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TRANSACTIONS
OF THE
glemcAL SOCIETY
OF
**w'm"’ ' _\
‘ ‘ V
CITY HOSPITAL ALUMNI
FOR THE YEAR
1898.
SAINT LOUIS.
With Constitution, By-Laws and List of Members.
MEDICAL REVIEW PRESS, ST- LOUXS, MO.
TRANSACTIONS
of the
MEDICAL SOCIETY
CITY HOSPITAL ALUMNI
FOR THE YEAR
1898.
SAINT LOUIS.

With Constitution, By=Laws
and
List of Members.

MFDICAL .REVIEW PRESS,
ST. LOUIS, M0.
THE SOCIETY WAS ORGANIZED
UNDER THE NAME OF
THE CITY HOSPITAL MEDICAL SOCIETY.
THE PRESENT NAME WAS ASSUMED
FEBRUARY 24, 1898.
as M3~ dm 11" 5w.
ORGANIZATION FOR 1898.
OFFICERS :
I GEORGE HOMAN. M.D., President.
FRANK R. FRY, M.D., Vice-President.
HORACE W. SOPER, M.D., Secretary.
WM. C. MARDORF, M.D., Treasurer.
STANDING COMMITTEES.
EXECUTIVE:
H. WHEELER BOND, M.D ,
AMAND RAVOLD, M D., ]OHN McH. DEAN, M.D.
SCIENTIFIC COMMUNICATIONS:
NORVELLE WALLACE SHARPE, M.D.,
OTTO SUTTER, M.D.. GREENFIELD SLUDER. M.D.
PUBLICATION:
LUDWIO BREA'IER, M.D.,
CHARLES ]. ORR, M.D., ‘M. GEORGE GORIN, M.D.
ENTERTAI N MENT:
ERNST MUELLER, M .D.,
LOUIS H. BEHRENs, M.D., ALBERT E. TAUSSIG, M.D.
ERRATUM.
Notice Of the Stated Meeting Held May 5, should .
immediately precede the “Case Of Meningitis,” -
reported on page 118.
CONTENTS.
Address of the President: . . . . . . . . . . . . . . . . . . . . . . . .
Recent Observations on Intubation of the Larynx. . .
By Wm. Shirmer Barker. M.D.
Some Practical Points in Regard to Herniotomy. . . .
By A. H. Meisenbach, M.D.
The Value of Modiﬁed Milk in the Feeding of Infants.
By Horace W. Soper, M.D.
Some Points in Practical Surgery . . . . . . . . . . . . . . . .
By Francis Reder, M.D.
Specimens Of Renal Calculi and a Horse Shoe Kidney.
By Robert Amyx, M.D
The Use of the Refractometer for the Identiﬁcation of
Oleomargarine —]ZZustraz‘ed. . . . . . . . . . . . . . . . . .
By Howard Carter, M.D.
The Treatment of Septic Endometrial Diseases . . . . . .
By Frank A. Glasgow, M D.
Notes on Two Cases of CerebrO-Spinal Fever . . . . . . .
By Charles L. F ahnestock, M.D.
A Case of Sudden Death Following an Immunizing
Dose of Antitoxin . . . . . . . . . . . . . . . . . . . . . . . . . .
By Wm Nifong, M.D.
Report Of Spontaneous Recovery in a Case of Axillary
Aneurysm in an Infant—With Presentation of
Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
By Wm. C. Mardort, M.D.
Some Modern Ideas About Blackheads, Pimples,
Dandruff and Baldness . . . . . . . . . . . . . . . . . . . . . .
By joseph Grindon, M.D
12
30
47
56
58
64
77
86
98
102
vr MEDICAL SOCIETY OF
The Relative Value of Digitalis and Strychnia in
Pneumonia, as Observed in a Few Cases, With
Remarks on the Beneﬁcial Effects of Quinine in
this Disease _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 14
By Carl A. W. Zimmermann, M D.
A Case of Meningitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . I 18
By M. A. Bliss, M D.
An Apparatus for the Application of Dry Hot Air to
Different Portions of the Human BOdv'-[llur-
z‘ratezi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . T r 22
By Vilray P. Blair, .\I.D.
The Sanitary Redemption of Havana -The Need and
the Means— Wit/z map . . . . . . . . . . . . . . . . . . . .. 134
By George Homan, M.D.
Partial Report of Eight Hundred Cases Of Labor— -
Wit/z tall/e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 146
By H. S. Crossen, M.D.
A Report on the Histology of a Cystic Sarcoma of the
Kidney -—lllurtmz‘ea’ . . . . . . . . . . . . . . . . . . . . . . . . 172
By L. Bremer, M.D.
T wo Fibroids — One a Large Sessile Submucous Tu-
mor; the Other a Retro-Peritoneal . . . . . . . . . . . . 179
By Mary H. McLean, M.D.
Impetigo Contagiosa, Remarks on . . . . . . . . . . . . . . . . 188
By Joseph Grindon, M.D.
Cutaneous Hygiene in the Army, Remarks on . . . . . . 191
By I. B. Girard, M.D. '
Rabies in the Dog and Man, Remarks on . . . . . . . . . . 192
By Frank Hinchey, M D.
Report of a Case of Symp~hysiotOrny-With Presenta-
tion of Patient—ﬂ/ustmted . . I . . . . . . . . . . . . . . . . 196,
By H. S. Crossen, M.D
Two Cases of Pseudo-Hypertrophic Muscular Paral-
ysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 207
OITY HosPrTAL ALUMNI. VII
Double Athetosis of Central Type. .. . . . . . . . . . . . . . . . 208
Bilateral Facial Paralysis . . . . . . . . . . . . . . . . . .' . . . . .. 209
By Given Campbell, M.D.
Report of a Case Of Hydrophobia . . . . . . . . . . . . . . . . . 21 1
By Benno Bribach, M.D.
Perplexing Mishaps in Surgical Cases . . . . . . . . . . . . . . 218
By Garland Hurt, M.D.
Some Anomalous Urethral Cases . . . . . . . . . . . . . . . . . 2 30
By Bransford Lewis, M.D.
Ovarian Tumor Complicating Pregnancy in an Un-
married Young Woman, Remarks on . . . . . . . . . . 245
By Henry Jacobson, M.D.
A Case Of Inveterate Facial Neuralgia Treated 'with
Strychnia after the Dana Method, Remarks on. . 247
By Joseph Grindon, M.D. '
A Case of Thoracic Aneurysm, Remarks on . . . . . . . . 2 5r
By Elsworth S. Smith, M.D.
Passage of a Darning Needle Armed with Twine
Through the Intestinal Canal of a Young Dog. . 254
_ By George Homan, .VLD.
Some Cases of Fracture Of the Skull . . . . . . . . . . . . . . . 255
By H. C. Dalton, M.D
A Case of Laryngeal Cancer . . . . . . . . . . . . . . . . . . . . . 266
By Charles I. Orr, M.I).
Hereditary Human Cryptorchidism-—[/lusz‘rafed. . . . . 272
By George Homan, M.D.
Empyema of Frontal Sinus Secondary to Abscess of
Orbit (Discussion) . . . . . . . . . . . . . . . . . . . . . . . . . . 278
By Greenﬁeld Sluder, M.D.
The Treatment of Chronic Heart Disease by the Sys-
tem Of Medicated Baths known as the Schott
Method, With Report of Cases (Discussion). . . . 281
By Elsworth S. Smith, M.D.
vrn MEDIOAL SOOiETY OF
Aortic Regurgitation with Attendant Stenosis and Mi-
tral Regurgitant Murmur . . . . . . . . . . . . . . . . . . . .
By Louis H Behrens, M.D.
A Study of Acute Arthritis of Infants (Discussion). . .
By Phillip Hoffmann, M.D.
Some Interesting Cases in Rhinological and Otologi-
cal Practice (Discussion) . . . . . . . . . . . . . . . . . . . .
By M. A. Goldstein, M.D.
A Case Of Glycosuria with Anomalous Symptoms,
Remarks on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..
By Elsworth S. Smith, .VLI).
' The Care and Management Of the Pregnant Woman.
By B. M. Hypes, M.D.
Report of a Case Of Irritability of Urinary Bladder
Relieved by Rapid Dilatation of the Urethra .
By M. George Gorin, M.D.
Urinary Calculi - With Report of Two Cases and Pre-
sentation of Specimens . . . . . . . . . . . . . . . . . . . . . .
By H. Wheeler Bond, M.D.
292
295
298
302
308
. 323
327
MEDICAL SOCIETY
...Of...
CITY HOSPITAL ALUMNI
ST. LOUIS
1898.

STATED MEETING THURsDAY EVENING, JANUARY 6.
After some routine business had been disposed of the
President elect, Dr. George Homan, was presented to
the Society by the retiring President, .Dr. Joseph Grin-
don, and spoke as follows:
Address of the President.
GENTLEMEN:
I desire to express formal and grateful acknowledg-
ment Of the honor you have conferred by making me
President Of this Society, and I take advantage of the
opportunity to express the belief that such action was
an invitation to diligent eﬁort and studious endeavor on
my part to the end that the interests of this body not
only may suﬁer no impairment or diminution during the
coming year, but that yet greater achievements shall
mark its course, worthily showing forth to the world
the aims and Objects it was formed to advance and
attain.
2 MEDIOAL SOOIETY OF
Let not those aims and Objects be forgotten: The
scientiﬁc investigation and discussion of medical and

allied subjects, and the drawing of the members into

more intimate scientiﬁc and social relations.

These being the declared purposes of our organiza-
tion, what are its resources in personnel and matériel
to accomplish them?
In attempting an answer to this question, I trust-I
shall not be accused Of undue egotism when I say that,
prfessionally, it is a picked body Of men by virtue Of
the conditions of membership, and the source from
which its numerical strength is drawn.
The tests applied to determine ﬁtness for City Hospi-
tal appointment certify'the due professional qualiﬁca-
tions Of the successful candidates, while the opportuni-
ties aiforded in such a large ﬁeld for congenial scien-
tiﬁc and medical work confers on those who diligently
improve them a great advantage over their professional
fellows without such training, and distinguishes the
body of graduates or alumni of such an institution as
having the promise and potency Of the highest scien-
tiﬁc attainments in their later careers if the talents
entrusted to them be not buried or neglected.
For the rule is that much having been given much
will be required, and this just expectation can not be
defaulted without incurring a measure of demerit, if
not of positive discredit and reproach, greater than
would attach to a body whose members, as a class,
lacked the early professional advantages and opportuni-
ties enjoyed by us.
To him that hath shall be given; perseverance keeps
honor bright; therefore, in view Of the intellectual re-
sources and skilled attainments found in the member-
ship of this Society, its contributions to the world of
science should be rich and varied.
More than one member will bear me out when I say
that I have always held the view that this body, peculiar
in its makeup, should be unique in respect of the de-
CITY HOSPITAL ALUMNI. 3
mands it makes upon its members—that is, that yearly
intellectual dues from every member should stand ﬁrst
and be exacted above those that are of a merely pecu-
niary nature; for the evidences of real life and useful-
ness in such a body lie in the Offerings of the mind
rather than those of the purse.
No one can successfully dispute the assertion that
every one of our members is abundantly able to Offer
here every year something that would interest and in-
struct his fellows, and my position now is, as it always
has been, that annual delinquency in this respect should
be regarded as a much- more serious Oﬂfense than the
mere failure to meet the treasurer’s demands.
If such an outpouring of the fruits of intellectual
gifts could be had our every program would be crowded,
and a treat would be spread before us which would
beneﬁt all whopartook of it, and by its inﬂuence stim-
ulate to still better and better work as time went on.
Permit me to address a few words especially to those
who have joined us but recently—the young blood, the
new blood, in fact, the life blood of our body: To
these younger members I would say that not only do
they owe to the Society regular contributions from their
mental storehouses but, most of all, they owe to them-
selves the beneﬁts that will follow the intellectual exer-
cise and training of such efforts. Difﬁdence, or other
cause, may lead to silence or inactivity, but as every
one has felt at sometime the insufﬁciency Of his knowl~
edge on given subjects, this consciousness should not
bar efforts, for it is Often the beginning of wisdom and
may prompt to renewed diligence in study and zeal in
Observation.
To those who have recently crossed' the threshold of
the profession belongs the just conviction and proud
distinction that they can know more than any who have
gone before them. This is the law of progress, the
world would not move forward if each succeeding gen-
eration did not improve on the last one. And Of medi-
cine this is especially true, now that its foundations are
4 MEDIOAL SOCIETY OF ‘ ‘
being laid on the bedrock of science, and the age of
empiricism is passing away. '
To those who are as yet but little versed in the prac-
tice of addressing their fellows on medical topics I
would say that, with rare exceptions, short papers are
always esteemed above those that are lengthy; indeed, -
it takes a master in the profession to instruct and enter-
tain his hearers for an hour. ~ ‘
In choosing subjects more advantage can Often be
had from taking a single feature or symptom of a dis-
ease, and, after thoroughly mastering its causation,
rationale, signiﬁcance, etc., presenting the conclusions
in a ﬁve or ten minute paper, than from an attempt to
deal with _a disease in its entirety—the total aspect of
which would probably be familiar to all.
A fact, a truth, sends its rays from many sides and,
even if not handled with the most perfect art, still its
light will reach some minds and produce results in un-
expected ways and places. SO that no one here need
fear that his honest efforts will fail of appreciation, or
entertain a doubt of his ability to offer to his fellows
that which would be well worthy of their attention.
I would thank you again for the honor done me and
for your kind attention; and, in conclusion, pledge my-
self to faithful work for our common good during the
year; but such effort on my part must fail without the
cOrdial co operation of all the members. I, therefore,
ask your aid in making this year a notable one in our
annals, and promise to those who come after me in
office my best endeavors to make each succeeding year
more. prosperous than the one last past.
CITY HOSPITAL ALUMNI. 5
MEETING STATED THURSDAY EVENING, J ANUABY 20 .
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
Recent Observations on Intubation of the
Larynx.
BY WM. SHIRMER BARKER, M D , ST. LOUIS, MO.
The death of Dr. Joseph O’Dwyer on January 7,
closes a career which, if estimated simply by the num-
ber Of human lives he has been the means of saving, is
indeed an exalted one. His life-work has been the in-
troduction and perfection of an operation which has
within the last few years deservedly gained a very gen-
eral acceptance in this country, and in spite Of Old
World conservatism and failure to readily adopt the
most approved modiﬁcations and methods given us by
O’Dwyer himself, is gradually ﬁnding a place in Euro-
pean surgery also.
There appeared in the Archives of Pediatrics for July,
1897, a comprehensivepaper by O’Dwyer, which has
thrown much light on some rather Obscure conditions of
pathology Of the larynx following intubation—condi-
tions which give rise to a diﬂiculty in getting rid Of the
O’Dwyer tube, or conditions calling for repeated inter-
ference to counteract recurring stenosis. This difﬁculty,
though occasionally met with, is rarely insurmountable,
as I think will be shown.
From some experience in such cases' which has come
to me, and from a comparison therewith of a vastly
larger experience of the great originator of the measure,
I' offer the following summary of the causes of persist-
ent or recurring laryngeal stenosis after extubation, and.
the procedures to be undertaken accordingly:
6 MEDIOAL SOCIETY OF
CAUSES OE RETURNING LARYNGEAL STENOSIS AFTER
EXTUBATION.
1; Persistent Diphtheritic Pseudo-Membrane.
2. Edema of Laryngeal Mucous Membrane.
3. Destruction of Cricoid Cartilage, Allowing Col-
lapse of Thyroid Cartilage on Trachea.
4. Cicatricial Contractions Due to Ulcerations.
5. Granulation Exuberances.
6. Abductor Paralysis.
1. The ﬁrst cause, that Of diphtheritic pseudo'mem-
brane, is now almost certainly removed by the adminis-
tration of antitoxin, thereby checking the disease pro-
cess and doing away early with the Obstructive pseudo-
membrane, thus admitting this cause of continued ste-
nosis only in cases where an unusually early removal of
the tube is practiced.
2. Edema of the sub glottic region is due, in most
cases, to undue pressure at this point, i. e., about %-inch
below the vocal bands where, normally, the lumen is
much smaller than is supposed and really constitutes,
according to O’D wyer, a sort Of anatomical constriction.
Here, on the removal of an improperly impinging tube,
due to improper construction or to employment of a tube
of too large a size, the tissues, which could only macer-
ate and erode while the tube was in situ, now swell, and
a more or less rapid edema occurs, and proportionately
produces stenosis and asphyxia. For the prevention of
such an event, two things are important: The employ-
ment of (1) properly constructed tubes; (2) tubes which
are of not too large a size. O’Dwyer is convinced, he
says, that the regular, or old 3 to 4 year size tube is too
large for many patients of that age, and should be con-
sidered 4 to 5 year size; while the old scale 5 to 7 year
size had better be called the 6 to 7 year size.
The latest sets of tubes from Ermold now have an
additional tube, making seven instead of six, and a scale
arrangement in accordance with Dr. O’D wyer’s idea on
this point, i.e., smaller tubes are used than formerly in-
dicated for at least the ﬁrst 4 or 5 years.
CITY HOSPITAL ALUMNI. 7
The treatment of this condition of edomatous stenosis
after extubation, is to employ smaller rather than larger
tubes, if necessary having the head and swell of good
size, but the part extending for 4 inch or more below
the head, as slender as or more so than the next smaller
tube. This would allow some edema and a gradual sub-
sidence of the inﬂammatory process at the point of
threatened constriction and an establishment of an ap-
proximately normal circulation at that point, with the
tube in situ.
I have had two cases in the last month illustrating
this point: H. K., aged 11 months, exhibited laryngeal
stenosis, diphtheritic, January 1, and was intubated with
the 1-year size of metallic tube. At the time I wished
for a somewhat smaller tube, as there was more resist-
ance than I like to feel as the tube slid down below the
Vocal hands. This tube was removed and reinserted on
account of returning stenosis, due to edema, January 3,
7 and 8, until, on Jan. 14, the returning stenosis seemed
slight enough to dispense with reintubation, and the
child progressed well thereafter.
, W. C.,aged 3 years and 10 months, presented diphthe-
ritic laryngeal stenosis, January 11. I felt that the old
3 to 4 year size would be rather large for the case, and
on slipping the tube into place, had the feeling con-
ﬁrmed by some degree of resistance to the caliber of
the tube. But as it was an emergency case, and this
tube was the nearest size available, it was made use of.
I substituted a smaller tube at the ﬁrst opportunity (the
3 year size of the newer hard rubber set), but the su-
perﬂous pressure by the ﬁrst tube caused a recurrence of
stenosis within the hour following extubation, and it-
was necessary to extubate and reintubate January 14, 19
and 24, until on the 27th the diminished stenosis, on re-
moving the tube, warranted dispensing with it. The
boy has since gotten along well.
3. The next cause of continued stenosis—destruction
of much‘or all of the cricoid cartilage, due to ulceration
proceeding to an extreme degree—is the least remedia-
8 MEDICAL SOOIETY OF
ble of all obstacles, and is due, perhaps, oftenest to the
use of successively larger tubes in cases where there is
trouble about retaining the tube originally placed.
The most advisable, thing to do where there occurs
ejection of the tube which would ordinarily be suited to
a case, is not to try larger tubes, but to make use of a
specially modiﬁed tube adapted to such cases. This
tube should be smaller, if anything, than the ejected
tube, but with a good-sized head and a retaining swell
equal to that Of a tube two or three sizes larger. The
swell is placed as near as possible to the lower end of
the tube. These tubes, according to an arrangement
about to be made with some of our leading instrument
dealers, can soon be Obtained without delay in .our
city.
In case cricoid destruction has been accomplished,
tracheOtomy, or the permanent wearing of an O’Dwyer
tube would seem to be the only resort. Theiwearing of
such a tube would today be less onerous than hitherto,
I think, owing to recent improvements. The latest tube
is made of hard rubber with a strengthening inner lin
ing of metal. The weight of the new tube, whose shape
is practically the same as the Older tube, is about one-
third of the latter.
4. Cicatricial contraction, due to the same cause as
that producing cricoid destruction, but proceeding less
far—instrumental traumatism—should be treated by en-
deavoring to bring about a gradual healing with as little
contraction as possible, by. the use Of a tube of less
pressure, such as described above, so as to allow a grad-
ual resumption of the natural condition. The perform-
ance of tracheotomy early in these cases seems exceed-
ingly ill timed, for, with the intubation tube withdrawn
(tracheotomy having been done) the cicatricial Obstruc-
tion goes rapidly on to its maximum.
5. Granulation formations after extubation or after
the originally placed tube has been in for Some days,
may occur above or below the glottis. When occuring
above and about the head of the tube, a tube similar in
CITY HOSPITAL ALUMNI. 9
shape, but with a built-up head, can be used, the head
overtopping the granulations. In a case where granu-
lations occurred below the glottis, Dr. O’Dwyer em-
ployed an ingenious method of treatment. He made a
local application to the granulations by coating a tube
with gelatine and dusting alum thereon before it hard-
ened. Three applications made by introducing three
alum-gelatined tubes accomplished a satisfactorily rapid
cure.
6. Abductor paralysis is a matter about which there
is much uncertainty, and O’Dwyer thinks that most
cases where this is supposed to be the trouble have a
different cause, especially those occurring at all early in
the diease, and without accompanying post-diphtheritic
paralysis of the pharyngo-palatal muscles. When the
continued stenosis is really due to post-diphtheritic par-
alysis, the treatment, of course, would be similar to
that of other forms of post-diphtheritic paralysis.
When, on the removal of the tube, stenosis seems
likely to recur and be dependent on emotional disturb-
ance on the part of the patient, it is well to administer
an opiate just before extubating, and insist on a quiet
environment, thus doing much to eliminate this factor. ~
SO, then, this diﬁiulty Of being unable to dispense
with the wearing of the tube in cases which have been
intubated, is not very commonly met with, and it is very
probable that such cases could be made still more infre-
quent by avoiding the errors described above. * *
It would doubtless be pertinent to discuss the merits
of many of the modiﬁcations which have been made in
the O’Dwyer tube in the last three years. I can not
speak very favorably of most of the changes made in
the older tube. The quite recent introduction of tubes
of hard rubber with metallic lining is, I have found, an
advantage, and these tubes are to be recommended, the
more so as they are constructed on a somewhat smaller
scale, decidedly better adapted to the larynxes for which
they are designed. There is one modiﬁcation now and
then seen, which must be avoided. It is a funnel-
10 MEDICAL SOCIETY OF
shaped depression on the head of the tube leading into
the lumen. Its purpose is to facilitate the removal of
the tube. I have found this depression a disadvantage
in that it drew into the tube milk and other liquids on
feeding, and much of the adjacent mucus during the
intervals of feeding. The frequent coughing and strang-
ling was suoh an annoyance that I made an early re-
moval of the tube—about 45 hours after its introduc-
tion. It was necessary to reintubate. I then employed
the older, ﬂat-headed tube, and the child was compara-
tively free from the previous annoyance. I had an ex-
actly similar experience some months ago, and have now
abandoned the tube causing it. * * *
Should the general practitioner himself go to the
trouble of acquiring skill in the operation of intubation
or had he better trust to the assistance of one who de-
votes especial attention to this line of work? It seems
to me there is but one answer. Since, very often, the
call for the relief of laryngeal stenosis comes to the
physician in the form of an emergency, when delay, in-
cident to the summoning of some special operator,
might easily mean a fatality, I take it, that it becomes
'the duty of the general practitioner to familiarize
himself with the technique of intubation just as he
should, for instance, with urethral catheterization, nor
do I think the opportunities for doing damage a whit
greater in the former than in the latter. The real difﬁ-
culties of the operation of intubation, I have always
thought, were exaggerated in the minds of those con-
templating the undertaking. It might not be out of
place to indicate a few rules, which are of importance:
1. Use only the most approved shape and size of
tube.
2. Let the tactile sense of the hand making- the in-
troduction always be on the alert for indications as to
the direction and amount of force to be used—or, in other
words, let the ﬁngers, not the ﬁst, do the work. As in
catheterization, avoiding force, use all gentleness.
3. Be sure of the position of the epiglottis, and
CITY HOSPITAL ALUMNI. 11
pressing it anteriorly against the base of the tongue, do
not fail to recognize the superior opening of the larynx
just beyond and beneath the base of the epiglottis, but
quite adjacent to it.
4. Keep the introducer (or extractor as it may be)
well in the median line, for the tube is not constructed
to enter at any other angle. '
5. Do not feel it incumbent upon the operator to in-
troduce the tube gracefully at the ﬁrst pass, but rather
be prepared to make a number of gentle and harmless
passesﬁnally successful.
6. In very young patients there is repeated failure
to introduce the tube, unless it is remembered that the
faucial spaces being quite diminutive and the ordinary
introductor being really rather too large, it is necessary
early in the operation to bring the tube close under the
epiglottis by raising the handle of the introductor before
the tube has passed beyond and posteriorly to the tips
of the arytenoid cartilages. For extubating with fa-
cility in infants as well as in older children, two sizes
of extractors are really needed. '
7. Do not resort to tracheotomy too hastily when, at
ﬁrst appearance, intubation seems not fully to meet the
requirements of the case. It is likely that a specially
modiﬁed tube will answer, unless the obstruction is
lower down in the trachea, when a low tracheotomy is
the proper thing. '
12 MEDICAL SocIETY 0F
STATED MEETING THURSDAY EVENING, FEBRUARY 3.
THE PREsIDENT, DR. GEo. HOMAN, IN THE CHAIR.
Some Practical Points in Regard to
Herniotomy.
BY A H. MEISENBAGH, MD., M. LOUIS,
Professor of Surgery in the Marion Sims College of Medicine.
The object of this paper is to call attention to some
practical points in herniotomy.
The cases of hernia that come to the surgeon for oper-
ation may be divided into two classes :
1. The non-strangulated.
2. The strangulated.
The non-strangulated hernias are either inguinal or
femoral in character, and come to the surgeon for oper-
ation, in order to establish a radical cure. Notwith-
standing the fact that the operation for the radical cure
of hernia (non-strangulated, of course) is one of the saf-
est operations in modern surgery, and the results, sur-
prisingly brilliant, we ﬁnd a strong opposition on the
part of the laity, or on the part- of the physicians, even
to operative interferences, and countless numbers of in-
dividuals go about daily with poorly adjusted trusses,
or none at all, whose hernia at any moment may be-
come a menace to life. What operation can give more
brilliant statistics than Bassini’s? In October, 1894,
Bassini had operated 715 times; no deaths, and only
nine relapses. Bassini’s ﬁrst operations were done in
1884, so that sufﬁcient time has elapsed to establish
their value. These operations apply in the main to the
inguinal variety. Within the last few years, however
the radicul cure of femoral hernia has received consid-
CITY HOSPITAL ALUMNI. ' 13
erable attention and has also been crowned with suc-
cess. '
The forms of radical operations in the inguinal vari-
ety that are looked upon withmuch favor, are Bas-
sini’s, Halsted’s or Ferguson’s modiﬁcation. In the
performance of the operation for radical cure, I would
call attention to several points that are of importance:
1. The incision.
2. Material for suturing.
3. The form of suture.
4. Drainage.
1. THE INOIsINON.—In regard to the incision, I be-
lieve it is a wise plan to adopt the suggestion of Fergu-
son, both as to the inguinal and femoral variety, viz.,
to make the incision so that it will be above Poupart’s
ligament. The incision is made parallel to Poupart’s
ligament and half an inch above it. The advantages of
this incision are: 1st. That the scar is above the fold
of the groin and hence not so liable to irritation, espec-
ially in ﬂeshy persons. 2d. If the operation is for the
femoral variety, this incision allows thorough inspec-
tion of the inguinal canal and rings, which is important.
2. MATERIAL FOR SUTURING.——Ill doing the radical
operation, the various layers of tissue are sutured to
Poupart’s ligament, (in both varieties, inguinal and
femoral) so that necessarily we have several tiers of
satures that are buried, all except the skin sutures.
Many operatOrs use silk, but in my opinion, catgut or
kangaroo tendon are preferable, because they are ab-
sorbable. Silk does at times give rise to irritation and
suppuration when buried, and it is very unpleasant in
an operation of this kind to have ﬁstulas kept open
for months on account of the presence of ligatures that
have not become encapsulated, but have caused suppura-
tion, and eventually must be removed as they loosen.
It is true that catgut or kangaroo tendon possibly
may not be sterile and infection take place, but if it
does, we do not have a non-absorbabl‘e material left in
the wound. Where suppuration does not take place,
14 MEDICAL SOCIETY OF
where an animal suture has been used, we need not pay
any attention to it whatever, but know that it will be
absorbed ultimately.
8. THE FORM or SUTURE.—In using the buried su-
ture, I much prefer the continuous form, especially be-
cause it can be more readily applied. Using a smooth,
large, full curved needle, not cutting at sides, I can
place a suture very rapidly. The only precaution nec-
essary is to have the catgut or kangaroo tendon of sufﬁ-
cient tensile strength and to fasten the suture securely
at the end of every tier or layer. The continuous su-
ture can also be used advantageously for suturing the
skin.
4. DRAINAGE.--Where a perfect operation has been
done by means of buried animal sutures, it is not neces-
sary to drain, not any more so than in a median lapa-
rotomy where the abdominal wound is closed without
drainage.
STRANGULATED HERNIAs.
These cases are the ones that give the surgeon the
most concern. The outcome in these cases is necessa-
rily doubtful, and this is due to the length of time the
hernia has been strangulated, the effect on the bowels
and the character of the operation. It is in these cases
that the inborn aversion of the laity to the early use of
the knife must be combatted. This aversion is at times
sustained by the procrastination and lack of apprecia-
tion on the part of the attending physician. Many
cases that would recover brilliantly if operated upon
early, are either irretrievably lost when they come to
operation, or are in a very precarious condition. I
would lay down the following axiom: Every ease of
strangulated hernia should be operated on at once, when,
by the gentlest taan's by a competent person, the hernia
can not be reduced. If there is anything that should
be condemned it is prolonged and ruthless
taxis. Were the axiom generally followed, the mortal-
ity rate in herniotomy for strangulated hernia would be
much lessened.
CITY HOSPITAL ALUMNI. 15
1. CAsEs WHERE THE BowiL SHows No MARKED
INJURY.-These cases are ones where the constriction
has not been very marked if of long duration, (say 24
hours or over), or where the condition has been early
recognized by patient or friends, and a progressive phy-
sician or surgeon called in and immediate operation ad-
vised. In these cases, the bowel can be returned with-
out much difﬁculty, and the amount of cutting necessary
of the constricting ring is not very great. They can be
treated exactly as a non-stangulated hernia, after the
bowel has been reduced. All the steps of a radical cure
operation should be carried out. In these cases recov-
ery is the rule.
2. Guam WHERE THE BOWEL SHOWED INJURY; NOT
DANGEROUS, BUT DOUBTFUL.—-IH these cases, usually
the bowel has been out for some time, taxis and many
other plans of relief have been tried without avail, and
ﬁnally the conclusion is arrived at that operative inter-
ference is necessary. It is in these cases that many
technical difﬁculties arise during the operation; adhe-
sions to the sac of the bowel and omentum; very tight
constriction at the internal ring and also profuse eﬁu-
sion of serum. It is well to completely isolate the sac
from surrounding tissues before opening it, as it can be
more easily accomplished than after it is opened.
When the sac is opened, we very frequently ﬁnd, on
cutting the constriction at the internal ring, that the
band is very ﬁrm and after cutting freely that the bowel
is not reduced. Now, here is a point that comes under
discussion, and it is one of the most important ones in
this paper, viz., as usually taught, the knuckle of pro-
truding bowel is to be reduced through a comparatively
small opening; we are told to draw out the bowel be-
yond the constriction so as to guard against internal
strangulation. I would put the queries, Is this a ra-
tional procedure? Can we guard against the liability
of internal strangulation? If we succeed in reducing
the bowel, how do we know that it is free on the inside
of the abdomen; that it is not knuckled or constricted?
16 MEDICAL SOCIETY or
My answer to these queries is, that the whole proced-
ure is not based on a rational surgical principle; that it
is groping in the dark. Let us examine for a moment,
what happens when we divide the internal ring. We
divide the peritoneum at the internal constriction more
or less. Practically we know that the peritoneum is
very readily peeled off from the abdominal parieties in
the living subject. The manipulation of reducing the
bowel is very liable to detach the peritoneum from its
parietal attachment at the site of the division, so that it
is not at all difﬁcult to form a pocket between the ab-
dominal wall and the peritoneum, into which the
bowel may be pushed. Externally the bowel may be
reduced, but Internally it is incarcerated in this pocket.
Now, it may be argued that this can be determined by
touch from the external wound. I do not believe this
to be always true, hence there is the probability of er-
ror in regard to the true state of affairs. I would pro-
pose, therefore, as a rational procedure in these cases
where reduction is difficult, to open the abdomen in the
median line in addition to our incision at the hernial
site, the median incision to be large enough to admit
several ﬁngers or the whole hand. We now have the
means of bi manual manipulation, one hand intra-ab-
dominal, the other exta-abdominal at the site of the op-
eration. With the hand in the abdomen we can extri-
cate the intestine from the internal ring, and if neces-
sary we can ocularly inspect the condition of affairs
within the abdomen. It may be argued that this addi-
tional incision in the abdominal parieties adds addi-
tional risk to the operation. I am not convinced that
it does; but would it not be better in such a case to do
this than to assume the risk of an imperfect opera-
tion? The median incision also provides for additional
advantages; for instance, as a means of drainage. In
these cases we should make a radical operation in the
groin; the median wound affords a means of drainage
of the peritoneal cavity at a site remote from the groin,
thus leaving this in a state of rest and consequently in
CITY HOSPITAL ALUMNI. ' 17
a more favorable condition for perfect union. If subse-
quent interference from any cause should become nec-
essary, the median wound can be so sutured that it can be
easily opened without additional cutting and the peri-
toneal cavity made aCcessible. Knuckling of the bowel
and subsequentobstruction is an accident that may oc-
cur after any abdominal section. I have made this me-
dian incision several times as a means of drainage in
herniotomy and have not found that it is an additional
factor of risk. Should there be any question as to the
condition of the bowel, it can be much more easily an-
chored in the median incision, and made more readily
accessible for subsequent operation than in the groin.
3. Cum WHERE THE BOWEL IS PERMANENTLY IN-
JURED.-GANGRENE.—These are the cases that offer the
largest percentage of mortality, On account of the time
the strangulation has existed and the effect on the con
stitution of the patient. Not alone have we here ‘the
effect on the nervous and circulatory system but on ac-
count of the lowered resistance of the tissues, especially
those of the gastro-intestinal tract, we have the most
favorable conditions for the migration of the micro-or.
ganisms,—especially the bacterium communis 001i,—
that infect the gastrointestinal tract. In that way we
have an infection established in many cases before the
patient comes under the surgeon’s knife. Added to
this is the effect of prolonged anesthesia, and'the addi-
tional shock of more or less severe operation.
How shall we deal with the bowel, is the important
query that arises in these cases; shall we anchor the
bowel in' the abdominal wound and form an artiﬁcial
anus, or shall we resect it? On this important ques-
tion, there is still a great diversity of opinion. If an
artiﬁcial anus is made the life of the patient may be
spared for the time being. An artiﬁcial anus creates a
ﬁlthy condition and in many instances death would be
just as desirable. Should life be spared and a secondary
operation—resection—done, the spectre of a frightful
mortality again stares us in the face. In the primary
18 MEDICAL SOCIETY OF
resection of the bowel for gangrene, we have, it is true,
one of the most fatal and difﬁcult operations under con-
sideration;-yet, with improved technique, the percent-
age of recoveries is becoming greater; at present it is
about 50%.
If a fecal ﬁstula (artiﬁcial anus) is to be established, it
is a question whether the groin would be the best site.
It certainly is not from an anatomical standpoint, and
especially not in reference to a subsequent operation.
The median incision, with anchorage of the bowel,
would also, in my estimation, be better in thesei'cases
than incision in the groin. I base this opinion on anat-
omical and operative considerations. If a resection of
the bowel is done, several practical points .are 'of ex-
treme interest.
1. How much bowel should we excise?
2. What method of anastomosis shall we use?
3' How shall we treat the wound?
The question as to how much bowel we should ex-
cise, is an important one, as this pertains to the‘ future
welfare of the case. If we go too near the demaration
line, there is danger of recurrence of the gangrene.
We know from practical experience, that in most cases
the aﬁerent part of the constricted bowel is edema-
tous and distended, While the efferent end is empty and
normal. I believe that the mistake is generally made
that too little of the edematous portion is excised. It
is exceedingly diﬂicult to establish just how far from
the demarcation line to excise in an edematous bowel
We must keep in mind that this part of the bowel has
lost its normal resrstance and hence the walls are prone
to be invaded by micro-organisms. I believe that it
matters very little, as far as the shock of the operation
is concerned, whether we cut out six inches or two feet
of the bowel. It is always better to err on the right
side and cut out a little more than is necessary, than to
cut out too little. "
As to the method of anastomosis to be used, we are
confronted, at present, by a great many forms of rings,
CITY HOSPITAL ALUMNI. ‘ 19
plates and buttons. Senn’s plates and Murphy’s but-
tons have received much favor, especially so from the
standpoint that time is saved. We hear of operations
that are done in from six to seven minutes with a Mur-
phy button. This may be true in uncomplicated cases,
and by as skillful an operator as Murphy, but it is not
true in the average operations done at random and by
the average operator. The same I will say of Senn’s
plates or any other mechanical device. Intes-
tinal work is the most delicate in surgery and no one
can expect to be skillful without practice, either on the
human being or on the' animal. The violin-virtuoso or
the opera singer would not dream of appearing on the
stage 'without daily and laborious practice of the part
to be performed; yet, intestinal surgery is essayed by
individuals who perhaps never have placed a suture in
the intestine of either an animal or the human being, or
who perhaps can not close up a rent in pantaloons, or
sew on a button with an ordinary cambric needle.
As far as my own individual preference 'goes, it is in
favor of the direct suture, either end-to-end or lateral
anastomosis. Of the two, I consider the lateral method
as being the preferable. I cannot here discuss the pros
and cons of the various methods, but base my opinion
on the mechanical principles and questions involved,
the work of the best operators here and abroad, and my
own experimental and practical work. Whatever form
we may adopt, We should open the sac, draw out the
bowel sufﬁciently to be able to resect enough, and after
having united the ends, we should make a median incis-
iOn and reduce, as already described. The groin
wound should be closed as is done for radical cure, and
now we can drain or anchor the resected part in or near ‘
our median wound.
CONCLUSIONS.
1. In view of the success of the radical cure opera-
tion, an existing hernia is a possible menace to life, and
more so than a radical operation.
2O MEDICAL SOCIETY OF
2. This fact ought to be impressed on the laity by
the family physician.
3. Taxis is a dangerous proceeding as usually carried
out.
4. In all hernia operations a radical cure technique‘
should be carried out.
5. An animal suture should be given the preference
over silk as a buried suture.
6. In all cases of strangulation where the bowel can
not be easily reduced after the sac is opened, tht" abdo-
men should be opened in the median line, for frcilitat-
ing reduction, establishing drainage, or for anchoring a
doubtful, gangrenous or resected bowel.

DISCUSSION.
DR. H. J ACOESON said he would liked to have had Dr.
Meisenbach touch upon congenital hernia. He had op-
erated on a case of this kind not long ago in a child
about 8 years old, and thought they were more difﬁcult
to handle than ordinary hernias, for in these cases one
has not only to open the sac, but to open it in the back
in order to let out the spermatic cord, and then go
through the ordinary procedure. He liked the method
of using the animal suture described in the paper, the
kangaroo tendon for the abdominal rings and the catgut
for closing up the canal—which the speaker used with
good results.
He reminded the Society of a case he reported nearly
three years ago, in which he was called three days after
strangulation occurred, and after relieving it and exam-
ining the gut the grayish appearance disappeared and it
assumed a nice rosy color and was apparently all right,
but for safety he attached it to the internal abdominal
ring, and three days afterwards gangrene appeared;
there was a slight suppuration from a ﬁstula which
formed, and he tried the ordinary procedure for closing
the ﬁstula without an operation; that is, restricting the
diet to milk and foods which would be absorbed before
CITY HOSPITAL ALUMNI. 21
they reached the gut, for about three weeks with no suc-
cess; then he tried to close the ﬁstula, and had a very
difﬁcult time relieving adhesions and getting down to
the opening in the gut. This was about the size of a
quarter-dollar, and after bringing it together the re-
paired gut‘ was packed down with gauze, which was for-
tunate, as union did not take place and the ﬁstula reap-
peared. Then the man was put on the same treatment
as before the operation, which was, very restricted diet,
the opening was washed out with peroxide of hydrogen
and a very mild bichloride solution, and after about six
Weeks the ﬁstula closed. That was a case where the
operation of resection was a failure, but it closed by
granulation. One has to be very careful in doing resec-
tion where there is an old ﬁstula. It is very difﬁcult to
prevent infection, and the best thing is to pack down to
the gut with gauze. He thought there were a number
of interesting points for discussion connected with the
subject.
In answer to several questions by Dr. Meisenbach, the
speaker said the bowel was separated from the adhesions,
peritoneal and other, and that the abdominal cavity was
opened all around it. These adhesions were very thick,
quite extensive, and the iodoform gauze was packed
right down to the double line of sutures, in all three
rows of these were used.
DR. W. A. MCCANDLESS said that this subject grows
more interesting to everyone the more operations of
this kind they make, and the more cases he operated on
the more anxious he became as to the result. He had
made every kind of operation, because some of each
kind had failed with him. He operated ﬁrst after the
manner of McEwen and McBurney, and later, that of
Bassini. For anatomical reasons as well as results, he
thought Bassini’s method the best. He had seen Fer-
guson, of Chicago, .make his operation, which some-
times has its advantages. The serious question in deal-
ing with hernia ordinarily is the sac. In hernias that
have existed for some time, without any strangulation
22 MEDICAL SOCIETY OF
having occurred beyond that which the patient himself
was able to relieve, the operation is generally simple,
unless it is a congenital hernia. The sad, he thought,
was a matter of great‘importance, but Dr. Meisenbach
had said little upon this subject, perhaps, because these
- are subjects which can be got along with pretty well.
But the condition of the gut was a serious matter, and
he had tried all the buttons in dealing with it, and
thought Murphy’s the best button that ever has been
adopted. He had tried the bone button three times in
resection of the gut, and with it had had two failures.
He used it in a gastro-enterostomy with success, but
found it unsuitable in many cases, the reason being that
the pressure is not sufﬁcient, and a fecal ﬁstula is apt
to follow, which is a serious matter. In ope'rating to
relieve a fecal ﬁstula when opening the abdominal cavi-
ty, the exact outlines of the ﬁstula itself need not be
followed, for to be cured it must be separated carefully,
fully and completely from the abdominal wall, so that
free access to the peritoneal surfaces covering the gut
may be had and the gut itself can be inverted, its mus~
cular wall as well as its peritoneal surfaces. To properly
prepare and treat the fecal oriﬁce depends upon the
caliber of the gut, and that usually is so reduced after
an old fecal ﬁstula, so much has been lost in the ab
scesses that occur as the result of strangulation, where
the gut'has sloughed, or in those cases following ap-
pendicitis, that in nine cases out of ten, one must begin
work by resecting the bowel. Frequently, in old ab-
scesses in the inguinal region, following appendicitis,
it is necessary to deal with the large gut and the small
one, and that form of anastomosis is not always the most
successful (end to end). Usually the Bassini operation
is an easy one. The intention of Bassini was not to
re establish the canal, but to create a new channel, to
change the course, to make a new, oblique direction,
harder for the gut to pursue than the straight course
which it followed before. At least, in nearly all these
CITY HOSPITAL ALUMNI. 23
operations, the object is to make a new canal rather
than to re-create the old one.
In a case where a gut had become inﬂamed from press-
ure, its walls thin' and the opposing surfaces of the
knuckle adherent, there were objections to attempting
to pull it out or push it back. Sometimes in pushing it
back it is pushed into the peritoneum and harm done in
that way. To obviate that, if the gut is tight, no at-
tempt to pull it out is made, but the hole is enlarged,
and the way this is done is to cut from the outside and
keep dissecting down until the internal ring is reached,
and the gut loosened and drawn out for examination; I
nor is the gut pushed through a narrow and contracted
oriﬁce which remains strong and quite ﬁrm, for this is
the reason for the strangulation; or, it might be said,
the gut had become congested and swollen after its
escape from this opening; therefore the procedure is
to enlarge the hole, which is an easy and a scientiﬁc
one, rather than to open the belly and examine the gut
that had been worked back through the little hole. The
internal ring must be enlarged anyhow, he claimed, and
advised cutting through the belly-wall from the outside,
the withdrawal of the gut for examination as to its
condition, whether healthy or not, and its return into
'the abdominal cavity if advisable, without disturbing
the parts around it by too much manipulation, too much
infection and too much dirt.
DR. H. P. WELLS desrred to ask Dr. Meisenbach, in
regard to the incision, whether it was considered an
advantage to make it far enough above the canal to
carry the cicatrix in the skin entirely away from the
point of possible recurrence of the hernia. He had
heard of' this having been advised, and had seen a num-'
ber of operations performed, where that point was ob-
served; but regarding its effect on the re-appearance of
the hernia, he had not had the advantage of observing.
It presented itself to his mind as being, at least, worthy
of consideration, and he desired to hear the weight of
authority on it.
24 MEDICAL SOCIETY OF
DR. CHARLES J. ORR asked Dr. Meisenbach whether
he advised operation in congenital umbilical hernia, and
if so, how early.
DR. JOHN P. BRYSoN said he would like to have Dr.
Meisenbach say something about the kinds of animal
sutures he uses, and how they are prepared. He did
not wish, of course, to open up that large discussion,
but simply wanted his experience—his own observation.
He remarked, in this connection, that he had recently
seen that catgut by being soaked for 48 hours in a 5- per
cent solution of formol, could then be boiled to almost
any extent without destroying it. He would like to
know if anyone presenthad used catgut in that way,
and whether they used the aseptic catgut—or that which
they supposed to be aseptic—or used any antiseptic
with it.
THE PRESIDENT said that while it might be a little
beside the question, still he would like Dr. Meisenbach
to explain, in his conclusion, the present status of the
truss from the surgical standpoint—whether it had been
entirely superseded by the knife, even in the absence of
strangulation. He had looked forward with considera-
ble interest to the paper, because the subject had come
to his notice last fall through. several cases of non-
strangulated hernia, which seemed threatening, and in
which the application of the truss was unsatisfactory.
He would like to know whether operation would be the
proper thing in such cases, viewed in the light of the
surgery of to-day.
DR. JACOBSON asked Dr. Meisenbach what his expe-
rience had been with very stout women having umbili-
cal hernia, as regards a permanent cure—the radical op-
eration; if the fat, which is very extensive in these cases,
interfered with ﬁnal union and ﬁnal cure. _
DR. MEISENBACH said it had not- been his experience
to ﬁnd that old, large sac hernias, without adhesions,
were easy to operate on. Some of these. large hernias
had proved an awkward'job in his hands, because he
found almost everything in that form of hernia, small
CITY HOSPITAL ALUMNI. 25
and large intestines, the appendix, in fact, almost the
whole contents of the abdomen; he had never found the
bladder there, though it does cocur. Headded that in
many of these cases he thought it might be necessary to
resect quite a length of intestine in order to accommo-
date the bowel to the abdominal cavity.
The'speaker said that he had perhaps been somewhat
misunderstood in regard to the technique of cutting.
He agreed with Dr. McCandless perfectly that the sci-
entiﬁc way was not to cut from within outward, as was
the old way of lancing an abscess, which is very unscien-
tiﬁc because one never knew where the knife point was
going; and it was just as unscientiﬁc to liberate a stran-
gulated knuckle of bowel, adding insult to that bowel,
by pressing it with the ﬁnger. So that the manner in-
dicated is the rational and scientiﬁc procedure. But he
thought that did not at all weaken the position he had
taken, which was that thereby the peritoneum may pos-
sibly be detached from its parietal connection, and a
pocket be thus formed. In German literature it has
been noted that this is one of the accidents met with in
operating for hernia.
He remarked that, of course, dealing with the sac was
what gave their distinctive features to the various her-
nia operations, aside from the form of suturing; but his
experience had been that'the Bassini method had given
the greatest number of satisfactory results, because it
was based on correct anatomical principles, that is on
the re-establishment of the tissues in their. continuity—-
each form of tissue being sewn to its» like, fascia to
fascia, and skin to skin. The inguinal canal is oblitera-
ted and instead of having the oblique canal in the old
form—depending somewhat upon the variety of the
hernia, of course—the entrance to the inguinal canal is
situated so high that the abdominal pressure is not ex-
- erted at that point; in other words, out of the old canal
a buttress is made where intra-abdominal pressure bears,
thereby obviating the tendenCy to recurrence, because
the cord is then at a much higher level. Many surgeons
26 MEDICAL SOCIETY OF
advise an operation to pass the cord through the abdom-
inal wall an inch or so above the normal location and
thus make the point of weakest resistance higher in the
abdominal wall. .
The location of the scar, he believed, did not play a
very great role in preventing the recurrence of hernia.
The abdominal wall should be fortiﬁed and a perfect
result can be gained only by thoroughly suturing and ‘
getting a close approximation of the tissues that have
formed the old canal. If that is not obtained there, may
be a recurrence of hernia.
The advantages of the operation advocated by Fergu-q
son, especially in the femoral variety, was that the in-
cision was made above Poupart’s ligament, which brings
the scar above the fold in the groin, and therefore it
necessarily takes it out of the way of irritation, which
all scars are, more or less, Subject to; so in those cases
he thought the Ferguson suggestion a‘good one.
He very rarely operated for congenital umbilical her-
nia, but treats them by means of fastening, with adheg
sive plaster, a wooden button with a little pad or T like -
projection in the center, that presses into the opening
causing irritation and producing adhesions and the sub-
sequent obliteration of the ring—at least, that was his
, experience. I h 1
In regard to animal sutures‘his preference had always
been catgut. The kangaroo tendon is, in some respects,
an ideal suture, but in the ﬁrst place it is very expens-
ive, and in the next place one does not always get it in
suﬁicient length for making a long continuous suture.
The method he always used for preparing catgut was
one learned in Martin’s 'clinic, in Berlin, which is
known after Martin, or more prOperly speaking, Kues-
ler. He buys the raw catgut and prepares it himself,
being somewhat skeptical about the materials in the
stores, while, if prepared by himself, he knows exactly
what process it has gone through and feels that he can
rely upon it, and if found faulty he could poSsibly ﬁnd
out where the mistake had been made.
CITY HOSPITAL ALUMNI. 27
The speaker, in answering some questions, said that
he buys the raw, unglazed gut, which is made for surgi
' cal purposes. For about $3 or 84 he can get as much
as he could for $10 or $15 in the stores The No. 4 is
strong enough for all purposes. It is immersed for 24
hours in ether, then in a watery solution of bichloride of
mercury, 1—1000, for 24 hours, and then put in two parts
of alcohol and one part of juniper oil. This has given
him very satisfactory results.
DR. BRYSON observed that he used the antiseptic in-
stead of the aseptic gut, and Dr. Meisenbach said it was
necessary to use antisepsis to obtain asepsis, although
there were surgeons at the present time who were an-
tagonistic to that idea. He commended a form of cat-
gut preparation, mentioned by Keene, in the Annals of
Surgery, for December, 1897. It is-immersed in mer-
cury bichloride, and then in an alcoholic solution of pal-
ladium chloride. He said that while he did not know
what the qualities of palladium chloride were, he had
conﬁdence in Keene’s judgment.
DR. BRYsON asked if he had used the formol prepara-
ration.
DR. MEIsENBACH said he had not, although at ﬁrst he
had made some unsatisfactory experiments with it.
As to the truss in modern surgery, he thought it had
a very inferior position, because it was not a scientiﬁc
surgical sppliance. There were many forms of hernia
which, no doubt, could be held in position by such
~means; it would depend entirely on the character of the
individual, on the anatomical formation of his belly, and
upon the hernia. There were forms of hernia that no
truss would hold in place. He believed that all forms
of- hernia, if not carefully looked after, would sometime
become a menace to life._ In his experience men had
gone on for years wearing trusses, and suddenly the ap-
pliances would not hold the hernias back, and they would
become incarcerated. So he believed that, taking into
'consideration the results of Bassini, and various other
operations, and} their low mortality, that a man with
28 MEDICAL SOCIETY OF
hernia would be much safer to have an operation done,
than to wear a truss for his lifetime. '
DR. BRYSON asked whether there were any strangula
ted hernias among the 700 successful cases reported by
Bassini. ‘
DR. MEISENBACH answered that his recollection was
that they were of all characters, that he took them as
they came. Probably they did not include the severe ‘
forms of hernia where the gut had been very materially
injured. There is a condition in which, at times, no
operation can be successfully performed. "
In regard to large women and umbilical hernia, he
said the ﬁrst cases of umbilical hernia operated on by
him were two women in whom the hernias had become
strangulated, and both terminated fatally. He had had
one or two other experiences where this did not occur,
but would say, however, that these long standing cases
in very fat women were. some of the'most unsatisfactory
to operate on that occur. And, here again, comes into
play the condition of the abdomen. When seeking to
replace the bowel after having loosened all the adhesions,
great difﬁculty is found in keeping the bowel within the
abdominal cavity, and that, in his estimation, was one
of the reasons why many poor results follow the opera-
tion for radical cure of hernia.
In answer to Dr. J acobson’s question as to whether he
used wire in those cases for suturing, he said that catgut
was used in cOnnection with wire. ' A method had been
devised within the last year for operating by splitting
the recti muscles in the middle, cutting transversely, and
then crossing them—carrying one part of the muscle to
the opposite side, the other to the other side, and then
suturing them in position. The originator had claimed
some good results for this operation, and he thought of
trying it the ﬁrst opportunity.'
DR. WELLs asked as to the advisability of impressing
upon the patient the importance of wearing some kind
of a support for a time after the operation.
DR. MEISENBACH thought that a good deal depended
CITY HOSPITAL ALUMNI. 29
on the physical condition of the patient right after the
operation. A man operated on for inguinal hernia, or a
woman for a femoral hernia, ought to be kept quiet for
at least six weeks, to give the wound an opportunity of
becoming pretty solid. Then some form of pad ought
to be worn, so as not to allow any great stress to be sud-
denly placed upon the operative site. It was very much
like all other recent wounds, liable to yield, and recurs
rence may take place from improper after-treatment.
DR. H. WHEELER BOND asked Dr. Meisenbach how
he treated strangulation. ,
DR. MEISENEACH said it was a very difﬁcult question
to answer. He liberated the bowel so that all constrict-
ion should be removed and the circulation re-established,
then, observing the line of demarkation, he applied wa-
ter, a little above the temperature of the blood, and al-
lowed that to pass over it to wash it off thoroughly, and
then waited and watched, and if he found that the
bowel assumed, approximately, a normal color, why
then, he felt pretty safe in returning it. If the bowel
was very deeply surcharged with blood and of a blackish-
brown tinge, he felt very doubtful, while if it was
rosy-red, he would feel that the circulation was pretty
good. Yet it depended on other intra-abdominal con-
ditions, perhaps. If these tissues have been infected,
even in spite of the fact that they may apparently re-
gain a normal color, the circulation may be interfered
with and subsequent gangrene take place. Whether or
not infection existed was a very diﬂicult question to
determine.
30 MEDICAL SOCIETY or
STATED MEETING THURSDAY EVENING, FEBRUARY 17.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

The Value of Modiﬁed Milk in the Feeding
of Infants.
BY HORACE w. SOPER, MD., ST LOUIS, MO., .
Assistant in the Clinic for Nervous Diseases, St. Louis Medical
College.
For originating and elaborating the scientiﬁc method
of modifying cows’ milk, we are indebted to Rotch.
By the practical application of our physiological, chem-
ical and bacteriological knowledge, he has succeeded in
simplifying the problem of the substitute feeding of
infants, and placed the subject on a rational scientiﬁc
basis.
His labors have marked a great advance in this most
important department of preventive medicine. The
value of a physiological development in early life, in its
inﬂuence on the future welfare of the individual, can not
be overestimated; and, undoubtedly, much that is now
attributed to the influence of heredity is in reality due
to improper nutriment and faulty hygienic conditions
during the ﬁrst years of life.
Botch, in approaching the solution of this problem,
determined to imitate Nature’s methods. Human milk
was found to be not an especially prepared food, but a
combination of foods, consisting of sugar, fats, proteids
and salts, in varying proportions. It was shown that
variations in the perc‘entages of the different constitu-
ents occurred from time to time at different periods of
lactation. That in the mammary glands—Nature’s lab-
oratory—the food is constantly being modiﬁed to suit
the varying needs of the infant.
Selecting cows’ milk as being mpst available for mod-
CITY HOSPITAL ALUMNI. 31
iﬁcation, the problem then consisted in obtaining the
elements of the food separately and combining them in
the propOrtions required by the individual case. This
led to the establishment of the milk laboratory. The
elements used in the modiﬁcation are as follows:
1. Cream containing a deﬁnite percentage of fat.
2. Separated milk from which the fat has been re-
moved.
3. A standard solution of milk sugar.
By combining these it is possible to accurately vary
the percentages of fat, proteid and sugar as desired.
The laboratories are managed by specially trained men
in such manner as to insure the freshness and purity of
the milk as well as the accuracy of the modiﬁcation.
They certainly deserve the support of the medical pro-
fession, and should occupy the same relative position
that we accede to the profession of pharmacy.
As illustrative of the method, I will present a brief
.report of a case of infantile atrophy. The patient, a
female, aged 6% months, had been a breast-fed infant,
healthy and vigorous, until the end of the fourth month.
The mother’s milk then seemed to disagree with her,
and substitute feeding was determined upon. Diluted
' cow’s milk was given at ﬁrst and then, under the super-
vision of the attending physician, various artiﬁcial
foods were tried. She continued to fail, losing weight
rapidly and showing the usual evidences of general di-
gestive disturbances. Physical examination failed to
reveal any visceral lesions. Weight, 9 pounds; rectal
temperature, 98°F.; pulse weak and rapid. The skeleton
form, wrinkled skin, cold extremities and general apa-
thy presented a characteristic clinical picture of genuine
atrophy. The case was treated on the theory that the
pathological condition is that of a lack of absorption.
Following Rotch’s suggestion the milk was modiﬁed so
as to produce a mixture containing a low percentage of
fat, a high percentage of sugar and a moderate percent-
age of proteids.
The results of his experiments with these cases show
32 MEDICAL SOCIETY OF
that they are able to digest and assimilate a rather high
percentage of proteids, provided they are combined
with a low percentage of fat. ’
The ﬁrst prescription given was as follows:
October 13, 1897, age 27 weeks, weight 9 pounds.
Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Proteids . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Number of feeding, 8; amount each feeding, 3 oz\.., '
Alkalinity, 5 per cent; heat to 167°F.
You will note that in this prescription, the amount
given at each feeding is about one half the average gas-
tric capacity at this age. The child began to improve
atonce, vomiting ceased and the stools soon became
normal. The weight increased at ﬁrst, gradually and
later, with great rapidity. The fats and proteids were
increased as'rapidly as the digestive powers permitted.
I will give the diﬂerent prescriptions used, including
also the age and weight records. In all 5 per cent lime
water was used, also heat at 167°F. (pasteurization).
October 20, 1897, age 28 weeks, weight 9 pounds 1
ounce. . ‘
Fat . . . . . . . . . . . . . . . . . . . . . . . . 1.50
Sugar . . . . . . . . . . . . . . . . . . . L . . . . . . . . 6
Proteid . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.50
Feedings, 8; amount, 4 oz.
October 28, 1897, age 29 weeks, weigh 10'pounds.
Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 1.50
Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6
Proteids . . . . . . . . . . . . . . .I . . . . . . . . . . . 1.50
Feeding, 8; amount, 4% oz.
November 11, 1897, age 31 weeks, weight 11%.pounds.
Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2‘
Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Proteids . . . . . . . . . . . . . . . . . . . . . . . .. 1.50
Feedings, 8; amount, 5 oz.
CITY HOSPITAL ALUMNI. 37
November 26, 1897, age 33 weeks, weight 13 pounds. v
Fat . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 3
Sugar.._ . . . . . . . . . . . . . . . . . . . . . . . . .. 7
Proteids . . . . . . . . . . . . . . . . . . . . . . . . .. 1.50
Feedings, 8; amount, 5% oz.
December 24, 1897 , age 37 weeks, weight 16 pounds.
Fat . . . . . . . . . ._ . . . . . . . . . . . . . . . . . . . . 4
Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . ._ 7
Proteids . . . . . . . . . . . . . . . . . . . . . . . . .. 2
Feedings, 7; amount, 5% oz.
January 20,.1898, age 40 weeks, weight 18 pounds.
Fat . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . 4
Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Proteids . . . . . . . . . . . . . . . . . . . . . . . . . 2.50
Feedings, 7; amount,.6 oz.
The patient, now at the age of 11 months, weighs 19
pounds, and is digesting and assimilating pasteurized
unmodiﬁed cow’s milk, with the addition of cats to two
of the daily feedings. To some physicians this method
may appear complicated, but, in truth, it is exceedingly
simple. It is rarely necessary that analyses of the stools
are required, as it is possible, in the great majority of
cases, to determine which element of the food is at
fault, merely by the symptoms presented—a subject,
however, too extensive to enter into here;
In beginning to use modiﬁed milk, I believe two prac-
tical points to be of value, and are applicable to all
classes of cases, viz.:
1. Always begin withflow percentages.
2. Begin with aless quantity at each. feeding than
the estimated gastric capacity.
The practice of using many of the proprietary or pat-
ented infant foods during the ﬁrst year ' of life is to be
condemned as absolutely dangerous. The usual method
of “trying” the different artiﬁcial foods until one is
found. to “agree” with the baby is, at best, a groping in
he dark, thoroughly unscientiﬁc and unworthy of mod-
ern medicine. The chief objections to their use may be
stated as follows:
34 MEDICAL SOCIETY OF
1. They are lacking in fat.
2. The proteids are chieﬂy of vegetable origin.
3. Nearly all contain too large a percentage of the
carbohydrate, many of them a large amount of un-
changed starch.
4. Last, and most important of all, all authorities of
large clinical experience, agree that their prolonged use
has often been the cause of rickets and scurvy.
Regarding condensed milk, Holt says: “I have seen
many infants reared exclusively upon it, but as yet, not
one who did not show, on careful examination, more or
less evidence of rickets.”
In my own experience I have observed a case which,
from the sixth to the twelfth month was fed on a food,
which is at the present time very popular. The child
increased steadily in weight and digestion seemed good.
At the twelfth month I was astonished to ﬁnd marked
signs of rickets. I wish to emphasize the fact that a
food may be easily digested, yet be lacking in essential
nutritive properties.
I believe that in the use of modiﬁed milk we have a
method by which it is possible to so adjust the equilib-
rium between digestion and nutrition, as to insure a
physiological infantile development.

DISCUSSION.
HENRY EDWARD HOWLAND, chemist to the laboratory
for the preparation of modiﬁed milk, being present by
invitation, said: “To-day the physician who ﬁnds it nec-
essary to resort to substitute feeding in the nursery,
recognizes human milk as the standard to be followed.
Only a Short time ago the mixture of milk, cream, sugar
and lime water, as formulated by Dr. Arther V. Meigs,
and probably familiar to you under the title of “The
Meigs Mixture,” was accepted by many of the leading
physicians of the country as a possible solution of the
problem of artiﬁcial infant feeding. This mixture ap-
proximated:
CITY HOSPITAL ALUMNI. ' 35
Fat. . . . . . . . . . . . . . . . . . . . . . 4.00 per cent.
Sugar.. . .' . . . . . . . . . . . . . . . . 7.00 “ “
4 Proteids. . . . . . . . . . . . . . . . . . 1.00 “ “
Lime water. . . . . . . . . . . . . . .25.00 “ “
which made it strongly alkaline in reaction. But while
the mixture was a success. in many instances, it was
found that in a majority of cases it was not in the least
a satisfactory substitute for the breast, and the reason
this non-success was soon ascertained, for instead of
humanvmilk being composed of unvarying proportions
of fat, sugar and proteids, as held by Dr. Meigs, it was
found that almost no two were alike, and that the term
normal breast milk did not signify any one combination
of the constituent parts of milk, but should only be ap-
plied to milk suited to the requirements of the individ-'
ual infant who was in normal health and in normal con-
dition. Commercial milks and creams were then used
in home modiﬁcations, and under the direction of the
physician, but the non success of these attempts caused
by the variation in both the quality and percentages of
the milk and cream used, joined to the inability of the
average mother or attendant to accurately follow the
physician’s instructions, soon made it evident that some
thing of vital importance was still lacking and the na-
ture of this missing factor was readily understood when
the milk laboratory was established. The milk labora'
tory guarantees to the physician that his prescription
will be accurately ﬁlled and that the component parts of
the modiﬁcation will be pathogenically pure, fresh, and
practically aseptic. Breast milk and cows’ milk analy-
ses are written in percentages, and the use of the milk
laboratory permits the physician to follow the same
train of thought in writing his prescription. The
trained clerk in the laboratory receiving a prescription
reduces the percentages to their equivalents in ounces
for the use of the modifying clerk, who compounds it
by using a deﬁnite percentage of cream, a fat free milk,
a deﬁnite percentage solution of sugar of milk, an alka-
kine agent, usually a saturated solution of lime, and
36 MEDICAL SOCIETY OF
freshly distilled water, also accurately prepared cereal
jellies and deﬁnite percentage wheys.This modiﬁcation is
measured into tubes, each tube one feeding, tube stopped
with cotton. A majority of those present are familiar
with the component parts of modiﬁed milk that .are
' used in the laboratories, but for the beneﬁt of those
who have not visited a milk laboratory, nor seen a pack
age of modiﬁed milk, I have here samples of the mate-
rials used, and three packages of modiﬁed milk; one
basket contain-ing a modiﬁcation comprising:
Fat . . . . . . . . . . . . .2.00 per cent.
Sugar . . . . . . . . . . .5.00 “ “ 10 feedings, ﬁjss each.
Proteids . . . . . .- . .050 “ “ -
One,
Fat . . . . . . . . . . . . . 3.50 per cent.
Sugar . . . . . . . . . . .6 50 ‘-‘ “ 8 feedings, ﬁiij each.
Proteids . . . . . . . . . 1.00 “ “
.And one,
Fat . . . . . . . . . . . . .4.00 per cent.
Sugar . . . . . . . . . . .7.00 “ “ 6 feedings, ﬁvij each.
Proteids . . . . . . . .2.00 “ “ .
“Also one quart- and one pint-package of milk as sent
out by the Walker—Gordon laboratory department of
the St. Louis dairy company, and containing:
Fat . . . . . . . . ._ . . . . . . . . . . . .5.00 per cent.
Sugar. . . . . . . . . . . . . . . . . . . ..4.50 “ “
Proteids . . . . . . . . . . . . . . . . . .4.00 “ “
“To insure that this pure milk will not be contaminat-
ed, or tampered with, after leaving the laboratory it is
sealed with a metalic cap, and wire and lead seal. The
deﬁnite percentage milks and creams ordered by physi-
cians for home modiﬁcation are put up and sealed in the
same manner: Fat, 0.02 per cent to fat, 40.00 per cent.
All of the-empty packages received by the laboratory
are sterilized in live steam under pressure, then the
tubes and bottles are washed and rinsed in three waters
and sterilized again before being used. Too greata
stress can not be laid upon the necessity of using a milk
' specially produced for infant feeding, and the barn rules
of the milk laboratories I governing the selection and
CITY HOSPITAL ALUMNI. ' 37
care of the cattle, the cooling, aeration, and care of the
milk and the absolute cleanliness of the cows, attend-
ants, utensils, barns“, and milk-houses are exceedingly
strict and arbitrary.” -
DR. MARY H. MCLEAN said that the deﬁnite modiﬁ-
' catlon of pure cows’ milk in the feeding of infants is
now a well established principle in pediatrics. The
value of the Walker-Gordon laboratory, she thought,
Was quite beyond discussion. She was especially inter-
ested in the success which those workers have achieved
in their efforts to secure an excellent quality of milk for
modiﬁcation. Dr. Irving M. Snow, in a recent article
on “Certiﬁed Milk in Buffalo,” gave some interesting
statistics which seem to demonstrate that the rigorous
requirements in matters of cleanliness in the dairy can
be enforced, and that the results are most gratifying.
The medical committee of the Buffalo dairy required
that the number of bacteria per c.c. should be below
10,000. In March, 1897, they reached the minimum-
766 per c.c. A short hot spell of weather without ice
raised the number to above 150,000; a neglect of wash
ing of 'udders in August, 1896, increased the number to
over 70,000, and an enforcement of rules brought the
number down very quickly to 7,500.
The excellence of the milk, the speaker added, was
maintained also by the scientiﬁc supervision of the health
of the cattle, frequent tests for tuberculosis, etc., and by
feeding them pure foods in deﬁnite percentages. Com-
petent observers have said that the milk of cattle fed
on pastures in limestone regions is alkaline in reaction;
and that alkaline milk will ‘keep sweet 2. much longer
time than acid milk, and will bear transportation per-
fectly, even without preliminary cooling. It is thought
that alkaline cows’ milk' Is a much better food for
infants than the acid milk. In Dr. McLean’s opinion,
there is a broad ﬁeld for research open to students just
in this direction, and one that promised a rich harvest
in the near future.
DR. ROBERT LUEDEKING said that since the establish-
38 MEDICAL SOCIETY OF
ment of the Walker-Gordon laboratory in the city he
had availed himself of it at every possible opportunity
and had met with the most gratifying success in each
instance. Before that time his habit was to order do-
mestic modiﬁcation, particularly as laid down by Meigs
-proteids, 1 to 2 per cent; fats, 2 to 4 per cent; sugar, ’
7 per cent. The use of this mixture was always attended
with good results. He used Meigs’ mixture because he
was impressed from the start with the statement of
Rotch that all mammalian young in their ﬁrst life have
a food which is essentially an animal food; a food which
lacks, absolutely, the vegetable element. And Rotch
makes the statement, which is trite and to the point, that
human offspring in the ﬁrst 12 months are carnivorous.
Following, then, these precepts, he had abandoned
patent foods for artiﬁcial feeding and had turned to
the Walker-Gordon laboratory. In the feeding of
children from the laboratory he had closely followed
the abstract of ﬁgures from their medical report. It
exhibits rising percentages of fat from 2 to 4 per cent,
milk sugar 5 to 7 per cent, to the end of the thirty-sixth
week, and then a decline in the milk sugar. The reason
of this is that fat is more calorifacient and of a greater
potential energy. The proteids rise from §' to 4 per
cent up, to the end of the year. In nearly every instance
he had strictly followed out this table and never had
reason to regret it. He had some ﬁgures which were
absolutely up to the best normal standard—36 days’
feeding with a gain of 36 ounces in that time. The
modiﬁcations and variations as laid down by the Walker—
Gordon laboratory were followed. The infant was ﬁrst
fed on breast milk. Diarrheal disturbances, with vom-
iting, emaciation and loss of weight, were quite mani-
fest toward the end of the second week. The mother’s
milk at that time showed 6.5 per cent sugar, 3 per cent
fat and 3 85 per cent proteids. In consequence of this
enormous excess of proteids breast feeding was aband-
oned and the child put on Walker—Gordon milk, with
the result that in the ﬁrst week there was a gain of 41}
CITY HOSPITAL ALUMNI. 39
ounces, next week a gain of 8% ounces, next week a gain
of 6 ounces, next week a gain of 6 ounces, and in the
past week the almost incredible gain of 11 ounces—36
ounces in 36 days. He would always recommend aclose'
adherence to the ﬁgures of the abstract.
Another matter of importance is the question of pas-
teurization or sterilization of milk. The sterilization
of the Walker-Gordon product is not the best method
of dealing with that food. Rickets and scurvy may
develop. With reference to pasteurization, too, some
objection obtains. Pasteurization has the effect of de-
stroying, in modiﬁed milk, the bacillus of lactic acid
fermentation, and destruction of that makes the food
open to the activities of other micro-organisms. Pas-
teurized milk should be .used within 24 hours, otherwise
harmful micro-organisms become active and begin to
exert their inﬂuence, bringing about a degree of alkalin-
ity Which neutralizes the normal acid secretion of the
stomach.
If the mother failed to provide for the infant it was
formerly his habit to recommend a wet nurse—that
curse. and abomination of the doctor, the household and
the infant; all are dependent upon her caprices; moral
and other objections are also to be considered. He felt
that, -with his experience with the Walker—Gordon lab
oratory, he was done with wet nurses and will never
recommend one if the. child will thrive on Walker—
Gordon milk. ~
Another point is the feeding of syphilitic infants. In
most instances the mother is unable to nurse, and to
provide a wet nurse for the child is extremely hazardous,
even in those instances where it is reasonably certain
that the child is not contaminated. Still one must feel
great diﬂidence in putting such a child to the breast of
a healthy nurse even if the nurse be fully informed of
the danger which threatens her. Such individuals are
usually not able to comprehend the degree of the dan-
ger. Such children have a precarious existence and
40 ‘ MEDICAL SOCIETY or
modiﬁed milk will surely prove a great assistance in the
roaring of them.
DR. GEORGE M. TUTTLE congratulated and thanked
the Society for having brought forward this important
subject once more; important from the standpoint of- the
present health and life of the infant, but equally so
from the point, frequently Overlooked by physicians and
laity, of the future strength of the child and adult. He
believed much impaired health in adult life was the re-
sult of error in feeding in infancy. The subject in-
cluded two points—digestion and nutritiOn. Nutrition
does not mean simply the laying on of fat on the out-
side of the child, it means a proper nutrition of all the
tissues of all the organs of the body. As a result of
too large a quantity of food being put into the stomach
there is dilatation of that organ. He believed also the
peptogenic glands are harmed by improper food being
forced into the stomach. Holt has said somewhere that
frequently, present success in infant feeding is gained
at the cost of future trouble, expressing this idea in
speaking of the subject of the common form of artiﬁc-
ial food for feeding infants—condensed milk. If the
baby can not have its own mother’s milk, then some
form of modiﬁed fresh cows’ milk shOuld be used.
Condensed milk, he thought, was a satisfactory sub-
stitute for a time, but would, if kept up permanently,
produce errors in nutrition if not in digestion. In the
modiﬁcation of cows’ milk there must be a standard, or
idea], with which to compare artificial food. _ There is
only one standard, yet no two breast .milks are alike. '
At the same time there is an average which may be
used in writing prescriptions for modiﬁed milk and must
be kept in mind, namely, proteids 1 to 2 per cent, fat 3
to 4 per cent, and sugar 7 per cent; this is easily re-
membered. Cows’ milk averages 4 per cent proteids,
4.5 per cent sugar, and 4 per cent fats. The difference
between the two lies in the great excess of proteids and
the diminution in the quantity of sugar. Remembering
these two things it was not difﬁcult to make modiﬁca-
CITY HOSPITAL ALUMNI. * 41
tions. Where there is a milk laboratory to which pre-
scriptions can be sent it is unnecessary to think about
any thing except the partiCul'ar child under treatment.
This laboratary has everything to be said in its favor,
and only one thing against it. Pure, aseptic milk is
furnished in precisely the quantity and quality wanted
with the assurance of giving the child the proper food,
and even though things may not be going exactly right,
still this course was the proper one. The only disad-
vantage, he thought, was the expense; the large mass of
the people can not afford it.
Frequently, when the child has been sickly the family _
can be persuaded, as a temporary thing, to use the lab-
oratory milk until the child improves, then some of the
home modiﬁcations can be substituted and the child will
stand it. A good way was to use the different cream
percentages which the Walker—Gordon laboratory pre-
pares. These could be diluted one-half or two thirds.
But there should be some method of home modiﬁcation.
This, he believed, was the most important question now
for the great mass of people who can not afford the ex-
pense of the laboratory milk.
DR. HARRY N. CHAPMAN said that he had just now
an infant passing out of his hands, professionally, which
shows result with the Walker-Gordon history. The
mother had no milk and the child was put on condensed
milk, which he approved for the ﬁrst four or ﬁve months
--not longer; this child thrived nicely, and leaving the
city last summer, he told the mother in case the infant
seemed to make no progress, not to make a sudden
change to cow’s milk, but to add cream to the condensed
milk with the white of an egg. The mother crowded
the cream and upset the child’s digestion. The physic-
ian used almost every food and 'at last tried Reed &
Carnrick’s soluble food, which agreed for a time. The
child was brought home in November last and had not
gained a pound all summer. He was at last forced to
use the Walker-Gordon milk, which agreed, and the
42 MEDICAL SOCIETY OF
child increased in weight rapidly, and in six weeks was
doing well and is still increasing in weight.
The use of Pasteurization in the preparation of food
was, he thought, a mistake. He had in mind a case of
an infant fed on peptonized food prepared by Fairchild
Brothers—peptogenic milk powder, at a temperature of
160°F. At seven months of age the child was distinct-
ly rickety, sweating head, constipated stools, beaded
ribs, tenderness, etc. He immediately put the child on
fresh cow’s milk, but about ten days afterwardskthe
baby doing well, he had an analysis of milk from one
of the St. Louis dairy milk wagons made in which tu-
bercle bacilli were found.~ He took the baby oﬂf and
Pasteurized the milk, and the week following it was
doing as badly as ever. To his mind the Walker—Gor-
don people were doing a good work, but he agreed with
Dr. Tuttle that it was too expensive for the average
patient. 9
DR. ELLA MARx said she had had but little experience
with the Walker—Gordon laboratory, her experience
being largely among people unable to bear the expense.
She was interested in the case of rickets spoken of by
Dr. Chapman because she had a case fed on peptogenic
powder, and it was found that the child could not take
cream and milk at all. 'Every time cream was put into
the milk the digestion was very much upset. The child
grew decidedly fat—one of the healthiest looking she
had ever seen, but constipation and sweating head, and
other symptoms made her feel that there was something
wrong. While it could not take cream it could take
cod liver oil and progressed very well, and later she
found it could take the milk without the cream.
DR. CHAPMAN said that the Bethesda Home had used
almost exclusively condensed milk, and the result was
many cases of rickets, most of them mild. They are
now using Walker—Gordon milk with the effect-that
there is not a case of rickets in the house—and the milk'
isnot pasteurized. _
DR. AMAND RAVOLD said that the question of infant
CITY HOSPITAL ALUMNI. 43
feeding was a very large and important one and the So-
ciety was to be congratulated upon the very sound views
expressed by its members on modiﬁed milk.‘ In the
years 1885-’86—’87 he was‘associated with the late Dr.
Chas. E. Briggs in the children’s clinic of the St. Louis
Post Graduate School of Medicine where he necessarily
saw a number of cases of mal-nutrition and diseases due
to improper feeding, but his acquaintance with modiﬁed
milk began with the publication of Dr. Arthur V.
Meigs’ work upon “Milk Analysis and Infant Feeding,”
in 1886. During the summer of 1885 they were con-
stantly experimenting with artiﬁcial foods, Condensed
milk, milk powders, etc., in the feeding of the children
brought to the clinic, but he could truthfully say that
the results were always unsatisfactory. In 1886 Dr.
Meigs’ method of modifying coWs’ milk was tried and
the results obtained were so satisfactory that it was
adopted. The instructions to mothers were to ﬁrst purge
the little one and then give the food prepared with two
tablespoonfuls of cream, one of milk, two of lime water
and three of boiled water, and to sweeten with one tea-
spoonful of milk sugar. The quantity of cream and milk
to be increased with‘the increasing age of the child and
the ease of assimilation of the food. Let it be remem-
bered that the mothers were almost invariably poor, liv-
ing in hygienic surroundings never of the best, and as a
rule, ignorant, yet the results obtained in 1886 under
these adverse conditions were so far superior to those of
1885 that the speaker collected a number of the cases
and published them in the. Courier of Medicine for 1887.
As a safeguard against diseased milk boiling‘ was often
advised and as a result occasional cases of rickets and a
few cases of ‘scorbutus were seen among the patients.
At ﬁrst they did not suspect the boiled milk, but subse-
quent experience in infant feeding with sterilized and
non-sterilized milk convinced him that the cooked milk
was the fault. He said that he could not be too emphatic
in the statement of the belief that sterilization or pas-
_teurization of milk for infant feeding is wrong. Both >
44 MEDICAL SOCIETY or
processes injure seriously the casein of the milk, and
infants fed upon it will be found almost invariably
rachitic'or scorbutic, providing a careful search is made.
It was his opinion that milk for infant feeding should
never be heated above 120° F. Here, however, appeared
the horns of a dilemma. Shall the modiﬁed milk be
fed uncooked and chance the ' dangers of tuberculosis
and other diseases conveyed by milk, or shall it be
sterilized or pasteurized and thus brave the other dis-
eases? .
The speaker said when contemplating the ﬁlthiness
of the ordinary dairy and the many conditions to which
the milk is subjected in the handling that favor the
transmission of disease, and further, the great and ever
increasing percentage of tuberculosis among our dairy
cattle, it was enough to make us pause and to turn back
to sterilization and pasteurization. Pasteurization prob-
ably does less harm than sterilization, but of this he
was not sure.
When the Walker-Gordon laboratories were estab-
lished under the scientiﬁc guidance of Dr. Rotch all
felt that the millenium in infant feeding was at hand,
and when, ﬁnally, a laboratory was started here by the
St. Louis Dairy Co., he, for one, hailed it with rejoic
ing, not only for the good it had done in other cities,
but from the promises held forth in its circulars—and
that meant exit sterilization and pasteurization. He
had heard tonight the remarks of the Walker-Gordon
representative (Mr. Howland) and also the encomiums
of all who preceded him in the discussion upon the lab-
oratory, its modiﬁed milk and its methods. To step in
and sound a discordant note in all the song of praise
might seem rather harsh and presumptuous, but inas
much as Mr. Charless Cabanne and Mr. Howland of
the dairy company, were here, he would relate his ex-
perience in the hope that they would try and explain
the cause for discontent. Soon after their labora-
tory started here, said Dr. Ravold, he prescribed their
modiﬁed milk for an infant, a few weeks old, whose
CITY HOSPITAL ALUMNI. _ 45
mother was unable to nurse it, and who was rich enough
to afford it. He ordered fats, 3 to 4 per cent; proteids,
1.5 per cent; sugar, 7 per cent; and lime water sufﬁcient
to redden blue litmus paper; milk not to be heated. The
child did fairly well upon the mixture, but inasmuch as
curds pasSed in the stools,he gradually reduced the prote-
ids to .5 per cent,when the child assimilated the food nice-
ly and grew apace and was healthy. Suddenly the child
began to refuse the food, lost weight, etc., and indiges-
tion followed. The mother discovered that the milk
separated into water below and milk above inthe bot-
tles, something that had not happened before. This
was reported to the laboratory and one of its represen-
tatives went to the patient’s house to investigate. Along
with a lot of gratuitious medical advice that a layman
generally has stored somewhere in his anatomy, be ad-_
vised the mother by all means to sterilize the milk and
the fault would be corrected. The mother’s faithin her
physician was somewhat disturbed by the medical lec-
ture on milk she had received, but she had the good
sense, to report the interview—and he has not used
modiﬁed milk from that laboratory since. Further, be-
fore this trouble occurred, one of his students in bacte-
riology carried out a series of platings in gelatin of
milk taken from different dairy wagons and he found,
in some cases, that the number of bacteria in 1 c.c. of
milk ran into the hundred thousands. A few platings
made from the Walker-Gordon modiﬁed milk and that
of the St. Louis Dairy Co., which was delivered to the
speaker’s home, did not show a surprisingly large differ-
ence in the number of bacteria in the milks; that from
the wagons always contained more, but not a very large
number more. This was nicely explained sometime
later when one of Dr. Saunders’ assistants visited the
dairy at Meramec Highlands and found that the cows
and the milk taken from them were i not handled as the
Walker-Gordon circular stated. He had listened with
4 pleasure and also with amusement to the stable rules the
Walker-Gordon laboratory impose upon the dairy that
46 . MEDICAL SOCIETY OF
is to furnish them with milk and in his humble opinion
they are idealistic and not practical. As well ask a
dairyman to translate a chapter from the Greek testa-v
ment before milking as to carry out all the details of
the requirements demanded by the laboratory;
Dr. Ravold did not for a moment wish to be under-
stood as being opposed to the Walker—Gordon labora-
tory, nor to the efforts they were making to supply a
good, wholesome modiﬁed milk; only this, that his ex-
perience was disastrous and he wanted to help point the
way to a better, further effort on the part of the labora-
tory. What physicians wanted was an assurance that
the milk for which so much pay is asked comes from
well-cared for, well-fed, healthy cows (cows that have
been tested for tuberculosis by the State veterinarians
and so certiﬁed), and whose sanitary surroundings are
good. Further, that the milk be handled with all rea- .
sonable care and cleanliness and be ﬁltered in the labor-
atory through germ proof ﬁlters which can be sterilized
after use, such as the Pasteur or Bergfeld, then modiﬁed
and sent out in sterile vessels. ' \
MR. HOWLAND said, in reply, that the milk now sent
out by the Walker—Gordon laboratory was the product
of a private farm at Clarksville, Mo., and they have
the guarantee of the farmer that the milk is pure and
free from diseases, and the guarantee of the veterinary
surgeon that the cattle are in every way perfectly
healthy; and they therefore can guarantee this milk as.
pure and in no way diseased. Formerly when they had
a farm at Meramec Highlands the farmer was found to
be careless and did not carry out the instructions, nor
follow the rules laid down. As soon as their contract
with him expired they had changed to the present source.
The man in charge is thoroughly honest and ambitious
to have a pure milk produced, and they can guarantee it.
DR. ADELHEIDE C. BEDAL asked whether in the case
of high proteids mentioned an effort . had been made to
change the quality of the breast milk by exercise or
diet, and Dr. Luedeki'ng replied that while the fat per-
CITY HOSPITAL ALUMNI. 47
centage could be easily inﬂuenced it was impracticable
to put the nursing mother on a course of physical exer.
cise that would favorably affect the proteids percentage.
DR. ALBERT E. TAUSSIG instanced a case within his
experience where a modiﬁcation of milk dietary had a
very favorable result.
Some Points in Practical Surgery.
BY FRANCIS REDER, M.D., ST. LOUIS, MO.
In operations on the hand—partial amputation of the
ﬁngers and thumb—utilize any available skin for the
ﬂaps. Let your main object be to leave as long a stump
as possible; do not sacriﬁce length in order to follow any
special method of amputation. Let the cicatrix be, if
possible, posterior, using the tissue on the anterior as
poet of the digit for the principle covering of the divided
bone. When the injury or disease is such as to necesi~
tate amputation at a higher level than the attachments
of the ﬂexor and extensor tendons of the second phal-
anx, is it right to go at once to the knuckle and perform
complete amputation of the ﬁnger? If the tendons can
be saved and attached to the bone, then the ﬁrst phalanx
should be left; if this can not be done, then amputate at
the metacarpo phalangeal joint.
In amputating a digit, or a digit along with a portion
of its metacarpus, avoid, if possible, any interference
with the palm of the hand; avoid a cicatrix in the palm
—-a cicatrix in this situation is apt to be tender, and this
interferes with the grasping power of the hand.
In amputating a ﬁnger, do not Interfere with the
breadth of the hand. In a case requiring the removal
of one or more metacarpals, leave, if possible, healthy
periosteum; new bone is formed, and a more useful
hand is the result. Let this rule, regarding the perios
teum hold good, very specially in connection with the
metacarpal bone of the thumb. Any osseous projection
at the radial edge of the hand is a point of attachment
48 _ MEDICAL SOCIETY or
for the muscles of the ball of the thumb, and it' is of the
greatest use as an opposing point to the ﬁngers.
In patients in whom manual labor is their source of
income, do net, in amputating the index and little ﬁn-
gers, interfere with the heads of the corresponding met-
acarpals, if a sufﬁcient covering can be obtained. In
other cases, for the sake of appearance, the head of the
metacarpal may be removed obliquely. '
Take, if possible, your main ﬂap in amputating any ‘
of the ﬁngers from the ﬂexor aspect of - the ﬁnger. ‘.Do
not approach the palm in, your incisions. In the middle
and ring ﬁnger the best result—looking to use and not
to appearance, is obtained in the following way: '
Enter the knife at the knuckle, carryit outward and
forward toward the web until a point _midway between
the anterior and posterior aspects of the web is reached.
Do the same on the other side of the ﬁnger; these two
incisions form a right angle with each other. A ﬂap is
then made from the anterior aspect of the ﬁrst phalanx.
The ﬁnger is removed and the ﬂap is turned. backinto
the angle where the incisions begins over the knuckle.
By this method the incisions do not approach the palm,
the breadth of the hand is not interfered with, and the
resulting cicatrix is posterior.
In crushes of the hand save as much as possible; save
‘a ﬁnger or a portion of a ﬁnger; save any part of the
thumb; save any portions of the metacarpals. The most
useless natural hand is more useful than anyvartiﬁcial
substitute.
In contractions of the palmar fascia, Busch’s opera-
tion in severe cases affords the best results. In simple
cases the subcutaneous division of the tense ﬁbers is
generally sufﬁcient. It is to be remembered that there
are two directions in which the contracted fascial ﬁbers _
must be divided, parallel to the skin surface and at right
angles to the skin surface; by the ﬁrst, the ﬁbers at right
angles to the skin surface, which drop down between
the ﬂexor tendons, are divided; by the second, the long-
CITY HOSPITAL ALUMNI. 49
itudinal ﬁbers of the contracted palmar facia are
divided. '
Busch’s operation consists in dissecting the contracted
fascia from the ﬂexor sheaths by a V-shaped ﬂap, the
apex of the ﬂap looking to the wrist; the ﬁngers are
then extended, and the ﬂap attached by suture to the
edges of the incision, while the opposing edges of the
proximal portion of the raw surface are accurately
stitched together. The result is a Y-shaped cicatrix,
and an extended ﬁnger or ﬁngers with no tendency to
subsequent contraction.
In wounds of the palm the persistent hemorrhage is
often due to palmar vessels being simply punctured and
not cut fairly across." Divide the artery woundedby
deepening the accidental wound. Retraction of the
wounded vessel takes place, and simple pressure is gen-
erally sufﬁcient to arrest the hemorrhage. Check the
force of the blood ﬂow by fully ﬂexing the forearm on
the-upper arm with a pad at the bend of the elbow. By
these means the hemorrhage is arrested; if it still per-
sists tampon the wound in the palm.
Hemorrhage in a severely crushed hand is sometimes
very persistent, frequently requiring careful dissection
to expose the wounded artery, thus allowing the appli-
cation of a ligature. In some instances it is necessary
to tie the brachial artery. _ -
In deep seated digital inﬁammations over the ﬁrst and
second phalanges, the cause is either an inﬂammation of
the ﬂexor or sheath, or it may have a periosteal origin.
In inﬂammations over the anterior aspect of the termi-
nal phalanx, the cause is periosteal, and the worst that
can happen is necrosis of the terminal phalanx. In all
cases make your incision early, central and in the long
axis of the ﬁnger. ‘ Relieve tension and prevent spread
of the inﬂammation from the ﬂexor sheath on the ﬁnger
to the common sheath on the anterior aspect of the
wrist. In periosteal cases, early and deep incisions pre-
vent necrosis of the affected phalanx. _
In inﬂammation of the common ﬂexor sheath, relieve
50 MEDICAL SOCIETY OF
the tension by making an incision into the sheath in the
forearm above the annular ligament. Take care and
not injure, in your incision, the median nerve.-(After
opening the ﬂexor sheath in the forearm, pass a curved
probe pointed bistoury from the wound under the an-
nular ligament, divide it with the knife, and in this way
the palmar tension is effectually relieved).
In amputation for injury or disease in the upper ex-
tremity, do not follow, at the cost of length, any special
method of amputation; get your ﬂaps as best you can,
so as to obtain as long a stump as possible; the longer
the stump the easier it is to ﬁt on an artiﬁcial substitute.
In severe injuries of the upper extremities, where an
effort is made to save the limb, more especially in cases
in which the bones are injured, and in which the line of
fracture is oblique, or in which, from comminution of
the bones, it is diﬂicult to keep the fragments in accur-
ate position, remember that the use of the extension ap-
paratus is as valuable in the upper as it is universally
acknowledged to be in the lower extremity.
In all fractures near the joints the soft tissues are, to
a certain extent, saved from injury when the bone gives
way, but still in all cases there must be some injury to
the tendons, muscles, joint and ligaments. These struc-
tures require, for the proper performance of their func-
'tions, mobility; prolonged rest to prevent any risk of
non union of the fractured bone, may be followed by
stiffness of the neighboring joint, by adhesions of the
ligaments, and organized effusion into the sheaths of
the tendons. The result is a united fracture with a
stiffened joint.
Non-union of bone does not occur in consequence of
occasional gentle passive movement along with massage,
if, in the intervals, the parts are kept at perfect rest.
Non-union is much more likely to occur if slight con-
stant movement is allowed between the broken ends.
For example, in a fracture of the shaft of the humerus,
and in fractures of the shaft of the radius and ulna, it
is important to keep the elbow-joint at rest by means of
CITY HOSPITAL ALUMNI. 51
a rectangular splint. If the elbow-joint is not kept
' quiet, there is more or less constant movement at the
seat of fracture. This movement is very different from
gentle passive movement every second day, with perfect
rest in the intervals, as in fractures in the region of the
wrist, elbow and shoulder. ~
In Colles’ fracture allow the patient to move his ﬁn-
geris and thumb after the ﬁrst week, and after ten days
remove the splints every second day and move the ﬁn-
gers, thumb and wrist joint gently. Take off all splints
at the end of four weeks. Too prolonged rest in this
injury often ends, more especially in old people, in ir-
remediable‘stiﬁening of the ﬁngers, thumb and wrist-
joint. ’ '
In fractures into the elbow-joint, early gentle passive
movement at the end of a fortnight every second day,
will often wholly prevent any stiffening of that joint.
In fracture of the upper extremity of the humerus,
begin passive movement after a fortnight.
The fractures of the metacarpals are frequently diag-
nosed with diﬂiculty, and this is especially true of the
third and fourth of these bones. Oblique fractures are
the most troublesome. It may be necessary, in such
' cases, to apply extension. An anterior splint, carefully
padded, so that there may be no pressure on the ball of
the thumb, stretching from the bend of the elbow well
beyond the tips of the ﬁngers, is ﬁxed tO to the forearm
with adhesive plaster. An elastic band is attached to
the injured ﬁnger also by adhesive plaster, and extension
is kept up by ﬁxing it to the extremity of the anterior
splint. -
In fractures of the phalanges, utilize the neighboring
ﬁngers as lateral splints, padding carefully between the
ﬁngers so as to prevent discomfort, excoriation and
itching. Skin should never be allowed to remain for
any length of time in contact with skin. In ﬁxing the
arm to the trunk, in fracture of the clavicle and in frac-
ture of the upper extremity of -the humerus, if a layer
52 MEDICAL SOCIETY OF
of lint is not placed between the arm and-chest, much
discomfort willfollow.
In fractures of the clavicle and upper extremity of
the humerus, it will generally be found that the broken
ends of the fractured bone are best brought into appo-
sition by bringing the arm well across the chest, so that
the hand lies at the opposite shoulder. .
In securing the arm the use of a long strip of adhe's-
ive plaster, ﬁxing the limb to the trunk, is a simple and
efﬁcient way of treating these injuries. In greenstick
fracture of the clavicle, a common accident often over-
looked at the time of injury, the strip of adhesive plas-
ter is the best method of treatment. '
In fracture of the clavrcle at the coraco-clavicular
ligament there is no displacement. In fracture of the
clavicle external to the ceraco-clavicular ligament there
is no downward displacement, and the forward displace-
ment is not observed at the time of fracture, but be-
comes very evident at a subsequent date. Such frac-
tures are best treated by simple means. Avoidance of
all special forms of apparatus is advisable.
In amputation Of the toes, a partial amputation may
be performed in the great toe; in the other toes partial
amputations are inadmissible; avoid any incision in the
sole of the foot. Remember the foot is a tripod, and
its stability rests in the integrity of three points of sup-
port—the ball of the great toe, the ball of the little toe
and the os calcis; interference with any one of these
lessens the value of the foot as a basis of support. Any
narrowing of the foot approximating the two anterior
p01nts of support also renders the foot less Stable.
Use the plantar surface for the principle ﬂap in am-
putations through the tarsus and at the ankle-joint. In
amputation at the tarso-metatarsal joints and in ampu-
tations through the center of the tarsus, after marking
out the ﬂaps by incisions down to the bones, it is best to
disarticulate, and then dissect the bones off the long
plantar ﬂap from behind forward.
In all amputations in the lower extremity sacriﬁce
CITY HOSPITAL ALUMNI. 53
length in order to obtain a stump that will bear pressure.
A painful stump is worse than useless; with it the pa-
tient has no comfort, and can not wear an artiﬁcial sup-
port.
In amputation above the ankle the long anterior ﬂap
gives the best result. In amputation below the knee
the modiﬁed circular is, as a rule, preferable to the long
posterior ﬂap.
In sawing the bones in amputations in the leg, always
enter the saw upon both bones at once, so that the ﬁbula
may be divided before the tibia.
In amputation below the knee it is often difﬁcult to
secure the arteries. When such difﬁculty arises, take a
curved needle, armed with catgut, and pass it into the
tissues behind the bleeding point so as to include the
tissues around the vessel in the ligature.
In amputation for injury through the shaft of a long
bone the periosteum may be divided at a lower level
than the bone; if this is done it is best to save the per-
iosteum on the anterior surface of the bone, and allow
a ﬂap of periosteum to hang over the divided medullary
cavity. Do not stitch it for fear of deep seated tension.
In fractures of the leg, use the box splint till the
swelling has subsided. A well applied plaster of-Paris
splint is to replace the box splint. See that the foot is
kept at right angle to the leg, and thus retraction of the
heel prevented. Take care that there is no eversion of
the foot. '
In oblique fractures use extension.
In fractures of the patella, ﬁx to the anterior aspect
of the thigh a large piece of adhesive plaster, and make
thorough extension on the quadriceps extensor curis—
elevating the limb on an inclined plane with a foot-
piece. If this method proves inadequate, exposure of
the fractured patella and subsequent “wiring” of the
fragments, will have to be resorted to. Exercise care in
drilling the holes into the fragments so as not to wound
the cartilage.
For all fractures of the thigh, the Hodgen splint,
54 MEDICAL SOCIETY or.
properly applied, has most satisfactorily demonstrated
its eﬂiciency,
In conclusion, I beg to say that in diagnosing an in-
jury, look before you touch the limb. ' Remember the
normal relations, of the styloid processes in diagnosing
injuries in the region of the wrist; the relation _of the
head of the radius to the external condyle, the relation
of the olecranon to the internal condyle of the humerus
in the elbow joint; and let the 'coracoid process and its
relation to the head of the humerus be» the principle
guiding landmark in injuries -in the region of the
shoulder.
[JAlways expose the uninjured corresponding region,
examine it in the ﬁrst instance, and let it be your stand-
ard (having satisﬁed yourself that it is normal), in diag-
nosing the injury on the opposite side.
When a patient is brought under your notice With
pain in the knee, for which you can not ﬁnd any evident
local reason, always carefully examine the hip, and in
a patient who limps as if from hip-joint disease, if you
do not ﬁnd in the hip evident objective symptoms of
joint disease, alWays carefully examine the back—he
may be suffering from vertebral disease, with effusion
into the psoas muscle under the psoas fascia. '

