to the operation
the pain had been excruciating, the attacks occurring with ex
haustin

e frequency. ‘The whole right side of the face was ey
| :

quisitely tender, particularly in the neighborhood of the infra
orbital and mental foramina. The tongue was sore and tende
it all times, this greatly interfering with speech During at

tacks the right angle of the
Violent

buecinator was almost constantly present during the attacks

pain was most acute about thi

mouth and the angle of the right jaw spasm of

Treatment—A 2 per cent. solution of osmic acid was in
jected into the supraorbital, infraorbital and inferior denta
nerves at the supraorbital notch and infraorbital and menta
foramina. The manner of operating was precisely that prac
ticed by Dr. John B. Murphy and described by him at the At
lantie City meeting of this year. ‘Ten drops of a 2 per cent. so
lution of the osmic acid were jnjected jnto each branch, and tw
or three drops were forced into the perineural fat of each fora
nerve. At the time of the injection of the
slight

the foramina and held during the injection, but the

men around the

osmic acid the nerves were drawn with very force fron
trunks
were not stretched as in the operation of neurectasy.

Re sult.

the pain since its abatement one week after the operation. Dun

Up to the present time there has been no return ot

ing the first week several rather severe paroxysms occurred

these gradually decreasing in severity. It is possible that the
pain in this case may return, but even if it should, the respite
for a few months justifies an operation so easy of performance
and attended with se little danger.

An interesting feature of the case was the severe nephritis o
casioned by the elimination of the acid. The urine passed dur
ing the first twelve hours succeeding the operation showe
nothing unusual; however, on the second day nephritis resulte:
There were no symptoms either subjective or objective pointing
to its onset or presence excepting the appearance of and find
ings in the urine. The patient did not compiain of pain in the
loins. Urine passed thirty-six hours after the operation showe
the following:

Reaction, 1086; color, dark claret

The specimen was centrifuged, and the sediment

very slightly acid;

sp. g
composed
little over a quarter of the volume. The clear fluid above thi
sediment was light claret in color, the sediment being dark red
Examination of the fluid portion showed a small amount of al
bumin, with no sugar, bile or other abnormal substance pres
Examination of the sediment

ent. showed it to be eon pose

almost entirely of red blood cells. There were no casts, epithe

lial eells or pus cells. The red blood cells disappeared from the

urine on the fourth day.

S94

THE - JOURNAL OF THE
AMERICAN MEDICAL ASSOCIATION

~~.» <cmrcaco, Tin.

103 DEARBORN AVENUE .
Cable Address . . . “Medic, Chicago”
Subscription price..... Five dollars per annum in advance

SATURDAY, SEPTEMBER 24, 1904.
PROGERIA, A FORM OF SENILISM.
Among the still obscure physiologic problems must
ve reckoned those relating to the mechanism regulating
srowth and decay. While we are in possession of 1so-

lated of knowledge which shed an occasional

vlimmer of light on the subject, our knowledge can onl)

scraps

pe deseribed as fragmentary. The studies ot the last
few years on acromegaly and giantism indicate that the
pituitary body has some influence on development.

though just what this influence is remains obscure. In

some cases of dwarfism, too, this gland has been found

liseased. In some forms of dwarfism again the thyroid
seems to play a part, as is the case in cretinism and al-
ied conditions. Then, again,certain glands seem to beara
relation to certain systems rather than to the body as a
whole, an example of this being the curious relation
which exists between excessive or premature develop-
ment of the genitalia and some of the diseases of the
idrenal glands. The question as to the factors which
lelay or accelerate decay, though less frequently studied,

Why

Some are so

is equally as important as that relating to growth.

is it that in individuals of the same
much older and some so much younger, so far as their
are concerned, than the
Why is it that in the

individual one organ, or group of organs, may be older

age

intellect average

individual of that age?

and

tissues

same

or younger than the rest of the body structures? To
use the term originated by Sir James Paget, what is it
that regulates the “chronometry of life” ?

In a recent article, Hastings Guilford’? has reported.
the name of progeria, some extremely interest-
ing cases in which there existed a combination of prema-
and infantilism, but in which the former
the Ce

predominating syndrome of premature decay was far

ture senility

ses the

condition greatly predominated. In all

beyond the limits of possible normal variation, and was

unassociated with any previous disease which might

have acted as a causative factor. Without considering

the eases 1n detail, it will be of interest to briefly sketeh

salient points in the natural history of the two most

characteristie cases, these being SO similar that one de-

scription will suffice. The disease begins in early in-

]

fancy, with loss of hair so marked that at six months

more than half the hair may have disappeared. At the

same time the child begins to emaciate. The shoulders

also Isrit

1904 and
1904, p, 691

1. The
Med. Assn.,

Practitior
THE JOURNAL,

ver, August, report of

Sept. 3,

BRDITORIALS.

Jour. A. M, A

are rounded and the chest narrow on account of the lack
The head is relatively
large, and may resemble the head of hydrocephalus. As

of development of the clavicles.

the child grows the hair becomes more scanty and turns
gray so that as early as the age of seven only a ver)
scanty gray crop may remain. ‘The growth is stunted
and the child takes on all the appearances of the de-
erepitude of age. The skin becomes loose and shriveled.
the arteries show senile changes, and the whole ap
pearance and even the mental attitude is that of th
adult rather than that of the child.

easily fatigued, partly on account of muscular weak

The ehildren are

ness, partly on account of shortness of breath, the lat
ter symptom being of cardiae origin. Physical exam
ination shows a curious mixture of the physical signs of
senility and those of lack of development. The skin.
the hair, the vascular system, and the ends of the long
bones are those of an old individual, and, on the othe
hand, the shafts of the long bones, the bones of th
skull, the teeth, and the mammary glands show marke
lack of development. The liver, the blood-forming Ol
gans and the genitalia seem to develop in a normal man
ner. The functions ot the body seem to he earried on il

a fairly satisfactory manner. The bowels are reguliat

the appetite is good, and most foods are normally di
gested, though curiously enough in both well-marke«
Death took

of seventeen: in one ease

cases the patient was unable to digest fats.

place

in both eases at the age
in an attack of angina pectoris, in the other from ear-
diae failure.

In the one case in which Guilford was able to pro
cure an autopsy, the same curious mingling of senile
and infantile changes was found. There was marked
sclerosis of the arterial system, the coronaries and
The

a fibrosis of a typica

aortic and mitral valves being especially affected.
kidneys and adrenals showed
senile type. On the other hand, he noted a persistent
thymus, a great lack of development of the clavicles.
and an undeveloped state of the shafts of the long bones
The liver and thyroid gland were normal, and no defi-
in the

nite changes could be made out in the brain or

pineal or pituitary glands.

In his discussion of the pathogenesis of the disease.
the author sums up the condition as being one of “re-
tarded development, combined with premature old age
and with indications of some attempt to attain a nor-
mal condition.” He is unable to explain the causative
factors in the disease. There was no evidence that it
was due to previous disease of some particular organ.
the thyroid, pituitary and brain being normal, and th
author evidently does not think the adrenal changes of
importance enough to lead to serious results Tle com-
pares the eases to the form of infantilism known as
ateliosis, and thinks that possibly these may be eases
of ateliosis combined with premature senile decay. He
neglects to state the condition of the panereas in the
case examined postmortem, and apparently regards this

of no moment. In the light of the cases of pancreatic

Sept. 24, 1904.

infantilism, recently reported by Bramwell and others,
it would have been of interest to have the
condition of this organ in his cases, particularly as in

known

both of them there was a marked aversion to fatty food,
and in one there were also periodic attacks of abdom-
inal pain.

AID WANTED FOR CONVALESCENT INSANE.

It is well known that the average patient discharged
from the hospital for the insane, as recovered or im-
proved, is in a most helpless and pitiable situation if
he has no friends to look after him, and there are
many such. In his efforts to obtain employment he is
more heavily handicapped than is the discharged pris-
oner. At the very moment, therefore, when he should
be protected, well nourished and cheerfully employed,
he is plunged into difficulties and discouragements, and
frequently is reduced to abject want. It is not strange that
he too often again succumbs to his malady; neither is
it to be wondered at that, in view of this well-recognized
danger, convalescent patients are sometimes retained in
the asylums by humane superintendents too long for
the good of the asylums and too long for their own
good, could they be sent out into the world under even
a temporary guarantee of safe and wholesome living
societies

In this country there are

conditions. many
for the aid and encouragement of discharged convicts.
but none, so far as we are aware, which provides assist-
ance for the recovered patient discharged from a_hos-
pital for the insane. The general charitable societies,
of course, do much to relieve the families who are re-
duced to helplessness by the insanity of their bread-
winners, and in some cases patients are assisted in ob-
taining work on their return. All this, however, quite
fails to meet the situation.

Special organizations are necessary, which should, in
fact, perform the function of lay auxiliaries to the
asylums. Such societies should have a temporary home,
where a patient without family or friends could go im-
mediately on leaving the asylum, so that he would find
himself at once in an atmosphere of friendly encour-
agement. He should be aided to find work, and to re-
gain the habit of independence which is too often per-
manently lost in the asylum. If the patient had been an
alcoholic, great pains might be necessary to prevent a
return to his former associations and a relapse into
his former indulgence. The functions of such a soci-
ety, however, must go still further. It should concern
itself with such matters as the humane care of patients
during the period when they are in custody awaiting
inquiry as to their mental state; it should combat the
popular ignorance and dread of the asylum, and above
all, should aid in popularizing the knowledge that acute
and transitory cases should have immediate care under

surroundings so closely approximating those of the gen-

eral hospital that the old asylum stigma would be lost.
Such societies should have the right of entry to public

EDITORIALS.

ROD

institutions, as have the valuable State Charities Aid So
cieties of New York and New Jersey. They would un-
doubtedly succeed in greatly improving the condition
of the insane under county care in the various states.
The creation of societies for the aid of discharged

would have foreign

instance,

patients many precedents. In
fifteen

societies organized for the aid of the insane, the first
]
i}

Germany, tor there are voluntee!

of which was begun in 1842. In general terms, their
purpose is: “To give moral and material assistance to
indigent, discharged patients in order to facilitate their
return into society and to prevent a recurrence of their
malady.” “To improve the public care of the insane.
and to combat the popular prejudice against the in-
sane and against asylums.” In the organization of
these German societies the initiative has been taken by
medical men, and usually by the physicians in charge of
the regional asylums. Physicians are members, and
aid in directing the work, though the majority of the
members are, of course, non-professional. Persons can
become members on annual payment of a small
by lending their personal aid in caring for individual
The that

money are indicate

considerable sums of

that the

Cases, show

reports

SsOCI tle S

disbursed, and

have large memberships and perform a most useful
work.

There are similar societies in other continental eoun-
tries. In Paris there are at least two Sociétés de Pa

: ] . ry
ronage des Alienes. There is no doubt that such orean-

izations would prove even more useful in America than

abroad, and, if onee started under wise auspices, there
ean be no question of their successful appeal] to public

sympathy

NATURAL AND ARTIFICIAL ANTHRAX IMMUNITY

Che study of immunity and susceptibility to diseas

]

by test-tube experiments, has brought to light a num-

ber of seemingly paradoxical results. It has been shown
for instanee, that human blood serum is strongly bac
tericidal im vitro for typhoid and dysentery bacil
and that it may retain this property, although son

times in a less degree, during the course of these dis
eases. Chickens and swine are practically immun
anthrax infection, and vet it is found that the b

and the blood serum of these animals form evood cul-

ture media for anthrax bacilli. Dogs also are relative]
Lune, and their blood likewise Is a good nutrit
medium for this form of miero-organism. Rabbits. or

the other hand. are very susceptible to anthrax infe:

tion, while their extravascular blood serum

almost N-

ke ee ie ee
stantly kills large numbers of the bacilli. Cattle and
sheep are susceptible To anthrax. and their bh ood seTrun
also forms good culture medium, but it has been show1

that this serum contains a large amount of ambocentoy

which, with a suitable complement, may take part
the destruction of the bacilli. These experiment

therefore. do not clve us the shiehtest hint as to

mal is susceptible to a certain infection and

immune to it. They show that the results

test-tube experimentation do not necessaril\

vive us anv information regarding that which takes
place in the animal body.
if is olten veen th alm of mvestigators to Mak
e tes ibe experi nts as simp Ss POSSI This
simp | is doubtless a desirable thin Dut necessarii
yroduces a set of conditions entire:y ditferent from that
CoO red nh tik ani DOU) ahi Ihé results 1 =
ybtammed must accordingly be oO { value im g@ivine
is an insight into the processes going on in the anim
yrevanism Reco ne this fact, Bail and Petterson
e made a series of experiments in which they at

empted to approximate the conditions that are found

n the body, and the results thus obtained are entirel\
{ferent from those obtaimed by tl S mpl r exper
ments They have shown tl rabbit serum which is

inthracidal in vitro is deprived of that property by th

: —
iddition of onlv a small quantity of an emulsion of 01
ran cells, such as liver, spleen, bone-marrow, et his
sae ee he le TO Tih CT that 1 rvan Ceils 1UVE
vrTeacel flint y Lor 1 ( LIwvOoct Dpto 1 { Sel Ih) U! i
have tl iwntha Daclill, thus taking them aw irom
he | Le! In 1 sina ( ) ra) ne org
r wocepnrors Nn C\WIs ( Liye orval
( ls nad t! 2 > preventer Ol ne pat nm thre
structiol ot ti acl at ( l dsthe in
‘his sees oO ¢ SALIS aCLOryV. ¢ ) la ) ) Lie Sus
Ch is t 1 satl r\ nation of t
eptibilit of rabbits to anthrax 1n] On, 1n pite oO
the fact that a iT tr iscular Pio~ood serum Is strong iy
hr ial | ] ) sre nr + mn Ne althoneh
unthracidal. Chickens are practica:!V immune, aithoug
) 1] 1 1
tHe eNTTAaAVaA™M 1] nNiood Sel mn) possesses no anthra-
ida powers It does iowever } nh amboceptors.
is is shown by the fact that it can be made active by a
! = 4 & S . { , .
very small quantity of rabbit serun If, now, norma

ehicken serum is mixed with bone-marrow or with |

ecoeytes, it at once becomes anthracidal Beef, goat and
swine serums also may be made active by the addition
of chicken’s bone-marrow. Bail and Petterson conclude

from this observation that the bone-marrow and leuco-

evtes of the chicken contain a complement which. acting

the amboceptors in the serum, destroys

eonjointly with

anthrax bacilli, and thus protects chickens against in-

Dog serum with leueoeytes or bone-marro\

fection.

ilso has anthracidal powers, thus explaining tlie rel;

tive immunity of dogs. The

1 ? 1}
ieucoeytes and bone-matl

row seem to be e@a

of complement TO the serum. as is sh wh by

the serum is slightly

anthracidal when obtained

that

twenty-four hours after the intravenous Injection o|

of anthrax bacilli: also by the fact that the

large dose

cell-free exudate obtained from the ple ra of a rabbit

dead from an intrapleural injection of anthrax is ea-

pable of activating dog, she nor hoo -erums. None o}
is the cell-free exudat

these serums is anthracidal, nor

when used alone.

" EDITORIALS

Jour... A. M. A

Bail and Petterson immunized young dogs and ehicken-
by repeated injections of anthrax bacilli until these ami
mais could stand about ten times the ordinary fata
dos (Young dogs are mor

infection than older ones.) The

susceptible to anthrax

then studied the o1

}

ins and body fluids of these animals to determine the
change produced in them during the process of im
munization. The blood serum, in no instanee, had ae
quired anthracidal powers, but it was found that th

defibrinated blood was capable of destroying the baci

blood Was shown toy tye

This anthracidal power of the
ttional to the number of leucoeytes contained 11

it, and these were greatly

The

had aequired a much higher anthraeida

increased by the injections

of anthrax baeilli. mixture of serum and bone

marrow Howe!
I

!

mixture from a normal dow of the same

re. The

amboceptors in the serum, but be

investigators could not detect an nerease ol

lieve that there

Was ah

merease mM complement, because there was a marked in

CPCCA ne the leucocytes, and thre “/ they believe COT)
in e¢ complement. ‘These experiments show. very
nicely the great complexity of the phenomena of infe

again the im

sO emphasize
i

and a]
and a

Immunity,

} 4 } Te | } .
inf part plaved by the leucocytes in protecting thy

bacterial invasion

OUV against

KUTHANASIA FOR THE DEFECTIVE AND INCURABLI

Kvery little while some enthusiastic or noteriet

; ] ] ]
writer bobs up advocating thre

curtailing of

man eXstence

in hopeless and ineurable cases. Th

idea of thé sacredness of human life is hardly sufficjenth

nstalled in such people’s intelleet, hence these lueubra

tions. . Moreover, it is apparently a belief of many of
)

the laitv that physicians do assist hopeless cases out of

the world. Not long since a writer in a daily paper
speaking as an ex-mayor of a large city, told of a eas
o” this kind, admitted by the physician and claimed to
he justifiable, which he was foreed to investigate. Hy
says he consulted the best physicians in the city, and
that they justified the act. We doubt
We do believe that

phvsicians in any city would express sueh an opinion

this statement

throughout. not any number of

It is directly contrary to the spirit of the profession

and it is certainly unfortunate that one writing as

municipal reformer should be willine to publish suel
a statement

Now comes the announcement that a French professor
- advocating premature euthanasia for ineurables and

death

the establishment of rooms in hospitals where

hopeless patients, at their own volition. may he pain-

lessiy sent out of the world = Sueh publieations are dan

gerous as tending to diminish the respeet for human

life which should prevail in any civilized community.

as directly encouraging homicide, and as vicious. in

tendency as any other incitation to murder.

We may excuse the person who commits suieide to

avoid inevitable torture or dishonor, but we ean not

SEPT. 24, 1904. MINOR
justify in any way the physician who deliberately cuts
short his patient’s existence under any conditions what-
ver. It is his business to prolong, not to curtail hu-
inan life, and under no circumstances whatever can he
iter this rule. For professional reasons, altogether
tpart from those of public policy which would a‘so pro-
hibit such taking of human life under any cirewn-
-tances, a physician should be the last of all men to ad-
ocate or excuse it. Death rooms in hospitals for thi
purpose proposed would be about as respectable as sui-
cide elubs.
PATENT MEDICINES CONTAINING ALCOHOL BARRED
IN SOUTH CAROLINA.

\ccording to the South Carolina newspapers, tlie)

ire tiking effective action regarding certain “patent

medicines” that it might be well for other states to

Probably it is heeause South Carolina, throug

follow. I)
ts dispensary law, controls the sale of aleoholic liquors
that it is able to do what it seems to be doing. One
miper speaks of drug stores being prohibited from selling
peruna on account of the aleohol it contains, and that
ereafter it can be had only on the prescription of

hvsieian Another shows that it is not only peruna
that is barred, but Hostetter’s bitters, De Witt’s stomach
itters, and some others less known because less adver-
tised. According to the state chemist’s analysis, Hos-
Witt’s

stomach bitters 37.6 per cent.. and peruna 26 per eont.

tetter’s bitters contains 41.3) per cent., De

if alcohol, and consequently are to be classified as m-

roxieants,

CARBOLIC ACID AND ITS DANGER.

Carbolie acid has long been regarded as a harmless
chemical and as such forms part of the domestie equip-
ment of many homes. Its dangers, however, are coming
to be appreciated. We have learned that even in dilute
solution it may cause serious lesions and its lethal possi-
bilities are recognized by an increasing number of
It is on account of this last named
fact that the health authorities of New York City have.
it is reported, made a regulation requiring the registra-
tion of all sales of carbolic acid of strength above a 5
per cent. solution. This is a measure which can be com-
mended and should have been adopted before. It is to
he hoped that the example will be followed in other eom-
munities. It is rather a eurious fact that suicides often
choose most repulsive and uncomfortable methods, and
this may aceount for the preference in so many cases
for earbolie acid, which can hardly be considered an
igreeable method. Be this, however, as it may, the
chances of accidents from the common domestic use of
this poison are of themselves sufficient to justify restric

would-be suicides.

tions of its sale.

NERVOUSNESS IN SCHOOL CHILDREN.

\ccording to statistics, reported in the daily press,
yne in three of the school children of the city of Chi-
ago is affected with some form of nervous disor.ler.
showing itself usually in the form of s!uggishness and

mental depression, with melancholic tendencies or by

COMMENTS. 39;

some degree of choreic manifestations. ‘The causes ai
leged are the strenuous city life, the impure atmospher
of dwellings, the bringing up of children in that build
ings with deficient facilities for exercise, ight and ven
tilation, the constant noise, day and night, and lat
hours and lack of sufficient sleep and nutrition. Bb

side the danger of overdevotion to study, city childret

+

are subject to excitements and social temptations t
whieh those in smaller Communities are far less labi
The introduction of manual exercises in schools wil
rove remedial to some extent, but it seems from the list
of alleged causes that some of them are almost irremed)-
able. The urban tendencies of population at the pres-
ent time are not favorable to the production of a robust
race, and any sanitary measure that will counteract
this tendency should be encouraged. It may be that a
pecial city type of mankind will be evolved; we fear
’ more or less defective or degenerate one. In the mean-
time we wil! have to go on enlarging and multiplying
our asylums for the defective and the insane, and _ re-

rit as heretofore the best blood from the countr

COMMISSIONS ON PRESCRIPTIONS

A Philade!phia chemical company is trying to corrupt
those of our profession whos may be corruptible by the

old secheme—for it has been tried several times befor

without success—of offering commissions on preserip-
tions in the shape of shares of stock in the COMLpPAan
“A eredit will be allowed, equal to 25 per cent of the
wholesale price of the prescriptions prescribed, redeem-
able in stock of the company.” The company in its
wooklet assures the reader that the concern “is strieth
a co-operative pharmaceutical house, owned. controller

Ninety-

men, ale

indd operated in the interest of the profession.
five per cent. of the stockholders are medical
no stock Ww] he sold or disposed ot except tO members

of the medical profession and doctors of

very.” This certainly will reassure anvone who may hav
any doubts as to the ethieal nature of the scheme. Posi-

tively no stock-exechange operators or other gamblers

will be allowed to get within reach of this plum, whoss

stock is so valuable “that only a reasonably short time
will elapse before the company will be able to pay divi
dends equal to the par value of the stock.” Each phy
sician is supplied with a-book of blanks, wherein he
s to enter, day by day, opposite the name of each prep
aration of the company. the amount he has thet da

prescribed. Once a month he is to send in this drum
mers sheet and seeure his rake-off. The prospectus
does not sav so, but we suppose that those who sell th

most goods will be put on a regular salarv basis an

be considered regular drummers for the house. There

is one sion of eonscienee about the managers of this

scheme—thev doubtless fear that some practitioners
inav preseribe the company’s goods without proper dis-
eretion and increase their commissions without du
regard for the welfare of the patients. The following
statement appears, therefore. in’ conclusion: ‘You
should make vourse! f aequainted with the formulas
and uses of the preparations and preseribe them when
Wd v..

,:
ever you pelleve They Wi as emmheacious } { Ose

inv other manufacture.’

SUS

MINOR

CHE BACTERIOLOGIC DIAGNOSIS OF DIPHTHERIA.
While the specificity of diphtheria and the diphtheria-
bacillus is universally admitted, it is recognized that,
on the one hand, membranous deposits may form in the
\lr passages from other causes, while, on the other hand,
the bacillus may be present in with ca-
tarrhal manifestations alone or even without oéher evi-
dences of diphtheria. Diphtheria-bacilli have been
found also in the throats of persons suffering from

association

‘ther diseases, scarlet fever especially. In order to
‘lear up some of the mooted points in connection with
the presence and the pathogenicity of diphtheria-bacill,
Dr. B. Czerno-Schwarz' made a study of the nasal and
pharyngeal secretion from the patients admitted to
the department for contagious diseases at the Wladimir
Children’s Hospital of Moscow. Of 385 patients re-
ceived into the division for cases of searlet fever and
measles, 45 (11.6 per cent ) vielded, on first examina-
tion, a growth of diphtheria-baci.li, divided as follows:
Eight of 207 cases of scarlet fever, 3.6 per cent.; 37 of
Of the former
patients, seven presented necrobiotic angina and one
follicular angina, while of the latter only two presented
symptoms of diphtheria. As a
tions made, the conclusion is reached that negative re-
sults from repeated examination for the presence of
liphtheria-bacilli are of undoubted and absolute value.
By this means it has been demonstrated that mem-
branous angina, laryngitis and croup may be of non-

160 cases of measles, 21.92 per cent.

result of the observa-

liphtherie origin. The significance of positive results
from bacteriologic examination is undoubted
when the elinical picture is that of diphtheria. When,
however, there is a discrepancy between the clinical
picture and the
liagnosis must be considered as doubtful.

likewise

results of bacteriologie examination the

FIBRINOUS BRONCHITIS

Fibrinous bronchitis is a. rare disorder, probably ot

liverse etiology. ‘The diagnostic feature is the expecto-

ration of casts of the bronchial tree, of varied

ind length, in conjunction with a sense of suffocation,

shape

and
respiratory murmur, and unaltered percussion-resonanc

‘yanosis, shallow frequent respirations, entfeebled

mless the alveoli become occluded or atelectasis devel-

ps. ‘Lhe symptoms disappear temporarily with the
expectoration of the coagula, to return on their re-

There

is to whether the casts consist of fibrin or of mucus, the

formation. has been some difference of opinion

instances and the
Krom all of the

however, it would appear as if both substanees

me substance being found in some

ther substance in other instances.
evidence,
ire often present, sometimes together, sometimes alone.
Confirmation of this view is afforded by a communiea-
tion recently made 1) Dr, Gusta Lely rmeister,? who re-
ports in detail a ease of fibrinous bronchitis, and also
gives the results of a study of the casts obtained from
twelve other eases of similar kind. He found that the
coagula expelled in a case of grave heart disease during
the death agony differed only in their great thickness

from the easts expelled in cases of true fibrinous bron-
1. Archiv fiir Kinderheilkunde, vol. xxxix. Nos
2. Deutsches Archiv fiir klin. Med, vol. Ixxx, Nos. 5-6, p. 551

COMMENTS.

Jour. A. M. A.

chitis, although they agree chemically and histologically
Idiopathic fibrinous bronchitis is to be strictly differen-
tiated, with reference to both the etiology and the mor-
phology of the coagula, from descending diphtheria and
from diphtheria of the bronchial tubes without involve-
ment of the Jarynx. The coagula of true fibrinous
bronchitis are honeycombed in structure, more or less
completely filling the lumen of the bronchial tubes and
generally containing a moderate amount of air. Mi-
croscopically, the appearances presented are those of a
reticular structure, consisting of fibrin and mucus, and
having spaces containing few cells. Fibrin was demon-
strable in the easts in all of the cases and mucus alse
in seven. In cases of descending diphtheria, structure:
analogous to the deposits on the tonsils and the laryny
are formed in the bronchi. These consist of a dense.
compact, finely fibrillated fibrinous network, containing
enormous numbers of cells, and they appear as simple
or dendritie cylindrical membranes that ean be detached
from the mucous membrane surface only with the loss
of epithelium. Curschmann’s spirals were found in
only one case among thirteen. The presence of Charcot-
Leyden erystals and of eosinophile cells in the casts
could not be demonstrated in any case.

THE SPECIFICITY OF THE BODY-CELL TOXINS.
The observation that the blood of one species of ani-
mal is toxic to members of another species is an old one,
and the modern studies set on foot by the work of
Bordet and others have greatly extended our conception
of body-cell toxicity, and have shown that it is not
confined to blood cells alone. It appears at first sight
such a simple matter to inject a particular cell or organ
from one species of animal into a member of another
species, that this line of research has been extensively
followed in the last two. Then the results
achieved in some instances by this work have illuminated

year or

some of the dark regions of pathology, and further re-
It has
been pretty generally assumed by the workers along these

search has seemed likely to give good results.

lines that a cell specificity existed, i. e., that if an ani-
mal is injected with ciliated epithelium it will produce
antibodies for ciliated epithelium only; but it seems
probable that this presumed specificity has been greatly
overestimated, ‘This whole question of specificity has
As Pearee indi-
rectly brings out, many of the previous investigators

recently been investigated by Pearce.?

seem to have assumed that morphologically similar cells
Pearce’s work
had for its object to demonstrate that the chemical com-

would give rise to similar antibodies.

position of the cel! and not its morphology is the factor
He likewise en-
deavored to show that many of the results supposedly
due to the specific action of one eytotoxin are really

determining its specificity of action.

due to other evtotoxins adventitiously elaborated as the

result of improper methods of immunization. As a re-

sult of his observations, Pearee concludes that the cells
of the
morphology and function. have certain receptor charae-
teristics in and that one type of cell may,

therefore, produce antibodies affecting several cell

various organs of the body, while differing in

common,

1. Journal Med. Research, vol, xii No.1

Sepr. 24, 1904.

yroups of differing morphology, but with like receptor
yroups. He also concludes, from comparing results
obtained with organs as ordinarily removed with those
obtained with organs freed from blood, that many of
the positive results deseribed as specific are due, not to
specific action of the particular cell or organ used, but
rather to the blood introduced with them. It would seem,
therefore, that not a little of the published work on
cytotoxins is valueless on account of mistakes in tech-
nic, and that much of the valuable work has been mis-
interpreted. This means that a great deal of research
must be done over again by the more careful methods
suggested by this study.
Medical News.
ILLINOIS.

Personal.—Dr. Anna FE. Blount, Oak Park, has returned after
t year in Europe-——Dr. Pliny W. Blanchard is seriously ill at
his home in Harvard.

Smallpox.—The smallpox situation at Belleville is causing
vrave anxiety, and the authorities are taking all possible pre-
‘autions to limit the spread of the disease-——Dr. John J.
Leahy, Lemont, who claimed $5,750 for services during a
smallpox epidemic, was allowed $5,000 in full of all claims.

Copper as a Germicide.—The State Board of Health is con
lucting investigations to determine whether water with typhoid
fever or cholera germs can be purified simply by being kept in
copper containers for a few hours. The experiments are being
made under the direction of Dr. John H. Long of the North-
western University Medical School.

Chicago.

Smallpox.
tion hospit al.

During the week 5 cases were sent to the isola

Two unvaccinated children died at the hospital

Thousands for Hospital. At the annual benefit concert for
the Samaritan Hospital, held September 16, $2,000 was realized
for the institution.

College Lengthens Course. ‘The College of Physicians and
Surgeons, the College of Medicine of the University of Illinois,
has extended its course to nine months. The term opens Sep
tember 27.

Pneumonia Deaths Increase.--The deaths from pneumonia for
the week ended September 17, were 34, an increase of 15, or
nearly 80 per cent. over the mortality of the previous week
from this cause.

