(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "International record of medicine"

HANDBOUND 
AT THE 



UN1\'ERSITY OF 
TORO>rrO PRESS 






Digitized by the Internet Archive 

in 2010 with funding from 

University of Toronto 



http://www.archive.org/details/internationalrec98wash 









NEW YORK MEDICAL JOURNAL 

INCORPORATING THE 

PHILADELPHIA MEDICAL JOURNAL 

AND THE 

MEDICAL NEWS 
A WEEKLY REVIEW OF MEDICINE 

EDITORS 
CHARLES E. de M. SAJOUS, M. D., LL. D. 
CLAUDE LAMONT WHEELER, A. B., M. D. 



Assistant Editors 
Paul F. Baktholow, A. B., M. D. 



Charles F. Bolduax. M. D. 
Carv Egcleston, M. D. 
Albert Robin, M. D. 



Elsie Fox, M. D. 



P. Brynberg Porter, M. D. 
A. L. SoRESi, M. D. 

C. S. WiTHERSTINE, M. S., M. D. 



Special Editors 



Genitourinary Surgery. 

Ej)WARD L. Keves. Jr., M. D. 

Orthopedic Surgery, 

H. Augustus Wilson, M. D. 

General Surgery, 

Benjamin T. Tiltox, M. D. 

Xeurology and Psychiatry, 
Samuel D. Ingham, M. D. 



Dermatology and Syphilology, 

Jav F. Schambekg, a. B., M. D. 

Ophthalmology, 

Matthias Lanckton Foster, M. D. 

Otology and Larjmgology, 
Rltus B. Scarlett, M. D. 

Pharmacology and Therapeutics, 

Louis T. de M. Sajous, B. S., M. D. 



Pathology and Bacteriology, 
Guthrie McConnell, M. D. 



VOLUME XCVIIL 

JULY TO DECEMBER, 1913. INCLUSIVE 

NEW YORK: 
A, R. ELLIOTT PUBLISHING CO 
1913 



3<E,3 






^y "^ 



^H, 



Copyright, 1913, 
By A. R. ELLIOTT PUBLISHING CO. 



INDEX TO VOLUME XCVIU. 



Pack. 

AIUMt'lT'S method of treating scoliosis, 
mod itication of ioSa 

Ahdcrhalden's dialysis in the insane 1238 

in psychiatry 1227 

mcthnd in carcinoma 1132 

in sick and healthy 1031 

in tuberculosii!^ of lungs 831 

serodiagnosis in epilepsy 1270 

in psychiatry I93 

01 cancer 1249 

of pregnancy 

S*'. 194. ^42. ^50, 436. 583. 635. >"8. 1249 

Abdomen, acute disease of 1 107 

apparatus for support of 489 

chronic enlargement of S39 

condtiiun ot, in relation to gallbladder. .1274 

X rays in diagnosis of diseases of 664. 70S 

Abdominal adhesions 1184 

cavity, adventitious tissues of 741 

conditions, acute, diagnosis of 1107 

obscure, x rays in diagnosis of 40 

fascia, transverse incision in 1133 

fat. electrotherapy for reduction of 73* 

lumboiliosacral support, uses of 489 

measurements, value of. in pregnancy.. 586 
operations, blood pressure in relation to 

prognosis in 204 

suction tip tor aspiration in 1277 

panhysterectomy, Wertheim's 733 

ptosis, medical aspect of 334 

surgery, iodine in 739 

local anesthesia in 739 

will] in puer])cral women, Bergonie tech- 

nic in treatment of 1271 

Abortion, threatened, treatment of. 673, 721, 773 

Abscess, acute retropharyngeal 227 

brain, following suppurative processes of 

liver and lungs 434 

hepatic, in amebic dysentery 89 

effects of emetine on 983 

oiI>ital, from infection through ethmoid. 1194 

ovarian, following labor 534 

peritonsillar, general sepsis following. . 989 

retropharyngeal 227, 571, 771 

subdiaphragmatic 1037 

Ab>>cesse:5, fixation, treatment of infections 

by means of 933 

late', after appendicitis 1127 

ABSTRACTS AND REVIEWS: 

Chapin, Charles V. The air as a vehicle 

of infection 970 

Hoffman. Frederick L. Cancer mortality 

of C.reater New York 1217 

Parker. Ti. H. The ner\'Ous system; its 

origin and evolution 1167 

Schmidt, Adolph. Severe anemia in gas- 
trointestinal diseases 822 

Waller. A. D. The origin and scope of 

electrocardiography 7^9 

Acanthosis nigricans 202 

Accidents due to electricity 93o 

Acetone bodies in urine, clinical signifi- 
cance of 536 

Acid base equilibrium 588 

intoxication, acute 40, 1081 

Acidosis, nature of 588 

postoperative complication 985 

Acne bacillus, growing of, from comedo.. 147 

vulgaris, treatment of 676 

Acromegaly and polyglandular syndrome 589 

pregnancy following 534 

tumor of hypophysis in 47.294 

Acromion process, auscultation at 251 

Adalin. therapeutics of 889 

Addison's disease and pregnancy 630 

Adenitis, tuberculous cervical, treatment of. 1276 

Adenoid origin of infections 188 

Adenoids, removal of 537, 888 

causes of disappointment following. ... 1274 

Adhesions, abdominal 1184 

in relation to chronic constipation 5 

intestinal 347 

resulting from enteroptosis 348 

parametrial, dissolution of. by the x ray. 1179 

peritoneal 349 

Adiposis dolorosa 485 

Adipositas hypophysarea 487 

Adolescence, intermittent albuminuria of.. 592 

Adrenal glands and glycemia 146 

anomalous situation of 683 

insufficiency, functional, conditions re- 
sulting from I178 

syndromes 931 

Adrenalin, action of, on coronary arteries 95 
sodium chloride solution in cardiac failure 

in pneumonia 1226 

Aged, body temperature in 1077 

medical care of 946 

Agglutination of micrococcus melitensis.. 583 
Agglutinin, specific, formation of. in ar- 
tificial tissue cultures 96 

A^nhu^^ description of, as seen in Canal 



Pagb. 
Air emboti»m in intravenous injections.. yB6 

expired, remspiration of 1185 

fresh, an eliminator of exanthemata.... 481 

hot, in aural and nasal disorders 56 

temperature of tissues during treatment 

with 1181 

supcrht-ated, ui treatment of suppurating 

W.MiHtU 1273 

vehicle of infection 970 

Albumin reaction in sputum 386,437 

.Mbuminuna. intermittent, nutritional ef- 
fect of S92 

orthostatic, treated by exercise 1081 

physiological, from mihtary medical 

standpoint 1127 

Alcohol as a therapeutic agent 826 

from biochemical standpoint 388 

in infectious diseases 581 

injections into nerves, effect of 144 

in treatment of trifacial neuralgia 987 

Alcoholic neuroses, premonitory auras in 46 
Alcoholism, from biochemical standpoint.. 388 

in Russia 1076 

.Meucocytic animals, studies on 534 

Alexander. Isadore Henry, and Montague, 

Helen. Acute retropharyngeal abscess 227 
Alexander. Robert M. Artificial pneumo- 
thorax in treatment of pleurisy with ef- 
fusion 4^ 

Intestinal obstruction due to a benign 

pelvic tumor 1163 

Polycythemia, with report of a case in 

an insane patient 278 

Alimentation, duodenal, in cirrhosis of liver 295 

Allergy, nonproteinogenous 930 

AUis ether inhaler, suggested improvement 

in 137 

Alkaloids, administration of, before anes- 
thesia . 633 

Alopecia areata, circulatory disorders in 

relation to 932 

Altitude, effect of, on the blood 984 

great, behavior of leucocytes in 485 

pulmonary tuberculosis in 882 

rapid change in, and blood pressure 202 

Amblyopia, toxic, from tobacco 429, 442, 594 

Amebae in relation to dysentery 1036 

of !^kin 742 

Amebic lesions, treatment of, with emetine, 1129 
Amenorrhea, prolonged, with ovarian cysts. 1084 

treatment of 624 

Amentia, frequency of, in relation to sex 935 
.\mino acids and sugars in rectal feeding 146 

in cachexia of malnutrition 619 

nitrogen content of serums I57 

Amniotic fluid, source of 730 

Amputation in diabetic gangrene 892 

Amputations, major, study of 539 

Amyloidosis, local 881 

Anacidity. chronic, therapy of 1127 

Anal Assure, treatment of 1172 

Anaphylactic poisoning 96 

Anaphylaxis and asthma 688 

bacteriological aspects of 1181 

in diagnosis of cancer 37 

Anastaltics. use of, in infants 533 

Anastomosis, arteriovenous, for impend- 
ing gangrene 885 

Anatomv. pathological. Wassermann reac- 
tion in 436 

Anemia as an operative risk 205 

in children, treatment of 88 

in malaria, cause of 579 

in rheumatic patients, treatment of 1031 

malarial 536. 721 

pernicious 5o 

experimental production of . ; 103 

nervous phenomena in 47 

salvarsan in treatment of 1174 

symptomatologv' of 440 

treatment of 7/6, 1024. i370 

severe, in gastrointestinal diseases 822 

treatment of 885 

Anesthesia, administration of alkaloids be- 
fore ..._ 633 

and anociassoctation 346 

ciliarv. enucleation under 203 

general, in children 41. 633 

studv of blood pressure during and 

after 204 

important advance in 1073 

in inflammations of mouth and pharynx 686 

intratracheal insufflation 39. 633 

Kuhlenkampf's. in brachial neuralgia 630 

local 39, 633 

in abdominal surgery 739 

in obstetrics and gynecology 836 

studv of blood pressure during and 

after M4 

nitrous oxide and oxygen 39. 633 

oil-ether "Oi 

rectal uoi 

spinal, dangers and disadvantages of. .349, 897 



Pack. 
.\nc»ihc»la. bpmal, in ob»tctric» and gyne- 
cology 836 

in operation for appendicitis 396 

surgical, lacryrnal gland in 97 

symposium on 39 

warmed ether in Mj 

Anestlieiic, local, potassium permanganate 150 
Anesthetics, various methods of adminis- 
tering 934 

Anciirys-iii, aoriic, rupture of i.*27 

Angina pectoris, reflex or protective phe- 
nomena of 918 

pseudomembranous, of nose and throat.. Ht^M 

treatment of pains of 2$0 

Vincent's 468 

Anginal pains, treatment of 49 

Angioma of choroid iis6 

scrpiginosum 42 

Angulations, intestinal, in relation to 

chronic constipation 5 

Ankle clonus without gross disease of cen- 
tral nervous system 34a 

Ankylosis of jaw. use of mucous mem- 
brane flaps in 394 

.\nkylostoma ceylonicum 197 

infection 536 

Ankylostomiasis, acute, autogenous vaccine 

in 876 

Anociassociation and anesthesia 346 

and surgical shock, kinetic theory of.. 297 

value of 631 

Anodal treatment 244 

Anorectal line, clinical significance of 640 

Anteflexion of uterus, glass or silver stems 

in treatment of 1084 

.\ntigen in Wassermann reaction 1130 

Antigens, corpus luteum, complement de- 
viation by 300 

for Wassermann reaction, comparative 

study of 42. 586 

Antiluctin in syphilis .-••;•• S* 

Antimeningitic serum, subdural injection 

of 56 

Antiseptics, urinary 685 

Antitetanic serum in wounds of eye 882 

Antitoxine, diphtheria, action of, on bacil- 
lus of diphtheria 4S8 

treatment of tetanus 344 

.'\ntityphoid vaccine in an epidemic 200 

inoculations of 253 

Antrum, chronic suppuration of 589 

empyema of. conservative operation for 180 

Anus, formaldehyde in surgery of 1122 

fissure oi. treatment of 1172 

z-plast'c operation for stricture of. .... . 639 

Aortic insufficiency, diagnosis of, with 

sphygmomanometer 52 

regurgitation, diastolic pressure in...... loi 

Aortitis, syphilitic, inequality of radial 

pulses in 389 

with insufficiency of left ventricle 535 

.\phasia. surgical 222 

Aplasia of gallbladder 96 

.\pparatus. bioronteenugraphic 13 

narcosis, value of 1^=6 

new, for colostomy 1082 

for proctoclysis 1022 

Appendicitis, catarrhal 295 

gastric juice 162. 224 

operations for ; 79' 

pinching the appendix in diagnosis of 588 

value of X rays in study of 835 

claudicans 981 

chronic, in relation to hyperacidity of 

late abscesses after 1127 

pathology and treatment of 440 

relationship of. to inflammation of Meck- 
el's diverticulum 732 

simulated by tumor of omentum 342 

spinal anesthesia in operation for 296 

with carcinoma of pelvic colon and 

ovarian tumor 733 

.Appendix, differential diagnosis of. by aid 

of X ray 697 

diseases of 373 

of unusual size 78< 

pigmented ,- 339 

pinching of. in diagnosis of chronic ap- 
pendicitis 588 

Apraxia. knowledge of 57 

.Arm. circulation of 100 

fracture of, use of pegs in i*70 

venous thromboi^is of 1032 

Army surccnns. work of, in last few years. 543 

tuberculosis in 127 

Arsenic cancer 339' 390 

in viscera after salvarsan injections 1032 

poisoning 96 

preparation in tabes 95 

susceptibility to^ 38s 

Arsenical paralysis 96 

Arsenre^enerin and regenerin 1031 

Arteries, calcified, rigidity of. ...-...; 93* 

inferior and superior thyroid, ligation of 889 



1282 



LXDEX TO VOLUME XCl'III. 



Pace. 
Arteries, ligation of, in treatment of can- 
cer of pelvic organs 1083 

overtcnsion of i44 

spasm of 391 

Arteriosclerosis 636 

diagnosis of 1050 

effect of drugs on high blood pressure in 685 

etiology of 582 

experimental, and cholesterinemia...784, 1031 
high blood pressure in, effect of drugs on 685 

occurring before age of thirty 386 

senile, amorphous phosphorus in 1042 

treatment of 252, 544 

Artery, anterior coronary, embolism of. . 433 
posterior inferior cerebellar, occlusion of. 

47. 249 

Arthritis, chronic 537 

focal infections a cause of 38. 632 

streptococcus 586 

deformans, genitourinary surgery in 887 

improved by physical means 794 

experimental, streptococcic 102, 1232 

gonococcal, treatment of .1122 

gonorrheal, local application of salicylic 

acid in 884 

monarticular rheumatoid, of hip, surgical 

treatment of 614 

rheumatic, extract of pituitary body of 

ox in treatment of 793 

rheumatoid, primary cause of 1182 

Arthroplasty for bony ankylosis of joints 149 

Asbestos minerals, action of 1182 

Ascaris lumbricoides complicating typhoid 



Asphyxia neonatorum, infant pulmotor in 
Aspiration in treatment of closed pneu- 



otho 



153 



244 



mask. Kuhn's substitute for 

Asserson, M. Alice. Food for babies 182 

Astereopnosis, covtical 442. 443 

Asthenia, lymphocytosis in 193 

Asthenopia of muscular imbalance 45 

Asthma and anaphylaxis 688 

bronchial, cause of 591 



or true 99 

treatment of 196 

tuberculin treatment of 290 

cause of paroxysms in 194 

in children 196 

treatment of 528 

vaccine treatment of 53 

Ataxia, cure of 1045 

Atmosphere, colds in relation to physics of.1231 

Atony, gastrointestinal, treatment of 380 

of vagus and seasickness 630 

Atophan. action of. on uric acid elimina- 
tion 542. 10S5 

Atresia, congenital, of duodenum 343 

of esophagus 1233 

Atrophy, lactation, of uterus 691 

Atropine in stomach disorders 89 

inverse action of 487 

Auditory centre, localization of 54 

meatus, external, furunculosis of 974 

ner\*e, division of, for tinnitus and ver- 



Auerbach, Julins. Chr 



liddle 



suppuration of 



and limitations of .paraffin in 

the treatment of ozena 566 

Auras, premonitory, in alcoholic neuroses 46 

Auricular fibrillation 202 

flutter 591 

Aurometer 1016, 1090. 1190 

Auscultation at acromion process 251 

Auslander, M. Treatment of threatened 

abortion 774 

Austin, F. D. Treatment of chancroids. ... 1120 
Austin. H. \V. Importance of early op- 
eration for radical cure of hernia 319 

Autoplasty, spontaneous, through extension 



Ax 



cylinders, regeneratii 



of. 



535 
T270 



DABCOCK. W. WAYNE. The dangers 
^ and disadvantages of spinal anesthesia 897 
Bacillary dysentery, chronic, treatment of. 1130 
epidemic, diagnosis and treatment of. 1 131 
Bacillus, acne, growing of. from comedo 147 
bulgaricus in treatment of diabetes. .70. 131 

coli, acute epididymoorchitis due to 83s 

diphtheria, action of antitoxine on 488 

means of distinguishing the true 1178 

lactis bulgaricus. intestinal implantation 

of. in treatment of diarrhea 249 

lepr.T. cultivation of 103. 789, 1183 

perez. relation of, to ozena 290 

pseudodiphtheria. in urinary tract 49 

subtilis, hemolysin of 194 

Back, paralysis of, delivery in 97 

Bacteria, action of oxygen, hydrogen di- 
oxide, and ozone upon growth of to66 

from house fi\\ Empusa muses as a car- 
rier of ' 1182 

instrument for determining the number 

of 882 

intestinal, in pellagra 199 



Page. 

IJactcria, nitrifying, of biological filters.. 292 
related, differentiation of, by precipita- 
tion of their albumins 486 

specific differences among 1033 

Hacterial preparations in tabes 95 

llactericmia in pneumococcus infection of 

rabbit 838 

intravenous injections of bichloride of 
mercury in treatment of.. 436 

Bacteriolysins in mothers* milk 436 

Bacterization, scientific and natural, to pro- 
duce immunity in self limiting diseases 229 

Baetz, \V. G.. and Deeks. W. E. An an- 
alysis of five hundred fatal medical 
cases in the tropics 401.462 

Baker. Frank. Faculty of Paris in seven- 
teenth century 115 

Baldwin. J. F. Csesarean section with hys- 
terectomy in cases of positive infec- 
tion 372 

Baldy-Webster operation, study of end re- 
sults of ....886 

Balkan War, gangrene of feet of soldiers 
in 1128 

Dalkans and health of the world 925 

Ball, C. F. Serodiagnosis (.\bderhalden) 
of cancer and pregnancy 1249 

Callagi. John. Epidemic of trichinosis in 

Pennsylvania 1166 

Treatment of chancroids 1219 

Balsam of Peru, uses of 479 

Bandler. Samuel Wyllis. Internal secre- 
tions as they concern the gynecologist iii 

Barnes. Francis M., Jr. General paralysis 
in the negro 767 

Bartholow , Paul. Etiology of pellagra 1262 

Bartlett. Charles J. Pye'litis in the adult 756 

Basedow's disease, internal treatment of.. 831 
thymin in treatment of 1228 

Basophile patches in protoplasm of neu- 

trophile polymorphs 437 

Bass's method of cultivating Plasmodium 
vivax 1079 

Bates. W. H. Myopia prevention by teach- 
ers 410 

Baths, carbonic acid, influence of, on body 

temperature 385 

hot. in bronchial diseases 831 

in disturbances of circulation 289 

mud, influence of, on body temperature 385 
water, influence of. on body tempera- 
ture 3S5 

Battleships, discarded, as sanatoria and 
open air schools 501. 53c 

Beattie, William J., and Myers. Edward 
E. Value of turtle tuberculin in treat- 
ment of tuberculosis 503, 811 

Bechet, Paul E. Etiology and treatment 
of hypertrichosis '. 313 

Bedbugs and leprosy 1028 

carriers of typhoid infection 191 

in new role 350 

Bedrossian. Edward H. Treatment of in- 
somnia 873 

Behan. Richard T. Surgical experiences 
during the Servian-Bulgarian War 905 

Behrine's diphtheria vaccine, report on- . - i22'i 

Bell. F. McKelvey. Treatment of threat- 
ened abortion 723 

Benzol treatment of leucemia 122? 

of leucocythemia 96 

Bergonie technic in treatment of abdominal 
wall and pelvic floor in puerperal 

Beriberi 730 

etiology and treatment of 1124 

experiences with 887 

experimental, extracts of spinal cord in 

treatment of 1085 

in Japan and Philippines 543 

Besson, John H. Proper indications for 
the use of phosphorus 546 

Beveridge, J. Wallace. Diabetes mellitus; 
treatment with Bacillus bulgaricus. .70. 131 

Bichloride tablets, safeguarding the sale of. 1027 
regulating the sale of 1176 

Bier's method in treatment of gonorrheal 
epididymitis 1131 

Biggs, Hermann M. retires from Depart- 
ment cf Health 1173 

Bilharziasis 127: 

Bilharzia^i-s. urethral calculus in 630 

Biliary passages, rontgenoscopy of 39, 687 

tvphoid infection of 96 

Billings. W. C. and Wilson, J. G. Retro- 
pharyngeal abscess 571 

Binet-Simon system of mental measure- 
ment of juvenile delinquents 175 

Biochemistry, dynamic side of 734 

fundamental principles of 1134 

Biorontgenographic apparatus, new 13 

Bishop, Louis Faugeres. Diagnosis of ar- 
teriosclerosis 1050 

Bismuth gauze, preparation and use of 147 

paste. Beck's, active portion of 1270 



Page. 

Blackwatcr fever, etiology of 240,441 

suppiession of urine in 54 

unusual forms of parasite of malaria in 438 

Bladder, cysts of 784 

gumma of, salvarsan and neosalvarsan in 

treatment of 1232 

infections, thermostabile toxines in 58 

primary suture of 623 

prolapse of 890 

removal of, for tumor 784 

simple ulcer of 785 

stones in 784, 785 

suprapubic operations on, method of ap- 
proach in 1 133 

topography of, with special reference to 

cystoscopy 353 

transverse incision in suprapubic opera- 
tions on 48 

tumors of. diagnosis and treatment of.. 48 

high frequency currents in 148 

in aniline dye workers 631 

Blepharitis, treatment of 80, 487 

Blepharochalasis 46, 735 

Blindness, preventable 45, 736 

Blood, acidity of. in osteomalacia 1179 

bacterial invasion of. by way of lymph 

nodes 934 

blue 636 

calcium content of. in pregnancy. .194, 205 

cells, red, method of counting 436 

coagulability of 1179 

complement content of, in malignant 

disease 298 

condition of, after removal of thyroid 

gland 534 

corpuscles, hypersplenic destruction of. . 1 178 

effect of altitude on 984 

malignant growths on alkalinity of... . 685 
repeated ^ injections of salvarsan and 

neosalvaisan on 194 

estimation of urea in 195 

examinations in diseases of central ner- 
vous system 832 

ferments in, diagnostic significance of. . 193 

human, new spirochaeta found in 98 

immunization of, against septic disease. .1128 

in mumps 339 

letting apparatus 966 

leucemic. cultivation of leucocytes from 435 

of general paretics, syphilis infection 

directly from 47, 934 

of hepatic patients, variations of chol- 

esterin in 247 

peripheral, influence of tuberculin on 

eosinophile cells in 937 

poi^^oning, legal aspects of 926 

[)recipitation of uric acid in, by means 

of uranium acetate 243 

pre.>;snre. action of digitalis upon 686 

acute lowering of 144 

clinical observations on 591 

diastolic, clinical determination of 791 

during and after operations 204 

effect of change of posture on loi 

high, clinical significance of 791 

diseases resulting from 178 

in arteriosclerosis, effect of drugs on 685 

significance of 144 

in aortic regurgitation 101 

in tuberculosis at great altitudes 1186 

influence of atmospheric conditions on 143 

rapid changes in altitude on 202 

intracerebral, headaches caused by low- 
ering of 435 

Knv. clinical significance of 791 

maximal and minimal 884 

phenomena, auscultatory 791 

relation of. to prognosis in abdominal 

operations 204 

re'^ults of intravenous injections of ex- 
tracts of goitre on 53!* 

\enous. influence of certain drugs upon, 

50. 399 
vihropalpatory method of estimating.. 786 

ptosis 916 

relations, coincident disease in 945 

resistance of white corpuscles of 1128 

serum of gouty patients 1031 

of pregnant animals 783 

reaction of. in diagnosis of cancer 788 

..erums, analyses of, in neurology 51 

sugar content of 930 

supply of uterus, influence of ectopic 

pregnancy on 204 

iiihercle hacilli in 1227 

viscosity of 1179 

Bloodvessels, diet in diseases of 484 

Bodies, acetone, in urine 536 

digitalis, elimination of 393 

foreign, detection and extraction of 245 

failure of magnet extraction of 245 

in eye, treatment of 188,988 

perforation of uterus by 629 

removed from larynx by direct laryn- 
goscopy 31^ 



INDEX TO rOLUME XCVIIl. 



1283 



Uody .Kt.niii.jiiiincnts of psycliu- changes. . IJ71 

effect of skeletal anomalies upon loSj 

influence of baths on tcmperatijre ol.. 385 

temperature in aged 1077 

pharmacology of 878 

Bochiiie, llustav F. Therapeutic value of 

oral prophvlaxis and treatment 516 

tloland, Frank' K. Treatment of burns., jjs 
Bone carcinoma of. spontaneous fracture 

in io8s 

clauip anil plate in treatment of fractures 6S7 
m trcaiment of fractures of long bones 37 

fonration in a corpus albicans 1179 

graft in surgery, original uses of 39 

plastic operations on spine for Pott's 
disease '08' 

plate in treatment of fractures of long 

bones 37 

regeneration of 890, 1080 

transplantation for flail joint 1082 

necessity of preserving periosteum in.. 39 

Bones, long, fractures of 37 

.t ray diagnosis of osteomyelitis of.. 201 

tuberculosis of 44* 

BOOK REVIEWS: 

Aarons, S. Jervois. Aids to Gynecology 643 

.\bbott. Eleanor Hallowell. The While 
Lintn Nurse "043 

Abel, Rudolf. Bakteriologisches Taschen- 
buch "9" 

Adam. C. Ophthalmoscopic Diagnosis. 
Translated by Matthias Lanckton Fos- 
ter. M.D 547 

Adams, Joseph E. Acute Abdominal Dis- 
eases .• ,• ^ *39 

Adan'S, Samuel Hopkins. The Health 
Master '-39 

Arrou, Joseph. Maladies du cou 207 

Bacon. Gorham. Manual of Otology 1043 

Bill, James Moores. Modern l)phthal- 
mology 995 

Billings, Frank, and Salisbury. J. H. 
General Medicine. Volume i. Prac- 
tical Medicine Series for 1913 ,. 398 

Binet, Alfred, and Simon, Th. A Method 
of Measuring the Development of the 
Intelligence of Young Children 302 

Binnie, John Fairbairn. Manual of Op- 
erative' Surgery "39 

Birnbaum. R. Clinical Manual of Mal- 
formations and Congenital Diseases of 
Foetus 695 

Illai.chara, C. Elton. Wayside Experi- 
ences >24-' 

Bodkin. Martin L., Diseases of the Rec- 
tum and Pelvic Colon 742 

Burdett's Hospitals and Charities for 1913 &42 

Cabot. Richard C. Physical Diagnosis 302 

Chavannaz. G. Maladies du pancreas, de 
la rate et du mesenterc 302 

Chetwood. Charles H. The Practice of 
Urology 255 

Cheyne, Sir W. Watson, and Burchard. 
F. F. -'V Manual of Surgical Treatment 206 

Collie, Sir John. Malingering and Feign- 
ed Sickness 303 

Creazzo, Arcangelo. Studio su la Morte 
Apparente e la Morte Reale 303 

Dalton. Gerald. Practical Manual of Ve- 
nereal and Generative Diseases 795 

da Malta. Alfredo Augusto. Flora Med- 
ica Braziliense 107 

Deaver. John B. Appendicitis. Its His- 
tory. .Anatomy. Clinical Etiology. Path- 
oIoRv. Symptomatology. Diagnosis. 
Prognosis. Treatment. Technic of Op- 
t-ration. Complications, and Sequelje.. 107 

de Quervain. F. Clinical Surgical Diag- 
nolis iisS 

Dresslar. Fletcher B. School Hygiene.. 59 

Duhressen. .A. Vademekum der Geburts- 
hilfe und Gvnakologie 59 

Ehrlich. P.. und Lazarus.. A. Die Anae- 
mic ^' 

Ehrlich. P.. I^zarus. A., und Pinkus. F. 
Leukemia and Pseudoleukemia 742 

Ellingcr. A. Enpinger. H.. Falk. F., 
Schulz. F. N.. Spiro, K., und Wiechow- 
ski W. Analvse des Harns 255 

Faulhabcr, M. Die Rontgendiagnosis der 
Darmkrankheiten i "91 

Faulkner, Richard B. The Tonsils and 
the Voice 593 

Findlev. Palmer. Treatise on Diseases of 
Won^en "39 

Fischer Louis. The Health Care of the 
Babv 254 

Fritscti. Heinrich. 1870-1871 Erinnerungen 
und Retrachtungen 742 

Garre. C. Surgery of the Lung 206 

Graham. Rouglas Massace 894 

Gray Henrv. Anatomy. Descriptive and 
Aoplied (New American Edition.).... 843 

Haffkine. W. M. Protective Inoculation 
Against Oiolera z^i 

Halliburton. W. D. Handbook of Phy- 
siology 943 



1 Aue. 

Hanna. William. Siudict in Smallpox 

and Vaccination iSS 

Harsion, G. Montagu, Care and Treat- 
ment uf European Children in the 

Tropics 207 

Haskins, Howard D. Organic Chemistry 499 
Martntaiui, Henri. Gynecological Oper- 
ations 1138 

Head, Gustavus P„ and Mix, Cbarlet L. 
Practical .Medicine Series for 1913. 
Volumes 1 and II 39* 

Heine. U. (Jpcrationen am Ohr 1090 

Henson, Graham E. Malaria B43 

Herman, lieorge Ernest, and Maxwell, R, 
Drummond. Diseases ol Women, A 
Clinical (iuido to llieir Diagnosis and 
Trealnicnt 595 

Herz. Hans. Die Storungen des Ver- 
dauungsapparates als Ursache und 
Folse anderer Erkrankungen 59 

Hirschmann, Louis J., Handbook of Dis- 
eases of the Rectum 107 

Hitschmann, Eduard. Freud's Theories 
of the Neuroses 446 

Iluhncr. Max. Sterility in the Male and 
Female and Its Treatment 447 

Humphries. Francis Howard. Electro- 
therapeutics for Practitioners 303 

Hun, Henry, An Atlas of the Differential 
Diagnosis of the Diseases of the Ner- 
vous System I5S 

Hurry, Jameson B. Vicious Circles in 
Disease 841 

Jones, H. Lewis. Ionic Medication 942 

.Medical Electricity 895 

Keogh. Sir Alfred. Melville. C. H., 
Leisliman, Sir William, and Pollock, 
C, E. A Manual of Venereal Diseases 79s 

Kraepelin, Emil. General Paresis 499 

Lectures on Clinical Psychiatry 843 

Krause, Rudolf. A Course in Normal 
Histology 995 

Krehl Ludolf. Die Erkrankungen des 
Hcrzmuskels und die nervosen Herz- 
krankheiten 303 

Lamb. William. Practical Guide to Dis- 
eases of the Throat, Nose and Ear 155 

Leftwich, Ralph Winnington. Tabular 
Diagnosis 399 

Lewis. Thomas, Clinical Electrocardio- 
graphy 399 

Lbhlein, M. Die Gesezte der Leukozy- 
tentatigkeit bei Entziindlichen Prozes- 
sen 255 

Lorenz. Adolf, and SaxI, Alfred. Ortho- 
pedics in General Practice 995 

Lowrv, E. B,, and Lambert, Richard J. 
Himself. Talks with Men Concerning 
Themselves 547 

McCaw. John. Aids to the Diagnosis and 
Treatment of Diseases of Children 842 

McKisack. Henry Lawrence. Systematic 
Case Taking 302 

McLaughlin. Allan J. Sewage Pollution 
of Interstate and International Waters 795 

Mauclaire. PI. Chirurgie generale et chir- 
urgie orthor>ediquc des membres 59 

Melville. Colonel Charles M. Military 
Hygiene and Sanitation 1043 

Minett. E. P. Diagnosis of Bacteria and 
Blood Parasites 1239 

Moon, R. O. The Prognosis and Treat- 
ment of Diseases of the Heart 351 

Much, Hans. Krankhcitsentstehung und 
Krankheitsverhfltung und geheimnisvolle 
Lcbensausserungen des Korpers 155 

Murphy, John B, General Surgery. 
Volume II, Practical Medicine Series 
for 1913 .- 398 

Mvers, Victor C, and Fine Morris S. 
Essentials of Pathological Chemistry ... 1279 

Naegeli, O. Leukemia and Pseudoleu- 
kemia 742 

Onodi. A. The Relations of the Lacry- 
mal Organs to the Nose and Nasal Ac- 
cessory Sinuses 447 

Panton,' P. N. Clinical Pathology.... 106 

Pembrev. M. S., and Ritchie, J. Text- 
book of General Pathologv 398 

Pettcv. George E. The Narcotic Drug 
Diseases and Allied Ailments 351 

Pitfield. Robert L.. A Compend on Bac- 
teriologv 994 

Plaut. F.. Rehm. O.. and- Schottmiiller, 
H. Leitfaden zur Untersuchung der 
Zerebrospinalfliissigkeit 499 

Politzer. .\dam. Geschichte der Ohren- 
heilkunde 548 

Pope. Amy E. Textbook of Anatomy 
and Phvsiology for Nurses ..894 

Portner. Ernst. Genitourinary Diagnosis 
and Therapy 994 

Prescott. Samuel Cate. and Winslow, 
Charles Edward Amory. Elements of 
Water Bacteriology 1190 

Price. George M. Hygiene and Sani- 
tation. A Textbook for Nurses 151 



Pace 

I'yle, Waller I.., and Brtird, Charlr. H. 
.\n International System uf Ophthal- 
mic Practice 106 

Uadasch. Henry ErdmaOD A Compend 
of Histology Wt 

Uae, lames. The Deaths of the Kinga 
ol England li»J 

Rector. Frank L. Underground Waters 
lor Commercial Purposes 1091 

Reed. Charles A. L. Diteasci ol Women. 1041 

Register ol I'urchaset and Amount Used 
of Alkaloid Cocaine, etc 399 

Robinson, William J. A Practical Tre- 
tise on the Causes, Symptomi. and 
Treatment of Sexual Impotence and 
> ither Sexual Diiiorders in Men and 
Women 743 

Kuscnau, Milton J. Preventive Medicine 
and Hygiene 1279 

Kubner, Al., von Gruber, und Ficker, 
M. Handbuch der Hygiene. Band III. 

3»8, 1190 

Satterthwaite, Thomas E Cardiovascu- 
lar Diseases 499 

Saundby, Robert. Old Age 94] 

Sawyer, Sir Jam-s. Coproslasis 99s 

Schafer. E. A. Experimental Physiol- 
ogy 498 

Schall. Hermann. Berechnele arztliche 
Kostverordnuiigcn nebst voUslandigen 
Kochbuch fur Zuckerkranke 399 

Schmidt, Rudolph. Diagnosis of Malig- 
nant Tumors of Abdominal Viscera,. 11J9 

Schorer, Edwin Henry. Vaccine and 
Serum TTierapy 1139 

Schroeder. Henry H. Insurance Medi- 
cine 447 

Sill. E. Mather. The Child, Its Care, 
Diet and Common Ills J06 

Simon, Charles E An Introduction to 
the Study of Infection and Immunity, 1042 

Sophian, Abraham. Epidemic Cerebro- 
spinal Meningitis 155 

Sopp, ,'\. Suggestion und Hypnose, ihr 
\\esen, ihre Wirkungcn und ihre Be- 
deutung als Heilmitlel .,. ISS 

Starr. ^L Allen. Organic and Functional 
Nervous Diseases 84a 

Stenhuuse, John. Pathology, General and 
Special 1239 

Steven. Edward Millar. Medical Super- 
vision in Schools 59 

Stewart, Francis T. Manual of Surgery. 1239 

Stitt, E. R. Practical Bacteriology, 
Blood Work, and Animal Parasitology 894 

Thomson, H. Hyslop. Consumption in 
General Practice 399 

Torok. Ervin, and Grout, Gerald H. 
Surgery of the Eye jtu 

Thresh. John C. Examination of Water 
and Water Supplies 155 

Trendelenburg. Wilhelm. Die vergleich- 
ende Methode in der Experimentalphy- 
siologie ■ • . 2S5 

Tyson. James. The Pr.ictice of Medicine. 1279 

\'aughan. Victor C Vaughan. Victor C, 
Jr., and Vaughan. J. Walter. Protein 
Split Products in Relation to Immunity 
and Disease 12-9 

von Hoffmann, Geza. Die Rassenhygiene 
in den Vereinigten Staaten von Nord- 
amerika 743 

von Oettingen, Walter. Leitfaden der 
praktischen Kriegs Chirurgie 1090 

Weaver, Edward E. Mind and Health. 
With an Examination of Some Systems 
of Divine Healing 447 

Webster, Ralph W. Diagnostic Methods 642 

Wegele. Carl. Therapeutics of Gastroin- 
testinal Tract 69s 

Wharton. Henrv R. Minor and Opera- 
tive Sureerv 1239 

White William A., and Jelliffe. Smith 
Ely. The Modern Treatment of Ner- 
vous and Mental Diseases 84* 

Whitla, Sir William. A Dictionary of 
Treatment Including Medical and Sur- 
gical Therapeutics 30J 

Woglom. William H. Studies in Cancer 
and Allied Subjects. Volumes I and 
III 1090 

Wood. Neville. Health Resorts of the 
British Islands 59 

Woods. Frederick Adams. The Influence 
of Monarchs 742 

Wright, Sir Almroth E. The Unexpur- 
gated Case against Woman Suffrage. .1191 

Zuelzer. Georg. Innere Medizin. II. 

Teil 89s 

Borderline cases, advantages of Cesarean 

section in 69> 

Borneval. new. experience with 68> 

Boston. L. Napoleon. New pocket clinical 
sphygmomanometer 219 

Special technic in palpation B47 

Boston. L. Napoleon, and Ulman, Joseph 
K. Movements of two halves of chest 
in disease 705 



1284 



INDEX TO VOLUME XCVIIL 



Pace. 

Botanic family physician 520 

Bovaird, David. Obesity and emaciation.. 168 

Bowel, inplantation of ureter into 48 

large, surgical anatomy of 639 

Bowels, obstruction of 74© 

Bowers, Paul E. Causes of crime 128 

Bowers. Rose A. Treatment of bums 281 

Brachial plexus, exposure of 148 

Bradycardia, analysis of cases of. 



■ 339 

to adrenal insufficiency 1:78 

Brager, Louis R. Treatment of burns 236 

Brain abscess, metastatic 434 

rupture of 987 

circulatory disturbances of. 47» ^94 

in paresis, presence of syphilitic organ- 
ism in S7 

of paralytics, spirochetes in 1030 

of paretics, transmission of Treponema 

pallidum from 198 

of patient with cortical astereognosis. . 442 

tumor, treatment of ■ . . 686 

visualizing power and dreams following 

removal of . 1275 

Bram. Israel, Gelatin and olive oil in lib- 
eral diet of typhoid fever 230 

Braunstein, Joseph E. Two cases of lue- 
tic keratitis 672 

Brav, Aaron. Ocular vertigo 955 

Breast, cancer of 74° 



of. 



739 



cystic tumors of 

feeding of infants 54 

female, benign tumors of 1185 

lymphaniiis of, in nursing women iiyi 

male, tumors of 142 

milk problems 4I1 i^74 

Breathing, acromial, in diagnosis of pul- 
monary tuberculosis 1261 

audible, pause in 783, 1030 

mouth, cure of 138 

Brecht. Nelson Du Val. Suggested im- 
provement in the Allis ether inhaler.. 137 

Treatment of burns 282 

Treatment of cholera infantum 475 

Treatment of threatened abortion 721 

Brewer. Isaac W. Tuberculosis in the 

United States Army 127 

Broadman, Joseph. Need of the micro- 
scope in the treatment of gonorrheal 

urethritis and prostatitis 28 

Bromide preparations 243 

Bromidrosis, treatment of 479 

Bronchioles, reversible action of epine- 

phrin upon 1085 

Bronchiolitis, hot baths in treatment of.. 831 
Bronchitis, acute, hot baths in treatment 

of 831 

chronic, treatment of 894 

vaccine treatment of S3 

in infancy, treatment of 576 

Bronchopneumonia, hot baths in treatment 

of 831 

in children, treatment of 1263 

lobar form of 634 

Brooks, Harlow. Etiology of hypertrophic 

pulmonary osteoarthropathy 608. 669 

Broun. LeRoy. Cancer of uterus and the 
American Society for the Control of 

Cancer 1104 

Brown. Claude P. The bacteriology of 

pyorrhoea alveolaris 1201 

Brown, Samuel Horton. Efficiency and 

health 232 

Bryan. R. C. Early diagrnosis of renal tu- 
berculosis 20 

Bubo, chancroidal, treatment of 785 

Buckley, Albert C. Relation of hyperthy- 
roidism to nervous system 1112 

Buildings, regulation of height of 636 

Bulls, cutaneous, cytology of fiuid con- 
tained in .'.... 14s 

Bullets, removal of, from vicinity of gas- 

serian ganglion 930 

Bunion, operative treatment of 1133 

Burn of eye, treatment of 988 

of eyeball due to caustic contents of 

golf ball 1135 

Burns, treatment of 234, 281, 32S, 1172 

Burr, Charles W. A case of dementia pre- 
cox with autopsy 109 

Burrows, Elliott C. Blood letting appar- 
atus g66 

Bursitis, retrocalcanean 263 

Bunvell. Hartwell R. Treatment of Chan- 
croids I2r9 

/*• ACHKXTA of malnutrition, treatment of 619 

^ Caesarean section, abdominal 692 

advantages of, in borderline cases.... 692 

extraperitoneal, best technic for 794 

high short incision for 891 

technic of 97 

with hysterectomy in cases of positive 
infection 372 

Calamities, postoperative, avoided by pre- 
operative caution 549 

Calcium content of blood in pregnancy. 194, 205 
estimation of 787 



Page. 

Calcium salts, influence of, on constitution 

and health 290 

Calculus, renal 738 

pathology and therapy of 582 

ureteral 19S. 738 

urethral, in bilharziasis 630 

vesical, spontaneous fracture of 1271 

California, climate of, in treatment of tu- 
berculosis 3^ 

Cancer 1116 

Abderhalden's serodiagnosis of 1249 

American Society for control of.. .1088, 1104 

anaphylaxis in diagnosis of 37 

arsenic 339. 390 

associated with tuberculosis 637 

best methods of educating American 

women concerning 205 

campaign committee, report of 1088 

cervical, trachelorrhaphy as prophylaxis.. 583 

chemicals in treatment of 966 

education of public in regard to 206, 1088 

effects of colloidal copper upon 736 

experimental, investigation in 732 

mechanism of immunity in 1185 

gastric, operative treatment of 490 

preceded by ulcer 1082 

genesis of 884 

geographical distribution of 930 

hematuria with .ureteral colic a symptom 

of 1161 

in Canada 189 

inoculations, sterilized 632 

inoperable, of uterus, cauterization in... 1266 

radium in 391 

treatment of 428 

investigation at Johns Hopkins Univer- 
sity 1136 

laryngectomy for 889 

menace of 154 

mesothorium in treatment of 830, 930 

mortality of Greater New York 1217 

of esophagus, esophagoscopy in 199 

lungs 96 

pelvic organs, treatment of 10S3 

prostate, radium treatment of 1181 

uterus 1 104 

early diagnosis of 791 

from clinical standpoint 740 

prophylaxis of 534 

operative technic in treatment of 740 

oxidation ^ 498 

pathogenesis of 1080. 1277 

patients, colloidal nitrogen in urine of 685 

public education in 597 

radium treatment of, 

535. 779, 930, 1222. 127s, 1276, 1277 
reaction of biood serum in diagnosis of 788 

recurrences, treatment of 428 

research hospital 1241 

statistics, educational value of 1135 

true value of operation for 634 

A'accination treatment of iizS 

value of X rays in 490 

Wassermann reaction in 440 

X ray treatment of 50, 1275, r277 

Carbon, oxygen, hydrogen group 693 

plus nitrogen 376, 594 

Carbonic acid baths 385 

snow, treatment Vi'ith 433 

Carbuncles, surgical aspects of 590 

Carcinoma, Abderhalden's method in 1132 

bone, spontaneous fracture in 1^5 

complement forming reactions with cere- 
brospinal fluid in 1030 

epitheliolysis against 1232 

gastric, with tuberculosis 100 

inoperable, of esophagus 19S 

powdered sugar in treatment of 194 

mammary, operative treatment of 739 

meiostagmin and epiphanin reactions in 

diagnosis of 102 

mouse, influence of copper on growth of 389 
of cervix uteri, radical operation for.. 791 

esophagus, resection of 1031 

face 1069 

gastrointestinal tract 387 

stomach, early diagnosis in 930 

operations and metastasis in 878 

primary, of Fallopian tube 832 

of jejunoileum 582 

pelvic colon 733 

prostate 755 

reaction of Salomon and Saxl as a diag- 
nostic test for 936 

urethral, of fossa navicularis 630 

uterine, hypothesis as to cause and pre- 
vention of 153 

Cardiac load and overload 791 

Cardiorenal patients, paroxysmal dyspnea 

in 1229 

Cardiospasm ggj 

Cardiovascular disease, diuretics in 49 

fruit diet in 727 

therapy in regard to venous blood pres- 
sure 393 

Carmin in diagnosis of gastrointestinal dis- 
eases 791 

Carotid, external, bilateral ligation of 733 

Carpal .<;caphoid, fracture of 248 



Page. 

Carpus, injuries of 14S 

Carrier, bacteria 1182 

Carriers, human, in poliomyelitis 1085 

typhoid fever 292 

Carrington, P. M. The climate of San 
Diego, Cal., region, with relation to 

renal diseases 559 

Carson, G. R.. Cummins. W. T., and Cof- 
fey. W. B. An unusual case of septi- 
copyemia 377 

Carstens, J. H. Nervous conditions and 

their relation to pelvic diseases 407 

Caruncle, urethral, high frequency cauteri- 
zation in 1115 

Castration without wounding scrotum 250 

Cataract, black 51 

delirium following extraction of 46,736 

Smith's method of operating on 632 

Stancleanu's operation for 104 

Catarrh, bacteriology of 150 

postnasal 793 

spring 299 

Cathartics, use of, in infants 533 

Catheter, renal, value of 738 

retained urethral, ureterovaginal fistula 

healed by 1 181 

Cauda equina neuritis 445 

Cauterization, high frequency, in prostatic 

obstruction 170 

in urethral caruncle 1115 

in inoperable cancer of uterus 1266 

Caution, preoperative, to avoid postopera- 
tive calamities 540 

Cavihlen therapy, practical results with... 1228 
Cecum and ascending colon in lesser sac 

of peritoneum 195 

fibroma of 732 

inflanimaiory conditions of 835 

membranes about, etiology of 37 

Cedar oil poisoning 492 

Cells, eosinophile, of peripheral blood, in- 
fluence of tuberculin upon 937 

Cerebellar manifestations in cerebrospinal 

meningitis 535 

Cerebellum, tumor of 58 

Cerebral hemorrhage, serological tests in...i23i 
Cerebrospinal fluid, bacterial invasion of, 

by way of lymph nodes 934 

coaguktion of. in tuberculous menin- 
gitis ■ 1272 

complement forming reactions with, in 

carcinoma 1030 

diagnostic significance of 1210 

examinations, in diseases of central 

nervous system 832 

in Qongenital syphilis 148 

mumps 339 

nervous and mental diseases 294 

Lange's goldsol test of 47. 148 

micrococci in. in mania 1131 

meningitis, atvpical. manifestations of. . . 936 

in New York 524 

Cervix, cancer of 583 

laceration of, a cause of salpingitis. .. . 740 

uteri, carcinoma of 791 

Chancre of conjunctiva of upper lid 1128 

Chancroids, treatment of, 

777, 1117, 1169, 1218, 1264 
Chapin. Charles V. The air as a vehicle 

of infection 970 

Chapman. William L.. Morris, H. A., and 

Simrell. G. W. Surgical aphasia 222 

Charbonneau, Lionel C. Treatment of mus- 
cular rheumatism 88 

Charity, use and abuse of * 963 

Chaulmugra oil in leprosy 531 

Cheek, cicatricial formations in 294 

Chemotherapy 488 

Chest, movements of two halves of, in 

disease 705 

wall, repair of large defects in 683 

x rays in diagnosis of diseases of.. 664, 708 
Chetwood operation for retention of urine, 

ultimate results of 645 

Childbearing. psychoses associated with. .1037 

Children's bureau, federal 41 

Children, crippled, gymnastics for 1085 

diseases of 40 

healthy sick 106 

Maori, bacteriology of mouth in 1273 

school, care of. at 'Moorficlds 1136 

eye-; of 1223 

health of 1093, 1149 

medical inspection and nutrition of 1186 

vigor of 1093, I149 

skin diseases of 43 

China, sanitary organization of 437 

Chloasma, treatment of 924 

Chloride free treatment of epilepsj^ 53 

inorganic, in gastric secretion, origin of. 54 
Chlorides in urine, quantitative estimation 

of ■ 34S 

Chloroform, dosimetric method of admin- 
istering , 489 

ether narcosis 1226 

Cholangitis 739 

Cholecystitis, phlegmonous 642 

with gangrenous enteritis 1276 



INDEX TO VOLUME XCVIII, 



1285 



Pace. 
Chulclithiasis. diUferential diagnosis of . ... 1 179 

medical treatment of 300 

mi^tnkeii *iiaKnuses of 1239 

Cholera in Europe 637 

infantum, treatment of 475» 525.573 

Cholcsterin stones, origin of 629 

variations of. in blood of hepatic pa< 

tients 247 

Cholesterinemia 1079 

cxtterimcntal arteriosclerosis in 784* 1031 

hypiTtension in connection with 1178 

Chondrodystrophia foetalis, changes in thy- 
roid gland in 345 

Chorea, hereditary 1034 

minor, treatment of 478 

treatment of 238. 7^4 

Chorioepithclioma. fatal case of 1276 

Choroid, angioma of 112S 

Cinematograph in study of embryology and 

tissue growth 393 

Circulation and metabolism, relation be- 
tween 

baths in disturbances of 289 

col!atcraI. in gangrene of foot 249 

direct arterial, vein grafting for main- 
tenance of 147 

disorders of. in relation to alopecia 

areata 932 

greater and lesser, anastomoses between 584 

in arm 100 

gangrene of foot 38 

of brain, disturbances of 47* ^94 

renal, effect of kidney function of occlu- 
sion of 345 

respiration a mechanical aid to 386 

Cirrhosis of liver 295 

diabetes with 1079 

experimental 439 

nonsurgical treatment of 50,294 

of malarial origin 247 

splenomegaly with 788 

Clark, A. Schuyler. Internal causes of 

skin diseases S^i 

Clay, pipe, in gastric diseases 1172 

Ciendening. Logan. Use of the x ray in 
diagnosis of diseases of chest and ab- 
domen 664, 708 

Climate of California, influence of, on tu- 
berculosis 300 

Climatology, place of. in medicine 53, 98 

retrospect and a prospect _. ... 590 

Clinic and laboratorv, reciprocal relations 

of : 538 

Clonus, ankle, wiihoiit disease of central 
nervous system 34^ 

Coal tar products. toxicit_y of 855 

Coagulation of cerebrospinal fluid in tuber- 
culous meningitis 1272 

Cobra venom activation test in mental 

Cocaine records in New York State iai+ 

Cocamism. symptomatology and treatment 

of - 1078 

Coccidioides inimitis found in case of gen- 
eralized infection 1231 

Coccvx. laxitv of fingers an index of mo- 
bility of . .' 786 

Cocks. Herard Hutchison. Indications for 

operating in acute mastoiditis iiio 

Codeine derivative, new. therapeutics of.. 533 

Codeonal. experience with 144 

Codliver oil, administration of, in form of 

jelly 576 

with iron and iodine 1024 

Coffey. \V. B.. Carson. G. R., and Cum- 
mins. W. T. An unusual case of sep- 

ticypvemia 377 

Cohen. Myer Solis. The use of a very- 
minute initial dose in tuberculin 

therapy 268 

Colds, common, bacteriology of 150 

in relation to physics of atmosphere. . . .1231 
Colic, ureteral, with recurring hematuria, 

symptom of cancer u8i 

Colipyelitis, tendency of, to spread 486 

Colitis, ulcerative 540 

Collargol enemas in septic processes 5' 

injections of. into kidneys 291 

Colles's fracture, treatment of 822 

Colliculitis 792 

Collings. Howard Paxton. The resorts we 

visited 1257 

Colloidal minerals, application of principles 

of biochemistry in study of 1134 

palladium hvdroxvdul leptynol 1030 

Colomba ....". 44 

Colon, ascending, and cecum, in lesser sac 

of peritoneum I95 

etiology and significance of membranes 

about 37 

pelvic, caricinoma of. with ovarian tumor 

and appendicitis 733 

reflex contractions of 291 

stasis due to altered position of I45 

Color adaptation 539 

Colostomy apparatus, new 1082 

Colpotomy in puerperal infection 1031 

Coma of cerebellar origin 786 



Page. 
Lumplement content of blood in malignant 

disease J98 

deviation by corpus luteum antigens aoo 

forming reactions with cerebrospinal fluid 

in carcinoma 1030 

Condon. .\. P. Unilateral septic infection 

of liic kidney 279 

Conjunctiva, bulbar, primary lues of.... 46, 736 
flap ui. used to cover wounds of sclera.. 46 

of upper lid. chancre of 1128 

temperature of 45. 735 

Conjunctivitis. Pariaaud'a jBa, 44^ 

^ vernal, treatment of 33^ 

Constipation, chronic, intestinal adhesions 

and angulations in relation to s, 348 

dietetic treatment of 683 

habitual, pathogenesis of 12 

in acute gastrointestinal intoxication 474 

infants, treatment of 624 

nonmeilical treatment of 1233 

operative treatment of 841 

spastic, treatment of iiaa 

surgical 840 

treatment of 379, 724 

Constitution, influence of calcium salts on 290 
Contagions, hospital management of. . .41, 1133 

Contractions, reflex, of colon 291 

Contracture, Dupuytren's 933 

Convergence insufficiency 4^ 736 

Coon. Clarence E. Traumatic periostitis of 

the lumbosacral spine 57© 

Copaiba balsam, exanthema after use of.... 50 

Copper chemotherapy 254 

coin sound, in pleuritis and inflammation 

of lungs 2^ 

colloidal, effects of, upon cancer 736 

influence of, on growth of mouse car- 
cinoma 389 

Cord, umbilical, care of 97 

Cornell, William Burgess. The mental 

symptoms of renal insufficiency 220 

Coronary artery, action of adrenalin on 95 

isolated, action of nitrites and digitalis 

group upon 10S5 

Corpus albicans, bone formation in 1179 

callosum, puncture of i97 

luteum and pregnancy, relation between 95 
antigens, complement deviation by. . . . 200 

Corpuscles, white, resistance of 1128 

Cortical astereognosis :••■■. 442 

lesions, overrcsponse to affective stimuli 

from ■ 439 

Coryza due to chemical irritation 478 

Costales, Alfred. Treatment of threatened 

abortion 773 

Council on Public Health and Instruction 
of American Medical Association, work 

of. in connection with cancer 1089 

Cough in advanced pulmonary tubercu- 
losis ...* 149 

Coughliu. Robert E. The sense of smell 

an aid in diagnosis 121, 942 

Coxa vara 1272 

Coxalgia in childhood 290 

Crampton. C. Ward. Blood ptosis 916 

Crawford. Albert C. and Twombly,^ Mar- 
garet M. The response of veins to 

epinephrin 327 

Crime, causes of 128 

Criminal, place of, in psychiatry 1058 

Cripples, gvmnastics for 1085 

Crises, gastric, treatment of 193 

Crocker. W. J., and Smith. Allen J. The 

action of testicular extract 1 

Crotalin, eosinophilia produced by injec- 
tions of 651 

Cultures, pure, of smallpox germs...... .1127 

tissue, formation of specific agglutinin in 96 
Cummins, W. T.. Coffey. W. B., and Car- 
son, G. R. An unusual case of septi- 
copyemia 377 

Cunningham. William P. Cutis-index 

morbi 4^5 

Vincula pnteritorum 958 

Curette, uterine 52 

Current, high frequency, endovesical and 

endourethral treatment with 785 

in prostatic obstruction 170 

tic doloureux 935 

t'e:iiment of tumors of bladder 148 

urethral caruncle tli5 

Currents, negative, role of, in growth of 

neoplasms 689 

Curtner. M. L. Treatment of threatened 

abortion 77^ 

Cutis-:nd(x morbi 4^5 

Cutter. John Ashburton. Neosalvarsan and 
malaria, with some reflections on sui- 
cide 864 

Cvanosis. permanent congenital 245 

Cymarin in chronic myocarditis 1226 

Cyriax, Edgar K. Mech an o therapeutics of 

acute croupous pneumonia 1205 

Cyst, cortical astereognosis from 442 

mucous, of nasal septum 930 

ovarian, hemorrhage into, following de- 

liverv 739 

thyroglossal, origin of 39 



Pacc. 

Cysititib. cItroniL-, in women 4S, lajt 

treatment of 773 

Cystomata, ovarian, malignant degeneration 

^f , *»• 

Cystophotuijraphy 1*71 

Cystoscope and cvacuator, combined a6s 

Cystoscopy findint'b in enuresis 1077 

topography of bladder with reference to 353 
Cyst^, bilateral ovarian dermoid, with pro- 
longed amenorrhea 10B4 

gas, uf intestines 544 

hvdatid. enucleation of 733 

of bladder 784 

synovial, at wrist, treatment of 713 

ureterovesical 48. 1034 

r\ABN'EY, S. G. Amblyopia due to to* 

'^ bacco smoke 594 

Davison. Robert E. Surgical aspects of 

Graves's disease 1065 

Day, George H, Modified drainage for 

suprapubic prostatectomy 42$ 

Deafness, prevention of 305 

Death, cause of, in intestinal obstruction 983 

prevention of, and resuscitation 160 

sudden, from artificial pneumothorax 687 

Decks, W. E., and Uaetz. W. G. An an. 
alysis of five hundred fatal medical 

cases in the tropics 401, 462 

Defective;,, mental, among the immigrrants 760 

problem of caring for 346 

new tests for detection of 522 

skeletal, influence of. upon the bod3r....ioB3 
Deficiency, mental, inherited syphilis in.. 879 
Deformities, congenital, Wassermann re- 
action in 988 

nasal 585 

correction of 638 

Deformity in infantile paralysis, tendon 

fixation for prevention of 1085 

Degeneration, amyloid, of kidney, in the 

tuberculous 1180 

malignant, of ovarian cystomata 292 

zone, in liver of pregnancy 1227 

Delinquents, juvenile, mental measurement 

of, by Binet-Simon system 175 

Delirium, postcataract extraction 46, 736 

Delivery, artificial, in treatment of uterine 

inertia 152 

followed by hemorrhage into ovarian cyst 739 

in paralysis of back and extremities 97 

Delusion, psychoanalytic 587 

Dementia, epileptic 982 

praecox, case of, with autopsy 109 

Dengue and phlebotomus fever, similar- 
ities existing between 1131 

Densten. J. C, Carbon, oxygen, hydro- 
gen Kroup, plus nitrogen or nonnitro- 

genized and nitrogenized food 376.693 

Depression, manic, laboratory studies of.. 962 
Dercum. F. X, The clinical forms present- 
ed by nervous syphilis 745 

Dermatitis, bullous, cytology of fluids ob- 
tained in 145 

exfoliativa or pellagra 1070 

Dermatology, use of radium in 930 

Dermatoses in relation to diabetes 43 

Dermoid cysts of ovaries with amenorrhea. 10S4 
Development, effects of ductless gland upon 781 

under, obstetric si'-;niticance of 534 

Diabete azoturique of the French 990 

Diabetes, infantile and juvenile 992 

in pregnancy, treatment of 252 

insipidus and the polyurias of hypophy- 
seal origin 55 

mellitus. Bacillus bulgaricus in 70,131 

diet ir 144 

medicinal treatment of 6Si 

sodium and potassium metabolism in. . 1226 

nitrogenuric 975 

(|tiestion of, at international medical 

congress II93 

relation of, to dermatoses 43 

skin complications in 198 

theory and treatment of 990. 1145 

with hepatic cirrhosis 1079 

Diabetic gangrene, amputation for 892 

Diagnosis, sense of smell an aid in 121, 841 

Diaphragm, repair of large defects in 683 

Diarrhea, acute, of infants 937 

causes, types, and treatment of 735 

chronic, dietetic treatment of 143 

cooked green vegetables in treatment of 537 

dietetic treatment of 682 

infantile, saline injections in treatment of 391 
treated bv intestinal implantation of 

Bacillus lactis bulgaricus 240 

summer, on Boston Floating Hospital.... 9^0 

of children X132 

treatment of 90 

Diastase content of feces 832 

Diathermy, temperature of tissues during 

treatment with I181 

therapeutic experiences with 831 

Diathesis, psychasthenic ^4 

Diet and stomach function 99 

fruit, in cardiovascular and renal dis- 
eases 727 



1286 



INDEX TO VOLUME XCVUL 



Page. 

Diet in constipation 682 

^liabctes mcllitus 144 

diseases of iKart ami bloodvessels 484 

gout . 147 

lieatment of diarrhea i43i 632 

liberal, in typhoid fever 230 

meat free, indications for 386 

Dietetics in nephritis, present status of 582 

Digestion, disturbances of. in chikiren.... 973 
end products of, metagastric administra- 
tion of, in cachexia of malnutrition. . 619 
Digestive tract, disturbances of. examina- 
tion of feces for diagnosis of 986 

Digitalis, action of, on blood pressure 686 

btdiLS. elimination ot 50- 191 

emetic action of 50, 580 

group, action of, on isolated coronary 

artery 1085 

D i o X y d i amidoarsenobenzenemonomethane 
sodium sulphonate in syphilis of ner- 
vous system 254 

Diphtheria, active immunization against.. 382 

bacilli, action of antitoxine on 488 

means of distinguishing the true 1178 

carriers, treatment of 988 

treated with culture of staphylococcus 

pyogenes aureus 1082 

diagnosis and treatment of 55 

droplet infection in 102 

epidemiology of 142 

eve coloration in relation to incidence 

antl severity of iJ3'J 

following piercing of ears 73^ 

lactic acid spray for 393 

new prophvlactic remedv for So 

treatment of .' 777. 988 

vaccine, Behring's. report on 1226 

Disease, acute myocardial, treatment of.. 1024 

coincident, in blood relations 945 

high pressure 178 

internal, pain a symptoiji of 143 

radium treatment of 1227 

malignant, complement content of blood 

in 298 

septic, immunization of blood against 1128 

skin, an index of ., 4<Ss 

white spot, anomalous case of +2, 393 

Diseases, congenital, mortality from.' 383 

contagious, hospital management of. .41, 1133 
functional, in relation to pathology of 

stomach 294 

infectious, alcohol in 581 

internal, sweat cure for 386 

thorium x in 784 

mental, in relation to internal secretions 381 
nervous and mental, cerebrospinal fluid in 294 

of children 40 

Porto Rico 735 

school 1021 

self limiting, immunity by scientific bac- 

terization in 229 

touch n>42 

tropical, AnitricRu journal of 191 

Disinfection by formaldehyde 1078 

routine, of schools 615 

Dislocation of cervical vertebrae, spon- 
taneous reaction of 338 

recurrent anterior of ulna 586 

Diuresis, new methods of 581 

Diuretics, action of. in uranium nephritis 541 

classification of 1129 

effect of. in acute nephritis 589 

in cardiovascular disease 49 

heart diseases _ 34' 

value of. in acute nephritis 49 

Doctor, countr>% obstetrical experiences of. 622 

in court 977 

Doses, massive, of x rays 490 

Douglas, John. Surgical indications of cer^ 

tain gastrointestinal symptoms 359 

Drainage^ for suprapubic prostatectomy. . . 425 

ocular 735 

experimental study of 43 

tubes, double, for nares 473 

Dreams following removal of brain fumoi'. 1275 
Dres=;ings, plaster, in treatment of frac- 
tures I i8a 

Drug addiction, treatment of 55 

substitutes and peddlers 1123 

Drugs, quality of, sold to dispensing phy- 
sicians . .' 49.633 

Ductless glands, effect of. upon development 781 
influence of removal of. on growth of 

sarcoma 292 

neuroses of 53' 

relation of, to work of surgeon 1137 

Ductus arteriosus botali. patent 1227 

Duncan. Charles H Thermostabile toxines 

in urethral and bladder infections 58 

Duodenal alimentation in cirrhosis of liver. 205 

instruments, new and improved 751 

Duodenum, bacteriology of 589 

congenital atresia of 343 

intussusception of 890 

normal, technic of speedy intubation of. . y^'i 

physiology of. as observed by x rays 586 

ulcer of 891 

diagnosis and prognosis of 295 



Duodenum, ulcer of. experiences with 538 

in children 732 

posterior gastroenterostomy in 37 

scarlet red in treatment of 298,301 

X ray in diagnosis of 1083 

Dupuytren's contracture, hereditary 933 

Dye workers, bladder tumors in 631 

Dyschezia is 

Dysentery, amebic, emetine in treatment of, 

138, 193. 438, 1086, 1 129 

salvarsan in treatment of 393 

treatment of hepatic abscess in 89 

bacillary, diagnosis and treatment of....ii3i 

treatment of 1130 

in tropics 257,544 

relation of amebae to 1036 

Dysmenorrhea, infantile uterus in 1234 

membranous, endometritis a cause of.... 886 

nasal treatment for relief of 203 

pseudomembranous 1071 

Dyspepsia, chronic, h-^art disturbances in.. 825 
Dyspepsias, sodium citrate in treatment of. 924 
Dyspnea, paroxysmal, m cardiorenal pa- 

ti--nts .' I. -.^9 

Dystocia and the unflexed head 105 

EAR diseases, hot air and iodoform in 
treatment of 56 

middle, chronic suppuration of '-55, '-74 

Ears, piercing of, diphtheria following. ... 731 
East River homes, antituberculosis work in. ^2 
Eclampsia and tetany during pregnancy, re- 
lationship between 535 

diagnosis and treatment of 441 

hypophysin extract in 51 

in relation to tetany during pregnancy.. 535 
mammary toxemia theory of origin of. . . 20! 

prognosis of 689 

puerperal, treatment of 188, 200, 588, 638 

treatment of 188 

recurrent 1127 

treatment of 1078 

Edema, angioneurotic, with purpura and 
urticaria in an infant 148 

EDITORIAL ARTICLES: 
Air, fresh, an eliminator of exanthemata 480 

Alcohol as a therapeutic agent 826 

Alcoholism in Russia 1076 

Ambylopia, toxic, from tobacco 429 

American Journal of Tropical Diseases 

and Preventft'e Medicine 191 

Anemia in malaria, cause of 579 

pernicious, salvarsan in treatment of. .1174 

Anesthesia, important advance in 1073 

Ankylostomiasis, acute, autogenous vac- 
cine in 876 

Appendix of unusual size 781 

Arteriosclerosis, fruit diet in 727 

Balkans and health of the world 925 

Battleships, old. as sanatoria 530 

Bedbug in new role 191 

Bedbugs and leprosy 1028 

Beriberi, etiology and treatment of 1124 

Bichloride tablets, regulating the sale of. 1176 

safeguarding the sale of 1027 

Biggs, Dr. Herman M.. retires from New 

York Department of Health 1173 

Blackwater fever, etiology and treatment 

of 240 

Blood pioisoning. legal aspects of 926 

Body temperature, pharmacology of 878 

Buildings, regulation of height of 626 

Cancer in Canada 189 

inoperable, cauterization in treatment 
of 1266 

radium treatment of 779 

Carcinoma, operations and metastasis in 878 

Cholera in Europe 627 

Cocaine records in New York State 12:11 

College of Surgeons gt 

Conjunctivitis. Parinaud's 382 

Deportation. Bureau of. for Hlinois 529 

Diabetes, nitrogenuric 975 

Diarrhea, summer, treatment of 90 

Diet, fruit, in cardiovascular and renal 

diseases 727 

Diphtheria, active immunization against 382 

Diseases, congenital, mortality from 383 

Doctor in court 977 

Drug substitutes and peddlers 1123 

Ductless glands, neuroses of 531 

Dysentery, amebic, emetine in 138 

East River homes, antituberculosis work 

in 33 

Epilepsv. pathogenesis of 431 

Eruptions, self inflicted 829 

Erysipelas, treatment of 189 

Eugenics, clinical 239 

misdirected 429 

Exanthemata, fresh air an eliminator of 480 
Ev^s in relation to glare 1076 

of school children, care of 1223 

Feebleminded, death rate among 92 

Fever, postoperative, sympathetic aseptic. 1125 
Fly. biting, life cycle of 140 



Page. 

I'Vactures involving knee joint 532 

Friedmann's antituberculin vaccine 92 

Fumigation of vessels for destruction of 

rats 727 

(Hand, ductless, effects of, upon develop- 
ment 781 

(Jlands, ductless, neuroses of 53i 

(llaucoma, vertigo in 383 

( ioitre. medical aspects of 482 

< '.ynecology, one problem in. . i.;66 

Headache, novel procedure for relief of 778 

Heart block, treatment of 975 

in syphilis 877 

Heat exhaustion and heat stroke 285 

Hematuria, essential, treatment of 726 

Hemorrhage, pulmonary, methods of ar- 
resting 1074 

Hippocrates and modern medicine 1125 

Hookworm disease 33 

Immigrants, feebleminded, examination of 828 

Indians. American, medical survey of 285 

Infant mortality, causes of 625 

neglected aspects of 1075 

Insane asylums of Pennsylvania 679 

Insanity among immigrants 35 

Inspection, medical, of infants and chil- 
dren 578 

Intestine, large, reflex contractions of.. 828 
Iodine, intrathoracic injections of, in tu- 
berculosis 480 

Kidneys, production of an internal se- 
cretion by Z3Z 

f-egislation. social reform 1224 

Leprosy and young China 626 

chaulmugra oil in 531 

Life, prolongation of 333 

Malaria, cause of anemia in 579 

etiology of relapse in 93 

Malta fever and goat's milk 780 

Marriage and State laws 628 

Medical inspection of infants and children 578 

Medicine, social aspect of .' 778 

^leningitis. tuberculfus prognosis of . . . . 2S7 

Mental disease, menace of 926 

Mercuric chloride tablets 678 

^lodern hospital 431 

Mosquito extermination, thoroughness in 827 

:Mouth breathing, cure of i3;> 

Xeedles, poisoned, jn medical jurispru- 
dence 1173 

Neosalvarsan. intramuscular injections of. 1268 
Nervous system, syphilis of, intramus- 
cular injections of mercury in treat- 
ment of 35 

Xucleoproteins, truth about 11 75 

Ophthalmology, training for the practice 

of 876 

Paracentesis abdominis, closure of open- 
ing in cases of 1 126 

Pellagra in England 7-7 

natural history of 286 

treated with salvarsan 680 

Pituitary extract in obstetrics, dangers of 529 

gland, relation of. to growth fcs 

Play, sociological, and medical profession 679 
Pregnancv. newer methods for diagnosis 

of ..■. y 677 

positive and early sign of.../. 482 

Prisms, therapeutic use of 577 

Psychoanalytic Review 1224 

Psychology of crowds 1027 

Ptosis, abdominal medical aspect of 334 

Puerperal fever, treatment of 1025 

()uinine and rabies 977 

Rabies, apparent cure of 927 

diagnosis of • 1267 

pathogenic organism of 577 

Radium institute, philanthropic .'... 925 

treatment of cancer 779. 1222 

of myelogenous leucemia 241 

Rats, fumigation of vessels for destruction 

of 727 

where they go to die 780 

Salvarsan in pernicious anemia 1174 

intramuscular injections of 1268 

treatment of syphilis, recurrence and 

reinfection after 878 

Sanitarv results of American occupancy 

of the Philippines 578 

Scorbutus, infantile, early diagnosis of. . 1025 

Scrofula, vicissitudes of 431 

Secretions, internal, mental diseases in re- 
lation to 381 

.Sepsis, oral, dangers of 677 

Smallpox and vaccination 139 

Smoke and health 139 

nuisance and pernicious court decisions 480 

Social reform legislation 1224 

Slokes-.\dams syndrome, treatment of... 9;?; 

S'lbst'tnters. punishment for 928 

Substitutes, drug, and peddlers 1123 

.'syphilis and hypocrisy iqo 

experience of Toronto physicians in sal- 
varsan treatment of 977 

inherited, in congenital mental deficiency 879 

late, Spirochaeta pallida in 1268 

of nervous system, intramuscular injec- 
tions of mercury in treatment of 35 



Pace. 

Syphilis, studies of 5-(j 

Tetanus, treatment of 430 

Thermometer, clinical, accuracy ol 122J 

Thorium x, therapeutic use of. 7^5 

Thvroid gland and chronic rheumatism.. 8a6 

Tobacco a cause of toxic amblyopia 429 

Tonsil operation 140 

Tropical diseases in the United States.. 34 
Tuberculin as a cure of progressive par- 

.alysis 976 

doses, nomenclature of 680 

Tuberculosis, intrathoracic injections of 

iodine in 4go 

work of combating, in East River Homes 33 

Tumors, cardiac, diagnosis of 1 124 

Typhoid fever, autogenous vaccine in.... 482 

epidemics of 780 

etiology of 1074 

in New York City 627 

fly 1026 

Uterus, elastic area in isthmus of, an 

early sign of pregnancy 482 

Vaccine therapy 335 

Venereal diseases in Canada 240 

Vertigo in glaucoma 383 

Wassermann reaction 241 

test, a modified 92 

Water, pure distilled, importance of 725 

Women physicians, interneships for 431 

Kducation. foundation of 457 

Efficiency and health 232 

vasomotor, lest of 916 

Effusion, pericardial, diagnosis of 931 

Ehrmann's palmin tests 637 

Ela. Paul I'. Treatment of threatened 

abortion 675 

Elbow joint, surgical management of in- 



37 



Electrargol in smallpox 

in treatment of rheumatism 534 

Electricity, accidents due to 930 

in treatment of trifacial neuralgia 4SS 

Electrocardiograph, diagnostic value of, be- 
fore g>'necological and obstetrical opera- 



205 



Electrocardiography, origin and scope of. 
Electrocoagulation, temperature of tissues 

during treatment by 1181 

Electroh-eis in rhinophyma 337 

in simple tumors 428 

Electrotherapeutics, value of 587 

Electrotherapy for diminution of abdomi- 
nal fat 731 

Elephantiasis, surgical treatment of 394 

Eliot. Ellsworth. Jr. The legal responsi- 
bility of the surgeon and practitioner 
which the use of the x ray involves 797 

Ellis, C. J. Treatment of burns 282 

Ellis Island m relation to public health 172 

Emaciation and obesity 168 

Embarin. therapeutics of 831 

Embolism, air. prevention of, in intraven- 
ous injections 786 

of anterior coronary artery 433 

pulmonnry, treatment of 331 

Embryology, cinematograph in study of. . 393 
Embryos, effect of lack of oxygen on de- 
velopment of 884 

Emergencies, surgical, interpretation of 

pain in 84 

Emetine, effects of. on abscess of liver.. 983 

in amebic dysentery 138, 193, 438. 1086 

in intestinal hemorrhage 528 

in treatment of amebic lesions 1129 

of hemopty si s 833 

of hemophysis 973 

Emmenagogue oils, action of. on isolated 

uterus 198 

Emotion a factor in production of psycho- 
pathic disorders 883 

increased susceptibility to, in neuras- 
thenia 46. 1034 

Emphysema, pulmonary, Freund's theory 

and operation in 982 

treatment of 137 

Empiricism in dermatological therapeutics 43 
Empusa muscae a carrier of bacteria from 

house fly 1182 

Empyema, aseptic 1228 

pn-ral. ronservati' e opTation for 180 

pulsan-; interlobare 487 

tuberculous, pneumothorax occurring in 245 

Encephalitis, exudative 47 

Endocarditis, acute, following gonorrhea.. 338 

treatment of 248 

experimental, study oC 193 

gynecological or obstetrical operations in 204 

_in children, studv of 24b 

ng membranous dys- 



orrhe 



puerperal, treatment of 77^ 

Endourethral treatment with high frequency 

currents 78s 

Endovesical treatment with high frequency 

currents 785 

Enemas, salvarsan. in tuberculosis 388 

Entamebas. clinical notes of patients in- 
fected with 537 



IXDEX TO rOLL'MIl XCl'IU. 



)--nian)4trba histolytica and Entamoeba tct- 

ragcna, identity of 541 

tctragcna, trophozoites o( 101 

Kntcniis. chronic interstitial g8j 

^angrt-nuus 64J, W7O 

in infants, treatment of 777 

Kntcrocolic infections, etiology, prophy* 

laxis. and treatment of qSv 

llnttrroptosis 741 

intestinnl adhesions and angulations re* 

suiting from 348 

l-'nuclcation under ciliary ganglion anes- 



the 



«>3 



cystoscopy findings in... 

X rays findings in 1077 

Enzymes, actiun of ultraviolet rays on., tga 

Epididymis, tuberculosis of 55 

Epididymitis, gonorrheal. Bier's method in. 1131 

radical operative treatment of 440 

Epididymoorchitis, due to bacillus coli.... 835 
Epididymotomy for treatment of epididy- 
mitis 440 

Epilepsy, Abderhalden's seroreaction in... 1270 

cause of paroxysms in 194 

chloride free treatment of 53 

etiolog>' and ticatment of 53 

gastric and intestinal stasis in 392 

in railway engineers 47, 537 

inheritance of 491 

pathogenesis of 431 

study of. at Kansas State Hospital for 

Epileptics 891 

treatment of 95. 104 

variety of attack in 1197 

Epileptic dementia , 982 

Epinephrin in hemorrhage of kidneys 148 

injections of, producing changes in the 

ovary 832 

reaction in diagnosis of carcinoma 102 

response of veins to 327 

reversible action of. upon bronchioles... 1085 
Epiphysis, lower femoral, separation of... 248 

of metacarpal bone, separation of 148 

Epiphysitis tibialis dissecans traumatica 

adolescentium 682 

Episcleritis 736 

etiology of , 45 

Epistaxis, simple method of arresting. . . . 380 

treatment of 1072 

Epithelioma and rodent ulcer in same pa- 
tient > . . . 196 

Epithelioma, morphealike 202 

of lower lip in a woman 617 

squamous 534 

Epitheliomata, cutaneous, treatment of.... 989 

Ej.itheliolysis against carcinoma 1^32 

Epstein, J. Touch diseases 1042 

Eruption, creeping , 294 

Eruptions due to secondary infection dur- 
ing measles 435 

self inflicted 829 

Erysitjelas, bacterial vaccine in treatment 



of 



1231 



salicylate of iron in 428 

phylacogen treatment of 1231 

treatment of 189. 350, 576, 825 

Erythema nodosum 585 

symptomatic significance of 684 

of scarlet fever and German measles, 

differentiation of 341 

in relation to tuberculous septicemia. .. 1229 
Erythematodes. cyanide of gold and potas- 
sium in treatment of 830 

Erythemia with unusual manifestations. . . 535 

Erythrocytes, reticulated .- • ■ • 3^5 

Erythrocytic resistance, abnormally high.. 291 

Eskimos, hysteroepilepsy among 445 

Eosinophilia produced by hypodermic in- 
jections of crotalin solution 651 

Esophagoplasty, extrathoracic and intra- 
thoracic 38 

Esophagus atresia of. congenital 1233 

cancer of, present status of csophagoscopy 

in 199 

carcinoma of 1031 

inoperable carcinoma of. relation of gas- 
trostomy to 198 

removal of false teeth and plate from.. 243 

Esophoria, apparent 736 

apparent, in relation to convergence in- 
sufficiency 46 

Vs^^enson. S. J. Exopthalmic goitre 80 

Ether and chloroform narcosis 1226 

e.xctssive, result of 154 

in treatment of infections 923 

inhaler. Allis's, improvement in 137 

irrigation with, in ^rforation peritonitis 731 

local use of. in peritonitis 1265 

\' armed, in anesthesia 883 

Ethics and publicity. .1088 

professional, in relation to prophylaxis 

of syphilis 838 

Ethmoid, orbital abscess from infection 

through 119* 

Ethvlhydrocuprin. chemotherapeutic treat- 
ment with 730 

Fucalyotus in pulmonary tuberculosis 98 

Ei'cenics and the public health 602 

antenatal, applications of, in heredity... 932 



1287 



Pace. 
Kiigeiiics in tclatiun to public welfare.... 345 

misdirected 4^ 

Evacuation, gaatric, rapidity of 337 

Kvacuator and cystoscopc, combined j6s 

Exanthema after uk of copaiba bal»am.... 50 

fre&b air an eliminator of 480 

Kxcrclion, uric acid, action of atophan 

and novaiophan ui>on 1085 

Exercise in treatment of orthofttaiic al- 
buminuria 1081 

physical, in open air. a prophylactic 

mcdsure in tuoerculokis SM. 986 

Exertion. venou!» thrombosis of arm lol* 

lowing lojj 

Exhaustion, beat, treatment of 2S5 

Kxtract, hypophyseal, in placenta prsvia..ii79 
of rice politihings, in polyneuritis sal- 

linarum 1276 

ovarian, uses of jja 

pineal gland, in obstetrics 68a 

pituitary, in obstetrics 631 

suprarenal, in hiccough 117a 

testicular, action of 1 

Extracts, gl.vcerin, of gonococcus, in diag- 
nosis of gonorrhea 632 

leucocyte, curative action of, on infective 

processes 633 

of goitre, intravenous injections of 538 

of spinal cord in experimental beriberi. .1085 

Extremities, gangrene of 387 

lower, infantile paralysis affecting 908 

paral>[sis of. delivery in 97 

Extremity, upper, support for, in trau- 
matic cases 786 

Ewing, James. The Cancer Research Hov 

^ P»ti»' .••••. I24t 

Eye, antitetanic scrum in wounds of B82 

coloration in relation to incidence an'l 
severity of diphtheria and scarlet fe\cT.i.-3o 

diseases, differential diagnosis of 817 

drainage of 735 

foreign bodies in 988 

injections of, vaccines in loi 

lime burn of. cacodylate of sodium in 

treatment of 988 

muscles, operations on 1188 

pressure within, experimental study of... 735 

treatment of foreign bodies in 188 

tuberculin in diseases of 45 

Eyeball, burn of 1135 

Eyelid, upper, extirpation of tarsus of 1186 

Eyes, diseases of, lipojodin in 388 

in relation to glare from reflecting sur- 
faces io7< 

injuries to. during Russo-Japanese War. 244 

myopic 736 

diminishing percentage of 45 

of school children, care of 1.J3 

phlyctenular inflammation of 245 

struma a factor in disease of 93J 

teeth in relation to 755 

Eynon, William G. Mental measurement 
of juvenile delinquents by the Binet- 
Simon system ,. 175 

CACE. carcinoma of 1069 

* surgery of 733 

tuberculosis of presence of tubercle 

bacilli in 1227 

unilateral spasm of 724 

Eaculty of Paris in seventeenth century... 115 

Fads, present tendency to follow .'.42. 393 

Fainting, tendency to. due to adrenal insuf- 
ficiency 1 178 

Fallopian tube, carcinoma of 83a 

Family substance and coincident disease in 

blood relations 945 

Farrar. Lillian K. P. Interpretation of 

pain in surgical emergencies 84 

Fascia, free flap of. for fixation of kidney. 683 
Fat, abdominal, electrotherapy for diminu- 
tion of '. 731 

implantation of. in Tenon's capsule 1135 

uses of. in surgery 1187 

Fatigue, nervous, hydrotherapy in 50, 633 

relation of, to localization of lead paral- 
ysis 1185 

Feces, diagnosis of gastrointestinal ulcera- 
tions by studv of 1129 

diastase content of 832 

examination of. in relation to digestive 
disturbances 986 

s*"dy°f ■■.■,:••: 3!>4 

tubercle bacill in jjy: 

Feebleminded, death rate among 93 

immigrants, examination of 828 

in Pennsylvania, legislation in regard to. 641 
school children 491 

Feeding, artificial, etiology of 41. 1274 

of infants, difficulties in 53 

breast, of infants 54 

of infants 182 

rectal, amino acids and sugars in 146 

Feet, gangrene of njg 

weak, treatment of 449 

Femur, fracture of, Steinmann's nail ex- 
tension method in 587 

Fermentation saccharometcr, inexpensive. .1271 



1288 



IXDHX TO VOLUME XCi'IIl. 



Page. 

Ferments in blood, diagnostic significance 

of ; : 193 

proteolytic splitting, organ specihcity of.. 1.^70 

propliylactic, as specifics 783 

Fertility, unusual, of women 535 

Fetus, weight of, in relation to nutrition of 

mother 290 

Fever in tuberculosis, treatment of 824 

postoperative, sympathetic aseptic H2«, 

undulant, serums and vaccines in 1036 

Fibrillation, auricular 202 

Fibroids, uterine, x ray treatment of 201 

Fibroma of cecum 732 

Fibromyomata. uterine, of lower uterine 

segment 740 

Fields. Sterling O. Treatment of threat- 
ened abortion 723 

Finch. S. E. A study of the action of ox- 
ygen, hydrogen dioxide, and ozone gas 

upon the growth of certain bacteria 1066 

Fingers, laxity of, an index of mobility of 

coccyx 786 

Finsen light treatment 54 

Fishberg, Maurice. Nontuberculous apical 

lesions 14 

Percussion of the pulmonary apices 799 

Fisher, Jessie Watson. The rational treat- 
ment of pustular skin diseases 469 

Fissure, anal, treatment of it;2 

Fistula, anal, postoperative treatment of... 102.-^ 

treatment of 641 

operating on, without cutting muscular 

tissue 63S 

rectal, treatment of i54 

ureterovaginal. following hysterectomy.. .iiSt 
Fistulas, pleuropulmonary, due to artificial 

pneumothorax 33^ 

thyroglossal. origin of 39 

vesicovaginal, operative treatment of 1086 

Fitch. William Edward. The theory and 

treatment of diabetes 1145 

Flexor profundus digitorum, tendon of. torn 

from sheath S44 

Fluctuation, three finger 542 

Fluorescence of human lens 5' 

Fluid in cutaneous bulla, cytology of 145 

Fly, house, carrier of bacteria from 1182 

larvre as parasites of man T018 

Food for babies .^ iSr 

nitrogenized and nonnitrogenized 376 

use of ice and other means of preserv- 
ing 687 

Foodstuffs, exchange of. in parabiose rats. 486 

Foot, flat, operation for. . . _. 492 

gangrene of, circulation in 3S 

collateral circulation in 249 

hollow 1133 

lipoma of 793 

verrucose tuberculosis of 337 

Forbes. A. MacKenzie. Surgical treatment 
of nonarticular rheumatoid arthritis of 

the hip 614 

Forbes method of treating lateral curva- 
ture 1085 

Formaldehyde disinfection 1078 

quantitative estimation of 49 

use of. in anal surgery 1122 

Fossa navicularis. urethral carcinoma of.. 630 
Fourth of July injuries, eleventh annual 

summary of 538 

Fowler. Edmund Prince. Report of twen- 
ty-five cases of inflammatory affections 

of the labyrinth 209 

Fracture, Colles's, treatment of 822 

comminuted, of larynx ii33 

compound, of patella 344 

of carpal scaphoid 248 

of forearm, treatment of ._ ■ .1270 

of femur. Steinmann's nail extension 

method in 587 

olecranon, treatment of 344 

pelvis in a child 907 

petrous bone, treatment of 434 

spontaneous, in bone carcinoma T085 

of vesical calculus 1271 

Fractures, external bone clamp versus in- 
ternal bone plate in operative treat- 
ment of 687 

holding of, with absorbable material 934 

involving knee joint 532 

mechanics of 687 

mechanism of production of 37 

near wrist loint. treatment of 822 

of long bones, external bone clamp and 

internal bone plate in treatment of 37 

old. of patella 787 

plaster dressings in treatment of 1180 

spinal _ 1036 

study of union of 1080 

uncomplicated, of tarsal scaphoid 1277 

Francis. Charles F. d'Artois. Oxidation 

in cancer 498 

Frankel. Julius. Reasons for advising no 
delav in operatine in all forms of 

hernia 37^ 

Freezine jioint determinations, new appara- 
tus "for 680 



Page. 

I"'reudian conception of psychoneuroses. . . . 1184 
school, conclusions of 913, 1042 

Kreud's theories, conclusions drawn from.. 913 
criticism of 587 

Freund's theory and operation in pul-- 
monary emphysema 982 

Friedman, Henry M. The criminal's place 
in psychiatry 1058 

Friedmann's antituberculin serum 104 

vaccine 92 

Friedenreich, Irving. Treatment of threat- 
ened abortion , 722 

Frink, H. W. Sexual theories formed in 
early childhood and their roU in psy- 
choneuroses 949 

Frostbite, extensive 1133 

Fruit diet in cardiovascular and renal 
diseases 727 

Fulton, Enoch S. Treatment of chancroids. 1171 

Fumigation of vessels for destruction of 
rats 727 

Inunction test of kidneys 144 

I'unctional disturbances, inhibitory, asso- 
ciated with organic lesions 930 

liiugus of pulmonary origin, sensitization 
of system by 435 

Furuncles, surgical aspects of 590 

Furunculosis of external auditory meatus, 

treatment of 974 

/GALLBLADDER, abdominal conditions in 

^-* relation to disease of 1274 

aplasia of 96 

Gallstone disease, errors in diagnosis and 

prognosis of 845 

(Gallstones, rontgenoscopy in diagnosis of.. 687 

surgery 741 

riallstones, Rontgenoscopy in diagnosis of. 6S7 

rialyl in treatment of syphilis 1129 

(Ganglion, gasserian, operations upon 1039 

removal of bullets from vicinity of.... 930 

tumor of '. 485 

Ciri-grene. diabetic, amputation in 892 

imjiending, arteriovenous anastomosis for 885 

incipient, opium in 1023 

mercurial vaginal 1128 

neurovascular 1035 

of extremities, treatment of 387 

of feet, collateral circulation in 240 

in Balkan War 1128 

study of circulation in 38 

phenol, treatment of 875 

treatment of r88 

Gas cysts of intestines 344 

observations on 836 

Gastric crises, treatment of 193 

diseases, sedative for 971 

disorders, pipe clay in treatment of 1172 

glass bulb, new ^37 

juice, chronic appendicitis in relation to 

hyperacidity of 162, 224 

solubility of lend salts in 249 

tetany 39 

ulcer 891 

perforation of 681 

scarlet red in 298, 301 

Gastrocolic reactions 145 

Gastroenterostomy, method of pyloric clo- 
sure in 1039 

posterior, in perforating ulcer of duod- 
enum 37 

with aid of Jaboulay's button 981 

X ray study of stomach after 890 

Gastrointestinal atony, treatment of 380 

diseases, carmin in diag:nosis of 791 

digestion of lecithin in 289 

severe anemia in 822 

disorders, secretin in 315 

intoxication, acute, with constipation 474 

pi esclerosis 283 

symptoms, surgical indications of 359 

tract, carcinoma of 387 

dangerous tendencies in radiography of 348 

radiographic studies of 886 

rontgenoscopy of 39, 836 

X ray examinations of 341 

ulcerations, diagnosis of, by study of 

feces 1129 

Gastrojejunostomy, posterior, in ulcer of 

stomach and duodenum 197 

principles which determine the use of. ..1040 

Gastroscopy 836 

Gastrostomy, relation of. to inoperable car- 
cinoma of esophagus 19S 

Gauze, subgallate of bism.uth 147 

Gehrung, Edwin W. Pellagra in Maine... 1212 
Gelatin and olive oil in t>T)hoid fever.... 230 
Genital function and stricture of urethra.. 785 

organs, tuberculosis of 49, 1236 

Genitals, female, pseudotuberculous ulcers 

^ 9n 388 

Genitourinary diseases, tuberculin in diag- 
nosis of S37 

mucous membranes, potassium permanga- 
nate a local anesthetic to 250 

surgery for cure of arthritis deformans.. 887 
system, tuberculosis of 197 



Page. 
Germ content of milk, conditions influ- 
encing 42 

Germs, carrying of, into tissues, by the 

knife 337 

Gestation, ectopic, statistics of 492 

Giltner. H, A. Treatment of chancroids. .1220 
Ginsburg, Morris. Treatment of insomnia. 920 
Gland, ductless, efTects of, upon develop- 
ment 781 

Glanduitrin. action of 386 

Glanduovin in treatment of disturbances 

of ovarian secretion 882 

Glands, ductless, in relation to nervous 

diseases 46 

influence of removal of, on growth of 

sarcoma 292 

neuroses of 53* 

relation of, to work of surgeon 1137 

of thoracic cavity, contamination of.... 340 

Glaucoma, modern viewpoints of 43, 735 

new operation for 542 

operative treatment of 839 

vertigo in 383 

Gloster. Harold S. Treatment of insomnia 972 

Glucose in urine, detection of 734 

Glueck, Bernard. The mentally defective 

immigrant 760 

Glycemia. adrenal glands in relation to.... 146 

Glycosuria, nondiabetic 834 

occult , 143 

renal factor in 882 

Glycuronic acid excretion in tetanus 683 

Goitre, exophthalmic 80 

thymin in 1228 

internal treatment of 831 

irradiation of ovaries with x rays in 

treatment of 96 

ligation of thryoid artery in treatment 

of 737 

pathology of 538 

surgical aspects of 1065 

treatment of 284. 47^ 

extracts of, results on blood pressure of 

intravenous injections of 538 

hyperplastic and nonhyperplastic, relation- 
ships of 537 

medical aspects of 482 

question, summing up of 1138 

simple, pathology of 538 

Gold chloride test. Lange's. on cerebro* 

spinal fluid in congenital syphilis 148 

cyanide of, in treatment of lupus vul- 
garis 830 

Goldmark, Josephine. Work of women in 

department stores 134 

Goldstein, Hyman. Treatment of cholera 

infantum 525 

Goldstein, Sam. Double drainage tubes for 
nares after submucous resection of the 

septum 473 

Goltman. Abraham. Treatment of broncho- 
pneumonia in children 1263 

Gonococcus, biological studies of 1228 

complement fixation test 641 

vaccines in diagnosis of gonorrhea 632 

Gonorrhea, complications of 535, 1228 

diagnosis of 632 

followed by endocarditis ' 338 

in female, iodine treatment of 540 

phylacogen 1131 

role of staphylococcus in 541 

sensitized virus vaccination in 1080 

silvtr treatment of 1227 

therapeutic and prophylactic experiments 

in 1228 

vaccine treatment of 731, J228 

Goodhue, E. S. The surgical cure of lep- 
rosy based on a new theory of infec- 
tion 266 

Goodman. .-\. L. Ileocolitis with meningeal 

symptoms 1247 

Goodman, Edward H. Acute dilatation of 

stomach complicating pneumonia 271 

Gout, blood serum of persons suffering 

from 1031 

dietetic treatment of 147 

mesothorium in treatment of 485 

Gouty manifestations, treatment of 676 

Graft, autoplastic ovarian, clinical value of 788 

Grafts, extensive, use of pigskin in 892 

Thiersch, modified technic in application 

of 583 

Granulations in lower part of female 

urethra 479 

Gravida, tuberculous, sanatorium treat- 
ment of 586 

Graves's disease, surgical aspects of 1065 

treatment of 284 

Green. Leo. Vincent's angina 468 

Growth of sarcoma, inhibiting influence of 

spleen upon 433 

of tissues, cinematograph in study of 393 

relation of pituitary gland to 625 

Growths, malignant, with tuberculosis. . . . $37 

effect of. on alkalinity of blood 685 

Guaiacnl chloriodide compound, new 390 

Gumma of iris after use of salvarsan 203 



IXDHX TO rOLUMIi XCI'IIL 



128Q 



tiuinma uf prostate and bladder, salvarsaii 

and oeosalvarsan in treatment of 123J 

Guthrir, J. A. Cancer 1116 

Gwatlimey. James T. Oil-ether anesthesia. iioi 

Gymnastics for crippled children 1085 

Gynecological operations, diagnostic value 

ot c'ecl'oc.irdiogroi*h 'icfor* . J05 

operations, diagnostic value ut electro- 
cardiograph before J05 

in heart disease 20$ 

in presence of endocarditis 304 

patients, diagnosis and treatment of 

syphilis in 557 

Gynecologist, internal secretions in rela- 
tion to lit 

Gynecology, conservatism in 296 

Ivcal and spinal anesthesia in 836 

one problem in 1266 

pathology the basis of 154 

Wassermann reaction in 93J 

HABIT, dietetic, and gastric function... 99 
Hair, premature loss of 1080 

Hallux valgus, operative treatment of 1133 

Hand, infections of 1056 

Handley's method of lymphangioplasty. 344 

Hands, fissured, treatment of H2i 

proieclion of, in pus operations 629 

narrower, Henry R. Secretin in gastro- 
intestinal disorders 315 

Hartel's method of injecting alcohol in 

treatment of neuralgia 987 

Harvard University's expedition to South 

America 1034 

Hay fever, treatment of 7^j 

Ha'ynes. Irving S. Infections of the hand. 1056 
Hays, Harold. Use of pharj-ngoscope by 

the general practitioner 6s4 

Hazen. Charles M. Anterior poliomyelitis. 81 
Head, disproportionate, prolonged parturi- 
tion due XCh disengagement of 350, 49* 

unflexed, with dystocia 105 

Headache caused by lowering of intra- 
cerebral pressure 435 

in children, treatment of 676 

novel procedure for relief of 77^ 

rheumatic 575 

Health and efficiency 232 

education of the public 1088 

effect of correct posture upon 301 

influence of calcium salts on 290 

of school children, how to preserve and 

increase it 1093 

of world, Balkans in relation to 925 

officers, whole time, need of loSi 

public. Ellis Island in relation to 172 

eugenics in relation to 602 

smoke in relation to I39 

Hearing, an instrument for exact record- 
ing of 1016 

Heart, action of strophanthin upon 884 

acute disease of 1024 

affections in childhood 789 

anomalies, nephritic, in scarlet fever. .. .1128 
beats, premature, arising in auriculoven- 

tricular bundle 100 

block 202 

conductivity, disturbances of, in salv^rsan 

treatment of syphilis 1271 

failure in pneumonia, treatment of 1226 

perforation of gastric ulcer into 1274 

treatment of 975 

conservative surgery of 337 

diet in diseases of 484 

disease, congenital, with acute nephritis. 735 

diagnosis of 1037 

diuretics in 34^ 

fruit diet in 7^7 

gynecological operations in 205 

hydrogen ion concentration of urine in 588 

industry in relation to 69 

pregnancy and labor in 205 

disturbances in chronic dyspepsia 8^5 

hydrothorax due to lesions of 343 

involvement in syphilis 251, 877 

isolated, action of strychnine on 430 

lesions complicating scoliosis 10S4 

perfused, action of serum on 1085 

relation of stomach to 834 

sound, second, pseudoreduplication of..-. 833 

tumors, diagnosis of ^'r^ 

wounds *86 

Heartburn in pregnancy, treatment of.... 478 
Heat exhaustion and heat stroke, treat- 
ment of 285 

stroke, character and treatment of 244 

Helenin pharmacological action of 54' 

Hematemesis, treatment of 1221 

Hematoblasts. number of. in morbus macu- 

losus Werlhofi "79 

Hematology 73° 

Hematoma, perirenal IS^ 

Hematoporphyria, theory of 5° 

Hematuria, essential, treatment of 726 

in typhoid patients treated with hexa- 

methylenamine ^84 

recurring, with ureteral colic, a symptom 
of cancer ^^81 



Page. 

IlinialurKi. renal 48 

aticr nephrectomy 1181 

<iLn;iii:;uKc and management of 738 

lUniicht'itu. treattncni of 981 

Utniupii: pupillary reaction, diagnoatic 

value of 45 

liemiplrgia, cerebral, serological tests in.. 1231 

following syphilis 835 

Hemolysin of Itacillus subtilis 194 

Hemolysis, role of spleen in 24S 

Hemoptysis, emetine in treatment of., 833. 973 

pituitarj' extract in treatment of 47y 

Hemoirhage from nonpregnant uterus 537 

gastric lo^u 

in scarlet fevc r 292 

in typhoid fever 397 

internal, control of 49, 294 

intestinal, emetine in 528 

in the tuberculous 633 

of kidneys, epincphrin in treatment of-. 148 

ovarian, in myoma of uterus 1179 

pulmonary, methods of arresting 1074 

Hemorrhagic ilisrasts. treatment of. . . .40, 791 
Hemorrhoids, internal, Ball's operation 

for 639 

operations on, in office practice 250 

Henson, Graham E. A clinical study of 

the leucocytes 861 

Hepatic diseases, variations of cholesterin 

in blood in 247 

Hcpatoptosis, x ray diagnosis of 245 

Heredity, applications of antenatal eu- 
genics in 932 

Hernia, temoral, Lotheissen-Foederl's radi- 
cal operation for 683 

immediate operation in 37^ 

importance of early operation for 319 

inguinal, radical cure of 733 

treatment of 4'. Ji33 

protruding, method for replacing 4?6 

retrograde incarcerated 54- 

umbilical, treatment of 790 

vaginal, method of repair for 1134 

Hernial sac in relation to intestinal inju- 
ries 1036 

Hernias, incisional, methods of closing 741 

Herniotomy, autoplastic thread for use in. 244 
ixerrman. Charles. Acute infectious jaun- 
dice in children 260 

Hess. \V. C. Treatment of threatened 

abortion 673 

Hexal, experience with 48s 

Hexamethylenamine, prevention of post- 
operative tympany by 1172 

surgery 149 

in typhoid fever 584 

internal use of 49. 985 

Hiccough, postoperative, a sign of uremia.. 1 181 

suprarenal extract in treatment of 1172 

treatment of 924 

Hielscher. Helen Hughes. The appendix 

and some of its diseases 373 

Hip, monarticular rheumatoid arthritis of.. 614 

snapping 539 

Hippocrates and modern medicine 1125 

Hirsch. 1. A new biorontgenographic ap- 
paratus 13 

Hirschspruns^'s disease with fecal tumor... 639 
Hirshberg. Leonard Keene. Treatment of 

Histopin in hordeolum and blepharitis 487 

therapeutics of 289 

Hodgkin's disease, bronzing with cutaneous 

tumors in 986 

etiological study of 1082 

treatment of 468 

Hoffman. Frederick L. Cancer mortality of 

Greater New York 1217 

Hoguet. J. P. Spina bifida 1156 

Holladav.' Grav G. Wounds of pericardium 

and ' heart ' 186 

Holloway. H. S. Treatment of chancroids. ij6i 
Holmes. Bayard. The ' family substance 
and the theory of coincident disease in 

blood relations 9^5 

Homosexuality, conception of 47. 34i 

Hookworm disease 33 

in the Middle States 890 

Hordeolum, treatment of. with histopin 487 

Hospital administration, needs of the fu- 
ture in 735 

research, for study of cancer 1241 

Hydrocele, operation for, without wound- 
ing scrotum 250 

Hydrogen dioxide, action of. upon growth 

of bacteria 1066 

ion concentration of urine in heart dis- 
ease 588 

Hydroneohrosis in relation to abnormality 

'of kidney vessels 785 

Hydrophobia, injections of quinine in treat- 
ment of 934 

Hydrophthalmos, histologrical report of two 

cases of 735 

symptomatology and treatment of 44 

Hydrorrhea, nasal 930 

Hydrotherapy in nervous fatigue 50. 633 

in pulmonary tuberculosis 682 



llydruihorax, ntjoLjrdi 

Hygiene of lead indu^ 

of icalp 



3 



xpcri 



oi suKi»r 83J 

H L.ttmcnt fi 479 

H>l.tiiKi.lir> i;,.. in a Iroij 97 

HyperpUsia. production of $8 

studies uf nervous mechani-ni in produc- 
tion of 58 

llypertcnsion and choleslerinemiA, connec- 
tion bet wt en 1 178 

Hypcrthyroidi>ui, injection of boiling water 

in treatment of 38, 196 

ligation in joi 

relation of» to nervous system 1112 

variations in thyroid colloid in 589 

Hypcrthyroidosis, intestinal urigin of 127s 

Hypertrichosis, etiology and treatment of. 313 
Hypophyseal extract in placenta prxvia..ii79 

origin of polyuria 55 

Hypophysin in eclampsia, 5» 

•n low blood pressure 144 

investigations of 831 

Hypophysis, surgery of 340 

tumor of, in acromegaly 47. *94 

transfrontal method of approach in re- 
moval of 98s 

Hyposphyxia, treatment of 488 

Hvpothyroidism. variations in thyroid col- 

' loid m 589 

Hypoiony due to adrenal insufficiency X178 

Hysterectomy, ureterovaginal fistula follow- 
ing 1 181 

with Cesarean section 372 

Hysteroepilepsy among the Eskimos 445 

Hysterotomy, diagnostic 739 

Ice, use of, for preservation of food 687 

Icterus, hematogenous 386 

Ignorance and moronism, differentiation be- 
tween 564 

Ileocecal valve, incompetency of 56 

Heocolitis, etiology of 40. 73s 

' with meningeal "symptoms 1247 

Ileum, terminal, value of x rays in study 

of inflammations of 835 

Heus, mesenteric 634 

postoperative 37 

llioway. H. Chronic appendicitis in its 
relation to hyperacidity of gastric 

juice 162, 224 

ImSecilc with paresis 419 

Imbeciles, adult, test for 1017 

Immigrants, feebleminded, examination of. 828 

mentally defective 760 

Immigration as it affects orthopedic sur- 

gerjr 836 

Immunity by scientific bacterization 229 

in experimental cancer, mechanism of. . .1185 

natural, dependent upon nourishment 143 

Immunization against rabies, use of dessi- 

cated virus in 541 

Implantation of fat in Tenon's capsule 1135 

Impregnation, influence of spermolysins 

and ovariolysins on 392 

Indians. -American, medical sur\*ey of 285 

of Oklahoma, skin diseases among 43 

skin diseases in Z49 

Indican in urine, tests for 814 

Indicanuria 394 

Indigocarmtn. intravenous administration 

of, as a test for renal function 48 

Industrv tn relation to diseases of heart and 

lungs 69 

Inertia, uterine, treatment of 151. 153 

Infants, mortality of, causes of 625 

in hospitals 1077 

increased, in the spring 830 

neglected aspects of 1075 

plans for reduction of 3 

Infantilism with pituitary neoplasm 101 

Infants, acute infections of 385 

atrophy of, principles of treatment in... 297 

difficulties in artificial feeding of 53 

feeding or with undiluted cow*s milk 1134 

Infection, air a vehicle of 970 

Chapin's work on the sources and modes 

of 994 

ethmoid causing orbital abscess 1194 

focal, a cause of chronic arthritis 632 

generalized, coccidioides immitis found 

in 1231 

of lungs from umbilicus 291 

pneumococcus. bacteriemia in 838 

postoperative, of kidney 687 

puerperal, colpotomy in 1031 

treatment of -5^. 635 

sccondarv, during measles, eruptions due 

to 43S 

in pulmonary ttiberculosis 103 

spontaneous, puerperal sepsis due to 833 



1290 



IXDUX TO rOLUME XCl'lU. 



Page. 

Infection. «t tphylo-o^ciis of urinary pa.-sagci 785 

theory of. in leprosy 266 

unilnttral, of kidney 279 

Infections, acute, during infancy 385 

adenoid, origin of 188 

bladder and urethral, thermostabile tox- 



chronic fucal. a cause of arthritis 38 

curative action of leucocyte extracts on.. 633 
enterocolic. etiology, prophylaxis, and 

treatment of 989 

ether in treatment of 923 

latent acute, treatment of 77^ 

local specific therapy of 439 

mouth, constitutional effects of 791 

of bodv cau-iing joint disease 886 

of ' 



of hand 1056 

of prostate, role of, in toxemia 38 

of seminal vesicles, role of. in toxemia.. 36 
pelvic, needs of general practitioner in 

treatment of • 1085 

peridental, in relation to neighboring or- 
gan- 1 187 

specific treatment of * 1133 

sterilized pus for treatment of 632 

symposium on 38 

treat 111 tni of, by means of fixation ab- 



Inhale 



Alii; 



Lith and pharynx, anes 



rther, suggested improve- 



ulou 



137 



Injections in treatment of tube 

joints 887 

intraganglionic. of alcohol in treatment of 

neuralgia 987 

intramuscular or intravenous, of neosal- 

varsan 83, 1268, 1277 

intraspinous in syphilis of central nervous 

svstem 936 

intrathoracic, of iodine in tuberculosis.. 480 

intravenous, in rheumatic fever 870 

of bichloride of mercury in treatment 

of bacteremia 436 

of distilled water in puerperal sepsis... 833 
of magnesium sulphate in puerperal 

streptococcemia 690 

intravenous, of melubrin 1270 

of quinine, in hydrophobia 934 

of salvarsan and neosalvarsan 7^3 

near death from ii34 

of sugar producing hyperglycemia 832 

of toxynon ■ • 881 

prevention of air embolism in 786 

rapid, of saline solution, result of i54 

of alcohol into nerves, effects of 144. ^50 

of boiling water in hyperthyroidism. . .38. 198 
of streptococci, ulcer of stomach produced 

by "84 

oily, of salvarsan 865 

saline, in infantile diarrhea 39i 

subcutaneous, of oxygen in acute psy- 
choses "21 

subdural, of antimeningitic serum 56 

Injurie-;. Fourth of July, eleventh annual 

summary of 538 

Inoculation therapv, observations on looi 

Inoculation-, sterilized cancer 632 

Insane. Abderhalden's dialysis in 1228 

asylums of Pennsylvania 679, 1238 

cutaneous affection in 89 

Insanity among immigrants 35 

condition preceding 47 

manic depressive 1189, 12.34 

lab<^ratory studies of 962 

minimizing of 490 

pathological findings in 47 

prophylaxis of 620 

states preceding 537 

Insomnia, treatment of 380, 871. 920, 972 

Instruments, surgical, preservation of. in 
tropic? ■••- ^24 



y. adrenal, conditions resulting 



aortic, diagnosis of 52 

convergence • - ■ 73^ 



expern 



_ apparent esophoria ... 46 

parathyroid, tetany during 

pregnancv a result of 535 

of left ventricle with syphilitic aortitis 535 

renal, mental svmptoms of 220 

Insufflation method of anesthesia 39 

tubes, intratracheal, technic of insertion 

of 1234 

Insurance companies, education value of 

cancer statistics to ii33 

International Congress on Physical Educa- 
tion in Paris, report of 544 

Intertrigo, phophvlactic and curative treat- 
ment of 237 

Intestinal adhesions 347 

resulting from enteroptosis 348 



Page. 
Intestinal angulations in relation to chronic 

constipation 5 

excitants, pituitary medication as 434 

hemorrhage, emetine in 528 

injuries, concealed, hernial sac in relation 

to 1036 

obstruction, cause of death in 983 

due to pelvic tumor 1163 

occlusions, postnatal, fetal peritoneal folds 

in relation to 39 

Intestinal stasis, chronic 274, 736, 1137 

origin of hyperthyroidosis 1275 

postoperative, intraabdominal use of oil 

in 986 

surgical aspects of 39, S37 

toxemia, treatment of iiai 

Intestine, large, reflex contractions of 828 

work of 1272 

small, sarcoma of 987 

Intestines, adhesions of 347 

dangerous tendencies in radiography of.. 10 

experimental transplantation of 490 

fetal peritoneal folds in relation to post- 
natal occlusions of 537 

gas cysts of 344 

hemorrhage of. in the tuberculous 633 

in infants, radiographic studies of 40 

radiographs of 10 

obscure diseases of 348 

stasis of. in epilepsy 392 

Intoxication, acid 40. 1081 

gastronointestinal, with constipation 474 

Intraocular pressure, experimental study of 43 
Intravesical operative methods in diagnosis 

and treatment 57 

Intussusception, absence of "'sausage shaped 

tumor and "mass per rectum" in 688 

irreducible, resection of colon for 150 

of stomach and duodenum 890 

Iodic acid in treatment of trachoma 637 

Iodine an aid to aseptic vaccination 933 

and iron with codliver oil 1024 

in abdominal surgery, use of 739 

in ophthalmological work 528 

in sterilization of skin 1038 

in typhus fever 1079 

intrathoracic injections of. in tuberculo- 
sis 480 

treatment of gonorrhea in female 540 

Ionization, secondarv rays in connection 

with 883 

Iodoform in aural and nasal diseases 56 

lodostarin, therapeutics of 486 

Ions as therapeutic and climatic factors 582 

Iris, gumma of, after use of salvarsan 203 

persistence of nerve plexus of 1033 

Iron and iodine with codliver oil 1024 

Iron salicylate in erysipelas 428 

Ischias cyphotica 1227 

Itching in jaundice, treatment of 676 

Ivory plates for holding fractures 934 

TABOULAY'S button, use of, in gastroen- 

•^ terostomy 981 

Jackets, corrective, in treatment of lateral 

curvature 1084 

Jackson, J. Allen. An imbecile with pare- 
sis 419 

Laboratory studies of the manic depress- 
ive group 962 

Jackson's membrane, surgery of 891 

Jaundice, acute infectious, in children 260 

epidemic of 1081 

hemolytic, congenital 985 

treatment of itching in 676 

Jaw. ankylosis of 294 

Jejunoileum. primary carcinoma of 982 

Jejunostomy. technic of ; 52 

Jennings. Walter B. The present status of 

serum therapy 420 

Johns Hopkins Hospital, investigation of 

cases of cancer recorded at i\^6 

Joint affection, chronic, autogenous vac- 
cines in 53 

disease due to infections of other parts 

of the body 886 

flail, transplantation of bone for 1082 

knee, disarticulation of 886 

Joints, ankylosed. mobilization of 39 

bony ankylosis of. arthroplasty for 149 

Charcot, symptom of tabes dorsalis 1081 

tuberculous, injection treatment of S87 

tuberculosis of 441. 837 

Jopson. John H. The medical treatment 

of surgical cases 105 1 

Jugular vein, effects of unilateral section of 434 
Junor, Kenneth F. Clinical observations 
on cancer: its treatment and cure by 
chemicals alone 966 

KAHN. L. Miller. Chronic intestinal 
stasis 274 

Kaliski. David, The luetin skin reaction in 

syphilis 24 

Kaplan. D. M. The importance of sero- 
logical analvses in neurology 308. 366 

The quantitative amino nitrogen content 
of syphilitic and nonsyphilitic serums.. 157 



Page. 
Kaplan. D. .\I., and McClelland. J. E. A 
quantitative chemical reaction for the 
control of positive Wasserman reac- 
tions 1012 

Kaufman. Bernard. A new method of di- 
agnosticating masturbation in girls 772 

Kemp. Robert Coleman. Relation of adhe- 
sions and intestinal angulations result- 
ing from enteroptosis to chronic con- 
stipation 5 

Keratitis, due to lime burn 988 

luetic 672 

Keye.s. E. L. Ultimate results of the Chet- 

wood Operation for retention of urine. 645 
Kidney, action of sodium chloride on se- 
cretion of 1129 

amylo'd degeneration of. in tuberculosis. 1180 

diseases, fruit diet in 727 

functional tests in diagnosis of 48 

in relation to climate of San Uiego... 559 

dumb bell 334 

fixation of. with free flap of fascia 683 

floating, operative treatment of 142 

function in inflamm.ation due to corrosive 

sublimate 881 

phenolsulphonephthalein test for, 

sources of error in 881 

movable, treatment of 7^2 

normal, rontgenoscopic study of ^7 

study of 47 

pathological conditions of 48 

postoperative infection of 687 

stones 784 

surgery, experimental 48 

suturing of 344 

symposium on diseases of 47 

syphilitic and parasyphilitic diseases of.. 433 

test, functional, in scarlet fever 836 

functional, in uremia 1186 

tests, functional 144, 687 

tuberculosis of 63.S 

diagnosis of 63.1; 

early diagnosis of so 

in children 1181 

new method of diagnosticating 195 

unilateral septic infection of 279 

vessels, abnormalitv of, in relation to hv- 

dronephrosis ..." '. 785 

Kidneys, function of, effect of occlusion of 

renal circulation on 345 

hemorrhage of. epinephrin in 148 

injections of collargol into 291 

irrigating pelves of. in treatment of pyeli- 
tis 4S6 

phenolsulphonephthalein test for estimat- 
ing activity of 249 

production of an internal secretion by.. 333 

supernumerary 1271 

svmmetrical necrosis of cortex of 984 

wounds of 884 

Kinetic neuroses and psychoses, treatment 

of ." 1160 

Kirby-Smith. J. Lee. Tubercular leprosy 

in a negress 70S 

Klauder. Joseph V. Treatment of burns.. 234 
Klotz. Hermann G. A plea for oily injec- 
tions of salvarsan 865 

Knee, excision of. for tuberculosis 293 

joint, disarticulation of 886 

fractures of , 532 

lesions, diagnosis and treatment of 98,1 

Knopf. S. Adolphus. Discarded battleships 
to be used as sanatoria and open air 

schools 501 

The physical, mental, and moral vigor of 

school children 1093. ^ ^49 

Knox, Howard A. The differentiation be- 
tween moronism and ignorance !;64 

Test for adult imbeciles and six year old 

normals .' 10 1 7 

Two new tests for detection of defectives. ^22 
Konkle. W. B. The eternal medical ver- * 

ity 649 

Kopetzky, Samuel J. Report of twentv-five 
cases of inflammatorv affections of the 

labyrinth 209 

Kordalen, experiences with i22'> 

Kraurosis 534 

Krauss. F. The differential diagnosis of 

some ordinary eye diseases 817 

Kuhlenkampf's anesthesia, influence of. on 

neuralgia of brachial plexus 630 

Kuhn's aspiration mask, substitute for 8c 

K'-mograph and kymatograph 994 

I ABOR, calcium content of blood during -o; 

*-* conditions complicating 693 

followed by ovarian abscess 534 

in heart disease 205 

management of third stage of 527 

operation for appendicitis four days after. 

under spinal anesthesia 296 

nains. induction and augmentation of.... 295 

pituitrin in j86 

rupture of symphysis in 69.? 

T.-tboratory and clinic, reciprocal rela'ions. 538 
w rk in relation to clinical tub-rculosis. 592 



L\Dt.\ TO i OLUME XCi'JU. 



LaLiynntli. inHammaiory atlectiuiis ui J09 

Labyrinthitis, suppurative, ^urgtcat ircat- 

meni i-f 1^75 

Laceration <.>f cervix a cause of salpingitiis. 740 

Lacrymal s'and in surgical anesthesia 97 

Lactation atrophy of uterus 691 

influence of thyroid gland on 890 

Lactic acid spray for diphtheria 393 

LanRc's gv\i\ chloride te*st on cerebrospinal 
fluid m congenital syphilis 148 

goldsul test uT cerebrospinal fluid 47 

Lapar-jtotnit-s intraabdominal complications 



folio 



Laryngectomy for cancer 869 

Laryngitis, tuberculous, relief of pain in. . 332 
treatment of 721 

Laryngoscopy, direct, for removal of for- 
eign bodies from laryn.x 313 

Larynx, changes in. in tuberculosis 1082 

comminuted fracture of 1133 



safely pm removed from, by direct Tar 

yngoscupy 313 

Laxative and stomach tonic, formula for 

combination of 624 

preparation^;, formulas for 137 

Laxity of fingers an index of mobility of 

coccyx 786 

L^ad industries, hygiene of 49. 249 

poisoning, industrial, treatment of 536 

in New York city 586 

salts, solubility of. in gastric juice. .. 249 
Leads, white, solubility of. in human gas- 
tric juice 49 

Lecithin, digestion of. in gastrointestinal 

disease j89 

Lederle. Ernst J. Plans for the reduction 

of infant mortality 3 

Leg. lipoma of 793 

Legislation in regard to saniution 637 

social reform 1224 

Lemon. Ferguson. The use of phosphorus 

in disease*^ of the lungs 320 

Lens, human, fluorescence of 51 

Lenses, spectacle, equivalent values in..X4< 735 
Lepine. R. The question of diabetes at the 
international congress of medicine in 

London 1193 

Leprosy and bedbugs i02i> 

and young China 626 

bacillus 789 

cultivation of 103. 118.^ 

differentiation of. from other acid fast 

bacilli 103 

bscteriological aspects of 1229 

chaulmugra oil in 53' 

clinical aspect of 687. 1229 

congenital malformations in 983 

dermatological aspects of 687 

new theorv of infection in 266 

public health aspects of 6?7 

research work in 392 

surgical care of 266 

tubercular, in a negress 708 

Leptynol. experiences with 193 

Lesions, amebic, treatment of. with eme- 
tine 1129 

chancriform, in syphilitic reinfection. ... 1272 
cortical, overresponse to affective stim- 
uli from 439 

knee, diagnosis and treatment of 985 

nontuberculous apical 14 

of auriculoventricular bundle in relation 

to heart block ^2 

of urinary tract, diagnosis of 1087 

organic, inhibitory functional disturb- 
ance-* associated with 930 

pulmonarv. in chronic pleurisy 103 

surgical, treatment of earlier stages of. 39 687 
vascular, relation of gastric and duodenal 

ulcer to loi 

Leslie. Charles T. Treatment of cholera 

infantum 4/6 

LETTERS TO THE EDITOR: 

Besson. John H. Proper indications for 

the use" of phosphorus 54^ 

Coughlin. Robert E. The sense of smell 

in diagnosis 942 

Dabney. S. G. Amblyopia due to tobac- 
co smoke 594 

Densten. J. C. Carbon, oxygen, hydrogen 

group, plus nitrogen, etc 69.I 

Duncan. Charles H. Thermostabile tox- 
ines in urethral and bladder infections. 58 

Epstein, 7. Touch diseases 1042 

Francis. Charles F. d'Artois. Oxidation 

in cancer 498 

Lubman. M. The aurometer 1190 

Nascher. I. L. Amorphous phosphorus 

in senile arteriosclerosis 1042 

Rambaud. George Gibier. Friedmann's 

antituberculin serum 104 

Roehr. C. G. Proto7oa or ameba of the 

skin 742 

Treatment of recta! fistula 154 

Rose. A. Aurometer 1090 

Bedbug in a new role 35o 

Cerebrospinal meningitis 642 



Page. 