DISCUSSION.
DR. A. H. MEISENBACH said that Dr. Reder’s paper
covered an extensive subject. One of the most inter-
esting topics in the realms of surgery was, to his mind,
the surgery of the hand. There is no organ more in-
sulted and less understood. Every day almost he saw
the results of maltreatment of this member both in his
clinical work and general private practice. He fully
agreed with Dr. Reder that every individual ﬁnger
should be saved if possible or as much of a ﬁnger or
portion of the palm as possible, because even the stump
of a ﬁnger is of more use than an artiﬁcial one. In all
his work he said he had been led by .the principle laid
CITY HOSPITAL ALUMNI. 55
down by Dr. Reder, namely—save as much as possible.
of the hand. Two little works he would suggest every-
one should read—Hilton, on “ Rest and Pain,” and
Bryant’s work on “ Tension.” If these books were
read more extensively many of the defects in sur-
gery would be obviated. In regard to the application
of splints he thought non-union of bone does not de-
pend on immobility alone, but on many other causes.
He had never seen the clavicle thoroughly immobilized,
yet non-union of this bone is a rarity. Almost every
day he saw the lack of the use of the knife. The knife
is looked upon as an instrument of torture, whereas it
is really a means used for relief. He recalled a case of
diﬁuse cellulitis involving the lower leg. The case was
in a hospital four-weeks under the care of a surgeon.
The question of amputation came up. He found the
leg wholly undermined by pus which was liberated by
free incisions. Had the knife been used at the proper
time in this case no question of amputation would have
come up; as it is, the patient will have to possibly sacri~
ﬁce a foot. In regard to the Hodgen splint he wanted
to say that of all apparatus in use in the surgical world
at the present time for fractures of the thigh—and he
had seen many of them—he would rather have his own
leg put up in a Hodgen splint if fractured, and treated
by a man that knew how to use the splint, than by any
other means that he knew of. He had had the pleasure
and opportunity to use the Hodgen splint in the City
Hospital under the direction and supervision of Dr.
Hodgen himself and would say that he had yet to see a
bad result from the use of this splint when applied by
one who knows how to use it, but he had seen many
bad results from the use of plaster-of-Paris in fractures
of the femur.
- DR. NORVELLE W. SHARPE agreed with Dr. Reder in
regard to the application of the Hodgen splint. He had
never seen a bad resultafrom its proper use,buthad seen
bad results where the splint was wrongly put on. He .
56 MEDICAL SOCIETY OF
thought but little stress was laid upon the use of this
splint in the East.
DR. FRANCIS REDEE said in injuries to the thumb
where non-union of the phalanx results, amputation
should be resorted to because a good serviceable stump
can be given. In injuries to the great toe he would
give that member every chance and ﬁrst resort to resec-
tion of the joint. Failing in this there was a good ex-
cuse for amputation. In regard to the remarks on
Hodgen’s splint he thought it was certainly the most
comfortable splint. He had had occasion to apply this
splint while in the German Hospital In New York. The
hospital surgeon in going through the division noticed
the peculiar contrivance and sent for the speaker and
ordered it taken down. The latter urged that it remain
until the visiting surgeon should see it. When he arrived
the matter was talked over and the splint was allowed
to remain. It was a source of much interest to them. ‘
The following week another case of fractured femur
was brought into the division and the ordinary splint in
use there was applied—a variation of Volkman’s—simi-
lar to Buck’s splint. It was interesting to note the dif-
ference in the comfort of the two patients. From that
time the Hodgen splint has been the adopted splint in
the German Hospital.
STATED MEETING, THUEsnAY EVENING, MARCH 3.
THE PEEsIDENT, DR. GEo. HOMAN, IN THE CHAIR.
Specimens of Renal Calculi and a Horse-
Shoe Kidney.
DE. RoBEET AMYX said he was not prepared to pre-
sent the subject of renal calculi at length, as he sup-
posed when he received Dr. Sharpe’s request that all he
was expected to do was to bring the specimens for in-
spection by the Society. He said, however, the kidney
containing the calculi had a most important history.
CITY HOSPITAL ALUMNI. 57
The patient during life did not present any symptoms
that would lead to a diagnosis of renal calculi, although
the stone found was a very large one, and with it were
quite a number of smaller ones.
DE. BBANSFORD LEWIS, discussing the specimens of
renal calculi, said the history of the specimen before
the Society illustrated one peculiar feature about renal
calculi and that was the fact that a man can carry a
stone like the one on exhibition, and not suffer any ac-
tual pain. This had been remarked by a number of
people. Clinically this patient gave no history of cal-
culus, yet in the pelvis of the kidney was found a stone
as large as a pigeon’s egg. Other cases had been ob-
served by the speaker where a stone was found in the
kidney upon post mortem examination, but there had
been no history of pain during the lives of the patients.
He said the diagnosis of calculus may have been made
_ from other causes, such as bleeding, and other reasons,
but no pain was complained of pointing to such a
trouble.
DR. AMAND RAVOLD asked if there was no history of
pain in this case.
DE. AMYX replied that there was not.
DE. CHARLES H. DIxON asked if the convex potion
of the horseshoe kidney was directed upward or down-
ward. He said the convexity was usually downward.
DR. AMYx replied, taking his information from the
notes of the postmortem, that the kidney lay in the
lumbar region, as usual, with the lower extremity turned
forward and toward the median line and pushed back in
the shape of a horseshoe. The convex portion of the
kidney was directed downward, the upper and free ends
were directed backward.
58 MEDICAL SOCIETY OF
STATED MEETING, THURSDAY EVENING, MARCH 17.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
On the Use of the Refractometer for the
Identiﬁcation of Oleomargarine.
BY HOWARD CARTER, M.D.,
Milk Inspector, City of St. Louis.
All transparent substances possess the property of
deﬂecting rays of light which pass through them. This
principle has been seized upon by Professor Abbe, who
has applied it to the detection of oleomargarine and the
identiﬁcation of such transparent substances as glycer-
ine and the numerous varieties of oils.


FIG. 1.—REFRACTOMETER.
The instrument consists of a rectangular metal cham-
ber Into the upper end of which a telescope is inserted.
CITY HOSPITAL ALUMNI. 59
This chamber is divided diagonally into two water-
tight compartments A and B hinged together at C and
locked at F.
A prism is inserted into each section in such a man-
ner that when the chamber is closed the faces of the
prisms are in contact. The sections of the chamber are
further connected with each other by means of a rubber
tube, thus enabling a stream of water to be kept con-
stantly ﬂowing through that part of the instrument
which contains the prisms for the purpose of maintain-
ing a uniform temperature. A thermometer inserted
through a screw hole in the front part of the chamber
enables the obServer at all times to know the tempera-
ture which must be maintained at 25° C. This is done
by having a supply of hot and cold water which can be
suitably proportioned to each other by the use of a two-
way stop cock, the stream entering the chamber at D
and emerging at E. '


FIG. 2.—EMPTY. FIG. 3.--CEDAR OIL.
A beam of light X entering this instrument at H acts
in the following manner: When there‘is no transparent
substance between the faces of the prisms it is deﬂected
at P to X' so that no light whatever enters the telescope
and we have an absolutely black ﬁeld, represented by
Fig. 2. . ‘
When, however, a transparent substance is to be ex'
amined, it is ﬁrst melted and then uniformly interposed
. 60 MEDICAL SOCIETY 0]?
between the faces of the prisms, the beam of light suf-
fers deﬂection proportionate to the refrangibility of the
substance through which it passes. The direction of the
deﬂection beingfrom the left of the observer towards
his right only that portion of the telescopic ﬁeld will be
illuminated which lies to the left of the point of en-
trance of the ray. A scale which is marked off into 100
divisions is contained within the telescope in a horizon- ,\
tal position, and the illuminated portion cuts the ﬁeld '
sharply at right angles to the scale.


FIG. 4.—BUTTER, PURE. FIG. 5.—OLE0MARGARINR.


FIG. 6.—-COTTON—SEED OIL.
For example, if cedar oil is placed between the faces
of the prisms the beam of light follows the course XPR
and the entire ﬁeld is illuminated as in Fig. 3. A
CITY HOSPITAL ALUMNI. 61
greater or less illumination will take place according to
the refractive power of the substance examined.
Thus when pure butter is examined the beam of light
takes the course represented by XPS and presents a
ﬁeld similar to Fig. 4, giving a reading of from 50
to 54 on the scale; whereas, if the substance under
examination should be oleomargarine, the beam of light
would take the course indicated by XPO, and we would
have a reading of from 56 to 60, as shown in Fig. 5.


3C
FIG. 7.—LATERAL SECTION OF REFRACTOMETER.
At a temperature of 25° 0., pure butter is never known
to give a lower reading than 50 nor higher than 54.
When cotton seed oil is examined, the beam of light
takes the course XPH, and we have a correspondingly
high reading of from 70 to 75, as shown in Fig. 6.
When cotton-seed Oil is examined the border between
62 MEDICAL SOCIETY OF
the illuminated and the dark portion of the ﬁeld is
marked off by a deep blue line. In a considerable num-
ber of samples of oleomargarine, which have been ex-
amined, I have found a blue line, and it is highly prob-
able that it was caused by the presence of cotton-seed
oil, the color being almost identical, although the width
of the line was less than that of the pure oil.
Referring again to the readings of the instrument, I
wish to say that the reading of the scale does not repre-
sent the angle of refraction although the angle of refrac-
tion can be calculated from it.

DISCUSSION.
Returning to the 011 then in the ﬁeld DR. CARTER
said that it was olive oil; the deep blue line showed
plainly, but he stated that if it were cotton-seed oil the
line would be twice as wide and very much more bril-
liant. The instrument, he said, although valuable in
obtaining approximate results could not take the place
of chemical analysis; it would enable the analyst to de-
termine in a few moments from a number of specimens
submitted which were worthy of further examination,
as the readings of the instrument would determine
which were pure butter; all examinations reading 54 or
under might be considered as pure butter, those reading
over 54 should be classed as adulterated and chemical
analysis would unquestionably verify the verdict.
In regard to the detection of the purity of olive oil,
he had seen no reference to the importance of the blue
line in the literature he had examined. No mention of
it was made in the instructions accompanying the in-
strument. He was inclined to think that many of the
vegetable oils would show the blue line; it was present
in cotton-seed, olive, and bergamot oils.
DR. FRANCIS REDER asked what the signiﬁcance of
the blue line was.
DR. CARTER replied that he did not know the import-
ance of it. He had found it in some specimens of oleo-
margarine, but never in pure butter. The blue line and
CITY HOSPITAL ALUMNI. 63
cotton-seed oil were associated and where the blue line
was found it might possibly signify the presence of cot-
ton seed oil.
DR. REDER asked if this bore any relation to the pur-
ity of the article.
DR. CARTER said he did not think so.
DR. JOSEPH GRINDON asked in what proportion of the
specimens examined he found the absence of the blue
line.
DR. CARTER replied that in the samples of butter he
had never found the blue line; in 30 or 40 specimens
submitted to determine how many were oleo he had
found perhaps a dozen with the blue line; but he had
also found some oleomargarine without the blue line.
DR. GRINDON asked what proportion of the specimens
of alleged butter were found to be pure butter.
DR. CARTER said that out of 30 or 40 samples sent
him, and which had been sold for pure butter, he found
only three or four not oleomargarine.
DR. AMAND RAVOLD asked what oleomargarine was.
DR. CARTER said it was a compound made to simu-
late butter which could be sold at a lower price than
butter. It is manufactured from beef suet and neutral
lard, usually with the addition of a little pure butter
and a certain amount of pure milk which is churned up
with it in order to improve the ﬂavor. The milk is
afterwards removed in the process of manufacture. It
presents a very fair appearance and so far as keeping
qualities are concerned is better than ordinary butter,
owing to the absence of the fatty acids.
DR. CHARLES H. DIxON asked if the degree of tem-
perature at which oleomargarine melts is not higher
than butter.
DR. CARTER replied that it was. Butter, he said, had
a low melting point, but he did not know the exact
point. Neutral lard melts at a low point but it is lower
than suet fat.
THE PRESIDENT asked if it was possible that ﬂuores-
cence had anything to do with the causation of the blue
64 MEDICAL SOCIETY OF
line. He said it had occurred to him, since examining
some specimens in Dr. Carter’s ofﬁce, that this might be
an explanation of it, such a phenomenon being present
in a number of chemical solutions.
DR. CARTER said he was not prepared to give an ex-
planation as to the presence of the blue line; it may be
as Dr. Homan suggested, but he could not say. He
thought, if it was ﬂuorescence pure and simple, it would
be seen more frequently in the samples of oleomargar-
ine. In coal oil and many of the lubricating oils there
is a ﬂuorescence in certain lights, but whether it was
seen in a refracted light, as in this case, he was not pre-
pared to say; he was inclined to think not, but he had
made no experiments on that point.
The Treatment of Septic Endometrial
Diseases.
BY FRANK A. GLASGOW, M.D., ST. LOUIS, MO.
In a discussion last fall with several gentlemen of our
profession, all more or less prominent, I was amazed to
hear the uterine douche decried, if not altogether con-
demned.
Reﬂecting on this, I could not help saying to myself,
if these gentlemen are still in this benighted condition,
there must be many others in the same fog.
I determined to start out on mission work and write
a paper which, however poor and ill-prepared, would
serve to call attention to what can be done in these com-
plaints. We may look on endometrial inﬂammatory
diseases as divided into two great divisions, viz., acute
and subacute, or chronic.
The acute may be divided into those due to necrotic
tissue infection, and those due to speciﬁc infection irre-
spective of tissue of low vitality. Under necrotic tis-
sue infection we may mention cases of decidual remains,
blood clot, sloughin g ﬁbroid, placental remains and even
genuine infective puerperal fever, for this is infection
CITY HOSPITAL ALUMNI. 65
of semi-necrotic tissue. In all these cases common
sense should teach us to remove the special pabulum on
which the putrefactive germs are feeding, also the germs
themselves, as far as practicable. After doing this we
should make the cavity of the uterus as unhealthy for
the germs as possible without interfering with the vital-
ity of the walls. Here is the great diﬂiculty.
If we introduce antiseptics strong enough to destroy
germs they certainly will destroy some of the endome-
trium which will become new necrotic material for the
germs not removed or killed to thrive on. No one who
understands the histological structure of the endome-
trium can admit, that it is possible to make a septic uter-
ine cavity perfectly aseptic. The penetration of putre-
factive and other germs into the uterine glands renders
this impossible. The best that we can do is to remove
all on the surface and even scrape away the superﬁcial
portion of the endometrium itself. After this we must
either keep the endometrium so dry that germs will not
ﬂourish, or we must see that free drainage is secured, so
that the serous exudate which always follows trauma
may ﬁnd free exit. This is Nature’s method of washing
away irritating material. We can also imitate Nature
and wash freely with a double uterine canula. A con-
tinuous washing would be the ideal method, and normal
salt solution the ideal washing ﬂuid. The great major-
ity of cases will recover on this treatment if instituted
before active infection has occurred beyond the endo-
metrium. By active infection I mean a focus formed
which is beyond the powers of Nature to subdue.
We know that small quantities of living septic germs
are often walled in and ﬁnally destroyed by the phago-
cytes or other blood elements. There is one point which
to impress on you, which is, that these early cases of
post-puerperal or abortive infection often look worse
than they really are. They may have high fever, a
quick pulse, a bloated and sensitive abdomen, and an
anxious look—a picture of a fatal case of peritonitis; it
66 MEDICAL SOCIETY OF
most certainly will be such unless treated very energet-
ically.
The old, false teaching to keep out of the uterus if
there was periuterine inﬂammation present, is probably
responsible for the present let alone policy. There
could be no worse, and I will say foolish, treatment
than this.
Trusting to vaginal douches after the vagina has been
cleared of clots is just as bad. This is, perhaps, worse
for you to lead the family to think that you are doing
something when you are not. You are simply playing
into the hands of the undertaker. I said that these
cases looked worse than they are, I now wish to explain.
If you will take such a case as I have pictured, which
has not existed more than, perhaps, two or three days,
and will wash out the uterus ﬁrst, then curette suﬂ‘icient-
ly to remove the necrotic tissue, then continue your
washing several times a day, keeping good drainage in
the meantime, you will be amazed at the rapid recovery
of your patient. You ought in every case wash well
before curetting so as not to inoculate the fresh surface
by means of the curette. The sharp irrigating curette '
is by far the best instrument in early abortion cases, on
account of the thinned, softened condition of the walls
of the uterus.
In order to make the sharp ring curette of the Sims’
~ somewhat safer I have placed a back to it. This really
takes away some of the cutting qualities and converts
it into an excellent scraper. It is far better than a
spoon, for the edge is turned toward you, it also holds
the material better than a spoon. I have been using
this modiﬁcation of Sims for many years and am well
pleased with it. After curetting and washing you will
have to continue the use of the intra uterine douche
three or four times a day for some time.
A chill and high fever will sometimes follow after
using a uterine douche. This I believe can be almost
invariably avoided by using luke-warm water in the
douche. I believe that the hot water of the douche
CITY HOSPITAL ALUMNI. 67
causes contraction of the uterine muscular structure and
so forties some septic matter, which was in the lymphat-
ics or blood vessels, out into the general circulation.
I never use hot water in these cases and consequently
have only seen one case as above described. I have
heard of others having this experience.
In using the intra uterine douche I never employ a
speculum. I place the patient on her back, with a bed-
pan or Kelly pad under her, and wash out the vagina
thoroughly with some mild antiseptic as 1 to 6000 or
8000 bichloride solution; a teaspoonful of creoline to a
quart of water or a half-ounce of Labarraque’s solution
to the pint of water. 1
After cleansing the vulva and my hands thoroughly I
beat the canula until the droplets of water on it boils,
then let it cool, and after oiling introduce on your fore-
ﬁnger. You, who have not done this, will be surprised
at how little pain it causes. '
If you should attempt to place a speculum in a post-
partum case several times a day you will cause fearful
agony and will soon have rebellion. You will ﬁnd some
cases in which the uterus will lie so far forwards that
you will have to raise it with your ﬁnger before the
canula will go in readily.
This double canula which I show you is one which I
devised some years ago, because I was dissatisﬁed with
what was then obtainable. My object was to make it
as simple as possible and easily cleaned. You can clean ,
it without removing it from the uterus by simply with-
drawing the inner tube a little and replacing it. It has,
I understand, supplanted all other uterine canulse in
this market.
To go back to the patient. After washing out the
uterus in such a case you will often ﬁnd the whole aspect
of the patient changed in twenty-four hours. Often the
fever will be almost entirely gone inside of thirty six
hours. You will ask, how is this possible if there was
peritonitis. It would not be possible if there was peri-
tonitis; so I hold that there was no true peritonitis. I
68 MEDICAL SOCIETY OF
think that we might call this toxic peritonitis due to the
toxins given off by the septic activity in the uterus.
This toxin poisoning would naturally cease when the
supply was out OK. Had there been a free exit from
the uterus there probably would be no poisoning.
We hear of many such cases after labor. There is a
very offensive discharge for days with perhaps little
immediate inconvenience to the patient. These are
the cases our do-nothing friends cure with vaginal
douches. They would recover anyway for the uterine
os is patulous.
I think that it is well, in some of these cases where
we can not wash often enough, to devise some good per-
manent drain.
I do not like gauze, for it is not so easy to place with-
out a speculum, and it is not a perfect drain. Here is a
drain which I bought some years ago. It has served me
well in several cases. It is called Schapp’s spiral drain.
You can see that it is merely a spiral cut out of a hard
rubber tube. For a post-partum case I know of nothing
better. You can introduce it with a pair of forceps after
washing out the vagina. It does not tend to fall out
while the patient is recumbent.
If you will handle your cases of puerperal sepsis in
this way I feel sure that you will lose very few. I can
truthfully say that I have never lost a case of sepsis
after abortion or labor when called in within a week of
the occurrence of the said labor or abortion.
There is a kind of septic puerperal infection which I
believe is rare—I refer to that very contagious malig-
nant type which we sometimes see in hospitals, but sel-
dom in private practice. The poison or rather the sep-
tic organisms in these cases seem so virulent that they
penetrate the living tissues and circulate in the blood.
There may be none in the uterine discharges, although
they gained entrance by the denuded mucous surface.
These cases will probably die in spite of all that you can
do. They do not disprove what I have said in the pre-
ceding cases. You should treat them like the other
CITY HOSPITAL ALUMNI. 69
cases. You can do little more; you should not. do less.
Perhaps the streptococcus serum may help us out. For
my part I do not believe that the utility of this serum
has been demonstrated.
As regards gonorrhea, when the gonorrheal poison
has once fairly entered the uterus, I do not believe that
we can eradicate it, however energetic our treatment
may be. I do not believe in energetic intra uterine
treatment in such cases, while in an acute stage, so I
should except them from the above treatment. They
do better on general anti-phlogistic measures, viz , hot
injections and applications, saline laxatives, low diet, etc.

DISCUSSION.
DR. MARY H. MCLEAN said she was much interested
in the paper mentioned by Dr. Glasgow as having been
published in the Amer. Jour. of Obstetrics and Diseases
of Women last January. He had some ideas not gen-
eral on the subject of chronic metritis. She thought
douches were not used frequently and copiously enough
in puerperal endometritis. She also said she was much
interested in the spiral stem spoken of,. but which she
had never seen. She thought, however, that in early
puerperal cases there would seldom be diﬂiculty in hav-
ing the cervix patulous enough; it is rarely contracted
to such an extent as to have insuﬂicient drainage, unless
there is a ﬂexionr
DR. ELLA MARx Said She would like to know how Dr.’
Glasgow differentiated between a septic puerperal infec-
tion and one due to the gonococcus when it was not a
recent gonorrheal infection, but a lighting up of a latent
infection. At other times the differentiation could be
made by means of the microscope, but she doubted that
it could be done in puerperal cases.
DR. LOUIS C. BOISLINIERE said his experience with
puerperal cases was a sad one. While interns at the
Female Hospital puerperal septicemia broke out in a
most virulent type and the mortality was high; in ﬁfteen
cases there were seven deaths. They used the intra-
70 ‘MEDICAL SOCIETY OF
uterine douche, but he thought now, not with suﬂicient
frequency; they did not curette. Curetting was done in
one case but without beneﬁcial result, as the patient
died—it may have been used too late. He had occasion
to make post mortems in some of these cases, and found
a necrotic condition, as Dr. Glasgow had mentioned,
very marked. The entire interior of the uterus pre-
sented a dirty, Slate colored mass of necrotic tissue not
unlike a diphtheritic membrane, which extended far up
into the veins and sinuses; sometimes it was found ex-
tending a half inch into the veins. Dr. Boisliniere said
he had been using Dr. Glasgow’s most admirable intra-
uterine injector since he ﬁrst invented it; he has im-
proved on it somewhat, having made the openings
larger; it is anatomically correct, the return ﬂow is free
and the instrument can be easily cleaned; he was sorry
that Dr. Glasgow did not have the instrument at hand.
DR. BENNO BRIBACH said he thought the washing and
cleansing of the uterus, especially after abortions, was
self indicated; but now and then cases of septicemia are
met with where there is no evidence of necrosis, no Of-
fensive discharge, etc. He said he had met these cases
often, where washing out and curetting was without
good result, and he thought the reason of the beneﬁt in
some cases while in others there was no beneﬁt from
this treatment, was due to the different kinds of infec-
tion. He thought it a good ﬁeld for the bacteriologist.
He had met some cases where washing out and curetting
did no good and the cases ﬁnally terminated fatally.
Some cases of irrigation, where all precautions had been
taken for the return of the ﬂuid, would be followed by
alarming symptoms, such as a chill, high temperature,
etc. A recent case of a primipara, who had been under
the care of an intelligent midwife, came to him. He
could not account for an infection, but there was an in-
fection and he believed it was erysipelatous. The symp-
toms were alarming fromrthe beginning, but there was
no‘ offensive discharge such‘as might be expected. With
a skillful gentleman he explored the uterus, but the re-
CITY HOSPITAL ALUMNI. 71
sult was negative. The case ﬁnally recovered and he
thought that it was due to the injection of the strepto-
coccus serum. He thought the infection was entirely
beyond control, and due to different kinds of bacteria,
and believed a study of this subject would give good re-
sults. He did not think rules could be laid down for
the care of these cases by washing out and curetting;
some would be beneﬁted while in others it would be of
no avail and he did not think we would have any real
light on the subject until we can differentiate.
DR. HARRY P. WELLS asked if Dr. Glasgow was al-
ways satisﬁed with the means of drainage described.
Only two were meptioned—the tampon and the spiral-
and he thought it was often adVIsable to pack. In re-
gard to the route of infection he would like to ask if the
involvement of the tubes and ovaries with resulting
pyosalpinx was by continuity of tissue, or through the
lymphatic channels. He also desired to know if Dr.
Glasgow would curette all those cases, so frequent, with
the characteristic glairy mucus and thin milky dis-
charge from the cervix, and if he considered this always
an evidence of infection of the endometrium. The large
number of patients complaining Simply of the whites he
regarded as important on account of their frequency,
and wanted to know how to determine whether it was
advisable to dilate and curette. The nervous symptoms
following in these cases and resulting in the modern
hysteric were well known. He also asked what were
the chances of conception after inﬂammatory process in
the endometrium, whether involving the tubes or not.
It was said that one who had suﬂfered with inﬂammatory
trouble of the endometrium never, or at most but very
seldom conceived.
DR. LLEWELLYN P. WILLIAMSON mentioned a case of
septic infection at the City Hospital which was ﬁrst
treated by packing. The woman’s temperature rose to
101—103° F., the pulse rapid, and she presented a typi-
cal picture of septic infection. Then a No. 10 catheter
was substituted for the gauze and pushed well in. In a
72 MEDICAL SOCIETY OF
little while the temperature went down to 100° F., and
the patient soon recovered. ‘
DR. FRANCIS REDER said, in regard the treatmentof
endometritis, especially the acute forms following puer-
peral cases, he believed they received too much instru-
mentation. Gynecologists were not inclined to allow-
the constitution-of the patient to afford a favorable
change. The treatment of acute endemetritis should
receive efﬁcient topical medication and rest, to encour-
rage restoration to normal-circulatory conditions, to re-
duce to their normal size the distended vessels in the
uterine mucosa. The introduction of the uterine canula
is a delicate matter and must be delicately performed
for fear of injury to the congested mucous membrane of
the uterus. Too often there is not a suﬂicient amount
.of water used; from three to ﬁve gallons should be al-
lowed to ﬂow over the surface and the fountain syringe
' should be at least three feet overhead in order to get
the proper force of the stream. The douche should al-
ways be given in the recumbent position. The temper-
ature should be 108° F. and gradually increased, say one . -
degree at each Sitting, until it is as hot as it can be borne;
douche morning and evening. Most patients suffer from
the chronic form which requires energetic treatment,
for this form of the disease he looked upon the surgical
treatment as the only one to be’used. 111 results are
often due to the improper use of the curette. He be-
lieved the sharp and not the blunt curette should be
used, and the organ given a thorough‘ cleaning, and the
after-treatment he considered of much importance.
Tamponing of the uterine cavity he thought a delicate
matter and improperly performed was likely to result
_ in disappointment. Packing the cavity of the uterus
thoroughly immediately after curettage assured good
results. He did not think a cure was to be expected in
the advanced chronic forms, they being very obstinate;
yet an effort should be made to rectify the existing sub-
involution, so frequently the cause of endometritis. In
endometritis membranosa, which was sometimes mis-
CITY HOSPITAL ALUMNI. 73
taken for dysmenorrhea, there was generally a condition
of stenosis, or narrowing at the internal os, and he
thought the only relief was to divide the internal os with
curettage and douche of the cavity followed by gentle
packing with iodoform gauze.
DR. WELLS said he desired to emphasize two points
brought out by Dr. Reder. The complete curretting
was a matter of great importance. There had been
cases in which a little piece of the placenta remaining in
the uterus and acting as a foreign substance kept up a
chronic inﬂammation and only its removal would bring
relief. The necessity for the protracted after-treatment
was another point he wished to call attention to. He
did not believe treatment should cease as soon as _the
discharge stopped, but should be kept up for weeks and
sometimes for months.
DR. CHARLES H. DIxON said he would like to have
Dr. Glasgow’s views on the injection of super-heated
steam in the treatment of diseases of the endometrium.
DE. A. H. MEISENBACH said he thought there was a
great deal of misconception in regard to the proper use
of the gauze drain. ' In surgery nothing is ever packed
very tightly. Where it is desired to drain the uterus
this is overlooked and the organ is packed so tightly as
as to cut off the capillary circulation and the gauze is
held responsible for the result. He had seen this occur
in a case of appendicitis, after the incision was closed
thegauze was packed in so tightly that it did not drain.
It occurred to him that the case Dr. Williamson spoke
of was probably due to this. _
DR. 'WILLIAMSON replied that he thought the gauze
was packed rathor loosely in his case.
DR. NORVELLE WALLACE SHARPE said he used the
Dorsett retractors and by thus separating the labia it
was possible to see what was being done. He did not
believe in manipulation in the dark. In a great many
cases it is necessary to dilate the neck of the uterus and
it Seems good surgical practice to use an aseptic dilator
and get the uterus well opened. He did not think it
MEDICAL SOCIETY OF
good practice to push the packing up through the va-
gina nor to insert the uterine douche tube within the
uterus by sense of touch without seeing what was being
done, as had been advised by the essayist. He said he
had not met with satisfactory results in the use of the
double canula, but had with the use of a simple glass
tube douche, point open at the end and with lateral per-
forations. He thought there would be little trouble if
the neck of uterus was properly dilated and if not suf-
ﬁciently open at time of manipulation it should be di-
lated. He said he had not seen the Glasgow curette,
but had been satisﬁed to use the ordinary'surgical spoon
and had never out too deeply in using it nor-perforated
a uterus. In regard to drainage, he said a spiral drain
did not appeal to him. He did not think it could be
kept aseptic when in position from the fact that the
spiral curves would be excellent places for bacteria to
lodge, and it would serve but little purpose in severe
ﬂexions. It had been suggested that ﬁrm packing of
the uterus was bad practice and in this he said he agreed.
He thought drainage in the uterus _by this means was
practically m'l. The packing of the vagina usually em-
ployed at the same time by the upholders of this method
often came out dry, or practically so. The best results
were obtained by dilating the neck and washing out
with peroxide of hydrogen and sterile water or normal
saline solution, and then inserting clear to the fundus a
wick drain of sterile plain gauze about the size of a lead
pencil, which is covered with rubber tissue properly
perforated at the end which goes into the uterus. This
long wick extends outside the vulva and is received into
a mass of gauze and cotton. The vagina is packed
around the wick. The actual utility of this method of
drainage, had been abundantly proved upon a recent
case. There was a vicious uterine infection.- The cer-
vix was dilated, cavity cleaned, thoroughly curetted
and a properly graduated wick-drain appropriately per-
forated at the uterine end was carried to the fundus,
it was attached to the cervix by a sterile safety pin, the
CITY HOSPITAL ALUMNI. 7 5
vagina was packed around the wick, and the distal end
was received into a large mass of gauze and cotton.
The drainage was excellent; three large extra-uterine
dressings were liberally soiled within twenty-four hours
and then drainage ceased. The local symptoms were
greatly improved. All symptomatology had been pel-
vic in character, but the patient ﬁfty hours later sudden-
ly died in collapse. A post mortem was made and a
universal purulent peritonitis was found, no evidence of
which was shown during life. The drainage was satis-
factory, uterine cavity dry and clean, wick in place hav-
.ing served its end as no other agent would or could.
He said that fortunately he had seen but few cases of
gonorrheal infection, but that he believed the same
broad surgical principles should be followed as in infec~
tions from other agents—proper and adequate dilata-
tion, cleansing, curettage and drainage.
DR. GLASGOW replying, said there was not always
free drainage after labor and Dr. Boisliniere could test-
ify to this fact. In a case seen with that gentleman at
one time the uterus contained a pint of pus; he said he
put in the dressing forceps and the pus , poured out like
water from a spigot; this was a case where the cervix
could be opened easily, yet a large amount of pus was con-
tained in the organ simply on account of the position.
This Showed that something was needed to facilitate
drainage in infected post-partum cases. Where gonor-
rhea was suspected he acted as he does in certain cases
of diphtheria—he treated them as if they were diphthe-
ria—they might not get well but that was no reason not
to treat as if they were true cases. There were septic
cases, no doubt, where there was no offensive discharge.
In regard to the chill after ﬂushing, he said that his assist-
ant, Dr. G. A. Keehn, called his attention to some arti-
cles on this subject. He had never had that happen to
himself until last summer and he had wondered at it;
he thought it probably due to the fact that he never
used hot water when washing out the uterus but always
~luke warm water; hot water, he said, caused the uterus
76 MEDICAL SOCIETY OF
to contract and forced the septic matter out into the
circulation and then a chill followed. One case he re-
ferred to which he thought he had infected himself; he
had a bronchitis at the time and, although he did not
put anything in the uterus, there was an infection. The
woman was a very nervous person and the fever would
constantly rise; he put in, after washing for a few days,
_ a spiral drain, and in a few days she was well and had
no further trouble. In regard to packing a large cavity,
he believed that to ﬁll it to a certain extent was " .good
practice; the secretions were absorbed even if they did
not come out and the walls of the uterus kept practi-
cally dry. Iodoform gauze, he thought, the only gauze
to be used inside of the uterus.
I In regard to the route of infection, the speaker said
he heard a learned gentleman speak of that last summer
saying that gonorrheal infectionqalways traveled along
the surface into the tubes, and streptococcus and other
infectiOn through the lymphatics, but this was simply
and purely theoretical and men in practice knew it was
not true. Ordinary septic infection does cause pyosal-
pinx, About the glairy mucus as an evidence of endo-
metrial disease, he said this was an evidence of cervical
trouble and the fact of the glairy mucus being present
would not induce him to treat the endometrium, but to
treat the cervix.
In regard to the necessity for protracted treatment
after abortion, he said that was a mistake. He cleansed
out the uterus thoroughly, packed it for one or two
days, put in a drain and let it alone, and in a few days
there was no further trouble and continued treatment
was not necessary. He thought the case of Dr. Wil-
liamson’s at the City Hospital showed the superiority
of the open drain over the gauze drain. He did not think
the gauze a perfect drain. He said he had used the
lamp-wick but did not like it as well as the iodoform
‘ gauze; it was too easy to pack the lamp-wick tight and
he did not think it drained as well. _
As to injuring the softened mucous membrane he
CITY HOSPITAL ALUMNI. 77
said it was not only necessary to injure it but to get it
out; it should be curetted Out and after it was out there
was no more softened mucous membrane to injure.
In regard to super-heated steam he said all the fools
are not dead yet. Super-heated steam had this one ob-
jection, if no other—it destroyed the surface mucous
membrane just as a strong caustic would do. It will
kill the germs, if hot enough, but will leave the dead
tissue to decompose.
DR. MEISENEACH asked if it was not always desirable
to get an active contraction of the uterus as soon as pos-
sible. He had always been taught that one of the safe-
guards against infection was the active contraction of
the uterus, and Said he always felt safe when he found
the uterus contracting actively.
DR. GLASGOW said the rule in regard to the contrac-
tion of the uterus after labor was undoubtedly true, but
not when the uterus was practically a large abscess cav-
ity; when in this condition he doubted if .it was good '
practice‘to induce contractions, and the douching with
hot water will do it, therefore he never used hot water
douches.

STATED MEETING THURSDAY EVENING, APRIL 7.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

Notes on Two Cases of Oerebro-Spinal
Fever.
BY CHARLES L. FAHNESTOCK, M.D., ST. LOUIS, MO.
L. B., aged 21, single, occupation laborer. Admitted
to City Hospital March 12, 1897. Family history:
Father died of dropsy at the age of 64; mother living
and in good health. Past history: Scarlatina at 10
years of age; no venereal history; very moderate
in habits. Present trouble began Tuesday, March 9,
with a hard chill; pain all over the body; nausea,
vomiting and intense headache. Present condition:
78- MEDICAL SOCIETY OF
When admitted was delirious, restless; almost. continu-
ous vomiting of a dark brown liquid, and purging with
stools of a dark brown, semi solid, soupy Consistency;
vomiting and purging have ceased to some extent. On
Sunday, March 14, the patient was semi-conscious for a
short time and answered questions somewhat intelli-
gently; he stated that he had had aphonia since the .be-
ginning of his illness, and complained of intense head-
ache. Pupils equal and reacting fairly well to light.
March 15, vomiting and purging have almost ceased;
patient hyPeresthetic (which was present during the en-
tire time in the hospital). Head retracted; muscles of
the neck stiff; brow contracted; right pupil about normal
size, left dilated and neither reacting well to light; great
delirium; patient moving about constantly; almost im-
possible for patient to- receive nourishment. Urine
analysis: Speciﬁc gravity, 1024; rather high colored;
slight trace of albumen. Physical examination: Respi-
ration somewhat accelerated; pulse rather full—about
100; no change of percussion note over the lungs; on
auscultation a roughened breathing is heard in left lower
axillary region; heart sounds normal; Splenic tumor de-
monstrable; liver, upper line normal but extends about
a ﬁnger’s breadth below the costal margin in the mam-
mary line. Diagnosis: Cereibro-spinal fever.
TREATMENT.—Head shaved and ice-bags applied;
quinine and frumenti internally. ,
March 12, evening; pulse, 100; respiration, 2,6; tem-
perature, 102.4°. ' '
March 13, morning; pulse, 90; respiration, 24; tem-
perature, 103°. '
March 13, evening; pulse, 108; respiration, 26; tem-
perature, 105.4°.
March 14, morning; pulse, 100; respiration, 26; tem-
perature, 101.8°.
March 14, evening; pulse, 100; respiration, 34; tem-
perature, 104.2°.
March, 15, morning; pulse, 120; respiration, 36; tem-
perature, 101.8°.
CITY HOSPITAL ALUMNI. 79
March 15, evening; pulse, 118; respiration, 34; tem-
perature, 103 8°. .
March 16, morning; died; temperature after death,
106°. ‘ '
Poet-mortem held 10 hours after death: Rigor mortis
present; body fairly well nourished; chest cavity opened
and no adhesions of lungs; pericardium opened and a
small amount of clear, straw-colored exudate present;
heart slightly eftlarged, valves normal, beginning arte-
rio;sclerosis at the beginning of aorta. In the upper
_part of the right apex was found a small old cavity
about the size of a quail’s egg; in the lower part of the
lower lobe of the left lung was found a small area of
pneumonic consolidation.
The liver extended about one inch below the costal
margin—mammary line. Spleen enlarged. Kidneys
swollen and in a state of cloudy swelling. Solitary
' lymph follicles of the ileum were enlarged and the
muCouS membrane hyperemic; no ulcers; Peyer’s patches
not demonstrable.
Brain, veins distended, very much congested and a
purulent exudate between araChnoid and pia mater all
over base and cortex and extending over the cerebellum
and on the coroid plexus. Purulent inﬂammation of
soft membranes of entire cord, also small hemorrhage
‘in- the dura. Ventricles contained Only a small amount
of clear ﬂuid.
CASE 2.—-C. B., aged 45, single, occupation laborer.
Admitted to the City Hospital October 29, 1896. Fam-
ily history: Mother died at the age of 52 of some
trouble which produced dropsy. Father living and in
good health. _Past history: Had usual diseases of child-
hood, also diphtheria. UnComplicated case of gonor-
rhea ten years ago, no other venereal history. Up to
15 years ago he used alcoholics to great excess, and
since then would go on sprees occasionally. Present
trouble began on October 27, two days previous 120' cu-
trance into the hospital. During the morning, while at
work, patient had a severe chill and pain soon developed
I
80 MEDICAL SOCIETY OF
in right knee, but he did not stop working and by even
' ing the knee was very tender and painful, which condi-
tion prevailed, with some swelling, when he entered the
hospital; the patient also complained of tenderness and
pain in the left scapular region; he seemed perfectly
conscious but complained of great pain; pers-piring at
intervals profusely. Up to this time the disease was
thought to be one of acute rheumatic fever. The case
continued about the same until Saturday evening, OctO-
ber. 31, when a mild delirium developed and by morning
he was very delirious; eyes drawn upward, browcon-
tracted, lids not completely covering the globe. The
patient had drenching sweats, and by evening seemed
semi conscious, although very drowsy.
Physical examination: Abdomen and lungs negative;
heart,“ increased impulse, apex in ﬁfth interspace-in
mammary line, double friction murmur at base of the
heart with rough ﬁrst sound at apex; tongue coated with
yellowish fur; good muscular development and body
well nourished. .
Urinalysis: Speciﬁc gravity 1024, high colored, no
albumen, on ' standing deposit of heavy sediment of
urates. Death occurred November 3, seven days after
onset of disease, stupOr and delirum having continued
about the same as from the beginning.
October 29, evening; pulse, 100; temperature, 100.2°;
respiration, 28.
October 30, morning; pulse, 72; temperature, 100.4°;
respiration, 20.
October 30, evening; pulse, 88; temperature, 101°;
respiration, 28. ‘
October 31, morning; pulse, 88; temperature, 100.4°;_
respiration, 28. .
October 31, evening; pulse, 100; temperature, 103.4°;
respiration, 28. ‘ -
November 1, morning; pulse, 96; temperature, 104.4°;
respiration, 32. I
November 1, evening; pulse, _108; temperature, 100.6°;
respiratiOn, 24.
CITY HOSPITAL ALUMNI. 81
November 2, morning; pulse, 116; temperature, 103.6°;
respiration, 28.
November 2, evening; pulse, 140; temperature, 102°;
respiration, 28.
Post-mortem held 12 hours after death: General ap-
pearance—body well nourished; good muscular develop-
ment; rigor mortis present. Abdomen: No ﬂuid in
peritoneal cavity; stomach and intestines normal; liver
slightly enlarged; connective tissue increased; gall-blad-
der and duct normal; spleen somewhat enlarged, cap-
sule thickened and increase of connective tissue on cut
surface; kidneys—capsule readily removed; substance
dark and congested, cut surface dripped blood, papillae
dark in color. Thorax; Lungs retracted, no adhesions;
cardiac area increased, pericardium contained a small
amount of yellowish ﬂuid; left heart muscle thickened,
otherwise normal; valves normal; relative insuﬂiciency
of tricuspid and bicuspid oriﬁces. Brain: Veins con-
gested, most marked about cerebellum; at base of the
brain, probably 15 c.c. of purulent exudate was found;
small area of pus on vertex of cerebrum; purulent exu-
date also extended down cord.
I regret that the microscopical examination of these
cases was neglected.

DISCUSSION.
DR. FRANK R. FRY asked if a tuberculous condition
of the lungs was found.
DR. FAHNESTOCK answered that there was.
DR. FRY said he thought the time had come when, in
~ all situations of this kind, especially in institution prac-
tice, as a means of diagnosis and for scientiﬁc purposes,
lumbar puncture should be performed. The operation
is very simple. The subsequent bacteriological examin-
ation is a more diﬂicult matter but he thought there were
a number of enthusiastic bacteriologists in the city who
would like to avail themselves of an opportunity to ex-
amine matter obtained in this way, as the question of
bacteriology in these cases becomes constantly more in-
82 ' MEDICAL SOCIETY OF
teresting and important. He said he had recently read
~with interest the report of an epidemic in Boston. One
hundred and eleven cases were reported, covering a
period from June 1, 1896 to October 1, 1897, by Dr.
Councilman, of Harvard. In this series lumbar punc- -
ture was performed in 55 subjects, in some several times.
In 38 of the cases the diplococcus. intracellularis of
Weichselbaum was identiﬁed. This shows the import-
ance of this means of investigation. Only 35 post-
mortems were made; the same meningococcus was found
in 31 of them. In some instances by cover Slip prepa-
rations and in others by cultures. He emphasizes the
fact that in a number of cases where the meningococcus
intracellularis was found by cover slip preparations it
was impossible to grow it on account of the fact that it
is a diﬂ‘lcult organism to grow. The medium he found
best for their growth was the blood serum mixture of
Loefﬂer. Dr. Fry said he thought it very important
that in any case of meningitis, a bacteriological diagno-
sis be made if possible. Among Dr. Councilman’s cases
there were found 13 cases of simple congestion and
edema of the lungs; in several a broncho-pneumonia; in
1 a typical croupous pneumonia and in 8 a pneumonia
due to the diplococcus intracellularis, and these 8 were
found in the latter part of the epidemic, seeming to im-
ply, possibly, a secondary infection of the lung. In the
2 cases of croupous pneumonia the ordinary pneumo-
coccus was found. Until very recently the pneumococ-
cus has been considered to be the etiological factor, the
characteristic organism, of cerebro-spinal meningitis;
even after Weichselbaum had identiﬁed the diplococcus
intracellularis there was little attention paid to it for
some years, but now there does not seem to be much
doubt but that this is the organism of epidemic cerebro-
spinal meningitis. Of course meningitis is caused by
the pneumococcus and streptococcus, but these cases are,
perhaps, aiways fatal, and when a case gets well there ‘
is a strong supposition that the disease was due to the
CITY HOSPITAL ALUMNI. 83
diplococcus intracellularis. Hence the importance of
the bacteriological phase of the matter.
THE PRESIDENT said he would like to have Dr. Fry,
or some one of the members, explain the route of- the
invasion. If the epidemic form of the disease be caused
as stated by what route does the micro organism reach
the cerebro-spinal meninges.
In regard to puncture which, he understood, was
simply for diagnostic purposes, he desired to ask in
what respect the cerebro spinal ﬂuid was changed. Also
what the results of medication by this route were.
DR. FRY, replying, said that the main value of lumbar -
puncture was for diagnosis, but it is also done to relieve
pressure and does relieve it temporarily sometimes. Med-
ication has been undertaken by the injection of ﬂuids,
but experience shows that little can be expected In that
line.
_So far as the invasion of the diplococcus intracellu-
laris is concerned it is an organism which has an elec-
tion for the meninges; it is of feeble resisting power,
but if it reaches the meninges it grows there. It has
been found in cases of otitis media, and in the eyeball
secondary to the meningitis; it has also been found in
the upper portion of the nasal cavity. The question is
whether it is secondary there; some think that it is, that
it may appear in the nose from an invasion of meninges
just as it may in the ear.
THE PRESIDENT asked if the entrance was through
the air passages.
DR. FRY replied that it could not be afﬁrmed that the
entrance was through the air passages, at least, not al-
ways. He said that generally the ﬂuid is opaque and
coagulates easily, but sometimes it is a little changed.
It is only when-we ﬁnd in it certain organisms that it
possesses diagnostic value.
DR. C. M. HIEBARD said that he had had the privi-
lege of seeing quite a number of cases of cerebro-spinal
meningitis in the epidemic that has been prevalentjin
Boston for the past year and a half. Between January,
84 MEDICAL SOCIETY OF
1897 and December, 1897, 72 cases of this disease en-
tered the wards of the Boston City Hospital. During
the last week of February of this year he saw four or
ﬁve cases admitted to that hospital, thus showing that
the epidemic still prevailed to that date. Instead of
the normal clear straw-colored serum the ﬂuid with-
drawn by the lumbar puncture varied in character from
a slight cloudiness to a purulent ﬂuid. The sediment
showed pus cells and the diplococci intracellularis when
stained. The only way to differentiate a case of cere-
bro-spinal meningitis of the so-called epidemic form
from one due to the pneumococci or other bacteria is by
cultures and the use of the microscope, as stated by Dr.
Fry.
DR. C. FISCH said his acquaintance with the meningo-
coccus was very Slight and superﬁcial and that he had
only met with it once with certainty. In that one case
he said he was able to demonstrate its presence in the
meninges as well as in the lungs and kidneys. He had
been able to cultivate it through several generations,
but had never succeeded in infecting any animals. As
to the lumbar puncture he thought Continental statis-
tics bearing on about 300 cases had shown the great
value of it as a means of diagnosis. At Leyden’s clinic
in 70 cases the presence of the meningococcus was
demonstrated out of a whole of 76 cases. The attempts
at medication through the puncture had been abandoned
entirely in Germany, the only value sometimes ascribed
to it being a temporary relief.
DR. AMAND RAVOLD said that he had read carefully
the admirable and exhaustive report of Drs. Council-
man, Mallory and Wright upon “Epidemic Cerebro-
Spinal Meningitis,” in both the Johns Hopkins Hospital
Bulletin and the American Journal of the Medical Sci-
ences, and they were of such marked beneﬁt to him that
he would advise every member who had not read the
report to secure the Bnlletin as it contained a very ﬁne
disicussion on the article.
He said that the former speakers had discussed the
CITY HOSPITAL ALUMNI. 85
subject so practically and intelligently that there re-
mains nothing new to be said upon the subject. Re-
ferring to the cases presented, however, he said he
hoped no offence would be taken with what he was
about to say, as he intended no reﬂections upon the his-
torian or his histories, for they were admirable as far
as they went; still, in his humble opinion they were
woefully lacking in the very essential details to make
them of scientiﬁc value—namely, the pathological and
bacteriological investigations; and let it be understood
that the fault is not with the historian but with the
very unfortunate condition that obtains at the City Hos-
pital. Here was the specticle of a great City Hospital,
one of the very largest in this country, treating,he was
told, over 5,000 patients a year, and yet not equipped
with a pathologist to follow up and report upon just
such interesting cases as were brought before the So-
ciety this evening. He said he really doubted whether
the Hospital is provided with a ﬁrst-class microscope.
He considered it a crying shame, and that a duty was
owing to the Hospital, to the Society, and to the city to
see that this fault was corrected. AS Alumni of the
institution the members of the Society should unite in
petitioning and urging on our Municipal Assembly
the absolute and immediate necessity of providing at
the earliest possible moment a competent pathologist
to the Hospital, at a remuniative salary—for such a man
would not only be of incalculable value to the patients
and physicians of the Hospital but of a lasting beneﬁt
to the profession at large throughout the city.
DR. JOHN ZAHORSKY said Dr. Fisch had reported a
case of menigitis occurring under his (Dr. Zahorsky’s)
care and he wanted to say a few words on the post-
mortem made. It was a typical case of cerebro-spinal
meningitis, that is both the spinal cord and the cere-
brum were affected. He said the same organism was
found in the heart, lungs and kidneys and the diagnosis
was meningitis and pneumonia in one lobe. On post-
mortem a consolidation was found, but not very marked,
86 MEDICAL SOCIETY OF
it resembled a pneumonia in the ﬁrst stage; the kidneys
were also very much congested and he wondered at the
time whether it was the same organism in the lungs and
kidneys. He thought possibly this diplococcus intra-
cellularis might cause other lesions besides those in the
meninges.
A Case of Sudden Death Following .1.
Immunizing Dose of Antitoxin.
BY WM. NIFONG, M.D., ST. LOUIS, Mo.
B. W., male, aged 15 years, occupation student. Fam-
ily history: Father 53, mother 53, brother 26, two Sis-
ters 24 and 28, all in good health. Grandmothers on
both sides died at about 70; grandfather on father’s side
died at about 50; grandfather on mother’s Side still liv-
ing and about 80 years old, in good health. No heredi-
tary troubles known on either Side. .
History of previous illnesses: Had catarrhal fever
when about 6 years old, which lasted about four weeks;
had had none of the zymotic diseases; soon after he re—
covered from the attack of catarrhal fever it was noticed
by the family when he tookjviolent exercise, or during
excitement, that the lips, nose and eyelids would become
swollen and have a cyanot-ic appearance, and he was
frequently cautioned by the family as to the amount and
kind of exercise he should take.
Present condition: Not well developed 1 except in
height; rather a delicate physique; very sympathetic and
affectionate; timid; of a nervous and-lymphatic temper-
ament; easily excited; always ready to assist or sympa-
thize with anyone in trouble or distress. He came to
me on the evening of April 4, complaining of Sore ,
throat; the throat was red, tonsils slightly enlarged,
temperature 99°; had been exposed to diphtheria. I
CITY HOSPITAL ALUMNI. 87
made light of his trouble and told him to come back the
next evening. On his return the conditions were about
the same; said his throat was sore but he was not sick.
I requested him to meet me at the Orphan’s Home the
next day at 2 P.M., and I would give him a dose of anti-
toxin; he was on hand at the appointed time; his condi-
tion was about the same as the day previous. I admin-
istered a dose of antitoxin, strength 1500 units, amount
between 3 and 4 cc. ; about the same quantity and out
of the same bottle that I had just a few minutes before
given to two girls without any bad results whatever.
The administration was made between the shoulders and
a little to the left of the spine; in about 8 or 10 minutes
after the injection was made his sister came into the
room and said her brother was feeling badly. I went
at once to see him and met him at the door of the hall;
he complained of a numbness of the extremities and
looked as though he was frightened and was very pale,
which soon changed to a cyanotic appearance accompan-
ied with rapid swelling of the face, and sick stomach;
vomited freely. I discovered that the heart was failing
rapidly and I administered 1-50 of a grain of nitrogly-
_ cerin hypodermically, which was about 20 or 25 min-
utes after the injection of the antitoxin. Artiﬁcial res-
piration was used as best we could, but dissolution was
rapid and in 30 or 35 minutes he was dead. Failure of
respiration and heart seemed to come on simultaneously.
I wish now to make a report as to the results of im-
munization. A few' days after the death of the boy,
with the assistance of Doctors Ravold and Moore, we
' _ immunized 46 children, varying in age from 2 to 14
years, and 3 or 4 adults; all had been exposed to diph-
theria, and of the 46, 2 had diphtheria, as veriﬁed by
cultures; 2 others had sore throat but no culture was
made. All were mild cases and required little or no
treatment.“ At this time we had 22 cases, 3 of them
diphtheritic laryngitis and very serious cases; all of them
recovered. About 7 weeks after the house was fumiga-
ted we had a second outbreak; all recovered and the
88 MEDICAL SOCIETY OF
_house was fumigated on September 10. A third out-
break with 5 cases and 1 death—diphtheritic laryngitis.
This last outbreak, in my opinion, was caused by new
children who were brought from Centralia, Mo. Only
one of them had been in the house over twelve days.
Following the last attack, 36 were immunized with no
bad results and no cases.
January 21, 1898,another case developed—a nurse, 24
years old, who had been in the house twelve days. I
diagnosed the case diphtheria and she was sent to the
City Hospital where a culture was made and the diagno-
sis veriﬁed. On the day following we gave antitoxin to
62 children, internally; 8 babies from 3 weeks to 3
months old, the rest from 2 to 14 years old, and no new
cases developed. I will say, in addition to this, we
treated 7 cases in private practice, making a total of 41
cases treated, with 1 death; 5 of this number were bad
cases of diphtheritic laryngitis. In all these cases the
antitoxin was furnished by the City Chemist.
DISCUSSION.
DR. AMAND RAVOLD said that inasmuch as the anti-
toxin used in the case reported was prepared by him it
was, he felt, absolutely necessary to know all about the
preparation of the serum and the horse from which it
came, so as to Show that the death could not be ascribed
to any fault in the preparatlon of the serum. The serum
used was from the blood of “Bob,” horse No. 3, of the
City Health Department, and quartered at the Poor
House stables, where it receives the very best of care
and feeding. He was 6 years old, weighed about 800
pounds at the time of bleeding, and had been purchased
by our worthy President, Dr. Homan, in 1895 for the
Health Department. He had been under treatment for
about 2 years and had been bled 6 times. On February
17, 1897, he was injected with 300 c.c. of toxin, 0.01 c.c.
of which killed a guinea-pig, weighing 600 grams, in 48v
hours. The horse had a temperature of 102.2° follow-
ing the injection, which fell to the normal on the Sixth
CITY HOSPITAL ALUMNI. _ 89
day and remained so up to the time of bleeding, March
13, 1897. On that day 3 liters of blood were drawn
from his jugular vein into the sterile glass bottles, and
on March 17 the serum was taken off by Mr. Thomas
Buckland, the Assistant City Chemist, as he was out of
the city, and to it Mr. Buckland added 0.4 per cent of
tricresol. Upon his return March 20 the serum was
tested upon several guinea pigs and found to contain
over 150 units (Behring) to 1 c.c. and was so marked
April 1, 1897. It was this serum that Dr. N ifong used.
On theafternoon of April 7, he received a telephone
message from Dr. Nifong asking him to please come out
to the Christian Orphans’ Home immediately as he was
having a bad result with the antitoxin. He hurried out
and when he reached the Home found everyone greatly
excited, and in a small back room was shown a young
man dead upon a couch. Dr. Nifong said that he had
given him an immunizing injection of about 3.5 c.c. of
serum from a 10 c.c. bottle from which two other pa-
tients had also been injected. He examined the body
carefully; it was still warm—he could not have been
dead more than 10 minutes. There was a waxy pallor
about the forehead, side of the face and neck. Dr. Ra-
vold said that the most remarkable thing about the
- young man was a marked swelling of the eyes, nose and
lips, and they were as black and congested-looking as if
he had been strangled. On examination he found a
number of glands on both sides of the neck enlarged to
about the size of an almond. The tonsils were enlarged
and the mucous membrane of the pharynx swollen and
rough-looking as if it had been inﬂamed. There was
no membrane to be' found in the nose or pharynx. Four
swab cultures were made from the throat and taken di-
rectly to the City Bacteriological Laboratory. They
were examined by Dr. Ravold the next day and also on
the 9th, but in not one of them was the Klebs—Loeﬂier
bacillus found, although a most careful search was made
for it. .
A post-mortem was made the next afternoon—April
90 MEDICAL SOCIETY CE
8, by Dr. Wolfort from the Coroner’s oﬂice; Dr. Kodis,
pathologist of the St. Louis Medical College, was also
present as anunprejudiced witness. The post-mortem
was held in a room lacking all the facilities for such an
operation, the body lying upon a rattan couch. The
brain, lungs, heart, spleen, kidneys, liver, and the
larynx and trachea were removed for Dr. Kodis. The
trachea and larynx were split up posteriorly and just
beneath the vocal cords, on the anterior aspect of the
larynx, were seen several small isolated patches of pseu-
do membrane, pronounced So by Drs. Kodis and Wol-
fort, measuring about i by %-inch in width. All of these
organs were taken to the St. Louis Medical College by
Dr. Kodis and placed in the ice chest.
The speaker said that on April 9, he was unable to
visit the college, but April 10, he ‘went there, took out
the larynx, removed the small patches of mucous mem-
brane from it and inoculated four tubes of Loeﬂler’s
medium with them. He further said the reason this
was not done immediately upon opening the larynx
at the post-mortem was for the want of culture tubes.
April 11, the growth in the four culture tubes was ex-
amined; in three of the tubes the diphtheria bacillus
was found and they were marked 1, 2 and 3. In tube
No. 4, the medium was badly contaminated and partially '
liqueﬁed by the bacillus subtilis. From tubes 1, 2 and
3, a number of colonies were picked out and sown on
Loeﬂler’s medium, from tubes 1 and 3 pure cultures were
obtained; these were again sown in one tube of Loeﬂler’s
medium, and on April 14 broth was inoculated from
the pure growth in the last tube; when 48 hours old, 1
c.c. of the broth was injected into each of four guinea
pigs. April 20, three of the pigs died, and on April 21,
the fourth died, all with the characteristic lesions of
diphtheria. The bacillus was not highly virulent. The
young man, therefore, had diphtheria of the larynx—
laryngeal diphtheria.
‘ Dr. Ravold said that he felt satisﬁed that the antitoxin
was as perfect a product as could be produced, and to
CITY HOSPITAL ALUMNI. 91
prove his conﬁdence in it, took 80 c.c. to the Home a
few days after the accident and inoculated over 30
children and a few grown people with it, and with ab-
solutely no untoward results. _
DR. FRANK G. NIFONG said he thought the most im-
portant question in connection with this case was the
cause of death. He said he had seen an interesting
article in the New York Medical Journal, July, 1897 , by
Dr. James Ewing, in regard to the cause of sudden
deaths and accounting for them, and the study of two
cases. The author of this article said there was an ill-
deﬁned condition which seemed to be more or less rec
ognized, especially byskilled pathologists of the Vienna
school, called the “lymphatic constitution” and persons
,with this condition have been noticed to be peculiarly
liable to sudden unaccountable death following chloro'
form narcosis, slight injuries, etc. The condition is
characterized by certain anatomical conditions, all seen
at one time and only some at another, consisting of a
hypoplasia of the heart and aortic system of vessels,
that Is, not a full development of them, and possibly a
patent foramen ov-ale. Also a condition. of excessive
lymphatic tissue development distributed to all or part of
the lymphatic areas of the body—the cervical, inguinal
and maxillary lymphatic glands, and possibly the mes-
enteric glands and Peyer’s patches. The thyroid gland
was abnormally developed in a number of cases and also
the thymus gland. The spleen was enlarged and there
was a greater amount than normal of the red marrow of
the bone; that is what was found as far as the lymphatic
system was concerned. On examination of the blood
leucocythemia and different forms of anemia were found
and other evidences, such as rickets. These people
seem to have little physical vigor, the genitals are some-
times poorly developed, the pubic hair absent, the
uterus smaller than normal, and' all these points went to
make-up what they called this ill-deﬁned, “lymphatic
constitution,” and these were the things noticed in cases
of sudden death from these slight injuries. Dr. Nifong
92 MEDICAL SOCIETY 01?
thought it probable that people so constituted were
peculiarly liable to Shock and cardiac paralysis follow-
ing slight injuries. If this was so it occurred to him
that possibly the child was such a person. He said
the boy was of a ﬂabby physique, did not have the phy-
sical vigor which he thought a boy of that age should
have; slow and deliberate in his movements; ﬂesh ﬂabby
and soft and usually had his mouth slightly open Indi-
cating enlarged pharangyeal tonsils interfering with
nasal respiration, and altogether he looked as if his lym~
phatic system was too much developed. He thought
there was such a condition, from these observations,
which would explain a good many of the otherwise un-
accountable deaths, but he thought it would be a diﬂi-
cult thing to ﬁnd them before killing them. He thought
it would be a difﬁcult matter to diagnose a hypoplasia
of the heart. The lymphatic glands might be found
enlarged and there might be a goitre present and all the
lymphatic system in sight might be pronounced, but it
would be practically impossible to make such a diagno-
sis; still, he thought, these cases of sudden death might
be due to this lymphatic constitution.
DR. WM. NIFONG said the woman who was sent to
the hospital had twelve children in her room and had
been with them at least twenty-four hours after she had
fever and possibly half of the sixty children had been
with her half of the day, but none of them took diph-
theria. The children under her charge werefrom three
weeks to three months old. The others were from three
to fourteen years old, all had an immunizing dose of
antitoxin by the stomach and none had diphtheria.
DR. ZAHORSKY said he had tried to cure diphtheria
clinically by the administration of antitoxin by the
mouth. In eleven cases all were saved by the adminis-
tration of one to three thousand unit. If the disease
is recognized early he thought recovery followed with
as great a certainty, if not quite so promptly. In one
case three thousand units were given twice with no
perceptible effect. It was judged that diphtheria was
CITY HOSPITAL ALUMNI. 93
coming on and three thousand units were given; the
nextday there was no mitigation of the symptoms and
three thousand units were given again; the next day the
larynx became involved and injection was resorted to.
In other cases the cure was so prompt that there could
be no doubt that the effect was due to the antitoxin. In
the one case the antitoxin did not seem to be absorbed,
or if absorbed, was nOt utilized, consequently he had
decided that antitoxin for diphtheria should not be
given per os except in rare cases, As 'an immunizing
agent it was used in sixty or seventy cases, all of which
had been exposed. In one family of seven children, all
remained in the room with the patient and no attempt
was made to isolate them; they all received antitoxin
by the mouth but none took the disease.
Twelve hours or more seems to be necessary for the
antitoxin to reach the circulation when administered by
the mouth. ' ~
It has been suggested that absorption takes place
only in the large intestine, for it could not be demon-
strated in the blood by experiments in animals until at
least twelve hours had elapsed. This forms an argu-
ment against its use in this way as twelve hours is a
long time to wait for the antitoxin to reach the blood.
As a prophylactic, however, it is safe and a preferable
way of administration. It is best administered in a
little water. He said Dr. Fisch had made some interest- ‘
ing experiments in this line and found positive evidence
of its absorption; and the results of these experiments
are contrary to those of Escherich, but nevertheless be-
ing positive and most carefully made, he believed were
entirely to be taken as evidence that antitoxin can be
used per os. In the vast majority of cases it was ab-
sorbed, only rarely as the one case mentioned it did not
act, and therefore this method should not be relied upon
to cure diphtheria.
DR. BENNO~ BRIRACH said this was certainly a deplor-
able accident for the friends of the child, and a calamity
for the physician; but what killed this child? It would
V 94 MEDICAL SOCIETY OF
evidently be wrong to argue this way: “The child was
injected with serum, the child died, ergo, the serum
killed the child.” It was to be regretted that there was
no exact data of the child’s previous physical condition,
and of the results of the autopsy; with a basis of that
kind, he thought, there Should not be much diﬂiculty in
ﬁxing the cause of death by a process of exclusion. One
\ of three immediate factors must be assumed as a cause
of this sudden death: First, coma; second, asphyxia;
third, syncope or Shock from heart failure. Asphyxia
could be excluded at once. Coma, a sudden paralysis
of the vital nerve centres in the pons or medulla, might
be excluded unless it could be shown that the antitoxin
contained a virulent narcotic poison, or that there was
a preexisting diphtheria, that might suddenly have
manifested its fatal toxic effects. The harmlessness of
the serum used in this case appears to be established; as
to the possibility of poisoning by diphtheria toxins, he
said all were familiar with cases of sudden death
from paralysis of the pneumogastic from that cause, and
the autopsy ought to either establish or exclude this
factor.
If the child did not die from coma or from asphyxia,
then it must have died from syncope or shock. A sud- _
den fatal failure of the heart’s action occurs in organic
lesions, or from central inhibition, or from reﬂex per-
' ipheral inhibition. The report says that the child would
become cyanotic and Short of breathing upon slight ex-
ertion; did the autopsy Show organic heart disease?
Was there in the case a violent mental emotion, fear or
fright, sufﬁcient to produce a fatal central inhibition of
the heart’s action? Could the puncture of the needle,
or the slight trauma caused by the distention of tissues
from the injected ﬂuid have produced a sudden sensory
irritation, sufﬁcient to bring on a peripheral inhibition
to a possibly diseased heart? He thought one of
these causes was possible, and that an analysis of the
case on these lines certainly would explain the cause of
death. He felt certain that the serum, per se, could not
CITY HOSPITAL ALUMNI. 95
have' caused death, and that in this case the same results
would have followed the injection of four cubic centi-
grammes of distilled water or salt solution.
DR. L. BREMER said he had been much pleased by the
ingenuity displayed by his friend Dr. Bribach in ex-
plaining the cause of the death of this child. In addi-
tion to the numerous possibilities enumerated by Dr.
Bribach he desired to mention two others, not to com-
plete the list, but topossibly shed some light on the
nature of the death of the patient. He desired to ask
Dr. Ravold whether the site of the injection had been
examined post-mortem?
DR. RAVOLD replied that it had.
DR. BREMER asked what was found there, and Dr.
Ravold replied that practically nothing had been dis-
covered; the line of the needle was seen but that was
all. Dr. Bremer then asked Dr. Ravold if the possi-
bility of the injection having been made into a vein had
been excluded. _
DR. RAVOLD replied that that had been examined into
and excluded.
DR. BREMER said it was known that sudden deaths
after the injection of morphine or other were not so
very infrequent and all were familiar with the effect of
air being injected into a vein, even a minute quantity
of air being capable of producing instantaneous death,
and it was, after all, he said, possible that a vein might
have been punctured and the needle contained air; he
did not mean to assert that it was so but this considera-
tion should not be lost sight of. 'He agreed with Dr.
Bribach that it would not have made any difference
whether it was antitoxin, water, salt solution, or any
other substance, the effect would have been the same.
Another possibility, which he desired to insist upon,
was the fact that in some patients certain drugs will
have poisonous effects. Instead of obtaining the thera-
peutic result quite the contrary is seen. All drugs, he
said, whether administered per os, subcutaneously, or
by friction, or in any other way, depend for their
96 MEDICAL SOCIETY OF
therapeutical effect upon a combination with the ﬂuids
of the body. We all know that there are incompatibles,
not only in the stomach but in the' entire system. It
was only necessary to mention the incompatibility of
quinine and the iodides. A person taking quinine
should not take' any of the iodides because if he did
serious nervous disturbances resembling poisoning would
occur; this fact, he said, had been establised, or veriﬁed
by a French observer, in one case experimentally. ' When
a drug is administered to a person it might meet in the
body with certain constituents of that body and, com-
bining with them, form an intense poison. He could
readily understand how the antitoxin introduced into the
body of an individual in whom there were certain unde-
ﬁned substancesj with which a chemical combination
might act as an intense poison. He said he would therefore
suggest, not as a certainty, but as a possibility, a vague
possibility, that the combination of ,the antitoxin with a
substance circulating in the blood of an individual, pr0-~
ducing a poison and acting with intense activity. He said
he was perfectly sure that the antitoxin per se, did not
kill the patient, although he believed the injection did
so, yet the result would have been the same with any
other substance. He said such occurrences were liable
at any time and no excuse for them was neCessary in the
course of the administration of a" remedy, and an acci-'
dent of this kind could not be used as objection to the
remedy applied. He said he was sorry that the report
of the case was not complete and the pathology and re-
sults of the post-morten presented.
DR. H. W. SOPER said he had had an experience with
a case of diphtheria in a young lady about twenty years
old. He ﬁrst saw the case With Dr. Zimlick, and the
patient had been sick three or four ‘ days; although the
temperature had never been above 100°, he had a culture
taken from the throat and suggested antitoxin. The
family declined to allow this and in a day or two had
another culture examined and received notice of the
presence of diphtheria bacilli. Antitoxin was urged
CITY HOSPITAL ALUMNI. 97
again, but again refused. A gargle and other remedies
were given for a week, during which time patient had
never been in bed, when, walking down stairs one day,
she suddenly dr'opped dead. He saw her about ﬁve
minutes afterwards and thought the sudden collapse
was due to heart paralysis caused by the diphtheritic
poison.
DR. GIVEN CAMPBELL said he did not believe the pa
tient had died from the effects of the diphtheria anti-
toxin. He thought it might be the effects of psychic
shock.
He said he would like to know what had been the re-
sult of experiments made by any of those present of in-
jecting air into a vein. He said he had tried it on rab-
bits by injecting 1 or 1.} cc. into the vein of the lobe of
the ear of several rabbits weighing about 350 grams,
and, while there would be a great disturbance for about
two minutes, at the end of ﬁve minutes they would eat
cabbage and seem to be about as well as ever. He did
not know how human subjects would be affected.
DR. WM. NIEONG, in closing, said the impression
made on him at the time of the child’s death was that
it was as much from fright as anything else, taking
into consideration the circumstances and surroundings.
It had been talked of in the home for twenty-four hours
and all were excited over it, and when he got there
there was quite an uproar. Of course, he said, this was
quieted as much as possible. After inoculating three
girls be commenced on the second bottle with two other
girls. The boy had been prepared, his back having
been made clean, and, to give him an opportunity
to get away as soon as possible, he used the last
of this bottle on him. He was out in the ball away
from the others and appeared much excited so that he
hesitated about giving the injection at that time,
but the boy was anxious to have it done. In about ﬁve
or six minutes his sister came in and said her brother
was feeling badly; he went at once and met him
at the door and saw that he was much excited, or
98 MEDICAL SOCIETY OF
appeared so. By this time the sister was so excited she
began crying and making considerable noise and the
other children werecrying. He then led the boy to- a
couch where he laid him down but hené-ver'spoke and! in
a few minutes was dead. The swelling of the. face was
intense; the lips were three times. the normal. size, the
nose, eyelids and eyeballs seemed puffed out.
STATED MEETING, THURSDAY EVENING, APRIL 21.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
Report of Spontaneous Recovery in a Case
of Axillary Aneurysm in an Infant,
With Presentation of Patient.
BY WM. C. MARDORF, M.D., ST. LOUIS.
The case I have to report this evening is that of a
female infant which I ﬁrst saw when it was 9 days old.
Family history was negative as regard'sh-ereditary taint,
its general health appeared to be good, butin the left
axilla wasa tumor, soft and compressible, dilating syn-
chronously with the heart, and over which a bruit could
be heard, but no aneurysmal thrill was apparent. Noth-
ing out of the ordinary had been noticed when the child
I was born, at which time a midwife was in attendance,
but several days later a small soft swelling was noticed
in theaxilla, which gradually increased in size until at
the time I saw it the aneurysm ﬁlled out the whole ax-
illary space, at its inner extremity extending under the
pectoralis muscle, and at the external end appearing to
involve a portion of the brachial, artery. The tumor
was not round and deﬁnitely outlined, but was ﬂattened
and soft, covering the. anterior aspect of the. shoulder
and a small part of the upper arm; beneath it extended
beyond the posterior border of the axillary space.
Iwas afterwards informed that the child had been
rather roughly handled when it was but a. day or two
CITY HOSPITAL ALUMNI. 99
old, during the performance of some occult ceremonial
rites designed to insure to it good luck through life,
part of which consisted in handing the child from one
person to another over the railing of a stairway, dang-
ling by one arm. Whether the origin of the dilatation
is to be found in this rough usage, causing a rupture of
some of the coats of the artery, I am unable to say, but
the swelling in the axilla was observed on the following
day. I watched the child for about ten days, after
which I lost sight of it until recently. During that
time the. aneurysm increased rapidly in size and the
child, at ﬁrst very good tempered, began to grow fretful
as if in pain. Ligature of the artery was dismissed
from mind as being almost certainly fatal at that age,
and without interference the child seemed equally
doomed. The parents were informed of this state of
affairs, and an unfavorable prognosis given.
I forgot to state that when I ﬁrst saw the child I as-
pirated the tumor, withdrawing a hypodermic syringe-
full. of blood. -
I am told that after I lost sight of the case the child
suffered intensely for some months; the swelling became
hard and black, and afterwards went through the usual
changes of color observed in subcutaneouseifusions of
blood. It gradually decreased in size, pain left, and
after six months the swelling was entirely gone, since
which time the child has enjoyed exceptionally good
health.
I have not as yet been able to make a careful examin-
ation to see what route the circulation is at present fol-
lowing, but from my previous knowledge of the case I
have but little hesitation in saying that spontaneous co-
agulation took place in the dilatation, with consequent
absorption and cure.
DISCUSSION.
DR. C. W. HIRBARD desired to know how the possi-
bility of hematoma was ruled out.
DR. MARDORF stated that that possibility had been
100 MEDICAL SOCIETY OF
fully considered at the time the case was under his ob-
servation. At no time, he said, was there any thicken-
ing of the walls of the tumor, they being soft and
ﬂabby. There was no increase in size such as might be
expected in the case of hemorrhage in the tissues, and
the general appearance of a hematoma such as the con-
stant swelling and gradual hardening and thickening Of
the sac and increase of density and the turning and
changing of the coloring matter of the coagulated blood,
and the rise and fall of the tumor from being in con-
tact with the artery; instead of all this there was noth- '
ing but the ﬂesh color of the Skin to be expected in a
child of that age, the expansive dilatation of the tumor
in all-directions and, at the same time, a weakening of
the pulse to such an extent as to be almost impercepti-
ble. When, however, axillary coagulation took place
then was seen the changing colors so characteristic of a
hematoma. One thing, excluding everything else, which
conﬁrmed him in his opinion was the expansive dilata-
tion in all directions of the tumor. He could not con-
ceive anything. else in that locality giving rise tolthese
symptoms except an aneurysm; cernainly not a hema
toma.
DR. FRANCIS REDER said he was sorry he did not
have an opportunity to examine the arm of the patient.
He thought that Dr. Mardorf was very fortunate to have
such a recovery take place. The only way in which he
could explain the recovery was to attribute it to an in-
ﬂammatory process of the tunics of the affected artery,
thereby causing a thickening of the coats and a consol-
idation suﬂ‘icient to obliterate the aneurysmal sac. He
desired to ask Dr. Mardorf how much of a pulse there
was at present. Dr. Mardorf replied that it was about
eighty.
Continuing his remarks, Dr Reder said he did not
remember what the records were in regard to spontane-
ous cures of aneurysm of the axillary artery, but‘he
could not recall any report of such a cure in an aneu-
rysm not arising from wound or injury. Such a course
CITY HOSPITAL ALUMNI. 101
for the aneurysm to take was very fortunate and rare,
inasmuch as operative interference presents inconveni-
ence of a very discouraging nature.
DR. HIBBARD said that as far as the tumor increasing
gradually in size was concerned, he thought this occurred
in both aneurysm and hematoma. He had seen hema-
‘tomae do so for four or ﬁve days, especially in this re-
gion. A hematoma in the region of the scalp, he said,
will increase in size for several days. But in regard to
the expansibility of the tumor, he said this seemed to
be the most important point in differentiating between-
a hematoma and an aneurysm, especially if it is synchro-
nous with the heart beat. The clinical history of a
hematoma is usually recovery without an operation;
that of aneurysm the opposite.
DR. MARDORF said he had looked up this matter in
literature but he had been unable to ﬁnd anything like
it in infants. He thought he remembered reading of
some cases of axillary aneurysm in adults recovering
spontaneously, but could not give the reference.
He said he was positive of his diagnosis. Leaving
aside entirely the expansibility of the tumor, there were
other points in the case to conﬁrm his diagnosis. The
tumor was perfectly ﬂabby, its walls soft and thin; no
pulse could be made out underneath it; the radial pulse
was almost gone, being scarcely perceptible. The reason
there was no aneurysmal thrill was because of the rather
lax condition of the tumor; there was no tenseness about
it. In regard to the spontaneous recovery he thought
it due to a clotting He said clots were found in almost
every kind of aneurysm. He did not think this was a
sacculated aneurysm; he believed if it had had room to
expand it would have assumed the fusiform appearance,
in which case there would not have been so much tend-
ency to clotting. Supposing the rough handling the
child received produced a rupture of the coats of the
artery, he thought this of itself was suﬂicient to pro-
_ duce a clot, and clotting once started would probably
continue. The arm was swollen and the circulation
102 MEDICAL SOCIETY OF
very poor, but this might have resulted from a hemato-
ma pressing upon the artery—if a hematoma could exert
that much pressure, which, in this case at least, he did
not believe was true.
Among others, Dr.,Henry Schwarz had seen the case
and thought the nature of the tumor was unquestiona-
ble. In regard to the production of coagulation by in-
serting a hypodermic needle and drawing off blood, he
thought that was a little exaggerated. Treatment W-as of
very little service in these cases; even the passing of '
coils of wire in order to produce a beginning coagula-
tion fails and has to be repeated. All these things taken
into consideration caused him to doubt the eﬂicacy of
the introduction of a hypodermic needle for the purpose
of bringing about a coagulation of the blood, especially '
since the needle is usually withdrawn in a very short
time. 'He stated, however, with due deference to the
opinion of the gentlemen present, that he felt convinced
his diagnosis of aneurysm in this case was correct.