Deaths of the Week.—The total deaths for last
445, the same as for the previous week. ‘The increase in pneu-
monia mortality was more than compensated by the decrease
in deaths from the more directly controllable diseases, and
notably from those of the intestinal tract, such as acute in-
testinal diseases and typhoid fever.

INDIANA.

Sanitarian Appointed.-Dr. T. Victor Keen has been ap
pointed city sanitarian by the Indianapolis Board of Health.
Che board will equip a laboratory for the chemical and bae
teriologic research work of Dr. Keen.

Takes Strychnin by Mistake..-Dr, H. M. Connelly, Shelby
ville, who has been in ill health for a long time, recently took
strychnin in mistake for other medicine. He became violently
ill, but his life was saved by prompt medical eare.

Pre-Medical Examinations._On September 15 and 16. the
State Board of Medical Registration held an examination at
Indianapolis of applicants tor admission to the medical colleges
of the state whose preliminary education had been outside of

week were

the regularly accepted sources.

IOWA.

Hospital for Poor and Oid.—.\. W. Buell, Mount Pleasant,
has donated a building and grounds of ten acres in that city
is a home and hospital for the aged.

Physician Re-located.—Dr. Alonzo Kk. Rodgers, formerly ot

Stanhope, who was contined in the Tipton jail for several
months on a charge of forgery, which at the trial was shown

MEDICAL NEWS.

S99

to have occurred through a misunderstanding, has been re
leased and will practice at Homer.

Jury Trial for Inebriates.—On the completion of the new
state hospital for dipsomaniacs at Knoxville, the authority te
hear and pass on cases of dipsomania will be taken from judges
and in each such case a jury will decide whether or not the in
dividual is a fit subject for commitment to the hospital.

New Rules for Diphtheria Quarantine.—The State Board ot
Health has promulgated the following rules regarding the quar
antine limit after diphtheria:

Quarantine shall be released in those houses in which diphtheria
has been diagnosed when synchronous cultures taken from the
noses and throats of all infected persons quarantined show tw«
consecutive negative examinations, providing the regulation of the
hoard regarding disinfection and fumigation have tirst been com
plied with.

Those who have been quarantined with diphtheria patients may
be released from quarantine when both nose and throat cultures
on examinaticn by a bacteriologist of the state board of health do
not show the presence of diphtheria bacilli.

In districts where it is not possible or desired to use the
laboratory findings as a means of regulating quarantine, those suf
fering from diphtheria shall be quarantined for a period of not less
than four weeks for initiai symptoms where antitoxin is used, and
ive weeks where antitoxin is not used.

LOUISIANA.

Generous Donation for Italian Hospital.—Capt. Salvatore
Pizzati, New Orleans, has given $250,000 as the nucleus of 4
fund for the establishment of a hospital for Italians in New
Orleans.

Medical Student Dies.—E mile Hussey, New Orleans, a medica!
student at Tulane University, died September 1, as a result of
injuries to the spinal cord received while diving into shallow
water at Bay St. Louis, in July last.

Health Board Matters.—The St. Bernard Board of Healtt
assembled, September 6, and organized with Dr. Louis E. Fon
druat as chairman and ex-oflicio health officer. On Septem
ber 6 Drs. J. A. Harper, J. F. Polk, and Phau R. Outlaw were
elected members of the Slidell Board of Health.

MARYLAND.

Faculty Honors Osler.—The Medical and Chirurgical Faculty
of Maryland, at its semi-annual meeting in Ocean City, Sep
tember 9, authorized the president to appoint a committee te
take marked action in regard to the departure from the state
of Dr, William Osler. A portrait of Dr. Osler is to be painted
and placed in the hall of the faculty in Baltimore.

Personal.—Dr. Herbert L. Rich, of the science department of
Western Maryland College, has been made a resident physiciar
of the Tome Institute, Port Deposit. Dr. J. B
Schwatka returned from Europe September 16. Dr. Herman
Bruelle has gone on a southern trip, and will visit Fredericks
Dr. William Hewson Baltzell will spend the winter it

Jaeob

bure.

Rome.
Baltimore.

Lowered Mortality.—The mortality rate last week was at

the annual rate of 15.48 per 1,000, viz.: white, 14.00; colored

ooo

2 for the previous week the respective rates were 20.47
16.95, and 39.62 per 1.000.

The course at the College
September 30,

College Opens. of Physicians and
Surgeons will open the evening of
address by Prof. Wm. Royal Stokes, who will speak on “Some

if the Great Achievements of the Last Century.”
MASSACHUSETTS.
Surgical Building Offered.—The Brockton Hospital Corpora
tion has accepted a surgical building donated by Hen. Willian
L.. Douelass, to cost $22,000.

Alleged Counterfeiter Held.Dr. Frank Sanft, at
house in R xbury $10,000 in counterfeit money was found, has

with an

whose

been held to the grand jury.

Hospital Building Permit Granted.
eranted to the Waltham Hospital Association to build a two
story concrete building, to cost $25,000.

Member Expelled.

Pittsfield, and now

Permission has beet

Dr. George S. Hatch, Boston, formerly ot
a fugitive trom justice, was expelled fron

the Berkshire District Medical Society at its meeting last
month.

Imprisoned for Refusing Vaccination._\ resident of Nort!
\dams js serving a sentence of eight days in the House of Cor

He will not only have té
serve out his time, but, in accordance with the rule of the insti

rection for refusing to be vaecinated.

tution, must be vaccinated.

Leicester, has retired on
health Dx. Nathaniel Wallis, Fitch-
\ustralia Dr. Julian D. Lucas,
medical offiver of the

Personal.—Dr. Charles G. Stearns,
impaired
start fo
(‘helsea, has been made assistant to the

wcountl ol
urge. will

soon

port of Boston. Dr. William L. Smith, Worcester, has been

ippointed honorary physician to the Shah of Persia. Dr.

John A. Bruce, Everett, is taking a four months’ tour of Europe.
MICHIGAN.

Fire Loss. \t i fire whi h at one time threatened to de

stroy all the business section of North Branch, the office of Dr

\Ibert E

nsurance was earried,

Weed, with its contents. was entirely consumed No

the examination for entrance to

received
liplomas from high sehools or colleges, was held in

Pre-Medical Examination.
Michigan medical colleges, for students who have not
0 Detroit,
September 14 and 15, under the direction of the Michigan State
Board of Registration in Medicine.
Diseases. Meningitis
whooping cough at 24
diph-
places; smallpox at
and consumption at
1 place less; whoop
6 places more;

The Most Dangerous Communicable
vas reported during August at 7 places;
at 26 places;
fever at 74
161 places,

pneumonia measles at 38 places;

it 66 places: scarlet
wes: typhoid fever at
Meningitis was reported at
ne cough at pneumonia at

neasles at 35 places less;

10 places more:
diphtheria at 9 places more; searlet
fever at 4 places more; smallpox at 10 places less; typhoid
fever at 88 places more; and consumption at 7 places more in
\ugust than in July.

Comparative Disease Prevalence.— For \ugust, 1904, compared
vith the average for August in the last 10 vears, pleuritis,
smallpox and diphtheria were more than usually prevalent;
ind cholera infantum, dvsentery, intermittent fever, erysipelas,
remittent fever, whooping cough, pneumonia, measles, and in
ammation of brain were less than usually prevalent. This
essened prevalence was probably due, in great part, to the
lower than average temperature during the month. So far this
vear, in Michigan, the average temperature each month has
been lower than the average for the ten vears preceding.

August Mortality of Michigan.—There were 2,593 deaths
luring August, 83 more than in the previous month. The
leath-rate was 12.1 per 1,000 population. By ages there were
976 deaths of infants under 1 year of age, 199 deaths of chil-
lren aged 1 to 4 vears, and 677 deaths of persons J
years and over. Important causes of death were as follows:
fuberculosis, 190; typhoid fever, 41: diphtheria, 20; scarlet
tever, 7; measles, 3; whooping cough, 7; pneumonia, 56; diar
rheal diseases, under 2 vears. 351: meningitis, 29; cancer, 134,
ind accidents and violence, 203. The mortality from typhoid
fever and diarrheal customary

ine rease,

aged 65

diseases showed the seasonal

MISSOURI.

Medical Schools Open.—University Medieal College, Kansas

itv held its opening exercises September 6, and Central
Medical College and Ensworth Medical College, St Joseph,
eptember 15.

Gift to Hospital Fund.--The St. Joseph’s Orphan Society, a

‘haritable organization of JelYerson City, has given all its
issets. amounting to $2,298, to the new hospital of the Sisters
f St. Mary, now being erected at Jefferson Citv. at a cost of
$75,000.
Epidemic at Wien.
lvsentery has been raging for six weeks among the children
f Wien, Chariton Fifteen children
many are seriously ill. The State Board of Health is making

istrict investigation into the nature of the disease.
Personal._-Drs. Frank L. William J. Loler
1ave been appointed assistant physicians at the St. Louis
Insane Asylum. Dr, Joseph F. Robinson has been re-elected
superintendent of State Hospital for the Insane No. 3, Nevada.
Dr. F. L. Sutton, Sedalia, has returned after an absence of

t year on account of ill health, and has resumed practice
Dr. John R. A. Crossland, St
an altercation with

An infectious disease resembling tropical

County. have died, and

\Whelpley and

Joseph, was recently shot in the
‘ourse of a brother practitioner He will

ecvover
NEW YORK.

Personal. Dr. Wallace Clarke, Utica. has been appomted by
the State Commissioners of Health a smallpox expert in his de

4

partment Dr. Clarence \

Potter, Gowanda, has been ap

OO VEDICAL NEWS.

Jour. A. M., A

pointed first assistant physician at the Gowanda State Ho-
pital.

Buffalo.
Personal.-_Dr. Charles G. Stockton has” returned fron
Kurope Dr. Emil S. Tobie will soon sail for Europe. eT

John Hauenstein, oldest practitioner in the city, recently cele
brated the seventy-third anniversary of his arrival in Buffalo

Dr. Francis EK, Fronezak was re-elected general medica
examiner of the National Polish Union at its last convention

Vital Statistics of August.-The monthly report of the d«
partment of health for August shows an annual death rate
of 15.57 per 1,000. The principal causes of death were: Con
sumption, 40; infantum, 67; typhoid fever, 4; de
bilitv, 30; eancer, 18; apoplexy, 16; meningitis, 11; valvular
heart disease, 2: appendicitis, 9; diarrhea, 15
dysentery, 10; enterocolitis, 15; gastro-enteritis, 25; ileoco
litis, 10; nephritis, 14. and violence, 31. The total deaths for
\ugust were 487, as compared with 538 deaths for August
1903.

( hi lera

pneumonia, 17;

Scarlet Fever from Infected Milk.—An epidemic of scarlet
fever has oceurred which is directly attributable to milk sup
plied to the families. This milk is supplied by the Certified
Milk Company from dairies in Elma. ‘Two years ago these
dairies were inspected by a number of Buffalo physicians, who
refused to certify that the milk as then handled was cleanly
In this present epidemic it has been tound that the danghters
of the man who milks the cows has scarlet fever, and that
the son of the proprietor of the dairy also had the disease
The health authorities have stopped the further supply of
milk from this source and reported the matter to the State
Department of Health, which has jurisdiction. State Health
Inspector Dr. Johnson of Albany has arrived to make an in
vestigation of the scarlet fever epidemic. Dr. Henry R. Hop
kins, in an open letter to the Buffalo Express, holds the healt}
commissioner to blame in that he allowed the sale of infected
milk when the milk register inaugurated by the former health
commissioner showed a number of scarlet fever cases on the
milk route of the Certified Milk Company. It is deplorable
that the health officer of Elma did not stop the supply of milk
from the infected dairy at Elma as knew that
scarlet fever existed on the premises. One death has already
occurred, it is claimed, as a result of this infection, that of
Mrs. Sicard. A further epidemic of scarlet fever in which 10
cases have already occurred has been traced to the milk sup
plied by another dairy. The sale of this milk has been
promptly stopped by the health department.

New York City.

Pasteurized Milk Stations Closed.-lhe summer season ot

Nathan Straus’ pasteurized milk depots has closed. During

the summer 2,149,194 bottles were distributed, and more than
800,000 glasses of milk were sold in the parks and recreation

soon as he

piers.

Bellevue Doctors Want Men Servants.—The president o!
Bellevue Hospital Medical Board recently issued an order that
hereafter should be employed as servants for the
hospital internes. The 44 physicians and surgeons interested
have made a formal] protest asking the president to revoke his
order.

Better Pay at Bellevue——To obtain better service from a
better class of men, the pay of orderlies at Pellevue Hospita!
has been raised to $30 per month, and each will be held strictly
accountable for the accuracy of his work. It is hoped that this
with many complaints of ill treatment at this

women

will do AWAY
institution.

Contagious Diseases..-In the ended September 12
there were reported 391 cases of tuberculosis, with 139 deaths:
176 cases of diphtheria, with 25 deaths; 146 cases of typhoid
fever, with 21 deaths; 60 eases of scarlet fever, with 2 deaths:
40 cases of measles, with 8 deaths; 2 cases of varicella and 15
deaths from cerebrospinal meningitis.

W eck

\lexander Lambert has Canada
Dr. James R. Healy has recently under

Personal.—Dr. gone to

hunting.

moose

gone a serious operation at Roosevelt Hospital, and is now
convalesing Dr. H. Holbrook Curtis arrived from Europe
September 17. Dr. Follen Cabot, Jr. has been appointed

genito-urinary surgeon to the City (Charity) Hospital.
Bequests._-Under the will of the late Solomon Gerber the

Lebanon Hospital and the Home tor Aged and Infirm Hebrews

Under Dr. Henry Tuck’s
telief of Widows and

each received a bequest of $250.
will the New York Society for the

Sep. 24, 1904. MEDIC
Orphans of Medical Men of New York City, the Society for
the Prevention of Cruelty to Children and the New York
Charities Organization Society were the recipients of generous
legacies.

Begin to Fight Trachoma.—'The board of health inspectors
have begun the work of examining the eyes of all school chil
dren for trachoma. Every child affected with the disease is
kept from school until an operation has been performed o1
treatment initiated. A new trachoma hospital has
opened where the operations will be performed by the depart
iment free of charge.

been

Physicians’ Aid Association Prosperous.—The recent report
of the New York Physicians’ Mutua] Aid Association, now in
its thirty-fifth year, shows the organization to be in a very
prosperous condition, with a membership of nearly 2,000. The
association has on hand a permanent fund of nearly $50,000.
Much good has been done in relieving its members during
periods of illness, and in paying the families of deceased mem-
bers $1,000 each.

Cornell University Medical College.—Dr. Frederick Whiting
has been appointed professor of otology vice Dr. Gorham
Bacon, resigned. Dr. Adolf Mever has been appointed pro
psychiatry vice Dr. Allan McLane Hamilton, re-
Many students are registered for the coming first
The campaign

fessor of
signed.
year class to begin work on September 28.
carried on so vigorously in the medical press for better pre
liminary education is beginning to bear fruit, for 78 per cent.
of those applying present evidence of having studied chemistry
ind physics.

Druggists Protest.—Committees of druggists have been ap
pointed to wait on Commissioner Darlington and ask him to
rescind or modify his recent ruling that pure ecarbolic acid must
not be sold except on the presentation of an order from a
licensed physician. The druggists claim that the health de
partment is usurping the functions of the State Board ot
Pharmacy by amending the sanitary code so as to regulate
the sale of poisons. This move is also viewed with alarm be
cause it ean not be seen where the commission may stop. If
it is permitted to discriminate in regard to carbolic acid there
would be nothing to prevent its making regulations in regard
to the sale of opium, morphin, cocain, or even whiskey or beer

PENNSYLVANIA.

Nominated for Congress.—Dr. Salem Heilman, Sharon, has
been nominated as Democratic candidate for congress.
Dr. George D. Morton, Moores, has been named a
Hf. Schneider, de

Personal.
member of the board of health, vice Dr. A. C.
veased,

New Staff Members at Reading Hospital.-Dr. Harry F

Rentschler has been made assistant physician, vice Dr. John
Shartle, resigned. Dr. Frank G. Runveon has been nomin
ited as assistant to Dr, William S. Bertolet. Drs. Fred

L. R. Mattern and George W. Overholser were made assistant
physicians,

Charged with Illegal Practice.—Drs. Denston.
Emilie D’Antonio and Guiseppe Villone, Scranton, have had
warrants issued for their arrest on the charge that they
violated the act of 1893, which provides that every physician
practicing medicine in Pennsylvania shall have a certificate
from the State Board of Examiners and that this certificate
shall be shown to the prothonotary of each county, who shall
register the physician.

Joseph LU,

Philadelphia.

Bequest.—By the terms of the will of Amos Wert $5,000
is given to the Methodist Hospital to provide a free bed to
be known as the “Wert bed.”

Physician Robbed.—Dr. Berthold Trautmann’s residence was
entered by burglars, September 13, who secured a_ large
imount of clothing, a watch and a moderate sum of money.

Personal.—Dr. and Mrs. Donnell Hughes, Dr. and Mrs. George
C. Stout. and Dr. and Mrs. Charles P. Nobie, have returned
home after spending the summer in Europe. Dr. W. L. Rod
man has removed his residence and office to 1904 Chestnut
Street.

Germantown Hospital-—The new building of the German

town Ilospital for the treatment of private patients has been
completed and was opened for inspection September 12. The
building is a three-story brick and stone structure, and has
accommodations for 25 patients.

‘AL NEWS. 901

Pink Eye Prevalent.—An epidemic of pink eye prevails 1
the northwestern part of the city, particularly among schoo
children, On account of the highly contagious character of
the disease, medical inspectors from the Bureau of Healt!
have been detailed to inspect the schools and suspend al
afflicted children.

Work at Hospitals.—In the Presbyterian Hospital 405 pa
tients were admitted and treated during August. In the dis
pensary 2,744 patients were treated. Thirty-four patients
were admitted to the Howard Hospital and 1,033 were treatec
in the dispensary. Sixty patients were admitted to St
Timothy’s Memorial Hospital, and 161 were treated in the out
patient service.

Health Report.

abatement, the report for the week shows the presence of 134

The prevalence of typhoid fever shows mn

cases, an increase of 34 over the previous week, with 15 deaths
There are only
four wards in which no new cases were reported. The total
number of deaths for the week was 408. an increase of 8 over
last week, and a decrease of 10 compared with the correspond

an increase of one over the preceding week.

ing period of 1903. In all there were 254 cases of contagious
disease reported, an increase of 29 over last week.

Work of City’s Bacteriologic Department.
lishment of the bacteriologie laboratory in 1897, 32.878 Widal
examinations have been made, representing 28,375 cases of
typhoid fever. Statistics show that in 1894 when the use of
antitoxin went into effect, 33.3 per cent of the eases of diph
theria reported to the Bureau were fatal. Since the use of
the agent has become more general in the city, the mortality
Last year a mortality of only 17.1 per cent
Was reported. Since 1896 there have been 38.981 doses of
antitoxin distributed by the city. The milk report of the
department for July and August of this year, shows that in
July 15,447 quarts were examined; 8,679 quarts were con
demned, and 5,958 quarts were infected. In August 194.58]
quarts were examined, 6,400 quarts were condemned, and 3,449
quarts were infected, making a total of 352,028 quarts exam-
ined, 15,079 quarts condemned, and 9,407 quarts infected.

GENERAL.

Typhoid in Winnipeg.—The number of typhoid patients in
the Winnipeg (Man.) General Hospital one week ago num-
bered 130.

Panama Canal Hospital.—New Orleans is to be the site of a
hospital built by the United States Government for Panama
Canal patients.

Lack of Physicians for the Poor.—It is stated that the
reduction in the force of government physicians in Hawaii has
return on the part of many natives to the witch
the death rate is increasing.

Since the estab

is much lower.

eaused a
doctors and that

The Dental Congress.—At the Fourth International Dental
Congress held at St. Louis, September 1, a gold medal was
offered for the best pauper. Ten papers submitted
Willoughby D. Miller, Berlin, received the
and Eugene S. Talbot, Chicago, received honorable mention foy
the seeond and third best papers.

were

Germany, medal,

Foreign Visitors —Among the noted medical men from
abroad who are speakers at the International Congress of Arts
and Science at St. Louis are Dr. Ronald Ross, Liverpool; Dr
Shibasaburo Kitasato, Tokio, Japan,and Dr. Theodore Escherich
Vienna. Dr. Ross, the great authority on malaria, will visit
Panama and Jamaica before returning to Europe. While Dr
Escherich was in Albany, N. Y., a reception was given in his
honor by Drs. Henry L, K. Shaw and Andrew MeFarlane
September 12, and on the following evening Dr. Albert Vande
Veer gave a dinner in his honor at the Fort Orange Club. hh
Chieago, Dr. Escherich Medical and
Chicago Pediatric societies, and was given a banquet. He als¢
made an address in the amphitheater of Cook County Hospital
While in Chieago he was the guest of Dr. A. C. Cotton, whe
gave a reception in his honor. Dr. Kitasato, the famous bac
teriologist of Japan, received a very warm greeting in Hono
lulu. The Hawaiian Territorial] Medieal
a reception and banquet, and there were other functions in his

addressed the Chicago

Association gave hin
honor

THE RECENT ARMY MANEUVERS.
Field Practice for the Army Medical Department
(From our Special Corre spondent.)
The recent maneuvers in Virginia have attracted much pubh
interest, both because the number of troops participating v

ar larger than has ever before been assembled in this country
n time of peace for such a purpose, and because the extensive
trea covered by them embraced the historic fields of the first
ind second battles of Bull Run.

ihe operations of the medical department of the two nan

uver divisions, the’ “Blues” and “Browns,” which together
nustered 26,000 men, presented several features of interest Che
nedical organization comprised the regimental dispensaries,
ield hospitals, and a base hospital for each army. ‘The fune
ion of the regimental dispensaries was to render first aid on

he march and in battle and to treat in camp the mild cases

hich did not require transfer to the base hospitals. The
versonnel of these was, for the state troops, furnished by thei
mwn medical officers and hospital corps men, and they brough

vith them the medical equipment furnished by their respective

states Many of the regiments had the new U. S. Army reei

nental field chests and pouches recently issued to the states
inder the previsions of the Diek militia bill. while, in the eas«
ft others, the n edical « juupment yas ore or less obsolete o1
vanting. Some regiments brought sureeons. but no hospital
|
orps men: “broom handles, but no brooms.” There were two

tield lospitals and two ambulance con panies Or eacn army.

These were manned and equipped, as were the base hospitals.

wv the Medival Department of the Regular Army, although

surgeons and hospital corps men were taken from such militia

regiments as could spare them, and attached to these organiza

tions for purposes of instruction and to fill up as far as possible
heir shortages in personnel.

The field hospitals are mohile orear Zations, which march
vith the troops, there being theoretically one for each brigade.
Their function is to give temporary care and shelter to the
vounded after battles until the ean be transferred to a
stationary or base hospital here can be found the rest and
laborate equipment which field hospitals ean not afford

The ambulance company is in battle the connectine link be
ween the regimental dressing stations on the line of battle
ind the field hospital] in the rear. The widely extended order
ft modern tacties and the great: range of rifles and artillery

nake this gap a broad one, and the duties of the bearers and

im!

uulances correspondingly arduous In these maneuvers
the labors of the ambulance companies were, however, much
lightened by the military ardor of the soldiers desienated to
Nay the part of the wounded, for these, being unwilline to
eave the exciting scenes at the fr nt, in most cases concealed
heir tags in their pockets or dropped them behind a convenient
uush and remained in action. But though wounded were lack-
ing there were abundant applicants for seats in the ambulances
m the part of the undeveloped youths whose strength was not
qual to the burden of the blanket roll, rifle and haversack,
ind who strewed the roadsides during the first maneuver.
iter these were left to guard the camps.

The two hase hospitals at Thoroneht ire and Manassas re-
spectively were models of complete equipment and orderly ad
ninistration. These received all serious cases of illness or in
jury which required treatment in bed. Each had the capacity
f a field hospital, namely, 168 beds, and while neither was
it any time full, several hundred patients were treated in
hem. including some severe cases of injury. such as fractim
f the femur, ulna, radius and clavicle, and one penetrating
zunshot wound of the chest caused by the paper bullet of a
ifle blank cartridge. The paper bullet usually, flies to pieces
it the muzz'e of the rifle, but in this case the weapon was dis-
‘harged nearly or actually in contact with the body of the
soldier and the conical wad penetrated the blouse, shirt and
‘hest wall in the region of the liver. There was severe shock,

}

ut under an aseptie occlusive dressing the wound has done
vell and the patient is expected to recover.

These maneuvers have been of the greatest educational value
o the medical personnel, beside affording an opportunity to
test the medical organization and equipment on a large seale,
Their value to the state treops would have been vastly increased
ould they have arrived in camp several days before the begin

ning of the field operations so as to have had an opportunity

to have gained coherence of organization by regimental and

MEDICAL NEWS. Jour. A. M, A.

brigade drills. This would also have afforded time for the in
siruction of the regimental medical personnel in their duties
\s, however, the movements began the day after the troops

assembled, no time was given for the regimental surgeons to

learn their place and function in the scheme of medical organ

ization, and some lack of co-ordination was the natural result

FOREIGN.

Plague is reported in Paraguay and the sanitary eondition-
are not such as to promise its ready extermination.

Italian Hospital Receives Gift.-—The Italian Hospital in the
City of Mexico has received $2,000) from = Wing Vietor En
manuel.

European Physicians Studying Yellow Fever in_ the
Americas. The French OMmMAttee Now mn Brazil consists of
Drs. Marchoux, Simoni and Salimbeni Dr. G. Coechi is 1
Mexico fon ve same purpose, delegated by the Italian eos

ernment. jhe Associated Press report for the week states
that there are only fifteen cases of the disease in all Mexico
and half of these are in the hospital at Vera Cruz. This is a
remarkably favorable showing tor the month of Septemben
ind demonstrates what has been accomplished in the way ot
preventive sanitation

Cholera in Persia. The Tribune Med, comments on the fact
that one province of Persia, ot Which Tauris is the capital
has remained tree from cholera during the epidemic that has
been devastating the country. ‘The crown prince resides there

'

and his physician was tt ined in the medical schools of Paris
They co operated to prevent the portation of the disense
establishing quarantine stations and a lopting the measures
necessary to stamp out the few cases known to exist. Phen
efforts were successful, and probably for the first time in his
tory a Persian city has passed unharmed through an epideimi
of cholera sweeping ove) the country. \ St. Petersburg ex
change sta Ihe death-
in Meschhed numbered 417 between July 26 and August 1
Refugees from this place have carried the disease into Russix

4
{

es that the disease is still spreading.

and a Cossack regiment at Merw has become infected, 9 death-
‘

in 53 eases being reported, amone the dead being the troo}
physician There have also been 9 deaths in 13 eases in the
town Phe shipping on the Caspian and t1 ivel on the centra

\siatie railroad is under medical inspection

DUBLIN LETTER.

Smallpox in Ireland.

Considering how widely distributed smallpox has been 1
England and Scotland during the past few years Treland is
fortunate in having escaped without any outbreak that could
receive the name of epidemie. Both Dublin and Belfast hac

1 considerable number of cases last year, but in neither city
did the disease spread to any great extent, and the number of
deaths was very small. This is no doubt due chiefly to the
very efficient system of vaccination practiced in Ireland, where
neither ‘conscientious obje‘tors” nor “antivaes” are known
This vear, while there is nothing in the nature of an outbreak
at any center, several cases of smallpox have been reported
from various towns throughout the country. In Armagh, a
town of seven thousand jnhabitants, there have been over
twenty cases, while in Drogheda, Monaghan, Castleblayney
and Dublin smaller numbers are reported. The infection
seems to have been imported from Glasgow to Drogheda and
\rmagh, whence it has spread to the other places mentioned

The Queen’s Colleges.

The annual reports from the presidents of the Queen’s Col
leves of Belfast and Cork, which have recently appeared, give
evidenve of increased activity in both those institutions. In
Belfast, in particular, advance, during the past few years, has
been very rapid. Following on the establishment of the Royal
Victoria Hospital, and in part as a result of the opportunities
it gives for clinical work, the Belfast School of Medicine is
now one of the largest in the Kingdom. It is stated that the
number of students on the rol] this vear is greater than that
of any other school in Ireland, with the exception of the
Catholic University School in Dublin, while only two English
schools—Cambridge University and Guy’s Hospital—exceed it
The college in Belfast has recently received special funds to
provide tor pathologic research and teaching, in the endow
ment of a Musgrave chair and a Riddel demonstratorship in
pathology. In none of the Queen’s Colleges did the origina!
scheme inelude a chair of pathology, so that considerable diffi

Serr. 24, 1904. QUERIES AND
culty has been met in providing for the teaching of that sub
ject, but it has now been successfully coped with in all three
colleges. Great regret is expressed at the departure from
Belfast of Dr. Lorrain Smith, who has accepted the chair of
pathologic anatomy in the Victoria University of Manchester.
The president of the Cork College, Sir Rowland Blennerhassett,
has, in consequence of ill health, resigned his office. Ie was
given this post, for which he was little fitted, a few vears ago
as a reward of political services, but it occupied only a small
share of his time, as he spent most of each year on the
continent.

Sir Thomas Browne and the Medical Profession.

Che proposal which is before the public at present to raise
a memorial to the author of “Religio Medici” has roused the
wrath of Dr. Conolly Norman, the well-known alienist of this
eity, and he appears in the columns of the British Medical
Journal in the character of advrocatus diaboli. Whatever
claims Sir Thomas Browne has to the admiration of merely
literary people, as a great imaster of Fnelish prose, he has no
‘laim whatever, savs Dr. Norman, in effect, to the respect of
the medical profession. He is not a great physician, since he
is neither scientific nor humane. Koy proot of the first of these
charges Dr. Norman refers to Browne’s works and thinks the
charges jis justified, while the second charge is based on his
action in the trial of the women Demy and Cullender at Bury
in 1664, on the charge of causing fits in children by witehcraft.
“Sir Thomas Browne of Norwich, the famous physician of his
time, was in court and was desired by my lord the chief
baron to give his judgement in the case, and he declared that
he was clearly of opinion that the fits were natural, but
heightened by the devil, co-operating with the malice of the
witches, at whose instance he did the villninies.” Browne's
great influence turned the jury, and the women were con
lemned. Dr. Norman thinks that belief of this sort in an
educated man—a contemporary of Hobbes, Butler and Locke
Many lovers of
letters who demand thought as well as expression will thank
Dr. Norman for his very just depreciation of one of the most
over-rated persons in the history of literature

Death of Dr. Cranny.