Uosf, .\. ( ur cclion IU4J 

EntcropioMa 741 

hternal medical verily 795 

Kymograph and kymatogrsph 994 

I'odialros 893 

Schaefrr, Theodore \V. Carbon oxygen 

hydrogen group |>lus nitrogen, etc.... 594 
Simpson. F. F. Right sided overtension 
and prolonged Trendelenburg position, 
exce-sivc ether, and rapid intravenous 

saline iniectiun 154 

Solomon. Meyer. Conclusions of Freud- 

^ lan school 1042 

Toney, L. C. The cure of chronic bron- 
chitis 8g4 

Tousey. Sinclair. Radium treatment 942 

Walker. J. T. Ainslce. l>octor Chapin's 

Stturces and Modes of Infection 994 

Wilson. A. M. Treatment of erysipelas. 350 
Woodbury, Frank. Pennsylvania's Insane 

Asylums 1238 

Zangger. Theodore. Sense of smell as an 

aid to diagnosis 841 

Lcucemia. acute 1030 

btu/ol therapy in 1228 

cnmhincil lymphatic and myelogenous. ... 1179 

hemorrhagic myeloid 88i 

radium ireatment of 241 

new. significance of, in independent life 

of its cells 783 

nodulai 33S 

splenocytic 783 

Leucocyte count in meningitis and pneu- 
monia 41 

counts, abnormal, new method of influenc- 

iitg • • 1270 

extracts, curative act'on of. on infective 

processes 633 

Leucocytes, behavior of, in great altitudes. 4fis 

clinical study of 861 

experimental culture of 435 

in syphilis 986 

in tuberculosis, effect of oils upon 989 

role of 245 

Leucocythemia, benzol treatment of 96 

Leucoplakia uteri .'>88 

I.evinson. Frank. Treatment of burns 330 

Life, prolongation of 333 

r^igaments. sacrouterine, anatomy of 791 

I-igation. arterial, in cancer of pelvic or- 
gans 1083 

bilateral, of external carotid 733 

in hyperthyroidism 201 

Light, effect of, on metabolism 289 

Lip. lower, epithelioma of. in a woman 617 

primary sarcoma of 43 

Lipojodin in diseases of optic nerve and 

retina 3S8 

Lipoma, diffused, of foot and leg 793 

Literature. English, physicians in 716 

Liver, abscess of. effects of emetine on. . 98.1 
brain abscess following suppurative pro- 
cesses of 434 

cirrhosis of, duodenal alimentation in... 295 

in diabetes 1079 

malarial origin of 247 

nonsurgical treatment of 50.294 

experimental cirrhosis of 439 

in chronic malaria 1079 

palpation of 52 

rontgenoscopv of 39. 687 

wounds of 88Li 

zon-^ degeneration of, in pregnancy 1227 

Lloyd, Samuel. Wounds 6s 

Longevity and reiuvenescence 61. 545 

T^bsenz. Jacob Munter. .^cute mercury 

poisoning 187 

Lubman, ^L The aurometer 1016. 1190 

Lues, primary, of bulbar coniunctiva. . .46, 736 

Luctin skin reaction in syphilis.... 24 

Lumbar tumor with latent spint bifida... 1078 

Luminal 436 

Lung diseases, influence of smoke on 592 

infection from umbilicus 291 

Lungs, auscultatory determination of path- 
ological changes in 99. 59o 

brain abscess following suppurative pro- 
cesses of 434 

cancer of 9*5 

diseases of, industry in relation to 6g 

inflammation of. significance of copper 

coin sound in 292 

lesions of. in chronic pleurisy 103 

nontubercutous lesions of 14 

nercussion of apices of 799 

tumor of. simulating tuberculosis 1082 

use of phosphorus in diseases of 320 

wounds of. treatment of 96 

Lupus erythematosus, nature, varieties. 

causes and treatment of 436 

vulgaris, cyanide of gold and potassium 

in treatment of 830 

Lymph node, mediastinal, rupture of 40. 886 

nodes, bacterial invasion of blood and 

cerebrospinal fluid by way of 934 

drainincr pelvis, findings in q34 

Lymphangioma circumscriptum 341 

Lymphangioplasty. Handley's method of... 344 



Pack 

l.yinp:i..i.K.'i- -i ■.-....i III nursing women. 117. 
pancrealK 739 

Lymphatic block m treatment of caocer of 
pelvic organ* 10A3 

Lymphocytes in serous cavities 534 

Lyniphocyto»i>i in asthenic:> and neurai- 
thenics 193 

Lymphoma, malignant, brunsing with cu- 
taneous tumor» in 986 

Lymphosarcoma, treatment of 974 

Lyssa investigations, present status of 12>7 

McCLLLI-AND. J. E.. and Kaplan. D. 
M. .\ quantitative chemical reaction 
for the control of po»itive Wassermann 

reaction^ 1012 

McClurc. J. R. Treatment of cholera in- 
fantum 573 

.MacKee. (;corge M.. and Kemer. John. 

External causes of skin diseases 513 

.McMurtrie, Douglas C. Further notes on 

prostitution in japan 7^ 

.MacWhinnie. .\. Morgan. The teeth and 

their relation to the eyes 755 

.Macula, familiar progressive degeneration 

of 683 

Macy. Mary .Sutton. Medical sociology in 

the public schools 1164 

Methods of teaching sex hygiene 856 

Magida. Nathan, .\cromial breathing an 
aid in diagnosis of pulmonary apical 

tuberculosis 1261 

Magnesium sulphate, intravenous injections 

of. in puerperal streptococcemia 690 

.Magnet extraction of foreign body 24S 

Magrudtr. E. P. Infantile paralysis affect- 
ing the lower extremities 908 

Makuen. G. Hudson. The prevention of 

deafness 305 

Malaria, administration of quinine in 1183 

cause of anemia in 579 

chronic. liver in 1079 

clinical study of 55. 247 

eradication of 1 1B6 

etiology of relapse in 93 

larval 1078 

neosalvarsan in treatment of 864 

pernicious, unusual forms of parasite of. 438 

relapses in 790 

spider webs in relation to 54 

Malarial anemia 536 

treatment of 721 

origin of hepatic cirrhosis 247 

Plasmodia, cultivation of 1036 

Malformations, congenital, in leprosy 983 

Malignant disease, complement content of 

blond in 298 

radium in 535 

growths, association of. with tuberculosis 637 

effect of. on alkalinity of blood 685 

tumors, radium treatment of 487 

Malnutri'ion. cachexia of, treatment of... 619 

principles of treatment in 297 

Maloncy, William .L M. A. The cure of 

ataxia 1045 

Malpractice suits, x ray in 797 

Malta fever and goat*s milk 780 

serums and vaccines in r'<036 

Maltose, metagastric administration of. in 

cachexia of malnutrition 619 

Mammals, possibility of regeneration in — 831 
Mammary toxemia a cause of eclampsia. . 201 
Mania, micrococci in blood and cerebro- 
spinal fluid in .1131 

\fanion. R. .T. \cute eastrointestinal in- 
toxication with constipation and a sug- 
gested method of surgical treatment.. 474 
Nfann C. M. Report of a case of retro- 

pharvpgeal abscess in an .-idult 77* 

Maori children, bacteriology' of mouth in. 1273 
Markowitz, Morris. Treatment of insomnia 972 

Marriage and state law 628 

and syphilis 8&* 

Masland, H. C. .Antral empyema t8o 

Mastoid operation, indications for.... 889, iiio 
Afastoiditis. acute, indications for opera- 
tion in ..iiio 

Masturbation in girls, diagnosis of 77= 

Maxson, Edwin S. Carcinoma of the face. 1069 

NIeasles complicating piegnancy. 4^ 

eruptions due to secondary infection 

during 435 

experimental t079 

German, and scarlet fever, differentiation 

of erythema of 34t 

Meat free diet, indications for 386 

Mechanotherapeutics of croupous pneu- 
monia 1305 

Meckel's diverticulum, inflammation of. 

and appendicitis 73- 

Mediastinal lymph node, rupture of, into 

bronchus 40 

Mediastinum tuiror of, simulating tuber- 
culosis '^- 

Medical cases, fatal, in the tropics 401. 462 

inspection of infants and children 578 

of school children *'86 

profession and the sociological play.... 679 



1292 



IXDEX TO VOLUME XCl'II!. 



Pace. 

Medical profession, work of. in India 834 

sociology in public scliools 1164 

treatment of surgrical cases 1051 

verity, the eternal. 649, 795 

Medication, supertcnsive 146 

Medicine, internal, relation of patholog- 
ical physiology to 985 

modern, and Hippocrates 1125 

onomatology of 1184 

preventive, and the family doctor 903 

social aspect of 778 

state control of the practice of 642 

tropical. Harvard's expedition to South 

America for the study of..-; .•io34 

Meiostagniin reaction in diagnosis of carci- 
noma 102 

Melubrin. intravenous injections of 1270 

new experience with. .■•*.•• ^^43 

Membrane, pericolic, etiology and signifi- 
cance of 294 

Membranes about cecum and colon, etiolog>' 

and significance of • 37 

pericecal, anatomical and surgical study 

of 933 

Meningitis acute internal 9S7 

aseptic 4i 

atypical forms of 41 

cerebrospinal 642 

atypical manifestations of 93^ 

in New York 5^4 

with cerebellar manifestations 535 

epidemic, leucocyte count in 41 

prophylaxis of 102 

posterior basic 4i 

satumina 1270 

staphylococcus ■ ■ • ■ 4o 

tuberculous, coagulation of cerebrospinal 

fluid in 1272 

in an infant 1230 

prognosis of 287 

Menorrhagia, x ray treatment of 201 

Menstruation, precocious 41. 49^ 

Mental conditions, internal secretions in 

relation to 587 

deficiencv. congenital, inherited syphilis 

in ...' 879 

disease, cerebrospinal fluid in 294 

cobra venom activation test in 981 

in relation to internal secretions 381 

menace of 926 

metabolism in 783. 1030 

measurement by Binet-Simon system.... 175 

symptoms of renal insufflciency 220 

vigor of school children 1093, 1149 

Mercurial treatment, dangers of, and their 

prevention 1128 

Mercuric chloride tablets 678 

Mercury, bichloride of, in treatment of 

bacteremia 436 

regulating sale of 1176 

dangers of. and their prevention 1128 

poisoning, kidney function in 881 

methods to prevent 678 

Merycism, treatment of. 875 

Mesenteric artery, thrombosis of 251 

ifesentery. neuromatous myoma of 835 

Mesothorium in cancer 830 

in gout and rheumatism 485 

in malignant tumors . 93° 

Metabolism and circulation 19S 

effect of light on 289 

in mental diseases 783. 1030 

nitrogenous, as reflected in urine, in- 
vestigation of 583 

protein, in pregnancy 936 

sodium and potassium, in diabetes mel- 

litus 1226 

Metals, heavy, toxic effect of. after sub- 
cutaneous injection 389 

Metastases, tumor, production and growth 

of 298 

Metatarsalgia*, Morton's 837 

Metrorrhagia, x ray treatment of 201 

Meyer. Karl A. Treatment of muscular 

rheumatism 3' 

Meyer, Willy. Public education in cancer. 597 
Micrococci in blood and cerebrospinal fluid 

in mania 1131 

Micrococcus melitensis, agglutination of. . 583 
Microscope, need of. in treatment of gon- 
orrheal urethritis and prostatitis 28 

Migraine, treatment of 52S 

Mifk. breast, problems regarding 41,1274 

certified 41. 1230 

commission, medical, efficiency of 42 

cow's, undiluted, infant feeding with... 1134 

germ content of 42 

goat's, and Malta fever 780 

immunized, as a prophylactic and cure 

for typhoid and tuberculosis 718 

isolation of typhoid bacillus from 736 

mothers', bacteriolysins in 436 

supply, necessity for thorough control of, 

in combating surgical tuberculosis ^ 

safe municipal, production of 44i 

Miller, Daniel Tucker. Intravenous injec- 
tions of salvaisan and neosalvarsan. . . 713 



Pace. 

Minerals, asbestos, action of 11S2 

colloidal, application of principles of 

biochemistry in study of 1134 

Mininghara, William D. A new apparatus 

for proctoclysis 1022 

Minor. J. C. So called latent syphiliiics, 

or paretics and tabetics 327 

Mirror writing without palsy.... 58 

Mitral stenosis of rheumatic origin 777 

valve, sclerotic involvement of 638 

Mobilization of ankylosed joints 39 

Montague, Helen, and Alexander, Isadore 

Henry. Acute retropharyngeal abscess. 227 
Montgomery. C. E. Treatment of burns.. 328 
Moore, J. Walker. Treatment of chan- 

■ croids 1 117 

Morbidity reports 687 

Moronism and ignorance, differentiation be- 
tween 564 

Morphine combined with general narcosis. 

danger of 630 

Morphinism, symptomatology and treatment 

of ^ 1078 

Morris, H. A.. Chapman. William L.. and 

Simrell, G. W. Surgical aphasia 222 

Mortality, cancer, of New York 1217 

infant, in hospitals 1077 

plans for reduction of 3 

neglected aspects of 1075 

Mosquito extermination, thoroughness in. . 827 
Mother, nutrition of. in relation to weight 

of fetus 290 

Motor paths, false, creation of 125 

Mountain sickne^js 1 183 

ilouth, anesthesia in inflammations of 686 

bacterial vaccines in septic conditions of. 1184 

bacteriology of, in Maori children 1273 

breathing, cure of 138 

infections, constitutional effects of 79t 

possible dangers of 809 

therapeutic value of prophylaxis in rela- 
tion to 516 

Mud baths, influence of, on body tempera- 
ture 385 

Mulford, Henry Jones. The foundation of 

education 457 

Mullan. E. H. Epilepsy ....1197 

Mumps, blood and cerebrospinal fluid in.. 339 
Muscle reflexes, signs of diminution and 

increase of 881 

Muscles, atrophy of, in myopathic diseases. 684 

extraocular, operations on 1188 

ossification in, traumatic origin of 1273 

Mushroom poisoning 882 

treatment of 825 

Mycoses, cutaneous .■■■■-I3 393 

Mj'cosis fungoides following psoriasis. .43. 341 
Myers, Edward E., and Eeattie, William 
J. Value of turtle tuberculin in treat- 
ment of tuberculosis 503, 8ri 

Myiasis or fly larvK as parasites of man..ioiS 
Myocarditis, chronic, with decompensation. 1226 

Myoma, neuromatous, of mesentery 835 

of uterus with ovarian hemorrhage 1179 

Myopathic diseases, muscular atrophy in.. 684 

Myopia, diminishing percentage of 45 

increase of 736 

prevention of. by teachers 4^0 

Myotonia atrophica 444t "84 

NAIL extension method in fracture of 
femur 587 

Narcosis apparatus, value of 1226 

chloroform and ether 1226 

general danger of combining with nar- 
cotics 630 

inhalation, supported by morphine, sco- 
polamine and certain soporifics 1226 

Narcotics, addiction to 55 

Nares double drainage tubes for 473 

Nasal hydrorrhea, postoperative 93o 

septum, deformities of 585 

mucous cyst of 930 

submucous resection of. sutures instead 

of packing after 836 

Nascher, I. L. Amorphous phosphorus in 

senile arteriosclerosis 1042 

Longe\-ity and rejuvenescence 61 

Medical care of the aged 946 

Nasopharyngitis 793 

Nasopharynx, tumor of _ • 839 

Neary. John B. Physicians in English lit- 
erature 716 

Necrosis, acute, of pancreas 73- 

Needles, poisoned, in medical jurispru- 
dence 1173 

Negro, general paralysis in 767 

Nematode, filiform, passed from urethra.. 1276 
Neoplasms, negative currents in growth of. 689 

pituitary, and infantilism 101 

Neosalvarsan, action of 292 

administration of, by enteroclysis 633 

death due to 1277 

effect on blood of repeated injections of- 104 

experience with 687 

fatality from 792 

in gumma of prostate and bladder 1232 

in malaria 864 



Page. 

,\cosalvarsan in outpatient service 95 

in scarlet fever 935 

in syphilis 987 

results of 1185 

injections of 83, 1030 

intramuscular injections of 1268 

intravenous injections of 7*3 

investigations for arsenic after intra- 
venous administration of 586 

personal experience with 394 

poisoning by, treatment of 676 

Nephrectomy, renal hematuria following. .1181 
Nephritis, acute, effect of diuretic drugs in 589 

etiology and treatment of 892 

post mortem findings in 41 

theobromine sodium salicylate in lor 

value of diuretics in 49 

with congenital heart disease 735 

bacteriological examinations of urine in. 1030 

chronic, experimental • 345 

chronic, sugar content of blood in 1270 

classification of, according to functional 

tests 149 

dietetics in - 582 

experimental diuretic drugs in 294 

interstitial, in children 1 130 

overtension of 100 

parer^chymatous, of tuberculous origin... 433 

prognosis of 63^ 

superpermeability in 202 

surgical problem 38 

thyroid treatment of, preliminary to op- 
eration 393 

unil?teral hematogenous 738 

uranium, action of diuretics in SAi 

urinary pepsin in 5' 

Nephrolithotomy, untoward results of 1035 

Ner\e. auditory, intracranial division of, 

for tinnitus 34» 

plexus of iris, persistence of 1033 

roots. X ray treatment of. in neuralgia.. 195 

tissue, process of disintegration of 245 

twelfth dorsal, neuralgia of ...983 

Nerves, diseases of, in relation to pelvic 

diseases 407 

effects of alcohol injections into 144,250 

higher functions of 93i 

precautions to be taken in surgery of... 931 

transplantation of 148 

Nervous affections, syphilitic, intensive 

treatment of 586 

conditions in relation to pelvic diseases. 407 
diseases, analyses of blood serums and 

spinal fluid in 5' 

cerebrospinal fluid in 294 

fatigue, hydrotherapy in 50 

manifestations in pernicious aneniia 47 

symptoms of pelvic disease "93 

system, blood and cerebrospinal fluid ex- 
aminations in diseases of :••••■ 832 

central, syphilis of, intraspinous injec- 
tions in treatment of 93^ 

in pellagra, histopathology of 201 

in relation to multiglandular syndromes 46 

origin and evolution of.. 1167 

relation of hj-pertbyroidism to 11 12 

sympathetic, disorders of 833 

syphilis of, dioxydiamidoarsenobenzene- 
monomethane sodium sulphonate in 

treatment of 254 

Neuhof, Selian. Intravenous injections of 

theobromine sodium salicylate 814 

Neuralgia, brachial. Kuhlenkampfs anes- 
thesia in 630 

of twelfth dorsal nerve 983 

treatment of "22 

trifacial, electric treatment of 488 

injections of alcohol in treatment of 987 

X ray treatment of nerve roots in 195 

Neurasthenia, condition preceding . . _. 47 

increased susceptibility to emotion in. 46, 1034 

lymphocvtosis in 193 

pelvic disorders in relation to 886 

senile, treatment of 974 

states preceding 537 

Neuritis, cauda equina 445 

effect of climatic changes on 59' 

hereditao' optic 933 

peripheral, in Amazon Valley 888 

Neurologv. importance of serological an- 

alvses' in 308. 366 

Neuroma of skin 42.393 

Neuroses, alcoholic, premonitory auras in 46 

kinetic, treatment of 1160 

of children, development and treatment 

of 1035 

of ductless glands 53i 

Neurosis, traumatic, typical case of 14^ 

Neutrophile leucocvtic picture as a guide 

for tuberculins 637 

polvmorphs. basophile patches in proto- 
plasm of 437 

Nitrites, action of. on isolated coronary ar- 
tery - 1085 

Nitrogen and urea in urine, method of 

separating ; 583 

colloidal, in urine «f cancer patients 685 



ixDiix to I 01.1 Ml- xcrui. 



<-i93 



PAGf. 

Nitr.i^cn. rcuiUK'n i.iid phcnolsnlphoncph- 

thuli;iii excretion 9j6 

Nitroglycerin, indications for use of 198 

Nitrous oxide and oxygen anesthesia. . .34, 633 

Normals, six year old. test for 1017 

Nose, correction of deformities of 63S 

diseases of, hot air and iodoform in treat- 
ment of 5fi 

pseudomembranous anginn of 892 

treatment of, for relief of dysmenorrhea 203 
Novatophan, effect of, on uric acid excre- 
tion 1085 

Novifonn, experience with 244 

in laryngology 831 

in rhinology 484. 831 

Nourishment, natural immunity dependent 

upon 143 

Nucleoproteins, truth about 1175 

Nursing, efficiency in 1.75 

Nutrition, injurious eflftct upon, of exces- 
sive starch feeding 40 

of mother in relation to weight of fetus 290 
of school children 1186 

QBESITY and emaciation 16S 

Bealtie. William T., M.D., of Littleton. 

N. H 680 

Corson, Joseph Kirby, M.D.. of Ply- 

niouth Meeting, Pa 242 

Doyle, Gregory, M.D.. of Syracuse. N, Y. 242 
Fitz, Reginald Hebei. M.D. of, Boston 728 
Tacobson, Nathan. M.D., of Syracuse, 

N. Y 628 

Ja^ne. Horace. M.D.. of Philadelphia... 141 
Leon, Alexis Marcy. M.D., of Xew York 928 
Leonard, Charles Lester, M.D., of Phila- 
delphia 628 

Maverick. Augustus. M.D.. of San An- 
tonio. Texas 483 

McBurney. Charles. M.D.. of New York 
Van Riempst. Theodore Schaepkens. 

M.D.. of New York S?o 

Warren, John S.. M.D.. of New York.. 242 

Obsessions in medicine 342 

Obstetrical experiences of a country doctor 622 
operations, diagnostic value of electro- 
cardiograph before 205 

in presence of endocarditis 204 

patients, diagnosis and treatment of syph- 
ilis in 357 

Obstetrics. local and spinal anesthesia in 836 

pineal gland extract in W: 

pituglandol in 830 

pituitary extract in 529, 631, 936, 1129 

pituitrin in 251 

Obstruction, bowel, unusual cases of 740 

intestinal, due to pelvic tumor 1163 

prostatic, high frequency current in 170 

pyloric, x rays in 40 

vesical, relief oi 638 

Occlusion of central artery of retina 245 

of posterior inferior cerebellar artery. 47. 249 
Occlusions, intestinal, fetal peritoneal folds 

in relation to 39 

Ocular diseases, tuberculin in 45 

Oculomotorius. cyclic paresis of 96 

Ogan. M. L. Cerebrospinal meningitis in 

New York 524 

Ogilvy, Charles. Orthopedics in general 

practice .., 449 

Recent progress in orthopedic surgery.. 997 

Oil-ether anesthesia iioi 

intraabdominal use of. in postoperative 

intestinal stasis 986 

Oils, effect of ingestion of. upon leucocytes 

in tuberculosis 989 

Olecranon, fracture of 344 

Olive oil and gelatin in typhoid fever 230 

Omentum, tumor of, with twist of pedicle 342 

Operating room technic 893 

Operations, necessity of consent to 393 

pelvic, method of reducing mortality of 933 

preparation of patient in 893 

prevention of shock in 989 

surgical, acidosis a complication after. .985 

Ophthalmia, metastatic 44. 736 

phlyctenular 736 

etiology of 45 

Ophthalmic questions, three 735 

Ophthalmologists, training of. along the 

line of physiolo^cal optics 43 

Ophthalmology, clinical, physiological op- 
tics the basis for teaching 733 

three problems in 735 

tincture of iodine in 528 

training for the practice of 876 

Opium in incipient gangrene 1023 

action of 1270 

Opsiuria, pathogenesis of 246 

Optics, physiological, basis for teaching 

clinical ophthalmology 735 

need of training ophthalmologists along 

the line of 43 

Optometry 735 

Oral prophylaxis, therapeutic value of 516 

sepsis, dangers of 677. 809 



PACt. 

«'ihi-.n, li>..ii.;,> J. ihc kinetic neuroses 

and p»ycho^c* 1160 

Orbit, foreign bodies in 988 

Orb.ial abscess from infection through 

ethmoid 1194 

tirchitis. acute in children 388 

Wrgaii specificity of certain ferments ij7o 

( >rKan^, independent life of 389 

Ormsby. Robert. Injections of neosalvar- 

san 81 

Or-'va (ever .0^ 

< ►rthopedic surgery as afTected by new im- 

migration 836 

< >rthupcdics in general practice 449 

recent progress in 997 

< irlhoiherapy 301 

( >ssi6cation, traumatic intramuscular 1J73 

Osteitis, fibrous, role of syphilis in etiol- 
ogy of 1083 

(osteoarthropathy, hypertrophic pulmonary, 

etiology of 608, 669 

Osteochondrosis dissecans 1081 

Osteomalacia, acidity of blood in 1179 

( Jsteomyleitis, x ray diagnosis of 201 

Osteoplasty, laws to be observed in 151 

(_)sieosarct)ma, healing process of 50 

X rays in treatment of 490 

Otitis externa, treatment of 875 

Otorrhea, treatment of 238 

Otosclerosis 888 

Ovarian activity, tests of 832 

extract, uses of 332 

graft, autoplastic, clinical value of ^ 

hemorrhage in myoma of uterus 1179 

therapy in pulmonary tuberculosis 675 

tube, new method of anastomosing 1275 

Ovaries, glanduovin in treatment of dis- 
turbances of secretion of 882 

irradiation of, with x rays in treatment 

of exophthalmic goitre 96 

malignant degeneration of cystomata of 292 
Ovariolysins. influence of, on impregna- 
tion 292 

Ovary, abscess of. following labor 534 

changes in. due to injections of epine- 

plirin 832 

hemorrhage into cyst of. following deliv- 
ery .' 739 

( Jvertension, clinical aspects of 791 

nephritic, clinical and experimental 

studies of 100 

right sided 154 

Oxalic acid, decalcifying action of 340 

formation and elimination 95 

Oxidation in cancer 498 

Oxygen, action of. upon growth of bac- 
teria 1066 

effect of lack of, on development of 

chick embryos 884 

subcutaneous injections of, in acute psy- 

< izcna in atrophic rhinitis, treatment of. 735. 888 

paraffin in treatment of 566 

relation of bacillus Perez to 290 

treatment of 824 

vaccine treatment of 1179 

with atrophic rhinitis 888 

Ozone, action of. upon growth of bacteria. 1066 
bactericidal action of 736 

p.MX in laryngeal tuberculosis, relief of 933 

* in relation to sleeplessness 631 

in surgical emergencies, interpretation of 84 
in tuberculous laryngitis, remedy for re- 
lief of 332 

metatarsal 837 

symptom in tuberculosis 631 

of internal disease 143 

Pains, anginal, treatment of 49.250 

labor, induction and augmentation of. . 295 
Palate, soft, functions of, in production 

of voice 1187 

Palefski. I. O. New and improved duo- 
denal instruments 751 

Palladium hydroxydul. colloidal 193 

leptynol, colloidal 1030 

Palpation, special technic in 847 

Pancreas, acute necrosis of 732 

experimental studies of secretion of 630 

Panhysterectomy, abdominal, new method 

of performing 733 

Panniculitis 58.«; 

Paracentesis abdominis, closure of open- 
ing in X126 

Paracodeine. therapeutics of S33 

Paraffin, uses and limitations of, in treat- 
ment of ozena 566 

Paralysis, acute central infectious 81 

arsenical 96 

atvpical infantile 938 

general, asthenic form of 584 

in negro 767 

presence of Spirochaeta pallida in 937 

hvpoglossai nuclei 57 

infantile 783 

affecting lower extremities 908 

atypical cases of 938, 1213 

etiologv of 1031 

spinal ' 81 



Pace. 

Paraly^l^. inlantile, Aurgrry of 985 

icndun fixation fur prevention uf de- 
formity in 1065 

of back and extremities, driivrry in.... 97 
of plumbibm. fatigue a factor in localiu- 

<'wn wf ; 1185 

progretiitive, »alvarsan treatment of 5M 

tuberculin a cure of ^6 

pseudobulbar, presenting bpakiic muve- 

incnis simulating laughter 934 

spasiic. uperativc treatment of 24^. 11&4 

Paralytics, ^piruchetcs in bramb of 1030 

I'arauxyphenylelhylaminc 1031 

Parasite, new human 197 

of malaria, unusual forms of. found at 

endemic hlackwaler fever center 438 

Par.Tsites of man 1018 

I'arasyphilis, pathology of 790 

I'aratyplioid fever 345 

ubsuciatcd with epidemic of typhoid 

f?r" .■•••■•. M9 

epidemic of, in army na? 

Paresis, cyclic, of oculomotorius 96 

general, inhtraspinous treatment of 1235 

prognosis and trcatuieiu of - 46, 791 

prophylaxis of 103 

syphilis infection directly from blood in 934 

in an imbecile. 4,9 

in railway englneer^ 47.537 

syphilitic organism in brain in 57 

Paretics, blood of, infection of rabbits with 

virus of syphilis directly from 47 

brains of. transmission of Treponema pal- 
lidum from 198 

Parinaud's conjunctivitis 382, 442 

Parker. (;. H. The nervous system; its 

origin and evolution 1167 

Parotiditis, interstitial, fatal cases of 390 

Paroxysms in epilepsy and asthma, cause of 194 
Parrott, \V. T. Treatment of insomnia.... 922 
Parturition, prolonged, due to disengage- 
ment of disproportionate head 350, 491 

Patella, compound fracture of 344 

old fractures of 787 

Pathology the basis of gynecology 154 

Paths, false motor 125 

Patterson, Paul M. Intravenous treatment 

of rheumatic fever 870 

Pedersen. Victor Cox. Pus in the urine.. 1141 
Topography of the bladder, with special 

reference to cystoscopy 353 

Pediculosis capitis among school children 656 

Pellagra, etiology of 1202 

histopathology of nervous system in 201 

in England 727 

in Great Britain 338 

in Maine 1212 

intensive study of epidemiology of 588 

intestinal bacteria in 199 

natural history of 286 

or dermatitis exfoliativa 1070 

surgery, the colloids and strong drugs in 

treatment of 21^ 

treated with salvarsan 6S0 

Pelvic disease, conservatism in surgery of.. 738 

in relation to neurasthenia 886 

nervous symptoms of 793 

Pelvic floor. Bergonie technic in treatment 

of ■-. ; 127X 

operations for restoration of 201 

repairing of 793 

restoration of function of 204, 1038 

infections, needs of general practitioner in 

treatment of 1085 

operations, method of reducing mortality 

of 933 

organs, cancer of, arterial ligation in 1083 

relation of inferior vena cava to 4S8 

tumor causing intestinal obstruction 1163 

Pelvis, change in, with atrophy of testicles. 1273 
diseases of, in relation to ner\'ous con- 
ditions 407 

fracture of. in a child 907 

rantgenoscopic study of 687 

Pemphigus foliaceus 42. 198 

Pepsin, urinary, in nephritis 51 

Percussion of pulmonary apices 799 

Pericarditis, chronic adherent 586 

Pericardium, puncture of 931 

repair of 683 

wounds of ,86 

Pericolitis, membranous, symptoms and di- 
agnosis of '. 39 

Peridental infections in relation to neigh- 
boring organs 1187 

Periosteum. preser\'ation of. in bone trans- 
plantation 39 

Periostitis. traumatic, of lumbosaoral 

spine 570 

Peritoneum, cecum and ascending colon in 

le^i'ier sac of 195 

Peritonitis, biliary An 

without perforation of gall ducts vSi 

general, local use of ether in 1265 

perforation, irrigation with ether in 731 

tuberculous, and rhachitis. new sign in 

differential diagnosis of 539 

Perrheunal »86 

Pescav.,s ,?S 



13 14 

Pace. 

IVstilencc, danger of, in war. ......•■•■•• "=' 

Pharmacopoeia, L'. S., proposed ninth de- 
cennial revision of 252 

Pharyngitis, treatment of 87s 

Phar'vngoscopc, use of. by general prac- 

ti'tioner °54 

Pharvnx. anesthesia in inflammations of.... 686 
Phenolsulphonephthalein excretion and ni- 
trogen retention 936 

test tor kidney function =49. °o« 

of kidney in scarlet fever 836 

in uremia •■ ;'""> 

Philippine Islands, sanitary problems ol 543 
Phillips. E. W. Treatment of chancroids. . 1218 
Phillips Wendell C. Report of twenty- 
five cases of inflammatory affections ot 

the labvrinth ^°9 

Phlebitis, acute, treatment of 974 

clinical notes on .•■-.;•■.-•.•• 39° 

Phlebotomus fever and dengue, similarities 

existing between _. . .1131 

Phosphorus, amorphous, in senile arterios- 

sclerosis ^9^ 

and codliver oil in rickets.... 830 

proper indications for use of 540 

use of, in diseases of the lungs 320 

Phylacogen, gonorrhea. i '3i 

Phvlacogen treatment of erysipelas 1231 

Physician, botanic family 52° 

family, and preventive medicine 903 

future of -,-. ■/■•,■•■•• '•'° 

Physicians, dispensing, quality of drugs 

"sold to 49. 633 

in English literature : -.•- 7it> 

Physiology, pathological, in relation to in- 

ternal medicine... gS 

Physostol. therapeutics of o«3 

Piblokto among the Eskimos 445 

Picric acid and camphor in ringworm.... 392 
Pilleus ventriculi. physiology of, 

served by x rays 

Pineal gland extract in obstetrics 
Pisko Edward, Skin diseases i 

children • "'" 

Pituglandol causing rupture of uterus.... 630 

in obstetrics, advantages of 830 

Pituitary body, extract of. m treatment 

of rheumatoid arthritis , 793 

diseases, rontgenographic changes in.... 586 

extract in hemoptysis ---479 

in obstetrics 529. 631, 936, 1129 

in uterine inertia .- ■■.■., ; '51 

gland, clinical studies in irritation of 637 

relation of. to growth 625 

neoplasm in infantilism 'Oi 

preparations as intestinal excitants 434 

tumor, sella decompression in 1034 

Pituitrin in labor 486 

in obstetrics • ^51 

use of followed by rupture of uterus 97 

Pixlcy. Charles. Typhoid fever from un- 
cooked vegetables - 328 

Placenta, miliary tuberculosis of -1104 

prsvia. Cesarean section in treatment of 692 

hypophyseal extract in "79 

supplementary 9^0 

Plague, bubonic, prevention of 103 

treatment of ■ ^93 

Plasma cells in tonsil, significance of... 

Plasmodia, malarial, cultivation of 

Plasmodium vivax. Bass's method of t 

tivating V; ' ' » 

Plate bone, in treatment of fractures 37 

Play, sociological, and medical profession 679 

Pleurisy, chronic, pulmonary lesions in. . 103 

with effusion, artificial pneumothorax in 

treatment of .426 

Pleuritis significance of copper coin sound 

in .;... , 292 

Pneumococci. biological classification of.. 586 
Pneumococcus infection of rabbit, bacte- 



586 



school 



1036 



■ 1079 



Pneumogastric. effects of unilateral section 

of ; , 

Pneumonia, cardiac failure m i- 

cause of death in 

complicated by acute dilatation of stom- 
ach 

complications of 

croupous, mechanotherapeutics m , 

improvements in 1 

leucocyte count in : 

lobar, pneumococcus extracts in 

suggestions regarding 

f-eatment of by specific serums, ,,. ..50, 

with mercury and sulphur internally,, 

Pneumothorax, artificial, sudden death from 

effect of, on lung of opposite side...... 

in treatment of pleurisy with effusion 

of pulmonary tuberculosis 

pleuropulmonarv fistulas due to ,, 

closed, aspiration and over pressure in 
treatment of ■ - 

in pulmonary tuberculosis, treatment of, 

induced ; 

new diagnostic procedure in 

occurring in tuberculous empyema 

partial or complete 



treatment of.. 299 



IS DUX TO rotrME xcriii. 



Page. 

Pneumothorax, tlier.ipeutic 635 

a palliative measure in tuberculosis. 49, 632 

Podall, H. C. Prophylaxis of insanity 620 

Podiatros 893 

Poison protein, in relation to disease 40 

Poisonecf needles in medical jurisprudence. 1173 

Poisoning, acute mercury 187 

anaphylactic 96 

arsenic 96 

blood, legal aspects of 926 

lead, treatment of 53* 

mercury, acute 187 

mushroom 825, 882 

neosalvarsan, treatment of 676 

oil of cedar 492 

salvarsan 385 

turpentine 393 

veronal 9^4 

Polioencephalomyelitis 81 

Poliomyelitis, aborted forms and prepara- 
lytic stage of 58 

anterior 81 

communicability of 104 

epidemics of...... "31 

human earners in too,!; 

research, year's progress in 939 

tendon transplantation in talipes from.. 737 

transmission of, by stable fly 439 

traumatic acute anterior 785 

Polvadenoma "84 

Polyarthritis, acute in syphilis 73i 

Polycythemia in insane patient 278 

Polvglandular syndrome and acromegaly.. 589 
Polymorphs, neutrophile. basophile patches 

in protoplasm of 437 

Polvmyositis. acute 200 

Polyneuritis gall.inarum caused by different 

foodstuffs 888 

intramuscular injections of extracts of 

rice polishings in treatment of 1276 

Polyposis gastrica "84 

Polyurias of hypophyseal origin 55 

Pompholyx. histopathology of 294 

Porto Rico, diseases of 735 

Posture, change of. effect on blood pres- 
sure of toi 

correct, effect ol. upon health 301 

position of stomach in relation to 551 

Potassiomercuric iodide •• 634 

Potassium permanganate a local anesthetic 
to genitourinary mucous membranes., 250 

Potency, rare disturbance of 51, 

Pott's disease, bone plastic and graft oper- 
ations on spine in treatment of 1081 

treatment of 434 

Powers, A. H. Treatment of burns 2S3 

Pregnancy, .\bderhalden's serum diagnosis 

of 194. 243, 250, 436, 583, 635. 1128, 1249 

.Vddison's disease in relation to 630 

blood serum in 783 

calcium content of blood in :94. 205 

complicated by measles J27 

conditions complicating 693 

corpus luteuni in relation to ■ 95 

ectopic, influence of. on blood supply of 

uterus 204 

ectopic, theory of cause of 1275 

following acromegaly 534 

formation of skin striations during. .153, 103S 

heartburn in. treatment of 478 

in heart disease 205 

influence of thyroid gland on, 890 

interruption of. in tuberculosis 
intrauterine, de 

dix in "033 

membranous vaginitis in..._ 251 

newer methods for diagnosis of 677 

occurrence of measles during 427 

pernicious vomiting of 636 

positive and early sign of 482 

protein metabolism in 936 

psychoses of 881, 1037 

repeated extrauterine • • ■ ^94 

serum diagnosis of 56. 440, 583,988 

serology of 6qi 

serotherapy in toxicoses of 881 

tetanv during, a result of experimental 

parathyroid insufficiency 535 

toxicoses of 881 

treatment of diabetes in 252 

zone degeneration in liver of 1227 

twin uterine and tubal combined 105 

value of abdominal measurements in.... 586 

vomiting of -.• • ■ 484 

Pregnant women, tuberculous, sanatorium 

treatment of .■;■•.• 586 

Prejudices and superstitions met with it 

medical school inspection 1008 

Presclerosis, gastrointestinal, treatment of, . 2S3 
Pressure, intraocular, experimental study 

of 43, 735 

Prism phenomenon, Wilbrand hemianoptic, 

45. 736 

Prisms, therapeutic use of 577 

PRIZE ESS.^YS: , ^ 

.\bortion, threatened, treatment of... 673, 



ridual reaction in appen- 



Piir 



773 
treatment of 234, 281,328 



Pace. 
Chancroids, treatment of.. 11 17, 1169, 1218, 1264 
Cholera infantum, treatment of. ,475, 525, 573 

Insomnia, treatment of 871, 920. 972 

Rheumatism, muscular, treatment of. . .30, 87 
Pritchett. J. H. Treatment of threatened 

abortion 674 

Proctoclysis 151 

experimental and clinical study of 37 

new apparatus for ....1022 

Proctology, reminiscences upon the subject 

of 639 

Profeta's law and salvarsan 42, 198 

Prolapse of bladder .:.. 890 

uterine 791, 890 

vaginouterine, treatment of 791 

Prostate, atrophy of 630 

cancer of, radium treatment of 1181 

carcinoma of 785 

effect of tuberculosis of epididymis upon. 55 
gumma of, salvarsan and neosalvarsan in 

treatment of 1232 

infections of, in relation to toxemia,,,. 38 
obstruction of, high frequency current in 170 

pathology 48, 1230 

role of, in general toxemias (132 

stone in 784 

suprapubic operations on, method of ap- 
proach in 1133 

transverse incision in suprapubic opera- 
tions on '. 48 

tuberculosis of 784 

Prostatectomy in the aged 492 

indications for 8S9 

suprapubic, modified drainage for 425 

Prostititis, need of microscope in treatment 

of 28 

role of. in toxemia 

Prostitution in Japan 76 

Protein, absorption of. without digestion .. 1 185 

content of sputum of tuberculous 1227 

metabolism in pregnancy 936 

poison in relation to disease 40 

Protoplasm of neutrophile polymorphs, baso- 
phile patches in 437 

Protozoa or ameba of skin 742 

Pruritus ani, etiology of 640 

pertinax 1082 

treatment of 1072, 1265 

vulva;, treatment of 380 

Pseudodiphtheria bacillus in urinary tract, 

49. 985 
Psoriasis followed by mycosis fungoides, 43. 341 

pathogenesis of 98t 

Psychiatry, Abderhalden's serodiagnosis in, 

193. 1227 

place of criminal in 1058 

serology in 783. 1030 

Psychic changes, body accompaniments of, 127 J 

Psychoanalysis, transference in 446 

Psychoanalytic delusion 587 

Psychogenetic disorders '99 

Psychology of crowds ...1027 

Psychoneuroses, Freudian conception of.. 1184 
of children, development and treatment 

of '035 

sexual theories of children in relation to 949 

Psychosis, manic depressive 1234 

Psychopathic disorders, emotional reactions 

a factor in 883 

Psychoses associated with childbearing. . . . 1037 

kinetic, treatment of .....1160 

subcutaneous injections of oxygen in.,.iiji 

Psychosis, manic depressive 1189 

Psychotherapy in practice 290 

Ptosis, abdominal, medical aspect of 334 

blood, a test of vasomotor efficiency 916 

observations on 836 

problem, surgical aspect of 392 

Publicity and ethics 1088 

Puerperae tuberculous, sanatorium treat- 
ment 'of ■ 586 

Puerperal eclampsia, treatment of — 200.638 

fever, treatment of ■ 'O-^S 

infection, advanced treatment of 56 

colpotomy in '031 

treatment of 635 

thrombophlebitis, treatment of 205, 1037 

Puerperium calcium content of blood dur- 
ing 205 

conditions complicating - ■ ■ 693 

Pulley. W. T. Reflex or protective phe- 
nomena of angina pectoris 9i» 

Pulmotor, infant, in asphyxia neonatorum 153 
Pulse delayed, experimental studies of.. 433 
Pulse's radial, inequality of. in syphilitic 

aortitis 389 

Pupillary phenomenon, vagotonic .. 73' 

Purpura', urticaria and angioneurotic edema 

in an infant '4* 

Pus in urine • "4' 

operations protection of hands in 629- 

sterilized 'for treatment of infections.. 632 
tubes in the male, radiographic obser- 

vations of 45 

Pvelitis in the adult 756- 



LXDILX TO rOLi'MF XCi'IlI. 



Tace. 
I'yelitis, irrigating pelves of kidneys io 

treatment of 480 

Pyemia a cause uf death in skin tuber- 
culosis 20a 

Pyloroplasty 1087 

Pylorus, congenital stenosis of 5S7> 539 

obstruction of, x rays in 40 

physiology of, as observed by x rays.. 586 
rapid method of closure of, in gastro- 
enterostomy 1039 

Pyorrhora alvcolaris, bacteriology of 1201 

Pyrosis, treatment of 875 

QLIMBY. A. .1. Differential diagnosis 
of the appendix by aid of the Rbnt* 

gen ray 697 

Quinine, administration of, in malaria 1183 

effects of. on dogs 541 

in treatment of rabies 977 

injections of. in hydrophobia 934 

treatment of pneumonia, improvements in 299 

DABBITS. Mary Toft the pretended 

*^ breeder of 296 

Rabies, apparent cure of 92> 

control of 100 

cultural studies on virus of 787 

diagnosis of 1267 

effects of desiccation on virus of 541 

pathogenic organism of 577 

quinine in treatment of 977 

Rabinowitz. Meyer A. Treatment of burns 329 

Treatment of muscular rheumatism 87 

Race betterment, social evil in relation to 393 
Radioactive substances, dose and methods 

of application of 881 

Radiographic methods, scope of 887 

Radiographs of obscure stomach and in- 
testinal cases 10 

Radiography of gastrointestinal tract, dan- 
gerous tendencies in 10 

Radiotherapy in treatment of tumors 1086 

Radium, biological action of 1030 

emanations, treatment with 884 

external application of 684 

in cancer 930. 1181. 1222 

in inoperable cancer 391 

in internal medicine 50 

in malignant disease 487. 535 

in skin diseases 42, 198, 930 

institute, philanthropic 925 

:hanges in tissues under influence 



of 



therapeutic use of 930. 1178 

therapy in internal disease 1227 

treatment in cancer. 

930. 1181. 1222, 1275, 1276. 1277 

of disease 942 

of myelogenous leucemia 241 

Radius, curved 1181 

Rambaud. George Gibier. Friedmann's an- 

tituberculin serum 104 

Randolph, B. M. Vaccine treatment of ty- 
phoid fever 453 

Rash, scarlatinoid, from turpentine poi- 

393 



veronal 436 

Rats, fumigation of vessels for destruction 

of 727 

parabiose, exchange of foodstuffs in. . . . 486 

where they go to die 780 

Rays, changes in tissues under influence 

of 289 

secondary, in connection with ionization 885 

ultraviolet, action of. on enzymes 292 

Reaction, chemical, for control of positive 

Wassermann reactions 1012 

hemiopic pupillary 736 

diagnostic value of 45 

luetin skin, in syphilis 24 

Moriz Weisz, for urochromogen 883 

in tuberculosis 1271 

of bloo3 serum in diagnosis of cancer.. 788 
of Salomon and SaxI in diagnosis of car- 
cinoma 936 

Reactions, emotional, a factor in psycho- 
pathic disorders 88.1 

gastrocolic J45 

Rectocele. operation for cure of 204. 1038 

Rectum, deductions based on analysis of 

diseases of 639 

fistula of 154 

Reed. .\lfre(l C. The relation of Ellis Isl- 
and to the public health 172 

Reflex contractions of large intestine 828 

phenomenon, psychogalvanic ...1271 

Reflexes, tendon and muscle, signs of dim- 
inution and increase of 881 

vascular 73* 

Reflexotherapy 828 

Regurgitation, aortic, diastolic pressure in loi 

Reiuvenescence and longevitv 61. $45 

Relapse in malaria, etiologv of 93 

Remer. John, and MacKee. George M. Ex- 
ternal causes of skin diseases 5^3 

Renal calculi 738 

patho]og>* and therapy of 582 

catheter, value of 738 



I'AGt. 

Kriiul ilk»ca?>c and climate of San Uiegu.. 591 

lun^.ional icsik m diagnosis of 4^1 

hematuria 48 

insufficiency, mental >ympluni» in jju 

tuberculosis, early diagno-si* of « 

Research laboratory and the surgeon 37 

Resi>tance. erythrocytic, abnormally high J91 
Resonance, impaired, of thorax, a sign of 

typhoid fever 434 

Kcsorts. European 1257 

Uespiratitm. artificial, resuscitation by ihe 

production of 369 

mechanical aid to circulation 380 

Kespiratur, an appliance for resuscitation 
by producing enforced artificial respira- 
tion 369 

Resuscitation and prevention of death 160 

by production of enforced artificial res- 
piration 369 

Ketma. lipojodin in diseases of 388 

occlusion of central artery of ^45 

sclerotomy in detachment of 683 

Retractors, spring, in suppurative processes 487 
Uctroflexion, partial, of pregnant uterus.. 583 

Retropharyngeal abscess, acute 227 

Reynolds, R. \V. Treatment of chancroids. 1169 

Rhachms 682 

and tuberculous peritonitis, differential 

diagnosis of 539 

Rheumatic fever, intravenous treatment of 870 
Rheumatism, acute articular, treatment of 238 

anemia, treatment of 1031 

articular, treatment of, with electrargol 534 

chronic, genitourinary surgery 887 

thyroid gland in relation to 826 

eft'ect of climatic changes on 591 

mesothorium in treatment of 485 

muscular, treatment of 30, 87,284 

Rhinitis, atrophic, with ozena 735, 888 

Khinometry, clinical 833 

Rhinophyma. electrolytic treatment of 337 

Rhinoscleroma. treatment of 734 

Rice polishings. extract of. in treatment of 

polyneuritis galHnarum 1276 

Rickets, phosphorus and codliver oil in 

treatment of 830 

Riddell. William Renwick. The botanic 

family physician 520 

Ringworm, picric acid and camphor in 392 

X rays m treatment of 834 

Risser, .Arthur S. Treatment of insomnia 871 
Roberts, Stewart R. High pressure disease 178 
Robinson. Daisy Orleman. Hygiene of the 

skin 507 

Roe, John O. Orbital abscess from infec- 
tion through ethmoid 1194 

Roehr. C. G. Immunity by scientific bac- 
lerization versus natural immunization 
in selflimiting diseases of bacterial 

origin 229 

Protozoa or ameba of the skin 742 

Treatment of rectal fistula 154 

Rontgenograms of pulmonary tuberculosis. .1128 
Rontgenoscopy of gastrointestinal tract, 

technic of 39 

of liver and biliary passages -39.687 

Rontgenotherapy in measured massive 

doses ; 490 

Rose. A. Aurometei 1090 

Bedbug in a new role 350 

Cerebrospinal meningitis 642 

Correction 1042 

Enteroptosis 74i 

Eternal medical verily 795 

Kvmograph and kvmatograph 994 

Podiatoros 893 

Rosenberg. Julius. The value of immunized 
milk as a prophylactic and cure for ty- 
phoid and tuberculosis infection 718 

Rosenberger. Randle C. Oral sepsis and 

its possible dangers 809 

Rosenbloom, Jacob. Testing urine for in- 

dican 814 

Roseola infantum 41. 886 

Roussel. Albert E. Pulmonarj- syphilis. . 600 
Rubenstone, .Abraham I. Cerebrospinal 
fluid and its diagnostic significance 1210 

SALPINGITIS, laceration of cervix a 
cause of 740 

tuberculous, diagnosis of. 787 

Saccharometer, fermentative, inexpensive. . 1271 
Salpingooophoritis, medical treatment of..i07i 
Salvarsan. administration of. by cntero- 

clysis ■ ; 633 

and neosalvarsan in syphilis, a compara- 
tive study 987 

arsenic in viscera after injections of 1032 

dose of .433 

effect on blood of repeated injections of 194 

enemas of. in tuberculosis 388 

experience with 687, 1033 

bv Toronto physicians 977 

gumma of iris after use of 203 

in gumma of prostate and bladder 1232 

in pernicious anemia 1174 

in relation to Profeta's law 42. 198 

in syphilis, results of 1185 



Pack. 
<alvarkan m treatmeai ul ftmcbic dy^cDtery jga 

of pclliagra 6B0 

mjcctionii of 1090 

intramuscular injection^ ' ij68 

intravrnou* injections -i 713 

near death from .- 1134 

oily incclion- ol .. his 

one injrction of. resulting m ap|»arent 

cure of syphilik 7* 



pui* 



elap. 



ling 



clinical iind laboraioiy 49 

ircaimcni of i>rui{rc»»ivr paralyti, jjj 

• •( syphilis, tiisturhancci o( heart con- 

Juctjviiy ill ii7i 

recurrence an.l rrinfccliun alter 878 

icrsii-. I'rofcla'^ law 198 

San Dirgo. climate of. in relation to renal 

• lisease 559. »• 

Sanitation in China 437 

in the Philippines 543.578 

legislaliun in regard to 637 

value of. as applied to large corporations 791 
Sarcoma, growth of. inhibitini{ influence of 

spleen upon 433 

hereditary transmission of 1032 

influence' iif removal of ductless glands on 

growth of »tt 

of small intestine 9B7 

primary, of lower lip 43 

Sarcomata of tendon sheaths 246 

Scadion. Samuel .1. Measles complicating 

pregnancy 4^7 

Scalp, hygiene of logo 

seborrhea of i— t 

Scaphoid, tarsal, uncomplicated fractures of. 1J77 
Scarlet fever and fierman measles, differ- 
entiation of erythmea in 34t 

eye coloration in relation to incidence 

and s»d\-erity of X230 

functional test of 836 

hemorrhages in 292 

neosalvarsan in 935 

nephritic heart anomalies in liaS 

reappearance of 1077 

Scarlet red in gastric and duodenal ulcer, 

^ 301 

Scars, treatment of t03,T 

Schaefer Theodore \V. Carbon, oxygen. 

hvdrogen group plus nitrogen, etc 594 

Schell, .1. Thompson. Diagnosis of acute 

abdominal conditions tl07 

Schmidt. .\dolp'ii. Severe anemia in gas- 
trointestinal diseases 822 

School children, care of. at Moorfields..ii36 



of 



■—3 



feebleminded 491 

medical inspection and nutrition of.. 1 186 
mental, moral, and physical vigor of, 

1093. I '49 

skin diseases in 816 

diseases, expectant 1021 

disinfection, routine 615 

inspection, medical, superstitions and 

prejudices met with in too8 

.School', onen air. discarded battleships to 

be used as Sot 

public, medical sociology in 1164 

Schwait. H. Induced pneumothorax 8.w 

Sciatica, treatment of 297 

Sclera, wounds of ...46, 736 

Sclerokeratitis. experimental production of 636 
Sclerosis, disseminated, transmission of....gs5 

pathology- of 51 

multiple, symptomatology of 47- 440 

treated for incontinence 445 

Sclerotic involvement of mitral valve 638 

Sclerotomia cruciata multiplex, experiences 



ith 



54* 



Sclerotomy, grill-like 

in retinal detachment 683 

Scoliosis, fixed types of, complicated by 

visceral derangements lt*4 

Forbes method of treating >o8s 

history of '<»4 

modification of Abbott's method of treat- 

ing '^ 

prognosis in '™t 

i-otation treatment of i^ 

structural, corrective jackets in treat- 
ment of 1084 

Scorbutus infantile, early diagnosis of 1025 

Scrofula, vicissitudes of .43" 

Scrotum, operations for varicocele and hy- 
drocele without injury to 250 

Seasickness, treatment of 'J'4 

visceral and nervous forms of ejo 

Seborrhea sicca, treatment of 32 

scalp, treatment of 1221 

Secale, lenosin a remedy to replace 629 

Secalvsatum theraoeulics of . 082 

Secretin in gastrointestinal disorders 315 

Secretion, gastric origin of inorganic chlo- 
ride in 54 

internal obstetric observations on 200 

production of. by kidneys 333 

of pancreas and stomach, experimental 
studies of *3o 



1296 



INDEX TO VOLUME XCVIU. 



Pace. 
Secretion, renal, action of sodium chloride 

on ii^i) 

Secretions, internal, as they concern the 

gynecologist Hi 

mental diseases in relation to 381, 587 

Section, unilateral, of internal jugular and 

pneumogastric 434 

Sedative for gastric disturbances 971 

Sedobrol. a new bromide preparation 244 

Sella decompression in pituitary tumor.. 1034 

Seminal duct, radiography of 1133 

Sense of smell an aid to diagnosis 121, 841 

Sensitization of system by fungus of pul- 
monary origin 435 

Sepsis, collargol enemas in 51 

general, following peritonsillar abscess. . 9S9 

oral, dangers of 677, 809 

puerperal, due to spontaneous infection 833 
intravenous injections of distilled water 

in treatment of 833 

Septic conditions of oral cavity, bacterial 

vaccines in 1184 

disease, immunization of blood against.. 1128 

Septicemia, tetragenous 98 

tuberculous, in relation to erythema no- 
dosum 1229 

Septicopyemia, an unusual case of 377 

Septum, nasal, deformities of 585 

submucous resection of, drainage tube for 

nares after 473 

Serodiagnosis. Abderhalden's, of pregnancy. 1249 

of cancer 1249 

Serological analyses in neurology 308,366 

Serology in psychiatry 783, 1030 

Serum, action of. on perfused heart of rab- 
bit 1085 

antiraeningitic, subdural injection of. ... 56 

antistreptococcic 50, 537 

blood, analysis of. in nervous diseases 51 
reaction of, in diagnosis of cancer... 7S8 

diagnosis, Abderhalden's, of epilepsy 1270 

in psy-chiatry 193 

of pregnancy 56, 988 

test of preg:nancv. Abderhalden's. .56, 194. 

243. 250. 436. 583, 635. 1 123 

therapy, present status of 420 

tests in cerebral hemiplegia 1231 

Serums, amino nitrogen content of 157 

federal control over manufacture of 537 

in undulant fever 1036 

specific, in pneumonia 50, 537 

Servian-Bulgarian War. surgical experiences 

during 905 

Sever. James Warren. The position of the 
stomach in children in relation to pos- 
ture 551 

Sex hygiene, methods of teaching 856 

Sexual infantile 587 

periodicity in the male 149 

theories in childhood and their role in 

psychoneuroses 949 

Shalet, "Louis. Management of pulmonary 

tuberculosis 423 

Sharp. J. Clarence. Report of twenty-five 
cases of inflammatory* affections of the 

labyrinth 209 

Shaw, John H. Treatment of muscular 

rheumatism 30 

Shock > . . 1230 

in operations, method of preventing 989 

sodium bicarbonate and allied salts in., 587 
surgical, and anoci association, kinetic 

theory of 297 

Shoemaker, Hsrlan. Pellagra: surgery, the 

colloids, and strong drugs 214 

Showers, cylinder, significance of 572 

Sidoroscope, detection of foreign bodies by 

means of 245 

Sigler. C. L. Obstetrical experiences of a 

country doctor 622 

Sigmoid, extensive incision of 490 

Sigmoiditis, perforating 889 

Simpson, F. F. Right sided overtension 
and prolonged Trendelenburg position, 
excessive ether, and rapid intravenous 

saline injection 154 

Simrell, C. W.. Chapman. William L.. and 

Morris. H. A. Surgical aphasia 222 

Singer. Gustav. Torpor recti; dyschezia. . 12 
Sinuses, accessory operative treatment of.. 1274 

nasal accessory, development of 593 

Skeletal defects, influence of 1083 

Skillem. Penn G.. Jr. Fracture of the pel- 
vis in a child 907 

Skin, bronzing of. in malignant lymphoma 98(S 

complications in diabetes 198 

diseases amone Indians 43,249 

empiricism in therapeutics of 43 

external causes of 513 

in insane, prevention of 89 

in schon! children 816 

indications from urine in treatment of.1133 

internal, causes of 511 

massive dose of x rays in treatment of 42 

of children 43. 249 

pustular, rational treatment of 469 

radium in 42. 198 

efHorescences. primary, metamorphoses of 830 
grafting, tunnel and caterpillar 392 



Page. 

Skin grafts, free air trc:itment of 1230 

hygiene of 507 

idiopathic atrophy of 43, 393 

index of disease 465 

neuromas of 42 

pig. in extensive grafts 892 

protozoa or ameba of 742 

reaction, luetin. in syphilis 24 

sterilization of. with iodine 1038 

striations, formation of, during pregnancy, 

153. 1038 

surfaces, denuded, treatment of 624 

tertiary syphilis of 203 

tuberculosis, causing death from pyemia.. 202 

presence of tubercle bacilli in 1227 

tumors of, in malignant lymphoma 986 

Skull, fracture of, treatment of 434 

Sleeping sickness and big game 98 

Sleeplessness in relation to pain 631 

-Slutier-tJallenger method for removing the 

tonsil 840 

Smallpox, electrargol in 885 

germs, pure cultures of 1127 

influence of vaccination upon 139 

Smell, sense of, in diagnosis 121, 841.942 

Smith, Allen J., and Crocker, W. J. The 

action of testicular extract 1 

Smith, Harmon. Safety pin removed from 

larynx of child by direct laryngoscopy 313 
Smithie, Frank. Treatment of cachexia of 

malnutrition 619 

Smoke and health 139 

influence of, on lung affections 592 

nuisance and pernicious court decisions 480 

tobacco, amblyopia due to 594 

Sobel, -Jacob. Pediculosis capitis among 

school children 656 

Prejudices and superstitions met with in 

medical school inspection 1008 

Social evil, social and medical aspects of 393 
service work at State Tuberculosis Dis- 
pensary, Philadelphia 594 

SOCIETIES. PROCEEDINGS OF: 
American Association of Obstetricians 

and Gynecologists 690, 738 

American Climatological Association 590 

-American Gynecological Society 151, 203 

American Medical Association 37 

American Proctological Society 63S 

American Therapeutic Society 252. 299, 349 

Canadian Medical Association 395 

Clinical Congress of Surgeons of North 

America 1039, 1086, 1135. 1187 

College of Physicians of Philadelphia.... 593 

Eastern Medical Society 1277 

International Congress of Medicine 493 

Medical Association of the Greater City 

of New York 105. 347, 543. 990 

Medical Association of the Southwest, 

838, 890 

Xew York Academy of Medicine 938 

New York Neurological Society.442, 1189, 1234 

Philadelphia County Medical Society. .641, 793 

Sociological play and medical profession.. 679 

Sociology, medical, in public schools 1164 

Sodium bicarbonate and allied salts in 

shock 587 

salicylate, natural and synthetic, clinical 

effects of 341 

Solomon, Meyer. Review of conclusions 

drawn from the Freudian school. .913. 1042 
Soresi. A. L. Prevention of death and re- 
suscitation 160 

Spangler. Ralph H. Eosinophilia produced 
by hypodermic injections of crotalin 

solution 651 

Spas, great European 1257 

Spasm, arterial 391 

idiopathic unilateral facial 724 

Spasmophilia, with reference to familial 

reactions and repeated absences 41 

Specifics in treatment of tuberculosis 440 

prophylactic ferments as 783 

Spectacle lenses, equivalent values in 44 

Speech, correction of impediments of, in 

public schools 98.!; 

Sperma. absorbed, in female organism.. 1178 
Spermolysins. influence of, on impregna- 
tion 292 

Sphincteric atrophy 639 

Sphygmomanometer in' diagnosis of aortic 

insufficiency 52 

new 491 

pocket clinical 219 

Spicer, Frank W. Treatment of cholera 

infantum 527 

Spider webs in relation to malaria 54 

Spina bifida 1156 

false 246 

latent, with lumbar tumor 1078 

Spinal anesthesia, dangers and disadvan- 
tages of 349 

in operation for appendicitis 296 

cord, extracts of, in experimental beriberi. 1085 

tumor of ii8q 

X rays in diseases of 436 

fluid, analyses of. in neurologry 51 

in syphilis, study of 42, 586 



Pace. 

Spine, apparatus for support of 489 

fractures of 1036 

graft operations on. for cure of Pott's 

disease xo8x 

lateral curvature of 1084 

Forbes method of treating 1085 

lumbosacral, traumatic periostitis of 570 

normal, position of, in relation to lat- 
eral curvature 1084 

tumors of 982 

Spirochxta pallida in late syphilis 1268 

presence of, in general paralysis, and 

tabes dorsalis 937 

Spirochetes in brain of paralytics 1030 

new, found in human blood 98 

resistance of. to combined treatment of 

syphilis 930 

Splanchnoptosis, treatment of 301 

Spleen, congestion of 1178 

inhibiting influence of, upon growth of 

sarcoma 433 

pathology of function of 730 

role of. in hemolysis 245 

wounds of 884 

Splenectomy, clinical observations on 199 

for splenomegaly with hepatic cirrhosis 788 

Splenomegaly 730 

hemolytic 245 

with hepatic cirrhosis 788 

Spondylotherapy 589 

Sporotrichosis, primary pharj-ngeal 684 

pulmonary, simulating tuberculosis 882 

Sprue in Porto Rico 888 

Spurgin. W. H. Acute pellagra or derma- 
titis exfoliativa 1070 

Sputum, albumin reaction in 386,437 

of tuberculosis, protein content of 1227 

Squier. T. Bentley. The modern diagnosis 
and treatment of gynecological and ob- 
stetrical patients with syphilis 357 

Stalberg. Samuel. Treatment of cholera 

infantum 574 

Standardization, physiological 254 

Stanton. E. MacD. A combined cystoscope 

and evacuator 265 

Staphylococcus inTection of urinary pass- 
ages 78s 

pyogenes aureus, cultures of, in treat- 
ment of diphtheria carriers 1082 

role of. in gonorrhea 541 

spray, tonsillitis following use of 393 

Starch, injuries produced by 791 

nutritional injuries produced by 40 

Stasis due to colonic displacement 145 

gastric, in epilepsy 392 

intestinal 736 

chronic 274. 1137 

in epilepsy 392 

intraabdominal use of oil in 9X6 

surgical aspects of 39, 537 

Status thymolymphaticus 40 

Steiner. Saul. The treatment of chronic 

urethritis 867 

Steinmann's nail extension method in frac- 
ture of femur 587 

Stenosis, congenital, of pylorus 537, 539 

mitral, of rheumatic origin 777 

ureterpl 785 

Sterility of women 836 

dilatation of Fallopian tubes in treatment 

of 338 

treatment of. by glass or silver stems.. 1084 

by intrauterine stems 296 

Sterilization destined to be a social menace. 1035 

of skin, use of iodine in 1038 

of tuberculous women 1179 

Sterling. Alexander. Supplementary or ac- 
cessory placenta 920 

Stevens. A. Raymond. The value of cau- 
terization by the high frequency cur- 
rent in prostatic obstruction 170 

Stillbirths, a study of 413 

Stimuli, affective, from cortical lesions, 

overresponse to 439 

Stokes-Adams syndrome, treatment of 975 

Stomach, acute dilatation of 347,681 

complicating pneumonia 271 

during operation 1130 

cancer of. operative treatment of 490 

significance of ulcer in regard to 1082 

carcinoma of, early diagnosis of 930 

with tuberculosis 100 

dangerous tendencies in radiography of.. 10 
differences in rapidity of evacuation of. . 337 

diseases of 398 

disorders, atropine in 89 

excitation of. causing reflex contractions 

of colon 291 

function of. in relation to diet 99 

functional disorders in pathology of 294 

hemorrhages of 1040 

intussusception of 890 

perforating ulcer of 105 

position of. in relation to posture 551 

radiographs of 10 

of obscure diseases of 348 

radiological studies on function of 783 

relation of heart to 834 



Pace. 
Stomach secretion, cxpirimcntal studies of. 630 

tube, collapsible weighted 737 

ulc-jr of, produced by injections of strep- 
tococci 1 184 

production of, in a rat 390 

scarlet red in treatment of 301 

sudden perforation of 681 

X ray in diagnosis of 1083 

water trap 836 

X ray study of, after gastroenterostomy 890 

X rays in diagnosis of diseases of 935 

Stomachic and laxative effects, formula for 

combination of 624 

Stomatitis, gonorrheal, diagnosis of 394 

Stone, bladder 784, 785 

kidney 784 

prostatic 784 

urethral 784 

Streptococcemia, puerperal, intravenous in- 
jections of magnesium sulphate in treat- 
ment of 690 

Streptococci, ulcer of stomach produced by 

injections of "84 

Streptococcus arthritis, chronic 586 

sore throat, epidemic 586 

Stricture, anal, z-plastic operation for 639 

Strophanthin. action of, on cardiac tissue 884 

Struma a factor in disease of the eyes 933 

Sirunsky. Max. Creating false motor paths 125 
Strychnine, action of. on isolated heart.. 436 

Substituters, punishment for 928 

Suction tip for aspiration in abdominal 

operations 1277 

Sugar content of blood 930 

intravenous injection of, producing hy- 
perglycemia 832 

of blood in nephritis 1270 

Suicide, reflections on 864 

Superstitions and prejudices met with in 

medical school inspection 1008 

acute and chronic, of middle ear 1274 

Suppuration, chronic antra! 589 

of middle ear 1255 

treatment of 188 

use of spring retractors in treatment of 487 

Suprarenal extract in hiccough 1172 

Surgeon and research laboratory Z7 

qualifications of 248 

responsibility of, in treating surgical le- 
sions in their earlier stages 687 

Surgeons, new college of 91 

of United States Army, work of, in last 

few years 543 

Surgery, abuses in practice of 147 

bone graft in. original uses of 39 

in Servian-JBulgarian war 905 

of children, general anesthesia in 41 

orthopedic, recent progress in 997 

practice of 38 

preparation of patient in 893 

Surgical aphasia 222 

cases, medical treatment of 1051 

curiosity 1132 

emergencies, interpretation of pain in... 84 
lesions, responsibility of surgeon in treat- 
ment of earlier stages of.... 39 

Susceptibility to emotion, increased, and 

neurasthenia 46 

Sutures after submucous resection of na- 
sal septum 836 

supracomeal 1033 

Swan. John M. The relation of industry to 

diseases of the heart and lungs 69 

Sweat cure for internal diseases 386 

Swelling, cloudy 439 

Swift. Edward. Treatment of threatened 

abortion 774 

Sympathetic nervous system, disorders of 833 
Symphysis pubis, rupture of, in labor.. 692, 693 

Syndactylia, treatment of 784 

Syndrome, uterine 491 

Syndrome?, adrenal 93^ 

multitrlandular. in relation to nervous sys- 
tem 46 

Synnott. Martin J. Observations on inocu- 

ation therapy looi 

Syphilis, acute polyarthritis in 73» 

and hypocrisy 190 

antiluetin in _. 51 

apparent cure of, with one injection of 

salvarsan 74/ 

atypical 194 

changes in methods of treatment of 106 

comparative study of salvarsan and neo- 

salvarsan in 987 

conirenital. Lange's gold chloride test in. 148 

salvarsan in 584 

dangers of, to the community. . . .■ 789 

experience of Toronto physicians in sal- 
varsan treatment of 977 

gaivl in treatment of 1129 

heart in 877 

hemiplegia following .^ 835; 

hereditan.'. Wassermann reaction in 988 

in animals, experimentally produced 831 

in relation to marriage 884 

in women, diagnosis and treatment of. . 357 



INDEX TO VOLUME XCVUL 



Pace. 

Syphilis, intcction of rabtuu wuh, directly 

from biood of general paictic» 934 

inherited, in congenital mental deficiency 879 

intensive mercurial medication in 819 

mvulviincnt of heart in 151 

late, Spirochxta pallida in 1 j68 

leucocytes in 986 

luetin skin reaction in 14 

neosalvarsan treatment of 1185 

nervous, clinical forms of 745 

intensive treatment of 586 

of bulbar conjunctiva 46 

of central nervous system, intraspinous 

injections in treatment of 936 

of nervous system, dioxydiamidoarseno- 
benzenemonomeihanc sodium aulphon- 

ate in treatment of 354 

organism of. in brain of paretics 57 

present situation in 1(^3 

progress in treatment of 49 

prophylaxis of, and professional ethics.. 838 

pulmonary 300 

complicating tuberculosis 298 

specific treatment of 600 

recurrence and reinfection after salvar- 
san treatment of 878 

reinfection of 731 

with chancriform lesions 1272 

resistance of spirochetes to combined 

treatment of 930 

role of, in etiology of fibrous osteitis i<^3 

salvarsan in treatment of 1185 

disturbances of heart conductivity in. 1272 

studies of 579 

study of spinal fluid in 42, 586 

tertiary, contagiousness of 884 

negative Wassermann reaction in 203 

virus of, infection of rabbits with, di- 
rectly from blood of paretics 47 

X ray diagnosis of 201 

Syphilitic disease of kidney 433 

Syphilitics. latent 327 

Syringomyelia, manifestations of 934 

pathological findings in .' 887 

System, sensitization of 435 

■y ABES, amyotrophic 1180 

^ arsenical and bacterial preparations in 

treatment of 95 

Charcot joints a symptom of 1081 

presence of Spirochaeta pallida in 937 

modern treatment of 837 

Wassermann reaction in 107? 

Tachycardia, paroxysmal 487 

pathogenesis and therapy of S31 

Talipes calcaneus paralyticus. Whitman op- 
eration for ^z^ 

from poliomyelitis, tendon transplanta- 
tion in 737 

Talma's operation for splenomegaly with 

hepatic cirrhosis 788 

Tarsus of upper lid, new method of extir- 
pation of 1186 

Teeth in relation to the eyes 755 

Telangiectases, multple 196 

Telfair, John II. Vagitus uterinus 711 

Temperature, body, influence of baths on 385 

pharmacology of 876 

lowered, due to adrenal insufficiency 1178 

of body in aged 1077 

of tissues during treatment by hot air..ii8i 
variations, local autogenous, a cause of 

labyrinthine vertigo 57 

Tendon fixation in infantile paralysis 1085 

of flexor profundis digilorum torn from 

sheath 544 

reflexes, signs of diminution of 881 

transplatation in talipes from poliomye- 
litis 737 

Tenon's capsule, implantation of fat in 1135 

Tenosin, a new remedy to replace secale 629 

Teratoma ovarian 588 

Terminology of medicine 1184 

Testicle, effect of tuberculosis of epididy- 
mis upon S5 

embryonic origin of tumors of 1230 

transplantation of 1 133 

tumors of. embryonic origin of 49 

Testicles, prepuberal atrophy of, change in 

pelvis in 1273 

Testicular extract, action of i 

Testis, undescended, operative treatment 

of * 49 

Tests. Ehrmann's palmin ._,. 637 

functional, in diagnosis of renal dis- 
ease 48, 687 

Tetanus, antitoxine treatment of 344 

experimental, in guineapigs 1180 

infantile, glycuronic acid, excretion in 683 

rational treatment of 200 

treatment of 430. 938 

Tetany during pregnancy S3S 

gastric ; 39 

Tetragenous septicemia 98 

Theobromine sodium salicylate in acute ne- 
phritis ; lOl 

intravenous injections of 814 

Therapeutics, advances in 252 

teaching of 49. 49© 



1297 



Pagl 

1 licrmumelcr, clinical, accuiacy u( luj 

1 hier«ch uraltk, modified technic in applica- 
tion 01 58J 

ihio&inamin. iieaimcnt of fccars by 1043 

Thoniua. Lee W. A »tudy of •tillbirtht.. 413 
Thum*. Ilcrljcrt K. Trcaiment of threat- 
ened abortion 775 

Ihuracic cavity, contamination of 540 

lliurax. impaired rcsunance of. a sign of 

Typhoid (ever 4*4 

1 helium X, charactcribtics of 366 

m internal dibcases 71I4 

therapeutic use of 725 

Thread, autoplastic, for use in herniotomy. 244 

Throat, epidemic streptococcus sore c86 

pseudomembranous angina of 89a 

septic sore, in Concord. N. H ioj 

Thrombophlebitis, puerperal, treatment of. 

205. 1037 

Thrombosis of mesenteric artery 251 

venous, following physical exertion 1032 

Thymus gland, biology of 534 

nature of 831 

Thymin, action of. in Basedow's disease. .. 1228 

as a soporific 1228 

Thyroid arteries, ligation of 737.889 

colloid, variations in, in hyperthyroidism 

and hypothyroidism 589 

gland, changes in 345 

condition of blood after removal of 534 

diseases of 398 

influence of, on pregnancy and lactation 890 

in relation to chronic rheumatism 8.^ 

surgery of 38 

Thyroidectomy, psychosis occurring after.. 11 12 
Tic douloureux, high frequency current in. 935 
Tilton. Benjamin T. Common errors in the 
diagnosis and prognosis of gallstone dis* 

ease 845 

Tinnitus, division of auditory nerve for re- 

lief of 47.34. 

Tissue cultures, artificial, formation of spe- 
cific agglutinin in 96 

growth, cinematograph in study of 393 

muscular, application of. adapted to phy- 
siological standardization 254 

Tissues, adventitious, of abdominal cavity. . 741 

carrying of germs into, by the knife 337 

changes in, under influence of rays 289 

extension of, causing spontaneous auto- 

plasty 535 

independent life of 289 

nervous, process of disintegration of 24s 

temperature of, during treatment by hot 

air 1181 

Tobacco a caus'^ of toxic amblyopia. .. .429, 442 

smoke, amblyopia due to 594 

Toe nail, ingrown, radical treatment of 492 

Toft. Mary, the pretended rabbit breeder.. 296 
Tompkins, H. E. The respirator; an appli- 
ance for resuscitation by producing en- 
forced artificial respiration 369 

The use and abuse of charity 963 

Toney, L. C. The cure of chronic bron- 
chitis 894 

Tongue, functions of, in production of 

voice 1187 

Tonsil, complete removal of. in its capsule 839 

faucial, surgery of 1 187 

pathological lingual 737 

plasma cells in 341 

Sluder method for removal of 839 

SIuder-Ballengcr operation for removal of. 840 
Tonsils, causes of disappointment following 

removal of 1274 

Tonsillitis following staphylococcus spray.. 393 

surgical treatment of 840 

Tonsillotome. new 839 

Ton^illoiomv and tonsillectomy, relative 

values of 790 

Tonsils, faucial, in relation to pulmonary 

tuberculosis 108 

human, toxicity of 938 

relation of. to pulmonary tuberculosis 592 

removal of 140, 537 

Torpor recti 12 

Touch diseases 1043 

Tousey. Sinclair. Radiographs of obscure 

stomach and intestinal cases 10 

Radium treatment 942 

Toxemia, intestinal, treatment of ii-i 

mammary, a cause of eclampsia 2ci 

Toxemias, general, role of prostate and 

seminal vesicles in 38, ^3^ 

Toxicoses of pregnancy, serotherapy in 881 

Toxinc« iherm^'^tabile. in urethral and 

bladder infections 58 

Tox>*non, intravenous injections of 88i 

Trachelorrhaphy as prophylaxis for cervical 

cancer 583 

Tracheotomv. accidental Ii33 

Trachoma 73S 

among immigrants 44 

Indians 44 

mountaineers of Kentucky 44 

treatment of. with iodic acid 637 

Tract, gastrointestinal, carcinoma of 38" 

Transference in psychoanalysis 4*6 



I2(jS 



INDEX TO VOLUMli XCl'I/I. 



Pace. 
Transfusion, therapeutic possibilities of. 39. 294 

theory and practice of 49 

Transplantation, bone, necessity of pre- 

stTving periosteum in 39 

of tt'siicle 1 133 

organic, present status of.'. 831 

tendon, in talipes from poliomyelitis 737 

Trauma, multiple 1133 

Trendelenburg position, prolonged, effects 

of 154 

Treponema pallidum, transmission of. from 

brains of paretics 198 

Trichinosis, epidemic of, in Pennsylvania. .1166 
Trophozoites of Entaniceba tetragena, bud- 
ding in lOi 

Tropical diseases in the United States 34 

Tropics, dysentery in 257, 544 

fatal medical cases in 401. 46- 

Trypanosoma americanum in naturally in- 

" fected animals 394 

Tube, ovarian, new method of anastomosing. 1275 
Tuberculin, administration of, by general 

practitioner 688 

as a cure of progressive paralysis 976 

doses, nomenclature of 680 

in ocular diseases, therapeutic uses of 4S 

influence of, on eosinophile cells in per- 
ipheral blood 937 

minute initial dose of 268 

neutrophile leucocytic picture as a guide 

for .We of 637 

polyvalent 1132 

proteose free 1182 

reaction in diagnosis of incipient tubercu- 
losis 985 

in surgical tubierculosis 1233 

treatment, ambulatory 1271 

daily weight chart a guide to 1273 

minute initial dose in 26S 

of bronchial asthma , . 290 

views on 437 

turtle. in treatment of tuberculosis 503 

value of, in tuberculosis 811 

Tubercle bacilli, in blood 1227 

in feces 1232 

use of 441 

in diagnosis of obscure conditions in 

genitourinary system 837 

value of. in tuberculosis 437. 503.811 

Tuberculomuzin, Weleminsky's ii7i> 

Tuberculosis, advanced, study of, in the 

Los Angeles County Hospital 592 

treatment of 300 

amyloid degeneration of kidney in ii8o 

association of, with malignant growths. 637 

blood pressure in. at great altitudes 1186 

changes in larynx in 1082 

clinical- laboratory work in relation to... 592 
diagnosis of, by means of guineapigs. . . . 194 
Dispensary. Philadelphia, social service 

work at' 594 

excision of knee for 29^ 

fever in. treatment of 824 

genital, operative treatment of 1230 

'ileocecal and pulmonary, coexistent 487 

immunized milk a prophvlactic and cure 

for 718 

in United States Army 127 

influence of climatic conditions of Cali- 
fornia on 300 

intestinal hemorrhage in 633 

intraocular .■■■•: ^36 

intrathoracic injections of iodine in 480 

tumor resembling 1082 

laryngeal, relief of pain in 933 

ieucocvtes in, effect of ingestion of vari- 
ous oils upon 989 

miliary, of placenta ..* _. 1184 

need for coordination in fight against.... 935 
nonvirulent. a factor in disease of the 

eyes 932 

of bones and joints 44i 

epididymis : . . 55 

Fallopian tube i95 

genital organs 49- i-3o 

genitourinary system 197 

joints, nonsurgical treatment of 837 

prostate 784 

skin, extensive, causing death from 

pyemia 202 

skin presence of tubercle bacilli in... 1227 

passing of 296 

phvsical exercise in open air. a prophy- 
lactic measure in 593 

protein content of sputum in 1227 

pulmonary. Abderhalden's dialysis in... 831 
acromial breathing an aid in diagnosis 

of 1261 

advanced, cough in 149 

artificial pneumothorax in treatment of. 436 

complicated by pulmonary syphilis 298 

continuous antiseptic inhalation in 686 

eucalyptus in 98 

faucial tonsils in relation to 198 

hydrotherapy in 682 

in great altitudes 882 

incipient, in pregnant woman, becoming 
latent after birth of child 1184 



Page. 
Tuberculosis, interruption of pregnancy and 

sterilization in 1179 

ovarian therapy in 675 

pain a symptom in 631 

pathogenesis of pneumonic forms of... 292 

phosphorus in treatment of 320 

pneumothorax in 1128 

prognosis of 1179 

progressive cases of 295 

Moriz VVeisz reaction in 1271 

relation of tonsils to 592 

rest and repair in 439 

rOntgenograms of 1 128 

secondary infection in 103 

surgery in 788 

treatment of 423 

tuberculin reaction in diagnosis of 98.S 

recalcificalion treatment of 576 

renal 635 

diagnosis of 635 

early diagnosis of 20 

in children 1181 

new method of diagnosticating 195 

responsibility for advanced case of 292 

role of physical exercise in open air in 

pronhylaxis of 986 

salvarsan enemas in 388 

sanatoria, discarded battleships to be used 

as 501 

special method of treating 990 

specifics in treatment of 440 

sporotrichosis simulating 882 

surgical, in relation to milk supply 489 

tuberculin in 1233 

work of combating, in western Europe. 684 
therapeutic pneumothorax a palliative 

measure in 632 

treatment of 300, 982 

turtle tuberculin in treatment of 503, 811 

two most important factors in treatment 

of 593 

value of tuberculin in 437 

verrucose. of foot 337 

vertigo in 145 

von Pirquet's test in 1232 

with gastric carcinoma 100 

work of combating, in East River homes 33 

X ray diagnosis of 201 

Tubes. Fallopian, dilatation of, for sterility. 338 

tuberculosis of 195 

Tumor, benign, of female breast iiS.v 

bladder, diagnosis and treatment of 48 

high frequency currents in treatment of 148 

in aniline dye workers . 631 

dreams following removal of 1275 

treatment of 686 

visualizing power after removal of 1275 

cardiac, diagnosis of 1124 

cystic mammary 39' 

fecal, associated with Hirschsprung's dis- 
ease 639 

fibroid, from clinical standpoint 740 

glioma, cerebellar s8 

hypophyseal, transfrontal method of ap- 
proach in removal of 985 

lumbar, with latent spina bifida m78 

metastases, production and growth of 298 

mixed, of testicle, embryonic origin of. 1230 
of Gasserian ganglion, operative cure of. 485 

of hypophysis in acromegaly 47- 294 

of male breast 142 

of nasopharynx 839 

of omentum with twist of pedicle 342 

of spinal cord 1189 

ovarian, with appendicitis and carcinoma 

of pelvic colon 733 

pelvic, causing intestinal obstruction. ...1163 

pituitary, sella decompression in 1034 

removal of bladder for 784 

vesical, diagnosis and treatment of 1133 

Tumors, cutaneous, in malignant lymphoma 986 
intrathoracic, simulating tuberculosis. . . . 1082 
malignant and benign, radiotherapy in. . 1086 

mesothorium in treatment of 930 

radium treatment of 487. 93o 

treatment of T030 

of testicle, embryonic origin of 49 

perinephritic 291 

simple, electrolysis in treatment of 428 

spinal, localization of T49 

surgery of 982 

X ray diagnosis of 201 

Turpentine poisoning 393 

Turtle tuberculin in treatment of tubercu- 
losis 503. 8ri 

Twin pregnancy, uterine and tubal com- 
bined ; lot; 

Tympanv. postoperative, prevention of. . . . 1172 
Typhoid bacillus, isolation of. from milk... 736 

carrier problem 248 

carriers, report on 1079 

epidemic of Quincy, 111 54i 

epidemics _. ; 780 

fever, antityphoid vaccine in epidemic of 200 

autoeenous vaccine in 482 

bacilli carriers in 292 

complicated by ascaris lumbricoides 202 

diagnosis of 438 



Page. 
iyphoid fever, epidemiological diagnosis of 102 

etiology of 1074 

from uncooked vegetables 328 

gelatin and olive oil in 230 

hematuria in, where patient was treated 

with hexamcthylenamine 584 

hemorrhage in 297 

inimuni/ed milk a prophylactic and 

cure for 718 

impaired resonance of right lower thorax 

a sign of 434 

in New York City .627 

paratyphoid fever associated with epi- 
demic of 339 

treatment of loi 

vaccination against 253, 792 

vaccine treatment of 453> 688 

fly 1026 

infection carried by bedbugs 191 

of biliary passages 96 

Typhus fever, treatment of, with iodine... 1079 

f TLCER. duodenal 540, 891 

^ acute, perforating 150 

diagnosis and prognosis of 295 

experiences with 538 

in children 732 

in relation to vascular lesions 101 

pathological data obtained from excision 

of 150 

perforating, posterior gastrojejunostomy 

in 19^ 

scarlet red in 298, 301 ^ 

value of x ray in diagnosis of 1083 

gastric 891 

acute perforating' 150 

in relation to vascular lesions loi 

perforating, posterior gastrojejunostomy 

in 197 

perforation of 68i 

perforation of. into heart 1274 

produced by injections of streptococci. 11S4 

production of, in a rat 390 

scarlet red in 298. 301 

significance of. in regard to cancer 1082 

value of X ray in diagnosis of 1083 

perforating, of duodenum 37 

of stomach 105 

pseudotuberculous, on female genitals... 388 
rodent, and epithelioma in same patient 196 

simple, of bladder 785 

varicose, treated by feeding it with cheese. 634 
llcerations, gastrointestinal, diagnosis of, 

by study of feces 1129 

Ulman. Joseph F.. and Boston. L. Napo- 
leon. Movements of two halves of chest 

in disease 705 

Ulna, recurrent anterior dislocation of 586 

Ulsanin. therapeutics of 534 

Umbilical cord, care of 97 

stump, care of 490 

Umbilicus. lung infection from 291 

Uranium acetate, precipitation of uric acid 

in the blood by means of 243 

nephritis, action of diuretics in 541 

Uranoblen, therapeutics of 1228 

Urea in blood, estimation of 195 

Uremia, functional kidney test in 1186 

postoperative hiccough a sign of 1181 

Ureter, calculi of parietal part of 195 

congenital stenosis of 785 

implantation of. into the bowel 48 

new. formation of 48 

normal, study of 47 

pathological conditions of 48 

repair of defects of 1034 

rontgenoscopic study of 687 

symposium on diseases of - 47 

Ureteral calculi 738 

colic with recurring hematuria a symptom 

of cancer 1181 

Ureterovesical cysts, surgical treatment of. 48 
Ureters, implantation of, into large intes- 

t'ne 10.^ 

snnernumerary 785 

Urethra, caruncle of. high frequency cau- 
terization in 1 1 15 

female, granulations in lower part of 47Q 

filiform nematode passed from 1276 

stone in 784 

stricture of. and genital function 785 

Urethral calculus in bilharziasis 630 

carcinoma of fossa navicularis 630 

infections, thermostabile toxines in 58 

Urethritis, chronic, trea^ent of 867 

gonococcal, treatment of 332 

gonorrheal, need of microscope in treat- 
ment of 28 

Uric acid elimination, influence of atophan 

on 542 

excretion, effect of atophan and novato- 

phan upon loSt; 

in blood, precipitation of. by uranium 

acetate 243 

Urinary passages, staphylococcus' infection 

of ., 785 

pepsin in nephritis 51 

tract, d'aenosis of lesions of 1087 



L\ULX JO I OH ME XCl III. 



l'A..t. 

Urinary Iraci, pseiidodiphihena urgani:<m 

in ; 49. 985 

Urine, acetone bodies in, clinical siRntfi- 

cance of 536 

action of antiseptics on (^s 

bacteriological examinations of, in nephri- 
tis 1030 

Chctwood operation for retention of 645 

detection of small amounts 01 glucose in. 734 

estimation of chlorides in 345 

hydrogen ion concentration of, in heart 

disease 588 

indications from, in treatment of skin 

diseases .». 1 133 

investigation of nitrogenous metabolism 

as reflected in 583 

of cancer patients, colloidal nitrogen in. 6iSi 

pus in 1 14 1 

sulphates of 394 

suppression of, in blackwatcr fever 54 

testing of, for indican 814 

Urochromogen. Moriz Weisz reaction for. 883 
Urological operations, midopcrative diagno- 

sis in i»9 

Urticaria, purpura and angioneurotic edema 

in an infant 148 

Uta. etiology of '034 

Uterus, anteflexion of. glass or silver stems 

in treatment of 10S4 

blood supply of, influence of ectopic preg- 
nancy on 204 

cancer of 79i. "04 

from clinical standpoint 740 

operative technic in treatment of 740 

prophylaxis of .' 534 

carcinoma of. hypothesis as to cause and 

prevention of iS3 

clastic area of isthmus of, a sign of preg- 

nancv 482 

emptying of, in treatment of puerperal 

eclampsia 588 

fibroids of, x ray treatment of 201 

fibromyomata of 740 

functional disturbances of 49> 

inertia of 151. 152 

infantile, with dysmenorrhea 1234 

isolated, action of emmenagogue oils on.. 198 

inversion of 97. 347 

lactation atrophy of 691 

myoma of. with ovarian hemorrhage 1179 

nonpregnant, hemorrhage from 537 

perforation of 97 

by foreign body 629 

pregnant, partial retroflexion of 58.1 

prolapse of 79'. 890 

retroflexed. treatment of 385 

rupture of 542 

following use of pituitrin 97 

from pituglandol 630 

L'zara, action of '270 

VACCIX.^TIOX against smallpox 139 
antityphoid 792 

progress in 537 

aseptic, iodine an aid to 933 

sensitized virus, in gonorrhea 1080 

therapy of cancer I128 

\'accine. antitvphoid. in an epidemic 200 

autogenous in acute ankylostomiasis 876 

in typhoid fever 402 

bacterial, in erysipelas 1231 

Behring s diphtheria, report on 1226 

Friedmann's 92 

therapy ' ._ 335 

developments and problems in 253 

for general practitioners 633 

scientific basis for 1274 

treatment of complications of gonorrhea. . 1228 

of ozena ''79 

of typhoid fever 453. 688 

of whooping cough _■ 389 

von Ruck's, animal experiments with.... 56 
Vaccines, autogenous, in chronic joint af- 
fections 53 

bacterial, in dentoalveolar abscesses li&» 

federal control over manufacture of 537 

gonococcus. in diagnosis of gonorrhea 632 

in chronic bronchitis and asthma 53 

in eve infections lOJ 

in undulant fever 1036 

Vaccinia, cultivation of virus of 938 

V'aginia, artificial, formation of 246,885 

mercurial gangrene of 1128 

Vaginitis, gonococcal, treatment of 874 

membranous, in pregnancy 251 

Vaginouterine prolapse, treatment of 79t 

Vagitus utermus 7" 

Vagotonic pupillary phenomenon 731 

Vagus, atony of, and seasickness 630 

Valve, ileocecal, incompetency of 56 

Varices, false ....1180 

operation for ^3 

Varicocele, operation for. without wound- 
ing scrotum 2,50 



\ ancosc ulcer treated Ijy lecding 11 witli 

cheese 634 

\ as deferens, new nietllod of anastomosing. 1..75 
\ ascular lesions, relations of gastric and 

duodenal ulcer to 101 

reflexes 731 

N'asomotor efficiency, lest of 916 

Vasostomy 1133 

X'egetablfs. cooked green, in treatment of 

diarrheas 537 

\'ein grafting for maintenance of direct ar- 
terial circulation 147 

\*eins, response of, to epinephrin 327 

\*ena cava, inferior, relation of, to pelvic 

organs 488 

Venereal diseases in Canada 240 

social and medical aspects of 393 

prophylaxis, past and present 792 

Xcntvcition in treatment of cardiac failure 

III iineuiiionia 1226 

Ventricle, lateral, rupture into 987 

X'entrofixation, method of S43 

N'eronal poisoning 984 

rashes 436 

X'erruga Peruana 203, 1034 

X'ertebrK, cervical, spontaneous reduction 

if dislocation of 338 

Wrtigo, division of auditory nerve for relief 

of 47 

in glaucoma 383 

in tuberculosis 145 

labyrinthine, local autogenous tempera- 
ture variations a cause of 57 

ocular 45, 736, 955 

Verumontanum. disease of 792 

X'^sical calculus, spontaneous fracture of.. 1271 

obstruction, relief of ...638 

Vesicles, seminal, infections of, in relation 

to toxemia 38 

Vesicles, seminal, role of. in general toxe- 
mias 632 

Vigor, physical, mental, .and moral, of 

schoolchildren 1093, 1149 

Vincent's angina 468 

X'incula pra-teritorum 958 

Vindaw Sanatorium, report of 684 

■^'irus of rabies, cultural studies on 787 

enects of desiccation on 54i 

of vaccinia, cultivation of .-••.••• 938 

Viscera, derangements of, complicating 

scoliosis to84 

\'isualizing power, actjuirement of, after re- 
moval of cerebral tumor 1275 

\'oice, functions of tongue and soft pal- 
ate in production of 1187 

Vomiting, cyclic, in children 391 

of pregnancy 484 

pernicious, of pregnancy 636 

von I^irquet's test in tubercuiosis 1232 

von Ruck's tuberculoproteins, animal ex- 
periments with 56 

Vulva, pruritis of 380 

Vulvovaginitis in children 4i 

W.\CHEXnElM, v. L. Atypical infan- 
tile paralysis I2i3 

Weakness, muscular, due to adrenal in- 
sufficiency 1178 

Weleminskv's tuberculomuzin U78 

Walker. J. T. Ainslee. Doctor Chapin's 

.Sources and Modes of Infection 994 

Routine school disinfection 615 

Waller. .\. D. The origin and scope of 

electrocardiographv 719 

War Servian-Bulgarian, surgical experi- 
ences during 90s 

Wassermann reaction, antigen in 1130 

application of. to medicine 293 

comparative study of antigens for 42. 586 

details in technic of 202 

in cancer 440 

in gynecological diagnosis 93? 

in hereditary syphilis 988 

in pathological anatomy 43* 

in tabes •.,-.-«>77 

negative, in untreated tertiary syphilis. 203 
quantitative chemical reaction for con- 
trol of «■>« 

theory of 241 

test, modified 92 

Water baths, influence of, on body temper- 
ature ■.•••■-•." ^' 

boiling, injection of, in hyperthyroid- 

ism 38. "98 

distilled, in medical practice .882 

intravenous injections of, in puerperal 

sepsis W 

hard versus soft 8»5 

pure distilled, importance of • •.• 725 

Weight chart, daily, guide to tuberculin 

treatment of '^73 

Wertenbaker. C. P. Eugenics and the pub- 

lie' health ^- 

Wertheim's abdominal panhysterectomy, 
new method of performing 733 



burfii -■•'J 

While, 1.. hoHaru, ine lo»icii> uf (.oal 

lar product k ^%i 

While split disease, anomatou» CA»e of 42 

W human uptratlon for talipca Ujb 

Whilniort, i':ugcnc K. Uy.eotcry in the 



Whiiuping c.iiigh, pathological Ic 



of. 



iil 



wt. nil trtalmcnt of jKc 

\\ icncr. .S'llijiiiuii. liigh Ircqueacy clutcr- 

izaiion in treatment of urethral car- 

uncle 'I'S 

\\ ilbrand hemianoplic prism ptienume- 

non .45. 73* 

Wilensky. A, U. Hi. 



the 



822 



Williams, U, G. K. I 572 

Wilson, .\. .M. Trcatn.. ; .u,... 359 

Wilson, H, Augustus. I'rr.iperinvc cau- 
tion to avoid postoperative calamiliei, 549 

Wilson, J. <;.. and Billings. W. C. Keiro- 
pharvngcal abscess 57> 

Wise, I'red. Epithelioma of lower lip in 
a «onian ;';';"- *'' 

W isenian Joseph K. Treatment of cholera 
infanlum • ■• •. 47<i 

Wohl, Michael G. Myiasis or fly larvjc as 
parasites of man. 



.lOiB 



Wolbarst, .\hr. I.. Seven cases of syphil 
apparently cured with one injection of 

salvarsan 747 

\vomen in department stores 134 

phvsicians, intcrneships for 431 

Wood Harold B. Expectant school dis- 

^.g^j,^ 1021 

Woodbury, i-rank. Pennsylvania's Insane 

asylums "3° 

Work of w6men in department stores l|4 

Wounds ; 65 

ahoominal, treatment ot g2 

of iVe, antitetanic serum in .. ... »2 

liver, spleen, and kidneys, healing ot,. 884 

of lungs, treatment of 9* 

of pericardium and heart "86 

.)f sclera, treatment of 4*. 736 

siu.purating, superheated air in treatment 

of 'f= 

treatment of •.• ., «4 

Wright, .\dam H, Preventive medicine and 

the family doctor 903 

Wright. S. .1. rrea'.ment of insomnia 973 

Wrist iniury. unuiuc ■ 586 

joint, fractures near, treatment of 822 

synovial cysts at 723 

XR.AY diagnosis of hepatoptosis 245 
of syphilis, tuberculosis, tumors, and 

osteomyelitis 201 

dissolution of paramctrial adhesions by,.ii79 

examinations of gastrointestinal tract 341 

of intestines in infants ¥> 

lindings in enuresis .1077 

legal responsibility of physician in use of 797 
photographs in pulmonary tuberculosis. .1128 
pictures in obscure stomach and intestinal 

cases »! 

scope of ?>7 

studv of stomach after gastroenterostomy. 890 

treatment of cancer 1086, 1275. '277 

of nerve roots in neuralgia '95 

of tumors .'086 

of uterine fibroids, menorrhagia. ana 

ipetrorhagia 201 

value of, in diagnosis ot ulcer of stom- 
ach and duodenum • ■ ■ '083 

X rays, changes in tissues under influence 



of 



280 



domen : 664, 708 

of obscure abdominal conditions 40 

lions 40 

of stomach diseases ■; 935 

in differential diagnosis of appendix 697 

in malpractice suits 797 

in pyloric obstruction - 40 

in treatment of diseases of spinal c rd. . 436 

of osteosarcoma 490 

of ringworm 834 

irradiation of ovaries with, in treatment 

of exophthalmic goitre 9* 

massive doses of 490 

in treatment of skin diseases 42 

value of. in cancer 490 

in chronic appendicitis |3S 

in inflammations of cecum |3.5 

of terminal cecum 835 

Z.XNGGER. THEODORE. Sense oi smell 
as an aid to diagnosis 841 

Zigler. M. \ plea for more intensive mer- 

curia! medication in syphilis 8iq 

Z-plastic operation fur anal stricture 639 



LIST OF ILLUSTRATIONS TO VOLUME XCVIII. 



Page. 
Adhesions and intestinal angulations in relation to chronic consti- 
pation. Eleven Illustrations 5->o 

Amino nitrogen content of serums. One Illustration 159 

Apparatus for proctoclysis. Two illustrations 1023 

Appendix, differential diagnosis of, by x ray. Eighteen illustrations. .697-704 

Arthritis of hip. One Illustration 615 

Aurometer. Three Illustrations 1016 

Biorontgenographic apparatus. One Illustration 14 

Bladder, topography of. Four Illustrations 355-356 

Blood letting apparatus. One Illustration 966 

Bursitis, retrocalcanean. Four Illustrations 263-265 

Cannula, curved. One Illustration 181 

Chest, movements of two halves of, in disease. Eleven Illus- 
trations 705-708 

Cystoscope and evacuator, combined. Two Illustrations 265 

Diabetes mellitus treated with Bacillus bulgaricus. Five Illustra- 
tions 70-73 

Drainage for suprapubic prostatectomy. One Illustration 426 

Drainage tubes for nares. Two Illustrations 473 

Duodenal instruments. Ten Illustrations 751-755 

Dysentery in tropics. Three Illustrations 258-260 

Education, foundation of. Three Illustrations 459 

Epilepsy. One Illustration 1199 

Epithelioma of lower lip in a woman. Two Illustrations 617 

Fracture of pelvis in a child. One Illustration 908 

Gastrointestinal symptoms. Eight Illustrations 359-365 

Imbeciles, test for. Two Illustrations loiS 

Intestinal obstruction due to pelvic tumor. One Illustration 1163 

Jaundice in children. Two Illustrations 261 

Kinetic neuroses and psychoses. Two Illustrations 1162 



Page. 

Labyrinth, inflammatory affections of. One Illustration 213 

Leprosy in a negress. One Illustration 708 

Leprosy, surgical cure of. Three Illustrations 266 

McBurney, Charles. Portrait 978 

Moronism and ignorance. Four illustrations 564-565 

Orbital abscess. One Illustration ii95 

Orthopedics in general practice. Thirteen Illustrations 451-452 

Osteoarthropathy, hypertrophic pulmonary. Two Illustrations 609-670 

Palpation, special technic in. Six Illustrations 847-850 

Paralysis, infantile, affecting lower extremities. Ten Illustrations. .90S-912 

Percussion of pulmonary apices. Ten Illustrations 799-804 

Pharyngoscope. One Illustration 655 

Pneumothorax, induced. Eight Illustrations 850-855 

Position of stomach in relation to posture. Thirty Illustrations. .551-556 

Respirator. One Illustration 371 

Roosevelt Hospital. Doctor McBurney operating in. One Illus- 
tration 979 

San Diego. Cal. Five Illustrations 559-562 

School children, health of. Four Illustrations 1095 

Servian-Bulgarian war, surgical experiences during. Five Illustra- 
tions 906-907 

Sphygmomanometer. One Illustration 220 

Spina bifida. Eight Illustrations 1159 

Teeth in relation to eyes. One Illustration 756 

Testicular extract, action of. Twelve Illustrations 2-3 

Tests for detection of defectives. Six Illustrations 522 

Vaccine treatment of typhoid fever. Eight Illustrations 453 

Wassermann reactions. Two Illustrations 1012 

X ray diagnosis of diseases of chest and abdomen. Seven Illus- 
trations 664-668 

X rays in diseases of chest and abdomen. Five Illustrations 708 



LIST OF CONTRIBUTORS TO VOLUME XCVIII. 

Those whose names are marked with an asterisk have contributed editorial articles. 



Alexander, I. H., A. B.. M. D. 

Alexander, Robert M., M. D., Werners- 
ville, Pa. 

♦Almgren, Ebba, M. D. 

*Appelgate, J. C, M. D., Philadelphia 

*Arends. Katherine, M. D. 

•Arrowsmith, Hubert, M. D., Brook- 
lyn. 

Asserson, M. Alice, M. D. 

*Atwood, Charles E., M. D. 

AuERBACH, Julius, M. D. 

AUSLANDER, M., M. D. 

Austin, F. D., M. D., Charlotte, N. C. 
Austin, H. W., M. D., United States 
Public Health Service. 

Babcock. W. Wayne, A. M., M. D., 

Philadelphia. 
Baetz, W. G., M. D., Canal Zone, Pan- 
ama. 
Baker, Frank, M. D., Washington, D. C. 
Baldwin, J. F., A. M., M. D., Columbus, 

Ohio. 
Ball, C. F., M. D., Rutland, Vt. 
Ballagi, John, M. D., Homestead, Pa. 
Baxdler. Samuel Wyllis, M. D. 
Barnes, Fr.^ncis M., Jr., A. M., M. D., 

St. Louis. 
*Bartholow, Paul, A. B., M. D. 
Bartlett, Charles J., AI. D., New Ha- 
ven, Conn. 
Bates, W. H., M. D. 
Beattie, William J., M. D., Littleton, 

N. H. 
Bechet, Paul E., M, D. 
Beduossian, Edward H., 'SI. D., Phila- 
delphia. 
Behan, Richard J., M. D., Pittsburgh. 
Bell, F. McKeltcy, M. D., Ottawa, 

Canada. 
Besson, John H., M. D., Portland, Ore. 
Beveridge, J. Wallace, M. D. 
Billings, W. C, M. D., United States 

Public Health Service. 
Bishop, Louis Faugeres, A. M., M. D. 
Boehme, Gustav F., Jr., B. S., M. D. 
Boland, Frank K., M. D., Atlanta, Ga. 
*Bolduan, Charles Frederick, M. ID. 
Boston, L. Napoleon, A. M., M. D., 

Philadelphia. 
Bovaird, David, Jr., M. D. 
Bowers, Paul E., M. D., Michigan City, 

Ind. 
Bowers, Rose A., M. D., Michigan City, 

Ind. 
Brager, Louis R., M. D. 
Bram, Israel, M. D., Philadelphia. 
Braunstein, Joseph E., M. D. 
Br.^v, Aaron, M. D., Philadelphia. 
Brecht, Nelson Du Val, M. D., Wash- 
ington, D. C. 
Brewer, Isaac W., M. D., Taughannock 

Falls, N. Y. 
Broadman, Joseph, M. D. 
Brooks, Harlow, M. D. 
Broun, LeRoy, M. D. 
Brown, Claude P., M. D., Philadelphia. 
Brown, Samuel Horton, M. D., Phila- 
delphia. 
Bryan, R. C, M. D., Richmond, Va. 
Buckley, Albert C, M. D., Philadel- 
phia. 
Burr, Charles W., M. D., Philadelphia. 
Burrows, Ej-liott C, M. D. 
BuRWELL, Hartwell R., M. D., Wash- 
ington, D. C. 



Carrington, P. M., Surgeon, United 
States Public Health Service. 

Carson, G. R., M. D., San Francisco. 

Carstens, J. H., M. D., Detroit, Mich. 

Chapman, William L., M. D., Brook- 
lyn. 

Charbonneau, Lionel C, M. D., Brook- 
lyn. 

Clark, A. Schuyler, M. D. 

Clendening, Logan, M. D., Kansas 
City, Mo. 

*Clouting, Charles A., M. D. 

*Clurman, M. J., M. D. 

Cocks. Gerard Hutchison, M. D. 

Coffey, W'. B., M. D., San Francisco. 

Cohen. Myer Solis, A. B., M. D., Phil- 
adelphia. 

CoLLiNGs, Howard Paxton, B. S., M. D., 
Hot Springs, Ark. 

Condon, A. P., M. D., Omaha, Neb. 

Coon, Clarence E., M. D., Syracuse, 
N. Y. 

Cornell, William Burgess, M. D,, Bal- 
timore. 

*CoRwiN, E. Lewinski, M. D. 

CosTALES, Alfred, M. D.. Brooklyn. 

CouGHLiN, Robert E., M. D., Brooklyn. 

Crampton, C. Ward, M. D. 

Crawford. Albert C., M. D., Stanford 
University, California. 

Crocker, W. J., V. M. D., Philadelphia. 

Cummins, W. T., M. D., San Francisco. 

Cunningham, William P., M. D. 

Curtner, M. L., M. D., Vincennes, Ind. 

Cutter, John Ashburton, B. Sc, M. D. 

CvRiAX, Edgar F., M. D., London, Eng- 
land. 

Dabney, S. G., M. D., Louisville, Ky. 
Davison, Robert E., M. D., Pittsburgh. 
Day, George H., M. D., Louisville, Ky. 
Deeks, W. E., a. M., M. D., Canal 

Zone, Panama. 
Densten, J. C, Ph. D., M. D., Scranton, 

Pa. 
Dercum, F. X., M. D., Philadelphia. 
Douglas, John, M. D. 
Duncan, Ch.\rles H., M. D. 

*Eggleston, Cary, M. D. 

Ela, Paul F., M. D., East Douglas, 

Mass. 
Eliot, Ellsworth, Jr., M. D. 
Ellis, G. J., M. D., Covington, Ky. 
Epstein, J.. M. D. 
Essenson, S. J.. M. D. 
EwiNG, James, M. D. 
Eynon, William G., M. D. 

Farrar, Lillian K. P., M. D. 

Fields, Sterling O., M. D., Newport 
News, Va. 

Finch, S. E., M. D. 

Fishberg, Maurice, M. D. 

Fisher, Jessie Watson, M. D., Middle- 
town, Conn. 

Fitch, William Fj)ward, M. D. 

Forbes, A. MacKenzie, M. D., Montreal, 
Canada. 

^Foster. M.\tthias Lanckton, M. D., 
New Rochelle, N. Y. 

Fowler, Edmund Prince, M. D. 

*Fox, Elsie, M. D. 

Frankel, Julius, M. D. 

Friedenreich, Irving, M. D. 



*Friedman, Henry M., M. D., LL. B., 
LL. M., United States Public Health 
Service. 

Frink, H. W., M. D. 

Fulto.m, Enoch S.. M. D.. New Therin, 
La. 

*Gakrison, Fielding H., M. D., Wash- 
ington, D. C. 

Gehring, EIdwin W., M. D., Portland, 
Me. 

Giltner, H. a., M. D., Portsmouth, Va. 

Ginsburg, Morris, M. D., Philadelphia. 

Gloster, Harold S.. M. D., Wheeling, 
W. Va. 

*Glueck, Bernard, M. D.. United States 
Public Health Service. 

GoLDMARK, Josephine. 

Goldstein, Hyman, M. D. 

Goldstein, Sam, M. D. 

Goltman, Abraham, M. D. 

Goodhue, E. S., A. M., M. D., LL. D., 
Hawaii. 

Goodman, Abraham Lincoln, M. D. 

Goodman, Edward H., M. D.. Philadel- 
phia. 

*Gf)TTHEiL, William S., M. D. 

Green, Leo, A. B.. D..M. D. 

Guthrie, J. A., M. D., Portsmouth, Va. 

Gwathmey, James T.. M. D. 

*Haneman, Frederick T.. M. D. 

Harrower, Henry R.. M. D.. London, 
England. 

Haynes, Irving S., Ph. B.. M. D. 

Hays, Harold, A. M., M. D. 

Hazen, Charles M., M. D., Richmond, 
Va. 

Henson, Graham E.. M. D., Jackson- 
ville. Fla. 

Herrman, Charles, M. D. 

Hess. W. C, M. D., Cresco, Iowa. 

Heilscher, Helen Hughes. M. D., 
Mankato, Minn. 

Hirsch, I., M. D. 

Hirshberg, Leonard Keene, M. D., Bal- 
timore. 

'Hitchens, a. Parker. M. D., Glenol- 
den. Pa. 

Hoguet, J. P., M. D. 

Holladay, Gray G.. M. D.. Portsmouth, 
Va. 

Holloway, H. S., M. D.. Jacksonville, 
Fla. 

Holmes, Bayard, M. D.. Chicago. 

*Huber, John B.. M. D. 

'*HuNT. Reid, M. D.. Ph. D., Boston. 

Illoway, H., M. D. 

'Ingham, Samuel D.. M. D., Philadel- 
phia. 

Jackson, J. Allen, M. D.. Philadelphia. 
*Jelliffe, Smith Ely, Ph. D., M. D. 
Jennings, Walter B.. Ph. B., M. D. 
jopsoN, John H., M. D., Philadelphia. 
JuNOR, Kenneth F., M. D.. Brooklyn. 

Kahn, L. Miller, M. D. 

Kaliski. David J., M. D. 

Kaplan. D. M.. M. D. 

Kaufman, Bernard, M. D., Marysville, 
Cal. 

Kemp, Robert Coleman, M. D. 

*Keyes. Edw.^rd L., Jr., M. D. 

*King, How.\rd D., M. D.. New Or- 
leans. 



INDEX TO VOLUME XCVIll. 



KiRiiV-S.MiTH, T. Lee, M. D.. Jackson- 
ville, Fla. 

Ki-AUDER. Joseph V., M. D., Philadel- 
phia. 

Klotz, Hermann G., M. D. 

Knopf, S. Adolphus, M. D. 

Knox. Howard .■\.. M. D., United States 
Public Health Service. 

KoNKLE. W. B., M. D.. Montoursville, 
Pa. 

KoPETZKv. Samuel J., M. D. 

Krauss. F., M. D., Philadelphia. 

Lederle. Ernst J., Ph. D. 

Lemon. Ferguson. M. B., B. S.. Mel- 
bourne. -Australia. 

Lepine. R.. M. D., Lyons, France. 

Leslie, Ch.^rles T., M. D.. Pittsfield. 
Mass. 

Levinsox, Frank, ^i. D., Portsmouth, 
Va. 

Lloyd, Samuel, M. D. 

LoBSExz, Jacob Munter, M. D. 

LUBMAN. M., M. D. 

MacKee, George M., ^L D. 

MacWhinnie, a. Morgan, M. D., Seat- 
tle. Wash. 

Macv. Mary Sutton, M. D. 

Magida. Nathax, M. D. 

Magruder, E. p., a, M., M. D.. Wash- 
ington, D. C. 

Makuen, G. Hudson, M. D.. Philadel- 
phia. 

Maloney. William T.. ^L A.. ^L D.. 
Ch. B.. F. R. S. 

jVL^nion, R. J.. M. D., C. M., L. R. C. P. 
and S.. Fort William. Ontario. 

Mann, C. M., M. D. 

Markowitz, Morris, }iL D.. Philadel- 
phia. 

Masland, H. C. M. D., Philadelphia. 

Maxson, Edwin S., A. M., M. D., Syra- 
cuse, N. Y. 

*Mayo, Caswell A., Ph. G. 

McClelland, T. E., A. B., M, D. 

McClure, J. R.. M. D.. Newark, Ohio. 

*McConnell, Guthrie, M. D.. Philadel- 
phia. 

McMurtrie, Douglas C, M. D. 

Meyer, Karl .A.. iL D., Hot Lake, Ore. 

Meyer, Willy, M. D. 

Miller, Daniel Tucker. A. B.. M. D., 
Terre Haute, Ind. 

*MiLLiCAN. Kenneth W.. M. R. C. S., 
London, England. 

Miningham, William D.. M. D.. New- 
ark. N. J. 

Minor, J. C, M. D., Hot Springs, .\rk. 

Montague, Helen, ^L D. 

Montgomery. C. E., M. D., Walla Walla, 
Wash. 

Moore, J. Walker, M. D„ Philadelphia. 

*Morgan, F. p., M. D., Washington, 
D. C, 

Morris, H. A., M. D.. Brooklyn. 

Mulford, Henry Jones, M. D., Buffalo. 
X. Y. 

Mullan. E. H.. M. D.. L'nited States 
Public Health Service. 

Myers. Edward E., M. D. 

Nascher, L L.. M. D. 
Xeary, John B., M. D. 
Neuhof, Selian. M. D. 

ocAN. iL l:. M. D. 

OciLVY, Charles, M. D. 
Orbison, Thomas J., M. D., Los An- 
geles, Cal. 
Ormsby, Robert. M. D. 

P.\LEFSKI, I. C M. D, 

Parrott, W. T., M. D., Kinston, X. C. 



Patterson, Paul M., M. D. 
Pedersen, Victor Cox, A. M.. M, D, 
Phillips, E. W., M. D., Chattanooga, 

Tenn, 
Phillips, Wendell C, M, D. 
PisKO, Edward, M. D. 
PixLEY, Charles, M. D., Missoula 

Mont. 
Podall, H. C, M. D., Xorristown, Pa. 
*Porter, p. Br\nberg, .\. M., M. D. 
Powers, A. H., M. D., Boston, 
Pritchettt, J. H.. M. D., Louisville, Ky. 
Pulley, W. J., M. D. 

QuiMBY, A, J., M. D. 

Rabinowitz, Meyer .A., M. D., Brooklyn. 

Rambaud, George Gibier, M. D. 

Randolph, B". M., M, D., Washington, 
D. C. 

*Reber. Wendell. M. D., Philadelphia. 

*Reed, .Alfred C, M. D., United States 
Public Health Service. 

Remer, John, M. D. 

Reynolds, R. W., M. D., Lincoln Xeb. 

Riddell, William Renwick, LL. D.. 
F. B. S., Toronto, Canada, 

Risser, .Arthur S., M. D„ Blackwell. 
Okla. 

Roberts, Stewart R.. S. M.. M. D.. .At- 
lanta, Ga. 

*Robertson, W. E., M. D., Philadelphia. 

*Robin, Albert, M. D., Wilmington, 
Del. 

Robinson, Daisy Orleman, M. D. 

Roe, John O., M, D., Rochester, X. Y. 

Roehr, C. G., M. D., Fort Pierce, Fla. 

*RosE. .A., M. D. 

Rosenberg, Julius, M. D,, Margaretville, 
N. Y. 

Rosenberger, Randle C, M. D.. Phila- 
delphia. 

Rosenbloom, Jacob, M. D., Ph. D., 
Pittsburgh. 

Roussel. Albert E., M. D., Philadelphia. 

*Roxby, J. B., M. D., Swarthmore. Pa. 

Rubenstone, Abraham L, ^L D., 
Philadelphia. 

*Sajous, Charles E. de M., ^L D., 
LL. D., Philadelphia. 

*Sajous, Louis T. de M.. B. S.. ^L D.. 
Philadelphia. 

ScADRON, Samuel J.. M. D. 

*Scarlett, Rufus B.. M. D.. Philadel- 
phia. 

Schaefer, Theodore W.. M. D.. Kansas 
City, Mo. 

*Schamberg, Jay F., A. B.. M. D., Phil- 
adelphia. 

ScHELL. J. Thompson, M. D., Philadel- 
phia. 

Schwatt, H., M. D., Edgewater, Colo, 

*ScoTT, R, J. E., B. A., M. D., B. C. L. 

Sever, Tames W.\rren, M. D., Boston. 

Shalet, Louis, M, D. 

Sharp, J. Clarence, M. D. 

Shaw. John H., M. D., Philadelphia. 

*Shively, Henry L., M. D., LL. D. 

Shoemaker. Harlan, .A. B., M. D., Shel- 
by, X. C. 

SiGLER, C. L., M. D., Pinckney, Mich. 

Simpson, F, F., M. D., Pittsburgh. 

Simrell, G. W., M. D., Brooklyn. 

Singer, Gustav, M. D., Vienna, Austria. 

Skillern, Penn G., Jr., M. D.. Philadel- 
phia. 

Smith, Allen J., M. D., Philadelphia. 

*Smith, E. Franklin, M. D. 

Smith, Harmon, M, D. 

Smithies, Frank, M. D., Rochester. 
Minn. 

SoBEL. Jacob, M. D. 

Solomon, Meyer, M. D.. Chicago. 



*SoRESi, A. L., M. D. 

Spangler, Ralph H., A. B., M. D., Phil- 
adelphia. 

Spicer, Frank W., M. D„ Duluth, Minn. 

Spurgin, W. H., M. D.. M. R. C. S., 
L. S. A., Xewcastle-on-Tyne, England. 

Squier, J. Bentley, M. D. 

Stalberg, Samuel. ^L D., Philadelphia. 

Stanton, E. MacD., M. D., Schenec- 
tady, X. Y. 

Steiner, Saul, M. D. 

Sterling, .Alexander, M. D.. Philadel- 
phia. 

Stevens. .A. Raymond, M. D. 

*Strickler, .Albert E.. M. D.. Philadel- 
phia. 

Strunsky, Max, M. D. 

Swan, John M.. M. D., Rochester, 
N. Y, 

Swift, Edward, M, D., Los .Angeles, 
Cal. 

Synnott, Martin J., -A, M.. M. D., 
Montclair, X. J. 

*Taylor, J. Madison, M. D., LL. D., 
Philadelphia. \ 

Telfair. John H., M. D. 

Thomas, Lee W., M. D. 

Thoms, Herbert K„ M. D., Xew Lon- 
don, Conn. 

TiLTox. Benjamin T., M. D. 

Tompkins, H. E., M. D., D. D. S. 

Toney, L. C, M. D., Los Angeles, Cal. 

TousEY, Sinclair, A. M., M. D, 

*Turxbull, Major C. S., M. D., Phila- 
delphia. 

TwoMBLY, Margaret M.. Stanford L'ni- 
versity, California. 

Ulmax, Joseph F.. M. D., Philadelphia, 

*Vail, William Penn. M. D., Philadel- 
phia. 

Wachenheim, F. L., M. D. 

W.xlker. J. T. Aixslie, F. R. S. M., 
F. C. S. 

*Wheeler, Claude L., A. B., M. D. 

White, Charles Stanley, M. D., Wash- 
ington, D, C. 

White. G. Howard. Jr.. A. B., M. D., 
Baltimore. 

Whitmore, Eugene R.. M. D. Major, 
Medical Corps, United States .Army. 

V\'ertexbaker,C. p.. M. D., Xorfolk. 
Va. 

Wiener. Solomon, M. D. 

WiLENSKY. A. O.. M. D. 

Williams, B. G. R., M. D.. Paris. 111. 

Wilson, .A. M.. M. D., Kansas Citv, Mo. 

*\\"iLsoN, H. Augustus, M. D., Phila- 
delphia. 

■nViLsoN. J. G., M. D.. United States 
Public Health Service. 

Wise. Fred, M. D. 

Wiseman, Joseph R., M. D., Svracuse, 
X. Y. 

*Witherstine, C. Sumner, M. S., M. D.. 
Philadelphia. 

WoHL, Michael G., M, D.. Philadelphia. 

Wolbarst, .Abr. L., M. D. 

Wood. Harold B., M. D., D. P. H., Prov- 
idence, R. L 

Woodbury, Fr.^nk, M. D., Philadelphia. 

*WooDRUFF. Charles E., M. D.. Lieuten- 
ant Colonel, Medical Corps, United 
States -Armv, retired. 

Wright. Adam H., B. A.. ^L D., M, R. 
C. S.. Toronto, Canada. 

Wright, S. J., M. D., Akron, Ohio. 

Zangger, Theodore, M. D., Zurich, 

Switzerland. 
ZiGLER, M.. M. D. 



New York Medical Journal 



INCORPORATING THE 



Philadelphia Medical Journal Th'e Medical News 

A Weekly Review of Medicine, Established 1 8 43. 



Vol XCVIII, No. i. 



NEW YORK, JULY 5, 191 3. 



Whole No. 1805. 



©risnial Cflmmuniratwns. 



NOTE ON ACTION OE TESTICULAR 

EXTRACT. 

By Allen J. Smith^ M. D., 

Philadelphia, 

Professor of Pathology, University of Pennsylv.Tiiia, 

AND W. J. Crocker, V. M. D., 

Philadelphia, 

Instructor in Veterinary Pathology, University of Pennsylvania. 