Some Modern Ideas About Blackheads,
Pimples, Dandruff and Baldness.
BY JOSEPH GRINDON, M.D., ST. LOUIS.
The various conditions mentioned in the caption of
this paper present themselves in a natural group. Black-
heads (comedones) and the common pimples so often
seen about the faces, Shoulders and backs of young per-
sons (acne), are closely allied, etiologically, and fre-
quently. exist side by side. Dandruff (pityriasis capitis,
seborrhea capitis sicca) is often the precursor of the
most common type of baldness (alopecia furfuracea).
The ﬁrst two are evidently connected with the sebaceous
glands and the last two have generally been conceded a
similar anatomical relationship. Seborrhea, that is, an
excessive secretion of oily matter by the skin, exists as-
the usual precursor or concomitant of these conditions.
There exists to day much difference of opinion as to the
pathology of the affection last named, which as the simp-
CITY HOSPITAL ALUMNI. 103
lest of the group, and presented ﬁrst by the patient enter-
inr'g upon the seborrh'eic state, should be ﬁrst considered.
The term seborrhea as here used does not include
dandruff (often called seborrhea capitis sicca) nor the
seborrhea ‘corporis 'sicca of old American text books,
these ,being inﬂammatory in nature (eczema seborrhoi-
cum of U nna). By seborrhea we mean, with Elliot, an
increased 'ﬂow of sebum, betraying itself as a constant
oiliness glistening about the nose, naso-genial furrows,
or general surface of the face in the young, or located
on the scalp, where after the fall of hair it may persist
as the well known sheen of the bald pate, furnishing a
head light frequently found in proximity to foot-lights
or to a light foot.
This condition, seborrhea ole'osa, long passed unques~
tioned as being merely an increase in the quantity, with
perhaps a modiﬁcation in the quality of the secretion of
the sebaceous glands. For some years, however, it has
been a question whether the excessive fatty matter is
furnished by these glands or by the sudoriparous glands,
Or by both.
The Vienna school, the French school—with some
exceptions—Cracker, Duhring and others, cling to the
older view, while the newer ideas, originating with Unna,
have found more or less complete adherents in Brocq
and others.
That the coil glands are at least in part fat formers
may be accepted as a physiological fact. F. Simon,ﬁrst
and afterwards Krause, found fat in the sweat. Koelli-
ker, in 1853, found fat in the 0011 glands of the axilla.
G. Meissner, in 1857, thought they were the only fat
formers. Henle, in 1861, taught that “the sweat glands
as a whole secrete fat, and, besides that, at times, watery
sweat Without fat.” This view has been held since 1881
by Unna, and now by Duhring, Broéq and others. It-is
believed that the fatty element is secreted normally and
continuously by the coiled portion of the glands, thus
providing for the lubrication of the general body sur-
face, while the watery secretion is occasionally poured
104 MEDICAL SOCIETY OF
in larger quantities into the straight portion of the tube.
Unna found fat in the coils of 48 out of 53 cadavers.
Fat, it is well knows, can be demonstrated in the secre-
tion from the recently cleansed palm, from which seba-
ceous glands are absent. The greasy feel of the palm
in many individuals is familiar to all.
To the question, what then, is the role of the sebace-
ous glands, it is answered by some that they serve only
to furnish oil to the hairs with the follicles of which
they ﬁnd a common oriﬁce. Admitting, however, that
the coil glands may, or even that they habitually do ex-
crete oily matter, does not settle the question as to the
source of the excessive secretion in seborrhea.
Unna teaches that this is to be found in the coil
glands, and therefore uses the term hypericlrosis oleosa.
A further exposition of his views would not be without
interest nor out of place but would unduly extend the
length of this paper.
Much interest has been aroused by the recent labors
of a representative of the French school, Sabouraud,
who places himself squarely in opposition to the doc-
trines emanating from Hamburg. Let us turn our at-
tention to a resumé of his views. According to Sabou-
raud, seborrhea is an affection of the sebaceous glands,
characterized by two symptoms: (1) an increased pro-
duction of normal sebum; (2) a dilatation of the seba-
ceous oriﬁces, to which symptoms may be added a third,
pertaining to hairy regions—namely, a diffuse alopecia.
Pure seborrhea, he maintains, is never scaly, but secon-
dary infections determining desquamation of inﬂamma-
tory origin may be engrafted upon it when seated upon
the scalp—thus constituting pityriasis capitis (dandruff).
Pressure upon an affected portion will cause the ex-
trusion from the dilated glandular oriﬁces of small cyl-
inders of sebum. On scraping after cleansing off this
sebum, a fatty substance is obtained in which Sabouraud
demonstrated the presence of an organism which he
calls the micro-bacillus of oily seborrhea.
This bacillus in its early stage resembles a coccus,
CITY HOSPITAL ALUMNI. 105
La in diameter. Older individuals measure about 1X51,
short chains may occur. It easily takes any anilin stain,
but the Gram-Weigert method gives the best results
The location of the bacillus in invaded Skins is always
the same. The sebaceous gland opens into the hair fol-
licle to which it is annexed, at the junction of the upper
and middle third. Between this point and the free sur-
face, that is, in the pilo sebaceous conduit, there will be
found a plug of sebum mixed with horny cells which
may be forced by pressure out Of the intact skin in the
shape of a little cylinder, as above stated. Encysted in
this plug is the colony of bacilli, absolutely free from
any admixture with foreign organisms, according to our
author.
The condition of simple seborrhea just detailed may
give rise to other manifestations. Some of the little
plugs may attain comparatively gigantic proportions,
thus constituting the comedo or “blackhead.” These
latter constantly harbor various secondary invasions,
thus giving rise to one or another of the forms of peri
glandular inﬂammation clinically comprised under the
term acne.
The comedone always contains at its center a pure
colony of the seborrhea bacillus, while its upper extrem-
ity and periphery are crowded with a variety of organ-
isms. Some ten forms have been enumerated, two of
which are constantly present. These are: (1) Unna’s
ﬂask-shaped bacillus; which Sabouraud holds to be non-
pathogenic, and (2) a white coccus, which differs from
the staphylococcus pyogenes albus in that it thrives best
in acid media, and that its cultures exhale an intense
butyric acid odor. This organism apparently causes the
little inﬂammatory foci of indurated acne which may go
on to suppuration (acne vulgaris). Boils may occur
from invasion by the staphylococcus aureus.
Infections secondary to oily seborrhea of the scalp
give rise, as has already been stated, to various inﬂam-
matory scaly aﬁections, which, however, may effect a
lodgement on a previously healthy scalp. In the latter
106 MEDICAL SOCIETY OF
case we have a very dry dandruff and in the former an
oily desquamation. The study of the ﬂora of these at.
fections as well as of that of acne is still far- from com-
plete. The organism oftenest found is the butyric acid-
forming coccus above mentioned.
A constant sequel of long continued oily seborrhea is
the death of the hair springing from the follicle to
i which the gland is tributary. This phenomenOn, over-
looked on smooth surfaces, that is, such as are furnished
only with lanugo hairs, becomes of prime importance
when occurring upon the scalp. This form of baldneSs,
when once developed, is irreme'diable, being due to atro-
phy of the hair-papilla. The precise mechanism of this
process is obscure. Its morbid anatomy, however, con-
sists in hypertrophy of the adnexed affected gland and
inﬁltration of leucocytes about the papilla, with gradual
atrophy and death of the latter. The papilla and hair
are several times re-formed to perish anew after fresh
seborrheic inoculations. Each succeeding regeneration
of the hair is more abortive until only a microScopical
hair survives. At this stage the gland is enormously
hypertrophied, the derma of the region is thinned and
atrophied, and the familiar picture of baldness is fully
constituted.
Of the various new ideas advanced by the learned
Frenchman whose work we have been reviewing, none
is so much at variance with accepted notions as his doc-
trine that alopecia areata is due to the same bacillus as
oily seborrhea and ordinary diffuse baldness, and is only
an acute circumscribed form of the latter. Time forbids
our going into a critical examination of this point, but
it must be admitted that he makes out a strong case.
By an original and ingeniOus method he succeeded in
obtaining pure cultures of the bacillus with which be
practiced inoculations and reports the production of cir-
cumscribed areas of baldness on the sheep, the rabbit,
and the guinea-pig. '
It will be seen from the above exposition of Sabou-
raud’s views that he considers oily seborrhea as an
CITY HOSPITAL ALUMNI. 107
affection of the sebaceous glands and the necessary ﬁrst
step toward the production of comedo, acne, the oily
forms of dandruff and the common type of baldness.
Unna, it will be remembered, refers the affection ﬁrst
~mentioned to the sudoriparous glands. He had, before
Sabouraud, found that investigator’s “ bacillus of oily
seborrhea” in the comedone, but considering the latter
lesion (and not seborrhea) as the starting point of acne,
he described it as the “ acne bacillus.”
I have essayed in this paper nothing but a presenta-
tion of modern thought on this subject, believing that
such a “ report of progress,” as it might be called, would
not be wholly without interest to those whose reading
does not extend into this special ﬁeld.

DISCUSSION.
DR. W. A. HARDAWAY said he was glad to have this
oppOrtunity of hearing Dr. Grindon’s paper. He would
have preferred hearing Dr. Engman’s remarks ﬁrst be-
cause of his having been associated with Unna, but it
was well known that Unna’s views were not universally
accepted. Sabouraud, a man of great eminence, disputed
them. But in regard to Sabouraud’s statement of the
parasitic origin of seborrhea there was no question of
the fact of his discovery of the micro organisms, but as
to their meaning he said there was considerable ques-
tion. He thought Dr. Grindon’s paper might have been
more properly entitled “A Modern View of Blackheads,
etc.,” because Sabouraud’s opinions were not generally
shared even, by French dermatologists. To the physi-
cian as a practitioner the interest in this matter was
from a therapeutical and clinical standpoint. If the
parasitic view is true, does it throw any light on the
clinical history of seborrhea?
In regard to the parasitic nature of seborrhea, he said
Sabouraud’s case was not a perfect one, for it did not
account for all the facts. Any number of people suﬁer
from seborrhea and never get bald and many people are
bald who never suffered from seborrhea. The ordinary
108 MEDICAL SOCIETY OF
dry seborrhea he thought closely associated with bald-
ness; men with dry seborrhea ﬁnally get bald in the
course of six or seven years, but the ordinary oily seb-
orrhea was not necessarily associated with baldness. If
it be an infectious disease he thought that, perhaps, the-
fact that men frequent barber shops might have some
weight in explaining its occurrence, at least in dry seb-
orrhea. He said in the ordinary form of baldness we
might expect the same conditions in other parts of the
body but this was not true for baldheaded men often
have heavy beards.
In the matter of alopecia areata he thought there was
a confusing number of conditions under one name.
Alopecia areata, he said, was comparatively rare in this
country and, as far as he was able to observe, not a con-
tagious disease. In the cases seen in this country, per-
sons having this disease did not infect other members of
heir families, but there had been some cases regarded
as alopecia areata, reported in a French public oﬂ‘ice,
where a number of men had been infected from using
the same hair brush.
Sabouraud, he said, would make ordinary seborrhea
responsible for comedones, acne, common baldness and
alopecia areata on the ground that the same bacillus was
found In all;but the theoretical deductions as yet lacked
practical demonstration. One practical thing we owe
to Unna is this: Unna has called attention to the con-
nection between dry seborrhea of the scalp and the vari-
ous types of seborrheal eczema of the body, and he has
rightly insisted upon the care of the scalp as a preven-
tive measure. He said he had often called the attention
of oculists to the connection between seborrhea of scalp
and affections of the eyes, and that they had been sur-
prised with the results of treatment of the scalp in these
troubles. He believed, also, that many styes were a re-
sult of infection from the head, and that cure of the
seborrhea of the scalp often brought about cure of the
styes.
DR M. F. ENGMAN said that while he had worked
CITY HOSPITAL ALUMNI. 109
with Unna in Hamburg for some time, he did not know
that he was much better informed as to that gentleman’s
views than the members of the were Society. In 1894
Unna published his discovery of the white diplococcus.
This coccus he had found in the scales of drandruﬁ from
seborrhea. He had also found them in the oily secre
tions of every portion of the body, but particularly in
great numbers around the nose and different portions of
the face when seborrhea was present. He attributed to
this coccus a great many diseases and among them cer-
tain forms of psoriasis and, as Dr. Grindon stated, he
believed it responsible for certain forms of alopecia.
Dr. Engman said he had cultivated this coccus and ar-
rived at some deﬁnite Ideas in regard to it. He said it
is very easily cultivated and forms little, colorless col-
onies. It is found in large numbers in the scales of
seborrhea, eczema, in the hair follicles of the skin when
undergoing pityriasis. Other cocci are found in these
conditions and, on one occasion, Unna had called his at-
tention to a small bacillus which is probably Sabouraud’s
bacillus. Experimenting with this bacillus, Dr. Engman
said he had been able to produce a slight eruption in
eight or ten days after inoculation at the point of intro
duction; this eruption got well without treatment.
Another bacillus Unna has written a good deal about
is the Flaschen bacillus. Dr. Engman did not believe
that Unna considered that this bacillus had any patho-
logical signiﬁcance, but thought it merely accompanied
the morococcus and is found in healthy scalps. It can
be obtained anywhere in the integument, he said, by
washing with ether and staining it can be readily dem-
onstrated.
In 1897, Dr. Huntington Morrell, of Massachusetts,
carried out some experiments in relation to seborrhea.
He and Elliott, of New York, worked together and pub-
lished a report in 1894-1895, and in 1897 Morrell pub-
lished two papers in the New York llledz'cal Journal,
showing the results of his investigations in seborrheal
eczemas. He took scales from diﬁerent areas and especi-
110 MEDICAL SooIETY on
ally in pityriasis and alopecia. In 68 cases out of 82 he
found this bacillus. This coccus grows very much like
the diplococcus of Unna and looks like it. Dr. Morrell
inoculated twenty eight cases from pure cultures of this
diplococcus and produced pityriasis. In some there
were typical areas of eczema of the scalp and some fall-
ing of the hair in individuals whose scalps were, prob-
ably, not infected before. He isolated another coccus
that was a yellow coccus and that also produced eczem-
ous condition with pityriasis. From these experiments
of Morrell he agrees with Unna in his (Unna’s) deduc
tion in relation to the morococcus. His experiments
were witnessed by Elliott. Dr. Engman said these ex-
periments of Morrell had strengthened his faith in
Unna’s views and the modern views, as Dr. Grindon
speaks of them, in regard to the causes of these dis-
eases.
Take a comedone, he said, and squeeze it and the gen-
eral appearance as described by Sabouraud will be
found; at the head will be seen the Flaschen bacillus and
some of the pyogenic cocci very superﬁcially. In the
center will be seen a very small bacillus. In his last
system of pathology Unna described this bacillus. He
claims, and Dr. Engman thought it pretty thoroughly
demonstrated, that this micro bacillus causes the
different forms of acne. The exact way in which they
did produce this trouble was not known, but it was
known that certain forms of bacillary acne existed. Dr.
Engman thought that Sabouraud had probably gone too
far in his deductions, and placed too many diseases un-
der the same category as being caused by this organism.
He said that the isolation of the bacillus causing sebor-
rhea would be a practical help in preventing baldness to
a great extent. His clinical experience convinced 'him
that there was an infectious form of pityriasis and other
affections of the scalp. He reported the case of a girl
who had been admitted to the hospital whose head was
almost bald; her hair was falling out in irregular patches.
She was treated and in the course of several months had
CITY HOSPITAL ALUMNI. 111
a very fair growth of hair and left the hospital. In about
a; month she returned with recurring alopecia. On
questioning the patient closely he feund she had been
wearing a bonnet and using a comb which she had used
before the ﬁrst attack. He said he thought this was
probably the infective agent. After treatment with an.
tiseptics the patient recovered and has since been in
good health. He thought the antiseptic treatment was
the best in these cases and yet, if the cause is from bac-
teria, how was it explained that many of these cases im-
prove under internal treatment? He said he did not
believe the researches of Unna and Sabouraud had
cleared up the pathology of the disease._
Dr. Engman had some of the bacteria isolated by
Unna which he placed under the microscope, for the in-
spection of the members. -
DR. P. J. HEUER said he would like to know if there
wasany explanation of the fact that the sites usually
attacked are the frontal prominences and spreading
thence to the posterior fontanelles.
DR. NORVELLE WALLACE SHARPE asked what were
some of the practical points in lhe way of- treatment and
cure. '
DR. GRINDoN said he did not wish to champion Sabou'
raud’s views as they had not as yet been proved true. Ac-
cording to Sabouraud, oily seborrhea may become com-
plicated with secondary infections and these may give rise
to inﬂammation. One of these is probably the morococcus
of Unna; besides that there may be others. Dr. Grindon
thought that Unna made the mistake so often made by
investigators, of generalising too rapidly; he thought this
was true in respect to the morococcus. The speaker
inclined to agree with Sabouraud in believing that adry
dandruff could ex1st without seborrhea—that some one
or more of the organisms responsible for scaly inﬂamma-
tion of the scalp could be implanted upon the scalp either“
with or without preexisting seborrhea.
In regard to alopecia: areata Dr. Grindon agreed with
Dr. Hardaway that cases usually seen in this country
112 MEDICAL SOCIETY OF
were eminently neuropathic. He was inclined to think
there were several conditions characterized by circum-
scibed smooth baldness. It was'quite possible that
Sabouraud’s seborrhea bacillus was responsible for cer'
tain cases, particularly those reported in France in 1889,
and since as having run through institutions. In this
country this type was not seen. In his experience he
had never seen a case of contagion, although he had
been on the lookout for instances. He thought, on the
contrary, it was a neuropathic affection and often oc-
curred in persons suffering from mental strain or sick
headaches. He admitted, however, that the contagious
forms did occua in other parts of the world and probably
inlother parts of this country, though he had seen noth#
ing of the kind. There was nothing unreasonable in
‘ attributing the latter type to Sabouraud’s micro organ-
ism. It certainly seemed strange that the same bacillus
should be responsible for seborrhea, acne, ordinary
forms of baldness and alopecia areata. This, Dr. Grin-
don said, was a great deal to accept but, as Sabouraud
said, the statement that osteomyelitis and boils were
dueto the same cause seemed equally strange a few
years ago.
As to why ordinary baldness starts at the vertex in-
stead of peripherally, he said he was unable to state;
nor could he say why men were more often‘ bald than
women.
DR. AMAND RAVOLD asked what bearing the wearing
of a tight hat had on this subject.
DR. GRINDON said he thought it possible that there
might be something in that. Exposure of the scalp to
all sorts of weather and removal of constriction favors
the growth of hair. He cited the case of a man in New
York some time ago who was bald-headed and who went
for a year without a hat. In all sorts of weather, rain
or shine, he was bare-headed, and the result was that his
hair grew again.
There might be some relation, Dr. Grindon thought,
between the weakness of the growth of the hair on the
CITY HOSPITAL ALUMNI. 113
scalp and its luxuriance 'elsewhere on the body. Th
growth of hair on the head of woman is heavier than on
that of man, and women less often become bald; and
then men with bald heads usually have heavy beards.
He thought it possible there might exist some relation
between these facts.
The treatment of these cases, he said, was a difﬁcult
matter. He agreed with Dr. Engman that the antisep-
tic treatment was the best, and with Dr. Hardaway that
the sulphur compounds were the most valuable of the
antiseptics. Sabouraud enumerates oil of cade, ichthyol,
resorcin and sulphur. Ichthyol was not a pleasant thing
to rub into one’s head and oil of cade was also objection-
able; even sulphur had some odor though less objection-
able than the others. Personally, he preferred salicylic
acid to be used either in the shape of an Ointment, or an
alcoholic solution of about 3 per cent. Resorcin could
be used dissolved in equal parts of water and alcohol.
However the treatment of baldness was not the province
of his paper at thi4 meeting.
DR. ENGMAN said there was one thing in relation to
baldness which he believed would prove to be a feature
in its etiology and which seems to have been overlooked
up to the present time, and that was the great subject
of evolution. He thought a great many people are bald
as the result of this doctrine of evolution—because of
their high development. Hair, he said, was undoubt-
edly becoming less on the human body, as is evidenced
in certain people in various countries and communities,
and he thought it would ultimately come to be recog-
nized as one of the theories of loss of hair, or absence
of hair, on the human body.
114 I MEDICAL SOCIETY OF
The Relative Value of Digitalis and Strych-
nia in Pneumonia as Observed in a Few
Cases, With Remarks on the
Beneﬁcial Effects Of Quinine
in This Disease.
BY CARL A. W. ZIMMERMANN, M,D., ST. LOUIS.
It is well known that the cause of death in the dreaded
disease pneumonia is failure of the right ventricle, that
pneumonia is a self-limited disease, that we can donoth-
ing to out it short, and that consequently the only thing
left for us is to keep the heart pumping until the pneu-
mococcus sees ﬁt to vacate.
Records show that a number of cases get well without
any medication whatever, and to such records I can add
one case. This was in a man, aged 42 years, who had
been sick nine days, gave a good history of pneumonia,
and on physical examination conclusive signs of the dis-
ease were elicited. He entered the hospital on the eve- V
ning of the tenth day of the disease, having spent the
ﬁrst nine at home, without any treatment other than
rest, with a temperature of 103° F., pulse 104, respira-
tion 30. He was given a heart stimulant, and on the
following morning the temperature was 98° F., pulse 70,
respiration 24.
I do not doubt that the result would have been the
same'if he had not received the cardiac stimulant Yet
the great majority of cases will need treatment, which
as before mentioned, though differently expressed,
should be directed to the heart.
Now of the heart stimulants generally used in the
treatment of pneumonia, the two most prominent are
digitalis and strychnia.
Of the few cases which came under my care at the
City Hospital, the majority were treated with digitalis,
and with satisfactory results. The drug in the form of
the tincture was given in small doses, often repeated;
preferably 5 drops every one, two or three hours as
seemed indicated; and in order to prevent any gastric
CITY HOSPITAL ALUMNI. 115
disturbances 1 to 3 drops of diluted hydrochloric acid
were added to each dose. In this manner the pulse
could be controlled very nicely.
In eight cases thus treated the pulse never ranged
above 106 after twelve hours, and in four of these the
pulse never exceeded 105 beats per minute; and in all
but one of them the pulse, when once brought down,
was held between 80 and 100 through the entire course
of the disease, the respirations at the same time ranging
between 28 and 40, and the temperature standing be
tween 102° and 104° F.
In one case the pulse took a spurt to 130 one morning
falling to 88 the same evening. In another case the
pulse was 120 in the morning falling back to 106 in the
evening. Under digitalis the pulse was, as a rule, a
good one, it being regular, 2'. a, one heat as strong as
another and full; in one or two cases it was very tense
for a time, but soon became softer. The heart sounds
were very distinct, well marked and regular. Nor were
there any digestive disturbances.
Of three or four cases treated in the same manner the
temperature charts were misplaced, but I remember very
well that the pulse rates were not rapid.
Of cases treated with strychnia—t0 which whiskey
was always added-I have records of three. The ﬁrst
never had a pulse of over 96, it usually ranging between
80 and 84, nor did the temperature run high. Here I
thought digitalis contraindicated, and administered
- strychnia, gr. ‘/u three times daily and twice at night,
each dose being accompanied by 20 c.c. of whiskey. I
believe this patient would have recovered without any
treatment.
A second case occurred in a man, aged 44 years, who
entered the hospital with a temperature of 101° F., res-
piration 32, pulse 122. He was given strychnia gr. 1/,,
three times during the day and twice at night.
This man’s pulse never was below 120 during the en-
tire period of the disease excepting two mornings when
it dropped to 112 and 116 respectively. It was only on
116 MEDICAL SOCIETY OF
the ﬁfth day after the crisis that the pulse reached 72.
During the course of the disease the pulse while always
rapid was often weak and irregular/ The heart sounds
in the beginning of the disease were distinct but later
became indistinct, and, as it were, confused; the second
pulmonary sound especially becoming weak.
The third case in which Strychnia was used was in a
boy, aged 17 years, who entered the hospital on the
fourth day of the disease, with a weak pulse, beating at
the rate of 114 per minute, respiration 52, and tempera-
ture 105° F. He was given on the ﬁrst day strychnia
gr. 1/3,, together with 20 c.c. of whiskey; each time the
pulse not being strengthened the dose of strychnia was
increased to gr. l/:w three times daily and twice at night,
the dose of whiskey remaining unchanged.
On the second day of entrance the pulse had grown
stronger and more rapid.
On the evening of the third day the pulse was rapid,
beating 122 times per minute and weak; the second pul-
monary sound was inaudible. I saw that the patient
was in danger and replaced strychnia by digitalis, quin-
ine and hydrochloric acid. '
On the following morning the pulse was 120, respira-
tion 36, temperature 102° F. That evening pulse was
96, respiration 42, temperature 102.6° F. ’
On the next day—morning, the eighth day of the dis-
ease, patient had his crisis with a pulse of 88, respira-
tion 36, temperature 97 .2° F.
In those cases in which I used digitalis quinine was
also employed, but never combined with the strychnine
treatment.
In such cases where quinine was used the temperature
never ran over 103° F., and one to three sponge baths
were all sufﬁcient during the. treatment of the disease;
whereas when quinine was omitted the temperatures re-
mained high, often reaching 105° F., and two to six
sponge baths were required daily for three to ﬁve days.
A sponge bath was given each time that the tempera-
ture reached 103° F.
CITY HOSPITAL ALUMNI. 1 17
The quinine was given in 5 grain doses three times a
day and sometimes once or twice at night, and I earn-
estly believe that it had antipyretic effects.
From the above it can be seen that under the digitalis,
quinine and HCl treatment the pulse became slow and
strong, the heart sounds being well deﬁned, that the
temperature seldom ran over 103° F., and that the pa-
tient seldom was in extreme danger Also that when
strychnine was used the pulse was as a general thing
rapid and towards the last weak; that in one case the
sound was indistinct, in the other it became almost in-
audible; that the pulse reached normal until several
days after the erisisyand that the temperature ranged
very high.
Now, since in treating any disease we can only assist
Nature, it Certainly is right that we select such drugs
in the treatment as produce effects nearest the natural
or normal.
Digitalis holds the pulse, quinine checks the tempera-
ture, and HCl removes a grave objection to the ﬁrst
named drug—namely, its ill-effects on the stomach.
Therefore I think they should be used, and see no con-
traindieation .
Stryehnine holds neither pulse nor temperature, but
on the contrary, in its administration with whiskey,
the pulse is rapid, and the heart Often is in a dangerous
condition, and sponge baths are too frequently required.
DISCUSSION.
DR. P. J. HEUER desired to know whether the cases
treated'were grippe pneumonia, or lobar pneumonia.
THE PRESIDENT asked if the treatment with strych-
nine was by the mouth or hypodermically.
DR. L. DRESCHLER asked if the area involved in the
cases treated was about the same in all, or were some of
them more extensive than others. He also asked how
many cases were under observation.
DB. ZINMERMANN said the cases treated were ordinary
cases of lobar pneumonia. In regard to the method of
118 MEDICAL SOCIETY OF
using the strychnine he said it was given per os. There
were eight easestreated with digitalis and quinine and
three with strychnine. The area of lung involved was
mostly the entire lower lobe. In three cases the upper
lobe was involved, but in most cases the lewer lobe of
the right lung was affected. In those cases treated with
digitalis, strychnine and quinine, the temperature never
ranged above 103° F., but where the quinine was omit-
ted the temperature often rose to 105° F., and sponge
baths had to be given from three to ﬁve times a day.
He found, however, that cases treated with digitalis
progressed to a better recovery than when strychnine
was used and the temperature, as a rule, was lower.

A Case of Meningitis.
BY M. A. BLISS, M.D., ST. LOUIS,
Neurologist to Mullanphy Hospital; First Assistant Neurological
Clinic St. Louis' Medical College.
John B., Italian, aged 36, widower, occupation saloon
keeper, always had fair health up to October, 1897 .
Family history negative. '
About October 4, he began to have fever, one week
later he entered a hospital where a diagnosis of typhoid
was made. He was dismissed October 27, weak, but
able to walk. November 15, he became paraplegic; he
thinks he suffered quite continuous pain in his back and
loins previous to the paralysis, but his recollection of
events in November seems dimmed.
He continued in a paraplegic state, suffering pain in.
the spinal region. Painful contractions of thighand
leg muscles gave him much distress. I saw him ﬁrst,
at the request of Dr. Bryson, January 8, 1898. He was
lying in bed and brought himself slowly and evidently
with great pain into a sitting posture solely by the use
of his arms. Upon assuming the sitting position the
lower limbs were thrown into a clonic state. ' He was
totally unable to stand erect.
CITY HOSPITAL ALUMNI. 119
The knee-jerks were tremendously increased and there
was a pronounced ankle clonus on both sides. The
thigh and leg muscles were quite tender. There was
hyperesthesia of the skin except over the inner aspect
of the thighs where there was slight anesthesia which
extended to some degree over the outer aspect. The
anesthesia could not be deﬁnitely outlined but was con-
ﬁned in a general way to the middle portion of the
thighs. The temperature sense was not greatly dis-
turbed but was slow in transmission. Tactile sense was
fair over the entire surface of both limbs except on
the toes, but there the calloused skin made the ﬁndings
uncertain. No electrical tests were made.
On returning the patient to bed he seemed greatly
exhausted and in a tremulous state. At intervals of ten
minutes or less there was a painful jerking in both legs
which the patient said continued throughout the night
and prevented him from sleeping.
The bowels and bladder were very slow to act; the
bowels moved only with enemas. No urine escaped
without the patient’s volition, but urination was slow to
start and the bladder got very full before the patient’s
attention was called to it; the catheter was necessary at
times. The sensorium was clear.
A diagnosis of meningo-myelitis was made and con-
curred in by Dr. Fry. The patient surprised us by the
amount of improvement within two weeks after enter-
ing the hospital. The painful jerking in the legs ceased;
the knee 'jerks gradually subsided. Within a month the
ankle clonus had disappeared except after exertion; the
anesthesia and hyperesthesia began to disappear coinci-
dentally with the subsidence of the deep reﬂexes. Feb-
ruary 12, a note was made of lessened pain-sense over
the outer side of the left thigh—the next day it could
not be determined. February 22, the patient began
walking with the support of a chair but it was with
much pain, and examination showed an increase of the
knee-jerks but no ankle clonus.
The history from this time was of slow progress to-
120 MEDICAL SOCIETY OF
ward recovery. By the last of March the patient was
able to walk twelve or ﬁfteen blocks without great fa-
tigue.
The original diagnosis had to be modiﬁed when later
developments showed no transverse lesion. But we think
the enormously increased deep reﬂexes associated with
paralysis, the distinct involvement of the bowels and
bladder, the anesthesia, the early pains in the back and
the course of the disease up to the time we saw him,
justiﬁed the opinion then expressed. The progress of
the case during our observation showed it to be menin-
gitis, probably accompanied with transudation. As to
etiology it may have been a typhoid infection, but of
this we can not be certain.
The treatment was largely of inunctions of mercury
and the internal administration of iodide of soda. Not
a luetic sign was discovered, and the treatment was pre
scribed on a bare possibility. The recovery of the
patient, on the other hand, does not prove the luetic
character of his troubles, as the treatment may have
acted simply as a stimulus to the absorption of an in-
ﬁammatory exudate. Dr. Bryson and myself made a
very careful search for a scar indicative of syphilis, but
were unable to ﬁnd even a suspicious mark.
At this time the patient is normal in all respects and
has returned to his usual occupation.

DISCUSSION.
DR. J. P. BRYSON said the case was of especial inter-
est to him because of the question of etiology involved.
He did not think it possible, after the thorough exami-
nation made by Dr. Bliss and himself, that any syphili-
tic lesion could have escaped their notice. One thing
which attracted Dr. Bryson’s attention early in his ob-
servation of the case was the absence of the distension
reﬂex of the bladder; there was almost complete paresis
of the bladder, with overﬂow. The speaker said he was
not familiar with the manifestations of the nervous sys-
tem produced by typhoid fever nor with the prognosis
CITY HOSPITAL ALUMNI. 121
in such cases, but as far as any syphilitic origin in the
case under discussion was concerned, it did not bear the
general outline of cases resulting from a speciﬁc lesion.
At one time he thought he had discovered a lesion about
the urethral meatus, but after repeated examinations he
was unable to ﬁnd anything of a scar; the examination
of the rectum was also negative and he felt positive
there was no syphilitic manifestation about this patient.
He desired to know what the prognosis was in cases of
typhoid nervous lesion as he was not familiar with that
view of the case.
The speaker said his chief reason for saying this pa
tient did not bear out the manifestations of a speciﬁc
infective lesion was the absence of the characteristic ex-
acerbation at night and in the morning. He considered
this one of the most general clinical manifestations of
syphilitic lesion. These cases, even when conﬁned to
bed, generally have an increased amount of pain
towards midnight. If it intermits, the intermission will
come in the day time.
DR. E. M. NELSON said he also would like to know
what the prognosis would be of cases of nervous mani-
festations following typhoid fevers. He had seen cases
with such pronounced mania following typhoid as to
make it difﬁcult to determine whether it was delirium
or insanity. Was the diagnosis usually favorable in
these cases.
DR. M. W. HOGE said, in regard to the nervous mani-
festations following acute diseases, such as typhoid
fever, the prognosis was as a general thing favorable;
more so than in insanity originating without any appar
ent cause. Insanity following fevers could usually be
attributed to some toxin in the blood which would be
thrown off during convalescence, or to the constitution
of the patient, and in these, as a rule, convaleseence
generally removed the nervous symptoms.
DR. BLISS said the reason for their careful search for
a syphilitic lesion was because it was so rare to have
these symptoms after typhoid fever, and also because
122 MEDICAL SOCIETY OF
antisyphilitic treatment had been given the patient un-
der which he improved and it was thought likely there
had been a speciﬁc infection. '
DR. AMAND RAVOLD asked if an examination of the
blood had- been made to determine whether typhoid
fever was present.
DR BLISS said no examination of the blood had‘been
made.
An Apparatus for the Application of Dry
Hot Air to Different Portions of
the Human Body.
BY VILRAY P. BLAIR, M.D., ST. LOUIS.
In line with the general Interest lately aroused on the
subject of the therapeutic eifectof the local application
. of dry hot air, I have attempted this treatment in cer-
tain cases to which I thought it applicable. Among the
cases selected is that of a girl ﬁxed in a sitting position
by the affection of both knees, as well as other joints,
with chronic articular rheumatism. ~ It was absolutely
impossible to move her on account of the pain induced.
The application of heat here was a problem the solution
of which is an apparatus that I think deserving of no-
tice from those interested in the subject
There are at the disposal of the profession two kinds
of appliances for the local application of hot air. In
one the fumes from an alcohol lamp are let directly into
the heating chamber. The other is a cylindrical oven
on four legs, with a ﬁre-box underneath containing a
Bunsen burn-er. The air in the oven is heated by radi-
ation through a metal plate. It will be appreciated at
once that machines of the ﬁrst mentioned class are
_ wanting in two or three elements, designated dry hot
air, as the products of combustion are water and other
things, not air. The scheme has prOVed unsatisfactory
in my hands.
The second kind ﬁlls the requirements, but the difﬁ-
CITY HOSPITAL ALUMNI. 123
culty of adjusting it to certain parts of the body led to
the construction of the apparatus I am about to
describe.


It consists of a doubled walled cylinder made of
Russia iron, 16 inches in diameter, inside measurement,
with a 1 inch circulating space between the walls; the
outer wall (1, ﬁgure 2, is lined with asbestos; one end of
the cylinder is closed; at the other end the inner wall a,
ﬁgure 2, is prolonged forward 2 inches, and grooved for
the attachment of the curtain. There are three small
openings from above into the inner chamber for the in-
sertion of the thermometer; one in the back, passing
through both walls (designated in ﬁgure 1, with the
thermometer in place, by D). The other is anterior and
passes only through the prolonged inner wall in front.
There are two openings in the outer wall, the lower 10
inches long for the Bunsen burner (ﬁgure 1); the upper
(E) 2% inches in diameter gives vent to the products of
combustion aft-er they have circulated entirely around
the inner chamber.
A temperature of 300°F. can be raised in the inner
chamber in 13 minutes. In instruments which have a-
124 MEDICAL SOCIETY OF
simple ﬁre box underneath it requires 45 minutes to ob-
tain this temperature. The ﬂame Of the Bunsen burner
plays on a sheet of asbestos which is separated from the
inner wall by an air space. This sheet 1s 11- inch thick
and just large enough to prevent the ﬂame from coming
in direct contact with the inner wall.


FIG. 2
In the lower half of the inside of the inner cylinder
(ﬁgure 2, a), and held parallel to and at a distance of =1»
inch from the inner wall, there Is a sheet of 1}; inch as
bestos (ﬁgure 2, c) to prevent too great a radiation of
the heat from this portion of the wall just over the
ﬂame. Superimposed on this sheet of asbestos and
parallel to it at a distance of 1} inch, is a sheet of heavy
wire gauze (ﬁgure 2, 6) upon which the bandaged limb
is allowed to rest. By this arrangement there are im-
posed between the ﬂame and the dressing covering, two
CITY HOSPITAL ALUMNI. 125
sheets of 1,1 inch asbestos (c and a). one sheet of iron (a)
and one of netting (b), and three 1} inch air spaces.
The stand is of 1 inch pipe with a horizontal portion
on the ﬂoor and a vertical shaft, 4 feet long, ﬁrmly ﬁxed
in the former. The connection is made by means of
of the cylinder being hinged to a collar (A, B), which
is freely movable on the staff. By means of this collar
the cylinder can be raised to any desired height and
swung around in any direction. By means of the hinge
any inclination can be attained and maintained by means
of a rod ﬁxed at the collar by a set screw (C) and hinged
to the cylinder. Besides this, there is a removable rod,
adjustable as to length, passing down from the anterior
inferior portion of the cylinder. The lower end of the
rod is pointed and may rest either in a groove in the
stand or on the ﬂoor; it is there to support the extra
weight of a limb in the oven but can be removed when
the oven is extended over a bed.
The curtain is a sleeve, 18 inches long, of cotton mack-
intosh, and of a circumference slightly larger than that
of the grooved projection of the inner wall of the cyl-
inder, over which it is ﬁxed by means of a draw string;
the other end is also surrounded by a draw-string. Run-
ning perpendicularly from this into the sleeve are two
slits like placket holes in a skirt; these are opposed to
each other and guarded by two free triangular ﬂaps of
cloth. The draw string is in two pieces, running along
each side of the end of the sleeve with the free ends
protruding at both placket holes. On the outside Of the
free end of the sleeve, close to the draw-string, are set
at equal distances from each other, four tap loops. So
much for the description of the machine. Now as to
its use.
If it is a hand or foot, with a certain adjoining por-
tion of the limb that is to be treated, the cylinder is
placed in a horizontal position at the proper level. The
aﬁected member is placed upon the screen inside the
cylinder and the curtain is drawn close around the limb.
If it is a knee in the ﬂexed position, as in sitting, the
126 M EDICAL SOCIETY OF
free ends of the draw string passing out of the upper
placket hole are knotted together and drawn tight so
that the hole is obliterated by the crossing of the afore'
mentioned ﬂaps. The kneeis passed into the sleeve and
the draw-string tightened around the thigh with the leg
through the lower placket hole.


FIG. 3.—APPLICATION OF HEAT TO THE FOOT, SHOWING
ANTERIOR SUPPORTING ROD IN PLACE
The same application can be made to the shoulder by
bringing the arm to the side and inserting the shoulder
into the sleeve and bringing the free ends of the draw-
string around the chest.
The hip may be reached by passing one of the ends
of the draw string around the waist and the other
around the thigh, the waist and thigh ﬁlling the placket
holes.
To make an application to a ﬂatsurfaee—as the chest,
the strings are drawn with both placket holes closed
CITY HOSPITAL ALUMNI. 127
until the opening in the sleeve corresponds in size to the
area to be treated. Tapes are then fastened into the
loops on the end of the sleeve and are passed around
the body.
To treat a part with the subject reclining the hori-
zontal portion of the stand is passed under the bed and
the cylinder swung over, the anterior supporting rod hav-
ing been removed. It may alto be necessary to give
the cylinder a downward slope.


FIG 4.—APPLICATION OF HEAT TO THE SHOULDER,
WITH ICE-BAG ON THE HEAD, AND FACE
SHIELDED WITH A TOWEL.
When a part treated occupies only the sleeve, the
thermometer should be in the anterior part of the cyl-
inder. It is also desirable to have the cylinder incline
upward toward the part treated to facilitate the circula-
tion of hot air. This, however, is not always pOSSIble.
For the better support of the elbow in the ﬂexed posi
128 MEDICAL SOCIETY OF
tion, a shelf of screening which is adjustable. can be
placed in the mouth of the cylinder. It is composed of
a cylindrical ﬂange ﬁtting snugly into the mouth; this
supports the shelf by two pins which rotate to any de-
sired inclination. This portion is removed when not
needed.


FIG. 5.—APPLICATION OF HEAT TO THE CHEST OF A
CHILD.
In an article upon hot air in the Therapeutic Gazette,
of November 18, 1897, Elwood R. Kirby, M.D., and
Joseph M. O’Malley, A.C., M.D., reviewed the subject
and gaveareport of over 300 cases treated. In the
course of the article they made this statement: “Our
experiments have also led us to believe that if an appa-
ratus could be constructed enabling one to adopt this
method of dry heat in pulmonic oongesticns, the vaso-
motor dilation ensuing, literally bleeding one into his
own arteries, many distressing and dangerous symptoms,
CITY HOSPITAL ALUMNI. 129
as cyanosis and dyspnea, might be relieved or mitigated. '
It seems to us that this subject is well worth further
investigation.” Also: “In cases of traumatism of the
shoulder it was impossible to get the full effect of the
heat because of the difﬁculty experienced in getting the
shoulder within the cylinder of the apparatus.”
The apparatus here described is applicable not only
to the chest, but to any part of the body in any position.
The indications for and the length of the treatment,
and the mode 'of protecting the part treated and the
temperature at which the treatment is carried on, have
all been dealt with by men With a larger experience than
mine, and I have nothing to add on these subjects. I
have always placed an ice bag on the patient’s head
during the treatment as a prophylactic to the headache
which sometimes ensues. The number of cases I have
treated is not large but I have had some encouraging
results.
The apparatus is made by the Emile Willbrandt Sur-
gical Manufacturing (30., of this city. '

DISCUSSION.
DR. FRANK R. FRY said he agreed with Dr. Blair
that the value of the hot air treatment had been well
attested in certain conditions. He thought eventually
all would owe a good deal to Dr. Blair for bringing
his ingenuity to bear upon the problem of applying heat
to localities diﬁicult to reach. He said he had talked
with Dr. Blair about the machine and found that he had
much conﬁdence in its eﬂicacy, and now after the exhi-
bition of the apparatus before the Society, the speaker.
felt that he could share this conﬁdence. This treatment
he thought very practical and some of the results he
had seen from its use could not, in his opinion, have
been attained so rapidly in any other way. It acted ad-
mirably in neuritis, and inﬂamedjoints, aﬁections where
there is often such exquisite sensitiveness that ointment
can not be rubbed, and even the putting on of cloths to
obtain a moist heat is painful.
130 MEDIoAL SOCIETY OF
DR. ELsWORTH SMITH, J B. said he had had no personal
experience with hot air treatment in conditions of the
chest, but he felt an apparatus of the kind exhibited by
Dr. Blair might be of great service. ‘ He said he thought
it might be of special service in heart affections by pro-
ducing a vaso motor dilatation of the superﬁcial vessels
of the skin and muscular system and thereby relieving
the overdistention of the ventricular walls. This
method, he said, was practiced by Schott who reached
this effect by means of a medicated bath; the peripheral
vessels are dilated and the ﬂow of blood made easier
and the work of the heart especially favored and some
marvelous results obtained. By this means edemas
were removed, the heart toned up and patients relieved
of serious symptoms and madezcomfortable where other
and ordinary remedies had failed. He thought this ap-
paratus would be of great service in acute congestions of
the thoracic viscera especially as it enabled the physi-
cian to reach parts of the body and subject them to
treatment without placing the whole body in _a bath of
hot air. In this way internal congestions could be re-
lieved and the effects of the older method of cupping
obtained, but in a much more effectual manner. The
speaker said he had simply noticed from time to time
allusions to this sort of treatment but had never worked
up enough interest in it to seriously consider it, chieﬂy
because he had never seen an appartus of the kind suf-
' ﬁciently perfected for treating chest cases. Now, how-
ever, he should feel like trying it, for Dr. Blair’s very
ingenious apparatus seemed to promise good results.
DR. NORVELLE WALLACE SHARPE said there was no
doubt of the extreme value of an apparatus of this kind.
He was anxious to know what method Dr. Blair had
found most serviceable in the use of the apparatus, and
whether he found there was any appreciable diminution
in the amount of heat applied to the surface of the part
exposed in view of the fact that the curtain was some
eighteen inches long.
CITY HOSPITAL ALUMNI. 131
DR. FEANOIS REDER said Dr. Blair had given a good
illustration of the application of heat in a mechanical
form. Heat, he said, was a chemical factor and always
gratefully received in all affections accompanied with
pain, whether inﬂammatory or non-inﬂammatory. He
thought if nascent heat could be generated in the appa-
ratus its application to phlegmons would be a material
gain over the present method of treating these affec-
tions; its superiority over the mustard plaster, hot water
bags, etc., was very evident. The question would arise,
how long could a patient afﬂicted with a phlegmon en-
dure a temperature of 300°? He desired to ask Dr.
Blair if he had given any thought to the generation of
nascent heat.
DR. M. A. BLISS asked Dr. Blair to give the Society
the result of his experience with the cases he has
treated and in what class of cases he found it most sers
viceable. '
DE. J. P. BRYSON said he thought there were many
surgical cases to which this treatment would be applica-
ble. He desired to know what the price of such an ap-
paratus would be, and more especially what could such
a machine be rented for. He thought it would be de-
sirable to rent the apparatus and, perhaps, have some
one acquainted with its working to accompany it. The
great majority of people could not pay any considerable
amount and the rental of the apparatus would be a way
to receive the beneﬁts of it without the necessity of
buying one.
THE PRESIDENT asked if the apparatus could be uti-
lized in the absence of gas and by what method.
DR. E. M. NELSON asked if the continued application
of dry hot air in this apparatus did not become an appli-
cation of moist hot air by the resulting perspiration on
the part exposed, and if SO, was not the susceptibility of
the skin to the heat increased.
DR. BLAIR said the part exposed to this treatment
come out very red and had much the appearance of hav-
ing been in hot water for a long time. The skin was
\
132 MEDICAL SOCIETY OF
moist and congested. He did not think that the amount
of moisture produced by the evaporation of the perspira-
tion brought on while in the oven was objectionable.
The price was about $35 or $40, but if they were made
in quantity it cOuld be reduced to $20 and still a proﬁt
be made. His had cost him about $7 8, but this included
several mistakes. The curtain was not air tight and hot
air would escape but cold air enters below and is heated
and thus a constant circulation is kept up but the tem-
perature is not reduced. He said he had tried to dem-
onsttrate what amount of moisture existed from the
evaporation of the perspiration, but had not succeeded
in ﬁnding any considerable amount. The limb is
wrapped in a layer of cotton, or several layers of blanket,
and this fact would necessarily interfere with the evap-
oration from the limb.
He believed that, in most cases, especially those where
there was an element of toxemia, the beneﬁcial effect
was due to the elimination concomitant with the evap-
oration which must be necessary to maintain the low
temperature of 300°F. The number of cases he had
treated was not large enough to admit of valuable de-
ductions from experimentation, but it seemed to him
that, if the foregoing premise was true, a more decided
effect would be obtained from carrying on treatment at
a temperature just as high as could be endured with the -
skin uncovered, but no higher. Even if the thermome-
ter registered a temperature higher than could be en-
dured by the bare skin it was not to be concluded that
the temperature next to the skin was as great, for the
cover must interfere with the circulation of air and evap-
oration and, to some extent, maintain a 'zone of mois-
tened. air in direct contact with the skin, tending towards
a condition to be avoided.
In the class of cases treated by the speaker he found
that chronic cases resisted treatment more than others.
Chronic articular rheumatism, except for a transient re-
lief from pain, did not seem to be beneﬁted. In gen-
eral, acute cases gave better results, especially injuries
CITY HOSPITAL ALUMNI. 133
to joints, sprains, etc., and, in this class of cases, he had
seen two applications do as much good as would be ob-
tained from a splint in two weeks. Acute rheumatism
also yielded readily. With pulmonary congestions he
had had no experience. In regard to the production of
nascent heat, the speaker said it would be impossible to
run the temperature up to more than 180°F. without
producing discomfort. In the treatment of fat persons
it had been noticed that at ﬁrst the pain would be in-
creased, but afterwards was mitigated as in other cases.
The treatments sometimes reduce the weight of thin
people and when this occurred they were to be discon-
tinued for a while. The heating of the machine without
gas could be done very readily by replacing the Bunsen
burner with an alcohol lamp, or probably, more econo~
mically, with a gasoline burner.
DR. BRYSON asked if Dr. Blair had had any experi-
ence with chronic rheumatic arthritis with more or less
anchy losis.
DR. BLAIR replied that he could not say the results
had been very satisfactory. One result of the treatment
, of these stiff joints was that after the treatment the pain
of breaking up adhesions was reduced in a marked de-
gree. In acute cases of gonorrheal rheumatism some
beneﬁt had been observed. Of tubercular joints he
had had no Observation but understood that some had
been derived. It was of special value in the after-treat--
ment of fractures where adhesions and an atrophic state
existed. The rental of the apparatus was a subject he L
had not considered. In regard to sending some one to
‘ properly, carry on the treatment prescribed, Dr. Blair
said he did not know of anyone at present who was ac-
quainted with the apparatus and its operation; it was
however, a very simple aﬂz'air and any intelligent person
should be able to carry out instructions.
DR. REDER asked if massage and the Swedish move-
ments were advisable as an after treatment.
DR. BLAIR said he thought that they might be bene-
134 MEDICAL SOOIETY 0F
ﬁcial, and asked Dr. Fry to give his opinion on that
subject.
DR. FRY said the hot air treatment undoubtly facili-
tated the passive movements by softening the parts to
an 'extent not obtainable by other measures.

[DR. FRANK R. FRY, Vice President, assumed the
Chain] "
' The Sanitary Redemption of Havana—The
' Need and the Means.
BY GEORGE HOMAN, M.D., ST. LOUIS.
No problem that concerns public health in thiscoun-
try, and that has relations beyond our own boundaries, is
of more weighty importance than the one presented by
the condition of the port of Havana as a persisting source
of exotic pestilence dangerous to every neighboring peo-
ple and state. This condition has been continuously
present for many generations, and is the outgrowth of
causes partly climatic, partly topographic, but in the
main of causes political, governmental, or administra-
tive in their nature. '
The presence of such pandemic infections as cholera
or small pox in Cuba would offer no new problems to
the skilled sanitarian; they would be oombated with the
_same weapons used elsewhere for the purpose among
similar classes of population. But it is as the chief nur-
sery of yellow fever, and the principal center for its dis-
semination to other countries, that has given to the port
of Havana its evil eminence in a sanitary sense, and this
country has felt the weight and blight of epidemic in-
roads from this direction more or less fOr above one
hundred years. ‘ , '
Science seems not quite able as yet to pOint to the
actual factors or conditions which have begotten yellow
fever as a deﬁnite pathological entity, and there are still
some other unsettled questions, concerning the nature of
CITY HOSPITAL ALUMNI. 135
the organism supposed to give it being, the means by
. which the disease extends, etc. _
A British writer (Creighton) has attempted to trace
the origin of this disease to the slave-ships trading be-
tween the West Indies and the Guinea Coast, but while
from trustworthy accounts the conditions obtaining in
the holds of slavers on the westward passage were oft-
times most revolting still the evidence that yellow fever
sprung directly from such a source is not conclusive,
however well such a conjecture may be made to square
with the demands of retributive justice for human
wrongs. The fact that the black race is immune to the
disease has been cited in support of the view of an
avenging Nemesis dealing out retribution for Outrage
and oppression, and if this view is accepted it must be
admitted that the measure of justice has been fairly ful-
ﬁlled, for while accurate records in both particulars are
lacking it yet appears probable that for every black that
was kidnapped by the slave traders to be sent to Amer-
ica one white person has perished from yellow fever.
The harbor of Havana, or Habana, received its dis-
tinctive _name (the Haven) because of the exceptionally
safe refuge it afforded the sailing craft of earlier times
from the stormy seas and tempests of that latitude. It
is a land locked bay, deep, spacious, easy of access, and
well,sheltered on all sides. ' Its general direction is
from southwest to northeast while the outlet points
about northwest, this passage being less than one thous-
and feet wide and about four thousand feet long.
With the exception of some arms, or inlets, that reach
in different directions the main bay, or harbor proper,
may be likened roughly to.a bottle or narrow jug with
the neck set on the shoulder in an oblique direction.
There are no streams of large size ﬂowing into the
bay, the Gulf tides are inconsiderable (only about two
feet), the sewage and surface drainage of a large popula-
tion have been poured for centuries into this almost
stagnant basin, and with a temperature seldom falling
below 70° F., and when it does of too brief duration to
136 MEDICAL SOCIETY OF
aﬁect either soil or water, the conditions afforded for
breeding and storing disease are well nigh perfect. It
is, indeed, a huge cess-pool festering in sub-tropical
heat. To borrow the terms of house drainage as applied
in modern dwellings Havana practically presents to the
world trading in its port the conditions that would fol-
low 1he continued use of sanitary conveniences in a
residence where only the most scanty means for ﬂushing
were provided. A
This situation, in so far as it relates to the genesis
and spread of yellow fever, is the result of mal-adminis-
tration, for while the local conﬁguration is peculiar as
affording an especially safe refuge for shipping it has
become through sanitary neglect an equally snug harbor
for a particular disease, so much so that for more than
half the year it is deemed unsafe for any unacclimated
or susceptible person to visit there. The danger that-
attends intercourse with this seaport is so great that the
chief commercial nations have recognized it for many
years, and special precautions are observed by their
shipping in order to lessen the risks incurred.
During the centuries when the slave trade ﬂourished
Havana was a principal mart for the traﬂic, reputable
writers stating that for many years not less than one
hundred ships annually discharged their human cargoes
at its wharves. Aside from other potent inﬂuences the
pollution of the harbor from this source was extensive,
and as no means were employed to freshen the waters
of the bay it is not surprising that the place became the
mother city of the most fatal infection having restricted
geographical range of which our profession has present
knowledge. Depots or centers of yellow fever were de-
veloped at other Cuban points and in other islands of
the West Indies, and on the mainland along the Atlan-
tic and Gulf coasts, but it is believed that these all
reached back, directly or indirectly, to Havana as the
principal source.
During the last century the appearance of the disease
as far north as New England was not unexpected; New
CITY HOSPITAL ALUMNI. 137
York, Philadelphia, Norfolk and Charleston did not es-
cape, while up to 1862 it was accounted an established
warm weather feature in New Orleans, and some of the
other cities on or near the Gulf coast.
The growth of knowledge with increased skill in san-
itation as applied to seaports, shipping, and cities in the
countries and colonies surrounding the Spanish islands
has served to thrust back the disease towards its origi-
nal habitat. Except as an occasional visitor it is
now no longer known in this country. To the west-
ward, Mexico has very nearly freed herself from the
disease as an endemic, an important change having been
effected at Vera Cruz in this respect, as late reports
show; to the southward Jamaica and other British col-
onies have substantially rid themselves of it except as it
may be brought in by shipping, and the same condition
is reported of the Danish islands to the eastward, so
that north of the equator Havana stands as the chief
source of this peculiar form of danger to the trading
nations of the world; and from them has gone forth the
demand that an end shall be put to a state of affairs that
is a perpetual menace to health and life in those waters.
The best sanitary opinion to-day holds the mainten-
ance of such conditions to be contraband of public
health between nations, just as the slave-trade has been
put under the ban of outlawry, and as polygamy has
been decreed contraband of morals by the leading civil-
ized governments. '
Whatever else may be urged in behalf of the Spanish
people it can hardly be claimed for them that they have
shown much care at any time for municipal sanitation
in their American colonial possessions. Engineering
problems having the most important sanitary bearings
were either unrecognized or neglected, and the hygienic
status of this principal Cuban city is a signiﬁcant in-
stance in point.
Yellow fever being essentially a disease of sea level,
thriving best in combined moisture, ﬁlth and heat, cling-
ing especially to the foreshore, wharves, docks, ship-
138 MEDICAL SOCIETY on
holds, etc., Havana presents special conditions for its
growth and harboring, and therefore requires special
means for its eradication. This implies one or two
things, to-wit., either that some method shall be found
by means of which the waters of the bay will be regu-
larly and frequently changed—ﬂushed out thoroughly
as a catch basin should be—br else that the pollution
now poured into it shall be diverted and safely dis-
posed of elsewhere.
These propositions necessarily raise questions of
engineering and ﬁnance, but there is no reason to
doubt that every diﬂiculty can be overcome, as the
normal commerce of Havana is of such magnitude, and
under changed administrative conditions would be so
greatly increased, that the ﬁnancial cost of the work
necessary for the regeneration of the port, if wisely un-
dertaken, could be easily carried and met.
As already pointed out the main sanitary problem
hinges on the possibility of either keeping the waters
of the bay clean by frequent changing, or by cutting off
the dangerous contamination that now enters It. To
effect the former it has been proposed to cut a canal
leading from the bay to a point on the north coast with
a view to establishing a current towards the Gulf. But
I am not sufﬁciently informed concerning the local top-
Ography to say whether or not this would be likely to
achieve the desired end. It has been claimed that a
work of this kind in one of the sea ports of the Danish
islands has proved to be a remedy for like conditions,
but still there may have been essential differences in
the two situations.
It will be remembered that Milwaukee, in order to
overcome the foul stagnant condition of the stream
whose course traverses that municipality, several years
ago installed a powerful pumping plant on the lake
shore and by this means forced fresh water across the
area separating river and lake and thus started a current
in the channel of the former; while at Chicago pumps
of large capacity have been employed for years in lift-
CITY HOSPITAL ALUMNI. 139
ing sewage out of the Chicago river and thence across
the divide ultimately into the Illinois river, the object be-
ing to create an inﬂow from the lake, and it has been sug-
gested that such means established near the Tallapiedra
bay could be employed to force the sewage into the
Gulf and thus induce an inWard current through the
harbor entrance. “
The other alternative is the diversion of the sewage
now delivered into the bay and its disposal elsewhere
without prejudice to public health. This would involve
the construction of an intercepting sewer along the
water front to receive the outfall of drains carrying do-
mestic and manufacturing waste, and is a measure so
commonly resorted to that no novelty presents itself in
connection with the suggestion. Generally, the adop-
tion of such a sewerage scheme requires in connection
with it the operation of receiving basins and pumps to
overcome adverse gradients, or for delivery of the sew-
age to its ﬁnal destination whether into the open sea, or
for irrigation purposes. At sea ports advantage is'some-
times taken of the outgoing tide to carry sewage as far
to sea as possible, Charleston being an instance of the
employment of this kind of tidal drain system.
The construction of an intercepting sewer as sug-
gested would probably eventually lead to a renewal of
the drainage system of the entire municipal area, such
as was accomplished at Memphis, whereby the sewage
proper or house drainage would be cared for apart from
the rainfall, and the initial cost of the reconstructed
work thus greatly reduced.
From a sanitary standpoint there would appear to be
no objection to allowing the rain fall from the munici-
pal surface to continue to ﬂow into the harbor, if proper
scavenging was regularly performed, but provision for
subsoil drainage would be necessary and, preferably, in
connection with the sewerage system on the score both
of economy and efﬁciency. Wherever the condition of
the ground demanded it subsoil drains should be laid
below and in the same trenches with the pipes carrying
140 MEDICAL SOCIETY on
the sewage and a dry sound condition of the subsurface
assured in this way.
The foregoing is in barest outline a statement of the
primary measures needed to redeem in the estimation
of the sanitary world this inportant port from the re-
proach and danger that now attach to it. This unhappy
situation has grown out of the longtime Spanish trait
of laisser join, together with the custom of those in
authority there to regard Cuba as merely a place of so-
journ for their material betterment, hence no sanitary
considerations beyond their own immediate environ-
ment appealed to them; and by successive steps in the
course of time what was once as fair a scene as ever came
from Nature’s hand became as a whited sepulcher full
of dead men’s bones, and fraught with mortal peril to
everyone not immune to the particular plague there
domiciled and entrenched.
To a progressive commercial world doing business by
clean methods in clean ships, and desiring exemption
from unnecessary risk in so doing, such a condition be-
came intolerable when it was seen that problems akin
to this elsewhere were successfully grappled with and
solved, and the time was deemed ripe for the abatement
of what in fact constituted a gigantic international
nuisance. The safety of our own people is yearly put
in too great jeopardy for things to continue as they are,
and with the present hopeful outlook for a radical
change of regime in Havana and Cuba—political,
racial and economic—it may be fairly assumed that
there are those now present here who will live to see
the day when yellow fever will become practically a lost
disease, and the deliverance of its one-time citadel from
this form of pestilential dominion be duly chronicled as
one of the victories of peace and science not less re-
nowned than those of war.

DISCUSSION.
As supplemental to the paper Dr. Homan said be de-
sired to submit some further remarks and to direct at-
CITY HOSPITAL ALUMNI. 141
tention to a Government chart of Havana harbor which
he had received only that morning. It was sent by Dr.
Walter Wyman, Supervising Surgeon-General Marine
Hospital Service, who had kindly caused to be marked
on it the principal localities of sanitary danger, and
these he proceeded to point out, namely, the Tallapiedra
wharf, San Ambrosia hospital, San Jose wharf, Regla
hospitals, etc. He said that the Tallapiedra wharf,
commonly known in nautical circles as “Dead Man’s
Hole,” was undoubtedly one of the most fatal spots in
the world to persons not immune to yellow fever, that
part of the bay being especially foul from the drainage
of the hospital near by, and other sewage, and its stag-
nant condition.
The principal precautions observed by the shipping
of the leading nations in order to avoid sanitary suspi-
cion or infection with consequent inability to secure
clean bills of health, which in turn would lead to quar-
antine detention at port of destination, in this country
at least, are to not go to the wharves but to discharge
and receive cargoes by lighter, to allow crews as little
shore leave as possible during the fever season, and to
permit none of the harbor water to come aboard for any
purpose.
He said further that the excessive morbidity rate in
Havana was in part attested by the hospital capacity
provided, and called attention to the Public Health Re-
ports of the Marine Hospital Service for April 29, 1898,
as follows:
“There are in Habana ﬁve military hospitals, the
largest being the Alphonso XIII, which has a capacity
of 3,320 beds. It is built of wood on the pavilion plan,
and is situated on a high eminence in the outskirts of
the city, and is well removed from all other buildings.
Its equipment is almost perfect, having been constructed
by a Spanish engineer who was educated in the United
States. The surface drainage is complete, and if this
building is not destroyed it could be utilized by the
United States as a hospital for the troops occupying the
city of Habana. The lightest mortality of all the mil-
142 MEDICAL SOCIETY OP
itary hospitals on the island was recorded here. Cases
of yellow fever and smallpox are treated at this hospi-
tal, several wards being set aside for that purpose.
Here it may be said that but few cases of smallpox have
developed among the soldiers.
“There is a second wooden hospital called Cuartel de
Madera, having 1,000 beds, and situated in the Parish
known as Jesus Maria. It is poorly constructed and
could only be used as a hospital for yellow fever cases
“The Beniﬁcencia Hospital has 2,000 beds; it is situ-
ated near the Gulf and is built of stone. This building
was formally used as a foundling asylum, but was taken
by General Weyler in 1896. It would be unwise to use
this structure as a hospital. No surgical cases were
treated in this hospital.
“San Ambrosia, is an old stone structure situated
near the Tallapiedra wharf, and beyond doubt is the
ﬁlthiest building in Habana, and has always shown a
heavy death rate. It should not be used for United
States troops. It has 900 beds.
“There are two hospitals in Regla, but in the ofﬁcial
reports they are made to appear as one, and will be so
spoken Of in th1s report. The buildings are old sugar
warehouses. They are poorly equipped, and the ad-
ministration was bad. They contained 3,000 beds. N 0
attempts to isolate cases of infectious or contagious dis-
eases have ever been made. Yellow fever and smallpox
were treated in the general wards.
“There are also in Habana the following civil or mu-
nicipal hospitals—Reina Mercedes, Paula, Quinta del
Rey, and Dependiente. With the exception of the ﬁrst,
all of them are ﬁlthy institutions, and were erected many
years ago. ‘
“The Reina Mercedes was built in 1885; it is of stone
and has 10 pavilions, each holding 24 beds. During the
past year it has been overcrowded, and a high mortality
has resulted. There were from 400 to 500 patients
treated at this hospital from August to December, and
there were over 750 deaths in that time. Such a bad
state of affairs existed that clinical lectures of the med-
ical college were abandoned on account of the danger
to the attending students.”
He pointed out that the capacity of the military hos-
pitals alone exceded 8,200 beds, and quoted from the
same oﬂicial source the statement thatin 1897 the deaths
CITY HOSPITAL ALUMNI. 143
from yellow fever in these hospitals numbered 2,583,
representing 10,000 cases of the disease; while the total
deaths on the island for that year from yellow fever in
institutions of the same kind were 6,034. The ﬁgures
of mortality from this cause among the civil population
of Havana were not at hand, but undoubtedly they were
very considerable.
DR. JOHN P. BRYSON‘asked if it was known how the
disease is contracted.
DR. HOMAN answered that professional opinion in
some quarters seems to hold that the water used was a
factor in its causation, somewhat as malarial disease
was induced by such means rather than by the air of
malarious regions.
The possibility of the communication of both yellow
fever and malaria by mosquitos has also found able ad-
vocates, but Dr. Homan said his opinion was that if in-
sect agency played a part in the extension of yellow
fever ﬂies would befound chieﬂy responsible as carriers
of the vomit and excreta, with attendant contamination
of food and water, this being the rOle played by these
insects in the spread of Asiatic cholera.
DR. M. A. BLISS inquired concerning the water sup-
ply of Havana, and in reply Dr. Homan said that the
original source was the Almendares river at a point
about four and a half miles from the city, but this water
was limited in amount and exposed to surface contami-
nation. Later, a better source was found in the Vento
springs situated about ten miles from Havana. Although
work was begun here in 1858 it was not completed until ,
1893, and then only after Americancapital and energy
had taken it in charge. It is stated on good authority
that this source now yields an abundant supply of ex-
ceptionally pure water.
DR. AMAND RAVOLD said he was sure the members
would agree with him that the Society was indebted to
Dr. Homan for his valuable and opportune paper. He
said Dr. Homan had clearly demonstrated why Havana
is the very worst yellow fever breeding center in the
14.4 MEDICAL SOCIETY OF
Western Hemisphere, and why the otherwise superb
harbor is ﬁlthy beyond belief (fouler, even, than Chica-
go’s polluted stream), and both the city and harbor a
menace to the health of all nations whose ships ﬁnd an-
chorage in its waters, or Whose sailors visit the shores.
It has been estimated by competent authorities that over
90 per cent of the yellow fever that reaches our shore
comes from Havana. For six 'months of the year the
people of the southern section of' our country live in
terror of that dread disease and when, as last year, it
eludes the vigilance of our quarantine and makes an en-
trance, many useful lives are sacriﬁced, great anguish
and distress prevails and millions upon millions of dol-
lars are lost through its ravages. Dr. Ravold thought
the time was at hand for this condition of things to
cease, and he further emphasized the fact that if the
great war we are now engaged in had no other object
in view than to drive the treacherOus and rapacious
Spaniard out of Cuba for the sanitary reformation of
the island, it was a just and suﬂicient cause. In regard
to Havana it mattered not, he thought, what the diﬂicul-
‘ ties of the problem were for its sanitary puriﬁcation, it
must be done, and the quickest way, once the island was
in our hands, would be to put a corps of competent
American sanitarians and engineers at work upon the
problem and its solution was assured.
He said that last summer he had a conversation with
Dr. John Guiteras, the Government yellow fever expert,
while in this city, and he told the speaker that the inte-
rior of the island of Cuba was salubrious and practically
free from yellow fever, but that the seaport towns, and
especially Havana, were the breeding places of the dis-
ease; that the disease appeared in June and lasted until
November; that the native Cubans are all immune to
the disease because they had had it in infancy, at which
age man seems best able to resist it. All foreigners ac
quire the malady sooner or later, generally in the ﬁrst
year’s residence. The Cubans look upon the diseasev as
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a just visitation of God’s wrath upon the haughty Span-
iards who are sent to govern them.
In regard to the etiology of yellow fever the speaker
felt conﬁdent that Sanarelli, in his bacillus icteroides,
had discovered the real cause of the disease. He was
convinced of this for a number of reasons, the principal
of which'were:
1. Sanarelli is a competent, working bacteriologist,
having demonstrated this by several pieces of work,
notably his observations upon the typhoid fever bacillus.
2. His work upon the bacillus icteroides was exhaust-
ive, and he clinched his claim by producing the disease
in willing human subjects with the toxins of his bacillus;
and, further, the efforts to prove priority in the discov-
ery of the yellow fever germ which so renowned a bac-
teriologist as Surgen-General George M. Sternberg is
making in behalf of his bacillus an, discovered by him
in yellow fever cadavers in Havana in 1889, claiming
that bacillus icteroides, Sanarelli, and bacillus a3, Stern-
derg, are identical, are certainly worthy of careful con-
sideration.
DR. L. BREMER said he did not think the micro or-
ganism of yellow fever had been discovered and isola-
ted beyond dispute. If yellow fever was a bacteriolog-
ical disease he thought it very strange that the cause
had not been discovered before now. He admitted that
Sanarelli was competent to isolate and stain the organ-
ism if discovered, but the means of investigating and
examining the matter were very inadequate. He thought
it probable that a bacillus was really at the bottom of
the disease but he would not like to go to the extent of
saying that the bacterium found by Sanarelli is the true
bacterium of yellow fever.
DR. VILRAY P. BLAIR asked whether seaweed grew
in the harbor.
DR. HOMAN said he did not know, but thought from
what he was able to gather that the bottom of the bay
was composed of foul slime and sludge, the organic
waste of the city for many generations.
146 MEDICAL SOCIETY OF
The method to be adopted in overcoming the unsani-
tary conditions of Havana, he thought, was largely a
question of sanitary skill, engineering judgment, and
ﬁnancial ability. The harbor contains the accumulated
unclean deposit of centuries, with no natural or artiﬁcial
means for carrying it off. It is certain that it can be
done by one method or another, either the pumping ser-
vice or a canal.
[See map, facing page 144.]
STATED MEETING, THURSDAY EVENING, MAY 19.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
_— I
Partial Report of Eight Hundred Cases
of Labor.
BY H. S. CROSSEN, M.D., ST. LOUIS.
Superintendent and Surgeon-in-Chargc of the St. Louis Female Hos-
pital—Member of the St. Louis Obstetrical and Gynecological
Society; of the Medical Society of City Hospital Alumni
of St. Louis; of the St. Louis Medical Society.
I call your attention to the fact that this is only a
“partial” report. Its scope is very limited, for it covers
only two items—sepsis and contracted pelvis; but these
two items furnish abundant material for proﬁtable dis-
cussion.
These patients came under my own care from July,
1895, to April 1, of the present year. As most of you
know, it was necessary to care for the patients in a gen-
eral hospital where were treated almost all the diseases
that humanity is heir to. Until very recently all the
obstetrical patients have had to be delivered in the same
building where patients with diphtheria, scarlet fever,
measles, erysipelas, puerperal infection and other forms
of sepsis were, of necessity, housed and treated. To
be sure, the obstetrical patients had one division to
themselves with nurses that were not allowed in other
CITY HOSPITAL ALUMNI. 147
parts of the Hospital; I laid down strict rules, given
elsewhere, for the care of the patients in order to ex-
clude infection; the wards were scrubbed with soap and
water and then with antiseptics, and then fumigated
with sulphur and steam after each set of patients; and
I endeavored in every practicable way to isolate this
division from the remainder of the Hospital. But all
this is not enough. Obstetrical patients should not be
handled in a general hospital if it is possible to place
them in a suitable building devoted exclusively to ob-
stetrical work. In spite of every thing that can be done
there is necessarily more or less communication from
ﬂoor to ﬂoor of a crowded hospital, and there is con-
tamination accordingly.
I make these remarks to emphasize the fact that the
report here presented is not the report of a maternity
hospital but of a general hospital. Under the same roof
that Sheltered those patients in labor there were many
times that number of patients sick with various dis-
eases, and while working with the obstetrical patients I
had also to care for the others.
It seems to me that no one who has not tried it can
fully appreciate the labor, the difﬁculties, the worry and
at times, the disappointment and discouragements that
come to one who attempts to do clean obstetrical work
in a crowed general hospital. Thanks to the energetic
action of the Health Commissioner and others interest-
ed in the matter, we have now a two-story brick build-
ing thoroughly modern in ﬁnish and equipment, and
admirably ﬁtted for the proper handling of those pa-
tients. The statistics for the years to come should show
a marked improvement over these I present to you to-
night. The only trouble with the new building is that
it is not large enough. Only the patients in labor and
those delivered can be kept there. All the waiting pa-
tients have to be kept in the old building to be trans-
ferred to the new when labor begins.
The report of a series of obstetrical cases suggests
several lines of classiﬁcation and many interesting and
148 MEDICAL SOCIETY OF
important questions, but I will conﬁne myself to the two
before mentioned.
I. THE PREVENTION OF INFECTION on THE BIRTH
CANAL—The following rules, with minor exceptions,
have been in force throughout this series:
1. When labor begins give the patient a large enema
of soap and water.
2. Then give a general bath with soap and water
(have water comfortably warm) and put on clean cloth-
ing—fresh from the laundry.
3. Then scrub the genitals, perineum, lower abdo-
men, thigh and buttocks with soft soap and warm wa
ter—using the brush vigorously. When the scrubbing
is ﬁnished wash off the soap with boiled water. i
4. Then the nurse should disinfect her hands as
follows:
' a. Trim ﬁngernails short and clean under them.
I). Scrub hands and forearms vigorously with brush
in soap and warm water, one to three minutes—giving
special attention to the irregularities about the nails.
Rinse off the soap with boiled water.
0. Then scrub them in bichloride solution (1-1000)
one to three minutes, with a separate brush kept for that
purpose. ‘
5. Then scrub the patient (genitals, lower abdomen,
etc.), with bichloride solution (140%) using special
brush kept for that purpose. After the scrubbing cover
the genitals with a pad of absorbent cotton soaked in
bichloride solution (1-1000) and wipe the other parts
dry from the bichloride solution with a clean towel.
The bichloride pad may be held in place by a piece of
gauze fastened to a-gauze strip around the abdomen.
The patient may then sit up or walk about until the
pains become Severe enough to conﬁne her to bed.
6. When an examination is to be made the hands are
to be sterilized as above directed, and the bichloride
pad is to be remoVed by the sterilized hands and, after
the examination, is to be replaced by the same. No
CITY HOSPITAL ALUMNI. 149
unsterilized object—hand, instrument or dressing—is to
be allowed to touch the genitals.
7. Immediately after the child is born:
a. A fresh bichloride pad is to be placed over the
genitals and left there until the placenta is expelled:
b. The nurse is to place one hand over the uterus
and keep it there until the binder is applied. When the
uterus relaxes it is to be gently stimulated to contrac-
tion by the hand placed over it.
c. The patient is to be given a teaspoonful of ﬂuid
extract ergot, unless otherwise ordered.
8. After the placenta has been expelled and the hem-
orrhage has ceased the genitals are to be washed off
with bichloride solution (1-1000), with clean hands,
sterilized as directed above, and the dressings applied
and the binder put on.
9. Every time it becomes necessary to remove this
dressing a fresh one is to be applied with the same an-
tiseptic precautions with which the ﬁrst was put in
place. The hands of the nurse are to be sterilized, as
above directed. Catheters, douche nozzles and every
thing else coming in contact with the genitals must pass
through the process of sterilization and nothing unster-
ilized is to be allowed at any time to touch the genitals.
10. No douche is to be given except by special or-
der. Patient need not be catheterized unless she expe-
riences diﬂiculty in urinating or has a severe laceration
of the perineum. Change dressings of patient regular-
ly every six hours and train them, as far as practicable,
to urinate only at those times.
11. In changing dressings:
a. Slip the bed-pan under the patient, remove the
dressing and allow the patient to urinate.
b. Cleans the hands as directed in the “Antiseptic
Rules.” ' '
0. Wash the genitals by allowing a warm bichlo-
ride solution (1—4000) to ﬂow gentlyr over them, apply
a fresh dressing and reapply the abdominal binder.
The practice in regard to douches before and after
150 MEDICAL SOCIETY or
q
labor has been to give no douche except there was a
special indication for it. The specal indications were:
1. An extraordinary amount of internal manipula-
tion, as forceps, version or repair of laceration.
2. A focus Of pus in or near the birth canal, as gon-
orrhea or ulceration of the genitals.
3. Macerated, decomposing fetus.
4. Hemorrhage.
These exceptional cases received one douche immedi-
ately after delivery. Some of the gonorrheal cases re-
ceived douches (creolin or bichloride) during labor, and
most of the operative cases receive a douche just before
delivery. You will notice that I have treated these
patients by the aseptic rather than the antiseptic
method. ~
The ﬁeld of operation was to be carefully prepared as
above described and the genital protected after labor by
a large aseptic dressmg.
Nice rules make very good reading but they are of
no real beneﬁt unless diligently practiced. And rules
for the prevention of infection must be carefully car-
ried out in detail from start to ﬁnish. One slip opens
the door to infection and may render void the watch-
fulness of days. Now comes the important question—
have the rules been carefully observed in the care of
these patients? I answer, in a general way, yes. I amv
satisﬁed that, almost without exception, all persons
coming in contact with these patients have endeavored,
carefully and conscientiously, to follow the directions
given; and yet, there have been slips—a number of them.
The fact that instances of infection occurred, proves
this. With a clean case and a strict observance of the
above rules I fail to see how there is a chance for in-
fection.
Eight hundred and sixty-three patients were treated
under these rules. There was no death from puerperal
infection. The following are not included in this list:
One case of rupture of the uterus, one case of Cesarean
section, two cases of uremic convulsions, two cases of
CITY HOSPITAL ALUMNI. 151
. symphysiotomy and one case of fatal post-partum hem-
orrhage. I have excluded these because they have no
bearing on the question of the efﬁciency of the treat-
ment under consideration for the prevention of infec-
tion of the birth canal, and also because it would not be
just to reckon as due to puerperal infection, as ordinari-
ly understood, deaths due to such complications.
For the purpose of analysis I have divided the cases
into two classes:
CLASS A.-—Includes all cases in which the birth was
spontaneous and with nothing to increase the chance of
infection.
CLASS B.—Include all cases in which there was some-
thing to decidedly increase the chance of infection, as a
focus of pus in or near the birth canal, an unusual
amount of internal manipulation or a macerated, decom-
posing fetus. .
In Class A, belong 662 cases. Divided according to
the temperature followmg labor, they are as follows:
Not above Ioo° F. - - - - - - 454
Not above IOO.5° F. - - - - - - 529
Temperature above 100. 5° F. Slight fever (either a slight rise
or of short duration) of unknown cause and disappearing
without treatment of the genital tract — - - 72
Temperature above 100. 5° F. Slight fever probably due to
trouble about perineal sutures or vaginal or cervical lacer-
ations and disappearing without treatment or after a few
vaginal douches - - - - - - 12
Fever, clearly due to intcrcurrent diseases and with no evi-
dence of Infection of the birth canal - - - 3o
Decided infection of the genital tract — - - - 19
In Class B. belong 201 cases as follows:
Ulcerations about the genitals — - - - 8
Gonorrhea - - - - - - - 28
Vulvo-vaginal abscess - - - - - - 2
Cyst of anterior vaginal wall - - - - — I
Macerated, decomposing fetus - - - - 23
Laceration of perineum, second degree - - — 44
Laceration of perineum, third degree - - - - 3
152 MEDICAL SOCIETY OF
Breech presentation, requiring considerable manipulation of
the head - - - - - - - 5
Hand presenting - - - - - - I
Prolapse of cord - - - - - - I
Adherent placenta requiring manual removal ' - - I4
Post~partem hemorrhage, moderate - - - - I7
Post-partem hemorrhage, severe ~ - - - 9
Double uterus and vagina, requiring manual dilatation of 05
uteri and application of forceps - - - - I
Craniotomy on a dead fetus - - - — - I
Podalic version - - - - - - 9
Forceps delivery - - - - - - 34
Divided according to temperature following labor:
Not above 100° F. - - - - - - 94
Not above 100.5° F. - - - - - 4 - 117
Temperature above 100. 5° F. Slight fever of unknown cause
and disappearing without treatment of genital tract - 47
Temperature above Ioo.5° F. Slight fever, probably due to
trouble about perineal sutures or vaginal or cervical lacer-
ations and disappearing without treatment or after a few
vaginal douches - — - - - - 2r
Fever clearly due to intercurrent disease with no evidence of
infection of birth canal - - - - — 6
Decided infection of the genital tract - - - - 10
The 36 'cases of intercurrent disease, in the whole
series, were as follows:
Acute nephritis - - - _ _ _
Biliary calculi - - - - - - -
Pleurisy, beginning before labor - - - -
Facial erysipelas, beginning before labor - - -
Arthritis of knee, beginning before labor — - -
Acute articular rheumatism - - - - -
Phlegmosia dolens, no apparent infection of genital-tract -
Pulmonary tuberculosis - - _ - _
Malaria, decided - - - _ - _
Caked breast - ' - - - _ _ .
Abscess of breast - - '- _ - _
Colitis, chronic ‘ - - - - - _
Entero-colitis - - - - _ _ _
Acute bronchitis - - - _ _ _
Measles - _ - .. .. _
Pneumonia - - - - - .. .
HIQHHHNQOOQJHNHMHHH
CITY HOSPITAL ALUMNI. 153
The 29 cases of decided infection of the genital tract
were as follows:
Suppuration of repaired perineal tear of second degree - 3
Abscess of vaginal wall - - - - - I
Location of infection not recorded, fever subsiding under va-
ginal douches - - - I - - - 3
Endometritis, subsiding aftar an intra-uterine douche, without
curettement - - ~ - - I
Endometritis, requiring curettement - ~ - - 20
Salpingitis, present before labor and forming an abscess after-
wards - - - ' - - - - I
There was no death. The morbidity from well-marked
infection of the birth canal was 3.4 per cent.
In these cases the rise of temperature began on the
ﬁrst day in 3; second day, 9; third day, 2; fourth day,
5; sixth day, 3; seventh day, 4; eighth day, 1; tenth day,
1; eleventh day, 1.
Thus, there were 19 cases in which the rise of tem'
perature appeared before the ﬁfth day and in which the
infecting germs probably found lodgement in the birth
canal during labor. In the remaining 10 cases the rise
of temperature appeared after the ﬁfth day, and the in-
fecting material probably reached the genital tract on
account of faulty dressing.
Nineteen of these 29 cases belong in Class A, and 10
in Class B, giving a morbidity of 2.9 per cent for the
former and 4.9 per cent for the latter.
The complications in the cases of infection occuring
in Class B, were as follows:
Breech presentation, with diﬂicult extraction of head - .
Lacerated perineum, second degree - - ~ —
Severe post-partum hemorrhage ' - - - -
Adherent placenta, requiring manual removal - -
Diﬂicult forceps delivery - - - - - ’
Ulceration about genitals (chancroids and gonorrhea -
Macerated, decomposing fetus — - - -
Ht-uNNNr-tn-t
Reverting now to the general subject of asepsis in
labor, I desire to call attention to a source of danger
sometimes overlooked, and that is the ﬁrst examination
154 MEDICAL SOCIETY OF
to determine whether or not the patient is really in
labor. '
If it is suspected that the pains she is complaining of
are labor pains no vaginal examination should be made
until the external genitals have been scrubbed and pre-
pared, as described in the preceding rules, and the phy- ‘
sician’s hands disinfected.
On the subject of douches in labor there has been a
great deal of discussion in the last few years. A large
amount of valuable experimental bacteriological work
has been done with a view of settling the question as
to when douches should be given. I will not enter into
a discussion of this subject but will simply state that,
in my opinion, douches are not indicated in clean cases,
and that in private practice and in any but the best ar-
ranged hospitals the vaginal douche is a source of dan-
ger. The danger is that infection will be introduced
into a clean wound and that the germicidal power of
the vaginal secretion will be diminished. When a douche
is necessary in labor it should be given by a person who
will employ strict antiseptic precautions.
A statement of the practice regarding douches in
several of the important lying-in hospitals in this coun-
try may be of interest to you.
In the Jefferson Maternity, of Philadelphia, which is
under the direction of Edward P. Davis, one douche
(1-5000 bichloride) is given before labor in normal cases
and also one afterward. If sutures have been placed in
the cervix orvpelvic ﬂoor, a douche (1-8000 bichlorlde)
is given night and morning after labor.
In the Philadelphia Lyingin Charity, which accom-
modates about 300 patients annually, abichloride douche
(1-4000) is given before labor in normal cases, but no
douche afterward. In cases necessitating forceps or
version, one bichloride douche (1-4000) is given after
delivery. -
In the Maryland Lying-in Hospital, of Baltimore, 200
patients per year, no douche is given in normal cases
either before or after delivery. In cases in which there
CITY HOSPITAL ALUMNI. 155
is an unusual amount of examination, one douche of
sterilized water is given before delivery. In cases of
version or forceps one douche (carbolic or bichloride) is
given immediately after the expulsion of the placenta.
In the Maryland Lying in Asylum, of Baltimore, 370
cases per year, no douche is given before delivery in
normal cases. After delivery one douche of plain ster-
ilized water is given. Following a forceps or version
delivery one intra-uterine douche of sterilized water is
given.
In the Maternity Department of Johns Hopkins Hos-
pital, about 400 patients annually, no douches are given
-not even in operative cases.
In the Sloane Maternity, New York, about 1,000 pa-
tients per year, normal cases receive one douche (1—5000
bichloride) before and after delivery.
In the service of the Society of the Lying-in Hospital,
of New York, which cares for 1,600 patients per year,
no douche is given before delivery in normal cases. One
douche (1—8000 bichloride) is given after delivery. In
cases necessitating forceps or version no douche is given
before delivery, but an intra-uterine douche is given
after delivery. In this institution the antiseptic prepa-
ration of the patient for labor, as detailed in their 1897
report, is almost identical with the practice throughout
the series of cases presented to you to night. When I
visited the institution, two years ago, I was much im'
pressed by their splendid out patient service. To any-
one looking for facts and details regarding obstetric
work I would recommend the 1897 report of the Society
of the Lying-in Hospital of New York.
In the California Womans’ Hospital. San Francisco,
no douche is given in normal cases either before or after
labor. In cases necessitating forceps or version, one
douche (1 per cent lysol) is given before delivery and
the same afterward. This is a general hospital with a
lying-in department.
In the Charity Hospital, New Orleans, no douche is
given in normal cases. After forceps delivery or version
156 ' MEDICAL SOCIETY OF
one douche (2'per cent creolin) is given. The Charity
Hospital is a general hospital but cares for about 270
labor cases annually.
In leaving this subject I can not better express my
present conviction than by quoting the following con-
clusions oflDr. Jewett, of Brooklyn, as given in the
“American Year Book” for 1898:
1. There is no clinical proof that puerperal infection
can occur from normal vaginal secretions. '
2'. I All childbed infection, in women previously heal-
thy, is by contact.
3. Prophylactic vaginal disinfection as a routine
measure is unnecessary and, even in skilled hands, is
probably injurious. ' . ‘
4. Its general adoption in private practice could
scarcely fail to be mischievous.
5. In healthy patients, delivered aseptically, post-
partum douching is contraindicated.
6. Clinically, in a pregnant patient, the amount of dis-
charge, its gross appearance, and that of the mucous and
adjacent cutaneous surfaces, usually indicate whether
or not the case may be regarded as a clean one.
7. Probable unclean contact within 24m 48 hours
before labor is an indication for prophylactic disinfec-
' tion.
II. THE MANAGEMENT OF CASES OF CONTEAoTEn
PELvIs.-—The number of patients is this series with
small pelvis in which interference was necessary, was
27. This does not, however, represent the whole num-
ber of contracted pelves, for a large number of patients
with contracted pelvis need no assistance, but are de-
livered spontaneously. _
In the last annual report of the Hospital, which is a
report of the work from April 1, 1897, to April 1, 1898,
I have given a detailed account of all the cases of small
pelvis coming under my care in that period. Out of a
total of 396 patients measured, 28, or 7 per cent, had
small pelvis. In 12 of these the delivery was instru-
mental, in 13 spontaneous, and 3 left the Hospital be-
CITY HOSPITAL ALUMNI. 107
p
5
fore delivery. Half were delivered spontaneously, and
‘I am satisﬁed that a careful analysis of the total 860
cases, such as I have made of the last 396, would dem-
onstrate practically the same percentage of cases of
small pelvis, viz., 7 per cent, or about 60 cases in all.
Of the .27 patients with small pelves requiring instru-
mental delivery, 21 were delivered by forceps, 3 by ver-
sion, 2 by symphysiotomy and 1 by Cesarian section.
The worse cases are given in the accompanying table;
In the management of a case Of small pelvis the ﬁrst
thing to do is to make an examination to determine how
much contraction is present. With but little trouble
the dimensions of the pelvis may be determined with
approximate correctness. In the Hospital I have had
the pelvic measurements taken and recorded as part of
the regular history of every pregnant patient, and I
have learned by experience to depend on these measure-
ments as establishing or excluding, as the case may be,
one of the most serious of obstetric complications.
When confronted with a case of diﬂicult labor almost
the ﬁrst question that suggests itself to me is as to the
size of the pelvrs. In the minor degrees of contraction
the labor will, of course, be only slightly inﬂuenced or,
if the child be small or the pains very strong, nothing
unusual may be noticed.
In the next grade come the cases of prolonged labor,
of high forceps _delivery and of version. These cases
require careful handling but present no special diﬁicul-
ties. The points in their successful management are:
1. Determine, by external and internal measure-
ment, the size of the pelvis—that is that there is a mod-
erate, and only a moderate, contraction.
2. Determine, as far as possible, by ordinary abdom-
inal and vaginal examination if there is any other
complication.
3, After the natural forces have had a fair trial,
examine the patient under anesthesia, with the whole
hand in the vagina, to determine more accurately the
relative size of the head and pelvis, and also to deter-
158 MEDICAL SOOIETY OF
mine if there is any complication not discovered in the
previous examination.
4. Deliver by forceps or version, after the thorough
examination has shown that the case is a suitable one.
It is better usually to have everything ready for
delivery before beginning the examination under anes-
thesia and then, if the examination shows the case to be
a proper one, deliver at once.
The examination under an anesthetic with the whole
hand in the vagina is very important. It gives one a
knowledge and grasp of the situation obtainable in no
other way. The relative size of the head and the prob
ability of further moulding can thus be approximately
determined. As to the choice between high forceps
and version, it has been my custom to use the
forceps if the head was in good position and pressed
ﬁrmly against the pelvic entrance, and to employ Ver-
sion if the head was not in good position or was freely
movable above the brim. When the pelvic contraction
is marked and the case promises to be a severe one, I
have more conﬁdence in the high forceps than in
version.
Next come the high grades of contraction where the
delivery of the living child at term through the intact
pelvis is impossible. In the case of ﬂat pelvis with a
slight general contraction (the pelvic deformity fre-
quently found in this country) an external antero-
posterior diameter of 16 c.c., with a diagonal conjugate
of 10 c.c. (4 in.), warrants the assumption that delivery
at term will be impossible without Cesarean section or
symphysiotomy or craniotomy. And these measure-
ments are, I think, a clear indication for the induction
of premature labor in the 36th week, or earlier if the
pelvic deformity be more marked. Occasionally it is
possible to deliver such a patient at term by forceps or
version, but such is very rarely the case, and it is cer-
tainly not proper to subject a patient to the risk of the
serious operations before mentioned when the induction
of premature labor will give the baby a fair chance of
life without great danger to the mother.
CITY HOSPITAL ALUMNI. 159
But the cases of marked pelvic deformity in which
labor has begun, or the child is at term, are the trying
ones. Then comes the question of choice between
Cesarean section, symphysiotomy or craniotomy.
This is not a theoretical theme. It is intensely prac-
tical. I have had this question come up for immediate
.solution a number of times and it has fallen to my lot
to do each of the operations mentioned. Any worker
in obstetrics may have the question forced upon him by
a case, at any time. Several persons present have, no
doubt, given this subject special consideration and I
hope to hear their conclusions. I am aware that the
tendency for some time past has been toward Cesarean
section or symphysiotomy in every case in which the
child is living. I think this is not a safe rule. Each
case is a study in itself and we should always bear in
mind that the life of the mother is of far more value
than the life of the child. Every effort to save the life
of the child is praise worthy if it does not unduly
jeopardize the life of the mother.
The mortality of Cesarean section, in favorable cases
and by skilled operators, is reckoned at about 10 per
cent, and symphysiotomy under the same circumstances
should show a decidedly smaller mortality. As given
in the American Textbook of Obstetrics (1895), in the
79 Cesarean sections which had, up to that time, been
performed in the United States since the adoption of
the present method of operating, the maternal mortality
was 35 per cent and the infantile mortality, 12 per cent.
In the 72 symphysiotomies which had, up to that
time, been performed in the United States, the maternal
mortality was 14 per cent and the infantile mortality 26
per cent. Of course these are old statistics, as that was
three years ago, but it shows what happened before
there came into practice the careful selection of cases '
and early operations of the present day. '
The best Cesarean section record of the world up to
that time came from Leipsic and was 54 cases with only
three deaths—a mortality of 5.5 per cent. Morisani’s
160 MEDICAL SOOIETY OF
results with symphysiotomy were 55 cases with 2
maternal deaths and 3 children lost—a maternal mor-
tality of 3.6 per cent and an infantile mortality of 5.5
per cent. Zweifel in 23 symphysiotomies had no
maternal deaths and lost but two children. _
But these are the results of experts, Of men who have
had an extraordinarily large experience in these particu-
lar operations, and the results, while furnishing a goal
to work to, can not be taken as a guide by operators
generally.
As near as I have been able to determine, the mor-
tality of Cesarean section, when undertaken at a reason-
able time while the patient is still in good condition,
can not be reckoned at less than 10 to 15 per cent. The
Porro operation, while ordinarily more dangerous than
the classical section, certainly gives better results in
cases that have been subjected to prolonged internal
manipulations. Being interested to know just what
results have followed Cesarean section in St. Louis, I
have made inquiries. From the extent 'of these in-
quiries I think I have gotten most of the cases in St.
Louis and vicinity during the last ten years. Some of
the cases have no doubt been missed, but probably not
many'. The number of cases reported to me of Cesar-
ean section or modiﬁcation, exclusive of operation for
extra uterine pregnancy, was 31. Of these, 16 mothers
recovered and 14 children recovered. I understand that
one of these patients was in collapse, from unavoidable
hemorrhage, and really dying at the time of the opera--
tion, and that the operation was for the purpose of
saving the child. Excluding this case, which it would
hardly be proper to class as an ante-mortem operation,
we have 30 cases with the recovery of 16 mothers and
14 children. Maternal mortality, 47 per cent and
infantile mortality, 53 per cent. Of course this is only
a rough estimate. The cases still not heard frOm might
reduce this high motality percentage. A classiﬁcation
of the cases according to the year Of the operation
might make a better showing for the last few years.
Instrumental Deliveries for Contracted Pelvis.