Yet another of Dublin’s best-known surgeons has died
Within the last twelve months no less than five —Croly, Smv!]
Meldon, Haves, Cranny
been removed by death.
man, was assistant master in the Rotunda Hospital, but of
late years had devoted himself altogether to surgery, and for
many vears before his death was on the surgical staff of Jervis
Street Hospital. For some years past he had been in bad
health, but his death came nevertheless as a shock to his many
friends

leprives him of respect from men of science.

\
livine within a stone’s throw, have
Dr. John Joseph Cranny, as a young

Queries and Minor Notes.

ANONYMOUS COMMUNICATIONS Will not be neticed Queries for
this column must be accompanied by the writer's name and ad
dress, but the request of the writer not to publish his name will be
faithfully observed

CONTRACT PRACTICE

\ physician of West Virginia writes us in regard to contract
sractice, and states that he has never been satisfied ‘that it was an
altogether ethical practice for a reputable practitioner to engage in
This system is much in vogue in my locality and throughout the
nining section of our state. The company or contract physician at
the mines agrees for the sum ef 50 cents per month for single men
and $1.00 per month for men with families to furnish them the
necessary medicines and medical and surgical attention The com
panies hold back out of the wages of their employes the above men
tioned amounts and turn it over to their physician, less 10 or 20
per cent. for collecting.”” He goes on to say that “this system
might be considered a blessing to a very improvident class of peo
le, but I have always thought it was prostituting the practice of
the profession too far It seems to me it would be more in Keeping
with the dignity of our professicn to let them call on whom they
please, when needed, and pay aecordingly Your opinion in the
Queries and Minor Notes’ column would be appreciated.’

ANSWER From a professional standpoint, nothing good can be
said for the so-called “contract” practice to which our correspondent
refers. Those who undertake it cheapen the public estimate of our
profession. In a few instances county societies have adopted by

laws against the practice, declaring it to be unprofessional conduct

'

would 1
ties would

practice there is “nothing in it’’

quate Ce mpensation, nothing attractive A strike cuts it short;
corporation shares the income, without adequate pretext Analyze
the practice is merely a poorly modificd form of health insurance
or, as our British confréres call it, “club practice.’ rhe meth
utlined above, which is the one usually followed, is bad The d
or sells himself cheap. the employes get what they pay for
no more A much better method, not so profitable to the orpo!
n, nor so degrading to medicine, would be the creation of a
und by an assessment on the employes, collected monthly
ompany Wwithort charge fhen a minimum but fair scale
ees for definite services should | agreed on and the physiclar
paid accordingly, each emplove to select Whomsoever he pleases. ¢
e n time of epidemics r disas asses n \ d
ere nd in helathy periods would recede, but this 1 be eq
ed by an average assessment to ver all conditions It is hig
tim hat our profession insisted on the universal adopt in
pora n company practices some such plan as tl and tl
e to it that no recognized physician underbids his fellow I}
vy no mepns Utepian. Some corporations have voluntarily ado
plan similar to this. contributing regularly h \ to
d, and the result has been itistace i \ i at
might be taken up bys ul societies ta ted
LIQUOR FERRI ALBUMINATI
\ ( rrespondent Ci lls 1 tention an ibstract I par i ae
THE JOURNAL, April 26, 1802, in which an author qj qd S
¢ th the standard liqu erri albuminati of the Norwegia
Pharmyvcopeia is the best means of administering iron, and d
o know the formula and the method for its preparat
ANSWI here is no formula for this preparation in the Norwe
vian Pharmacopeia There is a formula in tl Danish I’
rela (1895), but it is an exceedingly poor Phe itest S lis
Vharmacopeia (1901) vives the followit ‘ n rmula: 11
by weight in grams:
Dried egg albumin 41)
si ion sodium hydroxid
= n ferrie chlorid (50° pe it 120
(rlycerin 10
Alcohoj : 100
Cinnamon water, alcoholic, 10° per n 150
{rema tincture ae y
})is d water o make LOooo
rhe egg albumin dissolved by shaking in mix {f 2 grat
tl seda solution and 1,000 of water heated ¢
standing 24 hours the solution is decanted and stra (
ed td ¢ s slowly | ed, with mstant s y
xture « e ferric chlorid ution and the wate TI
precipita is coilected and washed with tepid w ti he
nes idified with nitric acid, are only slightly opalescent
er nitra | ed to drain and then mixed with 60
\ ch the maining © grains soda soiution has previ y
ded Ihe xture is then heated on the wate! t St) ¢
wed to cool, when th ulecchol, cinnamon wate nd
meture ireé dded ogether with wate oO Thak 1000 gran !
tion represents 4 per mille iron It must he kept in bott
otected against ligh
PHYSICIANS’ CARDS
FREDERICKTOWN, OHIo, Sept. 5, 1904
lo the Editor: —Viease inform me, through “Queries and Min
Notes,” the proper form for cards for medical men-—not for bus
s, but for social purposes E. V. A
ANSW This wholly a matter of individual taste rhe f
ving forms are merely suggestive, are acceptable anywhere
DR. JOHN Dot
IAMES JOINSON, M.D
2735 INDIANA AVI
Dk ALBERT SMITII
» Pennsyv'y \\ NI YoRK CIry
OSCAR O. JONES, M.D.,
NeW Onis
e above forms are social on Business cards may | err
ent office and residence addresse lephone numbet md
EXAMINATION OF MILK
RADCLIFFE, Iowa, Sept. 14, 1904
To the Editor Will yo plea inform me where I can i
Labcock's Method of Examination of Milk,” or state how t
reentage of fat Is obtained by him’
ITA. I’t A.B., M.D
\ Wi Send for eighth Report of the Wisconsin Agricul

xperiment

lot be a

MINOR NOTES.

ad thing

do likewise For the man

Station

Madison

Wis

who

no future,

1 al

undertakes

no satistactk

unt
in

ny,

V s I
hh i
no !

’

ABSENCE DOES NOT INVALIDATE LICENSI

De Ponesr, Wis., Sept. 10, 1904
Evditor:—1 graduated from the College of TP. and §&.,
Chicago, in 1886, cbtained a medical license and practiced part

lo the

f the same year in Chicago, but not since Would the same
icense permit me to legally practice in Illinois now Ve

ANSWER Yes

Marriages.

Lewis C. Dow, M.D.. to Miss Alice Lillie. both of Marion,
lowa, September 19.

Wittiam J. Awry, M.D., Moorhead, Minn., to Miss Ethel

ord of Charleston, Il.

RALPH CLINTON CUPLER, M.D., to Mrs. Isabella Larkin, both
! Chicago, September 1.

C. GRAHAM DoLp, M.D., to Miss Linda Peyton Manly, both

1 Lexington, Va c Septemben -

Murpocn BANNISTER, M.D., to Miss Neola Winona Williams

woth of Ottumwa, lowa, September 7

GARLAND Ligutrroor Mor is, M.D.. Miss Marie Louise
Rice, at Manchester, Va., September ‘-

JAMES CLAGETT ROBERTSON M.1D.. \liss Watherine§ |

rroppel, both of Baltimore, September 14

Joserpn L. ABELN, M.D., New Vienna, lowa, to
Luthmers of Dubuque, Iowa, September 6.

\liss Anna

\insworth, lowa, to Miss Olive
September “48

llowarp B. HAMILTON, M.D.,
MeClenahan of Monmouth, HL,

Marrin L. Brooksirer, M.D.,
Josephine Beier of Weldon, Ill. S« pteniber 7.

HoRACE WARDNER EGGLESTON, M.D., to Miss
Dunn, both of Binghamton, N. Y., September 8.

Miss

Graymon

Mable May

JAMES McCann Sropparp, M.D., Kennard, Ind.,
Kunice Palmer of Anderson, Ind., September 7.

\. BeRNARD KuuL, M.D., Walnut, Iowa, to Miss
Munechrath of Davenport, lowa, September 12.

SAMUEL W. Husron, M.D., Perry, lowa, to Miss Elizabeth J
Owen of Columbus Junction, lowa, September 13.

to Miss Ruby

Elizabeth

WILLIAM DUNN PoWELL, M.D., Harrodsburg, Ky., to Miss
Jane Cecilia Wise, at Leesbure, Va.,
M.D., of Apalachia, N. Y., to Miss
at Glen Burnie, Md., September 4.

September | 2

RAYMOND V. GLANN,
\melia Mewshaw,

DAVID Esre WraTueRtkaAp, M.D., Cincinnati, to Miss Clara
Virginia Yates of Covineton, Ky... at Chica
M.D., Morgantown, W. Va.. to Mis
H., September 7
Paul. Minn

September 14

0. sept niber 8

FRANK GRANT,
Emily Jenks Bray of Boston, at Wilton, N.

JUSTIN

KeETCHAM HAGAMAN, M.D., North St

Wilson Fagundus of Minneapolis.
Wittram HH, Htupson, M.D... Atehisor
Shreve of Chatham, Ont.. at Kansas City. IKan..
M.D... Harvard, lowa, to Miss Maliss¢

Belknap, lowa, at Shenandoah, lowa, Sep

(FEORGI

Miss Mary

Kan.. to Miss Esther

sep ember o

WititiamM Bay Sroker,

Shadlev of

)

leley

Deaths.

Alexander Trent Clark, M.D. Medical College of Virginia
wich l, 1869, vears chairman of the Llalifax

intv. Board of Health, and once a member of the State

Pol Priddy

Oard oO Medi i} | Yaininers, dit | at tis home mos muith B SLO.
)

i } von 1] : i.
i September 10, after an illness of several months, a

William L. Buechner, M.D. University of Giessen, Germany.
S53. one of the oldest pl wtitioners of Younestown, Ohio. and
{ September 11, 11

founder of the City Hospital, was drowned,

tb rum iv accident near Youngstown, it Which his” hors
ere over an embankiment and into a1 ine, aged 73
Charles M. Baker, M.D. Transylvania University Medical
eopartmient Lexineton., IN 1843. f nal vears a practi
ioner, and twice mayor of Henry, Ill., died at the Illinois

Vestern Hospital for the Insane, Watertown, of which he had
en an inmate for several vears, September 3, aged 82
Martin S. Kittinger, M.D. Colleve of Physicians and Sim
eons in the City of New York, 1853, surgeon with the Arm,

the Potomae during he Civil War, some-time president. ot

DRATILS.

Jour. A. M. A

the Niagara County Medical Society, died at his home in Lock
port, N. Y., September 11, after a long illness, aged 77.

Edward Payson Buffett, M.D. College of Physicians and Sur
geons in the City of New York, 1857, for many years visiting
surgeon at Christ’s Hospital and the City Hospital, Jersey City
N. J., died at his home in that city, September 9, from heart
disease, after an illness of seven months, aged 70.

John Cascaden, M.D. College of Physicians and Surgeon:
of Ontario, ‘Toronto, 1866, at one time representative for West
Kigin in the Ontario Legislature, died at his home in Dutton
Ont., August 31, after an illness of three months, aged 64.

James McCortney, M.D. Cleveland Medical College, 1853, one
of the oldest physicians of Davenport, Lowa, surgeon in the
\rmy during the Civil War, died at the home of his daughte)
in Chicago, September 8, from cystitis, aged 79.

Felix E. Schilling, M.D. Tulane University, New Orleans
1903, of Collins, Miss., died at the South Mississippi Infirmary
Hattiesburg, September 12, from typhoid fever, after an illness
of four weeks, aged 31.

George M. Kellogg, M.D. Medical College of Ohio, Cincinnati
1852, formerly of Carthage, IIL, and a lecturer for several yeai
in Neokuk Medieal College, died at his home in Pasadena, Cal.
\ugust 18, aged 75.

A. W. Butler, M.D. University of Tennessee, Nashville, 1905
formerly interne at the Nashville City Hospital, died suddenly
from nervous collapse, September 6, at his home in Nashville
aged 24.

Charles Hinkle, M.D. University of Louisville, 1861, sut
geon in the Confederate service during the Civil War, died at
his home in Hinkleville, Ky., September l3; after a long illne ss
aged 66.

Harvey C. Chappelear, M.D. Cincinnatj College of Medicine
and Surgery, 1871, died at his home in Mount Sterling, Ohio
14, after a long invalidism, from asthma,

James R. Kelch. M.D. Starling Medical College, Columbus
Ohio, 1864, assistant surgeon of the 155th Ohio Volunteer In
fantry in the Civil War, died suddenly at his home in Tarlton
Ohio, Se ptember 4, from heart disease, aged 70.

Richard J. Ough, M.D. University of the Queen’s College
Ont., 1869, supreme physician of the United Order of
Foresters, died at his home in Chicago, September 11, aged 65

Emery F. Redfern, M.D. Ohio, of South Perry, assistant
surgeon in the 90th Ohio Volunteer Infantry in the Civil Wat
died recently, and was buried at South Perry, September 4.

William M. Gough, M.D. 1848
surgeon in the Confederate service during the Civil War, died
at his home in Los Angeles, Cal., September 7, aged 79.

Christine Anderson, M.D. University of
nent of Medicine and Surgery, Ann Arbor,
home in Detroit, Mich., August 29, aged 40.

|

Charles Walton Chaffee, M.D. College of Physicians and Su
reons of Toronto, 1883, died at his home in Toronto, Ont.. May
’6, from pneumonia, after a short illness

H. H. L. Yeargan, M.D. Transylvania University Medical De
partment, Lexington, Ky., 1846, of Barefield, Tenn., died at his
home in that place, September 5, aged 54.

Alfred L. Keene, M.D. Jefferson Medieai College, Philadel
phia, IS888, died at his home in Lancaster, P

trom heart disease, aged 43.

P. W. Crum, M.D., died at Boreess Hospital, Kalamazoo
Mich., six months after a fall in which he fractured his hip

Sept mber 2, aged 91.

J. Maude George, M.D. Woman’s Medical College, Philadel
phia, a medical missiouary in China, died at her station it
\lacao, September B

S. Sylvester, M.D. University of the Victoria
Coburg, Ont., 1878, died suddenly at his home in
\pril 2, aged 46.

Isaac Pankake, M.D. Medical College of Ohio, 1886, a member
of the American Medieal Association, of Frankfort, Ohio, died
recently.

Robert S. Cheffey, M.D. College of Physicians and Surgeons
of Ontario, Toronto, 1871. died at Toronto, September 11
aged 77.

George \ Smith, M.D. Jefferson Medical College, Philadel
phia, 1850, died recently at his Groveport,

aged 79

sept embei

Coburg,

University of Louisville,

Michigan, Depart
ISSS8, died at her

a., September 6

College

Montreal

home in Ohio

SrEpr., 24, 1904. BOOK

Paul E. Malmstrom, M.D. University of Lund, Sweden, 1590,
lied at his home in Kenosha, Wis., September 13, from heart
lisease.

James K. Griffin, M.D. Columbus (Ohio) Medical
1878, died suddenly at his home in Fitzgerald, Ga., September 7.

Frank M. Reasner, M.D. Cleveland Medical College, 1865, died
if his home in Los Angeles, Cal., September 11, aged about 70

Francis X. Spranger, M.D. Ohio, 1864, died suddenly at his
ome in San Jose, Cal., from apoplexy, September 3, aged 61

Thomas E. Morris, M.D. McGill University, Montreal, 1899.
lied at his home in St. John, N. B., September 8, aged 30.

Willis Duff Green, M.D. \iedical College of Ohio, Cincinnati.
i844, died recently at his home in Mount Vernon, Il.

Albert M. Loop, M.D., » member of the Medical Society of the
State of Pennsylvania, died recently at Nelson, Pa.

John T. Smith, M.D., died at his home in Cedar Rapids, Lowa,
September 2, after an invalidism of ten years.

W. E. McBryde, M.D., dicd at his home in Colmesneil, Texas,

from congestion of the brain.

( ollege.

September 3,
William H. Colvin, M.D. illinois, 1896, died at his
hicago, July 6, from pneumonia, aged 34.

John H. Stork, M.D. Kentucky School of Medicine, L888, d

it his home in Stendal, Ind., September 6.
Albert D. Moxley, M.D. New York, 1877,

his home in Jetferson, N. Y¥., August 1.

A. S. Hayhurst, M.D. Indiana, 1887, died recently at his
in Evansville, Ind., after a lone illness.
Thomas S. Lackey, M.D., 1849. died at his home in May ti

\y., September 12, aged S82,

James A. Taylor, M.D., died at his home in Wayne, W. Va

Septe nber 6.

home 1

died suddenly at

Book Notices.

ELEMENTS OF GENERAL RADIOVHERAPY FoR PRACTITIONERS liv

Or. Leopold Mreund, Vienna lranslated by G. IL. Lancashire, M.D
Srux., M.R.CLS. Eng.. L.R-C.P. Lond., Assistant Physician t
* \fanchester and Salford Hospital for Skin Diseases. With 107
lustrations in the Text and One Frontispiece. Cloth Pp. 538
9 Price, $5.00 New York: Rebman Co, 1904.
RADIGTHERAPY, PHOTOTHERAVY AND HIGH FREQUENCY CURRENTS
The Medical and Surgical Applications of Radiviogy in Diagnosis
ind Treatment. ty Charles Warren Allen, M.D., Professor of

Graduate Medical School. With
131 Engravings and 27 Plates. Cloth. Pp. 618. Price, $4.50 net
Philadelphia and New York Lea Brothers & Co,

The rapidly growing literature on the medical uses of th
|
i

Dermatology in the New York Post

radiant some of which we have but

recently become acquainted with, receives here important addi

various forms of force,

Freund's work must be regarded as authoritative and

tions,

fundamental, especially in so far as concerns the essential
The introductory chapters
m physics are more exhaustive than in the other books on
The technic of the practical

these forces is also comprehensively described.

scientific principles of radiology.

application ot

\ fully illus

radiotherapy.

trated supplement contains adequate descriptions of the various

instruments necessary for using high-frequency currents
v-ravs, heat and light ravs. The index is full and a

list of the authors quoted, and the page where each may be
found, together with the corresponding references, is given.
The indications for and results to be expected from the various
radiotherapeutic measures are discussed on the basis of the
existing literature, but we miss anv statements concerning tli
diagnostie value of r-ravs. We believe we may safely reco:

mend this book to anv one who desires to know the fund

mental physical laws underlying radiotherapy, as well as its
should he

is the man to whom we owe more than to any other the inti

practical application. It remembered that Freur

duction of the Roentgen ray in therapy. The work gives ever
impression of having a commensurate basis of personal theo

retical and practical work on the part of the autho

Dr. Allen’s book
trequency currents.

deals with the «-ray, light and high

Here the therapeutic and = diagnosti

NOTICES. GQ:

aspects are elven predominance, the nature of and laws gov

erning the forces emploved,
tention. It

receiving Comparatively little at
that

parts

has seemed to the reviewe there is an un

necessary diffuseness in some of the dealing with the

therapeutic results of the z-ray. Surely much of the infor

mation here given in regard to the individual cases cited might
]

well have been condensed into snialler space. Both the work-

ure adequately illustrated, Freund’s especially from the sid
of physics and instrumentation, Allen’s from the clinical. The
sugevestion may be allowed that the field for the works of thé

}

represented by

)
KING

these two books is now well covered bv
these and other recent publications; it would, therefore, be
better if as much energy and attention as possible’ were giver
to investigation of the many and important prol s of
heoretical and fundamental nature that are arising as a re
sult of the introduction of the physical forces considered {
medicine,
A REFERENCE HAND! < 4 Mi AL SCIENCES, Et ny
he Entire Range of Scientific and Practical Medicine and A ‘
- nee vy Various VW ers \ New iedi I < ) y Rev
d Rewrit " Mdited (Ibe H. M.D Vew \ ‘
\ ime VIIi Ilin ied by Cl molithog hs and 455 H
1 Wood Eneravings Clotl Ip. 7S4 ¥ $7.0
New York Wm. Wood & ¢ 1904
Chis volume completes this Issue OF the cerel
| ] | ¢
MOIS, Tn uded In LAs Vv une Is in Lpenain Veil !
lis rticies that [ron ! vu O] \ Lhel l (
I their regular posit . 2 tpl " tica )
‘ ; ;
mnpiete imaex occupying nearly two undred page
tumns to a page, closes thi rk his ind i
rm ore t vaitie = 3 nhaKkesS retere ( Bal 1} ir <
is \ In the rdmaryvy works arrange \ i
s one, it is not niron to the ’ ,
tr vettl ) l etanied imdex ts fils ( ! l
necessary, it is certainly ve convenient
In our notices of the volumes as they ea :
peatedly spoken of the exc ! nanne hicl s
ects re vered We have also called atte) n t
hat ile the handboo s published as a revised editio i
| l ame our s tw it\ yveours a Is } (
1 new bool \ v articles appear unaltered. a fe .
e modified but slightly from those appearing in the f ‘
1On 1 thre oreat ] lk have heer entire ( rl
ny s jects appea that ere not treated in he orme!
lition | work is a complete enevelopedia of moder:
nedicine, for so far as we are able to dis vel not ’ that
’ :
elongs to such a work is omitted. As ari the t re

considered in an exhaustive manner. and if published in ir

= } :
1d Ls no KS not a Tew of the arti les \"\ yuld he iecepted i
eF 1 1:
nplete monographs on the subjects treated, The editor is te

be congratulated on the good judement displaved in allott

le amount of space to be given to a given subject, not an

when the
CF ! Ile is to he

he writers for the

SV matte! vhole field of medicine had to be «
especially congratulated on his selection
different subjects. In nearly every it
stance the one selected jis an authorit on the subject on whi
ie writes,

thus guaranteeing reliability. The publishers are

] meratulated on their liberality in illustrating the work
ind on presenting it in such a satisfactory manner. from
This Reference
Handbook js a library of itself: at least, it makes a good foun
lation for

nechanical and typographical point of view

a complete library.

ADENOIDS By Wvoatt Winernave M TD...

Physician and

st, Central Lendon Throat and Far Hospital Cloth Pp. 128
Price. $1.00 net Chicago: W. T. Keener & Co 1904
In this little book of 194 paves are discussed clearly the

various phases of nasopharyngeal adenoids, a subject in which

the medical profession has taken an increasing interest. sine

he attention was definitely directed thereto by Mever in 1868
\denoids are des«ribed thoroughly from the anatomic. etiologic
ind clinical points of view. The operative treatment is given
ith adequate detail, and a special chapter by Holten Georse

We ean re

trustworthy enide to a

\ ith the subiect of anestheties ommend the

book to the

general practitioner as a

thorough understanding of the subject with

Which it deals

906 ik
Miscellany.

A Charity Patient. .\

iote that a woman was given $600 by her husband to pay the

French exchange relates as an anec

expenses of an operation which her physician had declared
necessary. She disguised herself as a poor wornan and applied
to the free public hospital, giving a false address, after having
hired the persons at the address given to testify in her favor
She then bought a
3600 which should have paid for her operation.

Growth of Bacteria in Salt Solutions.—F.
Strasburg tested a micrococcus and

if questions were asked. jewel with the

Lewandowsky of
a mesentericus from a veg
table salt

cent. solution of

On the other hand, they

‘table and reports that a 25 pet
nhibited the growth of the bacteria.
ontinued to grow apparently unaffected in saturated solutions
ff potassium nitrate. In a communication to the Archiv f.
xlix, No. 1, 1904, he

iction of the solutions to the comparative insolubility of the

Huqvene, ascribes this difference in the

nitrate and the difference in the molecular concentration and
if the specific ions in the two solutions.
Intoxication from Unripe Tomatoes. \
Wed., August 21, some

he eating of tomatoes not perfectly ripe. The

French physician

cases of illness

reports in the Lyon
traced to discoy
ery of fragments of the tomatees was the only hint as to the
first The dilatation of the
pupils in all the sick members of the family was a noticeable

As the

Case,

ause of the trouble in the

symp.om. tomato belongs to the same family as the

potato, the intoxication may have been like the solanum
poisoning sometimes observed after ingestion ot unripe o1
spoiled potatoes. Recovery was rapid after emptying the

stomach

Automatic Compressive Dressings. The Gaueette Med. de
Paris for August 27 contains an illustrated article by P. Man
tel of Saint-Omer describing his method of applying a dress

ing to obtain automatic compression of the parts without straps
kind. It
an amputation.

f any is shown applied to the head and to the

stump atter The vauze or cotton are applied
Then four o1

placed tlat on the vertex or the bottom of the stump, crossing

is usual. more rather wide strips of gauze are

them at right angles to each other. An assistant pulls on the
ends of these strips, and another longer strip of gauze is wound
When
of the crossed strips are
fastened together
head does not re

iround over them from the periphery toward the center.

loose ends

this is all in place the

down over the wound bandage and

A dressing thus applied to the

brought
tlat be low.

juire any further support, but exerts great pressure on the

top of the skull, without the necessity for any straps unde

the hin or elsewhere

The Public Service.

Army Changes.

Memorandum of changes of station and duties of medical offi-

s. U. S. Army. week ending Sept. 17, 1904

Field, Peter ¢ asst.-surgeon, granted thirty days’ leave of ab

Bratton, Thos. S.. asst. surgeon, relieved from duty at Fort Sam
Hloustol fexas, and ordered to Chicago for duty as- attending

reon and examiner of recruits
Purvianee, Wm. E.. surgeon, relieved from duty as
xaminer of recruits, Chicago, and ordered to

1

attending
Manila,

named asst.-surgeons sre relieved from duty at

owing

sosts designated after their names, and will report on Oct. 1, 1904
o Col. Char'es L. Heizrrann. asst.-surgeon general, president of
the ieultv. Army Medical Schoo!, Army Medical Museum Building,
Washington. D. C., for a course of instruction at sehool: Davis
Wm. R.. San Francisco: Owen, Leartus J.. ort Myer, Va Zinke
Stanley G.. Fort Riley. Kan Culler, Kobert M.. Fort Jay, N. Y.:
Weed, Frank W., Fort Mclfenry. Md.: Wickline, Wm. A.. Fort Ethan
Allen, Vt Brown. Henry IL Columbus Barracks, Ohio: Baily
Howard H., VPlattsburg Garracks, N. Y.: Uemphreys

Harry G
Fort Totten. N. Y.: Freeman. Paul L.. Fort Slocum. N. \¥
Roberts, Wm. M., asst.-surgeon. granted
f absence
Tefft. Wm. H., asst.-surgeon, left
Camp Lakeview, Minn

twenty-one days’ leave

Fort Minn., for duty

Snelling,

Barney, Chas. N.. asst.-surgeon, left from duty at Gainesville
Va.. on twenty days’ leave of, absence

Thornburgh I MI asst. surgeon, reports at U S Army Gen
ral Hospital. Washington Barracks, ID. ©¢ for temporary duty,

Manassas, Va

from

PUBLIC

SERVICE. Journ. A. M.A

Rockhill, EK. P., asst-surgeon, order for temporary duty at Fort
Miley, Cal. revoked.
Chase, A, M., contract surgeon, reports his return to Fort Reno

Okla., from three months’ leave of absence

Burr, R, T., contract surgeon, granted leave of absence for three
months

Bailey, Edward
or one month
Griswold, W. Church
for one month.

Jones, John F
absence

Marshall, Jchn S.. supervising
urgeon, leave of absence extended

Treuholtz, C. A., contract
two months

Shellenberger, James [., contract
sence for one month and fifteen days

’
B., contract surgeon, granted leave of absence

contract surgeon, granted leave of absence

contract surgeon, granted fifteen days’ leave of

and examining contract dental
ten days.
surgeon, granted

leave of absence for

surgeon, granted leave of ab

Navy Changes.

Changes in the medical corps, U, S. Navy. for the week ending

Sept. 17, 1904:

Green, IE, H., medical inspector, ordered to the Navy Yard
New York, October 1.

Bertolette, D. N., medical inspector, detached from duty as a

member of the naval retiring board and of the naval and medical

examining boards, Washington, D. €., and ordered to resume othe!
duties

_ Price, A. F., medical director, detached from the Navy Yard
New York, October 1, and ordered to duty as a member of the
Naval retiring board, Washington, D. C.

Breck, F, W., pharmacist, ordered to the Naval Hospital, New
York

Marine-Hospital Service.

List of changes of station and duties of commissioned and non
commissioned officers of the Public Wealth and Marine-Ilospita!
Service, for the seven days erded Sept. 14, 1904:

granted extension of
1904, on account

general
from Sept. 1,

Purviance. George,
leave of absence for one
of sickness.

Vaughan, G. T surgeon
service at meeting of the Association of
held at St, Louis, Oct. 10-15, 1904

Peckham, C. T., surgeon, granted leave of
from October 8.

Wertenbaker, C. P., surgeon,
at the meeting of the Association of
Louis. Mo.. Oct. 10-15. 1904

Wickes, IIT. W.. IP. A. surgeon, directed to proceed to Wilmington
Del., for special temporary duty.

Parker, IL. B., VP. A. surgeon, granted
month from October 1,

Robertson, If. MeG., asst.-surgeon, temporarily relieved from duty
at Stapleton, N. Y¥ and directed to proceed to Washington, D, C
snd report at the Bureau for temporary duty

Rucker, W. C surgeon, granted leave of
three days from September §.

Goldsbcrongh, B. W., A. A
three days from September &.

Ilorsey, J. L., A. A. surgeon, granted
teen days from September 10

Mason, W. C., A. A. surgeon,
days from September 19.

Stevenson, J. W A. A
seven days from September 5

Tuttle, Jay. A. A. surgeon,
lavs from September 12

froodman KF. OS... pharmacist, granted leave of absence for three
days from Sept. 8, 1904, under Paragraph 210 of the Regulations

Scott, I. T.. pharmacist, granted leave of absence for twenty-five
days from September 19

Slough, Chas... pharmacist, Department letter of Aug. 38, 1904
granting leave of absence for thirty days from August 10, amended
to read nine days from August 17.

asst. surgeon

month

general, detailed to represent. the
Military Surgeons, to be

ASST

absence for one month

detailed to
Military

represent the service
Surgeons, to be held

leave of absence for one

absence for four

asst

surgeon, granted leave of absence for

leave of absence for fou

granted leave of absence for five
surgeon, granted leave of absence for
1904, on account of sickness

granted leave of absence for seven

RESIGNATION

Kolb, W. W.. pharmacist, resigned, to take effect Sept. 1, 1904

Health Reports.

yellow fever, chcelera and plague
General, Public Health ane
week ended Sept. 16, 1904

znallpox
Surgeon

The following cases of
have been reported to the
Marine-Hospita. Service, during the

SMALLPOX—UNITED STATES.
Florida: At
Illinois Chicago
Indiana: Kekomo, Sept

large,

Sept. 3.10, 19 cases
NS pt i

Louisiana: New Orleans, Sept. 3-10, 1 case

Massachusetts: Sept. 3-10. Lowell, 1 case; North Adams,
cases, 1 death

Michigan: Grand Rapids, Sept. 8-10. 1 case; at 42 places. Aug

27-Sent. 3,

present.