A,s a part of a series of investigations having as 
their ultimate purpose the production of tumors, 
the writers conducted a group of experiments 
in the summer and fall of 1910, with observa- 
tion for a period of twelve months thereafter, 
upon the combs of old hens subjected to frequent 
injection of a salt solution extract of the testicles 
of cocks. The underlying hypothesis tentatively 
assumed that in the development of neoplasms 
three factors are combined: (a) That the cells 
from which tumors grow should be afforded a full 
pabulum for growth (other things being equal, 
should be in a part well supplied with blood cir- 
culation) ; (b) that such cells should be more or 
less independent in their structural relations (cut 
off from their proper relations as congenital 
"rests" or disturbed in their relation by injury and 
imperfect repair) ; and (c) should be subjected 
to a stimulus to growth (such stimulus perhaps of 
external origin, or perhaps of internal origin as 
quantitative faults of internal secretions or faulty 
metabolites retained in the system). The comb of 
the hen was chosen because of its exposure to 
ready observation and manipulation, and because 
it is a part usually well vascularized and therefore 
well nourished ; and because o\ its commonly ob- 
. served variations in different times in the life of 
the hen it was supposed to be a part easily in- 
fluenced by stimuli or by depressants to growth. 
Moreover, several years previously Walker {Pro- 
ceedings, Royal Medical Society, Liverpool, April, 
1908, i. No. 6, pp. 153-156) in studying the devel- 
opment of secondary sexual characteristics in 
fowls had pointed out among other features the 
enlargement of the combs of hens injected fre- 
quently with a salt solution of cock's testicle. By 
a variety of means it was sought to establish the 
second hypothetical factor, that of disturbance of 
cellular structural relations, in the hens subjected 
to experimentation, these including such measures 
as producing inflammations of the comb by repeat- 



ed puncture, scratching, intruduction of various 
foreign particles, introversion of the superficial tis- 
sue, attempts to establish long continued but mild 
electric intrahislological currents, etc. Coinci- 
dentally a salt solution extract of cock's, testis 
was injected subcutaneously at a distance from the 
comb, usually under one or other wing, at first 
daily, toward the latter part of the period of in- 
jection every third or every fourth day. The ex- 
tract of testis was made of a ten per cent, strength 
of fresh sterile testis in normal salt solution. A 
fresh testis having been obtained and weighed, it 
was with due precautions cut into fine bits, and in 
a small amount of normal saline was well ground 
in a mortar with coarsely powdered sterile glass, 
sufficient normal salt solution being thereafter add- 
ed to bring the total amount of the solution used to 
ten times the weight of the testis.. This was then 
placed in a sterile protected flask in the refrigera- 
tor for twenty-four hours, and thereafter passed 
through a tested sterile Berkefeld filter ; and the 
filtered extract distributed in sterile vials. These 
vials were placed for forty-eight hours in the in- 
cubator and those showing growth of bacteria were 
rejected. At the same time tubes of ordinary media 
were inoculated with the filtered extract from each 
vial, and in case of positive growth the vial in ques- 
tion was rejected. 

It is almost needless to state that the attempts 
to produce tumors of any sort failed. The injec- 
tions were continued from the early part of July 
until well into October (a period of three months), 
and the hens were kept under observation for a full 
year longer before they were discarded. If the 
original hypothesis be correct, the writers are dis- 
posed to attribute failure to a lack of success in 
providing sufficiently well the second factor named, 
that of inducing deviations of cellular relations in 
the comb (i. e., of producing artificial "rests" of 
cells capable of responding to the stimulus of the 
testicular extract) ; for unquestionably the first of 
the three factors, that of the existence of suitable 
blood supply, existed in the site of manipulation ; 
and the third, that of induction of growth of the 
comb, was clearly successful, as evidenced by the 
following statements and illustrations. Until some 
more certain method of producing disturbance of 
cellular relations is at hand, the writers have post- 
poned further prosecution of this line of study, but 
feel that in confirmation of Walker's studies it may 
be of interest to record by publication the effect 
of the testicular extract upon the growth of the 
comb in hens. 

Twelve hens were obtained June 21, 1910, in the 
market, all mature, certainlv none of less than a 



Copyright, 1913, by A. R. Elliott Pnhlishing Company. 



SMITH AXD CKOCKHR: ACTIOS OT TESTICULAR EXTRACT. 



lull year of ag-c, and from their appearance all 
probably three or four years old. Tracings ot' the 
outline of the combs were made the same tlay, or 
on the day of beginning injection (line i in each 




of the diagrams) ; and general descriptions of each 
hen with particular description of the comb of each 
recorded Thereafter until July 6, 1910, the hens 
were allowed to become accustomed to their house 
and yard and were well fed. During this period, 
after the first day or two, from three to five eggs 
were collected daily until some time after the in- 
jections were begun ; and the hens thrived. ()n 
July 6th, injections of 2.^ c. c. of testicular extract 
were started, and continued daily until September 
.•^oth, after which the injections were made at in- 
tervals of several days ; and were finally discon- 
tinued on October 25th. During the same period 




the local irritation of the combs was performed at 
intervals of aljout one week. The combs were 
traced in outline on July loth (line 2 in diagrams), 
on August 3rd (line 3 in diagrams), and on No- 
veiTiber 23rd (line 4 in diagrams), the last about 
a month after the last injection. It should be 
stated that in October several severe frosts oc- 
curred, as well as in November. It was iiitended 
to measure the combs at about the same time that 
injections of extract were discontinued : but ju.st 
before this time a cold period occurred in which a 
distinct shrinkage of the combs took place, and 
measurement was postponed with the hope that with 



])ension of the testicular extract and to intercur- 
rent diseases of the hens, but might well be disre- 
garded so far as the influence of the testicular ma- 
terial is concerned because of the confusion un- 
questionably depending upon these other factors. 

In a general way, with few exceptions. Walker's 
statements were well supported by our own results. 
The combs of most of the hens actually increased 
in size, both in the flat outline, as shown in the 
diagrams, and also in thickness, not shown in the 
tracings. The combs brightened; the wattles in 
correspondence enlarged and brightened ; in some 
of the hens the neck feathers became somewhat 




more brilliant ; and slight growth and brilliancy of 
color appeared in the small feathers at base of tail ; 
in one a slight but distinct growth in spurs was 
recognized ; the production of eggs diminished, and 
ceased after August 24th ; some of the hens be- 
came combative, and several times individuals were 
seen to attempt to cover other hens after the man- 
ner of the cock. It would perhaps have been well 
to perform control experiments by injecting ovarian 
extracts in the same way into hens and cocks ; but 
this was not done, since the direct purpose of the 
work was not concerned with the broader biological 
fact. However, as far as the observations go, they 





a succeeding warm period there would follow res- 
toration. This did not occur, and the final meas- 
urement shows in almost all the hens a decrease, 
which in part is surely due to the cold weather to 
which the fowls were exposed in their yard and 
coop built of a well roofed piano box and kept out 
i)f doors: in ])nrt it is probably due to the sus- 



are suggestive of the credibility of the idea that 
upon some internal secretion from the testis, a hor- 
mone, the prominent secondary sex characteristics 
of the male bird are dependent ; and are here pre- 
sented merely for their "face value"' and no more. 
The variations in the size of the combs are suf- 
ficiently indicated by the outline tracings of each, 
and are submitted without further general com- 
ment : 

Hcii j: Comb on June 21, 1910. pale and dingj- red in 
color; measurement, line i. Comb on July 19, 1910, un- 
changed. Comb on August 2. 1910. unchanged. Comb on 
November 23. 1910. unchanged. (Fig. i.) 

Hen 3: Comb on June 21. igio. bright red: measure- 
ment, line I. Comb on July 19, 1910, unchanged. Hen 
combative, feathers of neck and base of tail becoming 
metallic green. Comb on .\ugust 2, 1910. measurement, 
line 3. Hen died in early part of November, with marked 



July 



i.Eni-.Ri.i.: ki:Dicriox of ixf.ixt .moktality 



tluid fxudate in perituneuiii. Had had a local infection 
under wing in region of injections; and this and exposure 
believed to have caused death. The hen had in the course 
of the injections manifested marked male characters in 
combativeness and attempting to cover other hens. 
(Fig.-... 
Hen .?.■ Cumi) on July 6. lyio. bright red, large, meas- 




urement, line I. Comb on July 19. 1910. measurement, line 
2; small papillary growths near base of comb; hen struts, 
combative. Comb on August 2, 1910, measurement, line 
3; hen continues to show male tendencies. Comb on No- 
vember 2i. 1910. measurement, line 4. (Fig. 3.) 

Hen 4: Comb on July 6. 1910. large, bright red; meas- 
urement, line I. Comb on July 19, 1910, measurement, line 
2; wing, neck, and rail feathers coarse and glossy. Comb 
on August 2. igio. no change. Comb on Xovember 23, 
1910. unchanged, line 4. (Fig. 4.) 

Hen 5.- Comb on June 21, 1910, small, pale; measure- 
ment, line I. Lomb on July 19, 1910, no change. Hen 
sick and droops. Comb on August 2. 1910, no change. 
Has been sick until last day or two. Comb on Novembei' 
2T„ 1910 measurement, line 4. Increased. Wartlike growth 
appeared on comb but disappeared (August 12th to Sep- 
tember 2d). Fig. 5. 

Hen 6: Comb on July 6. iqto. large, dirty red ; meas- 




urement, line I. Comb on July 19. 1910. increased, meas- 
urement, line 2: tail feathers coarse, showing growth. 
Comb on August 3. 1910. shrunken, line 3; a fungous dis- 
ease spreading from base of comb appeared first on July 
28th, with loss of color and constant shrinkage. Comb on 
November 23. 1910, shrunken, line 4. A new spur, one 
half inch long, had grown, tail Jarge. On September 5th a 
white false membrane appeared in mouth and throat, 
treated with mercuric chhsride swabs for a week, when 
the parts appeared and remained normal. (Fig. 6.") 

Hen y: Comb on June 21, 1910, small, bright red; meas- 
urement, line I. Comb on July 19, 1910, no change in size 

.■>'. 



^'y//i^"~f \ V; ''\, 




-lien 9. 



but with many fine papillary outgrowths upon it. Neck 
and tail plumage brighter. Comb on August 3, 1910, slight 
increase ; line 3. Comb on November 23, 1910, shrunken, 
line 4. (Fig. "."i 

Hen S: Comb on July 6. 1910. small, good red color: 
measurement, line i. Comb on July 19. 1910. increased, 
line 2; neck and tail feathers coarser and brighter. Comb 
on August 2. 1910. increased, line 3. Comb on November 
23. 1910. shrunken, line 4. (Fig. 8.) 



Hen p.- Comb on July 6. 1910. large, good red color; 
measurement, line 1. Comb on July 19. 1910, increased, 
line '2; neck and tail feathers larger; feathers on legs and 
feet urc'winj; Cmnb mi .Xuj-ust j. 1010. increased, line 3. 




Hen died .August 10. 1910. from a coccus infection at site 
of injection under wing. (Fig. 9.) 

Hen 10: Comb on June 21, 1910, large, good red color; 
measurement, line i. Comb on July ig. 1910, no increase. 
Hen combative. Infection at site of injection. Right eye 




swollen. Comb on August 2, 1910, no increase; infection 
in breast gone; eye still swollen. Comb on November 23, 
1910, shrunken; line 4. (Fig, 10.) 

Hen 11: Comb on June 21, 1910, small, not well col- 
ored; measurement, line i. Hen sick from time of injec- 
tion, and died July 15. 1910. from a pleurnperitonitis ; no 
change in size of comb. (Fig. II.) 

Hen !2: Comb on July 6. 1910. large_^good red color; 




measurement, line i. Comb on July 19. 1910. increased, 
line 2. Comb on August 3. 1910, no increase: hen sick 
and droopy from July 24th until .\ugust 4th. From August 
20th to August 24th fungous growths appeared on comb : 
dropped off between September l6th and September 25th. 
Comb on November 23, 1910. shrunken, line 4. (Fig. 12.) 



PL.WS FOR THE REDUCTIOX OF IXFAXT 

MORTALITY.* 

By Erxst J. Lederle, Ph. D.. 

rresident of the Board of Health. New York City. 

The \vork of the Department of Heahh for the 
reduction of infant mortality will be conducted dur- 
ing the coming^ summer alono- lines which have been 
graduallv developed and placed in full operation 
during the last few years. Before outlining the>e 

•Rea.l before the X:-.v York .\ca.lem.v of Me'lic'il-. May 2S. loi.v 



LliDEKLLi: KEDUCTION OF INFANT MORTAUTY 



plans in detail, il may therefore be helpful to recall 
l)riefly the history of the development of this func- 
tion of the department. 

In 1876 the Department of Health, having- re- 
corded an unusually high mortality among infants, 
applied for and obtained a special appropriation for 
the employment of a staff of physicians during the 
months of July and August. These physicians were 
known as the "summer corps," and they were as- 
signed to duty in the congested tenement house re- 
gions of the city, where they treated all sick babies 
whose parents were unable to obtain medical care. 
This plan was followed each summer for many 
years, and without doubt has been a contributing 
factor in the steady decreases in the number of in- 
fant deaths during the last thirty years. The ef- 
fectiveness of the work was limited, however, be- 
cause its purpose was restricted to the treatment of 
sick babies, rather than the prevention of illness. 

In 1902 seventeen trained nurses were employed 
by the department, primarily for the work of school 
medical inspection. These nurses, however, assisted 
the physicians of the summer corps during the va- 
cation months of July and August, and in house to 
house visits instructed mothers in the proper meth- 
ods of preparing food for babies and demonstrated 
the correct principles of bathing, clothing, and air- 
ing. Thus the real preventive work of the depart- 
ment was begun in a small >vay. 

With the establishment of a special Division of 
Child Hygiene in 1908, the summer work for babies 
became an important function of the new division. 
In May of that year the commissioner of health 
had organized a Conference on the Care of Babies 
in an effort to coordinate and make more eft'ective 
the work of public and private agencies. This was 
the first definite eft'ort to prevent duplication of 
such work, and the same idea is now carried out by 
the Babies' Welfare Association, organized in 191 2. 

The Division of Child Hygiene was formed in the 
autumn of 1908, and the appointment of a staff' of 
141 nurses made possible an important extension of 
the preventive activities of the department. Since 
that time the department has endeavored to visit 
mothers as soon as possible after the birth of the 
babv, and to provide continuous instruction in the 
eft"ort to keep babies well, rather than rely on cur- 
ing them after they have become ill. 

It was now possible to undertake lectures on the 
care of babies each week at the various recreation 
piers, public playgrounds, and other social centres 
throughout the city. In cooperation with private 
agencies, the department assigned medical inspec- 
tors and nurses to the infants' milk stations con- 
ducted by the Brooklyn Children's Aid Society and 
the New York Diet Kitchen Association in 1909, 
1910, 191 1. Another idea which has been success- 
fully developed and widely commented upon was 
the organizing of Little ^lothers' Leagues among 
the girls attending the public schools. 

In 191 1 another important step was taken, in the 
establishment of municipal infants' milk stations. 
Successful as the work has been since 1908, it was 
still limited to a special campaign each summer, 
whereas the idea of the department was to treat in- 
fant mortality as an all the year round problem. An 
experimental appropriation for the establishment of 



fifteen infants' milk stations under the administra- 
tion of the department, to be operated throughout 
the year, was an important step in this direction. 
The New York Milk Committee and other private 
agencies operated a much larger nimiber of stations, 
and the result of the combined efforts was so en- 
couraging in lyii that the city authorities granted 
an additional appropriation for 191 2 sufficient to in- 
crease the number of milk stations to fifty-five. The 
appropriations are so arranged as to permit of dou- 
bling the staff' of attendants during the six months 
from May to November, but the stations are op- 
erated throughout the year, and the work of the de- 
partment, along the lines which have been de- 
scribed, is now ceaseless. Moreover, the efforts 
of all private associations and individuals interested \ 

in saving the lives of babies are now coordinated in 
a more eft'ective way than ever before, by the Ba- 
bies' Welfare Association. 

PL.^NS FOR THE COMING SUMMER. 

The methods which have been referred to will be 
carried out during the coming summer under all 
the advantages of accumulated experience and im- 
proved organization. At each of the fifty-five milk 
stations a nurse is on duty all the time and a doc- 
tor is on duty two days each week. On May 1st 
an additional nurse was assigned to each station for 
the extra wor'k of the summer months. The milk 
stations are being developed constantly toward the 
ideal of educational centres, and breast feeding par- 
ticularly is encouraged as far as possible. The 
number of mothers who now come to the stations in 
order to obtain milk for themselves, so that they 
may nurse their babies, is encouragingly large. 

On July 1st, all of the nurses now doing school 
work will be assigned to duty in the instruction of 
mothers. Each nurse will have 150 babies to care 
for, and will work in a district which is not already 
covered by the activities radiating from an infants' 
milk station. This custom has been followed for 
the past two years with great success : the nurse 
visiting the baby as soon as possible after it is born 
and keeping it under continued observation during 
the hot weather. Every morning each group of 
two or three nurses meets with the department 
physician and consults with him regarding delicate 
or sick babies. If a child is not normal, the medi- 
cal inspector visits it himself and refers the family 
to the proper dispensary or hospital to have the baby 
treated, if necessary. In 1912, 38,000 babies were 
treated and 1,600,000 quarts of milk were dispensed 
at these stations. 

Beginning this week, lectures on the care of 
babies are being given in all the public schools to all 
girls over twelve years of age, in order to enlist 
their interest in the formation of the Little Moth- 
ers' Leagues. These educational groups will be 
kept together during the summer, as usual, by week- 
Iv lectures and demonstrations by the nurses and 
doctors of the department. 

The same splendid cooperation of private agen- 
cies which has been given hitherto is expected this 
vear. About eighty different agencies are now fed- 
erated in the Babies' Welfare Association, with its 
central clearing house for information and publicity 
at the headquarters of the Department of Health. 



Jul> 5. ljl.!.l 



KEMP: ADHESIONS AND INTESTINAL ANGILATIONS. 



PL'UE MILK. 

In addition to the specific preventive work, the 
elYorts of the department to steadily raise the sani- 
tar\- quality of New York's milk supply constitute 
an important factor in lowering the infantile death 
rate. The strenuous campaign for the extension 
of pasteurization, which has been made the first 
object of the Department of Health during tlu 
present admisistration, has had a marked effect, and 
the proportion of pasteurized milk to the total sup- 
ply has risen from fifteen per cent, to fifty per cent, 
in two years. In round numbers this is equivalent 
to an increase in pasteurized milk from 300,000 to 
900,000 quarts out of the daily suppl\-. The late-t 
step in the direction of pasteurization has been tli ■ 
adoption of the requirement that after July i, I9i,v 
cream shall be pasteurized, unless it is obtainel 
from Grade A or Grade B milk. Increasingly strin- 
gent regulations of the sale of "loose" or "dipped" 
milk is also an important factor in the programme 
of the department. 

COMPARATI\E STATISTICS OF INFANT MORTALITY. 

Deaths under one year of age and death rate in 1,000 
under one year of age, based upon estimated population 
at that age. 

.Ml causes: Diarrheal diseases: 

Year. Deaths. Rate. Deaths. Rale. 

1902 15,526 168 4,090 4428 

1903 14.413 151 3.769 39.56 

1904 16.125 164 4,726 48.08 

1905 16,522 163 4,945 48.75 

1906 17,188 164 4,943 47. oS 

1907 17.437 160 5.314 48.90 

1908 16,231 144 5.118 45.45 

1909 15,976 137 4,254 36.45 

1910 16.212 134 5,807 47.97 

1911 15.053 120 3,853 30.68 

1912 14.289 no 3,392 26.39 

IXFANT MORTALITY IN XEW Y'ORK STATE, I9I2, IX LOGO 
BIRTHS. 

Deaths under one year of age from all causes. Rate 
in 1,000 births. 

City. Rate. Deaths. 

Rochester '97.7 '539 

Xew York city 105.2 14,266 

Yonkers 1 14.2 275 

Binghamton ii4-9 125 

Buffalo 124.9 1,448 

Schenectady 132.9 241 

Syracuse 134.5 4i ' 

Albany 136.6 262 

Utica 142.9 300 

Troy 157.4 207 

Xew York State, not including New 

York city 1 14.5 10,393 

*Death from prematurity not included. 



THE RELATIONS OF ADHESIONS AND 
INTESTINAL ANGLTLATIONS RESULT- 
ING FROM ENTEROPTOSIS. TO 
CHRONIC CONSTIPATION. 
Persona! Ohsen'ations* 
Bv Robert Coi.emax Kemp, M. D., 
New York, 

Professor of Gastrointeftinal Diseases at the rordhain University 

Medical School: Consulting Physician (Gastroenterologist) to 

the Manhattan State Hospital ; Visiting Gastroenterologist 

to the Fordham University Medical School Clinic, etc. 

The subject for my paper this evening was se- 
lected with the belief that it would prove of interest 



to the general practitioner as well as to the special- 
ist, and with this object in view, I shall briefly re- 
coimt a few personal e.xperiences. It may be pre- 
mised that in what I have to say radiography will 
play a prominent part. One should take into con- 
sideration not only the radiograph, but also the 




physical signs and symptoms, in making the diag- 
nosis. For example, in a particularly interesting 
case, showing the transverse colon lying well down 
in the pelvis, or. rather, a portion of it extending 
down into that region, there are no evidences of 
interference by adhesions to the passage of bis- 
muth. The angulations and displacement alone can 
be determined by the x ray. The physical signs 
on examination and the history are, however, con- 
clusive. The patient, subsequently to the removal 
of a diseased appendix, suffered from a local peri- 
tonitis, evidently having its origin at the stump of 
that organ, and she had been" persistentlv tender 



*Read before the Medical .\ssociati( 
Vork, .Afril 21, 1913. 



of the Greater City of Ne 




l-iG. 2. — Case of Mrs. 1 
and ascending colon; angtilat 



KEMP: ADHESIOXS .IXD INTESTINAL AXGULATJOXS. 



[New York 
EDicAL Journal. 




KiG. 3.— (as 
lying in pcKis. 

over this reoion tor several years. Unquestionably. 
there are adhesions binding the descending arm of 
the transverse colon to the caput coli and the as- 
cending colon : so that the usual medical treatment 
of the enteroptosis, by application of adhesive strap- 
ping or special belt or corset, together with diet to 
increase the intraabdominal tension by accumulation 
of fat, etc., will prove of no avail. This senes as 
an illustration. .Advanced cases of chronic stenosis 
of the intestine can usually be diagnosticated with- 
out the X rays, but. even so, these should be em- 
ployed as confirmatory. For the early and positive 
diagnosis of adhesions producing chronic constipa- 
tion they are of great value. Prolapse of the ab- 
dominal organs can unquestionably be determined 
by other well known methods, but the actual an- 
gulations and distortions can be satisfactorilv 
demonstrated onlv by the Rontgen rays. One can- 
not always persuade private patients to submit to 
such an examination, either on account of the ex- 
pense or through timidity; or thev will insist that 
the physician should be capable of making a diag- 
nosis without their use. The moral effect on the 
patient, however, when he can see the actual condi- 
tions in the radiograph, is excellent, and he thus be- 
comes more amenable to treatment. The x ray is 
also of value as an aid to prognosis, and, further, 
enables the physician to determine whether or not it 
may be necessary to resort So surgery. 

The causes of constipation are too numerous to 
mention in this paper, and its etiology may. liter- 
ally, be said to be due to medical and surgical 
diseases occurring from the brain to the anus. 
Excluding all other causes, we have as a final classi- 
fication "constipation due to disturbances of the 
motor functions of the intestines." This is sub- 
divided into constipation due to retarded intestinal 
peristalsis^atonic constipation, and constipation 
due to enterospasm — spastic constipation. .Vmong 
the predi<;posing causes of atonic constipation are 



the type of nourishment taken {iood with little 
residue or constipating food), neglect of the call of 
nature, interruption of regularity, abuse of cathar- 
tics, large encmata, mental conditions, sedentary 
life, too prolonged exercises, etc. The prevalence 
of constipation among women is well known. 
Meynert found in fifty girls, aged twelve, that fifty 
per cent, suffered from enteroptosis, and that about 
eighty ])er cent, of all women in his gynecological 
clinic had the same complaint ; while it occurred in 
only five per cent, of males. Nephroptosis as a re- 
sult of traumatism, or in the form of congenital 
floating kidney, the writer believes occurs in only 
from five per cent, to ten per cent, of all cases ; 
while in the remaining ninety per cent, or ninety- 
rive per cent, it is one of the stigmata of entero- 
ptosis. The late Doctor Edebohls found nephro- 
ptosis in twenty per cent, of his cases, disregarding 
associated ptoses, while some even place it as high 
as thirt\--three per cent. In the community at 
large, the writer believes, at least from fifteen per 
cent, to twenty per cent, of all women have entero- 
ptosis, and he has found that fully thirty per cent. 
or thirty-five per cent, of women coming to him 
for treatment of the gastrointestinal tract are suf- 
ferers from this condition. In these cases the mus- 
culature of the stomach and intestines, and also the 
muscles of the abdominal walls, are relapsed, and 
these factors have also a bearing in the production 
of atonic constipation. The stigmata of typical 
cases of enteroptosis are readily recognized at sight, 
but many of the milder cases are apt to be over- 
looked by the general practitioner ; or a diagnosis 
of nephroptosis alone is made, and, in many cases, 
simply "atonic constipation." The more moderate 
types of angulation from enteroptosis, the writer 
believes, have a bearing on the disturbances of mo- 
tility of the intestines resulting in the symptoms of 
so called atonic constipation. The x ravs readily de- 




KI-MI': .iniir.SIOXS AND IXTESTIXAI. .ixaii..iri()\s. 



^^^^^■^'^ i^^l 


1 


1 


i 


f^^^^^^^^^l «-$>' l^Bi^l 


Br 






^Kfl 


^^^^1^^ 


it 

i 


1^ 



t'IG. $■ — Case of Miss D., showing markfd t-nteroiitosis; sigiiKjid 
rising to umbilicus; bismuth by anenia. 

monstrate the condition to the satisfaction of the pa- 
tient, as well as the physician, and correction of the 
enteroptosis relieves or cures the constipation. It 
is a well known fact that perigastric adhesions in- 
\ol\ing niit merely the pylorus but other regions 
of the stoiuach interfere with the motility of that 
organ and disturb its secretion. It is my belief that 
fref|uently adhesions afTecting the intestines, of 
slight or moderate degree, not sufficient to cause 
stenosis of the intestines, are often a cause of dis- 
turbance of their motor and secretory functions. 
In effect, therefore, careful investii^ation will 
demonstrate, in quite a large proportion of cases 
of so called atonic constipation, that enteroptosis 
with moderate angulations or that slight adhesions 
are factors. 

As to spastic constipation, it may be stated that 
diffuse enterospasm involving the small intestine 
occurs with spinal meningitis, diseases of the pon,- 
and medulla, and chronic lead poisoning; the ab- 
domen being retracted like a trough. Localized, 
or circumscribed, enterospasm is more frequent, 
and generally aff'ects a portion of the large intes- 
tine. Spastic constipation occurs most frequently 
in nervous patients, in true neurasthenics, and in 
the aged and debilitated. It is found as a seouel 
to chronic dysentery and ulcerative colitis and in 
cases of hy.steria and neurasthenia in women, as- 
sociated with uterine disease. In viev/ of the fact 
that, as already noted, Meynert reports that about 
eighty per cent, of all his gynecological patients 
suffer from enteroptosis, the statement ma'le al.ove 
is, to say the least, suggestive. Stenosis, also, re-ults 
from ulcerative conditions, and intermitting attacks 
of colic, with increased peristalsis above the 
stenosed region, may occur, with fecal accumula- 
tion above the point of narrowing in the gut. The 
writer believes that adhesions with narrowing of 
the intestinal canal, as well as enteroptosis with 
marked angulations, are frequent factors in the 
production of so called spastic constipation. He 
has seen the typical symptoms, with the evacuation 
of small balls (goat feces), or pencil shaped ma- 
terial, occur in the conditions stated above. 

Therefore, a careful study of so called atonic 
and spastic constipatinn niti demonstrate that 



many of these cases are due to adiiesions or to an- 
gulations from enteroptosis; the atonic tyi)e of con- 
stipation resulting from the lesser degree of these 
conditions, interfering with intestinal motility; and 
the spastic type, due to more marked adhesions, or 
.ingulalions. .-/// cases of chronic constipation 
should be carrfvUy studied with the .v rays, and it 
is this statement which the writer is desirous to im- 
press particuL'irly ujxjn his audience. 

1 shall not describe Lane's kinks or Jackson's 
membrane, which are doubtless familiar to you all, 
but merely give a brief resume of our cases. They 
are of interest, since any physician present may 
meet similar types in his practice, and they empha- 
size the necessity of careful investigation of all 
causes of chronic constipation. 1 shall not burden 
\ou with long histories, the bacteriology of the stool, 
etc., but simjjly refer to the salient symptoms. I 
have observed that long drawn out histories are 
likely to produce a "soporific eft'ecl" on the audi- 
ence : 

Case I. Mrs. C, aged furty-eigin years, referred by 
Doctor Tousey. Ill for fifteen year.s; belclied gas; very 
nervous; marked constipation, usually atonic in type; oc- 
casional attacks of intestinal catarrh with colic; had had 
two pelvic operations and asserted that adhesions were 
found o:-. both occasions. Urine, indicanuria persistent; 
stool, putrefaction. Hyperchlorhydria — total acidity 90+; 
free hydrochloric acid 50-)-. combined hydrochloric acid 
40-|- : total hydrochloric acid 90-|-. Physical examination 
showed gastroptosis and enteroptosis, but no angulation 
could be determined. 

Radiog,raph by Doctor J'oiiscy: Water trap stomach, 
enteroptosis (Figs, i and 2). — Stomach has a long verti- 
cal limb; horizontal limb short, at level of umbilicus; a 




Kio. 6. — Case of Mrs. 
colon; caput coli narrow 
transverse colon at -t-, 
normal high position. 



E.. showing noi 
and low ; hepatii 
near level of nr 



nal position of transverse 
flexure low; adhesions to 



.iDHESIONS AND INTESTINAL ANGULATIONS. 



[New York 
Medical Jourhai.. 




Fig. ;.— Case of Mrs. McM., 
olon at '^- ; hepatic flexure in 
lEcending colon dilated. 



showing adhe 
normal positi 



water trap stomach. Transverse colon dips below umbil- 
icus. Caput coli and ascending colon are much dilated. 
Marked angulation at the junction of descending limb of 
the transverse colon and its transverse limb, accounting 
for the dilatation. 

Indicanuria, nervous symptoms, and constipation persist, 
in spite of mechanical support, electricity, and usual medi- 
cal treatment. Operation advised — short circuiting the in- 
testine by joining ileum to descending colon. Up to the 
present time operation refused. Operative procedure on 
the stomach might also be indicated. 

Case II. Mrs. N.. aged thirty-one years, referred 
through Dr. Virgil Gibney. Intermittent gastric disturb- 
ances for six years; constipated habit; prolapse of rectum 
had occurred, according to patient's statement, when she 
was particularly costive: movements, cramplike and pain- 
ful Patient quite nervous, and marked erythematous 
eruption appeared on face during worst attacks. Physical 
examination showed moderate gastroptosis (semioblique 
stomach, lower border at umbilicus; nephroptosis, right 
kidney, third degree; systolic pressure, 90). Appendix 
slightly sensitive ; rectal examination showed tendency to 
rectal prolapse and sigmoid flexure prolapsed. Urine : 
slight indicanuria. Stool : No digestive failure, fermenta- 
tion, excessive intestinal putrefaction ; Gram positive, 
many. Gastric analysis — total acidity 70+; free hydro- 
chloric acid 44-|- : combined hydrochloric acid 24+. 

Radiograph by Doctor Toiiscy: Eutero/tasis (Fig. 3"). — 
Radiograph confirms diagnosis. The caput coli is narrow 
and situated low down ; transverse colon dips below um- 
bilicus; splenic flexure high; prolapse of sigmoid flexure 
into the pelvis is marked. 

The patient has greatly improved under repeated ap- 
plication of Rose's belt and medical treatment. From Xo- 
vember ist to early part of March has gained eleven 
pounds ; attending to her social duties as usual ; nervous 
symptoms have disappeared. There is no longer tender- 
ness at the appendix, while bowels are much less costive 
and movements no longer painful. Incidentally, it may 
be stated that it has always been difficult to increase her 
weight. In this case medical treatment has proved of 
value. 

C.^SE III. Miss D., aged forty-nine years. In the sum- 
mer of 1910 the writer first saw this patient at Williams- 
town, Mass., in consultation with Dr. Vanderpoel .^dri- 



nnce. The o\-aries had been removed in 1889 and the ap- 
pendix in 1901. Subsequent to the last operation, after a 
short period, the patient began to have considerable pain 
in the region of the appendix stump and there was some 
tenderness in that locality. She also began to be troubled 
with marked constipation. When the latter increased in 
severity the pain and tenderness in the right iliac region 
were more marked. 'I'here was, however, more or less 
lenderness here most of the time. The physical examina- 
lion showed moderate tenderness at the site of the old 
appendix operation and enteroptosis. Adhesions were also 
'Jiagnosticated. There were no facilities for x ray exam- 
ination. Diet, olive oil by mouth and rectum, laxativei:, 
mechanical support to the abdomen, and local iodine ap- 
plications were prescribed, with some resulting benefit, 
though the general symptoms continued. The patient 
would not consider operation. Subsequently, in February, 
1913, I examined this patient in New York. There was 
still tenderness in the right iliac region and unless ex- 
treme care was exercised, severe constipation would en- 
sue. The same diagnosis was made — enteroptosis with 
adhesions at the site of the appendix operation. 

Radiograph by Doctor Tousey. — Radiograph (Fig. 4) 
shows a low ascending colon, while the descending arm 
of the transverse colon is contiguous to the ascending 
colon; the transverse colon then dips down into the pel- 
vis; the ascending arm of the transverse colon passes 
obliquely to the lower part of the descending colon and 
then lies contiguous to it, up to the splenic flexure. 
There is a fixed splenic flexure high up (Fig. S), form- 
ing a sharp angle. There is an angulation at the hepatic 
flexure, a second angulation where the descending arm 
of the transverse colon passes from near the caput coli 
downward into the pelvis, and still another where the 
ascending arm of the transverse colon first comes in con- 
tact with the descending colon. (Fig. 5.) 

The adhesions in the right iliac region do not show in 
the radiograph, and evidently did not cause sufficient in- 
terference with the passage of bismuth to give evidence 
of their presence. The historj' and physical examination, 
however, rendered the diagnosis positive. Evidently there 
rs a thin web of adhesions uniting the caput coli and as- 
cending colon to the descending arm of the transverse 
colon. The writer advised operation — a double entero- 
enterostomy, short circuiting the upper loops, so that the 
feces would pass directly from the caput coli into the 
transverse loop and thence into the lower part of the de- 
scending colon. \\'ere the adhesions released and the 
transverse colon suspended a considerable portion of the 
latter would have to be resected on account of its great 
redundanc}'. The patient refused operation and contin- 
ued her medical treatment. About half a grain of a solu- 
tion of thiosinamine and sodium salicj'late was given three 
times a day by mouth in addition, with the possibility that 




KEMP: .IDHESIOyS AND IXTIISTI.WIL .'IXCIL.II lOXS. 




it might help absorption of the adhesions. Of its value 
I was skeptical. She was warned to always have the 
radiograph at hand and in the event of progressive con- 
stipation to at once consult a surgeon and show him this. 

Cask IV. Mrs. E., aged thirty-six years, referred by 
Doctor Peck, of New Rochelle. This patient had an at- 
tack of acute appendicitis ten years ago. Off and on for 
three years she had had vomiting spells, occurring most 
frequently near or at her periods, and usually one to two 
"hours after meals. No real nausea; vomiting acid; no 
blood visible. Pain occurred at the time of the attacks and 
food relieved this; there was also epigastric pain after the 
-vomiting. Patient fairly comfortable between attacks, and 
bowels fairly regular; during the attacks she was costive. 
Physical examination showed the right Fallopian tube to 
be tender; appendix also sensitive; uterus retroverted and 
■enlarged, presenting a fibroid condition. Gastric analyses 
average total acidity 90+ to loo-f ; free hydrochloric acid 
50+ ; combined hydrochloric acid 40 to 4S-|- ; no occult 
blood; tests for augmented secretion negative. Urine, 
indicanuria: stool, intestinal putrefaction; no occult blood. 
Hemoglobin eighty per cent. The patient unfortunately 
had no attack while in the hospital. 

Radiogra(<h by Doctor Tousey. — Radiograph showed the 
caput coli to be narrow and low ; hepatic flexure low ; 
transverse colon passing across umbilicus; splenic flexure 
in normal position. Adhesions to transverse colon shown 
by interference with the passage of bismuth. (Fig. 6.) 

The writer believes that the web of adhesions probably 
originated from the region of the appendix and that the 
gastric symptoms were reflex from the chronic appendi- 
citis, adhesions, and uterine condition. Disturbance of 
the motility of the intestines, with constipation, occurred 
when the gastric symptoms were pronounced. Operation 
on the adhesions, appendix, and uterus was advised. 

Case V. Mrs. McM., aged forty-six years, referred 
by Doctor Gonzales. The patient suffered from obstinate 
constipation apparently of the atonic type. There was a 
■ history of previous attacks of peritonitis. Physical ex- 
amination showed narrowing at the sigmoidorectal junc- 
ture, probably due to adhesions. Nothing further could 
be determined by the ordinary methods of examination. 

Radiograph by Doctor Tousey. — Radiograph (Fig. 7^ 
showed marked adhesions at the tranverse colon (consid- 
erable interference with passage of the bismuth at this 
point) ; also the caput coli and ascending colon to be 
considerably dilated. Hepatic flexure normal in position ; 
sli.ght adhesions at sigmoidorectal junction. 

Operation by Dr. Parker Syms confirmed the diagnosis. 
The patient did well for some months, the bowels mark- 
edly improving. There was then a recurrence of the 
■constipation. The radiograph taken by Doctor Tousey 
at this time showed a recurrence of adhesions at the 
transverse colon. A second operation by Doctor Syms 
confirmed their presence and they were again separated. 
Marked adhesions, however, were also discovered be- 
tween several coils of the small intestines and the ab- 
dominal wall on the left side, as well as adhesions to the 
ascending colon, but my recollection is that there was 



one majs of adhesions which it was considered inadvisa- 
I'le to operate upon. Doctor Syms can give you full par- 
ticulars. The constipation then again improved, after 
this second operation. Doctor Gonzales now reports the 
liaticnt If excellent condition. 

Case VI. Miss A. K., aged fifty-one years, referred 
liy Doctor Mucklow, of Brooklyn. In October, 1911, the 
liatient began to have nausea and later vomiting, both 
during the night and in the day time, of food eaten some 
lioiirs before. At times she vomited clear, watery ma- 
terial, though it was often yellow and sour to the taste. 
It is stated that she visited a specialist in diseases of the 
stomach in Brooklyn, who made the diagnosis of chronic 
appenditicis with pylorospasin. An operation showed that 
she had chronic appendicitis and pericolitis affecting the 
ascending colon. Many adhesion bands were separated, 
and the appendix was removed. The patient improved for 
a brief period, but nausea and distress later recurred, com- 
ing on one hour after meals. The family physician took 
charge of the case and, determining that there was en- 
teroptosis and believing that this was a factor in pro- 
ducing the symptoms, applied Rose's belt and the usual 
treatment for this condition. The symptoms, however, 
continued, and in January, 1913, he brought the p .tient to 
my office. At this time the nausea and distress after 
iiieals were still in evidence, there was pain over the right 
kidney, snd the patient suftered from severe constipation. 
Physical examination showed a movable right kidney, en- 
teroptosis, and apparently a semioblique stomach (mild 
gastroptosis). On account of the history the writer be- 
lieved adhesions had reformed in the appendicular region 
and gave this as his diagnosis, in addition to enteroptosis 
Total acidity 70+; free hydrochloric acid 30-|- ; combined 
hydrochloric acid 35+. The gastric symptoms were be- 
lieved to be reflex from adhesions. 

Radiograph by Doctor 7"oM.j<?y.— Radiograph (Fig. 8) 
showed a vertical hour glass stomach. The latter condi- 
tion had been unsuspected, and was evidently due to adhe- 
sions. The lower gastric border did not reach the level of the 
umbilicus. There was an enteroptosis with angulations and 
adhesions (Fig. 10) ; the ascending colon was short ; nd the 
hepatic flexure lower than normal. The descending arm 




ng en; 



:. 10,— Case of Miss .\. K. 
ing colon: low hepatic flexure; descending arm of iran . rse colon 
shar, ly angulatcd at -|- 1 ; adhesions at A; angula ion r--; trans- 

erse colon where it turns u. parallel with descen'^in colon; third 



augulatio 



nile 



fle 



3; la 



bismuth ene '-a 



TOrSEV: R.IDIOCR.tl'HS OF STOMACH .l.\D IXTIiSTIXIiS. 



of the transverse colon was vertical anil parallel with the 
ascending colon: it was sharply angtilatcd where it turned 
to cross the abdomen, and just above this point there were 
adhesions interfering with the passage of bismuth and 
evidently binding the descending arm to the ascending 
colon. On the left side there was a sharp angulation 
where the transverse colon turned upward. In its course 
to the splenic flexure, it lay parallel with and contiguous 
to the descending colon. 'I'he transverse arm crossed 
the abdomen about two and one half fingers' breadth be- 
low the umbilicus. The splenic flexure lay high up. and 
there was a sharp angulation at this point. The descend- 
ing colon lay side by side with the ascending arm of the 
transverse colon, as previously noted, while the sigmoid 
flexure lay in the pelvis. (Fig. 9.) 

Operation was advised by the writer. Apparently the 
operation of selection, would be an enteroenterostomy at 
each end of the transverse arm — short circuiting the por- 
tions of the colon above and avoiding the adhesions which 
lay just above the appendicular region. Operative pro- 
cedure was also indicated on the stomach. 

I\t!di''i;i(il^li by P.irlor ToKscy. — I'Fig. ii) is of interest 




Fig. II. — Dia^osis by x ray; gastric ulce 
gallbladder infection (gallbl.-.dder has been removed): excefsive sc- 
cietion (gastrosuccorhea). 

as demonstrating the presence of a small gastric ulcer 
secondary to gallbladder infection. Other methods of 
diagnosis had proved failures. 

There are many interestino: features in these 
cases. Abnormahtie? in gastric secretion, when 
there is gastroptosis. the writer believes, frum care- 
ful investigations carried on at the Manhattan State 
Hospital, are due to the misplaced stomach. He 
has reported in his work on gastrointestinal diseases 
the disappearance of hyperchlorhydria, after re- 
peated applications of Rose's belt alone. In patients 
with intestinal adhesions, functional disturbances of 
the stomach he believes to be, in most cases, a reflex 
from these adhesions: just as such reflexes occur 
froiTi disease of the appendix or gallbladder. Alanv 
instances of so called atonic constipation he attrib- 
utes to slieht or moderate ano;ulations from ente- 



roptosis, or to sligiit adhesions — that is, adhesions 
not producing stenosis, but merely interference with 
the motility of the intestines. ( )n the other hand, 
more marked angulations or adhesii,ins may, in some 
cases, produce the symptoms of spastic constipation 
— suggestive of commencing or mild stenosis. Un- 
questionably, correction of an enteroptosis, uncom- 
plicated by adhesions by medical means, such as 
belts, corsets, adhesive strapping, and the increase 
of intraabdominal fat, will do much lor the con- 
stipation in some cases ; while cases of enteroptosis 
which cannot be relieved by these means belong to 
the domain of surgery. All cases due to adhesions 
should be referred to the surgeon. 

Surgery. Regarding the question of surgery, the 
writer desires to present some problems for discus- 
sion this evening: the first in regard to adhesions. 
In the two operations for adhesions, both being 
[lerformed by skillful surgeons, the adhesions 
formed again, thus necessitating a second operation 
on both patients. Would it be preferable in such 
cases to short circuit the intestines by enteroenteros- 
tomy, and leave the adhesions undisturbed? In 
such event, what probability would there be of tor- 
sion of the gut. or of some other portion of the in- 
testine than the afiected part slipping beneath the 
adhesions or becoining adherent to them r 

.Second : In the case of enteroptosis witii marked 
angulations, there is always great redundancy of 
the transverse colon, and suspension of the in- 
testine would seem in some instance^ to be imprac- 
ticable, while revision of the recti muscles would 
seem equally so. Would a double enteroenteros- 
tomy, thus short circuting the angulations, be pref- 
erable? In one of my cases, even if this procedure 
liad been carried out. there would still have re- 
mained the sigmoid flexure completely prolapsed 
and anguiated and lying in the pelvis. The addi- 
tional problem would then remain, whether to re- 
sect, to short circuit, or to suspend the sigmoid. 
Unless some such procedure were carried out. there 
would probably be still sufficient mechanical ob- 
>iruction to produce constipation. 

It has been my endeavor this evening to demon- 
strate not only the great value, but also the neces- 
sity, of careful examination by means of the Roent- 
gen rays of all patients in cases of chronic constipa- 
tion, and if T have succeeded in impressing this 
fact upon my hearers I shall feel that I have ful- 
filled my task. 

103 E.SPT F"lFTV-SEVEXTH StREET. 



SOME RADIOGRAPHS OF OBSCURE STOM- 
ACH AND INTESTINAL CASES. 

Caution Regarding Dangerous Tendencies in Re- 
cent Radiography of the Gastrointestinal Tract* 
By SiNrr..\iR Tousey, A. iM.. ~Sl. D., 
Xcw York. 

The primary facts regarding x ray diagnosis of 
these cases are familiar to all of us. The patient 

■Head be'ore Ihe Mcdir.il .\?=.«:i,iti..ii .f the C-taT-r City rf New 
Vork. -April 21. 1913- 



")•}.] 



rorsiiV: K.inioch'.ii'iis or stom.ici/ .i.\i> ixrnsris'Fs. 



ci.)Uii.-^ with the stonuu-li and inli-stiiic empty. Xo 
soHd food and no milk arc laUen fur thirty-six 
lioiirs prior to tlic examination, and tlic bowels arc 
moved by a laxative the night before the examina- 
tion, and in many cases the night before that. A 
meal consisting of mashed potato, a glass of water, 
and an ounce or an ounce and a half of bismuth 
oxychloride forms an accurate mold of the stom- 
ach and casts such a dense shadow in the radio- 
graph as to show the size, shape, and position nf thu- 
stomach. Dislocation, ptosis, or displacement d'lWii- 
ward, and hourglass contraction arc e\ident at a 
glance, as seen in some of the radiographs shown 
to-night. Other lesions, like cancer, are indicated 
by changes in the outline of the stomach, changes 
in the time required to empty itself; and in the 
case of ulcer of the stoiuach, or ulcerative cancer, 
by bismuth remaining adherent to a portion of the 
stomach wall after the contents in general have 
passed on into the intestine. (Fig. ii. Doctor 
Kemp"s paper.) Obstruction and ulcer in the du >- 
denum and other parts of the small intestine are 
shown by radiographs made at various times after 
a bismuth meal. The best demonstration of lesions 
of the rectum, the sigmoid flexure, the descending, 
transverse, and ascending colon, and the cecum is 
by a radiograph made after a bismuth or barium 
enema. A radiograph of mine which shows the 
rectum and sigmoid flexure was made after an in- 
jection of barium sulphate, purified for radiological 
use and suspended in a thick decoction of potato 
flour. This formed a pasty ma^ which rain very 
slowly from a fountain syringe and filled only the 
required part of the intestine. The radiographs are 
specifically referred to in Doctor Kemp's p irtion of 
this paper. 

Dangerous tendencies in recent x ray work upon 
the gastrointestinal tract lie chiefly in the use of the 
fluoroscope and in the making of multiple radio- 
graphs of the same patient. The voice of the 
tempter tells us that we can watch the progress of 
a bismuth meal with the fluoroscope, while the 
patient is exposed to a radiance which would not 
hurt him if applied all day, and that when difTerent 
important stages are observed the photographic 
plate may be substituted for the fluorescent screen 
and a radiograph be made with a stronger ray ap- 
plied for a fraction of a second. It is very far from 
being true, however, that any ray which gives a 
perceptible fluoroscopic image through the abdomen 
can be safely applied indefinitely. I do not permit 
this at all in my .x ray laboratory; but if T did, it 
would be on condition that the dose of the ra- 
diance used for fluoroscopy should be measured, 
and the safe time of exposure determined before- 
hand and strict account made of everv second's 
exposure. Of course the fluoroscopic screen should 
be observed in a mirror while the operator is pro- 
tected from the x ray by a lead shield. 

Another dangerous use of the fluoroscope is in 
a preliminary observation to facilitate the location 
of the patient, the x ray tube, and the plate, in the 
efTort to secure the picture of the desired portion, 
say the stomach, upon a plate of rather small size, 
say eight by ten inches. The varying size and po- 
sition of the stomach make it difficult to be sure of 



a good jiieture upon a ])iate of this size, but the au- 
thor is so certain of the danger of fluoroscopy that 
he avoids it by using a larger plate. This would 
not be so practicable for an attempt at cinemato- 
graphy, but, as will be seen later, the author thinks 
this undesirable. The matter of clear definition 
oyer a larger i)late is secured by means of a flat 
diaphragm of say two and three quarters by three 
and one quarter inch orifice directly in contact 
with the wall of the x ray tube. The diajjhragm is 
of material opaque to the x ray, but not a conduc- 
tor of electricity. The objection to multiple radio- 
graphs, and especially cinematographs, is the dan- 
ger of overexposure. It is less than ten years since 
the radiologist of one of our largest institutions 
told the author that he never attempted a radiograph 
of the hip joint because his apparatus required an 
exposure of forty-five minutes, and patients knew 
that it was done elsewhere in about seven minutes, 
and were afraid of being burnt. As a matter of 
fact, the patient was subjected to the ■same amount 
of X ray by the exposure of seven minutes with t!ie 
stronger apparatus as by the forty-five minutes' ex- 
posure with the weaker apparatus. .\nd to-day, 
with vastly more powerful apparatus, the patient is 
exposed to the same amount of x rav in a second 
or two. 

Just as there was a very distinct limitation to the 
number of pictures that could be safely made 
through the abdomen with the long, weak 
exposures, there is also about the same limit 
with the short, strong exposures of to-day; and 
because it is easy to give the exposures in 
rapid succession, there is danger that the safe 
dose may be exceeded. The individual exposure 
may be reduced to a small fraction of a second 
by the use of an intensifying screen. The>e 
screens dififer so much in efficiency that the exposure 
may be one half or perhaps onlv one tenth that re- 
quired without the screen. This means that from 
two to ten times as many pictures may be safely 
made as without an intensifying screen. ' But when 
It comes to twenty, thirty, or fortv radiographs, as 
in radiocinematography, one is dealing with a dose 
which should be exactly measured, and its effect 
upon the individual patient most carefully consid- 
ered before applying it. The author has made 
measurements of the x radiance from all the modern 
transformers and from the unfluctuating converter 
which is partly his own invention. At a distance 
of ten inches from the anticathode to the skin, and 
with the current usually employed in rapid radio- 
graphy, most of these reach the danger limit a^ to 
burns in ten or twenty seconds; so that a great 
manv exposures, even though each lasts only a 
fraction of a second, present a danger from der- 
matitis and may have an undesirable efl^ect upon 
the general system. 

The modern apparatus makes it possible to make 
individual pictures of moving organs like the stom- 
ach, and this may be repeated at diflferent stages of 
digestion, but I think it dangerous to make a very 
large number of exposures to show the actual mo"- 
tions of the organs. 

850 Sevexth AvExrE. 



SINGER: TORPOR RECTI. 



[New York 
Medical Journal. 



TORPOR RECTI; DVSCIIEZIA. 

./ Contribution to the Pathogenesis of Habitual 

Constipation. 

By Gustav SingeRj M. D., 

Vienna, Austria, 

I'rofessor, University of Vienna; Primarius, Fiist Medical Divisinn. 
Rudolf Hospital. 

The treatment of constipation has always been 
a favorite field of research with ciualified and un- 
qualified practitioners. In the insistence on evacua- 
tion by way of the bowels is shown the great im- 
portance attached by the physicians of old to tlie 
regular evacuation of these by invalids, as well a* 
by healthy persons. While the therapeutics of 
habitual chronic constipation has long been a sub- 
ject of research in the laboratories of expterimental 
pharmacologists, it is astonishing that it is only in 
the last few years that scientific medicine has en- 
deavored to remove the prevailing vagueness in 
the knowledge of the subject by experience oli- 
tained from exact examinations. In this article, 
ifitended only for the practitioner. I wish to avoid 
discussions of controversial views and only to speak 
on one particular point, which must be regarded as 
an assured result, both for our comprehension of 
this form of ailment and for its therapeusis. On,^ 
who is accustomed to examine the rectums of many 
patients, whether they complain of constipation or 
not. will find, partly by digital palpation and partly 
by endoscopic methods, marked dififerences in the 
conditions present. 

In manv persons, even those who are suffering 
from obstinate constipation, we find the rectum, 
including the ampullar portion, empty or occupied 
onlv by insignificant fragments of feces. The ex- 
treme on the oiher hand is characterized by the 
presence of large masses of compact or loose feces, 
distending the ampulla and often reaching to the 
external sphincter. This condition of afifairs is 
found remarkably often in women, with or with- 
out genital affections, and the question has been 
asked what connection can exist iDetween the pres- 
ence of feces in the rectum and the physiological or 
abnormal evacuation of the bowels. Samuel G. 
Gant tells us in his Fecal Impaction that in about 
sixty per cent, of the cases of constipation impac- 
tion of feces is to be found in the rectum, an<l 
Ebstein. holding the same opinion, has described 
a peculiar method of palpation by means of which 
we can feel this accumulation of feces between the 
gluteal fold and the point of the coccyx withmit 
penetrating into the anus. 

Elenle. Hvrtl, and ()'i!eirne have discussed th ' 
question of the normal state of the rectum, empty 
or filled, but without going into any recital of this 
discussion, I will express my conviction tha' 
the famous anatomist Hyrti was undoubtedly cor- 
rect in his conclusions. I myself have never found, 
under normal conditions, any noteworthy impac- 
tion of feces in the rectum, and therefore believe I 
am justified in saying that the normal state of the 
rectum is emptiness. The examination of the 
physiology of the act of defecation made in experi- 
ments on animals by Langley. Anderson, and 
others in confnrmitv with the conditions specified 
by O'Beirne, has proved that in physiological de- 



fecation the bowel contents are broken off at the 
flcxura lienalis and evacuated below it. 

In a prompt act of evacuation by a person pos- 
sessing perfectly healthy bowels, the feces are really 
evacuated in one pillar, a fact which was cuifirmed 
by mv X ray examinations of the la.xative effects 
of bile acid. Even in healthy subjects, however, 
there are many deviations from this physiological 
standard, though I have convinced myself by va- 
rious observations, both rectoscopic and radiologi- 
cal, that this manner of evacuation is the jjliysio- 
logically correct one. The anatomical configuration 
of the parts at the junction of the lower end of the 
flexure with the rectum, showing the presence of 
an exceptionally strong muscle at the boundaries 
of the sphincter rectoromanus (Schreiber) and 
sphincter tertius (Hyrtl), is such as to present a 
barrier between the reservoir for feces aflforded by 
the lower flexure and the position of the rectum 
in evacuation. When the great colon begins 
to act (Holzknecht) it pushes forward the con- 
tents of the bowels toward the lower flexure, 
and it is the opening of the sphincter rectoro- 
manus which, under the pressure of the oncom- 
ing pillar of feces, causes reflex evacuation. 
This process, the result of combined muscular 
action, begins at the moment when a suffi- 
ciently large amount of stool advances into th; 
ampulla. At this point the opening of the sphincter 
begins, and I consider this as a specific action of 
the ampullar portion of the rectum. It is from the 
complicated action of the abdominal muscles, the 
diaphragm muscles, the pelvic floor (levator ani), 
and last, but not least, the muscular apparatus of 
the rectum, coordinating synergy of various im- 
pulses — that the regular act of evacuation results. 

In many individuals the introduction of an in- 
strument or even of a finger into the rectum is 
sufficient to call forth this reflex influence, resulting 
in the desire for defecation. This is made use of 
not only bv mothers and nurses, but also methodi- 
cally in the treatment of certain forms of constipa- 
tion (as in my treatment with bougies). 

When we consider the mechanism referred to it 
must strike us that so many people are going 
about with their rectums full to overflowing, yet 
without feeling the necessity of defecation. This 
characterizes a special form of constipation which 
has been long observed and is regarded by me as 
anomalous : produced by different causes connected 
with defective innervation and undersensibility- of 
the mucous membranes of the rectum. I have 
called this frequent form of constipation torpor 
recti and drew attention to it as late as n;0'). 
Years before that I had used methods of treatment 
for the relief of this condition. This torpidity of 
the mucous membrane of the rectum is mcst fre- 
quently acquired by voluntary resistance to the 
normal act of defecation, from false shame, etc. 
These organs concerned consequently becume in- 
sensitive to any lesser stimulus, and so that event- 
ually feces may accumulate to such an extent in the 
ampulla that they have to be removed manually. 

Nervous stoppages, however, are not the onlv 
cause which renders the act of evacuation diffictilt, 
or even impossible, for I believe that the quality 
of the stool entering the ampulla contributes to a 



July 



I9'3J 



IIIRSCH: NEW BIOROnXl GENOGRAPIIIC APPARATLS. 



13 



certain degree to the prompt course of the act 
(eccoprose). On referring to Adolphe Schmidt's 
researches we find that the want of water and the 
too complete absorption of the contents of the 
bowels are responsible for defective stimulus of 
peristalsis. To this class belong those varieties of 
constipation due lo the different cjualities of the 
food ; a meat diet, with its small residue on the 
one hand, and a diet of food rich in cellulose on 
the other. One must not ignore the fact that cause 
and effect can be confounded. Even l)owel contents 
in themselves well adapted for evacuation may by 
various causes be retained for a longer period than 
normal in the lower intestine, and there become 
thickened by absorption of water, so that in this 
way evacuation is rendered still more difficult. 

We know from numerous instances that anom- 
alies are met with in the intestines. Some patients, 
although treated with the most varied diets and 
those proving very effective in other cases, continue 
to have a marblelike stool. Hertz designates this 
condition very expressively as "greedy colon." 
Such an anomalous resorption may, I believe, be 
inherited through several generations, and this 
must be taken into consideration when we some- 
times find young infants atllicted with the most 
obstinate type of rectal constipation. 

In connection with the acquired forms of con- 
stipation, it must be mentioned that such ampullar 
constipation may arise also from weakness of the 
muscles of the pelvic floor, so that the evacuation 
of feces is rendered difficult or even impossible. 
This state is often found in women with severe 
ptosis and vaginal prolapse, with perineal lacera- 
tion. Like myself. Hertz has dift'erentiated this 
particular form of rectal constipation from the com- 
plex of habitual constipation and has given to it a 
special name, which has been generally adopted, 
dyschezia. Hertz defined with this term the state 
in which it is impossible to empty the rectum com- 
pletely. Some part of the stool always remains, 
and thus the feces accumulate gradually until large 
masses fill the ampulla. This has been compared 
to the somewhat similar condition met with in the 
bladder, and the larger or smaller quantity of feces 
found in the rectum after defecation has been called 
by Federn residual feces. 

The stimulus excited by such a filled ampulla on 
the muscular apparatus entrusted with the act of 
defecation is such that it acts frequently and in- 
completely, instead of once and thoroughly, a type 
answering to the fragmentary stool evacuation of 
Boas. But I must here remark that these and 
many other symptoms are to be regarded as sec- 
ondary, and as stimulus called forth only by the 
stagnant contents of the bowels. 

Dyschezia is divided by Hertz into two classes : 
I. Insufficient e\ acuation ; 2, the obstacles to a 
sufficient evacuation. I think that this second 
class does not strictly belong to the group of am- 
pullar constipation called by me torpor recti. In 
the first group of causes are : Habitual disregard 
of the call to defecation, weakness of the voluntary 
muscles of evacuation, weakness of the reflex de- 
fecation ; in short, complications completely agree- 
ing to the anomalies caused by the recurring torpor 
recti above mentioned. Characteristic is the fact 



that the x rays show the shadow band rcachin;; 
to the anal exit and a marked distention of the 
ampulla. I repeat that I do not go as far as Hertz, 
who includes in dyschezia forms of constipation 
properly belonging to other conditions. 

The name of torpor recti ought really to be re- 
served for rectal irregularities only, whi.h, as men- 
tioned, result Irciui a defective course of e\a na- 
tion caused by want of stimulus. The diagnosis 
of this special form of rectal or proctogenal con- 
stipation, as it is called by Strauss, is fairly simple. 
A description or observation of the stoul and digi- 
tal or endoscopic examination usually suffice. Im- 
portant is the fact that diet or purgatives are as a 
rule of no value. 

For many years I have used very small enemas, 
but not with glycerin, on account of the intense 
irritation caused by it. Water, chamomile tea, w arm 
olive oil, oleum hyuscyami and liquid jjaraffin, ap- 
plied morning and evening, are to be highly recom- 
mended. The paraffin, spreading over the surface 
of the bowel membranes, softens the dry feces at- 
tached to it and prevents excessive dryness of the 
contents. For children a cacao butter suppository 
is often sufficient. 

In addition to dilating tubes and bougies used 
by me in some forms of spasmodic constipation, I 
would chiefly recommend a form of treatment which 
was, I think, first recommended by Ewald and intro- 
duced into therapeutics under the name lavement 
electrique. A tubular electrode, furnished at its 
centre with a metal mandrel, is introduced into the 
rectum. Two hundred grammes of water are 
poured into it, and this probe can be charged from 
either electrical pole, according to the effect desired. 
A broad, flat electrode is applied alternately to the 
flexure of the colon and to the cecum. The ap- 
plication lasts ten minutes. After my experience 
with this method I can say that I have obtained 
sjood and lastinsf results in the most obstinate cases. 



A XHW BIOROENTGENOGRAPHIC 

APPARATUS.* 

By I. S. HiRSCH, M. D., 

New York, 

Uontgenolugist, Bellevue Hospital; Lecturer in Rontgenology, 
Po&t-Graduate l\iedical School and Hospital. 

The attempts made to obtain kinematoradiographs 
have been by two general methods. In one, the in- 
direct method, it is sought to photograph the image 
on the fluorescent screen ; by the other, the direct 
or serial method, a series of radiographs are made, 
which are then transferred to small films for projec- 
tion. The difficulties in the first method are great, 
on account of the inability to obtain lenses of suffi- 
cient rapidity to photograph the faint image on the 
fluorescent screen. The difficulties in the second 
method are, to obtain a mechanism which will rap- 
idly bring a full size plate opposite the part radio- 
graphed, properly expose it» and then remove it 
safely from the action of the rays, while another 
plate goes into the proper position for exposure; 

•Presented at the meeting of the Bellevue Alumni Association, 
held March 26, 1913. 



14 



I-ISHBILKO: SOSTUBIiKCL'LOUS Al'lC.ll. LliSIUX.^. 



LXew York 
Medical Journal. 



the main problem being a meclianical one. There 
is still a third method, Uy which it may be possible 
in the future to achieve the results \vc are striving 
for. h is that direct method — which will become 
possible when some genius shall have succeeded in 
the focusing of the x rays. This is not as remote 
as is iiuagined. That problem, and many others in 
rontgenology, will then have been completely and 
tinally solved. 

As earl\' as 1900 attempts were made to olnain 
kineniatoradiographic pictures of the lluorescent 
image, and, by means of the ordinary cinemato- 
graph, to thus make visible the movements of such 
1 rgans as the diaphragm, heart, stomach, and intes- 




Biorontgenograpli ; patient 



tine. At this time Cavallio, of Paris, was able to 
obtain radiographic films which, in the cinemato- 
graph projection apparatus, showed the movements 
of the stomach and the intestines in the frog and 
other animals. In 1901 Eyckman made the first 
cinematographic radiographs of the act of degluti- 
tion. .\bout ten years later Lomond and Coman- 
dan, by means of a special quartz objective and a 
camera, were able to obtain a series of images from 
the screen picture on a sensitive film which could be 
used in the cinematograph. They obtained sixteen 
photographs a second. They studied not only 
intestinal, but joint, movements of small animals. 
A'arious apparatus for the direct method have been 
devised by Levy-Dorne and IMacintyre, Kohler. 
Haenisch, and of late bv Grodel and Rosenthal. 



The most feasible method at the present time is 
the direct serial method. It has a decided advantage 
over the indirect methtid. in that more detail is ob- 
tained on the plate than can be gotten from the 
photographing of the lluoroscopic image. The 
( Irodel apparatus was described in igcx). but has not 
Clime into use. The Rosenthal apparatus, manu- 
factured in M'.mich, is the only one of any practical 
\ alue, and it is being used in several laboratories in 
Cermany. This apparatus makes thirteen plates, 
'ize 18 X 24 cm. It was stated that the apparatus 
was capable of making four exposures a second, 
but this has never been demonstrated. Twelve or 
thirteen plates are exposed during the course of a 
single peristaltic wave, the duration of which varies 
from twenty to twenty-five seconds. 

What is desired in an apparatus of this kind is 
not only a larger number of plates, but such a rapid- 
ity of cliange a^ will permit the making of at least 
three radiographs a second. The apparatus which 
r have devised will carry from sixteen to thirty-two 
plates, size 8 x 10 or 10 x 12, and is capable of ex- 
l^osing the active member in from thirty-two to 
eight seconds. The apparatus consists of a 
mechanism which carries the plates in an up- 
right po'^ition, underneath a lead covered hood. At 
the side of this hood is a slit, through which 
the plates fall in front of a lead screen pro- 
vided with an aluminum window for exposure. 
Against the other side of this lead screen, opposite 
the aluminum window, rests the patient, and be- 
hind the patient stand the tubestand and tube. The 
plates, carried in aluminum holders, are moved into 
])osition by a motor, pushed out by a mechanical 
de\ice. remain stationary for a fraction of a second, 
and are then returned into place behind the hood, 
while another plate is ejected. A primary switch 
circuit breaker, with a mechanism for varying the 
time of exposure from 1/120 to ^ second, works in 
unison with the falling of the plate, and at the end 
nf the thirty-second exposure the circuit is auto- 
matically permanently opened. Intensifying screers 
are not essential : with the aid of a 6 kilo-watt 
transformer we have been able to make satisfactor\' 
stomach exposures without a screen and do instan- 
taneous chest work with ease. The apparatus nnv 
be used for the purpose of making stereoscopic 
radiographs, from one to sixteen sets being possible. 
These are automatically exposed, by means of a 
double target tube, the primary circuit breaker 
being so arranged as to cause a reversal of current 
at ever}- other exposure. 

56 K A.ST XlXETV-THIRn .'^TREET. 



XOXTUBERCULOUS APICAL LESIONS. 

Rv M XfRICE FiSHBERG. M. D., 
New York. 

.\tteiKli.iir Physician. Tuberculosis Ward. Mantefiore Home an,l 
Hospital. 

Piecause practically all tuberculous lesions of the 
lung in adults first manifest themselves in the 
apices, any deviations from the normal resonance 
and breath sounds in these regions are apt to sug- 
gest phthisis. Most of the patients admitted to 
sanatoriums and soon discharged as nontuberculous 
show some defective resonance, altered breath 



July 5. 1913I 



FISHBERG: NOXTUBERCULOUS APICAL LESIONS. 



15 



sounds, and at times rales at the apex ; many per- 
sons are rejected by examiners for life insurance 
companies for the same reasons, lhouj;h the 
subsequent history of these alleged "tuberculous" 
persons shows clearly that they would have 
made good risks had they been accepted. The 
tuberculosis clinics and the day and night camps 
in this city have some patients under treat- 
ment who, though showing some signs of apical 
changes, yet cannot be considered tuberculous 
if a careful analysis of the history, symptoms, 
signs, and course of their trouble is made. 
It seems that at present, when we are care- 
fully looking for localized and circumscribed 
lesions at the apex in every one presenting him- 
self for examination or who coughs or is losing 
flesh from any cause, individuals who are unfor- 
tunate in showing differences in resonance and 
breath sounds when the two pulmonary apices are 
compared — and there are many such persons to be 
found among nontuberculous people taken at ran- 
dom — are in danger of being pronounced tuber- 
culous, irrespective of the cause of their apical 
lesion. I have of late paid special attention to non- 
tuberculous apical lesions, having met with many 
cases which have given me considerable concern 
before I could make up niv mind as to whether I 
was dealing with real incipient phthisis or with 
some innocent process not due to acid fast bacilli 
and not at all serious. In this paper I shall at- 
tempt to discuss these cases and hope to show that 
there are apical affections which are not tuber- 
culous. 

I find that the bulk of apical lesions met 
with in daily practice are undoubtedly tuber- 
culous in character, yet there are many cases 
which, though simulating tuberculous disease in a 
striking manner, have apical lesions which are bv 
no means caused by the tubercle bacillus, and which 
per se are not at all detrimental to the health and 
wellbeing of the affected person. The nontuber- 
culous lesions of the apex seen by me can be classi- 
fied into three groups : 

1. Collapse induration, usually found in mouth 
breathers. 

2. Apical catarrhs, often manifesting themselves 
after an attack of influenza or found in persons 
suffering from pulmonary emphysema or who are 
of defective muscular development, especially in 
women and workers in indoor and dustv occupa- 
tions. 

3. Apical indurations found in persons with heart 
lesions. 

Of these three groups, the first is the most im- 
portant and the most frequently met with. Kronig, 
who first described these cases in detail, showed 
that the lesion was due to collapse of the apical 
parenchyma, with subsequent induration.^ We deal 
here with a purely local, noninfectious lesion which 
is not due to the tubercle bacillus. Physical ex- 
ploration of the lung shows dullness and retraction 
of one apex, usually the right, rough inspiratory 
murmur, harsh and prolonged expiration, and even 
true bronchial breathing, with some dry crackling, 

'G. Kronig: Ueber einfarhe nichttnberkulose Kollapsindiiration 
der rechten Liingenspitze bei chronisch behinderter NasenatmutiK, 
Deutsche Klinik. xi, p. 63 t. 



The history shows that since childhood the patient 
has suffered from nasal obstruction or has been a 
mouth breather. Many give a history of frequent 
attacks of colds, catarrhs of the nose, throat and 
bronchi. But in spite of all this the physical de- 
velopment of the patient has been fairly normal, 
excepting perhaps some retraction and lagging at 
the upper part of the right chest. These people 
may live in comparative happiness till they submit 
to an examination by some one adept in physical 
diagnosis. The\' are then apt to be pronounced 
tuberculous, and even banished to a sanatorium for 
a cure. This form of apical lesion is most fre- 
quently met with among adults between fifteen and 
forty years of age, though it is not unknown among 
children under fifteen. They usually give a history 
of having been sickly children, subject to colds, 
coughing quite often and expectorating more or 
less profusely, especially during the morning hours. 
Many say that they have noted blood streaked 
sputum, and with some this was the cause for sub- 
mitting to an examination. Several of my patients 
have also complained of pains in the chest, palpita- 
tion, slight dyspnea, dfsturbed sleep, and night 
sweats. One important point is that nearly all of 
these patients have kept at work, never having 
been sick to such an extent as to be disabled, as is 
usually the case with true phthisis. It is only after 
being frightened by some blood streaked sputum, 
or by a rejection after a medical examination for 
life insurance, etc., that these patients be- 
come disheartened and may stop working. My ex- 
perience in New York city leads me to believe that 
collapse induration is not rare here. Examining 
over one hundred healthy adults weekly for the last 
eight years, I have found that there can be elicited 
differences in the resonance and breath sounds, 
when the two apices are compared, in about three 
per cent, of people engaged in indoor occupations, 
Blumel states that of 1,700 patients who passed 
through the sanatorium under his care, eighty-five, 
or five per cent., were not tuberculous. Of these, 
twenty-eight were cases of collapse induration ; the 
rest were cases of emphysema, bronchiectasis, etc. 
Thus, one third of the nontuberculous patients ad- 
mitted to that sanatorium had lesions of the type of 
collapse induration.- I am under the im])ression 
that conditions are not different in American institu- 
tions, as I have seen many patients of this tyjie that 
have spent some time in sanatoriums. 

The causes of collapse induration have been a 
fruitful source of speculation for manv writers. 
Kronig shows that it is usually due to the inhala- 
tions of dust. Why the apices (especially the 
right apex) are first affected, is explained by 
the fact that these parts of the lung, by reason of 
their anatomical relations, are at a disadvantage 
which predisposes them to pathological changes to 
a greater extent than the rest of the lungs. Their 
location outside the bony thorax, and the peculiar 
manner in which the bronchi entering the apex 
branch off from the main bronchus, favor a greater 
force and pressure of the inspired air in these 
areas ; while the expiratory pressure of the air, 
lacking the assistance of the ribs and intercostal 



^K. Blumel: Ueber Kollapsindiiration der rechten Lungenspitze 
bei chronifch behinderter Nasenatmung, Muiichcner medhiiiische 
Wochenschrift, !v, 1910, p. I5;3. 



i6 



lUSHBERG: NONTUBERCULOUS APICAL I.IiSIUSS. 



[New York 
'Mkdical Journal. 



niusclei, is much less in the apices than in the 
lower lobes of the lungs. The suckiiig power dur- 
ing inspiration is thus greater to a certain extent 
in the apices, and because of the larger calibre of 
the right apical bronchus and its larger number of 
branclies, greater in the right than in the left. The 
result is that the dust elements of the inspired air 
are easily deposited in the apices, especially the 
right. This has been proved experimentally, and 
also at autopsies in cases of pneumoconiosis — the 
apices are usually first affected. Nasal obstruction 
involves mouth breathing, with the following 
consequences : The inspired air, loaded with 
vegetable, animal and mineral dust of all kinds, 
reaches the bronchi directly. Moreover, the in- 
spired air, which normally meets with many ob- 
structions while passing "through the upper respira- 
tory passages before reaching the bronchi and is 
thus warmed and filtered, enters the bronchi and 
lungs with much greater force in mouth breathers, 
carrying along dusty elements. The right lung, re- 
ceiving more air than the left, also gets a larger 
deposit of dust. In these cases there usually occur, 
from early childhood, repeated attacks of catarrhal 
inflammation of the apical mucous membrane which 
interfere with the entrance of air into the afifected 
areas through the e.xtension of the catarrh from the 
larger bronchi to the smaller, and finally to the 
alveoli. This is followed by hyperplasia of the in- 
terstitial tissue of the lungs, which is slowly con- 
verted into scar tissue, contracting through shrink- 
age and collapse of the apex of the lung, just as 
in pneumoconiosis. Collapse induration is conse- 
quently a special form of chronic fibrous interstitial 
bronchitis of the kind seen in fibroid phthisis, 
chronic pneumonia, etc. 

W'iiile in many cases this is undoubtedly true, I 
am inclined to agree with Wolfif-Eisner, who main- 
tains that in many patients the pathological changes 
are not of an inflammatory character.'' Indeed, 
in many cases of nontuberculous apical lesions 
there is not only dullness, but also distinct 
signs of catarrh and refraction of the apical 
isthmus, with pronounced bronchovesicular breath- 
ing. Moreover, through respiratory exercises 
in the open air, as well as by clearing the nasal 
passages, I have often seen the apex expand 
again, which could not occur in cases of real in- 
flammatory induration. We may therefore con- 
clude that these apical lesions are often due to col- 
lapse atelectasis and not to collapse induration. I 
am of the opinion that the first stage of this process 
is catarrhal, due to the irritation of inhaled dust, 
and in these cases we have atelectasis of the apical 
alveoli ; but when the irritation is continued for 
years inflammatory changes make their appearance 
and induration may ensue. This view is confirmed 
by the fact that young persons under twenty years 
of age are often cured by the clearing of the nasal 
passages combined with respiratory exercises, as 
has been mentioned, while in older persons the pul- 
monar\- retraction at the right apex is usually per- 
manent. 

More recently Hofbauer has shown experiment- 
ally with Marey's pneumograph that collapse in- 

^A. Wolff-Eisner: Ueber nicht-tuberkulosen Snitzenkatarrh, Medt- 
::ittische Klinik, v, p. 423. 



duration is due altogether to insufficient respiratory 
activity of the upper parts of the thorax. Habitual 
mouth breathers do not at all expand the upper 
parts of the thorax, and this leads ultimately to 
collapse of the lung apex, absorption of the air in 
that area, etc' 

The differential diagnosis between tuberculous 
and nontuberculous apical lesions of the character 
just described only rarely presents great ditificulties 
if the following points are borne in mind : In tuber- 
culosis we have usually a history of exposure to 
infection, mostly in the family, while in the non- 
tuberculous cases this is usually lacking. In most 
of the cases of collapse induration the patients have 
suiTered from nasal obstruction since childhood, 
and generally have enlarged turbinated bones, nasal 
jxjlypi, adenoids, or enlarged tonsils. They com- 
plain that they have not been able to breathe 
through the nose for years, have expectorated con- 
siderably, suft'ered from dryness and itching of the 
throat, and had a strong tendency to colds, tonsil- 
litis, and frequent bronchial catarrh. The classical 
facies of the mouth breather is often seen in these 
patients — open mouth, enlarged and drooping lip. 
absence of the nasolabial fold, etc. In tuberculosis 
all this is usuallv absent. In addition to the absence 
of tubercle bacilli and the negative albumin reaction 
in the nontuberculous cases of apical lesion, the 
sputum also shows distinct evidences that it is de- 
rived from the upper respiratory tract. It is watery. 
mixed with saliva, and colorless ; sometimes con- 
taining grey or bluish globules, not unlike the kind 
seen in pneumokoniosis. Microscopically there are 
often found epithelial cells from the mouth, no-~e 
and throat, but no tubercle bacilli. The cough in 
tuberculous patients is apt to provoke vomiting, 
which is never the case with collapse induration 
In patients who complained of hemoptysis, I have 
observed that only blood streaked sputum was ex- 
pectorated, and not pure blood. What helped me 
most in distinguishing these cases from tho=e cf 
true pulmonary hemorrhages was that in all these 
cases the blood made its appearance in the sputum 
only during an acute attack of rhinitis, pharyngitis. 
or tonsillitis, while in true phthisis the nose and 
throat are usually normal during hemoptysis. 

The physical signs of collapse induration can not 
always be distinsruished from those of incipient 
tuberculosis. We may have, as has been stated. 
some lagging and depression in the supraclavicular 
space of the right side : dullness with narrowing of 
the field of resonance, rough inspiratorv and pro- 
longed or harsh expiratory murmur, bronchovesicu- 
lar breathine, and sometimes even true bronchial 
breathing. In many cases I have heard whispered 
bronchophony anteriorly, beneath the inner third 
of the clavicle, and posteriorly in the supraspinous 
fossa, especially near the spine. Rales are not fre- 
quent. Occasionally we hear some drv clackings. 
or sibilation, localized and circumscribed at the seat 
of the lesion, and persistent, just as in some cases 
of incipient tuberculosis. Moist, subcrepitant ra'es 
are very rare, and whenever I have heard them in 
these cases I almost always could convince mvself 

■*L. Hofbauer: Natur und hntstehung der Kronif^sclien Lungen- 
spitzenatclektase, Zeitschrift fiir cypcrimentetle Puthologie und 
Therapie. xii, 1912, p. 59. 



July 5. '9'3i 



FISHBERG: NONTUBERCULOUS APICAL LESIONS. 



17 



that they were transmitted from the nose and throat. 
In the patient breathing with an o])c'n moutli, 
cough, with clearing of the throat and nose, often 
brings about the disappearance of the rales, thus 
indicating that they do not have their origin in the 
secretion of the small bronchi, or in atelectasis of 
the apical alveoli, but in the nose and throat. In 
tubercidous lesions cough increases the rales, and 
often provokes rales when they are absent during 
ordinary or forced breathing. Kronig insists that 
the best and most reliable sign which distinguishes 
collapse induration from incipient tuberculosis is 
that in the former the motion of the base is normal, 
while in the latter it is restricted. But I have seen 
many cases of tuberculosis, even in the moderately ' 
advanced stage, in wliich tlie motion of the base 
was quite normal. Several important points 
are of great assistance in our attemjits to differen- 
tiate these cases from tuberculosis. To begin with, 
the general appearance of the patient is rather good, 
in spite of the fact that he gives a history of cough, 
pain in the chest, etc., for months or years ; he is 
well nourished and does not lose weight, as is usu- 
ally the case with ])rogressive phthisis. He is able 
to keep at his work, and the sense of fatigue and 
languor characteristic of tuberculosis is usually 
lacking. Moreover there is no fever, which, when 
carefully looked for, is discovered in practically 
every case of incipient tuberculosis. Xor is there 
any tachycardia and instability of the pulsc which 
are only rarely absent in tuberculosis. The patient 
is not sick and in the vast majority of cases can be 
speedily relieved of his cough, expectoration, etc., 
by a slight operation — clearing the nasal passages, 
tonsillectomy, removal of adenoids, or polypi. 

The question whether there are circumscribed 
apical catarrhs of a nontuberculous nature has been 
discussed quite extensively. Some writers would 
like to banish this term from medical nomenclature. 
On the other hand, there are many who can speak 
with authority and who recognize that there are 
often met with local catarrhs of the apex which are 
nc;t caused by the tubercle bacillus and are alto- 
gether innocuous. Mv experience amon j workers 
indoors and dusty occupations, like tailors, furriers. 
carpenters, iron workers, etc., has taught me that 
there are nontuberculous apical catarrhs, especially 
in persons who suffer from mild forms of pulmon- 
ary emph}-sema. and they are often mistaken for 
subjects of tuberculosis and treated as such. In 
recent years several writers have described these 
apical catarrhs in detail. F. Miiller speaks of a 
chronic pneumonic local process in the apex which 
can be mistaken for tuberculosis because of constant 
crepitation, but which at autopsv shows that it is 
not due to tubercle bacilli,, but to streptococci.'' F. 
Kohler mentions similar cases." .\mong manv who 
speak of catarrhal signs of the apex after influenza 
and w^hooping cough Kronig may be mentioned ' 
He shows that these catarrhal signs disappear with- 
in a few weeks. He also mentions small bronchi- 
ectatic cavities at the apex which may cause crepi- 

*F. Muller; Die Diagnose der Lungentuberkulose, V. Versamlung 
der Tuberkulose Aerzie, Munich, 190S. 

*F. Kohler: Kritische Reitrage zur Diagnose der Lungentuber- 
kulose, Muncliener mcdisinische IVochenschrift, 1910, Nos. 35 and 
36. 

■G. Kronig: D'e Fruhdiagnose der Lungentuberkulose, Deutsche 
KHiiik. xi, p. 588. 



tation for years, especially during coughing spells. 
Laser, in a recent paper, points out that among 
women and also in some debilitated men there is 
often heard iiarsh breath .sounds, especially a loud 
and ]jroliinged expiratory murmur over the right 
supraspinous fossa, and occasionally a short note 
on percussion. He insists that these signs must not 
be taken for evidences of a tuberculous lesion of 
that apex, because they are mostly due to other 
causes. *■ .More recently Kiilbs has described in de- 
tail a series of cases of apical catarrh occurring in 
emphysematous young men. He also finds that the 
crepitation is heard mostly in the right ape.x pos- 
teriorly and is due to local bronchitis and tracheitis. 
The crepitation may be localized and constant, and 
thus suggest tuberculosis.' 

These cases are not at all rare in this city. I '^ee 
them often in my daily practice. Usually the 
patients have been examined by some careful 
physician acting for a life insurance company, 
or for admission to some fraternal society, 
and have been rejected because of "lung trouble." 
.Some call for examination complaining of some 
mild cough and expectoration. Examination 
shows no retraction on inspection, and normal 
resonance on percussion : rarely a short note 
over the right apex, but never a narrowing of the 
resonant field. But on ausculatation we find rough, 
interrupted, or cog\vheel breathing during inspira- 
tion, prolonged expiration, and crepitant rales dur- 
ing or at the end of inspiration which may be pro- 
voked or increased by coughing. It is remarkable 
that these signs may persist for months in an indi- 
vidual without inconveniencing him in the least. I 
!iave a patient in whom these apical changes have 
existed for four years, yet she feels quite well and 
has not lost a day from her work, that of a stenog- 
rapher. In another woman, whose husband died 
from tuberculosis, she nursing him through a long 
illness, such apical signs have given me considerable 
concern, and only after observing that for a year 
the patient remained well, could I decide in favor of 
apical, nontuberculous catarrh. It is important to 
remember that in these cases there is no retraction, 
no lagging, and no atrophy of the muscles, which 
is so frequent in tuberculosis of a few months 
standing, while the temperature and pulse remain 
normal. .'Kn inquiry into the history of these pa- 
tients shows that they have been subject to frequent 
colds, coughs, more annoying during the night, ex- 
pectoration, and some dyspnea during the spring 
and autumn months. During such colds, which 
may last for a few weeks or a month', the patient 
may suiifer from anore.xia, w'cakness. etc.. with some 
loss of weight : the condition thus simulating tuber- 
culosis in a striking manner. Yet. he recuperates 
and regains his normal weight within a few weeks. 
In fact, those in whom a diagnosis of tuberculosis 
is erroneously made, and who are thus induced to 
take greater care of their health, often put on 
weifrht far above their normal standards. 

The temperature is always normal in these cases, 
which is an important point in distinguishing them 
from pulmonary tuberculosis. The same is true of 

"Laser: Zur diagnostischen Beu-ertung der Befunde uber die 
Lungenspitzen, Be'lincr ktinische Wachcnschnft, 1910, No. 4. 

^Kiilbs: Rasselgeriusrhe iiber den Lungenspitzen, Zcitschrift fur 
khnische Medhin, Ixxiii, p. 169. 



i8 



FISHBERG: XOXTUBERCULOUS APICAL LESIOXS. 



[New York 
Medical Joornj 



tlie pulse rate, which remains normal, while in 
tuberculosis an unstable pulse is the rule. An ex- 
amination of the nose and throat may show some 
mild local inflammatory changes, like redness and 
swelling" of the mucous membrane, indicating 
pharyngitis or tracheitis and sometimes enlarged 
tonsils, but only rarely do we meet with pronounced 
nasal obstruction and mouth breathing, as in cases 
of collapse induration, which were discussed above. 
From the latter these cases of simple apical catarrh 
are also distinguished by the fact that there is no 
dullness, nor any signs of narrowing of the field of 
resonance, or distinct retraction ; while a short note 
over the apex is extremely rare; in fact. I have 
quite often found a note of increased resonance 
over an apex which was the seat of an apical 
catarrh. It is also to be borne in mind that the vast 
majority of apical catarrhs disappear within a few 
weeks, or a month, while collapse induration per- 
sists — the dullness and retraction remain indefinitely 
unless replaced by emphysema. In short, simple 
catarrh is differentiated from incipient phthisis by 
the absence of tubercle bacilli in the sputum, the 
negative albumin reaction, the normal temperature 
and pulse, and the rarity of persistent loss of weight, 
which even if it does occur, is regained within a 
few weeks of rest and outdoor life. Kiilbs, who 
has described siinilar cases, finds that the tuberculin 
reaction is invariably negative, while the radiogram 
shows nothing abnormal at the apex. However, 
these cases are now and then dignosticated as tuber- 
culous and the patients kept under treatment in 
clinics for weeks ; some are even admitted to sana- 
toria and either soon discharged as nontuberculous, 
or kept for several months and discharged as 
■'cured." or more modestly, as "apparently cured." 
Kiilbs found among twenty-two of his patients with 
simple apical catarrh that eight had undergone a care 
at sanatoriums. I have seen many more. Some have 
gone to the mountains or as far as the Rocky 
^fountains or Southern California, and returned 
within a few months believing that the climate of 
these regions had cured them. 

The causes of the alteration of the breath and 
adventitious sounds in these cases are not definitely 
known. The striking- harshness and loudness of the 
breath sounds, the rough interrupted inspiration, 
and the prolonged expiration, which is sometimes 
bronchial in character, are ascribed by Kiilbs to the 
poor muscular development of his patients, which 
he says contributes greatly to the striking conduc- 
tion of the breath sounds and adventitious sounds. 
But I have seen these phenomena in persons with 
good muscles and considerable adiposity, and am 
inclined to attribute the physical signs in these pati- 
ents to the catarrh of the finer bronchial .tubes of 
the affected apex — their mucous membranes are 
swollen, thus producing stenosis which increases the 
breath sounds. The rales are produced in a similar 
manner by the secretion, or by the opening of the 
collapsed alveoli bv the inspired air. In some cases 
I was convinced that the adventitious sounds were 
transmitted from the mouth, throat or trachea; but 
ordinary care easily obviates such a mistake. 

There remains yet to be discussed the apical 
changes often found in cases of heart disease and 
of nephritis which are at times mistaken for tuber- 



culosis. It is agreed that patients suffering from 
congenital heart disease (pulmonary stenosis) and 
who survive the age of infancy and childhood, often 
succumb (luring adolescence to tuberculosis be- 
cause of the deficient circulation of blood and lymph 
in the lungs which this cardiac defect brings about. 
On the other hand, disease of the left heart, espe- 
cially mitral stenosis, is only rarely complicated by 
tuberculosis, and this is more striking when we 
bear in mind that lesions of the left heart are most 
frequent in early life, the period when tuberculosis 
is also most common. In 1846 Rokitansky stated 
that valvular disease is invariably antagonistic to 
phthisis, while later Traube modified this statement 
to the effect that only mitral stenosis can thus be 
credited. Fagge also held that mitral stenosis is 
an ahnost complete bar to tuberculosis, the post 
mortems record of Guy's Hospital supplying only 
four cases in the- course of thirty years. Kidd's 
statistics give one instance only in 500 cases, and 
\Valsham's one in 130 cases.'" \^'hile these state- 
ments may give the impression of too great rarity, 
because we occasionally meet with a case of mitral 
stenosis coinplicated by phthisis, yet we must be 
extremely careful before pronouncing a case tuber- 
culous when we find a defect in the mitral valve. 
It is. however, remarkable that many cases of mitral 
disease are mistaken for tuberculosis, especiallv at 
present when the apices are so carefully scrutinized 
for signs of phthisis. And signs are found at times 
in the apices because degeneration of the cardiac 
muscle, and especially mitral stenosis, very often 
produce congestion or even induration of one or 
both pulmonary apices. That this is not borne in 
mind by many of those who should be familiar with 
such a condition is attested by the fact that man\- 
cases of mitral stenosis are treated for months and 
years in the tuberculosis clinics and day camps of 
this city. I see every year about a dozen such "con- 
sumptives" who are being annoyed by inspectors 
and nurses of the Health Department, and are re- 
fused shelter in case the}' have to live with strang- 
ers, etc. Of the many cases of this character that 
have come under my observation, I shall mention 
but one which I saw while preparing this paper: 

M. B., thirty-five years of age, tailor. Family and per- 
sonal history negative, excepting that he had tN'phoid fever 
fifteen years ago. Did not recall ever having had rheu- 
matism. Three years ago he began to cough and expec- 
torate bloodstreaked sputum and to suffer from dyspnea 
on the slightest exertion. This dyspnea had been in- 
creased in intensity, until he became a semiinvalid. and 
orthopnea was at times so severe that he was obliged to sit 
up the greater part of the night. His cough was moderate: 
expectoration rather scanty, but at times tinged with blood. 
Two years ago his physician reported him to the Health 
Department as tuberculous: a nurse called and advised him 
to take treatment at one of the clinics. Ever since he has 
been visited at regular inter\-als, his family was warned 
against intimate contact with him, etc. Examination 
showed a case of mitral stenosis, with a loud presystolic 
and feeble systolic murmur with maximum intensity at 
the apex, which was displaced downward and outward : also 
cardiac hypertrophy, enlargement of the liver, edema of 
the ankles, etc. Percussion of the lungs showed defective 
resonance of left ape.x above the second rib anteriorly and 
in the supraspinous fossa posteriorly, bronchovesicular 
breathing, some sibilant rales, and some crepitation in the 
same region after coughing. Fluoroscopic examination 
showed a shadow at the left apex, thus confirming the 
findings by auscultation and percussion. That the process 

"S. West: Diseases of the Organs of Respiration, ii. p. 536. 



July 5, 1913 1 



FISHBERG: XOXTUBERCULOUS APICAL LESIOXS. 



19 



at that ;.pex was not tuberculous was evidenced l)y the fact 
that at no time did this patient have any fever, night 
sweats, etc. Also he maintained his weight during the last 
two years, and several examinations of the sputum did not 
show any tubercle bacilli. Vet an inquiry at the tubercu- 
losis clinic at which he had been under treatment brought 
forth the information that this patient had a tuberculous 
infiltration of the left apc.x, in spite of the fact that re- 
peated examinations of the sputum gave negative results. 

That the apical signs shown in this case are not 
of tuberculous nature is also confirmed by the fact 
that in most cases of mitral disease there is some 
alteration in resonance and breath sounds at one or 
both apices. Some simulate tuberculosis to such an 
extent that the patients are admitted to sanatoriums 
and hospitals and kept under observation for months 
before tuberculosis is excluded. At the Mon'.efiorc 
Home and Hospital we sometimes get this sort of 
cases in the tuberculosis ward. In one case it was 
very difficult to exclude tuberculosis, and in another 
similar case the patient was admitted to this hos- 
pital after having spent two years in another 
institution for advanced tuberculosis. The pul- 
monary signs in the latter case simulated tubercu- 
losis to an extreme degree, 3'et on autopsy it was 
shown that there was only a heart lesion, while 
the lungs were free from any lesion suggestive of 
present or past tuberculosis. Similar cases have 
been reported by Caussade and Questre.^^ I have 
carefully examined the cases of mitral disease that 
have come under my observation within the past 
six months, and found that of thirty-eight patients, 
twenty-seven showed either defective resonances, at 
times amounting to dullness, at one or both apices ; 
which would be sufficient to suggest tuberculosis 
had there been no other explanation for this abnor- 
mality. Twenty-two cases showed either small 
crepitant or subcrepitant rales, or some sibilation. 
Five of these thirty-eight patients gave a history of 
bloody sputum, and one stated that he had had a 
profuse hemorrhage. During a short ser\"ice of 
two months in the female ward of Lebanon Hos- 
pital I met with two cases of mitral stenosis show- 
ing pathognomonic signs of tuberculous involve- 
ment of the ape.x. One of these patients had even 
been admitted to a sanatorium, from which she was 
discharged in six weeks as nontuberculous, and now 
there was again presented the problem as to 
whether or not we were dealing with a case of 
mitral stenosis complicated by pulmonar\' tubercu- 
losis. Repeated examination of the sputum gave 
a negative result. In spite of the fact that there 
was a continued subfebrile temperature, I was not 
inclined to consider this case tuberculous. A simi- 
lar case in an adult male was believed to be tuber- 
culous by the attending physician because of the 
apical signs, yet no tubercle bacilli could be found 
in the sputum, and the patient kept on gaining in 
weight and strength after a rest and the use of 
digitalis. In children also I have often met with 
cases of mitral disease showing signs simulating 
apical infiltration, yet the subsequent course of the 
affection showed conclusively that we were dealing 
with congestion due to faulty circulation, and not 
with tuberculosis. 

"G. Caussade et P. Questre: De quelques congestions-oedemes pul- 
monaires localisees aux sorrmets des poumons simulant la tuber- 
culose et de quelques congestions pulmonaires perituberculoses. 
Presse yf^^dicale. xvii, 1909, p. 497. 



Resume. Unilateral apical signs which simulate 
those characteristic of ])ulmonary tul>erculosis are 
not as rare as is generally supposed. In mouth 
breathers we often find retraction of the right apex, 
dullness, altered breath sounds, and even rales 
which are circumscribed and localized, giving a 
clinical picture of pulmonary tuberculosis ; and the 
patient is often treated for a considerable time as 
being tuberculous. These patients are often ad- 
mitted to sanatoriums, and they are also respon- 
sible for the fact that so many methods of 
treatment and drugs have had the reputation 
of curing tuberculosis "when the disease is 
recognized in its incipiency." Many of the 
rapidly cured incipient cases are, in fact, in- 
stances of collapse atelectasis of the apical par- 
enchyma due to interference with the entrance of 
air into the right apex in mouth breathers. In- 
dividuals who neglect the nasal obstruction for a 
considerable time, and do not have their polypi, 
adenoids, or hypertrophied tonsils, etc., removed, 
may ultimately get collapse induration of the right 
pulmonary apex, which remains permanent, and 
thus be in constant danger of being pronounced 
tuberculous when their health deteriorates from any 
cause and they are losing weight, have cough, etc. ; 
or, even when feeling in excellent condition, they 
are liable to suffer unjust discrimination at the 
hands of examiners for life insurance companies. 
But a careful study of the history, symptomatology, 
and course of this affection obviates such a mistake. 
Collapse atelectasis and induration are to be borne 
in mind in all right sided lesions of the lung apex 
occurring in mouth breathers, showing no tubercle 
bacilli in the sputum, and manifesting no tendency 
to follow the usual course of pulmonary tuber- 
culosis, with fever, night sweats, tachycardia, 
malaise, languor, progressive loss of weight, etc. 
In such cases the fact that the patient has been 
working all along in spite of his cough, which may 
date back to childhood, and has developed physi- 
cally at a normal rate, speaks very strongly against 
tuberculosis, and the apical signs are indicative of 
collapse induration. Physical signs of a lesion at 
one apex occurring after an attack of influenza, or 
met with in persons with pulmonary emphysema or 
defective muscular development, especially in young 
women, and among indoor workers generally, 
should not be hastily pronounced as indicative of 
tuberculosis. It must always be borne in mind that 
a person who never coughs and has suffered no 
progressive loss of weight, anorexia, malaise, etc., 
for months before the onset of an attack of grippe, 
may have a simple localized apical catarrh giving 
signs simulatinc' those of incipient pulmonary 
tuberculosis, although it is not due to acid fast 
bacilli. On the other hand, the vast majoritv of 
cases of tuberculosis give a history of several at- 
tacks of "grippe," or "colds," extending over sev- 
eral months or years preceding the last "co'd," 
which, in their opinion, was the beginning of their 
present illness. Clinical observation for a few 
weeks, with the judicious use of the thermometer 
and several examinations of the sputum, usually 
clears up the diagnosis even in cases in which tbe 
physical signs persist for months. In persons hav- 
ing a defect of the mitral valve a diagnosis of 



BRYAN: RENAL TUBERCULOSIS. 



[New York 
EDICAL Journal. 



tuberculosis should not be made without the most 
valid evidence, i. e., positive bacteriological find- 
ings. Although mitral stenosis is not an absolute 
bar to j)hthisis, as some have maintained, it is ex- 
ceedingly rare to find this disease complicated by 
tuberculosis. To diagnosticate tuberculosis in per- 
sons suffering from mitral stenosis without acid 
fast bacilli in the sputum is rather risky. Still. 
there are often met cases of mitral stenosis present- 
ing symptoms and signs of tuberculosis of the 
lungs — subfebrile temperature, cough, hemoptysis, 
tachycardia, loss of weight, dullness, altered breath 
sounds. Tales, etc., localized at one apex — to a per- 
plexing degree. Indeed, I may say that the apical 
signs in some cases of heart disease have given m: 
much more concern at times than any other class of 
nontuberculous apical lesions. Often only careful 
observation for a long period of time will determine 
whether a given case of mitral disease is compli- 
cated by pulmonary tuberculosis or not. My rule 
has been to consider such cases tuberculous only 
when finding bacilli in the sputum or signs of cavi- 
ties on physical exploration. 
1337 J\I.\DisoN Avenue. 



THE EARLY DIAGNOSIS OF RENAL 
TUBERCULOSIS.* 

r,v R. C. Bryan, 11. D., 
Richmond, Va. 

Having had the opportunity during the past few 
years to observe several cases of renal tuberculosis, 
and having been attracted particularly by the vary- 
ing clinical manifestations which they have shown. 
and the extreme difficulty of getting at any satisfac- 
tory and definite diagnostic conclusions, I thought 
it would not be out of place, or uninstructive. for 
me to present to you the pitfalls, errors, and elusive 
symptoms which this not tmcommon and so mani- 
festly latent disease has presented to me personally 
in the earliest stages of its course. 

That renal tuberculosis is a frequently overlooked 
conditions is shown by the records of Kapsammer 
at the \'ienna General Hospital. He reports that 
from 1897 to '1907 there were found on post mor- 
tem examination 191 cases ; of these only two were 
correctly diagnosticated and four partially so, while 
in 185, sixty-seven of which were unilateral, the 
disease was not suspected. The writer will not at- 
tempt to consider in detail the pathology-, predis- 
posing causes, treatment, and other conclusions of 
the tuberculous kidney, nor the scrofulous kidnev 
'which is secondary to infectious diseases, stone. 
pyonephrosis, floating kidney, or those conditions 
in which there is an interference with the urinarv 
outflow, but would ask to call your attention par- 
ticularly to the diagnosis of primary kidney tubercu- 
losis; trying to unravel, in some kind of fashion, the 
clinical manifestations only in t'he very incipiency 
of the disease, and not in the terminal state of case- 
ation of the organ, in which the ureter and bladder 
are also most seriously involved. Kronlein states 
that 29.8 per cent, of all surgical affections of the 

*Kead before the Richmond Academy of Medicine, March ii, 
1913. 



kidney are tuberculous. Israel states that one third 
of all purulent processes which may be traced to 
the kidney are of this character. It may not be 
irrelevant here to say that by a large number of 
investigators the tut)ercle bacillus is found in only 
fifty per cent, of all cases. This includes not only 
the incipient, early, solitary, miliary type, but like- 
wise those instances where large caseating foci and 
marked involvement of the ureter and bladder are 
also found. Were we able to find the tubercle ba- 
cilli earlier, the diagnosis would naturally be much 
easier. Steinfhal asserts that fifty per cent, of all 
cases of renal tuberculosis are limited to one kid- 
ney, while James Israel goes so far as to say that 
eighty-eight per cent, of all renal tuberculosis is 
unilateral. This would seem to substantiate the 
contention of those authors who say that all tuber- 
culosis of the kidney is of a hematogenous origin, 
and to discredit the transmission of infection by the 
ascending route. It is in males, in the second and 
third decade, that the disease is most commonly 
encountered. Collinet states that one out of e\ery 
eighteen consumptives suffers from some form of 
genitourinary tuberculosis. He also affirms that the 
tuberculous process may start anywhere in the uro- 
genital tract independent of a pulmonary or general 
tuberculosis. It has been pretty well substantiated 
that the kidney may become infected from the blood 
without an established tuberculosis being found in 
any other part of the body. It has also been point- 
ed out that the blood infects the kidney as a second- 
ary expression in tuberculosis of the lungs or any 
other organ, and further that the kidney may be 
involved by continuity of surfaces in ascending tu- 
berculosis from the genital organs below. In this 
latter instance there must be a fibrotic degeneration 
of the ureteral os in order to permit of regurgita- 
tion, and since this is uniformly bilateral, hemato- 
genous infection would seem to be still further 
established as the recognized means of kidney in- 
jection. 

Tufiier subdivides tuberculous invasion of the 
kidney into some six or seven categories. Duret 
gives alx)Ut the same classification, and calls at- 
tention to the cavernous type, with single or mul- 
tiple cavities, and also to that condition of the fatty 
capsule (adipose sclerosis) which at times renders 
it so hypertrophic as to burst through the kidney 
into the pelvis, thus blocking it effectually. Senn 
classifies involvement of the kidney by tuberculo- 
sis as I, miliary tuberculosis: 2. caseous nephri- 
tis ; 3, tuberculous pyelonephritis. This is a 
classification which covers the dift'erent pathologi- 
cal findings which develop in the course of the dis- 
ease. Our consideration, however, will be limited 
to the first division, our intention being to ignore 
the diagnosis of strumous kidney with which there 
are associated distinct tuberculous lesions ; for, 
with a constitutional invasion by the disease, wifh 
the large renal tumor, the ureter, bladder, and ure- 
thra seriously invaded, numerous tubercle bacilli 
in the urine, and marked dysuria, hematuria, and 
pain, the positive diagnosis ought not to be in doubt. 
Since it is essential for our interpretation and diag- 
nosis of the obscure clinical signs of this primary 
miliary condition to have a familiarity with the 
pathological state which has given rise to this mor- 



July s. 1913- 



laiX.lL TUBERCULOSIS. 



I)id expression, a hasiy review of llie miliary kid- 
ney will not be uut of i)laee. I''ur it is in just lhi< 
form of renal tuI)erculosis, the incipient, miliary 
type, ill which there are only a few minute foci 
scattered here and there in the cortex of the or^an. 
that a diagnosis is most difficult. The-e foci uni- 
formly start subcapsularly and in the curlex of the 
organ. They are implanted here by llie bloo<l cur- 
rent of the kidney, which, entering at right angles 
to the pelvis, flows to the cortex, where its verti- 
cal twigs are given off; the centrifugal action of 
the blood current whirling the tubercle bacilli out 
to the furthest periphery of the organ. In this 
stage of tuberculous invasion the urine is negative, 
but it is now that the toxines cause the dysuria 
which we find so constantly present in the e:irly 
stage of the disease. Soon there follows the re- 
placement of the foci by fibrous tissue, and then 
there ensues polyuria, which, we have noted, seems 
to be one of the significant features of the disease. 
With a mixed infection occurring, these small nod- 
ules swell and discharge their product into the pel- 
vis, or, occasionally, the capsule is broken through 
and a perinephritic abscess is established. Xeifher 
this condition nor the invasion of the pelvis will, 
however, l>e taken up, as they belong to the second 
or more advanced stage of strumous kidney. We 
might take this opportunity to refer to the lymplf- 
atic supply of the primary tract and say that the 
drainage of the epididymis is different from th;it 
of the testicle, which flows into the retroperitoneal 
glands about the sacrum. The epididymal chain 
runs to the floor of the bladder, where its drain- 
age unites with the mural lymphatic drainage from 
the kidney about the ureteral mouth. It would not 
be extraordinary, then, to note a case in which one 
of the primary evidences of a cortical tuberculosis 
would be the establishment of a focus by means of 
this Ivmph stream in the epididymis. The writer 
had. on one occasion, such a case under hi; obser- 
vation. Nor will we overlook the possibility of this 
lymphogenous infection occurring in the oppositte 
kidney by way of the flow across the lumbar verte- 
bra or by means of the small veins which ply be- 
tween the kidneys. 

In the very earliest stages of implantation there 
is no urinary complication, but soon we are at a 
loss to know why a frequency of urination shoifld 
occur, particularly since the uranalysis and the mi- 
croscopical and X ray examinations have on re- 
peated occasions been negative jn their results. 
With the establishment of a new focus or the 
slight spreading of one of the former foci, the kid- 
ney becomes more congested, and a permanent po- 
lyuria ensues. Now and then some of the products 
of this invasion, dammed back in the organ, 
escapes, and the character of the urine is tem- 
porarily changed. This polyuria is the result of 
the stimulation of the glandular tissue caused bv 
the presence of miliary nodulc'^ which have mt de- 
veloped so far as to compromise the parenchyma 
of the organ. It is, indeed, an irregularly scattered 
interstitial nephritis of one or several parts of the 
kidney, and it is at this time that traces of albu- 
min and pus and a few red blood corpuscles may 
be detected in the urine which not' infrequently 
comes, bv virtue of a renorenal reflex, from the un- 



affected side. The slight dysuria at the time of 
these outbreaks is doubtless caused by the liberated 
toxines irritating the mucosa. This, at least, would 
appear to be the exi)lanation, and the frequency of 
urination simply Nature's method to throw off in- 
jurious products. Many patients have found that 
drinking large (juantit'ies of water helps the pain. 
This may be explained by the dilution of the irri- 
tating elements of the toxines which the ingestion 
of water causes. As an illustration of this early 
type of case, the writer would record the follow- 
ing: 

Case I. Mrs. J. B. L., aged thirty-eight years, referred 
by Dr. V,. \V. Gee, of Riclimond, had for several years 
had an annoying and intermittent frequency of urination, 
attended with considerable pain at times. This iiain was 
low down on the right side, in the region of the pelvic 
course (I the ureter. She had 1)een operated upon for ap- 
pendicitis with no relief. When seen by the writer the 
patient, weighing about 180 pounds and with good spirits 
and color, presented every appearance of enjoying the 
very best of health. Bimanual examination showed a very 
markedly retroflexed and retroverted uterus. Repeated 
uranalyses. cystoscopy, catheterism of the ureters, pyelog- 
raphy, and radioscopy (for stone) were all negative. 
After a careful consideration of her condition the dysuria 
was traced to the door of the retroflexed uterus, which 
had produced a slight degree of cystocele, and, since the 
climacteric had been passed, and in the absence of all 
urinary findings, hysterectomy was advised. The opera- 
tion was performed March 21, 1912. She remained in the 
hospital about four weeks, and was seemingly benefited. 
.\ few weeks later the frequent and painful urination de- 
veloped again, so that catheterism of the ureters was once 
more carried out. On July 17. 1912. Dr. E. G. Hopkins, of 
the University College of Medicine. Richmond, reported, 
"Tubercle bacilli present in the urine from the left side, 
none found in urine from the right kidney." .-Xugust 2nd 
the findings were the same as on July 17th. October 30th 
a small amount of pus and a few tubercle bacilli were 
found to be present; November i8th tubercle bacilli pres- 
ent in specimen from left kidney. 

It is interesting to note that the tubercle bacilli 
were found only on the sixth or seventh investiga- 
tion, no suspicion of a tuberculous condition having 
been previously aroused ; and, further, that during 
the entire course of the disease the pain and distress 
had been regularly referred to the right side, while 
the lesion was on the left. This woinan is now 
undergoing tuberculin treatemnt and seems to be 
improving daily. 

Case II. J. W. D., thirty-eight years old, male, for 
several years had been having periodic and irregular at- 
tacks of frequent and painful urination, for which he had 
consulted a considerable number of physicians who had 
prescribed varying treatments. December 24, iQii. a 
cystoscopic examination was made, and a slight trigonal 
injection observed. The ureteral ora were normal, and 
the capacity of the bladder was twenty ounces. The 
prostate pnd seminal vesicles were stripped and subjected to 
microscopical examination, but nothing unusual was found. 
For the past few months he had been urinating on the av- 
erage every two hours, day and night. There were periods 
of relief, which were usually of short duration — a day or 
so. He found that drinking large quantities of water helped 
the pain, but this doubtless aggravated the pollakiuria. Ex- 
amination of the urine showed it to be of a specific gravity 
of 1.009 and neutral in reaction. It contained occasional pus 
corpuscles and a few small and round reniform cells, but 
no casts. Catheterism of the ureters showed the urine 
practically identical on both sides and bilateral pyelography 
proved the kidneys to be normal in outline and in their 
proper beds. X rav was negative. May it, 1912. Patient 
returning for furtlier investigation of his case, still com- 
plained of vesical discomfort and constant pain about the 
left kidney which was usually worse at night, and although 
the frequency of urination was not so great as a few months 
ago. thert were considerable embarrassment and inability 



BRYAN: RESAL TUBERCULOSIS. 



[New York 
Medical Journal. 



to atteri'l to work in consequence of this nagging pain and 
frequent desire. His appetite was good, his bowels were 
kept well open, and he did not drink so much water as pre- 
viously. Cystoscopy, catheterisin of the ureters, and x ray 
examination were again negative; rectal and urethral in- 
vestigation gave no clue to his trouble. The urine contin- 
ued of p low specilic gravity and was acid, but was other- 
wise of a negative character. It was at this juncture 
that miliary tuberculosis of the left kidney was suspected, 
and a rigid examination instituted to find tul)ercle bacilli. 
The polyuria, which would seem to be signiticant in this 
case, might be explained not only by the slight irregular 
accomp;mying interstitial nephritis, but theoretically also 
by a greater or less involvement of the pelvis of the 
organ or the ureter, with partial retention of the urine 
in the pelvis of the kidney ; a condition which would 
necessarily lead to a pressure atrophy of the tubules in 
the pyramid, and thus influence the water absorbing power 
of the kidney. The retention of the urine in the kidney 
pelvis could also be caused by the fact that so great a 
frequency of micturition must mechanically interfere with 
the normal rhythmic contraction of the ureter. It is just 
such cases as this, with that indefinite, obscure, and in- 
direct train of symptoms, which should put the surgeon on 
the alert, so as to follow everj- clue to the possible diag- 
nosis of a disease so insidious in its incipiency and so 
fatal in termination. The condition of affairs was ex- 
plained to the patient and an exploratory nephrotomy ad- 
vised. The kidney was found somewhat enlarged and 
mottled, but no foci were discovered. A peculiar thicken- 
ing about the upper pole of the kidney was noticed. Dr. 
S. B. Moon, pathologist to Grace Hospital, Richmond, 
gave the following report from the examination of a 
small section: ''About half the kidney tissue is normal in 
appearance. Here and there are congested vessels. A 
large number of tubules are blocked with debris, which 
widely distends them, and the surrounding epithelial cells 
are largely disintegrated. The protoplasm, however, 
stains well. Diagnosis, moderate parenchymatous neph- 
ritis." It is now several weeks since the operation. There 
has been no return of the old pain, and the patient is 
apparently relieved of his dysuria. Although the findings 
and the operation would appear to negative tuberculosis, 
the writer is still of the opinion that a focus somewhere 
in the left kidney was the cause of the trouble. 

Case III. Mrs. E. C. L., aged twenty-four years, mul- 
tipara, intil recently had always enjoyed the best of 
health, weighed 170 pounds, and had had no illness since 
childhood. Family history negative. About two months 
ago she began to complain of frequent micturition, voiding 
the urine about everj- thirty or forty minutes. She noticed 
slight blood in the urine at times, and suffered constant 
pain, which was made worse by the act of micturition. 
There had previously been some sliglit pain in the kidney 
region, perhaps a little more on the left side than on the 
right, and also marked tenesmus. The condition came on 
gradually and insidiously, and she at length consulted Dr. 
Howard Armstrong, of Edom, Va., who referred her to 
the writer. 

In vaginal examination considerable tenderness was 
found about the trigone of the bladder. The capacity of 
the bladder was two and one half ounces; uranalysis 
showed albumin ; no casts ; occasional blood cells ; a few 
large, round, squamous epithelial cells ; no crystals ; a large 
quantity of pus. There was no pain posteriorly or along 
the course of the ureter, nor was the abdominal wall 
anterior to the kidney rigid. Cystoscopy, which was very 
painful, showed marked edema and inflammation about the 
floor, and particularly in tlie region of the left ureteral 
mouth, the congestion being so great that the ureteral os 
could not be located for catlieterism. By vaginal examina- 
tion a positive pulsation was felt in die left fornix, and a 
cordlike projection extending upward, which was taken 
to be the left ureter, was noted. With the x ray examina- 
tion negative for stone, a provisional diagnosis of tuber- 
culosis was made, and dailv examinations were made of 
the urine for tubercle bacilli. Numerous other bacilli w-ere 
observed, especially the colon bacillus and its analogues, 
but only on the twelfth examination of the urine was 
the tubercle bacillus in large numbers found. This con- 
firmed the diagnosis and the irrigations and instillations 
which had been enegetically carried on were stopped, and 
appropriate treatment directed toward the kidney proper. 
Lumbar ureteronephrectomy was performed. The capsule 



of the kidney was studded with minute foci, particularly 
about the poles anteriorly. One or two had burst 
through into the fatty bed and were surrounded 
by fibrous tissue, the kidney was mottled in appearance, 
and irregular areas of fibrosis were noticed in the 
cortex. There was one cavity about the size of a 
hazel nut in the upper pole, the walls of which were 
smooth and hard. The ureter was considerably involved 
in its upper segment, and after a swabbing out with pure 
carbolic acid it was tied off as low as possible. On the 
third day marked improvement was apparent, the fre- 
quency of urination being considerably lessened, and the 
pain not so severe. Already the remaining kidney secreted 
forty ounces in the twenty-four hours. Xo tubercle bacilli 
had been found in the urine since the second day fol- 
lowing the operation, and the course of convalescence so 
far had been uneventful and most happy, .'^t the present 
writing, one month after operation, the patient is up and 
about and seems to be going on to a satisfactory recovery. 

The narration of these three cases, selected from 
a series, is designed to emphasize particularly the 
cardinal features of diagnosis of early renal tuber- 
culosis. In our series we find first, that there are no 
pathognomonic evidences of the early stages of the 
disease; second, the distressing vesical disturbances 
would appear to be the leading clue to the diagnosis ; 
third, the repeated negative examinations for tu- 
bercle bacilli, in one instance twelve such being 
made before the germ was found ; fourth, the al>- 
sence of marked papillary hemorrhage, which is 
accorded a prominent diagnostic symptom, but 
\thich pathologically cannot be identified with the 
cortical invasion ; fifth, the stormy and febrile reac- 
tion following nephrectomy, with the liberation of a 
large number of toxic substances and endotoxines 
into the stirrounding tissues. The physical evi- 
dences in the early stages of renal tuberculosis are 
most indefinite and obscure. The patient has at 
irregular intervals a distressing and annoying fre- 
quency of urination, which is more evident by night 
and continues for an irregular period of time — days 
or weeks. During the height of the attack there 
may be some slight tenderness over the kidney, with 
a slight rigidity of the abtlominal wall anteriorly. 
On the left side an old varicocele may become con- 
gested, giving rise to some discomfort. Rectal pal- 
l)ation should always be carried out. At best the 
findings and chain of evidence are most unsatis- 
factory, and we must rely in our diagnosis of this 
condition upon i, uranalysis, 2. the microscope, 3, 
the c}Stoscope, with ureteral catheterism, 4, tuber- 
culin and its allies, 5, kidney efficiency. 

The uranalysis in incipient miliary tuberculosis is 
inconstant in the character of its results, for tubercle 
bacilli are not always implanted upon an absolutely 
normal kidney. The urinary findings, then, may 
show evidences of a nephritis of more or less 
severity, and, in fact, the laboratory returns con- 
stantly report the condition present as Bright's dis- 
ease of varying degrees, for in this early stage the 
urine is that of a renal congestion. The specific 
gravity, on account of the renal stimulation and 
water drinking, and because of the irregular thick- 
ening of the capsule producing a patchy interstitial 
nephritis, is low. Later on. with cellular elements 
coming away and the kidney not responding so 
proinptly to the toxic stimulus, it is considerably 
higher. It is, however, seldom as high as in the 
normal state. The reaction of the urine is one of 
the most notable features of the strumous kidney; 
this is regularly and constantly. Pus is one 



July 5. 19. 3] 



BkyA.X: RENAL TUBERCULOSIS. 



23 



of the characteristic indices of the invasion of 
the tubercle bacilh, and its production represents 
nature's attempt to prevent the spread of infection. 
Althougii the pus is not constant, but intermittent, 
a few cells in a regularly acid urine would at least 
give us a clue for diagnosis if we were satisfied as 
to the absence of stone. Pus in a constantly acid 
urine would appear to be the password for early 
renal tuberculosis. Blood is found in the urine from 
time to time, and, with the implantation of the 
process on the tip of a papilla, there may be severe 
hemorrhage. The bleeding may be so free as to 
cause a blocking of the ureter by the inspissation of 
the debris from above, resulting in an embarrassing 
train of disagreeable symptoms, a veritable Dietl's 
crisis. This papillary tuberculosis is rare, but occa- 
sionally the large loss of blood, with all other find- 
ings negative, gives a clue to the possible diagnosis. 
Albumin may or may not be present. With a con- 
siderable amount'of epithelium the test will be posi- 
tive : protoplasma and serum albumin must therefore 
be differentiated. The albuminuria of the ordinary 
tuberculous patient is bilateral, while that of a 
renal tuberculosis is imilateral. The character of 
the epithelium present represents the location of the 
morbid process. Uric acid crystals are frequently 
present as the result of the constantly acid urine. 
Casts, hyaline, granular, and epithelial, may be 
found in the urine as the result of the tuberculous 
invasion ; which would appear to be the kidney's 
response to the toxic irritant, and not as a phenom- 
enon of acute circumscribed nephritis. Hunner 
reports casts present in ten per cent, of his cases. 
Morris asserts that polyuria (the thalmuria of 
Tilden Brown) in a frail patient of tuberculous 
family, for which no other cause is assignable, 
should excite suspicion of renal tuberculosis. This 
pollakiuria is peculiarly nocturnal, and not relatively 
so marked during the day. 

In the microscopical examination the smegma 
bacillus and acidfast streptothrix must be differen- 
tiated from the tubercle bacillus. The writer would 
recommend that all the urine voided be carefully 
collected with the strictest precautions, preferably in 
a Stenbeck's sedimcntator, preserving it with boric 
acid, one grain to the ounce of urine, and that the 
best expert obtainable be employed to investigate it 
for the tubercle bacilli. It may require a week or 
more for a result in any way positive. Even then 
a negative bacteriological examination does not dis- 
prove the clinical diagnosis ; for, with only a few 
cortical spots well surrounded with unyielding 
fibrous tissue, the extreme difficulty of securing, 
segregating, and recognizing the offending tubercle 
bacillus must be at once evident. It is sometimes 
surprising how examinations for a w'eek or more 
give no evidences of the tubercle bacillus : yet then 
suddenly a large number will be found to have come 
away. This condition of affairs has obtained in 
several of our cases (see Case III). It would 
appear that the multiplication and evacuation en 
masse of the bacilli would be of less damage to the 
urogenital mucosa than if a constant stream of less 
numbers were to be always present. The urgent 
importance of repeated examinations cannot be too 
strongly emphasized. 

As to cystoscop)', in the very early stages nothing 



may be noted about the patient's bladder or ureteral 
ora. Soon, however, with the more marked invasion 
of the kidney jjroper, there is a lluftiness, bluencss, 
and injection of the ureteral opening which is conse- 
quent upon a librotic formation and retraction 
(Fenwick's golf hole orifice). Only recently Buer- 
ger has called attention to an "edema buUosum" of 
the ureteral os which is present even when the ureter 
is not involved. He considers this the most distinc- 
tive initial feature in the diagnosis of early renal 
tuberculosis. In the second and third stages of the 
disease well defined tuberculous ulcers are seen 
about the trigone and ureteral mouths. Catheterism 
of the ureters is here a tedious and difficult proced- 
ure. Ureteral spasm is easily provoked, and biting 
of the catheter ensues, which causes a considerable 
amount of pain and discomfort. Radioscopy may be 
used for differential purposes, but not with much 
hope of its confirming a possible diagnosis. Pye- 
lography would not seem to be of any material ben- 
efit in the diagnosis. The tuberculin or T. R. test, 
von Pirquet's reaction of the skin, and Cahnette's 
reaction of the conjunctivae may be used as corrobo- 
rative measures. These latter tests are to be more 
or less condemned or at least conducted with great 
caution, as they are dangerous procedures on ac- 
cotmt of the marked edema of the ureteral mouths 
which have been noted — in certain instances pro- 
ducing fatal suppression. Injections of the sedi- 
ment into the peritoneal cavity of the guineapig 
would appear to be an efficient diagnostic measure. 
Culture processes may be tried also. The renal 
efficiency may be investigated by one of the follow- 
ing means : Cryoscopy, the freezing point of the 
blood and urine ; the chromocystoscopy of \'olcker 
and Joseph with indigo carmin ; phloridzin, produc- 
ing a temporary glycosuria ; Morro's test, particu- 
larly good in the case of children ; Wright and Kill- 
mer's method of hemolysis ; the determination of 
urea secretion as perfected by Rovsing; and finally 
the phenolsulphonephthalein test, which the writer 
highly commends as the best means for ascertaining 
unilateral efficiency, consequent fibrotic replacement, 
and renal degeneration. It must be borne in mind 
that the kidney, like other organs, may suffer a 
pathological invasion and still possess sufficient 
resistance to ultimately attain a restitutio ad inte- 
grum. The adjustment of the actual kidney condi- 
tion and the pathological findings to what we hope 
to get by tiranalysis and microscopical and other 
investigations cannot always be so arranged as to 
be simultaneous and complementary. Although 
spontaneous cure of tuberculosis of the kidneyis 
unknown and the disease usually progresses per 
saltum, it might be possible to imagine a discreet 
miliary focus which had given rise to considerable 
embarrassment and yet on investigation yielding no 
definite findings to justify a positive diagnosis. The 
focus has healed, and patches of irregularly scat- 
tered fibrous tissue, here and there, just under the 
capsule and burrowing but a short way into the cor- 
tex, are the only remaining evidences of the former 
tuberculous invasion. 