[3% in.]


INITIALS ETC. PREVIOUS PELVlS. POSITION. DELIVERY. CHILD. WEIGHT. DIAMETER OF REMARKS.
LABORS LENGTH. HEAD.
M. W , Ameri- Three—1 instru- Simple ﬂat. 21 5, 27. O. L. A. Head failed to en- Female, living l0 lbs. B. P. 9.5 cm . . . . . . . . . . . . . . . . . . . . . . ..
- canI aged 32; mental, 1 still- 30, 19. 10%; Est. C. gage. Poualic 21 in. B. T. 7.5 cm.
5ft.1in., 142 birth, 1 long, V. 9% cm. [3%, in] version. 0, F 11 cm,
lbs . hard labor with
s p o n ta n eous
delivery.
C.W., colored, None. Simple ﬂat, 24, 27.0. L. A Head failed to en- Male, living. 6 lbs. B. P. 7.7 cm. Diagonal conjugate di-
aged 28; _5ft. 30, 18 5; Est._C. V. 38:88- _ High ap- 18.5in. B '1‘. 6 5 cm. ameter of pelvis not
6 1n.;_weight 9.5 cm. [3% 1n.] plication of for- 0, F, 11,5 cm, recorded.
not given. ceps. ‘
M. 0., Ireland, None. Generally contract- B eech Cesarean section, Male. Had de- 6%, lbs. B. P. 9.5 cm. Patient died the fourth
aged 25:4 ft ed, 25, 26. 29, 16, 10; S. L. A af t e r patient formity of 20.4 in. B. T. ? day of peritonitis. P.
9in.,115 lbs. Esr. (JV. 8%, to 8% had been in 121- head neck 0, F, 12 cm, 11, exam_; Edges of
cm. [3%in.] her about sixty due to long uterine wound well
hours, with no pressure ln approximated butin-
progress. Birth uterus. Died ﬂamed, .Peritoneum
0 f _ t he llVlnR‘ after 4 days. apparently infected
c h 1_1 d through an n arently from the uterus. Di-
the 111138012 pelws f 1‘ O m t h e real; me agurement of
impossible. cerebral in- true conjugate diam,
Jury. 8%, in. (3% in.) In this
case I was very much
in favor, of inducing
premature labor in
the 36th week of preg-
nancy and then doing
symphysiotomy, if
necessary. ButI
yielded to the consul-
tant in the case who
’ advised the course
v here pursued. I think
the former plan
would have been bet-
- _ ter.
A. K., Ameri- NODG- Simple ﬂat, 24, 26 O. L. A. Head failed to en- Female,living§.5 lbs. B. P. 10 cm. _ _ _ _ . _ _ _ _ _ _ _ _ ' . _ _ _ _ . _ _ n
can, aged21; 30.5,19: Est. C. V. gage. High for- - 19.3in. B. T. 9 cm.
4ft. Sin., 124 10 em. [4 in.] ceps delivery. ’ ~ 0. F. 12 cm.
lbs.
8- L-. colored. None- Generally contract- 0. D. A. ‘Symphysiotomy, Female,living 6 lbs. 13. P. 7.5 cm. 0
aged 24; 5ft ed. 22, 24.. 29,16,10; after patient Left the hos- 18in. B. T. '1 cm. Piﬁlegggfagﬁgrgﬁétfgg
2in., 90 lbs. Est._C V. 8% cm. had been in la pital when a O. F. 11‘ cm. walking about_ Had
- [3% 1n.] bor about forty month old. severe u M 1 ate r31
hours. de- Was then in h e a d a c h e 8‘ during ‘
livered by 1’01" gOOd health. pregnancy and two
“995 .after sym' convulsions after de-
physmlomy- livery Died sudden-
denly 1 month after
delivery. P._M. exam.:
' large tubercularmass
in rlght ol'cipital lobe
of brain. Two or three
tubercular bronchial
glands. Close, ﬁrm ﬁ-
brous union at pubic
joint. Uterus small
p and clean True conj.
diam. by actual meas-
urement between 8
and 8% cm. (3% in.).
Case reported in full
in MEDICAL REVIEW
of Oct. 31, 1896.
_ _ 61 n , None. Simple ﬂat, 25, 28, O. D. P. Head failed to en- Male livin 9lbs. B. P. 10 cm. - - - _
0 59111563; fi. 30, 20. 11.5; E_st. c. gage. _ Podalic ’ 8 21.5111. B. T. 8.5 cm. Ti'fo‘kmvﬁgstﬁflgefffhce
512 in" 150 V. 10 cm. [41n.] vergitpin lstt’nd 0. F. 11.5 cm. head being. such a
; _ very 1 on ex- ~ . _
1 8 traction of head gigs“ “3 1"" the 1"“
A_ B_ Ameri- None. Generallycontract- O. D. A. Head failed to en- Male, living. 8.5_1bs. B. P 9 cm. . . _
cam’amd 15, ed, 22.5, 26,28,17, gage. High for- 20 In. B. T. r [11,2218 Sg’figrexggégg
1; 856111,, 10; Est. C. V. 8% cepsdehver/l'. A O. F. 12 cm. form revealed head
100 lbs. cm. [3% in.] very seyere for small and yielding.
ceps ca‘e' Hence the choice of
high forceps instead
of symphysiotomy.
If the head had been
a triﬂe larger or more
completely ossiﬂed it
could not have been
delivered by t- e for-
ceps and the attempt
would h a v e been
B B colored " harmfln'
' " ' One— Probably Laterally contract- 0. L. A. Head failed to en- Female, living 8.75 lbs. B. P. 9.5 cm.
ﬂgfghiwgnﬁi a prematured ed. 22, 23, 30, ?; gage after long with B_ T 3_5 cm_ Unfavoﬁ‘abilet case f3;
weight n o t birth. History Est. C. V. 10 cm. labor. 28 hours. . F. 11.5 cm. Bymptgs ° omition
given not satisfac- [4in.] Est. trans- wit h stron g any 0 pr oper t ti .
' tory. Verse diameter of pains. Exami- Chron ° ilysf‘ 5~
pelvis 9 cm. [3% nation under 310351 1:13"? lrgm
to 4 in.] anesthesilatrei 1&1): fog; u562§tgn3r
Xoeniigﬁioanelga, Died one month later
the pelvis and of chronic sepsis ap-
head too large parently from blad-
for inlet De. der. Sinus into ub_lc
I livered by sym- Ointl Wiéch 1?} egg
ea . ous er
physmtomy' separation. N o pook‘
st of us nor dead
bone. 0 decided kid-
, ne lesion. Babywas
we 1 until two weeks
old and then died of
severe ent eritis.
M.M., German Eleven—6 boys. Simple ﬂat, 23, 28, O. D. P. Head failed to en- Male, living. 7.5 lbs. B. P. 10 cm.
aged 39; 5ft. all instrumen- , 19; Est. C. V. gage. Podalic 18 in. B. T. 8 cm.
A 150 lbs. tal: 5 girls, 9%-100m. [3%in.] version. For- 0. F. 12 cm.
no u e instru- c e p s to after-
mental. coming head.
S. 0., colored, None. Generally contract- 0. L. A. Head failed to en- Male, living. 11 lbs. B. P. 9 cm.
aged 15; 5 ft. ed, 21. 23. 30, 19,11; ter pelvis. High 20 in. B. T. 8.5 cm.
1 in , 125 lbs. Est. C. V. 9% cm forcepsdellvery O. F. 12 cm.


Smallest Pelves With Spontaneous Delivery, Shown in the Records.

A. De, can, aged 21.
5 ft., 104 lbs

One—No partic-
ular trouble.

Generally contract-
ed, 2 .5, 25, 29,18.
11; Est. C.V. 9%
cm. (8% in )

O.
L
A.


N.H., colored,
aged 25: 5 ft
6 in., 135 lbs.
Four — Normal.
Simple ﬂat, 24, 26,
39. 18, 11: Est. C.V.
9% cm. (3%, in.)
s cutaneous d e-
ivery. Duration
of labor, 51/, hrs;
no trouble.
Spontaneous d e -
ivery. Duration
of labor, 8% hrs;
no trouble.
Male, living.
Female,living
8 lbs.
20in.
8lbs.
21.2ln.
l O I I I I a o a n a o u a a.
B. P. 9.75 cm.
8. .8 cm.
0. F. 12 cm.
In these two cases the
labor was of short du-
ration. The average
duration of labor for
the last year in cases
of spontaneous deliv-
ery (342 casem was 15
hours for primipara
and 11 hours for mul-
tipara. There were
patients with alarger
antero-posterior pel-
v 0 diameter who had
prolonged labor on
account of the pelvic
contraction. For ex-
ample, in one case
with an estimated
true conj. diam. of 10
cm. (41m), the dura-
tion of labor was 39
hours—36 hours be-
fore rupture of the
membranes and 8
hours afterward.

CITY HOSPITAL ALUMNI. 161
A summary of only the cases operated on by persons
having a large experience in abdominal work would
probably show a higher percentage of recoveries. The
best individual record was four recoveries out of ﬁve
cases, the one patient dying being the ﬁrst operated on.
The high mortality percentage for St. Louis is, I
think, due mostly, not to lack of skill in operating or to
faulty asepsis during the operation, but to the poor con-
dition of the patient from long waiting and repeated
' manipulations within the birth canal. The high
infantile mortality bears out this view, for if the opera-
tions had been undertaken before the children were
seriously injured by the long continued uterine and
abdominal contractions, or by repeated attempts at de-
livery by forceps, we would not have had an infantile
mortality of 53 per cent. The loss of infants in properly
selected cases is only 5 to 10 per cent.
' This showing is not pleasant to face, but the more
promptly it is faced and thoroughly understood the
quicker will the remedy be applied. The remedy is
the general adoption of more thorough methods of ex-
amination of obstetrical patients, especially pelvimetry,
and, in difﬁcult cases, the examination under anesthesia
with the whole hand in the vagina to determine just
exactly what is the trouble before applying forceps.
This examination under anesthesia should be made be-
fore the patient i exhausted by long labor, the pelgicy
tissues injured by pressure and the birth canal infected
by too many digital examinations. There is another
lesson I draw from these cases and that is that if the
case is not seen until late, when the condition, general
' or local, of the mother is poor and the child probably
injured by long labor or attempts at deliver, it is better
to do craniotomy. The life of the mother should be
counted more valuable than the life of the child.
Cesarean section at the proper time in suitable cases has
achieved results that no amount of prejudice should
blind one to and that no number of unfavorable cases
can cover up. These splendid results censtitute one of
16.5 MbDlCAL SOCIETY OF
the signal triumphs of modern surgery. But Cesarean
section in unfavorable cases, such as those above men-
tioned, has sacriﬁced many mothers to save children
that could not live after all. It seems to me that the
following conclusions outline the proper proceedure in
cases of contracted pelvis:
1. When the true conjugate diameter is 71- to 9 cm.
(3 to 3'/a in.).
a. If seen before the 36th week of pregnancy, in-
duce premature labor and follow by symphysiotomy if
necessary.
6. If seen early in labor, perform symphysiotomy.
If the disproportion between the head and pelvis is
slight, give axis-traction forceps a fair trial before
symphysiotomy. If the disproportion between the head
and pelvis is so great that there is serious doubt as to
whether the head can be safely delivered after symphy-
siotomy, then choose Cesarean section instead.
0. If seen after prolonged labor or repeated at-
tempts at delivery by forceps, perform craniotomy.
2. When the true conjugate diameter is between 61,1
and 7% cm. (21} and 3 in.).
a. If seen before the 36th week, allow pregnancy
to proceed to term.
b. If seen early in labor, perform Cesarean section.
0. If seen after prolonged labor or repeated at-
tempts at delivery by forceps, perform craniotomy. If
the patient insists on Cesarean section, a Porro opera-
tion is the best form for these'late cases.
.The measurements given above apply to the ﬂat
pelvis and to a fetal head of normal size.
In a generally contracted pelvis a larger antero-
posterior diameter is required and in a laterally-con-
tracted pelvis, a still larger one.
If the head is decidedly small then, of course, a
smaller antero-posterior diameter will suﬂ‘iee.
The relation of the size of the head to the pelvis
and the' best means of determining the relative size of
the two I have given in detail in the report of a case of
i
CITY HOSPITAL _ALUMNI. - 163
symphysiptOmy, before the St. Louis Obstetrical and
Gynecological Society and published in the MEDICAL
REVIEW for October 31, 1896. Any one interested in
the subject of pelvic measurements and their indica-
tions for symphysiotomy will ﬁnd the subject reviewed
there at considerable length. [See table, facing p. 160.]

~ DISCUSSION.
DR. B. M. HYPES said he could hardly express his
admiration of Dr. Crossen’s paper. He said he had
been a member of various medical societies during the
last twenty years in St. Louis but could not recall a
paper containing such valuable results of practice and
experience in obstetrics as Dr. Crossen’s. The informa-
tion contained in it was so full and valuable that a sat-
isfactory discussion of it would not be possible without
some preparation. The ﬁrst part of the paper, the
speaker said, he had not heard, but the recommendations
in regard to douching the vagina and the general disin-
fection of the patient he heartily commended. Soon
after the recognition of sepsis and antisepsis, the habit
of douching the puerperal woman was adopted by most
up-to-date practitioners, and one eminent physician in
New York recommended that after labor a woman
should be douched every two to four hours, and after
each douche an iodoform suppository should be placed
in the vagina and this treatment to continue for ten
days. Happily this practice has been discontinued.
During the past three years, the speaker said, his I
practice has been to give no vaginal douche except
for positive cause, such as septic infection of the
canal; under other circumstances, either before,
during or after labor, it was, he thought, unjusti-
ﬁable. The vast number of midwives in the city, the
majority of whom practice vaginal douching in all cases
of labor, should be instructed properly about this mat-
ter. He did not agree entirely with Dr. Crossen about
the induction of premature'labor. The results in these
cases were not satisfactory. Winkel had gathered sta~
164 M EDIGAL SOCIETY or
tistics on this operation and found that about 60 per
cent of prematurely delivered children ultimately die.
If this were true, Dr. Hypes said, he thought premature
delivery should not be resorted to except in cases
where there were good grounds for preferring it to
other life-saving operations. Where parents were
desirous of having children, and having them live, the
induction of premature labor does not promise good re-
sults. In regard to symphysiotomy and Cesarean sec-
tion he thought symphysiotomy saved more mothers, but
Cesarean section ought to and does save a larger num-
ber of children, and this point ought to be fully ex-
plained to parents. He thought he noticed in his read-
ings that symphysiotomy was falling into disrepute, but
whether on account of the slight advantage it has over
Cesarean section in saving the life of the mother, or on
account of the bad state of locomotion resulting, he
could not say; but he thought the majority of the best
obstetricians were leaning toward Cesarean section.
The great trouble was that of the physicians and mid-
wives who practiced obstetrics but few had or used pel-
vimeters. He thought it was wrong for one to practice
obstetrics without this instrument; by means of internal
and external pelvimetry the exact dimensions of the
pelvis could be ascertained. This should be known be-
fore labor occurs, so that if an operation is found to be
necessary the woman can be prepared and put in thor-
ough condition for the operation. It is the elective op-
erations that give the brilliant results, and not those
upon women who have been many hours in labor and
who have been subjected to much handling and the in~
effectual efforts at delivery.
DR. MARY H. MCLEAN said the paper and its discuss-
ion was so complete that she found very little to say
except to express her admiration of it. One detail,
however, she thought would probably decrease the
chances of infection in obstetrical practice, and this was
the use of the operating stocking. A patient will some-
times use her feet in a very wild manner and the use of
CITY HOSPITAL ALUMNI. 165
the sterile stocking was a valuable addition to the prep-
aration of a patient. She agreed with Dr. Crossen
about the using of the vaginal douche only in cases
where an antiseptic douche was really indicated. For
this purpose she preferred lysol to bichloride of
mercury.
DR. ELLA MARX said she was glad to hear that early
operations were advised. Her only regret in two cases
that demanded operation was that the procedure had
not been resorted to earlier, for the hemorrhage was so
great she felt that under similar circumstances she
would not delay again. She said there was no real ob-
struction in either of the cases referred to, but simply
the fact that pains were so weak the patients were una-
ble to expel the child and the membranes had not rup-
tured. In a case of real obstruction, of course, it would
be foolish to put oﬁ operation, and she felt it would be
equally so in such cases as she referred to, and the op-
eration should be done early and not delayed until the
patient was utterly exhausted. She agreed with Dr.
Crossen that much manipulation and frequent examina-
tions lessened the chances for recovery and rendered
the patient less able to resist auto infection.
DR. WILLIAM SHIBMEB BARKER said he thought the
results recorded in Dr. Crossen’s paper were wonderfully
good considering the environment of the patients. He
said he would like to ask Dr. Crossen to what extent
suturing was practiced even in slight tears.
DR. HYPES asked what percentage of primiparae and
multiparae suffered with ruptured perineum.
DR. HENRY J ACOBBON said that important as the
measurement of the pelvis is, he thought the examina-
tion of the urine was equally so. It ought always to
be done. We should not wait until the day before la-
bor commences, but it should be examined for a month
or two months before and then if any kidney trouble is
manifest this could be treated and the patient prepared.
If this were done, he said, a great many times uremic
symptoms could be avoided.
166 MEDICAL SOCIETY OF
DR. FRANCIS REDER said that in no other operative
ﬁeld were the coolness and judgment of the operator so
tried as in the operations in obstetrical science. He re-
called an instance in his younger years while attending
an obstetrical case in the country with his father. The
case did not seem to be progressing well and the bus
band of the woman came into the room with an ax in
his hand and threatened to kill the physician if he did
not save his wife. The situation was a trying one, but
his father did not lose his head; simply looking at the
man and at the ax and then at the woman he told the
husband if he did not leave the room at once his wife
would be frightened to death. The man quietly left
the room and the woman was safely delivered after two
hours. Dr. Reder said he recalled the fact that there
was considerable hemorrhage.
In regard to the pelvimeter it was the speaker’s
opinion that if a number of physicians were called to
see a case and all measured the pelvis with a pelvimeter
none of them would correspond and it was probably
this difﬁculty which caused the pelvimeter to be neg-
lected. The pelvimeter, however, was, Dr. Reder said,
a valuable aid to the obstetrician and should be more
often employed.
The operation for symphysiotomy was one which
could be made in the country where assistance and the
necessary means for a more serious operation could not
be had. The ﬁrst operation of this kind, Dr. Reder
thought, was done in Texas. In cities the better facili-
ties for operating would ﬁnally crowd out the operation
for symphysiotomy and with proper aseptic and anti-
septic measures the rate of mortality ought to be en-
couragingly reduced.
In regard to craniotomy Dr. Reder said he would be
grateful to the man who would step in and take pos-
session of the case, were he so unfortunate as to meet a
case demanding it. He said he had seen several cran-
iotomies and was always sorry to be present. He did
not think he would ever perform this operation, but
ClTY HOSPITAL ALUMNI. 167
rather subject the woman to symphysiotomy or Cesarean
section,
THE PRESIDENT asked if any comparison had been
made of the condition of the Hospital as regards septic
diseases during the time these eight hundred cases were
observed and that existing in previous years at this in-
stitution, and what was the result of the comparison.
DR. A. H. MEISENBAOII said Dr. Crossen was to be
congratulated on having only twenty-nine cases of
sepsis out of the eight hundred treated. As gangrene
was the scourge of general surgery so puerperal fever
was the scourge of obstetrics before the introduction of
antiseptics. In Germany it was made obligatory that
all persons who practice midwifery be thoroughly
versed in the knowledge and use of antiseptics. The
avenues of introduction for sepsis were so many that the
most careful watching was necessary to keep everything
and everybody about the patient perfectly clean and
aseptic.
He said the statistics in Cesarean section showed the
mortality was high In private practice, and that was
probably due to the fact that the majority of the people
operated on were in unfavorable surroundings. He
thought it was perfectly justiﬁable to decline to operate
on these cases if surroundings were unsatisfactory unless
the patient would go to a hospital when the chances for
success were vastly better.
DR. E. W. SAUNnERs said he had not heard the ﬁrst
part of the paper and would have to gather the general
tenor of it from the remarks of the other gentlemen.
As to the use of the douche he heartily concurred in
what had been said. Douches are dangerous unless
there is a special indication for them. Not infre-
quently, however, cases are met which before labor dis-
charge a purulent matter, sometimes gonorrheal in
character, sometimes not. In these cases he always
carefully douched with lysol before labor and abstained
from it as long as possible after labor, though usually it
was necessary to begin douching earlier than in an
168 MEDICAL SOOIETY OF
ordinary case. Some years ago he had tried to do
without douching altogether, but he had had quite a num-
ber of cases of mild auto infection; he thought, there
fore, that douching should not be practiced, with this
proviso—if there has been any imported infection then
the douche should be used. Streptococci introduced
into the uterus soon get beyond reach and nothing
brilliant can be expected from douches, but they do pre
vent infection by keeping down auto infection.
In the treatment of contracted pelvis be inclined to
Dr. Crossen’s views. He had had no cases of Cesarean
section, and he regretted it very much. He thought
every obstetrician practicing during the past ﬁfteen to
twenty years without a Cesarean section having been
performed, regretted it. He had lately noticed an ac-
count of 42 cases of Cesarean section during the past
two or three years in a hospital in Boston without a
death. The success attained by skillful men in this
ﬁeld was astonishing. He supposed all were familiar
with the history of the darkey woman in Richmond
who had been operated on by Cesarean section by one
physician six times in the course of several years.
Without experience in Cesarean operations, his mind
gravitated irresistably toward it and without experience
in symphysiotomy his mind gravitated away from it.
From what he had heard from observers he thought the
results of symphysiotomy were very poor, and from the
literature on the subject he believed symphysiotomy
would soon be numbered among the lost arts.
In regard to the moral aspect of the question of
craniotomy or embryotomy on the living child every
man’s conscience would have to be his guide in that re-
spect. He did not know of any law in this or any
country deciding this question, nor did he think there
ever would be. In the vast majority of cases it was
impossible to say whether the child was living or not,
but usually the child is dead; at any rate no heart
sounds are audible. He had had to do craniotomy
a number of times and in only one case did he believe
CITY HOSPITAL ALUMNI. 169
there was life in the child when the operation began.
_ The child was enormous in size and at the time he
thought it was dead, but has since doubted this; still
he did not have regrets about it. He did not think
any physician would start in at an early time and kill
the child; it was done only as a last resort and a matter
of conscience. Three years ago he had been called to
a case where it was necessary to perform craniotomy.
The child was dead, or he believed it to be dead.
Attempt to extract by means of forceps were unsuccess-
ful, although tried for many hours; the mother’s pulse
was countless and heart sounds indistinguishable.
After the child was delivered it weighed 164} pounds
without the brains and the amount of blood lost during
the operation, so he thought it must have weighed at
least 171} pounds. The mother lived two days but
never rallied. The lacerations in the vagina from the
delivery of the child were dreadful. In this case
Cesarean section would have been the proper thing to
do had the conditions been recognized early enough;
and even as late as it was, he thought the mother would
have had a better chance had Cesarean section been
performed immediately.
As to the choice, in cases of contraction, between
high forceps and version, that is still a matter of choice
among authors. Personally, he preferred high forceps
if it is possible to bring the head into position; the
chances for the child living are far greater. In turn-
ing in cases of contracted pelvis the parents should
always be told that they might expect a dead child; and
and if the child should be very large the lacerations are
certainly greater internally. The speaker said he was
very partial to the Tarnier forceps where they could be
used. He recalled a case of exostosis across the brim
of the pelvis seen some years ago. He recognized the
condition before labor occurred and called Drs. Prewitt
and Brokaw. Turning was decided upon, as the head
could not be engaged. The child was very large but
after considerable difﬁculty and having worn out his
170 MEDICAL SOCIETY OP
muscles and Dr. Prewitt had worn out his muscles, the
child was delivered. Where the head came in contact
with the spur a deep groove was seen. This spur, he
said, was probably absorbed after that, for the next
child was born with only a slight groove and the woman
bore three children afterwards. They were all very
large children and he had no doubt the spur was largely
absorbed.
DR. HYPEs said he thought the matter of turning had
not been emphasized enough in the paper. This could
be appropriately done in that class of cases where there
was a narrowing of the anterior and posterior diameters
to 3 or 31} inches. A perfectly formed head of an
average size will readily pass through a 31} inch pelvis
after version, and for this reason he thought version
was preferable where the head was high up and would
not engage. When he was a student he said the late
Dr. Boisliniere recommended 'version in this class of
cases and related the following case: He was called to
see a woman who had borne a number of children all of
whom were born dead. Dr. Boisliniere delivered her
with forceps but the child was dead; he recognized the
narrow condition of the pelvis and told the woman the
next time she became pregnant, if properly attended
during labor, she would be delivered of a living child.
When she was again about to be conﬁned she called in
another physician who learned her past history and
what Dr. Boisliniere had told her. Going to Dr.
Boisliniere, the latter, remembering the case, told him
to deliver the child by version; this he did and the
child was born alive; after this the woman bore three
other live children, all by version. He thought in
carefully selected cases and with proper management
many children might be Saved by this method.
DR CRossEN said he was very grateful for the dis-
cussion .the paper had received; he had expected- a
greater difference of opinion than had been manifested.
In regard to the percentage of deaths of prematurely
delivered children he thought it was about 28 per cent.
CITY HOSPITAL ~ ALUMNI. 171
DR. HYPES asked if that was the percentage at birth.
DR CRossEN said he was not sure and might be mis-
. taken, but thought it included the total mortality.
Symphysiotomy he had performed twice, once by the
subcutaneous method; he looked upon it as a very
serious operation, but not specially diﬁicult. Its worst
. enemies were those who regarded it as a simple opera
tion and acted accordingly. It was a serious operation
and should be substituted only for Cesarean section or
craniotomy. The last symphysiotomy he did only a few
days ago and by the subcutaneous method. He had no
difﬁculty in ﬁnding and dividing the joint; perhaps, he
said, _he had just happened to strike it right. In regard
to the choice between symphysiotomy, Cesarean section
and craniotomy, he said it was a hard matter to lay
down general rules to govern these cases. The moral
aspect of the question was to be considered for some
think it was wrong to do a craniotomy at any time, if
' the child be still alive.
He said he was glad the matter of operating stock-
ings had been mentioned. At the Hospital the patients
are placed on a ﬂat table made of iron, enameled white,
covered with a water-proof mattress and the mattress
covered with an ordinary rubber sheet and that by a
sterilized sheet; then sterilized operating stockings,
made of ﬂannel, are put on the patient reaching half
way up the thighs, and the patient is covered with a
sterilized sheet. -
In regard to suturing the perineum he said all tears
of the perineum were sutured. He had counted as com-
plications only tears of the second degree, that is those
reaching half way down the perineum and requiring
three or four sutures to close. '-
The operation of craniotomy was, he said, of course,
not a pleasant one, nor were the other operations, be- '
cause all of them involved great risk to life. The physi-
cian should decide what plan was most advisable and
then inform the patient whose consent, or the conSent
172 MEDICAL SOCIETY OF
of her nearest relative, should, of course, be. obtained
before the operation was undertaken.
In regard to douches in gonorrhea he said the
gonorrhea should be treated before, during and after
conﬁnement.

A Report on the Histology of a Cystic
Sarcoma of the Kidney.1
BY L BREMER, MD, ST.- LOUIS.
Dr. Bremer presented some microscopic specimens
illustrating the histologic structures of a ﬁbro sarcoma
cysticum of the kidney, with the following remarks:
Unfortunately he had not been able to bring with him
the kidney laid before the Society by Dr. Bryson at a
previous meeting, but he thought most- of the members
had inspected the specimen when presented on that
occasion. He said that it had been pronounced by Dr.
Bryson to be a cystic kidney. This was true in a meas-
ure. On the whole, the specimen shown at that meet- '
ing was an enormOus kidney having, to outward appear-
ance, the shape of that organ. After a longitudinal
section had been made through it, it looked macroscop-
ically like a sarcoma, or rather cysto sarcoma. He 'had
brought a number of specimens verifying the prelimin-
ary diagnosis. They showed all the characteristics of
a cystic sarcoma. Before the members inspected the
specimens he desired to say a few words about the his-
tologic character of the growth. He said in substance:
The tumor, as mentioned before, represents a kidney
of enormous dimensions, dotted on its surface and per-
vaded in its substance by a great number of cysts of
varying shapes and different diameter; some containing
ﬂuid, others gelatinous material. Generally speaking,

1This report, with illustrative specimens, was submitted to the
Medical Society of City Hospital Alumni, March 3, I898.
CITY HOSPITAL ALUMNI. 173
they are small cysts, most of them not exceeding the
size of a large pea or bean; some, however, reach the
size of a small hazlenut, a few are even larger. In some
places they lie so closely together that the septa between
them are no thicker than card paper. On general
grounds there can be no objection to calling such a kid-
ney cystic. But, by a cystic kidney we understand, ac-
cording to usage in pathology, one in which the cysts
are caused by dilatation of some part of the uriniferous
tract due to obstruction; in other words, they are reten.
tion cysts. Such is the case in the congenital forms of
cystic kidney and in those due to inﬂammatory pro-
cesses. In the kidney under discussion the genesis of
the cysts is of a diﬁerent character. They owe their
existence to the breaking down in spots of the neo-
plasm. This, at all events, is true of the vast majority
of the cysts. A few I have found in which the walls
were lined with epithelium, proving them to be of the
nature of retention cysts. That these cysts should pre-
sent a globular form is very natural, when it is consid-
ered that they occupy the site of the obliterated glome-
ruli.‘ But even the cysts resulting from the softening
and ultimate disintegration of certain parts of the tu-
mor mass have a globular form, although many of them
show, under the microscope, irregular and ragged walls
in contradistinction to the smooth walls of the retention
cysts.
The material ﬁlling the globular spaces is of a differ-
ent composition in different cysts. Some of them, as
before stated, are ﬁlled with a ﬂuid substance, possibly
a mixture of urine and lymph, others contain granular
masses resulting from the disintegration of tumor cells
(ﬁg. viii) and others a gelatinous or colloid mass, whilst
others contain a substance which, on microscropic exam-
ination, revealed a closely-meshed networkof a ﬁbrinous
appearance (fig. ix). In some of the cysts crystals and
crystalloids can‘be demonstrated. Besides the needles
of fatty acids there are to be seen amyloid bodies (ﬁg.
viii, c c c), cholesterine (ﬁg. viii, e), imperfect uric acid
174 MEDICAL SOCIETY OF
crystals (ﬁg. viii, d) and ill deﬁned colorless crystals
having a tendency to assume the globular form, and
which I take to be calcium phosphate. Some of the
cysts are ﬁlled with a nearly homogeneous or slightly
granular substance. EnormOusly dilated veins furnish
the wall cysts in some of them. So it will be seen that '
both the origin of the cysts and the character of their
contents is of the most varied kind. I
As regards the nature of neoplasm, two distinct fea-
tures present themselves: There are well-deﬁned tumors
pervading the kidney, more or less globular in shape
and varying from the size of a pea to that of a' large
hazlenut. Again, the whole organ is inﬁltrated with
sarcomatous elements, the connective tissue cells being
in a state of proliferation. In some forms of sarcoma
the cells of the vessels, being mesoblastic in origin,
contribute toward the formation of the tumor. This
does not seem to be the case in the present instance; it
is the connective tissue proper of the kidney that pro-
liferates and constitutes the main mass of the tumor.
There is some diﬁculty in properly classifying the
growth under consideration, so far as the different sub
divisions of sarcoma are concerned. The fact is, that
nearly all the recognized kinds of this class of tumors
are more or less clearly represented.
Thus, the large round cell sarcoma can be demons-
trated in places (ﬁg’s ii and viii). This is particularly
the case in the neoplasms proper that are found to be
disseminated in the kidney. At the periphery of the
growths large spindle cells are often to be seen (ﬁg. ii).
There are some parts in which the spindle cells predom-
inate over the round cells; hence, large round cell and
spindle cell sarcoma would be the diagnosis according
as one or the other part of the tumor happened to be
examined. Again, in many places there are extensive
patches of myxomatous tissue giving the tumor the
character of a myxo-sarcoma (ﬁg. i, c). It is a well-
known fact that the existence of myxomata as special
kinds of neoplasms has been denied by some patholo-
CITY HOSPITAL~ ALUMNI. 175
gists, claiming that 'such formations represent nothing
more than a certain form of retrogressive metamorpho-
sis of ﬁbrous tissue, mucin supplanting the intercellular
substance of the latter, pushing the ﬁbers asunder. The
ﬁndings in this tumor favor this view as to. the genesis
of the myxomata. So far as appearances go, there is
no indication of embryonal cells forming the myxoma-
tous patches. In some instances it seems that the urin-
iferous tubules are ﬁlled with a colloid mass very much
after the fashion of casts, which on cross section ap-
pear as mucine masses ﬁlling up the meshes formed by
proliferating instertitial connective tissue. The tracts
of the latter may, by pressure produced by the swelling
up of mucine, undergo absorption, a cyst taking the
place of the ‘myxomatous tissue. In many of the cysts
formed in this manner traces of connective tissue net-
work are still visible. '
In some places formations presenting the appearance
of a cavernous angiomata occur. They arise from hem-
orrhages, the blood failing to coagulate and utilizing
spaces produced by connective tissue tracts pushed asun-
der, for channels of circulation
Lastly, bunches of lipomatous tissue are to be men-
tioned (ﬁg. vi). They occur near the periphery of the
tumor mass and seem to belong to the renal capsule
which has been invaded by the sarcomatous process,
thus forming part of the tumor. As is the case with
all the original or normal elements of the organ invaded
by the neoplasm, so the fat tissue of the capsule seems
to have increased in bulk stimulated by the morbid pro-
cess going on in the kidney. The connective tissue
tracts of the fat tissue show also the sarcomatous char-
acter (ﬁg. vi). This fat is different in origin and ap-
pearance from the fat resulting from degenerative pro-
cesses which are abundant throughout the kidney.
The most prevalent form, however, of the sarcoma-
tous ' new‘formation, is the ﬁbre-sarcoma (ﬁg. vii).
Throughout the mass of the tumor there is evidence of
an attempt on the part of the growth to form mature
17 6 MEDICAL SOCIETY OF
connective tissue (ﬁg. vii, e). In other words, there are
signs that the malignity of the tumor is very much
mitigated by an attempt at the formation of scar tissue.
Thus, while on the one hand there are pronounced char-
acteristics of malignancy, such as the presence of em-
bryonal tissue (large round and spindle cells) and the
breaking down of the tumor mass; there are, on the
other hand, evidences of an effort at repair, i.e., of a
benign nature.
As already remarked, there is a marked hypertrophy
of some parts of the kidney, whilst at others there is
extensive destruction Of its parenchyma. This phe-
nomenon is in keeping with the well-known law of con-
structive compensation taking place in organs whose
function has been impaired by pathologic processes.
It is owing to this compensatory tendency of function
that a hypertrophy of the parenchyma of the kidney
has taken place to a considerable extent. Not only is
the interstitial connective tissue in a decided state of
hypertrophy (ﬁg. vii), but the glomeruli—the convu-
ted tubules (ﬁg. iii, a), Henley’s loops and the tubuli
recti are enormously enlarged. The vessels, too, as
might be expected, are conspicuous for the thickness of
their walls and the increase of their lumina. In other
places, however, the opposite process is going on, a
wasting of the parenchyma being noticeable, owing
to the pressure produced by the rapidly prolifer-
ating tumor cells and to the shrinking and constricting
mature, tie , scar tissue. For instance, the glomeruli on
some parts of the tumor may be seen in theidiiferent
stages of shrinking and obliteration (ﬁg. iii, a, b, c, d).
Very marked is also the atrophy of the fat cells owing
to the encroachment of the sarcoma cells (ﬁg. v).
The mode and origin of the formation of the cysts
has already been alluded to. A short recapitulation
may not be out of place. Whilst a few of the cysts owe
their origin to a constrIction of some part of the urin-
iferous and uriniparous tract, the vast majority of them
owe their existence to the breaking down of the tumor
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CITY HOSPITAL ALUMNI. 177
owing to deﬁcient supply of blood, produced in most
instances by the rapid approach and encroachment of
the tumor elements. In consequence of a lack of new-
formation of vessels there is more ‘or less extensive ne-
crosis in the more rapidly growing parts of the tumor, ‘
notably in the large round cell formations (ﬁg. viii).
Here the cells undergo a fatty metamorphosis, large
cells having four or ﬁve times the diameter of the round
sarcoma cells, making their appearance and being recog-
nizable by their brown color (ﬁg. ix, a). In other places
coagulation necrosis is the mode of destruction, whereas
in still another catagory of destructive processes, hem-
orrhage, with subsequent softening, inaugurates the
cystsformation. All these modes of destructive pro-
cesses are easily made visible by staining, for instance,
with picro carmine or gentian violet, in combination
with acetic acid; even to the naked eye unstained areas
of varying sizes are noticeable. They represent the
sites of the necrotic changes and beginning of cysts.
The latter, when fully formed, show the contents
enumerated above. The ﬁbrine network ﬁlling the lu-
mina of some of them are due, probably, to hemor-
rhages being the remnant of the latter. Some of these
dense networks, however, have the appearance of com-
pressed ﬁbrillee constituting the intercellular ﬁbrils of
the large round cells which have undergone retrograde
metamorphosis (ﬁg. ix). In keeping with the origin
these cysts have lacerated and ragged walls with shreds
of torn parts projecting into the cavities. There are,
however, other cysts, as already remarked, with smooth
walls, probably retention? cysts. These, too, exhibit
projections, epithelium'lined, wart~like bodies, jutting
out from the walls, varying in size and number (ﬁg. x).
Owing to the preponderance of the ﬁbro-sarcomatous
tissue of the growth, and the presence of the cysts, the
diagnosis is: Cystic Fibro sarcoma. The histologic
character bespeaks semi-malignancy. This is borne out
by the clinical history. The sarcomatous process did
not spread beyond the kidneys, although postmortem
178 MEDICAL SOCIETY or
the remaining kidney showed the same pathologic
alterations as the one removed by operation.
EXPLANATION OF ILLUSTRATIONS.
Magniﬁed about 150 diameters. Picro-carmine, gentian
violet and diluted acetic acid, all in glycerine.
FIG. I.—A cross section of the cortical region; a a a a
represents the enlarged uriniferous tubules lined with
hypertrophied epithelial cells. Some of the latter are
seen in the lumina. At 6, ﬁbro sarcomatous change; at
c, myxomatous character, the connective tissue tracts
surrounding the uriniferous tubules forming the net-
work, the meshes of which contain mucine; at d, round
cells breaking down, beginning of cyst-formation.
FIG. II.—Large round cells and spindle cells with
ﬁbrillar intercellar substance.
FIG. III.--Glomeruli in different stages of compress-
ion and atrophy.
FIG. IV.--Formation of cavernous angioma.
FIG. V.—Lipomatous tissue in a state of progressive
atrophy and absorption. The fat cells have assumed
irregular shapes and appear shrunken.
FIG. VL—Sarco-lipomatous formation from near the
periphery of the tumor mass.
FIG. VII.—Fibro-sarcoma at a, dilated uriniferous
tubule; at b, uriniferous tubule compressed and atro-
phying; atId, the same process on cross section.
FIG. VIII.—Wall of cyst; at a, round cells, with ﬁb-
rillar intercellular substance, the character of the tumor
being that of a large round cell sarcoma; at b, the cells
are being disintegrated; c c c, amyloid bodies; d, incom-
plete urIc acid crystals; e, cholesterine.
FIG. IX.—Section of contents of a cyst; b, dense
ﬁbrillar network; at a a, large cells ﬁlled with fat gran-
ules; to the left large round cells in various stages of
disintegration.
FIG. X.—-An epithelium covered process jutting into
cyst. [See illustrations, facing page 176]
CITY, HOSPITAL ALUMNI. 179
STATED. MEETING, THURSDAY EVENING, MAY 19.
THE PREsIDENT, DR. GEO. HOMAN, IN THE CHAIR.
Two Fibroids—One a Large Sessile Sub-
mucous. Tumor, the Other a
Retro-Peritoneal.
BY MARY H. M’LEAN, MD., ST. LOUIS.
Perhaps no other pathological growth furnishes us
with a greater variety of conditions than myo-ﬁbromata
in size, location, histology, anatomical relations, clinical
history, systemic complications and operative diﬁiculties.
Between the small subperitoneal nodule found acci-
dentally on the fundus without any symptoms, and the
submucous variety which causes rapidly fatal hemor-
rhage, there are almost as many varieties as cases.
The two ﬁbroid tumors presented this evening are
. worthy of some little thought both on account of the
tumors themselves, their situation and relations to other
structures and on account of difﬁculties encountered in
dealing with them, operative and post operative.
The ﬁrst case presented is a large tumor with a his-
tory of 15 or 20 years, which began either as an inter-
stitial or as a submucous myoma and grew into the uter-
ine cavity, stretching the uterine walls into a thin mem-
brane, encroached upon the vagina, completely ﬁlled the
pelvic cavity and pushed the fundus uteri up to the level
of the umbilicus.
The history is as follows: The patient, aged 63, short
and stout, has been sterile through more than 30 years
of married life. For 15 years she has known that she
had a tumor, and the symptoms indicate its presence for
nearly 20 years. In the early years of its history, the
patient had severe and repeated hemorrhages, but little
pain. About 10 years ago she was operated by a sur-
geon who seemed to have attempted morcellation in
, several successive sittings. Such alarming hemorrhage
resulted from the early attempts that this method was
180 MEDICAL SOCIETY OF
abandoned. She has had no hemorrhage for about 2
years, but for more than a year she has had a profuse
purulent discharge from the vagina, necessitating the
use of at least 10 heavy napkins daily. During the past
year, also, the pressure upon the bladder and rectum has .
increased and interfered greatly with micturition and
defecation. An examination revealed an immense solid
tumor entirely ﬁlling the vagina and extending to the
level of the umbilicus. ‘
A very thin, sharp rim of tissue was detected by the
ﬁnger high in the vagina to the right, which we took
for the greatly stretched cervix uteri. Percussion of the
abdomen elicited dullness up to the level of the‘ umbili-
cus. A large quantity of pus escaped from the vagina
during the examination. Urine was normal, heart-beat
was fairly good, with a slight mitral murmur, and the
patient,was eager to be relieved of her burden. The
pressure of the tumor and the risk of septicemia led us
to advise its removal. The patient was kept on full
doses of strychnia for three weeks and had daily lysol~
douches. The douches were not effective because of
the close packing of the tumor in the vagina.
December 2, 1897, at the Protestant Hospital, assisted
by Drs. Bedal, Marx and Bishop, I opera-ted. Morcel-
lation by the vagina was considered but discarded on
account of the great size of the tumor, and the difﬁcul-
ties to be encountered in controlling hemorrhage. With
a long obstetrical intrauterine nozzle douche we cleansed
the vagina as thoroughly as possible. The patient was
then placed in the Trendelenberg position, and a 6 inch
incision made through the fat abdominal walls. A good
many adhesions to the omentum and intestines were
found and separated with little difﬁculty; then the great-
ly stretched right broad ligament was ligated with cat-
gut and cut as far down as possible. The ovarian artery
was tied on the left side, the bladder separated with
great care, and the uterus and tumor were with great
effort pulled over from the right side, forceps applied to .
the left uterine artery, the ligament severed and the
CITY HOSPITAL ALUMNI; 181
tumor delivered with uterus and appendages. The left
ligament and uterine artery were then ligated with cat-
gut and all oozing stopped with ﬁner catgut running
sutures. I
When the pelvis seemed perfectly dry, the two broad
_ ligaments were tied together and the peritoneal edges
united with catgut from one side: of the pelvis to the
other, completely closing the peritoneal cavity.. Inthe
' effort to pull out the tumor from the pelvis free hemor-
. rhage. was encountered with each puncturefof the large
tenacula; but this was quickly controlled with pressure
forceps, so that up to this point in the operation we had
lost very little blood. Then I made a mistake—I closed
the abdominal wound in the Trendelenburg posture.
The pulse up to this time had been good. I hastily
turned the table around- and had my patient slowly low-
ered from the Trendelenberg posture in order to pack
the vagina with sterile gauze. As she reached the lon-
gitudinal posrure, I found a free venous oozing, failed
to grasp the ligaments with forceps and so hastily
packed tightly with gauze. Her pulse went up to. 120,
and I gave at once a pint of normal saline solution un-
der the right breast and free stimulation with strychnia.
. She responded well to the stimulation and was put to
bed in fair condition but showed great shock for 24
- hours. Strychnia was given in 1/,, grain doses every .2
hours for 24 hours, then every 3 hours, and another pint
-of normal saline solution was given .on the ﬁrst day.
The pulse gradually came down and thoughintermitting
every ninth or tenth beatwas of fair quality. On the
second day the pulse was 110, and the temperature rose
to 100.6‘, and the patient seemed much stronger. At
the end of 48 hours..the patient; complained greatly of
the vaginal packing and it was very carefully removed.
To my great astonishment, free venous hemorrhage fol-
lowed its removal, so that I had to pack again very
tightly; 24 hours later some oozing from the vagina oc-
curred through the gauze and then more gauze was in-
troduced. The temperature ranged from 99.2 to 101°;
182 MEDICAL SOCIETY OF
pulse, 96 to 100; respiration, 24 to 26. Urine was in
good quantity and free from albumen, bowels moved
well, and the patient enjoyed her liquid diet.
On the morning of the ﬁfth day the patient expressed
herself as feeling quite well enough to sit up, and had
a delightful half hour chatting with her husband, who
felt quite safe In leaving her for the country home at
8:39 A.M. About 10 A.M. the patient began to breathe
rapidly and heavily and to look distressed. On seeing
her shortly afterward I found labored respiration—40 to
46 per minute, soft pulse and a tremendous splashing
murmur over the heart. This grew steadily worse in
spite of stimulation, and the patient died 24 hours later
with every evidence of embolism.
We found the abdominal wound and vaginal vault
sealed, but blood clots and free blood in the vagina on
the gauze. There seemed to be a failure on the part of
Nature to close up the veins, which must have been
enormously distended by the tumor. The tumor is ovoid
in shape and attached to the entire fundus, with no at-
tempt at a pedicle. The largest similar tumor I have
been able to ﬁnd in literature is one operated by Dr.
A. Martin, of Berlin, and referred to in Kelly’s new
“Operative Gynecology.” It was 16x12x9 c.m. The
cervix is stretched about it into a thin membrane, but
the fundus seems thickened. In its present state, after
six months in alcohol, it weighs 4 pounds and measures
20x14x13 cm. I have not been able to determine the
source of the profuse purulent discharge.
Dr. Charles T. Parkes, of Chicago, presented a some-
what similar, but much smaller specimen to the Gyne-
cological Society of that city in January, 1889. It was
reported in the American Journal of Obstetrics for 1889.
He says: “The body of the uterus stands directly on
top of the tumor and the tumor protruded far into the
pelvis and grew downward so that it almost presented
at the vulva, forcing itself into the pelvis and showing
very little tendency to project into the abdominal cav-
ity.” He seems also to have encountered great difﬁcul-
CITY HOSPITAL ALUMNI. 183
ties in the. operation, for he says: “For so simple a,tu-—
mor as this in size, it was in all respects the most form-
idable operation in the extent of the incision and dam-
age dcne to the organs of the pelvis I have had any-
thing to do with.”
This case is one more added to the many which go to
prove that we can not look to the menopause for any
certain relief in cases of ﬁbroid tumors. As it is uni-
versally admitted that the mortality in abdominal oper-
ations‘ is greater after 50 years of age than before; it
does seem that the treatment of ﬁbroid tumors previous
to the menopause should be more radical than at pres-
61115.
My second specimen is a retro-peritoneal ﬁbroid with
cysto-sarcomatous degeneration. The patient, aged 46,
was a healthy girl, with normal menstruation. She was
married at the age of 22 and had one child when she
was 26, with a placenta previa, and was an invalid for
2 years afterward. After this she was a fairly strong,
healthy woman until the tornado, which gave her a ter-
, rible shock. Since then she has had pelvic pains, back-
ache and diﬁculty in micturition, with constipation.
I do not propose, however, to present this case as an-
other of the strange. pathological entities caused by the
tornado. I must think that the ﬁbroid antedated the
tornado.
When I ﬁrst saw the patient, March, 1897, she was
very thin and weak and miserable, with an abscess in
the left groin which diScharged freely and healed very
slowly. A pelvic examination revealed a hard, ill-
deﬁned mass, back and to the left of the uterus, limited
in mobility, sensitive to the touch and with no lines of
separation from the uterus. There was some difﬁculty
in the differential diagnosis between pelvic abscess and
uterine ﬁbroid. We ﬁnally made the diagnosis of a
ﬁbroid of the uterus, however, and succeeded at times
in moving tife tumor through a limited range. The pa-
tient was kept under observation and on tonics and good
food for 6 months, and she greatly improved in general
health. ‘
184 - MEDICAL SOCIETY OF
October 15, 1897, at the Deaconess Home, assisted by
Drs. Marx and Bedal, I made an abdominal section, and
found the uterus almost normal in size and position,
with a small sub peritoneal ﬁbroid on the right corner,
appendages on both sides adherent, and the ﬁbroid en-
tirely separate from the uterus lying under the perito.
neum on the left side of the vertebral column from
about the second sacral to the third lumbar vertebra,
With the large intestine on its inner side, the mesentery
growing diagonally across its'upper half, and the left
ureter coursing along its left border. The appendages
were removed and catgut ligature used, the small ﬁbroid
was shelled out and the peritoneum covered over its bed.
Then a longitudinal incision was made over the tumor,
carefully avoiding both mesentery and ureter, and the
ﬁbroid was with considerable difﬁculty shelled out. In
this manipulation the whole colon seemed near the pel-
vic brim, the descending colon~twisted over to the inner-
side of the tumor and no small intestine was seen dur-
ing the operation. '
Since quite a cavity was left in the tumor-bed and the
oozing found diﬁicult to control, gauze packing was put
in and the peritoneal ﬂaps were stitched to the abdominal
peritoneum. The rest of the incision was closed with
through silk-worm gut sutures and interrupted catgut
in the fascia, as is my custom.
The patient rested well and endured well the nausea
of the ﬁrst day. On the third day we removed the
gauze drain and repacked. Drainage had been free.
On the 19th she‘had a rise of temperature—above
101°. I tried to move bowels, but with very slight re-
sponse. Temperature rose to 103°; pulse to 110—115.
There was some tympanites and no solid feces. Fearing
intestinal kinking and obstruction, I reopened the ab-
domen October 22, just one week after the operation,
Drs. Sharpe, Marx and Bedal assisting me. Union of
incision was good throughout and I was pleased to ﬁnd
good union of layer to layer. There was no pus any-
where, but the colon was adherent to the broad ligament
CITY HOSPITAL ALUMNI. 185
stumps on either side in- such fashion as to stretch it
around the peritoneal sack of the tumor cavity. The
colon was relieved and the site of adhesion sponged, the
sack repacked and attached at one point to the line of
incision, and the wound closed with silk-worm gut. The
patient rallied well, fever subsided at once and recovery
was uninterupted. The sac was drained and douched
daily until it healed, November 11. The patient left the
hospital November 25, ready'to resume her household
duties.
The origin of this retro-peritoneal ﬁbroid is a ques-
tion for discussion. It was widely separated from the
uterus and closely attached to the colon, which gives
some reason for believing that it may have originated
in the-intestinal wall.
. A tumor similar to this in shape, size and situation is
described by Dr. Richard Krukenberg in the Centralblatt
Gynecologic, No. 52, 1897. That tumor was more
intimately associated with the colon wall, however, than
this one.
Dr. C. Fisch, who kindly examined the specimen for
me,» ﬁnds the tumor to contain glandular remnants which
seem to demonstrate its uterine origin. I subjoin his
report:
“The examination of the tumor showed that it was a
ﬁbro-leiomyoma with some foci of round cell inﬁltra-
tion and myxomatous degeneration. The small ﬁbroid
proved of interest, inasmuch as it contained glandular
structures, which in the ﬁbroids are said to be remnants
of the Wolﬁian body. In some planes of the large tu-
mor a very active cell proliferation can be observed,
giving the tumor somewhat of a sarcomatous character.”
\
. DISCUSSION. .
DR. A. H. MEISENBACH had two specimens which
were shown in connection with Dr. McLean’s. Dr.
Meisenbach said the ﬁrst specimen was taken frOm a
woman, 41 years of age. He had seen the case once
before the operation. She was sent to him by a physic-
‘186 MEDICAL SOCIETY OF
ian who had diagnosed the case as abdominal tumor.
The diagnosis was simple as the tumor was very appar-
ent and readily outlined by palpation, and very charac-
teristic. The woman- was of the working class and
made. her living by manual labor, and the tumor was
beginning to interfere with her work. She had had
several ’hemorrhages at irregular intervals, and consulted ~
a physician with the suspicion that she was pregnant.
She was sent to the hospital April 27 , and the tumor
removed. The patient made an uninterrupted recovery.
On examining the tumor there was found a pregnancy
of about three or four months, inside the uterus. The
tumor was a good example of the submucous, mural and
sub-peritoneal variety of ﬁbroid.
The second tumor was taken from a woman 45 years
of age, and was a good example of the submucous form.
Up to a year and a half ago the patient had no suspicion
that she had anything the matter with her. She had
had hemorrhages of a profuse and irregular character,
and 18 months ago the tumor was ﬁrst discovered. Last
October she had a hemorrhage and was advised to have
the tumor removed. She said she thought Nature would
take care of the trouble, and refused. Another hemor-
rhage occurred late in the winter which she tried to
control without the aid of' a physician. He found the
tumor low in the pelvis and causing pressure on the
veins so that at times the limbs were edematous; urine
contained a slight quantity of albumen. After two or
three months’ treatment, she was Sent. to the hospital,
and April 30, the operation was performed.
This second operation was more difﬁcult than the
ﬁrst on account of the low position of the tumor and
the diﬂiculty of reaching the ovarian and uterine arte-
ries. In thisoperation he used the clamps before liga~
ting. He then opened the anterior ‘ and posterior cul-
de-sac and separated the tissue containing the uterine
arteries and removed the tumor. Afterwards the ques-
tion arose whether this tumor might not have been re-
moved by the vaginal operation. But the vaginal oper-
CITY HOSPITAL ALUMNI. 187
ation, he thought, was dangerous on account of the hem-
orrhage and possibility of infection.
This second operation: was not followed by such good
results as the ﬁrst. The vomiting was not excessive and
the pulse was fairly good; he gave strychnine in tonic
doses for a month or six weeks and a hypodermic of
strychnia before the operation and a saline injection be-
fore and during the operation. He followed this prac-
tice where he thought depression was apt to follow
either as a result of shock or hemorrhage. After the
vomiting ceased he attempted to open the bowels by
giving calomel in l/1° grain doses each hour for ten
hours but without effect, and the temperature began to
rise, running up to 101', and the pulse to 120. This
action of the pulse and temperature and failure of the
bowels to move caused him to think the case was One of
infection, but whether it was that or shock, he was not
sure. The abdomen became tympanitic and the patient
was suﬁering great distress. Dr. Hypes, who was pres-
ent and saw the case. suggested high injections of half
a pint of: water containing a teaspoonful of turpentine;
this was done and relieved the patient, but the bowels
'did not move freely until the third day.
From the subsequent action of the case he thought it
was one of atonicity, or paralysis, of the bowel. The
Faradic current was used and injections of salt solution,
and, ﬁnally the bowels were moved; the edema of the
limbs passed off, and at the present time the patient is
convaleScing nicely. The two tumors, he “thought, were
beautiful specimens of multiple and submucous ﬁbroma.
DR. ALBERT E. TAUSSIG exhibited a cancer of the
stomach which, he said, possessed -' some rather unusual
qualities; but discussion of the subject was postponed
to another meeting. -
Further discussion of Dr. McLean’s report, and of
Dr. Meisenbach’s two specimens was also postponed to
a later meeting.
.188 MEDICAL SOCIETY OF
STATED MEETING, THURSDAY EVENING, JUNE 16.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
No contribution from the announced program being
presented, Dr. Joseph Grindon took advantage of the
opportunity to make a few remarks on '
IMPETIGO CONTAGIOSA.
DR. GRINDON said the disease was quite prevalent in
St. Louis in certain localities, more especially among the
poor people. Although so cOmmon he thought quite a
number of general practitioners did not recognize the
disease, though it? once seen It Could hardly be forgotten.
The eruption always began as-vesicles upon the face and
hands, usually in children; then enlarged at the periphery
until they became as large as a 25 cents piece—he had
seen some as large as a silver dollar. The contents of
the lesion later became partially purulent, the pus seek-
ing the more dependent portion, according to the change
of position of the part affected, according to gravity,
and had much the appearance of the condition oculists
call hypopyon. A crust forms and has the appearance
of having been “stuck on” and this appearance is some-
what heightened by the edges being somewhat everted.
At one time the vesicle may look very. much like the
vaccine vesicle, when depressed at the center, 'but with-
out the areola. This depression at the center is not al-
ways present, but when present may merge into another
condition which has been described separately as the
type of impetigo in which there is a ring of vesicular
tion inclosing a reddened area. The more common
appearance, however, is the one where the crust ﬁnally
detaches leaving a reddened surface which looks exactly
like a surface burned With carbolic acid, which has a
peculiar glazed appearance. ' .
The treatment, he said, in these cases had fo
many years followed a routine which answered very
well. He ﬁrst removed the crust and cleansed the part
CITY HOSPITAL ALUMNI. 189
with soap and warm water. If the .crust was adherent
a little olive oil—or-any oily substance—would soften it
down so that it Would come off easily; he then rubbed in
an ointment of ungt. hydrarg. nitratis with vaseline or
some inert base, equal parts.
Some years ago it was supposed, and some books
stated that this condition only existed after vaccination.
Cases did occur after vaccination. The disease was due
-to a germ and this germ fOund access to the system
through the vaccine abrasion, but when it was epidemic,
as laSt year, it was found in many persons who had not
been vaccinated for years. Piﬁard, of New York, had
found a micrococcus in the lesion which he thought was
the same as Weigert’s micrococcus vacciniee. his not
now believed that that micrococcus is really the micro-
cOccus of ‘ vaccinia. There was no connection between
the two conditions, except that it is possible for the vac-
cinelesion to serve as the point of entrance. What the
speciﬁc germ of impetigo contagiosa is he did not think
had been determined. Ordinary impetigo was simply
one form of pyo-derma due to one of the ordinary pus
germs and had no connection, except a very superﬁcial
'resemblance, with the contagious form. ‘
THE PRESIDENT said _he was under obligations to Dr.
Grindon for light thrown on some cases last autumn
which had puzzled him up to that time, the location of
the disease being the chin. He asked whether a lesion
of the skin was necessary for the introduction of the
contagion.
DR. GRINDON said he did not know, and did not be-
lieve anyone knew, what the necessary conditions of in-
vasion were. He thought, however, a break in the in-
tegument might assist or favor infection, from the faCt
of the occasional occurrence of the disease after vacci~
nation, and also from the fact that in his clinical prac-
tice he had seen it frequently in children infected with
head-lice. Among people of cleanly habits the cases
were not so serious on account of the frequent washing,
but he had seen several cases among people of the upper
walks of life and in the persons of physicians.
' 190 MEDICAL SOCIETY OF
DR. FRANK HINCHEY said he recalled acase at the
hospital in a young boy who was aﬁiicted on the knees.
The case puzzled them very much. The leSions were
such as Dr. Grindon had described and looked like im-
petigo contagiosa. On questioning the mother as. to
whether she had any other children affected in a similar
manner, she said there was an older child at home with
the same kind of eruption on the face; this cleared up
the case of the boy in the hespital, although the unusual
site at ﬁrst puzzled them. ‘
DR. H. R. HALL asked whether Dr. Grindon had
found a febrile accompaniment and whether its appear-
ance was simultaneous with the infection.
DR. GRINDON said there might be a-slight febrile mo-
tion, but only such as would accompany any slight lesion
which would be liable to take on pustulation. In small
a children in hot weather there was usually considerable
irritation, and this might result in slight fever. He _had
never taken the temperature in these cases.
THE PRESIDENT asked if negro children were as sus-p -
ceptIble to this disease as white ones were. A I
DR. GRINDON said he did not remember having any
negro children under treatment; this, he thought, was
because so few negro children were treated at the clin-
ics. Negroes, as a rule, do not seek clinical treatment.
THE PRESIDENT asked if they were as liable to skin
diseases generally as white children.
DR. GRINDON said he would hesitate to answer that
question, for the same reason as the former. There are .
certain diseases to which they are more liable, for ins-
tance, keloid. The largest keloids, he thought, were
seen in the negro race; scars in the negrorace take on
hypertrophy very early. Some of the syphilitic erup-
tions are also larger in the negro race, for instance, the
papillomatous form of the tubercular syphilide. He
had seen it once in a white man but a great many times
in the negro. There is a good illustration of it in
“Morrow’s Atlas.” The annular form furnishes another
instance of racial predisposition. The circles are beau
CITY HOSPITAL ALUMNI. 191
tifully concentric, as if drawn with a compass. In
negroes the diagnosis o-fany eruption is difﬁcult. A
patient had been com-ing to him for the past six months
who had something the matter with her sktn; some
- places on the skin looked diﬁerent from others and she
said they itched, but the speaker said he was unable to
tell what it was, as her skin was too black.
CUTANEOUS HYGIENE IN THE ARMY.
DR. J. B. GIRARD, of the U. S. Army, said, in an-
swer to a request from the President, that he was una-
ble to discuss this question of skin disease, but appre-
ciated the courtesy of the invitation. Skin diseases in
the army, he said, were very rare, for the reason that
most of the people in the army were very healthy.
Soldiers are what might be called selected lives, and are.
looked after carefully and subjected to all sorts of hy-
gienic measures, and the oﬁ‘icers, especially, take good
sanitary care of themselves; for these reasons very few
cutaneous diseases are seen. Of course, there are cases
.of eruptive fevers, but such cases as Dr. Grindon de-
_ scribed, he had never seen in the army.
THE PRESIDENT asked if cutaneous diseases among
the Indians were different from those seen among the
whites.
DR. GRINDON said he did not know.
DR. GIRARD said such cases would rarely be seen un-
less at some of the Indian Agencies.
THE PRESIDENT asked if the barracks had ever be-
come infested with the cimex lectularius, the pest that
walketh in darkness and wasteth at noonday, and if so,
what measures were taken to deal with it. 1; '
DR. GIRARD saId the soldiers were compelled to kee
clean, bathe frequently, and if any of them suffered
with parasites the medical ofﬁcer had to be consulted.
He said the barracks seldom became infested, the meas
ures to keep things clean were too rigid. The beds were
inspected every morning by an ofﬁcer of each company
and the bedding exposed to the sun every week. If
192 MEDICAL SOCIETY OF
bugs. were found, the iron frame was washed with coal
oil and the ﬂoors scrubbed with it. Sometimes bichlora
ide, 1 to 1000'was used. _
THE PRESIDENT asked if negroes were troubled as
muCh as the whites, and said he was under the impress-
ion that negroes were exempt from the bite of this
parasite. ,_
DR. GIRARD said bugs would get into the beds of the
‘whites and black alike, but he thought the negro‘ was
lesssusceptible to the bite of any insect th-anthe white
man. '
DR. GRINDON said he thought there was a curious fact
in connection with the pediculus of the different races.
The pediculus of the white man is white; that of they
negro black, and that of the Chinaman yellow. The
parasites seemed to conﬁne themselves to the race of
their peculiar color. He thought this might be the re-
sult of natural selection but did not believe It to be due
to the ingestion of a certain amount of pigment because
the color is not conﬁned to the body but extends down
to the legs.
RABIES IN THE DOG AND MAN.
DR. FRANK HINCHEY said he had become interested
in the subject of hydrop‘hobia during the last year, and
particularly in the statements of Dr. Charles Dulles, of
Philadelphia, who has concluded that there is no such
disease as hydrophobia, or that it isa very rare disease,
and that cases usually described as such are cases of
error in diagnosis. Dr. Dulles has conferred with men
all over the world and studied it during the past ﬁfteen
years and has concluded that it should be regarded only
as a symptom, as we do convulsions. One of his strong-
est arguments is: Why do people who ought to have
hydrophobia, never have it? People who handle hun-
dreds of dogs in a year—such as policemen, dog catch-
ers, etc., never have it. He has investigated something
like two or three hundred cases and he has seen but one
pound master who died from a bite. Speaking of the
CITY HOSPITAL ALUMNI. l
Pasteur Institute he said he thought this treatment was
sometimes the cause of death of people bitten by dogs.
/ He described some cases which Dr. Hinchey thought
_ hard to believe were hydrophobia, as for instance: sev
eral people having been bitten by the same dog at the
same time; one of these would be treated and die, but
the others would go along with no treatment and get
well. Dr. Dulles ascribed the symptoms to fright, nerv-
ous phenomena and fear of the disease. Dog catchers
handle dogs in hot weather when the animals are with-
out water for a long tIme, and are'huddled tOgether and
beaten, and everything done to madden them, and the
men are frequently bitten on the hands and face yet
never contract the disease. These men are not of a
nervous disposition or temperament and pay no atten-
tion to treatment. .
In London where there is a home for lost animals
there are frequently 2,000 together at one time and yet
no one is affected. In a record of several hundred
cases he had noticed seven or eight deaths and most of
the deaths were from the Pasteur Institute. , There are
writers who claim that the simple infection of a
wound from the saliva from a dog, which saliva con-
tains so much excrementitious material, would produce
toxins similar to those from many poisonous wounds,
and perSons so affected and fearing hydrophobia would
work themselves into that frame of mind, but Dr. Dul-
les said there is nothing speciﬁc about hydrophobia. Dr.
Hinchey said he remembered seeing a case suggesting
this order of things. A woman was brought to the
Female Hospital with a large, deep cut on the wrist and
one higher up on the arm. The wounds were dressed carefully and in three or four days she developed acute
mania; was delirious, screaming and howling, refused
to drink water, etc., and presented all the symptoms of
hydrophobia, although at that time they were not looked
upon in that light. Everything possible was done for
her, but he died of septicemia in a day or two. Dr.
Hinchey said the articles of Dr. Dulles are particularly
194 " MEDICAL SOCIETY OF
interesting because they state that if there is such a
disease as hydrophobia it is exceedingly rare, and he
thought it certainly singular that people constantly
handling dogs seldom or never contracted hydrophobia, _
and that this disease always manifested itself in people
of ths better class who were of nervous temperaments.
THE PRESIDENT asked Dr. Hinchey if the writer
mentioned denied that there is such a disease as rabies
in animals. ' I 1
DR. HINCHEY said he did not. He did not say it was
never communicable to human beings but only states
that it is exceedingly rare. \
THE PRESIDENT suggested that he denied hydropho-
bia but not rabies.
DR. HINCHEY said Dr. Dulles denied the accepted
idea of hydrophObIa. A peculiar feature of the disease
is the period of incubation. Cases have been reported
as occurring a year or two after the 'bite. , He thought
it rather remarkable that any virus circulating in the
blood should manifest itself after a year or two.
DR. H. W. SOPER said he had observed a case some
time ago of supposed hydrophobia in an hysterical girl,
16 years old. The girl had been bitten by a dog about
oneiyear previous to the attack, but she did not dread
the disease and, as far as he knew, had never heard of
hydrophobia. Every time she was offered anything to
drink she would have convulsions. She was kept quiet
on bromides and in a few days cleared up and got well.
She had one attack of hysteria since that time but not
accompanied by the same manifestations.
DR. ELSWORTH SMITH said he had noticed in the ad-
dress of Dr. Sternberg before the last meeting of the
American Medical Association, that he takes the view
of the present status of medicine on this subject and
thinks hydrophobia certainly is a disease. Dr. Smith
thought this position of Dr. Sternberg’s should have a
great deal of weight as he is a man constantly in this
line of work. He thought, too, that while there were
- undoubtedly a great many cases purely hysterical, yet
CiTY 'HOSPITAL ALUMNI. 195
he considered it very diﬂicult to reconcile the mortality
in these cases on the ground of their being purely nerv-
ous affections. Deathafter hysteria is a very rare thing.
It has been suggested that death following the bite of a
dog was possibly due to the treatment. Dr. Smith said
he was rather inclined to doubt this, because in cases
of true hysteria, a fatal termination rarely occurs, though
such cases are generally subjected to just as vigorous a
plan of treatment, with about the same class of reme-
dies, as are cases of genuine hydrophobia; nor did he
think they could be explained on the basis of ordinary
septicemia because they do not follow such a course,
especially in cases where there is a long period of incu‘
bation. While there were, doubtless, many cases as the
result of suggestion following bites, he said he could
not but feel that rabies or hydrophobia is a well-deﬁned
disease, but thought it comparatively rare.
DR. GRINDON said the bacterium of rabies had been
referred to. He said he had never heard that any bacil-
lus had been found; and he wanted to know also if any
toxins had been isolated. He knew that the bacillus of
tetanus had been found and that as many as three toxins
had been isolated.
THE PRESIDENT said it had occurred to him to ask
the same question. Some years ago he had seen a pub-
lication emanating from a French source, possibly from
some one who was or had been connected with the Fas-
teur Institute, indicating that the identity of the bacte-
rium of the disease had been established, but had
learned nothing further since that time in regard to it.
DR HINCHEY said he did not mean, when speaking of
the investigations made, that bacteriological examina-
tions had been made but only the result of injecting
rabbits with the medulla of the dog. As Dr. Grindon
had said, the bacillus has never been discuvered. He
thought the Pasteur treatment would be called the toxin
treatment. It is a toxin, he said, not an antitoxin, pro-
ducing immunity by a gradual increase in the strength
of the injection.
196 MEDIOAL SOCIETY OF
DR. M. W. HocE said that as long ago as 1884 a
French authority discovered a micro-organism which he
considered curative of hydrophobia, in the medulla of
animals dying of that disease. ‘ ‘
DE. GEINDoN asked if he had cultivated it. ,
DR. HOGE said he did not think experiments in that
line had been successful, and he had seen nothing on
the subject recently.
In regard to'inoculations from one animal to another
Dr. Hoge said they increase the virulence of the disease
up to a certain point, at which, after having reached a
ﬁxed intensity, it remains stationary. In the Pasteur
treatment the plan is to take the spinal cord and subject
it to dry heat for a varying number of days, which at-
tenuates the virus. The ﬁrst inoculation is made from
a cord treated a certain number of days; the next from
one treated not quite so long, and so on.
Asto the disease being purely functional, the patho-
logical ﬁndings seem to contradict this view. Evidence
of an inﬂammatory process is usually found in the nerves,
spinal cord and medulla, consisting in dilatation and en-
gorgement of the vessels, with the presence of leuco-
cytes surrounding them and inﬁltrating the tissues and
forming so-called miliary abscesses.
STATED MEETING, THURSDAY EVENING, SEPTEMBER 1.
THE PRESIDENT, DR. GEo. HOMAN, IN THE CHAIR.
Report of a Case of Symphysiotomy.—
With Presentation of Patient.
BY H. 'S. CROSSEN, MD., ST. LOUIS,
Superintendent and Surgeon-in-Charge of the St. Louis Female Hos-
pital—Member of the St. Louis Obstetrical and Gynecological
Society; of the Medical Society of City Hospital Alumni
of St. Louis; of the St. Louis Medical Society.
The patient, an American, was 21 years of age, height
4 feet, 11 inches, weight 110 pounds. General good
CITY HOSPITAL ALUMNI. 197
health. No history of rachitis. N0 injury of pelvis.
No previous labors. One early abortion in July, 1897.
No menstruation afterwards. Pelvic measurements:
D. Sp. 22 c.m., D. Gr. 25, D. Tr. 28‘, D. B. 17.}; diag-
onal conjugate 10}, estimate true conjugate 9 cm. (3%
inches). \ ~
Position of child 0. L. A. Fetal heart sounds 145
per minute and in left lower quadrant. Labor began the
evening of May 9, 1898. Membranes ruptured at mid-
night before the os uteri was dilated. At that time the
os would admit only two ﬁngers and the head was not
engaging in the pelvis. As the patient complained of a
great deal of pain in the back, she was given chloral
and the dose was repeated later in the night. But the
pains kept her awake all night. At 6 A.M., May 10, the
0s was still undilated, admitting but three ﬁngers. It
was, however, easily dilatable. The pains had been
frequent and moderately strong during the night, the
liquor amnii had nearly all drained away, and the uterus
was ﬁrmly applied about the child. There was no en-
gagement, the head being above the superior strait
and apparently too large to enter. The patient was be-
ginning to show signs of exhaustion and the fetal heart-
sounds were becoming more frequent. After considera-
ble time the cervix was dilated manually and the axis
traction forceps applied and considerable traction made.
But the head still remained above the brim. The ex-
amination under anesthesia with the whole hand in the
vagina revealed marked lateral contraction. The trans-
verse diameter of the inlet appeared to be about the
same as the antero posterior (9 c.m.). So there was
contraction antero-posteriorly and laterally, but the lat-
ter was decidedly more marked. A thorough trial with
the high forceps was made without any progress. The
head could not be brought into the pelvis. It was then
about 10 mm. The fetal heart-beats, though still strong,
were very frequent and somewhat irregular. The geni-
tals were shaved and prepared for symphysiotomy. The
patient was catheterized. The urethra was held to the
198 MEDICAL SOCIETY OF


Bed prepared for applying adhesive plaster dressing to pelvis. (1) Four
strips of adhesive plaster, slightly overlap} ing, adhesive surface up. (2) Piece
of gauze which lies between adhesive plaster and outer surface of thigh,making
the dressing more comfortable. (3) A long piece of gutta-percha tissue which
protects the lower part of the dressing. The patient 15 seen in the adjoining
bed in the left lateral position.
CITY HOSPITAL ALUMNI. 199


Position of the patient when lifted from the adjoining bed and placed on
the new dressing.
200 MEDICAL SOOIETY OF


Dressing completely applied. (During the three weeks trealment the ad~
hesive plaster dres sing was changed twice).
CITY HOSPITAL ALUMNI. 291
right by the metal catheter and a sharp pointed bistoury
was entered into the vaginal wall to the left of the ure-
thra and in front of the lower end of the pubic joint.
The knife was pushed upwards in front of the joint
keeping the ﬂat surface close to the joint. When the
sharp-pointed bistoury had been pushed part way up the
anterior surface of the symphysis, it was withdrawn
and a blunt-pointed bistoury introduced into the wound.
When the point of the knife reached the upper margin
of the joint the cutting edge was turned towards it and
the symphysis carefully divided from before backward
and downward. While the joint was being divided, an
assistant on each side of the patient made some out-
ward pressure on the anterior superior iliac spines so
that separation would begin as soon as the main struc-
tures were divided. At the same time the assistants
furnished support to the side of the pelvis so that no
sudden excessive separation could take place. As soon
as the joint began to yield the knife was withdrawn and
the forceps applied to the fetal head. The head was
slowly delivered with the forceps while ﬁrm pressure
was being made on the sides of the pelvis to limit the
separation as much as possible. The greatest separa-
tion, measured as the head was passing the superior
strait, was 6 c.m. (21} inches). The tissues were so fria-
ble from engorgement with blood and serum that while
making the incision, there was considerable laceration
of the vaginal wall at the site of entrance of the knife,
and the lower part of the knife-tract was thus changed
from a subcutaneous into an open wound. To limit the
damage to the perineum and to the tissue immediate‘y
below the pubic arch an incision was made, during the
delivery of the head, in each side of the vaginal opening
(episiotomy). After the head was delivered the pressure
exerted by the assistants on the sides of the pelvis
pushed the joint surfaces to within about one‘quarter of
an inch of each other. It took considerable force to
keep the surfaces thus approximated.
The baby was a boy and weighed eight pounds. It
202 MEDICAL SOOIETY OF
was somewhat asphyxiated when born, but quickly re-
vived. There were forceps marks on the left side of the
frontal bone and below the right ear and also right facial
paralysis. The baby took nourishment very well and
had good bowel movements, but the respiration was
jerky and irregular and the baby was very restless. In
two days it died, and the post mortem examination re-
vealed a large intra cranial hemorrhage. The blood was
situated in the meningeal space, principally about the
cerebellum. There were also areas of inspiration pneu-
monia.
After the expulsion of the placenta a douche (1-4000
bichloride) was given and the vaginal tears and episiot-
omy wounds sutured.
Then came the most difﬁcult part of the whole pro-
cedure—namely, the immobilization of the pelvis in
such a way as to hold the joint surfaces together. As
it would be difﬁcult to keep the patient quietly on her
side while recovering from the anesthetic, I thought
best to temporarily encase the pelvis, the lower abdo-
men, and the upper part of the thighs in a plaster-of-
Paris dressing. In this case, as in a previous one, I
found the plaster-of-Paris dressing unsatisfactory. It
was disagreeable to the patient; it was, under the cir-
cumstances, difﬁcult to apply and after being applied
with much care and difﬁculty it failed to exert the
necessary pressure on the sides of the pelvis. The pa-
tient was kept in the left lateral position, however, and
the bones fell together fairly well. The next day the
plaster-of Paris dressing was removed and strips of ad-
hesive plaster were placed ﬁrmly around the pelvis.
This was found to do very well. Patient convalesced
nicely and at no time did she complain of pain about
the pubic joint. The only pain she complained of was
in the thigh. At ﬁrst she would become very restless
after lying on one side for some time, on account Of
pain in the outer surface of the under thigh. Sedatives
were given to quiet this restlessness and the patient was
lifted from side to side as necessitated by the pressure
CITY HOSPITAL ALUMNI. 203
on 'the skin. The lower border of the plaster would at
times curl up and make painful pressure over the outer
surface of the thigh. This was relieved by a piece Of
folded gauze slipped under the edge of the plaster and
also, when necessary, by cutting the plaster for a short
distance. The patient was kept in the lateral position
all the time.
In a case of symphysiotomy the after-treatment is
very trying. One must give a large part of his time to
relieving the restlessness Of the patient, changing her
from side to side, changing the dressings a little here
and there, and in every way endeavoring to keep the
patient quiet on her side. The excellent result in this
case is due very largely to my ﬁrst assistant, Dr. L. J.
Oatman, whose _tact in managing the patient and un-
wearied attention to every detail Of the after-treatment
kept the parts in the best position for ﬁrm union.
The manner of applying the plaster strips is shown in
the accompanying illustrations. The patient had to be
changed from side to side about twice daily for the ﬁrst
three days and after that she would lie on one side for
one or two days at a time. She was kept in the lateral
position for three weeks and was not allowed out of bed
for a month after the operation, though she was anxious
to get up long before that time. There was ﬁrm ﬁbrous
union. The patient walked without pain and with no
defect in gait. Even when she supported her weight
ﬁrst on one foot and then on the other, I was unable to
detect mobility at the pubic joint. You will notice in
examining over the joint that the original joint surfaces
are separated about a quarter Of an inch, the intervening
space being ﬁlled in with ﬁbrous tissue. The pelvic
measurements, taken June 18, the patient then being up
and about,were as follows: D. Sp. 24 c.m., D. Cr. 26,
D. Tr. 28.}, D. B. 17%. The lateral measurements are a
triﬂe larger than those obtained before3 the operation.
This patient evidently has a somewhat larger pelvis
now than before delivery and she has a much better
chance of spontaneous or forceps delivery in subsequent
204 MEDICAL SOCIETY OF
l
labors, not so much on account of the present triﬂing
increase in the size of the pelvis as to the fact that the
ﬁbrous tissue in the joint will, no doubt, soften with
advancing pregnancy and yield considerably during
labor.
There is one criticism I wish to make in this case, in
the light Of later developments. I think the operation
should have been done earlier in the labor before the
last application of the forceps. As to the indications for
symphysiotomy I have nothing to add to the conclusions
set forth in my paper read before this Society last May
(“Partial Report of Eight Hundred Cases Of Labor,”
American Gynecological and Obstetrical Journal, Vol.
XIII, page 45). -
Symphysiotomy is a very serious operation, not be-
cause of any special difﬁculty in the operation itself,
but because of the serious results that may follow in
unfavorable cases. It should be used as a substitute for
Cesarean section only—never for forceps or 'version.
Experience has changed my views somewhat as to the
best method of operating. In reporting a case of sym
physiotomy in 1896 (MEDIOAL REVIEW, October 31,
1896), I expressed a preference for the open method as
it gave a clear viewof the tissues as they were divided
and reduced to a minimum the chance Of injuring im
portant structures. I now think the “ subcutaneous
method,” introduced by Dr. Edw. A. Ayres, is decidedly
preferable. With the last mentioned method the dan-
ger of infection of the wound during the operation or
afterward, is very much reduced and with proper care
there need, ordinarily, be no injury to important struc-
tures near the joint. ’ ‘
DISCUSSION.
DB. FRANCIS L. REDER said Dr. Crossen had certainly
been very fortunate in getting such a good result in the
case presented, there being none Of the ill effects usually
following this operation. Dr. Scanzoni (1852) disap-
proved of the operation being performed on the living,
CITY HosPITAL ALUMNI. 205
and would only perform it when death was caused by
labor and the presenting parts of the child had descend ed
toolfar into the pelvis to permit of Cesarian section.
He never then performs symphysiotomy in the hope of
saving the child by quick and forced delivery. Scanzoni
did not speak encouragingly of the operation, but this
was probably due to the fault of the times and sepsis.
Afs-urgeon by the name of Sigault, in 1765, was the ﬁrst
one to call attention to the operation in the Academy
of Chirurgie in Paris. His idea was to give more room
to the pelvis by division of the symphysis. It was,
however, considered too radical, and for a number of
years the operation was forgotten. In 1777 Sigault re-
ceived a letter from a colleague telling him of a success-
ful issue of his (Sigault’s) operation, and urged him to
again presentshis idea to the Society, which he did.
Later, in 1786, it was followed by Dr. Aitken, of Edin-
burgh, who suggested excision Of the horizontal parts
of the pubic arch in the vicinity of the symphysis, and
suggested that the piece of bone removed be re~implanted
upon the ends of the arch in a manner so as to perma-
nently enlarge the diameters of the pelvis. This did
not receive any encouragement. In 1824 Dr. Galbiati,
of Naples, suggested the Operation which he called
pelviotomia. Galbiati would advise that the bones of
pelvis be divided into ﬁve sections, viz., at the two sy-
nostosibus pubo-iliacis, the two synostosibus pubO-ischi-
adicio and in the symphysis ossium pubis. He per-
formed this operation at one time and the mother and
child both succumbed. A second time he did the same
operation with the same result and that put an end? to
Galbiati’s operation. Dr. Reder thought, however, that
with asepsis and our better knowledge, symphysiotomy
in certain cases is the operation to be performed in
preference to Cesarean section. Cesarean section had
been discussed at a previous meeting 30f the Society on
the occasion of Dr. Crossen’s able paper on “Eight
Hundred Cases of Pregnancy.”
DR. NOEVELLE W. SEAEPE remarked that one of the
206 MEDICAL SOCIETY OF
features of the case which impressed him, was the per-
fect result. The operation, he thought, logically and
anatomically, and, if such good results as obtained by
Dr. Crossen could generally be secured, clinically ap-
peals. However, in the hands of the best men such
results were not always obtained. Wounding of the
bladder, tearing of the cellular tissue and tearing of the
urethra, were not at all uncommon, as well as vaginal
tears. During the last few weeks he said he had seen
reported some cases from gentlemen whose skill is
acknowledged, where, after the most scrupulous care,
both during and after operation, necrosis of the pubic
bone had followed, fOr no apparent reason. The bones
had been united in different fashions, some with heavy
catgut, some with silk and some with silver wire. Why
necrosis should occur could not be determined, yet it
did Occur and suppuration, deep and Of a serious char-
acter, followed, and recovery was greatly prolonged.
The result, usually, however, was fairly satisfactory.
He thought it might be advantageous in the average
caSe (though not as a routine treatment) to pin the
pubic bones together with a nail, whether steel or ivory
(to be selected) and cover the ends Of the nail with
periosteum, and then 'unite the peritoneal ﬂaps with cat-
gut, encircling the pelvis with adhesive plaster strips,
as had so admirably been done by Dr. Crossen. With-‘
out doubt, in selected cases, the subcutaneous method
of division of the interpubic joint was advantageous.
Another point of interest in the case was, he thought,
the perfect union of the pelvis after operation. The
woman being able to follow her usual occupation, no
Oscillation in walking and her ability to stand on one
leg without any giving or tilting of the pelvis is a result
not often attained in these cases. It was quite possible
that interpubic ossiﬁcation would ensue, and the woman
have a completely ossiﬁed pelvis of larger diameter than
formerly. V_
THE PRESIDENT asked whether, other things being
equal, the prospect of a good result was better in a
CITY HOSPITAL ALUMNI. 207
young woman than an old one; that is, would the result
be as good in a woman, say 40 years of age, as in. a
woman of 20 years—would reunion of the divided sym-
physis take place as readily in the former as in the latter
case. '
DR. CEOSSEN replied that he would suppose the result
would be better in the younger woman. A woman well
along in years would probably have an ossiﬁed sym-
physis.