Missouri: St. Louis, Aug. 27-Sept. 10, 5 cases, 2 deaths

=
Ohio Zanesville Aug. 6-123, 1 case
Pennsylvania PhiladeIphia, Sept. 2-10, 1 case, 1 death
‘Tennessee Nashville, Sept. 210, 2 cases.
SMALLPOX—FOREIGN,
Austria-Hungary: Prague, Ang, 20-27, 1. case.

death
Winnipeg,

tahia. Juiv 31-Aug. 123, 22 cases, 1

Relleville, Aug. 29-Sept. 12, 7
cases
Shanghai,
Paris, Aug. 20

Rrazil :

Canada Aug

CASES 5

o>) am 6 =
China:
France:

death

eases

Aug. 4-11. 1

Serr. 24, 1904. SOCTRTY

Great Britain and Ireland:
1 case; Newcastle-on-Tyne, 7 cases;
ifartlepool, 2 cases,

India: Bombay, Aug. 9-16, 1 death,

Italy: Palermo, Aug. 20-27, 14 cases, 8 deaths.

Mexico: City of Mexico, Aug. 21-28, 1 case, 4 deaths,

Russia: Moscow, Aug. 6-20, 15 cases, 2 deaths; St. Petersburg,
Aug. 13 20, 1 case, 4 deaths; Warsaw, July 31-Aug. 6, 22 deaths.

Turkey: Alexandretta, Aug. 18-20, 3 deaths.

YELLOW FEVER.

Keuador: Guayaquil, Aug. 8-15, 1 death.

Mexico: Aug. 27-Sept. 3, Coatzacoalcos, 4 cases, 1 death ;
(‘ruz, 14 cases,

Leeds,

West

Aug. 20-27, Dublin, 1
Nottingham, 2

case 5

cases ;

Vera

CHOLERA,
India 9-16, 38 deaths; Calcutta, Aug

deaths.

Lombay, Aug. 6-13, 4
PLAGUE,

Cape Colony, July 23-30, 2 cases.

Bahia. Aug. 5-18, 17 cases, 7 deaths,

Egypt: Aug. 6-13. 4 cases, 3 at Alexandria.

India: Bombay, Aug. 9-16, 44 deaths: Calcutta, Aug.
deaths: Karachi, Aug. 7-14, 3 cases, 2 deaths.

Mauritins: June 17-Juiy 7, 6 cases, 5 deaths.

Peru: Callao, Aug. 13, 1 case; Aug. 17, Colan, reported; La
Sullana, reported; Sechura, reported; July 31-Aug. 6, Lima, 11
cases, 5 deaths; Salaverry, 2 cases, 1 death; Payta, 4 cases, 2
deaths.

Africa:
Brazil:

6-13, 3

Society Proceedings.

COMING MEETINGS.

AMERICAN MEDICAL ASSOCIATION, Portland, Ore., July 11-14, 1905

Medical Society of the State of
tember 27-29.

Colorado State Medical Society, Denver, October 4-6.

Idah» State Medical Society, Lewiston, October, 6-7.

Tri-State Medical Society of Alabama, Georgia and Tennesset
Chattanooga, October 12-14.

Assn. of Military Surgeons of the U. S., St. Louis, October 10 15.

Mississippi Valley Medical Association, Cincinnati, October 11-13

Vermont State Medical Society, Rutland, October 13-14.

New York State Medical Association, New York, October 17-20

Medical Society of Virginia, Richmond, October 18-21.

Vennsylvania, Pittsburg, Sep

AMERICAN ASSOCIATION OF OBSTETRICIANS AND
GYNECOLOGISTS.
{nnual Meeting, held at St. Louis,

Sept. 13-16, 1904.

Neventeenth

Under the presidency of Dr. Walter B. Dorsett, St. Louis.
Addresses of welcome were delivered on behalf of the St
by Dr. Louis E.

Newman, and on behalf of the city and the exposition by David

Louis Obstetrieal and Gynecological Society

R. Francis, president of the Louisiana Purchase Exposition.
The respouses to these addresses of welcome were made by Di
L. WW. Dunning, Indianapolis, and Dr. Herman E. Hayd, Butfalo,
a
of a high seientifie character and the discussions on them full

The meeting was very well attended. The papers were

and spirited. ‘The association held only one session a day, in
the morning, thus giving the members and their guests an op
portunity to visit the exposition in the afternoons and even
ings.

Officers for the Ensuing Year.

The following officers were elected for the ensuing
President, Dr, H. W. Longvear, Detroit; vice-presidents, Dr. D.
lod Gilliam, Columbus, Ohio, and Dr. John Young Brown, St
secretary, Dr. William Warren Potter, Buffalo, N.Y
treasurer, Dr. X. O. Werder,

Veal

Louis;
(re-elected) ; Pittsburg re
elected).
The association will meet in New York City in 1905,
(T'o be

continued, )

AMERICAN ROENTGEN RAY SOCIETY.

held in

Louis, Sept. 9-13, 1904.

Fifth Annual Meeting,

Che President, Dr. James B. Bullitt, in the Chair.

Election of New Officers.
President, Charles Les-
Weston A. Price,

The following officers were elected:
ter Leonard, Philadelphia; vice-presidents,

the Louisiana Building, St.

PROCEEDINGS. 907

Cleveland; Henry Hulst, Grand Rapids, Mich.; Gordon G. Bur
dick, Chicago; secretary, Russell H. Boggs, Pittsburg; treas
urer, Leavitt E. Custer, Dayton, O.; member of the executive
committee, Pittsburg. The following
committees, to be appointed later by the president, were pro
vided for: Committee on Histologic, Physiologic and Bacteri
ologie Influence of the X-Ray, Committee on Technic of Radio
therapy, Committee on Technie of Radiography. The constitu
tion was amended to provide for a Board of Censors, said
board to consist of the three last presidents, Drs. George P
Girdwood, Montreal, Canada; A. W. Goodspeed, Philadelphia
and James B. Bullitt, Louisville, Ky. The place of next meet
ing will be either Detroit or Cleveland, to be determined later
by the Executive Committee.

The election of officers was followed by the president’s ad

dress.

George C. Johnston,

Comparison of X-Ray and Surgical Treatment for Tuberculosis

Dr. BULLITT put two propositions: 1. Is the present surgica!
treatment of the forms of tuberculosis imminently and entirely
successful and satisfactory? 2. What is the probability that
the Réntgen ray method of treatment is capable of rendering the
treatment of such diseases more rapid and successful? He
made inquiry of various operators as to results obtained in the
treatment of tuberculosis of long and flat bones, joint struc
tures, tendon sheaths, peritoneum, testicle and lymph glands
No mention was made of the length of time that elapsed be
tween the beginning and the end of the treatment, number of
exposures made, conditions of the exposures and technic; nor
is it stated that rather than better
under the w-ray treatment. <A possible mortality from a-ray
treatment is out of the question. The reports indicate that in
some cases at least the tuberculous process can be cut short by
exposure to the a-ray, that a cure can be affected in much
shorter time, and, in diseases of the bones and joints, with
much better functional results than is to be expected from the
usual surgical methods.

some eases get worse

The Réntgen ray, says the author, is
not to be regarded as a perfect method of treatment in tuber
eulous disease, but may be considered to be of great value
The following summary is presented: Long and flat bones—
Cases treated, 71; cured, 33 per cent.: improved, 35 per cent. :
Joints—Cases treated, 141; cured
improved, 37 per cent.: not benefited, 25 per
Cases treated, 27; 70 per cent. ;
improved, 22 per cent.: not benefited, 0.7 per cent.

Cases treated, 32: cured, 40 per cent.: improved, 25 per
eent.: not benefited, 35 per cent. Testicle—Cases treated, 21;
improved, 48 per cent.; not benefited, 19

not benefited, 29 per cent.

38 per cent.:

eent. Tendon sheaths cured,

Peritoneum
>

eured, 33 per cent.;

per cent. Lymph glands—Cases treated, 226: cured, 35 per
cent.: improved, 40 per cent.; not benefited, 25 per cent. Lu
pus—Cases treated, 616; cured, 68 per cent.; improved, 24 per
cent.: not benefited, 8 per cent.

This was followed by a symposium on a-ray in tuberculosis

The X-Ray in Tuberculosis and Malignant Diseases.

Dr. J. D
of deep-seated crowths a

said that for the treatment
made by

GIRSON. Denver, Colo..
light
ind capable of great penetration is required.

a powerful machine

The X-Ray in the Treatment of Pulmonary Tuberculosis

Dr. Emit. Grurere, Chieago, has found that the r-rav is par

ticularly valuable in the acute eases, in which prominent
svmptoms are loss of appetite, weight and strength, slight rise
of temperature, cough and expectoration, but no hemorrhage
the treatment is he

ind in chronie eases. and that the soone1

oun the better.
The Roentgen Ray in the Treatment of Tuberculosis.

Dr. OS.
early diagnosis and plenty of fresh air and
juvants of the

Rupis-J1cinsky, Cedar Rapids, Towa, insists on an

sunshine as ad
tuberculosis. He

uses a

r-ray treatment of
tube which has a prolongation from the middle of the a-ray
field proper made of lead glass except the end where the rays

emanate, which must be flint glass, enabling the ravs to

lesion

emerge at this point. which is laid right against the

YOS8 SOCGEETY

lhe remainder of the tube is enclosed in a special shield. This
loes not endanger the patient, and only the diseased area is
rayed. Since December, 1902, he has treated 20 cases; 5 were
f the hemorrhagic variety and improved in ten weeks and are
still doing well; 10 cases were of the fibroid variety, and 3 of
result of
plications and 1 from tubercular meningitis;

them died after six weeks, 2 as the intestinal com
the remaining 4
infection

tuberculosis of

ire slowly vielding to treatment: 2 cases of mixed

ire gaining steadily in weight. Of 6 cases of
the peritoneum, 1 died, and the other 5 are well and have not

had a reeurrence. Of 19 cases of lupus, 16 are apparently

ured, and in 3 the treatment was negative. In glandular tu

berculosis, 8 cases are cured, 6 are benefited, 19 are failures and

f cases are still under treatment and doing well. In tubercular

laryngitis he uses the ray as a prophylactic measure only, and

2 cases out of the S seemed benefited. FEieht eases of joint
} 1 ° 1 . ’ 1 .

tuberculosis were cured in six weeks: 4 chronie eases were

benefited in four months: 2 eases of tuberculosis of the testi

le were cured and have not recurred in three months

The X-Ray in Tubercular Adenitis.

1) May CusnMan Rice, Chicago, reported a case of tuber
ular adenitis in a girl aged 18, who had been operated on five
times, the disease recurring again. Y-ray treatments were
then given three times a week, ten-minute exposures, with a
medium vacuum tube, tube distance thi nches After the
third treatment the glands bevan to diminish in size, and at the
end of two months the largest @land is about the size of a
ean There was eorresm nding increase in weight and im
provement in general health. The secor 1S¢ 1 woman, aged
3? disease of five vears standing, was treated with the high

frequenev current by means of the Tes'a coil and statie ma
s

ine, with only slight improvement. The «ray was substi

tuied, and after five months the glands could searcely be felt
DISCUSSION

muportance ol

treatment of tuberculosis to the w-ray, but

not restricting the
0 look on the x-ray as a most valuable agent when used with
other remedial agents.

Dr. Grorce EF. Prauver, Philadelphia, suggested that a great

nanv eases of tuberculosis get well wi’ hout

they had

ever seeing a doe

tor and without ever knowing that tuberculosis, a

fact of which we must not lose sight when we draw conclu

sions as to the efficacy of the w-rays in the treatment of tube
eulosis. He has had very gratifying results from the use ol
treatment of all forms of tuberculosis In

especially those of the neck. we

the »-ray in the
treating tubereular elands,
should also expose the lung, because most of these cases have
some involvement of this organ. He never protects anything
xcept the hair and face of the patient.
Dr. C. L. Leonarp, Philadelphia, said
r-ray we must be governed by a dosage which is known and ean

that in using the
be measured, and that on this will depend the results that are
wbhtained. Its action in tubereulosis is that of an alterative
ind a stimulant, but we must not depend on that agent alone

Dr. EF. G. Wirittams. Richmond, Va., emphasized the fact
that all his patients had improved in general health under the
r-ray treatment. One case gained 70 pounds in nine months.
The x-ray stimulates metabolism more than any other agent

Dr. Henry Hurst, Grand Mich., has had good re
the treatment of tuberculosis of glands, joints and
peritoneum. He has never used it in pulmonary tuberculosis
hecause a perusal of the literature has convinced him that
vhen the a-ray is used critically no good results are obtained.

Dr. S. Tousty, New York City, reported a wonderful im
of tuberculosis of the larynx, using the

In four months the
He also reported con

tapids,

sults in

provement in a case
method advocated by Dr. Rudis-Jicinsky.
ulcerations had healed almost entirely.
siderable improvement in a case of tuberculosis of the pros‘ate
eland which was treated by raying the abdomen and by letting
the rays shine into the rectum through a specially constructed
tube.

Dr. C. FE. Skinner, New Haven, Conn.,
three eases of advanced pulmonary tuberculosis, but was un-

used the «#-ray in

ible to perceive any influence whatever in any of the cases.

PROCEEDINGS.

Jour. A. M. A.

Dr. Grorce C, Jounston, Pittsburg, reported similar results
His experience leads him to prefer climatic to « ray treat
ment. The treatment of tuberculosis under ordinary climatic
ronditions by means of the a-ray alone is a failure. ,

This was followed by a symposium on the treatment of ma
lignant diseases.

The Treatment of Epithelioma.

Dr. Grorce C. Jounstron, Pittsburg, divides his cases, first
those in which, owing to location, extent, metastasis, condi
tion of the patient, and various other factors, a cure can not
be expected, and, therefore, treatment is purely symptomatic:
second, those cases in which the location and other conditions
ire such as to permit of the expectation of a cure. He gives
daily treatments for the first ten days, unless an undesirable
treatments are viven at

oecurs, when the

\f er the first ten days treatments are given

deare e of react ion

longer intervals.
every third day until the desired results are obtained. Tf the
the dose

cumulative

results do not appear, may be increased cautiously.

mind the tendeney of the agent em

of success obtained will be in direet pro

bearing in
ploved., The degree

portion to the experience of the operator, the correctness of

his technic, his familiarity with the apparatus used and _ his
worthless tube Ile re

The

ibility to distinguish an active from a

ported 44 cases of epi helioma about the face. average
luration of these cases is four vears and eight months; 34
were primary and 10 recurrent cases. The average number of

trentments in each ease was 22. Metastasis oeceurred in onls

} enses: 30 eases were cured, 8 were benefited, 3 recurred, and
3 died
Radiotherapeutic Nihilism.

Chicago.

reliable technie which ean be foll

Dr. G. G. Burpier, insists on the importance of

having a wed by unskilled

is well as by skilled operators. He proposes the following

In lupus and other forms of local tubercular involvemen‘, the

tube distance should be four inches and the penetration regu
to take advantage of the
eathode ray. In

should be ten

lated to within half an inch in orde1
resembles the

tube

ray of low velocitv, which

earcinoma and epithelioma the distance

inches and the penetr: tion calculated to reach the center of the
producing irritation at least then
ing the degree of penetration to a high velocity, in order to get
cellular degeneration. high
of penetration, de pending on the density of the growth. When
it is desired to take advantage of the tonic effect of the rav a
high tube should be used. Where the lethal effect is desired a
low tube should be used. It must be that the
tonic action of the ray is due to its fluorescence, this being un
derstood as a form of motion, and that the lethal effee's are
All earcinomata which have

srowth twice, and increas

Sarcoma requires a very degree

remembered

the result of chemical radiations.
not ulcerated should be raved thoroughly before they are re

moved by operation.
The X-Ray Treatment of Sarcoma.
Dr. Josep F. Suiru, Chicago, reported 18 cases of deep
seated sarcoma in various organs and tissues in which a-ray
proved a most severe disappointment.

The Results of Treatment of Carcinoma.

Dr. J. N. Scorr, Kansas City, Mo., said that one great ad
vantage of the w-ray is that it can be applied to large areas
and to vital organs, if used with care. One disadvantage is
the long period of time over which the treatment must be ex
tended. All tumors operated on and found to be malignant
should have a course of a-rag treatment, and if at the end of
from one to three months no recurrence has set in the patient
may be considered as eured, but should be kept under obser
vation.

Carcinoma of the Breast.

Dr, Cuartes L. Leonarp, Philadelphia, said that the essen
tial factor of any successful treatment of malignant disease is
that it be radical and used early, its severity to be limited
only by the patient’s general vitality and of the normal tissues
that surround the affected area. Thorough surgical treatment,

SeEpr. 24, 1904.

wherever consistent with the preservation of the function of
life of the area involved should be advocated as the primary
treatment. If any aid is to be expected from Réntgen ray
treatment it must be commenced immediately after the surgi-
cal operation, before the patient is out of bed. The healing of
wounds and the closing of sinuses are hastened by Réntgen
ray treatment. A careful study of the results obtained by this
treatment in malignant disease of the breast shows that it has
been most affected where it supplements rather than sup
plants operation, In inoperable and hopeless cases it affords re
lief from intolerable symptoms, lengthens life and offers the
patient the most. ‘The best
in fact, the only favorable results of primary treatment have

results are obtained in scirrhus;
been obtained in these cases. Metastasis can be influenced and
held in check by the Réntgen ray treatment. In all othe
cases surgical removal of the breast and the adjacent lymph
vlands is always indicated. Technic and experience, as well
as local and constitutional treatment, are essential to success
in the treatment of malignant disease of the breast. He re
ported 26 cases treated since 1900. Of this number, 12 are
dead, 2 have not been heard from, and the remainder are liy
ing. Two had preparatory treatment, and they have lived
eighteen and sixteen months respectively. One had a primary
inoperable scirrhus; 4 had recurrences, in 3 the recurrence has
disappeared entirely and has not recurred in twenty-one, ten
and four months respectively. In 1, massive recurrence fol

lowed immediately after operation. Of the cases receiving
post-operative x-ray treatment, 4 are living and are free from
recurrence, nineteen, fourteen, twelve and seven months aftei
Of the 12 patients who died, all except 3 were bene

Two of them had post operative treat

operation,
lited when first seen.
ment, but died eighteen months after the operation. He con
siders the results very encouraging and urges further study
and observation in the treatment of malignant disease of the
breast with the «-ray.

Variations of Radiotherapeutic Technic.

Dr. RUSSELL H. Boaas, Pittsburg, advocated the employ
ment of more accurate methods and suggested that some per
fect results that are reported in the treatment of tuberculosis
perfect technie erm
He insisted

or malignant disease may be due to the
ploved by the operator or to a wrong diagnosis.
that the most important point is the tube distance, because
the intensity of the light varies inversely as the square of
the distance. For skin lesions there is no occasion to place
the tube more than from 4 to 6 inches from the skin, but that
is not the case in the treatment of deep-seated lesions. anothei
important point is that the 2-ray should be of large volume
when deep lesions are to be treated. A low-vacuum tube at a
distance of from 12 to 16 inches will penetrate the tissues ef-
fectively. With reference to cancerous disease, he spoke of
cases of small epitheliomata situated on the face, which can
be cured in from 6 to 8 weeks, depending on the vitality of
the patient. In cases in which the disease appears to be local-
ized, the tumor should be removed at once and followed up by
xr-rav treatment. Cases having considerable glandular in-
volvement should be treated for a time with the x-ray, then op
erated on, and treated again with the w-ray. Usually, twenty
treatments before and twenty after operation are all that are
required. Those cases that are considered inoperable should
be treated by the «-ray because of its inhibitory action on the
disease and for the comfort it affords the patient. All cases
should be given tonic treatment as well. Aleoholies, syphil
itics and anemic patients in general do not, as a rule, improve
rapidly. Such cases should receive individual specific medica
tion in addition to the w-ray treatment.

Cases of malignant disease were reported by the following:
L. Leonard. J. F. Smith. J. N. Scott,
Johnson, M. Kk.

(Creorge CU. Johnston, C.
G. G. Burdick, R. H. Boggs, W. W.
G. FE. Pfahler and E. G. Williams.

Kassabian,

The Compression Tube in Skiagraphy of Calculi.

Dr. Henry Hurst, Grand Rapids, reported the good results
he has obtained from the use of his compression tube, a modi

Albers Scho nberg “com pre esiones-ble ide.”’ in

fication of the

skiagraphy of fat people.

THERAPEUTICS.

QO9

The Interpretation of Radiographs of the Chest.

Dr. P. M. Hickey, Detroit, Mich., said that in order to secure
the best results perfect mastery of the tube and employment
of stationary secondary current and the use of developers
which will secure the greatest detail and contrast are necessary.
It is also necessary that the observer should be experienced
in the reading of these negatives. The exposure should be made
as rapidly as possible with a view to securing the greatest

amount of contrast. To interpret these negatives we should

know the position ot the target of the tube with reference
to the area exposed, and a suitable illumination of the nega
essential Further

tive by means of the illuminatine box is

more, careful distinction should be made between physiologic

and pathologic conditions, such as a large’ or vigorously p il

sating aorta and an aneurism of the aorta.
The X-Ray in Injuries Near the Wrist.
Mr. M. WILBert, Philadelphia, called attention to the fact that

]

fractures of the lower end of the radius are frequently con

pli ated by other more or less extensive injure s, and that the
other bones entering into the formation of the wrist nt are
also subject to fracture. Fractures at or near the wrist

are extremely common and vary considerably, both in locati

ind direction, and in the nature and extent of the

juries te
other structures. Of the 26.011 cases of fracture raved by him,
660 were at or near the wrist joint. When skiagraphing a
joint it is important to include as much of the surrounding
tissues as possible so that any fractures near the joint may ly
detected In fracture of the wrist joint. fracture of the carpal

bone is very common,
The Value of Stereoscopic Skiagraphy.
Dr. M. K.
and exhibited an apparatus which is used for stereosc pic ex

KASSABIAN, Philadelphia, discussed this subject

unination.
Diagnosis of Brain Tumors and Softening.

Dr. GEORGE E. PrAnLer, Philadelphia, exhibited a series ot

—
j

skiagraphs made for the purpose of diagnosing and locating

brain tumors and abscesses of the brain. He said that he
would never take the responsibility of an operation on the brain
purely on skiagraphic evidence. On the other hand, all cases ot

brain lesion should be examined by the I ray in orde TO eon

firm or add to the elinieal evidence.

Therapeutics.

|Our readers are invited to send favorite prescriptions 01
outlines of treatment, such as have been tried and found useful,
for publication in these columns. The writer’s name must be
attached, but it will be published or omitted as he may prefer.
It is the aim of this department to aid the general practi-
tioner by giving practical prescriptions and, in brief, methods
of treatment for the diseases seen especially in everyday prac-
tice. Proper inquiries concerning general formulae and out-
lines of treatment are answered in these columns without
allusion to inquirer. |

Heart Disease.

DIET.
Schott, in the Laneet, discusses the diet in heart affections
and gives the following two rules: 1. Patients must avoid

everything which exeites the action of the heart, and 2, they
must shun everything which embarrasses the heart’s action.
most cause excitation of the

The substances which readily

These stimu

heart are coffee, strong tea, and alcoholic liquors.

lants should be avoided, even in eases where there has been

habitual use of them, except in cases where the withdrawal

would result in collapse. In these eases, which have been a

customed to the use of alcohol, it is best to give Rhine wine,

Moselle. or ]

has been matured for from eight
toten vears. Jf it is found necessary to administer other than

Bordeaux. which

the light wines, Cognac or whiskey mixed with plain water ma)
]

be given. No aromaties should be given with the alcohol be

cause ot the danger ot irritability ot the stomach leading to

910)

and milk are the beverages to

Water
Cocoa deprived oft its tat is good, but chocolate

anoreXja and insomnia,
be prefe rred.
If it is desired to

does not usually agree. give fats pure cream

or cream mixed with milk may be given. ‘To avoid embarrass-
of the heart too heart vy eating of foods which produce
They prove harmful in

The diaphragm is pressed up against the lungs

ment
flatulence must de interdicted. may
three ways: 1.
so that respiration is impeded and dyspnea results. 2. The
diaphragm is pressed up against the heart, forcing it upward
and outward so that its action is carried on with greatly in
effort. 3.
the abdominal

is increased and
effer
or beer

reased Intraabdominal pressure

vessels are compressed, Therefore, all

vescing beverages, carbonated waters, champagne,

usually disagree with patients suffering from heart disease.

INTERVALS OF FEEDING.

Qm aceount of the necessity of avoidine overloading of the
stomach, it is best that these patients should eat at three
hour intervals, and the last meal of the day should be taken
from two to two and one-half hours before bedtime, otherwise

there Is danger ot disturbed sleep.
KINDS OF FOOD.
Soups should be taken sparingly, chiefly because their

nutritional value is too low in proportion to the bulk. A few
New bread and
and zwieback or
those diffi

tablespoonfuls only should be recommended.

freshly baked cakes must be avoided. Toast

crust of rolls may be allowed. Of the vegetables,
ult of digestion and producing flatulence must be avoided, as

beans, peas, lentils, sauerkraut, red cabbage, leeks, onions,

Potatoes, boiled or in form of purées, are
Turnips

varlic and celery.
to be preferred to the less digestible baked potatoes.
Other fresh and easily
digested vegetables can not be too highly recommended. Meats
Kels, fat
mayonnaise on
salted fish, be

or Khacon, sausages,

ind carrots may be eaten when young.

are allowable, but the following must be avoided:

breasts, goose liver pies, rich sauces,

LOOSE

salmon, lobsters, or crabs; highly smoked or

cause of the thirst they produce; fat ham,

voulasch; seasonings and spices, red and black pepper, nutmeg,

mace, Cinnamon and yanilla.
FRUITS.
Kasily digestible stewed fruits are allowed because of their

favorable action on the intestinal peristalsis. Raw fruits

which have to be peeled are desirable. Grape stones should

he removed before grapes are eaten. R ispberries, vooseberries,

currants, billberries. cranberries. pineapples, walnuts and Brazil

nuts are to be prohibited.

HOT AND COLD DRINKS,

any form, either as iced drinks, fruit ices, etc., is prone

6 cause gastrodynia, and may produce congestion of the liver.

This should be kept in mind when ice is prescribed for yom

GENERAL INSTRUCTIONS TO PATIENT

\ mixed diet of both meats and vegetables is to be

Thorough mastication and ensalivation of all the food is as

indispensable in affections of the heart as in diseases of the

stomach. Of the use of tobacco the author states: “I always

recommend patients suffering from heart disease either to give

altogether or else to indulge in it most sparingly,

ip smoking

_

ind in the latter case to use very dry tobacco and a long

\ patient should informed

]

disease

mouthpiece or a pipe. always be

that smoking is bad for his heart Drinking at meal

restricted. Gentle exercise in the open air fon

time atter
studied and the

time should be

a short meals is to be recommended, Kach case

should be

correspondence with the symptoms

treatment should be modified in

rREATMENT OF CASES WITH ADEQUATE COMPENSATION,

Abram 1904, vives the following sug

gestions for the

in the Lance f Aug. 6,

treatment of various conditions under the
following subdivisions:

When compensation is practically equal to the lesion, the
iuthor believes that the patient should be told of his trouble
in order to obtain his intelligent co-operation in conducting his

He should he warned against excesses of all

living.

mode of

THERAPEUTICS.

Jour. A. M. A.

Exercise in moderation may be
If eveling is indulged in

kinds, mental and physical.
permitted, but never in competition.
care should be taken not to struggle against head winds or up
hill.

enjoined ; in fact, abstinence is advised.

Moderation in the use of aleohol and tobacco must be
In this stage of a
mitral stenosis if a hemoptysis occurs, the author uses a free
saline If the patient is a

woman and the lesion aortic she should be barred from mar

purge with a dose of opium.

Well compensated cases of mitral regurgitation often

riage.

pass through pregnancy without trouble. Cases of mitral

stenosis should be carefully watehed during pregnancy. “Our

advice should certainly be against marriage.”

IREATMENT OF CASES WITH PAIN AND DYSPNEA ON EXERTION.

In this subdivision are cases in which palpitation, precordial

pain, and dyspnea are manifest on exertion, and jn a more

advanced degree, some passive congestion, with its results

in the kidney and liver. In aortic cases throbbing in the neck

vessels, headache, and giddiness may be troublesome. Abso
lutely the best treatment is rest in bed for a week, with
limitation of fluid and regulation of the diet and moderate

purgation. In aortic cases bromid and iron give relief. Gen
eral tonics, iron and strychnin, and small doses (two to three
digitalis, where rest can not be
If there are

high tension, a rigid milk diet and diuretics are indicated.

minims) of the tincture of
taken, will aid materially. diseased arteries with

CASES WITHL SIGNS AND SYMPTOMS OF FAILING HEART.

Such cases have to sit upright. Limitation of fluid is often
serviceable. The
and the

trional,

bowels may be gently acted on. For in-

somnia maniacal states frequently seen in aortic

sulphonal or paraldehyd are useful, but

Of the use of digitalis in aortic

disease,
“our sheet anchor.”
“When we find thickened arteries and

opium is
cases the author says:
possibly some increase of tension there is no doubt that the
best line of treatment is to limit the fluid taken, open the

diuretics. If cardiac stimulants are

When the pulse tension is low

bowels, and give renal
used I prefer strophanthus.
digitalis is demanded, and also in cases where the mitral valve
Dyspnea is often relieved by the use of atropin
The

the administration of solid opium or ‘neat’

has \ ielded.,

and strychnin hypodermically. ‘sinking’ sensation may

be alleviated bv

brandy.”
Chronic Colitis.

Wed., gives the following suggestions for the

Shoup, in Amer,

treatment of this condition:

l. He

displacement of the abdominal organs and the consequent in

believes the cause to be due in a large measure to

digestion and its sequel: therefore, he replaces the organs and

holds them in place by a properly fitted corset. It is the in

vention of a Paris physician, and has a long, straight front,

coming well down over the hips, and as Jow as ean be worn

in front, and is held down to the hose by elastie fasteners. It

is made to give firm pressure around the hips, and should be
put on while the patient is lying down, and laced from below.
It may be necessary To change the eorset several times before
it is suited to the individual case.

2. Make a

? chemical examination of the stomach contents

ind select a diet to suit the needs of the individual ease. It

hydrochloric acid is much diminished or absent, meats should

be partially or wholly excluded in the beginning of the treat

ment. In cases with extreme constipation and passage of

mucus, the diet of von Noorden, leaving a large residue and

consisting of graham, whole wheat, or corn breads, spinach,
cabbage, lettuce, asparagus, cresses, ete., has given the best
‘results. The explanation offered is that a bulky meal

passes more quickly out of the stomach and through the jin
testine and overcomes the constipation, which is a most trou-
If diarrhea is present the diet should be
peptones. If the
patient is nervous, a rest of two hours after the main meal
When patients are thin, fats are indi

blesome symptom.

milk, broths, gelatin, eggs, eustards, and

should be insisted on.

eated, and of these butter. cream and olive oil are to be pre

ferred. The olive oil may be civen before breakfast. and in

before other meals as well.