A hasty review of the foregoing signs would lead 
us to attach particular significance to the subjective 
complaints of dysuria and pollakiuria, for these 
would appear to be the constant and cardinal symp- 



24 



K.tlJSKI: LUETIN REACTION IX SVI'HILIS. 



toms given by the patient in his distress. Objec- 
tively there are no physical findings of value in the 
early stages of cortical tuberculosis. The question- 
able rigidity in the abdomen anteriorly, or the tender 
spots posteriorly, cannot at all times be elicited. The 
general practitioner must confine his energies 
toward the investigation of the urine, the significant 
features of which are a constant acidity and inter- 
mittent pyuria, for it must rest with the expert 
microscopist to dilTerentiate the renal morphology 
and stain for the germ of tuberculosis. Cystoscopy 
and the tests for renal efficiency should be placed in 
the hands of one peculiarly skilled along this line. 
Too much importance cannot be attached to these 
two means of diagnosis. At best, however, all our 
investigations and clues are hazy and indecisive, so 
that it is by a combination of agencies rather than a 
single one, that we are made acquainted with the 
pathological processes which in the large majority 
of cases is constantly progressing unfavorably. 
There are many of us who doubtless during our 
professional lives have witnessed a considerable 
number of cases which have been characterized by 
a frequent and painful urination and in whom the 
findings have been repeatedly negative. Could not 
this condition be put at the door of a renal tubercu- 
losis of limited extent which ultimately became ab- 
sorbed or replaced by connective tissue? The writer 
is of the opinion that the strumous kidney occurs 
more frequently than is generally believed, and in 
the absence of stone, tumors, floating kidney, and 
diseases of the kidney and pelvis proper, that an 
earnest and repeated investigation of the physical 
findings and urine will on certain occasions be re- 
warded by the establishment of a tuberculous 
trouble. It would appear, then, that reduced to its 
final analysis, the diagnosis of renal tuberculosis is 
actually one of exclusion rather than substantiation. 
In conclusion, we would recommend the less radical 
means for treatment in the early stages, such as 
tuberculin and dietetic and hygienic measures. Dur- 
ing its entire course the physical condition and the 
urine must be investigated most carefully and thor- 
oughly. Any evidence of progressive invasion 
should be interrupted by immediate nephrectomy or 
nephroureterectomy, provided the kidney of the 
opposite side has been tested as to its capacity. It 
would seem, from a review of the cases which have 
fallen under the observation of the writer, that 
nephrectomy is preferable. We cannot, however, 
believe that such heroic measures should be adopted 
in any instance without proper investigation di- 
rected along the most scientific and deliberate lines. 
301 \\^EST Grace .Street. 



THE LUETIN SKIN RE.\CTION IX 

SYPHILIS. 

Bv David J. Kaliski, M. D., 

New York. 

From the Pathological Laboratory of the Mount Sinai Hospital. 

Great progress has been made during the past 
decade in the diagnosis and treatment of syphilis. 
The impetus given by the disco\-erv of the S/^iro- 
chccta pallida and of the application of the Bordet- 



Gengou phenomenon of complement fixation to the 
diagnosis of luetic conditions has resulted in the 
accumulation of a mass of scientific data, making 
possible the application of the newer chemothera- 
peutical principles in a practical, as well as scien- 
tific manner. 

However, in spite of great strides forward, 
the detection of syphilis by means of laboratory 
aids has not been perfected to such an extent that 
additional help would be superfluous. While the 
means at our command are on the whole quite sat- 
isfactory, they occasionally fail in the detection of 
conditions which, etiologically and clinically, are 
syphilitic or the result of previously existing active 
sypliilis. Therefore the recent endeavors of work- 
ers to cultivate the Spirochwta pallida in pure cul- 
ture have been of interest in view of the possibility 
of applying cutaneous tests analagous to the well 
known skin reaction of von Pirquet in tubercu- 
losis. The scientific labors of Noguchi in the field 
of syphilis research have been productive of re- 
markably fruitful results. He has, for the first time, 
cultivated the spirochete, or Treponema pallida, in 
pure culture, differentiating it morphologically, as 
well as culturally, from similar organisms. He has 
infected Laboratory animals with these cultures and 
has been able to recover the spirochete from the 
tissues and fluids of the infected animals. He has 
also proved by means of biological tests the pres- 
ence of the infection in the blood of the animals 
experimented upon. And now, as a result of this 
work, he has devised a means of applying a sus- 
pension of a number of strains of the killed cul- 
tures of the spirochete locally by intradermal injec- 
tion. This test is based upon the fact that animals 
suiifering with a chronic infective condition enter 
into a state of altered reactibility or allergy. In- 
dividuals sensitized or made allergic by passing 
through certain infectious diseases, or still harbor- 
ing the organisms of such disease, react peculiarly 
when vaccinated with a concentrated culture of the 
organisms or with the extract of the tissues or 
organisms of the infective process. In this respect 
the person injected behaves analogously to certain 
animals reinjected after an interval following sen- 
sitization with a foreign protein. 

Numerous methods of cutaneous and subcutane- 
ous vaccination in syphilis have been tried, but up 
to the present time none has proved of any definite 
value. The results have hardly been either specific 
or of sufficient constancy to be depended upon.^ 
.\ recent repetition of most of the methods tried 
up to date by Fontana proved that the results do 
not approach those obtained by the use of the Was- 
sermann test. They were not of sufficient constancy 
or specificity in syphilis to give any of them a 
place in our clinical armamentarium. 

It is of interest, therefore, to inquire into the 
merits of the reagent prepared by Noguchi for in- 
tradermal injection. The first material used con- 

'Neisser and Bruch used extracts of organs rich in spirochetes; 
Tedeschi used extracts of hard chancres containing numerous or- 
ganisms; Nicolai, Favre. Gauthier. and Chorlet, used a glycerin 
extract of syphilitic livers. They called it syphilin. Leper. Des- 
bouis, and Dureaux used concentrated solutions of sodium glycho- 
cholate; Oppenheini and also Ciuffio used lecithin solutions. Otlier 
workers used extracts of guinea pig heart and other normal and 
specific extracts in alcohol and other solvents, both hypodermically 
and into the skin. Quite recently Fischer and Klausner publisheil 
the results of injection of a sodium chloride extract of fresh tissue- 
trom the lungs of infants who had died of pneumonia alba. 



K.ILISKI. Ll'l-TIX REACTIOS IS SYPHILIS. 



25 



tallied Uvo straiii> of the Treponema pallida. The (free from orj^anisms) preserved with tricresol or 

reagent was first injected into rabhits infected with phenol. 

svpliilis. and later luuiian beings were injcc ed. A satisfactory reagent is one that is rich in spiro- 

The appended table gives the results of the first 315 chsetae, preferably containing as large a number of 

TABLE I.— lA'KTlN UKAe TlUN IN VARIOUS SYPHILITIC CONDITIONS AND IN CONTROLS. 

Cerebro- 
iVimary Secondary Tertiary I'oimcnilal spinal ? 

syphilis syphilis syphilis syphilis syphilis . J Controls 



I uctin reaction 

No antisyphilitic treatment 

Slight mercurial treatment 

Kegular mercurial treatment 

Salvarsan and mercurial treatment. 



ma 
+ — 



+ — + — + 



2 = 

+ — 



3 25 56 15 43 



case.-- iiijccteil by .Vinjnclii. There were 250 nor'ral 
controls, none of which reacted positively. The 
luetin prepared recently has had incorporated in it 
six or seven strains of the Treponema pallida. 
There have been a number of confirmatory reports 
by clinicians using the material prepared by 
Xoguchi. (7)wiug to the great difficulty of isolating 
the Treponema pallida in pure culture and grow- 
ing the organisms in any abundance, all the reports 
that have been published up to date, including the 
author's, have been the result of the injections of 
the reagent (called luetin). prepared by Noguchi. 
The luetin is prepared as follows : Th? orsrani^ms 
obtainerl originally from chancres, condylomata, 
etc.. are grown in ascitic ag^.r and ascitic broth con- 
tainiiTT sterile tissue, usually placenta or kidnev. 
The cultures are sjrown anaernhical'v in the thermn- 



strains of the pallida as available, and as free as 
possible from irritating culture medium and pre- 
servative. Up to the present time the great diffi- 
culty of obtaining the organisms free from the 
medium in which they grow has in all probability 
been a factor in the number of nonspecific reaction*; 
obtained. It is essential to dilute the concentrated 
luetin sufficiently to prevent a local irritative re- 
action. Thus, each new preparation of luetin should 
be tested on a number of normal controls to de- 
termine its irritative properties before suspected 
cases are subjected to the test. 

The reagent is injected into the superficial layer 
of the skin with a very fine and smooth hypodermic 
needle until a small, pale wheal is produced. About 
0.05 c. c. to 0.07 c. c. are usually injected. The 
fiexor surface of the forearm or the outer side of 



No. cases. 
I'rimary and secondary lues.. 30 

Tertiary lues (active) 30 

Latent lues (old cases) 7 

Cerebrospinal lues 13 

Tabes and Taboparesis 32 

Hereditary lues 10 

Control cases -~54- 





TABLE 


Luetin 

■f — 


Wassermann 
reaction 
-t- — 



Wassermann positive and luetin negative 20 cases 

Luetin positive and W^assermann negative 1 case 

Positive luetin and negative Wassermann 4 cases 

Wassermann positive and luetin negative 7 cases 

Luetin positive and W'asserniann negative o cases 

Wassermann positive and luetin negative 4 cases 

Wassermann positive and luetin negative 7 cases 

Luetin positive and W'assermann negative cases 

Wassermann positive and luetin negative 13 cases 

Luetin positive and W^assermann negative o cases 

Wassermann pi.isitive and luetin negative 7 cases 

Luetin positive and Wassermann negative 6 cases 

Wassermann positive and luetin negative o cases 

Luetin positive and W^assermann negative 12 cases 



Stats for periods up to fiftv days. Bits of culture 
medium are isolated which appear (macroscopi- 
callv and microscopically) to contain the organ sms 
in large numbers. Then the solid and fluid media 
are ground together in a sterile mill until a medi im 
of moderate fluidity is obtained. This is then 
heated for one hour at 60° C, and is preserved 
with one half per cent, tricresol or phenol. 

The inocuousness of the reagent is determined by 
animal inoculations and cultures on the medium d -- 
scribed before injection into human beings. It is 
of great importance to make bacteriological te<ts 
from time to time to determine the continued ster- 
ility of the final product, otherwise nonspecific re- 
sults may be obtained from local infection at the 
site of injection. A control injection is prepared by 
grinding up in a similar manner the culture medium 



the upper arm may be used for the injection. 1 
lave been in the habit of using the left forearm 
for the luetin injection and the right forearm for 
the control. According to the published reports of 
.Xoguchi and others, there is either no reaction at 
all at the site of injection in normal individuals or 
a small erythematous area which recedes w^ithin 
forty-eight hours. After observing the reaction to 
tbe injection in a large number of apparently nor- 
mal individuals I have come to the conclusion that 
with the present method of preparation of the lue- 
tin there occasionally develops at the site of the 
injection of the reagent, and also at the site of 
the control injection, a small area of infiltratiin 
varying in size up to about eight or ten millimetres, 
which is often surrounded bv a blush of erythema 
and which may persist for from two to four days. 



26 



KALISKI: LUETIN REACTION IN SYPHILIS. 



[New York 
Medical Journal. 



There is usually no marked infiltration present. 
The occurrence of this type of reaction has been 
of sufficient frequency to lead me to disregard what 
Noguchi calls the "papular" reaction as a specific 
phenomenon, unless the area is greater than eight 
or ten millimetres in diameter and is markedly in- 
filtrated. The reaction that I have learned to con- 
sider positive is a markedly infiltrated papule over 
eight millimetres in diameter, which persists after 
the third or fourth day as such or progresses to defi- 
nite softening or pustule formation. The inflam- 
matory area may be capped by a few small vesicles, 
which may rupture or become filled with pus. The 
pustule may begin to form after the second or third 
day in severe reactions and increase in size until it 
reaches the size of a plum. It may rupture spon- 
taneously or become absorbed ; in the latter event 
the site of injection may remain infiltrated and pig- 
mented for a month or more. The severe reactions 
are occasionally accompanied by intense itching and 
burning in the arm, but I have failed to observe 
general symptoms attributable to the local lesion. 
In only a few instances have the axillary nodes 
been slightly enlarged. 

It is usual for the reaction in positive cases to 
begin to disappear about the sixth or seventh day, 
but in some cases the local lesion may remain in- 
filtrated for a longer time and pigmentation may 
persist for manv weeks, or even a few months, after 
inoculation. There is a torpid or tardy form of re- 
action which has been observed in a small number 
of cases, usually of cerebrospinal lues or tabes. At 
the end of the usual period of observation the re- 
action appears to be negative, but about the seventh 
or tenth day a small vesicle or papule appears at 
the site of inoculation of the luetin. This lesion 
is usually about one centimetre in size and may rup- 
ture and discharge a small amount of serosanguin- 
eous material (hemorrhagic reaction) or go on to 
the development of a small p'ustule. In a very few 
cases I have observed, only at the site of the control 
injection, a definite reaction, similar in all respects 
to the positive papular or pustular reaction. These 
cases were in normal individuals. Similar speci- 
mens of control injection fluid in other individuals 
failed to cause any reaction whatever. I have no 
explanation to otter for this paradoxical reaction 
other than the possible presence of irritative fact- 
ors in the control material or local skin suscepti- 
bility to infection. 

In about ten per cent, of all active syphilitics who 
reacted positively to the luetin test there was a re- 
action of equal intensity at the site of the control 
injection. In a few instances the control injection 
reacted even more markedly than the luetin site. 
This peculiar phenomenon may be explained as 
follows : It is a \\ell known fact that the skin ot 
syphilitics is susceptible to trauma, and that not 
infrequently gummata form at the site of such in- 
jur)-. Finger was of the opinion that at such a 
place a locus resistenticr minoris is formed, into 
which the virus or organisms of the disease wander 
and cause a lesion. This is the theory of superin- 
fection. Xeisser, since he could never find the 
organisms in these lesions, denied this hypothesis 
and maintained that there was an altered condition 
of the skin itself responsible for the pathological 



condition. This condition of the skin Neisser called 
Umstimmung. It is this explanation that Noguchi 
ofl'ers for the occurrence of reactions at the site of 
the control injections in cases of syphilis. 

Marked U nistimmung was observed in a num- 
ber of tertiary cases and in one of the hereditary 
cases. Further, a few cases in which I have been 
unable to discover any specific taint (the history, 
clinical course of the disease, and the Wassermann 
reaction all being negative) gave definite Umstim- 
mung. Inasmuch as all the cases were injected in 
series, the reaction at the control site could not be 
attributed to too great concentration of the luetin. 
The reagent was always sterile when injected. Of 
course, we must always bear in mind the possibility 
of infection by skin bacteria of an area rendered 
somewhat susceptible by the injection of a slightly 
irritating reagent. 

This paper is the result of experience gained by 
the injection of nearly four hundred cases of 
syphilis and nonsyphilitic conditions. 

PRIM.\RY AND SECOXD.\RY SYPHILIS. 

In primary and secondary syphilis the propor- 
tion of positive results is so small as to render the 
test of little practical value. In thirty cases, in most 
of which there were active lesions, the reaction was 
definitely positive in three cases (ten per cent.). 
Some of the patients were injected before and some 
after treatment. The Wassermann reaction in 
these cases, ireated and untreated, averaged eighty 
per cent, of positive results. In one of the cases, 
in which the luetin reaction was positive after the 
patient had received salvarsan and mercury, the 
Wassermann reaction became negative and remained 
so. No definite relationship could be noted between 
the amount of treatment and the outcome of the 
test in this stage of the disease. It would appear 
that in the active stages of syphilis, when the tissues 
are invaded by the organisms, the body has not 
entered into a condition of altered reactibility or 
allergy. 

TERTIARY SYPHILIS. 

It is in the tertiary stage of the disease that the 
test seems to have its widest and most useful ap- 
plication. A few published reports by observers 
have shown a very high proportion of positive re- 
sults in tertiary syphilis. i\Iy figures are not quite 
so high. In thirty cases of tertiary lues I have ob- 
tained positive luetin reactions in nineteen (sixty- 
three and one third per cent.). In a number of the 
test was positive in twenty-three of these cases 
(seventy-seven per cent.). In a number of the 
patients the Wassermann test was positive, although 
they were under very active treatment. Two cases 
gave both a negative luetin and Wassermann reac- 
tion, one being that of a patient with malignant lues, 
the other a tertiary luetic with spinal symptoms. 
Four cases gave positive luetin reactions and nega- 
tive Wassermann reactions. One was that of a 
patient with marked periarthritis and synovitis who 
recovered after antispecific treatment. The others 
were cases of aneurysm of the aorta, myocarditis 
with tertiary luetic manifestation and cerebral en- 
darteritis. In all these instances the diagnosis was 
established or confirmed by the positive luetin re- 
action. In a case of spinal tumor both the Was- 



July 5. 1913I 



KALI SKI: lATJIS REACTION IN SYPHILIS. 



27 



serniann test and the liietin reaction were positive. 
The tumor removed by operation proved to be a 
glioma. Of course, there is the strong probability 
here of the existence of a neoplasm m a specific 
individual. In seven active cases the W'asserniann 
test vj'as positive and the luetin test was negative, 
while in four cases the luetin test was postive and 
the \\'assermann reaction resulted negatively. 

Thus, the reaction was of iletinile diagnostic 
value in a number of cases, although the figures 
were not as high as those obtained by the Wasser- 
mann test. It seems that the individual is in a 
state of allerg\- in this stage of syphilis, and it is 
to be hoped that with the further purification of the 
reagent anil the incorporation in it of a larger num- 
ber of strains of the Treponema pallida, the allergic 
reaction may be brought out in a larger percentage 
of the cases. 

HEREDIT.VRY SYPHILIS. 

The luetin test was postive in but one case, while 
the \\'assermann test was positive in five cases. 
Uiiisti);iiniiiig was marked in the positive cases. 
All of these cases were in children over three years 
of age who had manifest lesions, and but one of 
them had been treated. Two of these cases gave 
suspicious reaction to luetin. In four other mem- 
bers of luetic families in which a serum test could 
not be obtained the luetin tests were negative. 

TABES. 

In thirty-two cases of tabes in which the Was- 
sermann test was postive in the blood and spinal 
fluid in about half the cases, the luetin reaction 
was positive in but three cases. In no case in which 
the Wassermann test was negative did I obtain a 
positive luetin reaction. Many of these patients 
were in the late degenerative stage of the disease, 
in which all the tests, both of the blood and spinal 
fluid, were negative. In one of the cases, which 
also showed lesions of tuberculosis, a tardy pustular 
reaction with Uin.<!thnmung w'as obtained. 

CEREBROSPIN.^L SYPHILIS. 

The test is of more value in cerebrospinal syphilis. 
Of thirteen cases, four gave a positive luetin reac- 
tion and nine w-ere negative. Thus, in this form 
of lues, representing a more or less active invasion 
of the nervous system, the reaction tends to give a 
larger proportion of positive results. One of the . 
patients were injected three times, and each time a 
pustular reaction resulted. Two of the cases showed 
the tardy reaction and one of these gave the tardy 
reaction twice. 

LATENT LUES. 

In seven old luetics who had been well treated 
and had not recently presented lesions, the tests 
were uniformly negative. In four of these cases 
the Wassermann test was positive. 

CeXTROLS. 

As to controls, I was able to observe for a suf- 
ficiently long time to be able to rule out all latent 
or delayed reactions — 225 cases of the type, cne is 
apt to meet in the wards of a large hospital. It 
must be taken into consideration that while syphilis 
is a factor in the lives of the type of patient coming 
to the Mount Sinai Hospital and the Montefiore 



Home, this disease is not so frequently met with 
as in the jjatients of some other institutions. This 
is especially true of the older generation of He- 
brews. My results show that out of the 225 cases 
there were twelve definitely positive luetin reac- 
tions in cases in which the Wassermann tests and 
histories were negative. In none of the cases could 
any evidence of the disease be found intra vitam. 
( .\s mentioned above, I have not taken into account 
small papules at the site of the inoculation, else 
the number of "nonspecific" results would be 
greater and. it should also be mentioned, the pro- 
portion of positive results would approach the 
higher figures of other observers.) Each of the-e 
twelve cases presented a negative history ami re- 
peated Wassermann tests were negative. One was 
a case of gout, another cirrhosis of the liver and 
a third nephritis. The two latter occurred in in- 
dividuals who were fathers of large and healthy 
families. Three cases of tuberculosis gave definitely 
positive reactions. In thirty other cases of tul^er- 
culosis the test was negative, although I noted a 
tendency to slight papule formation in many of 
these patients. A case of myasthenia gravis gave 
a definitely positive reaction three times. The blood 
and spinal fluid yielded a negative result to all 
tests. A case of multiple sclerosis at the Monte- 
fiore Home twice gave a postive reaction. A case 
of scrofuloderma reacted positively three times. At 
various institutions this was regarded as a case of 
tuberculosis. Antispecific treatment w^as of no 
therapeutic value, but tuberculin treatment was de- 
cidedly beneficial. The three remaining cases were 
of nephritis, endocarditis, and psoriasis; all without 
ascertainable specific taint. 

That syphilis may be a latent factor in some of 
these cases is possible, though the usual criteria for 
determining the condition were absent in all. This 
leaves us with a small proportion of nonspecific 
results for wdiich I can offer no explanation. How- 
ever, I think that in any intradermal reaction the 
introduction of the reagent under or into the .-kin 
is occasionally attended with a certain traumatic 
risk to the skin, and the presence of skin bacteria 
must always be a latent factor in causing occasional 
nonspecific reactions. As I suggested before, a 
further purification of the luetin will probablv re- 
duce the proportion of nonspecific results to a mini- 
mum. In this event the reaction w'ill be of excep- 
tional negative value as a routine test for the pres- 
ence of latent lues. It will require further work, 
both on the part of investigators trying the reaction 
upon patients in the wards and dispensary, and on 
the part of the originator of this new aid to the 
diagnosis of specific infection, to whom we nuist 
look for a more virulent and less irritating product, 
before the final value of the test will be know-n ,-'nd 
before any comparison with other methods which 
have been in use for diagnosis for almost a decade 
can be made. 

To summarize, from what has gone before, it is 
apparent that the test, as now applied and with the 
luetin now in use, is of little value in the active 
early stages of syphilis — i. e., in the primarv and 
secondary stages. I have been unable so far to 
formulate any definite criteria from a prognostic 
standpoint concerning the value of the reaction in 



28 



BROADMAS: MICROSCOPE IX rRF.rHRITIS. 



York 



treated cases of active lues. The luetin test is of 
little help in so called parasypliilitic conditions, 
especially the old degenerative types, and I agree 
with NogTichi that it cannot compare with the Was- 
sennann reaction for diagnosis in such conditions. 
In cerebrospinal syphilis, on the other hand, it is 
of service, and the results in an extended series of 
cases in the active stages of this disease should aji- 
proach those obtained in the tertiary period. In 
the tertiary stage of syphilis the reaction seems to 
be of the most value and is a valuable supplement 
and adjunct to the Wassermann test. In a large 
series of cases the test was specific for lues with 
the exception of five per cent, of the cases in which 
syphilis may possibly have been a factor. 

I wish to express my sincere thanks to the at- 
tending physicians and surgeons of Mount Sinai 
Hospital for their courtesy in extending the privi- 
leges of the wards to me, to Dr. S. Wachsmann, 
of the Montefiore Home, for similar courtesies, 
and to Dr. David Beck, of the Mount Sinai Hospital 
House Stafif, and Doctor Palefsky, of the Montefiore 
Home, for their kind assistance. 

Bir.LIOGR.\PHY. 

I. H. NOGUCHI: Journal of Experimental McJuiue. xiv. No. 6, 
iQii pp. 99 and 556. 2. M. COHEN: Archiv fur Ofhthalmologte 
.xii S 1912. -1. D. ORLEM.\N-ROBINSON: Journal of Cutaneous 
Diseases July, 1912. 4. J. M. WOLFSOHN: Bulletin of Johns 
Hopkins' Hospital, x.xiii, p. 233, 1912. 5. IDEM: Journal of the Ameri- 
can Medical Association, 1913. No. 24. 6. NOBL and FLLsS: 
Wiener klinische Wochenschrift, y.x\\ f. ^7i, 1912. 7, K.MWMERER: 
Munchener medisinische Wochenschrift, lix, p. I534. 191=. 8 LOE- 
WENSTtlN: Mcdizinische Klinik , ix. p. 410, 1913- 9- RYTINA: 
Medical Record, Ixxxiii, p. 385. ■913- 10. R. n. H. GR.-\DWOHL: 
Ibidem, I.xxxi. ii. P. 973. 1912. n- FISCHER and KI..\USNER: 
Wiener klinische Wochenschrift. xxvi. p. 497. '9i3- 

1070 Madison Avenue. 

THE NEED OF THE MICROSCOPE IX THE 
TREATMENT OF GONORRHEAL URE- 
THRITIS AND PROST.'KTITIS. 

By Joseph Broadman, M. D., 
New York, 

\'i3ning Urologist, Washington Heights Hospital Dispensarj'; 
.Assistant Urologist, German Hospital Dispensary. 

Most of the textbooks and monographs outline 
the treatment of gonorrheal urethritis, according 
to different stages, each to last a certain number 
of weeks, into which the disease is arbitrarily di- 
vided. Each of these stages is supposed to last for 
"so long," and then another stage is expected to 
begin, and to be treated accordingly. If these con- 
ditions were treated .scientifically, and with the aid 
of the microscope, to actually see the changes that 
take place in the urethral canal, as shown in the 
discharge, no such unscientific stages and conse- 
quent treatment would be called for, as will be 
shown later. 

Concerning prostatitis, altogether too little is 
mentioned, and yet the existence of an uncured in- 
fection of this gland is the cause for more recur- 
rences of specific and nonspecific urethritis than 
many are willing to believe. The mere fact that 
there is enlargement of the prostatic gland, as found 
by palpation with the finger in the rectum of a 
young man, is not enough reason to suspect it of 
carrving infection. Nor is a small prostate always 
healthy. Even such prostatic glands as feel nor- 



mal or nearly normal on palpation may be infected, 
and the only certain way to determine the condition 
of this gland is to obtain the secretion therefrom 
for a thorough microscopical examination. 

Acute infections of the urethra. We all know 
that not every discharge from a meatus is of gonor- 
rheal nature, and yet, unless this is properly exam- 
ined to determine the cause we are apt to treat such 
cases as gonorrheal infections. Should it happen 
to be an infection due to some organism other than 
the gonococcus, appropriate treatment may cure it 
within a few days, while if such a case is to be 
treated as gonorrhea without first consulting the 
microscope, the patient would be much bettter oflf 
if he had not consulted the physician for a few 
days, because by this time he would probably be 
well without any treatment at all except the con- 
stant flushing of the urethra by the urine. 

More frequently than is generally supposed, an 
acute discharge from the urethral meatus is due to 
the presence of a chancre in the urethral canal. 
The presence of syphilis as the cause would not 
even be suspected in most cases if it were not for 
the fact that upon microscopical examination no 
gonococci were found in such acute discharge. 

If a patient who presents himself for treatment 
really has a gonorrheal infection, the diagnosis 
should be made or confirmed by making a smear of 
the discharge present and e.xamine with the micro- 
scope to determine whether the gonococci are 
intracellular or extracellular and the {Xjrtion of ths 
extracellular gonococci with the intracellular ones 
w hen both are present. Physicians who treat 
their patients in this manner know that a great deal 
of benefit results from these determinations. If all 
gonococci in a given case are extracellular, such case 
can sometimes, if not often, be aborted, and the 
probability of aborting these cases dimini.shes with 
the increase of the number of intracellular gono- 
cocci. It very often happens that a patient with dis- 
charge, and a large number of intracellular and ex- 
tracellular gonococci, or even only intracellular 
gonococci, being treated only once at the office, is in- 
structed how to treat himself at home, and returns 
to the office the next day, not showing a single 
gonococcus in the smear. In other cases the gono- 
cocci may not disappear for two or three days, while 
in others this may take a week or ten days, or even 
a longer time. In cases where the gonococci dis- 
appear promptly, after appropriate treatment is in- 
stituted, and if such treatment is modified accord- 
ing to the microscopical findings as the case pro- 
gresses, the patients get well in a very short time — 
certainly much less than the proverbial "six weeks." 

But beside having the gonococcus and its situa- 
tion to guide us. if we use the microscope, we have 
other constituents in the discharge to give us addi- 
tional information. Thus we find the presence of 
pus cells, epithelial cells, and mucus, and it is only 
by a thorough understanding and consideration of 
the presence of tiiese constituents in greater or 
less quantities or proportions, and an appreciatioii 
of the significance of their absence during the 
course of treatment, that we can treat our patients 
properly and in accordance with scientific principles. 
A great many of these infections, especially those 
which have been treated for some time with some 



July 5, 1913.) 



BKO.IDM.IX. MICROSCOPE IN LRETl IRITIS. 



29 



of the silver salts, show a very profuse purulent 
discharge, due to overtreatnient and consequent ir- 
ritation, as shown by the microscopical findings, 
an(,i not a few of such ]);Uients are treated even ninre 
vigorously because of this very discharge, whereas 
a proper examination would have indicated the ne- 
cessity of discontinuing the injections. It is un- 
doubtedly true that to treat a gonorrheal infection 
without the aid of the microscope as a control, is 
just as reprehensible as it would be to treat typhoid 
fever without taking the patient's temperature. 

Chronic urethral infections. Chronic infections 
of the urethra may be due to gonococci, or to some 
other bacteria. Unless we are quite certain what 
we are dealing with, how can we give appropriate 
treatment? It is true that in a small proportion of 
cases even the microscope is not of sufficient aid ; 
so that we have to resort to cultures to determine 
the nature of the infection. Chronic infections 
often require a great deal of instnmientation, and 
it would he very unwise to introduce instruments 
of any kind without finding out whether the canal 
is free from bacteria. The presence of a mucoid 
secretion, as we find it in such cases, does not neces- 
sarily denote the presence of bacteria, nor does the 
scantiness of a secretion exclude their presence. 
There are types of bacterial urethritis which, under 
appropriate treatment, will clear up in a couple of 
days, some that will take a few days, or even 
longer for this, and still others that are perhaps 
incurable. But who can diagnosticate and treat 
these without microscopical aid? 

The instrumentation essential in the treatment of 
chronic urethritis often gives rise to an irritative 
discharge, but since a discharge may also arise from 
the use of nonsterilized instruments, the only pos- 
sible way of making a diagnosis of the nonbacterial 
discharge in the first, and the bacterial one in the 
second instance, is by means of the microscope. 
Naturally, the treatment should vary in these dif- 
ferent conditions ; can this be done without a proper 
diagnosis? 

Rut few chronic cases of urethritis are due to the 
presence of gonococci, and it is of great significance 
when their presence can be demonstrated, because 
they are very resistant to treatment. Instances 
where gonococci persist for from tour to six weeks, 
or even longer, in the discharge should not be re- 
ferred to as chronic unless it is certain that their 
presence is not due to inappropriate treatment. .^ 
discharge does not have to be profuse, or even mod- 
erately large, to contain gonococci, and it is very 
surprising sometimes to find that a ver}' slight, in- 
nocent looking mucoid secretion contains them. It 
is important to examine microscopically the well 
known "morning drop" of chronic urethritis, 
though in most cases only an endoscopic examina- 
tion will reveal its cause ; for often the gonococci 
will be found in this drop, when during the rest of 
the dav non^ can be found. On the other hand, 
the morning drop may be due to diplococci. staphy- 
lococci, the micrococcus catarrhalis, or other mi- 
crobes. We often see instances in which two or 
three days after sexual intercourse a man has a' 
slight discharge from the urethral meatus which 
looks purulent and is more profuse in the morning. 
.Such dischargees are due to an irritative secretion 



the female was afllicted with, and on microscoi>ical 
examination they generally show, beside the other 
constituents of pus, a large number of other bac- 
teria, but no gonococci. If they aie properly diag- 
nosticated, from three to five days, or even less 
time, suffice for a cure. 

Acute prostatitis. To treat a case of gonorrheal 
infection, especially one in which the patient 
does not markedly improve or get well in 
the first two or three weeks, without making 
an occasional microscopical examination of the 
prostatic secretion, is almost equivalent to allow- 
ing a prostatitis to progress without treatment. 
These examinations are very important because, 
though we may have a prostatitis involvement 
of severe enough degree not to escape notice, 
we may also have slight involvements that deceive 
us for the time being, and later, if wondering why 
the patient does not get well, we do examine the 
prostatic secretion, and find that the delay has been 
due to a prostatitis, which may have steadily grown 
worse. Even those instances in which the last por- 
tion of urine is turbid, denoting a prostatic infec- 
tion, it w'ouJd be far more scientific to actually find 
an increased amount of pus in the prostatic secre- 
tion, because, after all, this is not the only condi- 
tion in which the last portion of urine is turbid. 
Gonococci are as apt as not to be found in a gonor- 
rheal prostatitis, and their presence is of importance 
because in just such cases are some of the severe 
complications, such as gonorrheal rheumatism, en- 
docarditis, epididymitis, orchitis, etc., prone to de- 
velop, and also because in such involvements of the 
prostate, the treatment would have to be more di- 
rectly and more vigorously applied to that source. 

According to many authorities the treatment of 
urethritis should be greatly changed as soon as an 
extension of the infection to the prostate takes place. 
It would therefore seem necessary to be able to 
make a positive diagnosis of such extension as early 
as possible. In prostatic involvements the urine will 
clear up long before the prostatitis, and if we are 
to have no microscopical examinations of tlie secre- 
tion, how are we to tell when the process is over? 
The appearance of the urine and the size of the 
])rostate are entirely untrustworthy as indices. The 
appropriate treatment at the outset of prostatic in- 
fections until microscopically cured would reduce 
the number of patients suffering from chronic pros- 
tatitis very appreciably. 

Chronic prnstctitis. This includes those slight or 
moderate infections of the prostate that have been 
overlooked and also those that became chronic in 
spite of our best efiforts and care. The size of the 
prostate may be normal or it may be larger or even 
smaller than normal, and therefore this is of no di- 
agnostic value. To illustrate : A patient came to 
me who had jireviously been to a number of physi- 
cians w^ho had treated him by copious massaging; 
and I cured him without massage. He complained 
of a discharge from the urethra recurring at fre- 
quent intervals, which was more marked after par- 
taking of alcohol. Upon examination I found him 
a man of twenty-eight years of age, of large stature 
and good development. He had a moderately large 
prostate, and it seemed that every physician he vis- 
ited took this, evidentlv on account of its enlarsred 



■JO PRIZE ESSAYS. [New York 

O^ Medical Journal. 

size to he the seat of his trouble. When I palpated customed sports are commonly 'observed. There 

his prostate, T had the same suspicion, but. upon are certain muscle groups which are particu- 

examination of its secretion with the microscope, larly prone to suffer: The muscles in the loins 

found it perfectly normal. Then looking for the and their tendonous attachments, giving the condi- 

seat of trouble elsewhere, and finding it in the an- tion commonly called lumbago. Torticollis is a 

terior urethra. I soon had the patient cured. This similar affection involving the trapezius and sterno- 

case is mentioned merely to show emphatical'y Inw cleidomastoid muscles. Pleurodynia is an involve- 

important these details are. ment of the intercostal muscles. The treatment 

In treating chronicallv infected prostates, we all of the condition may be divided into local and 

know that manv of them take months to cure ; vet, internal. A patient suffermg with myalgia of 

how are we to 'judge when treatment is no longer the hack often demands morphine, as the pain 

necessarv? The microscope is the onlv guide. ^ will be unrelieved by other drugs. He must be 

1510 West 144TH Street. P*^* *^o ^^ '^^'^ absolute rest enjoined. Catharsis 

^ if indicated is necessary, especially if the patient 

has a tendency to the affection. Salol and ace- 

j-lvi'T (L'SSiniS. tate and citrate of potassium or potassium iodide 

may be administered if there is especial indication. 

Qucstio„s for discussion i„ this department are an- J^e diet should be light and liquid principally. 

nounced at frequent intervals. So far as they have been 1 he main treatment together with rest in bed is 

decided upon, the further questions are as follows: the application of heat (not cold I in the form of 

CXXXV.—How do you treat burns? {Closed June fomentations, poultices, and hot water bags. Dry 

' CXXXVI.-How do vou treat cholera infantum. {An- cupping over the region of tenderness one half 

swers due not later than July i-,th.) hour twice or thrice daily is very beneficial. If 

CXXXVII. — How do \ou treat threatened abortion? there is electricitv in the patient's home, one or two 

{Answers due not later than August 15th.) electric light bulbs placed a half a foot from the 

li'hoever answers one of these questions tn the man- , , Hirprth- nvpr tlip -^ffprtpA mrt a niprp nf p«- 

ner most satisfactory to the editor and his advisers will °°°> a>rectl> over the attected part, a piece Ot as- 

receive a pri::e of $^5. Xo importance whatever will he bestos, tin, or woollen covering encircling, so as to 

attached to literary style, but the award will be based concentrate the heat, will produce a hvperemia, 

solely on the value of the substance of the answer. It is ^yhich will greatlv facilitate Nature's process. The 
requested {but not required) that the answers be short. 1 • 1 u u ' ^ ^ j u ■ *• -^u ^ 

if practicable no one ansvi'er to contain more than six .^km should be protected by anointing with petro-, 

hundred zi'ords; and our friends are urged to write on latum: blistering has resulted without its use. Ihe 

one side of the paper only. electric light baking apparatus is. however, more 

Alt persons will be entitled to compete for the prize serviceable. This Veatment I have found very 

whether subscribers or not. This prize will not be award- u... c • 1 t _ ^t uu r Ui. r^ u- 1 

cd to anv one person more than once within one year beneficial, together With light massage, after which 

Every anszi-er must be accompanied by Ihe writer's full a woollen cloth IS placed over the hyperemic area. 
name and address, both of which we must be at liberty to The galvanic current for five or ten minutes may 

publish. All papers contributed become the property of u r-j\ * u u ju^tu 

the JouRN.^L. Our readers are asked to suggest topics "^^ applied. Acupuncture has been used, but I have 

FOR DISCUSSION. fouud it not necessary. Turkish baths are very 

The price of $sf for the best essay submitted in answer helpful, especiallv in those predisposed, care being 

to Question CXXXIV has been awarded to Dr. John H. taken against exposure to cold afterward 
Shaw, of Fhiladclphia. whose article appears below. t • i ,. „ vi iU r v 1,1 i t, • 

' ' ' " Light massage with the use of a suitable lubri- 

cant which contains analgesic qualities I have 

PRIZE QUESTIOX CXXXIV. found serviceable. The following I prescribe : 

THE TREATMENT OF MUSCULAR RHEU- 5 Menthol. > .. ... 

MATTc;M Camphor, f aa oion , 

MAilbM. Hydrated chloral 3ss-3i; 

By Tohn H. Sh.A.W, M. D., Oil of gaultheria -...Sii-Siv; 

• Philadelphia. Pa. ,, 1^^:^^ ^" 5'-^"- 

■The treatment of muscular rheumatism or my- ^fj^^ ^^e patient is able to be out of bed a suit- 

algia depends entirely on the etiological factors ^ble adhesive plaster dressing will enable him to 

and the loca ity of the affection. ^^.^„^. ^^.-^^ ^u j^^ muscular fixation. 

Before taking up the treatment it will be neces- -phose who have a tendencv to mvalgia should 

sary to give briefly a description of the condition ^e directed to indulge in systematic.' but not vio- 

usualU seen. ^^^^^ exercise, to keep the skin open by the week- 

Aluscular rheumatism is an acute and sometimes h- or twice weekly Turkish bath. Any tendencv 
chronic aft'ection. characterized by pain, especiilly to constipation must be corrected bv the daily ha- 
on movement, tenderness, spasm, and more or less bitual movement without the usual drug addiction, 
localization in certain muscle groups. It is usually Anv tendency to visceroptosis will be helped bv ex- 
caused by unaccustomed overuse of certain muscles ercise or, if marked, a suspensory abdominal binder 
and may be brought on through exposure to cold will relieve. 

and wet. Localized chilling of the body by draughts In torticollis the same measures may be used, 

have caused the condition. Some persons have a If the condition should be of long standing, mv- 

certain predisposition to the disease. There is usual- otomv may be necessary. Pleurodynia is best 

ly, however, a history of a sudden exertion followed treated by 'hot applications, massage with an anal- 

bv severe pain which disables the person sometimes gesic lubricant, and strapping with'adhesive plaster, 
absolutely, lifting weights and indulging in unac- In summarizing the treatment of muscular rheu- 



July 5, 1913. J 



PRIZE ESSAYS. 



31 



matism is will be found that the most suitable uiau- 
agement of such a condition would lie the use of 



I. Rest. 



I dry. 

(lUOlSt. 



) Heat 

2. Hyperemia > Cuppin<; 

) I'^lectricity 

3. Galvanic current. 

4. Massage, at first light, later by friction. 

5. Correction of any tendency to the affection. 

6. Exercise (systematic). 

7. Baths. 

Dr. Karl A. Meyer, of Hot Lake, Orcs^on, says: 

The treatment of muscular rheumatism is of 
marked importance to the general practitioner for 
two reasons: i. The great number of these cases 
that come under his observation ; and, 2, his inabil- 
ity to secure results in the great majority of cases, 
these same patients securing results at the vario.is 
h\dropathic and osteopathic institutes. 

The first part of our discussion is to be taken in 
the prophylactic treatment of this disease. Here 
we should begin by educating the children of the 
great family of rheumatics. Xext, in case there is 
a history of previous articular rheumatism it be- 
hooves us to advise against exposure to cold for 
fear that this abarticular trouble may come on at 
any time. In immediate prophylaxis we have the 
treatment of all throat infections, sinus troubles, 
and pyorrhcea alveolaris. This latter is of marked 
importance. Then, too, we must guard against 
rheumatic symptoms of certain intoxications, as 
iodism, plumbism, food poisoning, and autointoxi- 
cations. 

The second part of our discussion will be given 
over to the general measures to be used in -a given 
case. 

1. General directions: The first thing to impress 
on the patient is rest and this means rest to its full- 
est extent — that is in bed. If this idea is fully car- 
ried out the duration of the disease is much short- 
ened. We need but mention here that the room 
should be light and airy. If we are dealing with a 
severe case a nurse should be in constant attend- 
ance. 

2. The diet as a routine should be liberal and 
consist of milk, eggs, light meats, farinaceous arti- 
cles and cruciferous vegetables. Between the reg- 
ular meals buttermilk may be allowed ad libidum. 
The drinking of water is pushed to its fullest ex- 
tent. 

3. The next in order of general treatment is hy- 
drotherapy. This phase of the subject is much 
neglected bv the general practitioner and is the rea- 
son that our various hot springs have their repute. 
Very few in the general field of medicine use this 
measure to the fullest advantage. After a thor- 
ough general examination we should outline the 
course of baths to be given and the duration. If 
in a private home the general bath should be used 
daily, increasing the temperature of the bath as 
judged by the condition of the patient. The dura- 
tion of the bath varies from five to twenty minutes, 
after which I give either a blanket or alcohol sweat. 
The length of time this is continued also varies 
with the condition of the patient. During this 



treatment all the hot liquids, that can be comfurta- 
bly borne by the ])atient, are given. 

Other measures that may be used are the vari- 
ous hot air equi])iiients that are on the market. My 
personal observation has been that moist heat has 
much the preference. 

4. The question of massage comes up at this point 
and has much to commend it, but always with the 
general rule, that it is not to be instituted until af- 
ter the pain and tenderness have been under con- 
trol for at least twenty-four hours. The massage 
should be general, with special attention to the area 
involved. One should always begin with light 
treatments. The success of the osteopath in the 
treatment of muscular rheumatism is due to the 
fact that he usually sees these patients after the 
acute symptoms have abated ; but allow him to use 
his manipulations in an early case, and he is usual- 
ly not called upon to give the second treatment. 

5. In some cases of lumbago and other localized 
muscular troubles we do not have results with any 
of the general methods at hand. Here I have used 
acupuncture to good advantage. Of use also has 
been the injection of ten c. c. ice cold normal salt 
solution. The injection is made directly into the 
muscle involved. 

6. Medicinal: The medicinal treatment I have 
purposely left to the last, for it is fully discussed 
in all works on treatment. In case of severe pain 
where our other methods are still to be instituted, 
we may have to use the opiates. Personally I use 
one or two injections of morphine in preference to 
the other derivatives of opium. Here, as in artic- 
ular rheumatism, the salicylates stand out preemi- 
nent. My directions are to give large hourly doses 
until symptoms of intoxication appear, and then 
rely on smaller doses. Sodium bicarbonate is 
given to lessen the gastric irritability. In cases 
where the gastric symptoms are such as to pre- 
clude their use, the hypodermic injection of so- 
dium salicylate or of salicylic acid in oil may be 
tried. Here also we may mention the use of so- 
dium salicylate per rectum. Instructions are given 
to use fifteen grain suppositories four or five times 
daily, but alwavs looking out for rectal irri- 
tability. 

In chronic cases the iodides and arsenic mav be 
of much benefit. As in other forms of rheumatism, 
we must combat the secondary anemia. A friable 
pill of iron carbonate, extract of nux vomica, and 
arsenic may be used three times daily after meals. 

Constipation is to be combated with the salines 
or vegetable cathartics. This feature is of marked 
importance, for when the bowels do not act the 
rheumatism is usually much worse. 

For local use we have the twenty per cent, sali- 
cylic acid ointment or a liniment of oil of gaul- 
theria. After these local applications we may ap- 
ply the flannel jacket or bandages with the addi- 
tion of local heat with water bottles or electrical 
pads. The constant current used locally is of some 
benefit. 

The third part of our discussion comprises spe- 
cific medication. First to be considered is mus- 
cular rheumatism of a gonorrheal nature. Here 



32 



rilERAPF.VTIC NOTES. 



we must treat the local symptoms and institute a 
course of mixed vaccine. Much of the general 
treatment given above should be instituted. Inter- 
nal medication is of no benefit. Next we have the 
muscular pains of syphilis. These are to be treated 
by mercury rubs or injections and possibly salvar- 
san. \\'e must also mention the use of quinine in 
the complication of muscular rheumatism with 
malaria. 

The general practitioner is now called upon to 
decide whether or not to use an alleged specific for 
all forms of rheumatism of a nongonorrheal char- 
acter. I refer* to the phylacogen treatment. As a 
personal measure I have never instituted the treat- 
ment, for I could not see my way clear in justice 
to my patients. However, I may add, that many 
cases have been brought to my attention in which 
this treatment has been employed without any ben- 
efit, and in several with much detriment to the gen- 
eral health of the patients. 

(To be concluded.) 



f Iixragtutit |[otes. 



Treatment of Seborrhea Sicca. — C. Sabatie. in 
Progrcs medical for March I. 191 3, states that in 
the treatment of dr\' scaly seborrhea of the face 
mild measures should alone be employed, as unduly 
energetic methods may bring on eczema. Wash- 
ing with hot water alone, without soap, is some- 
times sufficient to overcome the condition ; where 
this is not the case a teaspoonful of salt or sodiunp 
bicarbonate may be added to the wash water. If 
this fails the following solution should be applied 
locally every evening, with a pledget of cotton : 

I)c Acidi salicylic! gr. xv (i gramme): 

Alcoholis (65 per cent.) 5iii (10 grammes); 

AquK jii'ss (100 gram.mes). 

M. ft. lotio. 

After using this preparation the skin should be 
dried and the following ointment applied : 

5 Zinci oxidi 3i (4 grammes); 

Petrolati ) 

Adipis lanse hydros!.. [ aa 5!!ss (10 grammes). 

Aqure ross ) 

^[. ft. imguentum. 

\\'here the condition persists in spite of these 
preparations more active treatment is justifiable. 
If the skin is dry ointments containing tar. oil of 
cade, or oil of birch mav be used : 

IJ Ole! betiil.-e TTl. xv (i gramme) ; 

RosorcinoUs gr. !v (0.25 gramme) ; 

Z!nc! ox!d! 3i (4 grammes); 

Ad!p!s lanje hydros! 3!! (8 grammes) : 

Petrolat! 3!!! (12 grammes). 

M. ft. unguentum. 

If the skin is red and the scales greasy and moi<t 
a weak potassium sulphide lotion — ten drops in a 
glassful of water — or one containing the following 
powder, may be used : 

R Sulphuris prsec!p!tati gr. xv 

Talc! piilveris. 5'ss 

M!sce. 

Trouble of this latter type constitutes a connect- 
ing link between seborrhea and eczema. The treat- 
ment customary in eczema may thus become indi- 
cated. 



Treatment of Hyperchlorhydria, — Anthony 
iSassler. in the .-h?!ericiiii Journal of Gastro-Enter- 
ology for January, 1913, in addition to describing 
the dietetic treatment of these cases, recommends 
that alkalies be given in one of the following 
forms : 

IJ Magncs!! ox!d! ] 

Bismuth! subcarbonatis,. . . 

Sod!! bicarbonatis L .aa 3!iss (10 grammes). 

Sodii carbtnatis exsiccat! 

Sacchari lactis J 

Fiat pulvis. 
S!g. : One half teaspoonful in water one, two, or three 
hours after meals. 
Or, 

Ijc Magnesi! oxidi 3!iss (10 grammes); 

Bismuth! subnitratis 3v (20 grammes); 

Syrup! acaciae g. s. 

.■\qui-e destillat.-e q. s. ad jvi! (200 grammes). 

Fiat mistura. 

Sig. : One tablespoon fu!. plain or in water, one, two, or 
three hours after meals. 

\\'here constipation exists the following is suit- 
able : 

IJ Magnesi! oxidi •. 5iiss (5 grammes); 

Misturse rlici et sods },\'\i (200 grammes). 

M. Sig.: One tablespoonful in water after meals. 

If a powder or mixture is not desired, tablets 
may be prescribed : 

^. Magnesi! o.xidi | 

Bismuth! subcarbonatis,..?- ...aa 3vi (25 grammes). 

Rhe! pulveris j 

Ft. in tabelles No. L. 

Sig. : One or two tablets one, two. or three hours after 
meals. 

Belladonna, the drug next in importance, after 
alkalies, may be given thus : 

R Extract! belladonnae foliorum, gr. v (0.32 grammes) ; 
Bismuth!, jubcarbonatis 3iv (15 grammes). 

Ft. in tabellas vel pone in chartulas no. x.\. 

Sig.: Take one before meals. 

For a mechanical sedative elTect on the gastric 
mucosa, the following combination of Stockton's 
should be used : 

R Ceri! oxalatis 3iiss ( 10 grammes) ; 

Bismuth! subcarbonatis, 3v (20 grammes) ; 

Magnesi! carbonatis 3x (40 grammes). 

M. ft. pulvis. 

Sig.: One half teaspoonful every four hours. 

Gastric hyperesthesia is commonly present in 
these cases, the symptoms of it being most pro- 
nounced when irritation from free hydrochloric acid 
is taking place. To overcome it the author recom- 
mends the following : 

R Sodii bromid! ) 

Tincturx valeriame. . \ 3iv ( 15 grammes) ; 

Fluidextracti sumbul, ) 

Syrupi, 3!!! (go grammes). 

M. Sig.: One teaspoonful in water after meals. 

Olive oil, 100 or 200 c. c, by stomach tube each 
morning (Cohnheini), or in smaller quantities be- 
fore ineals, may be administered where there is no 
objection on the patient's part. Free use of butter, 
cream, or milk at meals is often advantageous. 

.\ morning dose of Carlsbad salts in a glass of 
warm water is very useful in cases of very high 
aciditv or marked oversecrction. The salts can 
also be used in doses of fifteen grains (one 
gramme) in \'ich\' after each meal. 



July 5. 1913] 



EDITORIAL ARTICLES. 



33 



NEW YORK MEDICAL JOURNAL 

INCORPl-lRATlNC THE 

Philadelphia Medical Journal 
and The Medical News. 

A Weekly Review of Medicine. 



Edited by 
CHARLES E. de M. SAJOUS, M.D., LL. D. 

Address all communications to 

A. R. ELLIOTT PUBLISHING COMPANY, 

Publishers, 

66 West Broadway, New York. 



Subscription Price: 

Under Domestic Postage, $5; Foreign Postage, $7; single 

copies, fifteen cents. 



Remittances should be made by New York Exchange, 
post office or express money order, payable to the 
A. R Elliott Publishing Co.. or by registered mail, as the 
publishers are not responsible for money sent by unregis- 
tered mail. 



Entered at the Post OfBce at New York and admitted for tr 
tion through the mail as second class matter. 



Cable Address: Medjour, New York. 

NEW YORK. SATURDAY. JULY 5, 19.3. 



THE ANTITUBERCULOSIS WORK IN THE 
EAST RIVER HOMES CONDL^CTED BV 
THE ASSOCIATION FOR IMPRO\^- 
ING THE CONDITION OF THE 
POOR. 
Among the papers presented at the recent annual 
meeting of the National Association for the Study 
and Prevention of Tuberculosis in Washington was 
a notable report by Dr. Edward C. Brenner, de- 
scribing the first year's operations of the Home 
Hospital in New York city. This unique institu- 
tion marks a new departure in methods of combat- 
ing tuberculosis in that it constitutes the first really 
adequate attempt at home treatment and control 
of indigent cases of tuberculosis in this country. 

Soon after the completion of the East River 
Homes, which were built with every modern hy- 
gienic device to bring sanatorium conditions as far 
as possible to the city patient, the Association for 
Improving the Condition of the Poor leased for 
a term of three years an entire section, consisting 
of twenty-four apartments. The objects of the as- 
sociation were not only to care for the tuberculous 
patient, but also for the family as a unit, to pre- 
vent the spread of the disease from the afflicted to 
the well, and particularly to protect the children 
from infection, to cure incipient patients, to pre- 
serve the family from sinking into dependency, and 



to restore at least to partial earning cajjacity the 
palienl^ in moderately advanced cases. To carry 
out these objects a sufficient medical and nursing 
staff was provided, and, where necessary, the in- 
come of the family, crippled in its resources by 
the illness of its breadwinners, was su])plemented 
sufficiently to relieve the patient of the an.xiety 
which is so often an unfavorable factor in the treajt- 
mcnt of the tuberculous poor. 

During the past year there have been cared for 
a total of seventy-nine patients, including thirty- 
four cliildren, distributed in twenty-seven families 
containing also fifty-six presumably healthy mem- 
liers, not a few of whom, however, were ill nour- 
ished, anemic, and likely candidates for tuberculo- 
sis in the unfavorable environment from which 
they were removed. The results obtained compare 
very favorably with those of sanatorium treatment, 
sixty-one per cent, having been apparently cured, 
twenty-two per cent, having had their disea-e ar- 
rested, and eleven per cent, being much improved. 
A striking feature in practically every case has 
been the marked gain in weight during the first 
two months of residence in the East River Homes. 
This in itself is an indictment of ordinary tenement 
housing conditions. The results have been espe- 
cially good in the care of children, not only for 
those who are frankly tuberculous, but also for the 
undeveloped, marasmic, and puny infants which are 
so numerous in the squalid tenement homes. 

The economic showings of this valuable experi- 
ment of the Association for Improving the Condi- 
tion of the Poor promise to be as satisfactory as 
are the medical results. If it can be demonstrated 
that the tuberculous poor can be efficiently cared 
for at home with actually less expense than is en- 
tailed in breaking up the family, placing the patient 
in sanatorium or hospital and the children in charit- 
able institutions, an important step toward the so- 
lution of a difficult question has been taken. 



HOOKWORM DISEASE. 
Humankind is prone to look to the macroscop"c, 
while losing sight of the microscopic, for the caus- 
ation of untoward epic events. Historians, for ex- 
ample, have almost entirely ignored the material, 
physical reasons for the deterioration of the Gre.k 
race, once the noblest in civilization and the foun- 
tainhead of most others since its Golden Age; in 
[loint of fact the decline and fall of Hellas began 
when Alexander and his men brought back 
anopheles and malaria (one of the most enervating 
of diseases) from terrible old Mother India. Here, 
as so oftentimes elsewhere in history, did the con- 
quered land avenge itself on its conquerors, and the 



34 



EDITORIAL ARTICLES. 



[New York 
Medical Journal. 



ethnic disaster was eventuated by means of tlie 
parasitic plasniodium. 

For decades past great numbers of the people in 
our Southland liave been considered perversely in- 
dolent and "no account.'' We now know that here 
was no fault of disposition, but that "the lazy man's 
disease" (from which at least 2,000,000 men, 
women, and children have been suffering) has been 
due to nncinaria. Its victims are unable to work : 
there is a physical reason for their languor, their 
lack of initiative and of ambition. However will- 
ing the spirit, their strength has been sapped and 
their blood drained by the vampire hookworm. 

.Such, then, is the essential cause of the common 
anemia in the South (the disease does not prevail 
above the thirty-fifth parallel of latitude, except 
among miners and brick and tunnel workers). Per- 
haps the first to rightly and justly interpret the 
phenomenon was Dr. V. W. Stiles, of the United 
States Public Health Service, who is now the scien- 
tific secretary of the Rockefeller Commission for the 
the Eradication of Hookworm Disease. And it was 
this physician's exposition of the subject which led, 
in October, 1909, to the formation of the commis- 
sion, to whose humane ends Mr. Rockefeller en- 
gaged to contribute one million dollars. Many 
agencies — local physicians (as a matter of course), 
State and municipal health departments, churches, 
boards of trade, women's associations, and the ever 
helpful lay press — have most loyally, earnestly, and 
efficiently worked with this commission since its in- 
ception, and its revenues have been supplemented 
frum moneys contributed, according to their 
abilities, by the communities benefiting. Its objects 
have been, and are, to deteniiine the area and the 
degree of hookworm infection, to treat the sufiferers, 
and to remove the source of infection by putting a 
stop to soil pollution. 

The third annual report of the commission 
(W'hose office is in \A'ashington, D. C.) tells a 
most refreshing story of achievement. Its pages are 
informing as to well nigh every phase of the sub- 
ject. In the three years past upward of 400,000 
have been treated ; 238,755 patients were taken care 
of in 1 91 2, an average of 762 every day, except 
Sunday ; 108,892 were treated in October, Novem- 
ber, and December last. The medication is by 
thymol and Epsom salt or castor oil, and it is almost 
invariably effective — at a cost of y/ cents the 
patient. Something over one half the rural children 
examined have been found infected ; many of them 
and their parents were destitute and well nigh over 
the edge of pauperism. And yet, though the poor 
suffered most, the well to do have been found by 
no means exempt ; thirty per cent, of students at 
the University of Georgia, many of them of fam- 
ilies of social distinction and material resources. 



were foimd affected. There is now a superb spirit 
of mutual helpfulness throughout our eleven South- 
ern States concerned which promises most redun- 
dantly for the eradication of this devitalizing dis- 
ease and for the physical, psychic, and economic 
restoration of those who have heretofore been its 
victims. 



TROPIC.VL DISEASES IN THE UNITED 
STATES. 

At first thought there does not appear to be any 
very intimate connection between the United States 
and tropical diseases, but, unfortunately, the asso- 
ciation is much closer than generally imagined. 
Although this country is in the so called temperate 
zone, we are approaching a season that in many of 
the States will indeed resemble the weather that is 
thought to be peculiar to the tropics. It therefore 
behooves the physicians of the country to be on 
their guard against the possibility of some alien 
disease gaining a foothold, or, if already present, 
from increasing. In past years there was not so 
much danger, because the communication between 
widely separated lands was slow and it took as long 
to go from city to city as it does now from one 
country to another. Consequently, tropical dis- 
eases, with some exceptions, did not demand much 
attention. But conditions now are very different; 
communication is rapid, and thousands of immi- 
grants from all parts of the world are pouring in. 
Of course, the barring out of disease is the correct 
method, but that is not always successful ; so all 
physicians should be prepared to recognize the in- 
vader whenever or wherever it appears. 

When a list of such diseases present in the 
United States is made it assumes a distinctly for- 
midable aspect. The eastern coast does not include 
so many, for it is in some respects further away 
from the tropics, but the epidemics of yellow fever 
that have occurred from New York as far down as 
the Gulf are historic. To-day in many parts of the 
country the stegomyia is present in large numbers, 
and all that is necessary is the importation of a case 
of fever. Along the southern portion of the 
Mississippi ^^alley many cases of abscess of the 
liver occur, and, according to the statements of 
numerous physicians in that part of the country, 
this condition is secondary to amebic dysentery. 
In Mexico, between whose territory and ours there 
is no sharp boundary line, typhus fever is endemic, 
and Brill's disease is also found. Inasmuch as the 
latter affection, when experimentally produced, gives 
immunity to typhus, there must be a very intimate 
relation between the causative factors of the two 
diseases. If we go to the Pacific Coast it will be 
found that bubonic plague must be carefujly 



EDirORIAI. ARTICLES. 



35 



guarded against, as one serious outbreak lias oc- 
curred tliere and many rats and squirrels have been 
found infected ; consequently, it is an ever present 
danger. To the diseases mentioned must be added 
leprosy, one which is supposed to be distinctly 
Oriental, if not necessarily tropical, but which does 
occur in northern countries. It is present, though 
the cases are not numerous, in all parts of the 
United States, from Louisiana to Wisconsin, from 
New York to California. Although none of the 
trypanosome infections of man have occurred 
primarily in this country, cases of these have been 
met within our confines, and as we have plenty of 
biting flies, some such might be capable of playing 
host. 

It would, therefore, seem more necessary than 
ever that the possibility of such infections be kept 
in mind, and that every graduate in medicine be 
sufficiently well informed as to be aware of the 
dangers of such foreign invaders. 



INSANITY AMONG IMMIGRANTS. 

The article dealing with mentally defective im- 
migrants, written by Senior Surgeon George W. 
Stoner, Chief Medical Officer at Ellis Island, and 
appearing in the Journal of May lo, throws new 
and heretofore unexpressed light on the immigra- 
tion question in relation to the increased number 
of insane inmates of our public institutions. 
Especially is this interesting in view of the recent 
attempts at legislation aimed at the immigrant, on 
the plea that a large number of them are undesir- 
able, because they are either actively or latently 
defective and thus tend to increase the. burdens of 
the State in their support, or have a tendency to 
lower the eugenic standard of this country. If, 
however, as Stoner says, only about thirteen per 
cent, of the in.sane admitted to public institutions 
are aliens who have been here less than three years 
and whose mental condition can, therefore, be 
ascribed to a mental constitution defective before 
arrival, then the immigrant population is showing 
up remarkably well ; when it is considered that the 
influences working upon a newly arrived immigrant 
are of such a character, probably because so dif- 
ferent from the conditions under which he was 
living previously, as to predispose to a breakdown 
of some kind. In an immigrant the rapidity with 
which life here, and of a bewildering kind, moves 
about him, is apt to cause a mental vertigo which 
must .sooner or later take him from his feet. But, 
in spite of this tendency, it does not seem to take 
the average immigrant very long to get into the 
whirl himself — much sooner in fact than natives of 
this country would, under similar circumstances — 



and be swallowed up and assimilated with the rest 
of the people. Indeed, Boas demonstrated that even 
their physical character changes in the succeeding 
generations. 

To a large degree the reason why immigrants 
flock to our public institutions is because they have 
been hearing, on the other side, of our wonderful 
public institutions and the treatment received 
therein, and they do not hesitate, on the slightest 
provocation, to apply to them ; whereas the native 
American naturally shims them either from pride, 
fear of publicity, or other reasons not, holding with 
the immigrant. Physicians practising in foreign 
settlements have this very complaint to make, that 
the people have more faith in institutional treat- 
ment than in private, even where they can afford 
the latter. 

The increase in the insane population of public 
institutions is general all over the civilized world, 
and is not merely local here and due to immigra- 
tion. It is the stress of modern civilization which 
is at the root of the increase of insanity;. so much 
so that the public is now aroused to the necessity 
of combating it. The large increase in the number 
of suicides in recent times is another manifesta- 
tion of the increasing tendency to mental break- 
down. For, in spite of the fact that in law suicide 
is not necessarily an act of an irrational mind, medi- 
cal men are inclined to place it at the door of a 
psychosis. The increase in insanity is, therefore, an 
evil of civilization and of the civilized, and not of 
those lacking it, as exemplified by the immigrant. 
It would be interesting, in view of the fact that a 
certain proportion of the insanity in the public in- 
stitutions is almost wholly ascribed to immigrants 
and inmiigration, to investigate the causes of the 
insanity in the admittedly larger proportion of 
natives ; then perhaps the immigrant would in large 
part be freed from the entire guilt, and beside, it 
would leave our minds open to finding possible 
causes in another direction. At any rate, ascribing 
the increase of insanity to the large immigration 
and leaving it there, is unscientific, to say the least. 
A little further infomiation on this question would 
be edifving. 



INTR.\MUSCULAR INJECTIONS OF MER- 
CURY (EMULSION) IN THE TREAT- 
MENT OF SYPHILIS OF THE 
NERVOUS SYSTEM. 

L. L. Cazenavette, in the Neii> Orleans Medical 
and Surgical Journal for May, states emphati- 
cally that mercury has been, and is still, our best 
weapon against the ravages of the spirochete, and 
of value in all stages of syphilis. While admitting 
that remarkable results have been obtained by a 
single dose of salvarsan, it is not only necessary to- 



36 



NEWS ITEMS. 



York 
Journal. 



repeat the injection of salvarsan two or three times 
at intervals of a few weeks, but to follow this by 
mercurial treatment, in order that the spirochete 
may be destroyed and the disease cured. The ad- 
vent of salvarsan. according to the writer, has 
helped to strengthen the belief in the therapeutic 
possibilities of mercury. In the treatment of 
syphilis of the nervous system rapid mercurializa- 
tion is necessary to arrest promptly the ravages of 
the disease. The writer's favorite method is the 
intramuscular injection method, as this has several 
advantages : The treatment is entirely m the hands 
•of the phvsician; the amount of mercury adminis- 
tered is smal). Salivation is infrequent and the 
amount absorbed ijUo the system is definite. Fm- 
ally, there is no disturbance of the alimentary 
canal. He favors the use of the biniodide in oily 
solution. 



"gfsas |tms. 



Changes of Address.— Dr. R. Pettit, to 544 ^Vest 
157th Street, Xew York. 
Philadelphia Laryngological Society. — At the annual 

^business meeting of this society, held on June 17th. the 
following officers were elected : President, Dr. E. B. Glea- 
son; vice-president. Dr. George W. Mackenzie; secretary 

.-and treasurer, Dr. Charles A. O'Reilly. For two vacan- 

.cies in the executive committee Dr. Ross Hall Skillern 
was elected to serve for two years, and Dr. Fielding O. 
Lewis for one year. 

American Society for Physicians' Study Travel. — At 

■a meeting of this society, held in Minneapolis on Mon- 

■ dav, June i6th, the following officers were elected to serve 
for the ensuing year: Dr. James M. Anders, of Philadel- 
phia, president: Dr. William J. Mayo, of Rochester. Minn., 

'first vice-president; Dr. Llewellys F. Barker, of Balti- 
more, second vice-president ; Dr. Frank Billings, of Chi- 

•cago. third vice-president; Dr. Albert Bernheim, of Phila- 
delphia, general secretary. 

Resolution Adopted by American Association for 
Cancer Research. — .\t the annual meeting of the .\meri- 

•can .\ssociation for Cancer Research, held on May 5, 
1913, the following resolution (the report of the Corn- 
mittee on Statistics and Public Education) was unani- 
mously adopted : 

It is the sentiment of this association that: 

I. The present instruction of medical students in the symptoms 
and early diagnosis of cancer is seriously deficient. 

_>. The medical curriculum should include special lectures in 
■the clinical departments dealing specifically with this subject. 

3. The universities should provide competent lecturers in this 
subject to address the local medical societies. 

4. The associate members of the association should be urged 
.to take up the question of the proper methods of approaching the 

public on the subject of cancer. 

5. The activities of this association should at present be chiefly 
confined to the education of the medical profession. 

6. This resolution shall be sent to the deans of the medical 
schools and the secretaries of the State medical societies in the 
United States and published in the medical press. 

A Hindi Translation of Doctor Knopf's Prize Essay 

on Tuberculosis. — Dr. Balkrishna Sharma. of Delhi. In- 
dia, has sent to this country a number of copies of his 
recent Hindi translation of Dr. S. Adolphus Knopf's in- 
ternational prize essay on tuberculosis. Doctor Balk- 
rishna has been fortunate enough to find a philanthropic 
publisher so that the essay can be retailed at five annas 
(about ten cents). In view of the great prevalence of 
tuberculosis in India and the fact that the Hindi language 
is spoken by more than eighty million people, the desire 

■to educate the masses in the combat of tuberculosis in that 
part of the world is a gratifying sign of the universal 
progress of the antituberculosis campaign. A new issue 
of Doctor Knopf's Seventh .\merican edition of Tuber- 
culosis as a Disease of the Masses and How to Combaf 
It has just come out so that, since the appearance of the 

•original first German edition in 1900, there have appeared 
in all, including this Hindi and the recently issued French- 
Canadian translation, thirty-six different editions in vari- 

• ous languages spoken in Europe, America, and Asia. 



The J. Hood Wright Hospital Changes Its Name.— 

The J. Hood Wright Memorial Hospital, which was in- 
corporated ill kS08 as the Manliattan Dispensary, has got 
permission from Supreme Court Justice Page to change 
Its name to the Knickerbocker Hospital. The petition 
says that since Mr. Wright's death the population of the 
district served by the hospital has increased greatly and 
tlic necessity for more funds has increased proportion- 
ately. The hospital managers and Mr. Wright's heirs be- 
lieve that the present name of the hospital leads to the 
l)elief that it is so liberally endowed it does not require 
outside assistance, and for this reason none has been 
forthcoming. It is said that Mr. Wright desired out- 
siders to contribute toward the maintenance of the in- 
stitution. 

Examination for Assistant Surgeons in the Public 
Health Service. — Boards of commissioned nu-dical olh- 
cers will be convened to meet at the Bureau of the United 
States Public Health Service, Washington, D. C, and at 
the Marine Hospitals in Boston, Chicago, New Orleans, 
and San Francisco, on Monday, July 7. IQU- and Monday, 
-August 4, 1913, at 10 o'clock a. m.. for the purpose of ex- 
amining candidates for admission to the grade of as- 
sistant surgeon -in the Public Health Service, when appli- 
cations for examination at these stations are received in 
the Bureau. Candidates must be between twenty-three 
and thirty-two years of age. graduates of a reputable med- 
ical college, and must furnish testimonials from two re- 
sponsible persons as to their professional and moral char- 
acter. For further information, or for invitation to ap- 
pear before the board of examiners, address Surgeon 
General, United States Public Health Service, Washing- 
ton, D. C. 

Changes in the Staff of the Rockefeller Institute for 
Medical Research. — The board of directors of this in- 
stitute announce a number of changes in the staff for the 
coming year, a.-nong them being the following new ap- 
pointments : Wade Hampton Brown. M. D., associate in 
pathology and bacteriology; Carroll G. Bull, M. D., assist- 
ant in pathology and bacteriology ; Frederick Lamont 
Gates, M. D., fellow in physiology and pharmacology. 
The following assistants have been made associates : 
Frederick Burr La Forge. Ph.D., chemistry; James Bum- 
gardner Murphy, M. D.. pathology and bacteriology; Gus- 
tave Meyer, Sc. D.. chemistry, and Martha Wollstein. 
M. D., pathology and bacteriology. Michael Heidelberger, 
Ph. D., has been promoted, from fellow to assistant in 
chemistry. Dr. G. Canby Robinson, formerly associate 
in medicine, has been appointed associate professor of 
medicine in Washington University, St. Louis. Dr. 
Jacques J. Bronfenbrenner, formerly assistant in pathol- 
ogy and bacteriology, has been appointed director of the 
pathological laboratory of the Western Pennsylvania Hos- 
pital, Pittsburgh. Dr. Richard Vanderhorst Lamar, form- 
erly associate in pathology and bacteriology, has been ap- 
pointed professor of pathology in the University of 
Georgia. 

Personal. — Dr. Joseph .\. Blake has resigned as pro- 
fessor of surgery in the College of Physicians and Sur- 
geons, Medical Department of Columbia University, a 
position he has held for twenty-five years, and as surgeon 
to the Presbyterian Hospital, after five years' service in 
that capacity. Both resignations took effect on July 1st. 
Doctor Blake is retiring from these positions in order to 
maintain his private practice. 

Dr. Francis Barnes, clinical director of the Government 
Hospital for the Insane, Washington, D. C, and Dr. 
Nicholas J. Dynan, senior assistant, have resigned their 
positions. An examination was held on July 2d to fill the 
vacancies. 

Dr. Francis H. Donoghue, of Boston, has been appointed 
by Governor Foss to represent the State of Massachusetts 
at the Third International Cancer Congress, to be held 
in Brussels, Belgium, during the first week in .-Kugrust, 
and also at the Seventeenth International Medical Con- 
gress, which will be held in London, from August 6th 
to loth. 

Dr. Stephen J. Maher, of New Haven, Conn., has been 
elected chairman of the Connecticut State Tuberculosis 
Commission. 

The degree of doctor ophthalmology was conferred upon 
Dr. George F. Libby, Dr. William H. Crisp, and Dr. Daniel 
G. Monaghan, all of Denver, by the University nf Colo- 
rado, at the annual commencement held on June 4th. This 
degree was never before conferred by an American uni- 
versity. 



July 5, 1913] 



.I.Wl .11. MJiirilXG OF THE AMERICAN MI:D!CAL ASSOCIAIJOX. 



37 



The American Medical Association, 

Sixty-fourth Annual Meeting, 



MINNEAPOLIS, JUNE id TO JUNE 20, IQ13. 



(Concluded.) 



iRcport of Sections. 

SECTION IN SURGERY. 

TUESDAY, JUNE I7TH. 

Chairman's Address: The Surgeon and the Research 
Laboratory. — Dr. A. F. Jonas, of Omaha, urges closer 
cooperation between the operating surgeon and the ex- 
.pcrimcntal research laboratory. Modern surgery is a 
science more than an art, and must be based upon scien- 
tific laws, which alone can be obtained by laboratory ex- 
perimentation. Clinical and bedside tindings and observa- 
tions arc more miportant than those obtained in the labora- 
tory, but arc insufficient. Apparatus and thoroughly equip- 
ped laboratories are necessary to the carrying on of such 
work, but it should always be remembered that architec- 
ture and apparatus are second to men. The work of the 
laboratory must not be detached, as shown by the fact 
that the blood pressure apparatus bad been used in ex- 
perimental laboratories for fifty years before taken up by 
the clinicians. 

Posterior Gastroenterostomy in Acute Perforating 
Ulcer of the Duodenum. — Dr. John B. Deaver, of 
Philadelphia, describes the symptomatology, as based upon 
a personal experience of over thirty cases. The condition 
is absolutely surgical, for death is certain without opera- 
tion, and cure practically certain when the interference is 
instituted early. The diagnosis is commonly confounded 
with that of acute indigestion. The pain is sudden, violent, 
and agonizing; rigidity extreme. The symptoms all come 
on very rapidly, and are sufficient to make the diagnosis a 
surgical diagnosis. Time should not be lost in the mak- 
ing of blood examination, etc. : when in doubt, operate. 
Of twenty-six cases, particularly within twenty-four hours 
of the perforation, there were twenty-five recoveries and 
one death. The early peritonitis, that is up to twelve 
hours, is largely chemical, rather than bacterial, peritonitis, 
due to the escape of irritating secretions from the duode- 
rum, which prepare the way for. the subsecjuent bacterial 
invasion and usual result in fatal peritonitis. This is 
borne out by clinical and bacterial observations. He ad- 
vises (l) infolding of the ulcer with plication of the duo- 
denum to throw it out of function; (2) posterior no loop 
gastrojejunostomy; (3) pelvic tube drainage through 
suprapubic stab; (4) avoidance of irrigation; (5) appro- 
priate aftertrcatment. consisting chiefly of sitting posture, 
continuous enteroclysis, nothing by mouth until peristalsis 
is resumed, and ice bags apphed to the abdomen. The 
results obtained make primary gastro enterostomy the 
operation of choice. 

In the discussion Dr. William J. Mayo, Doctor Ochsner, 
and Doctor Coffee advised that in localities where a 
skilled surgeon could not be promptly secured the prac- 
titioner should close the perforation and provide ade- 
quate drainage; never peforming the gastroenterostomy, 
which should be reserved for the expert surgeon, .^n 
operation performed within the first twelve hours by the 
amateur would save many patients who if operated upon 
later by the most skilled surgeon in the world could not be 
saved. 

Postoperative Ileus. — Dr. .\xgus McLean, of Detroit 
presents the records of much experimental work on dogs, 
from which he made the following conclusions : Patients 
attacked by ileus die from the loss of body fluids, and 
not from toxemia. Hence, the proper treatment is that of 
supplying the body with fluids by enteroclysis and intra- 
^'enous infusions. 

Proctoclysis: An Experimental and Clinical Study.— 
Dr. Hugh H. Trout, of Roanoke. \'a.. has made a study 
of the comparative value of plain tap water as a normal 



saline solution m abcnt 2.-,(X) cases. His conclusions are: 
Normal saline showed no advantages over the plain tap 
water, but had the following disadvantages: There was 
distinctly more rectal irritation, and increased amount ol 
thirst, some of tlu- indi\iduals actually tasting salt; and 
some of the patienls shuwiil buth edema and albuminuria. 

Etiology and Significance of Membranes about the 
Cecum and Colon. — Dr. David Cheever, of Boston, 
gives the results obtained from a study of embryos and 
infants. The conclusions reached are that there arc prob- 
ably several varieties due to several etioligical factors, 
some congenital, that is emoryonic, and others inflamma- 
tory. He cites clinical cases tending to prove that they 
are rarely of clinical significance. 

Anaphylaxis in the Diagnosis of Cancer. — Dr. J. 
Louis Raxsohoff, of Cincinnati, describes a method of in- 
jecting sensitized guineapigs with human blood serum for 
the purpose of diagnosticating cancer. In a careful study 
of fifty or more cases he found that ninety -two per cent, 
of advanced, incontestable cases of carcinoma gave posi- 
tive reaction, while eight per cent, were negative. The 
blooa serum of tuberculous and luetic patients was also 
tested and found not to give the reaction. He hopes that 
the test ultimately may prove of value as an aid in the 
early diagnosis of concealed abdominal carcinoma. 

WEli.N'ESDAV. tune i8tH. 

External Bone Clamp versus the Internal Bone 
Plate in Fractures of Long Bones. — Dr. Leon.\rd Free 
MAN, of Denver, mentions the following advantages: 
The simplicity of its use with minimum disturbance of 
the tissues; ease of remo\-al at any time, which may be 
accoinplished without anesthesia ; fewer cases of delay 
or nonunion ; and the great advantage of not burying a 
permanent foreign body in the tissues. He asserts that 
the reduction is just as perfect as with the internal bone 
plate. The clamp should preferably not be used too near 
the epiphyses in compound fractures, particularly when 
infection is anticipated. The clamp is by all means the 
method of choice, not alone not doing harm, but the 
screws themselves prove avenues for drainage. 

In the discussion Dr. J. B. Murphy recommended the 
use of the external bone clamp, saying that the plate 
should never be used in cases of compound fracture. 

Doctor MC.A.RTHUR reported very satisfactorv employ- 
ment in 210 cases of open fracture of the worst charac- 
ter occurring during the building of the Panama Canal. 

The Mechanism of the Production of Fractures. — 
Dr. Emmett Rjxfurd, of San Francisco, presents the sub- 
ject from the standpoint of the teacher, great stress be- 
ing laid upon the fact that the principles of the mechan- 
ism are most important to the proper understanding on 
the part of the student. Incomplete fractures in children 
in the majority of cases are fractures by buckling; they 
are improperly designated in this country "green stick" 
fractures. The Germans more correctly call them sub- 
periostea! fractures. Fractures of adult' long bones usu- 
ally resitlt from tensile stress. Spiral fractures result 
from twist, and so occur always in the direction of the 
twist. Fractures of short bones result from compressive 
or tensile stress. 

Surgical Management of Injuries to the Elbow Joint, 
Primary and Secondary. — Dr. John B. Murphy, of Chi- 
cago, states that the poor results obtained in the treat- 
ment of joint injuries is bringing more discredit to the 
profession than any other branch of the practice. The 
time is not distant when the profession will be held 
financially responsible for these avoidable evils. Poor 
results in the treatment of injuries of the elbow joint 
follow luxation, and fractures are next in frequency tr. 



38 



ANNUAL MEETING OF THE .IMERICAN MEDICAL ASSOCIATION. 



[New York 



Ihosf in Colles's and Pott's fractures. By more careful 
and thorough diagnosis, an insistence upon, perfect re- 
duction, and the maintenance of the same, these resuUs 
can be avoided. When perfect reduction can be obtained 
and maintained by conservative bloodless manipulation, 
operation and the nailing of fragments must be resorted 
to. Fractures of the external and internal condyle, or 
both, may be nailed with the ordinary eight, ten, or 
twelve pennyweiglit carpenter nail, through a small nick 
in the skin. ' This can be done with impunity, and great 
numbers of skiagraphs demonstrating practically perfect 
results were thrown on the screen. Fracture of the 
olecranon process is also held better by nailing than by 
the former method of subcutaneous wiring. The non- 
union of fractures has become a very common condition; 
ten times more common since the year 1895 than previous 
to that time. Doctor Murphy believes that this is due to 
the too perfect and rigid holding together of fragments, 
as by the bone plate and plaster cast. Slight motion and 
iiritation to the ends of fragments favors osteogenesis. 
Lane distinctly advises against the use of the bone plate 
in cases of nonunion for this same reason. The Ger- 
mans in applying plaster casts always have the patient 
walk about, so as to obtain this desired stimulation by 
iiritation of bone production. Volkmann's paralysis is a 
traumatic myositis followed by degeneration atrophy of 
the muscle fibres, due to too tight bandaging, and always 
occurs within the first forty-eight hours. He absolutely 
deprecates the practice of passive motion. Passive mo- 
tion causes irritation, laceration, increased hemorrhage, 
and so increased osteogenesis; resulting in the overpro- 
duction of callus formation, with the subsequent limita- 
tion to the function of the joint up to and including the 
degree of ankylosis. Very useful joints can be made of 
these ankylosed conditions by resections or the formation 
of artificial nonunion above the elbow joint. 

The paper was discussed by Doctor Cotton, of Boston, 
Doctor Lemon, of Milwaukee, Doctor Sherman, of San 
Francisco, and Dr. Willy Myer, of New York, all 
of whom agreed with Doctor Murphy in urging less pas- 
sive motion in the aftertreatment of fractures in the 
neighborhood of joints. They all, however, believe that 
the conservative nonoperative methods w'ere sufficient in 
the great majority of cases, and that operation should be 
the last resort. 

Surgery of the Thyroid; Observations on Five Thou- 
sand Operations. — Dr. Ch.\rles H. M.\yo, of Rochester, 
Minn., slates that drinking water seems to have much to 
do with the etiology of goitre. Transplantation of the 
gland in cases of defective thyroid is of no more value 
than the feeding of such gland, as it is in a short time 
eaten by the host. The vocal chords and all enlargement 
of the glands should be examined, as paralysis of one of 
the chords from pressure frequently occurs without altera- 
tion of the voice, due to the pressure of the recurrent 
laryngeal nerve; the left being more commonly involved. 
Substernal thyroid is more common than is generally ap- 
preciated, and should be regularly examined for. Diag- 
nosis is made by dullness on percussion over the ster- 
num and by x ray examination. Iodine is of benefit in 
the simple hyperemic goitre. It is of real danger when 
given to cases of fetal adenoma or old colloid goitre, in 
which, due to the stimulation, a state of thyrotoxicosis de- 
velops ; the latter condition in a short time giving myocar- 
ditis. X ray treatment is of value at times in carrying a 
patient over an acute exacerbation of the exophthalmic 
type. The operation of ligation is very important in severe 
cases as a preliminary step in the preparation of the pa- 
tient for the more radical procedure. Partial thyrodec- 
tomy cuies the progression of the thyrotoxicosis, but the 
injury already caused to the nervous system, heart, etc., 
is permanent. Removal of the superior and middle sym- 
pathetic ganglia frequently cures the exophthalmos. 

In the discussion of the paper Doctor Ochsner told of 
a village in Switzerland in which seventy per cent, of the 
inhabitants were afflicted with goitre. A change in the 
water supply very greatly reduced the development of 
more thyroid in young individuals. He advocated the 
boiline of water in thyroid districts. 

Study of the Circulation in Some Cases of Gangrene 
of the Foot. — Dr. J. E. Thompson, of Galveston, from 
a very careful study of three cases of gangrene, one of 
thrombosis, and two of diabetes, and a review of the liter- 
ature, concludes that the lower third of the thigh is in- 



variably the proper site for amputation. Even with the 
main trunks completely blocked, the collaterals will be 
surticicnt to nourish the flaps in this location. 

Extrathoracic and Intrathoracic Esophagoplasty.— 
Dr. Willy Mkvek, of Xcw York, urges complete radical 
extirpation for all malignancy of the esophagus; removing 
the diseased parts widely and providing for the replace- 
ment of the function of the esophagus later. A tube out- 
side the thorax will enable the patient to swallow as well 
as inside, or plastic formations of new tubes by employ- 
ment cf skin or even transposed coil of small intestine, 
which las been successfully employed. The rubber tube 
connection employed outside the thorax, between the stom- 
ach opening and the oral opening, is very satisfactory. 
Cancer of the lower third of the esophagus, in the light 
■of recent snimal experiments, will probably before long 
be likewise rac'ically dealt with. 

Oration on Surgery: Who Shall Do Surgery? — Dr. 
WiLLi.^M D. Haogard, of Nashville, believes that modern 
surgery has made such great advances and become such a 
large subject that special preparation is required for its 
practice. The profession must insist upon better trained 
men; otherwise great discredit will result. Of 4,500 grad- 
uates there are 3,000 hospital internes, which is not 
enough; and he recommends that all medical schools 
should require a fifth hospital year. He urges the estab- 
lishment of special courses for the training of surgeons, 
and then the conferring of a special degree, as of M. S.-— 
Master of Surgery — to those qualifying themselves. This 
work should consist particularly of the study of gross 
pathology-, surgical anatomy, operative surgery on the 
cadaver and animals, and research laboratory work done 
in connection with clinical work at hospitals. Following 
this, an apprenticeship of from three to five years with an 
established surgeon is recommended. 

Symposium on Infections. 

Chronic Focal Infections as a Causative Factor in 
Chronic Arthritis. — Dr. Fr.\nk Billings, of Chicago, 
states that as a result of work, experimental and clinical, 
performed in close cooperation by medical, nose and 
throat, laboratory, and surgical practitioners, a great deal 
of information regarding chronic arthritis, myositis, and 
neuritis has now been obtained. His conclusions are that 
these are practically all due to chronic focal infections. 
Focal infections of the tonsils, of the sinuses of the head, 
of the dental alveoli, of the prostate, of the seminal vesi- 
cles, and of the urethra, gallbladder, appendix, and else- 
where are causative. The treatment is removal of the 
cause. Gratifying results have been obtained by auto- 
genous vaccines. 

Infections of the Prostate and Seminal Vesicles; 
Their Role in Toxemia. — Dr. Hugh H. Young, of Bal- 
timore, says that prostatitis and vesiculitis are very com- 
monly involved in gonorrheal urethritis without symp- 
toms manifesting themselves in later life by rheumatic 
infections. Prostatitis is frequently caused by infections 
from the rectum, more commonly in cases of hemorrhoids. 
These lesions frequently cause lumbago, sciatica, multiple 
arthritis, bursitis, exostosis, myocarditis, and nervous 
symptoms, all of which have been cured by attention to 
the cause. For prostatitis and vesiculitis the treatment is 
massage, prostatectomy, or incision of the seminal vesicles. 

Injection of Boiling Water for Hyperthyroidism. — 
Dr. Miles F. Pokier, of Fort Wayne, Ind.. from a clinical 
observation of over twenty cases, recommends the em- 
ployment of this treatment in both severe and mild cases 
of hyperthyroidism. The immediate effect of the injec- 
tion of the boiling water is the actual destruction of the 
thyroid cell in the vicinity of the injection; resulting in 
diminution in the quantity of tissue forming the secretion. 

THURSD.W, JUNE IQTH. 

Nephritis as a Surgical Problem, and Its Treatment 
as a Preliminary to Operation. — Dr. J. F. Percy, of 
Galesburg, 111., advocates the use of dessicated thyroid 
gland in large doses as a means of improving the surgical 
risk in cases of nephritis. He reports some cases of ac- 
tual cure of the condition. The treatment is contraindi- 
cated in cases complicated by incomnensation of the heart, 
in severe chronic myocarditis, and in inflammations of 
the kidney secondary to infections of the genitourinary 
tract. The thyroid extract may be of value as an agent 
in cases of suppression of the urine. 



July 5. '913] 



ANNUAL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. 



39 



Technic of Roentgenoscopy of the Gastrointestinal 
Tract, and Interpretation of Screen and Plate Findings. 

— Dr. R. D. Caumax, of koclicstor, Minn., from the ob- 
servation of a large number of cases, advises more routine 
X ray examination, many unsuspected lesions being found 
by so doing. 

The Added Responsibility of the Surgeon when Called 
on to Treat Surgical Lesions in their Earliest Stages. 
— Dr. J. C Ui.ociuGoou, of Baltimore, makes a plea for 
greater attention lo and more careful examination of pa- 
tients \vith mild symptoms. A failure to diagnosticate 
malignancy in its incipiency is a much greater mistake 
than later in the disease, for in the early stage the condi- 
tion is curable by operation, and in the later never. The 
real problem of surgery to-day is the one of making early 
diagnose?, ami particularly in c.ises of malignancy. 

Fetal Peritoneal Folds and Their Relation to Post- 
natal Acute and Chronic Occlusions of the Large and 
Small Intestine. — Dr. J. Rins Eastman, of Indianapo- 
lis, cites cases of acute obstruction of the colon due to 
Jonnesco's parietocolic fold, or Jackson's membrane. 
Acute obstruction has been caused at various places in 
the alimentary canal by these membranes. Many of the 
cases of intestinal stasis and chronic autointoxication are 
caused by the persistence of these fetal membranes and 
folds. 

Symptoms and Diagnosis of Membranous Pericolitis. 
— Dr. Jauez N. Jackson, of Kansas City, Mo., states that 
pain along the course of the ascending colon, general dif- 
fuse tenderness over the whole abdomert. constipation, mu- 
cous colitis, tympanites, digestive disturbances, and neur- 
asthenia, all resulting in loss of weight, are the main 
symptoms in the diagnosis of membranous pericolitis. 
Roentgenoscopy is of great value in demonstrating the 
stasis and sites of obstruction. Increased temperature and 
pulse disturbances are always absent. 

The Necessity of Preserving the Periosteum in Bone 
Transplantations. — Dr. Clarence A. McWilliams, of 
New York, in this paper, which is based upon a large 
amount of experimental work in bone transplantation, 
concludes that the life of the bone graft depends exclu- 
sively upon its blood supply , the periosteum or marrow 
present or absent having no particular effect. Small frag- 
ments of bone denuded of their periosteum will live in 
tissues without absorption, due to a rich blood supply. 
Large fragments without periosteum die because of insuffi- 
cient blood supply. The periosteum is bone forming and 
lives when the bone dies, because of its ability to appro- 
priate nutrition. Complete subperiosteal bone resection is 
followed by the reforming of the bone. 

Roentgenoscopy of the Liver and Biliary Passages. — 
Dr. James T. Case, of Battle Creek. Mich., has found the 
X ray examination of the liver to be of value in diagnosti- 
cating cbanges in the size and shape of the liver, local 
tumors, hepatic and subphrenic abscesses, adhesions, and 
many cases of gallstones giving vague symptoms. 

Original Uses of the Bone Graft in Surgery. — Dr. 
Fred H. Albee, of New York, reports the results of his 
use of bone graft in the treatment of fractures of the 
spine, all long bones, neck of the femur, and club foot; 
showing a large number of skiagraphs and pictures as 
proof. His results are very satisfactory. Doctor Albee 
uses graft with periosteum and bone marrow, believing 
the lattei two, though not always essential, to be of value 
in insuring future life of the graft. 

Symposium on Anesthesia. 

Nitrous Oxide and Oxygen Anesthesia. — Dr. Harry 
G. Sloan, of Cleveland, believes that nitrous oxide and 
oxygen anesthesia is particularly indicated in very bad sur- 
gical risks ; these taking it the easiest. It is the anesthesia 
de luxe; it is pleasant to take and causes less subsequent 
nausea. Diabetics do well with this anesthetic. Owing to 
the inability to obtain complete relaxation, as with ether, 
local blocking of the nerves is resorted to. The principal 
disadvantages are the cost of the apparatus, the necessity 
of having a skilled anesthetist, and the difficulty of obtain- 
ing pure gas. 

Intratracheal Insufflation Anesthesia (Meltzer-Auer). 
— ^Dr. Charles H. Peck, of New York, gives his personal 
experiences with 334 patients operated upon at Roosevelt 
Hospital during the past two years under this form of 
anesthesia. The cases were distributed as follows : Op- 
erations on the thorax, sixteen; head and neck, fifty-six; 



goitre (simple and exophthalmic), sixteen; the kidney and 
ureter, twenty-two; breast, twenty; abdomen, 116; miscel- 
laneous operations, eighty-eight. The advantages and dis- 
advantages of its employment arc explained. 

Local Anesthesia. — E5r. J. F. Mitchell, of Washing- 
ton, "D. C. refers to the extensive use of local anesthesia 
in Europe, and predicts its greater employment by Amer- 
ii;an surgeons. It is particularly indicated in operative 
work in the aged, and whenever general anesthesia is con- 
traindicated. By the intravenous method of Bier all ma- 
jor surgery of the extremities may be performed, the 
particular value of its employment being the protection 
of the central nerve system from shock due to the blocked 
condition of the nerves. Practically all surface surgery 
of the torso, and all of the major surgery of the extremi- 
ties may be performed under local anesthesia. Novocaine 
is the anesthetic of choice. 

Surgical Aspects of Intestinjd Stasis from an Ana- 
tomical Point of Viewr. — Dr. John E. Summers, of 
Omaha, points out that mechanical obstruction and inter- 
ference are responsible for a large number of the cases of 
intestinal stasis. Neglect of the function and disease of 
the nervous system also play a part and frequently result 
secondarily from the mechanical condition, forming a 
vicious circle. The recent interest in these various con- 
stricting membranes has been occasioned by the writings 
of Lane and Jackson, who are, however, only redcscribing 
conditions observed and recorded by Jonnesco, Juvara, 
Treves, Reid, and others. These are mostly due to em- 
bryonic conditions. Some are of inflammatory origin, and 
give rise to conditions of obstruction and intestinal stasis 
which can be relieved alone by operative interference. 

FRIDAY, JUNE 20TH. 

Gastric Tetany. — Dr. W. L. Rodman, of Philadelphia, 
has met with great satisfaction in the treatment of gastric 
tetany bv means of gastroenterostomy or pyloroplasty. 
The relief obtained was usually very prompt. The indi- 
cation !n the treatment is that of gastric drainage. Gas- 
tric lavage continued for long periods of time may carry 
a patient along, and now and then result in a cure. Seda- 
tives such as morphine, bromides, and chloral are indi- 
cated. 

An Experimental Study of the Mobilization of Anky- 
losed Joints. — Dr. Nathan Allison and Dr. Barney 
Brooks, of St. Louis, present conclusions reached as a re- 
sult of a review of the literature and personally conducted 
experiments and clinical work. Mobilization of ankylosed 
joints is based upon the freeing of such ankylosis, and the 
interposing of materials to prevent a return of the anky- 
losis: Cargile membrane. Baer membrane, silver nitrate 
fascia, fiscia with a pedicle, free fascia, and killed fascia. 
Among these the interposition of fascia has yielded the 
most satisfactory results. 

Therapeutic Possibilities of Transfusion. — Dr. Ber- 
tram M. Bernheim, of Baltimore, states that transfusion 
of blood is indicated not only in cases of exsanguination, 
but also in toxemias, and in many of the abnormal blood 
conditions, as splenic and pernicious anemias. It should 
be performed in earlier stages of these conditions to ascer- 
tain its real value, as the method gives promise of great 
value. The difficulty in the past has been that it has been 
performed usually only upon moribund patients, though 
even then with marked success at times. With a sim- 
plification of technic, its field of usefulness is being grad- 
ually widened and the results are most encouraging. 
Therapeutically, the field is still practically unexplored, 
although a beginning has been made. 

Theory and Practice of Transfusion. — Dr. J. J. Hogan, 
of San Francisco, concludes, as a result of experiments to 
ascertain the comparative values of solutions for trans- 
fusion, that the beneficial effects from salines, while very 
marked, is also very transitory. Human blood serum is 
of much Aiore permanent value, and whole blood the su- 
perior of all. 

Thyroglossal Cyst and Fistulas: Report of Three 
Cases. — Dr. Hermann B. Gessner. of New Orleans, 
says that thyroglossal cysts and fistul^e are of embryonic 
origin, being remnants of the ducts leading from the 
foramen cecum to the isthmus of the thyroid. The fis- 
tula always open in the median line of the neck, in con- 
tradistinction to those resulting from permanency of 
branchial cleft structures. The skiagrams of injected fis- 
tulse are of great diagnostic and operative value. The 
treatment is by excision. 



40 



ANNUAL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. 



[New York 
Mkdical Jouknm. 



SRCTIOX IN DISEASES OI" CIIlLDki-.N'. 

irRSDAY. JUNE I7T1I. 

Chairman's Address: Radiographic Studies of the 

Intestines in Infants. — Dr. IIkxuv D. Chafin. of Xcw 
\'i..rk, refers first to tlic tlilfcrtiicc hctwci-n anatomical 
studies after ileatli and an x ray examination of the same 
parts during life. The great advantage of the latter meth- 
od is that it deals with a living, functionating body. He 
then goes on to say that post mortem studies of the vis- 
cera frequently give erroneous information. He empha- 
sizes the value of radiographic studies of movements of 
the viscera and the necessity of confirmatory conclusions 
from the movements observed. Two normal infants were 
given suspensions of bismuth by the mouth, and the 
course of these followed through the alimentary canal by 
X ray and the bismuth was found to pass from the sigmoid 
into the rectum in seven hours. .Another series of ex- 
periments was made to determine the location of the 
sigmoid, the distensibility of the colon, the form and po- 
sition of the hepatic and splenic flexures, and the patency 
of the ileocecal valve. Enemas of barium sulphate were 
:given, and, after being forced beyond the sigmoid, the 
fluid quickly passed to the cecum. Marked variation in 
the size and position of the sigmoid was observed. From 
the evidence obtained in these studies it seems improbable 
that rectal tubes pass above the sigmoid. 

The Use of the Rontgen Ray in the Diagnosis of 
Obscure Abdominal Conditions in Infancy and Child- 
hood. — Dr. J. 1.. Morse, of Roston. states that by this 
means information is afforded which can be obtained in 
no other way. He presents illustrative histories, with 
many fine radiographs ; the cases including pyloric steno- 
;sis, pyloric spasm, chronic gastric indigestion, splanchno- 
ptosis, abdominal adhesions, and intussusception. The 
-X ray is of value in determining the location of abdominal 
masses, whether these are ventral or dorsal, and a great 
help in the differential diagnosis between ileocolitis and 
intussusception. .-\ cup shaped upper end of the shadow, 
.after a bismuth meal has been .given, is diagnostic of in- 
tussusception. 

The Use of the Rontgen Ray in Pyloric Obstruction. 
— Dr. L. R. DeBuys, of New Orleans, makes a plea for 
early x ray studies of suspected cases of pyloric stenosis 
or spasm, and for further studies of such patients during 
■childhood and even adult life. He cites cases of spasm 
with palpable pyloric tumor, and shows the difficulty of 
differentiation between spasm and stenosis. In stenosis, 
however, the delay in emptying the stomach after a bis- 
muth meal is constant, while in spasm it is occasional. 
The speaker presents x ray plates showing various types 
•of pyloric obstruction, and concludes with a demonstra- 
tion of moving pictures showing peristaltic waves in a 
living infant. 

Rupture of Medicistinal Lymph Node into Bronchus. 
— Dr. .A. L. Goon.MAN, of Xew York, reports a case 
In which there was a sudden development of dyspnea and 
•cyanosis in a child. Tracheotomy was performed, and 
caseous material was discharged through the tube, afford- 
ing relief of the symptoms. The following day an x ray 
examination showed enlargement of a mediastinal gland, 
•and the conclusion was reached that the gland had rup- 
tured during the introduction of the tracheotomy tube. 
Inoculation of guineapigs with the caseous material failed 
to cause tuberculosis. The symptoms of pressure from 
mediastinal tumor are (i) respiratory — dyspnea; (2) cir- 
culatory — cyanosis; (3) digestive — vomiting and associat- 
ed meningism. The condition is likely to remain un- 
diagnosLicated unless an x ray examination is made. Ra- 
diographs of the case reported were shown. 

VkfEDNESDAV. JUNE i8tH. 

Report of Case of Staphylococcus Meningitis in a 
Child. — Dr. F. S. S. Churchill, of Chicago, reports 
this case, w-hich, after thirty days' duration, was treated 
v,'ith one injection of autogenous vaccine. There was 
marked relief of the symptoms within twenty-four hours, 
and the patient made a complete recovery. 

Acute Acid Intoxication ' in Children. — Dr. T. C. 
McCl.we. of Berkeley. Cal., has found acid into.xication 
most frequent between the ages of two and ten years; the 
letiological factors being acetone and diacetic acid. The 



primary cause is still obscure, but he believes that the 
condition may be due to any chronic infection, such as an 
intoxication producing interference with the storing of 
glycogen in the liver. The treatment consists in removal 
of the above mentioned factors, especially Ijy means of a 
diet low in fats and rich in fruits and cereals, and by the 
administration of glucose and sodium bicarbonate by mouth 
and rectum. 

Dr. J. Jahorskv says he thinks there is little value in 
the removal of adenoids in this condition. He has fre- 
quently lound the liver enlarged during the attack, and he 
considers the affection related to migraine. 

Dr. I. A. -AiiT has seen the acidosis sometimes develop 
at the time of weaning; causing vomiting and diarrhea at 
first, and, later, rapid breathing, pallor, and obstinate con- 
stipation. The urine contains tyrosin and leucin, as well 
as acetone and diacetic acid. He reports three cases oc- 
curring in one family, and states that the third child was 
saved by treatment with glucose and sodium bicarbonate. 
The cause of the condition, he thinks, may possibly be a 
toxic proteid. 

The paper was discussed also by Doctors Snyder, John- 
son, Morse. Price, DeBuys, and Lounsbury. 

The Protein Poison and Its Relation to Disease. — 
Dr. Vtcfor C. Vaughan, of .A.nn Arbor, Mich., has shown 
that all proteins, particulate and formless, cellu- 
lar and in solution, contain a poisonous group. If for any 
reason proteins taken into the alimentary canal escape di- 
gestion and are absorbed unchanged they undergo paren- 
teral digestion, and in this process the poison is set free 
in the blood and tissues and manifests its fiill effect. 
In enteral digestion the poison is most marked in its ac- 
tion at or about the pepton stage. When the digestion is 
normal ?nd proceeds beyond this point the poison is de- 
stroyed by farther cleavage. The intestines of children 
are more permeable to proteins than those of adults, and 
this is the reason why infants suffer more Iprgely than 
adults from gastrointestinal disturbances. There is no 
special bacterium which causes the summer diarrheas of 
infancy. Saprophytic bacteria may render the proteins of 
milk, and possibly of other foods, more readily absorb- 
able. The symptoms of poisoning are: i. Peripheral irri- 
tation; scratching (erythema; urticaria). 2. Incoordina- 
tion of movements; air hunger. 3. Clonic convulsions of 
increasing frequency; death. He believes death is due to 
the pouring of lethal amounts of the protein poison into 
the circulation. The different bacteria cause liberation of 
protein ir. different tissues, giving rise to the symptoms of 
various diseases. Sodium bicarbonate, in vitro, tends to 
neutralize the protein poison, and this effect may explain 
the value of alkalies in acidosis. 

The Nature of Ileocolitis from an Etiological Stand- 
point. — Dr. C. G. Grulee, of Chicago, mentions the fol- 
lowin.g theories regarding the cause of ileocolitis: t. Di- 
rect bacteriological action, most commonly by the dysen- 
tery bacillus or the streptococcus. 2. Bacterial action on 
food, forming endotoxines. 3. Primary disturbance of 
metabolism. 4. Heat. He discusses the relations of each 
of these to the others, and expresses the opinion that the 
most important element in the etiology is the decomposi- 
tion of food by the intestinal bacteria. 

In the discussion Dr. R. M. Smith said he believed th^t 
many cases were caused by direct bacterial action. In 
cases due to dysentery bacillus infection the patient did 
well when food with a high sugar content was given, but 
the reverse of this was true in some other forms of bac- 
terial infection. 

Nutritional Injuries Produced by Starch. — Dr. I. A. 
.\bt, of Chicago, describes the chemical changes observed 
in the infantile organism from excessive starch feeding 
and the disastrous clinical results, and presents case re- 
ports. 

Status Thymolymphaticus; with Report of Four 
Cases in One Family. — This paper is presented by Dr. 
W. L. I'.iEKKixc. Dr. D. T,. Gi.omset. and Dr. J. .\. Goon- 
RicH, of Des Moines. The four children all died sudden- 
ly within three months, and without known predisposing 
cause. In all the cases the autopsy showed enlargement 
of the thymus, spleen, and lymphatic nodes. X rav treat- 
ment w^s of most ser\-ice in lessening the size of the lym- 
phatic "-issues, but did not prevent the fntal result. 

The Treatment of the Hemorrhagic Diseases of Chil- 
dren. — Dr. T. B. CooLEY, of Detroit, states that in most 



July 5, 1913. J 



AXNUAL MEETING OF THE .IMEKJC.l.X MEDICAL ASSOCIATION. 



4t 



instances of these affections the blood is slow to coagu- 
kite; a condition due to a deficiency in fibrinogen or in 
prothrombin. A deficiency in c;Llcium has never been 
found. The injection of horse or human scrum is the 
most valuable means of treatment, and with the latter 
there is less danger of anaphylaxis. He advises earl> re- 
sort to transfusion, and describes his own method of as- 
pirating blood from the donor and its immediate intrave- 
nous injection into the patient. 

Treatment of Inguinal Hernia in Children. — Dr. A. 
K. Hekizlkk. of Kansas I'ity. believes that truss treatment 
is not only never curative, but may be extremely harmful. 
Operative treatment is the only escape, and it is certain 
and safe. 

General Anesthesia in the Surgery of Children. — Dr. 
\V. C. WtwiLsEV, of Brooklyn, assigns the following rea- 
sons for the greater danger of anesthetics in children : 
(1) Proportional greater heat radiation: (2) unstable 
vasomotor system; (^3) small air passages, liable to irrita- 
tion and occlusion; (,4) status lymphaticus. He believes 
ether is the anesthetic of clioice in children. Tracheal in- 
sufflation is especially valuable for operations such as 
those for cleft palate and sarcoma of the jaw. 

Spasmophilia; with Especial Reference to Familial 
Reactions and "Repeated Absences." — Dr. J. P. Sedg- 
wick, of Minneapolis, points out the probable relation of 
this condition to disturbed calcium metabolism, and its 
rarity in nurslings. He gives the histories of two cases 
characterized by convulsive attacks in which the "repeated 
absences" resembled petit mal, but were due to spasmo- 
philia. Charts w-ere presented show'ing electrical overex- 
citability in different generations of several families. 

THCRSD.W, TUNE I9TH. 

Election of Officers. — The follow-ing officers were 
elected lor the ensuing year: 'Chairman, Dr. F. S. 
Churchill, of Cliicago; vice-chairman. Dr. L. R. De Buys, 
of New Orleans; secretary, Dr. G. P. Gengenbach, of 
Denver; delegate. Dr. J. P. Sedgwick, of Minneapolis. 

Vulvovaginitis in Children. — Dr. Rich.^rd M. Smith, 
of Boston, believes the complement fixation test valuable 
in the diagnosis of questionable cases of gonorrhea. He 
reports a series of thirty cases of vulvovaginitis, seventy- 
five per cent, of 'which were known to have been pre- 
ventable by proper home care; showing the importance of 
the education of parents regarding the gravity of infec- 
tion and methods of preventing, it. The treatment, he 
says, must be thorough and prolonged. 

In the discussion the chairman. Doctor Chapin, said 
that by using vulvar pads of cheese cloth on all girl babies 
in wards, placing the soiled pads in bags, to be imme- 
diately sealed and burned, and employing individual ther- 
mometers, gonorrheal vaginitis can be reduced to a mini- 
mum. The eyes and other organs are rarely infected, and 
most cases of cure are spontaneous. 

Roseola Infantum. — Dr. John Zahorsky, of St. Louis, 
repurts thirty cases in children under two years with the 
following clinical syndrome : Prodromal fever, with tem- 
perature of from 103° to 105° F.. of from three to five 
days' duration. The temperature falls by crisis when the 
eruption appears. Eruption is mascular: most marked on 
the trunk. No Koplik spots, and no catarrhal symptoms. 
This affection differs from rubella in that the eruption 
does not take on a crescentic form, and the disease is not 
contagious. Practically all the cases observed were in 
bottle fed infants. 

Atypical Forms of Meningitis (Posterior Basic 
Meningitis; Aseptic Meningitis). — Dr. .\. Soi'ni.\N. of 
Kansas City, states tliat turbid, sterile s])inal fluid may be 
found: I. After a previous puncture: 2. after adminis- 
tration of Flexner's serum: 3, frequently in otitis media; 
less frequently in frontal sinusitis. There are many va- 
rities of meningococci, some of w-hich are not affected by 
Fle.xner's serum. Posterior basic meningitis may give a 
fluid containing meningococci, or may be sterile. The 
cases usually show signs of pronounced intracranial pres- 
sure, but on lumbar puncture only a few cubic centimetres 
of fluid are obtained. He advises puncture of both lat- 
eral ventricles and injection of serum if meningococci 
are present in the fluid. The prognosis is very grave. 

In the discussion Doctor Morse said that one must be 
very cautious about making a diagnosis in the absence of 
specific bacteria in the spinal fluid. He has found an in- 



creased cell count in the fluid in a number of cases of 
summer diarrhea, where the patients made a normal re- 
covery. He considers basic meningitis a hopeless condi- 
tion whether meningococci are discovered or not. 

Leucocyte Counts in Epidemic Meningitis and Pneu- 
monia. — Dr. J. 11. Hiss, of Cliicago, instead using the 
usual percentage method of differential counting, counts- 
the actual number of the different cells. He considers 
leucocyiosis in its relation t(j infections in general, and 
gives the result of leucocyte counts in epidemic meningitis, 
before, during, and after treatment by serum. From 
these may be derived indications for further treatment. 
He describes the findings in the stage of anaphylaxis, arid 
their significance. He also treats of leucocyte counts in. 
pneumonias of different types, as an aid to their classifica- 
tion. dilTerential diagnosis, and prognosis. 

Precocious Menstruation. — Dr. G. P. Gengenbach, of 
Denver, reports a case of this in an infant, and gives a. 
summary of the literature on the subject. Possible etio- 
logical factors mav be disturbances of the ovaries, ad- 
renals, thyroid, pituitary, or pineal glands. In his own 
case tlic cause was n(.it determined. No treatment for the 
condition is known. 

Clinical Report and Post Mortem Findings in the 
Case of a Child Dying from Acute Nephritis. — Dr. H. 
M. McCi..\NAHAN. of Omaha, reports this case. The 
heart showed disease of the tricuspid and mitral valves, 
with almost complete absence of the auricular septum.. 
During life the red blood count was eight millions, and 
the polycythemia was probably physiological, to compen- 
sate for the cardiac disease. 

The Hospital Management of Contagious Diseases. — 
Dr. D. L. Richardson, of Providence, R. I., describes a 
system of so called aseptic nursing. Many cases com- 
monly considered suitable for isolation are kept in the 
open wards of the provident hospital without spread of 
infection. Contact infection between patients is elimi- 
nated. He concludes the paper with statistics showing 
the frequency of "cross infections." 

Federal Children's Bureau: The Law, the Organiza- 
tion, the Scope of Its Present Work. — Dr. Julia C. 
Lathrop. of Washington, D. C. explains that this bureau 
was established to gather statistics relating to all phases 
of child welfare. It also distributes educational litera- 
ture, and is now making studies to determine the best civic 
measures to promote the health of children. The speaker 
makes a plea for a nation wide registration of births and 
for the support of the medical profession. At present the 
infant death rate is decreasing in the cities, but increasing" 
in rural districts. 

The Etiology of Artificial Feeding; a Plea for the 
Study of Breast Milk Problems. — Dr. H. Lowenburg, of 
Philadelphia, states that ilie causes leading up to the dis- 
continuance of breast feeding are: I. Psychic. — Fear on 
the part of the mother of inability to properly nourish her 
child or selfish desire for pleasure. 2. Economic. — The 
mother being obliged to earn a living. Vomiting, diar- 
rhea, colic, or fret fulness in the infant are not indications 
for weaning: neither is mastitis, unless the breast is dis- 
charging pus from the nipple. Too much stress is laid ouj 
artificial feeding, and too little is taught of the proper 
management of breast feeding. He believes that every 
mother can nurse her baby if she is willing to do so, pro- 
vided that she has proper surroundings and proper care. 
All obstetricians should be breast feedine enthusiasts. The 
money now contributed for summer camps, free milk, day 
nurseries, and floating hospitals would be better spent if 
given to worthy mothers to enable them to continue nurs- 
ing. He thinks the State should, if necessary, appropriate 
funds for this purpose. 

joint session of the section in wse.\ses of children, 

with the AMERICAN ASSOCIATION OF MEDICAL 
MILK COMMISSIONS. 

Certified Milk.— Dr. T. C. McCle.we, of Berkeley, 
Cal.. reviews the history of the development of the con- 
ception of certified milk, and of the standards required by 
the .\nierican .Association for its production. 

The Cost of the Production of Certified Milk.— Dr. 
SiEi'HEN Francisco, of Fairfield, N. J., discusses the cost, 
the possibility of reducing this, the narrow margin of 
profit, and the just price the consumer shou'd pay. 



42 



ANNUAL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. 



[Nkw York 
KDicAL Journal, 



FRIDAY, JUNE 20TH. 
JOINT SESSION CONTINUED. 

The Efficiency of the Medical Milk Commission, 
Graphically Illustrated.— Dr. H. L. Coit, of Newark, 
N. I., bv iiKuiis ul charts, shows the greater degree of 
efficiency of milk production, with the expenditure of a 
given amount of activity, under the supervision of med- 
ical milk commissions. 

The Effect of Barn Operations upon the Germ Con- 
tent of Milk. — Professor H. A. H.^RmNG, of Urbana. 111., 
recounts experiments made to show that the condition of 
the walls and floors of stables, failure to clip cows, and 
the presence of moderate amounts of stable dust are not 
the chief factors in raising the bacterial count in milk. 
More important are the proper sterilization of milk pails, 
their care after sterilization, and the proper cleaning of 
the cow and the milkman's hands. 

SECTION IN DERMATOLOGY. 

TUESDAY, JUNE I7TH. 

Chairman's Address: Our Tendency to Fads.— Dr. 
Joseph Zeisler, of Chicago, in his opening address, com- 
ments or. the way dermatologists tend to follow to ex- 
tremes certain new ideas in therapy and methods of diag- 
nosis. He censures especially the giving of salvarsan 
when not indicated, and the cutting down on a vein to give 
it; thus needlessly marking the patient for life. The too 
free use of various vaccines, and especially certain mixed 
vaccines,' is condemned. The taking of a Wassermann 
test in many easily recognized skin diseases is also in- 
cluded in the chairman's list of fads. 

Two Cases of Pemphigus Foliaceus. — Dr. J. B. 
ICessler, of Iowa City, after giving the description of 
typical cases of pemphigus foliaceus, and commenting on 
various well known points in the etiology, diagnosis, and 
prognosis, describes two cases which he has treated. The 
treatment employed, which was adopted after he had read 
of its being used successfully in pemphigus vulgaris, con- 
sists of large doses of quinine, as high as ten grains every 
four hours, given over a period of several weeks. Both 
cases responded to this treatment in connection with bran 
or bran and compound creosote solution baths. One pa- 
tient has relapsed, the other is still well after three months. 

Doctor PusEY said he had seen a case get well, and re- 
main so, with only bland local treatment. 

Doctor Sutton told of obtaining a pure culture of 
Bacillus fxocyaneus and treating successfully a case with 
a vaccine of this germ. 

An Anomalous Case of White Spot Disease. — Dr. H. 
H. Hazin, of Washington. D. C, describes a case of 
white spot disease which does not seem to come under 
either of the two general classifications of morphcea gut- 
tata and lichen atrophicus. He first made a diagnosis of 
morphcea guttata in a patient showing numerous white 
atrophic scarlike spots, but later, upon microscopical ex- 
amination, concluded that evidence w-as present of a 
change resembling a type of lichen atrophicus. Treatment 
gave no results. 

Radium in Skin Diseases. — Dr. Frank E. Simpson, 
of Chicago, in this preliminary report, describes the re- 
sults of radium treatment in forty-five cases, including fif- 
teen different diseases. Either cures or good progress was 
reported in nxvus, epithelioma, lichen planus and varuco- 
sus, verruca, lupus vulgaris, lupus erythematosus, blas- 
tomycoses, keloid, ringworm, and psorasis of the nails. 
He has found it especially of service in lesions around 
the mouth and lips where it is hard to give other treat- 
ment. 

Discussion brought out the fact that while many men 
have obtained good results, many others have not, and as 
a result of this and its prohibitive cost, the general senti- 
ment was that only a very few cases present special indi- 
cations for radium treatment. 

The Massive Dose X Ray Method in Treatment of 
Skin Diseases. — Dr. George MacKee, of New York, de 
scribes in detail by means of a lantern slide demonstra 
tion the exact method of giving a single large dose of x 
rays. This is done by means of measuring the rays quali- 
tatively and quantitatively. The qualitative determination 



depends upon a given current in the miliamperemetre and 
amperemctre with a tube that tests up to number nine of 
the W'ehnert scale; in the quantitative the dose is meas- 
ured by the Holtzknecht scale with the Saboraud pastile. 
lie holds that with this exact method fewer cases of der- 
matitis occur and that in treating ringworm of the scalp 
permanent baldness never results. By lantern slides the 
results obtained arc shown in cases of epithelioma, car- 
cinoma of the breast, and various dermatoses. 

Neuromas of the Skin (with Lantern Slide Demon- 
stration). — Dr. M. L. Heidingsfield, of Cincinnati, de- 
scribes two cases of neuromas of the skin. Both occurred 
after injury and consisted of small tumors on the anterior 
surface of the thigh, in which unendurable pain was caused 
by slightest pressure. A diagnosis was first made of 
myoma, and he thinks that many cases of myoma would 
be correctly diagnosticated neuroma if a biopsy were made, 
as an absolute diagnosis depends upon the micrciscopical 
finding of nerve tissue. Treatment consists of extirpation. 

Angioma Serpiginosum (Infective Angioma of 
Hutchinson) ; with Report of a Very Extensive Case. — 
Dr. Ereo Wi.se. o£ New York, presents an elaborate de- 
scription of this disease, together with histories and tabu- 
lation of previously reported cases. Then, three cases are 
described in detail, one of his own and two of Dr. How- 
ard Fox. 

Doctor PoLiTZER, who made the histopathological exam- 
ination in Doctor Wise's case, stated that out of twenty- 
three or twenty-four cases reported, probably only three 
or four were correctly diagnosticated ; showing that the 
condition is very rare. 

Vv-EDNESDAY, JUNE iStH. 

At the opening session on Wednesday morning a num- 
ber of cases were demonstrated by the local men. Doctor 
. Sweitzer, Doctor Butler. Doctor Boreen, Doctor Freeman, 
Doctor Crume, and Doctor Irvine. Among the cases were : 
Lichen planus, psorospermosis Darier, scleroderma, and a 
f&ur month old infant, whose illness had been diagnosti- 
cated as psoriasis by Doctor Irvine, but which resembled 
at the time of demonstration more a seborrheic dermatitis. 
Salvarsan and Profeta's Law. — Dr. A. Ravogli dis- 
cussed the recent work and literature to show the errors 
of Profeta's law, and described a case where a woman 
after having a syphilitic child bore a healthy one follow- 
ing salvarsan treatment ; a few months later this woman 
had mucous patches and the child was infected with initial 
lesion on chin. The case shows that the child has been 
given no immunity from its syphilitic parent. The con- 
clusion is also drawn that no immunity can be present 
except during the time the disease is present, it does not 
remain after a cure. 

A Study of the Spinal Fluid in One Hundred Cases 
of Syphilis. — This paper was presented by Dr. M. F. 
Engman, Dr. RrnoLPH Buhman. Dr. Robert H. Davis, 
and Dr. F. D. Gorham, of St. Louis. Doctor Buhman 
read the paper. Two classes of cases are examined, 
thirty-six early (infected within two years) and sixty-four 
late. Counting as positive only those cases which give a 
positive serological test and a cell count higher than ten, 
the authors conclude that only a very small percentage 
of cases give this positive test when no symptoms of lues 
of the nervous system are present. The majority of their 
cases that give this positive test also show other diagnostic 
symptoms. The value of the test as a check for treatment 
can not be stated, in a small number of cases the test is 
still positive after one years treatment. Ten c. c. of fluid 
is withdrawn and immediately a full dose of salvarsan in- 
jected intravenously, examination of the spinal fluid fails 
to show presence of arsenic, demonstrating the fluid is re- 
sistant to chemical invasion. 