DR. GIVEN CAMPBELL reported the following cases
and presented the patients to the Society: ‘
Two Cases of Pseudo-Hypertrophic
Muscular ParalYsis.
Patients, aged 9 and 12 years respectively, are Of good
family history. They have ‘three sisters, no brothers.
NO such disease in any relatives. Disease began in late
infancy (one year of age in both cases). Pseudo-hyper.
trophy not marked. Characteristic gait in older boy
for the last eight years; in younger boy for four years.
Marked atrophy of lower part of pectoralis major and
of latissimus dorsi with hypertrophy of infra spinatus.
Lower leg hard and rather large but not weak.
DISCUSSION.
DR. FRANK R. FEY said the two cases were undoubt-
edly pseudo hypertrophic muscular paralysis. He said
they did not present, in his opinion, any Of the compli-
cations sometimes seen in these cases. The elder Of
the two boys he had seen at his clinic. He did not think
the atrophied condition of the upper extremities any-
thing more than an attenuation of the muscles incident
to general emaciation. The nutrition of the little pa-
tient was bad.
DR. M. A. BLISS said he had seen the elder of the two
boys at the clinic as mentioned by Dr. Fry, and it was
with some hesitation that he diagnosed the case pseudo-
hypertrophic paralysis. There was undoubtedly some
wasting of the muscles and very marked atrophy, while
208 MEDICAL SOCIETY OF
the hypertrophy was very slight. The mother’s ignor-
ance made it impossible to ascertain how much hyper.
trophy there might have been at one time. She described
the child as having been a very “fat” baby, but said that
two or three years ago he began to get so weak and thin
he had diﬂiculty in walking. He had seen weakness
very marked in some other cases of pseudo hypertrophic
paralysis even during the hypertrophic stage. He had
a case at the clinic for several months where the mus-
cular tissue of the arm was quite large, yet the patient
was unable to lift his hand to his face. In the case
presented by Dr. Campbell there was considerable
strength still in the wasted muscles and it was for this
reason he found it a little diﬂicult to accede to the diag-
nosis, yet he had drifted to that because the case did
not present any of the usual symptoms of the ordinary
type of muscular atrophy,
Double Athetosis of Central Type.
Patient, a male, aged 2.} years, presents the follow-
ing history: His parents, healthy, Germans; two other
children, girls, aged 14 and 16 years. NO nervous dis-
ease in family. Patient born at seven months; diﬁcult
labor; since birth has been delicate; no paralysis, no
convulsive seizures; now fairly well nourished; exhibits
slight signs of rickets. From time of birth parents no-
ticed athetoid movements of neck muscles and of hands
and arms; a slight gradual improvement has continued
up to the present time; mother has noticed athetoid
movements of face for the last two months. Child
seems fairly intelligent, says a few words and remem-
bers strangers. Movements chieﬂy in upper limbs.
Viscera normal; exaggerated knee jerk and contracture
of ﬂexors of knee. Flexors generally mostly involved.
Has occasional retarded urination and is subject to pro-
fuse cold sweats. Patient was raised on cow’s milk.
DISCUSSION.
DR. FRANK R. FRY said the athetoid movements in
this case were more pronounced than usually seen. The
case was one of infantile paralysis. A great variety of
CITY HOSPITAL ALUMNI. 209
movements were seen in these cases of spastic paralysis,
various degrees of inco ordination and spasm, and of
paralysis. As the child gets Older it will probably be
found that the mental capacity will be low. It is yet
too soon to prognosticate deﬁnitely about this.
Bilateral Facial Paralysis.
Patient applied for treatment ﬁve weeks ago with
history of having sore eyes which be attributed to get-
ting some dust containing particles of brass into his
eyes several days before. The night previous to his
coming for treatment he slept in a draught and on
awakening found the right- side of his face completely
paralyzed and also noticed that he saw double. No
pain, tenderness nor sensory impairment. Physical ex-
amination revealed complete right facial palsy with
lagophthalmus; taste and palate both involved. This
condition continued for one week, mild galvanism be-
ing employed, at the end of which time patient noticed
gradual onset of an inability to move upper part of left
. side of his face and this gradually increased and ex-
tended downward until, at the end Of two days, the en-
tire left side Of his face was paralyzed. Paralysis now
complete of entire face. Lagophthalmus complete and
equal. With Onset Of paralysis of left side the double
vision disappeared and was entirely gone when lagoph-
thalmus became complete in left eye. Paralysis re-
mained complete for two weeks during which time
palate and taste were not involved. Then right side of
face began to recover and one week later, when right
side of face was almost well, the right side of palate
became paralyzed; this paralysis remained about ten
days by which time the left side Of face, which became
involved thirty days ago, began to show signs of im»._.
provement. Improvement has progressed rapidly and'
patient shows very little loss of power in right side.
Photograph shows lagophthalmus when paralysis was
complete and bilateral. NO marked reaction of degen-
eration at any time. No history of syphilis, alcoholism
or rheumatism; no sign-s of intra~cranial lesion.
DISCUSSION.
DR. FRANK R. FRY said this was the most interesting:
of the very interesting cases Dr. Campbell had shown
210 ' MEDICAL SOCIETY OF
during the evening. As Dr. Campbell had said, it was
a peculiar coincidence that there should be a double
facial palsy, yet the history indicated more than the or-
dinary etiology. The coincident paralysis of the ocular
muscles and the palate led him to believe the cause to
be some infection, especially as the man says he had a
conjunctivitis at the time. He thought the exposure to
‘ cold the immediate cause while the antecedent infec-
tious condition was the predisposing cause. ' The man
is not an alcoholic nor has he had rheumatoid or syphi-g
litic affections. That the Doctor failed to obtain a re-~
action Of degeneration in the muscles Of the face is in-
teresting and can not be explained. It reminds us that
there is some unreliability always about electricity for
diagnostic or therapeutic purposes. We do not appeal
to it with the same conﬁdence to differentiate one kind
of paralysis from another as in former times.
DR. M. A. BLISS said the case Of double palsy was
one which might be thought due to some central trouble,
but the ﬁndings Of Dr. Campbell led to the conclusion‘
that his diagnosis was correct. Dr. Bliss said the con-
dition wasa very unusual one and thought he had never
seen it before.
DR. GIVEN CAMPBELL, in closing, said that in
reference to the last case he agreed with Dr. Fry
in that the involvement of the left side of the.face
. and of the palate, both of which conditions were
of gradual onset, were probably due to a toxic neuritis,
parenchymatous in nature, but he thought the paralysis
on the right side due to sheath neuritis. He thought
the double vision might be due to the fact of the orbic-
ularis palpebrarum being paralyzed and one eye thus
losing the normal point Of support for the muscles to
work against, the eye did not center exactly on the same
Object as its fellow, and this slight deviation produced
the diplopia.
In the case‘of double athetosis he said that, although
it was a symptom it was a very deﬁnite one. He thought
CITY HOSPITAL ALUMNI. 211
there would probably be mental impairment as the child
grow, but at present there did not seem to be much.

Report of a Case of Hydrophobia.
BY BENNO BBIBACH, M.D., ST. LOUIS.
Fred Klages, a bright, strong lad, aged 11 years, was
brought to me in the evening of August 19, 1897. His
father stated that during that day he had complained of
pain in the throat with difﬁculty in swallowing. There
was an accelerated pulse, no fever, and an unusual ex-
pression of anxiety in the face and manners of the boy.
He drank some water apparently with some pain, but
without any difﬁculty. Examination of the throat and
cervical glands was negative in locating the difﬁculty.
He was dismissed with the request to return in the
morning for a more satisfactory inspection by daylight.
At 7 o’clock the next morning I was called to see him.
He lay on his bed, his face expressive of intense fright,
begging me, with tears in his eyes, to “ make his throat
well.” It appeared that the dysphagia and pain had in-
creased during the night, until ﬁnally every attempt at
swallowing would induce the most distressing spasms.
On attempting to have the boy take a drink of water,
I witnessed a most extraordinary paroxysm of respira-
tory spasm. He threw himself away from me in terror,
clutched his throat with neck extended; there was a
series of quick, interrupted, suﬁocative efforts at inspi-
ration, followed by easier expiration, evidently caused
by acutely painful spasmodic constriction Of the respi-
ratory passages. The ﬁt lasted several minutes, when
the patient became easier and piteously appealed for
help. Fifteen minutes later, encouraged by‘the promise
Of relief, he managed, with great difﬁculty, to swallow
a solution of 20 grains Of chloral in water, and shortly
' afterwards was soundly asleep. _
The spasm suggested tetanus. Examination disclosed
scars on left hand and forearm and in the face below
212 MEDICAL SOCIETY OF
the left ear. It was learned that they resulted from dog
bites. Forty-two days before the boy had been amus-
ing himself with the tricks of his pet Skye—terrier, who,
against his disposition, was morose and bit him. The
wounds had been treated with hydrogen peroxide and.
had healed readily. The boy had remained perfectly
well until now. The dog had been a pet for years and
never was vicious; he bit the house cat on the same day,
and then he was locked up'in the stable. The next day
he was morose, quiet and would not eat; the day after
this the boy tried to feed him milk, when the animal
dragged himself forward, the posterior extremities ap-
parently being paralyzed, and tried to lick the boy’s
hand, fell over and expired. Nobody had noticed any
violent or vicious actions, salivation, or convulsions in
the dog. Three weeks later the cat was found dead in
the cellar. The father told me that the cicatrix on the
face appeared Of a much brighter red than it had up to
a few days before. The history pointed to a diagnosis
of rabies. "
August 20, 11 A.M. Patient had slept quietly for
three hours; ate milk and cracker without difﬁculty;
pulse 120, temperature normal; nothing abnormal in -
appearance of mouth and throat; intellect clear; is
cheerful and full Of hope. Ordered 20 grains Of chloral
at 12 o’clock.
August 20, 4 PM. Is drowsy, no suffering, no dys-
phagia. Had slept until 8 o’clock; during a meal after
that, pain Of throat had annoyed him, when chloral was
repeated. Temperature normal, pulse 110. I became
hopeful of a mistaken diagnosis and ordered 20—grain
doses of chloral to be given Whenever indicated by act-
ual or threatening spasm.
August 21, 7 A.M. Had been restless -and slightly
delirious after midnight; after 3 O’clock frequent spasms;
deglutition became impossible after 4 o’clock. Noise of
closing doors and of speaking, disturbance of arranging
his position or the bed-clothes will induce spasm. He
is slightly delirious, but not violent; prays to God for
CITY, HOSPITAL ALUMNI. 213
help, implores the doctor for help, wants the preacher
sent for to pray for help for him. Saliva and mucus,
which he ineﬁectually attempts to clear, is dribbling
from angles of mouth. Respiratory spasm almost con-
tinuous; during the height of the paroxysm there is
muscular clonic spasm of neck and upper extremities.
Pulse 140, temperature 101.5. Gave 40 grains of chlo-
ral by rectum; sleeps soundly in ﬁfteen minutes.
August 21, 11 AM. Dr. R. C. Volker sees the case
with me and concurs in diagnosis of rabies. Patient
has been awake for an hour; his intellect is much con-
fused. During an anxious appeal for help he is seized
with a respiratory and general muscular spasm more
violent than ever; suffocation seems impending. Gave
40 grains of chloral by rectum with instructions to re-
peat the dose whenever he becomes too restless.
August 21, 5 PM. Chloral has been repeated at 3
o’clock; patient sleeps restlessly; there have been invol-
untary evacuations 0f bowels and bladder. Inability to
clear mouth Of saliva and mucus causes much trouble.
August 21, 10 PM. For the last two hours there have
been almost continuous muscular contractions of trunk
and extremities producing peculiar contortions which
cause patient to move all over the bed and which are
not diminished after the administration Of chloral, as
the violent respiratory spasms are. There are continu-
ous inspiratory dyspnea and delirium. Temperature
104, pulse 150.
August 22, 7 AM. Muscular contortions and delirium
continued all night; chloral has been given whenever
respsratory spasms threatened or Occurred, 40 grains
about every three hours by the rectum. Pulse 160, very
weak; temperature 104%; extremities cool; pupils con-
tracted; inspiratory efforts more labored. '
August-22, 5 PM. There has been no severe spasm
since 2 O’clock; lower extremities entirely paralyzed;
continuous movements of arms, all extremities cold;
body is covered with perspiration; pupil ﬁrmly con-
tracted; respiration labored and shallow. Immediate
214 MEDICAL SOCIETY OF
dissolution seems impending. Pulse 170 or more, hard-
ly perceptible at wrists; temperature 106. Patient'con-
tinued in this condition for nine more hours and. died at
2 A.M. August 23.
Dr. Ravold had promised to verify the diagnosis by
biological test requesting me to send to him the medulla.
I found, however, that the undertaker had, early in the
morning, embalmed the body by injecting the blood
vessels with strong antiseptic solution which would
have mall e the test uncertain, and no autopsy was made. ,
Recapitulating the history of the case we ﬁnd inocu-'
lation by dog bites July 8; good health without any
prodromata for forty-two days. Thursday, August 19,
difﬁculty in deglutition and marked mental excitement.
Friday morning, respiratory and pharyngeal spasms ex-
cited by eﬁorts at swallowing, which spasms are entire-
ly inhibited by repeated doses Of chloral; intellect is
clear; general condition good. Saturday morning, re-
spiratory spasms more frequent and easily excited by
slight sensory irritations; deglutition impossible; saliva-
tion, terror, clonic muscular spasm Of neck, trunk and
upper extremities during paroxysm. Slight delirium;
rising temperature; afterwards Continuous contortions
of wholebody. Sunday morning, hyperpyrexia; dimin-
ished mental sensibility; later, paraplegia and cardiac
exhaustion. Monday morning, dissolution.
An interesting feature of the case is the tolerance of
large repeated doses of chloral without toxic symptoms.
The patient took ﬁve deses of 20 grains by the mouth
on the ﬁrst day; ﬁve doses of 40 grains by rectum on
the second day; eight doses of 40 grains on the third
day, and three doses Of 40 grains on the fourth day;
none during the last eighteen hours. In all he had 740
grains of chloral in about eighty hours.

DISCUSSION.
DR. H. S. CROSSEN said he had never had the good
fortune to see a case of hydrophobia and had not looked
' up the disease recently. He would like to ask Dr. Bri-
CITY HOSPITAL ALUMNI. 215
bach what treatment he would employ if called to treat
a case of hydrophobia now, in the light of his investi-
gations in connection with this case. He would like
especially to know what are the latest results reported
from the Pasteur treatment, particularly when employed
after the symptoms appear.
DR. M. G. GORIN said that he had seen a case Of rab-
ies in a man of 35 years, who had been brought to the
' City Hospital. The man said he had been bitten by a
dog two months before admis'sion, and the dog was af-
terwards killed. There was no clear history as. to
whether the dog was rabid or not. On admission the
patient was seized with violent convulsions of the throat
muscles whenever he was Offered food or drink, and
emitted coarse, explosive guttural sounds, closely simu-
lating the barking Of a dog, so much so that it was
thought the patient was simply hysterical. The con-
vulsions, however, quickly became more violent, and it
was necessary to conﬁne the patient to a cell. Morphine
was administered hypodermatically, but did not in the
least calm the convulsions, and death resulted within
twelve hours. NO autopsy could be secured, and the
diagnosis, therefore, could not be veriﬁed by bacterio-
logical examination.
DR. HORACE W. SOPER said he believed the case re-
ported by Dr. Bribach to be one Of true rabies, and
mentioned the case of a hysterical girl under his care,
which was reported at the last meeting.
DR. HENRY JACOBSON said he had never seenja case
Of real hydrophobia but had seen a great many Cases of hysteria resembling the disease. He said the practice of having the dog killed after having bitten some one
should be discountenanced. He always cautioned peo-
ple not to kill the dog but to watch it for a week or two.
This usually had a good effect on them. He thought it
a great mistake to kill the dog until it was known
whether there were symptoms of rabies or not. He
thought the case reported by Dr. Bribach was rabies
and believed the Pasteur treatment would have been
beneﬁcial if the boy had been seen in time.
216 MEDICAL SOCIETY OF
DR. M. A. BLISS said he would like to bring out in
the discussion the popular idea in regard to cauterizing
wounds from dog bites. He said this was very gener-
ally done but he thought little could be expected from
it. Another point he wished to speak of was whether
the dog could not bear about with him the poison Of
rabies without himself becoming generally infected.
DR. JOHN C. F ALK said he had never seen a case of
hydrophobia but was deeply interested in the case re-
ported. The case under discussion he thought was un-
doubtedly rabies. He'did not approve Of the practice
of cauterizing every wound made by the bite of\ a dog,
but at the same time knew the physician would be
blamed if any bad effects followed such a bite and cau-
terization had not been done when requested. He had
himself been accused, not because, rabies followed the
bite, but because the wound was slow in healing. After
cauterizing the repair is necessarily slow. He said he
had of late adopted the practice of using something
less destructive than nitrate Of silver, such as a strong
solution Of bichloride. He thought that rabies is Often
simulated by hysteria and-tetanus.
DR. FRANCIS L. REDER said he had seen four cases at
the Gibier Institute in New York which had progressed
to the convalescent stage. ‘ In Dr. Bribach’s case he was
much interested. He had seen one case treated by
“mad-stone.” The people whose child had been bitten
traveled 18 miles to have a certain party apply the
stone. Removal of virus from poisonous wounds,
or bites, by suction is a very ancient remedy.
The stone adhered to the wound, probably on account
of the secretions from the wound. He said it would be
interesting to know whether the poison from a snake bite
and a dog act in the same way. The poison from snake
. bite he said acts like a phlegmonous wound, causing
high temperature. This is sometimes general and some-
times not. He thought a dog bite was certainly an in-
fectious wound from the ﬁrst and thought cauterization
indicated. It is a curious fact that there is a belief that
CITY HOSPITAL ALUMNI. 217
a dog bitten by a poisonous reptile will never have hy-
drophobia. In some countries a general notion prevails
that the bite Of a snake is best eombatted by rubbing in
some of the fat of the snake and by taking some of the
grease internally. So long a period of incubation has
made it difﬁcult forPasteur to prove the value Of his
inoculations, but the principle underlying his methods
may be of great value when extended to some of the
zymotic diseases.
' DR. BRIBACH, in closing, said the chief indications
were to keep the patient quiet, and treat the spasm.
Unfortunately it was impossible to say a patient has
rabies until the disease breaks out, and then it is too
late; and even after the outbreak Of the disease it is
difﬁcult to say positively that it is rabies. In this case,
before he had any suspicious what the spasms indicated,
he gave chloral to such an extent that, for 24 hours the
spasms were controlled even with small doses, and he
had hopes Of saving the patient. Later on the spasms
increased. In this Case, of course, the Pasteur treat-
ment would have been too late. The spasms come on
simply at the suggestion of swallowing. The boy knew
that an effort to swallow would bring on, a spasm and
anything that suggested the act Of swallowing would
produce a spasm, and he thought it was the dread of the
torture and pain of that act which threw the boy into a
spasm and not the fear of water itself He thought it
rather venturesome to deny the speciﬁcity of the dis-
ease, considering the large amount‘of testimony brought
forward. He felt sure the case reported was one of '"
speciﬁc hydrophobia. He had arranged to complete the
diagnosis by a biological examination, but the under-
taker had injected'the body with an embalming ﬂuid
which would have interfered with it.
In regard to cauterizing wounds from bites of dogs
he thought it ought always to be done and he always
did it. '
The disease was very rare, indeed, and he never heard
of a case in the neighborhood before. The case might
218 ‘ MEDICAL SOCIETY OF
have been mistaken for tetanus, but in tetanus the pe-
culiar respiratoryspasms noticed in this case are ab-
sent, and the contractions of the muscles of the chest
and back are conspicuous, which were entirely absent in
this case. Nor was it a case Of hysteria, for when he
was attacked there was no fear whatever of the dog bite.
If it was not rabies, what was it?

STATED MEETING, THURSDAY EVENING, SEPTEMBER 15.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
Perplexing Mishaps in Surgical Cases.
BY GARLAND HURT, M. D., NEWPORT, ARK.
Both physicians and surgeons are suspected of a habit
of reporting successful cases only. I propose, on this
occasion, to reverse the rule and report a few cases
which occurred under my care while in charge of the,
St. Louis City Hospital twenty years ago, in which the
surgery, though well directed and well executed, proved
unsatisfactory. '
But as considerable time has elapsed, and no records
at hand, I shall be excused, I trust, for want of minute-
ness or exactness of detail. .
I would say also, that, on taking charge of the hospi-
tal, I engaged with the professors of the schools, espec-
ially the surgeons, to give them the practice as far as
consistent with the best interests of the patients.
CASE I.—--()n assuming charge I found in one Of the
wards abrawny Irishman about 35 years Of age, with
a history Of paroxysms of dissipation, the last one of
which having terminated in his present illness, begin-
ning with a severe chill, followed by fever and great
nervous prostration. He had been in the hospital sev-
eral days, but without perceptible improvement except
a slight amelioration of his nervous condition.
He complained chieﬂy of pain in the right side, had
some fever, pulse full and slightly increased in fre-
“In
CITY HOSPITAL ALUMNI. 219
quency, skin dry and dusky, appetite nil, bowels con-
stipated. Percussion over the liver elicited pain and
tenderness with an increased area of ‘d'ullness.
He was treated by cupping, followed by a blister, and
internally with salines and diaphoretic mixtures, but
with little, if any, beneﬁt or change in the progress Of
the disease.
A few days later, there was more decided disturbance
in the respiratory function. Pain and dullness had ex-
tended tO the middle of the chest, and I suspected an
effusion either of pus or serum, and as Prof. John T.
Hodgen was at the hospital on that day, I called his at
tention to the case. He examined the patient, made
some suggestions in regard to treatment, and advised
delay. Some days later he again saw the patient, but
still hesitated as though he was in doubt as to the pro-
priety Of surgical interference. So there was a few
days’ further delay, and the patient became so much
distressed for want Of breathing capacity that I again
asked Prof. Hodgen to see him, and insisted on para-
centisis. The doctor pushed the trocar in—I think--
between the sixth and seventh ribs in the line of the
axilla, and on withdrawing it, not a drop of either pus
or serum followed. I was greatly disappointed, and
although Prof. Hodgen said nothing, he seemed per-
plexed and I reproached myself for having urged an
Operation that proved so unsatisfactory.
The patient died the next day, and on making a post.
mortem it was found that a large abscess situated in the
upper and posterior aspect of the right lobe of the liver
had perforated the diaphragm and poured its contents
into the right pleural sac, ﬁlling it completely and com-
pressing the lung, which was found not larger than a
man’s ﬁst crowded up under the clavicle.
The quantity of pus was enormous, and had pressed
against the mediastinum with so much force as to in
terfere greatly with the functions Of the left lung and
heart. In looking for the cause of failure to reach the
pus by the trocar it was found that the right margin or
220 MEDICAL SOCIETY OF
ﬂap of the diaphragm had become greatly thickened by
inﬂammatory or edematous processes and was pushed
or folded up against the chest wall where it received
and completely encapsulated the instrument. Had the
next intercostal space, either above or below been se-
lecten, the pus would have been reached, and possibly
the patient’s life prolonged, at least for a few days.
CASE II.—A few weeks later a man Of German descent
about 40 years old, medium height, fair complexion,
somewhat emaciated and a look of distress on his
countenance, was sent up from the City dispensary.
There was a history of dissipation, being greatly ad-
dicted to beer and occasional paroxysms with a more
potent stimulant. Physical examination detected a
swelling in the hypochondrium, seemingly a little to
the right Of the median line in which indications Of
ﬂuctuation though Obscure, could be made out.
An exploratory puncture with with a strong hypo-
dermic needle was proposed, but Prof. Lankford, who
was present and invited to do the operation, preferred
to use. the aspirator. The needle entered the abscess
cavity very readily, and in a few seconds pus was ﬂow-I
ing into the receptacle and continued to ﬂow until
about eight ounces were drawn Off. The track Of the
aspirating needle was slightly enlarged and a tightly
ﬁtting drainage tube inserted and secured by a bandage,
and as there were no pOsitive symptoms of peritonitis
on the following day, we were hopeful of the patient’s
recovery; but he went on from bad to worse, and died
in a few days of inanition and exhaustion.
On making the post mortem examination it was found
that the abscess which had been aspirated was situated
in the right margin of the left lobe and its cavity so
contracted that instead of the eight ounces which had
been withdrawn it did not seem possible for it to have
contained an ounce, and had this been the only trouble,
the patient would have had a possible chance of recov-
ering. But another and much larger abscess was found
in the posterior aspect of the right lobe. Having found
CITY HOSPITAL ALUMNI. 221
and emptied the smaller, the larger and more dangerous
one was overlooked and caused the death of the
patient.
Had our examination at the outsetv been more thor-
ough, this dangerous accumulation of pus might also
have been detected and removed, with a possible chance
for the patient’s recovery.
CASE III.—-A month or so later in the season, a
laundry woman about 36 or 37 years Old, single, medium
height, stout and seemingly well developed and well
nourished, was brought in and my attention called to
her immediately.
She was suffering intensely with symptoms of peri-
tonitis, and from'the lady who accompanied her I
learned that, on the preceding day, while menstruating,
she did a heavy day’s washing, and in the afternoon, on
lifting a tub Of wet clothes, was seized with a sharp
pain in the lower part of her abdomen. She grew
rapidly worse, vomited frequently, and although large
doses of paregoric were administered, she continued tO
get worse.
On physical examination the ﬁrst thing detected, in
addition to blood stains, indicating that she was men-
struating, was an inguinal hernia on the right side
which the lady also informed me had existed for a
number of years and was said to be irreducible.
After manipulating the tumor a little and noting that
pressure On it caused much pain, I jumped at the con-
clusion that there was strangulation.
I had the bladder and rectum emptied preparatory to 7
an Operation, when, Prof. Hodgen, whom we were ex-
pecting that morning, came in and, acting on my pre-
sentation of the case, performed herniotomy; which,
under chloroform, required only a few minutes, not-
withstanding the necessity of breaking up some adhe-
sions to the sac wall.
As there was very little hemorrhage during the oper- -
ation, and no positive indications of serious damage to
the gut, I concluded that there was a chance for the
222 MEDICAL SOCIETY OF
patient’s recovery; and yet, she died on the following
morning, in a state of coma and collapse; and at the
post-mortem a large clot of blood was found in the
posterior cul de-sac of the pelvic peritoneum.
On looking for the source of the hemorrhage, there
being no evidence that it had proceeded from the
hernial wound, or at extra-uterine or ovarian pregnancy,
I was forced to conclude that it came from a recently
ruptured Graaﬁan vesicle in the left ovary; and had I
succeeded at the outset in making a correct diagnosis Of the case, quite a different surgical procedure would "
doubtless have been adopted. ._
Permit me to say in conclusion that, in reporting
these cases, I trust I shall not be suspected of a dispo-
sition or purpose to shadow the good name‘ or memory
Of the two eminent surgeons who assisted me in the
operations. True, they did the surgery, but it was on
my diagnosis, at my suggestion and under my direction
in each case; and I, therefore, hold myself responsible
for these mishaps. Though I suppose most of us are
liable to err occasionally. I remember stepping into the
amphitheater one morning when a prominent professor
in one of the schools was concluding alearned clinical
lecture on ascites, while the patient on the table before
him was not dropsical, but had an enormously distended
bladder from retention of urine.

DISCUSSION.
DR. FRANK HINCHEY said he had assisted in a lapa-
rotomy a few months ago. The woman made anune-
ventful recovery with the exception of having a small
sinus left in the line Of the sutures. The patient went
to the Doctor’s ofﬁce every day to have something done
for her relief but he could no nothing, and told the
speaker she was his “Jonah.” He asked Dr. Hinchey
what to do but the latter declined to make any sugges-
tions, remarking that he was glad the patient was not
under his care. It was unfortunate, he said, that the
CITY HOSPITAL ALUMNI. 223
'mistakes of experience should have to teach us how to
do things properly. ' .
DR. JOHN P. BRYSON said he was very much interested
in the paper. Two things especially attracted his at-
tention. Those were the conditions during the pre-
antiseptic days when a surgeon sweated during an op-
eration even with the thermometer below zero. He
remembered the pus basin being regularly present. He
recalled the case of a young man who was hurt in a
railroad accident, having had his leg split open from
hip to foot; the amount of pus from this wound was
enormous. In regard to diagnosis, he said, he did not
know that there was a great deal more accuracy to day
than was exercised by physicians in those days, consid-
ering the difference in opportunity. In several of the
cases reported the diagnosis would have been much as-
sisted by the operation to day; for instance, the case Of
abscess Of the liver. A different operation would have
been performed now; the chest wall would have been
Opened and a search made with the ﬁnger. The great
advantage possessed by those of the present day over
the Older surgeons is in being able to make our opera-
tions, in part, and frequently in whole, exploratory.
Some time ago he had a patient come to him from
Texas with a history Of tumor. He had been a perfectly
healthy man up to 27 years past, and was about 55 years
old. He was sent under the impression that he had a
dislocated and diseased kidney. The tumor was situa-
ted a little to the left of the median line and slightly
above the umbilicus, (and seemed to be quite movable,
so that it could be pushed quite over to the right side;
it seemed to be swinging on a pedicle. There was no
colon resonance in front but it was distinct behind the
tumor. When the abdomen was opened by exploratory
incision, he discovered the tumor was attached by a
broad base in front of the spine and seemed to be quite
ﬁrmly attached there. Nothing further was done, of
course; the incision was closed and the patient recovered
from the operation. The kidney was sarcomatous and _
224 MEDICAL SOCIETY OF
it presented an opportunity of trying the serum treat-
ment, but no beneﬁt was derived from this.
The speaker said he did not think Dr. Hurt could
truly say thephysician Of that day took less pains to be
accurate in diagnosis than at the present time, but be-
lieved they Often searched their cases quite as carefully
as is now done. -
DR. FRANCIS L. REDER said these cases had evidently
made a profound impression on Dr. Hurt. Abscess of
the liver, he said, would in almost all Cases prove fatal,
Dr. Hurt mentioned “delay in treatment,” t'.e.,‘ surgical
interference, and the speaker said he thought that that
very treatment was the best, perhaps, even today. Ab-
scess of the liver frequently starts with numerous small
abscesses, and he thought it best, if the constitution of
the patient was well fortiﬁed, to allow such abscesses to
coalesce in the hope that a large abscess would form.
The older authorities say to allow such abscesses to take
their course and they would ﬁnd their way out between
the tissues and indicate to the surgeon the proper point.
for evacuation. Some of the more recent authorities
still advocate the use of the trocar, and only advise a
large incision when it could be demonstrated that the
cavity was a large one; in such a case a free incision
was made to establish good drainage. The cavity was
then washed out and packed. The patients usually died,
however, from exhaustion; few recovered.
In the case reported by Dr. Hurt, the speaker thought
Dr. Hodgenmust have struck the thickened and dis-
placed diaphragm, penetrating along on its abnormal
plane. He had found this condition to exist in several
cases. Dr. Hodgen did not make a number of punctures -
to locate the pus as is done now.
The remarks in regard to hematoma were very inter-
esting. Nelaton was the ﬁrst to say that hematoma was
caused by the rupture of the Graaﬁan follicle. Different
hematomas ﬁnd their source in the rupture of the mass
of vessels known as the bulb of the ovary—such a hem-
orrhage is direct into the peritoneal cavity. Also, from
CITY HOSPITAL ALUMNI. 225
the pampiniform plexus and network Of vessels under
the tubes and between the folds of the broad ligament.
Such a hemorrhage may be either extravasated into the
cellular tissue, or by rupture through the sides Of the
ligament ﬁnd its way into the peritoneal cavity. Then
again from the blood vessels about the vaginal junction,
at the bottom of Douglas’ cul-de- sac. Such an extrav-
asation would pass into the connective tissue of the
pelvis. ,
After inﬂammatory condition has been going on, in-
cited by the action Of bacteria upon the extravasated
blood, the symptoms become prominent. Nausea is
probably the most prominent feature, then pain and
febrile conditions. The hernia in the case under dis-
cussion was, of course, misleading as to the woman’s
condition. He recalled a case of hematoma in which
the symptoms were not pronounced, and were not be-
lieved to be genuine. The patient was made to walk
about simply for the purpose of diverting her mind in
the hope of getting a diﬁerent clinical picture. Upon
close examination hemorrhoids were found and removed,
presuming that they might be the cause Of this woman’s
distressing condition, but the patient continued to get
worse, and in the course of a week a ﬂuctuating tumor
was discovered ﬁlling Douglas’ cul'de sac. This was
incised per vaginam and a quantity of pus, blood and
serum evacuated. The cavity was cleansed and the
woman made a good recovery.
As to the present method of treating hematoma there
_ would be no hesitancy in opening the abdominal cavity
in an endeavor to control the hemorrhage by ligature,
removing all clots of blood and thoroughly cleansing
the abdominal cavity before closure. *
DR. BRANSEORD LEWIS said he thought the paper a
very admirable one and certainly contained some candid
admissions. He thought much was often left undone
which should be done, and more injury was done by in-
active surgery than by too aggressive surgery. He
-mentioned a case where a positive diagnOsis of hernia
226 MEDICAL SOCIETY OF
of the stomach through the diaphragm had been made,
but no operation was performed, and at the post mortem
it was found there was a hernia of the stomach through
the diaphragm. Another case was that of a ruptured
bladder, demonstrated by drawing oﬁ blood with the
catheter, yet no operation was performed, and the
. autopsy revealed a ruptured bladder. Another case was
of obstruction of the bowel: The man was an ignorant
laborer, and the fault was not with the doctors, for the
matter was explained to the patient who declared that '-
he would rather die than have the operation performed; he did die and the post-mortem showed the diagnosis
was correct. I
He said he had always been told that abscess of the
liver was a very rare disease, especially in this climate,
but while he was in the hospital he had seen as many
as twenty-ﬁve cases. Some were saved by operative
measures. One case he recalled, in which the whole
liver seemed to be full of small abscesses. He did
not think anything could have saved that man.
DR. NORVELLE W. SHARPE said he was much im-
pressed with the great diﬁerence in the method of
treatment of to-day and in that of Dr. Hurt’s time.
We hardly realize that such strides have been made
in medicine. Without reﬂecting, for he certainly
deserved great credit, on Dr. Hurt, he said he was in-
clined to think the diagnosis in these cases very accur-
ate, and their inaccuracy was on account of the lack of
competent operative measures. Whether a more search-
ing physicalexamination might have brought out the
conditions more clearly could not, of course, be stated.
He thought the physical condition of these cases would
certainly have been discovered if a competent operation
had been performed in time. He thought Dr. Hurt
must possess a good memory to have recalled so vividly
these case histories. But the clinical picture presented
Was not what would be recognized to-day save as an in-'
complete sketch of extensive liver abscess. Nothing
was said of the almost characteristic posture of these
CITY HOSPITAL ALUMNI. 227
patients; they almost invariably rest on their right side,
or at least assume the position which aﬁords the great-
est relief, pillows under the liver, etc. Pain is usually
' present, located frequently over the site of the abscess,
and from these radiating upward to the right shoulder,
and at times downward into the lower abdomen. Pain
in sub-diaphragmatic abscess is noted at times in the
thorax, and dyspnea, with irregular cardiac action may
accompany it. As a rule, the more superﬁcial abscesses
rather than those more deeply/situated, are those which
induce the - greater pain; the latter, at times, causing
' comparatively little subjective inconvenience. In some
cases pronounced constipation is present, and at other
times persistent diarrhea obtains; gastrointestinal de-
rangement is almost invariable; hectic is not unusual;
there may or may not be vomiting, but loss of appetite
is the rule; emaciation from the beginning and persist-
ing progressively to the end of the disease is note-
worthy.
Dr. George Ben. Johnson, of Richmond, Va , in an
interesting article on this subject, about a year ago,
emphasized the erratic temperature curve seen in these
cases, so erratic that it is of no value except on account
of its erraticism; it is not infrequent to have the tem-
perature range rapidly from 96.5 to 103.5°F. with no
apparent causation. He had endeavored to ﬁnd some
tangible reason for this but failed, and was forced to
the conclusion that the process of destruction in this
large calorifying organ possibly produced the subnormal
temperature followed by the rapid rise to a higher
scale.
One point in the second case Dr. Sharpe thought was
beautifully brought out, and that was the tendency of
hepatic abscess cavities to contract- after evacuation.
After drawing out eight ounces of pus the abscess cavity
contracted until it would have barely contained an
ounce. Although there are on record several cases of
hepatic abscess where the pus proved sterile, that was a
possibility not to be assumed. I Peritonitis arises in
228 MEDICAL SOCIETY OF
various fashions; among them: The liver' changing its
posture when not anchored to parietes, with escape of
pus into the peritoneal cavity and the soiling of the per-
itOneum by escaping pus during or after an aspiration.
In short, it may be said, that with this wider knowl-
edge of today a surgeon is not fulﬁlling his duty to a
patient who would attempt the treatment of an hepatic
abscess by aspiration. Section must be made, all possi-
ble aid, secured by sight and manipulation, enlisted; the
number and extent of abscess cavities determined, and
thorough evacuation, cleansing and drainage of these
pus foci instituted; with appropriate measures for pro-
tection of the peritoneal cavity, such as walling off ﬁeld
of operation by sponges, and union of visceral and pa-
rietal peritoneum. Though the mortality in hepatic
abscess is higher even to day than the future will doubt
less exhibit, yet it is interesting to note the great im-
provement in statistics that literature affords, upon this
operation, since aggressive surgical methods have been
instituted. We are indebted to Dr. Hurt for this glimpse
of surgery (though but twenty years ago) as an incent-
ive to renewed eﬁorts to-day.
DR. H. W. SOPER said during his year of service at
the City Hospital he had an oportunity to observe six
cases of abscess of the liver. In ﬁve of the cases rad-
ical measures were taken by opening up thoroughly and
draining, but they all died. In the sixth case the tro-
car was introduced and all pus possible withdrawn, and
he got well. These cases would seem to show that old
time surgery had some value.
DR. BRYSON said Dr. Sharpe’s remarks led to the
thought that to-day we have a great advantage in two
respects so far as making a diagnosis is concerned.
The ﬁrst is the extensive tract observation, and the
second the vast amount of hospital work done and re-
corded. For instance, at the time mentioned by Dr.
Hurt such a thing as a temperature curve was not
thought of as a matter of record, at least during the time
of the speaker’s service there in 1869 it was not done.
CITY HOSPITAL ALUMNI. 229
There was no such thing as a blank for the temperature
curve. There is also an immense advantage over the
physician of those days in our being able to directly
observe so much of the different tracts. For instance,
in Dr. Hurt’s time, who would have supposed that any-
one would ever be able to look into the bladder, or far
up the rectum; or suppose that we should be able to
enter the cavities of the body with such impunity as we
do to-day. Nevertheless, he said, whether from neglect
or from want of further knowledge, there are a great
many surgical mistakes made to day.
THE PRESIDENT said that he was Acting Superintend-
ent—Resident Physician, as it was then called—and
was succeeded by Dr. Hurt, and thought that all who
knew him would recognize the candor and honor the
conscientiousness shown in the paper, which was both
instructive and entertaining.
As Dr. Bryson had well said. the surgical conditions
then obtaining were very different from those of to day.
The pus basin was a not uncommon feature of the sur-
gical ward and, after an amputation for traumatism, if
“laudable” pus dripped from the stump it was consid-
ered to be doing not badly; and such occurrences were
witnessed in the surgical service of a man‘ so justly
eminent as Dr. Hodgen.
As the paper touched on professional misadventures
a brief account of his own ﬁrst experience in obstetrics
as junior assistant might not be without interest. He
said that he was in attendance nearly all night on a case
of labor in a stout German primapara which progressed so
slowly that, from his teachings, he supposed was delayed
by an unruptured bag of waters, as this condition
seemed recognizable to the touch. Attempts to rupture
.it, however, were not successful, and when the child
was born its head was found to be considerably scratched,
and with no good reason for supposing that the ag-
grieved and perplexed infant had done it with its own ..
hands.
To add to his chagrin the nurse, who was an old-
230 MEDIcAL SOCIETY OF
fashioned sort of person without love for young doc-'
tors and their wisdom in her soul, invited his attention
to the child’s head the next day, and not infrequently
afterwards as healing went on.
The matter, of course, could not be kept quiet and in
due time the story reached the ears of Dr. Hodgen, who
was as candid and free in acknowledging his errors as
anyone. He took the ﬁrst opportunity to counsel the
speaker not to be too much mortiﬁed over the blunder,
and went on to relate his own ﬁrst experience .in mid-
wifery which, brieﬂy, was that he had carefully made
out, as he thought, a breech presentation because he
could insert a ﬁnger into the anus of the child, but
when it was born one eye was found to be missing.
This incident, with the lesson it taught, was repeated
some years later by Dr. Hodgen in an address before a
medical society in Southern Illinois.
Some Anomalous Urethral Cases.
BY BRANSFORD LEWIS, M.D., ST. LOUIS.
In collecting the material for this report, it was not
my desire to present anything that was wonderfully
unique, nor, on the other hand, to mention the every-
day, well-regulated, reasonable gonorrheas that get well
in a proper and gratifying length of time. But I wished
to refer to some cases of urethral inﬂammation that
show not only interesting phases of a very erratic and
ubiquitous conditiOn, but elucidate certain stumbling
blocks to its cure and make it the beta noir of the ami-
able, but often long-suffering practitioner.
This being the class of cases selected, they will not
show any marked promptitude in recovery; they eculd'
not be put on parade as illustrations of “three day
cures;” which I hope will be looked on as an extenuat-
~ ing circumstance concerning their treatment.
CASE I.—AcU'rn GONORRHEA OF THE ANTERIOR URE-
THRA; INFECTION AND SUPPURATION 0F Two on THE
CITY HOSPITAL ALUMNI. 231
GLANDS or LITTRE.—O. E. J ., merchant, aged 29 years,
consulted me March 15, 1898. His last exposure had
been on March 7, and a urethral discharge made itself
evident on March 11—four days’ incubation.
Numerous gonococci were present in the abundant
discharge from the urethra; and in three days the cloud-
ing of both urines indicated the progress of the infec-
tion into the posterior urethra.
Anterior injections of argonin, and almost daily an-
tero-posterior irrigations with protargol, brought about
very satisfactory and prompt improvement in ten days;
the second portion of the urine cleared entirely, while
there was not very much discharge anteriorly.
But what there was, persisted; and it kept on persist-
ing—that one large drop of creamy pus—for a month.
There was no pain and none of the signs of active, dif-
fused inﬂammation. On the contrary, the trouble seemed
to be localized in the front part of the anterior urethra.
Endoscopic investigation at ﬁrst failed to disclose
any suﬂicient ground for such a daily outbreak; and va-
rious treatments were tried to overcome it, but without
success. Until about April 20, when a very careful in-
spection with the endoscope detected two points on the
ﬂoor of the urethra from which, if pressure were made
on the outside at the same time, pus would exude in a
small drop. Here, then, it seemed, was the reason for
the hitherto unaccountable conduct of the affection:
Two follicular abscesses of the glands of Littré.
A sharp, spear shaped knife introduced through the
endoscope opened successively the two focuses of sup-
puration. But they did not stay opened; union of the
- cut edges occurred, retaining the pus in the follicle and
no headway was gained. So I had a small cautery knife
constructed to go through the endoscope. With this
I opened and thoroughly cauterized both abscess cavi-
ties; and in ten days the patient was well; both urines
were perfectly clear.
It may be suggested that I should have discovered
the points of suppuration before I did; and have saved
232 MEDICAL SocIE'rY OF
the patient a corresponding drain on his time and pa-
tience. But I must respond that that was more easily
said than done. The simple introduction and with-
drawal of the endoscope did not show the suppurating
points, they were obscure and were only shown by co-
incident pressure from the outside. So that though I
had looked for just such a condition several times, I did
not discover it positively until I made use of this little
maneuver. v
CASE IL—An'rnno-Po STERIOR URETHRITIS OHnoNIc;
URINARY INFECTION; PHIMOSIS.—— Mr. J. H., Illinois,
aged 28 years, single, consulted me January-.7, 1898.
His complaint was of a “gonorrhea” that had been
keeping him steady company for fourteen menths; and
this, notwithstanding he had had both internal and lo-
cal treatments, with anterior and posterior irrigations,
soundings and the use of other methods that, apparently,
had been ably administered. He said that though the
various treatments seemed to do good for a time, the
beneﬁt each time was only temporary, and the trouble "
returned with their discontinuance.
No gonococci were found by me in the slight dis-
charge from his urethra. The urine was clouded In both
ﬁrst and second portions; and under the microscope,
after sedimentation, the freshly passed urine was seen
to contain myriads of rod-shaped bacteria—colon bacilli.
It was evident, then, that the case' was one mainly of
urinary infection, coming from a point higher up than
the urethra. _
Thinking that the long, phimosed foreskin present
might contribute to the likelihood of recurrent infec-
tion, and remembering the proneness to recurrence of
this condition, I ﬁrst advised circumcision; and follow-
ing the healing of the wound, began the use of urethro-
vesical irrigations, complete and often-repeated, of pot-
assium permanganate. To bring an antiseptic effect to
bear internally, urotropin was given in ten grain doses,
three or four times daily. In a week the second part
of the urine was clear. With continued improvement
CITY HOSPITAL ALUMNI. 233
he was thought to be well enough to return home and
there keep up the measures already undertaken. He
therefore left on January 27 , only to return February 7
with renewed complaint of post-urethral irritation
(manifested by frequent and painful urination, etc.).
This was a type of the manner in which the disease
conducted itself. For some time it seemed that as long
as the patient remained in the city under direct super-
vision he would do well; and shortly after returning to
his home, although he learned to perform all necessary
measures properly, he would have a relapse. Of course
this was all very well—from my standpoint, but not
from his. He wanted to get permanently well.
That end has, I think, been ﬁnally accomplished. His
urine has now been steadily clear since May 30, and he
- has been free from the very disagreeable and harassing
symptoms of his disease.
Of the various means used in his case I think most
highly of '(internally) urotropin and benzosol; and (lo-
cally) irrigations of silver nitrate, boric acid and kathar-
mon, permanganate, and formaldehyde. Permanganate
douches were even given in the rectum to guard against
that as an avenue of infection, as much as possible.
CASE III.—Posr ALCOHOLIC NEURASTHENIA; ANTE—
RO-POSTERIOR URETHRlTls; SPERMATORRHEA.—The fol-
lowing case elucidates the bearing of general nervous de-
pression on the sexual and urinary organs; and incident-
ally throws a side-light on that much discussed condition
(not disease) spermatorrhea.
The patient, F. W., aged 43 years, married, had been
for many years a high liver in the matter of drinking;
beer, whiskey, champagne—any or all just suited him,
so that there was a suﬂiciency in quantity. First con-
sultation November 29, 1897 . For an indeﬁnite length
of time, but certainly during a number of months, he
had noticed slight discharge from the urethra, especially
of mornings.- He had paid little attention to it until he
had ﬁnally made up his mind to reform; and one of the
features of his reformation he thought, should be the
elimination of that discharge.
234 MEDICAL SOCIETY OF
Carrying out my advice, he became a total abstainer
from intoxicants. His discharge, free from gonococci,
was speedily diminished and relieved by the irrigations
used: katharmon, alum, zinc sulphate, etc; but one
thing that did not disappear so easily was the invaria-
ble appearance of abundant spermatozoa in the ﬁrst
part of the urine, whether passed in the day or night.
Repeatedly I had him urinate at my oﬂice, into two
glasses, and always with the same effect. The ﬁrst
glass would contain by far the most of the organisms.
Besides the local treatments mentioned, general tonics
were given—Fellows’ compound syrup of hypophos-
phites, Wampole’s elixir of codliver oil, etc.,. among
them. A practical rejuvenation was ﬁnally worked by
his reformation, and the following March he was dis-
charged, well. i
It is often claimed that so-called spermatorrhea is a
matter of the imagination; that patients only think they
have it from observing the discharge of prostatic mu-
cus from the urethra after a hard stool. The patient
above mentioned never thought anything about it until
I observed the spermatozoa as related.
CASE IV.-Another case somewhat similar is that of
a young man, aged 19 years, unmarried, who consulted
me at ﬁrst in June, 1897, for a “morning drop” that
had been left over from a urethritis of two years before.
After taking a few treatments, irregularly, the patient
discontinued his visits for a year, when he reappeared, ‘
saying that he had not recovered in the meantime.
Examination did not disclose gonococci in his slight
discharge; but it disclosed numerous spermatozoain the
ﬁrst portion of his urine, passed in two glasses. There
was no active inﬂammation of either prostate or seminal
vesicles. Questioning developed the fact that he was
one 'of the numerous habitués of sexual dallying without
intercourse—a practice which I look upon as much more
injurious to the sexual organism than intercourse, in-
dulged in even to an excessive degree. His was a con-
dition of sexual neurosis—presenting a paretic condition
CITY HOSPITAL ALUMNI. 235
's
of the ejaculatory ducts, and at the same time, a cat-ar'
rhal tendency of the urethra. The patient was unable
to carry out the treatments advised and shortly again
discontinued his visits. He, however, furnishes an il-
lustration of sexual neurosis not at all uncommon
amongst young men who would fain taste of forbidden
delights yet hesitate on account of other evils more
greatly feared.
CASE V.—AcUTE OXALURIC UBETHRITIS. -— A case
whose study is more cheerful is that of Mr. L. I., of
Missouri, aged 29, single. Consulted me October 5,
1897; no antecedent venereal history. Six days before
his visit, and three weeks after a suspicious intercourse,
the patient had noticed marked burning in his urethra
at the time of urination, together with the discharge of
a rather thinnish purulent ﬂuid. There was no unusual
frequency in urinating.
Examination showed no gonococci present. Both
urines markedly cloudy, and on sedimentation showed
pus, blood corpuscles, and, most important of all, loads
of oxalate of lime crystals. On summing up the case I
gave it as my opinion that there was no venereal or in-
fectious element in it; and that dietary and simple local
treatment was all that was needed, notwithstanding the
fact that the activity of the symptoms had made him
hurriedly take a several hundred mile trip to the city in
order to catch the disease in as early a stage as possible.
Almost an exclusive meat-diet was therefore pre-
scribed, with lithia waters ad libitum; and a combina-
tion of citrate of lithium, sodium salicylate, salicylic
acid and ﬂuid extract of stigmata maydis, which I have
used much in such cases, served to bring about his cure
in about a week. A correct interpretation of an anoma-
lous urethritis, therefore, not only dissipated his anxiety
but also led to an easy cure.
A case that is equally as instructive and as gratifying
from a therapeutic standpoint, is the following:
Cass: Vl.—-URIc A011) URETHRITIS AND PROSTATITIS.
—-S. R, aged 38 years, single. First conference Sep-
236 MEDICAL SocIETY OF
tember 16, 1897. He had had urethritis in 1890,
1894, and 1895; and the condition then present had
begun in February, 1897 , seven months before the con-
sultation. During this latter time and previous to it,
he had been under the care of two practitioners, whose
treatments consisted especially of urethral injections
and periodical soundings. His complaint was of a
slightly increased frequency of urination, some burning
connected with the act, a small amount of muco pruu-
lent discharge at the meatus each morning, and certain
ill deﬁned deep-urethral or perineal sensations that con-
stantly reminded him of “youthful indiscretions” and
their effects. He had noticed that several times, fol-
lowing the drinking of even a moderate quantity of
beer or spirits, the various symptoms were markedly in-
creased; and at the same time his urine would become
high colored and apparently more irritating.
I found no gonococci or other evidence of venereal
contamination present; no stricture, meatus and urethra
easily admitting No. 28 bulb sound. The prostate, un-
der rectal palpation, was found to be unusually tender
and irritable; and on massage emitted ﬁve drops of
milky muco-pus containing many cocci and epithelia.
I In this case, also, although there had been chances
for infection, I declined to believe in a venereal'condi-
tion as the sub-stratum of the disease, mainly because
‘of the history above noted when considered in connec-
tion with the urinary examination. The urine was
found to be very high colored and dense, speciﬁc grav-
ity 1,030, acid; no albumen, no casts; and on settling
deposited numerous crystals of uric acid. It was loaded
with uric acid. '
This was a type of cases concerning which I. have
written at greater length elsewhere,1 and a type which

1 “ The Relation of Oxaluria and Uric Acid Excess to Genito-Urin-
ary Inﬂammations and Disorders ;” read before the American Asso-
ciation of Genito-Urinary Surgeons, 1897; journal of Cutaneous and
Genito-Urinary Diseases, July, 1897.
CITY HOSPITAL ALUMNI. 237
has won a high degree of respect from me in my prac-
tice. It was one of uric acid urethro-prostatic irritation:
increased by an increase in the uric acid excretion, and
decreased when that product was being stored up in the
body _and not contaminating the urine so much.
The primary means of relief adopted was a regenera~
tion of the patient’s diet; red meats were entirely ex-
cluded; likewise the rich foods, such as spices, pastries,
sweets, and alcoholic beverages. He was instructed in
the matter of wholesale water drinking. His dietary,
for the time being, was a milk and-water-and vegetable
one. He was given the citrate of lithium combination
previously mentioned (lithine compound), and, later on,
gentle vegetable-astringent irrigations were given to
the whole urethra and prostate. His improvement be-
gan immediately and was very gratifying. But in J an-
uary of the following year he had another acute attack,
following dietary in-discretions, and a uric acid crisis,
and this time it was accompanied by acute and severe
epididymitis. -
Since recovering from this attack in January of this
year, he has been more careful of his regimen, has had
no more of the urethro prostatic irritability—and has
become involved in matrimony without regret.
While there is no especial connection between the
half dozen cases herewith reported, they serve to show
some of the numerous varieties of origin for urethral
inﬂammation, and I hope will serve even the better pur-
pose of a basis for discussion in which others may be
brought out.
Indeed, their name is legion. Otis used to teach that
a chronic urethritis meant stricture. He wrote a forci-
ble book to that effect. It was more forcible than accu-
rate. Chronic urethritis may mean any one of several
dozen causes, more or less closely connected with that
outward indication of trouble, and more or less easy of
recognition in that light. It remains for us to still fur.
ther study those relationships—to both recognize them
and control them—in order to place this ﬁeld of prac
tice on the scientiﬁc basis at which we all aim.
238 MEDICAF SOCIETY OF *
DISCUSSION.
DR. JOHN P. BRYSON said he appreciated the value -
and importance of the paper but would allude to only
two of the features brought out. In regard to the ab-
scess of the glands of Littré he said it was very easy
to overlook the openings in these cases. They are fre-
quently closed, and when making examinations with
the endoscopic tube, sometimes so tightly, that even
pressure on the outside will not cause the pus to exude.
The question of the presence of the uric acid'and the
oxalic acid combinations in the production of disease
was a point about which we should like to know at great
deal more than we do. Many of these patients are
gouty. They have uric acid “storms” as they have been
called which inﬂuence inﬂammatory conditions in many
parts of the body at such times. A chronic inﬂamma-
tory condition existing in the urethral tract will be
much exaggerated and heightened during these periods;
but, on the other hand, there is sometimes almost
incredible elimination by the kidneys of uric acid and
without any surface inﬂammation. He said he had
seen a case which deVeloped locomotor ataxy during the
last four years; the patient had an intermittent glycosu-
ria for probably eight months in the early stage of his
affection and the amount of uric acid in the crystallized
form was sometimes enormous. In one instance he drew
from this man’s bladder with the catheter a full tea-
spoonful of uric acid sand; when the catheter was with-
drawn several of the sandy particles were seen in the
urethral meatus and scraped. away with a blunt spoon.
The spoon was then introduced into the bulbous urethra
and a large amount of uric acid crystals drawn out, yet
there was no evidence of inﬂammation, the urine did
not contain pus, nor was there any retention or extra
sensitiveness, so that be doubted very much if uric acid
except in combination with more than one factor would
produce inﬂammatory troubles of the mucous surfaces.
The second case was a conﬁrmed diabetic who con-
stantly disregarded instructions as to diet and mode of
CITY HOSPITAL ALUMNI. 239'
living, and went on to a miserable death. This patient
would frequently have periods when large quantities of
uric acid were eliminated. There was no aching of the
kidneys which so commonly occurs during the elimina-
tion of uric acid, but a good deal of frequency of urin-
ation, only slightly painful, though tenesmus was pres
ent; this disappeared immediately on the introduction
of an instrument and pumping out quite an amount of
uric acid sand. In this case, again, there were no in-
ﬂammatory manifestations whatever, and the urine was
free of pus. Therefore he thought that in studying the
etiology these cases of trouble about the uro genitalia
which occur during the course of uric acid elimination
more than one factor must be looked for. He thought
the colon bacillus might, in such cases, very readily in-
cite a purulent inﬂammation. ‘
In regard to the morning drop so often complained of
by patients, he said it was a condition which should be
attended to, especially before matrimony is permitted.
He had seen a number of, these cases in which the pus
had undoubtedly an extra-urethral origin, that is to say,
either originated in the prostatic follicles or in the sem-
inal vesicles. In these cases were frequently found
spermatozoa, and he had sometimes observed them with
their heads imbedded in the pus corpuscles. He thought
this an important point and he felt satisﬁed that the pus
seen at the meatus came from the posterior and not
from the anterior urethra, and in some cases probably
from the seminal vesicles. He thought the appearance
of the morning drop coming from the posterior urethra
might be accounted for by the fact of the verumonta-
num in a state of turgescence blocking the vesical end
of the urethra at the time of exuding of the seminal
ﬂuid so that instead of entering the bladder it is thrown
into the anterior urethra; the discharge being a mix-
ture of urethral and prostatic mucus with some seminal
ﬂuid. He spoke of a patient who came to him with
what some one had pronounced al‘soft” stricture. The
speaker said he had never seen a “soft” stricture, as de-
240 MEDICAL SOCIETY OF
\
ﬁned by those who use the term. Number 30 F. blunt
sound would enter the bladder. The patient had a very
small stream of urine, sometimes not being able to pass
\it at all and had to use a catheter; had intense pain in
the perineum radiating towards the anus. There was
. very little pus in the second glass. The patient was a
married man and for two years had refrained from hav-
ing intercourse for two years for the reason that in
ejaculation seminal ﬂuid failed to pass from the urethral
meatus (aspermation), and also because the act became so
painful and the distress lasted so long. It was subsequent-
ly drawn by the catheter. After examining the man he
concluded that this could only be produced by a valve
whose free border was turned backward and located
in the prostatic urethra, and it was this that had been
called a “soft” stricture. At this point the instrument
met with a slightobstruction and had to be lifted up
and its transit was quite painful. The patient had at
one time been treated with electricity by some one, but
.. without relief. When the urethra was opened it was
discovered that a ﬂap, which was very hard, existed in
the membranous portion of the urethra, and the speaker
thought it the result of the electrical treatment. The
perineal opening was enlarged and this ﬂap dissected
out and is now in his possession. It is composed of
ﬁbrous cicatricial tissue and covered with ﬂat epithelium.
All of the symptoms promptly disappeared after the
operation. The speaker used this case as an illustration
of the manner in which a distortion of the verumonta-
num may make non-emissions; the reverse condition
may cause a discharge from the posterior urethra to ap-
pear at the meatus. ‘ .
THE PRESIDENT asked Dr. Lewis whether, in using
the terms uric acid and oxalic acid, he always meant
crystals.
DR. LEWIS said sometimes only; he meant both the
amorphous form and the crystallized form.
DE. HORACE W. SOPER said he had a curious case of
urethral discharge and he wanted to know if anything
CITY HOSPITAL ALUMNI. 241
(if the kind had been observed by Dr. Lewis or Dr.
Bryson. The patient simply complained of a very of-
fensive odor, especially about the anus. He-had been
under treatment ‘for rectal disease, but the odor still
persisted. There were no urethral symptoms whatever.
On examination nothing was found about the rectum,
" but he observed a little moisture about the meatus and
found a slight mucoid discharge and it was from this
the odor arose. There was no pus. After using several
injections it ﬁnally subsided under peroxide of hydro-
gen. This was during the very hot weather of summer
before last. A drop of the exudate would ﬁll a whole
room with its odor. -
DR. BRYSON asked if any bacteriological examination
had been made.
DR. SOPER replied that there had not.
DE. F. L. REDER said he still adhered to the old meth-
od of treatment, viz., zinc sulphate and permanganate
of potassium. He had been fortunate in getting most
of his cases of gonorrhea in the acute stage. In the
course of ﬁve or six weeks, and by adhering strictly to
the diet and the local treatment, had been able to cure
most of his patients. He said he had often thought he
was able to draw a close relationship between chronic
gonorrheal inﬂammation in the male and chronic cellu-
litic inﬂammation in the female. In the male a return
of gonorrhea is often seen in the course of six to ten
weeks, marking the beginning of the chronic stage.
The chronic stage of gonorrhea might almost be said
to be incurable. He thought physicians ought to keep
track of their cases and really know whether they are
cured. He said he would like to know if the sound was
still used in the treatment of gleet and if its introduc-
tion had proved successful, and whether the “morning
drop” would in the course of time really be cured.
. DB. M. J. LIPPE said he had been rather unfortunate
in some of his cases and had them hang on sometimes-
for a long time. In some cases he had found a stricture-
of large caliberwhich would admit passage of a ﬁliform,
242 MEDICAL SOCIETY OF
but would obstruct a No. 20 or 22 sound. Some get
well on the passage of a full-sized sound. In some
cases, although there was no history of frequent mictu-
rition nor anything very deﬁnite, he had found the sem-
inal vesicles enlarged on examination per rectum and
had succeeded in curing several of them by repeatedly
stripping the vesicles. In regard to the local treatment
by irrigations with permanganate, etc., he thought the
irrigations did not hasten a cure, although the patients
always felt better afterwards. _ _
DR. BRYSON asked where a stricture of large caliber
had been found and how large was it. ‘
DR. LIPPE answered, in the penile portion, and said
he had one case, treated ﬁfteen months before he saw
him with balsamics and injections in which he could not
introduce a sound at all. He found a stricture about
half an inch back of the meatus; on dilating this he
found another further back which admitted a No. 22
sound with little diﬂiCuIty. He called that a stricture
of large caliber. .
m DR. H. R. HALL said he would like to ask Dr. Lewis
if he did not always ﬁnd some local cause for the morn-
ing drop, that is, was there not some local lesion, a
stricture or something of that sort, -to account for the
drop.
DR. FRANK HINCHEY said he would like to have Dr.
Reder speak at greater length on the connection between
I the gleety discharge in the male and cellulitis in the
female. He said he had been trying to trace the path-
ological connection between the two but found it rather
difﬁcult to do so.
THE PRESIDENT said Dr. Lewis had not made quite
plain the origin of the colon bacilli found in one of
the cases reported.
DR. LEWIS said he did not agree with 'Dr. Bryson in
his conclusions regarding uric acid and the oxalates. He
did not think the observations made by Dr. Bryson in
the cases cited should be accepted as conclusive that
there oculd be no suppuration from that cause alone. A
CITY HOSPITAL ALUMNI. 2 t3
man aﬁected with a rheumatic diathesis did. not neces-
sarily have rheumatism all the time. There were peri-
ods of quiescence, followed by outbreaks of pain—
whose exciting cause might or might not be discerned.
The speaker had observed a number of cases of urethral
inﬂammation, recurrent ones, with periods of quiescence
and activity, that had undoubtedly come from excess of
uric acid or oxalates, that were cured by dietary regula-
tions, with little or no local measures. Whether these
inﬂammations occurred as a result of mechanical irrita-
tion or of the localized effect on the urethra of the
passage of the uric acid, he could not say. The condi-
tions were still under discussion, but the speaker be-
lieved the uric acid crystals in the urine capable of pro-
ducing this condition.
DE. BRYSON asked Dr: Lewis if he thought the in-
ﬂammation along the urinary passages, for instance, was
analogous to that in the toe in an attack of gout.
DR. LEWIS said he did.
DR. BRYsON said the treatment was based upon the
supposition vof uric acid being the cause, and a cure was
effected. There was some suppuration in the urethra
but no active outbreak of pus. In the cases of oxalate
of lime there was suppuration but no gonococci.
DR. LEWIS said his paper was really only a straw to
show the drift of these cases. There were other causes
for the continuance of gonorrhea. The subject was a
big one, and when speaking of the treatment of these
cases one should do so in the light of the origin of each
case. In reference to stricture the speaker said he had
decided views and could not agree with Dr. Lippe. He
did not think anyone could be decided in his diagnosis
of a stricture by the use of the blunt steel sound. He
said he used either the bulb sound or the urethrometer,
either one of which would decide the question. The
bulb sound would often show contractions which the
steel sound would not. The use of the steel sound in
the treatment of chronic gonorrhea was probably bene-
ﬁcial in some cases.
244 MEDICAL SOCIETY or
In reference to the case of Dr. Soper’s the speaker
said it was probably due to some putrefactive bacteria
infecting the lower part of the urethra or the sub-pre-
putial membrane. .
DR.BRYSON said he thought a bacteriological examina-
tion of the case Dr. Soper mentioned would have de
veloped the colon bacillus, which causes changes in the
smegma and the urethral mucus giving rise to these
odors. In regard to the use of the sound he said he
agreed with Dr. Lippe that it was often of great value
in the treatment of certain cases of chronic urethritis.
In those cases of urethritis glandularis of Oberlander,
he had demonstrated by his ingenious urethroscope that
the use of the steel sound makes numerous tears in that
part of the urethra and in such a way that an applica-
tion made is very much aided by the introduction of
the steel sound, and Dr. Bryson thought perhaps most
of Dr. Lippe’s cases were of this character. In poste-
rior urethritis, or prostatitis of the chronic form, he
thought the introduction of the steel sound was harm-
ful.
DRfLEWIS said in reference to the curability of gon-
orrhea, that he believed, from his observation of many
cases, that gonorrhea was curable. Many of them took
a long time and there were undoubtedly some which
were never cured; but he did not believe in the dictum
—-“once a gonorrhea, always a gonorrhea.” The speaker
asked Dr. Bryson if he would depend upon the blunt
sound for diagnosis of stricture.
DR. BRYSON replied in the negative. .
DR. LEWIS further remarked that patients frequently
come complaining of a stricture, that they have been
examined by physicians who told them such was the
case. On questioning them closely and showing the
various instruments, they usually pointed to the 'conical
sound as the one used by others in making the diagno-
sis. The use of the blunt sound or the conical sound
alone would never positively establish the presence of a
stricture. '
CITY HOSPITAL ALUMNI. 245
'In answer to the query as to the source Of the colon
bacilli mentioned 'in one of his cases, Dr. Lewis said
that the infection might have come from the kidneys or
the rectum, a constipated condition of the bowels
favoring the passage of these bacteria through the in-
. testinal walls. '
STATED MEETING, THURSDAY EVENING, OCTOBER 6.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

DR. HENRY JACOESON reported a case of
OVARIAN TUMOR COMPLICATING PREGNANCY IN AN
UNMARRIED YOUNG WOMAN.
The patient, twenty-seven years of age, was oper-
ated upon for supposed ovarian tumor. She was
an unmarried woman from the country and said
‘ her menstrual ﬂow had appeared regularly up to
three :months before. She denied positively having
had intercourse with anyone. The physician who sent
her here had made a diagnosis of ectopic pregnancy.
The surgeon and several physicians examined her and
found a tumor ﬁlling the whole pelvis, especially on the
right side; the womb was enlarged but did not feel
like a pregnant uterus. The only symptoms pointing to
pregnancy was the deposit of pigment about the nip-
ples, and suppression of menses. Dr. Jacobson said he
felt sure that there was a pregnant uterus, and the ques-a
tion was brought up by the physician, before the opera-
tion, of the possibility of ovarian tumor and pregnancy
who was, however, inclined to believe it was an ovarian
tumor.
A section was made into the abdomen and a four
months’ pregnant uterus was found, together with an
ovarian cyst the size of a cocoanut. The cyst was re-
moved and the uterus replaced. The condition, he
thought, was quite rare in a woman of that age.
The speaker said he brought up the question of the
'0
246 MEDICAL SOCIETY OF
possibility of the abdominal stitches giving way should
the woman abort. The surgeon in charge said he re-
membered two cases in which vomiting caused a rup-
ture of the abdominal wound.
In answer to questions by the President Dr. J acob-
son said the cyst was attached to the uterus behind;
this was one reason why the diagnosis was somewhat
obscure. He thought abortion would probably affect
the sutures and produce a hernia in the abdomen, as
‘ there were always more or less abdominal contractions
and strainings when that took place.
DR. FRANCIS L. REDER asked why the operation had
been performed.
DR. JACOBSON said he did not know. He simply wit
nessed the operation.
DR. REDER asked if the operation was an exploratory
one.
DR. J ACOBSON said he did not know.
DR. REDER asked Dr. Jacobson if he would not, un-
der such circumstances, put a woman under observation
for some time. . v
DR. J ACOBSON said he would, but after the cyst was
lodged in the pelvis he believed it was proper to operate.
DR. REDER said the existence of the tumor was not
really the cause for operation. The general practice
was to allow the pregnancy to go on to full term and
later on perform the operation, if necesSary, i. a, if the
tumor offers no serious impediment to the good health
of the woman or to the progress of pregnancy.
DR. ELSWORTH SMITH, JR. asked if Hegar’s sign was
present—the softening of the lower segment of the
cervix.
DR. JACOBSON said it was not; he could not feel it.
DR. SMITH said he did not quite understand how the
tumor would interfere with pregnancy. He asked what
were the indications for the operation. .
DR. J ACOBSON said he didinot know what the {urgency
in the case was; he simply witnessed the operation.
Whether the patient was in pain-or not he did not know.
CITY HQSPITAL ALUMNI. 247
He added that he thought it probable if the cyst had
been allowed to grow the danger to the life of the pa-
tient would have increased with the increasing size of
the tumor.
DR. SMITH said he thought the operation not justiﬁa-
ble with such strong indications of pregnancy, unless
there were urgent, symptoms for it.
_-
A CASE OF INVETERATE FACIAL NEUBALGIA TREATED
WITH STRYCHNIA AFTER THE DANA METHoD
DR JOSEPH GRINDON reported a case in connection
with which he desired to speak of a certain procedure
which had given good results.
About ten years ago he was called to see a woman, at
that time about 50 years of age, who was suﬁering with
severe neuralgia of the second branch of the trigeminus.
Diﬁerent remedies were used, each giving relief for
a short period. At that time the measure giving the
most relief was that of chloroform cataphoresis by
Adamkiewicz’ method, carrying the drug through the
skin along the positive current from a galvanic battery.
Whether the relief was due to the rubefacient effect or
not he could not say; there was considerable reddening
of the skin, with subsequent scaling. After trying all
the remedies he knew of or could ﬁnd in the literature,
he thought he had reached the end of his string and
decided to turn the case over to someone else, so he
sent the patient to Dr. Fry. Dr. Fry used a variety of
remedies, each of which gave some relief for a short
time, but no permanent relief could be obtained. The
tendency of the case was to grow worse and worse. The
attacks became more and more intense in character so
that .the patient, who was a very courageous person and
of great resistant power, ﬁnally broke down under the
strain. Then it was determined to remove the nerve,
and the operation was performed something like three
years ago by Dr. H. H. Mudd. He out in along the
ﬂoor of the orbit, picking up and cutting the nerve in
24.8 MEDICAL SOCIETY OF
the infra-orbital groove and bringing it out through the
infra-orbital foramen, then severing the branches some
little distance from the foramen, and even turning back
the cut ends so as to prevent or delay as much as possi-
ble the re formation of the nerve—the well-known clas-
sical operation. That operation was followed by entire
relief which continued for about eleven months. At
the end of that time the pain re appeared and rapidly
became as intense as ever, so that at the end of about
thirty days the patient’s condition was as lamentable as
' before the operation. A second operation was proposed
and the patient consented. This was also performed by
Dr. Mudd. The entire length of the nerve which had
been removed from the point where the infra orbital
groove becomes a canal to a point a little beyond its
exit, had been in that period of something less than
eleven months, completely re-formed. The new nerve,
however, was only a fraction of the diameter of the Old
nerve—it was simply a thread. In the second operation
Dr. Mudd went into the spheno- maxillary fossa, severing
the nerve at that point as well as its connection with
Meckel’s ganglion. That operation was also followed
by complete relief, but the relief did not last quite as
long as after the ﬁrst operation, for in something less
than ten months pain again appeared. Medical treat-
ment was given with the usual temporary relief and
soon after, for the ﬁrst time in the history of the case,
she was driven to the use of morphine, against which
she had fought all the time. Soon such amounts of the
drug were used that nutrition and the general health of
the patient suffered, and from being a stout and well-
nourished person she became thin and but a shadow of
her former self. Dr. Grindon was again called about
this time, and decided to try strychnia according to the
Dana method. The use of strychnia for the relief of
neuralgias is not a new thing at all, but Dana’s method
has not been in use more than two years.
The method consists of the introduction of strychnia
hypodermatically, beginning with the ordinary adult
CITY HOSPITAL ALUMNI. 249
dose of one thirtieth gr. of the sulphate, and as rapidly
as the patient’s reaction to the drug will permit, push-
ing up the dose'to the maximum size of one ﬁfth or
one quarter gr. In this case this was done in ten days.
After the third daily injection the patient expressed
‘ considerable relief. Whether this was due to sugges-
tion or, the effect of the drug he did not know; the
woman was an intelligent person, the method had been
explained to her and what was hoped for it. On the
ﬁrst day she received one~thirtieth gr., the second one-
twenty ﬁfth gr., the third one twentieth gr. By the
time one-twelfth gr. was reached (on the ﬁfth day) the
pain had entirely disappeared, but the treatment was
continued until one quarter gr. was injected. With such
large doses there were well-marked symptoms of strych-
nia poisoning, but these “symptoms would pass off in
the course of an hour or two. Under this treatment
the patient improved wonderfully in general health and
appearance, and said she felt better than she had in
years. After reaching the dose of one quarter gr. the
treatment was discontinued. The relief continued for
a week, at the end of which time the pain re-appeared,
though in a slight degree, yet enough to alarm the pa-
tient. The treatment was renewed and pushed rapidly
from one-thirtieth gr. to one ﬁfth gr., beyond which it
was not carried because of the toxic symptoms being
very marked. Instead of interrupting the treatment
as was done before, the dose was decreased. For
three days the maximum dose of one ﬁfth gr. was given;
then a day was allowed to elapse and one-sixth gr. was
given; then an interval of two days when one-seventh
gr. was given, three days later one-tenth gr. and, keeping
the dose at that point, the intervals were made greater
until now seventeen days have elapsed between the
doses. All this had occupied considerable time, but the
result was very gratifying and the doctor hoped to keep
the pain in abeyance by these doses. He intended to
allow a still greater interval to elapse between the doses
and later to discontinue the treatment altogether.
250 MEDICAL SOCIETY OF
DE. FRANCIS L. REDER said he did not understand
why the pain should continue after Meckel’s ganglion
had been removed, since there was no tissue left to _cause
recurrence. The fact of the nerve re-forming was very
interesting.
THE PRESIDENT asked whether the supposition was
that pressure or a degeneration of the nerve tissue
caused the trouble.
DR. GRINDON said there was no reason to suppose
that pressure existed along the nerve trunk. He thought
the trouble was due to degeneration.
DR. M. A. BLISS said Dr. N. B. Carson had operated
on a case similar to the one reported by ‘Dr. Grindon.
When the ganglion was reached it was found to be very
much smaller than was expected and had probably
atrophied. He thought it probable that in most of these
obstinate neuralgias there existed a condition somewhat
simulating that found in other degenerative troubles—
such as locomotor ataxy. In most of the cases operated
on for this trouble the ganglion was found to "be smaller
than normal. Before operating on his case, Dr. Carson
had examined all the literature on the subject and that
point was mentioned several times, although Keen re-
ported one case in which the ganglion was found to be
larger than normal. Dr. Carson’s patient was about 60
years of age. Every medicinal means had been tried
without success. What the result of the opertion will
he remains to be seen as it was performed only about
six weeks ago.
In regard to Dana’s method Dr. Bliss said Dr. Fry
and he had tried the method, running rapidly down from
one-thirtieth gr. to _one quarter gr. without success.
This was the experience of Dr. Dana also, who found it
successful in a certain number of cases only, and in
some he failed.
DE. GRINDON said Dr. Dana reported a number of
cases in 1896 and had ﬁve successes with a few failures;
the total number of cases was small but the majority
were successful; one of the successes being in a patient
74 years of age.
CITY HOSPITAL ALUMNI. 251
DE. BLISS said the treatment had been tried soon after
being reported. He felt satisﬁed that the operation for
the removal of the ganglion was one which would be
attempted by comparatively few surgeons, being a very
extensive operation.
DE. HENEY JACOESON said he thought the return of
the pain after the removal of the ganglion indicated
that the trouble was located deeper, and suggested the
possibility of the habit having been formed such as is
found in old traumatic epilepsy, in which operation for
the primary cause does not help because the habit has
been established. He thought it would be interesting
to bring the case up again in about six months and see
if she has not had a recurrance of the neuralgia.
DR. GRINDON said the pain disappeared for ten
months and when it reappeared there was found to be a
nerve there.
DR. JACOBSON asked if the supposed nerve had been
examined microscopically.
DR. GRINDON said it had not.