Some eases

Sept. 24, 1904.

3. Assist digestion by the administration of hydrochloric
acid and some one of the digestive ferments, such as pan-
creatin, papain, and diastase and bitter tonics, such as gentian
Allay fermentation by the use of intestinal
antiseptics, such as salol, resorein, and creasote.

or nux vomica.

4. Keep the bowels open by the use of oils by mouth; when
the diet and olive oil fail castor oil is the best remedy to use.
Salines are not effective. Massage of the colon is also useful.

5. Local treatment should consist of high enemas of alkaline
solutions, followed by an astringent, such as krameria or silver
nitrate.
tient is in the recumbent position, and allowed to flow by gravi-
tation high up into the colon; they are soothing, healing and
lessen constipation.

6. See that the patient gets suflicient rest in the recumbent

Large enemas of olive oi] should be given while the pa

position, and when practical, a change of air, at the mountains
or seashore.

7. Treat the attack of pain which precedes the passage of
mucus by a hypodermic of morphin and atropin, and promote
evacuation of the bowels by the method mentioned above.

Urticaria.

Van Harlingen recommends the following:

Iy.. Moagnesti-sulpnatis: .........5<.0.0805 .3i 30|
Ferrj sulphatis ...... or, iv 25
SOdib CRIOPIGD <s.6s.ce cee 388 2)
AGIA SUIPNUMICN GW, .. 6 acs ees eae Sil 8|
Inifiis.. QUASSI® <q. Si a0... 2... 6s ..5iv 120]

M. Sig.:

fast.

Duhring recommends the following for local use:

R. Acidi earbolici 3iss 6|
Glycerini ele Sli 8|
Spiritus vini rect. |
Aque amygdale amare, ai 3vill =240

M. Sig.: Apply locally two or three times daily to relieve

itching and burning.

The following is recommended for use in neurotic subjects:

Tablespoonful in glassful of water before break-

R. Liquoris potass. arsenitis .... ..M. XXi1V 1/60
Potassii bromidi |
Syrupi aurantii corti, 44.............3iv 16 |
Aque dest. q. s. ad..... See 90!

M. Sig.: Teaspoonful three times a day.

Medicolegal.

Insane Delusion Defined. New
Jersey holds, in the case of Davenport vs. Davenport, that an

The Court of Chancer) ot

insane delusion is a fixed belief based on supposed facts which
exist only in the diseased imagination of the deluded person,
persisted in against indisputable evidence of its falsity. <A
mistaken conclusion, arrived at on consideration of existing
facts, is not an insane delusion, although the facts may not
justify the conclusion.
Physical

that the case of

Indecent Examinations.—The Supreme Court ot
lowa Garvik vs. the B., C. R. & N
Railway Company was tried as if the charge was rape, by an

says

employe of the company, and that counsel for the company
asked that the jury go into a room and examine the man, who
consented that it be done. The Supreme Court does not think
that the examination by the jury should have been permitted.
It says that there was no showing that the private parts were
in the same condition as they were when the assault was said
to have been committed. Moreover, the ultimate question was
not the exact condition of this member, but whether or not
the owner was physically incapacitated from having sexual in
The court doubts if this could be determined by a
Again, it

tercourse.
non-expert from a mere examination of the penis.
says, the examination was indecent and should not have been
tolerated. Wounds resulting from injuries may undoubtedly
be exhibited in open court to the jury, but even here no inde-
Furthermore, the evidence was
adds that it has

cent exposures should be made.
The court

not demonstrative in character.

MEDICOLEGAL.

ou

found no authority which justified the ruling made by the
trial court, and that it doubts if there is any to be found in the
3e it remembered, it continues, that the plaintiff was
entitled to be present during the entire trial with her counsel,
and that there were others aside from the witness (employe)
who were entitled to be present at the examination of his pri
vate parts. “Let it be said, once for all, that we can not lend
our support to such a shocking and indecent performance as
was permitted in this case.”

What Are Included in Privileged Communications.
4,608 of the Iowa Code contains the provision: “No practicing

physician

reason of his employment

books. 1}

Section
who obtains such information by

shall be allowed, in giving
testimony, to disclose any confidential communication properly
entrusted to him in his professional capacity, and necessary
and proper to enable him to discharge the functions of his of
fice according to the usual course of practice.” The Supreme
Court of Iowa says, in the personal injury case of Battis vs
C. R. I. & P. Railway Company, that all will agree that the
manifest purpose of this statute is to make it possible for
every person to fully and freely consult with a physician, 01
submit himself to the examination of such physician, without
anticipation or fear that the confidence repostd may be broken
in on by a subsequent examination of the physician as a wit
ness in some form of legal proceeding. This being true, the
statute should have a liberal construction by the courts. Ac
cordingly this court has held that the expression ‘“confidentia!
communications,” as used in the statute, is not to be restricted
to the mere verbal statements made by the patient, but must
be construed to include all knowledge or information acquired
by the physician through his own observation or examination
In the case at bar the interrogatories propounded to the physi
cian were intended to elicit from him certain facts respecting
the condition of the plaintiff, and it was manifest that what
ever knowledge the witness possessed was acquired from the
statements made to him by the plaintiff, and from his own
examination and observation. Clearly in such a case the
statute applies, and the privilege may be insisted on. Nor is
the privilege taken away, as contended for, by the fact thar
while on the witness stand, and elsewhere, the plaintiff had
stated that he was unconscious when taken to, and while he
remained in, the office of the physician, and that the testimony
sought to be elicited had relation solely to the condition of
the plaintiff as to consciousness, the purpose thereof being the
impeachment of the plaintiff as a witness. It may be true,
possibly, that the knowledge acquired by the physician was
not, in point of fact, and strictly speaking, necessary and
proper to enable him to perform the functions of his office
But of this the court is not in position to judge, nor is it called
on to determine what the fact might be when reduced to
analysis.

a last
It was the condition of the plaintiff that was the
subject of the inquiry, and it was the professional judgment of
the physician that was called for. The privilege can not be
subject to measurement by metes and bounds, and the court
may well assume that all that was told to the physician, and
all that was developed by his examination or came under his
observation, was necessary and proper for his understanding
of the condition of his patient. The relation of physician and
patient being established, if by any fair intendment communi
cations made have relation to the physical or mental condition
of the patient, the court is bound to hold them privileged
With reference to the local surgeon of the company, called b:
the station agent to see the plaintiff, the court says that it
may be conceded that the sole purpose of the agent in eallin
this physician was that the latter might ascertain the condi
tion of the plaintiff, and thus be prepared to advise the coi
pany should occasion therefor arise, or be a witness on its bx
half if necessary. Certainly, if the visit of the physician had
been confined to the limits incident to such purpose alone, his
eligibility as a witness on behalf of the company might not be
open to question. Without doubt a railway company with the
utmost propriety may thus advise itself of the fact of injury
and the character and extent thereof, in anticipation of a pos
it for damages. And with that end in
view it may send a physician to inspect and take notes, or

sible claim against

912 CURRENT MEDICAL LITERATURE,

otherwise intorm himself of existing conditions. But this can
avail the company nothing unless the physician shall strictly
If, on re-

assumes to advise or adminis-

retain his character as an employe of the company.
quest or on his own motion, he
ter treatment to the patient, and the latter in any manner ac-
quiesces therein, the physician thereby casts aside his relation
as an employe of the company and transfers his allegiance to
the patient. In such instances a case is presented where one

The al

legiance of the physician must be wholly on one side or the

an not serve two masters at one and the same time.

other. It matters not, in this connection, who ealls him in the

first instance or who pays him. He may present himself at the

-ide of the patient on his own motion, and he may not expect,

or in fact receive, pay. It the physician assumes to advise o1
reat he in possession of all

should be put facts necessary or

if the patient ac

and should, communicate

material to enable him to do so properly.
he should have the right to,
freely and fully, without fear of exposure or ol having his con
that the
purpose thereof may

qulesce,

fidence made commen property. It was to this end

was enacted, and manifestly the

statute
not be frustrated by proof that, at the time of rendering pro
fessional service, the physician was under control of employ-

ment to serve the interest of the person or company subse

quently charged with responsibility for the identical injury he
assumes to treat.

is called on o1

Current Medical Literature.

AMERICAN.

*) gre abst acted below

Titles marked with an asterisk (

American Medicine, Philadelphia.
Nepte pmber 19

Indications for Operation for Fibroid
Charles P

1 *The Nature of the
rumors of the Uterus
Pathogenesis of Ch
Callum ;
*Recent Experimental Work on Anesthesia
*Fariy Recognition and Treatment of Intestinal
Andrew S. Lobingier.
the General Practitioner in the
Tuberculosis IK. M. Pottenge

ic Uleel W. G. Mac

ronic (ast

Torald Sollmann
Obstruction.

Prevention of Pul

monary i gel fifa
6 *The Principles of the Preservation of Food Geo. Richter
7 The Advertising Specialist = Fred D. Lewis
S Sea Versus Land Burial. Phomas R. Evans.
] See abstract in THE JOURNAL, xhi, p. 1585.

MacCallum

gastric ulcers may be produced by any thing which causes

2. Pathogenesis of Chronic Gastric Ulcer. says

that

necrosis of the mucosa of the stomach. and thus subjects it

to the digestive action of the gastric juice. In some cases the
inception is very obscure. The persistence of some of these
ulcers offers the ereatest difficulty of explanation.

that all gastric ulcers tend to heal, but frequently

It is prob-
ably true
thev last a long time because new ulceration occurs in the same
spot.

anesthetics:

» Anesthesia. Sollmann considers the following

Chloroform, ethy] chlorid, ethy] bromid, gaseous anesthetics,
petroleum ether, scopolamin-morphin, cocain adrenalin, anes
thesin, and vohimbin, describing their action and dosage.

emphasizes the fact

Obstruction. Lobingier

true

4. Intestinal

that the treatment oft intestinal obstruction is imme

diately and at all times surgical. Late operative interference,
due ww late diagnosis or to procrastination, is the principal
cause of the mortality. A preliminary gastric lavage will do
much to quiet and rest the patient when vomiting is an early
and depressing symptom. But the deceptive tranquility, which
should not allay the fears of the attend

ant or induce him to believe that his first diagnosis was wrong.

it sometimes brings,

straighten out volvulus and intussusception by

Kiforts to

hydrostatic pressure must be made early and with great care,

but that is doubtful surgery, and many a life has been lost

rupture and pe ritonitis when the manipulations

until the

from were

violent or continued intestine was gangrenous. If

the patient is seen early. before serjous necrosis occurs, simple

release ff the eonstricting band will often suffice. If de

structive changes have occurred, and if the patient is very weak

Jour, A. M. A.

and unable to stand prolonged anesthesia, a primary enter-
otomy should be done, to be followed by an anastomosis as
If the patient
strong, immediate exsection of the gangrenous

soon as the patient is sufficiently convalescent.
is sufficiently
segment and anastomosis are indicated. Karly diagnosis is, ot
course, necessary. The symptoms which appear early and on
which the diagnosis depends, are obstipation; vomiting, persist
ing more than fifty hours; pain, more or less severe and con-

stant; shock or collapse; meteorism, of localized character ;

normal or subnormal temperature; a small rapid pulse and a
leucocytosis between 15,000 and 20,000, with a strong reaction
taken before the third

of imdicanuria, if dav, and if the

ileum is involved.
G. Preservation of Food.
ot food by

Richter considers the preservation

drying, freezing, sterilization and the action of

chemicals. lie has devoted considerable time to the study oft

the preservation of artificial foods, and has worked out a

method which he claims has yielded favorable results. It is
well known that gelatin. prepared by the hot extraction of
bone and cartilage is a digestible proteid, forming no mean part

Dried

subject

of our regular diet. velatin, even if contaimed in open

packaves, Is not to decomposition, but
time, \s

Gelatin, if prepared in very

remains wun

changed for any length of au jelly. it soon be

OMes

putrid. thin films, will take up

moisture trom. the atmosphere according to the dew point

Richter has made practical use of this by constructing a selt
registering psychrome tel and to preset ve food, esp ( ially native

albumins. His process demands that the materia] to be

preserved should be in solution. For instance, the juice pressec

out of raw meat, or a beet soup. containing all the necessary

condiments, or strong tea or coffee or ox wall, is mixed with

about 1 per cent. of primary gelatin (commercial gelatin can
not be used for the purpose on account of its elue-like taste)
\fter cooling,

di ied in

a jelly forms. This is cut into thin films and

a cold-air current until it becomes brittle The leaves

are then converted into a fine powder, which will keep in

definitely. If not packed airtight it will take up moisture,

but not enough for decomposition to set in. It may eventually
cake, but the cake is brittle. Insects find the dry substance too
hard for thei
luke

organisms,

uses. The powder is instantaneously soluble in

warm water. To insure the absence of septic or othe)

the dry powder is heated to about 1O0 Ro before

packing, or in the package. Whole milk ean not be preserved
\tter

the powdered milk turns sour and exhibits a taste and smell

on this principle as oxygen can not be excluded. a while.

of cheese. Egg-gelatin powder has excellent keeping qualities
for about ten months, when its solubility becomes less, though
it remains perfectly digestible. These preparations are not
on the market nor are they likely to be manufactured for the
present. ,
New York Medical Journal.
September 14,

Following the
Dislocation

*The Treatment
genital Ilip
Mueller

10 The Present Condition of Tenontoplasty (To be
Professor Vulpius

11 Treatment of Mucomembranous Colitis by ¢
M. Hider :

12 *What Can Be Done to Check the Progress of the Age
erations?’ Bradford CC. Loveland.

13 *Influenza or Acute Articular Rheumatism? Their Diagnosis,
with a Report of My Own Illness. Max Talmey.

14 *Treatment of Status Epilepticus, with Report of Two Cases
Annie M. Tremaine

15 *Immediate Repair of Injuries of the Velvie Floor. H. CC. Coe

16 Case Presenting Unusual Difficulties in Diagnosis (Chole
eystitis Simulating Appendicitis.) Walter G. Elmer

Reduction of Con
Ashley and Frederich

Bloodless
Dexter D
continued.)
John

‘olostomy.

Degen

17 Large Fibroids of Uterus Complicating Pregnancy; Porro
Operation. William C, Wood.
’. After-Treatment of Congenital Hip Dislocation. Ashley

and Mueller consider the after-treatment of unilateral and
bilateral congenital dislocations of the hip of group B, that
have been corrected hy the bloodless reduction method.

method is that

Their

advocated by Lorenz.

12. How to Check the Age Degenerations.
siders those changes in the arteries and

Loveland eon
smaller arterioles or
capillaries incident to advancing vears, and imperfect elimina
tion or the habit, in which the walls he

SOUTN ome thickened,

SEPT. 24, 1904.

stiffened, harder than normal, and later pass through the cal-
careous or atheromatous degeneration. Many conditions are
dependent on these changes as a fundamental cause, and a con-
siderable majority of all deaths occurring after middle life may
be charged to the account of degenerated arteries. All the
causes, save two, nephritis and old age, are removable. Hence,
says Loveland, it is logical to suppose that after a removal of
the cause the disease should be stayed in its progress. He
reports three cases, in which he followed a definite method ot
treatment, which point to the fact not only that there was a
limiting of the process, but from the relief of certain svmptoms,
it would that,
circulation in the parts supplied by the diseased blood vessels

seem in some degree at least, an improved
would indicate a certain amount of restoration in the diseased
territory. This improved circulation and nourishment might
result from the absorption of thickenings which had narrowed
the lumen of the vessels, or a bettered circulation, with more
dilated arterioles and capillaries, affecting to some degree the
hardened and thickened vessels with the rest, thereby allowing
the passage of more blood. Two of the cases were diagnosed
as arteriosclerosis affecting the cerebral circulation. The third
case involved the coronary arteries. The treatment of one case
consisted of a definitely prescribed diet, cool bathing, and
moderate exercise, strychnin, 1/30 gr.,
1/6 gr., three times a day. In the treatment
ease electricity and sodium phosphate each morning, and 5 gr.
each of sodium salicylate and sodium benzoate, in a large glass
of water, three times a day. were added. The results in the
three cases were excellent, but the author does not believe that
the patients referred to will not die from some disease de-
pendent on arterial degeneration. Yet, it seems natural that
the mode of living, which will result in so much improvement,
if persistently adhered to, should leave the patients to be
taken off by some acute disease or to “burn out” with old age.

13. Differential Diagnosis of Influenza and Acute Articular
Rheumatism.
diagnosis of acute articular rheumatism made by a

and mercury protoiodid,
of the second

Talmey cites his own case and questions the
brother
physician. He bases his contention principally on his family
history and his personal history.
which he suffers, and which involves the muscular attachment

He terms the disease with

around the joints, “rheumatoid” influenza.

14. Treatment of Status Epilepticus.
cases in which she used intravenous saline injections with
benefit, hence concludes that in this solution we have a valu
able remedy for the treatment of status epilepticus.

Tremaine reports two

15. Immediate Repair of Injuries of the Pelvic Floor.—Coe
emphasizes his belief that by careful attention to these lesions
immediately after labor the patient can be spared the necessity
of subsequent operations for pelvic floor lacerations, prolapsus,
etc. He says that the modern accoucheur must be a thoroughly
trained gynecic surgeon, who not only recognizes the true

lesion at the time of its occurrence, but looks into the future

and sees the patient’s condition months after the injury.

Medical News, New York.
September 10
IS *An Analytical Study of Twenty-eight Cases of Arthritis. with
Special Reference to Gout and Its Treatment Charles C
Ransom.

1% Contribution to the Pathology and Treatment of Acute Gon

orrhea. (To be continued.) Ludwig Weiss.

20 Recent Advances in the Therapeutics of Pediatrics Noble
P. Barnes.

21 Hereditary Chorea in Fighteen Members of a Family, with a

Report of Three Cases. Maleolm Mackay.
2 Influenza in Children. Kenneth FE. Kellogg
22 Report of a Case of Addison’s Disease Treated by
Suprarenal Extract and Adrenalin Chlorid
Symmers
24 The Gastro-intestinal Crisis of Erythema
ulating Appendicitis. A. M. Pond,

18. Arthritis and Its Treatment.

of arthritis, 12 of which (45 per cent.) were gout.

Means of

Douglas

Exudativum: Sim

Ramson reports 28 cases
The diag
nosis is unquestioned, therefore it is interesting to note thi
relative frequency of gout. Five of these 12

7 were of the chronic type of the disease.

cases were acute
gout, while the other
Of the other
acute and |
arthritis, 1

16 cases 5 were cases of rheumatic arthritis, 4

chronic; 5 cases of gonorrheal arthritis, 1 septic

arthritis deformans and cases of erythromelal

CURRENT MEDICAL LITERATURE.

913

gia. The cases of acute gout were put on a milk diet, the
joints were painted with a mixture composed of oil of gaul
theria, 1 dram; ichthyol, 1 ounce, and then wrapped in cotton
wool, oiled silk and a roller bandage. Colehicin, 1/100 of a
grain, was given every two hours, and, as a rule, could be re
peated at two-hour intervals for forty-eight hours. After the
acute symptoms had subsided the drug was continued at in-
tervals of four hours until the patient was discharged. In the
chronic cases the same method was employed in the case of
inflamed joints. Stiff joints were massaged and given passive
movements and the patients directed to use the joints as much
as possible—a very important factor in the treatment. ‘To af-
fect his purpose Ramson employed an apparatus which he calls
consisting of a piece of board twenty-one inches
About three inches from the lower

a “teeter,”
long and eight inches wide.
end another piece of board about ten inches long is fastened
at right angles to the first piece by means of a bracket. On
the shelf so formed the foot of the affected leg is placed. the
longer board being in contact with the posterior aspect of the
leg. The patient, seated in a rocking chair, rocks to and fro,
thereby producing a greater or less amount of motion in the
knee and ankle joints. It is an advantage over walking, as it
not only keeps the weight of the body off the knees, but com-
pels a much greater angle of motion. The apparatus elimin-
ates muscular rigidity and the movements of the joints are
limited only by the actual structural changes, which are
gradually overcome by persistent use of the “teeter.” He also
favors the use of colehicum in chronic gout. The ichthyol bath
is another measure which he has found useful in chronic cases.
An ounce of ichthyol is put into a tub of water. The water
is fixed at a temperature of from 98 to 100 F., and the patient
remains in the bath for from ten to twelve minutes. The
effect of the bath is the immediate relief of stiffness and sore
ness, which often lasts for forty-eight hours: sueceding baths
give longer periods of relief. It is a good plan to precede the
massage and movements of the joints by such baths, as there
will then be much more freedom of movement and
Good food and tonies are, of

less sore
ness on manipulating. course,
essential.
Boston Medical and Surgical Journal.
September 8.
25 *What Shall We Do with Patients Having Pulmonary Tuber
eulosis? Frederick I. Knight.
26 *The interrelation of Medicine and Surgery in the Treatment
of Gastric Uleer Hugh Cabot and George S. C. Badger
27) «=Spindle-cell Sarcoma of Foot, Amputation. Recovery Lung
Metastases. Death. Autopsy. Charles L. Scudder
25. Pulmonary Tuberculosis.—Knight’s paper is a discussion
of the present treatment of tuberculosis by means of fresh air,
diet and rest.
26. Gastric Ulcer.—The indications for the medical and sur
treatment of
In acute bleeding ulcer operation is to be advised: 1.

gical gastrie ulcer are discussed by Cabot and
Badger.
After failure of good medical treatment to promptly stop acute
hemorrhage. 2. If, though the
controlled. slight but frequently reeurring

sists. 3. If, after the control of a

acute hemorrhage has been
hemorrhage pei

large acute hemorrhave a

second hemorrhage occurs within a short time. It is not wise
to defer operation until the patient is so far reduced as to
render the risk of surgical operation very great Medical
treatment should be persisted in: 1, in cases of acute hemor

rhage not preceded by a train of dyspeptic symptoms and not
showing a marked tendency to recurrence; 2, in cases in which
acute hemorrhage is followed by apparent complete recovery
and in which the patient is free from serious annoyance from

dyspeptic symptoms. Operation is also indieated in pertfos

ating ulcers of the stomach; chronic dyspepsia without dilata

tion, which fails to yield to proper medical treatmeni, and
eases of chronic dilatation of the stomach which fail to vield
to medical treatment and are not due to a general viscera
ptosis.
Medical Record, New York.
September 10
28 *The Cycie of the Tubercie Bacillus A Preliminary A
ment Stephen J. Mahet
"9 *Clinieal and Other Features of the Recer Inpid ar

Ilenry W. Berg

brospinal Meningitis

Y]4

30 *Mastoiditis with Varalysis of Facial Nerve: Recovery of
Paraiysis Following Operation. Seymour Oppenheimer.
garding Hamlet's Sanity John W. Wainwright.
lluminating Gas Poisoning: Its Rational Treatment
V. Ilubbard

28. Cycle of the Tubercle Bacillus
ings in the cultivation of a large bacillus which he has named

Ernest

Maher details his find
Bacillus maternus and which he believes represents a mother
shape of the tubercle bacillus. He found the organism in a
dark The blood or

measure from three to eight microns in leneth and from three

barn. individual rods from milk cultures

fourths to two microns in width, One average rod would cover
dozen average tubercle bacilli. It is a non-motile facultative
It forms a
turbid.
the surface of agar o1 elyeerin agar in tubes or petrie dishes.

anerobe. sediment and scum on bouillon and ren

ders it It forms an opaque, non-spreading colony on

Deep colonies in agar resemble those of anthrax. It grows at

room temperature, and its spores resist more than 100 degrees

of moist heat for an hour. It digests but does not curdle

milk [t forms a sunken colony in blood serum and only
slightly digests the serum. It quickly dissolves gelatin and
shrinks to smaller rods. On ammoniated gelatin the rods are

somewhat stouter, with

After fifty

large

a vrowth of diplococcei.
hours on sugar gelatin the colony consists of many

spores and an immense amount of acid-fast amorphous spore

matter, which fills to bursting many of the rods. and which is
also found in various rounding shapes, free in the microscopic

fields

is formed

On potato, a dry opaque gray or lemon-colored growth
Maher has not yet been able to grow a pure colony
of Bacillus maternus from tubercular sputum, but is satisfied
that he
of this organism in the fields of
acid-fast

isolated what seems to be a

recognized indi\ iduals and

blue

which we are all

has several times groups
biscuits and pus-nuclei

familiar. He
Bacillus mi

and rods, with has

pure culture of ifernus

from smegma and also from the spleens of guinea-pigs dead
with tuberculosis.

29. Cerebrospinal Meningitis. Berg’s usual method of treat
ment consists of repeated lumbar punctures only when, afte
a period of improvement, the temperature rises again and

svmptoms of increased intraspinal and intracranial tension
If the cerebrospinal fluid flows from the canula in a
15 to

If it escapes drop by drop

eceur,
continuous stream under tension, the withdrawal of from
30 ¢.c. of fluid will do much good.
the puncture will have no effect from a therapeutie standpoint.
from 5 to 10

i vear old; from 15

Sodium jiodid is given in considerable doses,

vrains every three hours to a child ovei

Adults also receive
the back of
In children with

to 20 grains every three hours to adults

15 grains of mereuric ointment by inunction in

the neck twice daily, until the gums are red.
open fontanelles, the oleate of mercury in proper doses is rub
hed the the
curial ointment is rubbed into the back of the neck and spine,

into anterior fontanelle. In older children me

times a day. Icebags
applied to the head, neck and spine. With these
together with the treatment of symptomatic indica
When the

he uses a warm bath, tempera

in pieces as large as a bean, several

should be
methods,
tions 10) per cent. of recoveries may be expected,
temperature goes above 103 i
minutes. The

and the

ture 8O F., in which the patient remains five

temperature of the bath is then raised to 90 F patiem

allowed to remain five minutes more. Care must be taken ty
prevent bed sores, local infection of the skin, eyes, ear, ose
and throat. The patient should be placed in a large licht
room, With plenty of air space and proper ventilation. Sun
light is desirable, as it is one of the most powerful antidotes
to the bacteriologic cause of this disease.

30. Mastoiditis and Facia] Paralysis.—Oppenheimer reports
paralysis of the facial nerve,

He offers

mastoiditis with

TWO CuseSs ¢ f

which recovered after operation nothing

32. Illuminating Gas Poisoning. Hubbard reports a case ot

this kind in
abdominal hypodermoclysis was done.
been thready and barely perceptible began to improve within
The injection was continued until 1,200 ©. e.

After an hour the patient showed the tirst
nightfall had

a woman, aged 75, in which, following venes ction,

The pulse, which had

minutes,

a few
had

signs of

been given.

returning consciousness and by she

CURRENT MEDICAL LITERATURE.

Jour. A. M. A.

Venesection removed much of the poison and
the saline infusion diluted the remaining and fur-
nished the heart with fluid to until the
blood making organs could furnish a new supply. ‘The vene-

quite recovered.
poison,
continue its work
section must be performed early in order to ensure success.
blood to be will Indi-
When the pulse becomes feeble it is time to stop

The amount of withdrawn vary in the
vidual case.
The saline infusion is injected until the radial artery at the
wrist gives a full steady beat. If four or five hours have passed

with no evidence of returning consciousness, a second venesec-

tion may be done, but with great caution.

Cincinnati Lancet-Clinic.

Seple mber 10

Ductus Cysticus Bilis The Duct of the Cholecyst or Gall
Bladder Byron Robinson.
o4 Ice-Cream Balls: a Report of Two Cases of Ptomaine Poison
ing 2 Lloeffer MceMechan.

Buffalo Medical Journal.
Nepte mber

oo *Post-partum Hemorrhage. J. W. Grovenor

36 <Adulteration of Food and Food Products. John H. Grant
37 An Analysis of 50 IHerniotomies Marshall Clinton
35. Postpartum Hemorrhage.Grosvenor, in a very excel-

article on this subject, calls attention to the following
The gravity of the subject: 2, uterine

lent

important points: 1,
the

3, meddlesome midwifery, a prolific cause of postpartum hem-

the need

atony, most frequent cause of postpartum hemorrhage:

orrhage; 4, profound anesthesia a causal factor; 5,
of watehfulness and alertness on the part of the accoucheur,
6, the treatment demands that the accoucheur be prompt and
resourceful; 7,

tion of the

the necessity of both contraction and retrae

uterus: 8, although cases left to nature have re-

covered, a do-nothing policy is strongly condemned; 9, the
usefulness of prophylactic treatment, especially in cases which
a hemorrhagic diathesis: 10, heredity

11, the advantage

indicate the existence of
a causal factor of the hemorrhagic diathesis:
from its incipien:y

of medical superintendance of pregnancy

to its close; 12, the importance of after-treatment,

Archives of Pediatrics, New York.
tugust

38S *Some Considerations Regarding Substitute Feeding During
the First Year. Thomas M. Rotch

39 *The Influence of Breast Feeding on the Infant's Deve:iopment.
Henry D. Chapin

10 *Primary Malignant ‘Tumor of Both Adrenal Glands with
ondary Affection of the Liver Samuel Amberg

11 Simple Method of Modifying Milk in the Tenements
I Coolidge

Sec-

Emelyn

oe; This article h is appeared elsewhere. Se TH Jor RNAL

September 3, {68, p. 697.
39.—Ilbid.,
10. Primary Malignant Tumor of Adrenal Glands.
reports a case of this kind occurring in a child two months old.
The slight the
which examination he found
largement. some edema of the abdominal walls and the super-

title 65, p. 697.

Amberg

parents first noticed a swelling of abdomen,

increased rapidly. On the en

ficial veins much distended. On palpation, a hard smooth mass

was felt. chiefly jn the right side of the abdomen, extending

from the costal margin down to the right inguinal region,
passing deeply into the right flank and filling up the whole
between the ribs and the iliac crest. In the right in-

space
vuinal region a firm edge was felt, which could be traced from
Poupart’s ligament toward the navel, passing below the navel
and then left of the
notch eould indistinctly be felt, but it was not possible to dis-
The leneth of the tumor mass
in the the the

clavieular notch to the umbilicus was 21.5 em., and the greatest

oradually ascending. To the navel a

tinguish two separate masses,

median line was 16 em., distanee from inter-

circumference of the abdemen was 46 em. The uniform tumor
apparently the

numbered 2,800,000; the white 11,000, of which 79 per cent.

represented liver. The red blood corpuscles

were polymorphonuclears, 18.5 per cent. small mononuclears, 2.3
per cent. large mononuclears and transitionals, and 0.2. per
The child

after it was seen the first time

cent. eosinophiles. died in convulsions six days
The autopsy disclosed a tumor

The

masses

of the left adrenal gland and a very much enlarged liver.

liver was cirrhotic and fatty, and contained numerous

SEPT. 24, 1904.

of cells, the same as those in the adrenal tumor. The tumor
was apparently a malignant one, taking its origin, probably,
the medulla of the adrenal
adrenal itself was too far advanced to give any information re

from gland. The growth in the

garding its origin. Morphologically, the tumor may be classed

as & Carcinoma or as an alveolar sarcoma.