Comparative Study of Antigens for the 'Wassermann 
Reaction. — Dr. H. R. Varney and Dr. F. W. Baeslack 
are the contributors, .\fter a discussion of the various 
antigens used in the Wassermann test. Doctor Varney 
describes an antigen used from a gumma produced in the 
testicle of rabbits by inoculation with the spirochete. This 
is an alcoholic extract made after the method of Citron. 
Thev could not find that the test was more specific with 
this antigen than with that from syphilitic organ (liver). 
Positives" were obtained with florid scarlet fever and lepra 
serum as with the other antigen. In making a luetin test 
with this material a somewhat stronger positive reaction 



July 



■ «)>3.) 



.-/A' AT.//. MI-.ETISC OF THE .IMIiKIC.LX MI-.DICAI. ASSOCIATIOS. 



43 



was obtained than with the old method. Doctor Baeslack 
said thai he thought the Wassermann test might depend 
upon three substances, first a lipoid, second a substance 
from the spirochete, and third a substance from the cflfect 
of the spirochete upon the tissue. 

A Study of Skin Diseases among the Indians of 
Oklahoma. — Dr. Everett S. Lain, of Oklahoma City, 
Okla., lias made a very interesting study of skin diseases 
in the lull blooded Indians of Oklahoma, with a view to 
■comparing them to the white. Out of 5.000 crises, 1,000 were 
carefully examined. Tuberculous glands of the neck were 
found more frequently than any other disease, some 238 
positives. The ne.xt most frequent was pitiryasis capitis 
■occurring in 210 children, and these practically all in 
children going to school, and using a comb and brush. 
Acne and verruca were the next most common. Ring- 
worm was quite rare and no cases of psoriasis, pellagra, 
alopecia, erythema multiforme, or sycosis were found, also 
no malignant growths of the skin. .\ surprisingly small 
amount of lues was found, only forty-six cases. There 
was an absolute immunity to most toxic plants. 

The Newer Cutaneous Mycoses. — Dr. Ernest Dwight 
CinrMA.x, San Erancisco. after going over the diagnostic 
points of the pathogenic fungi, concludes that more study 
should be put on this work by dermatologists. He is in- 
clined to think there is some difference between the blas- 
tomycosis and the granuloma coccidioides of the Califor- 
nia writers. All suspicious cutaneous nodules should be 
carefully examined and cultures made, fewer cases would 
then be missed. 

Cutaneous Affections of Childhood. — Dr. .\lfred 
SciiALEK. Omaha, thinks that troubles with metabolism 
and errors in feeding are related to many skin conditions 
in children. There must be a considerable difference in 
resistance in children and adults accounting for the dif- 
ferent appearances of the same disease. Correction of 
general conditions and a plea for more careful attention 
to the following out of treatment are emphasized, many 
children with severe skin lesions should be placed in the 
hospital. Local treatment should not be neglected, the 
importance of this is demonstrated by the fact that many 
cases of very faulty feeding and hygiene are observed 
with no skin lesions. 

Empiricism in Dermatological Therapeutics. — Dr. ^L 
L. R.wiTCH, Louisville, Ky., makes a plea for more spe- 
cific therapy. He found as high as seventy drugs being 
suggested for the treatment of one disease in several text 
books. Arsenic and sulphur are the drugs most used. .\n 
attempt should be made to get at the actual relation be- 
tween the disease and the therapy, ancl to use then a 
given drug for its specification. 

Primary Sarcoma of the Lower Lip. — Dr. .\. J. 
M.\RKLEV. Denver, comments on the few cases in the lit- 
erature End describes a case of small round cell sarcoma 
-occurring on the lower lip in a man, sixty-five years old. 
Clinically it was not diagnosticated, as it had all the ap- 
pearances of an epithelioma. Owing to the importance of 
the necjssary treatment a biopsy should be made in these 
<ases before treatment is instituted. In his case six 
months after extirpation a nodule was found on the neck 
which was promptly excised: since then no other recur- 
rences have appeared. Dependence should not be placed 
on lymphatic involvement to diagnosticate carcinoma as it 
■can also occur in small round cell sarcoma. 

THURSD.W, JU.VE IpTH. 

Relation of Diabetes to Various Dermatoses. — Dr. 

BuRXSiuE Foster, St. Paul, calls attention to the number 
of dermatoses connected more or less intimately with dia- 
betes, stating that the deimatologist could frequently be 
the first to suggest diabetes. The most common skin 
complication is the dry itchy skin ; this with the scratch- 
nig is likely responsible for the furuncles and carbuncles 
which are so frequently seen. Genital eczema from di- 
rect irritation of the sugar laden urine also occurs fre- 
ijuently. Treatment should be directed toward the dia- 
betes. 

Idiopathic Atrophy of the Skin with Report of a 
Case. — Dr. H. G. Irvixe, Minneapolis, presented a case 
with his paper showing very marked atrophy of the skin 
of the arms and legs and extending a little on to the 
trunk. The inflammatory stage of the disease was well 
shown on the lower legs. Comparatively few cases have 



been reported in the United States, and many of those 
very meagerly. This is undoubtedly a distinct disease and 
cases of secondary atrophy and scleroderma should be 
excluded. No satisfactory treatment is known; only two 
cases have been reported as recoveries. — Doctor Sutton, 
Doctor Pusey, and Doctor Heidingsfeld discussed the 
paper. 

Mycosis Fungoides Following Psoriasis. — Dr. How- 
.\R[) Eo\, Xew ^ork, observes that although there are 
many cases in the literature where some mention has been 
made of psoriasis and psoriasislike lesions occurring early 
in the disease, Fox was able to find only two cases that he 
considered actually had a psoriasis preceding the diagno- 
sis of mycosis fungoides. This case was seen by several 
dermatologists, and there appears to be no doubt as to 
the diagnosis of both diseases. Two interesting points 
were brought out, there was no itching which is unusual, 
and the patient was a heavy drinker, although alcohol is 
not supposed to play any part in the etiology many have 
have been alcoholics. 

SECTION IN OPHTHALMOLOGY. 

TUESD.W, JUNE I7TH. 

Chairman's Address. — Dr. Hir.\m Woods, of Balti- 
more, calls attention to the sociological aspect of medicine 
and the need of a more extensive training for the future 
ophthalmology, and recommends that a committee be ap- 
pointed to report on the subject. 

Physiological Optics the Basis for Teaching Clinical 
Ophthalmology. — Dr. W alter B. Laxcester. of Boston, 
urges the more extensive training of the ophthalmologists 
on the line of physiological optics. Physiological optics 
so permeates the whole of ophthalmology that no part of 
that large field can be mastered w-ithout a good under- 
standing of this subject. Nowhere in this country has 
there been offered a systematic course in physiological 
optics founded on laboratory work and covering all the 
main subdivisions of the subject in reasonably adequate 
fashion. Courses in physiological optics should include 
not only dioptrics and refractions, but binocular vision, 
ocular movements, light sense, and problems of illumina- 
tion, color sense, visual fields, and all other subdivisions 
of the subject. Doctor Lancaster then speaks of the value 
of a diploma or degree of some sort as a guarantee that 
its holders have had adequate training before they join 
the ranks of specialists in any of the special fields of 
medicine. 

Some Modem Viewpoints with Regard to Glaucoma. 
— Dr. Robert Sattler, of Cincinnati, discusses these ques- 
tions : Should glaucoma simplex and acute inflammatory 
glaucoma be assigned to separate categories? Is glau- 
coma a lymph or blood stasis, or is it a sudden choking 
off of both and retention of greater blood volume? Is 
this the glaucomatous impulse which starts biochemical or 
intraocular chemical forces? Is increased intraocular ten- 
sion a distinctive feature only, which chronic and acute 
inflammatory glaucoma have in common? He then dis- 
cusses the modern views of normal tension. 

Experimental Study of Intraocular Pressure and 
Ocular Drainage. — Dr. M.\rk J. Schoexberg, of New 
York, states that the intraocular pressure, measured by 
the Schlutz tonometer, records three factors. The steady 
application on a normal eye of a weight gradually reduces 
the intraocular pressure. This diminution is mostly due 
to the expression of intraocular fluid through certain 
channels outside the eyeball. The rapidity of reduction, 
while the tonometer is kept steadily applied on a given 
eye, constitutes its rate of ocular drainage. The au- 
thor's study of ocular drainage has revealed: I. In a nor- 
mal eye a gradual reduction of intraocular pressure if the 
tonometer is applied for a certain number of seconds. 
2. Variety in the rate of ocular drainage, not only in dif- 
ferent eyes, but also in the same eye, at different periods. 
Changes of intraocular pressure in one eye, sometimes 
followed by similar changes of intraocular pressure in 
the other eye. 4. No conclusive evidence regarding the 
possibility of some kind of action starting from distant 
organs and influencing the intraocular pressure. 5. The 
probability that ihe extraocular muscles play an important 
role in the various normal fluctuations of intraocular 
pressure. 6. Different rate of ocular drainage in glauco- 
matous eyes from that of normal eyes. 

In the discussion on these three papers. Doctcr Jones, 



44 



AXXr.lL MEETIXG OF THE AMERICAX MEDICAL ASSOCIATION. 



[Ne 



York 
Journal. 



of Cumbfrlaiul. said he had had good results with sub- 
conjunctival injections of 1/1500 cyanide of mercury 
and sodium. 

Doctor .\i.T. of St. Louis, said he thought the chemis- 
try of the blood had some relations to glaucoma, and he 
gave large doses of calcium chloride with fairly good 
results. 

Doctor Fox, of Philadelphia, said he had had five or 
six cases of congenital glaucoma, and believed that the 
condition was due to a lack of development: there being 
no canal of Schlemm. In cases of chronic interstitial 
nephritis there was often a plus tension: also in condi- 
tions wherever there was a high blood pressure. In these 
cases he always reduced the blood pressure as much as 
he could before operating, and then found that eserine 
would work where it had not nreviously done. He would 
then do an iridectomy. He performed the Elliott opera- 
tion in a great many cases. 

Doctor SIcReynolds, of Dallas, recommended the Elliott 
operation with some modifications. 

Doctor Greenwooii, of Boston, recommended the Le- 
grange operation, and said he had found a marked im- 
provement in the field as a result. He had only lost one 
eye in twenty-five operations. 

Doctor P.\RKF.R. of Detroit, said he thought the eye pos- 
terior chamber filtration probably caused a great part of 
the trouble, especially in these cases where iridectomy 
was not successful. He recommended the Elliott opera- 
tion, also. 

Hydrophthalmos: With a Histological Report of Two 
Cases, One of Which Presented a Congenital Coloboma. 
— Dr. Wii.i.i.Mt Zentm.wer, of Philadelphia, describes the 
symptomatology, etiology, pathogenesis, and treatment of 
this condition. Iridectomy has not stood the test of ex- 
perience. It is dangerous in most cases because the natu- 
ral barrier between the vitreous and external wound has 
given way before the process of distention of the globe. 
The danger is further increased by vomiting and restless- 
ness after general anesthesia. Objection to posterior 
sclerotomy and paracentesis of the anterior chamber is 
that the operation must be repeated, and often has to be 
supplemented by other procedures. Sclerectomy appears 
to be the operation which best meets the requirements. 
De Vincentii's operation also appears to be well adapted 
to the conditions present. He gives an analysis of replies 
received to a circular letter to surgeons throughout the 
country. Some form of sclerectomy was the only proced- 
ure wliich gave satisfactory results to the majority of sur- 
geons employing it. Histological study of the eye with 
congenital coloboma showed an absence of the canal of 
Schlemm and a blocking of the angle of the anterior 
chamber by a proliferation of connective tissue which rep- 
resented the pectinate ligament. .\ case of a child born 
without eyes and another case of infantile glaucoma were 
shown. The glaucoma had been trephined with good re- 
sults. 

Equivalent Values iii Spectacle Lenses. — Dr. William 
E. Sh.\h.\n of St. Louis, says the advantages of menis- 
cus lenses are largely lost because their effective values 
differ from those of trial case lenses. Compensatory 
computations for these discrepancies can be made by cal- 
culating the advancement of the second gaussian points 
and the posterior poles of the lenses from the plains of 
their rims, and finding the corresponding equivalent diop- 
tric values. A number of points can be calculated for the 
equivalent values of each lens of given posterior curva- 
ture and the result platted on coordinate paper. From 
this chart, the values of the two surfaces of any meniscus 
lens of value equivalent to that of any given' trial case 
lens can be read off and the prescription written without 
any laborious computation. 

SvMPosifM ox Tr.\chom.\. 

Trachoma, Its Prevalence and Control among Immi- 
grants.— Dr. John McMullex, of Wasliington, D. C 
of the L'nited States Public Health Service, speaks of 
trachoma as a chronic, communicable disease, often caus- 
ing disastrous results. Diagnosis and prognosis is the 
most troublesome subject with which the medical exam- 
iner of aliens has to deal. It was classified in 1897 as a 
"dangerous contagious disease'' by the federal govern- 
ment. Despite the fact that the steamship companies 
maintain an inspection service abroad, many hundreds of 



cases arc found annually among immigrants, the majority 
of them from Russia, Italy, Austria-Hungary, Turkey, 
Armenia, Syria, and Greece. Any modification of 
the present classification by the government would mean 
the addition to our population of thousands of aliens suf- 
fering from trachoma, whose immigration to this country 
is niiw prohibited. Trachoma is an important public 
health pioblem. 

Trachoma among the Indians. — Dr. J. W. Scheres- 
CHEWSKY, of Washington, D. C, st;ites that 39,000 In- 
dians in the L'nited States were examined, with the re- 
sult of finding that over seventeen per cent, were suffer- 
ing from trachoma. The incident of the disease varied 
from over seventy per cent, of the Indians examined in 
Oklahoma to 0.2 per cent, of the Indians of New York 
State. The disease was found to be most prevalent 
among the inmates of Indian boarding schools, and least 
prevalent among reservation Indians. All grades of the 
infection were seen. Its prevalence among Indians is 
due to their ignorance of hygiene and sanitation. The 
percentage of Indians suffering from visual defects due 
to trachoma is high, and the Indians are likely to prove 
a means for the widespread dissemination of trachoma in 
the West. Energetic efforts should be directed toward 
limiting the spread of trachoma among the Indians and 
attempting its eradication among the younger generation. 

Trachoma among the Mountaineers of Eastern Ken- 
tucky: Illustrated by Lantern Slides. — Dr. J. A. Stlcky, 
of Lexington. Ky.. says that the large increase 
in the number and gravity of cases of trachoma coming 
to him from the mountains of eastern Kentucky in the 
past twenty-five years led him to make a trip of investi- 
gation on muleback throu,gh five counties. He describes 
the people (genuine Anglo-Saxon) and how they live. 
There are unmistakable evidences of the infectiousness and 
destructivcness of the disease, and an appalling number of 
cases with destructive sequels of trachoma (pannus, en- 
tropium. trichiasis), corneal ulceration with perforation 
and symblepharon. The solution of the problem of eradi- 
cating the disease is diflicult: the Kentucky State Board 
of Health has been unable to adequately cope with the 
condition for financial reasons. Lantern slides showed the 
people with trachoma, their homes, and how clinics 
are conducted in the tent and cabin hospital. 

Metastatic Ophthalmia. Report of Three Cases, One 
of Which Resulted in Recovery of Vision. — Dr. WiL- 
Li.\M H. Wilder, of Chicago, describes these three cases. 
In Case i, a woman aged sixty- four: general sepsis of a 
cryptogenetic character, thrombosis of one leg. paratiditis 
and cystitis ; and also metastatic ophthalmia in left eye, 
followed by similar inflammation in right. Bacillus coli 
communis in urine, Stal^liylococcus aureus in blood. 
Death from terminal pneumonia. The second patient, a 
young woman aged twenty-five, suffered from tonsillitis, 
otitis media, pneumonia, synovitis of wrist and knee, and 
finally metastatic ophthalmia of left eye. Inflammation 
severe, but eye did not suppurate. Virulent streptococcus 
in tonsil, ear, and eye. General recovery with tuberculous 
bulbus. The third patient, a girl of eighteen, had had 
diphtheria followed by streptococcus infection of the 
tonsils. Sudden loss of vision of both eyes with violent 
uveitis, severe pain, and chemosis. L'ltimate subsidence 
of inflammation and recovery of normal vision in both 
eyes. The speaker then takes up the general considera- 
tion of the disease, the symptoms, etiology and prognosis: 
referring particularly to the grave prognostic significance 
of this affection in general septic conditions. 

In the discussion. Doctor Greenwiwd, said that five 
years igc they had in Boston, an epidemic of cerebral 
spinal meningitis, in which metastatic stages developed in 
a great portion of the cases in which optic atrophy oc- 
curred. Most of the patients died. 

Doctor C.^SY Wood, of Chicago, reported a case of 
pregnancy where bilateral metastasis developed. He also 
stated that most bilateral metastasis of this kind was fatal, 
not only to sight but to the patient. 

Doctor J.^CKSON, of Denver, reported two cases of me- 
tastasis following pneumonia, in which panophthalmitis 
developed. 

Doctor Alt said that panophthalmitis of cerebral spinat 
meningitis is not a metastatic, but a direct infection of 
the nerve sheath. 



July 5, 191.1.1 



./.VAT.//. Mil- I IXC or Tim AMIiRICASMIiDICAL ASSOCIATIOS. 



The Diagnostic and Therapeutic Uses of Tuberculin 
in Ocular Diseases, with a Review of Some of the 
Claims Made for It. — Dr. .\ Ijiuwkij 1),\m^, oI .\\\v 
■^'urk. speaks lirst uf tuberculin rcactinn.s— tlicir nature, 
the factors comprising them, and the part they have per- 
formed in establisliing tlie great lrec|uency of tubercu- 
lous infection in the human race. Xcxt immunity is con- 
sidered; then a description of the tuberculin tests and 
some of the more important tuberculin preparations. 
I he author gives a review of sbme of the diagnostic and 
therapeutic results obtained by the use of tuberculins in 
the various ocular diseases, togetlicr with a report of 
personal e.xperieiices 

Phlyctenular Ophthalmia and Episcleritis: A Study 
of the Bearing of the Newer Research on their Etiology 
as the Basis of a Scientific Therapy. — Dr. Will \\ .\lter, 
of Chicago, states that this study is an attempt to har- 
monize the various views and tlieories as to etiology, and 
tends to show their interdependence. He divides the 
theories into (a) ectogenous theory, which concerns bac- 
terial invasion from without: not proved, (h) endoge- 
nous theory embracing, i, malnutrition and autointoxica- 
tion theory, important and fundamental, but not specific 
causes; 2, endogenous infection theory, consideration of 
latent 'uberculosis as most probable source; 3, bacillary 
fragment theory, proved for tubercle bacilli and some 
evidence of occasional similar action from streptococci : 
to-xines but finer subdivisions of fragments in harmony 
with colloidal chemistry findings ; 4, anaphylaxia theory, 
important for reactivation of preinfection. .Arguments 
and relative interdependence of theories are considered, 
and general and specific theory based on the findings met 
with is advocated. The speaker states that practically no 
progress has been made in the treatment of phlyctenular 
conjunctivitis for twenty years. He has been able to 
produce the condition by an overdose of tuberculin. 

In the discussion, Doctor G.amble recommended small 
doses of tuberculin injected near the spinal column, and 
continued for two years. He thought the Von Pirquet 
test only reliable when positive, and that the Calmet test 
should not be used. He advised outdoor treatment and 
bringing the patient up to the physiologal reactions. He 
believed the condition was a latent tuberculous condition. 

Doctor DERnv, of Boston, had used tuberculin in only 
a few patients, as practically all got well without it. He 
said that ninety per cent, of patients with phylectinular 
conjunctivitis gave a tuberculin reaction. He did not 
know why the other ten per cent, did not, because he was 
sure it was tuberculous. In these cases he invariably 
found other members of the family with an active tuber- 
culous focus. 

. Dr. Ch.\rles Sr.\tt, Jr., of Minneapolis, showed a so 
called cured case of tuberculous scleritis, which he had 
treated with tuberculin giving some sixty-four doses. 
The condition cleared up under the first treatment, but 
after a lapse of treatment, it returned. 

Doctor BuLSON, of Fort Wayne, Ind., said he used 
tuberculin in phlectinular conjunctivitis, beginning with 
small doses and increasing every five or seven days. 

Doctor Wood, of Minneapolis, said that all seemed to 
agree that the treatment for tuberculous conditions of 
the eye was plenty of fresh air and good food, with 
tonics, that the antituberculin injections did not seem to be 
universally used ; nor could the eye men always realize 
that a great majority of these patients had enlarged 
tonsils and adenoids, which sliouUI always be removed, 
and that the bowel condition sh.iuld always be watched. 

The Temperature of the Conjunctiva. — Dr. Licie.v 
Howe, of Buflfalo, states that if two thermo couples are 
placed in a circuit and one heated or cooled more than 
the other, the difference in temperature can be registered 
on a galvanometer. If one such couple is introduced into 
the conjunctival sac, and another into the month, the 
difference in temperature is registered by the galvano- 
meter. The couple described measures easily 0.06 of a 
degree, or even 0.015 C. The new data obtained by these 
measurements are: The temperature of the cul-de-sac 
near the outer or inner canthus is from about 0.3^ to about 
0.4° C. lower than that of the mouth; the temperature 
immediately over the cornea is still lower; it is possible 
to measure the extent to which cold or hot applications 
change the temperature of the conjunctiva. It is prob- 
able that the thermo couples described will prove of 



value in indicating changes of temperatures in the globe 
itself, and met.iliolic changes in eyestrain. 

The Topical Diagnostic Value of the Hemiopic Pu- 
pillary Reaction and the Wilbrand Hemianoptic- Prism 
Phenomenon with a New Method of Performing the 
Latter. — I )r. CLiiioKu |',. \\ .m.kkk, «.i lioiioii, describes 
the nietiiocjs of performing the hemiopic pupillary reaction 
test, and the method of performing the VVilbrand hemi- 
anoptic prism phenomena. He then gives eximination re- 
sults on twelve cases in the neurological surgical clinic 
of Dr. Harvey Gushing. Summarizing discussion: 
Hemiopic pupillary reactions; I. possible errors; 2, the 
combination Wcrnicke-Wilbrand test of Heine; 3, central 
scotoma cases. Wilbrand hemianontic prism phenomenon: 
1, possible errors; 2, the factor of intelligence or power of 
observation; 3, pseudorefixation. Conclusions: Hemiopic 
pupillary reaction ; i, nothing noted in disagreement with 
the work of Hess; 2, the possibility of a hemiopic pupillary 
reaction within the central pupillomotoric area ; 3, concen- 
tric movement psychic reflex ; 4, clinical failure. Wilbrand 
hemianoptic prism phenomenon: i, diagnostic value 
greatly depreciated if not entirely nullified by psychologi- 
cal complex; 2, especially by the presence of pseudorefixa- 
tion as demonstrated by the new method. 

Preventable Blindness. — Dr. Henry Copley Greene, 
of Boston, field agent of the Massachusetts Commission 
for the Blind, presents reports of investigations made by 
the Commission, and deductions therefrom. 

THURSD.W, TVNE IpTH. 

Election of Officers.— Dr. Frank S. Todd, of Minne- 
apolis, v. as elected chairman for the ensuing year; vice- 
chairman. Dr. William Zentmayer, of Philadelphia; sec- 
retary for three years, Dr. George S. Derby, of Boston; 
executive committee. Dr. Hiram Woods, of Baltimore; 
Dr. .\lbert E, Bulson, of Fort Wayne, Ind. ; Dr. .Adolph 
-■Mt, of St. Louis; delegate. Dr. Melville Black, of Denver. 

Ocular Vertigo. — Dr. .A.llen Greenwood, of Boston, 
states that a good deal of vertigo of moderate severity is 
undoubtedly caused by the eyes. Experience will show 
that patients with astigmatism at oblique axes are those 
most prone to ocular vertigo. Labyrinthine disturbances 
by means of rotation and thermic tests will produce ro- 
tary nystagmus, and it is reasonable to suppose that dis- 
turbance of the eyes which calls for unusual and un- 
natural actions of the ocular muscles will in turn disturb 
the labyrinths and produce vertigo. Whether all of the 
vertigo produced by eyestrain is a reflex disturbance of 
the eighth nerves, or whether possible dizziness may be 
jiroduced by disturbances of the higher centres without 
intervention of the labyrinths, is not positivelv known. 

Is the Percentage of Myopic Eyes Diminishing? — 
Dr. S-\muel D. Risley, of Philadelphia, explains that his 
paper is a continuation of the statistics set forth in an 
article on school hygiene, showing the steadily diminish- 
ing percentage of myopia from 1874 to 1803, inclusive, as 
a consequence of the careful correction of the anomalies 
of refraction by ophthalmic surgeons. These figures are 
given to demonstrate the truth of the claim made in a 
report of the examination of the eyes of school children 
in Philadelphia, published in 18S1. It was there shown 
that the increase in myopic eyes during school life was 
due to the congenital visual defects with which children 
entered on their school work, rather than on faulty en- 
vironment in the schools. The present study is under- 
taken to discover whether the steady diminution in the 
percentage of nearsight has continued since the studies 
completeo in 1894. 

The Asthenopia of Muscular Imbalance. — Dr How- 
ard F. H.vxseli.. of Philadelphia, refers first to the well 
known relation of errors of refraction to heterophoria. 
Then the less well considered relative accommodation and 
convergence as a cause of asthenopia from persistent or 
changing diopters of accommodation in their relation *n 
the muscular coordination and incoordination is de- 
scribed, and attention is particularly directed to frequently 
changing axes of astigmatism, power of adduction and of 
abduction in presbyopia, depending less on ocular condi- 
tions than on the general health and individual peculiari- 
ties. Muscular balance or imbalance, without paralysis, 
does not depend on one muscle, but on the simultaneous 
and harmonious or inharmonious action of the entire 
ocular musculature and its nerve connections. 



46 



ANNUAL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. 



[New York 
Medical Journa 



Apparent Esophoria smd Its Relation to Convergence 
Insufficiency. — Dr. H. B. Lemkrk, of Omaha, says that 
apparent csoplioria is the condition of ocular imbalance 
in which there is an esophoria in the distance and con- 
vergence insufficiency for near vision. The convergence 
insufficiency is the true cause of the trouble, and the 
symptoms are relieved when convergence power is 
strengthened cither by operation or exercise. The opera- 
tion used is the tuck with some important modifications. 

Blepharochalasis. Report of Two Cases with 
Microscopical Examination. — Dr. Walter Baer Weid- 
LER, of New York, states that blepharochalasis is an atro- 
phic condition of the skin and subcutaneous tissues of the 
eyelids. It occurs most often in young girls, appearing usual- 
ly at the age of fourteen, and always hmited to the upper lids. 
This condition must not be confounded with ptosis adi- 
posa. There are no subjective symptoms, but the deformity 
and disfigurement makes them seek advice and treat- 
ment. The skin of the upper lids is slightly pinkish red, 
and smooth in the early stage of the disease; later there 
is a distinct atrophy of the skin of the lids, and countless 
fine linis appear. The superficial veins become more con- 
spicuous as the stretching and atrophy of the skin in- 
crease. The skin and subcutaneous tissues hang down in 
a baggy, pouchlike mass, the lids seem to be lower than 
usual, but there is no true ptosis of the lids present. As 
regards treatment of this condition, excision of a portion 
of the skin, and subcutaneous tissues and orbital fat is 
the only thing that litis given any satisfactory results. 

Postcataract Extraction Delirium. Report of Eleven 
Cases. — Dr. Walter R. Parker, of Detroit, gives a his- 
torical sketch of this condition, followed by a reference 
to the theories of the etiology. While all agree that here- 
dity plays an important part, and that weakness incident 
to the operation or disease preceding is only the excit- 
ing cause, there is no agreement as to the class of cases 
which should be included. There is no demonstrable re- 
lation betw^een the character of the operation and the 
psychosis, and no single form of mental disturbance is 
characteristic of postoperative delirium. Eleven cases are 
reported and the following' observations made : I. The 
delirium occurred in 0.29 per cent, of the cases operated 
on. 2. No case showed marked signs of mental disturb- 
ance while under observation. 3. One case showed possi- 
bilit}' of infection from an old cystitis. 4. The urine was 
noimal in nine cases, not recorded in two cases. 5. Co- 
deine was administered in two cases. 6. Cocaine poison- 
ing is eliminated. 

In the discussion. Doctor Jackson, of Denver, reported 
several cases of delirium after midriatics. He thought 
the complete change in life might be the cause. Doctor 
GreenVvood, of Boston, thought the condition due to a 
mental rhock. He tries to do the operation in the home. 
Doctor Wescot. of Chicago, reported one case, seventy- 
eight years old, with arteriosclerosis. Delirium develop- 
ed on the tenth day: patient iumped over the banister 
and was killed. He believed that the delirium is due to 
a senile condition. Doctor Rislev, of Philadelphia, re- 
ported two cases. He never gives morphine after operat- 
ing, but rather small doses of hyocyamus. He aUvays 
puts his patient on a tonic of nux vomica, tincture of 
gentian, and compound tincture of chinchona. He often 
lets them smoke. Doctor Black, of Denver, gives one 
eighth grain of morphine one half hour before opera- 
tion, so as to give the patient perfect mental rest. He 
lets him sit up the next day. 

Surgical Treatment of a Certain Type of Penetrating 
Wounds of the Sclera by a Double Conjunctival Flap. 
— Dr. Lee Masten Francis, of Piuff-alo. says that the use 
of a flap of conjunctiva, as described by Kuhnt and 
others, to cover penetrating scleral wounds, a well estab- 
lished surgical principle. He explains the reasons for 
closing all scleral wound of three millimetres or more 
with sclera! sutures in addition to conjunctival plasty. In 
wounds located far enough back from the limbus to ad- 
mit of proper elevation of the conjunctiva, two flaps 
may be made of the conjunctiva, which will serve the 
dotible purpose of drawing the wound edges together and 
providing a proper conjunctival covering. The advantages 
of the double flap are: i. Because of the traction exerted 
by the two flaps, the scleral wound lips are held in firm 
apposition. Consequently relatively large scleral wounds 
may be rapidly and safely closed without stitching the 
sclera. 2. The resulting scar is thicker, firmer, and more 



unyielding. 3. Two layers of sound conjunctiva protect 
the contents of the globe from outside infection. 

Pritnary Lues of the Bulbar Conjunctiva. — Dr. 
Chakles Nelson Spratt, of Minneapolis, believes that 
from six to seven per cent, of all thancrcs are extra- 
genital. .'\bout the eye. the margins, and skin of the lid 
are the mo-St, and the- bulbar conjunctiva and limbus the 
least frequently involved. The author reports the case 
of a nurse girl, aged thirty-seven, who had the care of 
a syphilitic infant. Twenty-one other cases have been 
found in the literature. .Ml except one were in adults. 
There were five nurse maids and two physicians. Right 
eye involved ten times, left six. not given six. Eight were 
situated on the nasal ; four on the temporal ; four on 
the inferior; four on the limbus; two not given. Mode 
of infection: i. Direct, as by kissing, coughing, splash- 
ing of fluids, etc. 2. Indirect. Infection carried by the 
hand. 3. Mediate, instruments, etc. Symptoms : No pain 
noted, except when chancre is on limbus. Diagnosis : 
Marked chemosis, with hard indurated area with a cen- 
tral tilcer, and enlargement of preauricular gland. 

SECTION IN NERVOUS AND MENTAL DISEASES. 

TUESDAY, JUNE l/TH. 

Chairman's Address: Neurasthenia and Increased 
Susceptibility to Emotion. — This paper by Dr. H. T. 
Pershing, of Denver, is based on an experience of over 
1,000 carefully studied cases. He excludes from the list of 
neurasthenics those cases where the nervous condition is 
due to some previously existing organic disease which, be- 
ing cured, the nervous condition disappears. He is also 
careful to distinguish those symptoms which, though 
ordinarily due to some underlying physical condition, may 
here be due to the neurasthenia. The neurasthenic state is 
not due to overwork, but to a lowering of the emotional 
threshold. On this basis, the habitual repetition of an emo- 
tional disturbance maintains a vicious circle of fatigue and 
emotional excitability'. Clearly the treatment must rest in 
the reestablishment of this emotional stability. It must 
include an attempt to displace the false ideas, and requires 
a sympathetic and understanding attitude on the part of 
the physician, as well as a thorough examination. Opium 
is recommended as the most useful drug available. 

Dr. A. A. Brill insists on restricting the field of neuras- 
thenia further, and ordinarily looks upon depression as 
suggesting something more than neurasthenia. He also 
considers a greater degree of fatigue in the morning than 
in the evening as suggestive of depressive conditions. 

Premonitory Auras in Alcoholic Neuroses. — Dr. T. 
D. Crothers, of Hartford, distinguishes clearly between 
alcoholism and inebriety. The latter bears a close relation 
to epilepsy, and auras are common. These are of varied 
character, sometimes physical and sometimes psychic, which 
he describes at some length. Alcoholism lacks these auras, 
but in both, the memory early becomes deficient. In treat- 
ment the author recommends excessive hydropathic and 
eliniinative measures and mental suggestion. 

Multiglandular Syndromes and the Nervous System, 
with Lantern Slide Demonstration. — Dr. D'Orsay 
Hecht, of Chicago, refers to our limited knowledge con- 
cerning the action of the ductless glands and to the rela- 
tion between the disturbed action of tliese and various 
nervous phenomena. Lantern slides are shown from sev- 
eral cases where pains, asthenia, bone diseases, and ner- 
vousness w'Cre all probably dependent upon some disturb- 
ance of the ductless glands. Treatment is largely experi- 
mental and more or less unsatisfactory, but one case of 
osteomalacia is cited where castration was followed event- 
ually by considerable benefit. 

Diagnosis, Prognosis, and Treatment of General 
Paresis. — Dr. C. R. Ball, of -St. Paul, discusses the 
changing views concerning the relation of syphilis to gen- 
eral paresis from the time, in 1S57, when syphilis was first 
pointed out as a cause of paresis, to a period when syphilis 
was looked upon as the chief cause, and to a more recent 
period when the doctrine of "no syphilis, no paresis" is 
rather generally held. We have been slow in coming to 
this latter view, largely because the pathology of syphilis 
is not that of general paresis, and because of the general 
failure of antispecific therapy in the latter disease. Nogti- 
chi's recent findings mark a distinct change in our view 
of the pathology of the so called metasyphilitic condi- 
tions. The speaker looks with disfavor upon the com- 



ANXUAL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. 



nioii tcmiency to regard all cases of paresis as hupelcss. 
Ten per cent, undergo more or less prolonged remissions. 
He recommends injection of sodium nucleinate and sal- 
vaisan. Under this treatment Nonne"s reactions were de- 
creased but did not disappear. The clinical condition also 
improved. 

Pathological Findings in Insanity; Illustrated with 
Lantern Slides Showing Gross and Microscopic Lesions. 
— llie <tnii.iiistraii.in >.l Dr. II. IJ. \'.\i.i.\. of Mankatfi. 
Minn., consists largely of lantern slides illuslmting a vari- 
ety of pathological conditions found in insane persons. 

WEDXESU.W, JUNE iSlII. 

Tumor of the Hypophysis in Acromegaly; a Clinical 
and Post Mortem Ret>ort, with Photomicrographs. — 
Dr. JuLiis Gm.NKEK, of Chicago, reports that this patient 
showed the ordinary symptom of acromegaly, along with 
epileptic attacks and. later, mental disturbances with un- 
cinate i'its. After fifteen ;ears of invalidism he died, and 
the po?t mortem examination showed a large adenoma 
pushing up the optic chiasm and bilateral hydrocephalus. 

Symptomatology of Multiple Sclerosis. — Dr. L. H. 
Mettlei;. of t hicago. says that in the eyes of some this 
is the most common of organic nervous diseases. Others 
consider it excessively rare. In order to make a positive 
diagnosis he believes that the post mortem findings are 
necessary unless one is dealing with a very typical case, 
such as of the Charcot type. In view of this, it is im- 
possible to determine the exact frequency of the disease. 
One must especially distinguish from it instances of dis- 
seminated encephalomyelitis. The most important signs 
of multiple sclerosis are: A certain type of optic atrophy, 
intention tremor, speech disorders, and signs of motor in- 
volvement, less marked than in lateral sclerosis. 

Dr. C. D. C.\MP believes that the study of the cerebro- 
spinal 'luid is very important in the differential diagnosis 
of these conditions. 

Dr. J. Grixker states that with the newer methods, the 
Wasserniann test never gives a positive reaction in mul- 
tiple sclerosis. 

Epilepsy and Paresis in Railway Engineers and Fire- 
men. — Dr. C. D. C.\MP, of Ann Arbor, Mich., says that 
in questioning the medical officers of railway and motor 
companies he has found little attention given to paresis 
and epilepsy in enginemen and firemen, though his own 
experience shows that the coincidence is not rare. He re- 
ports four cases seen recently and several from medical 
literature Suggestions are offered in the paper for the 
detection of the two conditions in railway employees. 

At the close of the discussion the following resolution 
was passed : "That the secretary of the section be asked 
to communicate with the publicity bureau of the associa- 
tion to the effect that the section believes it highly dan- 
gerous tor epileptics and paretics to be employed on rail- 
road trains and that means be taken to prevent it." 

Two Cases of Circulatory Disturbances of the Brain. 
— Dr. C. Eugene Rigcs and Dr. E. M. H.\mmes, of St 
Paul, report these clinical cases, with the results of a post 
mortem examination in one. .A full description of the 
clinical phenomena presented is given. In the first case 
the syndrome appeared to be that of occlusion of the pos- 
terior inferior cerebellar artery, and in the second, at 
necropsy, a ruptured aneurysm, before the division of the 
right posterior cerebral and posterior communicating 
artery, was found. 

The Conception of Homosexuality: Its Theories, 
Psychological Mechanisms, and Treatment. — Dr. .\. A. 
Brill. ■.! .\'ew York, reviews the theories as to the origin 
and development of homosexuality, and discusses its re- 
lation to degeneracy. Illustrative cases are given, and 
the therapy with its results fully gone into. 

Can Rabbits be Infected with the Virus of Syphilis 
Directly from the Blood of General Paretics: Observa- 
tions on the Recognition of the Virus in the Later 
Period of the Disease. — Dr. W. W. Gr.wes. of St. Louis, 
has succeded in infecting two rabbits directly from the 
blood ot two cases of general paralysis and in trans- 
mitting the disease from one of these rabbits to two other 
rabbits, and from the other of the original two rabbits 
to four other rabbits. The spirochetes have the indenti- 
cal morphologA' of the Treponeiita pallidum in tissue 
emulsions, india ink. and Giemsa stains. His studies of 
the morphology of spirochetes show the ringlike bodies 
first described by Xoguchi. from which spirochetes seem 



to develop, hurther studies in morphology and special 
straining of the Treponema pallidum in pure culture may 
enable physicians to recognize these forms microscopic- 
ally in the blood and spinal fluid of syphilitics. 

Exudative Encephalitis. — Dr. A. li. Sterne, of In- 
dianapolis, discusses the condition of the brain in exuda- 
tive encephalitis, including the grosser and finer changes 
so far as they have been observed, and also reviews the 
clinical signs presented and the differentiation of this 
from other cerebral conditions. 

THUKSU.W, JUNE IQTH. 

Further Notes on the Preneurasthenic and Preinsane 
Conditions. — Dr. Ross Moore, of Los Angeles, in this 
paper makes an attempt to define certain types of phy- 
sical and mental constitution in which a distinct mental 
disease is likely subsequently to develop. The physical 
signs are: Evidences of ready fatigue, fullness of the 
eyelids, twitching fingers, and full abdomen — all in con ■ 
nection with mental apathy. 

In the discussion, almost all the participants agreed 
that, with careful methods of operation, it is possible to 
foretell an oncoming mental breakdown, and, in some of 
these cases at least, to prevent the development of a 
full fledged attack. One of the speakers. Doctor Mettler, 
said that while he realized the importance of investigat- 
ing the mental conditions in childhood, he thought there 
was some danger of meddlesome interference in the 
training of children. 

.A motion was finally adopted that a committee be ap- 
pointed, to report in one year, as to methods by which 
this section may be helpful in the question of the hygiene 
of childhood with reference to nervous and mental dis- 
eases. 

A Division of the Auditory Nerve for Persistent Tin- 
nitus and Vertigo. — Dr. C. H. Frazier, of Philadelphia, 
has found a large field for surgical work in the cranial 
nerves. One of the last of these to come under the care 
of the surgeon is the auditory nerve. He considers par- 
ticularly operations on the intercranial portion of the 
nerve. When tinnitus is combined with vertigo we should 
operate on the nerve, rather than on the end apparatus 
As a rule the patient is already deaf on the affected side: 
consequently the effect of the operation on hearing is 
not to be considered. A small portion of the occipital 
bone is removed. The cerebrospinal fluid is withdrawn. 
In the case quoted by the author the result was very grati- 
fying, and the tinnitus wholly disappeared. 

Occlusion of the Posterior Inferior Cerebellar Artery; 
Report of a Case. — Dr. G. W. Roeixsox. of Kansas 
City, remarks that so far there are very few cases of 
this condition in literature. He reports a case, with a 
very careful analysis of symptoms, and a summary of 
the characteristic features of the lesion. 

Demonstration of Lange's Goldsol Test of the Cere- 
brospinal Fluid. — Dr. B. W. Sippev, of Chicago, pre- 
sents the result of a study of the cerebrospinal fluid in 
150 cases. This study showed the method to be of great 
value in diagnosis. Blood in the cerebrospinal fluid will 
interfere with the value of the reaction, just as it does 
in the Xonne test. The technic of the examination is not 
particularly difficult, but extreme care is necessary in pro- 
ducing the gold solution. All syphilitic lesions react with 
a maximum intensity in dilutions one to forty and one 
to eighty. Nonsyphilitic processes react with a maximum 
intensity in dilutions of about one to 640. 

Certain Nervous Phenomena in Pernicious Anemia. — 
Dr. C. E. Rices, of St. Paul, states that in several cases 
seen by him the nervous phenomena have long preceded 
the presence of any characteristics of pernicious anemia 
in the blood. The cord symptoms are much like those 
of ataxic paraplegia, and, in some instances, distinct men- 
tal symptoms, like those of dementia paralytica, were ob- 
served. Ginical cases are cited and the literature re- 
viewed. Salvarsan intravenously is recommended in the 
treatment 

SECTION' IX GEXITOURIXARY DISEASES. 

TUESD.W, JUXE I7TH. 

Symposium ox Dise.vses of the Kidxev .\xd Ureter. 

A Study of the Normal Kidney, Its Pelvis and Ureter; 
with Stereopticon Views. — Dr. S. B. Childs and Dr. 
W. M. Spitker. of Denver, state that the object of work 
performed by them in studying ten cases as nearly normal 
as possible was twofold : First, to attempt to establish a 



4^ 



AXXl'.lL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. 



norinal kidney, pt'lvis, and ureter; second, to note the ap- 
pearance of the pelvis with the x ray. Young patients 
wore selected, and wherever any fault could be found 
with the urine it was rejected. Pictures were taken in the 
lying and standing positions. Colargol was injected into 
the pelvis of the kidney by inserting catheters in tjie ure- 
ters, to :\ point when slight pain was produced. The fol- 
lowing points were noted in the study: i. The catheter 
usually entered :lie upper part; 2, the ureteral length is an 
important point determined, as it tells whether there is 
any ptosis; 3, in sixty per cent, of the cases kinks of 
varying degrees were demonstrated; 4, the shape of the 
pelvis was determined. This was found to be pear shaped, 
quadrilateral, concave, and in one instance bell shaped 
In the lantern slides the shape of the pelvis and position 
of the catheter were shown. In the standing position the 
kidney is from o to 3.5 cm. lower than in the lying jjosi- 
tion. 

Stereopticon Views of Pathological Conditions of the 
Ureter and Kidney, with Methods of Examination, and 
Their Bearing on Diagnosis. — Dr. Bk.\NSFoRn Lewis, of 
St. Louis, shows upon the screen a number of .x ray pic- 
tures of papilloma, malignant papilloma, anamalous sac- 
culations of the bladder, stones in the bladder, and stones 
in the ureter. He states that the importance of his sub- 
ject is that the "general practitioner should be taught diag- 
nosis of renal conditions, as many cases of renal calculi 
have been treated for prostatic trouble. This teaching 
should be done by the specialists, by showing pictures of 
the conditions and the methods of passing sounds and 
washing out the bladder. 

Renal Hematuria. — Dr. W. F. Br.\.\sch, of Rochester, 
Minn., presents statistics of cases in which no essential 
cause of the hematuria could be shown. A differentia! 
diagnosis is considered. Chronic nephritis should be dif- 
ferentiated by the urine findings, and the hematuria in 
this condition is regarded as a terminal symptom. In 
infectious nephritis there is really a pyelonephritis present, 
and the pain is more marked. In bleeding pyelitis the 
kidney is normal; there is a dull persisting pain and pus 
can always be found. Neoplasms, lithiasis, and angioma 
should also be differentiated. In sixteen cases of essen- 
tial hematuria operated on. nephrectomy was performed, 
with fourteen living patients, one patient having died of 
complications and another being lost sight of. Nephroto- 
my was performed in a number, and showed a fair number 
of good results. He denies that epidemic hematuria is a 
cause of essential hematuria, and state-, that after opera- 
tion it was invariably found that nephritis was not the 
cause of the hematuria. 

Experimental Kidney Surgery. — Dr. O. S. Fowler, 
of Denver, considers the causes of renal calculi. There 
is always some evidence in the kidney of obstruction to 
the outflow of urine. He believes that in a large measure 
the stasis of urine in the pelvis is due to the upright posi- 
tion. The profession should be taught early diagnosis of 
renal calculi, and prophylactic treatment after operation 
should be insisted upon. The operation performed and 
advised by the author is a nephropexy, in which the kid- 
ney is sewed in a transverse position, strips of fascia lata 
being used to braid into the capsule of the kidney, and 
the fascia lata fastened into the deep muscle. He consid- 
ers this field a new one. 

The discussion brought out considerable criticism of the 
operation. 

The Use of Indigocarmin Intravenously. — Dr. He.nrv 
D.\wso.v FuRXESS. of New York, advocates this in mak- 
ing the test of the relative value of the functions of the 
two kidneys after a determination of the combined suffi- 
ciency with phenolsulphonephthalein. .As the intramuscular 
injection of the twenty c. c. of a 0.4 per cent, solution is 
quite painful, he uses the drug intravenously in a solution 
of 0.3 pel cent, in amounts of from five to ten c. c. This 
is without pain, and the time of appearance in the urine 
is shorter and more uniform as the variable factor of ab- 
sorption from the muscles is eliminated. The only case 
in which there was any untoward result was that of a 
patient who had a choking sensation, with feeble and rapid 
pulse; but he recovered immediately. 

The Value of Various Functional Tests in the Differ- 
ential Diagnosis of Renal Disease. — Dr John F. 
Ger.\ghty. of Baltimore, explains that retention tests are 
made by testing the amount of solid substances retained 
in the blood. Fifty-five grammes per litre is regarded as 



borderline ; anything above being accumulative. As to- 
effect, the total, the relative, and the absolute functional 
values should be obtained. Inhibition is determined by 
using the alein as an indicator. In medical cases the 
glomerular function is determined by using lactose, water,, 
and salt. In nephritis a functional test of the kidney is 
of value in making the prognosis and the condition of the 
heart as a possible factor should be determiiied. L'rerhia 
may be foretold by the same test. The author emphasizes 
the value of the phthalein test in acute infections of the kid- 
ney, pyelonephritis, and double renal tuberculosis. In the 
latter the test will only indicate which is functionating the 
better, and the amount of pus may be misleading. 

WEDNESD.W, .TUNE i8tH. 

Ureterovesical Cysts: An Endovesical Operative Pro- 
cedure for Their Relief. — Dr. J. R. Caulk, of St. Louis, 
presents a summary of the cause, the pathological changes 
of this malady and the operative procedures which have 
been proposed. He reports a series of six cases. Of 
these, he believes five to have been of acqiiired origin. 
He describes his method of removing the cysts by means 
of a small long handled forceps, or by resection with the 
knife. In connection with one of the cases he gives a 
description of cystoscopic operation which was done' for 
the relief of the condition. 

The Formation of a New Ureter: Experimental Study. 
— Dr. D. N. EiSEXDR.VTH. of Chicago, states that his ex- 
periments have been performed largely on dogs. He re- 
moved portions of the bladder for transplantation, attach- 
ing them to the proximal and distal ends of the severed 
ureters. His attempts by using a section of an artery or a 
vein or a segment of bowel, failed, owing to the neces- 
sity of having an epithelium which is accustomed to the 
presence of urine. Even though these experiments failed, 
he believes that eventually a successful method will be 
evolved, based on the idea of free transplantation of a 
portion or the entire thickness of the bladder wall em- 
ployed to act as a permanent bridge between the two 
ends of a severed ureter. 

Implantation of the Ureter into the Bowel; with Re- 
port of Two Cases. — r)r. C-\rl Beck, of Chicago, re- 
ports two cases in which the ureters were implanted into 
the bowel. The end of the ureter was made to project 
well into the lumen of the gut. 

Symposium ox Bladder Tumors. 

Chairman's Address: The Present Status of the 
Diagnosis and Treatment of Tumors of the Bladder. — 

Dr. Hugh H. Young, of Baltimore, asserts that nearly all 
tumors of the bladder in persons over forty years of age 
are malignant in character. The method of treatment ad- 
vised is removal, with a wide resection of tissue beyond 
the tumor. He advises the use of a twenty per cent, solu- 
tion of resorcine painted over the surface of the tumor, 
and extreme care in handling the growth, during removal, 
in order to prevent implantation elsewhere in the mucosa. 

Chronic, Cystitis in Women not a Disease. — Dr. 
George C. Smith, of Boston, from a study of ninety- 
eight cases at the Massachusetts Genera! Hospital, con- 
cludes that in every case, carefully studied, the cause of 
the cystitis will be found to be in some lesion higher up 
in the urinary tract. These lesions include tuberculosis of 
the kidney, pyelitis, and pyonephrosis. He asserts that 
the cystitis is a secondary manifestation of one of these 
lesions. 

The Transverse Incision of the Skin and Abdominal 
Fascia as a Method of Approach in Suprapubic Opera- 
tions on the Bladder and Prostate. — Dr Granville 
MacGowan. of Los Angeles, in this paper shows very 
clearly the advantages of this incision, iudsmuch as there 
is less danger of infection of the suprapubic tissues. It 
also affords a better exposure of the bladder, and is fol- 
lowed 'ly better drainage. 

Pathology of the Prostate, with Lantern Slide Dem- 
onstration. — Dr. E. D. Smith, of Cincinnati, presents 
an interesting description of the embryology and micro- 
scopic .matomy of the prostate, followed by an account of 
malignant growths in the gland. The symptoms and re- 
mote effects of prostatic obstruction are also enumerated. 

Radiographic Observations cf Pus Tubes in the Male. 
— Dr. William T. Belfield, of Chicago, states that infec- 
tion of the seminal duct may produce an abscess in the 
duct, or there may be recurring infection of the seminal 



ANNUAL MEETING OF THE AMERICAN MEDICAL ASSOCIATION. 



49 



duct tliiiiugh the prostatic urethra. He advises drainage 
through either the vas deferens or the urethra. 

mURSD.W, JUNE 19TH. 
.SvMl'OSIUM ON DlSK.\SKS (IK TIIF. Tf.STICLK. 

Operative Treatment of Undescended Testis. — Dr. 

ARiiirK L)E.\.\ Bkv.x.n, of (.'hicago, mentions the types of 
undescended testicles referable to anatomical location, and 
speaks of the dtmgers a patient with this anomaly is ex- 
posed 10: Hernia, injuries, malignancy, psychic results, 
etc. N'ext, he discusses the history of the operations, and 
describes the technic of what he believes to be the best 
method of procedure. He emphasizes the importance of 
saving the tunica vaginalis. The absence of one testis 
must be considered. The so called supernumerary testes 
are often shown to be cases of diagnostic error. 

The Probable Embryonic Origin of Tumors of the 
Testicle, with Report of Two Cases and Lantern Slide 
Demonstration. — Dr. .\. C. .Siokks, of (Jniaha. has pre- 
pared a number of sections showing the probability of the 
embryonic origin of these tumors. In some of the sec- 
tions are clearly demonstrated cells of different types. He 
emphasizes the extreme malignancy of the tumors. Me-r 
tastases of various kinds occur. He points out the proba- 
ble evolution from the sexual cells of the testicle. Tumors 
of similar character are found in the kidney, ovary, and 
other parts of the genitourinary system. Operation must 
be both immediate and radical. Every tumor of the tes- 
ticle with pain should be treated as malignant and re- 
moved. In one of the two cases reported the operation 
was completely successful. 

Primary Tuberculosis of the Genital Organs in Chil- 
dren. — Dr. O. Lyons, of Denver, states that tuberculo- 
sis is rare in undescended testes. When this infectinn 
occurs in the testes it is almost always primary. He re- 
ports three cases. 

The Operative Treatment of Genital Tuberculosis. — 
Dr. Hugh C.\uot, of Boston, says that the order of prim- 
ary foci in genital system is usually, epididymis, testicle, 
prostate. The operation of choice is epididymectomy with 
removal of the vas from the pelvis, obviating complicated 
convalescence. Tumors of the prostate should not be sur- 
gically interfered with. He describes the operative tech- 
nic. and gives lantern slide demonstrations 

The Pseudodiphtheria Organism in the Urinary Tract. 
Dr. P. W. TowNSEND. of Rutland, Vt.. in this paper re- 
ports a case of cystitis with the cystoscopic appearances 
and subjective symptoms of renal tuberculosis. Bacterio- 
logically the tubercle bacillus' was not demonstrated by 
smear or animal inoculation. The pseudodiphtheria bacil- 
lus was found in pure culture. The pseudodiphtheria bacil- 
lus is considered to be a nonpathogenic organism. A re- 
view of the literature reveals only one similar case, which 
was reported by Dr. Rosenow, of Chicago. The pseudo- 
diphtheria organism is frequently associated with other 
organisms in chronic urethritis. The author gives a sum- 
mary of the literature and a report on the bacteriological 
examination of eighty specimens of apparently normal 
urine. 

An Experimental Study of the Value of the Internal 
Use of Hexamethylenarnine, with the Report of a Sim- 
ple Clinical Method of Quantitative Estimation of For- 
maldehyde. — Dr. Fr.wk Hixm.xn. of Baltimore, relates 
his observations and findings in administrations of he.xa- 
methylenamine internally. He discusses its antiseptic 
value as regards the urine, and calls attention to the fact 
that in many cases the amount in the urine is too small 
for effective antisepsis. It must be present to the extent 
of I :30,ooo in the urine. He details the qualitative and 
quantitative tests, and gives tables for estimation. He 
states the conditions upon which urotropin conversion 
depends. The intervals of administration should not be 
less than eight hours, and the dose should be fairly larye. 

Clinical and Laboratory Salvarsan Relapses, and 
their Remedy. — Dr. M. L. Heidixgsfei.d, of Cincinnati, 
speaks of untoward results and their prevention. Very 
careful technic is required in the administration of sal- 
varsan. The dose should be large and often repeated 
The therapy should be controlled by frequent Wassermann 
tests. 

Progress in the Treatment of Syohilis. — Dr. Victor 
Vecki, of San Francisco, critically reviews the later meth- 
ods in che diagnosis and treatment of syphilis. 



SECno.N' ().\ l'H.\R.\lACOLO(.V .\XI) THKRA- 
PEUTICS. 

TUESDAY, JUNE I7TH. 

The Teaching of Therapeutics. — Dr. R.\y L. VVilbek, 
of San I'Vancisco, chairman, in his address points out the 
present unsatisfactory condition in the therapeutic art. 
Much ol this was attributed to the unscientific basis on 
which iberapeutic agents arc employed. Ihis has led to 
therapeutic nihilism and the origin of the drugless culls. 
.•\s a remedy toward correcting this condition of affairs, 
he lays stress on the importance of keeping the mind still 
at work after the diagnosis has been made, and of asso- 
ciating therapeutics with clinical medicine and surgery; 
which, he says, should be accomplished through the prac- 
tice of bedside pharmacology and therapeutics. 

The Quality of Drugs Sold to Dispensing Physicians. 
-Dr. W . .\. I'rcK.NEK, of t hicago, reports no evidence of 
sophistication found in the drugs sold to pliysicians by the 
smaller manufacturers catering to the trade of the dis- 
pensing physician. They may be a little less reliable in 
that tablets and pills showed a greater variation in weight 
than those put out by the larger manufacturers, but this 
was not universal. He concludes that the criticism by 
pharmacists is unjustified though for the proprietary spe- 
cialties it i~ wan anted. 

The Solubility of White Leads in Human Gastric 
Juice and Its Bearing on the Hygiene of the Lead In- 
dustries. — Dr. .\. J. C.'iRLSON, of Chicago, has deter- 
mined the solubility of lead carbonate and lead sulphate 
m human gastric juice, obtained from a gastric fistula. He 
finds the former soluble to the extent of forty-si.x per 
cent., while that of the latter is only seven per cent. Ex- 
perimentally, lead carbonate was found more toxic to dogs 
and cats than the sulphate. The solubility is largely de- 
pendent upon the amount of free hydrochloric acid pres- 
ent, as he has found that the ingestion of milk delays the 
absorption which may be due to fixation of the hydro- 
chloric acid by the proteid of the milk. Owing to the great 
difference in the solubility of the two salts, it is pointed 
out that the carbonate should be eliminated for inside 
painting where there is danger of lead poisoning. 

WEDNESD.VY, JUNE i8tH. 

Treatment of Anginal Pains. — Dr. C. L. Greene be 
lieves tlie chief factor in anginal pains is due to strain on a 
weak and laboring heart, and that the treatment should be 
directed along the lines of relieving fatigue by having in 
mind all the factors that produce this condition. 

In the way of drug treatment he relies principally upon 
morphine, since this also tends to quiet the psychic element 
so frequently associated with the attack. 

Internal Hemorrhages: Can We Control Them? — 
Dr. Frank Billings contends that the thirg desired in in- 
ternal lieniorrhage: is to produce thrombus formation, 
which is liest accomplished by abstinence of food and 
keeping the patient quiet by morphine. Ergot, epinephrin, 
and hypodermoclysis are contraindicated, since they tend 
to prevent clot formation by raising blood pressure. 

Diuretics in Cardiovascular Disease. — Dr. .A. D. 
HiRscHFELDER calls attention to the methods employed to 
produce diuresis in cardiovascular diseases and holds that 
digitalis is the diuretic of choice through its effect on the 
circulation, increasing systolic output of the heart and 
pulse pressure and dilating the renal vessels. 

The Value of Diuretic Drugs in Acute Experimental 
Nephritis. — Dr. H. .-X. Christi.\n experimenting on rab- 
bits, finds that nephritis induced by uranium nitrate is not 
benefited by- diuretics of the caffeine group when the 
nephritis is severe, but in moderate cases these drugs are 
effective in imiiroving the renal function as shown by the 
phenolsulplii iiK|i!iti!aK-in test. 

Therapeutic Pneumothorax as a Palliative Measure: 
A Report of Twenty Cases from the Cincinnati Tuber- 
culosis Hospital. — Dr. Kfxnon Duxh-\m •'iid Dr. 
CH.\kLES S. RorKHiLL have produced an artificial pneumo- 
thorax in tuberculous patients with very encouraging re- 
sults. Sufficient gas is injected into the pleural cavity on 
one side to produce collapse of the lung. This measure 
was found very effective in checking and preventing pul- 
monary hemorrhage and at the same time the tuberculous 
cavities become obliterated bv the pressure of the gas, as 
shown by the 'kiagraph. The treatment is only claimed 
to he palliative in certain favorable cases. 



I'lTH Of i-Roai<i:ssirii literature. 



Treatment of Pneumonia by Specific Serums. — Dr. 
Runs CuLt classitics piieumococci into lour different 
groups, each differing in toxicity. Tlie scrum produced by 
the organism of one group does not operate against the 
to.sines of the other groups. This is one of the explana- 
tions offered why antipiieuinococcic serums have not proved 
successful in the treaunent of pneumonia. Stress is layed 
upon the importance of determining the specific group to 
which the infecting organism belongs, which may be de- 
termined by the agglutination test. All patients have shown 
a marked reaction where the appropriate serum has been 
employed. 

Antistreptococcus Serum. — Dr. G. H. Weaver em- 
phasizes the importance of using antistreptococcus serum 
that is active arid employing larger doses than has usually 
been given. No improvement may be expected unless a 
irne streptococcus infection is present. 

The Treatment of Lobar Pneumonia with Partially 
Autolyzed Pneumococci and Pneumococcus Extracts, — 
Dr. E. C. RoSEXow in a series of cases =.hows tliat the 
partially autolyzed or detoxicated pneumococci may cut the 
disease short if given early, and does reduce mortality. In 
the last stages it has not proved so efficient, but he believes 
■t is a u^clul remedy in the treatment of pneumonia. 

Nonsurgical Treatment of Cirrhosis of the Liver. — 
Dr. X. S. D.wis reports good results in the treatment of 
hepatic cirrhosis by keeping the patient at rest, a milk diet, 
and the use of hexamethylenamine and cathartics. Under 
this treatment the ascites entirely disappears and by observ- 
ing a careful diet fairly good health may be enjoyed for 
years. 

Venous Blood Pressure as Influenced by the Drugs 
Employed in Cardiovascular Therapy. — Dr. J. A. 
Capi's. experinientiiig on dogs, finds that the drugs com- 
monly employed in cardiovascular therapy have little, if 
any, effect on venous pressure. Small doses of epinephrin 
IS ineft'ective, while large doses produce a rise. A fall 
is produced by the nitrites and large doses of morphine. 

The Elimination of the Digitalis Bodies. — Dr. R. .\. 
H.xTCHER by animal experimentation finds no evidence that 
the digitalis bodies are destroyed in the circulation, 
although they disappear very rapidly. 

THURSDAY. JUNE IQTH. 

Clinical Observations on the Emetic Action of Digi- 
talis. — Dr. C.vRV EcGLESTON produces evidence to show 
ihat the nausea and vomiting resulting from the adminis- 
tration of digitalis is not due to its local irritant action 
upon the stomach, as commonly supposed, but that it acts 
directly upon the vomiting centre. In no case should 
nausea and vomiting be induced by the administration ot 
a single large dose of the drug. This phenomenon only 
occurs after absorption of the drug, as evidenced by the 
slowing of the heart and diuresis. Where there is no evi- 
dence of digitalis absorption there is no nausea and vom- 
iting. 

Radium in Internal Medicine. — Dr. L. G. Row.ntree 
in a review of the literature states that about eighty per 
cent, of all cases treated in continental Europe show signs 
of improvement by radium treatment. The methods of ad- 
ministering are by the drinking and inhaling of the watei 
emanations. Kis experience in this country, where only a 
small number of patients have been treated, have not been 
encouraging, although cases of arthritis deformans show 
.=ome improvement. 

Hydrotherapy in Nervous Fatigue. — Dr. C. Pope 
points out the beneficial results of hydrotherapy in nerv- 
ous fatigue if carried out in a scientific manner, which is 
best accomplished in sanatoria, while in the hands of the 
unskilled it is condemned. It is emphasized that hydro- 
therapy is a remedial agent and belongs to medicine and 
not to charlatans and quacks. 

What Can be Done in Cancer with Rontgen Rays. — 
Dr. W. -A. PuSEY states that epithelioma without metas- 
tasis may be symptomatically cured (i. c. scar tissue only 
remaining) by the use of the Rontgen rays. Where gland- 
ular involvement is present surgical measures should be 
employed. 

The Healing Process of Osteosarcoma. — Dr. G. E. 
Pf.\hler is able to demonstrate by the skiagraph that in 
the healing process of osteosarcoma treated by the Rontgen 
rays the deposit of lime salts is one of the chief factors 
leading to the formation of bone tissue and replacing the 
tumor mass. 



]\\\ Df Ircgrtsstbt f ittrature. 



DEUTSCHE MEDIZINISCHE WOCHENSCHRIFT. 
.l/,i.,' ;. hill. 

Theory of Hematoporphyria. — C. llegler, E. 
I'racnkel, and O. Schumin report the following 
resume of their work : The histolog'ical examina- 
tion of a patient showed that, in various internal 
organs, great amounts of pigment exist: part con- 
taining iron, part no iron. The bone substance 
was sHghtly pigmented with iron ; the bone mar- 
row contained many erythroblasts of the normo- 
blastic type, which was an expression of active re- 
generation of red blood cells. The afterproof of 
iron free cells in connection with the pigment cells 
pointed to the loss of many red cells. This re- 
sulting loss of red blood cells, possibly from earliest 
youth, should give us the key to the entire pro- 
cess. By it the distribution of pigment in the skin 
and different organs is explained, as also continu- 
ous dark color in urine, darkness of bones, and 
roots of teeth, and the reddish brown coloring 
of the skeleton. The examination with the spec- 
troscope has proved that hematoporphyrin is a 
characteristic biproduct of hemoglobin. 

Exanthema after the Use of Copaiba Balsam. 
— W. Fischer, from his personal observations, ques- 
tions whether he can recommend copaiba balsam 
preparations or return to the use of santol oil. 
Even this last is not free from slight untoward 
action, which results in gastric distress and pain in 
the region of the kidneys. 

May S. 1913. 

A New Diphtheria Prophylactic Remedy. — 
\'on Behring believes that a remedy for diphtheria 
which, after one or two treatments, would result 
m protection for an extended period of time, such 
as is the case with the vaccine lymph of Jenncr, 
and which would leave no ill effect on those vac- 
cinated, would not be a superfluous discovery. In 
the face of advances which we owe to the diph- 
theria serums in coping with the disease, and in 
spite of the indisputable fact that we may also se- 
cure prophylapsis with the therapeutic serum, sta- 
tistics show that, for instance, in Berlin the diph- 
theria mortality increased from 2,997 in IQ06 to 
11,578 in 191 1, and since then appears to have 
gone still higher. Further, as we know that, for 
good reasons, the general use of preventive serum 
injections have discontinued, it can be readilv un- 
derstood with what energy, and that the author is 
vigorously proceeding to have his remedv proved 
by other investigators for the purpose of securing 
more extended observations. Jenner, it is known, 
had to depend on a large number of statistics for 
the success of his remedy. 

Pernicious Anemia. — Oueckenstedt says it 
would be gratifying if the familiar diminution or 
absence of hydrochloric acid would permit of be- 
ing properly substantiated. Large experience in 
this matter is not at hand, though several single 
important observations have been made. Of three 
children who were found to have gastric achvlia, 
one died of pernicious anemia, and in four more 
showing variations of acidity one other such case 
was observed. Meagre as are these results, thev 



July 



/'//■// or PliOURISSSIlE LITEK.ITCKE. 



5' 



help in assuming a const ituiidiial achylia made 
possible by the aniniia. Sunic imixirtaiicc may 
perhaps be attached to the fact that not a few of 
the individuals siitTering from pernicious anemia 
become ill al an early age. What role the 
achylia plays in the genesis of pernicious anemia, 
and how important a factor it is, is at present only 
a matter of conjecture. 

May If. 191s. 

The Action of Collargol Enemas in Septic 
Processes. — W. Wolf believes that the good 
effect of callargol enemata has been clearlv dem- 
onstrated. He purposely waited after each injec- 
tion until the next rise of temperature, so as to 
more et?ectually .show the action of the remedy. 
When there was no (juestion of the favorable ef- 
fect of the treatment the enemata were given in- 
dependently of the temperature every fifth day. 
That the intravenous injection of collargol was in- 
effectual in a case reported was probablv due to 
the prompt development of a thrombus of the ba- 
silic vein, by reason of which a large part of the 
fluid was not distributed in the circulation. The 
author was put on his guard by this accident, and 
refrained from injecting the other arm of the pa- 
tient. He also states that eight collargol enemata 
given his patient did not cause the least irritation 
of the rectal mucous membrane. 

May -v. iSls. 

Antdluetin. — AI. Tsuzuki states that antihielm 
promises good results used alone or in combination 
with the old antisyphilitic remedies. Antiluetin is 
injected subcutaneously under antiseptic precau- 
tions, and the author prefers the intrascapular 
region. Patients are not hampered in their dail\- 
occupation by this method. The treatment is by in- 
creasing doses, beginning at 0.025 gramme and in- 
creasing to 0.05 gramme. Then smaller doses given 
for four or five days, until the total amount of from 
0.15 gramme to 0.3 gramme is reached. Should 
patients bear these injections well, the treatment i- 
continued. In the case of less sensitive persons one 
can give daily doses of from o.oi gramme to o. i 
gramme of antiluetin. 

Case of Rare Disturbance of Potency. — Liss- 
maim relates the case of a married clergyman, de- 
sirous, like his wife, of ha\'ing children, who had 
suffered from years from lack of ejaculation. On 
examination of semen, procured by masturbation, 
the spermatozoa were found to be normal in char- 
acter. The condition was thought to be possibly 
due to inactivity of the ejaculatory centre, and two 
eiMdural injections of yohimbine were given within 
an interval of four days (thirty c. c. of normal 
saline solution, with from twenty to thirty drops of 
a two per cent, solution of yohimbin). This stimu- 
lated the erections for a time, but otherwise was 
without effect. Owing to the great desire of the 
couple for offspring, the author suggested the pos- 
sibility of ejaculation by means of masturbation up 
to the moment of ejaculation, when the penis was 
to be inserted into the vaginam. Conception, how- 
ever, did not result, and finally the patient was ad- 
vised to resort to artificial impregnation. 

.1/,7V .'0. 101;. 

The Importance of Analyses of Spinal Fluid 
and Blood Serums in Neurology. — D. M. Kap- 
lan asserts: i. .Serology is of the greatest impor- 



tance for the iliagnosi.>5 and therapeutics of nervous 
diseases. _>. h is possible to distinguish between 
syphilitic and nonsyphilitic alTeclions on the one 
hand, and between dementia paralytica and lues 
cerebrospinalis, on the other ; even when the differ- 
ential diagnosis is not clear clinically. 3. The cell 
content of the spinal fluid is to be considered in 
treating a case of tabes specifically or otherwise. 4. 
The serological picture is one in which most syphil- 
itic affections will be modified by specific treatment, 
5. It is capable of exhibiting serologically a char- 
acteristic picture for beginning and for fully devel- 
oped paralysis. The latter is not to be treated 
specifically. 6. In spinal cord compression one 
usually finds high protein content and a decrease in 
cell multiplication. 

Two Cases of Eclampsia Resulting Favorably 
after the Use of Hypophysen Extract. — .\. 
.Schlossberger suggests the use of hypophysen ex- 
tract in all cases of eclampsia which are to be con- 
servatively treated, so as to determine whether the 
remedy has antieclamptic properties, in fact, or 
whether the -uod result noted in the author's cases 
was sini]!!)- a matter of past hoc. 

ZEITSCHRIFT FUR AUGENHEILKUNDE. 

Max. WIS. 

Black Cataract. — A. Elschnig and R. von Zey- 
nek have, they assert with positiveness, determined 
from the results of chemical analysis that the col- 
oring matter in black cataract is in no way con- 
nected with the coloring matter of the blood. 

Experimental Studies of Fluorescence of the 
Human Lens. — J. von Sepibus gives the results of 
a large number of experiments with uviol glass 
light and states that he obtained a yellow green 
fluorescence of the human lens which is more 
marked as age increases. The color of this tends in 
youth more toward green ; in age toward vellow. 
.\o fluorescence worth mentioning was obtained 
from the swollen masses of lens substance in trau- 
matic cataract, and no distinctly visible fluorescence 
could be seen in remains of the lens capsule or in 
exudates in the pupil. The aphakic pupil was not 
fluorescent. 

LYON MEDICAL. 

May .M. I'JI.;. 

Pathology of Disseminated Sclerosis. — L. 
Beriel states that from the standpoints of etiology, 
symptomatology, and course, disseminated sclero- 
sis {sclerose en plaques) can only with difficulty 
be conceived of as a definite, single disease. The 
unity of the disorder now depends chiefly upon its 
pathological substratum. For the production of the 
sclerotic plagues there is required merely a iliffuse, 
subacute, nondegenerative myelitis or myeloenceph- 
alitis, upon which are engrafted localized vascular 
changes. These conditions having been supplied, 
the lesions are readily accounted for according to 
the general laws of the nutrition and evolution of 
tissues. The original myelitis does not depend 
upon a single, specific cause. 

PARIS MEDICALE 

Urinary Pepsin and Nephritis. — M. Chirav and 
R. L. G. Clarac state that, of al! the methods of e.s- 
tiniating the urinary pepsin hitherto employed. 



52 



FITIl OF PROGRESSIVE LITERATURE. 



[New York 
Medical Journa 



that in which edestin is employed as the alhuniiii to 
be digested is the best, though even this procedure 
is nof altogether satisfactory. The gastric nnicoiis 
membrane produces propepsin, of which a portion 
is not converted to active pepsin, passes into the 
blood, and is eliminated by the kidneys ; becoming 
in part activated to pepsin when in contact with 
the renal epithelium. The urine contains both pep- 
sin and propepsin, and the latter is activated by the 
acid present in the edestin solution used in the test. 
Whereas in but one of nine patients suffering from 
various aflfections — cirrhosis, pleurisy, rheun^atism. 
cancer — was the urinary pepsin found above n ir- 
mal by the authors, it was above normal in five out 
of six cases of chronic nephritis. Urine treated 
with toluene and placed in the incubator was found 
to be the seat of a pronounced autodigestion, c:ius- 
ing a progressive diminution of its albumin content. 
Palpation of the Liver in the Standing Position. 
— L. riant. er asserts that, in view of the frequency 
with which unsuspected abnormalities of the gall- 
bladder are found at autopsy and upon laparotomy, 
there is evidentlv something w-rong with present 
methods of physical examination of this organ. 
He has found, indeed, on many occasions, th^t 
where no s.gn of gallbladder trouble can be elicited 
upon examination of the patient in the recumbent 
posture, characteristic gallbladder tenderness i-s 
noted upon deep pressure at the appropriate point 
when the patient assumes the standing position. 
.\pparently the gallbladder recedes above the costal 
marg'n dur.ng recumbency, and is thus not accessi- 
ble to examination. 

PRESSE MEDICALE 

May SI, IQIS. 

Diagnosis of Aortic Insufficiency with the 
Sphygmomanometer. — Camille Lian, in thirty-six 
cases of aortic insufficiency, found the maximal 
pressure higher than normal in twenty-two in- 
stances, normal in eleven, and slightly subnormal 
in three. The minimal pressure was nonral in 
twenty cases, subnormal in fifteen, and sl'-ghtly 
above normal in one. The most valuable diagnos- 
tic information is afforded, however, by the rela- 
tionship of the two pressures. In sixteen cases the 
maximal pressure was above normal and the mini- 
mal pressure normal ; in seven, the maximal was 
normal and the minimal sttbnormal, and in five, the 
maximal was above normal and the minimal sub- 
normal. The charcteristic features in aortic insuffi- 
ciencv are thus an increase in the pulse nressure 
and usually a normal or subnormal diTPtolic pres- 
sure. These features are preserved even where 
there coexists another valvular lesion, arteriosclero- 
sis, or chronic nephritis. In the average case of 
aortic insufficiency sphygmomanometry is only an 
additional confirmatory factor in diagnosis : but in 
cases where the murmur is but sl'ghtly marked or 
absent (including cases in which there is muscu'ar 
w-eakening), where tachycardia renders precise 
ausculftion difficult, and where other vlvular le- 
sions 3re present, the procedure is likelv to be of 
great service. In one half the cas^s of Hodgson's 
disease ("aortic insufficlencv of svphilitics and a'te- 
rioscleroticsl, viz.. those in which there is w-»ll 
chir^rterized chronic arteritis and interstitial neph- 



ritis, the maximal pressure is very high and the 
minimal normal or also above normal ; but in the 
remainder the typical pressure conditions are the 
same as in Corrigan's disease (aortic insufficiency 
of rheumatic origin). 

REVUE DE CHIRURGIE. 

Miiy. '<".■■ 

Technic of Jejunostomy and Its Untoward 
Sequelae.^- T^. IJerard and H. Alamartine report 
a case of death following jejunostomy by the 
Witzel-EIselsberp; technic. .All necessary preciu- 
tions had been taken during the operation, and th; 
fatal ending, due to intestinal obstruction four days 
after, must be ascribed to the procedure itself. -A.t 
autopsy the jejunum was found kinked at an acite 
angle at the point operated on. Two similar fatal 
cases reported by other surgeons are referred to. 
The authors consider this form of jejunostomy too 
dangerous a procedure and too time consuming, 
and much prefer to it the older "omega" technic 
advised by Albert and Mayo Robson. This opera- 
tion they perform under novocaine-epinephrine 
local anesthesia. The laterolateral anastomosis be- 
tween the two halves of the loop of jejunum 
brought to the surface is effected w-ith a Jaboulay- 
Lumiere button ; at least ten minutes' advantage 
being thus gained over the ordinary suture method 
With this procedure perfect continence is secured 
and accidents from occlusion of the gut cannot 
occur 

REVUE MEDICALE DE LA SUISSE ROMANDE. 

May, igit. 

Banti's Disease in Infancy. — A. D'Espine re- 
ports two cases in which the anemia and splen- 
omegaly characteristic of Banti's disease were 
noted, respectively', at the ages of seven and fifteen 
and a half months. In neither case was syphilis a 
factor. The author is led to emphasize the early 
onset of ISanti's disease. Splenic enlargement may 
often have passed unnoticed until adu't life and the 
disease actually have started in infancy. Some 
cases of racliitic splenomegaly, considered as aris- 
ing from syphilis by certain authors, are actually 
incomplete (friistes) cases of Banti's disease. 
Spontaneous recovery from Banti's disease may 
occur in children, as in two cases to which D'Espine 
refers. That the injection of splenic tissue from 
one of the author's cases into a monkey gave nega- 
tive results would appear to show that the disease is 
not due to infection 

New Uterine Curette. — Janibe describes an in- 
strument consisting of an ordinary sharp curette 
blade borne by a metallic ring, which is slipped 
over one or two fingers in such manner that the 
tips of the latter project. The chief advantages of 
the de\'ice are that direct control of the curettin? 
by the fingers is afforded and that the leverage of 
the long handle of an ordinary curette, with the at- 
tendant danger of undue injury in the deeplv seated 
uterine cavity, is avoided. The sm^aller monodigital 
device is to be used wdiere dilatation is insufficient 
to admit two fingers, in cases of abortion or prema- 
ture labor, while the larger bidigital instrument is 
intended for post partum curettage in cases where 
co"''"lete evacuation cannot be secured with the 
hand al-^nc. 



July 



ririi or i'kogresshe uteratvki- 



53 



Chloride Free Treatment of Epilepsy. — V. 
Deiiiole reports the results obtained in four epilep- 
tics by the use of Ulrich's sedobrol, a mixture of 
pt>tassium bromide with a minimal quantity of 
sodium chloride and with fats of extracts of vege- 
table albumins, intended to aftord the advantages 
of "chloride free" treatment without the disadvan- 
tage of anorexia and dyspeptic disturbances arising 
because of distaste for unsalted food. The sedobrol 
tablets are dissolved in chloride free soup, to which 
they impart an attractive flavor. The efficacy of 
the remedy was shown in each of the patients re- 
ceiving it, the number of seizures diminishing, on 
the average, by twenty-nine per cent, from what 
they had been during bromide treatment alone, and 
becoming more frequent again when the prepara- 
tion was discontinued. No dyspeptic trouble wa^ 
experienced during its use. The remedy was al>o 
employed with success in a case of hysteroepilepsy, 
both the body weight and mental conditinn showing 
distinct improvement under its influence. 

BRITISH MEDICAL JOURNAL. 



On Avoidable Difficulties in the Hand Feeding 
of Infants. — Eustace Smith ascribes much of the 
trouble to the careless handling of the infant at the 
time of birth and shortly thereafter. At birth the 
infant passes from a temperature of about ioo° 
F. into one of from 65° to 70° P., and care- 
lessness in bathing and attending to it subjects 
it to prolonged chilling, which gives rise to con- 
siderable shock and disorders the digestive powers. 
Such children vomit even the mother's milk, and 
are then put upon formulas. On the bottle thev 
suffer even more than at the breast, and the food 
is blamed. The real trouble, however, is a catarrh 
of the stomach. The continued exposures for each 
day's care serve to keep the condition aggravated. 
For the avoidance of much trouble in artificial feed- 
ing the first rule given by .Smith is, "Take care that 
the infant is bathed as quickly as possible in hot 
water, and that his feet and legs are never allowed 
to get cold." The second rule is directed to the 
maintenance of proper digestive powers and their 
encouragement by variety of flavor in the food. 
Smith believes that this is of great importance in 
hand fed infants, and especially to those whose 
digestive difficulties have already been a cause of 
anxiety. It will usually be sufficient to give two 
difTerently tasting foods alternately during the dav. 
and a third for the night. In exceptional cases a 
greater variety may be needed. 

Autogenous Vaccines in the Treatment of 
Chronic Joint Affections. — Basil Hughes con- 
siders the so called rheumatoid arthritis as a meta- 
static arthritis due to some primary focus of infec- 
tion. Such foci have been most frequently found, 
in his cases, to lie in the mouth about the teeth, 
in the nose and nasopharynx, in the ear as a chr.nic 
otorrhea, in the lungs as bronchitis or bronchi c asis, 
in the intestinal tract associated with dyspepsia and 
intestinal stasis, and, lastly, in the female pelvic 
organs as leucorrhea of septic origin, usually due to 
Bacillus coii. In all such conditions the offending 
organism or organisms should be isolated from the 
primary focus (it is usually impossible to cultivate 



them from the joints), and an autogenous vaccine 
should be given for one or two doses. Tiiis raises 
the phagocytic powers of the patient and it is then 
time to give the infected region the needed local 
treatment. The use of the vaccine is to be persisted 
in for long periods of time if one is to succeed in 
the treatment. Hughes believes that chronic g. n or- 
rheal arthritis is due to a mixed infection with the 
gonococcus and the staphylococcus, both of wli ch 
can be cultivated from the interior of the urethra. 
A vaccine containing from 100 million gonococci 
and 150 million staphylococci up to 500 million of 
the former, and 1,000 million of the latter, is to be 
used, and after the second dose the chronic gleet is 
to be treated locally. Excellent results follow this 
method, but it often requires many weeks or m jnths 
for a cure. 

Vaccines in the Treatment of Chronic Bron- 
chitis and of Asthma. — J. H. Harvey Pirie has 
treated some sixteen cases of the former condition 
with autogenous vaccines made from the sputum, 
and containing all of the probably pathogenic organ- 
isms present. The most commonly found organ- 
isms are the pneumococcus. Micrococcus catarrhalis 
group, streptococci, and staphylococci. Attention is 
called to the necessity for the inclusion in the vac- 
cine of colonies of each of the several strains of 
the Micrococcus catarrhalis group which are 
usually found, as many of the strains are nonpatho- 
genic, and the selection of the one which is offend- 
ing is impossible bacteriologically. Seven of his 
sixteen patients are almost cured, four show 
marked improvement, four slight improvement, and 
one no improvement. In asthma the same varieties 
of organisms were found as in bronchitis, but in 
the former the pneumococcus was found in every 
case, while in the bronchitis cases two of the sixteen 
showed no pneumococci. Of nine patients with 
asthma, two have been practically cured, five con- 
siderably improved, one shows slight improvement, 
and one, none. 

LANCET. 

June 14, IQIi. 

The Place of Climatology in Medicine. — W'il- 

liam Gordon discus.'ses the general factors which 
go to make up a climate, and outlines their influ- 
ence on healthy humans. As to their effects upon 
disease, he recalls that he has shown that expos -ire 
to prevalent rain bearing winds is a marked factor 
in both the occurrence and the prognosis of pul- 
monary tuberculosis. In pneumonia, a small series 
of observations would seem to indicate that great 
altitudes, and particularly cold dry winds, exert a 
considerable influence leading to the greater fre- 
quency and intensity of the disease. On the other 
Iiand, in bronchitis damp wind seems to increase its 
prevalence. Knowledge of the influence of such 
factors, and of the nature of the factors of climate 
which characterize given sections of the country, 
gives us an important element in diagnosis and in 
prognosis, for if a patient is known to come from a 
region in wh.ich pneumonia is prevalent and severe, 
we are justified in anticipating a doubtful outcome. 
The influence of climate does not seem to be con- 
fined to the infectious diseases, for it has been 
found by analysis of the frequency of cancer and of 
the age of its incidence, and that at which it kills. 



PJTH or PROGRESSIVE LITERATVRE. 



tliat in certain rural districts the disease is relative- 
Iv rare, occurs later in life, and death results from 
it at a much more advanced age, than is the case 
in towns or in the coiuitry in general. 

The Finsen Light Treatment at the London 
Hospital, 1900-1913. — ]. II. Sequeira reports that 
oi a total of 1.039 patients treated efficiently for 
lupus during the past thirteen years, 544 have re- 
mained cured for from three to thirteen years; i86 
have remained cured for less than three years; it" 
have been essentially cured. rec|uiring, however, 
occasional treatment for slight recurrences ; 161 pa- 
tients have improved ; and thirty-one have been 
wholly uninfluenced by the treatment. Not all of 
the benefits recorded are ascribable solely to the 
light treatment, for some cases were also helped out 
in a few exposures to x rays, and some were treat- 
ed surgically, in addition to the use of the light. 

Breast Feeding. — David Forsyth had an infant 
carefully weighed before and after each nursing for 
a period of seven weeks, beginning on the fourth 
day after birth. The results show that there is a 
general increase in the average daily consumption 
of milk from week to week, but that this is neither 
unifomi nor uninterrupted. Further, the daily 
amounts taken vary within wide limits, and the 
amount taken at a single feed is even more vari- 
able. In the second week so large a single feed as 
125 c. c. was taken on two occasions. The average 
feeds ran ; Twenty-eight c. c. for the first week ; 
fifty-seven c. c. for the second; forty-six c. c. for 
each of the next two weeks ; sixty-six c. c. and 
sixtv-five c. c. respectively for the fifth and sixth 
weeks ; and seventy-seven c. c. for the seventh week. 
From the finding of enormous variations in the 
sizes of individual feeds one is forced to believe that 
the "test feed" method of estimating the needs of 
a child is worthless. Another notable feature of the 
oh-;ervations was that the variable consumption of 
the milk did not seem to run in cycles, but was quite 
irregular. Forsyth believes the variation due in 
large measure to maternal factors, rather than to 
differences in the infant's appetite. Xo food or drug- 
reputed to have galactogogue powers had any in- 
fluence on the flow of milk in the case thus carefully 
.studied. 

Breast Feeding. — Disney H. D. Cran advocates 
the teachii.gs of Variot to "let the child on the 
breast drink according to its appetite." From a 
large series of cases, all of which were conducted 
along this plan, it was found that the infant mor- 
tality did not exceed 4.5 per cent., being only 3.14 
per cent, in 1912. The amount of milk thus taken 
by the child may vary from one sixth to one 
twelfth of its body weight in twenty-four hours, 
and is never so low as one tenth, as is generally 
taught. If the child has taken a little too much 
milk there is simple regurgitation. The restricted 
feeding advocated by many almost always leads 
to underalimentation, with crying, vomiting, diar- 
rhea, wasting, etc. The use of scales more often 
than once a week in the case of a young mother 
who is healthy is to be deprecated, for it often 
leads to worry if the child happens to take but a 
small feed at the meal chosen as the test one. The 
methodic use of the scale is indicated when a child 
on the breast ceases to increase in weight, and this 



will usually show that the secretion of milk is de- 
ficient. 

A Case Having a Bearing on the Localization 
of the Auditory Centre. — W illiam Boyd and J. S. 
ilopwood report the post mortem finding of a case 
of complete destruction of the entire left temporal 
lobe except the third convolution, and the anterior 
extremities of the second and first convolutions, the 
last of which bears on its upper surface the ante- 
rior gyrus of Heschl. In this latter the auditory 
centre has been thought by some to lie, and the 
present case seems to lend confirmation to this 
view, for the patient showed no deafness during 
life. 

An Experimental Research into the Origin of 
the Inorganic Chloride in the Gastric Secretion. 
— Charles Singer obtained gastric juice from fast- 
ing cats by means of a stomach tube and pilocar- 
pine. Seven dififerent samples were tested for the 
inorganic chloride, and it was found to be present 
in all. He therefore concludes that the inorganic 
chloride in gastric juice is in large part due to se- 
cretive or osmotic processes in the stomach wall, 
and not to introduction in the food, and that it 
must, therefore, be affected by pathological changes 
in the wall. Hence the amount of inorganic chlor- 
ide becomes of pathological and clinical signifi- 
cance. 

JOURNAL OF TROPICAL MEDICINE AND HYGIENE 

Treatment of Suppression of Urine in Black- 
water Fever. — H. .S. Stannus reports a case in 
which, after hemoglobiiniria had been present 
twenty hours and complete suppression forty-eight 
hours, nephrotomy (unilateral) was performed. 
This resulted in the passage of small amounts of 
urine, beginning within twenty-four hours after the 
operation and continuing until death took place in 
the presence of uremic symptoms, on the evening 
of the fifth day after operation. Although the pro- 
cedure was unsuccessful in saving life in this case, 
the author thinks it possible that intervention at an 
earlier period in the suppression would succeed in 
cases of this kind. The first desideratum is to 
ascertain how long suppression can exist before a 
spontaneous return of renal function is precluded 
in a large proportion of cases. 

Spider's Web and Malaria. — Frederick Knab. 
referring to the view recentlv urged that the web 
making spiders are effective destroyers of malaria 
transmitting mosquitoes, points out that while it 
has been generally taken for granted that 
mosquitoes are actually entangled in the webs, just 
as are other diptera, records based upon first hand 
observ'ation of such occurrence are exceedingly few. 
On the other hand, the author has observed 
mosquitoes to choose spider webs as a resting place 
and habitually to repose there, without in the least 
becoming adherent to their meshes. In every case 
the mosquitoes so observed were ayiophrlcs. and 
furthermore, in the vicinity of \\"ashington. D. C, 
the author found that all the anopheles on the webs 
lielonged to the species Anopheles quadrimaculatus. 
although a second species. Anopheles puncttpcnnis. 
was present in the locality in large number. The 
latter species carefully avoided the webs. Since 



I'lTIl or /'ROUKESSIIH LITER. ITi'HE. 



.Inoplu'lt's ijiiadriituicitltitiis is ih" princiiwl malar a 
transmitter in the northern I'nited States, wliile the 
more abundant Anopheles pitnetipennis has been 
proved incapable of serving as the host of the 
malarial parasites, it would appear that in some 
cases at least, the spider webs have no effect in 
checking malaria. The author could not find a 
single record of anopheles caught in a web. 

May 15. ivf;. 

A Clinical Study of Malarial Fever.— J. P. 
Bates, from a study of malaria begun in Panama in 
1905, and covering a large number of cases, con- 
cludes that this affection is not analogous to other 
infectious diseases in that the greater the infection 
the more prolonged the course, but either responds 
to quinine within three to four days — in a lew in- 
stances of primary infection and in children, within 
si.x days — or rapidly terminates in a fatal issue. 
Systematic examination of the stools, W'idal tests, 
blood cultures and a careful study of symptoms, 
have convinced the author that the idea long preva- 
lent that malaria is in some instances only slowly 
influenced by quinine is incorrect, and that the 
cause of this mistake has been confusion of three 
conditions, viz. — uncinarial anemia, kala azar, and 
mild typhoid fever, with malaria, owing to the 
great clinical similarity. True malaria is a very 
simple entity and is not difficult to cure if treatment 
is begun before the organism is overwhelmed by 
the infection. Mild typhoid fever, as proved by 
cultivation of the bacilli from the blood, has given 
rise to much confusion, because its temperature 
curve is often irregular, as in the so called "re- 
mittent" or "subcontinuous" type of malaria, and 
because some typhoids of moderate severity termin- 
ate abruptly, as malarial fevers often do. At least 
some of these cases have malarial parasites in the 
blood, along with the typhoid infection. In differ- 
entiating mild typhoids from malaria, the blood cul- 
tures must be made within from twenty-four to 
thirty-six hours after admission. 

BOSTON MEDICAL AND SURGICAL JOURNAL. 



Concerning Diabetes Insipidus and the Poly- 
urias of Hypophyseal Origin. — Harve\' lushing 
summarizes the experimental data by saying that: 

1. The infundibular region contains, in addition to 
the substance capable of glycogenolysis, a chemi- 
cal body or hormone capable of eliciting diuresis. 

2. Under certain operative conditions which entail 
posterior lobe manipulations there often occurs a 
diuretic response, and occasionally an extreme 
polvuria, whereas a temporary diminution in the ex- 
creted urine is apt to follow other operative pro- 
cedures requiring an equally long anesthetization. 

3. Posterior lobe implants may cause a temporary 
polyuria, which subsides on the removal of the im- 
planted tissue. 4. Stimulation of the autonomic sys- 
tem of nerves to the gland elicits diuresis. 5. Cer- 
tain operative procedures, such as separation of the 
infundibular stalk, and occasionally a simple pos- 
terior lobe excision, may call forth a somewhat pro- 
longed polyuria. In connection with clinical ob- 
servations he suggests not only that the emotional 
polyurias are in all likelihood the expression of a 
neurogenic discharge of hypophyseal secretion, but 



aLso that the clinical polyurias of longer duration 
are in many instances merely the symptomatic ex- 
pression of an internal secretory disturbance 
brpught alx)ut by injury or disease involving the 
hypophyseal neighborhood. Hence, whether or not 
there actually jiroves to be a form of polyuria of 
l)rimary renal origin, our present conceptions of so 
called diabetes insipidus need to be recast, with 
especial reference to the factor of the secretory ac- 
tivit\- of the pituitarv hndv. and particularly of its 
posterior lobe. 

Diagnosis and Treatment of Diphtheria. — 
Joseph p.. Greene makes the following points: i. 
The diagnosis of diphtheria depends primarily on 
finding the organism, (."ultures should be taken of 
every sore throat in children, and of suspicious nasa! 
discharges. I'.ut in the absence of a positive find- 
ing, if the symptoms point to diphtheria, antitoxine 
should be given, especially if the symptoms are 
severe. 2. Much larger doses of antitoxine should 
be given than tho'^e suggested in the textbooks. 3. 
Laryngeal cases are serious, partly from mechanical 
obstruction, requiring prompt relief from the sten- 
osis, and large doses of antitoxine. Intubation is 
preferable, in the main, to tracheotomy. Laryngol- 
ogists should perfect their technic in this operation 
until it becomes a fairlv simple one. 4. Epidemics 
of diphtheria are kept up largely by "carriers."' 
They should be sought out, isolated, and the ab- 
normality treated. Diseased tonsils and adenoids 
may require removal. 

Tuberculosis of the Epididymis: Its Effect 
upon Testicle and Prostate. — T. Bellinger Barney 
says that the epididymis is the primary focus in 
the vast majority of cases of genital tuberculosis. 
The disease is bilateral in 41.6 per cent, of all cases, 
and becomes so Avithin six months of the involve- 
ment of the first side in thirty per cent. The pros- 
tate and vesicles are infected in seventy-five per 
cent. ; this infection taking place in the first six 
months in thirty per cent., and in the first year in 
fifty-four per cent. The infection takes place quite 
as often in the presence of unilateral as of bilateral 
epididymitis. The urine is pathological in forty- 
three per cent, of all cases ; bladder irritability is 
found in thirty-five per cent., and in about half of 
these it occurs in the first six months. Tuberculosis, 
past or present, of organs other than those of the 
genitourinary tract, is to be expected in thirtv-three 
per cent. Clinical observation shows tuberculosis 
of the testicle in forty-four per cent., but the path- 
ologist finds it in sixty-six per cent., and of these 
the infection takes place in the first six months in 
fifty-three per cent. .\s the infection may become 
widespread in the first six months, removal of the 
epididymis is indicated at the earliest possible date. 
It is rarely necessary to remove the testicle, as it 
was not required in sixty-seven epididydectomies. 

JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. 

The Treatment of Narcotic Addiction. — .\le.x- 
ander Lambert describes a treatment for alcohol, 
morphine, and other drug habits, the essentials of 
wliich cannot be altered. The treatment consists of 
the persistent administration of a belladonna mix- 
ture, in small doses, and thorough elimination bv a 



56 



PITH OF PROGRESSIVE LITERATURE. 



[New York 

JOURNAU 



mercurial cathartic, as blue mass or calomel, giveu 
in the form of compound cathartic pill or alone. 
Some patients who are easily salivated by calomel 
can take blue mass. The cholagogue action is essen- 
tial. Mere catharses is insufficient in the process 
of elimination, as are also colonic enemas. There 
must be the cholagogue action from above. This 
treatment is not offered as a cure of morphinism or 
as a cure of delirium tremens or chronic alcoholi-m. 
but it will remove the terrible craving accompanying- 
these addictions, when, unaided, the patients en- 
deavor to give up the drugs or are made to undergo 
the slow withdrawal without some sooothing substi- 
tute. It is superior to the old methods of slow or 
rapid withdrawal. Deprivation of a drug is not 
equivalent to the elimination of that drug from the 
system. Suffering follows deprivation, relief fol- 
lows elimination. This treatment, and no other 
known treatment, can prevent patients, after being 
freed from such addiction, from repoisoning them- 
selves by resuming the use of the drug, which has 
previously poisoned them and led to their habitual 
intoxication. Though each individual presents a 
separate problem, this treatment is suggested as the 
best means of "unpoisoning" the patient and placing 
him in a position where he can be approached with 
a clear, unpoisoned mind, and protected from self 
destruction. 

Animal Experiments with von Ruck's New 
Tuberculoproteins. — From a series of experi- 
ments made with this vaccine upon guineapigs, R. 
S. Cummings concludes that immunit}^ was not pro- 
duced by the vaccine, but it would seem possible 
that as the vaccinated animals became sick first, they 
were more susceptible at the time of inoculation 
than the controls. 

Accidents Following the Subdural Injection of 
Antimeningitis Serum. — Simon Flexner admon- 
ishes us not to lose sight of the fact that in epidemic 
meningitis we are dealing with a highly fatal 
malady, and the one means now possessed to com- 
bat it is the antimeningitis serum. It is not justi- 
fiable, therefore, to withhold the remedy, in spite of 
some small risk, in view of the far greater dangers 
from the disease itself. Nor should we always 
ascribe serious symptoms to the serum, even when 
they follow closely on the treatment. Sudden 
death not infrequently occurs in epidemic menin- 
gitis ; cases have been reported in which death has 
taken place while the serum injection was being 
prepared, and even before lumbar puncture had been 
done. The antimeningitis serum should not be dis- 
credited because of an unfortunate experience. 
When everything is considered, such action seems 
hardly defensible. 

Advanced Treatment of Puerperal Infection. — 
The rational treatment of puerperal infection, ac- 
cording to Robert T. Gillmore, demands that we 
ascertain by a blood culture the germ causing the 
infection. To this end a tight bandage is applied 
to the upper arm, and the distended median basilic 
vein punctured with a large needle, under strict 
aseptic technic, after which about half an ounce of 
blood is withdrawn into a sterile glass container. 
From this an autogenous bacterin is made. It re- 
quires five days to be absolutely certain that no 
other living germ is present ; it is wise, therefore. 



after the microorganism has been isolated, to in- 
itiate a bacterin treatment with fifteen c. c. of serum 
intravenously, to be followed with a reliable stock 
vaccine. The nonoperative treatment of an uncom- 
plicated case of puerperal infection demands com- 
plete physical and mental rest, good ventilation, and 
sunshine, and that drainage be favored by the 
Fowler position. Cold sponging and an ice bag on 
the head should be used to control hyperpyrexia. If 
there is local pelvic inflammation an ice bag is placed 
over the affected area. Elimination by the bowels 
and the kidneys should be favored, and normal 
saline .solution, introduced by the drop method into 
the rectum, will save the stomach, allay thirst, and 
favor renal elimination. Since this preparation of 
an autogenous vaccine requires about five days, a 
serum or antitoxine should first be administered, to 
be followed by a reliable stock vaccine if the blood 
count is favorable, and there is an indication that 
the patient lacks sufficient reaction to combat the 
disease. The stomach should be carefully guarded, 
and all useless medication avoided. Reserve the 
stomach for nourishment only. Feeding should be 
done with care and at regular intervals. Dispense 
with breast nursing, unless the mental effect is too 
depressing. The operative treatment should be lim- 
ited to cases with absolute indication. The use of 
antiseptic vaginal and uterine douches is deprecated. 

Conservative Treatment of Some Aural and 
Nasal Conditions by Hot Air and Iodoform. — 
Edward J. Erown presents a simple and practical 
method of treating some aural and nasal conditions. 
Sore throat and earache from acute pharyngitis 
have been relieved by a single application of hot air 
and nascent iodine, with no return of the trouble on 
the following day. This result seems to be due 
specifically to the destruction of the less resistant 
bacteria and the drying and shrinking of the tissues 
with the secondary increase of cellular activity and 
removal of inflammatory products which interfere 
with drainage. 

The Serum Diagnosis of Pregnancy. — Charles 
C. ^^'. Judd, in considering the Abderhalden serum 
tests, remarks that if putrefactive changes can be 
excluded, a positive reaction indicates that the 
tissue was digested by an enzyme of the patient's 
serum, which, so far as investigations have been 
able to determine, is present only in the gravid state, 
the puerperium. and in cases of retained mem- 
branes. A negative reaction, however, is strong, if 
not conclusive, proof that placental tissue is not or 
has not recently been present in the patient's body. 
Some thirty or more cases under the care of the 
writer, and tested by this method, have shown the 
strict specificity of this test when putrefactive 
changes, fresh serum, and the proper selection of 
dialyzers have been carefully controlled. 

MEDICAL RECORD. 

June .'I. lOlS- 

Incompetency of the Ileocecal Valve. — John 
H. Kellogg describes the disorders arising from 
this condition and their treatment. In complete in- 
competency of the ileocecal valve the passage of a 
large amount of undigested food from the small 
intestine into the colon may cause indigestion and 
diarrhea. When the contents of the small intestine 



July 5, 19131 



/•/■/// OF I'h'Ol.RISSSJfL LlTliRATl'Kli. 



pass rapidly into the colon, insteail u\ being intro- 
duced in small successive quantities, the colon be- 
comes overdistended, stasis occurs, putrefactive 
processes are encouraged, colitis, pericolitis, or ap- 
pendicitis may result, and conditions arc produced 
wliich favor the development of tuberculosis and 
cancer; pathological conilitions which occur with 
special frequency in this part of the canal. The 
drag of this accumulated material upon the root of 
the mesentery produces obstruction at the j unci ion 
of the duodenum and jejunum, and so causes duo- 
denal and gastric stasis, the natural consequence of 
which in these parts, as in every other part of the 
alimentary canal, is the abnormal development oi 
bacteria and toxines, with infection of the mucous 
membrane and resulting gastritis, duodenitis, gas- 
tric and duodenal ulcer, cholecystitis, cholangitis, 
gallstones, pancreatitis, adhesions about the py- 
lorus, and the duodenum with chronic pain in the 
pyloric region, and various other morbid conditions 
connected with the stomach and digestion. Ap- 
pendicitis and the various troubles referable to ad- 
hesions about the ileocecal region are a natural, al- 
most necessary, consequence and incompetencv of 
the ileocecal valve. Ileocecal valvular incompetency 
interferes with the movement of gases even more 
than of liquid material, and the bowel is practically 
unable to deal with gaseous material. Constipation 
and intestinal intoxication of the highest degree is 
produced by incompetency of the ileocecal valve. 
The palliative treatment of the condition includes 
increased activity of the bowels (three movement^ 
daily) and a change of the intestinal flora ( b\ the 
use of acid forming ferments — Bacillus bul'^an'ciis. 
Bacillus hi-fidns). The radical cure, seldom needed 
in the writer's opinion, consists in reconstructing 
the damaged habenula and reproducing the in- 
tussusception of the small intestine. 

A Clinical Study of the Application of Im- 
proved Intravesical Operative Methods in Diag- 
nosis and Therapy. — Leo Buerger reports eight 
interesting cases demonstrating the useful endovesi- 
cale operation procedures that can be carried out 
through the modern cystoscope bv means of spe- 
cial instruments. These include the extirpation of 
tumors, the excision of suspected pathological le- 
sions, the crushing and removal of calculi, the re- 
moval of foreign bodies, the snaring of papillomas, 
the dilatation of ureters, the excision of ulcers for 
diagnosis and therapy, the exploratory or therapeu- 
tic incision of cysts, the synchronous catheteriza- 
tion of three ureters and the synchronous em- 
ployment of three or more catheters, and the exci- 
sion of portions of a ureteral orifice for the diagno- 
sis of rena! tuberculosis. The technic of operative 
cystoscopy is minutely described by the writer. 

Local Autogenous Temperature Variations, a 
Cause of Labyrinthine Vertigo. — Edmund P. 
Fowler states that sufficient heat or cold applied 
near the static labyrinth will produce vertigo and 
usually nystagmus in definite directions, depending 
upon the position of the head. The degree of ver- 
tigo, nystagmus, etc., varies with the sensitiveness 
of the organ and the amount and kind of tissue be- 
tween the labyrinth and the place where the heat 
or cold is applied. The semicircular canals and 
utricle are protected from extreme temperature va- 



riations by the poor heat conductivity of the tissues 
surrounding the labyrinth, and of the blood and tis- 
sue currents, and with the usual methods of apply- 
ing heat or cold, the temperature reaching the ca- 
nals can be but slightly dift'erent from that already 
surrounding them. The bony walls are only rela- 
tively good conductors of heat and their specific 
heat low, but, being surrounded by poorly conduct- 
ing bone and tissues of high specific heat, they are 
quickly aiTecttd by temperature changes, and such 
variations will persist near the area of application 
for appreciable periods of time. Portions of the 
static labyrinth are near the surface, and localized 
inflammations or congestions or anemias may cause 
variations in temperature which will afifect the flow 
of the endolymph. and, if sufficiently intense, will 
cause vertigo and cither similarly produced phe- 
nomena. 

JOURNAL OF NERVOUS AND MENTAL DISEASE. 

March, nii:. 

A Case of Hypoglossal Nuclei Paralysis. — A. 

M. Moll reports a case which seems to support the 
theory that the hypoglossal nuclei contain cells 
which at least partially enervate the orbicularis oris 
through the seventh pair. The case was apparentl}' 
one of bulbar thrombosis manifesting difticulty in 
eating and swallowing with almost complete par- 
alysis of the tongue. There was no involvement of 
the distribution of the facial nerves except the mus- 
cles about the mouth, which were weak and gave 
electrical reactions of degeneration. There was also 
weakness in the legs, with increased reflexes, show- 
ing involvement of the motor tracts. Improvement 
gradually took place in all of the symptoms. In the 
absence of histological studies the case is, of course, 
not conclusive, but indicates the possibility that some 
of tlie facial fibres may arise in the hypoglossal 
nuclei. 

Occurrence of the Syphilitic Organism in the 
Brain in Paresis. — J. W. Moore has been suc- 
cessful in establishing another link in the chain of 
evidence connecting paresis and syphilis. In post 
mortem examinations of the brains of seventy 
patients with paresis for the organism of syphilis 
the treponema was found in twelve specimens. 
Difficulties in the technic indicate that the organism 
is present in a much larger proportion of the cases. 
Wiether it is present in all, in other words, 
whether paresis is invariably syphilitic, has there- 
fore still to be proved. The most of the organisms 
found in these brains were in the cellular layers of 
the cerebral cortex of the frontal lobe and gyri 
recti. None were seen in the superficial neuroglia 
layer nor the pia, as is the case in cerebrospinal 
syphilis. 

Alrril, 1013. 

The Present Status of the Knowledge of 
Apraxia; with the Study of a Case. — Alfred 
Glascock, in a continued article (March and April) 
considers the evolution, as well as the present status, 
of the agnosias and apraxias, and their relation to 
the aphasic states. To Liepmann is given the credit 
of having clarified the subject, and it is his classifi- 
cation that the author has mainly adopted. By the 
term agnosia is understood a mental inabilitv to 
reco<rTiize objects bv the aid of the senses when 



5« 



LETTERS TO THE EDITOR. 



L^'i^w York 
Medical Journ; 



sensation itself is intact. This ma\ be referred to 
any of the sensory organs, and constitutes tactile, 
visual, or auditory agnosia : it includes, or is closely 
allied to. word blindness, word deafness, and as- 
tereognosis. Apraxia, on the other hand is a motor 
condition or defect of the performance of voluntary 
movements in the absence or independent of motor 
weakness. This not only includes the inability io 
write, but also the inability to handle objects and 
perform movements which previously required but 
little effort. The symptoms of agnosia and apraxia 
are frequently associated in the same case, and, as in 
disturbances of the use of language, the left cerebral 
hemisphere in righthanded individuals is principally 
concerned in their development. An interesting and 
vital point in the theory of leftsided apraxia is the 
fact that it may be caused by a lesion of the corpus 
callosum, or even in the left hemisphere, thus indi- 
cating that the extremities of the left side, in asso- 
ciation with the right cerebrum, is ultimately con- 
trolled by centres in the left cerebrum via the cor- 
pus callosum. Precise localization of the different 
centres concerned in these functions is as yet a mat- 
ter sub jitdicc, and for its consideration the reader 
is referred to the original article. The case reported 
is a careful and detailed study of the clinical mani- 
festations in a patient presenting symptoms of ag- 
nosia and apraxia. 

The Aborted Forms and Preparalytic Stage of 
Acute Poliomyelitis as Observed in the Buffalo 
Epidemic. — Edward Affleck Sharp, in analyzing 
the epidemic of poliomyelitis which occurred in Buf- 
falo during the summer of 191 2, has collected twen- 
ty-nine cases, from a total of 310, which were either 
aborted forms or cases studied during the preparaly- 
tic stage of the disease. The classification is based on 
symptomatology, into abortive, meningeal, ataxic, 
and paralytic types. Almost constant symptoms in 
the preparalytic stage were fever, drowsiness, stiff- 
ness of the neck, and constipation, headache, irrit- 
ability, and twitchings were also generally present. 
The findings in the cerebrospinal fluid were fairly 
constant lymphocytes and increased globulin r - 
action ; conditions not sufficient in themselves to dif- 
ferentiate the condition from tuberculous meningitis 
or the meningeal irritation of acute infectious dis- 
eases of different origin. 

Mirror Writing and Other Associated Move- 
ments Occurring without Palsy. — Charles \\ . 
Burr and C. B. Crow describe the case of a man of 
twentv-seven years who was congenitally unable to 
individualize the movements of his two hands : ex- 
cept for very simple movements the two hands 
moved symetrically. with the result tliat when he 
wrote with a pencil in each hand, the left pri'duced 
"mirror writing." In the absence of any evidence 
of a lesion, the hypothetical explanation is advanced 
that there was a congenital lack of development of 
certain association pathways or centres in the brain. 

Cerebellar Tumor Glioma ; Operation : Re- 
covery. — Max Mailhouse and William F. X'erdi 
present the report of a remarkable case of cerebellar 
tumor occurring in a girl of fifteen years, and its re- 
moval by two stage operation. Location was difti- 
cult on account of the bilateral invasion. In spite 
of the size of the tumor (weight. 107 grammes: di- 



mensions, 7.5 x 6.8 x 4.7 cm. ) it was successfully re- 
moved one year after a primary decompression, and 
eight months later the patient had to a large extent 
regained motor coordinations. 

Experimental Studies on the Nervous Mechan- 
ism in the Production of Hyperplasia. — W alter 
limnie re]X)rls some experimental operations upon 
cats in which the pneumogastric nerves were ligated 
in the thorax below the esophageal plexus. ( )f nine 
animals operated on, five lived ; they also gained 
in weight, but were sluggish. They were killed at 
from III to 140 days after operation, and five or 
six hours after a full meal, and control animals 
were killed under similar conditions. In the control 
animals digestion was well advanced, while the 
stomach contents in the experimental animals were 
but slightly digested and almost dry. On the other 
hand, the capacity of the stomach was greater, and 
the stomach wall much thicker, in each of the ex- 
perimental rmimals than in the controls. In par- 
ticular, the mucosa was thrown into heavy folds, and 
a microscopical examination revealed an abnormal 
number of gastric glands, as compared with the 
controls. The hypothesis is advanced that nervous 
impulses are dependent upon electric circuits 
through the nerves, and that ligation of the vagi di- 
minished the currents through them, at the same 
time tending to increase those to the stomach via 
the sympathetics. The result of this condition might 
he to stimulate the trophic influences, and to inhibit 
the functional activity (secretion and motility) of 
the stomach. 



f ettm t0 \\t (giitor. 



THERMOSTABILE TOXIXES IN URETHRAL AND 

BLADDER INFECTIONS. 

233 Lexington Avenue, 
New York City, June 24, 1913. 

To' the Editor: 

In tho June 21, 1913. issue of the New York Medic.\l 
JouRX.M.. in an article entitled "Use of Thermostabile 
Toxines in Urethral and Bladder Infections." Dr. Frank 
S. Crockett states that the bactericidal activity of the 
blood "is accomplished by a new process, a short cut." 
Further on he states: "The first use of my toxines were 
carried out, etc.'' In the spring of 1912. D. J. Mangan. 
D. V. S., made a series of autotherapeutic tests on inany 
animals by heating the exudate of disease, filtering it 
through some coarse material, such as several thicknesses 
of cheesecloth or gauze, to remove heavier particles, and 
then injecting the filtrate hypodermically. He published 
his result;, in the American Veterinary Re?-iezi.i, July, 1912, 
under the title : "Autotherapy." This article was repub- 
lished in the London J'eteriiiary Journal for October. 
1912, and was referred to by me in my article on "Auto- 
therapy" in the December 21. 1912, issue of your Jovrn.\l. 
There I stated : "The writer is making many tests of 
treating rheumatism and kindred diseases by using the 
patient's own morning urine, he believes successfully." 
Since then I have received reports from physicians who 
had filtered the discharge of disease with filter paper, and 
injected the filtrate. One of these reported bad abscess 
formation. 

I would respectfully refer Doctor Crockett to the 
Croonian Lectures on "The Pathology of Immunity." by 
Dr. Leonard Dudgeon (Laneet, June 15, 22, 29; July 6. 
1912). Doctor Dudgeon made many tests upon animals 
by centrifugation and pipeting the top fluid before injec- 
tion. He did not assert that it was a ''new process" As- 
suming that it is a "new process." is it a "short cut" or 



HOOK RiiriJiirs 



59 



simpler to centrifugalizc, Iicat, ami filter, than just to 
lilter through porcelain? 

This is neither a "new process" nor a "short cut.' Con- 
tinuing, Doctor Crockett says : "The first use of my 
to.xines was carried out, etc." This is not the "first use" 
of these toxines. nor are the toxincs his. Doctor Crockett 
appears to be alive to the very grave danger attending the 
injection of living pathogenic microorganisms into the 
tissues, for he says: "It is open to the objection that the 
infecting organism might be carried through the blood 
stream with the resultant localization of the disease at 
some other part of the body.'' Mangan emphatically 
states: "This method is unreliable unless great care is 
exercised in its preparation. If it receives too much heat 
it is useless, and if too little heat it is dangerous. Possibly 
a water bath for two hours at a temperature of 60° C. 
may be a good way to prepare the pus for injection. The 
filtering method is according to Duncan and is the meth- 
od I suggest to be adopted," 

Doctor Crockett says: "Using Duncan's theory as a 
working basis," It would appear that he is using and 
appropriating it, for there is nothing new about the method 
he describes, not even the advantages enumerated at the 
close of his paper, since these are mentioned in my article 
in the New York Medic.\l Journ.vl for December 12 and 
at. iqiJ. Ch.\ri.f.s H. Dintw-. M D. 



f oolt |lcl)ifH)s. 



[IVe publish full lists of books received, but we acknowl- 
edge no obligation to review them all. Nevertheless, so 
far as space permits, we review those in which we think 
our readers are likely to be interested.] 

Health Resorts of the British Islands. Edited by Neville 
Wood, M. D., Member of the Council of the Section in 
Balneolog},- and Climatology of the Royal Society of 
Medicine, \\'ith the Assistance of an Advisory Com- 
mittee .\ppointed by the Council of the Section, With 
Forty Illustrations and Three Maps, London: Univer- 
sity of London Press ; Published for the University of 
London Press by Hodder & Stoughton, 1912, Pp, xii- 
253- 
This reference book to the health resorts of the British 
Islands is excellently gotten up, and well arranged. Thus, 
it is really a handy book which carries out what the title 
promises. It gives all the information a physician could 
desire : Location, climate, indications, attractions in the 
way of recreation, etc, and also the chemical analysis and 
physiological action of the various waters, with mode of 
employment and therapeutic action, indication, and con- 
traindications. The addendum with maps and index con- 
cludes a very useful book. 

Chinirgie generate et chirurgie orthopedique drs mcmbres. 
Par PI. M.^UCL.'MRE, professeur agrege a la faculte de 
medecine, chirurgier de la charite. Avec 317 figures 
dans le texte, Nouveau traite de chirurgie, public en 
fascicules sous la direction de A. Le Dentu et Pierre 
Delbet, XXXIIL Paris: J, B, Bailliere et fils, 1913. 
Pp. 542. 
The thirty-third volume of this new and important treatise 
on surgery by French authors is devoted to the subject of 
surgical injuries, deformities, and diseases of the ex- 
tremities. It includes those of general surgical and ortho- 
pedic interest. The subjects treated are traumatism, in- 
fections, tumors, and congenital and acquired deformities 
of the upper and lower extremity. This combining of gen- 
eral and orthopedic surgery has a distinct advantage, and 
emphasizes the fact that both the general surgeon and 
the orthopedic specialist should be familiar w-ith the sub- 
ject so arbitrarily divided between them by the pre\^uling 
practice of the day. The subjects are treated in minute 
detail and the author demonstrates a knowledge that could 
only have been gained by long experience at the bedside 
and in the operating room. There are more than .^,00 il- 
lustrations, most of them original, including many radio- 
graphs or outlines of x ray plates. At the end of the 
various chapters a very complete bibliography is given, so 



that the reader can find more detailed descriptions in vari- 
ous monographs and special treatises. The book is thor- 
oughly abreast of the times and represents not only the 
author's practical work in this field but also the results 
of years of research along special line. The work deserves 
a cordial reception not only among general and orthopedic 
surgeons but also among general practitioners, who should 
be familiar with the main aspects of this very practical 
field of surgerv. The present volume is fully up to the 
high standard of the preceding thirty-two numbers of this 
great I'rench work on surgery. 

Medical Supervision in Schools. Being an Account of the 
Systems at Work in Great Britain. Canada, the United 
States. Germanv. and Switzerland, By Edw.^rd Mill.\r 
Steven, M, R,,' Ch, M., Royal Commissioner of South 
Australia 1909, London: Bailliere, Tindall, & Cox, 1910. 
Pp. 268, 
The author has acquired a great deal of valuable informa- 
tion in his official position as commissioner appointed by 
the government of South .Australia to investigate the 
methods of medical supervision in schools in Great 
Britain. Canada, the United States. Germany, and Switzer- 
land. The impressions received during his extended tour 
Mr. Steven has carefully noted, and we have thus a val- 
uable work w^hich brings out the methods adopted in the 
five countries visited, making comparison very easy. The 
hook is certainly very instructive. 

I'adcmekum der Geburtshilfe und Gvniikologie. Fiir 
Studierende und Aerzte. Von Prof. Dr. A, Duhrssen, 
in Berlin. 2 Telle. I, Geburtshilfliches Vademekum, 
11, Gynakologisches Vademekum. Berlin: S. Karger, 
1913, Mit 43 Abbildungen. Zehnte, verbesserte und 
vermehrte Auflage. Pp. xii-308. 
This excellent compendium deserves to have seen ten edi- 
tions in twelve years. It helps to introduce the student 
to the subject of obstetrics and gynecology, and assists 
him to memorizing certain essential points in this branch 
of medicine. The size of the book makes it also very 
easy to carry and to refer to. 

School Hygiene. By Fletcher B. Dresslar. Ph, D., Spe- 
cialist in School Hygiene and School Sanitation. United 
States Bureau of Education. New York: The Macmil- 
lan Company, 1913. Pp. xi-369. (Price, $1.25.) 
The author has succeeded in setting forth in a simple 
and untechnical way some of the hygienic requirements of 
school life, together with suggestions as to how such re- 
quirement may be put in practice. He has selected the 
most important topics, and discusses these more for the 
benefit of the busy teacher than for that of the specialist 
in school hygiene. But not only the teacher will receiye 
new and fresh ideas, the physician and even specialist will 
obtain irstructions and valuable advice. The book shows 
that its cuthor is thoroughly conversant with the subject 
of which he treats. 

Die Storungcn des rcrdauiingsapparates als I'rsaclic und 
Folge anderer Erkrankungen. Von Dr. H.\xs Herz, 
in Breslau. Zweite, umgearbeitcte und vermehrte 
Auflage. II, Teil : Die akuten Infektionskrankheiten 
in ihren Beziehungen zum Verdauungsapparat. Berlin : 
S, Karger, 1913, Pp. 219-449. 
This publication deals at some length with the relationship 
between the digestive system and the acute infectious 
fevers. The first portion discusses the etiological impor- 
tance of the digestive system. Lender this heading are 
considered the changes in the intestinal flora, the decrease 
in the resisting power of the tissues, the simultaneous 
occurrence of digestive disturbances and invasions by for- 
eign organisms, and the changes of temperature that are 
brought about by diseases of the digestive tract. The sec- 
ond part, which is the longer, gives a very good presenta- 
tion of the symptoms in acute infectious diseases that 
arise from gastrointestinal disturbances. The different 
portions of the alimentary tract are dealt with individual- 
ly, and, in addition, are included the liver, pancreas, 
spleen, and peritoneum. The author, among other things, 
calls attention to the valuable information that may be ob- 
tained from a careful examination of the stools. In the 
pages of this book there is to be found much that is 
useful. 



6o 



OFFICIAL XEIFS.— BIRTHS, MARRIAGES, AND DEATHS. 