CASE OF THOEACIC ANEUEYSM.
DE. ELSWOETH SMITH, JE. said he had a case of tho-
racic aneurysm under observation which was of interest
from the standpoint of diagnosis. The most important
signs in the diagnosis of thoracic aneurysm are the
presence of a tumor and pressure symptoms. These
are considered the most important signs, but the
presence of the bruit in the tumor, or a thrill, was also
classed as one of the important signs. He, however,
considered these not to be the most important of
the physical signs in the diagnosis of aneurysm of
the aorta. He had seen several cases in which both
these signs and the pulsation were entirely absent, yet
a diagnosis of aneurysm was made and the autopsy veri
tied it. He therefore felt that the most important signs
~ were the determination of a tumor with the presence
of pressure symptoms. The case he wished to speak of
illustrated these points.
252 MEDICAL SOCIETY OF
The patient was ﬁrst seen at the throat clinic under
the charge of Dr. Sluder and gave a history of- gradual
loss of voice dating back about ﬁve weeks. No history
of pain—absolutely no pain in the mediastinal region or
chest, which is also considered an important symptom—
and otherwise nothing to point to trouble in the vascu-
lar system; no dyspnea and no palpitation or discomfort.
Dr. Sluder examined the throat and found the vocal
chord paralysed on the left side. He looked carefully
for the cause of the paralysis but could ﬁnd nothing in
the throat to account for it. He then brought the pa-
tient to the medical clinic and during the examination
it was found he had very distinct evidence of a medi-
astinal tumor. Under the manubrium sterni from the
second costal cartilage up he had a distinct dull area and
over this area there were accentuated heart sounds—the
heart-sound being more distinctly audible over this site
than over the heart itself. There was no bruit at all;
no pulsation and the only pressure symptom aside from
the paralysis of the chord was evidence of weaker res-
piration on the right side than on the left, that is less
air entered the left lung than the right. Of course it
was not possible without an autopsy to say positively
that this patient had an aneurysm, but there is beyond
doubt a tumor in the mediastinum. There is nothing
on which to base a suspicion that it is of a malignant
character, while that it is an aneurysmal tumor is sug-
gested by the distinct repetition of the heart sounds
over this dull area. Over no other tumor is this repe-
tition:of heart-sounds found, nor has he ever seen \a case
'nor heard one reported in which this sign was present
and was not due to an aneurysm, so that this case showed
how insidiously an aneurysm can develop without ap-
parently any of the ordinary symptoms, especially with-
out pain.
He thought if the conclusion in this case proved cor-
rect it showed the importance of the pressure symp;
toms combined with the evidence of a tumor and also
the imporiance of the physical sign of the repetition of
CITY HOSPITAL ALUMNI. 253
the heart-sounds over the area occupied by the tumor in
the differential diagnosis between aneurysm and other
forms of tumor. In this case the diagnosis was made
on that sound combined with the evidences of pressure,
and it was made in the absence of other signs—such as
the bruit, pulsation, thrill, etc.
DR. HENRY JACOBSON asked if the pulses were both
equal, and if the a: ray had been tried.
DR. SMITH said the pulses were both equal. The a:
ray had not been tried but he expected to try it.
In reply to several questions Dr. Smith said the age
of the patient was 49 years, and that there was a history
of syphilis.
DR. GRINDON asked what proportion of all cases of
thoracic aneurysm he thought were due to syphilis.
DR SMITH said he could not give the ﬁgures, but they
were in the large majority. '
DR. BLISS asked if the pain in thoracic aneurysm was
not usually of the character of angina pectoris.
DR. SMITH said the pain, as he had observed cases,
was of the ordinary boring, persistent, constant charac-
ter, and not like angina pectoris.
THE PRESIDENT asked how long the case had been
developing. ‘
_ DR. SMITH said he could not say. The ﬁrst pressure
symptoms were noticed about ﬁve weeks ago. He thought
the tumor had been growing some time.
DR. FRANCIS L. REDER asked what treatment was
being pursued. ‘
DR. SMITH said he was giving the patient iodide Of
potassium, but he did not expect to do much with it in
the way of a permanent cure in this case. He said he
had tried it on several cases but without result.
DR. REDER asked if he would allow the sac to get
larger and then resort to the wiring treatment and elec-
tricity. ‘
DR SMITH said he would if the patient insisted on
being experimented with.
DR. REDER asked Dr. Smith if he did not regard the
254 MEDICAL SOCIETY OF
bruit too much, and whether he would not feel more
satisﬁed of the presence of an aneurysm if he heard
the bruit.
DR. SMITH said the presence of the bruit would not
materially alter his judgment of the case, for he had
found cases with this sign present and yet no aneurysm
was discovered.
THE PRESIDENT asked if only the ascending aorta
was involved.
DR. SMITH replied that it probably extended either
backward or downward from the transverse aorta so as
in some way to involve the left bronchus.
DR. P. J. HEUER said he thought it would be inter-
esting to have the patient brought before the Society.
DR. SMITH said he contemplated having him before
the Society later on.
STATED MEETING, THURSDAY EVENING, OCTOBER 20.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
_—
Passage of Darning Needle Armed With
Twine Through the Intestinal
Canal of a Young Dog.
BY GEO. HOMAN, M.D., ST. LOUIS.
About the middle Of last September while seeing a
patient who has ﬁne dogs he mentioned that a nine-
months-Old pointer puppy had just passed a large needle
armed with twine, or rather that one of his men, ob-
serving the string depending from the animal’s anus,
had by drawing on it succeeded in dislodging and re-
moving the foreign body from the bowel.
The needle was somewhat rusted, is of the kind used
in darning, and measures 2'/, inches in length—the
point having been broken off, whether before swallow-
ing or afterwards is not known. It is threaded with
bagging twine which was knotted together at the ends,
and, thus doubled, measures 21'/, inches in length.
CITY HOSPITAL ALUMNI. 255
It is the opinion of the owner that the dog swallowed
the foreign body about one month before it was re-
moved, as at times during that period, he had noticed
the animal with drawn ﬂanks, back bowed upward, and
evidently in pain. This condition was observed the day
before the needle was recovered, and a dose of castor
oil was given in the belief that the dog was suffering
with colic.
If the needle was swallowed in the blunted condition
it now presents of course its passage through the dog
was somewhat facilitated by the fact. The cord with
which it was armed shows the eﬁect of maceration, but
otherwise seems little changed. It is probable that the
string went in advance pulling the needle after it, but
there must have been an especially strong tug required
when it turned the corner of ileum avenue and colon
boulevard. The animal now appears to be in perfect
health.
Some Cases of Fracture of the Skull.
BY H. C. DALTON, MD., ST. LOUIS.
The few remarks I shall make on fractures of the
skull will be conﬁned to a report of some interesting
cases and a discussion as to‘the treatment of the same.
When I was a student at the Missouri Medical College,
our Professor of Surgery, Dr. Paul F. Eve, stated to
the class that 25 per cent of all cases of trephining died.
This remark referred to trephining for all causes. Such
results following the mere act of trephining would to-
day be justly considered gross malpractice.
When we consider the inattention to asepsis on the
part of operators of that day (1868) we are surprised
that the percentage of death was not greater. Neither
the surgeons’ hands, instruments nor ﬁeld of operation
were sterilized. To day, thanks to thorough aseptic
methods, we would feel culpable did a single patient
die from a simple exploratory trephining; in fact, we
256 MEDICAL SOCIETY OF
look upon such a procedure as practically devoid of
danger. .
On preparing a patient for an operation upon the head,
in addition to a strict observance of all the details of
asepsis, I insist that every particle of the hair shall be
removed. I am satisﬁed that I have seen cases in which
this was not done rendered septic duringthe operation.
In talking to a Society composed of members who
have all hadhospital experience, I am sure I can dismiss
the further consideration of asepsis. In choosing cases
to present this evening I have tried to get fairly good
examples of different varieties and present them in a
way to bring out some discussion on the subject. Some
of these cases were seen at the City Hospital some
years since, and doubtless some of you may remember
them. The treatment in each case was such as was at
that time in vogue; in the light of later experience I
should vary the treatment in some particulars.
CASE I.--Thomas M., Irish, admitted to the Hospital
December 22, 1891. One hour before admission he Was
struck on the head in a saloon row; besides numerous
bruises upon the scalp he had a slight depressed frac-
ture, about the size of 'a silver half dollar, over the
junction of the frontal and parietal bones, an inch to
the left of the median line. The fracture was at the
bottom of a large ragged wound. After thorough
cleansing, the wound. was lightly packed with iodo- '
form gauze, no attempt being made to raise the de
pressed fragments. The next day the wound was
sutured. He was discharged well January 8, 1892.
CASE II—RObert N., aged 25, American, white, ad-
mitted to the Hospital August 30, 1888. A large com-
pound depressed fracture was found on the left side, one
inch above and a little anterior to the mastoid process.
He was conscious but aphasic; he had great difﬁculty in
articulating words and in completing sentences which
he began without trouble; he could write no better than
he talked, showing apparently that he had a true word-
blindness. The scalp was turned back and the opening
CITY HOSPITAL ALUMNI. 257
in the bone enlarged. The dura was found lacerated
and the brain substance exuding. Upon recovering
consciousness the aphasia was gone. The wound was
packed with gauze for two days and then closed, leaving
catgut drainage only. He was discharged well Septem-
ber 14.
CASE III.-John B., German, aged 24, admitted Aug-
ust 20, 1891. There was a lacerated wound, three inches
long over the left parietal bone, and hemorrhage from
y the left ear; examination of the ear revealed a rupture
of the tympanic membrane beginning in the posterior
superior quadrant and running downward and forward
entirely across the membrane. Bleeding from the ear
continued all night. In twelve hours the patient was
perfectly conscious, complaining only of moderately
severe frontal headache. The scalp was sutured and an
antiseptic dressing applied, covering the ear. The pa-
tient remained well except for headache and an abnorm-
ally slow pulse; both symptoms, however, gradually im-
proved and disappeared after a few days. He was dis-
charged apparently well September 12.
CASE lV.--B. McC., Irish, aged 39, admitted May 9,
1887. The patient had fallen from a second story win-
dow upon a pile of stones; he was stunned but soon
regained consciousness. He sustained a Colles’ fracture
of both forearms, and a small lacerated wound over the
left eyebrow, at the bottom of which was found a frac-
ture of the skull. Upon enlarging the wound it was
discovered that not only was the perpendicular plate of
the frontal bone involved in the fracture but one ﬁssure
extended through the orbital plate into the base of the
skull, and another was traced as far as the external an-
gle of the bone, the two fragments inclosing a wedge-
shaped piece of bone which was sharply depressed. In
addition, there was great contusion of the face, extrav-
asation into the eyelids and free hemorrhage from the
nose and left car. It was considered inadvisable to
attempt to remove the depressed loOse bone, and it was
simply elevated to as near its normal position as possi-
258 MEDICAF SOCIETY OP
ble. The hemorrhage was controlled by packing; cold
applications were applied to the head and the pain re!
lieved by narcotics. The patient did well for a week,
when he complained of great headache, tinnitus aurium,
ﬂashes of light, etc. Unconsciousness soon developed,
which existed for ten days; he lost ﬂesh and strength
rapidly. Delirium at this time was noisy and violent,
but was usually of a low, muttering character. Incon-
tinence of urine and feces existed during this time; the
temperature was irregular, but not usually over two
degrees above the normal. He slept only when under
the inﬂuence of narcotics. Recovery was very slow,
but ﬁnally complete. _ -' '
These cases represent the different grades lof cranial
injury as well, I think, as could be done by any that
have come under my observation, and also Show the
diﬁerent‘methods of treatment employed.
The ﬁrst case illustrates that rather large class of
small depressed‘fractures which formerly were thought
to be safer without any other treatment except to guard
against infection. It was then thought if the fracture
was greatly depressed, or situated over the motor area
ofthe brain, further interference would be required.
At the present day, however, the weight of surgical
opinion would demand trephining in such cases. The
risk to the patient would have been but little increased
by the operation, and would have insured future safety
from untoward sequellae.
In the second patient we have a case of aphasia due
to pressure upon the special center relieved by prompt
surgical interference.
In the case of John B. we have an instance of proba-
ble fracture of the base with few symptoms and prompt
recovery.
In the last case we have a great amount of injury to
the base, with complete recovery.
The following cases have- occurred in my private
practice. ~
CASE V.-J. B., aged .32, was struck by a brick on
CITY HOSPITAL ALUMNI. 209
Pl
the left parietal bone on August 6, 1895. He was un-
conscious for an hour, after which he walked home, a
distance of several blocks. The wound extended to
the bone and was two inches in length; it was enlarged
and the bone inspected, but no fracture was found. The
next day the patient became delirious, the temperature
rose to 101°F., pulse 108 The wound was opened and
a button of bone removed. As there was no pulsation
of the brain the dura was slit open and about two ounces
of blood evacuated. A branch of the middle menin-
geal artery, which was bleeding, was tied with catgut,
and the dura closed by the same material. Recovery
was rapid and uneventful.
CASE VI --W. J., aged 21, while engaged in a family
ﬁght on January 6, 1897, received a blow on the right
parietal bone at its junction with the frontal bone. I
saw the case in consultation with Dr. Moore, in St.
Louis County, at 9 RM. As the light was poor we de;
layed the operation until next morning. A temporary
antiseptic dressing was applied. Upon my next visit I
learned that the patient had had several convulsions
during the night and had suffered great pain. Upon
enlarging the wound, which was two inches in length,
we discovered a sharply depressed fracture. A button
of bone was removed and the opening enlarged with
the rongeur forceps. The dura was lacerated and a
large blood clot was found underneath the same; this
was removed and the dura and the cutaneous wound
closed with catgut sutures. Recovery was rapid.
In reporting the above cases I have not attempted to
cover the entire ﬁeld of treatment of head injuries but
conﬁned my remarks to the treatment of the special
cases reported, believing that we can proﬁt more by
practical experience than by theoretical dissertation.
DISCUSSION.
DR. FRANCIS REDER said the subject of fractures of
the skull was always an interesting one, not alone be-
cause Of the fracture of the bone, but also because of
260 MEDICAL SOCIETY OF
the injury done to its underlying tissues, the brain sub
stance with its investing membranes. The diagnosis of
fracture of the skull is sometimes a difﬁcult matter,
especially when there is much ecchymosis, such a tame-
faction sometimes leading to the supposition that there
is a depressed fracture. He recalled two cases where
exploratory incisions were made in such cases, and no
fracture was found. In the more simple fractures, for
instance in ﬁssures,, where there are no cerebral symp-
toms, these cases frequently go undetected. Probably“
one of the most interesting fractures of the skull is that
known as contra coup. ‘ in
Dr. Dalton had mentioned several cases where it might
be expected such an injury existed, for instance a blow
on the side of the head on the parietal bone; this is a
favorable place. It, is necessary that the bone be broad
and resistant, in order to produce such a fracture, be-
cause the shock transmitted through the skull will gen-
erally cause the thinner portions to give way in prefer i
ence to the stronger portions, which received the force
direct.
Depressed fractures, the speaker said, are still treated
without interference—ysimply treating the symptoms.
Of course, as Dr. Dalton had said, where the symptoms
point to depression over the motor area, elevation
should be resorted to. There are frequent recoveries
with no bad results where such area is not involved.
He mentioned the case of a man who had been struck
on the head by a falling telegraph pole, causing a de-'
pressed fracture of the outer plate over the supercil-
iary ridge. There was profuse bleeding from the nose,
of a trickling character; it would check for a while and
then start again. He bled in this way for four days.
Shortly after the injury he was seized with convulsions
lasting several minutes. In an hour after the ﬁrst epi-
leptoid seizure he was again in a convulsion. Dr.
Reder advised operation. A piece of bone about an
inch long was ' removed; this piece of bone had been
detached from the vitreous plate, had penetrated
CITY HOSPITAL ALUMNI. 261
through the dura and lodged in the brain. The man re-
covered and remained in good health for a year and a
half. He was then again seized with epileptoid attacks
and these became as frequent as three or four a week.
Operation again performed and a button the size of a
quarter was removed. No thickening was found in the
dura, at the site of injury the dura was incised and a
wedge-shaped portion of the brain removed. The
wound was stitched and the man made a recovery.
This happy condition lasted for two years, when he
was again taken with epileptoid seizures. At present
he is emaciating rapidly. So far nothing more has
been done.
Another case was that of a man who fell from the
second-story of a building and lit upon his feet. He
immediately became unconscious, was taken to the City
Hospital and died 24 hours later. A diagnosis of frac-
ture of the base of the skull was made, though not
positively. The post mortem revealed a fracture at the
base, extending into the foramen magnum.
In ﬁssures at the base of the skull, the speaker said,
the signs to go by were: If in the anterior fossa, bleed~
ing (trickling) from the nose and the ecchymosis about
the orbital tissues, subcutaneous extravasation. If in the
middle fossa bleeding will be of an oozing nature from
the ear, or it may be the characteristic serous ﬂuid. If
in the posterior fossa, a diagnosis will be more obscure,
as there are but few signs that might be correctly inter-
preted.
In regard to the treatment he agreed with Dr. Dalton
that the shaving of the head, the application of cold,
rest, allaying of pain and restlessness by the use of
anodynes was about all that could be done, except
where the operation of trephining or elevation of the
depressed bone was indicated.
DR. NORVELLE WALLACE SHARPE said the cases cited
by Dr. Dalton were typical ones of the more ordinary
classes. The operation of trephining advised to day is
to be made with as large an opening as possible, a disc
262 MEDICAL SOCIETY or
of at least 1% inch to be removed, using the rongeur
forceps to subsequently secure such additional working
space as may be necessary. Some of the newer forms
of trephines are interesting and valuable. One invented
by a New York man is run by a dental engine, or elec-
tricity. It has a concavO-convex saw revolving over a
guard which will cut its way, after being started, and
the number of curves possible is almost unlimited.
One of the symptoms occasionally found in cases of .
fracture Of the skull, is the extravasation of the crebros
spinal ﬂuid in, or under, the tissues of the scalp, and
this is diagnostic. '
Reference to the ‘late trouble with Spain, the speaker
said, was possible in connection with gunshot wounds
of the head. He thought it rather unfortunate that our
naval medical men and. ofﬁcers accused the Spaniards
of mutilating the bodies of dead and injured Ameri-
cans at Guantanamo bay. As a matter of fact, it was
the usual effect of bullets of high velocity. Some inter--
esting experiments had been made recently of the effect
of bullets at a high velocity upon cavities, closed boxes
and cans, both ﬁlled and empty. The effect of a gun-
Shotv wound upon the abdominal cavity, thoracic cavity,
skull, bladder, stomach, heart, etc., organs, roughly
speaking, hollow, is primarily penetration, expansive
and explosive, and secondarily, collapsing. There is
' in all cases, primarily, a wave transmitted directly by
the bullet which, if immediately resisted, imperfectly,
by the organ or cavity wall, will be shown subsequently
to have pushed out the wall or side of the cavity oppo-
site to the point of entrance.
Then is brought into action the second wave which
starts centrally and radiates to the periphery. This is
a powerful force generated by the sudden injection of
a penetrative body of high velocity within a closed
cavity. (It may also be mentioned that the effect of
this second or expansive phase of the penetrative act,
is als'o noted in solid and semi-solid tissues, though not
as markedly as in hollow bodies). The result of this
CITY HOSPITAL ALUMNI. 263
phaseof penetration is to violently expand the walls.
This readily explains the tearing mutilation noted in
penetration by high velocity bullets. The effect is
seemingly disproportionately great to the comparatively
insigniﬁcant oﬁeding agent. The last event in this
cycle, is the collapsing or recoil wave which starts
peripherally, and neutralizes its actions. The effect of
of this wave is to bend inward the more or less rigid
walls of cavities. Boxes, cans, and such agents used
experimentally, If able to resist both the penetrative
and explosive force waves, are more or less collapsed
by this ﬁnal force dependent upon a number of agen-
cies, such as rigidity of walls, proportion of contents to
vessels, speed of missiles, etc. It is rare that a skull
can successfully withstand both phases of the penetra-
tive act, should it do so, we may expect the frag-
ments of fractured plates to be bent from without
inward.
In gunshot wounds of the skull there may be separation
of the sutures or a stellate fracture, centre coup. If the
ﬁrst and second phases of the penetrative act have no
effect, that is, are successfully resisted by the cavity
walls, then the return wave or recoil will almost cer-
tainly produce collapse of the skull as the walls of any
other cavity. ' ,
DR W. P. ROWLAND said he did not expect to dis-
cuss the paper, but, with the indulgence of the Society,
would speak of some of the diﬂiculties surrounding a
physician situated as he was, near the coal mines at
Bevier.
The great trouble he found was in getting an aseptic
wound because most of the patients were miners and
wounds were loaded down with coal dust. To one not
accustomed to this peculiar practice it might seem that
the wound could be cleanSed of this impurity, but with
. all the splendid teachings he had had at both school
and hospital he had been unable to get good results in
antisepsis, and the majority of injuries treated by him
had proved obstinate. He Stid he should never forget
264 ‘ MEDICAL SOCIETY OF
his ﬁrst case of fracture of the skull. The fracture was
apparent, and he trephinecl and treated the wound with
all the caution he found possible with antiseptic meas-
ures, yet pus formed in spite of all he did. This was
due, as. he afterward found, to the impossibilty of
cleansing the wound of all the particles. of coal dust.
But with this to ﬁght against, he said, good results
were yet obtained in most cases. Some cases, though
they are in the minority, unite by ﬁrst intention.
The speaker said he wanted to express his gratiﬁcai
tion at being able to meet with the Society. This was
his ﬁrst opportunity since leaving the city, although he
had often desired to be present. The loss of a day or
two, however, means much to a practicing physician,
especially a country physician. In his case most of the-
patients were such as seemed to need constant atten-
tion, and it was not easy to turn them over to another
physician as can be done in the city. Notwithstanding
this his desire was to be with the Society often. He...
had learned to love the State in which he lived, and
especially the City of St. Louis, and he felt that this
Society Was the nucleus from which would come much
to make the city noted.
DR. HENRY H. MUDD said he came in too late to
hear the paper, so he could not discuss it. In regard to
the symptoms of fracture of the base of the skull in the
posterior fossa, one of the symptoms which comes later
-—about the second to fourth day—is the extravasation
about the ear and low down in the neck following the
‘fascia of the muscles. his a difﬁcult matter to cleanse
a wound where the fracture was produced by a sub-
stance such as coal, or where the wound had been
rubbed in the ground. Rubbing the tissue with anti-
septic gauze might help, but it does not cleanse the
part thoroughly. Where these wounds occur, and
especially when in the ﬁbrous tissue—the fascia is
'not' very highly vascularized—he thought it might be
best to cut away the tissues, but even then, it is hard to
cleanse the wound. One comfort about such wounds
CITY HOSPITAL ALUMNI. 265
is, however, that the pus generated is not very virulent,
and the immediate danger of infecting the meninges is
not so-great as when the infection is more malignant.
If Dr. Rowland succeeds in getting his ﬁngers clean,
and the skin about the wound clean, he will, notwith-
standing coal dust, continue to secure the good results
he reports—though wounds may sometimes suppurate.
THE PRESIDENT asked if coal was necessarily septic.
DE. MUDD replied that it would act as a foreign body,
generating irritation, and in an open wound ultimately
beget suppuration.
DR. M. W. HOGE asked Dr. Dalton whether, after
trephining, he attempted to bring about reunion of the
bone that had been removed, or allowed the wound to
close simply by__the membrane. If only the membrane
covered the wound, he thought it a very weak 'place
and apt to be easily damaged. He mentioned the case
of an epileptic operated upon, and the wound allowed
to heal with only the membrane covering it. Later, in
an epileptic ﬁt, he fell from bed and was found dead.
Although there was nothing to indicate a brain injury,
yet the post mortem showed the man fell on the weak
spot in his skull, and died from a meningeal hemor-
rhage that ensued. ,
DE. DALTON said he never attempted to replace the
button of bone.
DR. REDER said he thought Dr. Dalton might have
found some fatal results had he reported more cases.
DE. DALTON said he could, of course, and a large
number of them with fatal results—in fact almost all
fractures of the base had been fatal, except the two re-
ported, and these were reported simply on account of
the rarity of recovery.
He said there was one symptom of fracture of the
skull where an operation is delayed, that was almost
pathognomonic; that was the edematous condition of
the scalp.
266 MEDICAL SoeiEtrY OF
A Case of Laryngeal Cancer.
BY CHARLES J. ORR, M.D., ST. LOUIS.
Malignant- growths of the larynx are usually divided-
into two classes, the epitheliomata and sarcomata. I
believe that all authorities agree that the epitheliomata
are of much more frequent occurrence than the sarco-
mata, and the statistics show a ratio of two to one of
the former. Primary carcinoma of the larynx is not a?
rare disease and is observed more often in male subjects.
The cases reported show a tendency for the left side to
be ﬁrst involved. Here, as elsewhere, the several types
of carcinoma exist but the epithelial and encephaloid
varieties predominates, the epithelial being more often
observed; all are attended by one- or more of the follow-
ing symptoms, viz, hoarseness, cough, expeetoration,
odor, hemorrhage, dysphagia, pain, enlarged lymphatics-
and general cachexia. \ .
The history of the patient from whom this larynx,
here shown, was removed, post-mortem, is as follows:
Mr. O., aged 53, American, widower; about 5 feet 7
inches in height, weight 150 pounds and rather robust
in appearance. He ﬁrst consulted me October 11, 1897 ,
complaining of hoarseness, that his voice tired quickly,
some slight dyspnea on making any unusual effort, some
slight soreness on swallowing solid food. He attributed
all his symptoms to having contracted a severe cold
some two months prior to his ﬁrst visit to me and stated -
that he had tried many simple remedies only to ﬁnd no
improvement. He denied ever having had syphilis and
Was sure his family was free from consumption or can-
cer. On further inquiry I found that his voice had
grown husky, after much talking, for a year past. The
external examination revealed .a greatly enlarged larynx,
but very uniform i appearance, no enlarged lymphatics,
not sensitive on manipulation, no cachexia was noticed.
The examination with the laryngoscope showed a
smooth pyriform swelling about the arytenoid (left) in-
CITY HOSPITAL ALUMNI. 267
volving the posterior portion of the false cord, a large
mass extending from the median line to the left phar-
yngeal wall and forward to the attachment of the epi-
glottis. The mucous membrane was of a dull grayish
hue, vocal cords slightly hyperemic, movement fairly
free. Absence of pain suggested a possible syphilitic
affection, and diagnosis was held in abeyance and the
patient was placed on antisyphilitic treatment. I also
wrote to the former attending physician regarding the
the patient’s previous health and family history. The
result of the treatment showed no change except grad-
iually. growing worse, and replies to my letters conﬁrmed
the patient’s statements _as above given.
October 20, the patient complained of having passed
a sleepless night owing to dyspnea and cough. I then
advised that he should enter the hospital, which he did.
During the night I was called and found him gasping
for breath and, upon examination, found the interior of
the larynx extremely edematous. I immediately scari-
ﬁed both sides over the arytenoids—the bleeding being
profuse—which gave great relief. He remained quite
comfortable for two days, when the dyspnea again be-
came alarming. and tracheotomy was performed. His
condition during the next four or'ﬁve days was very
trying, the cough being almost constant and he com-
plained of more or less pain about the canula. There
was profuse expectoration and great difﬁculty in expell-
ing it. Temperature ranged from 99 to 101.2°F._
Liquid nourishment only was given and always pro-
voked violent spasms of coughing. At the expiration
of a week he was much better and on the tenth day sat
up; at the end of the second week he was able to be up
and around the hospital and continued so to do until the
hour of his death, which occured December 10, from
asphyxia, brough on by the total obstruction of the
trachea by a clot of blood and mucus.
The patient was under observation about two months.
I was impressed by the extensive involvement of this
patieint’s larynx with the most dreaded disease and he
only conscious of having a bad cold.
26S MEDICAL SOCIETY OF
I call particular attention to the small amount of pain
since all authorities give it as a constant symptom in
such cases, and usually severe in character.
When not eating or coughing the patient suffered
absolutely no pain, and that on deglutition seemed
purely from mechanical obstruction.

DISCUSSION.
DR. HENRY JACOBSON said pain as a symptom of car-
cinoma was not constant, as Dr. Orr stated. The dis-'
ease might be very extensive without much pain. _
Especially had he found it to be the case in his line of
work, namely, rectal carcinoma.
DR. GREENFIELI) SLUDER said he had neticed the ab
sence of pain in carcinoma. In a case like the one un-
der discussion the question of removal naturally sug-
gested itself. If seen early enough, he thought removal
might be accomplished intra-laryngeal. Results by
such manipulation were often satisfactory. If seen ~
later half the larynx could be removed; this operation
had proved encouraging. He had seen a case operated
on by Prof. Billroth eight years before. The result
was quite all that could be expected. Cases are men-
tioned having lived ten or twelve years and ﬁnally dy-
ing of some other trouble. The operation for the re-
moval of the entire larynx was a much more serious
one. The patients are particularly-apt to die from an
aspiration pneumonia. '
DR. FRANCIS REDER said he thought a partial extir-
pation of the larynx when done early would be bene-
ﬁcial. The operation itself was not what might be
considerd one endangering life, while the surgical inter-
vention for the total extirpation of the larynx was a
very serious operation. Of ﬁve cases operated on dur-
ing his hospital experience, three for partial extirpation,
and two for total extirpation, two died—one of the
partially extirpated, and one of totally extirpated cases. .
The former succumbed to an attack of pleurisy, mani-
festing itself two weeks after complete recovery from
CITY HOSPITAL ALUMNI. 269
the operation, and the latter died from an attack of
pneumonia three weeks after the operation had been
performed.
Speaking of the anti syphilitic treatment of laryngeal
neoplasms, he said it was a singular fact that they will ,
improve under'such treatment for a time.
The fact that the case under discussion died from
suffocation produced by a clot in the canula, occluding
it, was interesting and emphasized the necessity of
closely watching these patients. One of the ﬁve cases
mentioned above, was found in a similar condition.
The patient was resuscitated with much difﬁculty.
DR. J. P. BRYSON said his observations had been
such as to indicate that little beneﬁt was to be derived
from anti syphilitic treatment in malignant diseases,
especially by the mixed treatment. He thought, too,
that hemorrhage was more apt to occur with anti syphi-
litic treatment, as he had observed that the parts seem
to become more vascular. In a case‘of epithelioma of
the recto vaginal septum, where the septum had been
extirpated, it was thought best to put the patient on
anti syphilitic treatment. The iodides alone were used,
and in 48 hours a bleeding occurred. This had not
been observed to occur before, and ceased on omitting
the'iodide. '
DR. HENRY H. MUDD asked Dr. Bryson if he thought
the use of the iodides for 48 hours had precipitated the
hemorrhage.
DR. BRYSON said he did not know. He would not
say it did, but that it had never occurred before.
Referring to the case under discussion, Dr. Mudd
said it was very interesting, and illustrated a class of
cases not uncommon. A peculiarity of the case was
that the inﬁltration should have become so marked
about the thyroid cartilage, should have extended out-
side of the larynx so much before the patient com-
plained. Ordinarily it is very considerable in an in-
trinsic growth of the larynx before the adjacent lymph
glands become involved. Where the growth is on
270 MEDICAL SOCIETY OF
the vocal chord it usually begins either on the anterior
or posterior extremity, and involves not only that
chord, but the tissues between that chord and the oppo-
site one. It is more frequently in the anterior than the
posterior. In those cases where the chord was involved
near the attachment the disease soon extended across
the median line, he said he would hesitate to trust to
extirpation through the larynx. Where it starts in the
middle of the chord, and is seen early, it might be
removed in that way, but it is the exception to ﬁnd a
case suitable for an operation through the larynx. His
experience in removal had been limited.
The Observations about pain in carcinoma were inter-
esting. They frequently develop to such a size as to
become serious without much pain. The patient will
come complaining of a growth evident to them only a
few days, perhaps, and observed more on account ofthe
change of the outside appearance than on account of
pain. That is true of hard and soft; true about the-
breast, the uterus and many other parts of the body;
the disease is often well advanced before the pain is
noticed. There are many exceptions. Some patients
come early with symptoms of pain before perceptible
development of carcinoma. But it is often seen that-
cases develop to quite a large size in many parts the
body without much pain. He mentioned the case of an
old woman under observation for some other trouble
who incidentally remarked that there was something
wrong with her breast. On examination he found the
breast almost gane—not more than a little l-um-p remain-
ing, which was easily removed. In this case there was
no pain at all. The last case of carcinoma of the larynx
_ he had was in an old man who had almost no pain.
DR. REDER said he thought it was Billroth who ﬁrst
advocated the extirpation of the larynx, and it was he
who put his patients on anti-syphilitic treatment before
resorting to surgical intervention.
DR. ORR, in closing, said the remarks of Dr. Mudd
only showed into what errors a limited experience was
CITY HOSPITAL ALUMNI. - 271
apt to lead one following the text of authors upon
a certain subject, because he, knew that most of the
literature upon the subject of carcinoma mentioned pain
as one of the most constant symptoms. In reply to Dr.
Heuer’s question, he said that no examination of
other parts of the body of this patient had been made,
and it was with some difﬁculty that the larynx was
obtained.
In regard to the treatment of this condition he felt
he was justiﬁed in this particular case in not doing
more as the growth was so extensive that nothing short
of complete excision would be of any beneﬁt to the pa-
tient. The early diagnosis of this condition he thought
was a difﬁcult matter, and even a microscopical examin-
ation often left one in doubt, as it does not always show
whether the tissue is benign or malignant in the early
stages. In the hands of careful and skillful men, able
to udge just how far the changes have gone on, how
much inﬁltration, how extensive the malignancy,
removal complete or partial may be safely attempted.
The operation itself is not so formidable but the con-
dition of the patient after removal of the larynx—the
~ difﬁculty of feeding, the danger to the respiratory organs
the frequent return of the growth, should justify conserv-
atism. The hemorrhage in the case reported he thought
was due to the granulations about the canula; these
were rather excessive and easily broken down. The
tube had been removed a number of times and always
showed unhealthy granulations about the wound.
'Oaustics were used to stop the oozing which gravitated
to the bronchus, but as the result showed, unsuccess-
fully.
Whether the extremities of the chords were ﬁrst in-
volved or not, he did not know.
DR. BRYsoN asked to what extent anti-syphilitic
treatment had been used, and what changes were
noticed.
DR. ORR said this treatment was used heroically for
two weeks, with apparently no beneﬁt; patient became
272 MEDICAL SOCIETY OF
slightly ptyalized, and the local symptOms seemed to
grow gradually worse. The iodides were used and
pushed.
Hereditary Human Cryptorchidism.
BY GEO. HOMAN, M.D., ST. LOUIS.
Two years ago there came under my professional ob-
servation an instance of cryptorchidism in the person of
A. B., aged about 40 years, the defect presenting itself
on the left side. A rudimentary or undeveloped testicle
was found imprisoned in the inguinal canal, and in the
course of questioning it appeared that the same physical
imperfection had been a feature in his family for sev-
eral generations, the known history beginning with the
maternal grandfather of the present subject.
He related that when a lad his attention was ﬁrst
directed to the peculiarity by this grandparent, the lat»,
ter calling the boy to him when the two were bathing
together, and after a careful examination, telling him
that they were alike in that the left testicle had not
come down, the deformity always manifesting itself on
the left side.
The mother of A. B. had one sister who had an only
child, alson, who was marked in this manner, the defect
sufﬁcing to exclude him from military service in France.
He has no known male issue. A. B. himself has had
two Children, both sons, by different mothers, in both of
whom the defeCt appeared—the eldest died at about
seven months of age, the other one is living and about
four years old.
A. B. has an only brother who is marked in the same
way, the only issue of this brother being a girl. He has
two sisters, the eldest having two children, both girls,
one of whom is married who has a son two years old
whose condition is not fully known but is believed to
be cryptorchid. The younger sister has three daughters
living, none of whom are married. She had several sons
CITY HOSPITAL ALUMNI. 273
who all died in infancy, and without inquiry as to‘jthis
feature being present in their persons.
Diagram illustrating the hereditary transmission of the Unilateral
Cryptorchid Condition, in direct and coliateral lines, in :the
family of A. B.
Generations:
T .... . .
A B’s mater-
n 2.1 g r a n d-
father


lMdterncl aunt
11....
A B’s mother No Uncles
AB'S AB’s AB's eldest


only youlvg'esl. SIS BEY IlI . . . . .. I25"- Slsfe_"_ _ 9n)\J_i_S$g -on| m ale
AB himself ISSUE; “3'19 "55“ zgiYlS QOUSH’I
lg"! 9H5 No females
NoKnov'm
ISSUQ
F -
Iv * . un c.med. _ _ uQm_¢i~_rIe8
A B’s 50.1.15 1).") “h lane ABEIEJ 0n|lys \SSUQ
\ S on
1 mos wiilemi—nSZQR. oil
ched in euﬂy \nj-ancg
eonikihtnn unKnown
v I I I I I. ( d _ _
(Collateral) _ ' — - ' ' _ — ' ' '
zyrs. old
Square mark denotes male, round female.
It will thus be seen that in every known generation
whenever males appeared this mark has unfailingly
shown itself in hereditary lines as direct as was possi-
ble where, obviously, only one sex could be aﬁected.
Indeed, from the known facts, so pronounced is the
transmission that the aboriginal progenitor may be said
274 MEDICAL SOCIETY OF
l
to have been prepotent, if to use this term does not im-
ply a paradox when applied to in‘heritable manifest
ﬂaws in development. ' -
The homologue of the testis is well known from em-
bryological evidence, but there can be no exact parallel-
in woman to undescended testicle, and no comparison
can be instituted as to the relative frequency of this
developmental abnormity, as would be possible in devi-
ations not affecting the sexual system, as harelip, poly-
dactylism, etc. Embryology teaches that the urinary
and sexual organs are derived from the two primary
germ-layers, and it rests with embryologists and pathol-
ogists to say whether structures thus derived are more
prone than others to hereditary inﬂuence, physiological
aberration, or pathological degeneration—certainly, the
efﬁcient causes of such anomalies must lie deeply placed
in the beginnings of embryonic life.
If this deformity were symmetrical it might perhaps
be viewed as a tendency toward reversion to lower or
ganic forms, it being well» known that in the largest
living mammals, both marine and terrestrial (whales,
elephants) the testes are permanently retained within
the abdominal cavity, lying below the kidneys, while in
marsupials, rodents, etc., the testes descend into the
scrotum only during the rutting season returning again
into the abdomen at its close. But these animals
branched off low down in the mammalian scale from the
stem followed by man in his evolution, they not repre-
senting the line of ascent culminating in the primates.
The entire natural history of the human sexual organs,
says Haeckel, affords the strongest proofs of the origin .
of man from the animal kingdom. “The general, and
the more intimate structure, the activity and the indi-
vidual evolution of the sexual organs, is exactly the
same in man as in apes. This is as true of the male as
of the female, of the internal as of the external geni-
talia. The differences in this matter between man and
the most man-like apes are far less than the diﬂEerences
between the various forms of apes.” He also asserts
CITY HOSPITAL ALUMNI. 275
that the higher the individual organism stands in the
.animal kingdom, the less completely does it reproduce
the entire series of its ancestors. This observation may,
perhaps, be~ understood in different ways by different
persons, but a fair interpretation should be that the con-
dition under consideration occurs more frequently among
the authropoids than in man, but whether or not this is
the fact,‘I have been unable to learn.
It has been claimed that the condition rests on the
principle (1) that the most highly specialized part or
function is most liable to vary, and, (2) that males are
more variable than females; but even if this betrue it
does not explain the ultimate cause of such malforma-
tions.
The persisting force of the progenital inﬂuence is
markedly shown in the cases' of the two sons of A. B.
by different mothers, and intermittent heredity is well
shown in that of his grand-nephew, the presumable at-
tenuation of the atavic impress having gone on through
four generations, and thus rather tending to disprove
the general belief that the son bears the maternal stamp,
rather than that of the father.
I have presented this subject only for the purpose of
illustrating some of the peculiarities of heredity and
showing how difﬁcult it is to understand its working.
Darwin in discussing inheritance says the whole subject
is wonderful, and that when a new character arises,
whatever its nature may be, it generally tends to be in-
herited sometimes in a most persistent manner. He
asks what can be more wonderful than that some triﬂing
peculiarity, not primordially attached to the 'species,
should be transmitted through the male or female sexual
cells, and afterwards through the incessant changes of a
long course of development undergone in the womb ulti-
mately appear in the offspring, as in the case of certain
diseases and deﬁciencies. He says further that when
we reﬂect on how imperfectly we understand the laws
governing inheritance, and bear in mind how much re-
mains to be discovered, we need not be surprised at the
276 MEDICAL SOCIETY OF ‘
intricate and to us unintelligible manner in which or-
ganic development has varied and will continue to vary.
. DISCUSSION.
DR HENRY JACOBSON said he had seen three cases
where only one testicle existed. In another case the sec-
ond testicle was lodged in the inguinal canal. In a case
at present under observation there is but one descended
testicle, but he told Dr. Jacobson that his brother had
two testicles. The speaker said he had never seen any-
thing so interesting as the hereditary condition reported
by Dr. Homan, as shown by the diagram.
DR BRYSON asked whether all the cases presented the
same features of undescended or partially descended
testicle.
DR. HOMAN said he had only come in contact with
A. B , and knew nothing personally about other mem-
. bers of the family. - In A. B.’s case there was an unde-
veloped testicle within the inguinal canal. He suffers
no inconvenience and seems to be of normal virility.
Longevity, fecundity, and virility in the family appeared
to be about the average. From something his grand-
father said A. B. thinks there was a like condition even
farther back in the family.
DR. BRYSON asked if there was any history of the
undescended testicle having been diseased.
DR. HOMAN said he had not been able to learn that
there was any such history.
DR. BRYSON said the subject was one of extreme in-
terest to him. The transit of the testis was a thing
hard to explain. We know it takes place, but the rea-
sons for it are diﬂicult to ﬁnd. It is not a descent, be-
cause it takes place in intra-uterine life and against
gravity. The relation of rodents to this condition was
interesting because the testes are in the sac only during
the rutting season, and ascend into the abdomen after
that season has passed. The question of transit must, of
course, have something to do with the development of
and function of the different portions of this apparatus.
CITY HOSPITAL ALUMNI. 277
The question of pressure on the testicle while intra-
abdominal is very important in connection with secre'
tion. The speaker said he had seen one case of total
’ cryptorchidism—neither testicle having descended. He
thought there was evidently a close relationship be-
tween the central nervous system and the testicle so far
as coitus is-concerned; even a small portion of a tes-
ticle with its relationship to the general nervous system
undisturbed will make a man virile. This was seen in the
cases of removal of one testicle and part of another.
He mentioned the case of. an old man under his care
and who was tuberculous. One testicle and part of the
other was removed, yet the man married a second time
and was capable of maintaining sexual relations as well
as any man of his age probably could do.
DR. HOMAN asked if Dr. Bryson, or other of the
members present, knew whether any authority takes
the view that the human testicles are complemental to
each other. In some of the lower forms of life (cirri-
pedes) thare are complemental males, it requiring the
co operation of two males to impregnate the female.
He had, however, always supposed that the human tes
ticles were functionally independent of each other.
DR. BRYSON said he did not know of any observa-
tions on that point; The removal of one testicle led,
according to the text-books, to the hypertrophy of the
opposite one, but he had never noticed this effect.
DR. HOMAN remarked that among country people he
had heard the term ridglin or rignal applied to horses,
either geldings or stallions, in which only one testis
had descended, and these animals were commonly ac-
counted to be of a more vicious nature than others in
whom such a peculiarity did not appear.
The term seems to be a corruption or abbreviation
of the word original, and this fact may posses a philo-
logic value as evidence pointing to the rise of man from
forms of life much lower in feature and function than
those with which he is now endowed.
To those who accept this view of the origin of man
278 MEDICAL SOCIETY OF
l
the- question must present itself: What was the outward
sign of the change of the ape-man into home—the
merging of the brute into the human, the dawn of rea-
son, conscience or moral nature in primitive man? The
answer would probably. be that this momentous transi-
tion was physically evidenced by the change of posture
in coitus from the ventro-dorsal to the ventro-ventral po-
sition, as such a posture would naturally follow a con
dition of permanent residence of these organs in the
scrotum as being attended with less risk of injury in
sexual intercourse, He added, that in diScussing this
subject with a medical friend, the latter mentioned that
in his own case during erection, and especially in the
act of coition, the testes were drawn almost within
the inguinal canal and were 'thus exposed to injury by
compression or concussion, of which fact he had had
painful experience.
STATED MEETING THURSDAY EVENING, NOVEMRER‘3.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

DR. GREENEIELD SLUDER reported a case of
Empyema of Frontal Sinus Secondary to
Abscess of Orbit.
\
The patient was brought before the Society and the
existence of an opening leading from the frontal sinus
into the right nostril, with. discharge of purulent mat-
ter, was demonstrated by Dr. Sluder.
DISCUSSION
DR. LOUIS C. BOISLINIERE said the case was unique
as far as he knew. In recent years this almost unknown
ﬁeld had been explored by rhinologists and great pro-
gress had been made, and any case which would throw
any light on this obscure subject he thought very valua-
ble. Undoubtedly many affections pertaining to these
different cavities had been entirely overlooked—many
CITY HOSPITAL ALUMNI. 279
severe headaches and many troubles most serious in
their results—and the advantages in this line would be
very great in the future. It would not anly enlarge the
ﬁeld of rhinology but would add a great deal to our
knowledge of those affections which had heretofore
been as a closed book. He felt much gratiﬁed to have
seen the case so beautifully put before the Society.
DR. M. HAYWARD POST said he had seen a case about
seven years ago with some features similar to the one
presented by Dr. Sluder. He had not expected to take
part in the discussion or he would have looked up the
points in the case. As near as he could remember they
were as follows:
Boy, aged 18 years, after camping out in the river
bottom was brought to the speaker for treatment. There
had been a gradual protrusion and divergence of the
right eye which was very marked when brought to
him. A large abscess formed pointing on the side of
the nose about half way between opening of the nasal
end of the palpebral commissure and the end of the nose
at which point it was lanced. Washing out with perox-
ide of hydrogen the ﬂuid passed into the nose and throat.
There was no indication of trouble in the nose. The
case progressed without any particular change for some
time until suddenly, after treatment, the eye slipped
back into place. The boy made a perfect recovery. Dr.
Charles assisted in this case. At that time there were
not the facilities for examining such cases as there are
at present, of which Dr. Sluder’s case received the
beneﬁt.
DR. FRANCIS REDER said he did not quite understand
to what extent the frontal sinus was involved. It was
not clear to him how, the abscess being post orbital, the
pus should ﬁnd its way along the ﬂoor of the orbit into
the nose. From anatomical relations we would expect
the pus to enter the antrum. Dr. Sluder states that he
made an exploration of the antrum but found no pus.
In what condition was the right lachrymal bone and to
what extent was the frontal sinus involved? The con-
280 MEDICAL SOCIETY OF
tinued pouring out of pus over a mucous membrane
would, to some extent, give rise to polypus growths;
for instance a chronic discharge from a diseased car will
frequently be the cause of numerous small polyps grow-
ing at the site of destroyed membrane and from the
middle car. This, however, he understood Dr. Sluder
to say, was not the case here.
DR. NORVELLE W. SHARPE asked why the sinus could
not be explored from the outside and treated as any
ordinary sinus would be treated—that is, by curettage,
packing, stimulating applications, etc., and Why such
treatment would not induce a satisfactory closing of
the sinus.
DR. SLUDER said in answer to Dr. Reder’s question
as to the involvement of the frontal sinus, it might
be better to preface his reply by outlining the lim
itations of the frontal sinus. The frontal sinus was
presumably never smaller than to be limited by the
orbital notch laterally and the superciliary ridge above.
As a matter of fact it is sometimes smaller than that,
although seldom, and frequently larger, sometimes run-
ning out to the angle of the frontal bone and much
higher up. Posteriorly it occupies the space between
the plates of the frontal bones as far back as the middle
of the orbit. Keeping in mind these limitations the
speaker thought it could readily be seen that there was
no great distance between the spaces. The cut was
made within the supra-orbital notch and the scar cov-
ered by the hair of the eye-brow so as to be invisible.
The ethmoid begins a little lower. It is not as large a
space as that made up by the frontal. In other words,
we cut across and involve the frontal bone so as to dis-
integrate and there is an opening through the upper
plate of the ethmoid.
In regard to the formation of polyps, Dr. Sluder said
he might have spoken of this in giving the history of
the case, but did not consider it necessary. Sixty per
cent of all polyps, he said, are supposed to be due to
disease of some one of the accessory cavities.
CITY HOSPITAL ALUMNI. 281
' DR. SHARPE asked why the sinus could not be explored
and dealt with surgically. '
DR. SLUDER said that had been thought of but Dr.
Ewing thought the result would be ﬁnally accomplished
by cleansing the orbit and keeping the opening free.
The sinus had been cleansed with peroxide of hydrogen
and for a stimulating application alcohol had ' been in-
jected. _
The picture which the case presents now shows an
enormous ﬁeld of nasal work in connection with the pus
oozing. Just enough pus pours out now to dry and form
a crust which decomposes and causes an offensive odor
identical with that seen in atrophic rhinitis. The foul-
smelling nose, he said, was familiar to everyone. It is
sometimes so bad as to be detected immediately on en-
tering the room and yet the case will not be genuine
atrophic rhinitis; and the prognosis is good if it has not
lasted too long. Even the chronic cases of empyemata
‘ are said to get well in the course of three or four years
by laying the caVIty open and treating as an open
wound.
STATED MEETING, THURSDAY EVENING, NOVEMBER 3.
THE PRESIDENT, DR GEO HOMAN, IN THE CHAIR.
DR. ELSWORTH SMITH read a paper on
The Treatment of Chronic Heart Disease
by the System of Medicated Baths,
Known as the Schott Method,
With Report of Cases.
DISCUSSION.
DR. G. BAUMGARTEN said he thanked the Society for
the courtesy extended him. He also thanked Dr. Smith
for inviting him to be present this evening and for the
able paper read by Dr. Smith.
282 MEDICAL SOCIETY OF
The subject was one of very considerable importance.
Hydrotherapy and mechanical measures were apt to be
neglected by practitioners in the routine of treatment.
The sole drawback to the Schott method was, evidently,
that it is difﬁcult to apply it in private practice under
ordinary circumstances. Especially the application of
the movements was diﬂicult to accomplish in private
practice. He was sorry Dr. Smith did not refer to
the management of the details. In hospitals it was,
of course, easy to train nurses to the proper perform-
ance ofv the movements. A point of value in the paper
was the demonstration of the effect of the continued
use of a small remedy, for the eﬁect of each single
bath could be only slight; it is the summing up of ef-
fects in the gradual training of the impaired heart not
only by the movements, but also by the baths, that
makes the heart able, after a while, to bear a great deal
more'work. This principle is applicable in a great
many cases of disease. The rationale of the treatment 3
had been very well presented by Dr. Smith, and the
speaker said he could readily understand Dr. McCand-
less’ attitude in one of the cases reported and his skep-
ticism of the result of stimulating the pneumogastric
nerve by means of a little salt added to the bath. The
value of the Schott method in treating heart disease
had come home to the speaker only since the report,
mentioned by Dr. Smith, of Dr. Camac published in
the Johns Hopkins Hospital Bulletin. He had had no
occasion to use the treatment since that time, so could
not speak from personal experience. But the use of
systematic muscular movements was a much valued
remedy with him, not only in heart diseases, but in
many other cases. He had, however, seldom used the '
movements with resistance, more often in the ordinary
way of gymnastic movements, causing a group of mus-
cles to contract to their full extent and repeating the
action a certain number of times, graduating the num
ber of movements as well as the force of the movement
according to the strength of the patient. For instance,
CITY HOSPITAL ALUMNI. 283
he might have the patient raise his body by means of
the gastrocnemius group as high as he could and then
gradually let it down again, repeating the action a num '
ber of times. Any muscular movement that could be
devised the patient is instructed to carry out to its full-
est extent. Many patients object to this sort of dis.-
cipline, because they say they get enough exercise. ,
Thus, one will say he walks to his Oﬂice every day. In
walking that distance, however, certain sets of muscles
are exercised in a routine way only, which does not by
any means have the desired effect. In walking, the
body is raised only just enough to clear the ground. To
render the movements useful in stimulating the circula-
tion and heart it is necessary to contract each acting
muscle to its full extent; it is only this which will give
the greatest amount of increased circulation with the
least amount of effort on the part of the muscles.
Therefore he was in the habit of telling patients who
objected to his directions that they would save much
time and strength by taking the cars and spending ﬁve
minutes at home in systematic exercise instead of
walking.
The great value of the Schott treatment, the speaker
said, consists in its being a method—a systematic appli-
cation of the remedial effects of the baths and the mus-
cular movements.
DR. JOHN P. BRYSON said he wanted to express his
pleasure in hearing Dr. Smith’s able paper and particu-
larly to have heard the principles upon which the treat-
ment is based so clearly enunciated. He considered
this a valuable feature of the paper. ,
There was one point, he said, to which Dr. Smith did
not allude and on which he hoped Dr. Smith would
speak later, namely, the necessity in these cases of sup-
plying the heart with blood, that is, having the blood
returned to the heart by way of the veins. The speaker
said he had had no experience in the treatment except in
connection with Dr. Smith in the sixth case reported.
This experience, was a very valuable and instructive
one, however.
28st MEDICAL SOCIETY OF
In regard to the previous history of the sixth case,
Dr. Bryson said all he could recall was that the onset
was quite sudden so far as the patient could remember.
The patient had been to some place of amusement, and
returning home, was suddenly seized with dyspnea on i
the street and had to be assisted. This occurred about
ﬁve months before he was seen by Dr. Bryson. He was a
very peculiar man, and perhaps there were many mani-
festations of which he took no notice. He grew worse
and consulted several :physicians who, doubtless, made
the correCt diagnosis, but who were not fortunate in
gaining his conﬁdence, so that his treatment must have
been very irregular. When ﬁrst seen by the speaker,
he was in a most distressing condition. He had been
a full week without any sleep and unable to assume the
recumbent position in that-time. He sat on the edge of
his bed, had a rapid pulse, was weak and had frequent
attacks of what appeared to be modiﬁed uremic convul-
sions. When ﬁrst seen the amount of urine passed for
the previous two or three days was not above ten ounces
per day and some days it was only six ounces. Edema
was considerable in the lower extremities, but the
dyspnea was the most distressing sympton. He was a
very stout man and no satisfactory examination of his
heart could be made, so that Dr. Bryson said he hesi-
tated to use an opiate, as he had desired to do from the
beginning. He had attempted to slow the heart by the
use of digitalis and improve the general condition by
proper diet; to increase the renal action by diuretin,
strontium lactate, small doses of mercury frequently re-
peated, but only with partial success. Some days the
urine would increase to as much as 25 ounces, but would
be only temporary and the patient seemed to be grow-
ing worse. Being anxious to afford some relief, especi-
ally to the dyspnea, he called in Dr. Smith to examine
the patient, especially with the view of administering
morphine. Dr. Smith agreed to this, and under mor-
phine, the patient obtained some sleep. Then Dr. Smith
suggested the use of the Schott method, to which the
CITY HOSPITAL ALUMNI. 285
speaker heartily agreed. The results he has stated
rather modestly in his paper. He would add to what
Dr. Smith had said that the edema of the lower ex~
tremities had been relieved in the beginning by ex-
tensive punctures by which large quantities of edemat-
ous ﬂuid had been drained away. The urinary secre
tion had been brought up to normal by the use of the
Schott treatment, and the patient was able to move
about and get in and out of the bath comfortably. The
speaker said he had no doubt this patient’s life could
have been prolonged many months, perhaps a year, or
even longer. The improvement in this man was main-
tained for some time, even after the treatment was dis-
continued, and after the services of Dr. Smith and the
speaker had been dispensed with. The patient left the
city and visited some Northern resort and was able to
attend to his business to a moderate extent and without
any further application of the baths and resisted move-
ments, so far as he knew.
Dr. JOSEPH GRINDON questioned the assertion made
in many text-books, that the coronary ateries were ﬁlled
during the pause. He believed the teaching today was
that these arteries were ﬁlled at the same time as other
arteries in the body.
Dr. Smith had spoken of nitroglycerine as dilating
the arterioles and in this way relieving the overloaded
heart. Dr. Grindon said this was, no doubt, a part of
the action of nitroglycerine, but it also acted directly
upon the heart itself increasing its force as well as
frequency.
The value of hyrotherapy in many diseases was un-
questioned. Some years ago he had his attention di-
rected to this matter very forciblv by some valuble ar-
ticles by Simon Baruch, of New York. Ideas which he
obtained at that time had since been put into practice
‘with good results. But he did not believe that the ad-
dition of chloride of sodium, or other salts, to the wa
ter in the baths, had the eﬁ'ects attributed to it He
thought the results, as far as the bath was concerned,
286 MEDIOAL SOCIETY ' or
were due to the water. He agreed with Dr. Smith in
believing that one of the most important ways of help-_
ing the lame heart was to improve its nutrition. The
baths do that in several ways. It was a fact that the
number ‘of erythrocytes could be brought up by a single -
bath. This had been demonstrated by taking a blood
count before and after. Then the bath restores the tone
of the arterioles. It might be said that the work of the
heart is increased in this way, but the chief obstruction
to the heart being at the valve, either through a leak or
a stenosis, and not at the periphery the total result
of increasing the resistance at the periphery is to help
the heart by increasing the general nutrition.
The increased ﬂow of urine would have the effect of
throwing off a larger amount of waste products, which is
an important item of the treatment. Especially so in
those diseases of the heart called functional, in which
the heart is suffering from the presence of waste
products which should be thrown 0ﬂ". He thought the
passive movements helped rid the system to a large ex-
tent of the leucomaines and alloxuric bodies which ac
cumulate in the blood, to which a variety of nervous
symptoms might be attributed, as particularly pointed
out by Ratchford, of Cincinnati.
Most of the cases quoted by Dr. Smith were, he
thought, very' favorable, and he felt that Dr. Smith
should not be discouraged. They were " cases which
would have died, probably, in a short time under any
circumstances andto get even a temporary improve-
ment was quite remarkable. In selected cases the treat‘
ment would undoubtedly give good results.
DR. M. W. Hoes: said he had seen most of the cases
reported, in connection with Dr. Smith, and conﬁrmed
his statements of the relief afforded. Several of the
cases were unable to lie down before the treatment was
begun, but after a few treatments they could do so com-
fortably.
DR. FRANK G. N IFONG emphasized the good of hy-
drotherapy and said one of the important points
CITY HOSPITAL ALUMNI. 287
brought out was the increased ﬂow of urine in these
cases. Several years ago he had noted in treating a
case of typhoid fever by baths that the urinary secre-
tion was much increased and in this way quite a good
deal of poisonous material eliminated. He thought it
probable that the skin absorbed much of the water.
Whether the result was due to increased action of the
heart or to osmosis, he could not say, but inclined to
think it was the latter.
DR. GRINDON, in corroboration of Dr. Nifong’s re-
marks, called attention to a very interesting article in
the American Journal of the Medical Sciences about two
months ago, which discussed this subject and showed
not only a total increase of urinary secretion but also
an increased elimination of urea by bathing in typhoid
fever.
DR. M. A. Buss said he thought Dr. Grindon was
mistaken in saying no beneﬁt was derived from the salt
in the bath. It was a fact that the addition of minerals
to the bath, and especially the chloride of sodium, had
a beneﬁcial effect on patients. This had been observed
in nervous conditions. He was unable to say just what
took place, but that the sedative effect of the bath was
undoubtedly increased by the addition of salt to the
water he knew from his own observation. He said Dr.
Fry often gave salt rubbings to a large number of pa-
tients. Of course, this was not exactly parallel to salt
baths and irritated the skin somewhat, but the feeling
- of well being and sedative effect of the bath was in-
creased by the addition of sodium chloride.
DR. BAUMGARTEN said he thought Dr. Grindon rad-
ically wrong in his remarks on the non-effect of salt in
the water. This matter had long ago been decided by
most accurate experiments, though, not being an expert
hydrotherapist, he was unable to quote details.
DR. BRYSON asked why, if absorption plays any part,
we do not get more effect from those salt solutions so
frequently introduced in the rectum and colon. In the
sixth case reported by Dr. Smith and seen together
288 MEDICAL SOCIETY 013‘
with him, large enemata had been given with hope of
thereby stimulating renal action, but the effect on the
kidneys was not noticeable.
DR. M. GEORGE GORIN asked whether age would not
play a prominent part in the selection of cases. Also,
whether in cases with marked arteriosclerosis the
bath alone would be used, or both the bath and the
movements. , _
DR. WILLIAM A. BROKAW said the question of age of
the patient had also suggested itself to him. He asked
whether Dr. Smith relied entirely upon the Schott
method, discarding all other treatment, or'did he use
the well-known aids to heart troubles when non com-
pensation was established, such as strychnia, digitalis,
etc. Was the result attributable entirely to the Schott
method?
DR. J OHN McH. DEAN said the case taken from the
City Hospital, and which made such marked improve-
ment, was one of mitral regurgitation, and had the pa
tient been more careful the improvement promised to
be much greater. The post-mortem conﬁrmed the
diagnosis.
DR. FRANCIS REDER said the paper was a very inter
esting one to him, for he knew very little of the prac-
tical application of the Schott method of baths. He
understood from the paper that the baths were given
with the object: First, of relieving the blood pressure;
and second, to remove waste products. In regard to
the effect of the baths he believed as Dr. Baumgarten
has said, that the beneﬁcial effect is due to a great ex-
tent to their systematic application.
It is not improbable that an organism subjected to
ordinary baths given with some regularity, would re~
spond so favorably to the Schott treatment, simply be-
cause this organism had become somewhat accustomed
to regular ablutions.
The beneﬁcial effect of a saline bath is undoubted.
Especially is this true when the percentage of salt is
deﬁnite and the temperature of the water is known to
CITY HOSPITAL ALUMNI. 289
a certainty, for results equally as good could certainly
not be expected from any bath at any hap hazard tem-
perature. '
The increased urinary secretion, as mentioned in one
case by Dr. Smith, he thought the usual effect of the
bath.
The cases where the most beneﬁt was hoped for he
thought should be under 35 years of age, as these cases
could be helped generally. How an aortic insuﬂiciency
or stenosis, or a mitral insufﬁciency or stenosis might
be cured, he confessed he could not understand. He
referred to those cases where the valve was tied down
and had become permanently impaired. In stenosis the
blood pressure being taken away of course would afford
some considerable relief and improvement but for how
long a time was questionable. In the old cases only a
tempOrary relief could be expected.
DR. NORVELLE WALLACE SHARPE asked if any sec-
tions had been made of the hearts of patients who died.
He suggested, that as Dr. Smith had had patients who
died, that the way to bring the results of the “Schott
method” to a scientiﬁc basis, would be to compare sec-
tions of the heart muscle at various stages of the treat-
ment, with both normal heart muscle ﬁbers and the well
known pathologic heart muscle found in similar stages
of the different diseases. Only by such method could
accurate estimation of the actual building up or repara-
tion process be estimated.
DR. SMITH, in closing, said he had hoped to get a
section of the heart muscle in one case, that of aortic in-
sufﬁciency where the amount of valve lesion was found,
post mortem, to be not enough to account for the great
break in compensation.
In regard to the question as to howa heart lesion was
cured, Dr. Smith said he spoke of a “cure” only in the
ense of securing to the heart the ability to do the work
in spite of the lesion. Dr. Reder’s remark that this was
possible only in the young was largely true, but, as said
in the paper, the whole question of prognosis in heart
290 MEDICAL SOCIETY OF
disease depends on the heart muscle. In a person past
middle life the heart muscle is apt to be in such a con-
dition that only a temporary relief is afforded, but this
relief would be for a length of time sufﬁcient to justify
the effort.
Dr. Smith said he wanted to thank Dr. Bryson for
his kind remarks about the paper. Also to thank Dr.
Hoge, who assisted him in many of the cases, and the
corps of physicians at the City Hospital, who aided him
in every way possible. ' '
In regard to the selection of the cases he said his idea
was to ﬁnd out whether this method possessed any
value beyond the remedies usually employed and for
that reason he had selected cases in which the ordinary
methods had failed in order to ascertain just how much
could be accomplished with this treatment. He said he
believed much better results could be Obtained in se-
lected cases, but it must be remembered that this treat-
ment is very onerous, both the baths and the move
ments, and patients are apt to object when called upon
to go through a routine of this kind, especially such a
man as the one seen with Dr. Bryson, a man who was
skeptical on everything and ready to object to any sug-
gestion made. The treatment would not, he thought,
supplant the ordinary remedies but would be an addi-
tion to them to be employed when the older methods
failed. .
In regard to the action of the salts, although his
knowledge of hydrotherapeutics was somewhat limited,
yet he believed there was virtue in the salts in the
water. The same result would not be obtained without
the salts. That substances could be absorbed by the
skin had been pretty well demonstrated, for instance,
in the use of mercury by inunction where the full effect .
is obtained, and he believed the same was true of salts
in the water. Schott claims the salts can enter the
skin through inﬁltration, but Dr. Smith said he was not
prepared to take any positive stand on this point. Of
course, he said, he agreed heartily with what Dr. Grin-
CITY HOSPITAL ALUMNI. 291
don and others had said in regard to the movements
playing an important part in the treatment. Their
beneﬁcial effect on the circulation made them a very
important factor.
In regard to the action of nitroglycerine as alluded to
by Dr. Grindon, Dr. Smith said be neglected to men-
tion the action of that drug, other than its vaso-motor
effect as he was at the time only alluding to its most
important action. rThat it does have a direct tonic
inﬂuence upon the heart is true besides its action as a
vaso motor dilator.
As to Whether the heart muscle receives its blood ,
during the systole or diastole his authority for his state-
ment was Dr. H. A. Hare, who distinctly states that
little or no blood gets into the coronary arteries during
the systole because of their oriﬁces being covered and
closed at that time by the aortic ﬂaps.
Another point he wanted to explain more clearly and
to beg pardon of Dr Bryson for not doing so early in
the paper. It was not his intention to attribute all the
good resulting in the case seen with Dr. Bryson to the
Schott method alone, nor, indeed, in any of the other
cases. The administration of morphine hypodermically
in the case of Dr. Bryson and the other remedies used
in the case undoubtedly contributed largely to the re-
sult, especially in securing to the patient rest at night.
His aim-was to take those cases in which the ordinary
methods had failed to give relief and, continuing that
treatment, add to it the baths and movements and
watch the results. If, during the course 'of treatment,
any other remedy was indicated that remedy was ad-
ministered.
As to the details of the movements, they are simply
to bring the principal muscles of the extremities and
trunk into action against a slight resistance. For in-
stance, the patient throws up his arm and the operator
holds it and against the resistance of ‘the operator the
patient attempts to replace his arm in its original posi-
tion. All the extremities and the trunk were exercised
in this manner.
292 MEDICAL SOCIETY on
STATED MEETING, THURSDAY EVENING, NOVEMBER 17.
THE PRESIDENT, DR. GEO HOMAN, IN THE CHAIR.

. DR. LOUIs H. BEHRENS presented a patient having
Aortic Regurgitation with Attendant Ste-
nosis and Mitral~ Regurgitant
Murmur.
The history was given as follows:
Patient, male, 36 years of age; occupation, glazier;
he was often compelled to lift boxes of glass weighing
100 pounds, or as much as a man could lift. He followed
this occupation for several years. He was also em
ployed on a moving van and frequently had to carry
heavy pieces of furniture up two and three ﬂights of
stairs. The family history is not reliable. No previ-
ous history of rheumatism or speciﬁc trouble. He is
the father of eight children, all healthy and with no
evidences of speciﬁc lesions. N 0 history of injury or
illness. Eleven years ago he was operated on for aneu~
rysm in the popliteal space. The patient was able to
attend to all his duties and was entirely ignorant of any
trouble about the heart. He had applied to Dr. Beh-
rens for examination in the latter’s capacity as examiner
for an insurance company, intending to take out a pol-
icy. It was at this examination the lesion was discov-
ered and the patient informed of his condition. To
induce him to go to the clinic Dr. Behrens informed
him he had heart trouble and said he desired watching
the case. This was the ﬁrst intimation the patient had
that his heart was in any way affected. Two years ago
a marked‘aortic regurgitation with stenotic murmur
with the ﬁrst sound was discovered, also mitral murmur
with each systole. No failure of compensation had
ever been noticed. The pulsation of the capillaries was
very marked; the apex beat very strong. Normally it
is in the ﬁfth interspace, an inch and a half below and
an inch to the right of the nipple; but in this case it is "
in the ﬁfth interspace and just below the nipple; rather
CITY HOSPITAL ALUMNI. 293
tremulous apex beat, indicating a marked hypertrophy
of the left ventricle. Dr. Behrens said he brought this
patient before the Society simply to show to what ex-
tent these lesions could exist without the patient being
aware of his condition. He had not treated the patient
medicinally.
DISCUSSION.
DR. BENNO BRIBACH said the case was very interest-
ing as showing what serious lesions may exist without
knowledge of them on the part of patients.
DR. L. DRECHSLER said he had seen a similar case in
a young man, 27 years of ' age, who had applied to him
for examination on an insurance policy. On examina-
tion an aortic regurgitation was found to exist. The
father of the young man accompanied him and when
told his son had heart trouble he became very indignant
and said the boy had been ahard worker all his life and
he never knew what sickness was. He,did not know he
had any trouble and had never been inconvenienced in
the least. He was employed in a brass foundry.
DR. CHARLES J. OER said he was glad to see this
case and considered it very interesting. The history of
the patient showed a popliteal aneurysm cured after
ligation. He asked how long ago this occurred.
DR. BEHRENS replied that it was eleven years ago.
DR. ORR asked if there was any history of a possible
injury to that artery precipitating the aneurysm.
DR. BEHRENS replied in the negative.
DR. ORR said he understood, of course, that the arts-
rial pressure was abnormally increaSed but he believed
there must have been either some injury, or a congeni-
tal condition producing a weakness of the walls of the
artery which resulted in the aneurysm. He thought the
man was fortunate in his occupation as the lesion being
probably congenital, had he been shielded in early life
and then later compelled to do hard manual labor, the
prognosis would not have been so good. He thought
there was no indication for treatment.
294 MEDICAL SOCIETY OF
DR. HoRACE W. SOPER said he thought these cases
were often looked upon too lightly in the matter of
V a prognosis. He recalled the case of a young man
with aortic regurgitation who went along for a year
without any break whatever in compensation. He was
an insurance agent and walked a great deal. One day
he had a slight attack of dyspepsia, compensation failed
rapidly and the man died in a week. He thought
the prognosis in aortic lesions should always be grave
even in congenital cases. When compensation once
fails he did not believe much could be doneto re.estab-
lish it
DR. M. A. BLISS said Dr. Soper’s remarks led him to
ask: What would occur if this patient had an attack
of pneumonia. The lesion was probably congenital but ‘
the hiStory did not show what would ensue if a severe
Strain was suddenly put on the system. His muscular
development had evidently been brought up from time
to time to meet the demands and in this way was the
heart muscle gradually made equal to do all the labor
called for. ‘
DR. GRINDON said the case strongly suggested syph-
ilis. The history of a sore twenty years ago and aneu-
rysm of the popliteal artery were very suspicious. How-
ever, Dr. Behrens had no doubt given this proper
weight and excluded it.
DR. BEHRENs, in closing, said he had had a case some
years ago of a young man who had articular rheumatism
at the age of 13 years and following this aortic regur-
gitation with over compensation at all times. In the
winter of 1896 he contracted pneumonia. The attack
acted like croupous pneumonia, the temperature being
as high as 105.5°F. The crisis occurred on the seventh
day. No extreme demands seemed to be made upon
the heart, and after the regular evolutions the patient
was treated at the clinic. To prove how careful the
physician should be in his prognosis, the young man
was able to be about and attend to all ordinary duties,
but would have occasional attacks of angina. During
CITY HOSPITAL ALUMNI. 295
the summer he attended a party where the game of
“please and displease” was being played. The question
was asked: ' “What would please you better?” to which
he replied that “Mary come and kiss me.” He sudden-
- 1y died, the excitement causing dilatation.
Another case, a clinic patient, 52 years of age, had a
heart lesion for many years. He was a hard worker and
the ﬁrst symptoms of failure of compensation were
noticed about a month before he came to the clinic.
Iodides and digitalis, as indicated, were administered,
but compensation steadily failed and the patient died.
In this case failure of compensation did not occur until
after the meridian of life was passed, though the lesion
had existed twenty years or more.
In regard to history of syphilis in the case before the
Society, Dr. Behrens said the man did give an indeﬁnite
history of a soft chancre twenty years ago, but there
was no secondary manifestations as far as could be
determined. He has a family of eight children, seven
boys and one girl (no history of miscarriages), and he
thought there would certainly be some indication
of the trouble in some of the children had the man had
syphilis. But the children were all in robust health
and without a sign of hereditary syphilis. He doubted
that the man had ever had a‘ speciﬁc lesion.

DR. PHILLIP HOPEMANN read a paper entitled
A Study of Acute Arthritis of Infants.
DISCUSSION.
DR. BENNO BRIBACH said Dr. Hoﬁmann was to be com-
plimented for bringing to the notice of the Society this
very interesting subject. It was certainly a rare affec-
tion or, if not rare, often overlooked. He did not re-
member that his attention had ever been called to this
particular disease, but thought he had seen a case of
this kind without recognizing it. The case was that of
a child 5 months old. The knee joint was affected and
296 MEDICAL SOCIETY OF
abscess suspected. It was lanced and pus came away,
evidently from the bone. The constitutional symptoms
were severe. The child made good recovery, though
witha stiﬁ joint for some time. Dr. Bribach was in-
clined to attribute the abscess to constitutional trouble.
A few years later the child was attacked with measles
and died. The microorganism causing this disease
must get into the system in some way and the thought
comes more and more to one that the reason some are
infected by these organisms when all are more or less
exposed to their inﬂuence, is dependent upon, the gen-
eral law of “the survival of the ﬁttest,” if this expres-
sion can be applied to these cases. He thought, too,
that these children probably had. some inherited, con-
genital weakness which made them prone to attack.
Later, he thought it probable that the large majority of
diseases would be properly classed as a “congenital in-
capacity for life.”
DR. B. M. HYPES said that he had been much inter-
ested in Dr. Hoﬁmann’s paper and that it emphasized a
very important subject.
Acute arthritis in infants, as reported by Dr. Hoff-
mann and others, must be a rather rare affection, as he
had not knowingly met with any such cases. In the ob-
servation of purulent affections of bones and joints, he
had been forced to the conclusion that these affections
are of septic origin, and are connected with or may fol-
low some disease or infection, the exact origin or nature
of which may not be recognized at the time.
That class of diseases, now recognized as infectious,
such as scarlatina, typhoid fever, pneumonia, etc., are
prone to joint infection and are frequently followed by
such manifestations, especially in children. There are
others, no doubt, in which the septic condition may be
latent in the child, such as tuberculosis, syphilis, etc.,
and which are only manifested after injury, sprain or
other debilitating inﬂuence, necessary to locate or bring
out the general systemic infection. He asked if Dr.
Hoffmann had found the tubercular bacillus in any of
his cases. -
CITY HOSPITAL ALUMNI. 297
As to the fact observed in most of these cases, that
the pus traveled through the bone to the adjacent joint,
he thought the explanation probably was that the soft-
ened bone structure offered less resistance to the bur-
rowing pus than the ﬁbrous periosteal covering sur-
rounding the bone.
But an important question presented itself in con-
nection with this affection, i.e., Why was this infec-
tious condition manifested, by preference, in the epi-
physeal development of the bone?
THE PRESIDENT mentioned that he had noticed re-
cently an account in a medical journal of an operative
procedure by a Scotch surgeon in acute rheumatism
and early manifestations of joint infection. He opened
the joint freely, washed it out and then immobilized the
limb. The results had been very satisfactory according
to the printed statement. In the article it was said
that the collection of ﬂuid was purulent in character,
and the speaker thought it_was a condition similar to
to, if not the same, as that ordinarily treated as articular
rheumatism.
DR. GRINDON said such a procedure had been prac
ticed in gonorrheal rheumatism.
DR. M. A. GOLDSTEIN said he thought the compara
tive etiology as portrayed in Dr. Hoﬁmann’s paper was
one of its important features and there was a certain
anology to the comparative obscurity surrounding the
class of diseases ordinarily called rheumatic. The fact
that diphtheria, scarlet fever, etc., play an important
part in this class of cases is emphasized by the essayist.
The speaker cited the fact that a large majority of
cases of acute articular rheumatism are reported to have
been preceded or succeeded by an attack of tonsillitis.
In a recent paper read before the St. Louis Medical So
ciety the essayist cited the interesting statement that
the ﬁve great avenues of infection were: the genito-
urinary system, respiratory organs, the digestive tract,
the skin, and the tonsil—grouping the tonsil, insigniﬁ-
cant as it is in size and function, with the four most im-
298 MEDICAL SOCIETY OF
portant systems in the body. The speaker said that it
was a fact that the tonsil played an important rule as
an avenue of infection, but whether the infection took
place through the lymphatic or the circulatory system
was still a question.
DR. HOFFMANN. in closing, said he did not lay special
stress upon the part the exanthemata played in the pro-
duction of the disease. Of the 102 cases he found re-
corded but few followed scarlet fever, measles or Small-
pox, and two followed whooping-cough. The rest did
not follow any of the infectious diseases. In the vast
majority of the cases, no source of infection could be
found.
In regard to the bacteriology, staphylo and strepto-
cocci, especially the staphylococcus aureus, had been
found most frequently when examinations had been
made. Those due to tubercle bacilli were a different
class of cases.
The disease usually occurred in children under 12
months. The oldest case recorded was 26 months. The
case mentioned by Dr. Bribach was very interesting, as
here the pus reached the surfaces without bursting into
the joint. This occurred oftener in older children, but
was not so common in a four months old infant, as Was
Dr. Bribach’s case.
Dr. M. A. GOLDS'TEIN reported
Some Interesting Cases in Rhinological
and Otological Practice.
DISCUSSION.
DR. CHARLES J. ORR said he had enjoyed hearing the
acccount of these interesting cases and could bear testi~
mony to the value of the galvano-cautery for overcom-
ing excessive bleeding. In one case recently he had
tried a number of styptics without success, and ﬁnally
he resorted to the galvano cautery which resulted in
controlling the hemorrhage.
CITY HOSPITAL ALUMNI. 299
DR. JOSEPH GRINDON said he would like to know the
character of the syphilic lesion spoken of in one of the
cases. Was it a primary lesion?
DR. NORVELLE WALLACE SHARPE said he had had
the pleasure, or misfortune, of observing the disastrous
effects of well-intentioned neighbors in attempting to
remove foreign bodies from the ear, as cited in cases by
Dr. Goldstein.
The paper also called attention to the widespread ef-
fects of a malign character which come from the so-
called “medical institutes.” He thought the people
comfortably situated in life, as noted by essayist, who
patronized these “institutions,” deserved all the adverse
effects derived from them, and in many cases, more
than they received. He said he had had occasion to see
two or three cases, in consultation, of severe hemor
rhage from the nose, in which the usual methods were
unsuccessful. It was possible that some of the members
present had not seen a severe hemorrhage from the nose.
It was not a joyous sight. A man bleeding for hours
is a pitiable object. The blood trickling. not only from
the anterior, but the posterior nares, the swallowing of
blood, the vomiting of blood, and afterward the passing
of blood, per rectum, prosented a woeful picture.
While it was true that the control of nasal hemor-
rhage was a difﬁcult matter, yet in another way, it was
a fortunate site for extreme hemorrhage, because the
cavity is bounded by comparatively unyielding walls.
He had been fortunate in controlling the hemorrhage
in the cases he had seen, not by the deft and delicate
manipulation of the specialist, but by the prosaic method
of packing. He had had occasion to use the Bellocq
canula in hospital practice, but in his hands it was not a
success. In one cae a simple gauze pack served; in
another, he used gauze saturated with peroxide of hy-
drogen, and in possibly the worst case of all; he had
used gauze saturated with the perchloride of iron. To
get the best use of the gauze it should be packed in
ﬁrmly, in spite of the positive suﬁering occasioned the
300 MEDICAL SOCIETY OF
patient. It should be packed from roof to ﬂoor, from
front to back, and packed hard. If this was done thor-
oughly he believed the majority of cases would be over-
come. If done as it should be done, he said it would
take from one to two hours to subsequently remove the
packing bit by bit. But it was necessary to be exceed-
ing careful in cases of a hemophilic character, because
there would often occur a secondary hemorrhage quite
as severe as the ﬁrst. He had never tried the galvano-
cautery, not being engaged in this special line, and
did not know how it worked, but the gauze packing
had been satisfactory as far as he had seen it used.
DR. W. A. BROKAW said he had seen the galvano-
cautery used in several cases and he considered it a use-
ful instrument, though he had seen perforation occur
from its use. In one case which he had cauterized the
patient returned the next day with a large slough at
that site. By treating daily and cleansing it, it ﬁnally
healed.
DR. LOUIS DRECHSLER said he had seen a case at the
City Hospital. The man was brought in about 11 o’clock
and bled for twelve hours. The nares were packed an-
teriorly and posteriorly. The packing came out about
2 o’clock in the morning and was replaced, but at 5
O’clock the same morning the man died.
DR. H. R. HALL said he noticed that a one per cent
solution of gelatin had been recommended as an effec-
tive hemostatic in epistaxis. He had seen one or two
cases of severe hemorrhage and witnessed the frequent
uselessness of the pack, and would like to know if any-
one had tried the gelatin as recomemded.
DR. GOLDSTEIN said, in closing, that the discussron had
been very interesting and many valuable questions had
been brought out.
Considerable interest has been centered in the subject
Of hemophilia. The literature does not especially refer
to the source of the transmission, whether from the
maternal or paternal side. The majority of hemophi-
lics are males. Fortunately so, as the very nature of
CITY HOSPITAL ALUMNI. 301
woman’s place as the mother of man would usually
kill her if she were a hemophilic.
In regard to the nature of the syphilitic lesion, he
said he was sorry he did not go into greater detail, but
he was not prepared to say it was a primary lesion. The
man had a distinct necrosis of the turbinated bones.
Dr. Sharpe had classed the medical institutes and free
clinics in the same category. The speaker expressed
himself emphatically against the institutes but did not
see anything against the free clinics; nor did he feel that
a patient misdirected to one of these institutes “deserved
all he got.” Well wishing friends, who know no better,
are usually responsible for the patient going there in the
ﬁrst place. The character and intelligence of the people
who have received treatment at these advertising insti-
tutes is surprising.
The Bellocq’s canula viewed in the present progressive
era is an instrument of past ages. The spring is hard
to handle and often the surface of the soft palate is
lacerated. Better results can be accomplished by the
use of the soft rubber catheter. The absolute useless-
ness of the gauze pack had been observed in the case of
hemophilia; no matter how densely packed anteriorly
and posteriorly, as soon as the blood reached the outer
surface of the pack the oozing began afresh. If the
blood would only clot there would be less difﬁculty, but
it does not; for that reason the suggested use of gelatin
or some oily substance is a good one. Dr. Berens, of
Philadelphia, advocates the use of wool tampons satur-
ated with liquid vaseline; this makes the substance of
the tampon impervious to the blood, and they have been
used successfully.
DR. GRINDON asked if the speaker meant an ordinary
soft rubber catheter to be used in the place of Bellocq’s
sound.
DR. GOLDSTEIN said yes; a simple velvet~rubber
catheter.
302 MEDICAL SOCIETY OF
STATED MEETING THURSDAY EVENING, DECEMBER 1.
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

