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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. 
Med. Prac., Milano, 1819, p. 4 
Am. Jour. Obst., 1901, xliii, p. 682 
Gaz. Med. Sicil., 1899, iv, p. 13. 
Ann. Surg. Oct., 1901 
Phil. Med. Jour., Dec. 7, 1901, p. 999 
Med, Ree., March 26, 1904 
rans. Pan-Am. Med. Cong., Wash., 1893, p. 264 
Jour. Am. Med. Assoc., June 15, 1895, p. 91 
Univ. Med. Mag., 1898, x, p. 641. 
Boston Med. and Surg. Jour., May 21, 1868 
Brit. Med. Jour., 1896, i, p. 1229 


Inaug. Dissert., Bucharest, 1887 

Rev, Méd. de la Suisse Rom., 1893, xiii, p. 130 
Lungenentziindung, Wien, 1897, p. 133 
Private Com. Surg. Gen. (1897-1901) 
Pneumonia u. Pleuritis, Wiirzb., 1880. 


Arch, f. Kinderheilk., 1891, p. 13 and 1892 p. 286 
srit. Med. Jour., 1898, ii, p. 297 
Allbutt’s Syst. Med., 1896, i, p. 655 
Wiener med. Wochenschr., 1857, No. 5 
Ranking’s Abst., No. 28, p. 92 
Settim. Med., 1899, liii, p. 285 
Arch. Pediat., Nov., 1902 

Brit. Med. Jour., 1900, i, p. 1897 

Ann. d. Charité, vii. p. 234 

Bull. de lAcad do Méd., 1862, xxvii. p. 676 
Kichhorst’s Spec. Path. u. Therap., Wien, 1896, i. p 
Korani, Klebs, Ill. Med. Jour., Dee., 1903, p. 488 
Gaz. d. Ospedal., 1896, xvi, p. 713 

Berichte d. med. Klinik, Miinchen, 1878 
Lungenentziindung, Stiittgart. 1850 

Iemiss. du Sang. Paris, 1838 

Braithwaite’s Retrospect, Jan.. 1859, p. 71 
Ranking’s Abst.. No. 28, p. 92 

Practitioner. May. 1869, p. 267 
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 
Touchet’s Dis. Chest, Lond., 1865, p. 320 

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 | 
{ , 
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1; 
GIserse 
31f et ( 
ot pn 
n ft] Nn? 
( n ( 
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e 
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I 
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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 

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7” Tt) 

aaai { 


tients broug! 
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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) 
, 6° 
= Sa? T , o% ad 
‘ a “™ + ‘ , “ 
aes "0 ’ a 7 Se o” - i 
Se ge eee 7 “a, 9 
. a wa 





® 
4 
) 2.2 
oO: 
@ 
- 
¥ 
> De eit 





a “395 &-* 9 
Ie 24S) 
a: * = : Ley 
a 3, § 
. 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 


Books Received. 


Acknowledgment of all books received will be made in this column 
and this will be deemed by us a full equivalent to those sending 
ihem A selection from these volumes will be made for review, as 
dictated by their merits, or in the interests of our readers. 

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. 
(loth Pp. 85. Price. $1.00. New York: John Wiley & Sons 


Chepman & Hall, Limited. 1994 

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 
on Medical College New (2d) Edition, Thoroughly Revised and 
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 
Gent Physician Johns Hopkins Hospital. Sew (2d) Edition Re 
vised and Enlarged. Cloth Pp. 500. Price, $3.25 net Philade! 


Bros. & Co. 
RePORT OF THI 


phia and New York: Lea 
THIRTY-EIGHTH ANNUAI 
ASYLUM for the 


COLUMBIA HOSPITAL FOR 
Year Ending 


WOMEN AND LYING-IN June 
«0. 1904, Washington, I. ©. Paper. fp. 35. Washington, D. C.: 
Covernment Printing Office. 1904. 

SEVENTEENTH ANNUAL REPORT OF THE SUPERINTENDENT OF THE 


Sr. LAWRENCE Sratre Hosprran to the State Commission in Lunacy 
lor the Year Ending Sept. 80, 19038 Paper Pp. 52. Albany: 
1. B. Lyon Company. 1904 

THIRNTIETIC ANNUAL Reporr OF THE SECRETARY OF THE STATE 
Roarp oF HKeALTH OF THE STATE OF MICHIGAN for the Fiscal Year 
Ending June 30, 1902 Cloth Pp. 254 Lansing Mich Robert 


Smith Printing Co. 1903 

TRANSACTIONS OF THE AMERICAN ASSOCIATION OF OBSTETRICIANS 
AND GYNECOLOGISTS Vol. XVI For the Year 1903. Cloth Pp 
{N35 New York: Rooney & Otten Printing Co. 1904 


FIFTEENTH ANNUAL RevPortT OF THE STATE BOARD OF HEALTH OF 


KLonipa. Jacksonville, Fla., Feb. 9, 1904 Paper. Pp.. 203. Jack 
sonville: The Drew Press 

ON FTISENS BEMANDLING Paa Sanatorier. Af Klaus Hanssen, 
Overlege ved Bergens Svgehus Paper Pp. 40. Bergen: John 


1904 

TRANSACTIONS OF THE 
YorK, for the Year 1904 
ciety, 1904 


Griegs Bogtrykkeri. 
THE STATE OF NEw 
Published by the So- 


MEDICAL Socrpry or 
Cloth. Pp. 508. 








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