INf.w Yokk 
Mruical Journal. 



mml iJtos, 



United States Public Health Service: 

Official list of changes in the stutions and duties of offi- 
cers serving in the United States Public Health Serz^ice 
for the sez'en days ending June 2$, J(>JS: 

Francis, E., Surgeon. Granted six months" leave of 
absence, without pay, from July I, 1913. Frost, W. H., 
Passed Assistant Surgeon. Directed to proceed to 
Philadelphia, Pa., for conference with the Director of 
Health, relative to certain typhoid conditions in that 
city. HoUman, H. T., Acting Assistant Surgeon. 
Granted thirty days' leave of absence from June 18. 
1913. Knight, C. P., Assistant Surgeon. Granted one 
month'5 leave of absence from June 27, 1915. Kuhn, 
C. F., Acting Assistant Surgeon. Granted six months' 
leave ot absence, without pay, from July 4, 1913. 
McLaughlin, A. J., Surgeon. Granted six months' 
leave, without pay, from July i, 1913. Markoe, W. W., 
Acting Assistant Surgeon. Granted sixty days' leave 
of absence from July i, 1913. Naulty, C. W., Jr., Act- 
ing Assistant Surgeon. Granted thirty days' leave of 
absence from July I, 1913. Porter, J. Y., Quarantine 
Inspector. Directed to proceed to Tampa Bay Quar- 
antine Station to investigate cause of fire, repairs and 
equipment needed, and to fix responsibility. Steven- 
son, J. W., Acting Assistant Surgeon. Granted three 
months' leave of absence, without pay, from June 16, 
1913. Withrow, M. R., Acting Assistant Surgeon 
Granted thirty days 'leave of absence, without pay, 
from June 16, 1913. 

Army Intelligence: 

Official list of changes in the stations and duties of offi- 
cers serving in the Medical Corps of the United States 
Army for the meek ending June 38, 1913: 

Coe, Henry C., First Lieutenant, Medical Reserve 
Corps. Ordered to active duty for the period from 
June 28 to July 6, 1913, for service at the encampment 
at Gettysburg, Pa., and upon completion of this duty, 
will stand relieved from active duty in the Medical 
Reserve Corps. Davis, \\'illiam T., Captain. Granted 
leave of absence for four months, with permission to 
go beyond the sea, effective on or about July I. 1913. 
Ducher, B. H., Major. Relieved from duty at Fort 
Sam Houston, Texas, about July i, 1913, and" will pro- 
ceed to San Juan, P. R., for diit. Gilchrist, Harry L., 
Major. Will proceed at the proper time to Columbus. 
Ohio, for the purpose of observing the camp of in- 
struction of sanitary troops of the organized militia to 
be held at that place June 22 to 29, 1913, and upon 
completion of this duty will return to his proper sta- 
tion. Lyster, William J. L., Major. Relieved from 
duty at Fort Oglethorpe, Ga., to take eflfect about July 
I. 1913, and will then proceed to the Army Medical 
School, \\'ashington, D. C, for duty as professor of 
military hygiene. Peck, Luke E., First Lieutenant, 
Medical Reserve Corps. Upon arrival in the United 
States will proceed to Fort Aloade, South IDakota, for 
duty. Shields, William S., Captain. Relieved from 
duty at Columbus Barracks. Ohio, and assigned to 
Fort Omaha, Neb. Will proceed to Texas City, Texas, 
for duty with the Second Division. 

The following officers of the Medical Reserve Corps 
have been ordered to active duty for the encampment at 
Gettysburg, Pa., June 28 to July 10, 1913, and on the com- 
pletion of this duty to return to their homes : First Lieu- 
tenants W. S. Cornell. George C. Kiefifer. Walter E. Lee, 
George C Beach, Jr., William S. Magill, Meyer M. Eckert, 
William E. Fitch, Howard tiume, Joseph V, Klauder, 
Charles B. J. Mittelstaedt. Raymond W. Wilcox. S. Mere- 
dith Strong. George S. Crampton. Arthur R. Jarrett. 
Navy Intelligence: 

Official list of changes in the stations and duties of offi- 
cers serving in the Medical Department of the United 
States Navy for the week ending June 28, IQI3: 

Butts, Heber, Passed Assistant Surgeon. Detached 
from the Naval Hospital, Canacao, P. I., and ordered 
to the El Cano. Camerer, C. B.. .\ssistant Surgeon. 
Detached from the Denver and ordered to the South 
Dakota. Melhorn. K. C, Passed .Assistant Surgeon. 



Detached from the South Dakota and ordered to the 
Denver. Smith, il. L., Passed Assistant Surgeon. De- 
tached from the Chester and ordered to the Des Moines. 



lW|s, llarriagw, anii gratis. 



Married. 

Connor — McAlduff. — In Boston, Mass., on Wednes- 
day, June i8th, Dr. George A. Connor and Miss Mabel 
F. Mc.Vlduff. Davis — Geesey. — In .\tlantic City, N. J., on 
Monday, June 23d, Dr. Bryon G. Davis and Miss Na- 
omi L. Geesey. Hammond — Lawson. — In Cambridge, 
Mass., on Wednesday, June 25th, Dr. William P. Ham- 
mond and Miss Sally J. Lawson. Hauss — Couzcs. — 
In Cincinnati, Ohio, on Wednesday, June iSth, Dr. Au- 
gustus P. Hauss, Sr., of New Albany, Ky., and Miss 
Rosetta V. K. Couzens. Hedblom — Pease. — In George- 
town, Colo., on Saturday. June 21st, Dr. Carl A. Hed- 
blom. of Boston, and Miss Ellenor Pease. Hurley — 
Walsh. — In Dorchester, Mass., on Wednesday, June 25th. 
Dr. Edward D. Hurley, of Boston, and Miss Isabel Bish- 
op Walsh. Jackson — Craig. — In Philadelphia, on Sunday. 
June 22nd. Dr. James .\llen Jackson and Miss Hazel 
M. Craig. Jones — Musgrove. — In Philadelphia, on Tues- 
day, June 17th, Dr. Frederick Jones, of Camden, N. J., 
and Miss Nora Musgrove. Smith — Lander. — In Cleve- 
land, Ohio, on Wednesday. Tune i8th Dr. E. Frederick 
Smith, of Lorain, and Miss -\lice M. Lander. Smyth — 
Kennedy. — In Haverhill, Mass., on Wednesday, June 
25th, Dr. P. Somers Smyth, of Boston, and Miss Irene 
L. Kennedy. Vietor — Woodward. — In Le Roy, N. Y., 
on Saturday, June 28th. Dr. John A. Vietor, of Brook- 
lyn, and Miss Eleanor Woodward. Vinup — Murchison. — 
In Westminster, Md.. on Saturday, June 14th. Dr. 
Frederick H. Vinup, of Baltimore, and Miss Marie 
Belle Murchison. Wiggins — Mollison. — In Brooklyn. 
N. Y., on Saturday, June 14th, Dr. Theodore C. Wig- 
gins and Mrs. V. Beulah Mollison. Young — Wales. — In 
Dorchester, Mass., on Tuesdaj', June 24th, Dr. Edward 
Lorraine Young, Jr., of Boston, and Miss Charlotte 
Elizabeth Wales. 

Died. 

Banfield. — In Worcester, Mass., on Wednesday, June 
25th, Dr. Francis L. Banfield, aged sixty-nine years. 
Buntitig. — In Kingston, N. Y.. on Tuesday. June 24th, 
Dr. J. M. Bunting, aged thirty years. Campbell. — In 
Boston, on Wednesday, June i8th, Dr. Matthew Philip 
Campbell, of Provincetown, aged thirty-seven years. 
Carter. — In Woodstock, Va., on Thursday, June 19th, 
Dr. Durus Desmus Carter, aged sixty-five years. 
Clowminzer. — In Brooklyn, N. Y., on Saturday. June 
2ist. Dr. William Henry Clowminzer, aged forty-six 
years. Davis — In Louisville, Ky., on Friday. June 
20th, Dr. Vincent Davis, aged seventy years. Devil- 
biss. — In Creagerstown. Pa., on Monday, June i6th. 
Dr. J. W. Devilbiss, aged si.xty-one years. Farrow. — 
In Peapack, N. J., on Saturday, June 21st, Dr. Edwin 
F. Farrow, aged fifty-one years. Gorman. — In New 
York, or Friday, June 27th, Dr. George J. Gorman, 
aged fifty-nine years. Hoyt. — In Chillicothe. O., on 
Friday, June 20th. Dr. Charles Hoyt, aged fifty-nine 
years. Jones. — In Williamsburgh. Iowa, on Thursday, 
June 19th, Dr. J. E. Jones, of De Soto, Mo., aged sixty- 
seven years. Lamborn. — In Saskatchewan, Canada, on 
Tuesday, June 17th, Dr. William H. Lamborn, of 
Highland Park. 111. Lever. — In Flushing, N. Y., on 
Tuesday, June 24th, Dr. John Howard Lever, aged six- 
ty-six years. Linn. — In Pittsburgh, Pa., on Saturday, 
June 2ist, Dr. James Madison Linn, aged forty-two 
years. Morgan. — In West Orange, N. J., on Friday, 
June 20th, Dr. John Howard Morgan, of Westerly, R. I., 
aged sixty-eight years. Shipley. — In Alpha, Md., on 
Friday, June 13th, Dr. Benjamin F. Shipley, aged six- 
ty-four years. Watt. — In Dunkirk. N. Y., on 'Tuesday, 
June 24th, Dr. James L. Watt. White. — In Grand Rap- 
ids, Mich., on Sunday. June 13th. Dr. W^illiam Hallock 
White, aged fifty-six years. Worthington. — In Tren- 
ton, N. J., on Thursday. June 19th, Dr. Anthonv' H. 
Worthington, aged seventy-six years. Young. — In 
Salisbury, N. C, on W'ednesday, June 18th, Dr. Rob- 
ert S. 'V oung, aged fifty years. 



New York Medical Journal 

INCORPORATING THE 

Philadelphia Medical Journal rt Medical News 

A Weekly Review of Medicine, Established 1843. 



\o[.. XCXIII. X<). 



NEW YORK, JULY 12, 1913. 



Whole Xo. 1806. 



(<Bnginal Communirations. 



L( iXCKN ITV AND REJUXEXESCMXCF..* 

Bv I. L. Xascher, xM. D., 

New York, 

I'rofessor of Geriatrics. College of Physician^ and Surgeons, Boston 

Single celled organisms like the amebic possess 
potential immortality. W'hen, however, two or 
more cells of different varieties combine to form a 
complex organism their diverse activities, reacting 
upon each other, disturb their mode of existence, 
sooner or later causing the death of the cells and 
the consequent death of the organism. So uniform 
is this procedure that like organisms have a like life 
history and a like duration of existence. If in addi- 
tion to this fact we accept the theory of tissue cell 
evolution, that the cells of the tissues pass through 
evolutionary stages, that at one stage they are best 
suited to their environment and available nutri- 
tion, and the tissue which they form is then in 
its most perfect state, that succeeding generations 
of cells become gradually less and less fitted for 
their environment and nutrition and reproduce 
fewer and still more imperfect cells, we can form 
u basic conception of senescence and death. 

Various formulas have been devised to estimate 
the normal duration of life in the animal kingdom, 
but none has a universal application or will apply 
to the human being. Buffon"s formula, seven 
times the period required to attain growth, would 
make the normal duration of life of man over 200 
years. Flouron's formula, five times the period re- 
quired for the consolidation of tlie shafts and 
epiphvses of long bones would place the normal 
duration between 75 and 125 years. Flouron 
divides life into two periods, development and de- 
cline.^ 

A more rational estimate of the duration of life 
is based upon the duration of the periods of de- 
velopment, maturity, and decline, since these in man 
are or should be fairly equal in length, and each 
is broken about the middle by a critical period or 
climacteric. A\"hile growth in height ceases about 
the twenty-first year, the body continues to grow in 
other dimensions, and the organs continue to increa^^e 
in size and in functional activity until about the 
thirtieth vear. About this time the brain is heaviest 
and fills the skull, the lungs have their greatest 
respiratory capacity, and the heart has reached its 

•Read before the Medical -Association of the Greater City oi 
New York, lune 2. 191 3. 

"Owing to the scope of the subject and the limited time I have 
been obliged to omit many statistics. e.Nplanations. and qualifica- 
tions of statements that may anpear dogmatic. 



limit of normal growth. The bones are larger at 
thirty than at twenty-one, and we need a larger hat, 
larger shoes and gloves, and a larger suit of clothes 
at thirty. Any further increase afterward will be 
due to fat accumulation and not to bone growth. 
The vertebrae are larger at thirty, but, as I ha\e 
explained in a former paper, when the body is erect 
the downward pressure upon the intervertebral 
disks, which are of uneven thickness, forces the 
spinal column into curves. As the pressure is 
greatest where the disks are thinnest, anteriorly in 
the dorsal region and posteriorly in the cervical 
and lumbar regions, the opposite side of these disks 
are relatively expanded, and we have, in conse- 
(|uence. the posterior curve in the dorsal region and 
the anterior curves in the cervical and lumbar 
regions. The body is longer on arising than on re- 
tiring, and there is an actual increase in length dur- 
ing a lingering illness which confines the patient 
to bed. This is due to the expansion of the inter- 
vertebral disks, when freed from the downward 
pressure. 

The normal duration of the period of develop- 
ment is about thirty years, and this period is broken 
about the middle by the climacteric which we call 
puberty. 

The brain begins to diminish in size soon after 
the thirtieth year, and about the same time the lungs 
diminish in capacity and functional activity, evi- 
denced bv a diminution in elimination of carbon 
dioxide, while the heart begins to hypertrophy. 
These changes are a departure from the state of 
jierfect development, and this justifies Flouron's 
division of life into development and decline. But 
for about three decades after development is com- 
pleted there is stable metabolic activity , the catabolic 
and anabolic processes counterbalancing each other, 
and the harmonious relations between organs and 
between functions are niaintained. This period of 
.stable metabolic activity is maturity, or middle age, 
and is broken about the middle by the menopause in 
the female and the male climacteric in the male. 
The male critical period is not as marked as the 
menopause, and usually occurs later. 

The individual who has been able to avoid the 
many incidental factors that contribute to and 
hasten senescence will not present subjective or 
objective manifestations of a.geing before the end 
of the '^ixth or be.ginning of the seventh decade of 
life. The early subjective manifestations are 
usually aches and pains in joints (which the in- 
dividual ascribes to rheumatism, but which are 
really due to arteriosclerosis), more rapid faticjue 
and a longer time required to recuperate, lessened 



Copyright, iqi,^, by .A. R K'iiolt Publishing Companv 



62 



NASClJliR: LOKGPJTIY AND REJLTEXESCP.XCE. 



sexual virility, weakened memory, names of 
familiar persons and dates of familiar events beinj 
first forgotten ; and one accustomed to mental 
labors notices that words and ideas do not come as 
readily as before, and whereas he may have bsen 
able to write or do other mental work for hours. 
he must now take frequent rests and divert his 
thoughts into other channels ; otherwise his mind 
becomes confused. A lessened interest in the 
events of the day and the tendency to fall asleep 
at the sermon or lecture are both objective and sub- 
jective manifestations. The ageing individual may 
find that he needs glasses, that his hearing is not 
as acute as formerly, that he is becoming hab tually 
constipated, gets out of breath when going upstairs, 
that he cannot stand the cold and that the cold 
shower gives him a shock from which he does not 
react as quickly as before. The objective mani- 
festations hardly need description. The attitude of 
the senile stoop or slouch, the folds and wrinkles 
in the darkened, weather beaten skin, the gray and 
thinning hair, arcus senilis, contracted pupils, tor- 
tuous arteries and enfeebled prominent filled veins, 
the apathetic expression and generally sluggish 
mentality, and bodily movements are all interpreted 
by layman and physician alike. It is ageing, or the 
period of decline. There are numerous factors 
which hasten or cut short this period, but where 
these can be avoided the period of decline will last 
about as long as the preceding periods, and it will 
be broken about the middle by a critical period 
which I have described as the senile climacteric. 
This would make the normal duration of life about 
ninety years, divided into three equal periods, de- 
velopment, maturity, and decline ; each broken by 
a climacteric. 

The tendency to complete the normal cycle of life 
is inherent. The child born healthy possesses a 
potential force of vitality which should carry it 
through the ]ieriods of development, maturity, an 1 
decline to physiological death. Few complete the 
normal cycle, but an analysis of the causes of death 
in those who do not will reveal in almost every case 
some avoidable cause ; either exposure, improper 
food, improper mode of life, including mental 
strain, insufficient sleep, etc., or else accident. It 
has been said that there never was an accident 
which might not have been prevented by foresight 
and prudence. The same may be said of diseases. 

I will not burden you with a mass of statistics 
Most of our statistics concerning longevity are 
based upon census figures which, Prinzing says. 
are very untrustworthy. More trustworthy are fig- 
ures dealing with the causes of death, though 
wrong diagnoses and improper classification where 
complications existed lea\e a wide margin for 
error." Better methods of treating diphtheria, 
tuberculosis, and other diseases of the period of de- 
velopment, and a better knowledge of sanitation 
have reduced the death rate up to the age of thirty, 
forty-seven per cent, between 1880 and 1910. The 
enormous increase in deaths due to diseases of the 
heart, kidneys, and circulatory system and indus- 
trial diseases, during the period of maturity, has 
almost wiped out the advantages gained during the 

-1 desire to express my thinks to the statisrical bureau of the 
Metropolitan Life Insurance Company for statistics and other mat- 
ters furnished me for the preparation of this paper. 



period of development. According to the 1910 re- 
port of the field secretary of the Provident Life 
Assurance Society of England, the death rate from 
diseases of the heart, kidneys, and circulatory sys- 
tem, including apoplexy, has increased 105 per cent, 
in the I'nited .States since 1880, while in England 
the increase in deaths from these diseases during 
this period was only three per cent. 

That this enormous increase in deaths from dis- 
eases of the heart, kidneys, and circulatory system 
is due to what is usually called the strenuous life, 
is unquestioned. In a paper on The Strenuous 
Life, which appeared in the Medical Record in 
October, 191 1, I endeavored to show that, as a 
result of this intense and excessive activity, the in- 
dividual is deteriorating mentally and physically 
and his mode of life tends to shorten his years. 
Prinzing has shown that in Germany industrial ac- 
tivity and city life have an unfavorable influence 
upon the duration of life, notwithstanding the more 
sanitary conditions in the cities, and the same will 
probably hold good for the United States. Accord- 
ing to H. Josse Johnson,^ the factors that tend to 
longevity are: i. Heredity, 2, climate, 3, sur- 
roundings, as occupation, housing, education, etc., 
4, average height and weight, 5, chest develop- 
ment and capacity, 6, proportion, i. e., distribution 
of weight. The last three factors may he omitted 
from further consideration, as they are not univer- 
sally applicable. The extremes of height and 
weight are rarely found, the chest development can 
be increased ; yet Johnson doubts the advantage of 
the military chest from an insurance standpoint, 
and improper distribution of weight is itself patho- 
logical. His conclusions concerning climate, that 
the increase of mortality is greater as the heat in- 
creases, and, consequently, less conducive to long- 
evity, is not borne out by statistics, for in Europe 
Bulgaria has the largest proportion of persons over 
eighty-five, while Germany and Finland have the 
smallest proportion. 

Heredity is undoubtedly the determining factor 
in longevity, but I cannot endorse the statement 
often made that there is a racial tendencv toward 
longevit}-. In support of this statement the long- 
evity of the Jews is often pointed out. This holds 
good only so long as they adhere to their religio- 
sanitary laws. When they depart from these laws 
they are subject to diseases which rarely attack the 
strict adherent. to the ^Mosaic sanitary code. One 
of the most important of these laws is that re'ating 
to kosher meat. The meat must be used within 
three days after the animal is slaughtered, the 
hind quarters are rejected, the bloodvessels are 
taken out, and if any carcass is found diseased it 
cannot be used. There are numerous other laws 
of a similar nature which have for their purpose 
the prevention of the introduction of food in process 
of decomposition. There is probably no one factor 
nxire potent in causing early arteriosclerosis, and 
consequent precocious senility, than the introdrcticn 
of food which rapidly decomposes in the stomach 
and intestines, as cold storage foods do. The Jew 
who departs from the strict kosher dietarj- may 
still possess the inherited influence of hereditary 
longevity, but one or two generations will suffice to 



'See Transactwns of the Life 
'latiou, London. 1910. 



auce Medical Officers' Asso- 



N.tSCH/iK: LOXChi II V .-l.\0 KFJCrEXESCllXCE. 



63 



(lostruy tliis inriuencc under the more inimedia.e 
intliieiice of iniproiier t'uoil ami improper liviiv^. We 
must remember tliat i^ood lieredily implies healthy 
parents, and healthy jiarents will heget healthy 
children. Such parents do not transmit any special 
quality to i^roduce longevity. As 1 said before, the 
tendency to complete tlie normal cycle of life is in- 
licrent m every livinjj creature. This tendency is 
weakened by inherited disease or predisposition to 
disease. Environment, including mode of life, is 
the immediate fattor in determining the lengh of 
life of the individual, yet persons have grown old 
under most insanitary conditions, having evidently 
acquired ;: tolerance 'o such conditions. Whn the 
crusade for fresh air and open bedroom windows 
began, many persons who were accustomed to sleep 
in close, windowless bedrooms became afthcted 
with laryngeal and bronchial troubles when they 
first attempted to sleep with open windows. A 
change in diet, sleeping hours, even in dress, may 
have unfavorable results, though such change be 
in itself more healthful. There is no law ap- 
plicable to idiosyncrasy, and what will injure one 
may l>e harmless or beneficial to another : and we 
must be content with a few generalities regarding 
the effect of environment upon longevity. More 
women reach old age than men. but this is probably 
due to their more protected lives and less exposure 
to the stress, strains, and casualties of industrial 
life. Where women are exposed to these to the 
same extent as men, as happens in Servia and Bul- 
garia, fewer women reach old age. In a recent 
article in the Medical Record, A. H. Stewart as- 
cribes their greater tenacity of life in the United 
States to a constitutional difference. Most persons 
who have reached old age were sparse eaters and 
led outdoor lives. Most old men were smokers and 
drank alcoholic liquors. Most old persons came 
from agricultural districts and were married, and 
nearly all were actively engaged in their labors 
until shortly before death. On the other hand, 
those who retire from active business early soon 
go into rapid decline. Insufficient sleep prevents 
complete repair and hastens degenerative changes, 
and the same applies to irregular hours, irregular 
meals, and irregular means of livelihood. Mental 
stimulus in work and recreation prevents mental 
depression, with consequent inaction and slowed 
circulation. This slowed circulation causes im- 
paired nutrition of the organs and their degenera- 
tion. 

Numerous theories have been advanced to ac- 
count for the process of senescence. While there 
is undoubtedly a determining cause, it is probabL- 
that many factors are involved and that most of the 
supposed causes which form the basis of the 
theories advanced are incidental or essential aids 
to the determining cause. Which of the many 
causes is the determining one is uncertain : possi- 
bly there are several which must act together, or 
different causes may act in different cases. I will 
mention briefly some of the theories. The old 
inechavical theory of wear and tear has been dis- 
carded, as organs and tissues undergo the same 
senile changes whether excessively or rarely 
employed. This is seen in the brains of the 
idiot and the sage and in the uterus of the 



virgin and the nuiltigravid woman. Thomas 
liistomechaiiical theory. < )wing to the unceas- 
ing activity of the bloodvessels, the constant 
stretching and relaxation of the muscular fibres 
of the media cause a loss of their tonicity and dila- 
tation of the walls of the vessels, with consequent 
slowing of the current.* Demange's histopatliolo- 
hgictd theory. Owing to the ceaseless activity of 
the vasa vasorum the\- become irritated and finally 
inflamed, their calibre is diminished, and an insuffi- 
cient blood supply is furnished to the larger ve-sels. 
Durand Fardel's 7ital theory. The purpose of the 
organism is to reproduce its kind, and it has an 
opportunity to do so during the period of sexual 
virility. When that period has expired, further 
metalx>lic activity is in the direction of destruction 
of tissue. Naunyn's deficient heat regulation 
theory. That the heat regulating centres become 
weakened, muscle activity is lessened, less blood 
is required to repair the diminished waste, the cir- 
culation is weakened, and organs and tissues do 
not receive sufficient blood for their nutrition. 
Metchnikoff's to.vine theory. That the products of 
intestinal decomposition are absorbed, and carried 
in the blood they act as irritants to the lining mem- 
brane of the vessels, causing endarteritis and subse- 
quent arteriosclerosis. Horsley's thyroid gland 
theory. That the thyroid gland becomes weakened 
in its functional activity and metabolism is dis- 
turbed. Lorand's glandular theory is similar to 
Horsley's theory, but he includes the thyroid, supra- 
renal, and pituitary glands. He ascribes ageing to a 
slowing of the processes of oxidation, defective 
activity of organs which should destroy and elimi- 
nate waste, and conse(|uent autointoxication from 
such toxic material, and hyperplasia of connective 
tissue. Canstatt's cell theory. That the cells of the 
body have a limited duration and when they die 
the tissue dies. Minot's cell theory. That there is 
a gradual increase in the protoplasm of the cell, its 
activity being thereby altered. Tissue cell ez'olution 
theory. This has been mentioned in the course of 
this paper. Pneumokoniosis theory. That the con- 
stant inhalation of dust diminishes the aerating sur- 
face of the lungs, causes impaired aeration of the 
blood, diminishing its capacity for carrying nutri- 
tion to tissues and carrying away waste material. 
Defective metabolism theory. It holds that with 
advancing age there is instability in the character 
of the blood with gradually increasing amounts of 
urea and calcium and diminution in other salts, 
due to disturbed metabolisn-i and elimination. This 
theory accovmts for the increased viscosity of the 
blood, and the consequent impairment of the cir- 
culation, causing deficient nutrition of the tissues. 
The excessive calcium is deposited in abnomia! 
situations, in bone, causing calcification with the 
greater tendency to fracture, in cartilage, aiding in 
ossification, in arteries, causing arteriosclerosis, in 
joints, causing tophi, etc. 

This theory would bear out the theory of tissue 
cell evolution if it could be shown that the late cells 

'The progress of the senile changes following slowed current 
and dilated relaxed vessels can be readily understood. There is a 
compensatory fibrosis in the vessel, increased activity of the heart 
to compensate for the diminished elasticity of the vessel, dimin- 
ished blood supply beyond the seat of the arteriofibrosis, and con- 
sequent impaired nutrition of the tissues resulting in their degen- 
eration. 



64 



NASCHllK: LOXGlirify AXD kEJVVENESCEKCE. 



have a greater affinity tor lime tlian earlier cells. 
The retention of lime in excess is the first step in 
senescence. If we examine carefully the causes 
upon which these theories are .based we will find 
that most of them can be controlled to some extent. 
Autointoxication, upon which Aletchinkoff's theory 
is based, is partly controlled by the measures he has 
advocated, proper food and the lactic acid bacilli. 
Any cause which produces increased heart action 
and consequent hypertrophy will increase vascular 
activity, with more rapid loss of tonicity of the mus- 
cular fibres of the vessels. Any disease associated 
with toxemia, such as syphilis, diabetes, gout, rheu- 
matism, alcoholism, will cause endarteritis, with 
consequent degeneration of the vessels. The 
glandular theories of Horsley and Lorand do not 
explain the cause of the initial change in the glands, 
and the onlv rational explanation for the initial 
change is a change in the nutrition, caused by some 
alteration in the blood. It is possible that the ad- 
ministration of the extracts of these glands will im- 
prove metabolic activity in the aged. 

There are many factors which are recognized as 
contributing to the production of early ageing, 
through causing arteriosclerosis or other tissue de- 
generation. It is hardly necessary to mention im- 
])roper living, improper food, excessive food, insuf- 
ficient sleep, mental strain, etc. Factors not gener- 
ally recognized, having a deleterious effect upon the 
organism, are. the fine, rapid vibrations of motor 
driven vehicles causing irritability and neuras- 
thenia f rapidly moving elevators causing cerebral 
anemia when going up and hyperemia when des- 
cending, the eyestrain produced by the flickering 
of moving picture machines, the earstrain and 
mental strain caused by listening to the telephone, 
ignoring at the same time surrounding noises, the 
man)' little shocks and momentary frights when 
crossing streets where there are many moving 
vehicles, and when avoiding other dangers, the 
startling city noises, etc. These all aflfect the ner- 
vous system, hastening its breakdown and degen- 
eration. 

Taking up rejuvenescence, we must consider two 
kinds of impossiliilities. the absolute, which from 
their nature can never be possible, and the tem- 
porary, which are impossible at present because our 
present means are inadequate or our present meas- 
ures are faulty. Rejuvenescence in the sense of 
restoring youth to old age is an absolute impossi- 
bility. But there is nothing inherently impossible 
in the idea that we can stimulate the functions of 
senile tissues, increase metabolic activity, control 
some of the factors that contribute to senescence. 
and improve the mentality and physical appearance 
of the aged. Some of these have been done, 
though not for the specific purpose of rejuvenes- 
cence. I have on several occasions spoken of the 
beneficial psychic influence of flattery, the stimula- 
tion of the sense of pride, especially pride in ap- 
pearance, sexual relations with young mates, and 
social iniercourse with the young generally. I will 
only refer to the marked change in personality of 
the old man who goes a courting or who takes a 
young wife. Social intercourse with the young 

*A guard on the elevated railroad informed me that when he 
was obliged to remain most of the day on the car containing ttie 
motor he felt mentally and physically exhausted. He did not^ feel 
the same effect when stationed on one of the other cars. 



e.xerts ;i pov.crful rejuvenating effect, and this has 
i)een recognized in parts of Switzerland, where de- 
pendent aged persons are sent to bc>ard with fami- 
lies in which there are young persons. The Xestor 
of our profession once said his association with the 
young tended to make him feel young. The im- 
jirovemcnts in the general appearance has a pro- 
found psychic influence, not only directly through 
the stimulatiqn of the sense of pride in appearance, 
but indirectly through the flattering comments 
which it arouses. This important measure is gen- 
erally neglected by men, yet aside from the bene- 
ncial psychic influence, for esthetic reasons alone 
the old man should endeavor to make himself ap- 
pear as attractive as possible. This does not mean 
that he should resort to the artificial devices that 
middle aged and elderly women employ to enhance 
their ch.arms. It does mean that the old man should 
stimulate the surface circulation by means of 
baths and massage, remove wrinkles and folds by 
inunction witli animal fats, try to stimulate the 
growth of hair on the head and remove hair from 
abnormal situations as the ears, use a cane and 
wear braces to overcome the tendency to stoop, em- 
ploy harmless cosmetic measures to improve his ap- 
pearance, and, above all. observe a sense of neat- 
ness in dress. Instead of decrying such a course 
as vanity, it should be encouraged as a laudable 
efifort to maintain a youthful spirit. Many of the 
factors that contribute to senescence can be con- 
trolled in a measure through change in the mode 
of living, in food, in occupation, means of trans- 
portation, and environment. Pneumokoniosis can- 
not be entirely prevented, but it can be retarded by 
living in a dust free atmosphere, as on the sea 
shore. A comparison between the lungs of an old 
sailor and an old resident of a city in which soft 
coal is used — the former light gray, the latter 
black — will show the disastrous effect of the con- 
stant inhalation of dust and smoke. 

Besides the hygienic measures, there are some 
medical measures which retard the senile changes 
and stimulate the functions of senile organs. The 
skin can be kept soft and moist through the 
occasional use of an animal fat containing a 
small amount of water. The fats most suitable are 
hydrous woolfat and sweet butter, both of which 
will take up a small quantity of water. \ egetable 
oils are not so readily absorbed, yet they are fre- 
quently used. The virtue of almond meal, which is 
extolled for this purpose, lies in its oil content. 
The most important medical indication for improv- 
ing the general condition of the aged individual is 
the increased elimination of calcium or the restric- 
tion of its introduction. As the lime is derived 
from the food, a lime free diet has been advocated ; 
but there are few foods free from lime, and the 
artificial abstraction of the lime diminishes or 
destroys the nutritive value. The iodides have been' 
recommended, but they have no influence upon the 
total amount or the elimination of the calcium salts. 
Trunecek's serum has been used upon the theory 
that by increasing the quantity of the other salts, 
the proportionate relationship between the various 
salts will be reestablished and the damage done 
when one is in excess, will be overcome. Weil has 
shown that in arteriosclerosis there is a deficiency 
of salts in the blood, the lime having- been de- 



LLOYD: IVOUXDS. 



]i(.viU'(i in al)iK>rin:il locations, the other salts bcinjj 
(.liininated. Tninecek's serum has been found to 
rclie\e symptoms in some cases of arteriosclerosis 
while it was used, but it did not increase the lime 
elimination, while the elimination of other salts is 
increased. A few \ears ago I began to use the red, 
amorphous phosphorus" as a substitute for the 
ordinary yellow phosphorus, and in a paper on 
Senile Debility, published in the Medical Record in 
jaiuK'.ry, iQii. I stated that in grain doses it had 
no appreciable eftect. I ft)und, however, that it 
was eliminated in the form of amor])hous phos- 
phate of lime, and by giving larger doses, larger 
amounts of this salt were eliminated. In four 
senile cases which I was able to folk)w closely, in 
which this substance was given for a period of 
several months, there was a lowering of the hlocd 
pressure and relief from the distressing symptoms 
of arteriosclerosis. In three of these cases vertigo 
was a prominent symptom, and this was relieved, 
while in one case there has been no recurrence 
of vertigo in eight months. In all four cases 
there was a general improvement in the physi- 
cal condition. Time does not permit me to 
go into detail in these cases, and I must con- 
tent myself with this general statement. Amor- 
phous phosphorus, besides its constitutional effects, 
will increase the elimination of calcium through 
its combination with the lime and its own elimina- 
tion. .\morphoiTs phosphorus will not rejuvenate- 
the aged in the sense that it will make an old per- 
son young. It will improve the physical condition 
and by employing, at the same time, a rational h\ - 
giene and those measures that will improve the 
mentality and the appearance of the aged individ- 
ual it may be possible to make the old person look 
vounger than he is and feel younger than he look^. 
631 E\si i68th Street. 



\\'OUXDS.- 

Bv Samuel Lt.ovu, M. D., 

New York. 

Heisler. in his Genera! System of Surgery, pub- 
lished in Xnremberg in 1718. says in his opening 
paragraph : 

The principal end of physic is to prevent or relieve the 
disorders of the human body. This, the first physicians 
endeavored to effect by three means, either by food, med- 
icines, or the application of the hand, or by all together, 
if the case required it: which method, reason and experi- 
ence teach us. is absolutely necessary at this time: .And. 
of these three branches of this salutary profession. the\ 
called the first, diet or dietical. the second, pharmaceu- 
tical, and the third, chirurgical. For since the end of 
physic could by no means be always obtained by diet and 
medicine alone (though thev are of very great service in 
preserving and restoring the health of mankind). Init 
manual operation is also found sometimes to be absolute- 
ly necessary, it is plain, therefore, that this branch of 
physic, which is called surgery, is very necessary to man- 
kind : more especially as it appears that by this means 
many grievous disorders are relieved, as wounds, frac- 
tures, lu.xations. and several others, where diet and medi- 
cine would afTord very little and sometimes no help at all. 
But that the excellence and necessity of this art may ap- 
pear more clearlj-, it may be necessary to observe that 

"The amorphous phosphorus of commerce contains impurities, in- 
cluding yellow phosphorus. 

*.\n address delivered under the ausnices of the Public Healtn 
Education Committee of the Medical Society of the County of Neu 
York, at the New V.irk .\cademy of Medicine. February 5. 1913- 



other arts only conduce to the convenience of life, but the 
art of surgery is frequently necessary for the preservation 
of life and the continuance of health, the most valuable 
treasure we can be possessed of. This necessity appears 
more particularly in dangerous wounds received in war. 
skirmishes, or sieges, where many brave men must neces- 
sarily perish from loss of blood and other causes unless 
they are restored and snatched, as it were, from the jaws 
of death by the skill of their surgeons. .And no doubt the 
better opinion the soldiers conceive of their surgeons, the 
more spirits they have for the combat; having good confi- 
dence that the wounds they receive shall be properly 
treated and their lives preserved. 

This was illustrated in the career of that great 
surgeon of the si.xteenth century, Ambro.se Pare. 
During the siege of Metz, in 1552, which was de- 
fended by the Duke de Guise, two hospitals had 
been established, l)ut the mortality was so .great, 
and the incompetence of the surgeons so evident, 
tliat the soldiers became convinced that the sick and 
wountled were being poisoned, and lost heart. The 
Duke then sent to Charles \'., saying that he could 
hold out for ten months, but needed medicine. Pare 
was sent for, supplied with money, and medicines, 
and finally succeeded in gaining entrance to the be- 
leaguered city. He entered Metz at midnight of 
the 8th of December. Sixteen years as a military 
surgeon had made him known to most of the offi- 
cers and many of the common soldiers, and when 
he was presented on the bulwarks the next morning 
he was received with shouts of: "We shall not die, 
even though wounded ; Pare is among us I" and it 
is generally believed that it was to the presence and 
the influence of this single man, a noncombatant 
at that, that the city owed its salvation. So, too. it 
is related of Baron Larrey, surgeon in chief to the 
Grand .\rmy, and whom Xapoleon I. called the most 
\irtuous of men, that during the Russian campaigns, 
when the flight of the French army was arrested by 
an almost impassable stream, he was seized bv the 
soldiers and carried across to the other side, that he 
might be able to minister to their wounded. 

.\etius (500-550 .\. D. ) quotes Leonidas of the 
first century in describing the surgical treatment of 
cancer of the breast, as follows : 

In the treatment of those cancers that arise upon the 
breast I rely entirely upon surgery, which is done thus: 
I make the patient lie upon the back, then I cut upon the 
sound part of the breast above the cancer, and burn in 
the incision with a redhot iron until a crust is formed, 
sufficient to arrest the flow of blood: I immediately in- 
cise again and dissect up from the deepest part of the 
mamma, and again burn the incised part; and after this 1 
repeat the cutting, following it with a redhot iron suffi- 
cient to arrest the hemorrhage. The first burning is for 
the arrest of the hemorrhage, but afterward the burning 
is for the removal of every vestige of the diseased tissue. 
But often, also, when the undurated cancerous tumor is 
situated less deep in the breast, the entire operation is per- 
formed without the cautery, for in such cases it is suf- 
ficient to amputate to the sound paj-ts. as there is no dan- 
ger from hemorrhage. 

This statement is interesting at the present time 
for two reasons: First, it illustrates that the cau- 
tery was in use then, as now. for the control not 
only of the hemorrhage but for the destruction of 
the malignant tissue. -At present, not onlv is ac- 
tual cauterization employed, but fulguration and 
electrical application is being actively exploited to 
achieve the same results. Second, it illustrates th.- 
incomplete method of removal of the cancerous 
breast which was in vogue for so many centuries 
and even up to the time when the present speaker 



66 



LLOYD: WOUNDS. 



Medical Jol- 



was a stiulcnt of luediciiu', and which led the hilc 
Doctor Gross, of Philadelphia, at that time the mas- 
ter of American surgery, to say that he had never 
cured a case of cancer of the breast and that he 
only operated to alleviate the pain and relieve thj 
anxiety of the patient. How different are condi- 
tions now, when surgeons the world over recognize 
the precancerous stage, and save by operative 
means from sixty to seventy per cent, of the pa- 
tients who seek treatment early enough. 

This method of treating hemorrhage continued 
up to the time of Pare. The introduction of the 
ligature by this surgeon may be considered as the 
first epoch of the modern treatment of wounds. At 
the time of Pare the method of treating hemorrhage 
was by means of a redhot iron, and this was .the 
only method described by him in his work published 
in 1552 — just a thousand years after the work of 
Aetius. But in 1564 he had adopted the ligature, 
and then he speaks of the cauterization of wounds 
as "a thing very horrible and too crude to men- 
tion," while he says of his previous employment of 
this method: "Whereof I am ashamed and ag- 
grieved. In conclusion, I counsel the \oung sur- 
geon to abandon this miserable way of burning an 1 
roasting." 

At this time wounds were treated by filling 
them with and pouring over them boiling hot oil. 
and Pare had for years followed his predecessors 
in this respect. In his \'oyage to Thurian, in 1 536, 
he says : 

I took courage to doe as the}- did. .At last I wanted 
oyle. and was constrained insteed therof to apply a di- 
gestive of yolkes of egges. oyle of roses, and turpentine. 
In the night I could not sleepe in quiet, fearing some de- 
fault in not cauterizing; that I made me rise very early 
to visit them, where beyond my expectation I found those 
to whom I had applyed my digestive medicine to feele lit- 
tle paine. and their wounds without inflammation or tu- 
mor, having rested reasonable well in the night, the others 
to whom was used the sayde burning oyle, I found them 
feverish, with greate paine and tumors about the edges of 
their wounds, and then I resolved with myselfe never so 
cruelly to burne poore men, wounded with gunshot. Being 
at Thurian. I found a chirurgian who had the fame above 
all others for the curing of wounds of gunshot, into whose 
favor I found meanse to insinuate myselfe. to have the 
receipt of his balme, as he called it. wherewith he dressed 
wounds of that kind; and hee held me off the space of 
two yeares before I could draw the receipt from him. In 
the end. by gifts and presents, he gave it me, which 
was this : he boyled young whelpes. new pupped, in oyle 
of lillies, prepared with earthwormes. with turpentine of 
Venice. Then was I joyful, and my heart made glad, 
that I had understood his remedy, which was like to that 
I had obtained by great chance. See, then, how I learned 
to dresse wounds made with gunshot, not by bookes.'' 

Thirty or forty years later there flourished in 
England William Close, a naval surgeon, and one 
of her Majestv's Chirurgians, who published in 151)1 
a book under the title, A Proved Practice for al! 
Young Chirurgiaiis Concerning Burnings with 
Gunpowder and Woundes, made zvith Gunshot. 
Szvord. Halfcrd, Pike, Launce, or such Other, in 
which he speaks of "the manner and order of tak- 
ing oiT a mortified and corrupt leg or arm, which 
Cometh oftentimes by reason of wounds made with 
gunshot, etc." In one place, he says : 

Then, as I have said, that oftentimes it happeneth that 
by reason of the evill accidents which follow wounds 
made with gunshot, etc., that the whole member cometh to 
gangrene, sideratio. or sphacelus, so that we are many 
times constrained forthwith to make a speedy dispatch to 



cut off the member which shall be done as Gale and others 
very skillfully appointed in the whole and sound parts. 
These things being observed, then, through the assistance 
of Almightie God, you shall luckilie accomplish this worke 
by your Industrie and diligence . . . and after that his 
body is well prepared and purged (a precaution taken 
even at the present time) then the same morning you doe 
attempt to cut off the member, be it leg or arme. Let him 
have, some two hours before, some good comfortable 
caudell or other broths, according to the discretion of the 
physician or chirurgian. only to corroborate and strength- 
en his stomach ; and in any wise omit not but that hee or 
shee have ministered unto them some good exhortation 
concerning patience in adversity, to be made by the min- 
ister or preacher. (.An admonition not entirely neglected 
to-day. ) And you shall likewise advertise the friends of 
the patient that the work which you go about is great and 
not without danger of death, for that many accidents and 
evill symptoms doe happen which in such cases many do 
admit no cure. All which being considered, then ordaine 
the night before some good defensative. and let it be ap- 
plied two or three times about the member (our present 
practice). 

After giving full directions for the amputation 
and the formula for his restrictive powder, he says : 

Take of this powder as much as will serve your turne, 
and mixe with the said powder the hair of a hare and the 
white of egg, of each as much as is necessary; let your 
hare's haires be the whitest and the softest that is taken 
from under the belly of the hare and cut so fine as pos- 
sible may be. and with the same powder let all be mixed 
together and so be brought to a reasonable thicknesse. 
-And note that before yee cut off the member, let there be 
in like manner made for the purpose three or foure small 
bolsters or buttons, fashioned in the upper part like a 
dove's egge or as a sugar loafe button, flat in the bottom 
to the compasse of a French crown, and round upwards, 
as aforesaid, and these yee shall make of a very fine tow, 
according to art. wrought up in water and vinegar; 
whereupon you shall apply some part of the restrictive, be- 
ing mixed, as I have before declared. But yee shall further 
note that ... a famous chirurgian in France, with other 
very learned and skillful men, counselleth thus, to drawe 
out the veins and arteries with an instrument called a 
raven's bill, and then they tie those vessels with a double 
strong ligature or thread, and so safely staye the bleeding. 
But for that. I never practiced this order by stitching the 
veins and arteries. I will leave it as before said, and pro- 
ceed with mine own approved practice. Place upon the 
veins the round endes of the small buttons, and upon them 
presently lay on a round, thicke bed of towe, made up in 
water and vinegar, so that it may be fit as near as you 
can guess it to the compasse of the stumpe or member, 
that is taken off, and thereon place the restrictive; etc. 

We have selected these quotations because they 
. illustrate the treatment of wounds at the period of 
the first epoch, and show where some of the present 
popular method of treatment of wounds originated. 
It is interesting to note that Shakespeare was cog- 
nizant of some of the methods handed down by 
tradition, and still employed. Thus, in "Midsum- 
mer Xight's Dream." Act III, Scene i. Bottom 
exclaims : "I shall desire of you more acquaintance, 
good master Cobwebb : if I cut my finger, I shall 
make bold with you" ; and, again, the Second Ser- 
vant in King Lear, Act III, Scene vii. says: "Go 
thou, ril fetch some flax and whites of eggs, to ap- 
ply to his bleeding face. Xow. Heaven help him." 
Even Homer, in the Ninth Centun-, B. C. wrote 
of surgeons and of wounds and their treatment. 
Thus in the Iliad we find him speaking of the sons 
of .-Esculapius : 

"Of two great surgeons, good Podallirius stands. 
This hour, surrounded by the Trojan bands, 
.-\nd great Machaon, wounded in his tent. 
Xow wants the succor which so oft he lent." 



LLOYD: WOl'SDS. 



67 



And then with the removal of 'deadly darts and 
stinging arrows' he sings : 
"Pairoclus, cut the forky steel awa\ 
\nd in his hand a bitter root he pressed, 
riie wound he washed, and styinic juice infused, 
riie closing ilcsh that instant ceased to glow. 
The wound, to torture, and the blood to How." 
While Xestor exclaimed: 

"A wise physician's skill, our wounds to heal. 
Is more than armies to the public weal." 
The second great epoch in the treatment ni 
woi'.ntis came with the discovery of anesthesia, 
l-'ngland and the United States divide the honor. 
In the former, chloroform was discovered, and still 
remains the favorite method of obtaining insensi- 
liilitv to the surgeon's touch ; while the United 
States gave us ether, the safer of the two, and now 
almost universally employed in this country. These 
hiHins to humanit)-, discovered by .Sinipson in Eng- 
land and Morton in the United States, have inade 
modern surgery possible, and robbed it of most of 
its terrors. Instead of a frightened, screaming, 
struggling victim, strapped to a table or held down 
by brute force, with a surgeon hurrying every 
motion to shorten the agony, we have now the 
peacefully sleeping patient and the surgeon, serene, 
calm, collected, with every faculty devoted to doing 
in a quiet and deliberative way wdiat is best suited 
to each individual patient. Instead of the piercing 
shrieks of the anguished victim, the operating room 
is c|uiet, suited to painstaking, scientific work. 

Hardly had the world become accustomed to 
anesthesia with all its benefits to mankind, than 
there appeared a poor chemist in Paris, the son of 
one of Napoleon's soldiers, a tanner by trade, who 
had developed to a high degree the deductive meth- 
od of reasoning. Aided by the recently perfected 
microscope, he began to study the subject of putre- 
faction and fermentation. It was not long before 
he was able to prove that the. change of wine to 
vinegar was due to the presence of a microscope 
microbe which floated in the air. A cork of sterilized 
cotton sut^ced to prevent its entrance into the bot- 
tle, and the wine did not change to vinegar. These 
conclusions were reached only after long study and 
acrimonious debate. On the other side of the 
Channel was a Scotchman, whose father had long 
been a patient and intelligent worker with the mi- 
croscope, who brought to the study of medicine not 
onlv a trained mind, but a desire to delve into the 
cause of things. Studying with his microscope, and 
at the same time walking his wards in the surgical 
division of a hospital at Edinburgh, he wondered 
from time to time what produced the suppuration 
and all the other diseases of wounds that infested 
ever\- hospital the world over. He had for a long 
time been convinced that wound inflammation and 
its consequences, erysipelas, pyemia, septicemia, hos- 
pital gangrene, etc., were due to the chemical 
changes which occurred in the putrefaction of b'ood 
and blcxid serum ; but it was not until, by chance, 
perhaps, he happened to read of Pasteur's experi- 
ments, in i860, and the following few years, as pub- 
lished in the Comptes rendits, that he began to 
realize that there might be agencies extraneous to 
the human body that would set all these diseases ui 
motion. This 'was the third great epoch in sur- 



gical hist<)r\ ; the revolution was on. At this lime 
the state of surgery can best be described in the 
words of our own Keen, who, in the Medical and 
Surgical History of the li'ar of the Rebellion, sa\s: 
The surgeon approachtil the operation with the clean 
hands of a gentleman; he usually wore an old coat cov- 
ered with the dried hlood spots from previous service, 
ills finger nails very likely were long, and no special at- 
tention was given to them. The instruments were taken 
<jut of a velvet lined case, and were as clean as ordinary 
table knives would be. The operation was done without 
any preliminary cleansing of the skin other than to remove 
any visible dirt. If the knife happened to fall on the 
rtoor, it was picked up. rinsed in a basin of ordinary wa- 
ter, and used as it was. The marine sponges then always 
used, were washed clean in ordinary water, and used over 
and over again, even after being saturated with foul pus. 
The bloodvessels were tied with ordinary silk ; one end 
w-as cut short, the other end hung out of the wound. 
After the amputation of a fleshy thigh I have often seen 
twenty-five or thirty such ligatures gathered into two 
bundles, one at each end of the wound. The flaps were 
then sewed together with an ordinary needle and thread, 
and the stump dressed first with an old rag or scraped lint 
spread with some simple grease. Over that would be 
placed some other rags, lint, cotton, or other dressing, and 
finally, a bandage. During the Civil War these greasy 
dressings gave place to simple cold water dressings. By 
the second day the patient would begin to have consider- 
able fever. By the third or fourth, the temperature would 
rise to what we now know ( for medical thermometers 
were not in general use in that early day) to about 103°, 
104°, or 105° F. Then we would poultice the wound. 
Every few hours the patient would be disturbed — a new 
poultice put on to replace the old one. now cold, foul, and 
ill smelling; and by this time bathed with pus. I have 
often seen the pus escaping by the tablespoon ful, and the 
wounds alive with squirming maggots, resembling chest- 
nut worms. By this time also it was hoped that the silk 
ligatures w-ith which the arteries had been tied, had liter- 
ally rotted loose, and each of them was gently pulled on, 
to the discomfort of the patient. Care was taken that 
the ligatures with knots tied on them ( in order to distin- 
guish those which secured the large bloodvessels) should 
not be pulled on severely until probably the tenth or twelfth 
day. Meantime, the patient was tossing about the bed 
with pain, with thirst, without apijetite. without sleep ex- 
cept such as morphine would secure. This, at the same 
time, dried up all the secretions, producing constipation 
and other evils. By about the tenth to the fourteenth 
day, suppuration having been fully established and quan- 
tities of pus pouring from the wound, the fever would 
subside and the wound begin slowly to heal. Of course 
the healing could not be complete so long as the silk liga- 
tures were still protruding from the wound. Sometimes 
they did not become detached for even months or years, 
but more commonly all of them would rot loose in from 
ten days to three weeks. W'hen the silk ligatures on the 
large bloodvessels came away, if the healing process had 
formed in the large bloodvessels a firm clot which had be- 
come adherent, and. so to speak, corked it up — all went 
well. But. as very frequently happened, when the liga- 
ture and the rotten end of the artery were pulled off. and 
there was no clot to act as a stopper, secondary hemor- 
rhage followed. This often came on after the patient's 
wound had been dressed, and the surgeon had left, and if 
so. very likely the first notice that the nurse had that any- 
thing was wrong would cither be the gasping for breath 
of the patient, or his moans and cries, or sometimes by 
the blood, which had not only saturated the mattress, but 
had even appeared in a pool on the floor. How fatal 
were such hemorrhages may be seen from the fact that in 
2,235 cases of hemorrhage in the Civil \\'ar, 61.7 per cent, 
of the patients died. .A large majority of the wounds were 
followed by erysipelas, lockjaw, pyemia, septicemia, or 
hospital gangrene. 

The latter at times was so common and caused 
such ravages that, as Keen says, ''it became a veri- 
table plague." To-day, I doubt if there are any sur- 
geons who have entered practice since 1880 wdio 
have ever seen a case. This disease has been prac- 



6S 



1J.())'IK irouxDs. 



lically \\i[)(.'(l out of existence. In ^.503 ^^'i^es of 
j^nngrene during- the Civil War, 1.142 died. Tlierc 
were 505 cases of tetanus, with 451 deaths: pye- 
mia claimed 2,818 cases, of which 2,747 died; of 
2,382 wounds of the knee joint where amputation 
was performed, 1,212 of the patients died: while 
out of 973 similar wounds, where amputation was 
not performed, 591 succumbed. Compound frac- 
tures were exceedingly serious, two out of three 
dying from some form of infection. Lister's dis- 
covery of the animal ligature, thus enabling us to 
close our wounds completely, added the needed fin- 
ish to Fare's great discovery. Perhaps it is not 
right to say discovery, for the ligature had been em- 
ployed before Pare, and had fallen into disuse ; but 
he made it popular, and by the force of his example 
compelled its adoption. Our Civil War was but 
just over when Lister published his first paper, 
which appeared in the London Lancet of the 
i6th of March. 1867. In this he said: "We find 
that a flood of light has been thrown upon this 
most important subject by the philosophical writ- 
ings of Monsieur Pasteur, who has demonstrated 
by thoroughly convincing evidence that it is not 
to oxygen or any of its gaseous constituents that the 
air owes this property, but to minute particles sus- 
pended in it, which are the germs of various forms 
of life long since revealed by the microscope, and 
regarded as merely accidental concomitants of pu- 
trescence, but now shown by Pasteur to be its es- 
sential cause, resolving the complex organic com- 
pounds into substances of simpler chemical consti- 
tution, just as the yeast plant converts sugar into 
alcohol and carbonic acid. 

The treatment of wounds, therefore, at the pres- 
ent day, is no longer the simple matter that it was 
in the olden times. The wound must be carefullx 
cleansed and the surgeon's hands prepared by care- 
ful scrubbing and protected by sterilized gloves to 
prevent any possible infection from that source. 
All instruments must be boiled for twenty minutes. 
and all dressings sterilized by steam under pressure. 
If pus appears to-day, we know it is due to a specific 
germ, and the surgeon seeks, not only to find the 
organism, but to ascertain if possible what error of 
technic allowed its entrance into the wound. Soine- 
times the germ is already present in the patient 
himself, and only makes known its presence when 
the injury provides the proper soil for it to grow 
and develop. In these cases, often, in spite of all 
that can be done, a general blood poisoning devel- 
ops, but nowadays the surgeon most successfully 
' meets this serious calamity by means of his serum 
or vaccine, one of the beneficent results of experi- 
ments on animals. 

The first consideration in the treatment of 
wounds is the arrest of hemorrhage. In small and 
comparatively superficial wounds this may be done 
bv simple pressure, but in more extensive and deep- 
er cases it is often necessary to enlarge the incision 
and secure the bleeding vessels. It is fair to as- 
simie that all accidental wounds are infected, and 
therefore a question of primary importance is the 
proper cleansing of the whole involved area. The 
greatest mistake usually made by people in handling 
cuts or incisions is by sticking them together by 
means of a piece of sticking plaster or sealing them 
up so that the natural serum thrown out by nature 



cannot escape, and any infection that might be car- 
ried out by that exudation is sealed up in the 
wound. It is very important that the wound be put 
in proper condition for healing at the primary dress- 
ing, if possible. It is also important to determine 
whether nerves, arteries, tendons, or other imp(jr- 
tant structures have been injured, and if so, to 
remedy the defect at once. It is also important to 
take into consideration what kind of infection is 
likely to occur. As it has been demonstrated in re- 
cent vears that wounds from the toy pistols and 
from firecrackers, etc., are apt to produce tetanus or 
lockjaw, and the greatest care must be taken in these 
cases not only to provide for the proper dressing 
of the wound, but to watch carefully for the devel- 
opment of s}Mnptoms that would indicate the pres- 
ence of the germ of this disease. In many cases it 
is better to give a dose of antitetanie serum at the 
time the patient is first seen. 

The dressing of a wound is equally important. 
These dressings must be sterile and absorbent, and 
they must be fixed in place so that they cannot be 
torn off or displaced by the motions of the patient. 
They should he abundant and comfortable. Rest is 
exceedingly important, and if the wound occurs 
over a joint, or where an internal organ may be in- 
jured, rest is absolutely essential. An incised wound 
is one in which there is a clean cut made by a sharp 
instrument. If nothing but the skin and superficial 
tissues are involved, the only thing necessary is to 
stop the hemorrhage and apply a proper dressing. 
In many instances the margins of these wounds fall 
together and unite very quickly. If it is extensive 
or gaping, it is necessary to sew the margins to- 
gether. Conttised wounds are open wounds 
in which the edges are bruised. They are usually 
produced by blunt objects, such as stones, clubs, 
etc. In most of these cases it is necessary 
to put a sterile dressing into the opening of 
the wound, and then apply a copious dressing. 
.\ lacerated wound is one in which there is 
tearing or crushing of the tissue, making the mar- 
gins irregular and ragged. Most of these cases 
have to be treated as open wounds. Stab wounds 
must always be considered as serious, for while the 
p>oint of entrance may be very small, the injury 
to internal organs may be very great. Internal 
hemorrhage or puncture of the intestine, of 
the lung, or even of the heart, may occur, and must 
always be taken into consideration. Wounds of this 
kind should always be treated by a surgeon. An in- 
fected wotind is the most serious condition that we 
have to deal with. The infection may be carried 
into the wound by the instrument producing it, by 
probing, if it is improperly done, or by the lack of 
surgical cleanliness in the dressing. When consti- 
tutional symptoms, that is, fever, chills, pain, and 
redness, appear in the case of a wound, it is cer- 
tain that an infection has occurred, and then it is 
important that the case be referred to a competent 
surgeon, who will determine the type of infection 
and adopt the best means to control its progress. 
Xeglect of an infected wound often leads to general 
blood poisoning. 

Manv diseases, formerly ver\- common, resulting 
from slight wounds, have, since the da\ s of Lister's 
discovery, been almost, if not completely, banished. 
F.rvsipelas. once so common, now is rarely seen : 



July 12. 1013.) 



SlfAX: /XDL'STKy AND DISEASES OF THE HEART A.\D I.LXCS. 



69 



and so with the different types of blood poisoning, 
pyemia, septicemia, etc. Few of the men <if the 
present day have seen a case of hospital gangrene, 
and yet a few years ago a compound fracture, which 
is simply a broken bone with a wound in the soft 
parts which communicates with the outside air, was 
one of the most serious conditions that we had to 
deal with, and was almost invariably infected. Af- 
ter all, it is proper treatment of the minor injuries 
that prevents these severe conditions, and one can- 
not emphasize too strongly the necessity of the 
most scru]Hilous cleanliness in the management of 
iiity external wound or injury. 
12 West Fiftieth Street. 



THE RELATION OF INDUSTRY TO DIS- 
EASES OF THE HEART AND LUNGS.* 

By John I\I. Swax, M. D., 
Rcxhester, N. Y. 

There are certain essential conditions that must 
be present in order that animal life may be de- 
veloped and maintained on the earth. Among these 
essential conditions may be mentioned a proper 
supply of air. the important element of which is 
oxygen ; a proper amount of water : the presence of 
a proper food supph' ; and a certain degree of at- 
mospheric temperature. In addition to these four 
essential elements, it is necessary that the living 
animal shall have alternating periods of rest and 
exercise. In order that human life may be devel- 
oped and maintained on the earth these essential 
requisites for the maintenance and development of 
animal life in general are also requisite. 

In particular relation to human physiology, it is 
necessary that the air furnished human beinys shall 
be fresh and clean. That is to say, the air supplied 
to people assembled in houses, work shops, and 
places of amusement, must be renewed sufficiently 
to prevent the accumulation of poisonous materials 
passed into the air by these same human beings, 
and. in addition, it must be uncontaminated with 
dust, which may be injurious on account of its me- 
chanical properties or which may contain micro- 
organisms capable of producing disease. The water 
which is furnished for drinking purposes must be 
pure and uncontaminated with bacteria. The food 
supply must be nutritious and devoid of adultera- 
tion. Among the lower classes of anima's the 
amount of exercise taken and its relation to rest is 
regulated entirely by the instinct of the animal. In 
the human race, on the other hand, the amount of 
exercise taken and the relation that it bears to rest 
is regulated in some purposeful manner. Among 
the inferior races of mankind the purpose of the 
exercise taken is to supply the bodily needs of the 
individual and to afford amusement. As we ascend 
in the scale of civilization the purpose of niuscukir 
activity becomes more than that required for fur- 
nishing simply the bodily wants of the individual 
and for his amusement, and the efforts of member- 
of the race, in one way or another, are directed to- 

*A public lecture given under the auspices of the Committee on 
Public Health Kducation cf the Medical Society of the County of 
JVlonroe. 



ward producing objects of art, improved articles 
of clothing, better food materials in larger quan- 
tities, etc. Thus has develojjed, in the course of 
many centuries, the industrial enterprises that have 
now reached the highest development in the history 
of mankind. 

In the last twenty-five years it has appeared that 
many of the individuals who are engaged in the 
production of the various products developed or 
perfected by modern industrial processes have be- 
come subject to serious diseases ; and a great many 
of the more humanitarian members of the State, at 
the present time, have been seriously disturbed 
about this phase of our modern life. It must be 
remembered, however, that exercise, and hence in- 
dustry, is a necessary element in the maintenance 
of life, and if industry is carried on under proper 
conditions it ought not to be productive of dis- 
ease. Indeed, a recent writer in the American 
Journal of Public Health, has said: "Industrial dis- 
ease is a misleading term, used for convenience 
only, or through ignorance, to indicate certain 
pathological states, the result of insanitation in in- 
dustry. Industry itself is never necessarily un- 
wholesome. Industrial processes, it is true, are ob- 
jectionable and crude, oftentimes, but bad indus- 
trial conditions are always remediable." 

In European countries a great deal of careful 
investigation has been made concerning tl;e influ- 
ence of certain industries upon the health of those 
engaged in them, and during this investigation it 
has been developed that certain occupations are 
dangerous occupations. Such, for instance, are oc- 
cupations connected with the manufacture of lead 
and products containing lead ; the manufacture of 
arsenic and materials containing arsenic : the pro- 
duction of mercury and articles in which mercury 
is used ; and certain industries that are productive 
of dust of various kinds. \A'e know that sometimes 
men employed in heavy labor, such as stevedores, 
porters, etc., will acquire serious heart disease from 
muscular effort. Clarinet players get emphysema 
of the lungs, coal miners get what is known as 
miner's asthma and bronchitis ; stone cutters some- 
times acquire a pulmonary disease w^hich is known 
as fibrosis of the lungs, etc. : but the number of 
cases of such diseases is probably not great. When 
we study the incidence of disease which can in one 
way or another be connected with industry, our 
information concerning the number of cases and 
the class of cases which occur is very incomplete. 
In fact, in 1910. at a meeting of the First Nati' 'nal 
Conference on Industrial Disease, the following 
resolution was unanimously adopted: "Resolved, 
that a special committee of five, who shall have 
power to add to their number, be herewith ap- 
pointed by the president of the American Associa- 
tion for Labor Legislation, to call upon the Presi- 
dent of the L'nited States and present to him at an 
early date a carefully prepared memorial of facts 
and conclusions, emphasizing the urgent necessity 
and practical expediency of a national expert in- 
quiry into the whole subject of industrial or occu- 
pational diseases ; their relative degree of frequency 
in various trades and occupations, the causes re- 
sponsible for their occurrence : the methods desir- 
able and practicable for their prevention or diminu- 



/O 



Bin BRIDGE: TREATMENT OF DIABETES. 



York 

JOURN 



tion. ami all otlier matter^ ha\ing- relation thereto, 
iiicludiiit;- methods of ainelinration and relief." 

W'c must he very careful in our discussion of the 
effects of industry upon the lives of those engaged 
in it, that we do not convey the idea that we believe 
human beings ought not to have to work. Work 
is a neeessarj^- element in the life of man, and con- 
ditions in the world would be vastly more liarmfn! 
to the human race if everybody could be idle than if 
everybody had to work. We can approach the sub- 
ject of the effects of industry on the health of the 
worker from two points of view. First, in how far 
is the employer to blame for the cases of sickness 
among his employees ; and. second, in how far are 
the emplo)'ees themselves to blame for them. Let 
me refer for a moment to the elements that are 
necessary to life: Air, water, food, warmth. It is 
the employer's duty to furnish to his employees a 
place in which to work which is warm, which is 
well lighted, which is free from unneces>^ary dust, 
which is pro\'ided with the necessary toilet requis- 
ites, and which is furnished with an abundant sup- 
ply of good drinking water. If the work comes 
under the head of dangerous occupations, the em- 
ployer must see that all possible safeguards are pro- 
vided to prevent the inhalation of dust and noxinns 
vapors. He must see that his employees have an 
opportunity to wash their hands and faces before 
leaving the factory for their homes. It ought not 
to be necessary to enact a law to compel an em- 
ployer to furnish reasonable protection to the men 
and women that worlc for him, nor should it be 
necessary to call his attention to the fact that cer- 
tain processes of work in his factory may be in- 
jurious to the health of his employees. 

On the other hand, the employee is responsib'e 
for his own health. He ougiit to know when he 
starts to work that he is well. He ought not to 
start to work with beginning disease in his lungs. 
If he does, and that disease develops, he ought not 
to say that it developed because he had to work. 
A man ought not to go to work with a compensated 
heart defect and then wlien his heart becomes de- 
compensated, lay that to his work. Furthermore 
the worker should regulate his life in sucli a way 
that he shall remain well. If a man who has been 
doing a day's work takes a stimulant at its close, 
when he needs food, he will get sick. .Such illness 
is not, however, due to his work. A girl who has 
been working all day and who spends her evenings 
in exciting and liilarious amusements, when she 
needs rest, cannot blame her occupation for anv 
heart disease or lung trouble that may follow. 

It is perhaps not necessary to say anything 
specifically relating to tuberculosis. Those who are 
engaged more particularly in disc^^sing the treat- 
ment of tuberculosis have iniblished nnich informa- 
tion available to the public concerning the methods 
by which that disease is disseminated. The one 
great source of tuberculous infection is drv hum-in 
sputum. This sputum need not be very large in 
amount to infect a fellow employee or to give a 
factory a bad name among workers. I believe that 
it is legitimate for an employer to insist that every 
person who works in his factory shall be examined 
before he is given employment. On the other hand, 
I believe that employees have the right to insist that 
one of their number who has a chronic cough shall 



he examined for evidence of pulmonary disease, 
if they arc to continue to work with him. 

I presume that the healthiest body of workers 
in the United States is to be found in the army 
and the navy. When a man applies for enlistment 
in either of these services he is first subjected to 
a careful physical examination ; not with part of 
his clothing on, l)ut with all his clothing removed. 
Work in the army and the navy, so far as the de- 
velopment of disease is concerned, is no more dan- 
gerous than work in a steel plant, a brass foundry, 
or many another industrial plant. 

In a discussion on industrial disease held jointly 
by the American Association for Labor Legislation 
and the American Medical Association, in Atlantic 
City, in 1912, the surgeon general of the navy said: 
"We have been looking after occupational diseases 
in the navy; but entirely on the basis of military 
efficiency. There is no humanitarian factor in it." 
Why should not a manufacturer look after the 
health of his employees entirely on the basis of in- 
dustrial efficiency? His work would be done b?t- 
ter and his employees would lead healthief, happier 
lives. 

I should like to suggest that some corporation, 
interested in the health of its employees, require 
a certificate of health, based on a careful physical 
examination, from each individual on its payroll. 
Then the subsequent medical history of the em- 
ployees might be studied and the occurrence of dis- 
eases among them could be recorded and investi- 
gated as to their relation to the work and to the 
habits of the employees when not working. Some 
one will want to knuw what provision will be made 
under such a scheme for the employment of those 
men who present certain physical defects when they 
apply for work. In such a system, it seems to me, 
patients with heart and lung disease can be given 
suitable employment, and not set to work at tasks 
too great for them, as is now very frequently the 
case. Such an inquiry would be productive of much 
valuable information concerning the effects of in- 
dustry on the health of the workers. It would re- 
quire, however, for the best results, that the physi- 
cian in charge of such a department should be a 
man of sound judgment, capable of undertaking 
original investigation. 

457 P.\RK AvEXfE. 



DIABETES MELLITUS. 
Treatment with Bacillus Bulgaricns Cultures. 

Bv J. ^^^\LL.\CE Beveridge, M. D.. 
New York. 

In presenting a new therapeutic measure for the 
treatment of diabetes, great caution should be main- 
tained toward an optimistic viewpoint until a suf- 
ficient number of positive recoveries are noted, 
which would warrant an assertion that such a pro- 
cedure as that herein recorded is of true value. The 
results in the 176 cases cited, and observations 
made by Dr. George F. Klemann and myself in this 
preliminary report, should in no way be considered 
as final. 

It is necessarv to portray a brief outline of the 



July 1.^. 19.3.1 



BEi'llRIUCE: TREATMENT 01- DI.IBETES. 



71 



main etioloj^ical factors in this tiisease, so that \vc 
may be enabled to indicate how the conditions caus- 
ing functional glycosuria are overcome. The pan- 
creas is the gland whose secretion is known to ha\ c 
the most power in breaking down the carbohydrate 
group, which is readily divided into the pol_\ sac- 
charides, starch, and cellulose, the dysaccharides, 
maltose, lactose, and saccharose, and the monsac- 
charides, dextrose, levulose, and galactose. Th'.- 
most important carbohydrate, as a food, is starch, 
but, as such, is valueless, though easily broken 
down by the digestive enzymes. The saliva and 
pancreatic juice contain a diastatic ferment capable 
of changing the molecular cohesion of starch into 
maltose as an end product, and in some of the hcrhi- 
vora an enzyme capable of attacking cellnluse. 
which has not been definitely isolated in the human 
being, has been demonstrated. During digestion 
the activity of the pancreatic secretion depends 
mostly upon the acidity in the duodenum and small 
intestine, this acidity causing a peripheral, local 
stimulating reflex action on the ganglionic cells 
scattered throughout the pancreas, while the re- 
flexes of central origin remain inert. 

Popielski, Wertheimer, and I.e Page demon- 
strated that when an acid was introduced into the 
duodenum, pancreatic secretion was excited, and 
they were able to prove that pancreatic secretion 
could be induced by the injection of acid into the 
small intestine, the effect diminishing as the acid 
neared the lower end of the intestine. The name 
of the product formed inducing pancreatic activity 
is known as "secretin." Bayliss and Starling con- 
firmed the results given above and justify the state- 
ment that "when the acid gastric juice of digestion 
reaches the duodenum, the prosecretin manufac- 
tured by the epithelial cells is converted into secre- 
tin, which is immediately absorbed into the blood 
stream, then carried to the cells of the pancreas 
which at once are stimulated to secretory activity. ' 
This process, showing the power exerted through 
the stimulation of acid digestion in producing se- 
cretin, so necessary to the normal functionating of 
the pancreas, has never until now been brought for- 
w-ard as a factor in glycosuria. Hence, one can 
readily perceive that when chronic conditions arise 
to change the acidity of the gastric contents, a cor- 
responding response will be noted in the produc- 
tion of secretin. According as a increased acidity 
or lowered acidity of the gastric chyle is apparent 
while passing through the duodenum and upper por- 
tion of secretion. According as an increased acidity 
manufactured is either increased or diminished, and. 
reflexly, the pancreatic secretions will also be in- 
creased or diminished. Should this abnormal 
chemical reaction continue, whereby the pancreas 
receives inadequate stimulation during digestion, se- 
rious chemical and metabolic changes will in time 
manifest themselves, which may eventually combine 
and prevent complete carbohydrate metabolism. 

The other causes interfering with a normal pro- 
duction of secretin are intestinal putrefaction, ulcer 
of the duodenum or pylorus, and any lesion involv- 
ing the mucosa of the duodenum and upper por- 
tion of the small intestine. 

The liver, next to the pancreas, furnishes the 
most important, etiological factor, but in this paper 



a complete exposition of its action in digestion is 
impossible. Only a very brief indication of a few 
cardinal points will be undertaken. The power "f 
the liver cell Uj change ammonia into urea is vital. 
When any abnormal cellular change manifests it- 
self the urea content found in the daily urine is les- 
sened and the ammonia output increased. This fact 
is observed in all severe cases of diabetes, in ane- 
mias, in some types of intestinal nephritis, in tox- 
emias, in hypertrophic and atrophic cirrhosis of the 
liver, in chronic inflammations of the gall duct, and 
in malignancy. .\ continued low urea output is an 
unfavorable sign in diabetes. ( ienerally, we find 
that when the liver is unable to normally change 
ammonia into urea the secretion of the bile is af- 
fected, the production is lessened, and the bacte- 
ricidal action diminished. 

The intestinal tract also plays a most important 
part in carbohydrate metabolism. In more than 




l'"ic. 1. — Transverse colon is adherent to the cecum as result 
of chronic appendicitis ACC-TC, resulting in acute angulation of 
hepatic tlexnre with stasis; stomach is ptosed. 

ninety ]ier cent, of the cases under observation there 
was intestinal putrefaction, usually traced to chronic 
constipation, intestinal stasis, or lack of proper 
bodily care. The normal action of digestion is de- 
pendent upon the daily intestinal elimination and 
nonabsorption of the waste products ; otherwise in- 
terference with oxidation, as a result of auto- 
intoxication, will coordinate!}' affect the entire in- 
ternal secreting glandular system, and, should such 
a chronic state ensue, cellular changes in the 
thyroid, pituitary, and pancreas, ofttimes begin. 
( >f course, constii)ation is the main cause of all in- 
testinal disturbances, and to-day we can be reason- 
ably certain whether a chemical or mechanical 
derangement is paramount. 

The chemical faults may be ascribed primarily 
to improper food, such as -food of poor quality, 
food badly prepared, or unbalanced food consisting 



BF.rr.RIDGE: TREATMENT OF DIABETES. 



[New York 
EDiCAU Journal. 



1 


R 








.y./: 


s^ 


r^ 






^^^ 


P 






o.c. 


l^^fttt 


^fl 






5^ 


c-^ i^M^I 


kmP 






h -?^^pr^B 


P^ 











Fig. ::.— Ga = t .. 
tween stomach aa 
patulous ileocecal 



:ing pixibable 
:, Sf ptosed 



either of carbohydrates or proteids in excess : in- 
terference with the chemical activating agents of 
peristalsis, i. e., bile, etc., and the noxious chemical 
products of intestinal putrefaction, come under 
this heading. The mechanical faults are demon- 
strated by the radiograph, briefly indicated from 
observations made by Dr. A. J. Quimby. professor 
of radiography at the New York" Polyclinic Medi- 
cal School, on some 350 patients and upon cases 
submitted by me, in which the patient's stomach 
and intestines have been radiographed following a 
test meal of bismuth. In this series the mechani- 
cal defects portrayed were frequently marked, and 
the data obtained through this accurate determin:i- 
tion of the stomach and intestines, have proved mo~t 
valuable, especially in the prognosis and treatment. 
The radiographic plates of the stomach, as a rule, 
show mechanical changes indicating dilatation or 
perhaps stenosis of the pylorus or duodenum, while 
in the ascending and transverse colon frequent 
sharp angulations are seen, probably due to ad- 
hesions, and should the accentuation of the hepatic 
or splenic flexures be well defined, caused by ad- 
hesions of sufficient density to deflect the relative 
position of the intestine, considerable delay in the 
passage of the semisolid bowel contents will result. 
In all conditions of intestinal stasis the sigmoid 
deserves special study. In infancy the sigmoid is 
much longer proportionally than in adult life, and 
Jacobi has frequently pointed this out as one of the 
dominant mechanical factors in producing constipa- 
tion. In adults, if the functions of the sigmoid 
are interfered with by direct pressure or by ad- 



hesions, and forced into acute angulations, a con- 
dition of stasis ensues, followed by stasis in the en- 
tire colon. The waste products of digestion ac- 
cumulate, and then the increased weight of the 
overloaded colon places undue tension upon the 
mesentery and, through pressure, interferes with 
the blood supply to the muscular coats of the in- 
testines, which in time will, by the development of 
a passive hyperemia, hinder active peristalsis. Ra- 
diographically, the sigiuoid can be divided into two 
sections, the iliac and pelvic. The dividing line 
occurs at the brim and is conspicuous by a point at 
which the angulations and constrictions are mani- 
fested when the patient is placed in a position 
which brings the two sections of the sigmoid into 
the abdomen. The iliac portion of the sigmoid is 
found close to the posterior abdominal wall, and 
the pelvic portion is invariably greatly dilated; in 
fact, it may extend to about the level of the um- 
bilicus. When the patient is placed in the upright 
position, the sigmoid, unless retained by adhe- 
sions, will drop into the bottom of the abdomen, 
resting partly in the true pelvis and partly just 
above the brim. These pictures just portrayed in- 
dicate some of the mechanical defects present in 
the intestinal tract that will establish a chronic con- 
stipation and maintain the colon in a state of dis- 
tention accompanied by all the phenomena result- 
ing from autointoxication and its complications. 

The preceding facts readily demonstrate why 
glycosuria often follows a grave cellular change in 
the pancreas, liver, or small intestine ; so that we 
now know that a chemical fault or a mechanical 




I'IG. 3. — -Adhesions of transx erse colon, AD, colonic peristalsis 
begins at AD instead of at C, resulting in stasis of cecum and 
ascending colon. 



Pliir.RlDGE: TREATMENT OF DIABETES. 



73 




and dilatation of cecum, C; redundant 

one, or both combined, is al\va\s necessary for a 
diabetic state to manifest itself. 

THE BACILLUS BULGARICUS. 

Much controversy has arisen, since the interna- 
tional employment of the Bacillus bulgaricus cul- 
ture for intestinal putrefaction, as to whom the 
credit should belong for first isolating this organ- 
ism. It seems that Professor Kern, in 1881, first 
];ublished an article describing the microorganisms 
found in Russian kefir. At this early period the 
bacteriological technic was perhaps untrustworthy 
for accurate information, and judgment should 
therefore be withheld on the question whether the 
true Bacillus biilgaricus of to-day was isolated at 
that time. Beijerinck unquestionably was the first 
to positively demonstrate the isolation of the Bacil- 
lus caucasiciis, which belongs to the bulgaricus 
group. Two distinct classes of this organism have 
been demonstrated, and the first investigators to 
prove this fact were Rist and Khowry. A true 
bacillus isolated from the Bulgarian yoghurt by 
Grigoroff. a member of Professor Massol's labor- 
atory staflF. and first described by him as the Bacil- 
lus bulgaricus, is the organism now us^d as a 
theraperitic agent. A further point of interest is 
the report by Heinemann and Hefferan that they 
were able to isolate this bacillus from many sources, 
asserting they found a bacillus identical to that of 
the bulgaricus in the human feces, in the feces of 
cows and horses, also in a great variety of sour and 
aromatic foods, in the human saliva, in the normal 
gastric juice, and in the gastric juice when hydro- 
chloric acid is absent in the fermented milk and 
ordinary sweet milk. Cohendy devised the pres- 
ent media for active growth. 



MliKI'lIOLOGV. 

The characteristics are similar in all strains. 
Length, two to fifty ; breadth approximately, one. 
.All viable bacilli are Gram positive and are regular 
in shape, the appearance is that of a straight line 
with rounded ends ; no granules or vacuoles ob- 
served. Two strains noted are, A and B. Their 
culture in whey (Class A) indicates a tendency 
toward degeneration and involution. In the be- 
ginning of incubation, at 37.5° C., the bacilli are 
uniform in size. In outline all are markedly Gram 
positive, while in the succeeding stages the irregu- 
lar, vacuolated, inllated, and ruptin-e(l forms of dis- 
integration predominate. 

Class B Cultures. — Xo stemmed nodules are 
present, small spherical bodies are seen attached to 
the cell wall. In the case of the stemmed nodule a 
single bacillus rarely, if ever, extrudes more than 
one bud, while in the latter instance the bacterium 
may have a number of these small spheres adher- 
ent. Strains of Class A culture grow in tl'.e form 
of a short bacilli arranged in chains. Strains of 
Class B culture develop to a greater length and ex- 
ist almost exclusively as single isolated forms. Ex- 
amined in a hanging drop, no motilitv is observed. 
Milk is the natural habitat of the Bacillus bulgaricus 
and the morphological features which the bacilli 
manifest in this media should constitute a standard. 
Early growths show a variable length, the width 
alone remaining stable. When grown with the addi- 
tion of yeast and more trivial ferments, the length 
of this bacillus is inhibited. \'ery little degeneracy 
occurs from the bacillus grown in milk media ; no 
vactioles or nodules observed. No spores were ob- 
served. The fact that these bacteria when young 




74 



BEVERIDGE: TREATMENT OF DIABETES. 



[New York 
Medicai, Jouknal. 



and most active exhibit a low degree of vitality 
would argue against the possibility of spore forma- 
tion. Nothing to suggest the presence or forma- 
tion of capsules was noted. All strains readily 
stained by the usual anilines. 

Other Media. — When freshly isolated from their 
natural symbiotic environment no growth is ob- 
tainable on ordinary media. After a year's solitary 
cultivation in milk, these bacteria show an increased 
vitality and adaptation to foreign environment. A 
feeble growth was obtained on nutrient agar from 
strain A. The same agar with two per cent, hc- 
tose added was barren of growth, while with dex- 
trose a strong collection of healthy colonies began 
to grow. In lactose bile enriched with peptone a 
feeble, though constant, growth ensues; proving 
that the inhibitory action of the bile on the Bacillus 
bidgaricus in the small intestine is absent. No gas is 
formed while the bacillus is grown in this bile me- 
dium. No difference as to growth was seen under 
aerobic or anaerobic conditions. Gregoroff states 
that the Bacillus bulk^aricus attacks mannite. sac- 
charose, maltose, and lactose, but not rhamnose, 
dulcite, or sorbite. Cohendy observed the active 
fermentation of lactose, maltose, saccharose, levu- 
lose and particularly dextrose. Bertrand and 
Duchacek state that the "'carbohydrates" fermented 
by the Bacillus bidgaricus are dextrose, mannose, 
galactose, saccharose, levulose, and lactose, while 
arabinose, zylose, and sorbose are not changed. 

Enaymes. — The addition of calcium carbonate, 
calcium chloride and zinc chloride in excess of the 



with an acid activity of from one to 3.6 per cent, in 
twenty-four hours upon sweet milk. 

In the preceding description of the Bacillus bid- 
garicus its action upon sugar, with the formation 
of lactic acid, is indicated. In diabetes the carbo- 
hydrate radicle is attacked in the intestinal tract 
by this bacillus and converted into lactic acid. The 
necessity for starch as a food is well known, and if 
digestion is unable to break down the molecules of 
starch, in glycosurias it is harmful. But by this 
action of the Bacillus bnlgaricns this much needed 
carbohydrate may be taken with little, if any, ex- 
cess of sugar appearing in the urine. This chemi- 
cal reaction is of great importance when the normal 
combustion of sugar in the alimentary tract is at 
fault, and if we are able to continue the use of an 
active culture aid is given the pancreas and liver 
to complete the carbohydrate digestion. When the 
pancreas receives weak stimulation by the lack of 
a normal C|uantity of secretin forming, as a result 
of a low gastric acidity, the potency of this bacillus 
to make lactic acid is of value in further stimulat- 
ing the duodenum and upper portion of the small 
intestine. The antiseptic and corrective power of 
the bacillus, by overcoming autointoxication and 
all conditions of intestinal putrefaction is very 
marked. Its distinct action in attacking the hosts 
of intestinal flora and the chemical action of the 
lactic acid upon the waste products such as indol, 
skatol, zanthin, and hyperzanthin, may possess, ac- 
cording to Professor Belonowsky, a still gfreater 
cleansing influence by an active product created 



URINE ANALYSES.' 

Diacetic Renal 

1912. Sp. Gr. Reaction. Indican. acid. Acetone. Albumin. Urea. Sugar. Casts. 

August 10 1.037 overacid normal none none none 1-5% 4-5% none 

August 23 1.036 acid, normal small amount none none none 1.1% 5.2% none 

August 31 r.031 overacid normal none none none 1.2% 3-9% none 

November 20 1.046 overacid normal none none none 1.6% 8.2% none 

December 3 1.034 overacid small amount none none none 2.4% 2.6% nope 

December 11 1-037 overacid normal none none trace 1.4% 4-9% none 

December jo 1.036 acid, normal normal none none trace 2.1% 3.6% none 

1913- 

January 3 1.027 acid, normal normal none none none 1.4% 2.8% none 

February 17 1.024 overacid normal none none none 2.0% 1.7% none 

March 18 1.038 overacid normal none none none 1% 2.4% none 

'Last three urine analyses made at French Hospital; sugar in each report, trace only. 

amount required to neutralize the acid production, during the proliferation of the bacillus. He posi- 
to prevent the coagulation of milk, failed. This tively asserts that this substance continuss exercis- 
might argue for the presence of an enzyme. ing a protective influence against reabsorption. 
Acids Produced. — From a five day culture Ber- The action of this culture is never manifested un- 
trand and Weissweiller isolated lactic acid bv less the microorganisms are viable when admin- 
means of the zinc salts and conclude that the acid istered. 

formed was a mixture of the levo and dextro report of cases. 
modifications, with a predominance of the latter. Case I. Mrs. A. M., Portland, aged forty years. mar- 
Besides lactic acid, acetic, formic and succinic "e^*- ^^^ children. Thin weight 120 pounds slightly 
-J, , J ii.ji T, ^ jTw- neurotic: mentahty low. Slept poorlv : arose from five 
acids have been demonstrated by Bertrand, Weiss- jg ^even times to void urine. Appetite poor. Severe 
weiller and Duchacek. Heinemann finds that the chronic constipation. Polyuria; painful menses; slight 
volatile acids constitute 5.8 per cent, to 6.1 per cent. vaginal discharge; prurittis Heart, normal; liver readily 
of the total aciditv palpable; stomach, no dilatation. Complained of severe 
n ., ■ ■. ' n'l r> -H 7 ; • • shooting pains in legs, burning and itching of vulva, head- 
Pathogenicity.— \\k Bac.'lus bidgaricus 1S_ non- ^^^e, excessive thirst, and constant desire to micturate: 
pathogenic to man or the usual laboratory animals. eyesight impaired; loss of appetite and inability to sleep. 
No untoward effects have been observed following Treatment: Patient difficult to control, going back home 
the ingestion of large amounts of this culture. during September and October; then returned with 8-fper 
rp. ° ,. r .tu o -71 1. ; • 1 J cent, sugar. Improved somewhat symptomatically. but a 
The cultures of the Bacillus bidgaricus employed ....g^e uncontrollable pruritus developed- Finallv, took 
by men are grown upon a modified Cohendy medi- her to the French Hospital and kept her under close ob- 
um, which from time to time I have had examined servation. A trace of sugar present upon her discharge, 
in reference to the puritv and viability of the or?an- Weight 1255^ pounds Modified diet; from four to six 
u 4.U r^ u- ' i-i, J i-u ^ tubes of culture used daily. Sodium bicarbonate, pan- 
ism by the Gram positivemethod. the average count ^^^tj^ ferments, and salol. Prognosis, excellent; no 
being 285.000.000-I- positive per cubic centimetre, pruritus. Discharged April 15th, without symptoms. 



July 12. 1913. J 



BEyERIDGE: TREATMENT OF DIABETES. 



Case II Mr. A. W. K.. contractor, aged twenty-nine 
years, married. Stout, weight i67'4 pounds : very neuro- 
tic : mentality medium. Slept well ; appetite good ; con- 
stipated chronically. Urine amount, from seventy to 
eiglity ounces; arose once at night. Habits moderate. 



mm. Hg. Complained of drowsiness, loss of vision, cramps 
in the legs, and severe thirst. Constant headaches with 
polyuria. Treatment: Modified diet; four tubes daily 
Bacillus bulgariciis. Last seen August 30th ; condition 
greatly improved; weighed i88'A pounds; amount of urine 



UKINE ANALYSES. 



1912. Sp. Gr. 

July 7 I.02J 

September 27 1.021 

October i 1.017 

October 14 1.017 

October 28 1.017 

November 15 1.012 

November 18 1.023 

December 19 1.027 

1913- 

January 13 1.012 

February 20 1.017 

February 22 1.021 









Diacetic 










Renal 


Kc.iction 




Indican. 


acid. 


.Acetone. 


Albumin. 


Urea. 


Sugar. 


casts. 


acid 




none 


none 


none 


trace 




0.12% 




acid, norr 


nal 


small amount 


none 


none 


none 


2% 


reduced 


none 


acid 




none 


none 


none 


trace 


I.6f% 


none 


none 


acid, norr 


n.il 


normal 


none 


none 


none 


1.1% 


1.10% 


none 


acid 




small amount 


none 


none 


none 


1-57% 




none 


acid 




normal 


none 


none 


none 


1.33% 


none 


none 


acid, norr 


nal 


small amount 


none 


none 


none 


2.4% 


none 


none 


overacid 




small amount 


none 


none 


none 


2.8% 


none 


none 


alkaline 




normal 




none 


none 


1.25% 


none 


none 


acid 




normal 




none 


none 


1.65% 


none 


none 


acid, normal 


small amount 


none 


none 


none 


2.2% 


none 


none 



Family history ; mother had diabetes ; report as to father 
negative. Previous history : diseases of childhood ; dia- 
betic state one year and a half. Heart, normal; liver, not 
enlarged; stomach, slightly dilated. Pulse lOO. blood pres- 
sure 160. October 29th. Pulse 90, blood pressure 148 
mm. Hg. ; complained of severe headaches; constipation, 
malaise; considerable loss of weight, from 215 pounds to 
^67'A pounds ; indigestion. Physical condition good ; pa- 



voided in twenty- four hours, forty-two ounces; no pains 
noted. On normal diet; discharged. 

Case IV. Dr. F. P. K., Brooklyn, aged forty-nine years, 
married. First seen September 13. 1912. Stout, pendulous 
abdomen, weight I79j4 pounds; slightly neurotic; men- 
tality high. Slept poorly : arose from three to four times 
each night to void urine; polyuria. 105 ounces daily. Ap- 
petite good ; markedly constipated ; habits moderate : ar- 



URI.NE ANALYSES. 



1912- Sp. Gr. 

July 12 1.046 

July 25 1.031 

July 29 1.026 

August 8 1 .022 

Augu^ 15 1.031 

.August 30 1.026 







Diacetic 






Keaclion. 


Indican. 


acid. 


Acetone. 


.Albumin 


acid, normal 


small amount 


none 


absent 


none 


overacid 


small amount 


none 


absent 


none 


acid, normal 


normal 


none 


absent 


trace 


acid, normal 


normal 


none 


absent 


none 


acid, normal 


large amount 


none 


absent 


none 


overacid 


normal 


none 


absent 


none 



1.7% 





Renal 


Sugar. 


casts. 


7-4% 


none 


1.2% 


none 


0.1% 


hyaline 


none 


none 


none 


few 


none 


none 



tient inclined to overeat: n trition excellent. Treatment: 
Three tubes of culture daily; pancreatic ferments; sodium 
bicarbonate ; modified diet. To-day. regular diet, one tube 
every other day. No symptoms ; weighed 176^ pounds. 
Prognosis, positive recovery; discharged. 

Case III. Mr. H. B., aged thirty-eight years, married. 
First seen July 17, 1912. Stout, pendulous abdomen; men- 



teries hard. Family history negative. Previous history; 
rheumatic attacks, sore throat, occasional periods of indi- 
gestion; otherwise negative. First noticed diabetic condi- 
tion in February, 1912. Heart, faint presystolic murmur, 
on percussion somewhat enlarged; liver, easily palpable; 
stomach, lower border of greater curvature found just 
above umbilicus. General condition good; skin moist; 



UKINE ANALYSES. 



1912. Sp. Gr. 

September 14 1.032 

September 25 1.03 1 

October 3 1.034 

October 10 1.030 

October 25 1.036 

November 11 1.033 

November 16 1.034 

November 23 1.032 

December 3 1034 

December ii 1.031 

December 18 1.036 

December 27 1.036 

1913- 

January 6 1.028 

January 15 1.029 

January 29 1.036 

hebruar)' 11 1.027 

February 19 1.027 

March 5 1.028 

April 17 1.025 







Diacetic 










Renal 


Reaction. 


Indican 


acid. 


Acetone. 


.Albumin. 


Urea. 


Sugar. 


casts. 


acid, normal 


small amount 


none 


absent 


trace 


0.4% 


4.9% 


none 


acid, normal 


normal 


none 


absent 


trace 


1.2% 




none 


acid, normal 


normal 


none 


absent 


none 


0.5% 


S.1% 


none 


acid, normal 


normal 


none 


absent 


trace 


05% 


4-9% 


none 


acid 


small amount 


none 


absent 


trace 


0.0% 


4-49'o 


none 


acid, normal 


normal 


none 


absent 


trace 


1.0% 


5.6% 


none 


acid, normal 


^mall amount 


none 


absent 


trace 


1.6% 


5-3% 


none 


acid 


normal 


none 


absent 


trace 


1.2% 


1.9% 


none 


acid, normal 


small amount 


none 


absent 


trace 


1.8% 




none 


overacid 


small amount 


none 


absent 


trace 


1% 


29% 


none 


acid, normal 


large amount 


none 


absent 


trace 


1.8% 


3-7% 


none 


acid, normal 


normal 


none 


absent 


trace 


1% 


4.7% 


none 


acid, normal 


normal 


none 


absent 


present 


i.zTc 


3-8% 


none 


acid, normal 


small amount 


none 


absent 


trace 


1.6% 


2.9% 


none 


acid, normal 


small amount 


none 


absent 


trace 


I ^f. 


2.1% 


none 


acid, normal 


normal 


none 


absent 


trace 


1.6% 


3.2% 


none 


acid, normal 


small amount 


none 


absent 


trace 


1.2% 


1.9% 


none 


acid, normal 


normal 


none 


absent 


trace 






none 


acid, normal 


normal 


none 


absent 


trace 


i.eTc 


0.1% 


none 



tality high ; slept too much ; appetite good ; constipated ; 
weight 179 pounds. Urine increased in amount ; during 
twenty- four hours, 126 ounces. Family history negative 
Rheumatic attack four years previous. Inclined to indi- 
gestion from over eating: heart normal: stomach dilated; 
liver slightly hypertrophied. Pulse 81. blood pressure 140 



bodily nutrition excellent : tongue heavily coated. Pulse 
91, blood pressure 165. Complains of severe thirst, con- 
siderable loss of weight, polyuria, excessive micturition, 
drowsiness, loss of ambition, disinclination to work, 
cramps in calves of legs, and great weakness. Treatment: 
Modified diet; from four to six tubes culture daily: so- 



UKINE ANALYSES. 



191J. Sp. Gr. 

July 23 1.046 

August 5 1.044 

•August 20 1.044 

.August 21 1.043 

September 5 1. 041 

September 25 1.049 

October 28 1.046 

Decem.ber 6 -■ 1.042 

December 21 1.042 

1913. 

January 20 1.019 







Diacetic 










Renal 


Reaction. 


Indican. 


acid. 


.Acetone. 


Albumin. 


Urea. 


Sugar. 


casts. 


overacid 


large amount 


none 


absent 


none 


1.1% 


7.4% 


none 


acid, normal 


normal 


none 


absent 


none 


0.8% 


7-4% 




acid, feebly 


small amount 


none 


absent 


none 


0.8% 


7-9% 


none 


acid, feeblv 


small amount 


none 


absent 


none 


0.9% 


6.9% 


none 


iicid, normal 


normal 


none 


absent 


trace 


2.3% 


5-7% 




acid, normal 


normal 


present 


present 


none 


..3% 


7.270 


none 


overacid 


normal 


none 


absent 




1.2% 




none 


acid 


small amount 


none 


absent 


none 


1% 


7-9% 


none 


acid, normal 


normal 


trace 


present 


none 


1.2% 


6.5% 


none 


feebly alkaline 


large amount 


none 


.absent . 


trace . 


:•?•«« ;. 


•-. •, r.6% 


none 



7(> 



M.MVRTRIE: PROSTITUTION IN JAPAN. 



[New York 
Medical Journ; 



diuni bicarbonate, five grains every three hours. Pancrea- 
tic ferments. This had been continued with sHght varia- 
tion ; instead of sodium bicarbonate, calcium chloride was 
occasionally administered. To-day patient's condition is 
practically normal. Diet regular ; no symptoms are pres- 
ent, sleeps all night; voids only from forty-five to fifty- 
five ounces of urine daily; bowels regular; weight i88^ 
pounds; is able to attend to all his professional duties 
without any inconvenience. Result, brilliant. Prognosis 
unquestioned toward recovery. 

Case V. Mr. F. N., aged forty- four years, married. 
Weight 166H pounds; stout; slightly neurotic; mentality 
high; slept poorly; appetite good; chronic constipation; 
some polyuria ; habits moderate. Heart, presystolic mur- 
mur at apex, size normal ; liver, greatly hypertrophied ; 
stomach, dilated; lungs, chronic bronchitis; involvement 
of right apex ; sputum examined ; tubercle bacilli present. 
Pulse 92. blood pressure 140. Family history; mother 
died from chronic nephritis, acute exacerbation; father's 
history negative. Rheumatic attacks during last five 
years ; first noticed present condition three years ago. 
Complained of excessive thirst, great weakness, cramps in 
legs, frequent micturition, severe headaches, and indiges- 
tion. Treatment: Patient inclined every few weeks to 
drink to excess. Acidosis present ; day following given 
from four to six tubes culture daily, with ferments and 
sodium bicarbonate. Glycosuria much improved and dia- 
betic symptoms absent upon last examination, but tuber- 
culous process in lung necessitated sending patient away; 
final outcome in doubt. Prognosis poor; weight 157 
pounds. 

(To be concluded.) 



FURTHER NOTES ON PROSTITUTION IN 
JAPAN. 

Abolition of the Slavery System; Early History of 

the Yoshivi'ara; Illicit Prostitution; Medical 

Inspection and Statistics; Jurisprudence. 

By D0UGL.\S C. MCMURTRIE, 
New York. 
I. 
The abolition of the absokite slavery of prosti- 
tutes in Japan took place in 1872, and was due more 
to chance than to any conscious demand on the 
pait of the people. In fact, the indirect effect of 
foreign influence was the most potent factor. A 
ship loaded with slaves bought in China stopped 
at Yokohama harbor on account of a storm at sja, 
and while it was at anchor one of the slaves jumped 
overboard and swarn to an English warship which 
was lying close at hand. The captain of the w.ir- 
ship reported the matter to the authorities and re- 
quested that the slaves be released, as the dealing 
in human flesh was contrary to the standards and 
principles of civilized countries. As at the time the 
Japanese government considered it most essential 
to maintain cordial relations with the civilized na- 
tions, the ship was detained and the captain was 
ordered to release the cargo of slaves. The cap- 
tain, however, filed a protest, and when the matter 
came up for decision before a special court, he pre- 
sented a copy of a contract or bill of sale of a girl 
then serving as a prostitute in the city of Yi^ko- 
hama. He claimed that he could not be interfered 
with because the sale of human beings was permitted 
by the Japanese authorities themselves. The court 
was much perplexed by this development and pust- 
poned the case. ^\'hen the matter came up for final 
hearing the court ruled that traffic in human beings 
was not legal in Japan, and that the reason such a 
traffic existed was because no one had appealed to 



the courts to prohibit it. In the case in point the 
law had been invoked, and the court maintained that 
it had the power to order the release of the slave 
cargo. The order was issued and executed, and the 
enslaved Chinese were sent back to China. Soon 
after, an order emanated from what then corre- 
sponded to the Department of Home Affairs, eman- 
cipating all women held imder contract for immoral 
purposes. An order from the Judicial Department 
followed, protecting the released women by enjoin- 
ing the courts from entertaining suits against them 
for debts due their masters.^ 

The actions already described abolished the legal 
status of the practical enslavement of prostitutes. 
The present system was established, the term for 
licensed houses being changed to kashi::ashiki or 
"parlor renting." Persons desiring to conduct 
brothels were required to locate in the section desig- 
nated by the authorities, and on receiving the neces- 
sary permit, they were expected to rent their rooms 
to women licensed by the police to ply their trade 
as prostitutes. Actually, however, the system has 
worked out far differently, and the original plan 
is adhered to only nominally. By making an ad- 
vance payment or loan the keepers of the houses 
executed contracts with the prostitittes securing 
their services for a specified term. At first this 
latter was generally set as three years. By this 
means most of the former ininates of the houses 
were released. "; 

II. 

In a previous article" I have referred to the peti- 
tion of 1612 of the brothel keepers of Yeddo 
(which was the old natne for Tokyo) for the es- 
tablishment of a special segregated quarter. The 
reasons given in this petition^ are of considerable 
interest in tracing the history of the \oshizvara. 
.A.fter ca'ling attention to the fact that such quar- 
ters already existed in other localities, it goes on to 
state that "houses of ill fame abound in everv part 
of the city, being -scattered hither and thither in all 
directions. This, for numerous reasons, is detri- 
mental to public welfare and morality." The rea- 
sons given are as follows: 

I. As matters stand at present when a person 
visits a brothel, he may hire and disport himself 
with yiijo to his heart's content, and give himself 
up to pleasure and licentiousness to the extent of 
being unable to discriminate as to his position 
and means and the neglect of his occupation or 
business. He may frequent a brothel for days, 
giving himself up to lust and revel, but so long as 
his money holds out the keeper of the house will 
continue to entertain him as a guest. As a natural 
consequence, this leads to the neglect of duty to- 
ward masters, defalcations, theft, etc. ; even then 
the keepers of the brothels will allow the guilty 
guests to remain in their houses as long as their 
money lasts. If brothels were all collected into one 
place a check would be put to these evils, as, by 

*For the record of this incident I am indebted to a small book 
entitled The Social Evil in Japan, by U. G. Murphy. This was 
issued from Nagoya. Japan, and is practically unavailable ill this 
country. The material, however, is unique and of very considera- 
ble interest in throwing light on some phases of prostitution in the 
island empire. 

=Uouglas C. McMurtrie. Prostitution in Japan. New York 
Medic.\l Journal, 1913. xcvii, p. 27S-281. 

"S. C. Martin. Jr., Prostitution in Japan. American Journal ot 
Dermatology and Genito-Urinary Diseases, St. Louis, 1903. vii. p. 



July l;:, 19U.J 



McMURTRIll: PROSTITUTION IN JAPAN. 



77 



means of investigation and inquir}-, a longer stay 
than twenty-four hours could be prohibited anil 
such prohibition enforced. 

2. Although it is forbidden by law to kidnap 
ciiildren, yet, even in this city the practice of kid 
napping female children and enticing girls away 
from their homes under false pretenses, is being 
resorted to by certain vicious and unprincipled ras- 
cals. It is a positive fact that some evil minded 
persons make it a regular profession to take in the 
daughters of poor people under the pretext of 
adopting them as their own children, but when the 
girls grow up they are sent out to service as con- 
cubines or prostitutes, and in this manner the in- 
dividuals who have adopted them reap a golden har- 
vest. Perhaps it is this class of abandoned rascals 
that even dare to kidnap other people's children. 
It is said to be a fact that there are brothel keepers 
who engage women, knowing perfectly well that 
they are the adopted children of the fTarties who 
wish to sell the girls into prostitution. If the pros- 
tutc houses were all collected into one place, strict 
inquiries would be made as to the matter of kidnap- 
ping and as to the engagement of adopted children, 
and should any cases occur in which such reprehen- 
sible acts were attempted, information would be 
immediately given to the authorities. 

3. Although the condition of the country is 
peaceful, yet it is not long since the subjugation of 
Mino province was accomplished, and consequently 
it may be that there are many ronin prowling about 
seeking for an opportunity to work mischief. 
These ruffians have, of course, no fixed place of 
abode and simply drift hither and thither ; so it is 
impossible to ascertain their whereabouts in the 
absence of properly instituted inquiries, even al- 
though they may be staying in houses of ill fame 
for a considerable number of days. If the authori- 
ties grant this petition and permit the concentration 
of the existing brothels in one regular place, the 
brothel keepers will pay special attention to this 
matter and will cause searching inquiries to be 
made about persons who may be found loafing in 
the prostitute quarters, and should they discover 
any suspicious characters they will not fail to report 
the same to the authorities forthwith. 

It will be deemed a great favor if the august au- 
thorities will grant this petition in the fullness of 
their magnanimous mercy. Another factor bear- 
ing on the segregation system was the attitude of 
the army authorities who favored it. It is related 
by Maget* that, about 181 5, Yorimoto organized th • 
first imperial standing army, and the divisions were 
stationed at various points, notable at Kamakura, 
Osaka. Kyoto, and Nagasaki. In order to protect 
the public from annoyance, Yorimoto segregated 
and regulated prostitution in the vicinity of the 
garrisons. 

The inmates of the Japanese houses are known" 
by various terms: Orian. or wife for an hour, is 
the least derogatory ; shogi, or prostitute, the com- 
mon appellation : joro. or harlot, implying the 
shatne of her calling; and yujo, or daughter of 

*G. Maget, La Prostitution au Japon. Annates d'hygUne, Pari^. 
1878. I fi878. second series), pp. S'S- 

'See Vr. S. Krauss. Das GeschlecUtsleben in Glauben. Sitte, utt.l 
Brauch der Japaner, Leipzig, 1907. Also .Albert S. Ashmead. Pros- 
titution in Japan. .American Journal of Dermatology and Genito- 
urinary Diseases. St. Louis, 1903, vii, p. 167. 



joy. corresponding to the I'Vench idiom Mc de joie. 
In addition to the citations alrcidy made it may he 
mentioned that general descriptions of the yuslii- 
ivara and it- history have been given by Ilintze" and 
Matignon.' 

III. 

Legalizing prostitution in jainin lias not settled 
the question, and there has always been a large 
amount of clandestine or illicit prostitution. In 
Tokyo in 1722 the latter had grown to such con- 
siderable proix)rtions that a proclamation' was is- 
sued by the governor of the city. The text of this 
was as follows : 

Whereas secret prostitution has been prohibited in the 
wards of this city, and whereas it appears that the prac- 
tice has been carried on in an audacious manner, it is 
hereby ordered that henceforth secret prostitutes shall be 
treated as follows : 

1. The person harboring secret prostitutes will be or- 
dered to yield up to the government his ground lot. fur- 
niture, house, and Rodown. and the woman oflfending shall 
herself have her furniture seized, and for the space of 
100 days shall be manacled with irons and committed into 
the custody of the responsible parties of her ward, an of- 
ficer being detailed off to visit the house every other day 
to inspect the seal on her manacles. 

2. The owner of grounds and houses in which secret 
prostitution takes place shall be held in the same penal- 
ties, even although he is not living on the premises, but 
only represented by a caretaker. The caretaker shall have 
all his furniture seized, and shall be manacled for a period 
of 100 days, during which period he will be committed into 
the custody of the responsible parties in his ward, and 
every other day the bonds shall be examined and the seals 
inspected. 

Three days after this date the appointed officials and 
yoshiwara authorities will proceed to search for persons 
carrying on illicit prostitution, and if those persons are 
apprehended they will be dealt with as stated above. 

Persons harboring offenders may be punished with ban- 
ishment or death, and, moreover, the members of the ward 
who are responsible for the parties may be likewise pun- 
ished, in accordance with the foregoing. Now, therefore, 
take notice, and let this be published throughout the city. 

An additional order was issued in 1876, as fol- 
lows : 

Persons practising secret prostitution and the keepers 
of secret houses used for that purpose shall be punished 
as follows: Principal or accessory: First offense — Fine not 
exceeding ten yen or two and one half months' imprison- 
ment. Second offense — Fine not exceeding twenty yen or 
five months' imprisonment. Keeper of the house: First 
offense — Fine not exceeding fifteen yen or three months' 
imprisonment. Second offense — Fine not exceeding thirty 
yen or t:x months' imprisonment. 

IV. 
Segregation of prostitution was of early origin in 
Japan, but medical inspection was not inaugurated 
until later. Its establishment was largelv the result 
of European influence. .\. memorial asking for 
the abolition of licensed prostitution tells of the 
English Contagious Diseases Acts, and then goes 
on to say that with the view of protecting the sol- 
diers and sailors then in Japan or going there, a 
hospital for the treatment and examination of pros- 

»R. Hintze. VoFhiwar ^ 

Zeitschrift fur Bekampfung de 



1907, VI. 

'J. J. Mati?non. La prostitution au Japon; le quartier du Yoshi- 
ara de Tokio, Archives d'anthropologie criminellc. Lyons and 
6977 IS- 

Prostitution in Japan. American Journal of 
to-Urinary Diseases. St. Louis, 1903. vii, p. 



Paris, 1906, 

"S. C. Martin 
Dermatology and (7. 
:95. 

•The Kyoto Memorial fo 
Japan; addressed to both 
their presidents. Kyoto, 
Journal, Tokyo. 1801, x. p. 



• .\boliti' 
members 
Decembe 



n of Licensed Prostitution in 

of the Impetnal Diet, through 

1890, Sei.i-Kwai Medical 



78 



McMLRTRlIi: PROSTITUTION IN JAPAN. 



[New York 
Mkpicai, Journ. 



titutes was established in Yokohama in 1867. 1 his 
was at the suggestion of naval surgeon Doctor 
Newton. In 1872, under the supervision ot an 
English army surgeon, Doctor Hill, the system was 
extended to Tokyo and also to the open ports of 
Kobe and Nagasaki. Later, in 1876, the govern- 
ment established the system in nearly all the cities 
and prefectures of the empire. 

The regulations of the central government re- 
quire that all prostitutes must be registered and 
examined periodically. The details of manage- 
ment are, however, left to the prefectural offices. 
The local police departments of a prefecture pre- 
scribed a code which is approved by the governor 
and put into force by his order. There is also an- 
other set of regulations made by the keepers of the 
houses for their own guidance and protection. 
Such regulations must be submitted to the police 
authorities, and when approved by them are bind- 
ing on both keepers and inmates. 

When a prefecture desires to license prostitutiun 
the governor makes application to the Department 
of Home .A-ffairs. Upon the granting of permis- 
sion by this authority the prefectural assembly must 
appropriate the funds necessary for the system of 
regulation. The prefectural regulations must be 
con-istcnt with the general code promulgated by 
the Department of Home Afifairs. This code came 
into force in 1900, previous to that time the Tokyo 
city regulations being taken as a guide. 

A translation of the code of regulations issued by 
the Department of Home .\ffairs in 1900 is here 
given : 

Regulations for the Control of Prostitutes. Department 
of Home Affairs Order No. 44. Issued October 2, 1900. 

I. Women under eighteen years of age shall not be al- 
lowed to become prostitutes. 

II. Only those registered as prostitutes shall be allowed 
to carry on the business of prostitution. Prostitutes' reg- 
isters shall be kept in the police stations that have charge 
of the districts in which prostitutes reside. Those regis- 
tered shall be subject to police supervision. 

III. Those who wish to become prostitutes shall make 
application in person to the police station and shall pre- 
sent the following items in writing: i. Reasons for be- 
coming a prostitute. 2. Age. 3. Written consent of near- 
est relative in applicant's home. Where there is no near 
relative, consent of the head of the family in which the 
applicant is domiciled; where there is no one to give con- 
sent, explain reason. 4. In the case of minors, in addition 
to the loregoing, written consent of real father, consent 
of mother; where there is neither father nor mother, con- 
sent of -.eal grandfather; where there is no grandfather, 
consent of real grandmother. 5. Place of business. 6. 
Domicile after being registered. 7. Present trade. In 
case of being supported by others, give particulars. 8. 
Whether applicant has ever served as a prostitute before. 
If so. give date of beginning and cessation of business, 
place of business while a prostitute and reason for cessa- 
tion of business, g. In addition, give all particulars re- 
quired by prefectural regulations. Application must be 
accompanied by a copy of the family registry, and r.ttested 
consent of persons mention d in .-Xrticles 3 and 4. 

All applicants must pass a physical examination before 
being enrolled. 

\y. Prostitutes who have been ordered to cease busi- 
ness shall be dropped from the prostitutes' register. In 
all other cases erasure from the official register shall take 
place only upon the application of prostitutes in person; 
provided that in the case of minors the persons named in 
Section III, .Articles 3 and 4. may make the application for 
erasure. 

V. Requests for erasure from the prostitutes' register 
may be either written or oral. Such requests shall not be 
entertained by the police unless made in person at the 



police station. Exceptions sliall be made, however, in the 
case of requests sent by mail or messenger when the police 
believe there are reasons that the applicant cannot appear 
in person. As soon as requests for erasure have been ac- 
cepted by the police the name of the prostitute making the 
request must be stricken from the register. 

VI. No person whatsoever shall be allowed to inter- 
fere with a request for erasure from the official register. 

VII. Prostitutes shall not reside outside of the districts 
determined by prefectural regulations. They shall not go 
out of ihe brothels except by police permission, unless it is 
in obedience to official order or to visit the police station, 
provided, however, that exceptions shall be made where 
prefectural regulations specify certain limits within which 
they may go out. 

VIII. Prostitution shall be carried on only in brothels 
which have official permits. 

IX. Prostitutes shall submit to the physical inspection 
provided for in the prefectural regulations. 

X. When the physicians or hospital authorities appointed 
by the police decide that a prostitute is suffering from 
contagious diseases or from any complaint that renders 
her unfit to receive guests, she shall cease business and not 
be permitted to resume until she has recovered and passed 
a physical examination. 

XI. The police authorities may refuse to register ap- 
plicants for prostitution. The prefectural authorities may 
suspend or prohibit prostitutes' business. 

XII. N^o person whatsoever shall obstruct the liberty of 
prostitutes in regard to correspondence, privilege of meet- 
ing people, reading literature, purchase and possession of 
necessary articles, or in any way interfere with their lib- 
erties. 

XIII. Persons committing the following named offenses 
shall be liable to a fine of twenty-five yen or imprisonment 
for twenty-five days: i. Making false statements to se- 
cure the registry of prostitutes. 2. Violating Sections VI, 
VII, IX, and XII. 3. Violating Section VIII and causing 
prostitutes to ply their trade outside of licensed brothels. 
4. Violating Section X and compelling diseased prostitutes 
to lesume work before passing official inspection. 5. Vio- 
lating suspension order of Section XI and compelling 
prostitutes who have had their business suspended to ply 
their trade. 6. Causing the registry or erasure of regis- 
try of prostitutes against their will. 

XIV. In addition to these regulations such other mat- 
ters as may be deemed necessary shall be determined by 
prefectural regulations. 

XV. Prostitutes who are already serving when these 
regulations go into effect shall be regarded as having been 
officially enrolled. 

The physical inspection referred to in Section 
IX is performed by designated physicians and 
occurs on the average of once every week.'" A 
special police officer enforces the examination when 
necessary. The inspection whenever possible is 
arranged for a day following the weekly holiday. 
Such prostitutes as are found to be suffering from 
venereal disease are sent to a special segregated 
hospital. In places where the number of prostitutes 
is small the examination is conducted by some phy- 
sician under police permit, and the girls are detained 
in a part of some local hospital. Cases of ordinary 
illness may be treated either at the home of the 
keeper or in ordinary hospitals, but in each case 
police permission must be secured. ^^ The length 
of detention in the segregated hospital varies with 
the nattire of the complaint and the strictness of 
the physician in charge. 

In 1899 fhe chief medical officer of the Japanese 
navy, Dr. Tatsurabo Yabe, alarmed at the increase 
of venereal disease, issued a plea for more stringent 
supervision and inspection of prostitution in the 

^"Albert S. Ashmead. Prostitution in Japan. American Journal 
of Dermatology and Genito-Urir.arv Diseases, St. Louis, 1903, vii, 
p. 167-168. 

'*IJ. G. Murphy. The Social Evil in Japan. Nagoya. 1906, p. S. 



July 12, 1913.] 



Mi-Mr hTRIE: PRUSTITUTION IN JAPAN. 



79 



seaports. He presented'- facts as lolluws: In i8<)ii 
in the whole country there were 43,570 registered 
prostitutes, and tlie number of medical examina- 
tions made during the year was 2,030,267. There 
were detected 8,856 cases of syphilis and 61.004 
cases of gonorrhea. Of course, a great number of 
the latter were relapses or reinfections. In Toky. ■ 
the number of cases of venereal disease in propor- 
tion to the total examinations made was seven in 
100. These figures, according to Doctor Yabe. 
show the necessity for rigid sanitary supervision. 
That venereal disease is more prevalent among 
sailors than among landmen is, he states, due in 
part to the frequency of clandestine prostitution in 
seaport towns and in part to the special character of 
a sailor's life. In the Japanese navy a sailor suffer- 
ing from venereal disease is forbidden shore leave, 
so that he cannot transmit infection to others. 

In 1806, during the year, 157.5 '"^'i '1 i-OOO in 
the navy contracted venereal disease. The total 
days of disability from all causes in the year was 
196.825. and of these 85,867, or over forty por cent, 
of the total, were due to venereal causes. 

In Japan the system of prostitution is entrenched 
more firmly than in almost any other country. An 
anonymous English author quoted by Buschan" 
places the number of houses of prostitution 
throughout the empire at 20,000 and the number of 
women employed in them at between 4CXD.000 and 
500,000. Buschan also notes with surprise that the 
houses are often the handsomest in a city, that they 
are located in proximity to temples, and that they 
have almost the status of public institutions. 

The figures just named are probably exaggerated 
to a large extent. The official figures for the year 
i8g6 show'* the average number of prostitutes in 
Japan to have been 43,570, but this was only the 
number who were registered and subject to actual 
medical inspection. The actual number of women 
engaged in prostitution was, of course, much 
larger. Murphy'' quotes figures gathered by him 
from the various prefectural offices. The number 
in 1896 (39.068) is but slightly lower than the one 
just given, and this difference might be expected. 
The other figures obtained by the same method are 
as follows : 



5S,2 5. 



iSS;.. 


••27,559 


10,326 




i8q6.. 


.•39,068 






"S'r- 


••47,055 


26,532 


6,836 


1898. . 


••50,553 


27,386 


6,720 


1S99.. 


.•52,410 


29,129 


8,139 


1901.. 


..40,195 


30.019 


3,430 


1902.. 


■.38,676 


28.130 


4,755 


1904. . 


• 42,502 


26,226 


1,049 


1906. . 


••44-542 


29,552 


7,200 



r- -O.J 
39,069.691 
43,288,863 



28.048 
28,817 

25.568 

21,076 

37,6li 

48,533.000 

'This classification includes only registered and licensed prosti- 
tutes. 

-This class is given to immoral practices to a considerable extent 
and must be considered. 

^These figures are very incomplete and are only given to indicate 
what a large degree of prostitution must go on' outside the limits 
set by the license system. The returns for 1897 are from thirty- 
two prefectures only; for 1S98, thirty-two; for 1899, thirty-eight; 
for 1901, thirtv-three; for 1902, forty-one; for 1904, twenty-four; 
and for 1906, forty-five. 

*These figures must also be qualified in consequence of incom- 
pleteness. The returns for 1897 are from thirty prefectures only; 
for 1898. twenty-nine; for 1890. twenty-three; for 1901, twenty-si.x; 
for 1904. twenty, and for 1906. fifteen. 

'The figures for 1887 and 1897 are taken from the statistical re- 
port of the Cabinet. Those for 1006 were furnished bv the secre- 
tary of the Statistical Bureau of the Cabinet. 



In addition to the articles already referred lu 
there have been other medical studies by Japanese 
physicians. Among the latter may be mentioned 
Kurimoto," Matsui," and Tanaka.'* 
V. 

Japanese jurisprudence has, following the exam- 
ple set by other countries, taken as little notice of 
prostitution as possible. Earlier in the present 
article has been described the incident which led 
to the prohibition of the absolute slavery of prosti- 
tutes. But through various devices the system 
lapsed back almost into its fonner state, and the 
status of the prostitutes as far as freedom was 
concerned. Girls who ran away from the bro:hels 
were searched for diligently by the police and if 
found were punished and returned to their keepers. 
It thus became practically impossible for a girl V* 
abandon an immoral life, even should she so desiro. 
In view of this state of afTairs, some American 
missionaries took an interest in the situation and 
endeavored, though unsuccessfully, to induce the 
crown procurator, or attorney general, to take the 
part of such women as wished to get away from a 
life of shame. Failing in this, an effort was made 
to get a test case before the courts. This proved 
impossible, however, owing to the fact that police 
rules are issued by the executive authorities, and 
their validity is not subject to review by the courts. 
The only way to secure the appeal of a regulation 
is to petition the department which has issued it. 
This was manifestly not possible. The law pro- 
vided that prostitutes could cease their business 
provided they made a report to this effect signed 
by the keeper of the brothel. Naturally, as long as 
the girl was of value this signature was impossible 
to obtain. The missionaries then sought to secure 
the freedom of a prostitute desiring to cease her 
trade on the following grounds: i. The contracts 
that bind prostitutes against their will must be de- 
clared null and void, because of the immoral pur- 
pose in^•olved ; 2. even though the financial part of 
the contract be considered as binding, still a person 
cannot be deprived of liberty because of debt, for 
that would constitute slavery : 3, the girl having 
attained adult age, could not be bound by a contract 
made by her father while she was a minor, es- 
pecially when such a contract had the effect of de- 
priving her of her liberty. This case and several 
subsequent ones were delayed and hampered in 
every possible way. The courts and pxjiice were in 
constant conflict, though no one seemed to be much 
disturbed by the situation. For several years 
\arious cases dragged along in the courts and in- 
junctions which were issued from time to time 
were impossible of enforcement. It was not until 
public opinion was aroused, largely through the 

"Tatsurabo Yabe, Necessite d'une surveillance sanitaire sur la 
prostitution dans les portes. id-i-Kwai Medical Journal, Tokyo. 
1899, xviii, No. II, p. 6-12. 

"Buschan. Das Sexuelle in der Volkerkunde. In Moll: Hand- 
t>uch der Sexualtfissenschaflen. Leipzig. IQ12. p. 277-280. The 
third section of this article is on Die Prostitution in der Volker- 
kunde and has several references to conditions in Japan. 

'*Tatsuraburo Yabe. Necessite d'une surveillance sanitaire sur 
la prostitution dans les ports. Hei-i-Kwai Medical Journal, Tokyo, 
1899. xviii. No. II, p. 612. 

"U. G. Murphy. The Social E-AI in Japan. [Nagoyal 1906, p. 
165. 

'•Kurimoto. [The regulation of brothels] Kokka Igaku Kwai 
Zasshi, Tokyo, 1905, p. 769-789. 

".M. Matsui, [The marriage of prostitutes] Kokka Igaku Kwai 
Zasshi, Tokyo, 1904, p. 205-217. 

"S. Tanaka. [ Discussion on prostitution] Iji Kwai Ho Ogata 
HyO'in, etc., Osaka. 1900, No. 98, 4. 



8o 



ESSEMSON: EXOl'HTHALMIC GOITRE. 