A CASE OF GLYCOSURIA WITH ANOMALOUS SYMPTOMS.
DR. ELSWORTH SMITH reported a case which he had
had under observation and which he thought ought to
be interesting because of its anomalous symptoms.
About three months ago he was called to see a lady
50 years of age whom he had seen before and whom
his father had also had under his observation. This
woman had always enjoyed good health, having had only
some transient disturbances of no-serious nature. When
seen previously it was thought that her trouble was of
a gouty nature; she had some gouty manifestations in
the feet, not in the classic sites, but more in the smaller
joints of the tarsus, causing pain and tenderness in the
soles of the feet. This condition improved under diet
and medication, and she did well for a while, up to the '
time that he went away for the summer.
Upon his return to the city in the fall, he found her
under the care of Dr. Willis Hall; she had been con-
ﬁned to her bed for about one week and had been
troubled with pain in the course of the sciatic nerve.
She presented symptoms typical of sciatica. Dr. Hall
had this condition fairly well under control. When she,
gOt up she exhibited not only disability but also a good
deal of general debility, and, as she got better of the
pain, it was thought that there must be some underly-
ing condition to account for these symptoms. He went
over her very carefully and, of course, this included a
careful examination of the urine, which revealed quite
an amount of sugar, much to his surprise, as he had ex-
amined the urine before and had never detected a trace
of it.
This excited his suspicion, and he observed her care-
fully,for other symptoms of diabetes. He said he was
very 10th to make the diagnosis of diabetes which is, of
course, never justiﬁed from the mere presence of sugar
CITY HOSPITAL ALUMNI. 303
in the urine. The amount of sugar ran rather high,
nearly always up to four or ﬁve per cent, but the other
classic symptoms of diabetes were absolutely absent
with the two exceptions of “debility” and emaciation.
The patient who had weighed somewhere in the neigh-
borhood of 200 pounds, in the course of about a year
had dropped to 170 pounds. Patient thought this loss
in weight had occurred mainly in the last four months.
With the exception of this debility and the emaciation,
there were no other symptoms present. This patient
never observed, nor has she since, any increase in thirst
nor any increase in appetite, nor was there any polyu
ria. The twenty-four hours amount of urine was from
1,500 to 2,000 cc.
In spite of all treatment and medication this glyco-
- suria persists. The emaciation is not quite so rapid _
now. The amount of sugar is sometimes controlled by
diet and goes down to two per cent at times, but the
sugar is never absent entirely from the urine, and often
is present in a‘large amount. He thought the case was
interesting on account of the absence of so many of the
classic symptoms and he said that he had never en-
countered a case of this disease without polyuria, al-
though he had observed the absence of both increased
thirst or increased appetite. In fact, this patient eats
less than formerly, and drinks less water than she did.
This case goes to show how the diagnosis sometimes
has to be made without the characteristic symptom-
grouping. He based his diagnosis on the glycosuria
persisting in spite of all dieting and treatment, and
upon the progressive loss of ﬂesh and strength.
DR. JOHN C. FALK said that the mention of Dr.
Smith’s case recalled one which he had seen, present-
ing some of the features that Dr. Smith particularly
notes. This was a lady 68 years of age. She came to
‘ him about two years ago, complaining of gradually de-
veloping weakness, without any other deﬁnite symp-
toms. Her appetite was good, she had a normal thirst v
and there was nothing in her case pointing to polyuria.
304 MEDICAL SOCIETY OF
The speciﬁc gravity of her urine always ran up to 1,035
or 1,040. Sugar was present at that time. She was
put on a limited starch diet, without attempting to elim-
inate all carbOhydrate food. She did fairly well for a
time; was not seen for six months, when sugar was
again found. In the meantime she had dropped off
from her prescribed diet and was eating her usual food.
She drank less, or at least not more than she had previ-
ously. He could not get her to keep a record of the
quantity of urine passed, but she never would admit
that she passed any more than was normal, two to three
pints in twenty-four hours. She has been seen several
times since then by him, the last being about two
months ago, when her condition was about as one would
expect for a woman of her age. She has lost ﬁfteen
pounds in weight in the last two years. One year ago '
she had an attack of delirium which had a psychical
cause, i. e., she was disturbed about some domestic af-
fair which was the immediate exciting factor. He
thought that possibly the diabetes was causing cerebral
symptoms at that time, and a very grave prognosis was
made to the family. There has been no medicinal
treatment, except a tonic oceasionally, as a placebo.
DR. HORACE W. SOPER said that the narration of Dr.
Smith’s case called to his mind a case which he had had
under observation for the past two years. While the
symptoms are now all present, they were not sov when
the case ﬁrst came under his observation. A provisional
diagnosis of typhoid fever was ﬁrst made in this case.
The patient had been ill for several days with malaise,
delirium, continuous high fever and there was an ab-
sence of any deﬁnite symptoms excepting a very dry
tongue and a continuous high fever. There was some
distension of the abdomen and some tenderness in the
right iliac fossa. The urine was not examined until later,
when much pus was found. From the microscopical ex-
amination be regarded the case as one of cystitis. Urin-
alysis did not speak for any inﬂammatory renal trouble.
When a test was made for sugar, it was found to be
CITY HOSPITAL ALUMNI. 305
present in large quantity. She afterwards recovered
from the acute attack and gave a clear history of dia-
betes mellitus and developed polyuria and polydipsia.
He explained the presence of the continuous high fever
by the presence of the acute cystitis, and believed that
the cystitis was caused by the glycosuria. There was
i also eczema of the vulva, which was not observed until
later in the case. After trying several remedies the pa-
tient was put on opium and did very well. The poly-
uria disappeared and she got fat, but as soon as the
opium was stopped, the polyuria began and she lost
in weight. The amount of sugar has decreased since
she has been taking pulverized opium, of which she is
given six grains daily. "
DR. SMITH asked how long after Dr. Soper saw the
case the sugar appeared in the urine and how long after
the appearance of the sugar did he notice the appear-
ance of the classic symptoms.
DR. SOPER .replied that he had observed her two
weeks during which time he thought she had typhoid
fever. Examination of the blood did not show the ty-
‘phoid reaction. It was several weeks before she showed
the polyuria. She gave a previous history of polyuria
and polydipsia antedating‘ this attack three years.
DR. SMITH remarked that that case would hardly be
called a parallel one. The classic symptoms were there
but they were masked very much by the acute attack.
He then asked'Dr. Soper if he supposed the cystitis was
due to the diabetes and the high fever was due to the
cystitis, to which Dr. Soper replied in the aﬁimative.
DR. SMITH asked Dr. Falk whether he had had his
patient under continuous Observation.
DR. FALK replied that he had seen her in the begin-
ning three or four times in the course of two or three
months, and that he had seen her three or four times
since then. ‘
DR. SMITH said that he thought the latter case was
one of true diabetes, especially since Dr. Falk was
of that opinion. Of course, one of the requisites in the
306 MEDICAL SOCIETY OF
establishment of the diagnosis of true diabetes is the
demonstration of the continuous persistence of gly-
cosuria. There might be a period of accidental .
glycosuria, which would not mean a true diabetes.
In the case mentioned by the speaker, he believed that
it was a rare one. From the literature at hand, he
thought that the absence of all these symptoms was
rather rare. It is also rare for it to pursue such an
acute course in one of that age. It is known that when
true diabetes develops in a person past'rmiddle life, that
this course of the disease is apt to be chronic, while, if
it develops in a younger person than that, the course is
more apt to be acute, and the termination more rapidly
fatal. He treated this patient with opium but found
that codeine was more efﬁcacious, but even with opium
or codeine the amount of sugar could not be brought
down below two per cent.
DR. JOHN GREEN, JR. asked Dr. Smith whether he
had noted any changes in the lens in this case.
DR. CHARLES J. ORR said he wished to make a few
remarks in regard to the treatment in this disease.
Seven or eight years ago he was unfortunate enough to
have the disease in his own family, his mother being
the sufferer, and in this case the outcome was fatal. He
read extensively about the treatment and consulted the
profession. From his own knowledge and from con-
sultation he found that the disease was one which was
invariably bewildering in many ways ' as regards its
course and the eﬂiciency of the treatments which were
championed by the various authors and practitioners.
Subsequently, a man for whqm he had great respect as
_ regards his therapeutic ability, suggested salol, and it
was tried for a time. In this case and in another since
that time, it seemed to affect the course of the disease
most favorably. He wanted to know from the mem-
bers present whether they knew of any similar observa-
tfons concerning the use of salol in this particular dis-
ease. He said that sixty grains were given daily and
that it had a decided effect for three months, more
marked than opium.
CITY HOSPITAL ALUMNI. 307
THE PRESIDENT asked whether salol then lost its ef-
fect, to which Dr. Orr replied in the aﬂirmative. '
DR. FALK spoke of another case which, though not
having any direct bearing on the case related by Dr.
Smith, Still was interesting enough to deserve mention.
The patient, a farmer, aged 65 years, when ﬁrst seen
seven years ago, had a mastoid abscess which opened
spontaneously and was discharging pus from a sinus.
A free incision was made over the mastoid and a little
of the bone was chiseled out, without chloroform. It
i was then daily syringed out with bichloride Of mercury
solution. In the course of the ﬁrst few days of treat-
ment he called attention to some trouble with his
“urinary organs,” his complaint being that the penis
was sore. In theisearch for the cause of this, it was
found that he had glycosuria. His urine was heavily
loaded with sugar, it being present in the amount of
four per cent. The patientwas then warned to be can
tious about his diet. He was under treatment almost
daily for about two months. During these two months
it was found, from weekly examinations of the urine,
that there was a progressive decrease in the amount of
sugar in the urine and a corresponding decrease in the
polyuria and polydipsia, which were marked in this
case. All the symptoms subsided and when he was
discharged with the mastoid sinus practically healed,
there was only a trace of sugar in the urine. He went
to his home in a distant part of this State and was
heard of at intervals. He died six months ago with
symptoms (described by a lay member of his family)
, that point to diabetic coma. The interest in this case
lies in the question: Did the diabetes disappear entirely
during that interval or did it continue in mild degree
until the end came? At that time it was the speaker’s
opinion that the suppurating focus was theexciting
cause of the glycosuria.
DR. SMITH said that there were no evidences of cata-
ract in the case mentioned by him. He admitted, how-
ever, that the eyes had not been carefully examined,
308 MEDICAL SOCIETY OF
but said that he was satisﬁed that there were no patent
evidences of cataract.
The Care and Management of the
Pregnant Woman.
BY B. M. HYPES, MD., ST. LOUIS.
Those of you who take interest in Obstetrics are aware
that great advances have and are constantly being made
in its practice. I
As a branch of medical science it is moving forward,
hand in hand, with medicine and surgery. But that degree
of success has not yet been attained, which we, as con-
scientious and progressive physicians, should strive and
hope for. There is still too great a mortality connected
with the physiological act of childbearing.
A-sad feature of these deaths, too, is that many of
them are preventable. When we are told by Various
statistics that 7 per cent of women, who die during the
child-bearing period (from 20 to 50 years), succumb to
puerperal septicemia, and when we note the number
of mothers and children annually lost from lack of
proper care and attention during pregnancy, it demands
that we pause and reﬂect; that our methods of practice
should be revised; that, if need be, laws should be
enacted to restrain this slaughter of the innocents.
Pregnancy is a natural physiological function. In a
state of perfect health it Should be accomplished with-
out disease or suffering. But, as a matter Of fact, how
rarely do we meet such fortunate cases? So generally
is pregnancy associated with discomfort and illness,
that a celcbrated French obstetrician has called it, "‘a
nine months’ disease.” Nor is it to be wondered at that
women should suffer in this condition. Greater the
astonishment, considering the rapid developments of
her physical nature, that she does not suffer more. Un- I
der no other circumstances do such extensive changes]
in organs and functions take place in so short a time.
CITY HOSPITAL ALUMNI. 309
In the comparatively slow and few modiﬁcations, which
occur during the development of the girl into woman-
hood, we observe her not only suffering pain but espe-
cially liable to many and severe diseases. Again, at the
climacteric, do we ﬁnd woman disturbed in her func-
tions and prone to all sorts of affections. How much
more then must she be liable to suffering and disease
when undergoing the cyclonic changes of pregnancy?
And yet, she is ridiculed for complaining; and too often
a deaf ear is turned to her entreaties for help to bear
this most uncomfortable burden. Asking for bread, she
is given a stone. Yearning for help and sympathy, she
is turned coldly aside, by both friend and physician,
with the remark, “Oh, this is only the result of preg-
nancy; nothing can be done for you.”
In this disturbed and hypersensitive condition of
mind and body, how readily the overworked organs
pass the boundary line from exaggerated physiological
function to a pathological condition? and how often do
we ﬁnd the latent or mild forms Of disease, especially
-of kidneys, heart and nervous system, slowly and in-
sidiously develop most dangerous and uncontrollable
symptoms? But proper care and management will les-
sen, if not entirely relieve, the many discomforts of
pregnancy; and. timely medical advice will generally
ward off disease and prevent it assuming a dangerous
character. By skilled attention during pregnancy, not
only will gestation be more successfully accomplished,
but woman will be so strengthened and fortiﬁed for the
demands of labor, that its difﬁculties and fatalities will
be markedly lessened.
Now, gentlemen, if skilled management during preg-
nancy will lessen disease, and frequently prevent death;
if this same attention better ﬁts the woman to go through
labor, and assures a safer result to both mother and
child,~I beg to solemnly ask you, is the pregnant woman
to day_recei»ving the care and attention from her physi- ‘
cian that the importance of her case demands? I fear
not.
310 MEDICAL SOCIETY OF
My observation and experience leads me to infer that
this is a ﬁeld in obstetrical practice that needs cultiva-
tion by us, as physicians. “The laity, too, need educa- '
tion on .the importance of caring for women throughout
pregnancy, not only for her own sake, but as Plato has
expresse i it, “That she may successfully bear children
to the State.”
We may very properly go still further back and de-
mand that the girls, who are to be .the future mothers
of the cOuntry, should receive such care, training and
education, as will properly ﬁt them for, this noble and
responsible duty. They should be taught the simpler
laws Of hygiene—how to eat, to exercise, to care for
their bodies and minds, in order that they may develop
into healthy women. The hygienic surroundings of
every school, factory, store, and workshop, should be
supervised, to protect them from injury and abuse.
Who can more appropriately and successfully work out
this much needed reformation than the doctor, as family
physician, as member of the board of health, as advisor
to the board of education, and as public legislator?
The time limit of this paper will not allow the tempt-
ing consideration of these vastly important subjects, but
the mere suggestion of them, at this time, will, I hope,
cause the members of this inﬂuential Society to think,
to write, and to propose practical reforms along these'
lines. .
Now, in viewing this subject from a practical stand-
paint, the inquiry naturally arises, “In what does the
care of pregnant women consist?” and, “Can such a
practical course of management be adopted that it will
meet with the approbation of the profession, and be-
come a feature of our routine practice?”
The care of the pregnant woman. should begin with
conception. The laity ought to be taught, that when-
EVer a woman ﬁnds herself pregnant, she should at once
select an attendant physician and place herself under
his management and direction. This she does, not that she may be “dosed” with medicine, but that she
CITY HOSPITAL ALUMNI. 311
may receive advice and instruction as to the duties and
dangers of pregnancy, and that her physician may gain
such knowledge of her as will enable him to success-
fully manage both her pregnancy and labor.
The physician upon being consulted and engaged to
attend her, should thoroughly familiarize himself with
the patient’s personal and family history, with all dis-
eases suffered, with all difﬁculties in previous labors,
with all personal and family peculiarities and idiosyn-
crasies, so that he may ﬁt his instructions and medica-
tion to her individual case.
He should' then advise her in regard to her food, its
character, and when and how it should be taken; as to
bathing, and how performed; as to proper clothing, and
mode of wearing it; as to danger of constipation, and
means of prevention; as to bad effects of coitus, and the
necessity of its control; as to the care of breasts, so as
to ﬁt them for the new function of lactation; and of the
necessity, especially after the sixth month, of frequent
examinations of her urine.
She should be given certain danger signals, and should
be thoroughly impressed with the necessity of informing
him at once, of any abdominal pains, of any ﬂow of
blood from the vagina, of persistent headache or dizzi-
ness, of any epigastric pain, of nausea and vomiting late
in pregnancy, and of the ﬁrst appearance of edema. She
should be informed of the danger of lifting heavy '
weights, of reaching, of overexertion and of fatigue, of
riding over rough roads, and taking long railroad jour-
neys. . ._
At the seventh month he should make a careful physi-
cal examination, both external and vaginal, to determine
presentation and position of child, and to note any ab-
normalities which might seriously complicate both labor
and pregnancy. PelVimetry must be regarded as a most
necessary part of this physical examination.
Included in the care of the pregnant woman, is the
‘ timely attention to the disorders of pregnancy. In this
312 MEDICAL SOCIETY OF
way not only may her condition be made more comfort-
‘ able, but many serious consequences averted.
To this management of pregnancy I apprehend two
objections, i. e., ﬁrstly, it it unnecessary, as seldom does
a pregnant woman need medical attention; and secondly,
that it is impracticable. '
As to the ﬁrst—that it is unnecessary—let me reply
that the same'may be said of labor.
In a large percentage of conﬁnements, the physician
need merely stand by, and Nature will do the work.
But his presence is nevertheless demanded to attend
the natural as well as the diﬂicult cases, for-what? To
watch for dangerous delay to mother and child; to pro-
tectjthe perineum; to see that the secundines are all ex-
pelled; to prevent post partum hemorrhage; to assist
when Nature fails; in short, to prevent all evil conse-
quences to both mother and child.
Likewise, as a preventive measure, should his care of
pregnancy be to instruct the woman in hygienic laws;
to watch for the ﬁrst signs of disease, and to check it in
its incipiency; to correct abnormalities when possible;
to obtain valuable knowledge of condition of mother
and child. Thus forearmed, with prior knowledge of
the condition of the pregnant woman, he will anticipate
and be prepared to treat most successfully emergencies
that may arise during labor, and to lessen the unduly
large mortality of childbirth- Thorough acquaintance
with the woman, and properly directed treatment, both
before and during pregnancy, will check this great
stream of abortions to which we are almost daily called
upon to administer. Puerperal eclampsia, that dire
calamity of child bearing, is a preventable disease, and
will almost disappear from the records when women
are properly cared for during pregnancy. The brilliant
obstetrical and surgical records of the maternities are
greatly due to the fact that the women are under ob-
Servation and the abnormalities diagnosticated during
pregnancy, and because the most favorable time for op-
eration is taken advantage of.
CITY HOSPITAL ALUMNI. 313
For the above, and many other valid reasons, it seems
to me there is a necessity for such a care and manage-
ment of pregnancy as is suggested in this paper.
As to the second question—is it practicable? To this
I desire to answer most positively—yes. For several
years past this has been my practice, and rarely do I at-
tend labor cases, except in consultation, without having
had the patient under previous observation and man-
agement. I make it a practice to visit expectant cases
of labor; to make'frequent examinations of the urine;
to measure the pelves of all new customers; to note pre-
sentation and other conditions of child in utero; to gain
history and fortify patients against probable or- possible
diﬂiculties. The patients, too, seem pleased to receive
such extra professional attention, and willingly pay a
good round fee for the same.
In conclusion, I hope that every member of this SO-
ciety, who attends pregnant women, will consider
thoughtfully the suggestions of this paper; and if, in
the slightest degree, the practice of Obstetrics shall be
made more successful, the object of the writer will have
been attained. I

DISCUSSION.
DR. WILLIAM SHIRMER BARKER said that he felt
these excellent words were very timely and that it was
beﬁtting for all physicians to regard the importance
of this matter and that he hoped in this way the mor-
tality in such cases might be lessened and not only that,
but also that many of the severe sequela of pregnancy
could be prevented. There was a point which was al-
luded to, but not mentioned speciﬁcally in the paper
read, the advice to women to notify the attending
physician immediately on the appearance of any hem-
orrhage. He had several cases recently where this
advice was disregarded and where serious results fol-
lowed because the women did not think the discharge
of a few drop of blood signiﬁed anything. The prac-
ticability of these suggestions on the part of the physi-
314 . MEDICAL SOCIETY OF
cian he thought was fairly evident. The physician
ought to give more time to these cases, visiting them
occasionally, examining the urine and making measure-
ments. The practicability on the patient’s part was
not quite so evident. Where lack of means exists, as
in the case of the wives of laboring men, the proper
care can not be taken. They must do hard household
work when they should not do so. Where the advice
is given to do less work, the reply is: “Thework must
be done.” He said that he believed the bees give a
good example to homo sapz'ens in taking extreme care of
the “queen bee.”
DR. HORACE W. SOPER asked Dr. Hypes what meas-
ures should be taken to prevent puerperal eclampsia
when albumin was discovered in the urine. He said
that in one case he had found albumin in the urine dur-
ing the eighth month of pregnancy. He was much
disturbed about it, although the woman appeared to be
in good condition. In this case there was also slight
edema of the feet; all the functions were normal, so he
did not do anything and she did well during labor.
DR. ’M. GEORGE GORIN said that he recalled one case
of puerperal eclampsia which resulted fatally. A wo-
man was brought into the City Hospital in an uncon-
scious condition and was delivered with forceps. She
died and it was found at the autopsy that the kidneys
were contracted to one third then normal size. He said
that he also would like to ask Dr. Hypes what meas-
ures should be taken in a case of that kind and whether
the urinalysis should not be made before the sixth
month and at what time, if an abortion or premature
labor was deemed necessary, it should be performed in
such a case. .
DR. NORVELLE WALLACE SHARPE said that he felt
that he voiced the feeling of the members present, when
he stated that they had enjoyed the paper the essayist
had presented. Unfortunately, however, Dr. Hypes
had suggested his ideas in too general a fashion. I He
had spoken of “the care of the breasts,” “danger sig-
CITY HOSPITAL ALUMNI. . 310
F
nals,” “clothing,” “food,” and other topics in rather a
cursory manner. Contrary to the usual custom the So~
ciety had an abundance of time this evening and he
suggested that it would be wise to ask the essayist to
occupy this surplus time by giving more elaborately the
results of his observation and experience in this line of
work. He felt conﬁdent that if Dr. Hypes would in-
stance an ordinary caseof pregnancy, and starting with
its inception sketch out, in his characteristic manner,
the directions that he ordinarily employs, covering
these different topics more in ewtenso, that the Society
would appreciate it. By so doing, not only would the
essayist’s personal views be secured, but a valuable
comparison might be made between his routine meth
ods and those of other men who follow the same line
of work.
DR. FRANK HINCHEY said that he was very much in-
terested'in the paper, especially the ﬁrst'part, where at-
tention is called to the education of the prospective
mother looking toward the development of her phy»
sical condition. It seemed to him that, if it could be
done, the Woman should live more in accordance with
the laws of nature, just as the savage women do and so
pregnancy would be more of a physiological act. The
muscular system should be more. developed and there
should be no necessity of resorting to the use of the
forceps. Dr. Hypes referred to the great number of
deaths from puerperal septicemia, seven per cent. He
thought that hardly'came within the scope of the paper
but would come under the heading of duties during
labor. He tnought that this high death rate could be
reduced by regarding labor as more of a physiological
act and by resorting less to interference. He believed
that antiseptics were not used as much now as they
formerly were. The vagina contains germs, under
normal conditions, which are fatal to the germs of sep-
ticemia, and these protecting germs can be destroyed
by irrigation, etc., before labor. So it is now the cus-
tom to dispense with much of the irrigation, etc., that
316 MEDICAL SOCIETY on
we may not remove the natural barriers to the develop-
ment of sepsis. When he was at the Female Hospital,
it was the custom to use the antiseptic method a great
deal, in fact, every case was douched freely before and
after laber but he had better success since then by leav-
ing out these antiseptic measures. He treats it as a
physiologic act just as when a woman delivers herself.
or just as the lower animals do. He has noticed no
temperature rise under this treatment, as was quite
common with the mistaken use of antiseptics. Of
course, these were all simple cases where it was not
necessary to place the hand in the vagina. Where op.
erative interference was called for, it is then necessary
to use douches. He said that he has been convinced of
this especially since reading the work of Hirst, who
calls attention to the forethought of nature in placing
protecting bacteria in the vagina to destroy the injuri-
ous bacteria which seek to gain entrance.
DR. CHARLES J. ORR said that Dr. Hypes calledi‘at-
tention to the fact that the pregnant woman did not
receive the proper sympathy and thoughtfulness not
only of the family physician but also on the part of
members of the family, and that while it was a physio-
logic process, still a French obstretician called it the
“nine-months’ disease.” This recalled to his mind an
impression made on him recently. He believed that
this observation had been made before and that it is
not an unusual experience to note‘that there is shown
to the pregnant woman not enough sympathy which is
due her, and perhaps along this line there is a ﬁeld of
work for the 'physician in placing her in the proper
light before her husband, that the little ills and com-
plaints which she suffers are justly entitle to the proper
appreciation and that the members of her family should
not turn aside coldly, for while the process is primarily
a physiologic act, in the modern civilization it is not
strictly so. The modern duties—social, domestic or
otherwise—are so absorbing of their time and make it
impossible for these women to give the proper time to
CITY HOSPITAL ALUMNI. 317
rest, fresh air, exerciSe of the character needed. Con-
sequent upon this inactive or improper life they de
velop many pains and conditions which make them
more or less diseased during a large part of this period,
and if the physician would exercise greater care and
dilligence, he would at the same time arouse those
about him to the need of more thoughtfulness and
greater sympathy which would contribute much to a
successful termination of labor.
'DR. FRANCES L. BISHOP said that there was urgent
necessity for the early training and eduCation of young
women in order that they might take care of their
health in the proper way and prepare themselves for
their later motherhood. It is true that every child has
a right to be bOrn well, but it is also true that its an-
cestors must have been well for the previous two hun-
dred years. If girls were educated in hygiene properly
they would avoid many difﬁculties later on. She thought
that education in the schools should be more along
the line of hygiene. If the science of being and keep
' ing well were more carefully instilled into the early im-
pressions, the question of getting well later on would
be a far less serious one. The more modern ideas in
regard to the way of living properly should be taught.
She said that she would be glad to hear the more deﬁ
nite instructions which Dr. Hypes gives to his patients
_ in regard to the proper care of themselves.
DR. HYPES said that he thought preventive meas
ures-during pregnancy would express the subject‘matter
of the paper better than the care and management of
the pregnant woman. He has noticed that many of the
older practitioners, and many of those with but a lim-
ited obstetrical experience, treat pregnancy as a physi-
logic function and think that women need no assistance
from the physician, as regards theircare. But since
the Society was composed of young men who were “up”
in the etiology and pathology of disease and who leaned
to the side of the prevention of disease, he said that
pregnancy should be viewed as a physiologic function
318 MEDICAL SOCIETY OF
which is complicated with many disturbances and some-
times disease, and that, in order to care for the woman
properly during the period of pregnancy, it is well to
teach her not that she is a sick woman and that she
needs medicine, but that she should follow the instruc-
tions of the physician attending her, and that she must
keep well in order that she may develop a well child,
and that labor will be a much less dangerous condition
with these advantages.
The public are “getting on” to this matter. It has
been seen during the late war that the papers have crit-
icized, and unfavorably too, in many cases, the medical
management of the war. He asked why this was. He
said it was not on account of the death rate, which was
small, but because diseases were not prevented. SQ, in
the practice of obstetrics, the ﬁrst step is to impress
upon the minds of the profession the beneﬁts of and
the necessity for employing preventive measures in ‘
the management of pregnant women; the next step
would be the education of the laity up to this point,
which will be a comparatively easy matter. He knew‘
that Dr. Barker’s objection was a good one, that it is
hard for poor people to follow these strict instructions,
but it is not so much the -work of the poor woman
which brings on the abortion as it is the neglect of the
minor matters during her pregnancy, about which she
should be instructed by her physician. For instance,
when requested, almost invariably the husband comes
around with a sample of the urine, with the _name of
the woman upon a Slip of paper. They seem to be
pleased to do this, because they think that the physi-
cian is taking particular interest in their case and they
are more apt to have their wives taken care of. As a
consequence the physician is able to get out of these
people twice the fee that he formerly was in the habit
of getting, when he only made one or two visits after
labor. He thinks that this plan of calling attention to
these things should be considered by every physician.
He hoped that this paper would make physicians pres-
CITY HOSPITAL ALUMNI. 319
out more interested in their pregnancy cases, and
would make them exhibit more sympathy for them
and more interested in their disturbances, so that better
success might be obtained.
_As to Dr. Sharpe’s request for more deﬁniteness in
regard to the care of pregnant women, he said that it
would be impossible for him to be more deﬁnite in a
ten-minutes’ paper, such as he had read. He said that
many of the subjects suggested are worthy of an eve-
ning’s consideration.
He wanted to emphasize the point made in his paper
regarding the care and education of young girls prior
to marriage. Many young girls are now working in
factories and are subject to abuses to their constitutions
from their long hours of hard work and from the nature
of their employment. It is almost a crime that the big
stores and factories should require such work of im~
mature women whose bones are soft and whose pelves
are apt to be deformed by this over-strain. This has
been noticed in sewing women, who sit all day in the
large sewing rooms in the city. It modiﬁes their phy-
sical development and impairs their ability for healthy,
proper child-bearing. I
As this Society is interested in the hygiene of schools,
a great deal of work might be done there, and a very
interesting paper might be written on the care of the
children in the public schools. The children are over-
worked, especially in the High School, were the pupils
use their minds for six hours in the school room, and
then go home and are compelled to work an equal
number of hours at night. It does not develop their
minds but it weakens both body and mind, SO that
one half of them have to stop school as a result of the
over work which is put upon them. When he went
to school, he said, he had three studies to prepare
every day, and found it work enough; but recently,
he was informed by a little girl, who went to the High
School, that she had eleven studies to prepare daily.
320 MEDICAL SOCIETY OF
This over-work helps to impair the physical and the
mental development of these young girls.
He did not think it necessary to particularize upon
each point in his paper. It was his custom to let his
patients know that he wanted to look after them and
that he wanted them to ask him for advice when neces-
sary. He advised them in regard to their hygiene,
about lifting and oversexertion, and the avoidance of
anything tending to bring onabortion; and he especi-
ally cautions them about the danger-signals and that
they should inform him when they notice one. For ex
ample, the presence of blood discharging from the va-
gina may be the Sign of an abortion, placenta previa, or
a diseased condition of the uterus, and should be re-
ported at once. If she suffers with frontal headache,
she should report it, as it is a symptom of the obstet-
rical kidney and if left alone might result in puerperal
eclapsia. They should report any swelling of the hands
or feet, or any epigastric pain which latter is a pathog~
nomonic Sign of eclampsia, according to Olshausen.
The remarks just made may give Dr. Soper an an-
swer to his questiOn as to the prevention of eclampsia.
It is recognized in 90 per cent of the cases as con-
nected with insufﬁciency of the renal function. The
urine should be examined; and, with albumin in the
urine, or a lessening in the quantity of urine passed and
a deﬁciency in the normal amount of uric acid, with
casts present Such as hyaline, granular or epithelial,
then he will know that he has a renal trouble to deal
with. She should be put upon a strictly milk diet until
the albumInuria disappears. Pinard, of the Baudelocque
Hospital, of Paris, reported in 5,000 cases of pregnancy
not a single case of eclampsia, as the cases were all
treated by diet, etc. But the diet is only one thing.
The simple matter of proper clothing will prevent the
eclampsia in some cases. A woman suffers with albu-
minuria; she goes out, has the function of the skin
suppressed by being exposed to cold, there is a result
ant condition of congestion of the kidneys and then she
CITY HOSPITAL ALUMNI. 321
is thrown into an eclamptic ﬁt. Every pregnant woman
should have ﬂannel clothing.
Should the kidneys continue to functionate badly,
medicinal measures are necessary. Thorough catharsis,
thorough diuresis and thorough diaphoresis should be
the rule. These measures failing, and her symptoms
growing alarming, then it is proper and justiﬁable to
perform abortion, of course, with consultation. That
called to his mind a case which he had last summer,
where all‘the danger-signals existed and where all the
ordinary remedieé failed. A friend was called in con-
sultation, in the morning. He was told by the speaker
that abortion ought to be performed, but the consultant
hesitated because he did not know the woman. He
suggested a line of treatment. She was put upon it but
grew worse and the Doctor was called at the beginning
of ecIampSIa; she had twitching of the face, dyspnea
and suppression of urine. At 11 o’clock PM. of same
day consultation was made and the consultant ac-
quiesced ’at once that abortion should be induced.
Prior to the time he arrived, twenty minims of the
ﬂuid extract of veratrum viride was administered hy-
podermically, and she improved. On the next day,
when it was contended that operative interference
should be instituted, the family objected and both phys
sicians left the case. Another physician, of high stand-
ing, was called in, who was told what had been done
and what had been advised but he thought that he
could get along without producing abortion. He treated
her for two weeks, during which time he had several
other physicians in consultation with him. Finally it
was deemed best to produce an abortion. but the WC-
man died while they were'attempting to deliver her.
This was a case where he believed hesitancy caused the
woman’s death. These cases of eclampsia often may
be prevented by the proper dietary and by giving the
proper treatment. -
In regard to Dr. Gorin’s case, where the woman died
in the hospital, all efforts on the part of the physician
322 MEDICAL SOCIETY OF
would probably have been in vain as she had a con-
tracted kidney, which was not an acute condition. The
condition of pregnancy made her condition worse, but
with proper treatment and management abortion might
have prevented death for the time being only, as the
condition of contracted kidney is generally fatal, sooner
or later.
THE PRESIDENT asked Dr. Hypes to explain a little
more fully what was meant by the condition termed
obstetrical kidney.
DR. HYPES replied that it was a condition of over-
work; that there was no other organ of the body
charged with excreting so much of the remains of meta—
bolic change as the kidney; and especially was the
kidney over-worked in the pregnant woman on account
of having to excrete the effete material from both
the mother and child. So marked is this increased work
in excreting effete material from both the mother and
child, that an attack of eclampsia may be checked by
the death of the child. In other words, kidneys charged
with the excretion of the eﬁete material from both
mother and child, will often fail to do their work and
will precipitate an attack of eclampsia. This condition
disappears after pregnancy. It is a condition which
resembles the kidney in diphtheria, or in scarlet fever,
where it is due to a poisonous condition of the blood
which renders this organ ineﬂiment to eliminate all the
poisons.
DR. JOHN GREEN, JR. wanted to know whether urin-
alysis could serve to differentiate a condition of con-
tracted kidney from one of obstetrical kidney, and
whether that would not have some bearing on the
treatment.
DR. HYPES replied that, of course, the differentiation
could be made by the microscopic ﬁndings. In the ob-
stetrical kidney there are not found the more serious
forms of casts that are present in contracted kidney.
CITY HOSPITAL ALUMNI. 323
STATED MEETING THURSDAY EVENING, DECEMBER 15.
THE PRE-IDENT, DR. GEO. HOMAN IN THE CHAIR.

Report of a Case of Irritable Urinary
Bladder Relieved by Rapid
Dilatation of Urethra.
BY M GEORGE G'JRIN. M.D., Sl‘. LOUIS.
Widow, aged 54 years; occupation, school-teacher;
family history, negative; previous history, during child
hood, good health. Menstruation, normal. No disturb-
ance at menopause. After a forceps delivery some
twenty-ﬁveyears ago, suffered from urinary retention
and cystitis. This cystitis persisted for about three
months. At the time of her delivery she suﬂfered from
hemorrhoids which were removed by ligature the same
year. Subsequent health good, until a comparatively
recent period. During last few years has suffered from
recurring attacks of appendicitis.
Present trouble began during the summer of 1897,
when she complained of spasmodic dysuria and frequent
micturition. This trouble was not sufﬁciently severe as
to cause her to seek relief from her physician, but was
considerably aggravated when she resumed her work in
the fall. During the month of October she was seized
with an attack of appendicitis, which was treated palli-
atively and patient recovered sufﬁciently to resume her
duties at school after a month’s time.
During a subsequent attack of appendicitis, in Decem-
ber, dysuria became so pronounced and painful as to re-
sult in complete retention. Attempts at micturition
were attended with agonizing spasms, which were with
great diﬂ‘iculty subdued, or even palliated to any degree.
Catheterization was extremely painful. On examination,
. a sessile vascular growth was found at entrance of
urethra, and extending well back into the channel. On
consultation with Dr. Tuholske, it was decided to re-
324 MEDICAL SOCIETY OF
move this growth with curette 'and cautery. Patient
was anesthetized, the growth curetted, and base cauter-
ized with chromic acid (40 grains to the drachm). This
afforded great relief for about a week, when, after sep-
aration ofthe eschar, micturition again became painful
and vesical spasms returned. The sufferings of the pa»
tient were most intense. The usual remedies for relief
of the condition were tried, with little or no beneﬁt.
Catheterization had always to be preceded by injections
of oleate of cocaine into urethra, but even that seemed
to have but slight effect in quieting the pain. The so
called “tripod of treatment”——rest, opium, alkalies, was
tried faithfully. Various local applications were equally
ineffectual. The patient could obtain only comparative
case from the constant inﬂuence of morphia. When
this was discontinued the trouble again returned.
Urethral suppositories containing chloral hydrate, bis~
muth subnitrate and morphia sulphate were used with
some apparent beneﬁt for a time, but soon lost their
soothing effect. The patient was losing ground rapidly
from the constant strain, and it was evident that some-
thing must be done, and that quickly, to afford relief.
Two courses of treatment suggested themselves—one, to
buttonhole the bladder, thus giving the tender urethra
time to heal; the other, to dilate the urethra forcibly,
under anesthesia, thus overcoming the spasmodic action
of the vesical sphincter. The former course was strongly
objected to by the patient, and to my mind also pre-
sented no encouraging outlook. A Vesical ﬁstula as we
all know, is not- an easy matter to close when it becomes
necessary, and a permanent ﬁstula is by no means a
pleasant memento of surgical skill to leave with a pa-
tient. On the other hand, the possibility of a perma-
nent incontinence, in case the'urethra should be dilated
too forcibly, presented itelf. After careful considera-
tion, the latter method was chosen.
The patient was anesthetized and Kelly’s conical cali-
brator introduced into the urethra to the full extent. "
- This stretched the meatus to the diameter of 19 milli-
CITY HOSPITAL ’"ALUMNI. 325
meters. The calibrator having been removed, sizes 9,
10, 11 and 12 of the cylindrical urethral dIlators were
successively introduced, and lastly the foreﬁnger, care
being taken to thoroughly overcome the action of the
vesical sphincter. A small roll of iodoform gauze
anointed with carbolized vaseline was then introduced
well into the channel, and allowed to remain there for
eight hours.
At the end of this time the gauze was removed. Be,
yond a feeling of soreness, patient experienced no pain.
The spasms had entirely ceased. Patient could sleep
most of the night, which she had been unable to do for
several weeks previous. There was, however, almost
complete incontinence, and I felt no little anxiety as to
the ultimateTesult. Nevertheless, by degrees the blad-
_ der began to regain its normal tone, and within a week
after dilatation, involuntary passages of urine had
almost ceased. Occasionally, when the patient would
be sleeping, involuntary evacuation of the bladder
would occur. Within two weeks she could retain urine
for three hours at a time and pain on urination had en-
tirely ceased. '
Eight months have elapsed sinpe the operation and
none of the distressing bladder symptoms has returned.
The method of rapid dilatation of the female urethra
for relief of irritable bladder is by no means a recently
discovered one, but I believe has been resorted to more
generally by English surgeons than by Americans. Sir
James Simpson, shortly before his death, suggested to
Lawson Tait the advisability of creating vesico-vaginal
ﬁstulas in this class of cases in order to give rest and
drainage. In 1884, T. Pridgin Teale, of London, dis-
covered in a purely accidental manner, the eﬂicacy of
rapid dilatation of the urethra in producing the same
results. From an exploratory dilatation, to his very
great surprise, an obstinate cystitis of several years’
,duration was completely and permanently relieved.
During the next two years he treated successfully more
than thirty cases in the same manner. Heath and
326 MEDICAL SOCIETY OF
Hewetson also, shortly afterwards, reported several
cases treated with good results in the same manner.
Skene, in his recent work, refers to the record of the
English surgeons in this line, but does not mention the
operation. '1
Many radical measures have been devised for the re-
lief of chronic irritable bladder. Cushing, of San Fran-
cisco, recommends, in cases of obscure etiology, to lay
open the urethra from below in order more readily to ap-
ply topical treatment. Emmet is an enthusiastic advocate
of permanent drainage through a vesico-vaginal ﬁstula.
Kelly, in his recent most excellent work, cites several
cases cured by the application of ichthyol gelatin, 2 to
5 per cent, applied by means of Clark’s vesical balloon,
which is introduced into the bladder, and then inﬂated,
thus bringing into contact with the bladder walls the
medicament with which the balloon has been previously
smeared. For exploratory purposes, Kelly dilates the
urethra to 12 millimeters, as measured by his conical
calibrator. Dilatation to this extent, however, is not
sufﬁcient to overcome entirely the action of the sphinc-
ter muscles, the meatus being the only portion widely
dilated, owing to the conical shape of the instrument.
With regard to the method of irrigation, I believe that
the consensus of opinion is that it is of value only when
used with the utmost care to prevent over distention.
Such solutions as creolin 2 per cent, corrosive sublimate
1-100,000 down to 1—500, have been used with reported
_ success. The amount of ﬂuid'injected at one time, ac-
cording to Skene, should not exceed one ﬂuidounce.
The discussion of the applicability of the foregoing
methods to various conditions of the bladder is beyond the
scope of this paper. I wish only, in conclusion, to repeat
that all ordinary measures in the case reported had been
tried and found wholly ineffectual, and that dilatation
gave immediate and complete relief. From this result
and the successful published reports I believe this
method is one deserving a thorough trial before more '
radical measures are adopted.
CITY HOSPITAL ALUMNI. 327
Urinary Calcu1i.-With Report of Two
Cases, and Presentation of Specimens.
BY H. WHEELER BOND, M.D., ST. LOUIS.
It is not the purpose of this paper to enter into an
exhaustive study of urinary concretions, but rather to
review in a general way their direct etiology and his-
tory, in conjunction with a report of two cases, which I
trust may be of some interest to you.
Urinary calculi are formed in the kidneys and blad-
der by the aggregation and consolidation of certain
constituents of the urine which, under normal conditions,
the kidneys eliminate and the bladder ﬁnally expels.
In its normal condition urine contains about 90 per
cent of water in which are dissolved 10 per cent of or-
ganic and inorganic materials. The principal organic
substances are urea and uric acid. Of these uric acid
plays an important part in the formation of calculi, for,
although it exists in the proportion of only 1 in 1000 in
the urine, it enters into the formation of a great major-
ity of both renal and vesical stones.
The chief inorganic substances are sodium, potassium,
and magnesium, bases with which uric, sulphuric, and
phosphoric acids unite to form corresponding salts.
Normal urine also contains chlorides, mucus, and
epithelium, as well as many other organic and inorganic
substances of less importance which the lack of space
forbids the mention here. While these substances are
held in solution all is well; but when they form deposits
and their particles aggregate around a nucleus, stone is
the result. Urinary calculi are usually classiﬁed accord-
ing to their composition into the uric acid and uratic,
the phosphatic and calcareous, the oxalatic, cystine and
xanthine formations. Uratic stones are seldom pure,
and like some of the other more common forms, are
often made up of a number of these different substances.
In the majority of cases uric acid crystals form the cal-
cular nudleus, the crystals being held together by the
renal and vesical mucus. A drop of dried blood or a
328 MEDICAL SOCIETY OF
foreign body in the bladder is sometimes the nucleus.
Nuclei composed of uric acid or of oxalate of lime
are frequently found in the kidneys and increase in '
size as they lie in the renal tubules, its pelvis, or after
passing into the bladder. When composed entirely of
triple phosphates the calculi begin to form in the blad-
der and owe their origin to ammoniacal urine. Renal
calculi vary greatly in size, shape and number. Fre-
quently they are round, and so small and smooth that
they pass with ease through the ureter and are voided
in the urine. Others are rough and pointed with crys-
tals, so that on their passage they lacerate the delicate
lining of the urinary passages and cause it to bleed;
others are so large that they can not pass away from
the kidney, but, continuing to increase in Size, produce
one of the most distressing conditions which a human
being can be called upon to endure—exciting inﬂamma-
tion, stopping the ﬂow of urine, and bringing about the
destruction of the kidney itself.
A large proportion of cases of bladder-stone will be
found to have had their origin in the kidney. The pas-
sage of- the stone thence to the bladder is usually marked
by an attack of renal colic, and the patient will proba-
bly give a graphic description of a terrible attack.of
pain which occurred weeks or months previously, and
which was followed by freedom from suffering until
the bladder began to give trouble. Chronic cystitis
should excite suspicion of stone, for it may be either the
result or the cause of a calculus. The irritation set up
by a stone invariably produces cystitis. The existence
of cystitis, on the other hand, is attended with copious
secretion of mucus or muco-pus, affording the colloid
material which binds together the particles that form
the nucleus of a stone. Enlargement of the prostate is
another powerful predisposing cause, owing to the
changes which take place in the urine and in the blad-
der as a result of obstruction to the ﬂow of urine and
the consequence of that obstruction, viz., atony .and re
tention. For similar reasons inﬂammation or catarrh of
CITY HOSPITAL ALUMNI. 329
any part of the urinary tract is a predisposing cause of
stone. The lithemic subject, and persons who have
been suﬂfering from gout and rheumatism, are particu-
larly liable to urinary calculus, and a history of either
of these diseases should arouse our suspicion and receive
due consideration.
As regards age, childhood and advanced life afford
the largest number of cases.
Children suffer from uric acid, old men from phos-
phatic calculi. The over-indulgent youthful and mid-
dle-aged subjects are the most frequent sufferers from
oxalatic stones. Females, on account of the shortness
of the urethra, and the freedom from causes of obstruc-
tion, rarely suffer from stone in the bladder, and are
sufferers in only about 5 per cent of all cases of urin-
ary calculi.
CASE I.--A. G. 0., American, aged 51 years, lawyer,
married; no hereditary history; habits luxurious—a high
liver.
During childhood, in connection with an attack of
scarlatina, he had some involvement of the kidneys, and
twenty years ago he had a slight attack of hematuria,
which lasted only a few days.
Ten years ago he was awakened one morning by se-
vere pain in the renal region. It lasted about two hours
and suddenly abated, returning again the next day, and
after three hours again subsided. These attacks were
accompanied by hematuria. Another similar attack
occurred six years ago, which, after a week’s duration,
culminated in a severe renal colic, relieved only by
hypodermatics of morphine. A few weeks later the
hematuria rapidly increased to an alarming extent, the
urine becoming thick and almost pasty with blood. As
it was accompanied with a chill and fever, the physician
in attendance at that time gave him quinine, 25 grains
daily, shortly after which both fever and hematuria sub
sided. For some time before that renal calculus had
been Suspected and constant vigilance had been observed
to detect either it or.sandy particles in the urine. But,
330 MEDICAL SOCIETY OF '
failing in this, and considering the apparent relief
afforded by quinine, and also the fact that some years
previously he had had a severe attack of malarial fever,
it was concluded that his hematuria and pain were due
to the same trouble. While on a pleasure trip down the
St. Lawrence River in the summer of 1896, patient had
another attack of hematuria, with slight and poorly de-
ﬁned renal colic. Thip caused him to Visit White Sul
phur Springs where he spent several weeks. During
his stay there hematuria and pain were in less evidence,
and regardless of the fact that no fever accompanied
these phenomena, his physician there concurred with
him in the opinion that they were also of malarial ori-
gin. Soon after returning home the severity and fre-
quency of the attacks of colic and hematuria increased,
and patient consulted me early in October with refer-
ence to his case. The hemorrhages occurred with more
or less periodicity, appearing about once in four or ﬁve
days and usually between the hours of 1 and 6 o’clock
in the morning. The quantity of blood varied greatly but
was continuously visible from twelve to thirty-six hours
after each attack, following which there was usually an
interval of comparatively clear urine. Pain always pre-
ceded and accompanied the hematuria and varied in in-
tensity from a dull ache to sharp shooting paroxysms
through the ilio-lumbar region, extending into the scro-
tum and down the thigh. The colic was conﬁned to the
left side and the more severe attacks were frequently
accompanied by rigors and cold sweating. Fever was
never present. Repeated urinalysis revealed the con-
stant presence of blood in varying quantities, and a
relatively large number of calcium oxalate crystals
which showed a tendency to cluster. Urine was other-
wise normal, but was passed frequently and in small
quantities.
I placed the patient on anti lithemic remedies—lithia
waters, etc., and a rigid diet, with suﬂicient quantity of
morphia to relieve the pain at night.
After a short perioi'd of such treatment a mulberry
CITY HOSPITAL ALUMNI. 331
oxalate calculus the size of a large grape seed was
passed per urethram. Immediately preceding the pass-
age of the stone patient had a severe attack of colic and
hematuria, both of which terminated abruptly. Since
then, with the exception of times when he oversteps the
bounds of moderation in diet, increasing his lithemic
state and bringing on oxaluric crystals with urinary irri-
tability and other symptoms of a similar kind, he has
been well and free from hematuria and pain.
On several occasions during the last two years it has
been clearly demonstrated in this case that the patient’s
diet has a great inﬂuence upon his urinary symptoms
and general health. My experience with his and similar
cases give me positive assurance that the lithemic state
is often the “cause, not only of renal calculus, but of irri-
tability or even inﬂammatory changes in the genito
urinary tract.
CASE II.--A. B. K., aged 42 years, American, sleep-
ing-car conductor; family history good, both parents
being still alive, healthy and active. Patient had measles
and searlatina in childhood and gonorrhea once in early
manhood. For the last twenty years or more he has been
rather a high liver and an excessive drinker, going on
frequent periodical debauches. Seven years ago he was
treated for a week or so for, what his physician termed,
irritability of the bladder. During that time micturition
was frequent and the quantity of urine small. The ﬂow
of urine was occasionally completely shut oﬁ during
urination as from the sudden closure of the urethra.
Otherwise his health has been excellent. Patient con-
sulted me in December, 1897 , complaining of irritability
of his bladder, stating that his suﬁering was much
aggravated by the motion of his car, and that he was
compelled to get up once or twice at night to void small
quantities of urine. The character of his pain was that
of a dull aching sensation about the neck of his bladder
and at the “fossa navicularis” of the urethra with more
or less frequent sharp shooting pains terminating at the
latter point. These pains were always increased by
332 lVIEDICAL SOCIETY OF
physical activity and vesical tenesmus was quite marked
at the end of micturition.
Urinalysis revealed a neutral reaction, 1/,0 of 1 per
cent of albumen, a considerable quantity of pus, blood
cells, bladder epithelium and mucus. Pure blood in
small quantities was occasionally observed immediately
I after urination. Urine in other respects showed no va-_
riation from the normal. A No. 30 F. sound was easily
admitted by the urethra, although it, as well as a No.
16 soft catheter, met with considerable resistance at the
prostate. Their passage through the prostatic urethra
I occasioned considerable pain and tenesmus which lasted
for only a few seconds, the latter of which explains the ap-
parent obstruction. Urine stream was of normal size and
conformation, and palpation of the prostate per rectum ‘
revealed no hypertrophy. On introducing Andrews’
searcher, a stone, evidently of considerable size, was
felt lying in its nest at the base of the bladder. It was
movable and could be indeﬁnitely felt by rectal palpa-
tion. After a few weeks preparatory treatment, look-
ing to beth his general condition and that of his blad-
der, patient was sent to hospital. On the morning of
January 3, I operated for removal of the stone, selecting
the suprapubic operation in preference to the perineal,
because of the apparently large size of the stone, the
minimum risk of inﬂicting serious injury to the bladder
appendages and because in careful hands the drainage
may be made equally as good. The parietal incision,
three inches in length, was made in the usual way, the
margins separated by ﬂat retractors, the bladder lifted
gently by a sharp hook inserted at each angle of the
wound and incised. On inserting my ﬁnger I found the
stone to be of large size, and seizing it with lithotomy
forceps lifted it out. The margins of the bladder-wound
being secured by silk ligatures, the bladder was thor-
oughly irrigated, a rubber drainage tube inserted, the
wound left wide open and dressed with an abundance of
gauze and cotton. The skin immediately surrounding
the wound was kept anointed with unguentine to pre-
CITY HOSPITAL ALUMNI. 383
vent scariﬁcation and the dressings Were renewed when-
ever saturated.
Patient’s convalescence was perfect, the drainage tube
being removed on the thirteenth day and the wound clos-
ing to vesical drainage on the nineteenth day after op-
eration. Patient was discharged from the hospital on
the twenty-sixth day, the wound being completely
closed with exception of the cutaneous covering about
the size of a ten cent piece. The seven days following
sufﬁced to complete the skin closure and patient was
discharged as well and resumed his former occupation.
His urine, after the operation and ﬁnal irrigations of the
bladder, which were continued daily through the drain-
age tube until its removal, was completely free of pus
and mucus, and at the time of his discharge from the
hospital urinalysis showed it to be normal both in quan‘
tity and constituency. No pain or tenesmus has been
in evidence since the day of the operation and patient
is, to all appearances, in perfect health. '
The calculus is of the ammonio—magnesian phosphate
and phosphate of lime variety with a probable uric acid
nucleus. Its shape is almost precisely that of a porcelain
door-knob, measures 15.5 cm. in. its greatest circumfer-
ence, and weighs 78 grms.
Judging from the history of this case and the large
size of the stone, it is evident that the patient carried it
in his bladder for at least six or seven years prior to its
removal. When patient consulted me he had suﬁered
absolutely none from his trouble up to the ﬁve or six
weeks immediately preceding, except for the few weeks
seven years previously already mentioned.
It is quite remarkable that so sensitive and active an
organ as the bladder should assume such a degree of
tolerance for a calculus until its growth should reach
such large proportions, and the fact stands out in vivid
and striking contrast to the great physical suffering
occasioned by the passage of the renal stone herein re-
ported.
334 MEDICAL SOCIETY OF
mscussron OF THE TWO PRECEDING PAPERS.
DR. H. JACOBSON asked Dr. Bond if the stone was
encysted.
DR. BOND replied that it was not. ,
DR. Jnconsorr said he was sorry he did not hear the
entire paper. An encysted stone does not cause trouble
because the stone does not come in contact with the
delicate mucous membrane during contraction of the
bladder walls. ' He asked which operation was per-
formed.
DR. BOND said the suprapubic.
DR. J ACOBSON said there were several ways of remov-
ing stones from the bladder and among them was the
crushing method. This answers except in cases of
young children where the stone is small or when there
is an enlarged prostate present. In that case two oper-
ations would probably have to be done at one time.
The suprapubic would then be the best because the op-
erator can see what is being done and can also ascertain
what portion of the prostate it might be necessary to
remove. 4
DR. CHARLES SHATTINGER asked Dr. Bond why he
did not suture the bladderin this case. He did not
understand that there was any cystitis present.
DB. NORVELLE W. SHARPE said he thought Dr. Bond
was quite justiﬁed in the suprapubic incision. He con-
sidered it preferable. He could see no advantage in
going through the rigid perineum when the suprapubic
operation was manifestly the more convenient mode of
ingress. The point made by Dr. Shattinger was worthy
of consideration, and in an operation where the details
were so perfected, he thought it was not mal apropos
to discuss the ﬁner points of technique. In cases
where there was no cystitis, and the bladder had be-
come tolerant of the existence of the stone, there was
no special value in leaving the wound open nor in unit-
ing the bladder to the abdominal wall; nor was there
any special advantage to be obtained in Vesical irriga-
tion in cases of this class. There was rather a disad-
CITY HOSPITAL ALUMNI. 335
vantage in that the bladder being sutured to the parietes
and forming a part of the subsequent cicatrix, would
be held to the abdominal wall in a malposition, and a
complete detrusor action would be impossible. Now,
this condition in a normal individual would probably
have no deterrent inﬂuence nor result; but in cases
where there is a lithuric tendency, the residual urine
resulting from incomplete contraction of the bladder
would, without doubt, favor subsequent stone formation.
He said he believed in cases where there was no cys
titis it was better to suture the bladder independently,
and then unite the abdominal wall. There had been
in the past a very considerable dread of suturing the
peritoneal duplication over the fundus. And this had
been a real diﬂiculty in a suprapubic section when the
stone was large and the peritoneum descended rather
lower than its classic limitations, but we now know
that if proper care and technique are observed, the
peritoneum may be incised to the required extent, and
subsequently united without deleterious eﬁect. Neces
sarily the operative scope has been enlarged by this
procedure. There are surgeons, chieﬂy of the English
and India schools, who almost always took the peri-
neal route. (In searching literature he said he had
never found any satisfactory reason why this should be
done). Among the inhabitants of Arabia and the desert
Bedouin tribes there is a strong lithemic tendency: In
children enormous stones are sometimes found, and
these men almost invariably choose the perineal route
for extraction, for no special reason, as far as may be
observed, nor with results not more brilliant than by
the suprapubic method; but often with great lacera-
tion and inconvenience.
Oomparatively recently the suprapubic method has
been coming to the front and its advocates certainly
secure desirable results.
THE PRESIDENT inquired as to the bacteriology of
these bladder conditions.
DE. GIVEN CAMPBELL did not think that any bacteri-
336 MEDICAL SOCIETY OF
ological cause for such conditions could be given. The
case of Dr. Gcrin’s he thought rather a nervous one.
. He considered it analagous to vaginismus. Dilatation
he thought a rational treatment and believed good re
sults shOuld be obtained from it.
DR. H. JACOEsON said the cystoscope was a very im-
portant instrument in the diagnosis of irritability of
the bladder, especially in tuberculous conditions. Tu-
berculosis of the kidney will cause irritability of the
bladder, and, in the male, if this is associated 'with tu
berculosis of the prostate and testicle, we can often de
termine the cause of the irritability. Other important
symptoms, of course, are the ﬁnding of tubercle bacilli
in the urine and elevation of the temperature and also,
of course, the history Of the patient’s family.
Calculus in the kidney or ureters, new growths and
other diseases of the genito-urinary tract cause irrita-
bility of the bladder. Besides reﬂex causes in the
neighborhood of the bladder, like hemorrhoids, worms
and other diseases of the gastro-intestinal tract, are-
mote reﬂex cause is adenoid of the naso pharyngeal
region. '
DR. CARL A. W. ZIMMERMANN said there was a case
at the Female Hospital which was very interesting It
was that of a woman delivered of a child eight years
ago by forceps, and before the birth of the child the
precaution of emptying the bladder had been neglected.
The bladder was ruptured in two places and the woman
has now a double vesico vaginal ﬁstula and no opera
tion to close them has been attempted. A year ago
she began to notice tenesmus, bleeding from the blad-
der and pain, and on making an examination herself,
she felt two rough surfaces on the roof of the vagina.
She did not seek medical aid until she came to the
hospital, where an examination revealed two openings,
one on either side of the median line, and each opening
plugged by a calculus. The calculi were united at the
top in horse-shoe shape and a catheter could not be in-
troduced into the bladder. She also has a tear in the
CITY HOSPITAL ALUMNI. 337
perineum of the third degree. The stone was crushed
through the ﬁstulous opening with heavy forceps by
Dr. Crossen. She has a cystitis from which she still
suffers, although doing well otherwise.
THE PRESIDENT asked whether no urine was passed
through the urethra before the stone was removed.
DE. ZIMMEEMANN said some urine was passed as the
stone did not, apparently, close the opening entirely.
DE. P. 'J. HEUER asked Dr. Gorin _if a microscopical
examination had been'made of the tumor removed.
DR B. M. HYPES said that irritability of the bladder
was a common complaint, especially in females. His
experience was that it was often a sympathetic trouble,
manifested in connection with various inﬂammatory
conditions of the pelvic viscera, and sometimes during
gestation. The cases, as a rule, usually respOnd to the
ordinary means of rest, and when connected with in-
. ﬂammatory symptoms, to douches of boracic acid solu-
tions. Occasionally medication fails, and in quite a
number'he had dilated with instruments or the ﬁnger.
In regard to Dr. Bond’s cases, though he had heard
only a part of the paper, he thought he noticed a great
Change on the part of profession in the treatment of
.calculi of the bladder. He said Dr. Bock, of this city,
deserved credit in pressing several years ago the ben-
eﬁts of the suprapubic operation in preference to the
perineal. After having seen a number of cases oper-
ated on by the suprapubic method he said he thought it
strange that this method was not resorted to earlier and
more generally, as it was certainly a more simple one
and very efﬁcacious in its results. He had seen several
cases of feeble, old men operated on in this way with-
out shock or bad results, and he thought it far simpler
- than the Bigelow method of crushing.
DR. GORIN, in closing, said the urinalysis at ﬁrst re-
vealed nothing except a low speciﬁc gravity. About
two weeks after the operation the urine was slightly
alkaline. ‘The cause of the irritability in this case was
the fact that the wound did not have an opportunity to
338 MEDICAL SOCIETY OE
heal on account 'of straining at micturition. As to why
the dilatation was‘not resorted to at ﬁrst he said he
thought it probable that the caruncle was the cause of
the irritability and that its removal would give the pa-
tient relief without the necessity of further operative
procedure. The cautery was made strong, as he thought
the patient would recover the normal use of the blad-
der, while the wound was healing under a ﬁrm, protect-
ing eschar. A microscopical examination of the growth
had not as yet been made. '
DR. BOND thanked the members for their interesting
and generous discussion of his paper.
The stone, in his bladder case, was not encysted but
occupied a nest at the base of the bladder and was
freely movable. This nest was a simple rounded in-
denture produced by the long presence of the stone and
the manner in which it had rested in the organ.
The cutting operation was selected in preference to
litholapaxy because he knew the stone was very large
' and because the crushing of a stone of its size cOnsumeS
a great deal of time and not infrequently particles were
left in the bladder in washing out the reduced sub-
stance. He thought litholapaxy in such cases was a
more or less dangerous and unsatisfactory procedure,
since a fragment left was very liable to be retained and
form a nucleus for the‘redevelopment of stone. The
danger from prolonged anesthesia should also be con-
sidered. -
Another reason for selecting the cutting operation
was that,after explaining the two methods to the pa-
tient and showing him the dangers attending each, he
was very decided in his choice of the clean-cut pro.
cedure.
Of the cutting operations the suprapubic was se
lected because, he said, some of the best surgeons of to-
day caused serious injury to the ureters, perineal ‘ves
sels, the recto-vesical space, or to the urethra or
bladder itself in operating through the perineum, and
"especially for the removal of large stones.
CITY HOSPITAL ALUMNI. 339
He did not mean to cast any reﬂection on the ana-
tomical knowledge or surgical skill of these operators,
for he knew full well that the most skillful artists some-
times blundered.
In this case, he said, he did not attempt to scrape up-
ward the pre-vesical cellular and fatty tissues as is ad-
vised in the old stereotyped operation, but made a clean
cut through it to the bladder wall, inserting the hooks
into the muscle and lifting it up for puncture. When
these tissues were not lacerated and contused there was
little, if any, danger from sepsis by virtue of urinary
extravasation, -whether the bladder be left open for
drainage or closed by suture. He did not close the
bladder in this case on account of the cystitis that ex-
isted at the time and because daily irrigation was de~
sired. The bladder responded promptly to the irriga-
tions after removal of the stone.
THE PRESIDENT asked what solution was used in irri-
gating. _ '
DR. BOND said he used warm two and one half per
cent boracic acid solution.
The case describedby Dr. Zimmermann, the speaker
_ said, showed how important an etiological factor cys~
titis was in the development of stone in the bladder.
DR. HYPES asked Dr. Bond whether the incision in
the skin was made longitudinally or crosswise.
DR. BOND said it was made longitudinally.
DR. HYPES said he had seen two cases in the last year
where the incision "was made crosswise, and he thought it
seemed to give the operator more room. The reason
for the incision was that in a case reported on, shortly
before, the surgeon said he made the ordinary incision
and when he attempted to extract the stone he found
great difﬁculty in doing so, owing to the size of the
stone, and he had to enlarge the wound crosswise to ex-
'tract it. With the cross section he said he had more
room and could take out a much larger stone. No diﬂi-
. culty from hernia or other ill consequences followed.
THE PRESIDENT asked if Dr. Bond thought only four
340 - MEDICAL SOCIETY OF
per cent of all cases of urinary stone were seen in
women. '
DR. BOND replied that such was the case, according
to the best information he had been able to obtain.
THE PRESIDENT asked if they were as subject to
renal calculus as men. '
DR. BOND replied that his information tended to show '
j that a greater number of men suffered from renal calcu- 1
lus, and that it was his opinion that such was. the case
because of habits and physical indiscretions peculiar to
men; but that he was unable to say, what the exact
proportion of cases of renal stone was between the male
and female.
He said that women seldom suffered from vesical
stone on account of the shortness and greater caliber of
their urethras,_and their freedom from causes of urethral
obstruction so common in men.
CONSTITUTION
ARTICLE 1.
NAME.
The name of this body shall be the Medical Society
of City Hospital Alumni.
\, ARTICLE II.
OBJECTS.
The objects of this body shall be the scientiﬁc investi-
gation and discussion of medical and allied subjects, and
the drawing Of the members into more intimate scientiﬁc
and social relations.
ARTICLE III.
MEMBERSHIP.
Only physicians who have served in the City Hospital
as assistants or superintendent, and who are Of reputable
social and professional standing, shall be eligible for mem-
bership.
Honorary membership may be conferred on Alumni
of the City Hospital.
ARTICLE IV.
ELECTIONS.
Election of members shall be by ballot. A majority
vote of members present shall be required for election, but
one-third of the members present voting in the negative
shall reject.
342 MEDICAL SOCIETY OF
ARTICLE V.
OFFICERS.
The Ofﬁcers “of the Society shall be: President, Vice-
President, Secretary, and Treasurer; to be elected by'ba-l-
lot at the last meeting of each year, and tO hold Ofﬁce
until their successors-are elected and qualiﬁed.
ARTICLE VI.
ADVISORY COUNCIL. ’
The ex-Presidents shall constitute an advisory council
of which the retiring President shall become the chairman.
The object of the Council shall be to promote the general
welfare Of the Society by suggestions or recommendatiOns
in matters Of policy, or scientiﬁc work. The members
shall be exempt from service on standing committees.
ARTICLE VII.
_ COMMITTEES.
There shall be four standing committees, of three
members each, appointed annually, Of which committees
the President shall appoint two members, and the Vice-
President one. These committees shall be known as the
Executive Committee. Committee on Scientiﬁc Commu~
nications, Committee on Publication, and Committee on
Entertainment.
ARTICLE VIII.
QUORUM.
Six members shall constitute a quorum for the trans-
action Of ordinary business, and ﬁfteen for the election of
Ofﬁcers and members.
ARTICLE IX.
MEETINGS.
Stated meetings of the Society shall be held on the
ﬁrst and third Thursday of each month (except july and
August), at 8 o’clOckP. M.
CITY HOSPITAL ALUMNI. 343
ARTICLE X.
AMENDMENTS.
The constitution may be :amended by a two-thirds
vOte Of the members present at any.stated meeting, but in
making amendments the following form of procedure
shall be Observed: Every proposition to amend the con-
stitution, or any part thereof, shall be submitted in writ-
ing, at stated meetings only, signed by at least two mem-
bers, and shall lie over for at least one stated meeting
exclusive Of the date of presentation, When called up
for action, it shall be the duty of the Executive committee
to make a written report on the advisability of modifying,
adopting, or rejecting the proposed amendment All mem-
bers of the Society shall be duly notiﬁed of all such pro-
posed amendments.
BY= LAWS
SECTION I.
ORDER OF BUSINESS.
H
. Action on minutes of prevrous meeting.
. Reports of committees.
. Miscellaneous business.
Elections. .
Presentation of patients and anatomical specimens.
Reading and discussion of papers.
Unannounced specimens and cases.
. Adjournment.
T e scientiﬁc program shall be the special order of
business at 9 O’clock.
SECTION II.
DUTIES OF THE PRESIDENT.
we erase!“
It shall be the duty of the President to preside at all
meetings, appoint all committees unless otherwise pro-
vided for, and to perform such other duties as the consti-
tution and by-laws prescribe.
344 MEDICAL SOCIETY OF
SECTION III.
DUTIES OF THE VICE-PRESIDENT.
It shall be the duty Of the Vice-President to perform
the duties of the President in the absence of the latter.
SECTION IV.
DUTIES OF THE SECRETARY.
It shall be the duty of the Secretary to record and
preserve an accurate account of the proceedings of each
meeting; to keep a corrected register of the members, the
dates of their service in the Hospital, and their addresses;
to conduct the correspondence of the Society, and to per-
form all other duties pertaining tO his ofﬁce assigned to
him by the Society. He shall submit a report at the an-
nual meeting which shall give in detail the work of the
Society for the year. He shall be exempt from the pay-
ment of dues.
SECTION V.
DUTIES OF THE TREASURER.
It shall be the duty of the Treasurer to collect and
take charge of the funds of the Society. He shall make
disbursements only when authorized by the President and
the Chairman of the Executive committee.
He shall submit annually, or when required by the
Society, an itemized statement of receipts and expendit-
ures, and a list of delinquent members. He shall be ex-
empt from the payment of dues, and shall furnish annually
a satisfactory bond, in the sum Of ﬁve hundred dollars, at
the expense Of the Society.
SECTION VI.
DUTIES OF THE EXECUTIVE COMMITTEE.
a The Executive committee shall conduct the business
affairs of the Society. It shall authorize expenditures and,
by its Chairman, order the payment of accounts, and it
'shall also act as an auditing committee.
CITY HOSPITAL ALUMNI. 345
The Executive committee shall also investigate and
report upon the names of candidates for membership, and
shall perform such other duties as are prescribed for it by
the by-laws
SECTION VII
DUTIES OF COMMITTEE ON SCIENTIFIC COMMUNICATIONS.
The Committee on Scientiﬁc Communications shall
provide suitable scientiﬁc material to engage the Society
at each stated meeting, and it shall send a program to the
members at least two days in advance of such meetings
SECTION VIII.
DUTIES OF COMMITTEE ON PUBLICATION.
‘ The Committee on Publication shall provide for the
recording and preservation of the proceedings Of the
Society.
SECTION IX.
DUTIES OF COMMITTEE ON ENTERTAINMENT.
It shall be the duty of the Committee on Entertain-
ment to provide a suitable place for the meetings Of the
Society, and to take charge of such entertainments as shall
be desired by the Society.
SECTION X.
ANNUAL DUES.
The dues from each active member shall be three
dollars annually. But members Of the City Hospital corps
joining the Society during their term of service shall be
exempt for that calendar year.
Honorary members shall be exempt from the payment
of dues.
SECTION XI.
DELINQUE NT MEMBERS.
Members in arrears for two years dues who fail to pay
same, after due notice from the Treasurer of arrearage
and penalty, shall forfeit membership. Three notiﬁcations
shall constitute due notice.
346 MEDICAL SOCIETY OF
SECTION 'XII.
EXPULSION OF MEMBERS.
Members accused of imprOper conduct against whom
charges have been preferred by a fellow-member and sus-
tained by the Executive committee, after due trial may
be expelled by a two-thirds vote of the members present,
all the members having been previously notiﬁed of the
proposed action. ‘- ‘ '
SECTION XIII.
AMENDMENTS.
These by-laws may be amended by a majority vote
at any stated meeting, previous notice of such proposed
action having been given to all the members.
SECTION XIV.
PARLIAMENTARY PROCEDURE.
The proceedings of this Society shall be conducted in
accordance with “RObertS’ Rules Of Order.’_’
_RU LES
I. The privileges of the ﬂoor in scientiﬁc discussions may be
extended to guests and visitors.
2. Remarks of members in discussion shall be limited to ﬁve
minutes each, unless by unanimous consent otherwise, and no member
shall speak a second time on the same subject until all others so de-
siring shall have been heard.
3. These rules may be suspended at any meeting on motioa
without previOus notice. '
ROSTER OF
OFFICERS AND STANDING COMMITTEES
From Time of Organization.
1893
ELSWORTH S. SMITH M.D., Secretary.
WM. C. MARDORF, M.D., Treasurer.
i Executive :
_ BRANSFORD LEWIS, M.D.,
WM. N. BEGGS, M.D., ALBERT H. MEISENBACH, M.D.
Scientiﬁc Communications:
LUDWIG BREMER. M.D.,
JOSEPH GRINDON, M.D., GEORGE HOMAN, M.D.
, - Publication :
_HENRY JACOBSON, M.D.,
HENRY C. DALTON, M.D., ELSWORTH S. SMITH, M.D.
Entertainment :
ISAAC N. LovE, M.D., '
JOHN C. FALK, M.D., IOSEPHUS R. LEMEN, M.D.
348 MEDICAL SOCIETY OF
1894
WM. SHIRMER BARKER, M.D., President.
LUDWIG BREMER, M.D., Vice-President.
LOUIS BOISLINIERE, M.D., Secretary.
WM.'C. MARDORF, M.D., Treasurer.
Executive :
BRANSFORD LEWIS, M.D.,
WM. N. BEGGS, M.D., AI BERT H. MEISENBACH, M.D.
Scientiﬁc Communications :
ELSWORTH S. SMITH, M.D.,
JOHN B. SHAPLEIGH, M.B., FRANK R. FRY, M.D.
Publication :
JOSEPH GRINDON, M.D.,
GIVEN CAMPBELL, M.D., H. M. PIERCE, M.D.
Entertainment :
ISAAC N. LOVE, M.D.,
L. M. PERKINS, M.D , CHARLES F. HERSMAN, M.D.
CITY HOSPITAL ALUMNI.
1895
ELSWORTH ‘5. SMITH, M.D , President.
JOHN B. SHAPLEIGH, M.D., Vice-President.
LOUIS BOISLINIERE, M.D., Secretary.
WM. C. MARDORF, M.D., Treasurer.
Executive :
CHARLES H. DIXON, M.D.,
FRANK G. NIFONC, M.D., WM. N. BEGGS, M.D.
Scientiﬁc Communications :
T. C. WITHERSPOON, M.D.,
M. A. GOLDSTEIN, M.D., ULVUS L. RUSSELL, M.D.
Publication :
WM. S. BARKER, M.D.,
ALBERT H. MEISENBACH, M.D., JOHN C. FALK, M.D.
Entertainment :
BRANSFORD LEWIS, M.D.,
HENRY JACOBSON, M.D., JOSEPHUS R. LEMEN, M.D.
.350 MEDICAL SOCIETY OF
1896 '
JOHN B. SHAPLEIGH, M.D., President.
HENRY C. DALTON, M.D., Vice-President.
JOSEPH G. MOORE, M.D., Secretary.
WM. C. MARDORF, M.D., Treasurer.
Executive :
ELSWORTH S. SMITH, M.D.,
GEORGE HOMAN, M.D., WM. S. BARKER, M.D.
Scientiﬁc Commu Rications :
CHARLES H. DIxON, M.D.,
WILLIS HALL, M.D., FRANCIS REDER, M.D.,
Public ation :
H. M. PIERCE, M.D.,
JACOB FRIEDMAN, M.D., GREENFIELD SLUDER, M.D.
Entertainment :
DAVID R. NOWLIN, M.D.,
BENJAMIN M. HYPES, M.D., HFIMAN F RUMSON, M.D.
1897
JOSEPH GRINDON, M.D , President.
LOUIS BOISLINIERE, M.D., Vice-President.
HORACE W. SOPER, M.D., Secretary.
WM. C. MARDORF, M.D., Treasurer.
Executive :
JOHN B. SHAPLEICH, M.D.,
LUDWIG BREMER, M.D., FRANK A. GLASGOW, M.D.
Scientiﬁc Communications:
T. C. WITHERSPOON, M.D.,
WALTER B. DORSETT, M.D., JOHN MCH. DEAN, M.D.
I
Publication ;
HARRY S. CROSSEN, M.D.,
H. M. PIERCE, M.D., WM. S. BARKER, M.D.
Entertainment :
'BENJAMIN M. HYPES, M.D.,
HOWARD CARTER, M.D., FRANK G. NIFONG, M.D.
LIST OF MEMBERS
Name.
Adelsberger, B.,
Amyx, R. F.,
Babler, E. A.,
Ball, W. F.,
Banks, H. L.,
Barker, W. S.,
Baumgarten, Walter,
Bechtold, L. 1.,
Beggs, W. N.,
Behrens, L. H.,
Bell, John,
Boisliniere, L.,
Bond, H. W.,
Bradley, T. L.,
Brady, 1. M.,
Bremer, L.,
Bribach, Benno,
Brokaw, W. A.,
Bryson, ]. P.,
C. M. denotes charter member.

Address.
Waterloo, Ill.
City Hospital.
City Hospital.
Batesville, Ark.
Hannibal, Mo.
1101 Tyler.
Boston (H arvard).
Belleville, Ill.
Denver, C010.
5 S. Broadway.
Pine Bluff, Ark.
3509 Olive.
3860 Olive.
Warrensburg, Mo.
City Hospital.
3723 West Pine.
7606 Michigan ave.
3200 Lucas ave.
Years of
Hospital
Service.
1884—85.
1897-98.
1898-99.
1897-98.
1890—91.
1896—97.
1886-87.
1894—95-
1891.
1889.
1890—92.
1896—97.
1898-99.
1870.
1879-80:
1896-97.
209 N. Garrison ave. 1868—69.
Date of
A dmz'sszon
to S oez'ety.
C. M.
Nov. 4, ’97.
Nov. 17, ’98.
Nov. 4, ’97.
May 5, ’98.
C, M.
Dec. 17, ’96.
C. M.
C. M.
Feb. 18, ’95.
C. M.
C. M.
C. M.
Dec. 17, ’96.
Nov. 17, ’98.
C. M.
Apr. 18, ’95.
Dec. 17, ’96.
C. M.
£ib2
MEDICAL SooIE'rY OF
Name.
Campbell. Given,
Carter, Howard,
Cole, Ernest H.,
Coleman, H. T.,
Crossen, H. S.,
Currie, D. H.,
Curtin, H. W.,
Dalton. H. C.,
Dean, Iohn McH.,
Dempsey, W. H.,
Denby, ]. P.,
Dice, H. F.,
Dixon, Chas. H.,
Dorsett, W. B.,
Drechsler, L.,
Ehrlich, Louis,
Epstein, J. M.,
Eyermann, E H.,
Fahnestock, C. L.,
Falk, I. C.,
Farrar, J. O’F.,
Flippen,]. H.,
Forbes, H. B.,
Friedman, 1.,
Fries, Wm. A., *
Frumson, H.,
Fry, Frank R.,
0
Address.
822 N. Grand ave.
City Hall.
4305 West Pine.
Female Hospital.
5173 Maple ave.
3233 Easton ave.
3536 Easton ave.
City Hospital.
City Hospital.
City Hospital.
3345 Morgan.
3941 West Belle Pl.
2701 Blair ave.
1823 S. Ninth.
905 N. Eleventh.
City Hospital.
6064 Horton Pl.
27oz Stoddard.
Poor House.
City Hospital.
City Hospital.
2804 Clark ave.
1544 S. Broadvvay.
1003 N. Broadway.
3133 Pine.
IQarsQf
jgoqmﬂal
S eroz'ce.
1889-90.
1893.
1885—86.
1895-96.
1892-95.
1897-98.
1895.
1872-75.
1887-91.
1896-99.
1898~99.
1898-99.
1897—98.
1878-79.
1878—79.
1896-97.
1893—95-
1893—94-
1898-99.
1896-97.
1890-91.
1896-97.
1898-99.
1898-99.
1878-79.
1883-84.
1889-90.
1879-80.
Date of
Admission
to Society.
Oct. 12,’93.
Feb. 6, ’95
Apr. 11, ’92.
Feb. 6, ’96.
Sep. 15, 94.
Nov. 4, ’97.
Mar. I7,’98.
C. M.
Dec. 17, ’96.
Nov. 17, ’98.
Nov. 17, ’98.
Nov. 4, ’97,
C. M.
C. M.
Dec. 17, ’96.
Feb. 14, ’95.
Jan. 2:, ’97.
Nov. 17, ’98.
Dec. 17, ’96.
C. M.
Dec. 17, ’96.
Nov. 17, ’98.
Nov. 17, ’98.
C. M.
C. M.
C. M.
C. M.
CITY HOSPITAL ALUMNI.
35%;
Name.
Garcia, Felix,
Ghiselin, A. H.,
Glasgow, F. A.,
Goebel, Arthur,
Goldstein, M. A.,
Gorin, G.,
Gradwohl, R. B. H.,
Grant, J. M.,
Green, John, Jr.,
Gieiner, Theo.,
Grindon, Joseph,
Hall, H. R.,
Hall, Willis,
Hamel, Geo. E,
Harris, R. C.,
Hempelmann, L. H.,
Henke, A. F.,
Heuer, P. J.,
-Hinchey, F.,
Holland, Thos. E.
Homan, Geo.,
Hurt, G.,
Hypes, B. M.,
Jacobson, Henry,
Kohl, Julius,
Lane, G. H. ,
Levy, A.,
Lewis, Bransford,
Address.
3205 S. Grand ave:
3894 Washington ave.
3508 Manchester ave.
3702 Olive.
4100 West Belle Pl.
City Hospital.
4132 Easton ave.
2670 Washington ave.
3506 Manchester ave.
3894 Washington ave.
925 Goodfellow ave.
2 332 Washington ave.
Kansas City, Mo.
City Hospital.
2210 Howard.
3620 Cook ave.
3342 Olive.
Hot Springs, Ark.
816 Olive.
Newport, Ark.
2005 Victor.
3001 Chestnut.
Belleville, Ill.
Chester, Ill.
Century Building.
Years of
Hospital
Service.
1893.
1897-98.
1 878-79.
1892-93.
1895—97.
1898—99.
1889-91.
1898-99.
1897-98.
1879~80.
1895—96.
1881.
1888.
1898—99.
1896-97.
1896-97.
1895-96.
1894.
l874—75-
l873—74-
1876.
1872—73.
1886-88.
1858-60.
1895—36.
a897—98.
1884-85.
Date of
Admission
to Society.
h4ar.17,’98.
Nov. 4. ’97.
Nov. 12, ’93.
Apr. 21, ’98.
Jan. 12, ’93.
Feb. 6, ’96.
Nov. 17, ’98.
C. M.
Nov. I7, ’98.
Nov. 4, ’97.
C. M.
Feb. 6, ’96.
C. M.
Nov. 17, ’98.
Dec 17, ’96.
Dec. 17, ’96.
Feb. 6, ’96.
Mar. 17,’98.
Aug. 11, ’93.
C M.
C. M.
C. M.
C M.
C. M.
Fee 6, ’96
Nov. 4, ’97.
C. M.
35kt
MEDICAL SOCIETY OF
Name.
Lippe, M. J.,
Loew, E. C.,
Love, I. N.,
Luedeking, R.,
Malz, C. 0.,
Mardorf, Wm. C.,
Mayes, J. W.,
McCandless, W. A.
McElroy, R. L.,
Meisenbach, A. H.,
Moberg, A.,
Montague, H. L.
Moore, J. G.,
Mudd, H. G.,
Mudd, H. H.,
Mueller, Ernst,
Nifong, F. G.,
Nowlin, David,
Oatman, L. J.,
Orr, Chas. J.,
Pauley, W. H.,
Perkins, L. M.,
Pfeﬁer, J. F.,
Pierce, H. M.,
Post, M. H., Washington ave. & Beaumont.
Printz, F. C. W.,
Ravold, Amand,
Reder, A. R.,
A d d ress.
F inney & Krum aves.
City Hospital.
303 N. Grand ave.
1837 Lafayette ave.
City Hospital.
1 1 1 I Chouteau ave.
City Hospital.
2329 Lafayette ave.
Louisiana, M0.
2229 S. Broadway.
2604 Locust.
Fulton, Mo.
2604 Locust.
2604 Locust.
3236 California ave.
4950 Easton ave.
Montgomery City, Mo.
Female Hospital.
701 N. Charming ave.
3180 Easton ave.
3206 Lucas ave.
1800 S. Eleventh
4046 N. Grand ave.
City Hospital.
2806 Morgan.
Aurora, Ill.
Years of
' Hospital
Seroica
1897-98.
1898-99.
1872-74.
1885.
1898—99.
1888-89.
1898-99.
1873—75
1896-97.
1876-77.
1897-98.
1896-97.
1889-90.
1881-82.
1865-66.
1884-85.
1889-91.
1890:
1893—94-
1891-92.
1896-97.
1886-88.
1895-96.
1887-89.
1877-78.
1898-99.
1881-82.
1894—97-
Date of
Admission
to S ociely.
Jan. 6, ’98.
lJov.17,’98.
C. M.
Mar. I7, ’98.
Nov. 17, ’98.
C. M.
Iiov.17,’98.
Feb. 18, ’97.
Dec. 17, ’96
C. M.
Nov. 4, ’97.
Dec. 17, ’96.
pa
U
\
ILY
0.00.000
222?.
M.
Mar. 17, ’98,.
Aug. 11, ‘92.
Dec. 17, ’96.
C. M.
Feb. 6, ’96
C. M.
Jan. 13, ’93.
Dec. I 5, ’98.
May 16, ’95.
Feb. 28, ’95.
CITY HOSPITAL ALUMNI.
3555
Name.
Reder, Francis,
Richards, E. E.,
Years of
Address. Hospital
S err/ice.
4629 Cook ave. 1884—85.
City Hospital. ' 1898—99.
Bevier, M0. 1888—89.
Rowland, W. P.,
Russell, U. L.
Saenger, N.,
Sauer, W. E.,
Schleiffarth, E. L.,
Schlossstein, A. G.,
Schucha', W. L.,
Scott, B. L.,
Seibold, John F.,
Semple, N. W.,
Shanahan, N. C.,
Shapleigh, J. B.,
Sharpe, N. W.,
Shattinger, Chas.,
Simpson, B. S.,
Sk ainka, Ph.,
Sluder, Greenﬁeld,
Smith, E. 8., Jr.,
Smith, U. S.,
Smith, W. F.,
Soper, H. W.,
Spore, Wm. D.,
Stack, John,
Stewart. S. 8.,
Sutter, Otto,
Talbot, H.,
Oklahoma City, I. T. 1893-95.
8 S. Broadway.
1916 Nebraska ave.
905A La Salle.
La Grange, Texas.
Brierﬁeld, Ala.
2411 N. Twenty-Second. 1895-96.
1897.
1881—82.
I894—95-
1896—97.
1897-98.
1891.
Union Trust Building. 1897—98.
Twelfth & Cass ave.
2608 Locust.
3505 Franklin ave.
2200 Sidney.
1894—95-
1881-82.
1890-91.
1886—87.
Washington ave. & 27th. 1897—98.
701 N. Channing ave. 1884.
2647 Washington ave. 1888.
3554 Pine.
City Hospital.
909 N. Nineteenth.
522 3 Minerva ave.
East St. Louis, Ill.
City Hospital.
Bell & Cardinal ave.
City Hospital.
1887—90.
1898—99.
1898—99.
‘1894—95-
1861-64.
1891~92.
1898—99.
1895—98.
1898—99.
Date of
Admission
to Society.
C. M.
Nov. 17, ’98.
C. M.
Sep. 14, ’94.
Feb. 6, ’96.
May 6, ’97.
C. M.
Nov. 8, ’94.
Dec. 17, ’96.
Nov. 4, ’97.
C. M.
Nov. 17, ’98.
Mar. 18, ’97.
C. M.
C. M.
C. M.
Nov. 4, ’97.
Mar 17, ’93.
C. M.
C. M.
N0v. 1 7, ’98.
Nov. 17,’98.
Sep. 13, ’94.
C. M.
C. M.
Nov. 17, ’98.
Dec. 5, ’95.
Nov. 17, ’98.
356 MEDICAL SOOIETY OF
. ‘ Years of Date of
- Name. Address. Hospital Admission
' Service. to Society.
Taussig, A. E., 2647 Washington ave. 1894—95. Feb. 14, ’95.
Thierry, C. W., Jr., City ‘Hospital. ' 1898—99. Nov. 17, ’98.
Thompson, Edgar, U. ‘~‘. Navy. 1894. Mar. 17, ’98.
Thompson, J., 1897-98. Nov. 4, ’97.
Vallé, Jules F., 3303 Washington ave. 1885-86. C. M.
Von der Au, 0. L., 1309 Geyer ave. 1892-93 Feb. 6. ’96.
Von Phul, P. v., 1896-97.’ Dec. 17, ’96.
Weiner, M., Linmar Building. 1896-97. Dec. 17, ’96.
Welch, Thos.. U. S. Army. 1897—98. Nov. 4, ’97.
Werth, D. C., 1897—98. Nov. 4, ’97.
West, W., Belleville, 111. 1897—98. Nov. 4, ’97.
Williamson, L., U. S. Army. 1897—98. May 6. ’97.
Witherspoon, T. C., 4318 Olive. 1889 -90. Sep. 13. ’94.
Wolfort, J., 1201 Dillon. 1895—96. Feb. 6, ’96.
Zimlick, A. J., I _ 1895. Feb. 6, ’96.
Zimmermann, C. A.W.Female Hospital. 1897—98. Nov. 4, ’97.
Charles Finley Hersman, 1888-89. C. M.
Clinical Professor of Medicine and Demonstrator of Anatomy;
Missouri Medical College.
Died October 11, 1895.


INDEX
Abortion to prevent eclampsia 321.
Abscess, glands of Lime 231, 238.
liver 219, 220, 226.
A Case of Meningitis 118.
Acute Arthritis of Infants—a study of 295.
Address of the President 1.
Air—inj ections of into veins 97.
Amputation~of ﬁngers 47, 48.
, lower extremities 52.
. toes 52.
upper extremities 50.
Aneurysm—-axillary—spontaneous recovery from‘98.
thoracic 251.
' Anomalous urethral cases 230.
Antitoxin—administration by mouth 92.
sudden death following immunizing dose of 86.
Aortic lesions—prognosis grave in 294.
Aortic Regurgitation with Attendant Stenosis and Mitral Regurgitant
Murmur 292.
Apparatus for Application of Dry Hot Air to Diﬂ’erent Portions of the
Human Body 122.
Army—cutaneous hygiene in 191.
A Study of Acute Arthritis of Infants 295.
Athetosis—double——of central type 208.
Atrophy—infantile 31.
Bag of waters—rupture of 229.
Baldness 102.
Bassini’s operation 12, 21. 25.
Bilateral Facial Paralysls 209.
Blackheads, pimples, dandruﬁ', baldness—some modern ideas of 102.
Bladder—irritabiltty of—symptoms 336.
rupture of 226, 336.
Bowel—gangrene of 17, 20.
injury in hernia 15.
obstruction of 226.
resection .of 18.
Bullets—effect of—on various organs 262.
Busch’s operation 49
358 MEDICAL SOOIETY OF
Calculi—formation of 327.
renal 56.
urinary—with report of two cases 327.
Care and Management of the Pregnant Woman—The 308.
Case of Sudden Death Following Immunizing Dose of Antitoxin 86.
Cerebro-spinal meningitis—lumbar puncture in 81.
notes on two cases 77.
Children in schools over-worked 319.
Chronic gonorrhea 232.
City Hospital—need of pathologist to 85.
Clavicle—fracture of 51, 52.
Complemental males 277.
Composition of oleomargarine 63.
Congenital hernia 20.
Colles’ fracture 51.
Constitution—the lymphatic 91.
Contracted kidney 322.
Contributions from younger members 3.
Cryptorchidism—hered tary in man 272.
Cutaneous hygiene in the army 191.
Cystic sarcoma of kidney—hystology of 172.
Dana—method of treating neuralgia 247.
Dandruff 102.
Darning needle—passage of—through intestinal canal of dog 254.
Darwin on inheritance 275.
Death following immunizing dose of antitoxin 86.
Diabetes 238.
Digital inﬂammation 49.
Digitalis—relative value of—in pneumonia 1 14.
Dog—rabies in 192.
Double Athetosis of Central Type 208.
Douches in labor 154, 163, 167.
Dry hot air—application to human body 122.
Eight hundred cases of labor—report of 146.
Elbow—fracture of 51.
Empyema of Frontal Sinus Secondary to Abscess of Orbit 78.
Endrometrial diseases—-septic—treatment of 64.
Examination of urine in labor 165.
Extirpation of larynx 268.
Extubation—laryngeal stenosis after 6.
Facial neuralgia 247.
paralysis—bilateral 209.
Fecal ﬁstula 18, 22.
Ferguson’s operation 26.
CITY HOSPITAL ALUMNI. 359
8
Fibroids—retroperitoneal 179.
sessile submucous 179.
Five great avenues of infection 297.
Form of suture in herniotomy 14.
Formation of—calculi—the 327.
polyps—the 280.
F racture—di agnosis- of 54.
non-union 50.
of clavicle 51, 52.
elbow 51.
humerus 51.
leg 53-
metacarpal bones 51.
patella 53.
phalanges 51.
skull 25 5.
thigh 53.
Frontal sinus—empyema of secondary to abscess of orbit 278.
limitations of 280.
Galvano-cautery as a styptic 298, 300.
Gangrene of bowel 17, 20.
Girls and hygiene 317, 319.
Glands of Littre—abscess of 231, 2 38.
Glycosuria—salol in 306.
with anomalous symptoms 301.
Gonorrhea 241, 244.
acute 230.
chronic 2 32.
Haeckel on natural history of sexual organs 274.
Haematoma 224.
Havana—sanitary redemption of I 34.
harbor 135.
“dead man’s hole” 142.
sanitary problems presented 138.
precautions required m 1 41.
civil and municipal hospitals 142.
military hospitals 140.
sanitary reformation demanded 144.
sewerage I 38.
water supply 141.
Heart—disease—treatment of—by the Schott method of medicated
baths 281.
Hereditary Human Cryptorchidism 272.
Hemorrhage—nasal 299, 301.
360 MEDICAL SOOIETY OF
Hernia—congenital 20.
inguinal 221.
of stomach 226.
trusses in 24, 27.
umbilical 28.
non-strangulated 12.
Bassini’s operation in 12, 21, 25.
strangulated 14.
fecal ﬁstula in 18, 22.
F erguspn’s operation in 28.
gangrene of bowel in 17, 20.
injury of bowel in 115.
. median incision in 16, ‘20.
Murphy’s button in 22.
operation for 14, 21.
resection of bowel in 18.
support after operation 28.
treatment of 29.
Herniotomy 221.
drainage in 14.
form of suture in 24.
incision in 13.
material for suture in 13, 24. 26, 28.
Histology of Cystic Sarcoma of Kidney 172.
History of human sexual organs 274.
Hodgen’s splint 5 5.
Horse-shoe kidney 56.
Humerus—tracture of 51.
Hydrophobia—report of a case of 211.
Hydrotherapy—value of 285.
Identiﬁcation of oleomargarine by use of refractometer 58.
Impetigo contagiosa 168.
Incision in herniotomy 13.
Induction of premature labor 158, 164.
Infant feeding—value of modiﬁed milk in 30.
Infantile atrophy 31.
Inﬂammation—digital 49.
Inguinal hernia 221.
Injury of bowel in hernia I5.
Intubation of larynx—rules for 10.
Irritabtlity of urinary bladder—relieved by rapid dilatation of the
urethra 323.
symptoms of 336.
Joint infection following infectious diseases 296.
l
CITY HOSPITAL ALUMNI.
361
Kidney—calculi of 66.
contracted 322'
histology of cystic sarcoma of 1 72.
horse-shoe 56.
sarcoma of 223.
obstetrical 320, 322.
Labor—Cesarean section in 158, 168.
contracted pelvis in 156.
craniotomy in 166, 168, 171.
douches in 154, 163, I67.
examination of urine in 165.
infection in—prevention of 148.
operating stockings in 164, 171.
partial report of eight hundred cases of 146.
pelvimeter in 164, 166.
premature —induction of 158, 164.
symphysiotomy in 166, 168.
version in 157, 169, 170.
Laryngeal Cancer—A case of 266.
Laryngeal stenosis after extubation 6.
Larynx—car. cer of 266.
extirpation of 268.
intubation of 5.
Leg—fracture 0f 53.
Limitations of lrontal sinus 270.
Liver—-abscess of 219, 220, 226.
Lower extremity—amputation of 52.
Lumbar puncture in cerebro-spinal meningitis 81.
Lymphatic constttution—the 91.
Meckel’s ganglion—removal of—for neuralgia 248, 250.
Medical institutes 299.
Meningitis 1 18.
Metacarpal bones—fracture of 51.
Milk—condensed 34.
Meigs’ modiﬁcation of 34.
pasteurized and sterilized 39.
modiﬁed—Walker-Gordon laboratory 34.
value of—in infant feeding 30.
Morning drop 239, 241, 242. I
Murphy’s button 22.
Muscular paralysis—pseudo-hypertrophic 207.
Nasal hemorrhage 299, 301.
Need of pathologist to City Hospiral 85.
362 MEDICAL SOCIETY OF
Neuralgia—racial 247.
removal of Meckel’s ganglion for 248, 250.
treatment by Dana method 247.
Neurasthenia—post alcoholic 233.
Non-strangulated hernia 12.
Notes on Two Cases of Cerebro-Spinal Fever 77.
Obstetrical kidney 320, 322.
OIeomargarine—composition of 63.
identiﬁcation of by use of refractometer 58.
Operating stockings in labor 164. 171.
Operative procedure in acute rheumatism with joint infection 297.
Ovarian tumor complicating pregnancy 245.
Oxaluric urethritis—acute 235.
On the Use of the Refractorneter for the Identiﬁcation of Oleomar-
garine 38.
Palm—wounds of 49.
Papers—short ones desirable 4.
Paralysis—bilateral facial 209.
muscular pseudo-hypertrophic 207.
Partial Report of Eight Hundred Cases of Labor 146.
Passage of Darning Needle Armed with Twine Through the Intes-
tinal Canal of a Young Dog 254.
Pasteurized milk 39.
Patella—fracture of 53.
Pathologist to City Hospital—need of 8 5.
Pediculi—diverse coloration of 192.
Pelvimeter in labor 164, 166.
Perplexing Mishaps in Surgical Cases 218.
Phalanges—fracture of 51 .
Phimosis 232.
Pimples 102-
Pneumonia—relative value of strychnia and digitalis in 114.
Points in practical surgery 47.
Polyps—forrnation of 280.
Post alcoholic neurasthenia 233.
Posture in coitus—signiﬁcance of 278.
Practical points in herniotomy 12.
Pregnancy—abortion to prevent eclampsia 321.
albumin in urine 314, 320.
care in early stages of 311.
complicated by ovarian tumor 245.
Premature labor—induction of 158, 163.
Prevention of infection in labor 164, 166.
Prostatitis 234.
CITY HOSPITAL ALUMNI. 363
Pseudo-hypertrophic muscular paralysis 207.
Puerperal eclampsia preventable 312.
Quinine—beneﬁcial effects in pneumonia 114.
Rabies 211.
in dog and man 192.
Recent Observations on Intubation of the La ynx 5.
Refractometer for identiﬁcation of oleomargarine 58.
Relative Value of Digitalis and Strychnia in Pneumonia as Observed
In a Few Cases, with Remarks on the Beneﬁcial Effects of
Quinine in this Disease 114.
Renal calculi 56.
Report of a Case of Irritable Bladder Relieved by Rapid Dilatation
of Urethra 323.
Report of a Case of Symphysiotomy—with Presentation of Patient 196.
Resection of bowel in strangulated hernia 18.
Retroperitoneal ﬁbroids 179.
Rhinological and otological practiceésome interesting cases in _298.
Rules for intubation of larynx 10.
Rupture of bladder 226, 236.
-Report of Spontaneous Recovery in a Case of Axillary Aneurysm in
an Infant, with Presentation of Patient 98.
Salol in glycosuria 306.
Salt in the bath—beneﬁt of 285, 287, 290.
Sanitary Redemption of Havana, the Need and Means 134.
Sarcoma of kidney 223.
histology of 172.
Schott method of treating chronic heart disease 281.
Septic endometrial diseases—treatment of 64.
Sessile submucous ﬁbroids 179.
Some Anomalous Urethral Cases 230.
Some Cases of Fracture of the Skull 255. _
Some Interesting Cases in Rhinological and Otological Practice 268.
Some Modern Ideas About Blackheads, Pimples, Dandruﬁ and Bald-
ness 102.
Some Points in Practical Surgery 47.
Some Practical Points in‘ Regard to Herniotomy 12.
Specimens of Renal Calculi and a Horse-Shoe Kidney 56.
Spermatorrhea 233, 234.
Splint—Hodgen 55.
Spontaneous recovery from axillary aneurysm 98.
Stenosis—laryngeal after extubation 6.
Sterilized milk 39.
Stomach—hernia of 226.
864: MEDIOAL SOCIETY OF
Strangulated hernia I4.
Stricture—of urethra 241, 243.
soft 239
Strychnia—relative value of—in pneumonia 114.
Surgical cases—perplexing mishaps in 218.
Symphysiotomy in labor 166.
report of case and presentation of patient 196.
Testicle—transit of 276.
Thigh—fracture of 53.
Thoracic aneurysm 251.
Tonsilitis and acute articular rheumatism 297.
Tracheotomy and intubation 1 1.
Treatment of Septic Endometrial Diseases—The 64.
Treatment of Chronic Heart Disease by the System of Medicated
Bat 5 Known as the Schott Method, with Report of Cases 281.
Trusses in hernia 24, 27.
Two Cases of Pseudo-Hypertrophic Muscular Paralysis 207.
Two Fibroids—One a Large Sessile Submucous Tumor, the Other a
Retroperitoneal 179.
Umbilical hernia 28.
Urethra—offensive discharge from 240, 244.
stricture of 241, 243.
Urethritis—antero-posterior 233.
oxaluric—acute 23 5.
uric acid and prostatitis 235.
Urinary Calculi—with Report of Two Cases and Presentation of
Specimens.
Value of continued use of small remedy 282.
Value of Modiﬁed Mllk in the Feeding of Infants 30.
Value of hydrdtherapy 285.
Version in labor 157, 169, 170.
Walker-Gordon laboratory 34, 35.
Wounds of palm 49.
Yellow fever and the slave trade 136.
bacteriology of 145.
geographical range of 136.
insect agency in spread of 143.
Young members—contributions from 3.