American Journal of Orthopedic Surgery, Philadelphia.
fucust.
iv = Tresident’s Address, American Orthopedic Association Reg
inald H, Sayre.
>; *Technic of Neuroplasty. Hans Spitzy.
! Report of a Case of Nerve Anastomosis for the
fanti'e Palsy. James K. Young.
1)6*Final Results in Tendon Transplantation Albert Hoffa
16 *Surgica: Procedures for the Relief of Infantile Paralysis of
the Lower Leg. John Dane and David ‘Townsend.
17 *Value of Bier’s ‘Congestive Method” in the Treatment of
Joint Tuberculosis. Albert H. Frieberg.
1S Distinetion Letween Fracture of the Neck of the Femur and
piphyseal Disjunction in Karly Life, with Reference to
Its Influence on Prognosis and Treatment. Royal Whitman
i? Operative Treatment of Intracapsular Fracture of the Hip:
a Report of Cases. Charles F. Painter.
5O))6Anatemic Treatment of Fracture of the Neck of the Femur
by Which Bony Union Can Be Secured in the Large Majority
of Cases. James KE. Mocre.
m1 Extirpation of the Tensor Vagina Femoris for the
tion of Internal Rotation in Spastic Varaplegia
Disease). V. P. Gibney.
52 The Heidelberg Splint: a New Bandage. O. Vulpius
a3) Treatment of Acute and Subacute Inflammations of the Knee
Joint by Apparatus Permitting Locomotion with Protected
Antero-posteriory Motion at the Joint. Newton M. Shaffer
od Influence of Growth on the Course and Treatment of Con
genital Clubfoot. A. B. Judson
o> Report of Experiments to Determine Whether Plaster of Paris
Contracts or Expands in Setting J. Porrence Rugh

Cure of In

Correec
(Little's

$3. Technic of Neuroplasty. animals, as

as operations on man, have proved that it is possible to

experiments on

well
establish reciprocal connection between two different nerves.
Splitting and grafting of nerves have also been performed on

man, and, im some cases, with good results. Spitzy carried on

experiments for the purpose of determining the kinds ot
paralysis that are observed most frequently, and the best
methods for correcting the same. Does were used, and his

results were good. The first rule is most scrupulous asepsis
The first experiment con-

Clinical

and a eareful closure of the incision.
sisted of grafting the perineal nerve on the tibial.

tests showed a good result. Microscopic sections made from

tissue taken from the site of union showed distinctly the pass

ing of nerve fibers from the stem of the tibial nerve into the

implanted peripheral stub of the perineal, Other experiments

were equally successful. Neuroplasty should be resorted to

in cases of paraly sis where the period of spontaneous regen
eration has passed and when other therapeutic measures have
proved useless, if the interruption of the conductivity can not
(excision of the sear,

be remedied by means OF an operation

primary or secondary suture, neurolysis.) Neuroplasty is to
be recommended jn any case before an extensive tenoplasty is
attempted. The author expresses the opinion that these plastic
operations are, at all events, worth a trial. The advantage
of the that it

methods known and practiced, but is an

method is does not interfere with any other

addition and an in

crease to our therapeutic resources.

15. Final Results in Tendon Transplantation. Hoffa says
that in order to achieve a good result after a tendon trans
plantation four conditions are necessary: 1. Perfect asepsis.

2. Prevention of hemorrhage. 3.

Healthy muscle material. 4.
Not

can be expected from an operation on a limb totally paralyzed

the tendons must be united under certain tension much
The leg cannot be made to functionate again, but the patient
can be freed from the annoyance of depending on orthopedic
apparatus. This ean be done in a great number of cases. In
other cases a certain amount of tendinous fixation of the joints
can be produced which still allows a certain amount of fune
tional activity. In some cases it is
to life.
erative powers are still present in the muscles. By
restored. \s to
the method of operating, Hoffa believes that the best results
Nicoladoni

individual ex-

possible to bring the

muscle back These are the ones in which the regen

shorten
ing the muscles their elasticity and tone is
can be obtained by
that of
perience in the performance of

combining the operation of
the
these operations counts for

with Lanee. Of course, factor of

CURRENT MEDICAL LITERATURE, 915

The

operation is to obtain the highest

much. most important essential for the suecess of the

possible tension with an

This necessitates the cor
operating The
better are the
Hlofta refers briefly to the good results he

over correction of the deformity.

rection of the deformity before longer and

more careful the after-treatment the final re

sults. has obtained

In paralytic club foot, shoulder joint paralysis, spastic con

tracture of the forearm and elbow. and paralytie talipes cal
caneus.

16. Infantile Paralysis of the Lower Leg. The authors lay

made a comparative study of the results of surgical

various
operations for the improvement of the conditions found in the

lower limb as a result of infantile paralysis in 50 consecutive

with a view to determining what operations offered th

Cases

best prospect of a useful limb. As the operations

were pel

personal techni

formed by various surgeons, the equation of ]

was practically eliminated. It is important to remember, how
ever, that all these cases were dispensary patients, and

ifter the

Were
yperation. The present
These

eared for in the dispensary
status of 14
would

could not be obtaing statistics

Cases
seem to show

1. That in all cases where an attempt was made to restore

balance of muscular power by means of a transference of eithe
the peroneus tertius or the extensor longus hallucis, the trans
planted muscle has failed to hypertrophy to an extent sufficient
to cause any benefit. (Kleven such cases fail to show any improve
ment.)

2. That simpty shortening the extensor tendons in cases
equinus, even aided by transplantation of the flexor longus hallucis

is of no prominent benefit (Two operations, both followed by x

lapse.)

3. That. where the peronei are inserted into a paralyzed tendo
Achillis for the relief of calcaneus, the result is usually disap
pointing (Five operations, the resuit in four being distines

fair.)
Where the

poor, 2nd in one only

4. That, in cases peronei are

ransplanted to

inner side of the foot for the correction of a valgus deformity
results are slightly better, but there are relatively few successes
(Six operations Two results were poor, two fair, and only
wood. )

>». That, where a portion of the tendo Achillis is transplanted
to the extensor side cof the foot for the relief of equinus, th or

is distinctly improved (Two operations, that in which the
tendon Was joined to the common extensor giving a
when it was united with the anterior tibial.)

6. That the best results following tendon insplantation we
Where the whole or a portion of the anterior tibial
transferred to the outer border of the foot for the relief of
varus (Three operations, shewing two good and one
The latter was performed by the so-catled Lange method
of lengthening the transplanted tendon by means of braided sill
The silk acted as a foreign body, and thus preventing a
good result. Experience with that sre too recent as vet
report would seem to show that, where the transplanted tendon

in be given a sub-periosteal insertion in the cuboid, the functiona
result is better then when it is inserted into the tendon of the
peroneus brevis All the latter cases promising well

7 astragalectomy uniformly yields a good. usef

aition

ih cases was

equine
was fair

sloughed,

eases

(. ‘That

(Three cases, and all successful.)

S. That the results of arthodesis of the tibioastragaloid joint
are, as a rute, excellent. (Nine operations, with seven good re
sults In one of these cases complete immobilization was not. s¢
cured at the first operation, but a second gave a most excellent
result In the other there was no improvement, due probably
a failure to remove a suflicient amount of the articular cartilag
A somewhat stronger foot was found in the cases of arthrodes

than these where astragalectomy had been performed.)

The conclusion would seem to be that, while tendon transp
tion may in certain cases vield a satisfactory result, the selecti
of cases for this operation shonld be much more careful than it w
three or four vears ago, and that for the great majority of hespita
eases either astra fectomy or arthrodesis offers by far the grentest
romise for obtaining a strong, vsetul foot several vears aft

operation

17. Bier’s Treatment in Joint Tuberculosis. reiberg dis
cusses Bier’s “congestive method” in the treatment of varit
tuberculosis. Originally, the congestion produced was as great
as possible; the parts became not only turgid with nous

}

blood, but also eold. Considerable pain had to be endured

the patient, and the constricting bandage was applied for hom

at a time. Bier has modified his method so that all possibilit

of damage by it would seem to he re moved As at present i
vocated, the congestion should never pass bevond the

stage.”

The patient should feel no pain; the treatment shoul

not be more than one hour dailv. Kreibere has found that |

using a bandage of elastie cotton webbing the degre rf ol

gestion is controlled more easily than when the rubber bandau

is used. In patients of ordinary intelligence the proper appli

cation of the bandage js very soon learned, so that it ean |

applied at home. In conjuunction with the Bier method, Frei

berg insists on immobilization and sme as

protect ion, the

heretofore. He regards the method as an adjuvant to the re

916

sources long at our disposal, but by no means destined to sup-

plant them. The improvement in results is unquestionable,
but not so great that he would be willing to trust to conges-
The congestion method of treatment has an in-
accelerating the reparative

The possibility of cure by congestion, says the au

tion alone.
fluence on muscular atrophy by
process.
would seem of special im-

thor, is never to be ignored. It

portance jn diseases of the wrist and ankle; but to attain suc-

cess by means of Bier’s method requires time, and patience,

and eare in Unreasonable should not be ex

pe ‘ted of it.

detail. things

Three cases are cited in which the method was

used suecesstully 7

Journal of the Association of Military Surgeons, Carlisle, Pa.
September.

56 Observations on the Campaign in Western Porto Rico During
the Spaish-American War. Bailey K. Ashford.
*Differential Diagnosis of Typhoid Fever in Its Earliest Stages
William C. Rucker, ;
9S Report of a Case of Malarial Sciatica.
59 United States Army General Hospital at the Presidio.
¢. Girard.

Klon O. Huntington
i Alfred

57. Differential Diagnosis of Typhoid Fever.
i splendid review of the differential diagnosis of typhoid fever,

Rucker gives

covering the entire field, including all the various laboratory
He had fused his
own experiences with those of many other observers and gives

methods that serve as a means of diagnosis.

an impersonal résumé of the whole, endeavoring to treat the
subject in its entirety rather than make the paper an excuse for
a dissertation on one particular point. He summarizes his
paper as follows: 1. which
alone an early diagnosis of typhoid fever can be made. It
is only by careful consideration of the symptom-complex that
2. The trust
worthy, as well as the earliest sign of typhoid fever is the
presence in the circulating blood of the bacillus of Eberth.
3. The demonstration of the bacillus of Eberth in the blood is
not beyond any fairiy well equipped laboratory. 4. The ba
cillus of Eberth is found in the feces later than in the blood,
The presence of the Bacillus ty-

There is no single symptom on

a cliniea] diagnosis can be arrived at most

but with comparative ease
phosus in the feces is of great value as a corroborative sign.
5. The presence of the Bacillus typhosus in the rose spots
is a trustworthy sign, but has no advantages over examina
tion of the blood from other localities.
of Widal is seldom demonstrable during the earliest stages of

6. The serum reaction

typhoid fever. It is of value only in the higher dilutions.

Medicine, Detroit.
August.
60 *The Early Lesions of Arteriosclerosis, with Special Reference
to Alterations in the Elastica. W. M. L. Coplin
61 Acute Suppurative Disease of the Mastoid Complicating In

fluenza, with Report of Three Cases. TP. 8S. Donnellan.
62 *The Mental Disorders of Neurasthenia Frank Parsons Nor

bury.

63 The Trophic Disturbances of the Fifth Pair of Nerves. Har
old N. Moyer.

64 The Limitation of Untoward Effects in Anesthesia Henry

B. Hollen.
Sepntembei

65> *Bacteriologic Study of Searlet TFeve1 J. F. Sehamberg and
Nathaniel Gildersleeve

S56 Report of a Case of Stokes-Adams Disease R. L

6O7 *Tentative Surgical Methods in the Treatment of
ach Maladies. Thomas H. Manley.

GS Importance of Antepartum Examination Frederick Leavitt

69 The Molar Tecth and the Patellar Reflex in Heredity Syphil
itic Interstitial Keratitis. George F. Suker

in Diseases of the Eye, Ear, Nose and Throat J

Pitsfield.
Some Stom

7o Brometone

J. Ky'e.
7 Syringomyelia Richard C. Newton
72 *Primary Carcinoma of the Vagina Charles G. Cumston
Ov This article has appe ired elsewhere. See THE JOURNAT

of July 16, 98, p. 226.

g? See JOURNAL of July 30, 52, p. 304

abstract in Tit
65. Bacteriological Study of Scarlet Fever..—Schamberg and

examined bhacteriologically a series of cases of

scarlet fever. The
and sixth day of the disease.

(r,iidersieeve

cultures were made between the second

The blood of twenty cases was

examined and negative results obtained in all. Streptococci

and staphyvlococei were found in the vast majority of the cases,

Cultures were made from the throats of 100 apparently well

persons, and streptococci were found in 82 per cent. Both

oubte 1i\ re

frequent ly eon

el and st iphv loco 1 un

streptoco

CURRENT MEDICAL LITERATURE.

Jour. A. M. A.

cerned in the complications of scarlet fever, but are not to be
looked on as the specific agent. ‘The diplococeus described by
Class as the cause of scarlet fever was found by the authors
in a comparatively small per cent. of the cases examined.
They do not regard this organism as bearing any etiologic re-
lationship to the disease. They believe that the failure to
discover the specific cause of scarlet fever may have been due
to the fact that
vegetable parasites and not for animal parasites.

made for
The find-
ings of Mallory, of protozoa-like bodies in the skin of scarlet

almost exclusive search has been

fever patients, will doubtless stimulate research along these
lines,

67. Tentative Surgical Methods in Stomach Maladies._-Man
gastric therapy and therapy
of the abdominal walls in to the treatment of
affections of the stomach, both functional and organic, review
ing accepted methods and procedures.

ley considers mechanical therapy,
their relation

72. Primary Carcinoma of the Vagina.—-This is a full discus

sion of this subject, particularly the surgical treatment, with

a report of one case, the patient dying about four months

after the operation.

St. Paul Medical Journal,

September.

i *On Certain Non-diphtheritic Membranous Anginas. Louis B.
Wilson

74 Duodenal Ulcer, Symptoms and Diagnosis
ham

7> Note&S on the
tremity. with
T. Adan:s

76 *Subparietal Iniuries of the Kidneys.

77 *Pneumonia A. T. Conley.

78 The Abuse of Drugs. C. R. Christenson.

79 *Surgical Treatment of Varicose Veins. CC. H. Mayo.

73. Nondiphtheritic Membranous Angina.Wilson divides
the non-diphtheritic pseudomembranous anginas into several
groups, each of which is a more or less distinct clinical entity

Christopher Gra-
Management of Fractures of the Lower Ex
Hodgen's Splint, with Report of Cases. W.

Walter Courtney.

associated with a species of micro-organism either alone or in
great preponderance. These nondiphtheritic anginas are im
portant not only because of the necessity of differentiating
them from diphtheria, but also because they are frequently
transmissable; and their treatment should vary according to
the micro-organism present. Careful clinical observations, in
with full should be
In order to determine as early as possible

connection bacteriologic investigations,
made in each ease.
the etiologic factor in anginas, cover-slip or slide preparations
from the membrane, as well as cultures on diphtheria media,
should be made by the physician on his first visit. These
dried healing, then fixed by heat, and

either stained by the physician, or sent to a laboratory with the

should be without

culture for further examination. Wherever possible, more
extensive bacteriologic investigation should be made. Among

the associated organisms found by Wilson were streptococci,
Friedlander’s bacillus, spirillum of

He believes that the blastomyces is
These
a eliniecal history of onset with chill, somewhat

diplococcus pneumonie,

Vincent, and blastomyces.
a much more common cause of angina than is believed.
cases present
rapid rise in temperature, malaise and considerable prostration.
The tonsils are congested, swollen, and rapidly become covered
by a thin, grayish white membrane, which in most cases ex
tended forward from the tonsils over the anterior faucial pil
lar, and in some cases upward, involving the uvula and soft
palate. The membrane does not yield readily to local treat
ment, to silver nitrate, iodin, laectie acid, carbolie acid, or for

malin. Antitoxin has been used without any effect on the

membrane. Two cases in which no other organisms were ob-
tained in culture proved fatal. Blastomyces were found alone
in 136 cases, and in 97 cases they were associated with ba
cillus diphtheria. The organism grows abundantly on the
ordinary laboratory media, forming a thick, white and moist
fluid

few days.

erowth. In media the growth sinks to the bottom of

the tube in a Glucose and maltose are fermented,
but without the formation of aleohol. No fermentation occurs
in lactose. The organism stains readily, but unevenly, show
ing nuclei, vacuoles, and chromatophilie granules. No spore
formation has been produced.

76. Injuries of the Kidney.—Courtney discusses this subject,

SEPT. 24, 1904. CURRENT MEDIC
reports four cases, and concludes by saying that the inference
to be drawn is that nephrectomy should only be performed
early when the renal vessels are known to be torn, or when
there such unmistakable disorganization of the kidney
structure as to make it reasonably certain that resumption of

Is

function can not be expected.

77. Pneumonia. short review of the treat

ment of pneumonia for the last fifty years, but offers nothing

( ‘onley QIN es a

new.

79. Surgical Treatment of Varicose Veins._-Mayo is of the
opinion that the essential predisposing cause of varicose Veins is
a congenital defect in the vessels or their innervation, which, in
some cases, may be aggravated by occupation, injury, childbeat
ing or constipation. He favors a partial Schede operation or
oval incision above a large uleer combined with excision of the
\t
operation, or the more extensive excision of the internal saph
|

uleer and skinerafting. the same time, the Trendelenburg
thigh to a point six o
The

of short areas of veins js reserved for those cases with involve

enous Vein from the upper third of 4
eight inches below the knee, is also performed. removal
ment of the veins of the posterior thigh or the external saph

enous. In a very few cases where the veins are enormousl)

and irregularly dilated, the stripping process, described below,

is impossible through the whole extent of the saphenous. The
Bristol method

treatment. The author's

is then used as an adjun

t to the enucleation

method is follows: The vein is

sought for and severed in the upper third of the thigh, The prox
imal end is ligated, the jower end is clamped an inch from tl
end, which is passed throuevh the ring of T the iwleatol l 1, l
ring of steel with a lone handle, not unl . blunt uteri
currette) or placed in the tube of the forceps (which are ]
lowed out in each blade so as to form a Jone tul \ los
about », of an inch in diameter umd the clamps are
ferred to the end of the vein By gentle pushing force th

or forceps Is pushed down the vein, eld unade tension Tor s
or eight inches, tearing off the lateral branches when the poi
of the instrument is forced against the skin from beneath, an
a small incision made in the skin to the ring or forceps,

is pushed through the opening holding the vein in it like a
The

Dist Vue

in a needle eve. vein

thre nt. hich Is removed l

trom

and again forced through the new skin opening
following the vein, and is pushed down to a lower point where
i small incision is again made and the same process of me
repeated. The small lateral branches are torn off and,
rule, have enough muscle structure to close themselves. Below
the knee he branches are larger and the vein is mor
herent. so that a short distance ean be traversed Ile 1 i
is avoided by position. An ordinary necologie standat .
placed in position and the leg raised in straig r exter
position and supported by the ankle. is renders
partially bloodless and secures elevation and access
ic field of operation. More than momentary hemo
be checked by a small pack, or an assistant can check
pressure pad held against the skin over the regio
t blood escaped from the vessels This n od has 1
time for operation very cons ' ind has }
t class of relatively trivial operat
ender jt one of the most serious
Cleveland Medical Journal
f hie
SO *¥ Sv] s of the Stomactl Cl es F. H
. . experience Vil he ¢ (
Hanser
S82 EF i d Its Tr I ~
as. ££ 1 i. CC. Brow.
80. Syphilis of the Stomach.—!]
haracters ot syphilis of the sto cl ind
rroduce, have so manv points 3 mymor t ti
that e diagnosis during life must rest on the tl tic tes
Three cases in point are reported, earch pres
erent symptoms In nor .
tumor or area of maximuim tenderness Ne
: ald bi tected in physical examination. as fat the st
3 ‘ In two « - 3

'AL LITERATURE.

917

after the ingestion of

two cases gave a clear history of syphilis,

the stomach were pain, and vomiting,
food. Although
no evidences of svphilis were apparent on physical examina

tion. The third case had a saddle nose and perforated sott

palate. In these cases it is important to make a diagnosis so
that proper treatment can be followed. Unless the physician

is strongly impressed with the possibility of syphilis being

the etiologic factor, iodid of potassium will not be given on ae

count of its irritating properties to the stomach When in
doubt, give iodid of potassium, is a maxim easily followed when
the stomach is not at fault But the administration of iodid
of potassium in a doubtful case in which gastrie pain and
vomiting are the conspicuous svmptoms, is abhorent to the

of the therapeutist unless the idea of syphilis is para

mount in his speculations.

mind

Hanson details his

Sl. Convulsions of Children.

vith the convulsions of children, making special reference
the etiology of the eases observed, and emphasizes the imp
ance of chloroform inhalations, chloral enemata, hy poder !

ection of morphin, and the inhalation of oxvgen in the treat

nent of these cases, ench to be used as indicated

Indiana Medical Journai, Indianapolis
tygust

Paretiec Dementia Mrnest C

ninistration 1)

SOD *Will the Long-Continued
Cardiae Hypertrophy Frank B. Wynn
S6 =Case of Mechanical Ileus Due to Cor ! | i |
Angulation with Adhesions L.. Ha Bo g
S7 Use of the Galvano Carterv in Enlarged Prostate T}
t} ‘iedian Perineal Ineisior Who N. W
wR P ine Prostate omy | Liiine! ( |
a pha Joseph Rilus Eastn
' ( h-f J If Olive
te he
“ Inte q) hte ( (a
| 7 ( ] 1} jdis I I
I I nceiptes ee t
ey Ye Poy It ? ‘ i s
J. Kempf
85 Vhis article appeared in Tie Jour if 1 lt th

’
“Vl

90. Intestinal Obstruction... Bowers d isses tl

ynamies, and symptoms of intestina bsti I I
O Case one a man aged 450 vears, 1 \ ( !
1 Mu is th ca ( 1} Iystt lot

\ en) old n hich ( ybsti |

he? t OW ¢ hy r throiue

14 e) ma ase } }
~ rormed n | <1 inf \ ( }
( nd patient wed he res
rene of the bowel

%1. Points in Treating Fractures and Dislocations... ‘lhis*i

, 4

neral discussion of 1e@ subject. as indi i!
Batt | !
i } ' |
t ire i
! ract re heen atter | |
es are ‘ to base t rj r
| pra ‘ t nd 1
]
< heca e ti rav’s 4
I ] = 1 t ead nee }
1
\ Ss } j I)
l
" ] l (
ol n
¢ : ) + > 1
Yeast Poultices. ix ist
Wit
| ,
= j Bee (
j , ‘
‘ !
» ,

OG Lhie \

vis

tugust

Ray as a Therapeutic Agent hdwin Waike!

97 *Mental Piserders of Neurasthenin Frank BP. Norbury

SS An Analysis of Last Year's Work in the Municipal Dispen
sary of the City of St. Louis. Henry J. Scherck

97.—See abstract in Tne Journar, xl, p. 1440

se \ pred
“0 Complications and Sequele of

]
i
j

ty] Success in

Virginia Medical Semi-Monthly, Richmond.
tvgust 12

John T. Graham

Parotitis. D

Muay Le

dicitis
lL. Kingsolver
Medicine and Achieved. George
Vaughan
Anesthesia A

the Way It
Tully

2) «Chloroform Jacoby

i083 Should the Proposed New Constitution and By-Laws of the
Medical Society Be Adopted George 6. Jennings
}in4 Professional Union Or, A United Profession J. G. Carpen
har
{tuqust t
105 Adenoids and Enlarged Tonsils Joseph A. White
” State Medical Organizations and the American Medical Asso
ation Landon B. Edwards
107 Smallpox Occurring During Pregnancy Lewellyn Eliot
Ss Arthritis Deformans,” with Report of Case Emmett F
Reese
"ny A Case of Acute Yellow Atrophy of Liver, Complicating Ap
pendicitis Lewis C, Bosher
110 lea for the Use of a Siandard Whisky Thomas R. Evans
1 Hebb's Improved Clamp for Earle's Method of Operating for
Hemorrhoids S. Earle, Jr
Annals of Ophthalmology, St. Leuis.
July
12 An Improved Secale for Determining Muscular Insufliciencies
Harold Bailes
Case of Bilateral Enlargement of Lachrvmal Glands William
lr. Shoemaket
$ Microphthalmos and Congenital Anklvoblepharon ; Two Cases
Walter H. Snyder
Paralysis of the pward Movements of the Eyes. William C
Posey
‘ Suggestions as » Postmydriatic Refraction Tests Georg
M. Gould
7 Pemphigus of the Conjunctiva, with Report of a Cass S.H
Brown
11S Observations on the Pathology « he ¢‘rystalline Lens K.S
rhomson
) Fistorie Note Regarding the Optic Chiasm and Some Points

22 «Normal

to Monocular and Binocular Vision M
Medicine.

Referring Marquez
Atlanta Journal-Record of
tvaust
Study ef a Case of Lateral Curvature of the Spine: A
of an Operation for the Deformity (Concluded. )
"loke
1 he Prevention of Diarrhea, with
eriology Robert W. Hlynds

Report
Michael

Special Reference to Bac

Denver Medical Times.
tudgust
Mitchel] Burns

Obstetrics To be continued.) ]

23 An Outline of Hematuria Edward C. Hill
124 4 Mode! Act to Protect the Public Health and Regulate the
Practice of Medicine. S. D. Van Meter

Merck’s Archives, New York.

tudgust
ito 06 Teaching and the Text-PRooks of Materia Medica and Thera
peutics. John Forrest
“45 Index of Disease Alphabetically Arranged, with Their Modern

i129 Technic of the Operation for Appendicitis J. EB

A Pneumonia
"“S Hints

Preatment G. Bjorkman,

Memphis Medical Monthly.
tuaqust

James S. Rawlins

on the Diagnosis and Treatment of

Young Children. Hermon Hawkins

Pneumonia in

» Johnson
Alfred Moore

In0)06Clinical Notes on Three Cases of Appendicitis

1; Two Recent Cases of Extra-Uterine Pregnancy John M.
Maury

132 The Management of Typhoid Convalescence. J. R. Nelson

Conjunctivitis BB. S. Penn

‘4 Preatment of Chronic Posterior Urethritis John L. Jelks
Texas Medical Journal, Austin.
fuqust
5 Phe Medical Profession; A Contributory Factor to the Death
Rate of Consumptives. CC. 11. Wilkinson
4 Albargin Joint Review. with Versonal Experience Dr. Sei

St. Louis Courier of Medicine.
tugust

7 Modern Treatment of Cholera Infantum Robert M. Sterrett

28 Value of Differential Leucocyte Count in the Diagnosis of the
Diseases of Infancy John Zahorsky

yf Angioneuretic Mdema: Report of a Case M. George Gorin

140 Brief Notes on Three Cases of Strangulated Hernia John
Young Brown

141 Serum Treatment of Typhoid Fever i. A. Babler
Oklahoma Medical-News Journal, Oklahoma City.

iudquat
142 Typhoid Fever: Diagnosis and Treatment Charles Blickens

143

a
derfer
Je

how int and Some of Its Abnormalities R. H. Tullis

CURRENT: MEDIC.

(L LITERATURE. Journ. A. M. A.

Interstate Medical Journal, St. Louis.

August.

144 Diagnostic Considerations of Hemorrhage from the Stomach
I’, Gregory Connell.
145 Fracture of the Forearm Followed by Contracture of the
Flexor Tendons: Report of a Case Clifford U. Collins
146 Surgery of Arthritie Deformans Hermann DB. Gessner
147 Plastic Surgery. C. E. Ruth
Medical Age, Detroit.
tuqust 25.
14S) Chronie Laryngitis as Treated by the General Practitioner
J. 2. Pratt
149 Tubereulous Spondylitis; Diagnosis and Prognosis John I.
Porter.
Carolina Medical Journal, Charlotte, N. C.
Aucust.
150 The Treatment of Prostatic Hypertrophy Lewis C. Bosher
1510 Cholera’ Infantum W. EF. Chenault
152 Fecal Vomiting in Intestinal Obstruction A. K. Bond
Medical and Surgical Monitor, Indianapolis.
{yvqust 75,
Ia) The Typhoid Uleer: Its Surgical Aspect Thomas B. Noble
1564 Important Triangles of the Thigh HT. R. Allen
155) «Etiology and Diagnosis of Searlet Fever A. 1. Wilson

o6 Intestinal Obstruction, with Report of Cases lL. Gi. Bowers

Io Fracture of Skull Base. Remote Effects. KF. W. Foxworthy
15S) Experience and Theory J. W. Crismond
Fort Wayne Medical Journal-Magazine.
Tuqust
po Surgical Diagnosis Miles FF, Porter
160° Some Atypical Cases in Abdominal Surgery Hal ©. Wyman
Northwest Medicine, Seattle, Wash
tuogust
161 Addres Washington State Medical Association Krantz IW
Cor

162 The Clean Milk Problem Kenelm Winslow

Colorado Medicine, Denver.

ligust

1633 Acute Otiti Median and > Mastoiditis Recent Cases Win €
Rane
1G4 Tuberenlosis in Tis Relation to Publie TIealth C K. Cooper
165 The State Board of Health and Tuberculosis J. N. Hall
FOREIGN.
Titles marked with an asterisk (*) are abstracted below Clinica

fectures, single case reports and trials of new drugs and

omitted unless of exceptional general interest,

artificial

foods are

The Practitioner, London.
Nentembes
1 * Tremors " W. Mott
“ Total Mnucleation of the Prostate for Radical
largement of That Organ Pp. J. Freyer
*The Diagnostic Value of Hemiplegia of
Sign ef Cerebral Tumor Be a
{ Diagnosis of Pulmonary Tuberculosis in Infants
Children Ss ". Pearson
D *Uleus Carcinomatosum Bh. G. A. Moynihan
6 Some Distinctions Between Hysteria and Neurasthenia, and
y

Cure of Tn

Gradual Onset as a
Williamson

and Young

Their Association with Other Diseases Ascherson
7 *An Unusual Variety of Plenrisv in Children (. Riviere
S Paralytiec Deformities and Their Modern Treatment Jd. Jack

Clarke
Work in

Mott the
Organic disease of the nervous system. 2. Tre

son

9 Recent Anesthesia J. Blumfeld

1. Tremors. classifies arising in disease

as follows: 1.

tremors

3. Tremors in infectious diseases.

4. Neuropathic tremors of degenerates.

mors due to poisoning.
5. Tremors of neu
roses: (a) exopthalmic goiter, (b) paralysis agitans, (¢) neu
rasthenia, (d) hysteria. No classification is quite satisfactory.