[New York 
Medical Journal. 



agency of the ilaily press, that any effective action 
could be taken, and when it was finally arranged 
that a girl could be free to cease her occupation a 
new set of regulations were issued by the Home 
Department. These, which have been quoted 
earlier in the present article, effectually abolished 
the situation which hatl existed. It is interesting 
to note, however, that in the meantime the courts 
and police have consistently avoided any legal 
decisions on the questions involved. 
298 I\1etropoi,it.\n Tower. 



EXOPHTHALMIC GOITRE. 

Report of a Case. 

By S. J. EssENSON, M. D., 

New York. 
Every physician has seen cases of e.xophtlialmic 
goitre, but the symptoms are so numerous and com- 
plicated that each and every case is a study by it- 
self. The excuse for reporting my case is the 
interest of the course of the disease and the various 
predominating symptoms due to thyroidism ; 

Mr. W. W., about forty-six years of age, born in Rus- 
sia; had been in this country about sixteen years, a farmer 
by occupation. He was married to a blood relative and 
two children were born from the union. The older one was 
a girl, mentally defective and having heart disease; the 
younger, a boy, had chronic bronchitis. The previous and 
family history of the patient was of no interest ; there was no 
lues, no tuberculosis, nor any nervous affection of organic 
type, but the members of the family I know were all neuras- 
thenics, and their nervous trouble of a functional charac- 
ter. He had never been addicted to alcoholic beverages. 
but, like most Russians, was a great tea and coffee drinker. 
His goitre affection appeared fourteen years ago; for the 
last f^wo years at least had been almost constantly under 
medical care. For several months in succession he was 
an inmate of a downtown hospital. About six weeks ago 
his wife brought him home, where I saw him the first 
time. lie was very weak; complained of pain in chest 
and abdomen; coughed much and the expectoration was 
bloody; suffered with headache and dryness of the mouth. 
He had no desire for food and had a diarrhea; any food, 
milk, or medicine was vomited about half an hour after in- 
gestion. He voided very little urine; the first twenty- four 
hours of my acquaintance with the patient, he passed about 
eighteen ounces. Uranalysis disclosed only a trace of 
albumin and some phosphates. On physical examination 
I found the following condition : 

On inspection, extreme emaciation ; very marked exoph- 
thalmus; the lids did not cover the eyes when closed, 
especially the upper lids, but vision was apparently unim- 
paired, even though there was a moderate conjunctival 
inflammation. The thyroid gland was symmetrically bi- 
laterally enlarged, but the swelling was not very promi- 
nent. The tongue was coated. The apex beat of the heart 
could be seen at the seventh interspace, rather to the 
right of the sternum. The respiration had a dyspneic 
character; rate about fifty-six a minute. The tempera- 
ture fluctuated between 100° and 103° F., morning and 
evening respectively. 

On palpation, the radial pulse was feeble and frequent, 
between 116 and 120. The artery was hardened and some- 
what incompressible. Arrhythmia was very marked, as nine 
beats could be counted, then it stopped, and was followed 
by t'lilsKS bigcminus. The first one stronger, but lacking 
the character of the arterial wave. On examination of the 
lungs I found an increase of vocal fremitus in the superior 
scapular region. On percussion, the heart dullness was 
increased vertically on the left side. In the pulmonary 
region there was dullness at the apex of the scapular on 
both sides, and scattered areas of dullness between the 
scapulae. The abdomen was tympanitic. On auscultation. 
the most striking feature was the marked intermission of 
the heart beats, the sudden pause followed by two beats. 



the first one of a tinkling quality. The apex beat was 
most distinct to the right of the sternum in the seventh 
interspace. A systolic bruit could be heard, its maximum 
intensity at the apex beat. The pulmonic second sound 
could not be made out with clearness, and the aortic sound 
was not heard, but a systolic murmur could be made out 
at the ensiform appendix. In the pulmonary region the 
respiratory murmur was very feeble, and bronchovesicular 
in quality at the superior and inferior scapular regions. 
Crackling rales were heard on both sides with inspiration, 
resembling crepitant rales. The interne of the hospital 
from which he was brought (where he had been an in- 
mate for several months) told me that such attacks of 
pulmonary congestion with threatening edema had been 
noticed several times. It had been the custom before I 
took charge to allow him to sit up or walk around as he 
pleased; he had no restriction in diet and took great quan- 
tities of fluid. Under proper care and precautions, re- 
stricted diet, perfect rest, and some medication, the patient 
improved. In about ten days his cough and expectoration 
ceased; he had no pain, no tympanitis; his temperature 
fell to 99° F., the pulse to 75-82, and he breathed more 
easily. His urine increased to fifty-five ounces in twenty- 
four hours. In a general way. he looked like a man on 
the road to recovery. The medical treatment consisted of 
tincture of digitalis, in drachm doses, small doses of 
codeine, and occasional intramuscular injections of epine- 
phrin. But the rejoicing of the family over his improve- 
ment did not last long, as in about two weeks he had a 
relapse to his former condition, which I ascribed to an 
error in attendance, as they allowed him to get out of 
bed. In addition he had an altercation over family affairs 
with some of his relatives. I found him one morning 
very weak and his pulse as intermittent as before. There 
was also constant vomiting, so that he could not retain 
any medicine or milk. I had to resort to rectal feeding, 
and gave him caffeine sodium benzoate. fifteen per cent, 
hypodermically. as well as morphine and atropine to keep 
him quiet; but his vomiting ceased only when he was 
given small doses of cocaine hydrochloride, grain .1/24 to 
1/12 every two or three hours. In three days he was able 
to retain fermented milk and in about a week his condition 
was again satisfactory. On the advice of his former 
physician, who had known him for the last fourteen years 
I gave him small doses of an antithyroid preparation, and 
then the pulse fell to 60, and was of a better quality than 
before. The nurse reported to me once that his pulse 
during the night was 30. I then stopped the digitalis for 
a time, but the intermittency became worse than ever. I 
noticed that he would grow weak suddenly, and his pulse 
fall to 50 or 40 and become very feeble. This was clearly 
a sign 0/ dissociation of the auriculoventricular junction, 
either through the hyperthyroidism affecting the bundle of 
His, the vagus or the breast muscle itself, and I warned 
the family that the end might be expected at any time. 
In a few days, however, he regained some strength. The 
last time I saw him alive he was cheerful and the family 
hopeful. They did not believe my prognosis correct; but 
he died during the night, probably in consequence of a 
heart block. 

The greatest interest in this case attaches to the 
condition of the heart, which was produced in all 
probability by the oversecretion of the enlarged 
thyroid. The latter did not effect the nervous sys- 
tem very much. The question in such a case is. If 
the thyroid had been removed by operation or li- 
gation of the thyroid artery been performed, could 
the patient have been saved? 

20 West 119TH Street. 



Treatment of Blepharitis. — \\'ecker. in Paris 
medical for January 2^, 191 3, is credited with the 
following ointment for use in these cases : 

IJ Hydrargyri oxidi rubri....gr. vii ss. (0.5 gramme); 
Liquoris plumbi subacetatis,. .gr. Ixxv (3 grammes) : 

Olei amygdalae expressi 3iiss (10 grammes") ; 

Petrolati 3! (30 grammes) ; 

M. ft. ungiientum. 

Sig. : Rub gently on the lid margins, once daily. 



July 13, 1913] 



UAZEN: ANTERIOR POLIOMYELITIS. 



81 



ANTERIOR POLIUMYliLlTlS; INFANTILE 

SPINAL PARALYSIS; POLIOENCEPHA- 

LOMYELITIS; ACUTE CENTRAL 

INFECTIOUS PARALYSIS.' 

Physical Therapeutics. 

By Charles M. Hazex, M. D., 
Richmond, Va., 

Professor of Physiology', .Medical College of Virginia; Deparluient 
of Physical Therapeutics, .Memorial Hospital. 

A disease causing deformity and death, occur- 
ring sporadically and in epidemics, having an acute 
stage, but mostly known by its paralytic afteref- 
fects; the result of a specific infection; localized 
chiefly in the central nervous system, although 
other organs are involved. The toxemia afT.cts 
parenchyma of heart, liver, kidneys, spleen, and 
lymphoid tissues (Robertson and Chesley). Infec- 
tious material is not found in liver, kidneys, spleen, 
bone marrow (Fle.xner). Bronchopneumonic areas 
occur (Sachs). The statement m.ade above is not 
a definition, but calls attention to prominent feat- 
ures of the subject. 

The names given as a heading are attempts to 
cover the pathological and symptomatic range of 
the disease. .interior poliomyelitis is the term 
which will probably be retained, as it points out the 
chief, but not all the pathology (destruction of 
cells in anterior spinal gray matter) of the average 
case. The second name is faulty because infantile 
patients are few in proportion, the bulk of cases 
including ages up to twelve or thirteen years. 
and patients being sometimes far advanced, one 
sixty-six years old (almost old enough for 
second childhood). The third name is wider 
in its range, recognizing that the pathology 
extends "from the cortex to the sacrum." In 
fact, since the nasal mucous membrane is 
proved to be the chief atrium of the disease and 
this communicates, by means of the lymphatic 
channels which accompany the short olfactory 
nerves, with the cerebrospinal fluid at that end of 
the nen'e axis, it is difficult to understand how any 
part of the central nervous system can escape in- 
fection. \'ariations of this name occur. Holt pro- 
posed to call it epidemic myeloencephalitis. The 
last name, acute central infectious paralysis, is a 
conglomeration which perhaps covers the most 
ground and is sufficiently definite. We may add 
that the extent of the central involvement is shown 
by many cases reported, such as those by Medin 
from Norway and Sweden, of cerebral spastic par- 
alysis due to encephalitis with destruction of cor- 
tical cells. Clarke reports epilepsy resulting in an- 
other case. It is likely, indeed, that we see patients 
with similar conditions more often than is suspect- 
ed. We ought also, since the posterior cord is af- 
fected, to expect, besides motor symptoms, pain, 
hyperesthesia and ataxia. In fact, such a disturb- 
ance of the sensory part of the refle.x arc should 
be important in its efTect upon tone, nutrition, and 
function. Degenerate cells have been noted also 
in Clarke's column (.Strauss). Other results, not 
usually observed, but easily understood from the 
widespread pathology, are spinal accessory par- 

•Read before the Richmond .\cademy of Medicine. March 11, 1913. 



alysis, alrojihic |)araly>is of the head and trunk 
muscles, throat, face, and eyes (Starr), larynx 
(Tetra), and deglutition, edema of the floor of 
fourth ventricle and Sylvian aqueduct, and death 
resulting usually from respiratory paralysis (as 
occurred in one of my cases). 

The varieties of the disease may be considered 
both from the locality of the lesion and from the 
symptoms. Four years ago Wickman proposed to 
distinguish them as follows : 

1. Spinal paralysis (anterior poliomyelitis). 

2. Progressive paralysis, usually ascending, 
Landry's. 

3. Pontine polioencephalitis. 

4. Acute encephalitis, giving spastic monoplegia 
or hemiplegia. 

5. Ataxic form. 

6. Polyneuritic, or multiple neuritic. 

7. Meningitic. 

8. Abortive (with no paralysis resulting). 
Other terms suggested are bulbar poliomyelitis 

(same as pontine encephalitis), the classical, or 
gastrointestinal type (sixty-seven per cent, of all 
cases in California) (Gundrum) : cerebral and 
unclassified are suggested by McClanahan, who 
has chronicled the Nebraska epidemic. Cerebral 
is the same as encephalitis ; there would be some 
doubt about a special ataxic form, and a question 
whether the polyneuritic exists at all, the pain and 
tenderness in these cases being due to posterior 
cord involvement. 

The stages of the disease may be roughly out- 
lined, although no agreement as to their exact di- 
vision has been arrived at. Incubation in inoculat- 
ed animals is from two days to five weeks (Flex- 
ner) and in the human two weeks (McClanahan: 
another statement from the Nebraska epidemic is 
from five to thirteen days). Laborde divides the 
further progress of the disease into initial (acute) 
stage, not over one week ; stationary, from one to 
four weeks ; regressive, from one to six months ; 
chronic, after spontaneous recovery has ceased. 

The question of the infectious period is impor- 
tant ; and while this has been considered to be about 
the same as the acute period, it is better to hold 
this sub jiidice from the standpoint of prophylaxis 
and treatment. The virus is associated externally 
chiefly with nose and pharynx, and the secretion of 
these parts may be scattered as spray or dust (vi- 
rulence not destroyed by drying or ordinary tem- 
peratures), or swallowed and pass through the di- 
gestive canal, or carried on the feet of the domestic 
fly, or transmitted by the bite of the stable fly or 
the bed bug (no other insect being under suspi- 
cion). We should therefore quarantine the patient 
from the moment of exposure to, at earliest, some- 
time after the fever has left. Also, Landsteiner 
and Popper have proved that there are human pas- 
sive carriers, and we must regard anyone with sus- 
picion who has come in contact with the disease. 

The etiology of this disease embraces climate 
only so far as wetness or dryness, cold or heat, may 
influence the vitality of the individual, or lead to 
infection from overcrowding and bad air in cold 
weather. Overwork and fatigue in some cases is a 
factor. A neuropathic heredity is distinctly causa- 
tive. The early age of most patients may be ex- 
plained by accompanying weakness, although, be- 



82 



HAZES: AXTERIOR FOLIOMYELITIS. 



[New York 
Medical Jol-bnai.. 



sides, there may also be favorable lyni[)hatic coii-_ 
ditions in cliildbood ; (central canal of cord is said 
to be open in childhood and this perhaps favors 
ascending type — Kramer). Frost, of the Marine 
Hospital Service, calls attention to possible indi- 
vidual susceptibility, and remarks that only a small 
proportion of those exposed contract the disease; 
that males are in excess, except in earliest years, 
and white children more susceptible than negroes. 
W'eakened condition from other contagions may 
predispose, and tonsillitis, measles, and other dis- 
eases have been occasionally seen in patients with 
poliomyelitis. Malaria and other severe cachexias 
would be favorable. 

The symptoms are those of severe constitutional 
infection, fever, headache, convulsions, vomiting, 
diarrhea (or constipation), sweating, etc., of more 
or less severity. There is a good deal of pain and 
tenderness; when fever disappears, patient is found 
to be paralyzed, nerves showing reaction of de- 
generation ; atrophy and deformity following. 

Treatment should be considered first as to pro- 
phylaxis. Public, domestic, and personal hygiene 
are of first importance. X.'nder the latter comes 
the toilet of the mouth, to which should be added 
the nose and throat. The routine use of suitable 
nonirritating antiseptic gargles and sprays or 
douches and the preservation of these parts should 
be carefully attended to. Menthol has been sh nvn 
to be effective against the virus, and children 
should be taught to use menthol tablets or confec- 
tions once or twice a day. 

The indications in the acute stage are those of 
any infection, as to elimination, support of patient, 
control of symptoms. (Hexamethylenamine is no 
doubt of value. Epinephrin may perhaps have a 
place in reducing local congestion.) Physical ther- 
apeutical methods at this stage are such as apply 
to similar conditions in other diseases. They 
should, however, be more actively applied. Kerr, 
of New York, who furnished Flexner with his first 
material for successful inoculations, proved the 
value of tlie hot pack and the use of hot drinks to 
favor elimination ; also the hot pack tends to re- 
lieve central congestion. Control of vomiting and 
other severe symptoms is favored, and likewise the 
abortion of the disease. A hot enema, followed by 
castor oil, should be given. Porter suggests tliat 
subcutaneous salt solution might be of use during 
this period. While using these methods vigorous- 
Iv, especially at the beginning, the strength and re- 
pose of the patient should be considered. Quiet' 
and a dark room, a single attendant, are in order. 
It is suggested that the patient's position should be 
changed occasionally and that he should not lie on 
the back. Plaster supports applied in slight lordo- 
sis have been used. Cold applications may be made 
over the spine, particularly the lumbar region. 
These active measures are of most value in the 
first twelve hours, during which no food is given, 
and thereafter the diet is to be fluid. The keynote 
to treatment, subsequent to the first twenty- four 
hours, should I>e rest, both motor and sensory. It 
is absolutely contraindicated at this time to begin 
massage or electricity. The use of strychnine 
should be condemned unless vitality of patient de- 
mands It, and its subsequent use in the chronic 



stage, except for short periods, is of doubtful 
value. Morse says, "Rest, not stimulation. Re- 
sults in New York epidemic show futility of too 
early and energetic use of massage, electricity, and 
forced movements." 

As the patient overcomes the acute symptoms 
and fever has ceased and paralysis appears, the 
physical therapeutical programme should be en- 
larged. A very important consideration is to sup- 
port the weakened muscular and joint structures, 
and pillows, cradles, and splints are to be used. If the 
muscles are left unsupported, stretching by gravity 
and nonparalyzed opponents will greatly increase 
atrophy and paralysis. This should be borne in 
mind during the whole subsequent course ; pros- 
thetic and surgical treatment must favor "the posi- 
tion of maximum relaxation" (Silver). Massage 
should be gentle and not too prolonged; fatigue 
must not be produced. Passive motion by an ex- 
perienced operator is of great value. Mechanical 
viiiration is a home method of value : apparatus can 
l-)e installed and relatives taught to apply it. .An- 
other method of home treatment which will greatly 
assist is hot and cold water once a day : the limb is 
steamed with hot cloths for four or five minutes 
and then cold water for an equal period is poured 
or nibbed over it. Circulation and reflex action are 
thus stimulated. 

Properly chosen electricity is of great value. The 
use of faradism is fraught with danger, unless well 
understbod; it is like strychnine, overstimulating. 
The object of electrical treatment is to improve the 
life of muscle and nerve, its vegetative function, 
nutrition, and metabolism ; this can be done with- 
without stimulating the nerve to manufacture en- 
ergy or the muscle to contract. The current of 
choice in my opinion and experience is that de- 
rived from the static machine, the unipolar continu- 
ous first, and later the bipolar continuous. The 
patient can take the static current as soon as well 
enough to be in a roller chair, for a short period, 
five minutes at first — remembering that fatigue may 
be produced by sitting up and being moved about 
too much. In case the static cannot be had, the 
next preference is the galvanic. A third choice is 
the unipolar high frequency vacuum tube current : 
this has some of the properties of the bipolar cur- 
rents (static and galvanic) and can be regulated 
so as not to be too stimulating. Electricity and 
massage should alternate. 

The majority of cases are seen after the chronic 
condition has begun. The orthopedic surgeon has 
as a rule been consulted. Physical therapeutics are 
now of the utmost value, it being recognized that 
"preliminary treatment must be instituted to deter- 
mine the degree and extent of the paralysis and to 
put the part in the most favorable condition." Sub- 
sequent prosthetic and surgical treatment is to be 
carefully chosen and physical therapeutics contin- 
ued. Parents should be taught that the child is to 
be especially cared for during all the years until 
growth is attained, the object being to preserve 
general health, keep the spine straight, and help 
paralyzed limbs keep up with the rest of the body. 
Besides electricity, given three times a week for 
three weeks at a time and then resting three weeks, 
careful direction of physical exercise and reeduca- 



July 



.9..1.I 



ORMSBV: NEOSALVARSAK IXJLCTIUX. 



83 



tioii of imiscles will be important. Results of 
thirty-nine cases in the regressive and chninic 
stages, treated during the last two years in my 
clinic, have demonstrated the value of the methods 
outlined above. 

CONCLUSIONS. 

Treatment of this disease and its results should 
embrace : 

1. Prophylaxis; mouth and throat hygiene, 
toothbrush, nonirritating douche and gargle, men- 
thol preparations. 

2. Rest, in acute stage, and prevention of fatigue 
at all stages. 

3. As af tertreatment ; prosthetic appliances, pas- 
sive motion, massage, electricity, hydrotherapy, 
mechanical vibration, exercise. 

4 Prevention of crooked spine and keeping up 
function and growth in damaged members ; reedu- 
cation of ner\e and muscle. 

5. Preparation for suitable surgical measures ; 
continuance of treatment after surgery. 

REFERENCES: 
J. J. NUTT: Orthopedics in Early Stages. New Vi.rk Medical 
JOURN.\L, February 29, 1908. McCL.AN.AHAN ; Nebraska Epidemic, 
Journal of the American Medical .4Moci(i(iOB, liv, January, 1910. LE- 
GR.AND KERR: Physical Therapeutics, Long Island Medical Jour- 
nal, November, 1909. ROBERTSON and CHESLEV: Pathology, 
Journal of the American Medical Association, Iv. September, 1910. 
l-Lt.XNEK: Mode of Infection, Ibidem, October 18, 1912. H.\ZEN: 
Certain Currents, Old Vomtnion Medical Journal. January, 1911. 
-MORSE: Poliomyeloencephalitis, Boston Medical and Surgical Jour, 
nal, January 12, 1911. DAVID SILVER: Treatment, Journal o> 
the American Medical Association. \v. September. 1910. 



NEOSALVARSAN. 
Intramuscular or Intravenous? 



By Robert Ormsey, 
New York. 



M. D., 



'"Under which king, Benzonian ; speak or die. " 
Though things may not be altogether as bad as that 
yet, I must admit that I never gave an intravenous 
injection of salvarsan without to a certain and a 
very appreciable extent feeling disturbed. It cer- 
tainly always appeared to me that I was playing 
with edged tools, and, from my point of view, if 
any disaster occurred to my patient I would feel 
morally responsible if not actually so. I am now 
speaking of the injection of salvarsan (in contra- 
distinction to neosalvarsan), but since the intro- 
duction of the latter I have abandoned the use of 
salvarsan altogether, either intramuscularly or in- 
travenously. I used salvarsan intramuscularly onl\ 
a few times, and when I saw the direful effects 
which were produced I quickly abandoned that 
method in favor of the intravenous route. As T 
said before, I never performed the operation intra- 
venously without some trepidation, yet I was will- 
ing to "iindergo the anxiety and worry incident to 
that operation rather than run the risk incurred b\ 
injecting salvarsan intramuscularly. 

With the discovery and introduction of neosal- 
varsan the whole aspect of affairs was changed — 
neosalvarsan, introduced either intravenously or in- 
tramuscularly, became more or less a matter of daily 
routine, and on account of its safety became a safe 
and sane remedy, with none of the gruesome char- 
acters of salvarsan. When we remember the amount 
of detail and care necessarily expended in prepar- 



ing for the intra\enipus introduction of salvarsan 
and the undoubted clement of risk which always 
accompanied the operation, it was no wonder the 
operation hung fire and many worthy and conscien- 
tious doctors adhered to the use of mercury intra- 
muscularly altogether. These preliminary details 
bring us to the beginning of the article, intramus- 
cular or intravenous. By which route shall we in- 
troduce neosalvarsan? We have, I think, eliminated 
salvarsan as a remedy ; therefore we can disiuiss 
it from consideration. (,)f course, there will be 
many opinions, and opinions will be pretty fairly 
divided, but the more often I use neosalvarsan, the 
more inclined I becoiue to the intramuscular 
method. While we had nothing but salvarsan we 
had no option but to use the intravenous route, be- 
cause any other method was beset by so many diffi- 
culties and dangers, but now we are in a new 
position, and we find the use of neosalvarsan in- 
tramuscularly atteniled by no danger. 

If a six inch quadrilateral of the upper and outer 
border of the glutei muscles is selectcfl as the site 
of infection there is very little pain. To further 
prevent pain I inject with an ordinary hypodermic 
syringe an ampoule of urea and quinine hydro- 
chloride into the site selected and leave the needle 
in situ for twenty minutes or more. It is the same 
needle I use for the subsequent injection of the 
neosalvarsan solution ; so I save the patient need- 
less pain by leaving the needle in situ while I pre- 
pare the solution of neosalvarsan. This employs 
me for the twenty minutes required for the ab- 
sorption of the urea and quinine hydrochloride, 
and if it requires longer than twentv minutes so 
much the better, because to produce anesthesia in 
this way it requires at least twenty minutes. It is, 
of course, absolutely imperative that the instruments 
used should be scrupulously clean. The ampoules 
and the files should be left in alcohol, and distilled 
water be freshly boiled for the occasion. Ten cen- 
tigrammes of this freshly boiled water, without 
salt, is to be used for dissolving the neosalvarsan 
and is amply sufficient. The syringe which is to 
be used for the injection of the neosalvarsan. and 
which should be graduated for centimetres, is 
now charged with the solution and screwed on the 
needle which has been left in sifii. and slowly the 
solution is injected into the same situation occu- 
pied by the urea and quinine solution, and the 
needle withdrawn and the aperture treated secun- 
dum artem. If these directions are carried out 
strictly there will. I think, be no doubt as to which 
method is the best, and you can go to bed at night 
and, like Macbeth, ■"tell pale hearted fear it lies, 
and sleep in spite of thunder." 

Martin, of Hot Springs, .\rkansas, recommends 
using larger doses : I recommend giving smaller 
ones. The only difference is that I demand more 
frequent injections. Xine decigrammes is most 
frequently used, but I think this amount excessive, 
and almost bound to cause reaction and disturb- 
ance. Five decigrammes for men and four for 
women is amply sufficient. Give this dose once a 
week for four \\eeks certainly, and then more, if 
required, and you will have every satisfaction both 
to patient and ohysician. A five decigramme in- 
jection with the precautions already laid down will 



84 



FARRAR: PAIN IN SURGICAL EMERGENCIES. 



[New York 
Medical Journal, 



cause no reaction whatever, and there need be no 
dread of any ill effects. I myself have used nine 
decigrammes, but prefer the smaller dose fre- 
quently repeated. I will leave to others the main- 
tenance of the opposite view, a preference for the 
intravenous method. 

I will close with telling what occurred once in 
my office. I told a man I was going to use neo- 
salvarsan. I said, in answer to his inquiry, 
that I was going to insert it into a vein. His 
eyes at this information became a little larger 
than good sized saucers. The fright and agitation 
of this individual were so extreme that I thought 
that perhaps these were largely responsible at 
times for the shock and disturbance attending this 
operation ; and then, I think, began my own dis- 
inclination to use this method of medication. It is 
needless to say that I chose the intramuscular 
method for this gentleman, and he bore it without 
flinching. 

368 Lexington Avenue. 



INTERPRETATION OF PAIN IN SURGICAL 
EMERGENCIES,* 
By Lili.\n K. p. Farr.^r, M. D., 
New York, 
The surgeon of to-day has many aids in diagnos- 
ticating the acute surgical conditions and arriving 
at a decision when or when not to operate in a given 
case. Medical teachings, his general knowledge of 
surgical diseases, his own experience in operative 
cases, or the experience of his colleagues, together 
with the history of the patient and course of the 
disease, of attacks past and present; the patient's 
general condition, his facial expression, temperature, 
pulse, and respiration ; blood pressure, blood count, 
either absolute, relative, or differential ; uranalysis 
and condition of the digestive tract, or menstrual 
history, are all of importance in making the diag- 
nosis. But the patient has little or no knowledge of 
surgical diseases; at most it is limited to the experi- 
ence of some friend or relative with somewhat sim- 
ilar condition. Often he does not know- whether he 
has fever or not, certainly does not know the con- 
dition of his pulse or respiration, whether his white 
cells are increased or diminished, or their relative 
value ; but one factor he has, and when he has it he 
usually knows it — and that is pain. It is pain that 
oftenest brings the patient to the surgeon, and it is 
on the patient's estimate of his pain that the sur- 
geon must rely in making his diagnosis, for no in- 
strument has as yet been devised to measure the 
amount of nerve irritation produced in any patho- 
logical condition. Consequently the surgeon, even 
after he has had the assistance of the thermometer, 
the microscope, and the sphygmomanometer and la- 
boratory technic, must often base his judgment of 
the gravity of the condition on the amount and kin 1 
of pain the patient has as it is related to him by the 
patient, or as he can himself estimate it by the pa- 
tient's expression. It is from the patient's point of 
view that I wish to consider to-night a few of the 

•An address delivered under the. auspices of the .Public HeaUh 
Education Committee of the Medical Societv of the County of 
N«w York, at the New York Academy of Medicine, February 5. 
I9I3- 



surgical emergencies that we most frequently en- 
counter — the importance of pain, its occurrence in 
these emergencies, and what value the patient can 
give to it as a symptom. As it is the only one con- 
stant symptom the patient knows. 1 shall not con- 
sider any other in following the course of a disease, 
except in its relation to this. 

Surgical emergencies : By this we mean surgical 
cases in which it is considered necessary to operate 
on, or shortly after, the admission of the patient 
to the hospital in order to preserve the patient's 
life. In the last yearly report of Bellevue and 
Allied Hospitals (Gouverneur, Harlem, and Ford- 
ham) there were 6,842 operations, of which 576 
were obstetric operations, leaving 6,266 total surgi- 
cal operations. No record is kept of actual surgi- 
cal emergencies, but 2,304 laparotomies (or open- 
ing of the abdominal cavity), including hernia, were 
performed. That is, more than one third of all 
surgical operations in Bellevue and Allied Hospitals 
for that year were done for abdominal conditions, 
or what we call major work. If we now consider 
in this number of 2.304 abdominal cases the three 
types of cases in which operation was most fre- 
quently performed, we find : , 

2.304 758 6.266 

abdominal abdominal all 

No. cases gynecological operations 



I. Appendicitis — > 

Acute 416 I in 54 linis 

Chronic 68 

II. Ectopic gestation... 58 i in 39 i in 13 i in 108 

III. Hernia- 

Strangulated .... 54 I in 42 I in 116 

Chronic 567 

This does not include all of the acute surgical con- 
ditions, nor is it to be considered as a record of sur- 
gical emergencies, which would require a more in- 
timate knowledge of the histories of the cases that is 
neither possible nor to the purpose of this paper ; but 
what I do wish to bring out by these figures is that 
the three acute surgical conditions for which the 
greatest number of laparotomies were performed in 
this year are characterized by pain, and as pain is 
the chief symptom the patient has by which he may 
judge of the seriousness of his illness, it is important 
to have some knowledge of the most common surgi- 
cal diseases, their course, and possible termination, 
in order to understand how best to interpret this 
symptom, 

I. Appendicitis. 416 cases, i in 54 of 2,304 abdo- 
minal cases, I in 15 of 6,266 operations. 

On the right side of the body, on an imaginary 
line from the umbilicus or navel, to a bony point 
on the right hip, called the anterior superior spin- 
ous process of the ileum, and two inch,es from this 
process, is McBurney's point, first described in 1886 
by Dr. Charles McBurney, of this city, as the place 
where lies the famous narrow "round part of the in- 
testine," as Gray, the anatomist, calls the appendix. 
The appendix of the cecum, as it is called from its 
attachment to that part of the intestine known as 
the cecum, or the vermiform appendix, from its 
wormlike appearance, is in its normal condition 
about three and one quarter inches long (its ex- 
tremes being from one to nine inches), and from 
five to six millimetres in diameter, resembling in 
appearance the garden worm boys dig for bait. One 
end opens directly into the cecum, the other is 
closed at the tip, and lies free and normally un- 
attached in the abdomen. It is sometimes found 



July 



FARK.iR; PAIN IS SURGICAL EMERGENCIES. 



«5 



pointing inward, at other times upward, or lying 
behind the cecum and then turned upward, again 
downward and inward, or directly downward 
into the true pelvis. It consists of two layers 
of muscle covered with peritoneum, which is 
the mucous memlirane lining the abdominal c:uity 
and covering over the intestines, and it is also Imed 
with mucous membrane, which is continuous with 
that lining the cavity of the cecum. 

Clinical varieties of appendicitis: There is m 
arbitrary way of dividing appendicitis into classes 
until the appendix reaches the pathologist, but the 
general surgeon classes the inflammation under one 
of five or six divisions, according to tlie severity 
of the symptoms. 

1. Colic of the appendix: Characterized by 
sharp attacRs of pain in the region of the appendix, 
occurring in patients who have an appendix bound 
down by adhesions, with the tip often bent upon 
itself and attached to .some neighboring portion of 
the intestine, or to the tube or ovary, with resulting 
permanent kinks in the appendix. Often colic is 
due to strictures or narrowing of the lumen of the 
appendix, as the result of obstruction following 
such an adhesion or kinking. Often atrophic retro- 
grade changes in the appendix are the cause of 
severe intestinal colic. If the organ is removed at 
this stage, there is usually no inflammatory change 
found microscopically in its tissue. This attack 
may be the first and last sufTered by the patient, or 
there may be an interval varying from years to a 
few days or u-ually weeks, and then a second simi- 
lar attack, or series of attacks, occurs. In the inter- 
val the patient may be entirely free from pain, or 
experience a slight soreness or a bruised feeling in 
this region. If cjnstipation occurs, this sorene s 
may be increased. Often women notice the occur- 
rence of pain only ilnring the menstrual period, and 
the pain passes for dysmenorrhea, or painful m.n- 
struation, while the real source of pain is the ap- 
pendix, which becomes more painful at the time 
when the pelvic organs are normally congested. 

2. Catarrhal appendicitis : This may be a later 
stage of the first condition, or the initial stage. The 
mucous membrane lining the ca\ity is consrested. 
showing a mild degree of inflammation. Pain is 
less acute than in colic of the appendix, but the 
symptoms are of longer duration and greater sore- 
ness follows. Subsequent attacks may occur at 
long or frequent intervals, with pain perhaps en- 
tirely absent, or present in but slight degree, during 
the interval. 

3. Ulcerative appendicitis: (a). \\'ithout ab 
scess. This is an acute suppurative condition, the 
wall being invaded by bacteria, with resulting local- 
ized peritonitis. In the wall of the appendix is an 
ulcerated spot, usually at the site of an old con- 
striction, or where a concretion is enclosed in the 
api>endix. The wall is thinned at this ulcerated 
area, and easily perforated if early operation is not 
performed. Pain is severe and constant in this 
type. During the interval of acute attacks a sore, 
tender area is usually present at or about McBur- 
ney's point. The patient naturally protects that side 
instinctively warding off a possible blow or injury, 
sits or walks with greater caution, and is subject 
to sharp, knifelike pains directly through the body. 
Palpation of this region evinces acute pain, the 



muscles becoming rigid to guard the sensitive 
organ. 

(b), With abscess: Infection progresses suffi- 
ciently slowly for Nature to form a limiting barrier 
or membrane, and wall off the infection at this 
ulcerated spot from the general abdominal cavity ; 
and an abscess forms about the appendix which 
may be now in its ulcerated condition or, in severe 
cases, have become gangrenous and sloughed off 
from the intestine. This abscess wall, if not opened 
by the surgeon, may burst and infect the general 
abdominal cavity, with general peritonitis or pyemia 
resulting. If recovery follows, other attacks are 
liable to occur, until the diseased appendix is 
removed. 

4.. Acute perforation of the appendix: This 
occurs in appendices where there are old ulcerations 
or strictures. The onslaught is so sudden that Na- 
ture does not have time to wall off the intestine 
with an inflammatory membrane, and so limit the 
infection to the region of the appendix. The in- 
fectious material is poured out from the perfora- 
tion in the appendix into the general abdominal 
cavity, and general peritonitis follows. This form 
of appendicitis is characterized by sudden onset, 
the most intense pain, with symptoms of collapse. 
The course may be either recovery or peritoneal 
septicemia w-ith symptoms of profound toxic 
poisoning, without much pain or tenderness in its 
terminal stages. 

Conclusion : Fortunately Nature usually gives 
ample warning. There is rarely an overwhelming 
fulminating infection where there has not been a 
history of previous attack, or several attacks, and 
sufficient time for operative measures. The colicky 
or sharp pain of the early invasion, and even the 
soreness, pass off, and, with each successive illness 
lived through, the hope and expectation grow that 
each attack will be the same as the others — even 
though the guide, pain, is more acute, more per- 
sistent, W'ith each recurrence. 

II. Ectopic gestation: 58 cases: i in 39 of 
2,304 abdominal cases; i in 13 of 758 g)-necological 
abdominal cases ; i in 108 of 6,266 operations. 

The term, ectopic gestation, derived from the 
Greek -.' (out of) and roz^ii (place), is used to de- 
scribe gestation which occurs anywhere but in the 
uterus or womb, i. e., out of its normal place. We 
speak of an interstitial pregnancy, or pregnancy in 
the wall of the uterus or in one horn of a malformed 
uterus ; of tubal gestation, as gestation in the tube 
attached to the uterus ; ovarian, if in the ovary ; or 
abdominal, if development has gone on in the ab- 
domen. The terms "false conception'' or "missed 
conception" were commonly used before the mture 
of this condition was known. Gestation is neither 
false nor missed, it is simply ectopic, or out of 
place. The pelvic organs in women consist of the 
uterus and two ovaries, one on either side, attached 
to the upper portion of the uterus, and between 
each ovary and uterus on either side is a narrow 
hollow tube of about three inches in length, and 
from eight to fifteen mm. in diameter (or the size 
of a lead pencil) composed of muscle lined with 
mucous membrane and covered with peritoneum, 
resembling somewhat the appendix in appearance. 
One end opens directly into the uterus ; the other 
end is patent, and into this the ova are conveyed 



86 



FARRAR: PAIN IX SURGICAL EMERGEXCIES. 



[Xew York 
Medical Jourmau 



from the ovary to the uterus. Tlie ovum is com- 
monly impregnated in the outer one third of the 
tube, and passes then into the cavity of the uterus. 
If now, for any reason, the impregnated ovum, 
which is to become the fetus or child, is prevented 
by a constriction or kinking of the inner portion 
of the tube from entering the uterus, as it nor- 
mally should, development of the ovum then goes 
on in the tube, which is not constructed to receive 
it. The wall of the tube is thinned and stretched 
bv the growth of the ovum. and. except in rare in- 
stances, rupture of the tube or expulsion of the 
ovum through the abdominal end of the tube occurs 
with severe shock and internal hemorrhage. If the 
condition is not recognized and an operation per- 
formed, death may result from the internal hem-r- 
rhage. In early cases the blood may clot and clieck 
the flow, especially if only a small bloodvessel has 
been opened. If the ovum has been destroyed, in an 
early case, there may be an absorption of tissue, 
but usually the patient goes on to a second hemor- 
rhage, or repeated hemorrhages, with greatest 
danger of a fatal termination — or, if recovery, 
peritonitis, possibly later suppuration and ulcera- 
tion through other tissues, or may persist indefi- 
nitely as a sac containing the fetus. 

Conclusion: The symptoms to give warning: of 
this condition are rarely absent. Usually a men- 
strual period is overdue, or one of two periods even 
have been missed, with intermittent flow and at- 
tacks of sharp, lancinating, tearing pain in one side 
or toward the back. A persistent aching, sore feel- 
ing is left after the bright blood or the brownish 
discharge has ceased. The patient often considers 
she has had a threatening or completed miscarriage, 
and neglects the symptom of pain — the indication 
that gestation is still going on. 

III. Strangulated hernia : 54 cases : i in 42 of 
2,304 abdominal cases ; i in 116 of 6,266 operations. 

Hernia is the condition commonly known as 
rupture. The word is derived from <"^"^', a 
"sprout," and in the surgical use of the word means 
a tumor formed by a portion of an organ (hence 
the term "sprout") or an entire organ which has 
escaped from the cavity in which it is usually con- 
tained, either by forcing its way through a natural 
iipening or bv making for itself a new (ipeninL;. 
until it comes to lie outside the body cavity or with- 
in some other cavity. The most common form of 
hernia, and the one we shall consider to-night, i^ ab- 
dominal hernia, of which there are several varieties, 
according to the abdominal opening through which 
the organ has escaped, i. inguinal: 2. femora'.: 3. 
umbilical. These three openin.gs are normal for the 
passage of i, the cord or round ligament; 2. 
the bloodvessels and nerves ; and 3, for the umbilical 
cord in fetal life, but they should not be open suffi- 
ciently far for the passage of any other organ or 
portion of an organ. If for any reason there is a 
weakness at any one of these openings, and undue 
pressure occurs, as in heavy lifting or straining, a 
portion of the bowel or omentum (even appendix, 
bladder, tube, ovary, and, in rare instances, uterus) 
may enter into one of these openings, carrying: 
ahead of it a fold of peritoneum, and, thus forcing 
its way between the muscles, passes throuEjh the ab- 
dominal wall until it lies outside the body just under 
the skin. This pouch of peritoneum which the omen- 



tum or intestines has pushed out of the body cavity, 
and within which it lies, is called the "sac" of the 
hernia, and its narrow part, where it passes through 
the opening in the abdomen, is the "neck" of the 
hernia. If this tumor can be pushed back again 
into the abdomen, we say the hernia is "reducible" : 
if it cannot be pushed back it is "irreducible." If 
there are symptoms of intestinal obstruction, (i. e.. 
the contents of the bowel cannot pass through the 
loop of prolapsed intestine), the hernia is "ob- 
structed" or "incarcerated." If now the constric- 
tion in the neck of the sac is so great as to inter- 
fere with the circulation, the hernia is "strangu- 
lated," and as its blood supply is cut off, the de- 
struction of this portion of bowel soon begins and 
gangrene quickly follows, with resulting sloughing 
of the strangulated loop. 

1. Reducible hernia: In this type of hernia pain 
is only a slight or negative factor. As the bowel 
enters the sac. or is pushed back into the abdom- 
inal cavity, there may be a momentary feeling of 
pain or discomfort, but on palpating the mass it is 
insensitive and examination gives no increase of 
pain, as in tumors in the same region. 

2. Irreducible hernia : As long as there is no 
obstruction to the passage of the contents of the 
liowel there may be no feeling of pain, or only slight 
discomfort or a dragging sensation. On examina- 
tion, the mass is insensitive, and only attempted 
reduction causes pain. ]Many cases go on for years 
with no further symptoms, but if at any time the 
adherent bowel becomes clogged, and the passage 
of the contents arrested, or if the omentum which is 
in the sac has its blood supply cut off. the third 
type occurs. 

3. Obstructed or incarcerated hernia: The 
tumor is now increased in size and markedly 
painful, pain being severe even if the patient is at 
rest, and no palpation of the hernia attempted. If 
the obstruction is not soon relieved, either by the 
contents of the bowel passing on through the intes- 
tine, or by the surgeon's opening the hernial sac 
and allowing them to make their escape, or the 
circulation of the omentum or other organ to be 
restored to normal, the fourth type results. 

4. Strangulated hernia : The condition is now 
most serious, the patient suffering intense pain, and 
immediate relief for the imprisoned loop is neces- 
sary, if it is to be saved, or, even if amputated, if 
the patient's life is to be saved. If help is not 
given, gangrene follows, and with its occurrence 
there is a cessation of pain : the feeling of relief is 
often now so great that the patient hopes the con- 
dition has improved for the better, but collapse and 
death soon follow. 

Conclusion: Pain is, therefore, in hernia, an in- 
dex of the inflammatory process going on in the 
tumor. While the passage of the fetal contents is 
undisturbed, and the circulation not interfered with, 
pain is light, if present at all ; but with disturbance 
of contents or blood supply, the pain increases in 
proportion to the disturbance until actual death of 
tissue results 

Final cc inclusions : In following the course of 
three of the most common acute surgical condi- 
tions I have endeavored to show that the inflam- 
matory process .going on in acute surgical diseases 
is accompanied by characteristic pain — that pain 



July 12. 1913.1 



PRIZE ESSAYS. 



87 



<lefiiiite in character has a definite cause. Nature 
does not permit any severe injury to the body tis- 
sues withf^Mt sending: a messajre of protest. The 
nerves of the body are the wires of transnii.^sion, 
and He quiescent if the tissues are in a normal stale. 
But if the tissues have received insult or injury, 
the nerves take up their work of transmission. l!y 
the report of paia the surgeon is able to locate the 
organ affected, to judge the degree of injury, and 
to give a prognosis of the result, whether he can 
see the inflammatory process in the organ affected 
or net, for the process is the same in whatever pirt 
of tlie liody it is found. The hernia one can see 
enlarge and redden as it becomes obstructed is no 
more dangerous to life than the ulcer eating its 
way through the wall of the appendix to pour its 
infection into the unprotected abdomen, or the 
ectopic gestation opening up bloodvessels preprira- 
tory to a fatal internal lieir.orrhage, but it is much 
easier to convince a jiatient of the urgent need of 
an operation in an obstructed hernia than in an 
acute appendicitis or ectopic gestation. Consider 
416 cases of acute appendicitis, 68 cases of chronic 
appendicitis, in comparison with 54 cases of stran- 
gulated hernia and 567 cases of chronic hernia. 
I'nlike the experience of our childhood, when tbe 
things we could see were not half as fearful as the 
things hidden in the dark, pain plus the sight of a 
tumor undoubtedly inllncnces to operation far 
oftener than pain hidden in the abdominal ca'-iiy, 
even tliough that pain n;ay be of a much more se- 
vere type ; but the si-ppurative process goes on 
equally in=ide or out and Nature's messenger 
records the pain, as a guide to him who will read 
her well. 

40 West \inety-sixth Street. 

f rije €s.s:ip. 

Questions for discussion in this deparlment are announced at 
frequent intervals. So far as they have been decided upon, the 
further questions arc as follows: 

CXXXV. — How do you treat burns? (Closed June i6lh.) 

C.\'XXVI. — How do you treat cholera infantum? (.Answers due 
not later than July islh.) 

CXXXVII. — How do you treat threatened abortion? (Answers 
due not later than August 15th.) 

IVhocver answers one of these questions in the manner most sa:- 
isfactory to the editor and his adzisers will receive a prise of J-',i. 
No importance whatever will be attached to literary style, but Ih ■ 
auard will be based solelv on the value of the substance of Hu- 
lUiswer. It is requested (.but not reouired) that the answers l\' 
short, if practicable no one answer to contain more than sir hnu- 
dred words; and our friends are urged to write on one side of tlw 
paper only. • . '\ 

.411 persons will be entitled to compete for the prise whether 
subscribers or not. This prise will not be awarded to any one 
person more than once within one year. Everv answer must b' 
accompanied hy the writer's full name and address, both of -.rhich 
we must be at liberty to publish. All papers contributed become the 
property of the Journal. Our readers .\re asked to suggest topics 

FOR DISCUSSION. 

The prise of $ss for the best essav submitted in answer to Ques- 
tion (pXXXlr has been awarded to Dr. John H. Shaw, of Phila- 
delphia, zvhose article appeared on page so. 

PRIZE QUESTION CXXXIV. 

THE TREATMENT OF MUSCULAR RHEl^- 

MATISM. 

(Concluded from page jj.") 

Dr. Meyer A. Rabinoivita, of Brooklyn. N. Y., 

says: 

A'luscular rheumatism is a dangerous diagnosis 

for a conscientious physician to make. The correct 

diagnosis may be either aortic aneurism, cancer of 

the pleura, tabes, osteomyelitis, spondvlitis deform- 



ans, Imiie lulxrculosis, syphiHtic periostitis, lead 
poisoning, morphine habit, alcoholic neuritis, trich- 
inosis, gonorrheal sepsis, onset of an acute infection 
(typhoid, influenza, variola, arterior poliomyelitis, 
meningitis), intestinal autointoxication, sacroiliac 
joint relaxation, local disease of muscle, hematoma 
due to trauma, hematoma following vascular 
change (as in typhoid, sepsis, jaundice), muscular 
cicatrices following fibrous myosites, atheroma of 
arteries in muscle (as in intermittent claudication), 
muscle abscess, infarct, gumma, echinococcus cyst, 
<ir new growth. 

Treatment begins with diagnosis, and the diag- 
nosis of muscular rheumatism must be made by ex- 
clusion. It is usually of acute onset following ex- 
posure and fatigue and the muscles afifected — usu- 
ally neck, back, or chest— are painful on movement 
and tender on pressure. 

During the acute stage, within the first twenty- 
four hours, the following will cut short the disease : 

1. Hot mustard foot bath ; then to bed. 

2. Plenty of blankets about body and hot bottles 
to feet. 

3. Dover's powder, one dose of ten grains for 
adult and plenty of fluids. 

4. A brisk saline cathartic : restricted fluid diet. 

5. Internally if necessary to relieve pain and tem- 
perature, and induce perspiration, full doses of 
sodium salicylate. 

6. A hypodermic injection of one fourth grain of 
morphine sulphate over site of pain, if very violent 
and acute. 

7. Locally, over site of pain, dry cupping or a 
few leeches. 

In the subacute stage : 

1. Diet. Reduce proteids, increase fluids, vege- 
tables and cereals. 

2. Drugs : 

(a) Add potassium iodide, five grain>. three 
times a day to the sodium salicylate. 

(b) Acetphenetidin, three grains everv three or 
four hours if an analgesic is needed 

(c) No codeine, morphine, opium, for the drug 
habit if fastened upon the patient is much worse 
than the original pain. 

3. Locally, the following are of decided value: 

(a) Massage, especially following hydrotherapv, 
and using a liniment as a lubricant. 

(b) Liniments — usually combinations in various 
proportions of tincture aconite, turpentine, chloro- 
form, ether, and alcohol. 

fc) Belladonna plaster mav be left on for sev- 
eral days. 

(d) Mustard pastes. 

(e) Electricity. 

(f) The actual cautery is an excellent counter- 
.rritant. Use a smooth broad platinum point at 
w hite heat, applied with rapid strokes, broadly and 
superficially, only for an instant. This is especial- 
ly applicable in muscular rheumatism of the back. 

(g) Injections of physiological saline to the 
amount of from five to ten cubic centimetres, at 
most painful points in muscles are of decided and 
rapid benefit. 

(h) Hydrotherapy is placed last, but is not least 
in value. Hot pack— electric or hot air— locallv 
until perspiration is excited. Circular douche 95° 
I- . follows for one minute : then Scotch douche lo- 



88 



PRIZE ESSAYS. 



[New York 
Medical Journal. 



callv at iio° and 70° F. for one or two minute;-, 
ending with massage, striking and kneading tlic 
muscles for twenty minutes. 

Dr. Lionel C. Charbonneau, of Brooklyn, X. V .. 
remarks: 

The word rheumatism is employed indiscrimin- 
atelv bv the profession to cover conditions bear- 
ing' no relation to the etiology of muscular 
rheumatism. 

When will physicians become specific in the.r 
nomenclature, more deliberate in their physical 
examinations and erudite in diagnosis? A little 
more painstaking, a little less hurry — and many 
perplexing situations would be avoided. Fre- 
quent uranalysis, constant use of the sphygmo- 
manometer, systematic application of the stetho- 
scope and paying particular attention to detail 
would strengthen the medical man in his profes- 
sion — enlarge his clientele. There would be less 
cry against hospital and dispensary abuses. The 
poor we always have and hospitals, dispensaries, 
and contract work must ensue. Another word be- 
fore coming to my subject. Our institutions of 
medicine are responsible for the pitiable lack of 
psychic, mental, organic, and physical therapeuti- 
cal knowledge possessed by graduates in medicine. 
If our professors in therapeutics did less unreason- 
able questionings and listened more to the smoth- 
ered inner voice of conscience, left their precon- 
ceived ideas in the background, showed less pre- 
judice, the mental growth of our graduates would 
not be stunted in "physical, organic, and mental 
therapy. 

Given a case of acute muscular rheumatism, with 
some fever and rapid pulse, the patient is put_ to 
bed, small doses of calomel are prescribed, fol- 
lowed by a saline. Sodium salicylate and double 
the quantity of sodium bicarbonate are given every 
two or three hours in one half a glass of vichy. 
The patient remains in bed for from one to four 
days. The diet consists of milk, fruit, and gruel. 
If pain or soreness continues after the fever is 
under control a mild and moderate massage 
is given, followed by the use of an ointment of 

5 Methyl salicylate. ?ji : 

Menthol 5i: 

Tircture of capsicum, ^^J?.- 

Ointment of rose water, q. s. ad ji'- 

M. S. To be smeared over painful areas. 

Patients with acute or chronic muscular rheuma- 
tism without constitutional disturbances, if possible, 
are treated at the office. At times a lumbago is 
so severe that the patient cannot be moved. Large 
doses, from ten to twenty grains, of sodium salicy- 
late, in one half glass of vichy is given each hour 
until relieved, then if the least soreness remains 
the patient is sent to the office for further atten- 
tion. 

The most frequent varieties of muscular rheuma- 
tism are lumbago, torticollis, pleurodynia, and 
rheumatism involving the muscles of the scalp. 
Uranalysis invariably shows that the waste 
and nitrogenous products are freely absorbed, there 
is intestinal indigestion, and in acute cases history 
of exposure to excessive cold or heat and draft. 
In acute cases the diet is limited to fruit, vegetables. 



soups, bread, and butter, and plenty of vichy and 
exercise in the open air is strongly urged. 

In lumbago the 500 candle power lamp is applied 
to painful area for fifteen minutes, followed by the 
static wave current for twenty minutes and conclud- 
ing the treatment by giving long sharp sparks from 
the brass ball electrode from one to two minutes. 
Acute lumbago is frequently cured with one such 
treatment ; chronic cases require from one to four 
weeks. 

In torticollis, the high frequency current with the 
vacuum tube, emitting a one half to one inch spark, 
continued in light contact with the skin from ten to 
fifteen minutes, given each day until cured. The 
same technic holds good for pleurodynia or the 
muscles of the upper or lower extremity. The treat- 
ment for muscular rheumatism of the scalp, if there 
is an abundance of hair, is different in technic. 
Place the patient upon the static platform, shoes off. 
The static wave is given, with the multiple pronged 
electrode in the operator's hand, sweeping the elec- 
trode over the scalp, the treatment lasting from ten 
to fifteen minutes. 

All chronic cases of muscular rheumatism are 
given autocondensation from twelve to twenty min- 
utes, 400 to 800 milliamperes administered. Solu- 
tion of nuclein, five minims, or dessicated thyroid 
gland, one grain three times a day. The following 
capsule at bedtime : 

IJ Phenolphthalein. 3i ; 

.■\cid sodium oleate gr. xl ; 

Menthol, gr. xx; 

Salicylic acid gr. xxv ; 

Magnesium carbonate 3iss. 

M. Divide in capsules. No. xl. 

Meat and eggs cut down and sometimes discon- 
tinued while under treatment. 

In two cases of chronic muscular rheumatism of 
years' duration the patients failed to obtain absolute 
relief under medicinal, dietetic, physical, or vaccine 
treatment, hypodermic injections of a twenty-five 
per cent, solution of magnesium sulphate, twenty 
minims, three times a week, cured the one in four 
weeks, the other in six weeks. These were treated 
and discharged cured in 191 1 and have remained 
free from stiff or sore muscles since. Physicians 
not in a position to treat with electrical modalities 
will often obtain brilliant results by giving mild and 
moderate massage over painful areas — the process is 
slow, but satisfactory. 



f lierapratic |[0Us. 

Treatment of Anemia in Children. — H. Lowen- 
burg. in the American Journal of Diseases of 
Children for September. 1912. advises the admin- 
istration of intramuscular injections of the follow- 
ing preparation in severe cases of anemia in 
children : 

R Ferri citratis gr. 3/10 (0.018 gramme) ; 

Sodii cacodylatis I ;;s „. t/ (•««„ -.„~~=^ . 

Sodii alycerophosphatis. \ '^^ "'■ ^ ^°°^ gramme) ; 

Aquje dcstillatse sterilisatae. ...ni. xx (1.25 gramme). 

M. ft. solutio. 

W'eeklv or biweekly injections should be sriven. 

The site and especially the manner of injecti' n are 



July 12. i9'j] 



TUEKAl'EUriC NOTES. 



89 



important. The needle should be thrust deeply into 
the muscles on the posterior and outer aspect of 
the arm, and its direction should be at right antries 
to the skin surface. A slight stinging sensaticm 
should alone result. A rapid increase in the hinm- 
globin and erythrocytic count results from the in- 
jections. 

Treatment of Hepatic Abscess in Amebic 
Dysentery. — LhautTard. in Bulletin dc l. tcadiinic 
lii- iiu-Jciiiic for I-ebruary 25, 1913, reports a case 
of hepatic abscess with bronchial fistula of five 
months' standing, due to amebic dysentery, in 
which subcutaneous injections of emetine (hydro- 
chloride probably, though the salt used is not men- 
tioned), as recently recommended by Rogers, gave 
most excellent results. The patient had been ex- 
pectorating bloody material to the amount of from 
one half to one pint daily, was feverish, and had 
two or three loose bowel movements daily. Though 
the case was about to be operated on. it was de- 
cided to try emetine first. Six injections of o.O-i 
gramme (two-third grain) each were given in the 
course of five successive days, two being adminis- 
tered on the third day. 

On the second day the patient already felt dis- 
tinctly better. Although even on the first day the 
amount of expectoration was somewhat lessened, 
on the third day it was reduced to two ounces and 
on the fourth to one and one-half ounce, while on 
the fifth the patient expectorated but three times 
in the entire twenty-four hours, this being, in fact, 
the last sputum obtained from the case. The tem- 
perature fell to normal on the second day and re- 
mained normal subsequently. The blood examina- 
tion showed corresponding improvement, an ulcer 
previously observed in the rectum promptly healed, 
radiography showed a return of the lower pulmon- 
ary area and diaphragmetic vault to normal, and 
the patient gained in weight. The results were so 
prompt that no other explanation seems to the 
author admissible than that of a direct fherapia 
sterilisans. Six weeks after the treatment had been 
discontinued there was no sign of recurrence. 

The injections caused but little pain and no local 
induration, no anorexia, nausea, malaise, change 
in the pulse rate or significant fall in the blood 
pressure were noted. 

A Substitute for Kuhn's Aspiration Mask, — 

T. \\'. \\'illiams, in the Joiintal of the Aiitcrican 
Medical Association for March. 8, 191 3, states that 
all the benefits from Kuhn's mask can be obtainel 
in a simple manner by breathing through a section 
of a small catheter (about Xo. 16 French), or a 
straw or quill. As with the mask, the result is a 
gradual, deep inspiration : the air is then held a lew 
seconds and suddenly expired. Negative compres- 
sion of the lungs is thus produced, and blood sucked 
from the right chamber of the heart into the lungs. 
When the heart is weakened and tired by overexer- 
tion for instance, and there is pain from overdisten- 
tion of the right chamber, if the patient will lie down 
for five minutes and breathe in the manner de- 
scribed through a quill toothpick or even through 
his teeth, immediate and remarkable relief will be 
experienced. The procedure is also often efficacious 
in nervous excitement and insomnia, and it is the 
author's custom to instruct anemic and nervous pa- 



tients to carry it out for five or ten minutes upon 
lying down at night. 

Prevention and Treatment of Cutaneous Affec- 
tions in the Insane. — Td A. Luther (Journal of 
Mental Science, January, 1913) is credited a dis- 
cussion of the skin affections occurring in the in- 
sane as secondary results of treatment by prolonged 
baths and the wet pack. In furunculosis, this 
author paints each commencing furuncle and the 
adjacent parts with five or ten ])er cent, salicylic 
acid collodion. If this treatment is employed early 
enough the furuncle in most instances dries up; 
in other cases, where it has gone on to softening, it 
remains small and only a little thin pus forms. 
Painful tension is speedily removed, and there is 
a high degree of probability that further infection 
will be prevented. When painted with tincture of 
iodine, furuncles will often shrivel : in adortin-r 
this plan the use of water must be absolutely 
avoided. 

Where eczema occurs, no course is open but to 
discontinue the baths : powders and a desiccating 
paste will then bring about a speedy cure. 

In ringworm, I.uther has found a five to ten per 
cent, chrysarobin collodion very useful ; in recent 
cases one daily painting generally suffices. Tinc- 
ture of iodine yields far less certain results. 

A measure useful in the prevention of these dis- 
eases and which permits of the continuance, in 
part at least, of hydrotherapy in the form of the 
wet pack, is to substitute for water partial or com- 
plete packings with a three per cent, boric acid 
solution. If the cloths are allowed to dry on the 
patient the acid becomes deposited on the bodv in 
the form of a fine powder, which acts subsequently 
as a certain prtitective against infection. If an 
excessive loss of heat in decrepit patients is appre- 
hended the solution can, of course, be applied 
warm. Equally as satisfactory results can be ob- 
tained in the case of the prolonged baths in adding 
boric acid to the water ; in this connection, how- 
ever, expense is an objection. Rath eczemas are, 
as a rule, readily cured by the boric acid p3c'< 
treatment, and the latter does not contraindicate 
painting with salicylic or chrysarobin collodion if 
sufficient time i^^ given for drying. 

Value of Atropine in Gastric Affections. — 

Pletnev, in Semaiiic medicalc fiir March 2(1, 1913, is 
credited with the statement that while atropine can 
at best only constitute a symptomatic measure in the 
treatment of stomach disorders, it deserves to be 
much more widely employed than has hitherto been 
the case. Where gastric acidity is increased, atro- 
pine will reduce it indirectly, viz., by diminishing the 
amount of gastric juice secreted, so that a greater 
proportion of it will be neutralized by the alkaline 
mucus present. In pyloric spasm atropine also gives 
relief, probably in part by reducing acidity, but also 
by a direct "antispasmodic" action, as is indicated 
by the fact that hourglass contractuie of functional 
origin is similarly removed. In cases of overacidity 
or gastric ulcer pain is favorably influenced by atro- 
pine, which is preferable for this purpose to iror- 
phine because the latter, after temporarily reducing 
the secretion of gastric juice, excites glandular ac- 
tivitv. 



90 



EDITORIAL ARTICLES. 



[New Yobk 
Medical Journal. 



NEW YORK MEDICAL JOURNAL 

INCORPORATING THE 

Philadelphia Medical Journal 
and The Medical News. 

A Weekly Review of Medicine. 

Edited by 
CHARLES E. de M. SAJOUS, M. D.. LL. D, 

Address all communications to 

A. R. ELLIOTT PUBLISHING COMPANY, 

Publishers, 

66 West Broadway, New York. 



Subscription Price : 

Under Domestic Postage, $5; Foreign Postage, $7; single 

copies, fifteen cents. 



Remittances should be made by New York Exchange, 
post office or express monev order, payable to the 
A. R. Elliott Publishing Co.. or by registered mail, as the 
publishers are not responsible for money sent by unregis- 
tered mail. 



Entered at the Post Office at New York and admitted for transporl.i 
tion through the mail as second class matter. 



Cable Address : Medjour, New York. 



NEW YORK. S.ATURDAY, JULY 



SUMMER DIARRHEA AND ITS TREAT- 
MENT. 

In our last issue Doctor Lederle, president of thj 
New York Board of Health, gave an outline of the 
efforts of the board in recent years to reduce infant 
mortalit}'. That these efforts have been attended 
with good results — a large share of which is of 
course to be credited to the progressive work of 
pediatricians and hygienists — is graphically shown 
by the fact that while the death rate from diarrhea! 
diseases for 1,000 children under one year was 
44.28 per cent, in 1902, in 1912 this proportion had 
been reduced to 26.39 per cent. Encouragint;- as 
these figures are, however, there is ground for the 
belief that they could be materially improved if 
modern methods in the treatment of the diarrheal 
diseases which are familiar to specialists were re- 
sorted to more generally — methods which have 
given death rates, for the number of cases treateil, 
below those usually obtained. 

Limiting ourselves to those measures which h:i\c 
won the sanction of man)' careful observers, and 
also to the form of infantile diarrhea which bv far 
causes the greatest number of deaths — that due to 
the toxines of pathogenic bacteria — we will describe 
those which are often neglected in the general field. 

That the time honored dose of castor oil. to clear 



I lie intestinal tract of its pathogenic contents, is in- 
creasingly being replaced by calomel, owing to its 
antitoxic and bactericidal virtues, is familiar to 
every practitioner; but the trend of modern thought 
is to adjust the use of this agent to the status 
presetis of the patient. Thus, as taught by Lesage, 
patients who have high fever, foul smelling 
though not abundant stools, and considerable tym- 
panites, will do best if given one grain (for infants 
under one year, and two grains for those over that 
,ige) at one dose, while patients with low fever 
and copious diarrhea, although the abdomen h soft, 
show better results when from i/io to 1/15 grain 
is given every half hour or hour until ten or twelve 
doses have been taken. 

A second feature too often overlooked is that 
milk favors the multiplication of intestinal patho- 
genic bacteria, unless the infant be breast fed; the 
milk under the latter conditions being antitoxic — 
the opposite of cow's milk after it has left the udder 
several hours. Hence the fact that artificially fed 
infants do best, when suffering from bacterial diar- 
rhea, when nothing but water is allowed until the 
-ymptoms of intoxication subside. This should nil. 
however, be allowed to weaken unduly the infant 
or cause material emaciation. When feeding can 
he resumed, white of egg, which, as is well known, 
is a nutritious and readily assimilated proteid, is to 
be preferred as soon as the stool? lose their offen- 
sive odor. Finkelstein's Ehveis Milch (casein 
albumen milk) is preferred by some, however, when 
there is marked weakne-s or emaciation. It is pre- 
pared as follows : A tablespoonful of essence of 
rennet is added to a quart of milk, which is then 
placed in a water bath at 108° F. for one half 
hour. It is then filtered slowly through cheese 
cloth. The coagulum is washed twice in a pint 
of water through a fine sieve, and forced through 
by beating with a wooden club. Then one pint of 
bf.ttermilk is added. This is given in quantities 
corresponding to the usual feeding mixture in- 
dicated at a corresponding age. 

Less complicated and probably quite as efficient 
is buttermilk, which is increasingly gaining advo- 
cates. Swarming as it is in its raw state with lactic 
acid bacteria, which have an inhibitory action on 
the development of other germs, it is especially effi- 
cient when the intestinal pathogenic organisms per- 
sist after the preliminary purgation and water diet. 
Besides, it is very nutritious and inexpensive. The 
infant will often refuse it, owing to its taste, but 
as recommended by Blackader, this mav be ob- 
\iated by adding cereal gruel and five grains (0.3 
gramme) of cane sugar to the ounce of buttermilk. 
The latter may or may not be pasteurized. Morse 
obtained excellent results from pasteurized butter- 



■niTOR/.lI. ARTICLES. 



9' 



milk, and prefers it to all other milk foods. \Vc 
are inclined to look upon pasteurization as a draw- 
back, since it tends to impair the activity of the 
lactic acid bacteria. 

It is perhaps unnecessary to emphasize the fact 
that cases differ and that the best results are ob- 
tained where a careful diagnosis has been made. 
Prophylactic and hygienic measures are also potent 
auxiliaries, but most potent of all in the prevention 
of infantile diarrhea is breast feeding, breast milk 
it-elf being a powerful antitoxic. 



THE COLLEGE OF SURGEONS. 

The College of Surgeons presents something new 
as an American medical society. Its object is not 
only "to elevate the standard of surgery"' in com- 
mon with all other surgical associations, but also "to 
provide a method of granting fellowships in the or- 
ganization, and to formulate a plan which will in- 
dicate to the public and the profession that the sur- 
geon possessing such a fellowship is especially qual- 
ified to practice surgery as a specialty." Its mem- 
bers are to be known as Fellows, and they are urged 
to append the letters F. C. S. to their names on pro- 
fessional cards and elsewhere to indicate their mem- 
bership. 

Few of our readers will be inclined to deny that 
both the profession and the public need some means 
by which to determine whether a would be practi- 
tioner in a surgical specialty deserves their support 
or not ; so we welcome the college as an attempt to 
fill this need. The plan is to list the names of all 
practitioners who are competent to act as special- 
ists in general surgery, or any of the surgical special- 
ties, to g^ve them a title by which they can be rec- 
ognized as such, and to formulate requirements to 
be met by future candidates for admission which 
are proposed to be sufificiently exacting to render 
the F. C. S. equivalent to a special degree in sur- 
gery. The fact that it seems to have been taken 
bodily from the custom of our British brethren 
should not weigh for or against it, but we believe 
that if the college is to succeed it must win the sup- 
port and the confidence of the profession at larg\'. 
which seems to be noncommittal at present. To do 
this it must make clear the benefits to be derived 
by the general practitioner from the organization. 

We do not believe that the founders have any in- 
tention to create a monopoly of surgical practice, yet 
it is not difficult to read such a purpose into the re- 
port of the proceedings at their meeting, which con- 
tains nothing definitely protective of the rights of 
the general practitioner. We feel sure that they do 
not wish to debar any surgeon from the practice of 
such surgery as he is competent to perform, and 



that they would be the first to condenm risking life 
in an emergency by delay in order to secure the 
presence of a more skillful surgeon. In almost 
every small conuuunity of physicians one of their 
number has proved to be a better surgeon than the 
rest, and furnishes valuable services as such, al- 
though his opportunities are too few to enable him 
to compare favorably in skill with the city spe- 
cialist, and we do not believe that the college wishes 
to stop him in his good work. If we appreciate the 
intention rightly it is to provide for the recognition 
of certain specially trained men as specialists and to 
prevent untrained men from posing for what they 
are not, so it would seein wise if the statement were 
made in positive terms that no wish exists to arro- 
gate to the Fellows the exclusive practice of sur- 
gery. 

.\ very serious objection to the plan presented is 
that it affords an opportunity for a certain set of 
men to brand as incompetent, by refusing them ad- 
mission, others as competent as themselves. We 
would not be understood to intimate that the gentle- 
men who are at present entrusted with the passing 
on the merits of candidates for admission to the 
college would do this knowingly or willfully, but 
they have the power to do so, and history tells us 
that such power has been abused in the past. It is 
possible for fifteen men to form a clique which will 
control the actions of so large a body as this in a 
manner highly detrimental to the best interests of 
the profession, and to render the possession of the 
titular letters more a matter of favor than of merit. 
This seems to us to be a source of serious danger 
that needs to be guarded against. It is another mat- 
ter that these gentlemen cannot be personally ac- 
quainted with the merits or demerits of all candi- 
dates, and may be misled ; so far as this is concerned 
mistakes are to be expected in every human under- 
taking. 

Finally, the information conveyed by the letters 
I-. C. S. is inadequate and may be misleading. The 
college includes not only general surgeons, but also 
ophthalmologists, otologists, and others who pretend 
to no special skill outside of one limited branch of 
surgery. Incompetent selfstyled specialists in vari- 
ous surgical specialties abound and rely for success 
mainl> on their social qualities as "good mixers." 
The public has no means of distinguishing them ; 
the profession a very imperfect one, through con- 
sideration of hospital appointments and society 
memberships. A certificate of study for six weeks 
or more, or an appointment on the staff of a hos- 
pital, is an invaluable asset for such a man. for the 
certificate is seldom read in full, and the appoint- 
ment, though only that of a clinical assistant, car- 
ries the prestige of the hospital to support his as- 



92 



liniTORIAI. ARTICLES. 



sumption of skill. \\. the school, or in the lios- 
pital, he may be considered an ignoramus and never 
allowed to do the most trivial operation without 
careful supervision, yet, outside, his pretensions arc 
accepted, he perfomis serious operations, and it 
often takes years to disabuse the minds of his con- 
freres and of the community as to his merits. We 
need a means of distinguishing the competent from 
the incompetent ophthalmologist, or otologist, quite 
as much as of marking the specially trained general 
surgeon, but here the plan of the college falls ; ii 
groups all competent specialists, as well as general 
surgeons, under the one title F. C. S. If it is wise 
for us to depart from our traditions, and to have 
specialists append certain letters to their names, we 
should be sure that those letters cannot be misun- 
derstood. It would be better that the college should 
follow the spirit of the founders of the Royal Col- 
lege, rather than the letter of their proceedings, and 
mark each Fellow for what he is as a specialist. The 
F. C. S. could be given a Fellow who is a general 
surgeon, other letters to Fellows in the various spe- 
cialties ; then the profession would receive some real 
help from this organization. 



THE DEATH RATE AMONG THE FEEBLE 
MINDED. 

Basing their results upon the mortality of four 
thousand cases of idiots and feeble minded ob- 
served by them, L. Pierce Clark and W. L. Stowell 
reached the conclusion (see our issue of February 
22d) that the feeble minded of all classes are shorter 
lived than those of normal intelligence. They divid- 
ed the patients into two groups, those whom they 
called idiots and those of a higher grade whom 
they called simply the feeble minded. Among the 
former the death rate for a period of nine years 
was 19.6 per cent. Among the latter for the same 
period it was 6.5 per cent. During the same time 
and at the same place nearly eight thousand chil- 
dren of normal mentality were treated. The mor- 
tality among these was 3.38 per cent. This was an 
excellent control and makes the conclusions of these 
writers as to the comparative death rate of normal 
and feeble minded of great value, for under the 
same management and service, and during the same 
period, the comparison of the death rates is pre- 
eminently fair. Thus it appears to be unquestion- 
able that the death rate of the feeble minded is 
double that of nonnal children. 

A closer analysis of the figures which these ob- 
servers furnish brings out the interesting fact that 
if the feeble minded succeed in passing the age of 
twenty their expectation of life is better than that 
of normal individuals. This is probablv because 



institutional life serves to protect thcmi against the 
infections, accidents, and acquired ailments to 
which the general adult population is exposed. The 
greatest divergence occurs in early childhood. At 
the age of three the feeble minded are six times 
more likely to die than are normal children. The 
disparity keeps up in a lessened degree until the 
"teens" are reached, when there is very little dif- 
ference between the defectives and the normals. Thf 
lower the grade of mentality the higher the death 
rate. Thus, idiots have much less chance of reachinsj 
adult life than have morons and high grade imbe- 
ciles. The causes of death are exceedingly varied. 
Sudden death, or death after a very short illness, 
is exceedingly common. Idiots of the Mongolian 
type are especially apt to die young, and they have 
a habit of dying without warning. Pneumonia is 
a common cause of death in all types. Tuberculo- 
sis is also a frequent occurrence and, according to 
some observers, causes death in nearly forty per 
cent, of the cases. In the series reported by Clark 
and Stowell, tuberculosis was not of such frequent 
occurrence, this disease having been responsible for 
only ten per cent, of the total. 

As feeble mindedness is without hope so far as 
cure of the affected individual is concerned, and as 
the longer the life of the defective individual the 
greater the danger to society through the reproduc- 
tion of his own kind, it is hardly a matter of regret 
that Nature has a tendency to curtail this morbid 
perpetuation by an early death of the afflicted. 



FRIEDMANN'S ANTITUBERCULIN 
VACCINE. 
In a letter to the editor, which appears on page 
104 of our present issue. Dr. George Gibier Ram- 
baud places before the medical profession the com- 
position of Friedmann's vaccine. He states that 
the "vaccine is simply a homogeneous emulsion of 
live avirulent tubercle bacilli in plain sterile distilled 
water. The germ was isolated several years ago 
from a turtle, and the culture has been maintained 
since that time by transplantation on artificial cul- 
ture media, according to the usual procedure." 



A MODIFIED WASSERMANN TEST. 

Dr. L. O. Thompson describes, in the Archives 
of Internal Medicine for May, a method designed 
to overcome certain drawbacks of the original 
Wassermann and Xoguchi tests, viz., the chance 
for error in that the human serum to be tested 
contains natural antisheep amboceptor, the diffi- 
culty of keeping a sheep, and the fact that 
the small quantity of serum used in the Noguchi 
test may not contain enough antibodies to cause 
binding of complement. In Thompson's modifica- 



July I.-. 1913 1 



NRirS ITEMS 



93 



tion antihiinian anilx)ccplur, ul)taiiicd alter in- 
jection of waslied human coriJiisclcs into rabbits, 
is used. A ten per cent, solution of fresli 
gui!ieai)i_q; serum is used for complement. From 
both rabbits and pigs the blood is obtained 
directly from the heart through a hollow needle, 
the animals surviving for future tests. The pa- 
tient's blood is easily obtained, and in sufficient 
quantity, by withdrawal from a vein at the elbow 
with a syringe. A suspension of human corpuscles 
is used. In performing the test, incubation is con- 
tinued for one hour, during which time the tubes 
are shaken several times to facilitate hemolysis. 
An elaborate system of controls, including eight 
different tubes, makes error impossible. 



THE ETIOLOGY OF RELAPSE l.\ 

MALARIAL INFECTIONS. 

James, in discussing the malarial fevers in the 
Canal Zone, in the Journal of Infectious Diseases, 
May. 1913, believes that a large part of the 
malaria prevalent in that district is due to the 
occurrence of relapses, and not to reinfections. This 
is apparently due to the presence, particularly in the 
bone marrow, of asexual parasitic forms, which 
when conditions are favorable increase and give 
rise anew to manifestations of the disease. In many 
instances it is found that infections treated insuffi- 
ciently w^ith small doses of quinine will in all prob- 
ability relapse, as such doses, even in the mildest 
injections, serve only to render the asexual cycle 
relatively immune! Also, the older such a cycle, 
the more resistant to quinine it becomes. As a re- 
sult of his obsenations, James believes that primary 
infections should be very vigorously treated in order 
to prevent the development of immune parasites. 
To that end he administers forty-five grains of qui- 
nine a day, in fifteen grain doses. By this method 
recurrent malaria has been practically eradicated 
from the Americans. When a relapse does occur, 
some other method than quinine by the mouth 
should be employed, preferably the intravenous 
method with high dilutions. This seems to more 
rapidly free the spleen and bone marrow from para- 
sites than can be accomplished by hypodermic in- 
jections. 

ietos Ittms. 



The Lane Lectures. — The fourteenth series of the 
Lane medical lectures will be given by Sir Edward 
Schafer, professor of physiologj- in the University of 
Edinburgh, on the evenings of September 3d, 4th. 5th. 8th. 
and 9th, in Lane Hall of Stanford University Medical 
Department. San Francisco. The subject of these lectures 
will be the Function of the Ductless Glands, Especially in 
Relation to Other Secreting Organs. 

American Society for Physicians' Study Travels. — 
In our issue for July 5th we published an item ccmcern- 
ing this organization, in which appeared the names of 
the newly elected officers of the society. We have since 
learned that we were in error in statiuat that Dr. \\'illiam 
J. Mayo, Dr. Llewellys F. Barker, and Dr. Frank Billings 
were elected vice-presidents, as the society has no vice- 
presidents, but four presidents. Dr. James M. Anders, of 
Philadelphia, is acting president, and the other presidents, 
in the order of their election, shall, in the absence or 
disability of the acting president, be required to perform 
his duties. 



A Merger of Medical Colleges. — The Atlant.i College 
of Physicians and Surgeons and the .\tlanta School of 
Medicine have been consolidated under the name of the 
.^t!anta Medical College. Dr. \V. S. Elkin will be dean 
nf the new institution, and Dr. W. V. Westmoreland, 
president. 

Manchester, N. H., Medical Society.— At a meeting 
of this society, held on the evening of June 20th. the fol- 
lowing officers were elected : President, Dr. F. N. Rog- 
ers; vice-president. Dr. G. C. Wilkins; secretary and 
treasurer, Dr E. A. lones: censors. Dr. Gustave Lafon- 
taine, Dr. W. H. Lyons, Dr. S. V. Fiske, Dr. G. S. 
Foster, and Dr. C. O. Coburn. 

Smallpox in Norristown, Pa. — It is reported that there 
has been an outbreak of sm.illpox in Norristown, Pa., 
four cases having been reported within forty-eight hours. 
On July 1st thirty-seven physicians were busy all day 
vaccinating the hundreds who crowded their offices. So 
many persons have been exposed to infection that the 
health authorities fear a serious epidemic. 

Massachusetts Medical Society. — At the one hundred 
and thirty-second annual meeting of this society, held re- 
cently in Boston, the following officers were elected : 
President, Dr. Walter Bowers, of Ginton; vice-president. 
Dr. Lyman A. Jones, of North Adams ; secretary, Dr. 
Walter L. Burrage, of Boston ; treasurer, Dr. Edward D. 
Buckingham, of Boston; librarian. Dr. Edwin Brigham, 
of Brookline. 

Medical Club of Harrisburg, Pa. — .^t the regular 
monthly meeting of thi ; society, held on the evening of 
June 22d, the following officers were elected : President, 
Dr. Park A. Deckard ; vice-president. Dr. George W. 
Bauder; secretary-treasurer. Dr. Edward K. Lawson, of 
Penbrook. The retiring officers are : Dr. Samuel Z. 
Shope, president ; Dr. W. H. West, vice-president ; Dr. 
John Harvey Miller, secretary: Dr. John Adam Sherger, 
treasurer. The paper of the evening, entitled History and 
Prevalence of Venereal Diseases, was read by Dr. Ed- 
ward K. Lawson. 

Death Rate in New York City. — During the week 
ending June 28, 1913. there were 1,182 deaths and a rate 
of 11.48 in 1,000 of population reported, as against 1,233 
deaths and a rate of 12.43 during the corresponding week 
of 1912. This is the lowest weekly death rate that the 
city has ever experienced, the next lowest being that of 
November 2, 1912, when the death rate was 11.59. Scarlet 
fever, typhoid fever, diarrheal diseases under five years 
of age, and deaths from violence showed a considerably 
reduced mortality. On the other hand, diphtheria and 
pulmonary tuberculosis showed an increase in the num- 
ber of deaths. Deaths from whooping cough, cerebro- 
spinal meningitis, combined heart and kidney diseases, and 
the pneumonias remuined approximately the same as in 
the corresponding week of last year. Deaths of children 
under one year of age were 28 less, under five years of 
age 5 less, between five and sixty-five years 44 less, and 
above sixty-five years of age 12 greater. The death rate 
for the first twenty-six weeks of this year was 15.04 in 
1,000, as against 15.06 during the corresponding period of 
1912. 

Personal. — Dr. Reid Hunt, chief of the division of 
pharmacology. United States Public Health Service, Wash- 
ington, D. C. has accepted the professorship of pharma- 
cology and therapeutics in the Harvard Medical School, 
succeeding Dr. Franz PfafI, whose resignation was ac- 
cepted last January. 

Dr. James R. Nydegger, of the United States Public 
Health Service, has been elected professor of tropical 
medicine in the University of Maryland. 

Dr. Wilfred Hamilton Manwaring, formerly assistant 
in pathology and bacteriolotn' in the Rockefeller Institute 
for Medical Research, has been aopointed professor of 
bacteriology and immunity at the Leland Stanford Junior 
University. San Francisco. 

The degree of doctor of public health was conferred 
upon Surgeon General Rupert Blue, of the United States 
Public Health Service, by the University of Michigan, at 
the recent annual commencement of the institution. 

Dr. William J. Mayo, of Rochester. Minn., has been 
elected foreign correspondent of the Academy of Medi- 
cine in Paris. 

Dr. George Fay Gracey. professor of chemistry and 
toxicology in the University of Texas, has resigned to 
enter the practice of medicine in New York. 



94 



NEMO'S ITEMS. 



IN'EW YoKK 

MtniCAL Journal. 



Gifts and Bequests to Hospitals. — A large poilioii of 
tht estate of the late Francis II. Wyeth is devised to the 
Jefferson, Episcopal, University, Methodist, Presbyterian 
and German Hospitals in Philadelphia. 

By the will of Karl llutter, who died in New York on 
June I5lh, the German Hospital of Brooklyn will receive 
$10,000, and the German Hospital and Dispensary of Man- 
hattan will receive one fourth of the residuary estate. 

St. Luke's Hospital, Detroit, will receive $50,000 under 
the terms of the will of Frederick E. Driggs. 

Among the bequests contained in the will of the late 
Mr. D. O. Mills are $100,000 each to the Home for In- 
curables, New York, and St. Luke's Hospital. San Fran- 
cisco, and $25,000 to the American Red Cross Society. 

Yale University will receive $475,000 from the estate 
of Dr. Francis Bacon, who died last year. The sum will 
be available for almost immediate use. 

Instruction in Sanitation by the Board Of Health of 
Hot Springs, Ark. — The recently appointed board of 
health of Hot Springs, Ark., is composed of the follow- 
ing members: President, Dr. J. C. Minor; secretary, Dr. 
William Turner Wootten, Dr. J. W. McClendon, Dr. Wil- 
liam O. Forbes, Dr. Gaston A. Hebert, and Mr. Schac- 
leiter. president of the State Board of Pharmacy. Dr. 
T. E. Sanders, city health officer. Dr. John S. Woods, 
county health officer, and Lee McLaughlin, Esq., city at- 
torney, are ex-officio members of the board. The work 
of the department has been divided into two parts, in- 
struction and execution, and it is the policy of the board 
that instruction of the public in sanitation does more 
good than coercion. The women's Civic Club has fur- 
nished from their membership fifty inspectors deputized 
by the board of healtli to inspect butcher shops, bakeries, 
restaurant and hotel kitchens, milk wagons, etc., and re- 
port their sanitation markings, the highest average to 
receive a prize. It is said that the plan works well. 

Medical Alumni of the University of Vermont Hold 
Annual Meeting. — Tlie Alumni Association of the Uni- 
versity of Vermont Medical College held its annual meet- 
ing and banquet in Burlington, on the evening of June 
24th. About sixty-five members were present. Dr. F. 
K. Jackson, of Burlington, was chairman of the commit- 
tee of arrangements, and Dr. W. A. Smith, of Springfield, 
Mass.. was toastmaster. The following officers were 
elected: President. Dr. Albert L. Bingham. '75. of Wil- 
liston, Vt. ; first vice-president. Dr. Mark R. Grain, '7g, 
of Rutland, Vt. ; second vice-president. Dr. John Wesley 
Cram, '88, of Colerain, Mass. ; third vice-president, Dr. 
George G. Marshall, '93. of Rutland, Vt. : fourth vice- 
president. Dr. Clayton G. .\ndrews, '97, of Canton, N. Y. : 
fifth vice-president. Dr. Frederick B. \\'illard. '00, of 
Hartford, Conn.; secretary-treasurer. Dr. F. K. Jackson, 
'99 of Burlington, Vt. Executive committee. Dr. D. A. 
Shea, '06, Dr. L. B. Morrison. '02, Dr. Robert L. May- 
nard, '11, and Dr. J. A. Archambault, '01. Obituary com- 
mittee. Dr. C. M. Ferrin, '65, of Essex Junction; Dr. F. 
K. Jackson and Dr. George H. Parmenter, '02, of Mont- 
pelier. 

New England Alumni Associations of Baltimore In- 
stitutions. — .'Vbout fifty members, from all parts of New 
England, attended the eighth annual joint meeting and 
banquet of the New England alumni associations of Bal- 
timore Medical College and the University of Maryland, 
held in Boston on the evening of June loth. Dr. Charles A. 
Glancy, of Providence, the retiiing president, w-as toast- 
master, and the speakers were Dr. Florence A. Sullivan, of 
Haverhill; Professor David Sweet, of Baltimore Medical 
College; Professor A. M. Shipley, of the University of 
Maryland ; Dr. L. E. Willard. of Saco, Me. ; Dr. E. B. 
Goodall, of Haverhill; Dr. H. H. Sumner, of Lowell; Dr. 
F. A. Sprague, of Concord, N. H. ; Dr. Roland T. Goss, of 
Wilder, Vt. ; Dr. C. B. O'Rourke. of East Providence, R. I. ; 
Dr. George M. Burroughs, of Danielson, Conn. ; and Dr. 
E. C. Conroy, of Andover. These officers were elected • 
Dr. E. C. Conroy, president; Dr. Harry W. Wood, of 
Brookline, vice-president; Dr. Charles S. Gilman. of Bos- 
ton, secretary; Dr. P. C. Devlin, of Lynn, treasurer. 
Other vice-presidents elected were: Dr. L. E. Willard. for 
Maine; Dr. F. A. Sprague, for New Hampshire; Dr. C. C. 
Waller, of Lydonville, for Vermont ; Dr. L. B. LeGro, 
of Haverhill, for Massachusetts ; Dr. C. B. O'Rourke. for 
Rhode Island; and Dr. George N. Burroughs, for Con- 
necticut. 



National Association for the Study and Education of 
Exceptional Children. — At the annual meeting of this 
association, held in New York recently, a board of di- 
rectors was appointed, whose membership includes the fol- 
lowing honorary vice-presidents of the association: Dr. 
Philander P. Claxton, United States Commissioner of Edu- 
cation, Dr. Charles W. Eliot, president emeritus of Har- 
vard University, Dr. G. Stanley Hall, president of Clark 
University, Dr. Abraham Jacobi, of New York, Hon, Wil- 
liam H. Taft, ex-President of the United States, and Dr. 
Ray Lyman Wilbur, of San Francisco, president of the 
.'\merican Academy of Medicine. Dr. Maximilian P. E. 
Groszmann, of Plainfield, N. J., Dr. Ira S. Wile and Dr. A. 
Emil Schmitt, of New York, and a number of prominent 
laymen are also members of the board. It was formally 
resolved to organize medical, educational, and sociological 
advisory boards, a general committee, and a women's aux- 
iliary committee. A vigorous campaign is to be started at 
once to affiliate with the association all organizations which 
are concerned in some phase of child welfare work. Dr. 
A. Emil Schmitt, of New York, is president of the associa- 
tion, and Dr. Maximilian P. E. Groszmann is educational 
director. 

Civil Service Examinations. — .\moiig the positions for 
which examinations will be held by the New York State 
Civil Service Com.mission on July 26, 1913. is that of med- 
ical superintendeat of the Montgomery County Tubercu- 
losis Hospital, at Amsterdam, N. Y. ; salary $1,000 to 
$i,2GO and maintenance. Candidates must be well edu- 
cated physicians, graduates of legally chartered medical 
colleges, with an experience of at least six years in the 
actual practice of medicine, including at least one year's 
actual experience in a hospital. Subjects of examination 
and relative weights : Questions relating to hospital man- 
agement, including the purchase of supplies, 3; questions 
on general medicine, surgery, and hygiene, and the treat- 
ment of tuberculosis, 3; education and experience, 4. In 
connection with the rating on the last subject, candidates 
may be summoned for an interview with the examiners. 
Special credit will be given for actual experience as ex- 
ecutive head of a hospital. Open to all citizens of the 
United States, preference in certification being given to 
residents of the State of New York. Another position 
for which an examination will be held on the same day 
is that of trained nurse to State institutions, which is 
open to men and women ; salary, $420 to $600 and main- 
tenance. Candidates must be graduates of a nurses' train- 
ing school registered by the State Education Department. 
No application blanks received at the office of the Com- 
mission after July 18. 19T3. will be accepted. 

Changes in the Faculty of the Harvard Medical 
School. — Many changes in the faculty of the Harvard 
Medical School have been announced, among them the 
most important being the appointment of Dr. Edward 
Hall Nichols and Dr. Charles Allen Porter to be asso- 
ciate professors. Dr. Herman Morris Adler becomes 
an assistant professor of psychiatry. Dr. Hugh 
Cabot, an assistant professor of genitourinary sur- 
gery; Dr. David Cheever, assistant professor of 
surgical anatomy ; Dr. Eugene Anthony Crockett, 
an assistant professor of otology; Dr. Channing Frothing- 
ham, Jr.. Dr. Thomas Ordway, Dr. William Henry Smith, 
instructors in medicine for three years. Dr. Alexander 
Forbes and Dr. Percy Goldthwait Stiles, instructors in 
physiology for three years, are promoted. The following 
have been reappointed : Dr. John Bapst Blake, to be as- 
sistant professor of surgery; Dr. Richard Clark Cabot, 
assistant professor of medicine; Dr. Robert Baty Green- 
ough and Dr. Howard Augustus Lothrop, assistant pro- 
fessors of surgery; Dr. Richard Clarke Cabot, assistant 
professor of medicine; Dr. Franklin Spilman Newell, as- 
sistant professor of obstetrics: Dr. Paul Thorndike. assist- 
ant professor of genitourinary surgery ; Dr. Ernest Edward 
Tyzzer, assistant professor of pathology: Dr. John W'ar- 
ren, assistant professor of anatomy; Dr. Malcolm Storer. 
Dr. Howard Townsend Swain, Dr. Ernest Boyen Young. 
Dr. Robert Laurent DeNormandie. Dr. Robert Montvalle 
Green, Dr. Henry Talbot Hutchins. Dr. Nathaniel Robert 
Mason, Dr. James Rockwell Torbert, instructors. Dr. 
Ralph Leavitt Reynolds receives the appointment of 
alumni assistant in obstetrics and Dr. Richard Goodwin 
Wadsworth is made a fellow in surgery for next year. 
.Ml of the appointments go into effect on September 1st. 



July 12, i9"3] 



PITH OF PROCRESSH'E LITERATURE. 



95 



Ipitl] of ^Iroorrcssibc f ilcraturc. 



BERLINER KLINISCHE WOCHENSCHRIFT 

,l/,iv 5. I') IS. 

Treatment of Epilepsy. — A. Erlenmeyer. in 
the drug treatment, employs the inorganic bromides, 
with hydratcd chlornl and opium at times as ad- 
juvants. In the diet he allows a limited amount of 
sodium chloride, as this serves to increase the action 
of the bromides. In view of the antagonistic re'a- 
tion of chlorides and bromides, it follows that the 
absolute withdrawal of sodium chloride results in 
severe bromism, while by the addition of sodium 
chloride the bromism quickly disappears. Of the 
countless remedies formerly used in epilepsy, atro- 
pine deserves to be mentioned. It may be given 
either in pills containing 0.005 gramme, one or two 
daily, or by subcutaneous injection. Krotalin is a 
substance derived from the poisonous glands of the 
copperhead snake, which exerts a double action on 
the organism. Its contained peptones have a para- 
lyzing etifect, while a second constituent, the globu- 
lin, decreases the fluidity of the blood. It has been 
given in epilepsy, but as it is maintained that hemo- 
philes are never epileptics, diminishing, by such an 
agent, the fluidity of nonbleeders who are epileptics, 
.'t would have the eft'ect, to a certain extent, at least, 
of making hemophiles of them. 

May /.', 191;. 

The Corpus Luteum and Pregnancy. — J. W. 
Miller states the following : There exists a close 
relationship between menstruation arid ovulation. 
The rupture of the follicle occurs, on an average, 
nine days in advance of the bleeding. While the 
ovum is moving along the tube, the transformation 
of the membrana granulosa to the corpus luteum is 
taking place. The epithelial nature of the corpus 
luteum has been proved, in comparative embryology, 
by the finding of the colloid substance (produced 
only by the epithelia) inside the lutein cells. The 
recent corpus luteum gives no fat reaction, and this 
is not obtained until the retrogression has begun. 
The corpus luteum gives almost no fat reaction 
during the entire term of pregnancy. The corpus 
albicans results from the fatty degeneration of the 
lutein cells. A histological differential diagnosis of 
the gravid corpus luteum is made by the negative 
fat reaction, by drops of colloid, and by calcareous 
concretions. The yellow spot is a periodic, self 
developing gland, with internal secretion. It accom- 
plishes the cyclic transformation of the uterine 
mucous membrane into decidua. The ovum has no 
part in this. A trophic centre for the uterus gen- 
erallv protects the new product of conception anil 
prevents the maturation of a new ovum. Alenstrua- 
tion signifies frustrated ovulation and the discharge 
of a hyperemic uterus. It has no importance as 
regards the accomplishment of conception, though 
the menstrual blood may possibly contain nourish- 
ment for the ovum. Rut in animals and menstrua- 
tion in the human female are developmentally and 
physiologically different processes. The tenth day 
before menstruation is the surest time for natural 
or artificial impregnation. The first ovum after the 
cessation of menstruation is usually the one which 
implants itself. 



The Question of Oxalic Acid Formation and 
Elimination in Man. — L. Lichtwitz and W. 
Thorner give the following conclusions: i. In most 
patients with icterus the urine contains an increased 
amount of oxalic acid. 2. .\s the ductus chole- 
dochus grows more permeable the oxalic acid is 
decreased. 3. The escape of a certain amount of 
oxalic acid in the bile has been demonstrated by 
other investigators as well as themselves. 4. The 
ingestion of from two to five grammes of glycocoU 
produces no increase of oxalic acid in the urine. 5. 
Gelatin increases the formation of oxalic acid. 6. 
The observations of Wegrzynowski prove again the 
importance of intestinal flora in relation to the 
formation of oxalic acid. In Fiirbringer's patient 
the action of bacteria (Asl)ergillis itiger) in causing 
its formation in the lungs is distinctly shown. 7. 
The ingestion of roasted partridge does not lead to 
an increased output of oxalic acid. 

May Neosalvarsan Be Used for Outpatient 
Service? — A. Wolff and P. Mulzer sound a 
warning against the use of neosalvarsan in am- 
bulatory patients. According to Lesser, some six- 
teen or eighteen such patients who had been treated 
with neosalvarsan have fallen unconscious in rail- 
road stations, workrooms, hotels, and other places, 
and died a short time after. According to the 
authors' and other investigators' obseryations, neo- 
salvarsan, even in small doses, produces much more 
toxic effects than the old salvarsan. The authors 
have abandoned the use of a remedy which they 
regard as so dangerous. 

, Action of Adrenalin on the Coronary Arteries. 
— F. Aleyer, from experimenting on animals, finds 
that the administration of adrenalin produces re- 
markable acceleration of the coronary circulation, 
the result of increased blood pressure, from the 
heightened action of the heart. As show'n also by 
other authors, adrenalin causes an increase in the 
calibre of the coronary vessels, as well as an in- 
creased flow of blood through them. 

May 36. igi;. 

The Treatment of Tabetic Manifestations 
with Arsenical and Bacterial Preparations, — 
Dollken's experience has =hown that mercury 
salicylarsenol (enesol) is a valuable remedy in 
tabes therapy. The lancinating pains diminished or 
were entireh' relieved ; there was gain in nutrition 
and strength ; ataxia improved ; also the crises were 
favorably influenced : but pupil and tendon reflexes 
never returned during treatment. On the other 
hand, the author also witnessed numerous relapses 
after from four to six months. Schaffer and 
Hudovernig have accomplished even better results 
with enesol. Aside from destructive processes in 
the spinal cord and posterior roots, there are found, 
during the entire process of tabes, subchronic, 
chronic, and other recurrent processes in the peri- 
pheral nerves and in other organs. Three kinds of 
remedies may produce therapeutic results : first, 
bactericides, if these can be brought into contact 
with the elements exciting tabes phenomena ; second, 
bacterial products and remedies which have the 
ability to inhibit the toxines and render them harm- 
less ; third, albuminous bodies and the like which 
force the organism to a powerful reaction under 
febrile conditions and hyperleucocytosis. The or- 
gans themselves may thus be excited to the making 



90 



rrni oi- ri<oGi<iiSSiVE liter.itlre. 



of antibodies, as well as the phagucylic and leiicd- 
cytic ferments in addition. Wagner has the credit 
of having first studied the systematic and favorable 
actinn of sncli agents as tuberculin on paralysis. 

Arsenical Paralysis. — (^borniillcr concludes 
from bis own observations and those of others that 
the unfavorable results which have been noted from 
salvarsan and neosalvarsan are purely symptoms of 
arsenical poisoning, and that the cerebrospinal acci- 
dents which sometimes occur from their use repre- 
sent only this, and therefore should be avoidable. 

WIENER KLINISCHE WOCHENSCHRIFT. 

Mi'Y I. :vis. 

Treatment of Exophthalmic Goitre by Irradia- 
tion of the Ovaries with X Rays. — J. Mannaberg 
reports ten cases of e.xopbthalniic goitre in which he 
obtained improvement of all the symptoms except 
the goitre by irradiating the ovaries with the x rays. 
He thinks that the ovaries play some part in the 
clinical picture of this disease, it may be from the 
formation of some substance in the ovaries which 
acts upon the thyroid and modifies its fimctions in 
such a way that exophthalmic goitre is the result. 
The X rays dry up the source of this substance in 
the ovaries, and so allow the thyroid to resume its 
normal functions. It might be wise to supplement 
the radiotherapy with a course of thyroid treatment. 
Eight of the ten patients treated by him gained con- 
siderably in weight, in one the exophthalmos disap- 
peared completely, and in half the cases there was 
more or less improvement. Subjectively, nearly all 
the patients feel quite well and are able to work. 
The ages of the women ranged from twenty-one to 
forty-two years. The number of exposures varied 
from three to fifteen. 

A Case of Cyclic Paresis of the Oculomotorius. 
— Hans Lauber reports a curious case of this rare 
condition, met with in a six year old boy, in whom 
it had been noticed since he was six months old. 
The left eye was normal. The right eye could not 
be moved voluntarily except a little by the abducens 
and by the superior oblique, the upper lid bung 
down in incomplete ptosis, the pupil did not react 
to light, convergence, psychic, or sensorv stimuli. 
Yet the muscles affected by this paresis of the oculo- 
motorius made certain involuntary contractions, 
especially during sleep. The upper lid would sud- 
denly rise, the eyeball would be adducted to the 
middle line, and the diameter of the pupil would 
change from four m.m. to 1.5 to 2 m.m. This con- 
dition would last for from fifteen to thirty seconds. 
and then, with slight twitchings. the lid would sink. 
the globe return to its abducted position, and the 
pupil dilate. After an interval of from thirtv to 
ninety seconds the phenomenon would be repeated. 

Arsenic Poisoning. — Erik Lindstroem tells of 
his personal experience and that of his son, eleven 
years old, the result of sleeping in two rooms that 
had just been painted. He occupied his room four 
months and then went on a vacation, during which 
time neuralgic pains developed, which were distress- 
ing, but subsided when he lay still. These pains 
lasted a month, and then subsided during the sum- 
mer, but returned the next winter with great sever- 
ity and became so bad that he could not use his right 
hand. .■\n obstinate conjunctivitis developed in the 



boy, who grew pale and thin. .Arsenic poisoning 
was suspected now for the first time, and arsenic 
was found in his urine, as well as in that of the 
other members of the family, and arsenic was found 
in large quantities in the f)il paint on the walls of 
the rooms. It \\a^ also found that the poisoning 
was most severe in the rooms that had received the 
greatest number of coats of paint. 

May S, igis. 

Operative or Conservative Treatment of Stab 
Wounds of the Lungs. — Ernst von Kutscha re- 
ports four cases in which operative treatment was 
required and eight in which it was unnecessary. He 
holds that severe hemorrhage and collapse from 
pneumothorax justify operation. If the thora.x is 
opened the opening should be made large enough to 
permit the wound in the lung to be readily sutured 
before any other measures are attempted. 

Cancer of the Lungs. — .Alfred .Arnstein reports 
another case of cancer in the lungs in a miner in 
the Schneeberg district of Saxony. According to 
the statement made by Haerting and Hesse in 1878 
and 1879, seventy-five per cent, of the deaths among 
these miners are caused by a lymphosarcoma of the 
bronchial glands, or an endithelial sarcoma. Arn- 
stein finds that the diagnosis made in one third of 
all the cases admitted to the hospital from 1907 to 
191 1 was cancer of the lungs, and that this was 
given as the cause of death in forty-four per cent, 
of the death certificates. He was able to examine 
two cases post mortem, and found chronic pulmon- 
ary tuberculosis in one and carcinoma of the lung 
with metastasis in the other. He is inclined to think 
that errors of diagnosis have been made, as autop- 
sies are luicommon, and that tuberculosis has been 
responsible for many of the deaths. 

May 15. JQis. 

Anaphylactic Poisoning. — R. Kraus and P. 
Kirschbaum declare that we should be very careful 
how we call a poisoning anaphylactic, for their re- 
sults show that the so called anaphylatoxine pro- 
duced in the test tube is not necessarily identical 
with the anaphylactic poison. 

Typhoid Infection of the Biliary Passages with 
Aplasia of the Gallbladder. — ."^^tefan Zarzycki re- 
ports the case of a woman, twenty-five years old, 
who proved to be a carrier of infection after re- 
covery from an attack of typhoid fever. Operation 
to remove the gallbladder revealed its congenital 
absence. Experiment on a rabbit confirmed the 
clinically proved fact that the large biliary passage^^ 
furnish a good nutritive bed for a permanent d ■- 
posit of typhoid bacilli, even when the gallbladder is 
absent. 

May .'.', igis. 

The Benzol Treatment of Leucocythemia. — 

Otto Alfred Roesler reports two cases in which 
great benefit seemed to be obtained from treatment 
with benzol, though final judgment cannot be passed 
upon the results as yet. 

The Formation of Specific Agglutinin in Arti- 
ficial Tissue Cultures. — T'. Przygode finds that 
tissue of the spleen, exposed to the action of an 
emulsion of typhoid bacilli in a plasma culture, 
forms in the test tube specific agglutinines against 
these bacilli. 



July 



t'lTll Ol- I'kCX.h'I'SSn'E LlTEKAiUKE. 



97 



Inhibition of Inflammation. — Hans Jaiuisclikc 
finds that the acute exudation in the inllaniinatory 
cheniosis of the rabbit's eye produeed by oil of mus- 
tard may be prevented by meiHcamental or degen- 
crative bhinting of the sensory lihunents of tlie 
trigeminus in the conjunctiva. 'Ihe sweUing of the 
conjunctiva caused by oil of mustard may also be 
greatly lessened or prevented by general narcosis, 
by the subcutaneous injection of such anesthetics 
and analgesics as morphine, antipyrine, sodium sal- 
icylate, or quinine, as well as by such sedatives as 
sodium bromide. The inhibition of the inflamma- 
tory exudation in the conjunctiva by narcotics takes 
place independently of narcosis of the central nerv- 
ous system. The swelling may be restricted some- 
what by the subcutaneous injection of salts of lime 
and of magnesium, and of epinephrin. .\lmiist all 
the materials tested experimentally have been ob- 
served clinically to be able to act antiphlogistical'.y 
in certain vascular regions and against certain in- 
flammatory agents. In many forms of acute and 
chronic coryzas the internal administration of cal- 
cium lactate seems to be indicated. 

ZENTRALBLATT FUR GYNAKOLOGIE. 

May //-, K/IS- 

The Technic of Caesarian Section. — Veit calls 
attention to the necessity of simplifying the technic 
as much as possible, in order that the comparatively 
inexperienced operator may get good results. Veit 
makes use of Frank's transperitoneal method of 
opening the lower uterine segment. By stripping 
oflf and reflecting the peritoneum he has succeeded 
in quite a number of cases in extracting the baby 
extraperitoneally. 

Inversion of the Uterus.— Froriep reports an 
interesting case of atony of the uterus complicated 
by placenta prasvia. In consequence of the e.xtreme 
thinness of the wall (from 0.5 to one cm.), the 
uterus became inverted, and was extirpated by the 
operator. On account of the great loss of blood 
preceding the operation, the patient died shortly 
afterward. 

A Case of Rupture of the Uterus Following 
the Use of Pituitrin. — Herz reports a case in 
which a twenty year old primipara was in labor for 
forty-eight hours, the pains not being at all mark' d. 
The patient was then given an injection of une 
c. c. of pituitrin. Within three or four minutes the 
pains began, and rapidly grew more and mi ire 
severe. In the course of about twenty minutes tlie\- 
became tetanic, lasting from five to seven minutes. 
An hour after the injection there was a terrific 
tetanic contraction, causing the patient to cry out 
and then collapse. Somewhat later the child was 
born, and examination showed that the anterior- 
portion of the cervix had been torn from the uterus 
wall (colporrhexis). At the end of fourteen days, 
when the last of the gauze packing was removed, it 
was found that the torn cervix had firmly united to 
the wall of the uterus. The author believes that 
pituitrin should be used with the greatest care dur- 
ing the early stages, when there is rigidity of the 
cer\'ical opening. 

May .'-I, :>iis 

Perforation of the Uterus. — Maly presents 
briefly a case in which a physician undertook to 



cause an abortion on account of the critical condi- 
tion of the patient, due to a cardiac lesion. The 
rigid cervix was being dilated by means of a blunt 
dilator when the instrument suddenly encountered 
no resistance. The abdomen was opened, blood re- 
moved, and a clean, sharp wound, 1.5 cm. long was 
found on the anterior wall of the cervical |)ortion 
of the uterus. This was sewed up, and the abdo- 
men closed, the patient making an uneventful re- 
covery. 

The Care of the Umbilical Cord.— After trying 
various methods, Nachjry recommends the follow- 
ing: lie ties the cord close to the skin with a silk 
ligature, cuts the ends short, and cuts the cord some 
one to 1.5 cm. above the ligature. The stump, as 
well as the umbilical ring, is thoroughly painted 
with iodine. After the infant's bath the iodine is 
again used. In the course of from two to three 
days, as a rule, the stump comes ofif. This method 
has been employed in fifty cases with good results. 
In this way all danger of infection is avoided, and 
the small stump rapidly shrivels. No bleeding oc- 
curs, the ligature preventing it. Then, after the 
separation of the stump, no further treatment is 
needed, as there remains only a smooth, clean scar. 

Delivery in a Case of Complete Paralysis of 
the Back and Lovi^er Extremities. — I'.ogdano- 
witsch gives in detail an interesting case in which 
there was paralysis of the lower extremities of the 
back and of the upper extremities as well. -Al- 
though there was this complete loss of muscular 
power, the uterus spontaneously contracted, and in 
the course of about three hours the baby was bom. 
The mother died two days later from respiratory 
embarra?sment. It is evident from this case that the 
motor functions of the uterine muscle are not de- 
pendent upon the spinal cord, but evidently upon 
the peripheral nerve centres that are localized in 
the uterus. 

CENTRALBLATT FUR ALLGEMEINE PATHOLOGIE UND 
PATHOLOGISCHE ANATOMIE. 

May 31, 1913. 

A Hypernephroma in a Frog. — Carl briefly re- 
ports the finding of such a tumor, one in which 
neither glvcogen nor chromaffin cells could be 
demonstrated. 

BRITISH MEDICAL JOURNAL. 

June 21. I'll}. 

The Lachrymal Gland in Surgical Anesthesia. 
— L. T. Rutherford seems surprised that the activity 
of this gland in anesthesia should have escaped notice 
for so long a time. He has given its behavior care- 
ful study in a series of over two hundred cases, and 
lays down its responses to the different stages of 
anesthesia as follows: i. In the first stage the activ- 
ity of the gland varies according to the strength of 
the irritation in the nose, and, if no vapor reaches 
the cornea, the canthus may be dry. 2. With the 
onset of the stage of excitement the glands become 
very active, and pools of secretion appear in the 
inner canthi. 3. During the stage of surgical 
anesthesia the glands cease to secrete, and with in- 
creasing depth of anesthesia they do not resume 
activity, so that in overdose they remain dry. There- 
fore, the inner canthi may be wet or dry in the 
first stage, are filled, in the second, and, if the secre- 



98 



PITH OF PROGRESSIVE LITERATURE. 



[New York 
MnoiCAi* Journal. 



tion from the second stage is kept mopped up. ilv- 
canthi remain dry after the inception of sur.aficnl 
anesthesia. The importance of these observations 
hcs in the fact that, when the pupil begins to dilau 
during the administration of ether or chlorofurni. 
and secretion remains absent from the canthi. an 
overdose is being given, whereas, if secretion a]'- 
pears in tlie canthi, the stage of surgical anesthesia 
is passing off and more anesthetic is needed. Ruth- 
erford believes that the observation of the canthi 
thus forms a very valuable aid to the estimation > ^f 
the depth of anesthesia, and provides a very certain 
and early sign of an impending escape from anes- 
thesia or of an overdose. 

Sleeping Sickness and Big Game. — Warring- 
ton Yorke's researches show that in Africa X\v: 
continuous supply of trypanosomes virulent for man 
and the domestic animals is to be found in the bit' 
game, from thirty-five per cent, to fifty per cent, n' 
all of the larger wild animals in nature being in- 
fected. From this source the several flies, more par- 
ticularly the Glossina morsitaiis, derive their infec- 
tion, which they then transmit to domestic animals 
or to man. The extermination of these flies is a 
practical impossibility, as sliown by previous studies. 
Yorke therefore suggests that an experiment be 
made upon the extermination of the larger wild 
animals in a given area, or that from such an area 
all such animals be driven out. He believes that 
their absence would not only soon rid the region of 
the infected flies, but that even the uninfected flies 
would become very much diminished in numbers. 
Owing to the nature qi trypanosomiasis, it seems 
wholly improbable that man and the domestic ani- 
mals would propagate the infection for long. 

LANCET. 

June .'/, igis. 

The Place of Climatology in Medicine. — \\ il 

Ham Gordon (lecture II) cites the elaborate 
statistics of Mueller, of Switzerland, for the years 
1865 to 1869, and in addition many other similar, 
though less complete sets of figures brought forth 
since the days of Koch. These statistics are care- 
fully analyzed by Gordon with reference to the 
eflfect of altitude alone upon the prevalence and the 
course of tuberculosis. He finds that altitude alone 
has no influence whatever on either factor. On the 
other hand, in the presence of prevalent rain bear- 
ing winds, increase in altitude brings about both 
greater frequency of the disease and a decidedly 
unfavorable effect upon the course, leading to a ma- 
terially increased mortality rate. This is true onlv 
to a limited extent, however, the eflfect increa-ing 
from low lands with rise in altitude up to the point 
at which exposure to winds remains great. Inn the 
relative humidity falls. There is a zone at a medium 
altitude in which exposure and rainfall are greatest 
for any given region, and in this zone tuberculosis 
is at its worst, both as regards morbidity and mor- 
tality rates. In conditions of shelter from rain bear- 
ing winds altitude has no effect on prevalence of 
the disease. 

Tetragenus Septicemia. — John Byers's and 
Thomas Houston's patient was a boy of eleven 
years who had suft'ered for years from recurrent 
attacks marked by respiratory catarrh, bronchitis. 



bronchopneumonia, throat, nasal, and ear troubles, 
and, at times, abscesses and diarrhea. His last at- 
tack began with nasopharyngeal catarrh and pain in 
the ears, .\fter a short period of improvement he 
became feverish, had an attack of epistaxis, and 
bronchopneumonia and catarrhal involvement of 
both ears developed. His condition progressed un- 
favorably, and he was becoming moribund when the 
Micrococcus tetragenus was isolated from his 
throat, nose, ear, blood and urine. Though it was 
in mixed culture in the throat and nose, the opsonic 
index lent confirmation to the belief that it was the 
prime cause of his infection. .\ pure autogenous 
vaccine of this organism was given, later being com- 
bined with one of the pseudodiphtheria bacillus for 
a local ear infection. Speedy recovery was made, 
though the patient was believed to have been mori- 
bund when the first dose was given. 

A New Spirochasta Found in Human Blood. — 
Helen Chambers was led by her histological inves- 
tigations of the thyroid gland in exophthalmic 
goitre to believe that the changes in many of the 
glands were of the nature of inflammatory responses 
to some infecting agent. Upon this hypothesis she 
was further led to make a search for an organism 
of a protozoal order, as she was unable to find any 
sign of bacterial infection of the gland itself. In 
her studies she found an actively motile spirochseta 
in the serum which separated from blood drawn into 
a small pipette The organism is from four to 
thirty microns in length, may be thick or extremelv 
thin, its curves are being constantly obliterated by 
its motions, the ends are usually rounded, and some- 
times the ends are swollen and look like spores. 
The spirochetes have been seen in process of divi- 
sion, which takes place longitudinally. They can 
be stained with Leishman and Giemsa's stain, when 
small, red, chromatin granules are often found at 
their ends, or sometimes occurring along their 
length. Other methods of staining can be used, but 
the best method of finding it is in the fresh serum, 
examined in the dark field. It has been possible to 
cultivate the spirochaeta in blood drawn into broth, 
in blood alone (allowed to clot), and in blood drawn 
into molten agar. In each instance the organisms 
are to be found in the region of the red cells which 
are present. No successful subculture on artificial 
media has been made as yet. The organism is often 
very abundant in the blood drawn from a person to 
all appearances in full health. In forty-seven cases, 
including fifteen persons in health. Chambers has 
found the spirochete in all but three. She offers 
no suggestions as to its nature or significance. 

INDIAN MEDICAL RECORD. 

May, I;<IS' 

Eucalyptus in the Treatment of Pulmonary 
Tuberculosis. — L. G. Pedigo has obtained good 
clinical results in pulmonary tuberculosis, as well as 
in ordinary colds, by the inunction of a teaspoonful 
of a twenty-five per cent, eucalyptus ointment. The 
premises of the treatment are : Oil of eucalyptus 
is known to be inimical to bacterial and parasitic 
life ; in whatever way this agent enters the circula- 
tion it will be eliminated chiefly through the lungs, 
the habitat of the tubercle bacillus in pulmonary 
tuberculosis. Essential oils, like the oil of euca- 



July IJ. :9n] 



FITll OF PROGRESSIVE I.IUiRATURE. 



')9 



hptus, are irritating; to the miu-oiis membrane of 
tlie stomach ; hence the oil cannot be administered in 
this way. Given hypodermically. it is a local irri- 
tant. It is very volatile, hut to give it by \ai)oriz:i- 
tioii the patient neetls to he suhjected to an ex- 
haustive vapor bath. It can. however, he introduced 
into the circulation readily by incorporating it with 
an oilv base and rubbing it into the skin. It is de- 
sirable to have a mixture that will remain firm at 
ordinary temperatures, but will melt rapidly at the 
temperature of the skin surface, and to have the 
base one that will readily jienetrate the skin. ( )ne 
that he recommends for the colder months is as 
follows : 

Olive oil, .^ij ; 

Benzoinated lard 5vj ; 

Cacao butter, 3iv. 

Cocoanut oil also makes a good base for summer 
use. 

JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION. 

J:nu- .-•*■, ivrs. 

The Auscultatory Determination of Early 
Pathological Changes in the Lungs. — Imoiu a 
study of this question Henry Sewell concludes tlr.it 
the earliest objective information of physical 
changes in the lungs may be obtained through the 
use of auscultation, but this demands analysis of 
the sound into those vibrations due to resonance of 
the viscera and those of the chest wall, which latter 
vibrations can be damped by i)ressure of an appro- 
priate form of stethoscope, \ibratioiis transmitting 
the whisper are confined almost wholly to the 
viscera. The modification of the vnice sounds by 
which this cjuality becomes more amphori: and their 
duration prolonged into an echo are the striking 
characters which, when accentuated by stethoscopic 
pressure, indicate iiathological changes in the 
viscera. The character and distribution of vocal 
signs over the normal chest are sufficiently constant, 
so that a topographic study of the chest by auscul- 
tation mav definitely suggest, through recognition 
of slight abnormalities, the intensity and distribu- 
tion of morbid intrapulmonary changes, which may 
be too slight to be revealed by any other mcthnd. 

MEDICAL RECORD. 

June ;S. lOlS. 

Dietetic Habit and Gastric Function. — Charles 
?. Fischer states that while the question. What 
shall I eat? when put to gastrolugisis, sin mid be 
answered v.ith facility, it is one of the most difficult 
to reply to promptly, in any given case. Notwith- 
standing the progress made in the physiology of the 
digestive processes during the past generation, not 
one particular dietetic scheme has been evo'ved 
which will meet the needs of the average run of 
ordinary gastric disturbances. Except in the very 
small proportion of abnormal functions, due to 
direct abuse of the digestive organs, most vagaries 
of gastric secretion represent, in the individuals 
possessing them, indications of constitutional taint, 
either metabolic, evolutional, or temperamental, and 
the secret of successful dietetic management of most 
dyspepsias consists in methodically meeting the^e 
conditions and adapting the food supply thereto. In 
most cases the food intake, in both quantity and 



quality, is adequate for the individual. Its distribu- 
tion is wrong. In a general way the greater the 
psychic strain, the more general should be the food 
distribution, while he whose labor is entirely physi- 
cal can endure longer intervals between meals as 
the exhaustion is more gradual, more cumulative. 
The exhaustion attendant upon mental effort is ir- 
regular, increasing and diminishing according to 
conditions, at various periods of the day, and there- 
fore more frequent support is required, the response 
being more rapid. The relief afforded depL'nds not 
so much on the nutrition involved, as on the relaxa- 
tion from the overtension which frequent feeding 
induces, under which the patient is laboring. In 
the treatment of the common mixed forms of gas- 
tric indigestion it has been demonstrated that a 
simple, nonirritating, rationally conceived mixed 
diet, distributed in such (|uantity and at such in- 
tervals as to meet the rc([uiremeiits of general 
encrgv disbursement and local muscular activity, 
will accomplish the desired results in most cases, 
irrespective of orflinary lo:al conditions of acidity 
or motility, and witlmtit the need of scientific gastric 
analysis. 

Some Remarks on Bronchial or True Asthma. 
— Harold Do Wolf de-cribes asthma as paroxysmal 
dyspnea, largely of the expiratory type, of more or 
less sudden onset, and variable though short dura- 
tion, which will at once exclude the so called asth- 
matic conditions developing in late cardiac and 
renal disease, and confine us to true or bronchial 
asthma with its allies — hay fever, rose cold, par- 
oxysmal sneezing, and spasinodic bronchitis of 
children, all having a common basis in patients of 
the so called nervous or neurotic type, all being of 
a paro-xvsmal nature, with sudden onset, and a 
tendency to recurrence at more or less definite in- 
tervals, and none in itself fatal, although any may 
lead to a fatal issue. The disease is twice as fre- 
quent in the male as in the female. While hay 
fever and rose cold have a specific time of the year 
to ai^pear, asthma itself is more frequent in thi- fall 
and spring, appearing frequently in family groups. 
The prognosis in early life, before the nervous 
system has acquired the habit, is good, it being 
often possible to train the little patient and entirely 
cure the condition. Later in life the hope of per- 
manent relief is remote. Prophylactic treatment 
includes good, wholesome food, abundant fresh air, 
proper bathing and exercise, care of the bowels, and 
prompt attention to any abnormal condition of the 
nose and throat. In treating the attack nothing 
has given as good results to the writer as morphine 
hypudermatically and amyl nitrite by inhalation ; if 
morphine is alone available, give enough and do 
not "iiutter around with minimal dosage." Chloro- 
foriu is recommended, but its effects are too transi- 
tory. .\drenalin chloride has never given good 
results in the writer's hands. Extreme exhaustion 
or threatened collapse will be relieved by a cup of 
strong coffee : strychnine, catifeine, camphor are use- 
ful stimulants, lielladonna or stramonium cigarettes 
will relieve a mild attack. Between attacks the 
treatment is climatic, hygienic, and medicinal. 
Autotherapy, as elaborated by Duncan t^see this 
JouRX.\L, vol. xcvi, Nos. 24 and 25), promises 
results far and awav bevond anv the writer knows. 



PITH OF PROGRESSIVE LITERATURE. 



[New York 
Medical Journal. 



AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 
May, igu. 

Nephritic Overtension; Clinical and Experi- 
mental Studies. — Theodore C. Janeway calls at- 
tention to the labor expended in the study of tlie 
suprarenal glarids, of which the net result is the 
solid, well grounded fact that the suprarenal glands, 
or at least their naedullary portions, prepare a sub- 
stance, epinephrin, which, introduced into the cir- 
culation, produces a rise in the systemic arterial 
pressure unequalled in intensity by any other 
known substance. While this rise is extremely 
transient the continuous, steady introduction of 
epinephrin is capable of maintaining a state of 
overtension as long as tlie introduction is con- 
tinued. Coincident with this rise in blood pressure 
is a reduction in the volume of the extremities and 
of many organs, due to local vasoconstriction, so 
that the actual blood flow through them is dimin- 
ished. Epinephrin, however, dilates the coronan.- 
artery, inhibits peristalsis, and abolishes intestinal 
tonus. Epinephrin also relaxes the bronchi when 
in a state of spasm. It is probable that during life 
epinephrin is constantly entering the general circu- 
lation from the adrenals, but except in the blood 
of the adrenal veins, epinephrin has never been 
positively identified in the general circulation of 
the normal animal or man. In renal disease the 
symptoms of overtension, the writer believes, can 
arise in three ways: Through a purely quantita- 
tive reduction of kidney substance below the fac- 
tor of safety : in connection with the unknown in- 
toxication called uremia, which causes disturbances 
of the central nervous system ; in primary irrita- 
bility of the vasoconstricting mechanism from un- 
known, probably extrarenal, causes, which lead 
eventually to arteriolar sclerosis. The vascular 
poisons back of these types of overtensive dis- 
ease are unknown. Lead poison certainly does, and 
excessive stimulation of the central vasomotor 
mechanism must play some part in this action. 
The first and second types of overtension may at 
any time be superimposed upon the third. While 
the second, the uremic t\'pe, must be considered 
dangerous in itself, overtension in the arterio- 
sclerotic or atherosclerotic kidney should be re- 
garded as a compensatory eft'ort to be interfered 
with only when danger threatens, either of cardiac 
failure or of cerebral hemorrhage. 

The Circulation in the Arm of Man. — Albion 
W. Hewlett finds that, in studying the local cir- 
culation in the arm of man, local conditions must 
always be considered. The tachogram, the volume 
pulse, and the finer waves of the radial pulse de- 
pend in large part upon the condition of the larger 
arteries. The blood flow and the temperature of 
the part depend largely upon the condition of the 
finer arterioles. The color of the part depends 
partly upon the condition of the cutaneous capil- 
laries and venules and partly upon the local flow. 
Changes in any of these cannot be referred en- 
tirely to changes in the heart action. Thermic ef- 
fects prod;ice many changes in the local circula- 
tion, and the function of the skin as a physical 
means of heat regulation must not be lost sisrht 



of in this connection. Chilliness or warmth, 
whether from external temperature or from fever, 
profoundly influence the peripheral circulation in 
an extremity. General and local warmth are the 
most efticient means we have to increase the cir- 
culation in an extremity. The efl^ect of drugs is in- 
significant in comparison with these thermic meas- 
ures. 

An Instance of Premature Beats Arising in the 
Auriculoventricular Bundle of a Young Child. — 
This case is reported by Thomas Lewis and Her- 
bert W. Allen, and concerns a child, aged four and 
a half years. The percussion outline of the heart 
is normal, the sounds everywhere clear, but the 
normal rhythm is interrupted by moderately fre- 
quent premature contractions, each of which is ac- 
companied by two heart sounds. No abnormalities 
found in the other organs. The point of origin of 
the beats is probably to be located in the main 
stem of the auriculoventricular bundle. 

Combined Tuberculosis and Carcinoma of the 
Stomach, vi^ith a Report of a Case upon Which a 
Partial Gastrectomy w^as Performed. — Henry H. 
j\I. Lyle observes that the present consensus 
regarding the coexistence of tuberculous in- 
flammation and cancer coincides with the views 
advanced by Bayle in 1810, notwithstanding the 
claim of Rokitansky in 1830, that there was a 
mutual antagonism between cancer and tuberculo- 
sis. Cancer and tuberculosis can occur in the same 
individual and in the same organ, as demonstrated 
by six cases collected by the writer, one of which 
was discovered by operation ; the remaining five by 
autopsy. The interesting point in the first case, 
beside the association of these two supposedly an- 
tagonistic lesions, is their sequence. From the 
clinical and pathological evidence the original le- 
sion of the stomach was probably a tuberculous 
ulcer of the pylonis, secondary to a possible old 
lesion of the right apex. From this tuberculous 
ulcer a difTuse carcinoma developed. 

The Control of Rabies. — Henry Albert gives 
the statistics bearing upon the prevalence of rabies 
in the world at present, the number of persons bit- 
ten by rabid dogs, the prevalence of rabies in the 
United States, and a comparison of the distribu- 
tion of the disease in this country' in 1908 and 191 1. 
The methods for the control or eradication of 
rabies considered are. immediate local treatment, 
Pasteur antirabic treatment, accurate diagnosis, 
and regulations aiming at the control of rabies in 
dogs and other lower animals (the licensing, muz- 
zling, detention, destruction, and quarantine of af- 
fected dogs). To effect extermination of the dis- 
ease the writer advocates the better instruction of 
the public, that they should realize that rabies is 
prevalent in most countries of the world, and that 
in parts of the United States it is on the increase; 
that it is possible to exterminate the disease by 
adopting certain regulations concerning dogs ; that 
the muzzling of dogs is not a hardship to the ani- 
mal, and that all the stray or ownerless dogs 
should be killed ; that eradication is worth while 
because of the loss to live stock ; that eflforts at 
eradication are justified by the loss of human life 
and the worn- incident to a dog bite. 



rrrii (.>!■ i'ROoRi-..ssiri- i.iTiiK.iriKi-.. 



ARCHIVES OF INTERNAL MEDICINE.- 

W,iv, }■::. 

Relation of Gastric and Duodenal Ulcer to 
Vascular Lesions. — W. (.)pliuls asserts that tin- 
O'Uinioncst t_\i)e of gastric or duodenal ulcer, at 
least in material obtained by necropsy, is the 
arteriosclerotic ulcer in persons over thirty years 
of age. Me presents a table in which details are 
given concerning eighteen such cases, found among 
iibont 1.500 necropsies. There is a second class of 
gastric or duo<!enal ulcer, in the young, which is 
probably due to local endarteritis (four cases). 
(.)nc also occasionally observes acute embolic or 
thronilxitic idcers (one case). 

Effect of Change of Posture on Arterial and 
Venous Pressures. — j. H. Barach and W. L. 
M.arks give the results of investigations on lorty- 
£ight students. The subjects were placed on a 
table with a movable top, and the experiments so 
conducted that the effects of change of fKDSture on 
the pressures were not vitiated by any muscular 
exertion of those under test. Change from the 
erect to the horizontal jxisture was found to cause 
an increase in the maximum pressure, a decrease 
in the minimum pressure, and an increase in the 
pulse pressure. Upton return to the erect position, 
.after five minutes, the reverse pressure changes 
took place. The venous pressure was lowered by 
■change of posture from the erect to the horizontal. 
In "'poor muscular cases" there was a tendency to 
reversal of the pressure curves, change from erect 
to horizontal position causing in over one half the 
•rases a decrease of maximum and an increase of 
minimum jiressure. 

Budding and Other Forms in Trophozoites of 
Entamoeba Tetragena.- -S. T. Darling concludj^ 
that the descrijnions of the life cycle of Entama'ba 
h-.stolytica by .Schaudinn and Craig are in all likeli- 
hood those of a spurious species, having resulted 
from observations of pathological changes in senile 
races of Entaimiini trtnii^Lvm. 

Therapeutic Value of Theobromine Sodium 
Salicylate in Acute Experimental Nephritis. — 
,H. A. Christian and J. P. O'Hare produced acute 
•nephritis with uranium nitrate in a large series of 
rabbits and gave diuretin in amounts varying from 
large doses to doses equivalent to a one gramme 
dose in the human subject. The results supported 
the view that in severe acute nephritis a diuretic 
drug such as diuretin is contraindicated, as in the 
experiments the drug shortened the life of the ani- 
mals. On the other hand, of the survivors three 
fourths had received diuretin. This rather indi- 
cates that in less severe cases diuretin may be bene- 
ficial, and so justifies the cautious use of the drug 
In moderately severe cases of acute nephritis. 

Infantilism and Pituitary Neoplasm. — E. J. 
Mullally reports a case presenting the following 
features: Marked underdevelopment of the skele- 
ton and organs : "infantile" mental state : brain 
tumor symptoms ; feminine contour of body, and 
slight myxedema. The patient weighed seventv 
pounds and appeared twelve years of age, though 
actually twenty-six. .\cetonuria. diaceturia, and 
fever preceded death. The necropsy revealed, 
ramong other conditions : Cystic degeneration of the 
pituitary, wifli complete disappearance of the 



posterior lol)e and only a few degenerated cells 
representing the anterior lobe; free communication 
through the pituitary stalk with the third ventricle : 
neoplasm of the chorioid ple.xus extending into the 
])ituitary : excessive colloid material in the thyroid; 
vacnolalion of the fasciculate laver of the adrenal-, 
ami underde\el('i>ment nf the te^le-. 

Determination of the Diastolic Pressure in 
Aortic Regurgitation. — A. E. Taussig and J. E. 
Cook conclude tb.it with the auscultatory method of 
sphygniomanometric observation the Ix-ginning of 
the fourth phase in the arterial sound — that is. the 
point at which it becomes dull — marks the diastolic 
pressure. .Since this point can readily be made out 
in aortic regurgitation, the auscultatory method is 
as applicable to this condition as to any other. The 
persistent arterial sound is not pathognomonic of 
aortic regurgitation, being often absent in this dis- 
ease and occasionally present in other conditions. 
In cases with very low blood pressure, in those 
with marked dyspnea, and in Cheyne-Stokes breath- 
ing, the auscultatory method is especiallv valuable. 

ARCHIVES OF OPHTHALMOLOGY 

.Uuv. j;lj. 

The Use of Vaccines in Eye Infections.— 
James Garfield Dwyer published in 1910 the results 
he had obtained from vaccine treatment in a series 
of infections of the eye, ear, nose, and throat ; since 
then the series has grown to cover 300, and time 
has strengthened his conclusion that in vaccines, 
properly used, we have an agent that has no equal 
in certain cases. Of twenty-seven patients with re- 
current hordeola, twenty-four have been free from 
the attacks since treatment, one did not seem to im- 
prove at all, and two are still under treatment. The 
Stapliylococcus aureus was found in the majoritv ; 
some contained the albiis, a few the citreiis. Auto- 
genous vaccines were used in all. The series was 
limited to cases that had lasted for years, and the 
recurring hordeola appeared to be small local foci 
of suppuration, due to infection with certain or- 
ganisms in persons whose resisting power was be- 
low normal. One .striking result is that the patients 
feel better generally after the treatment. Other in- 
fections treated were the tubercle bacillus, twelve ; 
gonococcus, six ; pneumococcus, three ; streptococ- 
cus, four ; staphylococcus, seven ; Friedlaender's 
bacillus, one ; JMora.x-.\xenfeld, two : xerosis, two : 
Micrococcus catarrhalis. one. The infections with 
the tubercle bacillus comprised phlyctenular lon- 
junctivitis and keratitis, five : iritis, one ; chorioidi- 
tis, one ; keratitis, three, episcleritis, two. The re- 
sults of treatment with tuberculin were excellent in 
all these cases, and Dwyer thinks that tuberculous 
eye affections are ideal ones for tuberculin treat- 
ment. The results from the use of vaccines in the 
other infections were equally gratifying, even in- 
cluding the three infections with the pneumococcus. 

INTERSTATE MEDICAL JOURNAL. 

The Treatment of Typhoid Fever. — I>om a 
careful study of this question O. H. Brown con- 
cludes that the ideal prophylactic treatment of ty- 
phoid is the proper disposal of human excreta. The 
inoculation of dead typhoid bacilli, however, is of 
very great value in preventing ty()hnid. and should 



I'lTII OP PRO(.h'i:.SSirE UrilKAIVRE 



be resorted to wherever there is suspicion of dan- 
ger. In dealing with typhoid carriers, and for pre- 
venting relapses during the course of an attack, 
inocuhitions of dead typhoid bacilli are decidedly 
useful and efficient. Xo specific serum of real value 
has yet been found, although the work has yielded 
very encouraging results. Frazier has recently 
claimed to have aborted six cases of typhoid fever 
through the use of large doses of ipecac exhibited 
in salol coated capsules. The diet in typhoid fever 
should include protein and fat in small amounts 
and a large amount of carbohydrate. The pre- 
ferred proteins are milk and albumen water. The 
preferred fat is cream. The preferred carbohy- 
drate is lactose, of which a pound may be given in 
twenty-four hours. This diet should reduce the 
grade of to.xemia and maintain the patient's weight, 
and therefore increase his immunizing power. Co- 
pious supplies of water should be given at regular 
intervals, and cracked ice may be taken continu- 
ously when the patient is awake. Pyrexia may 
often be controlled by keeping the patient in a cold 
room where the air is kept freely moving, the pa- 
tient being very lightly covered, with the exception 
of the arms and legs, which may require heavy 
coverings. 

Prophylactic Measures against Epidemic Men- 
ingitis. — A. Sophian emphasizes the importance 
of a rigid quarantine, which should not only in- 
clude the sick, but also the healthy members of 
families in which the disease occurs, and which 
should be for at least ten days, during which time 
active prophylactic treatment should be instituted ; 
cultures made of suspected carriers, both the sick 
and healthy, should be used to control the quaran- 
tine, which should be lifted only when the cultures 
become negative. Local medicinal prophyla.xis 
should consist of the application of antiseptic 
sprays, douches, swabbings, and inhalations to the 
nose and throat, and the exhibition internally of 
hexamethyelamine in doses of from twenty to 
forty grains daily, well diluted so as to eliminate 
renal irritation. Serum injected subcutaneously, in 
average doses of ten c. c. may be used temporarily 
as a highly efficient prophylactic, the protection 
lasting about two weeks. In those sensitized to 
serum, who later require serum therapeutically, in 
order to prevent the severe s)-mptoms of serum ana- 
phylaxis, small doses of from one to two c. c. 
had better be tried at first, when, if reaction occur, 
we must await its subsidence and administer a 
larger therapeutic dose later. Active vaccination, 
such as prophylactic typhoid vaccination, is the 
ideal prophylactic against infectious disease, the 
principal objections to which are the local and gen- 
eral reactions and the danger of the negative phase. 
Local reaction consists of redness, tenderness, and 
induration, lasting from twelve to twenty-four 
hours. Roth the local and the general reactions 
are, in the writer's experience, much less pro- 
noimced, in most instances, than in prophylactic ty- 
phoid vaccination. As to the negative phase, it is 
very doubtful whether, in healthy persons, it will 
ever be so pronounced as to permit the occurrence 
of active infection. .Among the several thousand 
vaccinated no instance of this has occurred. 



JOURNAL OF INFECTIOUS DISEASES 

.U.1.V, ;y/.;. 

Experimental Streptococcic Arthritis in Rab- 
bits. — Jackson, in experiments made with strep- 
tococci from a milk epidemic of sore throat in Chi- 
cago, was able to produce inflammatory conditions 
in the joints of seventeen rabbits. These were stud- 
ied at periods varying from two hours to four 
months, and the differences present were only such 
as were consistent with the varying phases of a 
single inflammatory process. Also there were no 
striking differences in the reactions produced by the 
various kinds of streptococci employed. 

Some Experiments Bearing upon Droplet In- 
fection in Diphtheria.— Teague undertook to de- 
termine whether diphtheria patients in coughing and 
talking emit diphtheria bacilli frequently or only 
rarely, and whether in large or in small numbers. 
He found that in both talking and coughing, such 
patients frequently emit droplets containing viable 
diphtheria bacilli, but that such droplets are usually 
in small niunber. It was also noted that the bac- 
teria in the suspended droplets would remain alive 
much longer in cool or cold temperatures than in 
warm. 

Epidemiological Diagnosis and Management of 
Typhoid Fever. — Hunt gives an interesting re- 
l-iort of an epidemic of typhoid fever and the means 
employed in determining the source of the infec- 
tion. It was also the first time (so far recorded) 
of an antityphoid vaccine being generally used dur- 
ing the height of an epidemic. Taking the number 
of secondary cases as a measure of the preventive 
work done, there were in this instance but four, and 
three of these were nurses. 

The Meiostagmin and Epiphanin Reactions in 
the Diagnosis of Carcinoma. — The first of these 
reactions is dependent upon variations in the sur- 
face tension of the serum, while the epiphanin re- 
actions depends in part on an acceleration of the 
rate of diffusion in a solution when antigen and its 
specific antibody are introduced. Bumieister found 
that a decidedly negative meiostagmin reaction is 
of more value than a positive one, and may be con-, 
sidered of some weight in ruling out carcinoma. A 
moderately or even strongly positive reaction is not 
necessarily indicative of malignant tumor. The epi- 
phanin reaction he considers valueless in the diag- 
nosis of malignant tumors. 

Study of an Outbreak of Septic Sore Throat 
Occurring in Concord, N. H., in January, 1912. — 
Mann reports an investigation made of an epidemic 
in whichi probably 1,000 persons were attacked by 
the disease. The milk was suspected, but could not 
be proved to be the source of infection. Further in- 
quir}-, however, elicited the fact that the cases oc- 
curred only among those who used cream from a 
certain source. It was shown that the milk became 
infected through the handling by persons suffering 
with the disease, and the cream when separated 
from the milk retained the infecting organisms. 
Mann holds that it is not safe to use market milk 
in the raw state, and that efficient pasteurization 
should be insisted upon where vending is engaged 
in. 



I'lTIl OF I'ROaiasSJili I.rn-.K.ITCRE. 



lu? 



JOURNAL OF MEDICAL RESEARCH 

.U.i.v, fjii. 

Concerning Secondary Infection in Pulmonary 
Tuberculosis. — Avery and Lyall first call atten- 
tion to tlie proper interpretation of the term> 
"mixed" antl "secondarv '" nifcctiun ; the first refer- 
ring to the simultaneous invasion of more than "iic 
species of pathogenic bacterium through the same 
portal of entry. The second indicates the entrance 
of infectious microorganisms at intervals followinj,' 
the implantation of the primary species. In regaril 
to the lesions in tuberculosis, it is at present gen- 
erally held that the combined action of other patho- 
genic organisms may aggravate and accelerate the 
ulcerative processes, and thus e.xert a grave influ- 
ence on the course and prognosis of the disease. In 
an attempt to determine the exact pathological sig- 
nificance of secondary injection, the authors made 
a bacteriological study of the blood with reference 
to organisms other than the tubercle bacillus in one 
hundred and fifteen cases of pulmonary tuberculosis, 
in various stages of the disease, and in five cases of 
bronchiectasis. The bacteriology of the sputum of 
twenty of these patients was studied at the time of 
the blood culture, to correlate, if possible, the find- 
ings of the one with the other, and of both with the 
clinical course of the disease. The examination 
of the sputum showed results that diflfered but little 
from those reported in a series of cases of non- 
tuberculous diseases of the respiratory tract ; and 
from the findings it was difficult to draw inferences 
concerning their clinical significance. In regard to 
the blood cultures, in no case was the presence of a 
secondary bacteriemia demonstrated. 

Further Studies upon the Leprosy Bacillus. 
Its Cultivation and Differentiation from Other 
Acid Fast Species. — Duval and Harris give an 
interesting review of this subject and demonstrate 
that the acid fast bacillus known in the human le-p- 
rous lesion as the Hansen organism can be culti- 
vated in vitro under special nutritive conditions. 
The initial multiplication awa}- from the tissues of 
the host occurs in the presence of the split products 
of animal protein, the amino acids, and under no 
other conditions. The authors have found also that 
the experimentally induced lesion affords no reliable 
means of differentiating acid fast species other than 
the tubercle family, since the lesion in all instances 
has the same general gross appearance. 

The Experimental Production of Pernicious 
Anemia in Rabbits. — As it has been shown that 
the hemolytic substance of the head of the Dibo- 
thrioccpha'lus latus is oleic acid, .Adler sought to de- 
termine whether the introduction of a hemolytic fat 
into the digestive tract would produce an anemia in 
a rabbit. In each case, at some period of the ex- 
periment, a severe form of anemia appeared as a 
blood crisis : Hemoglobin from forty to fifty per 
cent., red blood cells about four millions, poikilocy- 
tosis and anisocytosis, polychromatophilia, achro- 
mia, stippling, and the presence of normoblasts and 
occasional megaloblasts. Inasmuch as the hemolvtic 
substance is a fat, it is not capable of true solution 
in the body fluid ; the efifect is not a uniformly dif- 
fused one, but is dependent upon the meeting of a 
pirt of the hemolytic fat with a red cell. The ane- 
mia produced is, therefore, probably due to a de- 



struction of red cells in the bUjodvesscls, as the 
bone marrow showed nothing of note. 

MONTHLY CYCLOPEDIA AND MEDICAL BULLETIN. 

May, rji'. 

Unrecognized Pulmonary Lesions in Cases of 
Suspected Chronic Pleurisy. — ('. .M. .Montgomery 
is con\ inced that nustakes of this nature occur more 
frequently than is generally recognized, and em- 
phasizes the necessity of always suspecting a pul- 
monary lesion when one meets with signs suggest- 
ing fibroid changes in the jjleura. This is supported 
by autopsy findings. Sometimes, though, a diag- 
nosis of tuberculosis is made, the abnormal findings 
over most of the affected area (i. e., elsewhere than 
at the apices) are attributed to a thickened or oblit- 
erated pleura, to the neglect of an extensive, even 
if scattered, infiltration of the lung. The most im- 
|)ortant help in differentiating between a fibruid 
lung and a simple thickened pleura may be marked 
deformity and visceral displacement. Typical signs 
of consolidation, if present, will indicate lung in- 
volvement, and sometime- rales are of great assist- 
ance, but often a thorough knowledge of the his- 
tory and symptoms is required to establish the diag- 
nosis. In cases of pulmonary tuberculosis two 
signs in particular are apt to be neglected, except 
when occurring at the apices, viz.. weakening of 
the respiratory tnurmur and rales. The importance 
of these signs is as great if they are distributed over 
a large circumscribed area as if over a small one. 
Diminished respiratory movement on one side is a'so 
a valuable sign. 

Prevention of Bubonic Plague. — \'. J. P. Jour- 
dan asserts that ship fumigation is often carried 
out too superficially. The only evident effect of 
five successive fumigations which he witnessed was 
the death of one rat. The rodents appeared as 
numerous after as before the fumigations. Only 
the cabin, crew's quarters and holds had been dealt 
with. The coal bunkers, fire and engine rooms, 
chain lockers, and other storerooms, as well as the 
bilges, should also be fumigated. Two or more 
bilgeboards should be removed from each side of 
every hold, and at least two sulphur pots be placed 
in the most suitable bilges. Then a number of pots 
should be placed on the floor of each hold, and 
when all of these have been ignited the hold tightly 
covered. 

NEW ORLEANS MEDICAL AND SURGICAL JOURNAL 

General Paresis. — .A plea for more thorough 
prophylaxis in this disease is made by Henry Das- 
pit because of our inability to attack paresis with 
any success, owing to the fact that symptom,s of the 
disease are not in evidence until irreparable ; corti- 
cal atrophy having taken place. Though the diag- 
nosis is usually clear cut and may usually be made 
before the mental picture is complete, this early 
diagnosis does not help us. The usual tonic or 
mixed treatment, with incomplete courses of in- 
imction. is inadequate, no matter how long em- 
ployed, for it has been proved that organism- be- 
come tolerant in culture to the presence of weak 
solutions of mercuric chloride, etc. The writer be- 
lieves, also, that the pale spirochete grows in a 



104 



l.liTTIiKS TO run l-.DITOR. 



system where the mercurials are i;radually intru- 
duced, and even though finally pushed to the point 
of tolerance. When the disease is observed soms 
years after the initial lesion the usual procedure is 
to give a short course actively and then put the 
patient on mixed treatment or potassium iodide 
alone, which in neither case will keep a reaction 
negative for any length of time after ceasing treat- 
ment. As a rule, whether parasyphilis of the ner- 
vous system or any other demonstration, the idea 
should be that whenever there is a positive Wasser- 
mann reaction, clinically supported, there is an 
active syphilis, and except in cases of frank paresis, 
the case should be energetically treated for the 
three year period, irrespective of how recent or re- 
mote the initial lesion may have been. In positive 
reactions, even when clinically negative, the thera- 
peutic test will decide the advisability of long atten- 
tion. Tissue changes will not be cleared up, but 
the further progress of the disease will be arrested. 
The writer advises the use of salvarsan (not one 
dose, but several), followed by intensive treatment 
for a period of three years. By intensive he means 
the abrupt saturation of the patient with mercury, 
and bv anv of the various means at command. 

Epilepsy; Its Cause and Treatment. — H. L. 
Fougerousse avers that in spite of extensive in- 
vestigations by the foremost scientists, equipped 
with the latest instruments and appliances, practi- 
cally nothing has been learned as to the real caus? 
of epilepsy. No uniform anatomical findings ap- 
plicable to all types have yet been demonstrated. 
Because of the lack of this definite knowledge of 
the morbid anatomy, pathology, and etiology apjili- 
cable to all forms of this disease, experiment and 
empiricism stamp all elTorts at treatment. There 
is no specific, and none in sight. The most useful 
treatment, prophylactic in results, is the dietetic, 
and consists of the use of easily digestible, simple 
foods in reasonable variety and never in excessive 
quantity. This with moderate exercise, fresh air, 
and a simple life, is the best suggested. Surgical 
aid is seldom sought and is beneficial only in the 
reflex types of the disease. 

Poliomyelitis. — O. ]\I. Patterson relates his ex- 
perience with poliomyelitis or infantile paralysis 
as health officer for the parish of Morehouse dur- 
ing the year 191 1. He concludes from the study 
of seventeen reported cases that it is a communi- 
cable disease in which strict quarantine and isola- 
tion are very important and useful. The period of 
incubation in these cases was from three to eight 
days. Those who visit the sick are the carriers 
of the disease, and prophylactic measures offer the 
most hope, as a satisfactory treatment cannot be 
offered. Children over twelve years of age were 
not attacked : nearly all the cases were from two to 
six years old. The disease prevails and spreads 
more rapidly during the warm, dusry weather. 
Most of the cases occurred in .April, May, and 
June. 

OPHTHALMIC RECORD, 

-V.iv, mi:.. 

The Intracapsular Operation for Cataract 
after the Method of Professor Stancleanu, of 
Bucharest. — \\'. Likely Simpson describes this 



operation in detail. The incision in the cornea is 
a trifie larger than the ordinary and made with a 
small conjunctival Hap. An ordinary iridectomy is 
made. The anterior capsule is then grasped with 
the most prominent jjortion of the curve of a pair 
of forceps with no teeth, with which movements are 
made from side to side so as to rupture the zonule. 
.'\fter this has been done the forceps is removed 
and the cataract extracted by pressure with a .spoon 
over the cornea, a little below its centre, with slight 
counter pressure above the wound. 

f ttttrs tff \\t iititor. 

FRIEDMANN'S .■WTITUBERCULIN SERUM. 
\f,w York, July S. 1913. 
To the Editor: 

In my statement of May 2bih. addressed to the medical 
and lay press and setting forth the conditions on which 
I had accepted the direction of the F"riedmann Institute of 
New York-. I laid much stress on the fact that my chief 
aim was to remain for a year or so an impartial observer 
with all the data at my ready command; after which I 
would communicate to the medical profession the results 
obtained by the use of the Friedmann vaccine, whether 
those results were good, indifferent, or bad. I realized 
how arduous a task I was assuming. My work appeared 
to me in the light of a public duty; I felt that sooner or 
later my colleagues and the public would come to recog- 
nize the absolute sincerity of my purpose. 

My own observations had led me to conclude that the 
Friedmann vaccine was worthy of a fair, that is, of a pro- 
longed trial. Since they my convictions have only become 
deeper. 

My most serious objection was to the secrecy observed 
in regard to the vaccine. I had come to my own con- 
clusions when I read that it contained live bacilli and 
when, later on, Dr. Friedmann explained to me his method 
of preparation I found that I had been correct in my de- 
ductions ; I felt that he was working along the right path, 
for the results obtained in bacteriotherapy from the intro- 
duction of live germs into the organism are much more 
satisfactory than the results from the use of dead germs 
or bacterial extracts. In the Pasteur treatment, for in- 
stance, we inject an emulsion of live germs, avirulent for 
man. when properly used. The medical profession, how- 
ever, not knowing the composition of Friedmann's vac- 
cine, naturally showed itself averse to using it. On the 
other hand. Friedmann held, not without reason, that if 
would be unsafe to release all the data concerning his vac- 
cine and to place it in the hands of every physician before 
those wishing to administer it had made themselves thor- 
oughly familiar with its use. The correctness of his con- 
tention was evident, and I could not at the time raise any 
strong objection to it. But now I have concluded that the 
medical profession is entitled to know that the vaccine is 
sim/^ly a homogeneous emulsion of live, avirulent tubercle 
bacilli in plain sterile distilled water. The germ was iso- 
lated several years ago from a turtle, and the culture has 
been maintained since that time by transplantation on arti- 
ficial culture media, according to the usual procedure. 

Before long, full particulars concerning the culture and 
preparation of the emulsion will be made public, when 
sufficient time has elapsed to demonstrate the correctness 
of the present modus operandi. In the meantime I shall 
welcome any colleague who desires to familiarize himself 
with the administration of the vaccine, that he may use 
it personally on his own patients. I wish it distinctly un- 
derstood that I have not formed any final opinion as to 
the efficacy of the treatment. In a disease like tubercu- 
losis it would be most unscientific to draw any conclusion 
as to the value of a certain treatment at the end of two 
or three months. T can only say that I have now ob- 
served over 100 cases and that, in many of them, I have 
noted beneficial results, such as. according to my ex- 
perience, have not been obtained in the same length of 
time, with any other known method of treatment. 

Finally, I have not ol)served one case in which the judi- 
cious administration of this treatment has, in any manner, 
harmed the patient. Georcf, Gibier R.vmb.xud. M. D. 



rKOCEEvixus ur soc/etils. 



^xomVmp of .^ocittirs. 



rni-: medical association' of riii-: greatkr 

CITY OF NEW YORK. 

Sft-cia! Oiiifiis Borough Meeting, held at Jamaica. Afril 

7, 1913- 

Dr. L. MmvAKn M(-ss in the Chair. 

Report of a Case of Perforating Ulcer of the Stom- 
ach; Presentation of the Patient. — Dr. Albekt I,. Voltz. 
oi (Jueens. presented a male patient, twenty-six years old, 
with the following liistory ; F'or the past two years he had 
heen subject to eructations of gas, accompanied with the 
feeling of a "lump" in the epi.ijastrium. but without actual 
|)ain. and at no time was there any hcmateincsis. On Feb- 
ruary 22, 1913, he spent the night carousing, indulging 
freely in drinking and inordinately in crabmcat salad. On 
awaking the next day, at 3 p. m.. he ate a hearty break- 
fast and drank some highballs. At 6 p. m. he was seized 
with an attack of severe colicky pain in the epigastric re- 
gion, which was somew-hat relieved after vomiting of some 
mucus. Pulse 80; temperature gS.6° F. Doctor Voltz noted 
no particular rigidity or tenderness of the abdomen, though 
there was a slight firmness in the region of the stomach 
He administered morphine hypodermically and ordered 
castor oil and 2 grains of calomel in divided doses. He 
was summoned again at 2 a. m. on th(' 24th, and found the 
pain much worse and apparently without intermissions, 
though there was no vomiting. -\s the bowels had not 
moved, he gave an enema containing a drachm of turpen- 
tine. The pulse was now 88, but there was no increase in 
temperature. Xoting tenderness and rigidity along the 
whole right rectus muscle, he made a diagnosis of appen- 
dicitis and advised operation. This was refused, however, 
and he gave another hypodermic of morphine. At 6.30 
a. m. he was again called, and he then found the patient 
steadily growing worse. The pulse was 96. the tempera- 
ture 99.4° F., and the abdominal rigidity was intense. Af- 
ter consultation with Dr. L. H. Moss, the patient was re- 
moved to the Jamaica Hospital, where at 9.30 a. m. lapa- 
rotomy was performed ; the incision being made over Mc- 
Burney's point, .As soon as the peritoneum was opened 
several ounces of yellowish fluid escaped ; suggesting a 
ruptured gallbladder. The appendi.x. which was found 
much thickened from chronic inflammation and markedly 
congested, was removed, and after drainage had been estab- 
lished the incision was closed. .Another incision was then 
made, but the gallbladder was found to be apparently nor- 
mal. Considerable quantities of the yellowish fluid contin- 
ued to pour out, and on further search for the leakage it 
was discovered that the outerwall of the stomach, near the 
pylorus, had been perforated by a clean-cut ulcer, J^ inch 
in diameter, with perfectly smooth edges. .A pursestring 
silk suture surrounding it was passed' about ig inch 
from the border of the ulcer, tied, and buried in 
the gastric wall by means of Lambert silk sutures 
passed through the peritoneal coat. The peritoneum 
having been thoroughly washed with normal saline 
solution, a fenestrated rubber tube was placed be- 
hind the stomach, along the lesser curvature, and the 
wound closed about the tube. The patient was then put to 
lied in the Fowler position, and a Murphy drip started. 
The operations consumed about two and three quarter 
hours. There was more or less shock and the prognosis 
looked grave. Pulse 124; respirations, 28. On the second 
day the temperature was 101° F, and the respirations rose 
to 50, though the pulse rate remained the same. After 
that, however, the patient made an uneventful and rapid 
recovery. In this case. Doctor Voltz said, it was notice- 
able that the patient did not go into collapse, that vomiting 
was absent except at the beginning of the attack, when a 
small amout of mucus was thrown up, and that, although 
the operation was deferred for fifteen hours and the gas- 
tric contents bathed the whole right side of the peritoneum, 
general peritonitis did not occur and the local peritonitis 
was only moderate in amount. The maximum temperature 
was 101° F. The rapidity of respiration he thought migirt 
perhaps be explained by the proximity of the seat of dis- 
ease to the diaphragm. 

Report of a Case of Twin Pregnancy, Uterine and 
Tubal Combined, — Dr. C O. Stimpf, of Uuccns, rc- 



piirted this case. Mrs. C K. ; aged thirty-seven years; oc- 
cupation, house and farm work, llad had uu children; nuc 
miscarriage at three months. Last menstruation .August 25. 
r9i2. On October 29th, while pitching cornstalks on a 
wagon, overstrained herself, and immediately felt bearing 
down pains in the pelvis and radiating down the thighs. She 
felt feverish and went to bed, vomited, and passed some 
blood clots by the vagina; after which she had a slight 
uterine hemorrhage. She was admitted to the Jamaica 
Hospital November 21st, twenty-three days after the firs! 
attack of pain. She was then jaundiced and her condition 
one of extreme anemia. Pulse small and 92; respiration 
26; temperature 99.8° V. There was some fetid, bloody 
discharge, and on vaginal examination a mass was felt on 
the right side which appeared to be in the tube. The uterus 
was curetted, and a large placenta removed. On the day 
following there still remained a slight discharge tinged 
with blood, but the genera! condition was much improved. 
On the second day the temperature fell to 99° F., though 
the pulse continued between 80 and 100. The mass on the 
right side of the pelvis did not diminish in size, and on 
Deceinber 2nd the tube was removed, together with a semi- 
organized blood clot as large as the head of a new born 
infant. The patient made an uneventful recovery. 

Dystocia, and the Unflexed Bed. — Dr. .\. Ernest Gal- 
L.\.\T, of Manhattan, in this paper, said that in about sixty- 
five per cent, of his consultation obstetric cases the follow- 
ing combination was met with : a normal pelvic inlet with 
a relatively small head, which, failing to flex properly, failed 
to engage and stay in the grip of the inlet, to make any ad- 
vance, and to glide down the pelvic planes ; and thus caused 
delay for many hours or days. This showed the impor- 
tance of estimating the relative size of the fetal head to 
that of the inlet, for it was a fact that a relatively large 
head would flex more completely, be molded to fit the in- 
let more accurately, follow the planes more surely, and be 
delivered more quickly. In these cases of delayed labor 
the pains might be of good quality; yet the membranes did 
not rupture, the head did not engage, and the woman grew 
weaker and weaker. Finally, after an usually strong pain, 
delivery might occur, perhaps in the absence of the doc- 
tor, who on his arrival might, in addition to the complaints 
of the patient, be chagrined to find the perineum badly 
lacerated, and that by a child weighing only si.x and a half 
or seven pounds. Normally, flexion and rotation, with co- 
incident descent, were processes which every fetal head 
had to go through before it could enter the true pelvis. 
Before the beginning of labor every part of the child's 
body lay flexed, and as soon as the strong expulsive pains 
commenced, after the rupture of the membranes, the body 
became more completely doubled on itself under the com- 
pression e.xerted. Especially was this increased flexion 
marked as regards the head, in order that the smallest 
diameter, the occipitofrontal, might lie forced into the 
right or left oblique diameter of the inlet: after which the 
occipital bone would impinge upon the pubic plane, and. as 
it descended, rotate downward and forward under the 
symphysis. This was the normal process, and in the early 
recognition of the unflexed head as a source of delay in 
labor often lay the key for accelerating delivery ; which 
had a threefold benefit. For the mother it would min'mize 
the number of pains, as well as the wear and tear on the 
birth canal. For the child it would reduce the danger of 
prolonged compression, which had been demonstrated to be 
a frequent cause of stillbirth, asphyxia, paralysis, feeble 
niindedness, idiocy, etc. In the third place, it would enable 
the accoucheur to avoid long hours of needless watching 
and loss of sleep, the repair of the perineum, and all the 
incident unpleasant effects on the patient and her family. 

Now, how could we facilitate the mechanism of labor, 
and thus make the delivery a less onerous ordeal for 
mother, child, and physician? Our endeavor should be to 
promote flexion and the engagement of the head within the 
inlet, and to keep it there between the pains, and this might 
be accomplished by the following means: (1) External 
pressure on the buttocks at the fundus, increasing the flex- 
ion of the trunk on itself and of the chin toward the 
sternum; (2) external pressure on the occiput just above 
the syipphysis pubis, with the palm of the hand pressing it 
down into the brim; (3) internal pressure on the fore- 
head, with the fingers in the cervix tilting it upward dur- 
ing each pain; (.4) the introduction of a single blade of the 
forceps (preferably a solid blade) and gentle traction dur- 
ing a pain; (3) forceps traction by means of a high forceps 



io6 



BOOK REVIEW S. 



[New York 
Medical Journal, 



with loosely fitting blades, used chiefly as a guide and to 
prevent recession ; care being taken not to pull too suilden- 
ly or vigorously, in order to avoid too precipitate delivery 
and an unnecessary laceration of the i)erineum ; (Oi the 
judicious combination of two or more of these man.ruvres 
as required by the existing conditions. Having referred 
to the methods employed in delayed labor among unciv- 
ilized nations, as described by Rngelmann. Doctor Gallant 
said there could be no doubt that the squatting posture was 
the rnost natural one for the parturient woman, and that it 
had its advantages in accelerating the passage of the head 
through the pelvis. It was therefore to be regretted that 
the old fashioned obstetric chair, which in former times 
used to be carried from house to house, had been aban- 
doned among Anglo-Saxon peoples. The great practical 
value of compressing the lower abdomen on the thighs. 
with the woman in the sitting or squatting posture, had 
been clearly demonstrated in a case he saw in consultation 
with Doctor AIoss. The pains were frequent and of good 
force, but. although the membranes had been ruptured 
artificially, there had been no progress made for a long 
time, when the patient insisted on rising to have her bowels 
moved. A pail with a wooden seat was brought, on which 
she sat down, straining vigorously, and delivery followed 
so promptly that a seven and a half pound boy was barely 
saved from drowning in the pail. The change to a low 
sitting posture, in which she leaned forward with her 
elbows on her knees, accomplished the necessary flexion of 
the head, and the medium sized child was precipitated 
through the comparatively roomy pelvis. 

The advantages to be gained by early diagnosis of the 
unflexedhead. and appropriate measures for promptly as- 
sisting Xature, were shown in the case of Mrs. G.. whom 
he had attended in three confinements. She had previous- 
ly had one child, and when this was born the labor was 
very slow and prolonged. .-Xt the time he first attended 
her she was a frail, slender woman, five feet and two 
inches tall, and weighing no pounds. The first stage of 
labor lasted five hours. The head was found in the R. O. 
A. position, and the os externum dilated and dilatable. 
The protruding membranes were ruptured with a knitting 
needle, and the head, wabbling above the pelvic brim, was 
tilted into more acute flexion by external pressure upon the 
forehead. It then readily entered the inlet during a pain, 
and the edematous anterior lip was pushed upward behind 
the symphysis. The pains were forceful, and at the end 
of the fourth contraction, twenty minutes after the rupture 
of the membranes, the child was born. The total time of 
the labor, including the third stage, was five hours and fifty 
minutes. In this patient's next labor the first pain was at 
2.30 a. m. The occiput was to the left. 5.15 a. m.. ex- 
ternal OS dilatable : membranes ruptured. Standing be- 
hind the woman with his hands clasped over the fundus, 
he directed her to throw her body forward during the 
pains, so that her weight would be borne by his hands, thus 
compressing the fundus. The second time that this ma- 
noeuvre was practised the head came rapidlv down into the 
pelvis, and was guided through the vulva. The entire time 
occupied by the labor was but three hours and fortv min- 
utes. When he attended her for the third time labor com- 
menced at I p. m. and terminated at 9.15 p. m. The os 
externum being dilatable, he ruptured the membranes and 
repeated the procedures resorted to in the previous labor; 
and with the same successful result. External pressure 
on the fundus uteri and the breech of the fetus was al- 
waj^s combined with internal manipulation, to promote the 
flexion of the head and trunk, and thus help the occiput 
to engage during the pain, as well as prevent it from disen- 
gaging when the pain ceased. These three deliveries, he 
said, illustrated in a striking way the present day idea in 
obstetrics, namely, that by judicious interference at the 
right tiiTie w^e can reduce the hours of labor the working- 
man's limit of eight hours, or even less: and this, fre- 
quently, without the use of the forceps. He did not hesi- 
tate, however, to apply the forceps for this purpose, and 
for this alone. In other instances the forceps might be re- 
sorted to. to avoid more serious difiiculties. as in a case he 
had attended where the head lay occiput left, transverse. 
with the forehead lowest. In response to upward pressure 
on the forehead, through the cervix, the occiput was tilted 
downward into the left inlet. The pains being ineffectual 
and the advance very slow (although the membranes had 
been ruptured), and the patient being extremelv excited, 
chloroform was administered to the obstetric degree, and 



moderate, intermittent tractiim resorted to. The result 
was that in ten minutes the head was delivered and rotated 
to the left, and the shoulder drawn from under the sym- 
physis. Here there had been a medium sized head, wab- 
bling above the brim, with the face inclined toward the 
inlet. Correction to left occipital anterior was made by 
combining internal and external manipulation, and a safe 
delivery accomplished in fifty minutes from the perfora- 
tion of the memlfranes ; thus saving the mother from sev- 
eral liours of unnecessary pain and anxiety, and the child 
from the dangers of a face delivery. Other illustrative 
cases also were cited in the course of the paper. 

Healthy Sick Children. — This was the title of a paper 
by Dr. LeGr.vnd Kkrk, of Brooklyn, which was published 
in the Jour.nwl for June 21. 1913. 

Changes in the 'Treatment of Syphilis. — This paper, 
by Dr. Wiixi.km S. Gottheil, of Manhattan, was pub- 
lished in the Jot'RN'.\L for June 7. 1913. In connection 
with it a large number of lantern slides presenting various 
syphilitic lesions were shown. 



§ook Mfbiftos. 



[We publish full lists of books receiz'ed, but we acknowl- 
edge no obligation to review them alt. ^Nevertheless, so 
far as space permits, we reviczv those in which we think 
our readers are likely to be interested.] 



Clinical Pathology. By P. X. P.\Kms, M. A.. M. B., B.C. 
Cantab.. Clinical Pathologist to the London Hospital, 
Formerly Assistant Director of the Louis Jenner Clini- 
cal Laboratory. St. Thomas's Hospital. With Thirteen 
Plates (Eleven Colored) and Forty-five Illustrations in 
the Text. Philadelphia: P. Blakiston's Son & Co., 1913. 
Pp. viii-^46 (Price, $4.) 
W'ithin some 4-|0 pages the author has compressed a great 
deal that is both useful and valuable. There is. however, 
the fault that usually obtains under such conditions. When 
briefness is attempted there is always the danger that cer- 
tain valuable methods may be omitted. That, neverthe- 
less, is frequently a matter of purely personal opinion. 
What has been mentioned in this book is good, and the 
few sins are evidently more of omission that commission. 
In the preparation of tissues no reference is made to the 
celloidin method: paraffin alone is given. Then. too. in 
speaking of the rapid (freezing) method it is stated that 
a diagnosis may frequently be given within ten minutes : 
Wilson, of Rochester, please note. .Another point of criti- 
cism is the way in which the English authors ignore the 
apparatus of other countries. The English microscope 
alone is mentioned, and no other microtome than the 
Cambridge rocking type is given. The freezing microtome, 
as represented, cannot compare with the German models. 
On account, however, of the text and the most excellent 
thirteen plates, the book can be well recommended : the 
representations of the blood parasites and bacteria being 
particularly good. 

An International Svstcm of Ophthalmic Practice. Edited 
by W.VLTER L. PvLE, .A. M.. M. D., Philadelphia. Mem- 
ber of the -American Ophthalmological Society. Oph- 
thalmic Semiology and Diagnosis. By (^h.\rles H. 
Be.xrd. M. D., Surgeon to the Illinois (Tharitable Eye and 
Ear Infirmary. Oculist to the Passavant Memorial Hos- 
pital and the Xorth Star Dispensary. Chicago, etc. With 
Thirteen Colored Plates and Seventy-one Figures in the 
Text Phil.".delphia : P. Blakiston's Son & Co., 1913. 
Pp. xi-400. (Price, $4.) 
Doctor Beard tells us in his preface that his object in 
writing this book was to enable one "to get, in a single 
small volume, information not otherwise to be obtained 
save through research that, to the vast majority, would 
be impossible." and we wish to congratulate him on his 
success. So far as we know, he is right in the statement 
that there is no other separate volume, in any language, 
devoted exclusively to differential ocular symptomatology, 
and therefore we have no other work with which to com- 
pare it. The introduction to the first part considers the 
difiiculties of obtaining histories from patients, which are 
annoying at times, as we all know. Then follow chapters 
on the lids, the lacrimal apparatus, the conjunctiva, the 



OPrlCIAI. SEWS. 



107 



Rlobe. iIk' coriK-a, tlu' iris, the anterior cliamhi-r, llic pupil, 
tlic crystalliiK- lens, and cataract. The second part is de- 
voted to the interpretation of tlie oplithalmoscopic si^ns 
to lie seen in the fundus, and is well illustrated hy repro- 
ductions from the author's own drawings. \n exceed- 
ingly brief and unsatisfactory review of the chajiter on 
the pupil, pages 96 to 133. may perhaps convey some ideM 
of tile nature of the work. First come the jihysiological 
modilications of the diameter of the pupil, then an ac- 
count of the way in which meiosis is produced with the 
drugs and diseases that cause it. a similar C(jnsideration 
of mydriasis, congenital and acquired anisocoria. and the 
diseases in which the latter is a symptom, alternating and 
transitory anisocoria. the pupillary reflexes and the diag- 
nostic significance of their modifications, congenital and 
acquired anomalies of form, with the causes of the latter; 
closing with persistent pupillary membrane. The entire 
book is written concisely and clearly, while it contains an 
immense amount of diagnostic information. It is well 
worth having and reading, but is especially valuable for 
reference. 

Al'I'cndicitis. Its History. Aiiatowy, Clinical Etiology, 
Pathology. Symptomatology, Diagnosis. Prognosis. 
Treatment. Technic of Operation. Complications, and 
Sequels. By John B. Deaver. M. D.. Sc. D.. LL. D.. 
Professor of the Practice of Surgery. University of 
Pennsylvania. Surgeon in Chief to the German Hospital. 
etc. Fourth Edition, Thoroughly Revised. Containing 
Fourteen Illustrations. Philadelphia: P. Blakiston's 
Son & Co.. 191 3. Pp. xi-379. (Price. $4.) 
The author's very wide experience in this special branch 
of abdominal surgery has made him well adapted to be the 
author of a monograph on the subject. The present edi- 
tion brings the whole topic thoroughly up to date and. 
in preparing it. the author has found it necessary prac- 
tically to rewrite certain sections of 'he book. He has 
had the practical nature of the subject uppermost in m.ind 
and has striven "to portray the disease in its clinical as- 
pects for the benefit of students and practitioners whose 
opportunities for extensive experience are necessarily 
limited." Furthermore, those methods of treatment are 
given in detail which the author has found after his many 
years of practical experience to give the best results. The 
most important subject that has necessitated revision is 
that of general peritonitis of appendicular origin. Tlie 
recent advances in the operative treatment and the after- 
treatment of this complication have lieen such that the 
chapters in most textbooks have become hopelessly obso- 
lete. A technic which to-day saves ninety per cent, of 
these cases must be very different from that of fifteen 
years ago. with its ninety per cent, mortality. The mod- 
ern conditions such as Lane's bands. Jackson's membrane, 
and movable cecum receive some attention by the author, 
but he is not so enthusiastic in attributing symptoms to 
them as their respective discoverers and the followers 
of these have been. The subject of carcinoma of the ap- 
pendix is taken up in detail, and its pathology and diag- 
nosis put on a firm basis. In its new form the book is 
more valuable than ever in giving the last word on this 
most important branch of surgery. 

Plandbook of Diseases of the Reclnui. By Louis J. 
HiRSCH.M \x. M. D., Lecturer on Rectal Surgery and 
Clinical Professor of Proctology, Detroit College of 
Medicine, etc. With One Hundred and Seventy-two Il- 
lustrations. Mostly Original, Including Four Colored 
Plates. Second Edition. Revised and Rewritten. St. 
Louis: C. ■y. Mosby Company. 1913. Pp.339- (Price.$4.) 
The author has limited himself in this short work to a dis- 
cussion of conditions of the anus and rectum which are 
amenable to treatment in office practice. Local anesthesia 
is therefore relied upon chiefly in the operative treatment. 
The book is essentially practical and is a very useful addi- 
tion to our literature, especially from a technical point of 
view. Many practical "points" in the minor surgery of 
this region are given which will be very useful, not only 
to the general surgeon, but also to the general practitioner, 
who is so frequently called upon to treat the less import ■ 
ant ailments of the anus and rectum. The valiie of the 
x ray is demonstrated, not only in the diagnosis of ab- 
normalities in the sigmoid flexure and rectum, but also 
in the location of fistulous tracts. The more common af- 
fections, such as hemorrhoids, fistula, fissure, pruritus, and 



polypus are discussed in full, and the most up to dale 
methods of treatment which have stood the test of the 
author's wide experience are given in detail. The illus- 
trations are profuse and very clear. The same can be 
said of the x ray plates. The prompt appearance of this, 
the second, edition demonstrates the popularity of the 
book, as well as the rapid advances that have been recently 
made in these common but practically very important af- 
fections of this region. 

Flora Medica Brasiliense. Pelo Dr. Alfredo Augl'sto da 

Matta. Da I'aculdade dc Medicina da Bahia; medico 

dos hospitaes de Manaos ; exencarregado do Labora- 

torio de .Analyses do .\mazonas. etc. Manaos : Seccao 

de Obras da Impensa Oflicfal. 1913. Pp. 31S. 

This small work, written in Portuguese, describes the 

medicinal plants in certain parts of Brazil, and particularly 

in the State of Amazonas, The popular and botanical 

names being given with their synonyms, and the physical, 

chemical, and therapeutic properties of each being clearly, 

though briefly, described wherever possible, it represents a 

mine of information for seekers of new remedies: the 

majority of drugs described being strangers to our materia 

medica. 



®itial f £tos. 



United States Public Health Service: 

Official list of changes in the stations and dniies of com- 
missioned and other officers of the United Stales Public 
Health Sen-ice for the seven days ending July 3, 1913 ■ 

Cofer, L. E., Assistant Surgeon General. Directed 
to proceed to Ellis Island. N. Y., and make an inspec- 
tion of the medical examination of arriving aliens, and 
in returning to make an inspection ot the Delaware 
Breakwater quarantine station. Gumming, H. S., Sur- 
geon. Directed to make a sanitary survey of the Poto- 
mac River watershed for the purpose of an investiga- 
tion begun under the supervision of the director of the 
Hygienic Laboratory. Fox, Carroll. Surgeon. Directed, 
in cooperation with Dr. John S. Fulton, secretary of the 
Maryland State Board of Health, to examine the public 
health laws and regulations of Maryland, and make an 
investigation of the sanitary administration conducted 
under them. Frost, \V. H.. Passed .Assistant Surgeon. 
Relieved from duty at the Hygienic Laboratory, and 
directed to assume charge of the investigations of the 
pollution of the Ohio River. Hasseltine, H. E.. Assist- 
ant Surgeon. Directed to report at the Bureau of Medi- 
cine and Surgery, Washington, D. C, Wednesday, July 
9th. for examination to determine his fitness for pro- 
motion to the grade of passed assistant surgeon. Kerr, 
J. W., Assistant Surgeon General. Detailed to inspect 
certain laboratories in England and Germany, with a 
view to granting licenses ; also to attend, as a delegate 
on behalf of the United States, the International Con- 
ference on Infant Mortality, to be held in London, 
.August 4 and 5, 1913, and the International Congress 
of Medicine, to be held in that city, from August 6 to 
12, 1913. Kolb, L., Assistant Surceon. Directed to re- 
port at the Bureau of Medicine and Surgery, W'ashing- 
ton, D. C, on Wednesday, July 9th, for examination to 
determine his fitness for promotion to the grade of 
passed assistant surgeon. Leake, J. P., Assistant Sur- 
geon. Directed to reoort to the Bureau of Medicine 
and Surgery, Washington, D. C. July 9. 1913, ior ex- 
amination to determine his fitness for promotion to the 
grade of passed assistant surgeon. Lumsden, L. L.. 
Surgeon. Directed to resume investigations of typhoid 
fever in certain rural districts of Virginia, to be selected 
by the Virginia State Board of Health, to determine 
causes of its undue prevalence, methods of transmis- 
sion, and ineasures necessary for its control. 
McMullen, John. Surgeon. Directed to proceed to cer- 
tain counties in Kentucky, to be decided on after confer- 
ence with the State Board of Health, to take measures 
for the prevention and suppression of trachoma. 
Moore, Dunlop. Surgeon. Granted one month's leave 
of absence from July 10. 1913. Robinson, D. E., Sur- 
.geon. Granted one month's leave of absence from 
.August I. 1913. Wertenbaker, C. P.. Surgeon. Directed 



io8 



BIRTHS. M.IHKIAGES. ASD DEATHS. 



to take cliargc of the Cape Cliailcs (|uaraiitiiic station 
(luring the absence of Acting Assistant Siir.i;c(in Mac- 
CafTrey, on leave. 

Boards Convened. 

Board of coniniissioned medical officers convened to 
meet at the Bureau on June 30, 1913, for the reexamina- 
tion of a cadet of the Revenue Cutter Service to deter- 
mine his fitness for appointinent to the grade of first lieu- 
tenant. Detail for the board : .Assistant Surgeon General 
W. J. Pettus,. chairman. Passed Assistant Surgeon H. J. 
Warner, member; Assistant Surgeon R. A. Kearny, re- 
corder. 

Board of cominissioned inedical officers convened to 
meet at the Bureau. Washington. D. C, Wednesday. July 
9, 1913. to examine .Assistant Surgeons H. E. Hasseltine. 
J. P. Leake, and Lawrence Kolb to determine their fit- 
ness for promotion to the grade of passed assistant sur- 
geon. Detail for the board : .Assistant Surgeon General 
L. E. Cofer. chairman ; Assistant Surgeon General W. C 
Rucker. member: Surgeon B. S. Warren, recorder. 

Board of commissioned medical officers, which was con- 
vened to iTieet .April 7, 1913, at the Bureau. Washington, 
D. C. for the examination of applicants for appointments 
as assistant surgeons, reconvened to meet on Monday, 
July 7. 1913, for the same purpose. 

Boards of medical officers convened for the physical 
examination of applicants for appointment as assistant 
surgeons and for the presentation of questions for the 
written examination to meet at 10 o'clock a. m., Monday. 
July 7, 1913, as follows : 

Marine Hospital, Boston (Chelsea), Mass., Senior Sur- 
geon Fairfax Irwin, chairman; Surgeon H. AA'. Wickes. 
recorder. 

Marine Hospital, St. Louis, Mo.. Surgeon P. M. Car- 
rington. chairman; Acting Assistant Surgeon H. C. Wake- 
field, recorder. 

Marine Hospital. San Francisco. Cal.. Surgeon R. M. 
Woodward, chairman ; Passed Assistant Surgeon J. R 
Hurley, recorder. 

Marine Hospital. Chicago, 111., Surgeon J. O. Cobb, 
chairman : Passed .Assistant Surgeon H. de Valin. re- 
corder. 

Marine .Hospital. New Orleans, La.. Passed Assistant 
Surgeon .A. D. Foster, chairman; -Acting Assistant Sur- 
geon J. T. Scott, recorder. 

Fort Stanton Sanatorium. Fort Stanton. X. M., Passed 
Assistant Surgeon F. C. Sinith. chairman ; Passed .Assist- 
ant Surgeon F. H. McKeon. recorder. 

United States Army Intelligence: 

Official list of changes in the stations and duties of offi- 
cers serinng in the Medical Corps of the United States 
.Army for the week ending July 5, igJS: 

Bevans, J. L., Major. Reports his departure on leave 
of absence. Brooke, Roger. Major. Will return to his 
proper station, having completed his duties in ^\ ash- 
ington, D. C. Hill, E. C. Captain. \\'as retired from 
active duty in the iMedical Corps of the United States 
Anny on June 27. ioi3- Huntington, Philip \\'.. Cap- 
tain. Ordered to \\'est Point. N. \., on .August _'8th, 
for temporary duty until October 10, 1913. Kean, Jef- 
ferson R., Lieutenant Colonel. Will report on dutj- 
between July 7th and I3tb, at Gettysburg, Pa., for the 
purpose of delivering a lecture on personal hygiene at 
the military instruction camp at that place. Priest, 
Howard, First Lieutenant, Medical Reserve Corps. 
Resigned his coiumission on June 28th. Pyles. Will 
L., Captain. Ordered to W'est Point, N. Y., on .August 
28th, for temporary duty until October 10, 1913. 
Tarleton, L. O., First Lieutenant. Medical Reserve 
Corps. Relieved from duty at Benicia Arsenal, Benicia, 
California, to take effect on the arrival at that station 
of First Lieutenant Julius C. Le Hardy. Medical Re- 
serve Corps, and will then return to the commanding 
general of the ^^ estern Department and report for 
duty. Tasker, Arthur X.. Captain. Ordered to West 
Point. X. Y., on .August 28th, for temporary duty until 
October 10, 1913. 

The following named officers of the Medical Corps have 
arrived at the Gettysburg Encampment: Major P. L. 
Boyer. Captain W. L. Little. Captain W. M. Smart. Cap- 



tain C. E. Doerr. Captain .A. X. Tasker. Major C. C. Col- 
lins, and Captain 11. S. Purnell. 

The following named officers of the Medical Reserve 
Corps have arrived at the Gettysburg Encampment : First 
Lieutenants W. W. X'aughan. G. L. McKinnev. R. Slee, 
.\L M. Stark. W. M. Bickner. W. S. Magill. I. \'. Klander, 
S. M. Strong, R. W. Wilcox, G. C. Beach. G. C. Kuffer, 
A. K. Jarrett, T. Darlington. H. M. Havs. W. E. Fitch. 
C. B. J. Wittelstaedt. H. Hume. M. M. Eckert. and W. S. 
Cornell. 

United States Navy Intelligence: 

Offitcial list of cliangcs in the stations and duties of offi- 
cers serving in the .Medical Corps of the United States 
Xavy for the week ending July 5. /p/J/ 

Bass, J. A., Assistant Surgeon. Ordered to the Xavy 
Recruiting Station, Erie, Pa. Bunker, G. W. O., Passed 
.Assistant Surgeon. Ordered to the Uernionl. Hart, 
S. D., .Assistant Surgeon. Detached from the .Atlantic 
Reserve Fleet, and ordered to the Louisiana. Helm, 
J. B., Assistant Surgeon, Medical Reserve Corps. 
Ordered to the Navy Recruiting Station, Richmond, 
Va. Irvine, W. L., Assistant Surgeon. Detached from 
the Atlantic Reserve Fleet, and ordered to the Naval 
Training Station. Newport, R. I. Norton, O. D.. Medi- 
cal Director. Detached from the Naval Recruiting 
Station. Denver. Colo., and granted leave of absence. 
Robbins, I. W., .Assistant Surgeon. Ordered tQ the 
Xavv Training Station. San Francisco. Cal. 



lirt|s, Parriagts, ani ffat^s. 



Married. 

Anderton — Newman. — In Catonsville. Md.. on 
WediKsday. June 25th. Dr. George A. Anderton, of 
Greystdiu- I'ark, X. J., and Miss Minnie P. Newman. 
Blake — Barney. — In St. Louis, Mo., on Wednesday, 
June 25tli, Dr. John B. Blake, of Boston, and Miss 
Madge Barney. Klotz — Robbins. — In .Allentown, Pa.. 
on Tuesday, June 24th. Dr. Frederick G. Klotz. of 
Northampton. Pa., and Miss ^Margaret Grace Robbins. 
Knerr — Bransome. — In Philadelphia, on Monday, June 
30th. Dr. Bayard Knerr and Miss Ethel M. Bransome. 
Lowney — Barry. — In Boston, on Monday. June 30th, 
Dr. Francis Lowney. of Fall River. Mass.. and Miss 
Catherine Teresa Barry. Myers — Whartenby. — In Wil- 
mington. Del., on Tuesday. June 24th, Dr. Joseph 
Alyers, of Jersey Cit}-. X'. J..' and Miss Minnie Whar- 
tenby. Nichols — Eaton. — In Xorth Haven. Conn., on 
Tuesday. June 24th, Dr. Ralph ^\"ilbur Xichols and 
Miss Mary Margaretta Eaton. 
Died. 

Bacon. — In New York, on Sunday, June 22nd, Dr. 
Stetson L. Bacon, of Port X'orris, N. J,, aged seventy- 
six years. Boynton. — In Mount Washington, Mass., 
on Thursday, July 3rd, Dr. Frank H. Boynton, of New 
York, aged sixty-three years. Cain. — In Pittsburgh, 
Pa., on Saturday. June 28th, Dr. William Jonathan 
Cain, aged twenty-seven years. Carter. — In Tarry- 
town. N. Y., on Wednesday, July 2nd. Dr. H. Skeleton 
Carter, of New York, aged sixty-four years. Essex. — 
In Hope, Ind., on Thursday, July 3rd, Dr. Herman L. 
Essex, aged thirty-eight years. Foote. — In Brooklyn, 
X. Y.. on Monday, June 30th. Dr. A. Freeman Foote. 
Fumess. — In M alone. X^. Y.. on Saturday. July 5th, Dr. 
Henry Furness. Gregg. — In Pittsburgh. Pa., on 
Wednesday, June 25th, Dr. Edward Rollin Gregg, aged 
forty-three years. Hurlburt. — In Xorwich, N. Y., on 
Thursday. June igth. Dr. John E. Hurlburt. aged seven- 
ty-two years. McFadden. — In Philadelphia, on Wednes- 
day, July 2nd, Dr. William H. McFadden. aged 
eighty-five years. McFarlane. — In Oneonta. X. Y.. on 
Sunday, June 29th. Dr. \\illiam H. McFarlane, aged 
sixty-seven years. Morrill. — In Xorth Andover. Mass.. 
on Friday. June 27th. Dr. Charles P. Morrill, aged 
seventy-three years. Robinson. — In X'ewark, N. J., on 
Sunday, June 2qth, Dr. George W. Robinson, aged 
seventy years. Weber. — In X'ew York, on Wednesday, 
July 2nd. Dr. John G. Weber, aged seventy years. 



New York Medical Journal 



INCORPORATING THE 



Philadelphia Medical Journal Tht Medical News 

A Weekly Review of Medicine, Rstahlished 1 843. 



You XCVIII, Xo. 3. 



XFAA' YORK, JULY 19, 1913. 



Whole No. 1807. 



Original CDmmuniratiflns. 



A CASE OF DEMEXTIA I'R.ECOX Willi 
AUTOPSY. 

By Ch.vrles W. Burr, M. D., 
Philadelphia, 

Professor of Mental Diseases, University of Pennsylvania. 

The case is interesting clinically because of the 
difficulty in-diagnosis on account of the complexity 
and variability of the picture presented; the pati.ni 
seeming at one time to be suffering from gross or- 
ganic brain disease, at another from pure hysteria, 
while the correct diagnosis, which was made only 
after long and careful study, was dementia prscox ; 
and pathologically because the necropsy showed no 
gross lesion of any organ and the inost thorough 
and minute examination of the cord and brain re- 
vealed no evidence of disease. 

The patient, a white girl, nineteen years old, was first 
admitted to the Orthopedic Hospital and Infirmary for 
Nervous Diseases under the care of my friend. Dr. Fran- 
cis Sinkler, and later transferred to my wards at the Phila- 
delphia General Hospital (Blockley). Her parents stated 
that she had always been nervous and delicate, had never 
cared much for the society of other boys or girls and, 
since puberty, had had many spells of depression. But 
little could be learned of her family history; not enough 
to justify any opinion as to whether it .was medically good 
or not. Her illness began in January, 191 1, when she re- 
ceived a slight wound of the right hand w-hile at work; 
after which she immediately becatne very nervous. She 
had an hysterica! attack, in the vulgar sense of the word, 
immediately after tlie accident, and continued to cry 
throughout the night. A few days later she began to be 
forgetful, speech became stammering, and she seemed to 
have lost the sense of pain ; that is, when pricked with a 
pin she would deny that it hurt her; indeed she denied 
that she felt it, though she would withdraw the arm or 
leg which was pricked. 

When admitted to the Orthopedic Hospital she was in 
semistupor and speechless. When spoken to she laughed 
in a silly fashion. She obeyed a few simple commands. For 
example, after being repeatedly told, she finally put out 
her tongue. It seemed as if the process of thought was 
greatl}' slowed, rather than that she was obstinate. 
\\'hether there was a blocking of the efferent or afferent 
paths between the bulb and the cortex, or whether the 
trouble was cortical (mental), cannot, of course, be 
known, but her slowness certainly was not willful. It is 
hypothetically possible in these cases that a seemins men- 
tal sluggishness may really be due to a break between the 
cortical centres of thought and the tracks leading to or 
coming from them. The knee jerks were greatly exag- 
gerated. Her weight was ninety-five pounds. The urine 
was normal. She paid no attention to the bladder or 
bowels. Both the Wassermann and Noguchi tests were 
positive. After a couple of weeks superficial bed sores 
appeared on the heels and sacrum. They developed not 
only on parts subjected to pressure but elsewhere. Her 

Copyright. 1913. I'V .\. K 



legs were drawn up on the .ibdomen and stiffened, and 
there was some little rigidity of the right arm. She held 
her hands up when asked. The second Wassermann and 
.Voguchi tests, made two months after the first, and af- 
ter salvarsan had been given intravenously, were nega- 
tive. Dr. Thomas B. Holloway examined the eyes oph- 
thalmoscopically (December 6, 191 1) and found them en- 
tirely normal. Her mental stxite precluded taking the 
fields of vision. Early in December she began to have 
twitching of the right arm and right side of the face, 
most marked around the corner of the mouth. 1 he right 
arm was at this time not spastic, but. when not twitching, 
was held Hexed at the elbow. The knee jerks were nor- 
mal. There was neither a Babinski jerk nor ankle clonus. 
There were at times irregularly recurring contractions of 
the abductors of the right leg. On December 15th the Was- 
sermann and Noguchi tests were both doubtful. By Jan- 
uary 15, 1912, the bedsores were alinost healed, her gen- 
eral appearance was better, all spasmodic movements had 
ceased, and she answered questions responsively, though 
she spoke but little spontaneously and never save to ask 
for water or to have something done for her, .Altogether, 
she was greatly better both mentally and physically. On 
February 2d the Wassermann and Noguchi tests were again 
doubtful, but on the ninth day they were again weakly 
positive. On February 9th the patient again ceased to 
speak, and would not obey any simple command save to 
open her mouth. She had no trouble in eating after food 
was put in her mouth, but she would not use her hands to 
feed herself. Her legs were held strongly flexed, but she 
used her hands occasionally. Often she would hold her 
hands uplifted for a long time and keep her gaze fixed on 
them. She had several other tricks of muscular move- 
ment and many spells of grimacing. She gave no evidence 
of paying any attention to anything going on around her. 

On February i6th she was admitted to my wards at 
Blockley. When I visited her, she lay in bed taking no 
notice of her surroundings, seeming to be in a stupor, not 
speaking spontaneously or in response to questions. Both 
arms and legs were contractured and the contractures 
could not be passively overcome. Both thighs were flexed 
on the abdomen, the left knee was crossed over the right. 
and both legs were fle.xed at the knee. The knee jerks 
were increased. On February 20th she was still stupid and 
mumbled and talked incoherently. On March 3th she was 
much weaker. She would hold remnants of food in the 
mouth for hours, but did not choke in swallowing. When 
spoken to she made inarticulate sounds. Negativism was 
marked. Told to open the mouth or eyes, she closed them 
tight. Attempts to passively fle.x the head made the neck 
.stiffen. There was soine tremor of the head. The right 
arm was contractured in flexion, and also the fingers 
There were numerous superficial bedsores on the shins, 
ankles, and buttocks, and several scars of old healed ones. 
She used the left arm to pull up the bed clothes, but did 
not voluntarily move either leg or the right arm; but if 
the right arm was passively lifted would move it about 
for a time and then lower it to the bed. She gave no evi- 
dence of feeling pain from pin pricks. The biceps jerk 
was plainly present, the triceps very slight. The contrac- 
tures were so marked in the leg that it was impossible to 
tell whether the Babinski jerk, ankle clonus, knee jerk, 
and Achilles jerk were present or not. She was not in 
real coma, as was proved by the fact that she showed, by 
trying to pull up the bed clothes during an examination, 
that she disliked being exposed. At this time, at rest, the 
right eye wandered slightly up and out. The pupils were 

lliolt Publishing Company. 



BIRK: UEMIiXTIA PRAiCOX. 



[New Yoiui 
Medical Jours." 



equal and reacted lo light. SKepald iTof ?;tt?ntibn ^o the 
bladder and bowels. She died March 8, 1912. 

At irregular intervals during the course of her illnes.s 
she had fever lasting days at a time. The temperature 
chart was not characteristic of any disease. The tempera- 
ture would remain between 100° and 101° F. for a week 
or two, then vary night and morning from 102° to 98° F. 
for another week or two. then be normal for an indefinite 
time, and finally fever would recur. At first I thought 
the fever was correlated with the bedsores, but that 
turned out not to be true. There was always some fever 
when bedsores were present, but there was also fever at 
times when the skin was entirely healthy. Repeated ex- 
amination of the urine proved the absence of cystitis, a 
frequent cause of fever. Fever is, of course, not a symp- 
tom of either hysteria or dementia praecox. What its 
cause was in this case I do not know. The contractures 
came and went. When I first saw the patient the case 
looked like one of organic hemiplegia with the ordinary 
contractures of the palsied arm and leg. at other times 
all four extremities were contractured. or any one, and 
at still other times all the contractures would disappear 
suddenly. They finally, however, became persistent. 
Speech also varied ; at first it seemed to be truly aphasic. 
later it was bulbar, and finally the patient was mute. Her 
mental state, too. varied from apparent stupor to fair con- 
sciousness but ended in true stupor. 

Dr. Williams B. Cadwalader reports as follows concern- 
ing the condition of the brain and spinal cord : "The spec- 
imens were received some weeks after preservation in for- 
malin. The brain is rather small and the frontal lobes 
are slightly flattened. The convolutions and fissures are 
well defined, the membranes are not thickened, and tliere 
is no evidence of meningitis nor lesions of the cortex. 
On cross section through the lateral ventricles a few 
brownish red minute areas are seen scattered diffusely 
through the basal ganglia and internal capsules, but there 
is no evidence of softening or of hemorrhages. In the 
pons, medulla, and the cervical and thoracic cord the 
same appearance is found, but in the lumbar cord it is 
absent. Microscopical examination (with the Nissl and 
alum hematoxylin and fuchsin and Weigert's stains') ; Sec- 
tions taken from the frontal and occipital lobes and the 
paracentral lobules show nothing abnormal. With the Xissl 
stain there is no chromatolvsis. The cells are well 
formed and the nuclei are not displaced. Sections taken 
from the basal ganglia and internal capsules reveal no 
degeneration with the Weigert stain. The bloodvessels 
are not diseased, but are engorged with red blood cells, 
which are well stained. There are no perivascular infil- 
trations. Sections of the pons and medulla, cervical and 
thoracic cord, present the same appearance. The lumbar 
cord, however, does not show so much engorgement of the 
bloodvessels. The membranes of the spinal cord and 
brain are nowhere thickened, nor is there any evidence of 
round cell infiltration. The cells in the anterior horn 
throughout the cord are normal." 

When I first saw her in consultation at the Orthopedic 
Hospital the question was as to the possibility of brain 
tumor or serious cerebral vascular disease. She then 
showed hemiplegia with contractures, an apparent par- 
tial motor aphasia and semistupor. Brain tumor was ex- 
cluded by the absence of the classical symptoms — vomit- 
ing, vertigo, choked disc — and by the history of th> 
mode of onset. -\fter fully considering the matter Doc- 
tor Sinkler and I felt sure that syphilitic vascular disease 
also could be excluded, and there was no reason to sup- 
pose that vascular disease from any other cause could be 
present. We were somewhat perplexed by the variability 
of the results of the Wassermann and Xoguchi tests. We 
were forced, when the contractures and the speech defect 
suddenly passed off, to the conclusion that the disease was 
either hysteria or dementia prsecox. I confess that for 
some days I was not sure from which she was really suf- 
fering. By the time of her admission to Blockley the diag- 
nosis was well established. 

There is a similarity between dementia prascox 
and hj'steria, and "it i.s often hard to tell for some 
time in a given case with which di-ease we are deal- 
ing. The differential diagnosis is of great im- 
portance because of the difference in prognosis. 



An attack ot hysteria is usually cin-ed. though the 
hysterical tem])eraincnt remains, and there are al- 
most always recurrences which in time are re- 
covered from, while in dementia pr;ecox, though 
there may be a remission during which all symp- 
toms disappear, or a cure of the first attack, if one 
dare speak of it as such, there is inevitably a re- 
currence and finally complete dementia. Hysteria 
may recur many times over a period of years, and 
no dementia result ; dementia prjecox always lead- 
to permanent dementia after, in the ino.st favorable 
cases, a few years. 

The alleged cause of her illness, a trifling injury, 
cannot have heen anything more than a mere ex- 
citant. Xo healthy person would be made seriously 
ill by such an experience. There was no real 
shock — nothing to frighten, alarm, or horrify a 
normal girl. It is possible that the accident had 
nothing to do with her subsequent illness, but was 
a mere coincidence : it is more probable that she 
was in the ])rodromal stage of disease and ready to 
be influenced by any, even the slightest, stress. The 
real e.xciting cause, the material thing which acted 
on her organs, remains unknown. It is a very com- 
mon thing for jjatients, and their families, to regard 
as the cause of nervous or mental illness any un- 
usual, remembered thing which may have occurred 
soon before the illness became manifest. Some- 
times, when the element of legal responsibility and 
consequent damages exist, there is a distinct motive 
for assigning an accident as the cause, but in this 
case there was no question of damages, since con- 
fessedly the accident was entirely due to the girl's 
own carelessness. The real predisposing cause 
was within the girl herself, in her nature and con- 
stitution. Her protoplasm had power to resist the 
stress and strain of life for only so many years, or, 
rather, it could only do a certain amount of work, 
and when that had been done she succumbed. 
Gowers has explained several local physical dis- 
eases, such as idiopathic inuscular atrophy, on this 
theory (abiotrophy), and the same thing is a 
reasonable, though hypothetical, explanation of this 
case. 

The total absence of any discovered cause of 
death is very interesting. None of the organs gave 
any signs of disease to the naked eye, and a careful 
microscopical examination of the brain and cord did 
not reveal an\' abnormality. Every now and again, 
in any large series of necropsies in a large general 
hospital, a case will be met with in which the 
lesions do not seem to be adequate to have caused 
death, but it is rare not to find any lesion of any 
kind. \\'hen such happens it is reasonable to as- 
sume either that some intoxication has caused 
death without producing lesions sufficiently marked 
to be discovered by our present methods, or that 
there has been a real protoplasmic exhaustion due 
to the inherent weakness of the protoplasm itself. 
The case was a true insanity, and not a mere febrile 
delirium, because the mental symptoms existed for 
weeks before any fever existed and were not in- 
fluenced in any way later by the course of the tem- 
perature. Furthermore, contractures and articula- 
torv disturbances are not a part of febrile delirium. 

igiS Spruce Street. 



B-IXOLliK. JXTF.KXAI. SliCKIiTIOXS AX I) Tllli GYXF.COI.Oi.lSI. 



THI-: IXTKRXAI. SIXKETIONS AS TIJEV 

CONCERN THE CiYNECOLOGIST. 

Bv Samuicl Wvi.i.is Bakih.kr, M. D.. 

New York. 

The internal secretions play so ini]x)rtant a part 
in the development of the body and mind, and so 
important a part in the development of vital struc- 
tures and functions — they are such essential fac- 
tors in preserving these functions and structures, 
and in supporting the u|)keep of the body — that 
scarcely any field of medicine exists in which 
a study of the ductless glands is not to-day an 
essential point in the thorough understanding of 
normal and pathological processes. 

The proper development of the IxKly in the 
earlier years and up to adolescence is to a great 
extent under the control of the hypophysis cero- 
bralis and thyroid. This development, associated 
as it is with the ripening of the genital organs and 
the sexual glands, determines to a great extent the 
question of stature and genitalism. IMany of the 
glands of the body enter, each through its own 
particular field of work, and also induenced by its 
relations to other glands, into the realm of Ixiny 
growth, ossification, form of the bones, metabol.sin, 
and the mental state. When a physician sees an adult 
patient, the size of the patient, the proportii^n be- 
tween the body length and the length of the limbs. 
the shape of the pelvis, the amount of adipose tis- 
sue, certain peculiarities of the skull, hands, or feet. 
certain mental characteristics, many so called minor 
details^ such as distribution of hair, trichosis, etc., 
attract attention to the existence during infancy, 
childhood, or adolescence of certain alterations and 
anomalies of gland function, which show that at all 
times deviations from the normal in individual or 
related glands must be reckoned with. In other 
instances there is nothing in the physical makeup 
of the individual, nor in any of the points elicited 
by a careful history, to point toward any previous 
easily recognized alteration of function on the part 
of any gland or glands, and in such cases one must 
look for other than developmental alterations and 
tendencies, and must consider acquired irritations, 
injuries, and causes in the elucidation of the ques- 
tions involved. Then comes a large class in which 
the exercise of the normal functions of the body 
for the purposes for which thev were designed, or 
interference with such functions, or the failure to 
make use of such functions, or interference with 
these functions by disease or injury, are productive 
of those deviations in the nervous system, whicli 
practically constitute a pathological picture. We 
must not overlook a \ery large class who are- 
in that stage, or in those stages eventually reached 
by all, where regression begins, where glands 
naturally begin to cease their former activity, 
where the interrelation between the glands is Sd 
readily upset, and where abnormalities in glaml 
functions seem particularlv to turn in the direction 
of nervous and mental diseases. 

An important matter, and one which makes the 
study of the ductless glands so fascinating, is the 
interrelation between the glands. Animal exjieri- 
mentation has shown us how a removal of almost 
;.ny gland produces changes, sometimes compensa- 



tory, in others. If the changes which wire pro- 
duced in one gland were always to ])roduce the 
same changes in the others the question would lie 
simple, but, as we may have increasetl function of 
the anterior lobe of the hypophysis, associated with 
function or excessive function of the posteri<jr lol)e. 
or z'ice versa, we may have an anomaly in gland 
function associated with increasc<l or diminished 
function of one or other glands of the body. The 
pancreas, the pineal gland, the adrenals, the ovaries, 
the hypophysis, the thyroid, the thymus, with their 
interrelations, give us an endless series of changes 
and modificatiotis. physical. ner\ous, and mental, 
which are extremely difficult to classify, l-lach and 
every one of these glands is influenced by, or in- 
fluences ovarian and uterine function and we, who 
are interested in gynecology, are called upon to 
give these questions our most earnest study. There 
is nc> doubt in my mind, after years of observation, 
that this matter has l)een splendidly put by Lush- 
ing. that in certain families Mendelian jirinciples 
hold good. It is probable that some families have 
certain ductless .gland peculiarities. There may be 
instability of the thyroid, there may be instability 
of the hypophysis, there may be early or late genital 
maturitx-. This instability may be evidenced by in- 
creased activity in some members or generations, or 
decreased activity in other members or other gen- 
erations. 

Almost the first questions which a gynecologist 
asks his patient are : How old were you when > ou 
first became unwell ? Did your menstruation 
come every four weeks, or were there intervals of 
weeks and months? \\^ere you well during this 
period and before each period? Were you able to 
play like other children, or were you kept out of 
school ? A girl who begins to menstruate at thir- 
teen, fourteen, or fifteen shows that ovarian and 
genital development were probably normal. A 
patient who answers that she was able to play at 
that time and was perfectly well probably suffered 
from no palpitation, no nervousness, no functional 
cardiac neurosis. W'e know the important relation 
which the hypophysis and thyroid bear to genital 
development. We know that increased or de- 
creased function of the hypophysis in the pread- 
olescent stage is productive of failure of full de- 
velopment of the genitalia and the genital glands. 
We know that decreased function of the thyroid is 
an important factor in producing failure in complete 
development of the genital glands. Here, how- 
ever, care must be exercised to be sure that we 
are dealing with alterations in these gland struc- 
tures, for we know that congenital smallness of the 
arterial system, associated with narrow arch of the 
aorta, for instance, may be associated with sexual 
infantilism. The diseases of childhood, if these 
exanthemata involve the ovaries and uterus, may re- 
tard or inhibit the development of the genital struc- 
tures. Chlorosis. supjx)sedlv related to ovarian 
function, may. in these and later years, bear a re- 
lation to the points under discussion. 

Infantilism may be due to failure in proper func- 
tion of the thyroid, hvpophysis. and other internal 
secretions, or it may be part of the general failure 
of development resultin.a: ofttimes in the type of par- 
tial, scattered, or general asthenia. Frequently this 



B.IXni.HR: IXri-.kX.tl. SIX h'/-:T10.\'S .IXD THI-. CYXIlCULOClSr, 



ustheiiia is masked and is only brought to light b\ 
subseciiient events and phenomena. The involve- 
ment of the sexual organs in these types of cases is 
not to be confounded with that form in which infra- 
genitalism seems to be unconnected with any otlicv 
ascertainable physical or glandular alterations, nor 
must it be supposed that in this type the secondary 
characteristics are always deficient or wanting. 
Just as we may find infragenitalism a factor to be 
reckoned with, W'e may find in supergenitalism some 
points of great interest. Supergenitalism and 
pubertic precocity may be primarily the outcome of 
precocious development of the genital glands or 
may be the secondary results brought about by 
primary affection of other glands. Hypophyseal 
affections are frequently associated with gigantism, 
but generally with genital atrophy. Pineal tumors, 
however, produce abnormal growth in height, plus 
premature genital development. Suprarenal tumor 
results in exceptional development of the body, plus 
sexual precocity. Excluding these cases, there are 
a certain number which can be explained only by 
primary supergenitalism. 

In physiological puberty, proliferation of the epi- 
physes soon ceases. - Premature puberty is often 
associated with accelerated ossification, for the gen- 
ital glands have a great effect upon the growth of 
the skeleton. Thus, the age at which genital 
maturity takes place has an important influence on 
skeletal growth, and early maturity is associated 
with short legs, for the ovaries elaborate a hormon 
which stimulates the process of ossification. The 
effect of late maturity of the ovaries is to increase 
the height, especially the length of the legs. All 
gland functions are naturally stimulated at puberty, 
and, in addition to the influence which ovarian ma- 
turity has on skeletal growth, the influence which 
the hypophysis has at this stage must be taken into 
consideration. Many of the rapid growths are due 
to hypophysis activity, and come within the realm 
of the normal ; others do not. Since hypophyseal 
hyperplasia may be responsible for the rapid body 
growth which normally occurs at puberty, an exag- 
geration of the growth may produce what is knov,n 
as a "normal giant, an individual normally propor- 
tioned, sexually intact, with great physical strength." 
The relationship between the ovaries and those other 
secretory organs which influence the growth of bone 
is sufficiently remarkable to attract attention, and 
castration is followed by changes in the thyroid, the 
thymus, and the hypophysis. In passing, it may be 
mentioned, that the principal role in osteomalacia is 
played by the ovaries. These glands have always 
been considered as a factor in chlorosis, in which 
the amenorrheic type is the most frequent. The 
diminished power of blood formation is supposed to 
bear some relation to the female sexual organs, 
since from them come stimuli which act upon the 
blood producing structures. In the younger years, 
before adolescence, anomalies of the hypophysis 
cause as a rule failure of development of the 
ovaries, the uterus, and the other structures charac- 
teristic of the female. After adolescence anomalies 
of the hypophysis result in atrophic changes in the 
genitalia. The same thing, lack of development of 
the genitalia, holds true with giants and dwarfs. 
In the one case there is too little secretion, in the 



other there is Ujo much, and yet with either of 
these alterations genital dystrophy occurs. 

The distinctions between the genitalia of the two 
se.xes themselves constitute the "primary sex char- 
acteristics," but a number of dift'erences which are 
not connected with propagation, but which are char- 
acteristic of the female sex are called "secondary 
sex characteristics." .Among these are the greater 
tendency to fat under the skin, and the resulting 
rounding of the body, the width of the hips, and the 
marked development of the gluteal region, as well 
as the length of the hair, the absence of beard, and 
the difference in the larynx. The difference in the 
pelvis is very marked. There is a slighter develop- 
ment of the features of the face, especially the lower 
jaw. The brain is smaller. Physically, even as 
children, there is a taste for different forms of play. 
The differences are already apparent between the 
ages of eleven and fourteen, as concerns the round- 
ing of the features, the increase in the fat, especially 
in the mammas, in the gluteal region, on the thighs, 
etc. The most important of the secondary se.xual 
characteristics are the breasts. 

The element of the ovary which is responsible, 
directly or through modification of hypophysis or 
other gland activity, for the constitutional physical 
changes which characterize puberty is not known, 
but some assert that it is possibly the interstitial 
gland structure. As a consequence of sufficiently 
early preadolescent castration, the acquired charac- 
teristics of sex may fail to appear. As a result of 
failure of ovarian function the secondary sex char- 
acteristics may be poorly developed, though the 
reproductive functions, covered by the follicles, may 
not be impaired. Castration never produces the 
positive characteristics of the opposite sex, but, 
v.-hen carried out early, results in a continuation of 
the infantile type. The ovary exerts its influence on 
the growth of bone, on the accumulation of fat, 
and on the character of the blood. Castration is 
followed by excessive longitudinal growth, a lack of 
proportion between the length of the trunk and that 
of the extremities. Removal of ovaries causes 
atrophy of the uterus, but has little effect on the 
vagina, almost none on the external genitalia, and 
very little on the libido. Therapeutically, castration 
produces splendid results in osteomalacia. At 
puberty, when the ovary begins to assert itself in 
the economy, the thyroid likewise begins to enter 
the field of observation and attracts attention 
through periodic states of overactivity. How much 
the ovary has to do with bringing on these secretory 
alterations in the thyroid is still unsettled, but, in 
my opinion, the ovary, which so dominates in many 
ways the functions of a woman's body and mind, is 
responsible, because of its relation to the thyroid, 
for many of those thyroid deviations of which I 
now speak, and which I may mention later. 

Heart symptoms at puberty may develop for 
weeks or months before the first menstrual period. 
There is often an increased, objectively noticeable 
palpitation, which is frequently associated with 
vasomotor sensitiveness, blushing, tendency to 
pallor, tendency to fainting. There are cases where 
the pulse may be from 120 to 140. The symptoms 
usually occur in attacks, sometimes daily, sometimes 
at intervals of several days, ^^'hen the period be- 



B.lXDI.Iil'!: IXTHR.X.II. SI-.CHETIONS .IXD THE GYSECOLOOIST. 



"3 



ijins tlie attack disappears, and usually recurs at 
the following periods in milder forms. Kiscli de- 
scribes the paroxysmal attacks of tachycardia with 
very rapid i)ulse, which occur some time before the 
first period, then each time before every folhnv- 
ing period, and may last several months after the 
establishment of the menstrual function. These 
patients show an increased irritability of the sympa- 
thetic. In them there is neither anemia nor chloro- 
sis. In certain patients the heart symptoms and 
vasomotor disturbances mentioned above occur be- 
fore each period. Xoticeable irritability of the heart 
at the time oi menstruation is of course observed 
in most girls suffering from hyperthyroidism. The 
th\ roid may then be swollen, or may show no 
change in size. \\ omen with fibromyomata often 
have thyroid changes, especially if the tibromyomata 
are interstitial. The greater the proportion of con- 
nective tissue in the tumor, the more marked arc the 
thyroid changes. Rontgen rays cause a diminution 
in size of the myomata and favorably affect the 
associated struma. This regression is said by 
Frankel to be due to the effect of the rays on the 
ovaries. Probably the tachycardia, so often asso- 
ciated with tibromyomata. especially with marked 
uterine bleedings and generally attributed to the 
bleedings, may be due to the thyroid changes. We 
all acknowledge the connection between myxedema 
and Basedow's disease, Addison's disease, etc., on 
the one hand, and var\ing degrees of amenorrhea 
on the other. 

I wish, however, to devote a few moments to the 
question of relative and actual amenorrhea, especial- 
ly when associated with obesity and occurring, as it 
often does, many years before the awaited climac- 
terium approaches. Tt is of course recognized by 
all that the ovaries preside over menstruation and 
e.xert a tro[)hic influence on the uterus : senile atro- 
phy and lactation atrophy being simply physiological 
and expected processes, due to cessation of ovarian 
activity, ^^'e find a certain type of case in which 
menstrr.ation grows gradually less, the menstrual 
molimina less pronounced, the uterus and ovaries 
smaller : associated with which is a progressive gain 
in weight, l-'or ^■ears these cases have been a puzzle 
to me, and I have come to the conclusion that little 
can be done to reduce such patients in weight or to 
restore their menstrual function. I like to charac- 
terize these cases by the term "precocious meno- 
pause," and have previously explained them on the 
theor\- of an equal and harmonious diminution of 
function on the part of the thvroid and the ovaries. 
In recent months, especially since the work of Cush- 
ing has become known to us, we realize that a new 
explanation gives us a better understanding of the 
matter. A lowered function of the posterior lobi- 
of the hypophysis, with a coincident disturbance 
in metabolism, is responsible for the gain in weight 
and for the ovarian atrophy, and in all probab-l- 
ity is in many cases associated with thyroid low- 
ered function. Here, again, we find ourselves in 
the po.^ition of explaining the cause for the changes 
in the hypophysis, ^^'ith acromegaly, universally 
.'ecognized as due to superfunction on the part of 
the anterior lobe of the hvpophysis in the later post 
adolescent stages, the genital atrophy is usually so 
pronounced, and amenorrhea often so early a symp- 



tom, that in the minds of many men the ovarian 
alterations have been considered the primary ones 
and the changes in the hypophysis as secondary. 
At any rate, the trophic relation between the hypo- 
physis and the ovaries in the preadolescent and later 
periods seems to be closer even than the relations 
between the thyroid and the ovaries, and that is 
certain!)' saying much. 

The ovaries certainly bear some relation to cer- 
tain excessive uterine bjeedings. They are, after all. 
the cause of menstruation, and the va-t majority of 
cases of relative or absolute amenorrhea are due to 
involvement of the ovaries, directly or through the 
influence of other glands or certain diseases. Why 
may we not expect symptoms of the opposite ex- 
treme with overfunction on the part of the ovaries, 
if they produce a congestion or hyperemia of so 
marked a nature that only slight disturbances in the 
uterus are necessary to result in menorrhagia or 
metrorrhagia? Some of these cases in adolescent 
patients seem to be due to a too rapid and 
-udden maturation of the ovary. There is often 
an inherited tendency, the mother having under- 
gone similar troubles. This condition may be 
a family trait and may represent an inherited 
instability of the glands of internal secretion. 
Metrorrhagia may be due to a hyperemia resulting 
from underfunction of the ovaries and may be 
accentuated by masturbation. The normal uterus, 
lined with a normal endometrium, resists the pre- 
menstrual congestion up to that certain point when 
menstruation begins. The greatest wonder is that 
menstruation occurs with such marked periodicity 
and that the flow lasts a certain time and then ceases 
becau-e the endometrium is bled, the uterine wall 
contracts, and that substance secreted by the ovaries 
which is responsible for menstruation is thrown 
out of the system. If, then, we are dealing with an 
abnormal endometrium. perhaps hyperplastic 
through excessive ovarian stimulation, especiallv of 
the adenoid type, or if the uterus has lost its elas- 
ticity and if its contractile power is diminished, then 
even a normal ovarian congestion may, with per- 
fectly understandable ease, produce menorrhagia or 
metrorrhagia. \\'e observe these excessive bleedings 
very often in women in the late thirties and early 
forties, and they are usually healthy, well developed 
women. I have hysterectomized a large number 
of these, large enough to have my attention attracted 
to the fact that they have large, plump ovaries, and 
I have long since come to the conclusion that fail- 
ure of the ovaries to regress at this period naturallv 
prevents the uterus from undergoing atrophy, and 
the associated persistence of marked premenstrual 
congestion within the uterus of lessened elasticity 
readily explains the frequent bleedings to be found 
in the preclimacteric period. 

I have always felt that the internal secretions had 
much to do with sterility, aside from the effect on 
uterus and ovaries. To my mind a normal func- 
tionating ovary evidences itself by a certain, sup- 
posedly normal amount of menstruation. With 
this as an accepted standard, and with the added 
w-eight of certain degrees of premenstrual molimina. 
we have the right to presuppose the existence of 
follicles which produce ripe ova. The facts that 
some women who conceive menstruate onlv everv 



i"4 



B.lXDLi:i<: IXTERX.-IL SliCRETIOXS .IXD THE GYXECOLOGIST. 



two or three months, and that several cases have 
conie under my observation of women who have 
borne children and have not menstruated for inter- 
vals of from one to two years (not because of hu- 
tation), do not nullify the general principles jusi 
enunciated, for they are only clinical points that 
guide us in forming an opinion. Hence, with rela- 
tive amenorrhea, or with actual amenorrhea, or witli 
the amenorrhea associated with obesity, we have a 
right to presuppose the possibility that the ova ma> 
be at fault, either in not being what may be termed 
"ripe"' or through being retained in atresic unbroken 
follicles, which is of itself an evidence of follicular 
weakness. In this type of case, and also in the 
form characterized by the various degrees of genital 
hypoplasia, other factors may come into play. The 
tubes n-^ay be very small, they may be tortuous, and, 
what is most important, the cilia may be involved. 
(3n the activity of the cilia of the tube depends 
the entrance of the ovum into the uterus. It is a 
natural supposition that the ovaries, through their 
trophic effect on the uterus, may be among the 
factors which control the action of the cilia. If we 
have absence of spennatozoa or inactive sperma- 
tozoa in the male, why may we not have inactive 
cilia in the Fallopian tubes? So that, with abnorm- 
alities in the ovarian <ecretion, or in diseases involv- 
ing the thvroid or h}pophysis, it is only a rational 
opinion and not a reckless conjecture to point 
toward the possibility or inaction on the part of 
the cilia as a possible cause of sterility, and to hold 
the ovary and thyroid or some of the other internal 
secretions responsible. 

In gynecology, for vears reflex annoyances have 
been supposedly produced in the nervous and diges- 
tive systems by abnormalities in the genital tract. No 
change in the position of the uterus has been too 
slight, no tear in the cervix too small, no palpable 
or pathological alteration in position or function on 
the part of the ovary has been too slight to be con- 
sidered the cause, by reflex action, for slight and 
great changes in digestion, in cardiac activity-, in the 
functions of the nervous system, in the realm o/ the 
mind, and in the field of pain. This reproach. I 
hope, is no longer lx)rne by gynecology, that useles-; 
operations are advised because reflex causations a'e 
presupposed. As we view this question to-day we 
lecognize that a verv important class of patients, 
in whom there is a decided tendency to inelasticity 
and asthenia, come into the hands of the gynecol- 
ogist, and especially those who practise obstetrics, 
who realize the truth of thi^ statement. This asthenia 
may be constitutional and general, it may involve 
the nervous system or the circulatory system, it may 
be characterized by ptoses, or by lack of mental 
stability. Many of these cases go back to develop- 
mental physical alterations in infancy and early 
childhood and cannot be placed to the credit, .so far 
as we now know, of an}- one jiarticular gland, or 
set of glands. 

.\t all periods of a woman's life alterations of the 
thyroid functions may occur. Lowered function may 
be so marked as to produce the classic symptoms 
of myxedema. <">verfunction may be -o decided 
that exophthalmic goitre is evident. But we are 
now on the threshold of unanimously acknowledging 
that underfunction may be of all degrees and over- 
function likewise: sn thp.t the term hyperthyroid- 



ism is now of almost universal use. .Vnomalies of 
thyroid function concern the gynecologist, so far 
as menstruation is concerned, by occasionally pro- 
ilucing menorrhagia ; more frequently, varying de- 
grees of diminished menstruation. The intimate re- 
lation between the ovar}- and thyroid is such that it 
is more than probable that changes occurring in the 
ovaries themselves influence the thyroid to under- 
function or to (>\er function. These anomalies in 
thyroid secretion, whether in the way of amount 
or quality, concern the gynecologist because of the 
alterations which they produce in the digestive sys- 
tem, in the nervou- system, and in the psyche. 

It is worth while asking why thyroid aiTections in 
the form of myxedema and liasedow's disease are 
so much more frequent in women than in men. 
Whatever the real explanation may prove to be, it 
also serves a purpose by giving an explanation for 
the marked instability of the thyroid in the wide 
field of hypothyroidism and hyperthyroidism of 
minor grades, sometimes alTecting the genital 
sphere, the digestive functions, the nervous system, 
or the psyche. I may take a moment to state that 
It the theory of intimate relation between ovary 
and thyroid be true, if either of these glands stimu- 
lates the other, and at the same time has an antag- 
onistic action, then the elements of menstruation, 
])regnancy, and the climacterium, plus the luimerous 
injuries to which the ovaries are subjected, furnish 
a very rational basis for the frequent alterations in 
thyroid function and give us at least this much 
which may be stated, namely, that whatever may be 
the cause or causes for thyroid alterations in the 
male, those same causes naturally act with much 
greater readiness in the female. Then, too, comes 
the question of the uterus. I have often said that 
no woman is really so well as that one whose uterus 
plays no further part in her economy. So long as 
menstruation takes place, so long as the uterus and 
its lining undergo their premenstrual changes as a 
result of ovarian stimulation, just so long have we a 
factor which in turn reacts upon the ovaries and 
also upon the thyroid. So that the interrelations be- 
tween the ovary and the thyroid, on the one hand, 
between the ovary and the uterus on the other, and 
then, too, between the uterus and thyroid, furnish 
another reason for the instability of thyroid activity. 
Therefore, the almost universal recognition of the 
frequency with w^hich hypothyroidism and particu- 
larly hyperthyroidism influence certain periods, 
stages, or even the whole, period of a woman's life 
open to us a clearer imderstanding of the causation 
of these phenomena, which for so many years have 
been erroneously attributed to pelvic reflexes, anrl 
recent obser\'ations show that in this field, too, the 
hypophysis takes a position which demands atten- 
tion. 

Knowing, then, the relations which the important 
glands bear to the ovaries and genital functions, and 
the relation which the ovaries bear to other glands, 
we in gynecology must remember to view with sus- 
picion in every case the diagnosis that cessation of 
menstruation, as such, is a cause of nervous or men- 
tal disease, or vice versa, and must be on the alert 
to correlate, whenever justified by accurate diag- 
nosis, nervous and mental symptoms on the one 
hand and disturbances of menstruation or genital 
abnormalities on the other, hv referring- Ixith to 



HIKILR: r.lCVl.TY OF PARIS. 



affections uf the ductless glaiuls, and thus sci)araic 
ourselves, so far as is correct, from the former lixed 
ideas concerning hysteria, ueurastiienia, and reflex 
neuroses. The nerve phenomena in the climacterium 
show variations from the phlegmatic type to the 
excitable type. The psychic variations run from 
melancholic and psychasthenic to manic forms. In 
many cases the annovances are clearly the result of 
changes incident to the climacterium. In other- 
ihey resemble various forms of mental diseases an<l 
seem olttinies to have nothing to do with the inter- 
glandular upset. Kach is of course necessary to 
separate the forms which are coincident with the 
preclimacteric or climacteric phase from the forms 
which are due to the alterations of that period. 
Some women go through this time of life with 
scarcely a ripple to mar their good health, while 
others are miserable and unhappy f^r months or 
\ears. There are women who are in this so called 
change of Hfe state (if that be used to signif\ an 
abnormal relation between the secretions) during 
the greater part of their life or for certain months 
of their existence, or preceding a few or many, or 
all, of their menstrual periods. They sufi'er from 
the same variations in the way of annoyances as 
the patients of the class mentioned who are about 
to go or are going into the climacterium. There is 
too much ovarian stimulation, or too little ovarian 
secretion, there is too much thyroid actually or rel- 
atively, or there is too little thyroid, or there is a 
play between these various alterations. 

W'e are concerned in the climacterium with a pro- 
gressive failure on the part of the ovaries to pro- 
duce their normal secretion. Coincidently, and be- 
cause of this failure, there occur alterations in 
other glands in the body, the thyroid being the one 
most particularly involved. During a woman's ex- 
istence her good health depends, to a very great de- 
gree, on a proper balance, so to speak, between the 
ovaries and the thyroid. Overactivity or under- 
activity of the one affects the activity of the other. 
and this balance is frequently upset at each men- 
struation, or after certain causes have been pro- 
ductive of certain changes, during lactation, in the 
post partum period, sometimes during pregnancy, 
etc. If the ovar\- and thyroid diminish as to the 
secretion which they produce in equal ratio, the pa- 
tient goes through her menopause calmly and with- 
out upset. If the ovaries diminish with too great 
rapidity and the thyroid too slowly, the patient is 
in a state of hvperthvroidism. The thyroid func- 
tion diminishes too quicklv, the patient may be in a 
state of hypothyroidi-m. 

134 \\'f-:ST ElGIIT'l-SEVENTII StREET. 



THE FACULTY OF PARIS IN THE SE\E\- 

TEENTH CENTURY.^-^ 

Bv Fr.\nk B.xker. M. D., 

Washington, D. C, 

Professor of .Anatomy, Georgetown University. 

The seventeenth century was a period of transi- 
tion, the ideas and forces of the middle ages having 
not altogether passed away and those of modern 
times being as yet undeveloped and crude. The 



he .Ntedical Hi 



Chill of Washingto 



feudal system, although broken by the decline in the 
jiower of the nobles, still ruled the world in >pirit, 
and the free<k)ni of the individual was as yet an un- 
realized dream. The Chinch, which by its solidarity 
and force had kept Europe from lapsing into bar- 
barism, had !)y its unquestioned rule become a tyr- 
anny and largely controlled intellectual life. Every- 
where there was an exaggerated re.->|)ect for author- 
it\ which often stifled progress. In medicine the 
writings of the great ancients. .Aristotle, Hippo- 
crates, and (ialen, were still regarded as supreme 
authority, and exhaustive of the subjects which they 
treatetl. 

The Faculty of i'aris was the name given to the 
entire body of physicians authorized to jjractise 
medicine in that city ; what we should now call a 
medical association. The rules and regulatitms by 
which they were governed were, however, much 
more strict and precise than anything now in vogue. 
The organization claimed to go back to Charle- 
magne, and it is known that it was an indei)endent 
corporation in 1280. It was formerly called the 
/'hysiconiiii- Juu-iiltas, or I'aculty of Physics ; hence 
our own word physician. It fuifllled the function 
of an academy of medicine and of a board of 
health, and was the final authority in medicolegal 
matters. The organization had a strong ecclesias- 
tical flavor. Medicine, during the middle ages, was 
i!>ually practised by monks and subject to the dis- 
cipline of the Church. We shall therefore find in 
the customs and ritual of the Faculty nnich that 
reminds us of conventual usage. 

The number of physicians in this body was not 
very large. During the seventeenth century it va- 
ried from 100 to no, about four being added each 
year from the graduates. There was Uius one reg- 
ular physician to about 5.000 inhabitants. The 
ratio to-day is one to 960. It was a close corpora- 
tion difficult of access, whose members commanded 
respect, having a dignit}' only second to the 
iiohlcssc and often counting members of that body 
among its numbers. The cost of a medical educa- 
tion was so great that it was beyond the reach of 
anv below the state of the wealthy bourgeoisie. .\ 
candidate had to have a preliminary degree of mas- 
ter of arts or of philosophy, as he must be able to 
discourse fluently in Latin, which was still used 
to distinguish the learned from the vulgar herd. 
He must be a Roman Catholic, not even the re- 
quest of the king being allowed to prevail against 
this. 

The teaching was wboll\- theoretical, the stu- 
dents listening to lectures which began at seven 
o'clock in the morning and continued till noon, 
commencing again at one. The lecturer often 
added to the reading explanations and remarks. 
Questions on the lectures were asked once a week. 
There were but few professors and they were fre- 
quently changed, every member of the Faculty be- 
ing supposed to be competent to teach an\ sul)ject. 
Dignity was upheld by appropriate dress, as tlie 
statutes povided that each professor should pledge 
himself to teach in a long gown with wifle sleeves, 
a doctoral cap on his head, and a knot of scarlet 
ribbon on his shoulder, .\fter two years of attend- 
.mce the student was subjected to an examination, 
which lasted a week, and if he passed he became a 
i>achelor of medicine. He tf)ok a solemn oath: To 



BAKER: FACULTY OF I'ARIS. 



[New Vor 
Mkdical Jour 



observe lailhfiilly tlic practices and ciistoiiis of the 
Faculty and never in any case to act against it ; to 
treat witli honor and respect the dean and all the 
masters ; to as->ist the Faculty against any opponents, 
especially illicit practitioners. 

All this was only preliminary. He had to be ex- 
amined in botany during the next summer, and 
the following year had to dispute against members 
of the J''aculty--not his teachers — on some selected 
subject, sometimes such as appear to our modern 
minds trivial and absurd, such as : Is it well to get 
drunk once a month? .\re women imperfect 
works of nature? Are bastard children brighter 
than those which are legitimate" .Should the 
phases of the moon be considered when we have 
the hair cut? These disputations were of almost 
incredible length, lasting from six a. m. until 
noon. Commenced by nine doctors, who attacked 
successively, they were continued toward noon by 
all present. During Lent still more vigorous ex- 
aminations were held, the bachelor attending from 
live a. m. to twelve, and disputing with all present. 
each one of the doctors in attendance having the 
right to propose two questions. For seven hours 
he had to pit his wits against the assembled 1^'ac- 
ultv, men trained and e.xercised in subtle dialec- 
tics. The candidate was also re(|uired to furnish 
food and wine for his adversaries. 

After two years' trial of this kind the candidate 
could become a licentiate and be granted the right 
to practise. You will observe that he had had nu 
clinical experience ; indeed, many never saw a 
patient during the whole course of their study. 
The course was wholly in words, words, words. 
As Montaigne acutely says, they knew their Galen 
but not their patients. The license to pra"ctise was 
administered in the most solemn manner by the 
chancellor, a canon of the Church, in the presence 
of representatives of the Court and the municipal- 
ity. The candidate having knelt before him. the 
chancellor announced in sonorous Latin: "By 
authoritv oi the apostolic see which I wield in thi^ 
region I confer upon you the right to read, inter- 
pret, and administer the medical art here and 
throughout the world. In the name of the Father, 
tlie Son. and the Holy Ghost." The chancellor 
then proposed some questions to the candidate 
highest on the list. These also were sometimes 
quite puerile, such as: Does drunkenness have any 
curative effect on a quartan fever? Whence came 
the water that flowed from the side of Christ after 
death when he was pierced by a spear? This cere- 
mony over, the entire assembly proceeded to the 
cathedral, where the chancellor made a short 
prayer in which he admonished the new licentiates 
that thev now belonged in a special manner to the 
Church, for which they must sacrifice all things, 
even their lives. Needless to say, the whole cerc- 
monv was in Latin. 

The licentiate was not yet a doctor, not ent tied 
to full privileges as a member of the Faculty. After 
six weeks or more, and on application being made, 
the dean having inquired minutely into the life and 
manners of the applicant, the Faculty voted on his 
admission. If this was favorable, a session was 
held at which the applicant was solemnly admon- 
ished on the importance and dignity o the medical 



profession, and still more questions were proposed. 
-Some days after, he was expected to visit each one 
of the governing body and invite him to attend the 
ceremony of his reception. When the day for this 
arrived the applicant was required to swear to ob- 
serve the rights, statutes, laws, and customs of the 
I'aculty, to contend with all his might against any- 
one who practised medicine illicitly. "Vis ista 
jurare?"' Do you swear this? solemnly asked the 
grand apparitor. "Juro" replied the licentiate — a 
phrase to become afterward famous as we shall 
see. Receiving then the doctoral cap and the ac- 
colade borrowed from the ceremony of knighthood, 
he became a full fledged doctor.' 

The result of all this exaggerated respect for 
learning, for books, and for authority was neces- 
■■arily the formation of an ultrapedantic and con- 
servative body, jealous of innovations, a foe to 
progress, and wedded to tradition. Their peculiar- 
ities of dress and bearing were the target for many 
popular lampoons. This is one of the most fa- 
mous : 

Assume a most pedantic frown, 

Some Greek or Latin spout; 
Have on a wig and grotesque gown 

Of satin furred about; 
P'or such things almost make, we own, 

.\ doctor out and out.' 

The results of the narrow and bigoted attitude 
of the Faculty were very striking. Scientific medi- 
cine in France fell to a low ebb. While remark- 
able discoveries were being made in Holland, 
Germany, England, and Italy, France remained un- 
productive. Except some slight matters in anat- 
omy by Riolan, nothing was brought forth. Har- 
vey's demonstration of the circulation, Aselli's dis- 
covery of the lacteals, and Pecquet's discovery of 
the thoracic duct were forbidden to be taught. 

Another reactionary restriction which did great 
harm to the I'^aculty was its attitude with regard to 
surgery. Strange as this may seem to our modern 
minds, instruction in this important branch was not 
included in the curriculum, and the most bitter op- 
position was made to any who ventured to consider 
surgeons as of equal rank with the regular physi- 
cians. There were several reasons for this antag- 
oiiism. It probably arose in the tirst instance 
from the monkish traditions that affected the Fac- 
ulty, the Church always forbidding the shedding of 
blood : also from the fact that surgery was consid- 
ered a handicraft and therefore unworthv the at- 
tention of those engrossed in the interpretation of 
Hippocrates. Galen, and Avicenna. The surgeons 
did not tamely submit to be thrust out of the 
learned professions. It was Pigray. one of them, 
who used the oft quoted simile concerning a com- 
parison of the ancients and moderns : "We may 
say that we are a child standing on the shoulders 
of a giant, we can see all the giant sees and some- 
thing more." They established for themselves a 
separate school, the college of St. Cosmo, and 
claimed the privilege of teaching anatomw The 
prime difficulty was the obtaining of material, 
which was only granted to the Faculty. On the 

*A more complete account of this ceremony, and of the entire 
organization of the Faculty, is found in Maurice Raynaud, Ler 
mcdecins au ten]p$ de Molidre. Paris, 1862. 

^Translation of Chatfiekl-Taylor. 



July 19. 19"3] 



BAKER: FACULTY OF PARIS. 



rare occasions when the bodies of criminals toiilii 
be procured for dissection the surgeons would 
sometimes surround the scalTold and carry off the 
warm cadaver in spite of the authorities. As it 
was absolutely necessary for the members of the 
Faculty to have some surgical assistance, they rele- 
gated this department to a class of uneducated 
men, the barber surgeons, who practised blood 
letting as a trade, and the profession which Am- 
broise Pare had adorned was nearly destroyed. 
Persecuted incessantly and pursued by royal de- 
crees, they finally sank into temporary insignifi- 
cance, to revive again in the next century. 

Trained and inured to disputation as were the 
members of the Faculty, it is not surprising that 
they had violent disagreements among themselves, 
usually upon some point of diagnosis and treat- 
ment. There was always great jealousy of outside 
influence, whether this came from the rival Factdt\ 
of Alontpellier, from the surgeons, or from some 
bold innovator like Paracelsus or Van Iklmont. 
\'Lt there were not wanting in the Faculty itself 
those who were open to novel ideas, and the con- 
troversies were often bitter, as we see from the 
letters of Guy Patin. the dean and censor of the 
Faculty, a man of the keenest wit and a most un- 
compromising adherent to the ancient doctrines as 
interpreted by the commentators. 

Bleeding, cautiously recommended by Hippocra- 
tes, was carried to a most shocking extreme. Bou- 
vard, physician in chief to Louis XIII, bled that 
monarch forty-seven times in one year, Guy Patin 
bled a child seven years old thirteen times in one 
month, he also bled an infant of eleven months and 
another of three days who was attacked with ery- 
sipelas. He had the courage to perfom the opera- 
tion on himself seven times for a cold. He ex- 
presses himself verv' bitterly about a poor physician 
who did not believe in bleeding and declared he 
would rather die than be bled, which he promptly 
did. "May the devil bleed him in the other world ; 
the scamp, the atheist !" He defends this strange 
treatment by saying that all Parisians live too well, 
and consequently have a plethora which needs to 
be reduced. There was also the dreaded caco- 
chymia, or corruption of the humors, which had to 
be relieved. Botal compared the blood in the hu- 
man body to the water in a good spring, the more 
that we draw off the more it is replenished. 

Another famous controversy that raged at this 
time related to aiitiinonv. The somewhat apoc- 
ryphal story about this substance is that it was dis- 
covered early in the sixteenth century by Basil Val- 
entine, a monk of Erfurt, who tested its virtues bv 
feeding it to pigs, which then became very fat. He 
then tried it on his fellow monks, who immediately 
became sick. He therefore named it antimony — 
deleterious to monks. Its virtues were highl\ 
vaunted by Paracelsus, and its prom.pt and vigorous 
emetic action recommended it to those who wished 
to reduce the "peccant humors." As it was rec- 
ommended by the Faculty of Montpellier, the Fac- 
ulty of Paris declared it a poison and forbade its 
use. There was, at that time, but little known of 
the proper doses of powerful medicines, and. be- 
sides, the antimony then obtained was not free from 
arsenic, which explains the fattening of Basil \'al- 



entine's pigs. Consequently, fatal results quite fre- 
quently followed the use of the drug. The contro- 
versy concerning its use grew very hot, and a cloud 
of pamphlets and verses was issued for and against. 
Guy Patin declared that antimony had killed more 
men than perished in the Thirty Years' War and 
published in his "Martyrology of Antimony" every 
case that he could collect of its deleterious eflfects. 
During the campaign in Holland Louis XIV. then 
twenty vears old, fell dangerously sick of a fever, 
and was taken to Calais, where doctors from Paris 
were hastily summoned. As no amelioration oc- 
curred, a consultation was held, even bringing in a 
country doctor from Abbeville, who, disregarding 
ceremony, seated himself on the bed and, after ex- 
amining the young king, said, "Well, he is a pretty 
sick boy, but he won't die." Strange to say. Car- 
dinal ^iazarin presided at the consultation and rec- 
ommended the administration of antimonial wine, 
which was done by Dr. Guenaud, and the patient 
recovered. Great triumph for the antimonists. 
Guy Patin declared, what was probably true, that 
it was the robust constitution of the young king that 
saved him. 

There were still other controversies that vexed 
the medical world and which had much less cause 
than that about antimony. In 1638 the Countess of 
Cinchon, wife of the Spanish viceroy of Peru, in- 
troduced into Europe the powdered bark of the 
cinchona tree as a remedy for intennittent fever. 
Its use was approved by the Pope, and it became 
known as Jesuit's bark. Talbot used it to cure the 
King in 1679. Ipecac was another drug introduced 
during this reign as a remedy for dysentery. The 
use of both of these important new medicaments 
was bitterly opposed by the Faculty. 

It remains now to be seen how the growth of 
public opinion gradually ameliorated the tyranny 
and dogmatism of this august body. It was not 
from the medical profession that the greatest aid 
came, but from the despised and little considered 
realm of the theatre. Jean Baptiste Poquelin, the 
obscure son of a Parisian upholsterer, educated for 
the law, gave it up in 1643 and joined a strolling 
theatrical company then going to the provinces of 
France, thus abandoning the steady life of a bour- 
geois for a career of vagabondage. Young Poque- 
lin assumed the name of Moliere, and eventually be- 
came the most famous dramatic satirist that the 
world has ever seen. But little is known of his 
early life. He was probably for a time under the 
influence of the philosopher Gassendi, a pronounced 
antiAristotelian and astronomer, a correspondent 
of Galileo, Kepler, and Hobbes, who possibly as- 
sisted him to acquire that free and open quality of 
mind which enabled him to see things as they are 
and "shoot folly as it flies." It is beyond our limits 
to deal fully with the life of this great genius ; we 
are particularly concerned with his career in Paris 
at the court of Louis XIV and the result of his 
satires upon the celebrated Faculty. The stage at 
that time had a much more influential position than 
it has to-day. It was the principal means bv which 
the genera! public could be reached, and took the 
place of our daily newspapers w^ith their cartoons 
and amusing skits. Besides, a popular piece like a 
play of Moliere was presented night after night. 



ii8 



BAKER: FACULTY OF PARIS. 



iicAL Journal 



You can readily see the force of well directed sh:ifts 
of ridicule, emphasized by all the accessories of the 
theatre, and repeated in this manner. Probably no 
author has ever equaled Moliere in the delicacy ot 
his satire. It resembles the celebrated sharp sword 
of Baron Miinchhausen, which cut off a head so 
neatly that the victim never knew it until he came 
to blow his nose, bv which act the head was thr- nvn 
across the room. ' To be sure, he sometimes de- 
scends to farce, even a little broader than a culti- 
vated taste approves, but he had been a ''barn 
stormer" and knew his audience. He first appeared 
before the King in 1660. in the inimitable comedy 
of Les Prccicuscs ridicules, an untranslatable title 
which mav be roughly rendered The Utterly Ut- 
ters, in which he satirized the foolish whimsies of 
a certain set that had become the vogue at court. 
The courtiers were immediately up in arms and 
tried to shut up his theatre and prevent him from 
plaving, but the King had been vastly amused and 
took Moliere under his protection. 

A few words should be said about the "grand 
monarque," the "sun king" who shaped the des- 
tinies of France for nearly seventy years. He was 
not really a very great man nor a very wise one. 
He had a great capacity for work and was a fair 
judge of men, using them as tools to advance his 
own interests. It was probably some indescribable 
psychic quality of presence and his care never to be 
caught at a disadvantage that gave him his enor- 
mous prestige. He was icily callous, regardless of 
the feelings of others, greedily selfish, and fond ot 
adulation. It was through his powerful influence 
that I\Ioliere was able to maintain himself and to 
freelv satirize the follies of the time. 

I cannot dwell upon the famous plays m which 
he held up to the world Tartufife, the hypocrite; 
Harpagon, the miser ; M. Jourdain, the sham gen- 
tleman ; Alceste, the misanthrope ; my concern is 
with those in which he attacked medicine and the 
medical profession. In these he undoubtedly had 
the sympathy of the King, who had suffered many 
thing's from manv doctors. In Don Juan, a comedy 
first oroduced in ifi6s, and which served afterward 
as the foundation for 'Mozart's opera, Don Giovanni, 
we find Don Juan's attendant Sganarelle (the Le- 
porello of Don Giovanni) disguised as a doctor. 
He savs: 



Do vou know, this dress has obtained for me some 
consideration: People salute me when they meet me and 
come to consult me. Five or six country fellows and 
their women came to ask my advice on different diseases. 
It would be a droll thing if they should be cured and come 
and thank me for it. 

Don Juan. Why not? Should you not have the sat^e 
privileges as other doctors? They have no more to do 
with curing patients than you have: Their art is mere 
pretence. You will find that everything which may pro- 
ceed from r. lucky chance and the powers of Nature will 
be attributed to vour remedies. , ,. . , 

Sganarelle. What! Don't you believe in medicine? 
Don Juan. It is one of the 'greatest errors of mankind. 
Sganarelle. You do not believe in senna, cassia, or 
emetic wine ? 

Don Juan. Whv should I? ... 

Sganarelle. You have a very unbelieving disposition. 
Yet you know that emetic wine has lately made a great 
noise' in the world. Its miracles have converted the most 
incredulous minds, but three weeks ago I saw it produce 
a marvelous effect. There was a man who had been at 
point of death for six days; they did not know what to 



do for him as none of their remedies were any good, at 
last they took it into their heads to give him an emetic. 
Don Juan. He recovered then? 
Sganarelle. No, he died. 

Don Juan. What a wonderful effect! ,. ■ „ 

Sganarelle. Surely. For six days he had been trying 
to die and this killed him at once. Could anything be 
more efficacious? 

In Loz'e as a Doctor Moliere makes a more direct 
attack. Lucinde, in order to avoid a marriage into 
which her father is forcing her, feigns illness and 
her alarmed parent calls in four doctors. 

The bright and saucy servant remonstrates with 
the father : 

"What do you want of four doctors, Sir, is not one 
enough to kill anybody?" „ 

"Hold your tongue, four heads are better than one. 
"Can't your daughter die without the help of these gen- 
tlemen?" 

"Do people die by employing doctors? , , , . 

"Indeed thev do; I knew a man who contended that 
you never ought to say that such and such a person died 
of a fever or an inflammation of the lungs, but she died 
of four doctors and two druggists. Not long since our cat 
fell off the top of the house into the street; for three 
days he could not eat nor move; luckily there are no cat 
doctors to physic and bleed him. or it would have been 
all over with him." 
"Hush! the doctors are coming." , 

"Now. you will be highly edified, they _are going to tell 
you in Latin that your daughter is sick." 

The doctors then proceed to consult, but instead 
of discussing the patient, converse about trivial mat- 
ters. A difference of opinion has arisen between 
two practitioners and the rules of the Faculty had 
been violated, the junior consultant daring to dif- 
fer from his senior. Tlie senior killed the patient, 
but the worthy quartette hold him to have been en- 
tirelv right aiid the junior \Arong, although his ad- 
vice'was better. "A dead man is only a dead man 
and of but little consequence, but the whole pro- 
fession suffers injury if a formality is neglected. ' 
It should be remembered that at the time this play 
was produced a very scandalous scene had recently 
occurred at the death bed of Cardinal Mazarin, 
where four doctors had disagreed totally as to the 
manner of treatment, and had denounced each other 
in no measured terms. The doctors in this play 
were carefully made up to imitate the personal ap- 
pearance of those physicians, and the dialogue that 
ensues when thev come to prescribe for the patient 
is evidently based on the rumor of that famous con- 
sultation. ' The first doctor finds "great heat of ^ the 
blood" and proposes to bleed, the second finds "pu- 
trefaction of the humors" and proposes an emetic. 
High words ensue. "An emetic will kill her." "If 
you bleed her she will die." "Do you remember 
the man vou killed a few days ago?" "And you the 
woman vou recently finished oft'?" etc.. etc. They 
leave, and the remaining couple prescribe purga- 
tives and anodynes. "Your daughter may die, but 
vou will at least have the consolation of knowing 
that sh