Very often the tremor is polymorphic—at one time, or in one
case, existing only during repose, in another disappearing du
ing rest. Several diseases may present a fine vibratory tremor,

such as Graves’ disease, neurasthenia, emotionalism and alco

The author believes that tremor is due to a disturb
the the
spinal motor neurons to synergie groups of muscles, whether
these A fun
tional or organie disturbance of the nervous structures which
the the
from these spinal motor neurons would serve as a cause of

holism.

ance of normal innervation currents passing from

are in action or in passive tonic contraction.

regulate and adjust outflow of innervation currents

tremor. Tremors should be investigated by a consideration of
the following questions : 1. Are the tremors local or general
2. Are they continuously present, or only transitory and called
such as emotion, attention, irri

for by certain circumstances,

SEPT. 24, 1904.

tation or bodily fatigue? 3. Do they occur in the part at rest?
Do they cease during sleep? Are they provoked by intentional
movements? 4.
or not—in other words, is the tremor coarse and obvious or
fine and only discoverable by careful examination? 5. Is the
rhythm quick (8 to 9 oscillations a second) or slow (4 to 5
oscillations) ?

Is the amplitude of the oscillations extensive

3. Hemiplegia With Cerebral Tumor. Williamson calls at
tention to the value of hemiplegia of gradual onset as a sign
of brain tumor, even when optic neuritis is absent, or when
Stated

provided there are no indications of cerebral

optic neuritis, headache, and vomiting are all absent.
in other words
abscess—progressive hemiplegia, or hemiplegia of gradual on-
set, in which weeks or a few months elapse before the paralysis
is compete, may be regarded as strong evidence of cerebral
tumor «ven when optic neuritis is absent, or when optic neu
ritis. headache and vomiting are all absent.

5. Ulcus Carcinomatosum.
lignant disease of the stomach in which both the clinical his

Moynihan reports one case of ma

tory and microscopic examination showed that the origin of
the growth was a chronic ulcer.

7. Unusual Variety of Pleurisy in Children. Riviere reports
six cases of loculated effusion occurring over the middle lobe
and closely simulating other pathologic changes occurring in
children in the same situation, such as pneumonia with sub
sequent effusion at the base; fibrosis of the middle lobe; pul
monary or glandular tuberculosis:
chronie lung disease in the opposite side of the chest, eithe:

pulmonary collapse and

tubercular or bronchiectatic in nature. The diagnosis was not

confirmed with the exploring syringe in any of these cases, the
author not deeming such a measure justifiable under the eir
cumstances.

Intercolonial Medical Journal of Australasia, Melbourne.
July 20

10 Clinical Examination of the Blood. R. R. Stawell.

11 *T'wo Cases of Splenectomy. R. A. Stirling.

12 *Six Cases of Splenic Anemia in One Family. J. W
thorpe,

18 Notes on a Case of Splenic Anemia. H. Sexten

14. Notes on a Case of Leucocythemia. Alex. Lewers

15 Notification of Consumption. <A. Jefferis Turner

Spring

11. Splenectomy.
for splenic pseudoleukemia that recovered from the operation.
but makes no mention of their subsequent history. Both cases
were alive one month after operation. and the blood findings
had improved remarkably. The red cells in one case num-
bered 4,820,000. and in the other 4.600.000: leucocytes, 8.000:
hemoglobin, 85 per cent. The author considers the following
indications for splenectomy: Malarial spleen, splenic pseudo
leukemia, splenic leukemia, Banti’s disease, wandering spleen,
and possibly hydatids

Stirling reports two cases of splenectomy

abscess of the spleen, rupture, sarcoma,
of the spleen.

12. Six Cases of Splenic Anemia.
in the relationship of three sisters and one brother, and the
Two brothers and ten cousins+shave not

These six patients stood

latter’s son and niece.
been examined to determine whether they are or are not af
fected. There was no family history of congenital syphilis or
of acquired syphilis, except in one instance. The ages of the
patients were 28, 19, 23, 30. 7 and 10 respectively. Splenee
tomy was performed in two of the cases who were still doing
well one vear after the operation.

Australasian Medical Gazette, Sydney.
July on

16 Presidential Address. Melville Jay

7 *Alexander’s Operation on the Round Ligaments W. J. Stew
art MacKay.

18 Presidential Address A. Andrews

19 *Karly Operation in Typhoid Perforation, <A. Jefferis Turner

20 *Gunshot Wounds in the Abdomen. W. A. Verco
21 Gunshot Wound of Liver, Aorta, Spine; Survival for
B. Poulton.

22 Glioma of the Spinal Cord. J. MeDonald Gill

22 Two Cases of Macrocephaly. A. S. Joske

24 *The Recent Epidemic of Infantile Paralysis. kh. B
25 *Ibid. W. F. Litchfield
26 *Enidemic Polyneuritis
27 *An Unusual Case of Pneumothorax.

33 Days

Wade.

Patrick Blackall.
W. Morrison

17. Alexander’s Operation.
ander’s operation and concludes as follows:

McKay describes, in full, Alex
Retroflexion of
the uterus jn virgins and married women when there is no pro

CURRENT MEDICAL LITERATURE,

4

919

lapse and when there are no adhesions present is the condi-
tion for which this operation is most suitable. Retroversion of
the uterus he suitable condition, for, though a
retroversion may cause no symptoms, still if the uterus is al-

considers a

lowed to remain in its abnormal position the abdominal press
ure may in time convert the retroversion into a prolapsus or a
retroflexion. If after performing the curettage he finds the
uterus retroverted he shortens the ligaments as a routine prac
tice. If with retroflexion or retroversion there is slight pro
lapse of the uterus, shortening the round ligaments is a good
operation when used in conjunction with amputation of the
cervix and colporrhaphy. This allows the uterosacral liga-
ments (the chief supports of the uterus) to regain their tone.
In well-marked cases of prolapsus the operation may be done
if the woman is in the child-bearing period; if the menopause
is passed, or if near at hand, ventrofixation is the proper oper
ation for severe prolapse, though of late he has adopted a
plan of removing the uterus by vaginal hysterectomy. It is
such an easy matter to explore the ovaries and tubes through
the internal ring that he has adopted this method in prefer-

ence to the median incision when he wishes to remove a small
ovarian cyst or a hydrosalpinx,
19. Typhoid Perforation._-Turner savs that when a recog

nizable perforation occurs during an attack of typhoid fever
an operation should be performed, and at once.

20. Gunshot Wounds of the Abdomen.—Verco says that al-
though military authorities are agreed to leave abdominal bul-
let wounds alone, as they find that this treatment gives the
greatest percentage of recoveries, vet in civil cases, the sur
roundings being favorable, the abdomen ought to be opened as
soon as possible after the injury, and the wounds of the vis
cera, if any, sewn over. In military practice the wound is
often inflicted with the stomach and intestines comparatively
empty, and hence there is little danger of leakage. Just the
opposite is true of most civil cases. Again, when the stomach
and intestines contain fluid the “explosive action” of
the bullet makes a much larger hole. should
be remembered that in the case of missiles fired at close quar
ters there is much tearing of the hollow organs, and not the
clean penetration that occurs in a wound from a missile fired

much
Furthermore, it

at a distance.

24-25. Epidemic of Infantile Paralysis... Wade
observations made on 34 cases of epidemic infantile paralysis,
16 of them males and 18 females. The youngest patient was
i3 month olds, the oldest 7 vears.
sudden, the disease being initiated by anorexia, fever and vom
iting. In 2, the vomiting was absent; in 3, the attack was
ushered in with fever, vomiting and diarrhea; in only | case
were there convulsions, and this was in an epileptic; in 1, the
paralysis occurred during pneumonia: in 1, during measles, and
The fever in each case per

details his

In each case the onset was

in only 1 case was there apyrexia.
sisted for from four to ten days, ranging between 100 and 102.
The most marked symptom was pain in the affected limbs, and
this was present in 28 out of the 34 cases. Marked tender
ness existed in the affected muscles and persisted for some
time, in one case lasting two months, and in most cases from
three to four weeks. In only two cases was tenderness absent.
The muscles of the limbs which affected in all
either alone or in conjunction with others, belong without ex
ception to the extensor groups, and were the trapezius, supra
spinatus and infraspinatus, deltoid, triceps and extensors of
the fingers in the upper limb: while in the lower were tt
quadriceps, peronei and extensors of the foot. The flexors and
adductors were never involved alone, but only as a part of the
veneral paralysis of the limb. With the onset of paralysis the
affected muscles became limp and flabby, but no wasting was
tticed. A certain rule, but in
vy case there are some muscles or groups of muscles that

cases,

were

e

amount of recovery is the

»w no indication of it. Recovery is slow, does not begin un

til about six weeks afterward, and in some cases improvement

is still going on after four months. The superficial skin re

flexes and the knee-jerks were present or not, according as

their corresponding muscle was paralyzed or not Kernig’s

sign Cases: MW each ease the ereetor spina

Was

present in 3

pa

70)

ralysis,

as involved,

the

t he

tenderness of

facto1
the

essential

i

During the acute attack,

)

muscles.

CURRENT

be fore
help in arriving at a

the onset

VEDICAL

of the

diagno pres

LITERATURE

“8. Indications for Dechloridation.
salt

sion of the ingestion of

Jot I.

Dechloridation o1

sup
ot

is merely treatment a

\fter the appearance ot

single symptom, the retention of salt in heart or kidney dis

the paralysis, it has to be distinguished from multiple neuritis, ease. But this retention has so many consequences that it
which may be done by its acute onset, the want of symmetry is of great clinical importance, especially in Bright’s disease,
and the permanency of the paralysis The treatment must be and also in cases of cardiac edema, ascites, hyperchlorhydria,
expectant When the paralysis is established, massage and und even in certain cutaneous affections with exudation. Javal
the use of the constant current is indicated, but must be de vives the detailed history of 2 patients with severe Bright's
laved until the tenderness has become diminished. lisease under the influence of jntermittent dechloridation, The
Lite eld gives a. brief summary of 25 cases observed by curves are instruetive in several respects. They show that
hit ie treatment consisted of keeping the paralyzed limbs theobromin is valuable as an adjuvant but is unable to take
? massage and measures to prevent deformity, the lat‘er the place of dechloridation. \lso that the milk diet is un
some cases necessitating the use of splints necessarv— all that is needed is a diet free from salt This
6. Epidemic Polyneuritis.—Blackall reports six cases ol alone will frequently accomplish all that is needed or required,
emic polyneuritis, all between the aves of 3 and 18 Phe ind any medication is superfluous and henee more *r less
sease comes on gradually. The patient feels out of sorts for armtul, The changes in the body weight parallel the’ iluetu
ne , nd the next is verv i % 17 nplains of headache tions im the salf retention. Daily weighing is thus an im
Vomiting now us ally comes or et ith pains in the ab portant means of detecting sheht edema and its preliminary
men, more especially in the neighbe of the cecun Phe phases, lone beto hey become clinically evident \brupt in
ne hi ted and the 1 ‘ ‘ nstipated. Ter ease In Wweleht is pathognomonic of retention of salt) and its
ire, 101 or 102 Pulse is slight e breathine « etinue of tluids Keach or Oo of salt retained holds back
eloy At this s ; ‘ ta, it is an 1 ita or wate equi nt to a kilogram of weight,
S en f npendieitis { e isan re abser hat is, 2.2 pounds By dailv weiehit we learn the exaet con
l I lol vhnen p ssurs ~ e over the it ition of the retentio ol Lil ind can regulate the amount
\ er the vomiting is less severe or gone, the pain fo salt) alle dun the let to respon ith the amount
1 Cl l ~ 1 Ins ( ( ( {hig } Tare
Vv im the \t . ; ; uae 4. Otology in the Medical Curriculum. —Volitzer’s article
ss he < ( | nf hss presented to the recent International Congress
s { I ! F > j ot iflia \ \ Is coneclus * Phese
_ | . } ] | " i | Cs ek
( idl i ( eco
< | < |
‘
14 Diet in Nephritis. | ( NOS
vines wae : : ! ' ri | j il veut
1\ , } eo lad exacerbation
r eir usua t ( ! I . tO nan :
. 1? fre ee . , 1 ! ta } 1! reoinye
‘ n ’ ; zs not . S l i ~ a rt i
S r the nu \}
» Differential Diagnosis of Yell Feve '
sg . ( j 1 1 [ Joe
' rf nat fever, Tle
: ; , - MI ious] ' ldenly
> T ! i”) nt 1
Wa evel wh
Pneumothorax. | : iti ( ( rad l is] Phis
size otas ! ‘ } ( ‘ { an
Presse Médicale, Paris. shat ,
| ident
: ‘ : i s ptoms of
} | een? i " health
d sade | ( 1] iv re
T |
“A Absorption and Elimination by Leucocytes of Foreign
an \mong t phas ly of
uf aes ( ] re Cl Hee We
I rt n neces
. ( | | itt | | { Sur
w | ( ) i ( r) " l¢ oevtes
4
> ) 1 | ntl l J ovieal to
~ ( ( " Ww? il ! 1 the
( il nm ,
| 1} 1 tie | Heor] elon
if t the : estion ;
I 1 ( l ! il Vie tery
= ; * a i a
s
{ i | Lal ! vyrere eC) of the
( ( { ‘ Hrect
( } n=) { if ! i esita 1 i! luible
] N OH
\ Worl | ned herapeutics. I we act |e rapidly, but
: ‘ ( tilized in time | miter lation of the leuco
{ \ thou Ol it 1 1 ria nod \ th nore
\
d MUTA Phi rt pla i evtes in draining the
: vstem of it st ( transporti | out of

ad

Serr. 24, 1904.

the organisim, rehabilitates the old method of fixation abscesses
as a therapeutic measure of great value in certain infections
and intoxications.

34. Levurargyre.—This term is a combination of the words
meaning yeast and mercury, and is applied to a mercurial!
nucleo-proteid extracted from brewer’s yeast grown in a wash
containing a certain proportion of bichlorid of mercury. It
thus combines the properties of yeast and mercury and seems
to display therapeutic action against the general cutaneous
manifestations of syphilis. Jullien qualifies the clinical re
sults obtained with this new product as very encouraging.

37. Ships and Mosquitoes..-Dupuy’s investigations showed
that both steam and sailing vessels are liable to have mos
quitoes blown or brought on board. ‘They find congenial lurk
ing ploces in the cabins and hold. Mosquitoes bred on board
ean “ot be infected, but those that come on the ship in an
infected port are liable to be dangerous to man. He advises
that ships should dock where they would be inaccessible to
mosquitoes, and also that doors and windows should be kept
screened, especially toward evening. As soon as the ship is in
the open sea, ps rethrum powder should be burned in the
cabins, and they should be energetically aired and ventilated
The Clayton apparatus should be used in the hold, and again
on arriving.

38'4,. Simulated Perforation in Typhoid. Vhe classic argu
ments in favor of operating in case of typhoid perforation are
re-enforeed by Rochard’s experience with a case in which the
assumed perforation had no existence in fact, but the lapar
otomy had evidently a curative action. A convalescent from
typhoid suddenly presented the typical syndrome of intes
tinal perforation, and was operated on the third hour. ‘The
large intestine, duodenum, stomach, and gall bladder wer
carefully examined but found apparently sound, the only ab
normal appearance being exaggerated vascularization of tli
transverse colon. Nothing turther was done and the abdomen
was sutured, the patient recovering rapidly without complica
tions. Ile cites two similar cases published in France in which
at the laparotomy nothing was found to explain the syinptoms
of typhoid perforation, except slight redness of the small in
testine in one and congestion with false membranes at the
ileum in the other. Roehard thinks that the congestion ob
served was a sign of incipient peritonitis, and that the severity)
of the symptoms induced was due merely to the extreme
sensitiveness of the peritonewm in persons convalescing fron
typhoid. The uneventful recoveries in these cases, the mani
fest curative action of the laparotomy alone, and the iney
itably fatal outcome in case of unoperated trae perforation
impel to prompt surgical ttervention

11. Danger of Apparent Death. Icard of Marseilles, France,
has been investigating every case of resuscitation after ap
parent death of which he has learned during the last twelve
vears. The lay press frequently publishes stories of this kind
but in nearly every instance inquiry of the parties intereste
showed that the stories had no foundation. Kven a singel
authentic case of burial alive should impose on the conscien
of every physician the most scrupulous care before he signs
the certiticate of death. leard has collected eleven cases in
which the physician's certificate of death was followed by the
revival of the subject later, and another case in which ther
was no medical opinion. The revival oceurred before buria!
in every instance. Ile also knows of other cases, but they la
the strict scientific data of the series he describes in detai
In one case the revival oceurred in the mortuary room of

German city where the dead are kept by law until evident
signs of putrefaction. He includes in the list an instance yx
sonally observed. \ woman had taken lodgings at a hotel at
sent for her lawver to change her will. He arrived and wet
ty her room with a bell boy There was no reply to then
knock, and when the door was opened she was found inert an
insensible in the bed, the body eold and the limbs rigid lr}

police were notified, the family informed, and Dr. Teard

sent for to deliver the certificate so that the corpse could bi

removed When he arrived, the hotel-keeper me him. erin

CURRENT MEDIC.

iL LITERATURE. 921

bling at his delay, and urging him to sign the certificate at
once, as the presence of a corpse in the hotel was ruining the
business. leard found some warmth in the body, and_ per
ceptible but very faint heart beat, and the patient was soon
revived. Hotel-keepers are jn such haste to hurry a corpse
out of the building that they are liable to antedate the how
ot death, and the physician should be on his guard especially
in such cases. Im another instance the physician attending
iu prominent citizen was convinced that death had arrived and
so notified the family circle. The patient had long suffered
from gangrene and chronic arteritis, and in the presence of the
physician all the manifestations of life gradually ceased and
he was declared dead. Twenty minutes later faint signs ot
respiration were detected, and the physician’s stimulating
Ineasures restored him to life. Death occurred finally forty
days later. In another case the attending physician had signed
the death certificate, which was countersigned by the priest
The latter returned the next day to see the sick daughter ot
the deceased, and in passing through the room where th
corpse lay on the bier he noticed unmistakable signs of life,
and assisted in the woman’s restoration. The details of each
of these twelve cases are given with names, addresses and
dates. In conclusion, Icard presents the provisions of the laws
in France in regard to the certification of death. They ar
very prudent and conservative, but are practically a dead letter,
never being enforced according to the spirit of the regulations
They provide for careful examination of the subject before thi
certificate of death is signed by the registered physician, and
he must wait for cadaveric rigidity and putrefaction before le
signs. The legal interval of twenty-four hours before burial is
permitted should commence from the moment when the author
ities are notified of the death, and not from the moment ot
supposed death. Until the expiration of the twenty-four-houi
interval the subject should be regarded as a sick person an
not as a corpse, and treated as such. The publie authoritie
urge that every family should be instructed in the care to bi
viven the subject until the complete expiration of the legal in
terval. This interval may be shortened in certain cases on
condition that the death has been certified with the creates
care, and that it is known to he real and not apparent. Icard’s
study of the subject in other lands besides France shows him
that death certificates are liable to be signed haphazard ly
physicians any where, sometimes without actual mspection ot
the supposed corpse. Tle mentions one instance in which tlhe
certificate was signed blank and left with the mother of a si
child, for her to fill in the exact how of death and forward to
the authorities. [card has this blank certificate in his possession
and regards it as a monument of inexcusable ear adden He
cites Brouardel to the effect that 3 instances at least are know)
in which apparent death lasted a long time, but the suppose:
corpses were finally restored to lift The subjeets Jy ie
tions are the men hung at Boston and Perth, and Roger’s eas
of revival after burial. \pparent death is life unde)

ternal aspect of death. Every dying person passes thi

this phase before death is finally complete.

Semaine Médicale, Paris.

17 (NNIV Ni 5 Sra Mditorial Comment on Jacob 4s 7
Infusion De la sineérité dans les observation d
et des limites de Vexpeérimentation thérapeutig se
page 557
1S *Le chvlotho natiaue I. Munel
$9 *Repoert of Fourteenth French Cong ) Ni
Psychiatry. Pau, August 1-7 Commenced in N
OO (No. 34.) *Les formes innieyure tH re at I |
pard
1 Des troub india difs eo
Busyuet Abs
HTeti ’ ] rid i | Pay 4}
Etude des al sd oie et} nfar (
dren ( Vineton Abs

18. Traumatic Chylothorax. Four of the 10

natie chvlothorax on record terminated fatally In 2 ca
effusion was spontaneously reabsorbed Others re
ne rr te) put tures ind deat] in the fatal
ive bee dit prinempa o the lares woul (
( n liters—found j} t} ple ira vetu
patient. \spiration is not always” suecesst
subject suecumbine from inanition after the ter

Port has reported excellent results from thoracotomy in one
case, and it is quite a question whether immediate thoracotomy
is not the preferable procedure when the diagnosis of traumatic
chylothorax is once definitely established.

49a. Localization of Motor Functions in Spine.—This was
one of the subjects on the order of the day at the recent neu-
rologic congress. Addresses were presented by Sano of Ant-
werp, Grasset of Montpellier, and Parhon of Bucharest. They
emphasized the fact that much further study is needed on this
subject, and also that the various theories proposed are all too
exclusive.

49). The Criminal Insane.— After long discussion of this sub
ject the congress adopted resolutions asking for the creation
of special asylums for the particularly dangerous insane as an
urgent necessity. This would include the criminal insane.

4%c¢. Mode of Arresting Epileptic Seizure—Crocq of Brus-
sels has found that the clonic spasms can be suppressed and the
consciousness restored by placing the epileptic on his left side
during the tonic period. ‘This method of arresting the seizure
was first proposed by MeConaghey of Edinburgh, and Crocq has
found it successful in every instance in which he has applied it,

49d. “Combined Plantar” Sign of MHysteria._The same
author calls attention to the simultaneous abolition of the
cortical plantar reflex or flexion reflex, and of the spinal
plantar reflex or fascia lata retlex, which he galls the “com
bined plantar retlex.” He regards its abolition as pathogno-
monic of hysteria.

49e. Radium in Nerve Therapeutics. hoveau de Courmelles
describes numerous experiences to show the great sedative
power possessed by radium. It soothes pain, whether organic
or cancerous, nervous or neuralgic. Some cases of facial
neuralgia and one of sciatica, long rebellious to other measures,
yielded to the action of the radium rays. ‘The girdle pains in
2 cases of ataxia were cured, one by the radium and the other
by the
regard to the nature of the treatment, so he thinks that sug-

\éntgen rays. The subjects were not informed in

gestion may be excluded.

49/7. Sodium Nitrite in Tabes.—Oberthur has cured the pains
in rebellious cases of tabes by sodium nitrite given by mouth or
subcutaneously,

50. Clinical Forms of Cancer of the Stomach.
tentatively a classification of gastric cancers which he thinks

Sard proposes

will aid physicians in prognosis and in their decisions, and will
improve the results, both immediate and remote, of surgery.
He divides the 3 main groups, pyloric, extra-pyloriec and sub
peritoneal cancers, into the subgroups of typical, abortive and
latent. The abortive forms are the most puzzling. In the
pyloric group it includes the annular, colloid cancer, inducing
insufliciency of the pylorus instead of stenosis. The latent
form includes the submucous cylindroid cancer or Brinton’s
plastic linitis, which substitutes esophageal symptoms for the
ordinary pyloric ones. The abortive form of extra pyloric
cancer includes the painful dyspeptic form (generally an ulcer
cancer at some distance from the pylorus), and the cachectic
form without gastric phenomena. The latent form of extra
pyloric cancer includes the variety simulating pernicious
anemia, generally owing to frequent slight hemorrhages, and
the variety inducing symptoms of stenosis. The cancer in the
latter case may be near the cardia, and the secondary stenosis
may simulate cancer of the esophagus, or it may be gastro-
colonic, simulating cancer of the colon and terminating in a
gastro-colonie fistula. It may, further, be the cancerous form
of hour-glass stomach, or it may be a gastrohepatic cancer
with extensive perigastric adhesions, fixation of the liver and
effacement of the stomach from a longitudinal stricture, simu
lating a chronic subhepatie peritonitis. The latent form may
induce early and predominating symptoms in remote organs,
either in the liver, simulating primary cancer of the liver or
cirrhosis, or it may assume a peritoneal form, simulating
tuberculous peritonitis or portal cirrhosis. The subperitoneal
form is very rare. There is usually a palpable tumor, and the
symptoms all indicate peritonitis without apparent partici

pition of the stomach. Secondary cancers jn the stomach

922 CURRENT MEDICAL LITERATURE,

Jour. A. M, A.

generally occur in this locality. He has observed several of
this kind of thyroid, and some of ovarian origin. He urges
that the statistics of cancers operated on should be classified

according to this or some similar plan. By this means it would

be possible to Jearn which forms are legitimate subjects for
intervention, and which are best left alone. He is convinced
that operative results will be found particularly encouraging in
certain cases of scirrhous annular pyloric cancers, in_ ulcer
cancers, in the extra ric variety of the dyspeptic type and
in plastic linitis, no matter how extensive. He reviews in
detail the indications for the various palliative and radical
operations, concluding with the remark that the latent gastro
colonic variety of cancer might suggest benetit from an arti-
ficial anus, but this would entail only disappointment.

Berliner klinische Wochenschrift.

o4 {(XLI,. No. 32.) Fall von familiirer Tabes dorsahs auf
syphiiitischer Tasis. Tabes bei der Mutter und ihren
zwei hereditiir syph. ‘TOchter (mother and 2 daughters).
M. Nonne.

oo *Polymyositis und VPolyneuritis bei Morbillen (measles). W.
Jessen and EK. Edens.

96 Das Rhinophyma und deren operativen Behandlung. 8S. L.
Bogrow (Moscow).

57 Fracture of Neck of Femur in Child R. Lammers Fall von
Schenkelhalsfraktur beim Kinde.

oS Belladonna Poisoning in Ophthalmic Practice. J. Fejer
(Budapest). —Ueber Belladonnavergiftungen in der augen-
iirztlichen Praxis.

oo (No. 338.) *Stones in Gall Bladder and Their Treatment.
Franz Koénig.—-Steine in der Gallenblase und deren Be
handlung

60 *Recent Progress in Dentistry Warnekros Veber neuere
Fortschritte in der Zahnheilkunde,

61 Metastatische Sarkomatose der Lungen mit Epikrise, diag
nosticirt auf 4:rund des mikroskopischen Befundes der
Primirgeschwiilst. S. S. Burt (New York.)

62 *Weitere lirfahrungen zur Scopolamin-Morphin-Narkose (fur

ther experiences). BR. Korff (Freiburg).
63 (No. 34.) *Talma Operation. S. Talma (Utrecht).—Chir

urgische Oeffnung never Seitenbahnen fiir das Blut der
Vena Vortx.

64 Folliclis und Erythema induratum Bazin A. Alexander.

65> The Art of Increasing or Diminishing the Body Weight at
Will. M. Einhorn (New York).—Die Kunst das Kérper
gewicht nach Belieben zu erhihen und zu erniedrigen.

66 *Important Roentgen Findings in Case of Shot in Eye. A.
Kohler.—Schrotschuss ins Auge.

67 Electro-diagnostische Untersuchungen mit (‘ondensatoren
Entladungen (examination with condenser discharges). IL.

»)

Mann (Breslau). (Commenced in No. 33.)

55. Polymyositis and Polyneuritis in Measles. Jessen de
scribes in detail a case of measles diagnosed the sixth day. The
sixteenth day the symptoms indicated acute articular rheu-
matism, but these rheumatoid manifestations were evidently
the first indications of a severe, acute polymyositis, which he
attributes to the measles. Edens describes a case of poly-
neuritis due to measles. The illness began with stormy
onset, soon complicated by bronchopneumonia, and later with
otitis media, followed by the polvneuritis. He knows of only
one other case of polyneuritis due to measles on record.

59. Treatment of Stones in the Gall Bladder. —énig reports
the operative treatment of the milder forms of cholelithiasis
requiring surgical intervention, as practiced at the Charité
clinic. He describes 7 cases to show the variety of operations
devised to meet individual indications.

60. Hygiene of the Teeth.

Warnekros describes electrolysis to prepare a tooth for filling.

\s recent progress in dentistry
\ current of from 1 or 2 milliamperes is passed through the
tooth, wet with salt solution, for five minutes; a temporary
filling is applied and the electrolysis repeated a tew days later.
This sterilizes the tooth completely, ready for the filling. The
bactericidal action is due to the generation of nascent chlorin
and oxygen at the positive pole. He advises the alternate use
of hard and soft tooth brushes, of varying shapes. The use of
a single brush or of a single shape causes certain parts of the
teeth and gums to be unduly serubbed and others neglected,
with abrasions in some parts. Energetic use of the teeth in
chewing is the best mode of cleansing them. He urges
physicians to order their patients in prolonged illness to chew
some indifferent substance, and in all cases to chew vigorously.
The spectacle of a neglected mouth, a hot-bed for bacteria,
which is so frequently observed jin the sick, would become
rarer. Ile also advises physicians to order more solid food

for children who still have their first dentition. The best plan

Sept. 24, 1904.

for the development of the teeth would be to have weakly chil-
dren always given hard, black bread, but as this is impractica-
ble, hard slices of chocolate or the like might be used to ad-
vantage. This might hasten the decay of the milk teeth, but
would aid in the strong development of the permanent teeth.
He observed in Kgypt that the first dentition suffered from
caries, but that the permanent teeth were much more perfect
than among corresponding European children. He attributes
this soundness of the permanent teeth to the constant practice
of sucking and chewing sugar cane. It does not prevent the
decay of the milk teeth, but insures stronger permanent teeth.
He pays a high tribute to American dentistry, remarking that
America still leads the world in dentistry in the present as in
the past. In conclusion, he urges the general adoption in
ho*«ls, depots and other public places and private houses of
cwspidors fashioned on the principle of dentists’ basins with a
rinsing jet of water. Prohibition of spitting in public places,
and the uninviting aspect of the cuspidors now in use may lead
to the swallowing of infectious saliva or sputa. Dentists will
vladly co-operate with surgeons and hygienists and others in
this and similar questions, and their advice may frequently
prove very valuable.

62. Further Experiences with the Scopolamin-Morphin Nar-
cosis._—Korff summarizes the results observed in 200 cases of
this narcosis. In the dosage he uses (see THk JOURNAL, xIi,
page 1568), it is free from danger to heart or lungs. No dis-
turbances on the part of kidneys, liver, digestive tract, ete.,
have ever been observed. ‘The general practitioner can employ it
without a special anesthetist. The action of the narcosis
varies with different individuals. Sometimes a further dose
of .0002-3 gm. scopolamin and .005 to .0L gm, morphin may
be required, or chloroform or ether. The chief advantages are
the absence of the tendency to vomit during and after the
operation. Also that fluids can be ingested immediately be-
fore the narcosis and directly afterward. The precaution must
be observed not to allow the tongue to fall back and obstruct
the breathing, especially in toothless subjects, during the pro-
found sleep during and after the operation, the result of the
narcosis. Drawing the lower jaw forward draws up the tongue
and obviates this danger.

63. Talma on the Talma Operation. Three questions are dis-
cussed in this communication: Does the collateral deviation
of the. blood induced by the operation affect cirrhosis of the
liver favorably? Can the omentopexy reduce the danger of
hemorrhage from the overfilled veins? and can the establish-
ment of collateral circulation in case of portal thrombosis
compensate the worst of the circulatory disturbances? Talma
reports experiences which compel an aflirmative answer to the
first two questions. In respect to the third question, he cites
a case of pronounced phlebo-sclerosis of the portal vein, the
probable cause of the thrombosis observed. It is the only case
of which he has knowledge from which an opinion can be for
mulated in regard to the significance of omentopexy in case of
occlusion of the portal vein in man. The patient was a man of
0, who had been subject for fourteen years to atrophic, an-
nular cirrhosis of the liver, with ascites but no icterus: attacks
of violent pain from fibrous splenitis and caput Meduse.
Omentopexy was performed, and for two months the patient
was free from ascites. The collateral vessels became much
enlarged at the point of attachment and around the esophagus.
Chen the ascites recurred from portal thrombosis, a consequence
ot old phlebo-sclerosis and partial occlusion of the portal vein
with an old organized thrombus. In Umber’s case the portal
vein had been congenitally oecluded, and likewise the splenic
vein, but the collateral circulation had always been sufficient,
and no disturbances had been noted. The liver was sound
The omentum was adherent to the liver, kidneys, spleen, in
testines and abdominal wall, and there were numerous adhe
sions between the intestines, ete. The occlusion of the portal
vein was a necropsy surprise, the collateral circulation having
obviated all disturbances until fresh thrombosis occurred in
the collateral circulation. The conclusions which Talma draws
from this and his own case are that it is a good plan to make

the omentopexy multiple, that is, to fasten the omentum at

CURRENT MEDICAL LITERATURE. 925

several points. Another case of recent thrombosis in an old
phlebitis has recently been described in Holland, remarkable on
account of the hyperemia of the abdominal wall and the devel
opment of wide veins at the points where the spleen and
diaphragm had become adherent. Stephan has also reported
a case of acute thrombosis of the portal vein followed by fatal]
necrosis of a large part of the intestines. Comparing the
findings in this case with those in the case of long-established
occlusion of the portal vein, shows better than any words the
importance of collateral side routes circulation for the blood in
case of liver cirrhosis.

66. Radiogram of a Shot in the Eye.— Kohler obtained a good
radiogram of the shot, but when the subject looked upward the
rays cast shadows of two pieces of shot, when in fact ther
was only one. This confirmed the assumption that it was
located in the eyeball.

Deutsche medicinische Wochenschrift, Berlin and Leipsic.

68 (XXX, No. 32.) *Das Trauma als Aetiologie bei Aortenkia]
pen [nsuffizienz. EF. Sinnhuber (Berlin).

oo Fate of Nucleinie Acid Introduced Into “Circulation A
Schittenhelm and EK, Bendix.— Schicksal der in die Blu
bahn eingebrachten Nukleinsiiure.

70 *Ueber Misch-Infektion durch = ‘lyphus und Varatyphus
Bazillen. H. Conradi.

71 *Ueber die chirurgische Behandlung der otogenen eitrigen Cere
brospinal-Meningitis. E. P. Friedrich (Iiel).

72 *Ein never Gesichts-Punkt bei der Behandlung der Aphonia
spastica. EF. Barth (Frankfurt a. O.).

73 Zum 70 Geburtstag von Ewald Hering (seventieth birthday)
P. Griitzner.

$ (No, 33.) Zur Typhus-Diagnose. Kk. Walter

> *Ueber aktive Immunisierung des Menschen gegen Cholera

ki. Bertarelli.

i6 Ueber die Agglutination des Milzbrand-Bacillus (anthrax)
A. Carini.

77 *Beitrage zur Methodik der klinischen Stuhluntersuchuny
(examination of stools). FE. v. Koziezkowsky

7S *Der heutige Stand der Neuron-Theorie. A. Bethe

79 *Diabetes insipidus, behandelt mit Strychnin-Injektionen It
Leick.

SO Gout in Boy from Infancy. R. Lunz (Moscow) Fall von
Gichterkrankung bei einem 7 jaihrigen Kinde

Sl *Mein 60 bronchoskopischer Fremd-Ko6rper- Fall. G. Killiat

S2 *Ueber eine neue Methode der Behandlung der chronischen
Urethritis. H. Lohnstein.

S83 Xiphophagus Duplicitas parallela. H. Singe1 First part
in No. 27.)
84 Progress in Appliances for the Care of the Sick P. Jacob

sohn.—Fortschritte der Krankenpflegetechnik

68. Trauma in Etiology of Aortic Insufficiency... Sinnluber
thinks that far too little attention has been paid hitherto to
trauma as a factor in the production of valvular affections
The text-books suggest it only as a bare possibility, and vers
few instances have been published, among them Hektoen’-
case (1892) of rupture of the aortic valves. During the last
year and a half Sinnhuber has had occasion to observe 3 cases
at the Berlin Charité in which the symptoms of aortic insuf
ficiency were traceable to a contusion or fall on the chest. “Tw
of the patients applied for relief without referring to any trau
matism in their antecedents, and it was only learned by direct
questioning. ‘The particulars are detailed, and also the post
mortem findings in a fourth case. The latter was diagnosed as
traumatic aortic insuflicieney, but the necropsy revealed merel)
a chronic, recurring endocarditis. The patient was a man of
38, previously healthy, whose business was the moving of
safes. With 8 other men he had carried a very heavy safe uy
a flight of stairs, then walked a mile home and slept for severa
hours. When he awoke he experien ‘ed progressive dyspnea,
and the next day much pain in the abdomen and in the region
of the stomach, and vomited all that he ingested; the vomitus

was blood streaked. The dy spnea became so excessive that he

entered the hospital the tenth day. Traumatie aortic insut
ficiency was diagnosed, but the necropsy revealed mere]
chronie, recurring endocarditis. Notwithstanding these nega
tive findings in this case, Sinnhuber thinks there can be no
mistake in the diagnosis of the 3 other cases. One man had

been devoted to athletics and had been found perfectly sound

when examined eleven months before the accident. while four

1e

weeks after, a severe heart defect was discovered [le pre
sented the symptoms of severe aortic insufliciency, with hy per
trophied left ventricle, and other symptoms visible even
from a distance. The second patient was a cabinet-maker of
$2, who had worked steadily until the aceident Pwo months

ifterward he was unable to work at all on account of s\ mpton

suggesting aortic insufliciency. A year and a half later his
heart measured 22 em. at the base (over 8.5 in.). In the
third case a history of malaria eight years, and of gonorrhea
one vear before suggests the possibility ot endocarditis
ad valvulas aorta. But the man had been apparently in good
health when the trauma occurred, and it was followed by a
stormy onset of dyspnea, unbearable beating of the vein trunks,
symptoms of distress, suffocations and other signs of the
severest. aortic insuiliciency, compelling the diagnosis of a

traumatie valvular affection.

70. Mixed Typhoid and Paratyphoid Infection. A child ate
pieces of ice trom a pond known to be infected with typhoid
and paratyphoid bacilli. She developed an irregular fever,
enlargement of spleen, roseole, mild intestinal disturbances
and retarded heart action, suggesting an atypical typhoid.
Pyphoid and paratyphoid bacilli were found growing on agai
plates inoculated from the stools on the fifth day. Conradi
further deseribes an epidemic at Metz in which typhoid bacilli
were isolated from the stools of certain patients and the para
typhoid from those of others. The attending physician was
examined and, although he was and remained in the best of
health, both typhoid and paratyphoid bacilli were isolated
from his stools. They were not numerous, merely from three
to five on each plate. They were unmistakably derived from
contact infection, but the agglutination test was always nega
tive in his ease

+1. Surgical Treatment of Otogenous Suppurative Cerebro-
spinal Meningitis..-Friedrich advocates operative treatment of
otogenic suppurative arachnitis by opening up the cranial eay
ity and subarachnoid space combined with a counter-opening
it the lowest point of the spinal canal. He has thus operated
in 2 advanced cases, but was unable to avert the fatal termina
tion It might prove a very valuable measure, however, he
thinks, for the isolated basal and spinal form of suppurative
cerebrospinal meningitis of otitic origin, if taken in time
Fhe lesion here is, in fact, a kind of phlegmon of the posterioi
eranial fossa with involvement of the ventricle, basal cisterns
and spinal arachnoid sae, while the convexity of the cerebrum
is not affected. Such an affection is usually a gradually pre
gressive, chronic involvement of the arachnoid and pia. In its
insidious course the pus. collection becomes localized and
eneapsuls ted. Here be long the eases oT chronic otitis
media, especially those of cholesteatoma formation The ana
tomic findings in his 2 cases confirmed the assumption of a
localized pus collection in the basal and spinal subarachnoid
spaces. Why should we not apply, he asks. to irritated men
inges the same surgical principles which we employ so success
fully in purulent peritonitis? After the laminectomy and open
ing of the arachnoid the fluid must not be withdrawn too rap
idly by the lumbar puncture below. A tampon should be ap
plied to soak up very slowly the pus-containing cerebrospinal
fluid. With these precautions he has never had any mishaps
oecur from lumbar puncture in a single instance in his exten
sive experience with it. even when as much as 15 cc. are with
drawn at a sitting. It is not enough to drain away the fluid

lleect and adhere to the

ind pus the thick pus is liable to co
spinal canal and must be rinsed out Cordero has demon
strated experimentally the feasibility of such a procedure, sub
stituting the natural fluid with salt solution. He found it
possible to send from 10 to 49 ¢.c. through the spinal canal
vithout elheiting nervous symptoms If this rinsing out of
=pinal eanal seems too hazardous, the re-formation ot
brospinal fluid might be promoted by intramuscular injec
ns of salt solution Friedrich’s experience seems to indicate
the first svmptoms of the affection in question i. loeal
endocranial pus collection—are those of serous meningitis
| heh temperature indicates the toxie characte. f the exu
if and th rigid muscles at the back of the neck, with the
hsence of symptoms of brain irritation, aid in localizing thi
ion the base. When lumbar puncture fails. te
emonstrat iny permanent benefit. laminectomy is in order,

}

it is too late for it when the bacteriologic and cytologic

ndings of lumbar puncture indicate that the entire arachnoid

ac is diffusely suppurating FAt the International Congress

2 CURRENT MEDICAL LITERATURE. Jour. A. M. A.

of Otology, held at Bordeaux in August, Lermoyez and Bellin
of Paris reported 2 cases in which surgical treatment was ap
plied in otogenic meningitis, with the complete recovery of
the patients. The first was a young woman long subject to
otorrhea. After a month of vague general disturbances symp
toms of acute diffuse meningitis developed: Intense headache,
rigidity of the muscles of the back of the neck, facial paraly
sis and Kernig’s symptom. Lumbar puncture showed 58 pei
cent. lymphocytes and 40 per cent. polynuclears. The carious
petrous bone was widely opened up, the wall of the labyrinth
found necrotic, the dura fungous. The temperature returned
permanently to normal the next day, but the Kernig symptom
persisted several days longer. The lumbar puncture was _ r¢
peated a week later, and the lymphocytes were found very
numerous, but scarcely 1 per cent. of polynuclears. In *wo
weeks the fluid was entirely normal. The circumstances wre
similar in the second case, but the trouble was more pro
tracted. The first patient was cured by merely an ample
craniectomy, relieving the compression. In the second case
actual drainage had to be established both by the cranial and
the spinal routes. The meningitic symptoms reappeared twice
after a few days’ interval of peace. In both cases the infection
had spread to the meninges from pyo-labyrinthitis, but a cure
was obtained without trephining the labyrinth, leaving to
Nature the task of eliminating the sequestrum in the laby
rinth, This was successfully accomplished in time, although it
delayed the healing for several months in the second case.
The eure has been complete and permanent for eighteen months
in the first and for eight months in the second case. Neithes
of the patients display any evidences of impaired equilibra
tion.— Fp. ]

72. New Standpoint for Treatment of Spastic Aphonia.
Jarth noticed certain indications which convinced him that
spastic aphonia is a disturbance in co-ordination. The mus
cles forget their co-ordinating action, and by mechanically re
storing this action the idea of the co-ordination is rearoused in
the brain and transmitted to the muscles. He describes a few
eases treated on this principle with surprisingly favorable re
sults. Ile interposes a sound or the endolaryngea] electrode
hetween the arvtenoid cartilages. Normal tones were produced
at once and the aphonia was conquered in some cases perma
ne nily, while others required daily repetition of the co-ordina
tion exercise for a few days. The suecess depended usually on

the duration of the aphonia

75. Active _ Immunization Against Cholera._-Bertarelli’s re
search has confirmed the value of the Shiga method of im
munization by injection of free receptors. After positive re
sults on rabbits and guinea-pigs he tried it on himself with
equally positive results. The degree of immunization is very
small and the amount of receptors required is too voluminous
at present. The technie will have to be modified to obtain a
higher degree of immunity with more concentrated material

before it can be cenerally adopted

77. Clinical Examination of the Stools._-This article issues
from Senator's clinie and describes the methods in vogue there
The repeated finding of invisible blood in the stools seems to
he pathognome nie of eanecer, as in case of uleer the oceult
bleeding is more erratic and intermittent. The blood occurs
during exacerbations and vanishes as the ulcer heals. Blood
vas frequently found in the feces in cases of hypersecretion
vithout yp sitive clinical signs of uleer. These oceult bleedings
ive a valuable means of differentiating uleer from nervous
gvastralgia, cholelithiasis, ete., and also for the discovery of
gastrointestinal cancer inaccessible to palpation The aloin
test has proved much more reliable than the guaiae test (sec
Tne Journat. xli, p. 1566). No food or medicine containing
blood should be taken, and articles containing chlorophyll oi
iron should also be avoided. The diet should be restrieted to
milk. flour. bread. eggs, fruit and not too much fat The
sainple of stool should have the fat extracted by evaporating
the water-bath and then extracting with ether. It is some
mes advisable to rub up a dark stool with considerable alco
hol and then filter it out to remove the urobilin. After th

fat is removed the stool is digested with e@lacial acetic acid

SEPT.-24, 1904. CURRENT
for a minute or two, poured into another vessel and extracted

with a small amount of ether. For 5 gm. of stool 5 gm. of
acetic acid and 5 to 10 e.c. of ether are the usual proportions.
Over the filtered or unfiltered mixture is then poured, from a
eraduated pipette, 1 to 1.5 e.c. of ozonized turpentine, and
above this about .5 ¢.e, of a

verized aloin on hand and dissolve it in

fresh 2 to 3 per cent. solution of

aloin. most convenient technic is to have .3 gm. of pul

10 c.c. of a 65 to 70
On the above diet repeated positive findines
of this test Way he confidently accepted as evidence of occult

per cent, alcohol.

hemorrhage, in the absence of other known sources of the
blood found. The technie of determining the albumin residuum
in the feces is also described, and the determination and elini
cal significance of the leneth of time in which the food re
mats in the digestive tract. It is astonishing that so litth
attention has been paid to this latter point from the diagnos
tit point of view. A test diet is given, five meals during the
day, the totals consumed being 1.5 liters milk, .25 liter bouil

lon, 6 zwieback, 40 om. oatmeal, 40 gm. butter, 2 eggs (S80 em.).

and 200 gm. soft mashed potato. THe demarcated this test
diet with .6 gm, carmin given just before it was commenced

Ile found that it) remained in the digestive tract from fifteen
to twenty-five hours in subjects free from appreciable intes
disturbances. interval

tinal In pathologie cases the shortest

was four hours. and in such cases the sublimate test for trans
formation of bilirubin into urobilin in the feces was negative
He accepts as the standard unit the time from the commence
ment of the diet to the appearance of the first red-stained stool

the German term Verweildauer being used to express this
The author recommends this simple technii
for obtaining information in

them. The

standard interval

as a valuable method regard t¢

the intestinal functions and disturbances in find

ines are destined to throw light on many questions which hav
surmises. The alkaline or acid

hitherto been merely vague

reaction of the adding a small
of the

taining equal amounts of a 10 per cent

stools is determined by portion

stool to one of two wide-mouthed reagent glasses con

aqueous litmus tin

ture. Comparing the glasses by daylight will readily sho

the alkaline. neutral or acid reaetion

78. Present Status of the Neuron Theory. Bethe relates thi

particulars of recent research on the finer structure of th

nerve elements, especially in the lower forms of life. His arti

ele is illustrated. and he remarks in conclusion that he

net understand how anv one who reviews the material therein

]
}

presented ean fail to become convineed that the neuron theory

is plaved out The neuron is not a cellular unit. A fibrillan

anastomosis between the various neurons is unmistakably es
tablished in erustacea and is more than probable in man. Re
eent embryonal and histologie research has establishe that at
least the axis evlinders of the peripheral nerves are of multi
cellular origin. It is very probable that, besides the neuror
complexes, there are other nerve elements genetically indepen
The term neuron should be
aseribed to it Wi

make up the

dent of them. retained. but not th

hithert«

meaning must understand 11

these complexes do not entire nervous syste

do net nerve network, that thev are ne
that

point of view. and that

that they exist in the

morphologically of equal value, thev are not units t}

from the trophis physiologic
shelter euests. the neurofibrils. whose origin is still a myst:

79. Strychnin in Diabetes Insipidus.-—\ man of 49. previous!

healthy. develope V typical diabetes insipidus after a severe

concussion of the nervous svstem Strychnin was adminis

tered—tifteen injections during twenty ivws—a tota f .A90

om. strvehnin nitrate The urine subsided from a dai S.00

ce, to 3.400 ex The strychnin was discontinued on t

of svmptoms of intexication, but the urine ntinued its

ward course te »4100 and 1.700 e©e. and the patient is 1})

ently cured T} lensitv of the urine remained uninthuen

} the strvehnn vere from 1.007 to 1.002 | S

ence of this figure for the specific gravity forbids the as

tion of a complete cure, but the subsidence of all the

certainly justifies further trials of strvehnin in sue] ses
81. Bronchoscopy.—Killian reports the sixtieth cas

}

under

en body

traction of a fore}

ronchosecapy

MEDICAL

LITERATURE, Pf
understand why it is not more generally adopted. “Why make
a hole through the wall to get into the house when a wide front
door and spacious steps are at our disposal?”

82. New Instrument for Treating Chronic Urethritis— ‘Ili
instrument looks like a sound with two openings near the tip
\fter it is inserted in the urethra, by turning a thumbserew
in the handle, two small curette spoons merge from the tw
openings, spreading apart from each other at an angele of 45
degrees more or less. <A graduated seale in the handl

the exact distance between the tips of the curettes. The aiim

shows

is to spread them to distend the walls «
moving

f the urethra and by
done without causing
pain, twisting and working the instrument, to curette the walls

them just as much as can be

and evacuate the adjoining glands, combined with a sort of

massage of the parts. Lohnstein has used the instrument in 26

eases and found that it more than fulfilled all his anti ipations
It was particularly useful for the removal of polyps and othe

exerescences, and in case of infiltrations and chronic follientai

urethritis.
Munchener medicinische Wochenschrift.

S> (LI, No o2.) *Heart Disturbances — in Scarlet eve
Schmaltz Herzstérungen beim Scharlach und ihre Folgen
SG *Comparative Study of Hydrochloric Acid, ete.. in Stomach
Troubles. S. Heichelheim and H. Kramer Vergleichend:
Untersuchungen itiber die Wirkung von Salzsiiure, Sal:
siiure- Pepsin und Gasterine bei Hypochylia
gastrica.
ST *Physiologie Action of Naturai Gastric
Ueber die physiol
Schweinemagensaftes

und Achylia

Juice (pigs) W. Erb

Wirksamkeit des naturlichen

{Dyspeptine Dr. Hepp)

SS *Pressure in Auricle in Valvular Defects A. Horner Vel
den Vorhofdruck bei Klappenfehler.

Si) 62 Cases of Bullet Wounds of Brain A. Schott Zwei F ey
von Schussverletzungen des Gehirns

i) Zur Kasuistik der Perinealen Luxationen I’. Seidere:
91 Kinfaches Modell einer Milech-Pumpe (breast pump I]
Koeppe (Giessen)
"2 *Congestion and Age in Origin of Tumors R. RoGssle (hie
Die Rolle der Hyperiimie und des <Aiters in der G
schwulstentstehung (Commenced in No, 31.)
“ Superstition Before and During Childbirth \. M. Pachinge

Der Aberglanbe yo1

85. The Heart

necessity Ol

und bei der Geburt des

Menschet

in Scarlet Fever.—Schmaltz emphasizes t}

rest in case of searlatinal heart e¢

miplicat ic ts
He cites a number of examples from his own experience ti

illustrate the danger of allowing demands to be made on the

hefore it is entirely restored. He never witnessed a cas

of death from these heart complications unaccompanied by sep

~is or nephritis, but in 29 cases the cardiae svmptoms pe

the time the patient was dismissed. In 15 there wer
evidences of mitral insufliciency. in 9 merely a systolic

nur. and in marked dilatation without murmurs

Was notes

as the fifty first and SIXt\ second day Examination

of these patients later disclosed permanent mitral insufficiency
this number the }
|

svinptoms during thei

n lo In o O17 eardiae d rect had eaused it

stav in the

late in) of 1
latea

]
}
I

averavated ie patients with

d ceardiae defects at this examination there

l WN

een nothing abnormal when thev had been dismissed from thy

spital. In only 3 of the patients had the heart disturban
ad oon dismissal retrogeresst | later, The mter\ i] had hee
ri six months t ve years These experiences indicat
~( itinal heart ifTection entail perm iment
ne more frequently than the diphtheritic ind tl
ore serious. although never directly fatal. 1
. 1 wtoeps ( nt changes in the va
Vere in only 3 The disturbanees are vident] ce Te
hanges Greater attention should be paid te
! nd after searlet fev Prolonged rest for the ea
ibly ( iW application of the icehage are indicated HH
er) ! ] eclable benefit from digitalis in tl]

S6. Natural Gastric Juice and HCl in Stomach Affections

eC) tient CG Hy s were reat ee if
1
| l on of the same itt Cpsl
( 1 7 1 ral wastyl (
j ] st t gasteri
1 I } i] l hi
~ " Oo rod =< w1Vel if
} | ne r h
1! an 1 need fion t ?

Y20

secretion of pancreatic juice and possibly also of the bile. The
conclusions are ail favorable to the administration of hydro-
chloric acid, both transiently and continuously, in addition to
dietetic measures, in all cases of hypochylia or achylia gas-
trica when the appetite is depressed, and there are fermenta-
tions in the stomach, with diarrhea. The digestive power was
wonderfully increased, in many cases by giving from 100 to 300
cc, Of a one-tenth normal hydrochloric acid solution. When
pepsin was added it was in the proportion of 5 gm. to 100 ce.
of the same. Some of the patients drank the solution through
a glass tube; others had it introduced through a stomach tube.
None complained of the taste.

87. Physiologic Study of Natural Gastric Juice (Pigs).
Erb argues that the gastric juice derived from pigs by a Paw
low fistula can never be a physiologic secretion. The opera-

tive intervention renders it always more or less pathologic.

88. Pressure in the Right Auricle in Valvular Defects.
Horner has been giving the Gaertner test a thorough trial on
healthy subjects and on those with valvular defects. It was
described in these columns, page 687 of vol. xlii. The arm is
lifted slowly and passively, and the point at which the veins
collapse is marked by comparison with the standards Gaert-
tests value

restrictions. He

ner has established. Horner’s confirm the great

of this
number of cases of mitral incompetency, ete., to show the char

new technic, with certain reports a
acteristic findings in various valvular defects.

92. Role of Hyperemia and Age in Origin of Tumors.
proposes a theory to account for the origin of tumors by vari

Réssle

ations in the cells of the organism caused by age and conges

tion. Histologic and physiologic study of old age is the most

promising line for research on the origin of malignant cancer.

Gazzetta degli Ospedali, Milan.

Last indexed nage 850

94 (XXV. No areata in seguito a trauma V
Ramazotti.

95 *Infezione puerperale ed
corrosive. G. Fabio.

96 *Contributo alla cura della pneumonite crupposa colla digitale
ad alte dosi. A. Amucano

97 (No, 52.) Intorno alla radio-activita dei fanghi e delle acque
di Abano. De Giovanni

98 *Dell’ importanza della siero-agglutinazione
precoce della tubercolosi primitiva dell’
(of middle ear). A. De Simoni,

99 Study of Bullet Wounds of Brain. A. Amantini.--Contributo
allo studio delle lesioni cerebrali per ferita d’'arma da fuoco

49.) Alopecia

iniezioni endovenose di sublimato

diagnosi
medio

nella
orec chio

100 (No. 58.) Contributo alla setticemia pura da tetragono I
Baccarani.

191 Tl reflesso di Babinski. S. Ceraul

102 *Limitazione dell’ area cardiaca mediante il palpamento G
3assi

1 Contributo alla splenoplessia A. Ceccherelli,

95. Sublimate in Puerperal Infection.—Fabio describes a case
of severe puerperal infection, apparently in the
first He injected intravenously 3 mg. of a 1 per
thousand solution § of local The
temperature declined a little the same evening and there was
slight abatement of the Six
tions were thus made in the course of a
patient was soon restored to health, an extensive ulceration of a
laceration of the vagina having healed completely. | Bidoli has
recently published a similar case of recovery under sublimate
The patient was ap-

last stages
: .

when seen.

sublimate, with measures

intravenous injee

after which the

svinptoms.
week,

as a last resource (Polieli 1700, July 9).
parently moribund.—Ep. ]

96. Digitalis in Croupous Pneumonia._.The patient had pre
viously passed through four attacks of croupous pneumonia
16 and 33 They had been treated by the
the usual protracted course. At 34

and 4

between the ages of

ordinary measures, with

another attack occurred and om. of digitalis leaves

3
administered

were infused and on following days. The dis-
ease was arrested and recovery rapidly ensued, in marked
contrast to the preceding attacks, and notwithstanding the
fact that the onset had been stormy. Digitalis evidently has

different effects on a healthy and a pneumonia subject. It
mav have some specific bactericidal action on the causal germ,
or the intense leucocytosis induced may have the same result,

resistant. Carbone

or the leucocytes may be rendered more
insists that pneumococcus infection is due to an ‘intoxication
1} bv absorption of the produr ts of the elements of

rw sVsten

LOOKS RECEIVED.

Jour. A. M. A.

the blood, destroyed by the pneumococci. If this be true, then
treatment with digitalis, to enhance the resisting power of the
leucocytes, is the logical indication, and experience is crown-
ing it with success.

98. Sero-Diagnosis of Primary Tuberculosis of the Middle
Ear.—De-Simoni cites 3 cases to show how valuable the agglu-
tination test may prove long before other signs are available.
He tabulates the findings in 14 other cases in which the test
Was negative, and the course of the affection confirmed its
non-tuberculous character.

102. Palpation of the Heart Outlines. that
vreater reliance should be placed on the palpation findings in
the diagnosis of heart disease. He has found palpation a par-
ticularly valuable means of controlling percussion findings.
The heart action in children is so vigorous that palpa‘cion
gives very significant results in their case. He adds two dia-
grams to illustrate the findings in severe cases of organic
mitral defect. The heart area determined by palpation coin-
cides with the area of relative dullness in case of long estab
lished mitral defects, while it coincides with the area of abso-
lute dullness in The heart be outlined
by palpation in non-febrile adults free from heart affections,

? .
¢ ve
ASS] Urges

cases. can not

recent

Russkii Vratch, St. Petersburg.

Last indexed pages 437 and 851

O endotheliom plenri i eya histogeneseye. A.
(Commenced in No. 42.)
Cirrhosis of Liver and

i solintzeff.-Zheltzie tzirrosi i angiokholiti.
ikh priznakov v chirurgitcheskom otnoshenil.
106 Case of Ovarian Pregnancy. § G. Olekhno Slutchai
matotchnoi yvaitchnikoyoi beremennosti.
107 Preventive Legislation. LL. Y. Jacobsohn Kakimi myerami
slveduet borotsya s rasprostraneniem veneretcheskikh boly
ezni sredi utchastchikhsva ?

1o4 (II, No. 43.)
I. Burtzeva,

105 Differentiation of Angiocholitis. . G.

O-zvenka

vnye

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THE SUPPKESSION OF TUBERCULOSIS, Together with Observations
Concerning Phthisiogenesis in Man and Animals and Suggestions
Concerning the Hygiene of Cow Stables and the Production of Milk

for Infant Feeding, with Special Reference to Tuberculosis. By
Vrof. FE. von Behring. University of Marburg. Authorized Transla
iion by Charles Bolduan, M.D. First Edition First Thousand.
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Fooo INSPECTION AND ANALYSIS, for the
Health Officers, Sanitary Chemists and Food
Leach, S.B., Analyst of the Massachusetts State
787.

London :
Use of Public Anal
Keonomists. By
Soard of
With

VSts,

Albert I

Health Virst Edition, First Thousand. Cloth. Pp. 7§ i
120 Figures and 40 Full-page Half-tones, Price, $7.50. New York:
John Wiley & Sons London: Chapman & Hall, Limited. 1904

A TREATISE ON OBSTETRICS For Students and Practitioners

tv Edward V. Davis. A.M., M.D., Professor of Obstetrics in Jeffer
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Much Enlarged With 274 Engravings and 39 Full-page Plates in

Colors and Monochrome. Cloth. Pp. SOO. Price, $5.00 net Phil

adelphia: Lea Bros, & Co, 1904.

A Trext-Book oF PHYSIOLOGICAL CHEMISTRY For Students and

Practitioners of Medicine By Charles FE, Simon, M.D., late Resi
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Bros. & Co.
RePORT OF THI

phia and New York: Lea
THIRTY-EIGHTH ANNUAI
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COLUMBIA HOSPITAL FOR
Year Ending

WOMEN AND LYING-IN June
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SEVENTEENTH ANNUAL REPORT OF THE SUPERINTENDENT OF THE

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