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_ , MEDICAL SOCIETY
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,1
OF
crrv HOSPlTAL ALUMNI
FOR THE YEAR
1899.

SAINT LOUIS.

MEDICAL REVIEW PRESS, ST. LOUIS. MO.
TRANSACTIONS
of the
MEDICAL SOCIETY
of
CITY HOSPITAL ALUMNI
FOR THE YEAR
1899.
SAINT LOUIS
MEDICAL REVIEW PRESS,
ST. LOUIS, MO.
ORGANIZATION FOR 1899.
OFFICERS
GEORGE HOMAN, M.D., President.
BENJAMIN M. HYPES, M. D., Vice-President.
WILLIAM A. BRCKAW,’IE M.D., Secretary.
WILLIAM C. MARDORF, M.D., Treasurer.
ADVISORY COUNCIL
WM. SHIRMER BARKER, M.D. ELSWORTH SMITH, M.D.
JOHN B. SHAPLEICH, M.D. JOSEPH GRINDON, M.D.
STANDING COMMITTEES
EXECUTIVE.
H. WHEELER BOND.
AMAND RAVOLD, M.D. HARRY R. HALL, M.D.
SCIENTIFIC COMMUNICATIONS.
FRANCIS REDER, M.D.
JOHN MCH. DEAN, M.D. PHILIP J. HEUER, M.D.
PUBLICATION.
CHARLES J. ORR, M.D.
CHARLES SHATTINGER, M.D. R. B. H. GRADWOHL,T M.D
ENTERTAINMENT.
NORVELLE WALLACE SHARPE, M.D.
ERNEST H. CoLE, M.D. HORACE W. SOPER, M.D.
* Died May 9; succeeded June 1 by Dr. R. B. H. Gradwobl.
1' Succeeded by Dr. Meyer Wiener.
CONTENTS.
PAGE
Address of the President... .. .. .. . .. . . .
Report of a Case of Prostatectomy, With Remarks
on a Novel Procedure for Facilitating the Oper-
J. P. Bryson, M.D. .. .. .. ..
Specimen of Resected Bowel.
A. H. Meisenbach, M.D......... The Medical Inspection of Public School Children
in St. Louis.
ation.
A Report by the Committee in
Charge Of the Work to the Medical Society of
City HospitalAlumni
Remarks on an Ear and Throat Infection with Sub-
sequent Involvement of the Neck.
Ernest H.Cole, M.D......
Report of Two Cases of Prostatectomy following
Electrical Incision of the Vesical Outlet after
the Bottini-Freudenberg Method, with Remarks.
J. P. Bryson,
Burning Questions Relating to Paretic Dementia.
L. Bremer. M.D........
Cystomata of the Ovary. Henry Jacobson, M.D..
Cerebral Hemorrhage with Temporary Glycosuria;
Report of a Case. R. B. H. Gradwohl, M.D.
Sanitary Supervision of Schools. C. Shattinger, M.D.
Municipal Medical School Inspection.
Norvelle Wallace Sharpe, M.D. . . . . . . . . .
Nasal Specimens, with Demonstration of Methods of
Preservation.
1
11
13
39
66
73
85
. 101
Greenﬁeld Sluder, M.D.. .. . . . 137
VI MEDICAL SOCIETY OF
Gross Sections of the Human Body.
RobertJ. Terry, 139
Gonorrhoe'a. Its Complications and Sequelae.
HenryJaco-bson, 146
Dermatitis Ar'tiﬁcialis. M. F. Engman, M.D. . .. . 156
Strangulated Hernia Complicated wrth Retained
Testicle and Intra—Abdominal Hydrocele of
the Cord. Julius Kohl, M.D.. .. .. .. . . .. .. 162,
Cerebro-Spinal Meningitis; Presentationof Patient.
Given0ampbe11,167
A Specimen of Oyclo-Cephalus. J. C. Falk, M.D. 172 _
Diphtheritic Vaginitis. L. Drechsler, M.D. . .. . . . 17 7
An Endemic. of Pemphigus. Ella Marx, M.D. . .. . 185
A Case of Traumatic Rupture of the Long Head! of
the Triceps Extensor Oubiti. Geo. Homan,M.D. 191
The Hygiene of Pregnancy and Parturition. *
Garland Hurt, 197
'Gastric Tumor. Francis Reder, M.D. . . . . . . . . . . . 208
Some Interesting Genito-Urinary Specimens.
Bransford Lewis, M.D. . .. . . . . . .. 219
Some Remarks on the Treatment of Peri-Rectal _
Fistulae, with Presentation of Specimens. I
Norvelle Wallace Sharpe, M. D. . . . . . . .. . . . . 240
Some Remarks on Antistreptococcus Serum, with
Report of Gases. Norvelle Wallace Sharpe,M'.D. 254
Some Remarks on Dementia Paralytica, with Pre-
sentation of Patients. E. C. Runge, 264
Bacteriologic Examination of River \Water. '
AmandRavold, 278
Some Difﬁculties in the Early Diagnosis of Pneu-
monia. Louis Behrens, M.D. .. .. .. .. .. .. .. 289
MEDICAL SOCIETY
...of... I
CITY HOSPITAL ALUMNI
ST. Louis
r899.

STATED MEETING, THURSDAY EVENING, JANUARY 19.
THE PRESIDENT, DR.- Gno. HOMAN, IN THE CHAIR.
After the transaction of some routine business the
President addressed the Society as follows:
Remarks of the President.
ENTLEMEN.--A year ago I received the un-
@ sought distinction of election to the Presidency
of this Society with a high appreciation of the
honor then conferred upon me, and the expressed pur-
pose to diligently seek the advancement of its scientiﬁc
prestige and profesional inﬂuence by such acceptable
means as lay within my power. Again, by your indul-
gent kindness, I am called upon to accept the nnsought
honor of a re election; and, while deferring to your will
in the matter, I trust that I shall be pardoned for ad-
hering to the opinion heretofore expressed, that another
selection would better have been made and the. usages
of the Society preserved unharmed in this regard.
While not attempting by further words to express my
sense of obligation for this mark of your conﬁdence, I
beg to reserve the right to express through action my
estimation of the distinction bestowed; and, therefore,
2 MEDICAL SOCIETY OF
I will merely repeat my words of a year ago, that I re-
gard it as a reiterated call to labor for the Society’s
good during the ensuing twelve months.
Whether the year last past has been a successful one,
or otherwise, is not for me to say, but while in some
particulars the result may not have reached full expec
tations still this is a very common experience in human
affairs, and insteadeof bringing discouragement should
serve to arouse to further effort so that no just cause for
disappointment shall exist. .
The Society has assumed the toga virilis of profess
ional life, and its manly stature calls for corresponding
achievements in lines of scientiﬁc work. Not to pro-
gress is to begin to decay, standing still means deteri-
oration, therefore this year demands better work and
calls for more strenuous effort than any that haVe gone
before; and, in view of the circumstances of my re-
election, I shall feel all the more free to expect that
everyone will lend a helping hand, and to call again
upon the membership for a fair share of their very best
endeavors.
Such a body as this is can not aﬁord to rest, Its labors
are the outward visible sign of its inner invisible life,
its sustenance and recuperation must come from its own
activities. ‘
I desire to express my sense of most hearty and
grateful obligation to all of those who have so gener-
ously and ably aided me in conducting the aﬁairs of the
:Society during the last year. Without such help, so
fully and freely rendered, failure would have been inev-
itable; and if as willing and accomplished cooperation
is happily secured for this year our success will be
placed beyond the shadow of a doubt. ‘ .
With these remarks, I beg to invite you to a year of
labor in and for the interest of all, trusting that what
we may be able to accomplish will be but the forerun-
ner of better things yet to come in the lengthened use
‘iul life doubtless reserved for this Society.
CITY HOSPITAL ALUMNI. 3
REPORT OF A CASE OF PROSTATECTOMY. '
With Remarks on a Novel Procedure for Facilitating the
Operation.
R J. P. BRYSON presented a patient, aged 64
fears, on whom he had done a prostatectomy
which had some unusual features.
Suprapubic cystotomy had been performed on the pa-
tient by another surgeon eighteen months previously,
and for nine months he had suprapubic drainage. This
gave no relief of the symptoms, and when the tube was
removedit was discovered that he passed half of his
urine through the suprapubic opening There was no
relief of the frequency or of the terminal pain. He con-
sulted the speaker on December 1, 1898. He then had
.pyuria, frequency, suprapubic leakage and complained
of pain at the end of urination. The cystoscope was
used and the vesical opening of the suprapubic ﬁstula
was made out. The prostate appeared perfectly smooth,
posteriorly. The veins in the bladder seemed to be
large, tortuous and somewhat varicose. On December
,5, perineal prostatectomy was performed and some
moderate-sized masses removed. The right lobe was
found enlarged and bulging into the urethra; the left
lobe was also enlarged, but less so. The mass removed
from the right lobe was peeled out and was as large as'
the thumb; from the left lobe two masses were taken,
either one of which was about 1% inch long and about
the size of the little ﬁnger. The speaker said he thought
the suprapubic ﬁstula would heal when the prostatic
obstruction was removed; for he was convinced that
this obstruction still existed despite the sixteen months
Prostatectomy by the perineal route was done, a large
drainage tube of hard rubber placed in the bladder, and
the patient recovered satisfactorily from the operation,
the ﬁstula promptly healing. On December 8, a sharp
.hemorrhage occurred, after the tube had been removed
4 MEDICAL SOOIETY OF
for about twenty-four hours. This necessitated its re
turn. It remained until December 12. The bladder and
perineal tract were irrigated tive or six times a day with
a mild boric acid solution so as to keep the wound clean.
All drainage was removed on December 15. The supra-
pubic ﬁstula cea~el to leak immediately after the oper
ation and has remained healed. The progress of the
case, he said, had been altogether satisfactory and the
present condition of the patient quite so for a man who
had been afﬂicted with so serious 2. disease as an ob-
structing growth of the prostate gland. He said he
presented the patient with the View of calling attention
to some points which impressed him as of the highest,
importance in the surgery of hypertrophy of the pros-
tatic gland. .
The ﬁrst of these was the failure of suprapubic drain
age in securing a satisfactory shrinkage of the hyper-
trophied prostate. The patient had continuous supra
pubic drainage for sixteen months and then he had‘a '
suprapubic ﬁstula remaining up to the time the speaker
operated—sixteen months after ﬁstula had been estab‘ '
lished by Dr. Block, of Kansas City. The prostate at
this time, as felt through the rectum, was ﬁbrous,
tough, enlarged, bulging into the rectum, and was prob
ably about ﬁve times as large as the. normal gland. ()n
either side, running up the postero lateral ligaments of
the bladder, there was decided thickening. There was.
chronic cystitis and frequency of urination was'as great'
as before the operation, with no other improvement-
whatever. Moreover, the patient was rendered exces
sively uncomfortable‘by reason of the leakage.
The second point was the reason for not doing the--
electrical incision d Za Bottini, in this case. He had-
performed the Bottini operation on one patient and had-
subsequently to open and drain through the perineum»
and to secure healing of the ﬁstula. In another case.
the same operation had necessitated a suprapubic pros-
tatectomy, as an abscess developed.
The third point was that the operation done in this-
.IL ’ CITY HOSPITAL ALUMNI. 5
- patient’s case was different from anything he had seen
recorded. The device which he practiced was one
which had come to him at the moment of necessity and
was entirely unstudied. He did not wish to open this
bladder again by the suprapubic incision for two rea-
sons. The ﬁrst was that, having attempted it in other
cases, he found the abdominal wall around the ﬁstulous
_ tract cemented together by a growth of ﬁbrous tissue.
In other words, there was around these urinary ﬁstulas
material which was constantly condensing and increas-
ing at the expense of the normal tissues, which they
destroyed by pressure atrophy, so that to go into the
bladder the second time by the suprapubic opening is a
difﬁcult and often a serious thing.
i The second reason was the condition of the patient’s
heart. Aortic.\stenosis was present and of such a char-
acter that one gentleman who was present was inclined
to hesitate on account of the probable effect of the chlo-
roform. This was overcome, however, without any
difﬁculty.
‘ Therefore, he determined to open the perineum and
attempt to reach the prostatic growth by the perineal
route. The staff was introduced, the median perineal
incision made and the ﬁnger put into the prostatic
urethra. With one ﬁnger in the rectum and the other
in the urethra he could map out the prostate and ob-
served that the right lobe olfered the greatest obstruc-
tion, bulging into the urethra, and that the urethra it-
self was tortuous to a moderate extent and was also
narrowed. This, however, he knew before. But he
found he could not reach the vesical outlet from the
perineum in spite Of the fact that he could reach behind
the posterior border of the prostate with a ﬁnger in the
rectum. He saw that he would have to use some other
means; either open the bladder above the pubes, or in
vent some way of depressing the prostate to such an
extent as to enable him to reach its posterior border
from'the perineum. To do this he made a longitudinal
incision in the ab ior'ninal wall of about two inches until
6 MEDICAL SooIETY OF
he came down to the pre vesical, or supra vesical space;
he did not open the bladder, but having gotten into the
suprapubic space, he put two ﬁngers of his left hand
through the abdominal opening and with the other ﬁnger
in the perineal wound he could push the prostate down
so as to easily and comfortably get at the bladder and
explore the outlet. He then had his assistant put his
ﬁnger into this new opening and press down and in that
way the prostate Was easily brought within reach from
the perineum He then incised the prostate in postero-
lateral direction (not, however, cutting the ring at the
vesical outlet) and peeled out the right lobe of the
gland. The same thing was done with the left lobe.
This left quite a large prostatic urethral space. The
greatest difﬁculty was in detaching these excoohleattd
masses from the upper part of the wound, that is from
the vesical end of their attachment. He could feel with
the ﬁnger the vesical membrane, but when trying to de-
tach the posterior part of the masses he found it neces-
sary to resort to forceps and twisted them out. He then
found that the vesical outlet was situated abnormally
high and was quite narrow, and very much to his regret,
it was necessary to incise the base of the outlet so as to
“lower the ﬂoor” of the bladder. This was done and a
large-sized drainage tube inserted and retained for ﬁve
days. On the sixth day hemorrhage occurred._ This
undoubtedly came'from the posterior incision.
This particular procedure of incising the abdominal
wall'only, and not opening the bladder, using the inci-
sion for the purpose of depressing the prostate in order
to bring'its most posterior parts within reach from the
perineal wound, he had not seen mentioned in the liter-
ature; and he would feel obliged to anyone ‘who would .
call hi s attention to such, if mentioned. He was surprised
and gratiﬁed to observe the facility with which the
gland, and even the vesical cavity could be brought
down to the perineum; and believed this could be prac-
ticed in a considerable proportion of these cases, very
much to the advantage of these old men, for it would
CITY HOSPITAL ALUMNI. 7
prevent the necessity of a suprapubic opening into the
bladder with the consequent danger of inﬁltration, sep-
sis, venous thrombosis and persistent ﬁstula.
The fourth point, and one to which he desired to call
particular attention, was the behavior of the suprapubic
ﬁstula and the effects of urine on the unprotected tis-
sues. The patient already showed some symptoms
which convinced him that sooner or later he would need
a truss to prevent ventral hernia. It will be remembered
that he said the suprapubic ﬁstula healed immediately
after he took away the obstruction to the passage of the
urine by the way of the urethra. At ﬁrst, everything
seemed to be perfectly sound, but there was for a dis-
tance of about one fourth inch around the ﬁstula ahard
ﬁbrous wall. This wall is made up at ﬁrst of dense
inﬁltration of round cells. These undergo a ﬁbrous
change, develop into true cicatricial tissue and this is
done at the expense of normal tissue, the blood vessels,
nerves, glands, connective tissue, muscle tissue and
even the fascia will go down before the advance of this
ﬁbrous cicatricial tissue. The urine being taken away,
this undergoes absorption and the result is a hiatus, a
more or less extensive breach in the abdominal wall,
and that is what is now appearing in the patient’s case.
[Here the patient was asked to show the site of the
operation which was examined by the members]
Dr. Bryson said he wanted to say one word on the in
adequacy of the simple incision for the relief of these
cases of prostatic obstruction, whether done electrically
or with the knife. At the next meeting of the Society
‘ he said he would report two cases in which he had
done the electrical incision and where it- proved useless.
In both cases hemorrhage occurred on the sixth day. It
occurred on the sixth day in this case. He thought this
would offer one of the greatest obstacles to the univer-
sal adoption of this method. Again, where the work is
done through the urethra and the bladder not opened,
nothing like adequate asepsis is possible. The surfaces
cannot be kept clean and the introduction of an instru-
8 MEDICAL SocIETY OF
ment for either irrigation or drainage by the urethra
causes much pain. The patient before the Society this
evening made a good recovery, can start his urine
readily. It is clear and free from pus, acid, and he can
hold the urine easily for four hours, but he has a cer-
tain amount of leakage. In answer to several questions,
the patient said he did not lose any urine by the penis
at night; that he gets up at night about once, whereas,
before the operation, he often got up three or more
times; the leakage was growing less. Dr. Bryson said
the patient had been tested for residual urine and it was
found there was none. He said that the incision prac-
ticed in these cases necessarily divided the voluntary-
prostatic sphincter, and thus one could probably account
for the slight enuresis, which for a time follows in
cases of this kind. It is, however, subsiding. He
did not allude to the voluntary compressor urethrae
muscle, but to the striped muscular arrangement which
forms a part of the prostate. He showed some enlarged
copies of Finger’s serial and antero posterior sections a
of the bladder and prostate in order to illustrate his
meaning.
DISCUSSION.
DR. JosnPH GRINDON spoke of a case in which the
suprapubic operation had been performed by Dr Bry-
son and the after care of the patient had devolved upon
him. The ineﬁicient drainage and attendant discomfort
were illustrated. The suprapubic opening remained
open for a month, during which time the patient was
rendered thoroughly uncomfortable by the constant
leakage. After complete healing, through the action of
the urine on the cicatricial tissue exposed to the bladder
surface at the point of the incision, there was a protru
sion and ﬁnal breaking down of the tissue so that the
ﬁstula was reestablished and remained open for several
months. Various things were tried to obviate the dis-
comfort and constant chaﬁng of the skin due to the
leakage of urine, such as applying cotton to the open
CiTY HOSPITAL ALUMNI. 9
ing, using a tube, bottle and so on, without success. In
this case there was acute cystitis at the time of opera-
tion, and after four months’ drainage cystitis still re-
mained. This does not constitute an argument against
the suprapubic operation, but these points are among
the factors to be considered when the route of operation
is discussed. ‘
THE PRESIDENT asked if the perineal operation was
ﬁnally performed. '
DR. GnINDoN repliei that it was. There was no
ventral hernia. I
DR. FRANCIS REDER said he thought Dr. Bryson was
to be congratulated on the excellent result obtained in
'this case. The patient had good reason for feeling
grateful for the relief obtained. The Bottini operation,
he said, bids fair to supersede the operation of prosta-
tectomy‘. '
The greatest danger in performing the Bottini oper-
ation is the septic condition that may follow. The hy-
pertrophied gland lies in direct contact with the blad-
der and the rectum. Both these organs teem with bac-
teria that may cause infection of the wound made by
the cautery knife.
The Bottini operation has a very low mortality rate.
This may be partly due to the limited number of cases
in which it has been performed.
The operation of prostatectomy carries with itself a
large mortality rate. Many surgeons who have prac-
ticed it are inclined to favor the Bottini operation.
After an operation of prostatectomy the perineal
wound often refuses to heal kindly owing to the infec-
tion that has taken place, but infrequently ﬁstulous
tracts are formed, which prove very annoying on ac-
count of their obstinancy to closure.
The ventral hernia in this case shows that the perito-
neum had not been opened; a hernia subsequently formed.
In a good many abdominal incisions made for other
purposes than for suprapubic cystotomy, a ventral her-
nia is apt to follow, no matter how cautiously the peri-
1O MEDICAL SOCIETY OF
toncum and fascial layers are brought together. “There-
are cases in which a hernia will appear in spite of the
greatest care exercised by the surgeon.
DR. NORVELLE W. SHARPE said that he thought one
of the objections urged by Dr. Bryson to the Bottini
operation, in regard to hemorrhage, might be accounted
for by the improper use of the knife. In other loca-
tions, notably in rhinological work, hemorrhage is not
the rule, nor even a frequent manifestation. It is well
known that a red heat is not so apt to be followed by
bleeding as when the cautery knife is brought to a white
heat. It is also a fact that if the knife is permitted to
adhere to the tissues, hemorrhage is more likely to fol-
low. Greater attention to these details would probably
diminish our post operative hemorrhage records.
The point made by the essayist in regard to absorp-
tion of cicatricial products are well taken, but they
hardly cover the condition in hand. Save that the per-
itoneum was not invaded this hernia is somewhat anal--
ogous to the well-known herniation at the umbilicus, or
the hernias of the median line following operation. The
important factor in these cases is that the recti are not
sewed and properly united. There is a separation be-
tween their edges and a weakened spot in the abdominal
wall is the result; and, so here. It logically follows
that a truss is not the proper thing for this man, but
rather an operation that will obliterate this weakened
area by properly uniting the recti and fasciae in the me-
dian line. Truss pressure, as is well known, diminishes-
the resisting power of a previously weakened abdominal
wall.
A somewhat analogous condition exists in the result.
obtained by excochleating prostatic masses as is found
in the cavities left when uterine ﬁbro myomata are re-
moved. The dead spaces left in the latter are merely
more marked phases of the same condition that obtains
in the former, and in this lies one of. the dangers of
prostatectomy which we all wish to see overcome, as-
our operative work tends to produce better results.
OITY HOSPITAL ALUMNI. 11
In response to Dr. Bryson’s query as to whether men.
tion had been made in literature of the procedure
adopted'in this case to bring the prostate, more readily
Within the ﬁeld of examination (suprapubic manipula
tion), he said he had not seen this particular method
0 noted. It seemed to possess merit.
DR. A. H. MEISENBACH said recent reports on the
Bottini operation seemed to favor that mode of proced-
ure. Bottini had reported another series of ﬁfteen cases
With very few deaths. He said he thought the rea=on
there was a hernia in the case of Dr. Bryson was prob-
ably because the bladder was never full'y drained, and
being more or less distended at all times there was a
tendency to keep the ﬂaps from uniting. He had per-
formed suprapubic cystotomy a number of ﬁrms but
had never had hernia follow.
DR BRYSON, in closing, saidlhe still held to his orig-
inal view of the cause of the beginning hernia. The
patient had been going about with a suprapubic ﬁstula
for sixteen months before he operated on him. There
was then no sign of hernia. He had been attending
to his business. His explanation was that as soon as
the urine was no longer there to incite and continue the
devolopment of the ﬁbrous tissue, absorption took
place and left a hiatus in the abdominal wall; through
this the viscera are gradually protruding. The perito-
neum had never been opened in this case and could,
therefore, play no part in the etiology. The original
incision had been made by Dr. Block, of Kansas City,
and was below the vesico abdominal serosa

Specimen of Resected Bowel.
DR A. H. MEISENBACH exhibited a specimen of
bowel resected during the afternoon on account of
inguinal hernia. The patient was a man of 60 years,
who complained of pain in the inguinal region and irri-
tability of the stomach since Monday. He had been
seen by Dr. Hypes on Wednesday, who advised an oper-
12 MEDICAL SOCIETY OF
ation,but the man put it off, thinking he could overcome
the trouble. Dr. Meisenbach said he found the man in
fair condition, with good pulse; thestumor situated well
below Poupart’s ligament. He said he took this to be
a femoral hernia in the male. The patient was sent to
the hospital and an operation performed. The bowel
was found glued together, and on opening the sac he
was enabled to pull the bowel out and found about
three-quarters of it gangrenous; he felt that he would
either have to make an artiﬁcial anus or resect the
bowel, and decided to do the latter. In an operation
performed last summer with the Murphy buttOn the
patient was in such gJOd condition that he thought he
would recover; instead of closing the wound he drained
down to the site of the button. In about fourteen days
a ﬁstula formed and the contents of the small bowel
escaped through this ﬁstula, and the patient died of
inanition. '
This result with the Murphy button made him feel a
little chary about its use and in the present instance he
preferred end to end anastomosis by direct suture: The
specimen, he thought, very interesting because it'showed
the entire lumen of the bowel and the gangrenous
process.
The following report by the special committee on
the Medical Inspection of Public Schools was submit-
ted by the chairman, Dr. Homan. The report was
adopted and a copy was ordered sent to the Board of
Education of St. Louis. '
CITY HOSPITAL ALUMNI. 18
THE MEDICAL INSPECTION OF PUBLIC SCHOOL
- CHILDREN IN ST. LOUIS.
A Report by the Committee in Charge of the Work to
the Medical Society of City Hospital
' Alumni, January 19, 1899.
HE undersigned were appointed in December, 1897,
as a committee, with instructions to bring to the
nOtlOd of the Board of Education the matter of
the medical inspection of public r-chool children for the
better control of communicable diseases, and to repre-
sent tn that body the importance of inaugurating such
a service in St. Louis. This duty was performed and a
report thereon made to the Society in the early part
of has year.
The Committee was continued, and last September its
functions were so enlarged as to embrace within the
scope of its powers the supervision of an experimental
free service tendered by volunteers among the Society’s
membership, this work to be done under the auspices
of the SoCiety, with the permissive sanction of the
Board of Education, in order to practically demonstrate
the asserted value of such a service.
In the plan of organization of this service after ma
ture consideration a number of schools were selected
which, from their lecation, and other circumstances,
were deemed fully and fairly representative of all
classes and conditions of pupils to be found in the local
public school population. '
The schools thus selected were ten in number and
comprised those situated next north of the line of Wash-
ington avenue extending from the river to the western
city limits, the school population thus represented em-
bracing all classes and nationalities, and ranging from
those in the eastern part, where the home conditions
are of the worst, to those near the western suburbs,
where the home conditions are of the best. The
schools, and the assignments thereto, were as follows:
14. MEDICAL SOCIETY OF
Carr Lane. . '. . . . . Ur. JohnC. Falk, Dr. M. J. Lippe.
Crow . . . . . . . . . . .Dr. Charles J. Orr, Dr. N. W. Sharpe.
Dozier . . . . . . . . . .‘Dr. C. L. Fahnes'tock, Dr. H. R. Hall.
Franklin . . . . . . . .Dr. N. Saenger, Dr. A. E. Taussig.
Jefferson . . . . . . . .Dr.-J. M. Epstein, Dr. N. C Shanahan.
Riddick . . . . . . . . .Dr. M. G. Gorin, Dr. P. J. Heuer.
Shields . . . . . . . . .Dr. L. Drechsler, Dr. H. Frumson.
Stoddard . . . . . . . . Dr. Frank Hinchey, Dr. H. Jacobson.
Washington. . . . .Dr. F. G. Nifong, Dr. F. Reder.
Dumas (colored).Dr. Geo. Homan, Dr. H. W. Soper.
The map submitted herewith shows the location of
these schools and their relatiOn ‘to the municipal
territory, while the ﬁgures appended hereto show the
enrollment of pupils during the opening week, and at
the end of the ﬁrst quarter in November. > .
The work was commenced on October 10 and was '
conducted in accordance with the following rules, which
were ﬁrst submitted to and approved by the Society,
and they were in all material points also concurred in
by the school authorities: '
RULES.
1. The two physicians assigned to each school shall
alternate weekly in the service. -
2 The calls shall be made ‘daily at the hour of 10
o’clock, and the principal must be at once notiﬁed of
the presence of the physician.
3 Every pupil found ailing, or thought by the
teacher to be indisposed, will be brought promptly to ~
the notice of the physician for inspection—such facili-
ties as the school may afford for examination in private
being placed at his disposal, and the principal, or his or
her representative, must be present at every examina-
tion.
4. Cultures shall be taken in every suspicious case
of throat disease for the purpose of bacteriological tests
by the Health Department.
5. Wooden spatulas shall be used in making ex-
aminations of the throat and these when once used must
be immediately destroyed. - . V
6. N0 medicine shall be given, nor medical treat-
CITY HOSPITAL ALUMNI. 15
i-ment extended by the physician to the pupils during
such calls, but every case of illness must be at once re-
ported to the principal, with appropriate suggestions as
to the proper care or disposition of the pupils found
ailing; emergency aid may, however, be rendered on re-
quest of the principal.
‘ 7. No inspection of school buildings or premises on
complaint of sanitary defects shall be made by the phy-
sician under any circumstances.
8. Careful records shall be kept by the physician of
every case examined, which records shall include the
name, age, sex and residence of the pupil, the principal
symptoms observed, the ailment or disease found or
suspected to exist, the action taken and recommenda=
tion made in each instance.
9. Weekly reports shall be made to the Society and
a monthly synopsis of the returns submitted to the
Board of Education.
Same changes occurred in the medical personnel dur-
ing the course of the work, as follows:
Dr. Lippe resigned in December and the entire work
at the Carr Lane devolved on Dr. Falk.
Dr. Taussig was unable to undertake the’work at the
Franklin and withdrew, his place being temporarily
ﬁlled by Dr. Soper. Later, Dr. Saenger also withdrew
and the entire work was assumed by Dr. Soper, who,
for this purpose, relinquished his duties at the Dumas
to Dr. Homan, who continued in sole charge at that
I school.
At the J etferson, Dr. Epstein was in full charge, Dr.
:Shanahan from the outset having been unable to serve.
Dr. Drechsler withdrew from the Shields late in No-
vember and the work was continued by Dr. Frumson,
returns for two weeks in December from this school,
however, being wanting.
At the Stoddard, Dr. Jacobson resigned in November
andwas succeeded by Dr. W. A. Brokaw.
The necessary printed forms and blanks for keeping
records and making weekly reports were provided by
the Board of Education, the suggestions of the com-
mittee being followed in their preparation.
16 MEDICAL SOCIETY or
In the practical prosecution of the work the visiting
physicians used their own instruments for making
examinations; the Society supplied wooden tongue de-
pressors and absorbent cotton, while the Health De-
partment furnished culture outﬁts for bacterial tests.
It is a pleasure to be able to state that the oo-opera-
tion of the school authorities was hearty and effective,
the principals and teachers generally seeming to appre~
ciate the importance of the work, and its usefulness in
the early detection and prevention of spreading diseases.
MEDICAL ASPECTS AND RESULTS.
It will be seen from an examination of the table
which accompanies this report, and which gives the
complete ﬁgures for the eleven weeks service, that a
total of 1,565 pupils were examined and 1,601 cases of
ailments and diseases disclosed; while it was recom~
mended that 156 pupils in all be sent home on account
of existing infirmity or disease deemed dangerous either
to the child affected, or to its school associates.
Of the total morbidity found only 76 were of the
kinds included in the class termed Speciﬁc Infectious
Diseases, which embraces those maladies that are most
to be feared among the school population, as diphtheria,
scarlet fever; measles, whooping cough, etc. The cases
of diphtheria found were capable of exact identiﬁcation
only by means of culture tests, the symptoms being
mild to a degree that would not suﬂice to detain the
child at home; but, nevertheless, were potent for con-
tinuous wide spread communication of the infection to
susceptible associates. ‘
During December inﬂuenza manifested itself to a de-
gree unmistakable in a number of cases, but in many
instances masking its presence behind catarrhal symp
toms of the air passages, or a suﬁused condition of the
eyes (coryza). The full intensity of this pandemic visi
tation was probably not felt in the schools until after
the close of the service on December 23, and the evil
wrought by it is as yet incapable of full estimation.
THE MEDICAL INSPECTION
OF SCHOOLS.
The aopendel table exhibits the results of the medical inspection of certain public schools conducted under the auspices of the Medica
Society of City Hospitsl Alumni for the eleven weeks from October 10 to December 24. 1898.
Reports from the Shields School, for the weeks
ending December a and 17, were not sup Jlied. The physicians visiting the Carr Lane School reported that no pupils were presentedior
This service terminated with the December report.
inspection during October and November.

List of Diseases
found in. the
Schools.
S CH OOLS .

'- QuDFI-JJ’DQ
'ddﬂ i
"no
' “mOJ-Q
' 'Jepzog
' rimming
'HOSAQJZ'QI'
3192171”? H
' 'S‘PZWTIS
' swarms
' uowutusnm
" (palozogl
sprang
'92171013


'AON
'oeq
'ilQO
'AON
-oe(1
.100

Speciﬁc I nfecttous
Dtsea ses :
Diphtheria . . . . . . . . .. ..
Measles . . . . . . . . . . . . .
Whooping-cough. .. ::
Mumps ............ .. .
Chicken-pox . . . . . . ..
Inﬂuenza .......... .. ..
Tubercuiosis...... .. .. .
Malaria ........... . .
Diseases of Oral and
Respiratory Tract:
Stomatitis . . . . . . . . .
Alveolar 8hBC-:BS_ .. .: ..
Acute pharyngitis ..
‘0
Chronic
Acute tonsillitis. .. I.
\‘
yper. ..
Acute rhinitis . . . . .. _,
Chronic “
Ozaena ............ .. ,
Deviationsofsep'm .. _
Epistaxis. ......... .. .. -- 10..
Adenoiddisease.... .. .
Acute laryngitis... _
Nam-pharyngitis
‘0
Chronic _ _
Ac utebronchitis
Chronic “ -
Diseases of the Earl} '
Foreign bodies. . . .. ..
00
-'~ .-
- Otitis mediatcatrl) ..
lo
OIitiB
up.)-- .. Imperfect hearingit _,
Diseases of the Eye:
Foreign bodies..... .. _
Blepharitis ........ .. __
Stye.................
Pcoslsueuuco'nconn ~-
Coryza. . .. . ..
Oonjunctivrtis..._.._. _
Interstit’i keratitls ,_
Opacily . . .
Strabismus ........ .. .. Nystagmus._' . . . . . . .. .. Imperfect nizut’k... ..
Diseases of the Skin:
A008 . . . . . . . . . . . . . .. ..
2 : an n :
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38
Dermatitis ....... .. .. 'jj'
Eczema. ........... .. ..
Erytherna simplex. __ Furunculosis. .. . . .. ,_
Herpes ...... . .
Impetigo contag'sa ..
Pediculosis ....... .. .. Tinea ..... . . . . . . .. ..
Verruca ........... .. .. Oondyiomata....... ..
Miscel'aneous
D weases :
Anemia ........... .. ..
Debiiity . . . . . . . . . . . .
Headache(habitu’l):: . ..
Cervical ademtis... .. . .
Ohorea ............ .. .
Ulc'er..
Deformities .. . . ..
Rprains ..... . .. .... .. .
Fractures .... . . .
Contusions . ...... .. ..
Wounds . . . . . . . . . . .. .
Abscess........
Dental caries . . . . . . . . .
.. it"
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Neuralgia . . . . . . . . . .. ..
Epilepsy............. ..
Rheumatism ..... .. ..
Cardiac diseases.... ..
Gastricdiseases.... .
intestinal diseases. ..
Urinary diseases... ..
Torticollis . . .. .
Gangiion....‘....:... i: .. . ..
Oellulitis of face... ..
Totals....... .
Unclassiﬁed ...... .. ..
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MAP Snowrue LOCATION or SCHOOLS UNDER.
MEDICAL INSPECTION.
18 MEDIOAL Soorn'rr OF
Of the total ailments found 787, or more than forty-
two per cent, were affections of the oral and respiratory
tracts, and of these tonsillitis and pharyngitis lead the
list, the number being respectively 261 and 198, both
the acute and chronic forms being included in these
ﬁgures. Next comes 182 cases of bronchitis in both
forms, followed by laryngitis 51 cases, and rhinitis 49
cases] These ﬁgures serve to show how heavily the
brunt of morbid inﬂuences falls upon the anatomical
tracts under consideration, and what an important part
they play in the morbidity and mortality of school life.
Diseases of the ear numbered 37 cases, catarrhal and
suppurative discharges appearing in 27 cases, while 9
cases of imperfect hearing without visible cause were
reported. "
In affections of the eye 382 cases'were found, 227 of
which were returned as being imperfect sight without
visible cause. The limitations of the inspection natur-
ally forbade critical examination to ascertain the causes
of the defects, or to what extent the statements of the
pupils in this respect could be accepted as being trust-
worthy. ' i i i
The other principal ailments found in this classiﬁca-
tion were coryza 67, all forms of conjunctivitis 34, and
strabismus 20. '
Diseases of the skin numbered 45 cases, some of them
being of a communicable nature, as tinea, in several
forms, pediculosis, and impetigo contagiosa.
In the class Miscellaneous Diseases is a total of
274 cases, a number of which necessarily rest only upon
the statement of the child examined, as headache, neu-
ralgia, gastric, intestinal and urinary diseases, the pre-
scribed scope of the inspection not extending either to
a determination of their actuality, or cause, if really
existent. ' ‘
The principal ﬁgures shown here are gastric diseases
55, headache (habitual) 47, anaemia 31, intestinal dis-
eases 30, and cervical adenitis 25. '
In reviewing the results of this work it may not be
CITY HOSPITAL ALUMNI. 19
amiss to repeat that its fundamental and controlling
purpose was the instant detection of those diseases cap-
able of being passed from child to child, either directly
from person to person, or indirectly by means of in-
fected- things, as books, pencils, toys, clothing, etc.
In so far as the medical observation thus exercised
extended, it was found that the physical condition of
the pupils at the inception of the service was reasonably
good, the preceding summer having been not an un-
healthy one; and, notwithstanding the inclement
weather experienced more or less through the fall
months, no pronounced tendency toward the develop-
ment of the more dangerous diseases was observed in
the schools. ‘ » '
'Disorders of the throat and airlpassages were, how-
ever, very generally noted in the course of the work
which would predispose to and afford favorable condi-
tions and soil for the most malignant diseases of child
life, provided the efﬁcient agents of those diseases were
introduced.
Mention has already been made of the high percent-
‘ age which diseases of the oral and respiratory tracts
hold in the grand total, and in this fact lies a meaning
that must be obvious to every medical man. The ton-
sils and associated mucous surfaces when irritated or
inﬂamed constitute a highway for the entrance of diph-
theria, scarlet fever, tuberculosis, and probably other
infectious disorders; and, while such diseases in a se-
verely developed form suﬂice to detain a child at home,
yet there are many cases so mild in character that
school attendance is not interrupted, and it is this class
that serves to most actively and efﬁciently spread the
disease, while innocent of a knowledge of its dangerous
nature; and these walking cases constitute an obstacle
to the thorough control of dangerous disorders vastly
more formidable than those that are individually of a
more severe character. ' I
I Theicases of diphtheria that were found were of this
kind, and 'intheir detection and exclusion, aswell as in
2O MEDIcAL SOCIETY OF
the early recognition of other dangerous ailments, lie
the merit and justiﬁcation of this work as a public health
service. The circumstance that local conditions did
not concur to develop these maladies to an epidemic in-
tensity, as has been the case here in some other years,
does not weigh against this contention, the fact must
stand unchallenged that in the public schools are as-
sembled daily the largest numbers of the youthful pop-~
ulation anywhere gathered together, comprising all
nationalities, classes and kinds, and that here lies the
ﬁeld in which the most strikingly effective public health
work on preventive lines can be accomplished. '
A very considerable proportion of ear diseases with
impaired or destroyed hearing, and impending danger-
ous complications, undoubtedly have their origin. in dis
orders of the throat and air passages attendant upon or
consequent to measles, inﬂuenza, scarlet fever, or diph-
theria. '
The results of the inquiries incidentally made into the
condition of the eyes and eye sight emphasize the need
for expert skill in order to decide, in cases of complaint
of imperfect sight, the fact of real visual defect and
the proper remedy, or whether the asserted fault was
without good foundation. It may, however, be safely
assumed that the number of reported cases of habitual
headache bears a determinate relation to defective
vision among school children; and, indeed, some other
ailments may be found to possess such a relationship.
In conclusion, it is suggested that the thanks of the-
Society be tendered to the Board of Education for the
opportunity thus afforded, and to the executive oﬂicers.
of the department of education for valuable co opera-
tion and assistance, without which the work would have-
failed of its best results.
Also, an acknowledgment is due to the physicians-
who were engaged in the work for the conscientious
zeal displayed and scientiﬁc thoroughness evinced in its
performance. '
CITY HOSPITAL ALUMNI. 21
All of which is respectfully submitted.
GEO. HOMAN, M.D.,
JOHN B. SHAPLEIGH, M.D.,
ELswonTH S. SMITH, M.D.,
Committee on Medical Inspection of Schools.
The appended ﬁgures show the enrollment of pupils,
as oﬂicially reported, in the schools under medical in-
spection during the opening week in September, aud
at the end of the ﬁrst quarter in November. They
are respectively as follows:
SCHOOLS. WEEK ENDING QUARTER ENDING
SEPT. 9, 1898. Nov. 11, 1898.
Carr Lane . . . . . . . . . . . . . . 741 930
Grow . . . . . . . . . . . . . . . . . . 947 1043
Dozier . . . . . . . . . . . . . . . . . 854 996
Franklin . . . . . . . . . . . . . . . 608 761
Jefferson . . . . . . . . . . . . . .. 1412 ‘ 1361
Riddick . . . . . . . . . . . . . . . . 992 1162
Shields . . . . . . . . . . . . . . . . . 839 1137
Stoddard . . . . . . . . . . . . . . . 1080 1335
Washington ..... . . '. . . . . 602 700
Dumas (colored) . . . . . . . 638 1024
The following resolution was adopted at the meeting
held January 19, 1899.
WHEREAS, It is the sense of the Medical Society of
City Hospital Alumni that the inspection of public
schools, conducted under its auspices during the eleven -
weeks ending December 23d, 1898, has been pro-
ductive of good results to the public, to the pupils of
the several schools concerned, and to its own member-
ship from a scientiﬁc standpoint; therefore, be it
Resolved, That the thanks of the Society be and are
hereby tendered to the Honorable Board of Education
for the opportunity aﬁorded for initiating this service;
to Superintendent Soldan and Assistant Superintendent
Foster, and the principals and teachers of the several
schools, for the active sympathy shown and efﬁcient aid
rendered in furtherance of its successful performance.
22 MEDIcAL SOCIETY OF
STATED MEETING, THURSDAY EVENING, FEBRUARY 2,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
REMARKS UPON AN EAR AND THROAT INFECTION
WITH SUBSEQUENT INVOLVEMENT 0F
\ THE NECK. I.
BY ERNEST H. COLE, M.D., ST. LOUIS.
HE patient was 14 years old, a handsome Irish-
American girl. ' She consulted me because she
feared her ear was annoying to her girl friends. .
At 3 years of age she had an attack Of scarlet fever
which left her predisposed to periodic recurrent at-
tacks Of subacute otitis media, which appeared to be >
becoming chronic. When ﬁrst seen the left auditory
canal was ﬁlled with pus. For three days I syringed
with a weak antiseptic injection, each succeeding day ‘
the discharge diminishing materially, when on the
fourth there was no discoverable pus anywhere in the
canal or in the tympanic cavity.. On the ﬁfth day
she complained of marked sore throat. ()n inspect-
ing the mouth and fauces, marked evidence of erosion ~'
of the tonsils was seen, which, to me, indicated fre-
quent attacks of possibly follicular tonsilitis; also, in
the left region, a slight swelling which was very ten- ' '
der on palpation. On that day she had a tempera-
ture of 100°. The jaws were somewhat restricted in'
their movements—could be separated only to a ﬁnger
and a half’s breadth. Having frequently succeeded
with early incisions in that part of the throat, I de-
cided to do so then. I incised the tumor in the most '
sensitive part and secured a few drops of pus and
also a few drops Of bluish blood. The next day I
saw the patient, and 'she complained of pain in the
muscles of the neck, and the head was drawn in a
marked measure towards the left shoulder. There
had been no manifestations of heat, redness, or swell-
ing in or about the region of the left mastoid bone.
The symptoms had somewhat subsided, but the oriﬁce
CITY HOSPITAL ALUMNI. _ 23
made by lancing the throat was still open. On'the
seventh day the pain in the neck was more severe;
there was really no tumor discernible, but I felt it
fair surgery in such a location to make an exploratory
incision. I plunged the lance" down well towards the
base of the neck to what I felt might be the most
prominent part Of the tumor, the knife going in about
1.} inches, and was rewarded with at least two drachms
of thick, greenish, yellowish pus. Irrigated for sev-
eral days. All her symptoms had improved. She
did not go to bed, but was on liquid food for'three or
four days. The oriﬁce was still patulous when I
made the incision at the base of the neck. I was
much "temptedv to take a bougie and see if these cavities
were connected, but previous experience prevented
me from doing this.
My reﬂections were: Could this possibly be auto-
infection from the oriﬁce in the Eustachian tube?
Could the abscess in the base of the neck have been
caused by the abscess in 'the f auces, or was it caused
by any low-grade mastoid trouble? The latter is my
- belief. That the case was properly handled I ﬂatter
myself, because the results were so gratifying. But
I have never been able to solve satisfactorily the
conditions—whether cO-existent or interdependent.

DISCUSSION.
DR. R. B. H. GRADWOHL asked if he had had an
examination made of the pus found in the different
abscesses.
DR. COLE: NO.
DR. GRADWOHL said he thought some relationship
might have been established between these abscesses
if the pyogenic organisms had been examined. ,
THE PRESIDENT asked Dr. Gradwohl whether he
thought the demonstration Of the same micrococcus
in both abscesses would be evidence of the one having
extended from the other.
24 MEDIOAL SOOIETY OF
DR. GRADWOHL said he thoughtif the same organ-
ism that was found in the faucial abscess could be
demonstrated in the abscess at the base of the neck
he would consider it a fair inference that both ab-
scesses had a common origin. The microorganism
in question was a diplococcus similar in staining
qualities and cultural behavior to that known as the
diplococcus pneumoniae crouposae.
THE PRESIDENT said the remote possibility of the
existence of a branchial cyst there had occurred to '
him. Those more fully informed concerning the de-
velopment of the human embryo and its relationship
to the lower animals were better able to speak on that
subject than he was, but he had seen one or two cases
having both embryonal vestiges at the hospital, and
also recently the knowledge of a case was brought to
him in which such a condition was a fact—the re-
mains of a branchial cyst causing a suppurative
trouble in the neck.
DR. P. J. HEUER asked what was the most promi-
nent part of the abscess. .
DR. COLE said he selected what he thought was the .
most prominent point—a rather expanded swelling of
the muscles of the neck; but he put the knife in well
down towards the root of the neck to anticipate what
possibly might have been a gravitation of the ﬂuids,
but it was strictly a chance shot to reach the pus in
the root of the neck, although it was .not a chance
shot which had enabled him to get the pus in the
fauces, at that point he was going on very well-known \
land-marks. Had he waited for it to point it might
have been four or ﬁve days, perhaps ten days.
DR. H. WHEELER BOND asked at what point—the
exact point—the faucial abscess was found.
DR. COLE said it was a peritonsillar abscess; it was
outside of the tonsil, between that organ and the jaw-
bone articulation. '
DR. BOND said he would suggest, considering the
I
CITY HOSPITAL ALUMNI. 25
previOus otitis media, and viewing the subject from
an anatomical standpoint, there might readily have
been sufﬁcient lymphatic absorption of pus from the
middle ear to produce the abscess, and the abscess in
the neck was undoubtedly a sequel to and caused by
faucial infection. ‘
DR. COLE asked if he thought a'cute suppurative
otitis media accounted for the faucial abscess and the
cervical abscess also.
DR. BOND said he thought so. The lymphatics are
very closely associated there, and might easily absorb
sufﬁcient septic material to produce abscess.
DR. JOHN P. BRYSON asked what antiseptic was
used to irrigate.
DR. COLE replied that he used about a three-quarter
per cent. or one per cent. solution of carbolic acid,
warm.
DR. BRYSON said he didn’t mean to insinuate that
that caused an extension Of the trouble, but he noticed
from the report that the trouble gave way very
quickly to the treatment. He asked Dr. Cole if he
had ever made use of salicylic acid in clearing out
pus, and said he himself had used it quite success-
fully in chronic cystitis, where the cystoscope showed
the bladder hung with festoons of thick, tenaceous
mucus, 'which no other antiseptic solution would
wash away.
DR. COLE said he had never tried this use of sali-
cylic acid, but would be glad to do so when an op-
,portu'nity offered.
DR. BRYSON said it would not do in tubercular
cases, where it was very painful, but he said he
should like to have it tried in other cases and to know
how it acted.
DR. CHARLES SHATTINGER said he had had some
experience with salicylic acid in the successful treat-
ment of ear diseases, although he could not boast of
any special knowledge of otology. He used it as
26 M EDICAL SOCIETY OF
strong as 5 to 10 per cent, and preferred to have the
solution made of glycerine. He had found it an ad"-
mirable remedy in selected cases. He had also used’
it in speciﬁc vaginitis as a douche, two tablespoonfuls-
of a 10 per cent solution to the quart of water.
THE PRESIDENT asked if he used pure glycerine.
DR. SHATTINGER said the pure glycerine was apt to
be distressing, and it was better to use half glycerine
and half water. ‘ '
DR. BRYSON said he found that one ounce of good
glycerine would dissolve ten grains of salicylic acid
if it was warm, and then it might be diluted to any
- extent. He saidmost of the salicylic acids used in
surgery were made with alcohol and afterwards
diluted. He thought alcohol objectionable, as it was
very irritating. Glycerine was less so. He said he-
had never used it in any case as strong as Dr. Shat'
tinger had mentioned and asked how he got the-
solution. ' _
DR. SHATTINGER said he thought much'more than
ten grains to the ounce could be dissolved. He said:
a ten per cent. solution might "be made. e
DR. BRYSON said that was quite possible. He said
it might be interesting to know that the use of sali»
cylic acid as an antiseptic was ﬁrst practiced here, in-
St. Louis. Dr. Friedman had introduced it in the'
clinic of the St. Louis Medical College, using a two'~
per cent. solution. By accident, one of the assist-
ants in the speaker’s clinic used the solution as a-
vesical irrigation, in a case of chronic cystitis. In
this particular case they had not been able to
thoroughly cleanse the bladder to such an extent as-
to have the ﬂuid return clear, but after washing with
the salicylic acid, the ﬂuid returned clear. This was
brought to the speaker’s notice and he began using it
for irrigating those bladders in which there was an
accumulation of thick muco-pus. He found this--
would clear the bladder to such an extent he was-
CITY HOSPITAL ALUMNI. 27
enabled to see with the cystoscope into pockets not
otherwise visible, and often discover trabeculae, pre-
viously covered, enabling him to eliminate some of
the sources of error so common in cystoscopy.
DR. F. REDER was inclined to think, from the dis-
cussion, that the case was one of angina ludovici.
This affection, he said, was extremely rare. It is a
very serious condition, and generally aﬁects one side
of the neck. It was commonly known as “ quinsy.”
“Quinsy ” was a name commonly applied to ordinary
sore throat. This is erroneous, because “quinsy”
implies a condition of a severe sore throat frequently
resulting in abscess formation. The inﬂammatory
condition in the throat usually undergoes suppura-
tion. These swellings sometimes rupture inwardly,
causing danger to life, owing to the rapidity of tissue
destruction. Some open outwardly, and are less of a
menace to life, because they can be relieved by early
surgical intervention, their location favoring a better
observation. A swelling about the neck in connec-
tion with OtitiS media, he thought, was rather infre-
quent. It was more frequent in inﬂammation of the
mastoid cells. He asked Dr. Cole if the otitis media
subsided with the evacuation of the pus. ‘
DR. COLE said the acute suppurative condition sub-
sided by the fourth day from the use, he thought, of
the irrigation. . 4
DR. REDER said that would strengthen his supposi-
tion. The pus burrowed its way to the base of the
neck, and was evacuated as soon as discovered.
DR. COLE informed Dr. Reder that the trouble be-
gan in the ear, and in forty-eight hours the left frontal
region was involved; in forty-eight hours after that
the neck was lanced. It followed in quick succession.
DR. REDER said that was very characteristic of this
disease. It caused the death of George Washington.
He said he had himself seen a case in Hannibal, Mo.
The autopsy showed that the tonsil and the whole
28 MEDICAL SOCIETY OF
side of the neck was involved. The abscess had
ruptured inwardly, causing death. He considered it
one of the most dangerous conditions about the neck.
_—
REPORT OF TWO CASES OF PROSTATECTOMY
FOLLOWING ELECTRICAL INCISIOIN OF THE
VESICAL OUTLET AFTER THE BOTTINI=
FREUDENBERG METHOD, WITH
REMARKS.
J. P. BRYSON, M.D., St. Louis.
Professor of Genito-Urinary Diseases in the Medical Department
of Washington University.
- I-IINKING it might be interesting to have a
6 demonstration of the condition of the vesical
outlet and the prostatic urethra after electrical
incision of these parts by the Freudenberg modiﬁca-
tion of Bottini’s instrument, I report two cases
wherein I have opened the bladder, after having ﬁrst
attempted to deal with the obstructing overgrowths
by this procedure. -
Case I. Timothy F., act. 70, entered St. Louis Mul-
lanphy Hospital September 30, 1898, giving history of
disturbance in urination for the past seventeen years.
Beginning with slightly increased frequency, both
day and night, dysuria, pyuria, occasional hematuria,
gradually pr0gressed until the climax was reached in
an attack of retention about twelve days before ad-
mission. Treatment soon cleared up the urine, per-
mitted a cystoscopy which, with other physical ex-
amination, enabled me to arrive at a diagnosis of
hypertrophic enlargement of the prostate, with intra-
vesical projection, en collarette. The case appearing
to be one suitable for electrical incision, this was
done on November 3d. With the Freudenberg .modi-
ﬁcation of the Bottini incisor one incision was made
on the ﬂoor of the vesical outlet, beginning just
within the bladder, the beak of the instrument having
been hooked well down against the posterior surface
CITY HOSPITAL ALUMNI. 29
of the projecting collar before heating the knife.
The bladder was empty, and with the knife at a high
heat, the screw was turned until the register Showed a
projection of 2% centimeters. The patient complained
of no pain, arose from the operating table and went
to his room without assistance. There was very little
reaction for three days. On the fourth day there was
sharp bleeding, fever, greatly increased frequency,
and pain with sudden increase in pyuria, this, de-
spite the free use of urotropin and the strictest
asepsis. No catheter had been passed. By the 8th
day symptoms of a prostatic abscess opening into the
bladder had developed. This required the use of the
catheter and vesico-urethral irrigation. An atttmpt
to perform continuous drainage, with a soft catheter
tied in, failed. The condition steadily became more
serious, until on the 19th of November prostatectomy
became necessary. This was done by the combined
supra-pubic and perineal routes. In fact, a supra-
pubic cystostomy formed the ﬁrst step in the opera-
tion, and this was followed by a median perineotomy,
the splitting of the capsules of the prostatic over-
growths from their urethral sides and their removal
by excochleation. The prostatic capsule was almost
emptied, the large masses being easily removed, with-
out incising the bladder neck.
I ﬁrst searched for the incision made by the cau-
tery, and found it, somewhat to my surprise, to be in
the form of a curved instead of a straight line,
through the posterior part of the projecting collar.
The incision was largely of the bladder wall, as it
rose from a deep pouch to bend over the prostatic
projection. Thus the anterior part of the trigone
was divided by the cautery, and the ﬁrst joint of the
index ﬁnger could be pushed into a cavity, apparently
between the bladder and the prostatic mass. This I
took to be an abscess cavity which had dissected Off
the bladder from the base Of the prostate. Disturb-
30 MEDICAL SOCIETY OF
ing that part of the incision which involved the tri-
gonal angle caused free hemorrhage, and it was prob-
ably the source of the bleeding in the ﬁrst instance.
I have for a long time avoided incising the bladder
wall in doing a prostatectomy, believing this to be the
most proliﬁc source of bleeding, and I believe the
majority of operators hold to the same view. I
would say, in this connection, that I have ceased
for the past seven years to cut away these pro-
jecting growths with knife or scissors, and avoid
twisting them off, as much as possible. By the for-
mer method one cannot avoid cutting the bladder
wall in its most vascular part, and by the latter, con-
siderable portions of the mucous membrane may be
stripped up. In each case both hemorrhage and in-
fection are invited. Wherever it is possible I incise
the projection at a point well down the urethra, and
I push a ﬁnger through the incision and pull the
growth out by stripping Off the capsule. When ex-
cochleation cannot thus be done, it is better to use
the rongeur forceps, catching portions of the growth
ﬁrmly in their jaws, and pushing away the free parts
with a ﬁnger of the left hand, thus avoiding tearing
up the mucous membrane, which is usually the most
resistant part. 1-I have thus removed some large
prostatic masses by morcellation.
It remains only to add that this patient made a
satisfactory and uneventful recovery. His urine was
now almost clear, there was no residual urine, and he
rose once at night to micturate.
Case II. Wm. D., aet. 74; suprapubic prostatec-
tomy had been performed by me June 30, 1898;
satisfactory recovery had followed with the exception
of a persistent suprapubic ﬁstula, which, in my opinion,
was due to-the presence of a transverse bar stretch-
ing across the vesical outlet, and which had not been
incised for the reason just stated, viz.: the dangers
incident to dividing the trigone. The prostate had
CITY HOSPITAL ALUMNI. 31
been a large one, but its removal was not difﬁcult.
Unsuccessful attempts to close the ﬁstula by freshen-
ing its edges and suturing were made on September
' 10th and 21st. The patient’s health was poor, be
having suffered several attacks of entero-colitis. Not
desiring tO-anesthetize so weak and depleted a person,
I determined to attempt to divide the obstructing bar
with the electrical cautery incisor of Freudenberg,
on November 6, 1898. Despite the use of cocaine
and the cooling of the instrument with ice water, the
operation was attended with great pain. On the
seventh day there was sharp hemorrhage followed by
fever, pyuria and diarrhea. He thus continued to
suffer until December 13th when he requested an
operation, and the perineum was opened, a ﬁnger was
passed into the bladder, the bar incised and a large
hard-rubber drainage tube put in. This “lowering
of the ﬂoor of the bladder” resulted in closure of
the ﬁstula; but it also enabled me to ascertain the
condition of the prostatic urethra after prostatec-
tomy as well as the results of the electrical in-
cision. The prostatic urethra was found to be
wide, smooth and covered by mucous membrane.
One rather small ridge was felt to left posterior
side, but Since it ran longitudinally and seemed
to oti’er. no obstruction, nothing was done with
it. .The transverse band appeared to stretch across
( the middle of the trigone, and the incision by the
electro-cautery was felt as an irregular groove, prob-
ably crescentic in shape, as a ﬂap could be made out,
.the convex edge of which was directed to the left.
Manipulation of this groove, which was probably one-
_fourth inch in depth, caused rather free bleeding,
which was arrested by pressure of the Watson’s drain-
agetube. '
Referring to the operation of electrc-cautery in-
cisions for prostatic overgrowths, I consider that we
are not yet in position to estimate its value as a life-
02 q
MEDICAL SOCIETY OF
saving procedure, nor even to say in what cases it
should be performed. Of the etiology and early
stages of prostatic hypertrophy, we know practically
nothing. In well advanced cases, when the patients
are willing to entertain serious measures for relief, we
ﬁnd not one, but several conditions requiring correc-
tion, and this, too, in persons well past middle life,
and often presenting the degenerations of senility.
The enlargement is obstructive in a double sense; it
obstructs the urinary ﬂow, but probably even more
important, as a pathologic condition, it obstructs the
the venous drainage of the bladder by pressure upon
the periprostatic vein and the plexus of Santorini,
this causing not only stagnation of urine, but inter-
ference with the nutrition of the bladder wall—a
lowering of its vitality. Then comes cystitis, de-
composition of the urine, backward urinary pressure,
renal inadequacy and pyelonephritis. All of this
bears directly upon the choice of operation, Since it
renders free drainage almost always necessary.
Moreover, in the larger prostates there is a degree Of
intracapsular tension, which has a direct bearing
upon the question Of incision without enucleation and
drainage, with free, aseptic washing. The same
condition is found in uterine myomata. In incising
these larger prostatic growths, I have Often observed
that the incision gaped widely, separating the capsule
immediately adjacent, and opening the way for inﬁl-
tration of (most frequently septic) urine. In this
way the prostatic abscess was probably caused in the
first case reported. On the other hand, in two or
three cases I have removed such small projections of
overgrowth, and with such marked relief of all sym-
toms as to be truly astonishing. In the earlier stages
of prostatic hypertrophy the growths must be small,
and are Often localized. It seems to me that such
cases offer the best opportunity of being beneﬁted
by the electrical incisions, provided they could be
CITY HOSPITAL ALUMNI. 33
accurately diagnosticated. I should hesitate long
before incising, either with knife or cautery, a con-
siderably enlarged prostatic lobe, in high tension and
soon to be brought in contact with septic urine, with-
out free drainage and oppOrtunity for free washing.
It is of the highest importance that cases operated
on be reported with a view to criticism, for only in
this way may we be able to ascertain what we may ex-
pect and what we may promise from the operation.
The literature of this sort within my reach is limited.
In the, New York Record, Willy Myer reports in de-
tail twelve cases with four deaths (33%- per cent
mortality); 50 per cent were reported cured, 66 per
cent improved. Of those reported cured, one was
50 and another 52, making it doubtful if there was
a con-siderable degree of hypertrophy. In the IVez'ner
K'Jz'm'sehe Woehenschréft, December 1, 1898, A. Von
Fritch reports ten cases with one death (10 per cent) ,
10 per cent permanently improved. The death was
due to prostatic abscess. In an attempt to reach the
larger statistics of Freudenberg and Bottini, one en-
counters insuperable Obstacles. Von Fritsch com-
bines the tables of three operators, making 127 oper-
ations, with 7%,, mortality and 50 per cent cures.
He says that these tables probably do not represent
the true state of the case—a statement with'which ~
most operating surgeons will agree. Contrary to
Bottini’s asSurances, there are pronounced dangers in
the operation. Deaths have been reported as due to
phlebitis, thrombosis affecting the vesico-prostatic
plexus, pyelitis, embolic pneumonia, sepsis and ab-
scess. Some of these causes of death appear in
prostatectomy, it should be remarked. I have had
two deaths from septic thrombosis occurring, appar-
ently, in the plexus of Santorini. It still remains to
be Seen Whether electrical incision as at present prac-
' ticed accOmplisheS the desired object, and even
whether it has a lower mortality than prostatectomy
34 MEDICAL SOCIETY OE
at the hands of experienced operators. This can
only be determined by the reporting of all cases
operated on and observed for a Sufﬁcient length of
time. '
DISCUSSION.
DR. E. S. SMITH said he thought the important ques-
tion to be considered was, which operation would‘prob-
ably give the best results with the least mortality. Un-
fortunately, as Dr. Bryson has said, this was just the
question which was at present sub judice, and he felt
totally unable to answer it. The operator should
keep in mind the condition of these patients at the
time of operation—their ability to resist operative
interference. All of these patients become prostatic
along in the later stages Of life—somewhere about
ﬁfty or sixty. This is about the stage when degen-
erative changes begin in all the organs of the body,
and especially in the vascular system -- sclerotic
changes, which we call arterio~capillary sclerosis, and
which involve the entire vascular system and eventu-
ally the heart. As a result of this change we are apt
to have sclerosis of the coronary arteries along with
the others, and consequent disturbance of the nutri-
tion of the heart muscle, which is one of the serious
conditions to be found in attacking prostatic condi-
tions. Anyone with a damaged heart or blood-vessels
is not a safe subject for surgical interference for sev-
eral reasons, but principally on account of the dan-
gers of anesthesia on the circulation and on the heart.
He was inclined to believe there must be some who
succumb to what is called surgical shock. following an
operation, and which are doubtless in a large meas-
ure due to the effects of the anesthetic upon the heart.
He had seen several hospital cases succumb to either
heart failure or renal insufﬁciency following an anes-
thetic-at least, attributable to the anesthetic. If
the Bottini method could claim this advantage, he
CITY HOSPITAL ALUMNI. 35
thought it would be a most important one provided it
would accOmplish the result. Another feature which
seemed to him objectionable was that of hemorrhage
following the operation. The essayist also spoke of
septic infection leading to septicemia; this would
constitute a great disadvantage. However, this
method might protect the patient from the danger of
anesthesia, and at the same time expose him to
other dangers. He asked Dr. Bryson what had been
his results in prostatectomy in restoring the function
of the bladder, and how much difﬁculty he had in
preventing suprapubic ﬁstula.
DR. F. REDER said he would infer from Dr. Bry-
-1son’s remarks that he was inclined to favor prostatec-
tomy over the more recently advocated Bottini-
Freudenberg Operation; he probably felt that with a
knife in his hand he was more certain of his work.
A Cure was of course what was aimed at and desired;
but an individual who attained the age of three score
and ten, the number of years allotted to man’s life,
would feel grateful if only relief was afforded. The
two operations, Bottini’s and the radical, might be
looked upon at present almost as rivals. He thought
there were cases in which the one operation would do
more good than the other, and cases in which neither
operation would be of beneﬁt. Recalling the various
forms of prostatic hypertrophy, one in which there was
the glandular proliferation, andthe other in Which
muscular and connective tissue is abundant and dense,
these two forms he thought had their individual
chances for one of these operations. The gland nor-
.mally weighs some six drachms. In an hypertrophic
condition where the gland attains a size weighing frOm ‘
Six, eightto ten ounces, obstructing the ﬂow of urine
by a large middle lobe jutting from the vesical ﬂoor,
obstructing the vesico-urethral oriﬁce, the burning of
a canal of su‘ﬂ‘icient depth into this hard and sclerous
tissue is almost impossible. Such a "condition would
36 MEDICAL SOCIETY OF
demand the more herOic operation of prostatectomy.
It is improbable that we shall ever be able to know
which would entail the least mortality, but it is
almost certain that prostatectomy would carry with
it the greatest number of deaths. The Bottini-
Freudenberg operation may eventually be given
the preference, because it can be performed early,
'when the manifestations of hypertrophy are in
their incipiency. Then, too, the modus operandi is
simple and almost free from immediate danger to life.
Complications that may arise, however, can increase
the mortality rate. Another factor favoring the
Bottini operation is, that the operation of prosta-
tectomy is advised to be performed after all means to
evacuate the bladder have been exhausted, that is,
after catheter life has terminated. The general con-
dition of patients with enlarged prostates is usually
bad; their vitality is low; they are fagged out and ill
nourished. He did not believe any patient under such
circumstance should be charged to either operation
until his general condition can be brought up to the
best possible notch. Another condition constituting a
contraindication, would be a purulent state of the
bladder; also degeneration of- the kidney, or any
condition of the patient .where surgical tolerance
might be looked upon as more dangerous than the
operation.
' Dr. H. TALBOTT asked if Dr. Bryson had made any
selection of cases operated on, and if he had re-
frained from operating on cases because ,of degenera-
tive changes. The age at which we ﬁnd prostatitis
is one in which we usually ﬁnd other leSions, and the
condition of the patient is not calculated to stand an
operation as well as a person of younger years. He
thought the Bottinioperation carried with it less Of
danger than prostatectomy, and from that standpoint
was much to be favored.
DR. BRYSON said he had begun to operate with the
CITY HOSPITAL ALUMNI. 37
early introduction of' prostatectomy, and the mor-'
tality ran up so high that-he contemplated abandon-
ing it and tried palliative measures. At ﬁrst it was
thought necessary to operate upon every man who'
presented'himself; there was no selection of cases.
Later on, the lines on which selections could be made
were drawn and this put theoretical ideas out of court.
In regard to the question of hemorrhage, he said all
operators were now in favor of interfering as little as
possible with-the vesical wall. Whenever the bladder
wall is incised about the vesical outlet there is danger
of hem'Orrhage, and that is one of the advantages of
having a supra-pubic incision, because then the part-
can be packed and kept clean. In regard to anes-
thetics, he said he ﬁrst began using ether altogether.
In. ﬁfty-three operations he had two deaths from what
. was supposed to be anesthesia anemia. Both of
these were chloroform anesthesias, however. He
now used chlorofOrm and usually preferred it. The
danger from chloroform was immediate, whereas with
ether the danger comes later on—often after a week.
He said he had only one patient die of hemorrhage,
and it proved to be malignant—probably sarcoma of
the prostate. In regard to suppression of urine after
prostatectomy, he had never seen a case; on the con-
trary, some of the cases which died had polyuria up
to the time of death. What the condition of the
urine is, was impossible to determine, as it leaked out
in many places, and the amount passed was judged
by the saturation of the dressings. In reply to the
criticism, he said he had no prejudice whatever against
the Bottini operation. His desire was to operate
with the least mortality and ascertain whetherthis
Operation did one of two things—whether it simply
made a gutter or brought about involution of the
hypertrophy. He had heard a good deal about gut-
ters, but said he would not trust to one. Unless the
operation did more than that he did not see how it
\ 38 MEDICAL SOCIETY OF
was to be of any material advantage. One feature
which would probably make the operation popular
was that it required no anesthetic. If this method
will enable the surgeon to operate on people at an
earlier stage of the disease, he thought the mortality
would be greatly reduced, and we should also be. able
to ascertain what effect the electro-cautery had in
bringing about involution of the hypertrophied pros-
tatic tissue. In regard to the normal mortality of-
prostatectomy, he had seen it stated by a surgeon in-
the International Medical Congress at Moscow as
being nineteen per cent. Just how he ascertained~
this or what method he pursued in arriving at it was
not plain to the speaker. 'He had only one patient
die, he said, after prostatectomy, under ten days, so
i that he might fairly say none had died of shock.
The patient referred to died, he thought, of iodoform
poisoning. He had never been able to make out
any connection between glycosuria and prostatic over-
growth. He had seen prostatic hypertrophy in dia-
betes, but could discover no causal relationship. _
, DR. SMITH asked what caused the death of these
patients. - .
DR. BRYSON replied that hemorrhage, thrombosis,
and one died of pylophlebitis; two had died of pneu-
monia—probably anesthesia pneumonia.
DR. J ACOBSON asked if he remembered how many
kidney involvements there were. '-
' DR. BRYSON said it was impossible to estimate that.
The ureters could not be catheterized, and ammonia~
cal decomposition destroys any casts that might come
down. In regard to the percentage of cases operated
on, he said he thought he did not Offer operation to
mOre than ten per cent. Of the cases he saw, and this
was probably accepted by one-half Of those to whom
it was offered. The great majority are in such an
advanced state of prostration that only palliation
could be advised.
CITY HOSPITAL ALUMNI. 39
STATEDIMEETINC, THURSDAY EVENING. FEBRUARY 16, 8
THE PRESIDENT. DR. GEO. HOMAN, IN THE CHAIR.

‘BURNING QUESTIONS RELATING TO PARETIC
DEMENTIA.
BY L. BREMER, M.D., St. Louis.
HE subject of paretic dementia has Of late again
come to the fore in neurologic literature,
owing to its alarmingly rapid increase in all
civilized countries and the serious consequences which
it threatens to exert on our social, racial and economic
conditions. The remarks which I propose to make on
this subject tO-night are occasioned by the fact that
recently I have had an opportunity of clinically Ob-
serving until their fatal issue, and of making autopsies
on, two cases of this disease, which illustrate two dif-
ferent types of the malady and offer some points of
pathOlogico-anatomic interest.
Before reporting them, I Shall touch brieﬂy on some
_Of. the questions which from time to time have en-
gaged the attention of Observers, and still are await-
ing a ﬁnal and deﬁnite solution, and others which may
at the present time be called burning questions of
paretic dementia. Modern investigation and views
bearing on etiology, sociology, pathology, etc., will
brieﬂy be dwelt upon.
Clinically considered, there are two principal forms
of the disease, one, the original or classical form, and a
second one, the dement variety, which is steadily in-
creasing at the expense of the former, and is char-
acterized by a simple lowering of all the mental
faculties. The delusions of grandeur, which were
formerly looked upon as absolutely pathognomonic of
general progressive paralysis, either are completely
absent in this form or are present only in a feeble and
rudimentary manner. '
When early in the twenties the disease of general
progressive paralysis was for the ﬁrst time formulated
‘40 MEDICAL SOCIETY GP
in France by Dayle as being a combination of a mental
disease and paralysis, and when, a few years later, an
anatomical baSIs underlying the symptoms was estab-
lished, the salient point of the clinical picture drawn,
and one that presented. itself pre-eminently to ob-
servers, was the delirium Of grandeur coupled with
increasing physical weakness. This may at present
be styled the classical form, in contradistinction to the
one Observed with increasing frequency in the last two
or three decades, viz., the dement variety.
Even the original delineator of the clinical picture
discovered in his life-time that the disease had taken a
different aspect about forty years after it had been
described by him. It was at that time supposed that
manifestations of the disease had become milder, not
SO fulminating and violent as they had presented them-
selves to a former generation of psychiaters. The
weight of elaborate statistics in support of this Ob-_
servation was furnished by Mendel in 1880. Of late,
this subject has been discussed by a number of medi-
cal bodies, and at various meetings abroad, but I do
not think that this has been done to any great extent
in this country; still, every student of mental disease
will corroborate the statement that the character of the
mental syndrome is gradually verging toward the
milder or clement type. It must be remembered,
however, that there are tendencies at certain times of
medical history when certain diseases or types of dis-
eases become popular, so to speak, at least SO far as
the diagnosis is concerned, by physicians as well as
by laymen. Grippe may be cited as an instance.
Likewise, there are some forms Of dementia which
have been described as coming under the head of the
paralytic variety, but do not in reality belong to it.
What constitutes paretic dementia? A combination
of certain physical and psychic symptoms establishes
the diagnosis. Whenever you ﬁnd an individual who
presents the symptoms of disturbance of articulation;
CITY HOSPITAL ALUMNI. 41
if he cannot pronounce while conversing or reading, as
well as he used to do; shows a stumbling, stammering
or hesitating tendency and an unnatural slowness in
his delivery, contrary to his former manner of speak-
ing; and if, in addition to this, there is a permanent
pupillary rigidity and equality, the iris failing to
react to light or accommodation; whenever, at certain
times, this person is seized with epileptiform or
paralytic attacks; if there is a quivering and ﬂuttering
of the tongue, lips or cheeks; whenever, above all,
opthalmoplegia in one of its forms has set in, there is
a strong suspicion that this person is a victim of
paresis. Often one of the earliest evidences Of the
dread disease manifests itself in the commission
Of acts incomprehensible to the friends and family and
completely at variance with his former self; if his in-
telligence is on a lower plane and his judgment
exhibits serious ﬂaws, all out of keeping with his
natural character and intellect, we are warranted in
pronouncing his case one of paretic dementia.
The disease has. been said to be an aristocratic one,
seeking its victims most generally among the higher
strata of society. However, that is changed now;
like syphilis, which clinically differed in its Inani_
festations in the Middle Age from that of today,
paretic dementia has undergone material changes, not
only in its symptoms, but in its scope.
Syphilis is no longer a disease that ravages the
privileged classes as it used to do; neither is paretic
dementia. High and low, rich and poor, educated and
ignorant, all seem to be treated alike by this foe Of
mankind. There was a time when women were almost
entirely immune from paralytic dementia; now the
proportion is four men to one woman, and some have
observed three men to one woman. A peculiar fact is
that women of the lower ranks of life furnish more
victims than those of the better classes, so-called.
This bringsup the question, what causes paretic
42 MEDICAL SOCIETY OF
dementia? All agree that the cities furnish the
greater number Of cases; that in the country it is
comparatively rare. There was a time when in Ire-
land, outside of Dublin, not one case of paralytic de-
mentia co‘uld be found. There are now countries in
which the disease is absent. For instance, in Ice-
land it is absolutely unknown; it does not exist among
the savage tribes, where the struggle for existence
does not exist, where there is plenty of game and
fruit, and where the ﬁght of competition is not pushed
to such extremes as in civilized countries. There was.
a time when the negroes in this country were entirely
exempt, and I remember, years ago, an eastern
physician describing, as a curiosity, paralytic dementia
in a negro. It is quite changed now. The negroes,
especially the mulattoes in the large cities and those
more educated, are as subject to paralytic dementia as
are the other races constituting the American people.
I never heard of an Indian as being afﬂicted with the
disease, but have no doubt there are cases even among
them.
It has Often been said, that the reason why paresis
is more frequent in the cities than in the country is,
' because in the former the struggle for existence is
harder and the acquisition of syphilis is easier, and
Kraﬁ‘t-Ebing has tersely put it in this form: that
“civilization and syphilization ” go together; this
means that syphilitics furnish the recruits for the army
of paretic dementia. The generally prevailing opinion
among competent observers is, that syphilis is not the
only source of paretic dementia; the most reliable sta-
tistics give 95 per cent as due to this cause, or, at all
events, in that percentage syphilis can be demonstrated
to have existed at some period of life; but there are
other causes remote and immediate, primary and con—
tributory. The French school does not take kindly to
the idea that paretic dementia is always preceded by
syphilis, although it was in France that it was ﬁrst
CITY HOSPITAL ALUMNI. 43
\
' pOinted out by Fournier, that without syphilis there
was no locomotor ataxy (the nearest kin Of paresis),
and that at least one-half of the cases of paretic de-
mentia were met with in persons who had gone
through a syphilitic infection. -
What, now, is the relation of the two diseases?
Does syphilis increase the fertility of a preexisting
neuropathic soil upon which paresis is afterward gener-
ated, or, is it Syphilis, pure and simple, that creates
the soil upon which the disease is later on developed?
The Vienna school, led by Kraﬁt-Ebing, whose ﬁrst
assistant, Dr. Hirschler, has written very extensively
on this subject, declares paretic dementia to be ter-
tiary syphilis of the central nervous system, neither less
nor more. Others, however, say it is not syphilis, but
a disease which has sprung up on syphilitic soil, and
produces toxins of an unknown character, which de-
stroy the nerve elements. Syphilis, then, according
I to these authorities, paves the way for the outbreak of
the disease, but the disease itself is not syphilis. The
latter class of observers maintain that, because anti—
syphilitic remedies have no curative effect, but on the
contrary generally harm the patient, therefore it can-
not be syphilis as such that we have to deal with. It-
may be reiterated here, what has been contended time
and again, that exceptional cases of paretic dementia
(or, at all events, what seem to be Such) are beneﬁted
by anti-syphilitic treatment, when instituted at the ﬁrst
beginning of the symptoms; the majority of them are
injured by such medication, and I hold that especially
iodide of potassium as'generally administered to pa-
retic dements, i. e., in American doses, so-called, is
an extremely disastrous drug, and has only one thing
in its favor, viz., that it hastens the death of an in-
curable patient. In a paper read over a year ago be-
fore the St. Louis Medical Society, I alluded to a case
which presented all the symptoms of paretic dementia
following the administration, in excessive doses, of
44 4 MEDICAL SOCIETY OF
iodide of potassium. The physician who had pre- I
scribed the drug was ﬁrmly convinced that it was a
bona ﬁde case of paresis, arising on sy'philiticsoil, and
developing during, and in spite of, speciﬁc treatment.
Headache, ocular and articulatorydisturbance, apraxia,
mental confusion, impairment of moral tone and in-
telligence were present; there were feeble ideas of
grandeur. This individual recovered completely after
the discontinuance of the iodide of potassium. He
took 400 grains a day for over two months. This only
shows the extreme difﬁculty sometimes met with of 7
arriving at a diagnosis, if we do not take into con-
sideration the remedies administered, and the toxic
and disease—mimicking effect they mayproduce.
I said that paretic dementia had invaded the female
portion of the human race. This is explained by‘the.
fact that women have entered into competition with
men in a great many ﬁelds of labor. The anxieties,
ambitions, disappointments, etc., are now-a-days the.
same with a great many women as they used to be
with men exclusively. They go through the same
process which the law of the struggle for existence
and of the survival of the best adapted entails.
Again, in addition to the fact that paresis is increas-
ing constantly at the expense of the psycho-neuroses,
i. e., the more benign forms of mental trouble, it mani-
fests its spreading tendency by the fact that it has in-
vaded the ranks of the young. When I read for the
ﬁrst time one of Ibsen’s dramas, “ The Ghosts,” where a.
young man, a university student, is introduced as one
of the clramatis Personae, who presents the symptoms.
of paretic dementia as a result of inherited syphilis, I
set it down as a case of poetic license based on Ibsen’s.
ignorance of medical matters, and said to myself:
This young man is, from a psychiater’s point of view,
a scientiﬁc impossibility. We know now, however,
that paresis does occur in the young, even in children,
nine or ten years of age, and I myself have recently
CITY HOSPITAL ALUMNI. 45
seen a little girl of thirteen who presented the typical
symptoms of that-disease. All cases of juvenile pa-
retic dementia observed so far, bear the unmistakable
imprints Of hereditary syphilis, which again demon-
strates that between syphilis and paretic dementia
there is a very close connection.
Another very interesting and instructive point con-
cerns the changes which paretic dementia has under-
gone of late in the ratio of its spread among certain
classes, for instance, its occurence among the Jews.
In former years it was an axiom that syphilis was ex-
tremely rare among the Jewish portion of the com-
munity here as well as in Europe. This is not the
case now; Jews are as much subject to syphilis as
other people to-day; they are now also subject, pro-
portionately to their number, to paretic dementia as
much as other races, and in Europe it is claimed that
the Jews, when they do become paretic dements, do
not present the“ now generally prevailing mild and pro-
tracted form of the disease, but the violent, exuberant
and grandiose, in short, the classical form.
This is explained in the following manner: At the
, time when the Jews were persecuted and looked upon
as social outcasts, they did not associate with the rest
of the community in which they happened to live,
socially, sexually or otherwise; they kept to them-
selves, and their family life was superior to that of
others, so far as morality and purity were concerned.
A change, however, has taken place, and with the fall
of the barriers between the Jews and other portions of
the population, syphilis, and with it paretic dementia,
has invaded their ranks. In Europe, as I said be-
fore, certain observers claim that the Jews present the
classical form of the disease, and they explain this on
the following ground: We know that syphilis mani-
fests itself in a much milder form to-day than it did
in the middle ages, when it destroyed the populace of
whole towns, and swept like a virulent epidemic over
46 ~ MEDICAL SOCIETY OF
the peoples of the then civilized countries; that its
victims in those times would die in a few months after.
infection, and that it presented a sort of typhoid
character. The present comparatively mild appear-
ance of syphilis in civilized countries is due, they
claim, to the almost general infection of our ancestors
at that period, in consequence of which we of the
present generation are in a measure immunized, ‘and
are not apt to acquire the virulent forms such as was
common among the people of past centuries. I re-
member, when attending the clinics of Fournier at the
Hospital St. Louis in Paris, he pointed out a woman
patient just admitted to the hospital, who two months.
after infection presented the most aggravated, de-
structive and hideous form of .the disease imaginable.
Such fulminating manifestations of syphilis, he said,
were almost unknown in our days, and this case re-
minded him of the syphilis as described in the middle
ages. Now, what has this observation to do with the.
occurrence of the virulent form of dementia so fre-
quently observed in the Jew of the present time?‘
Simply this, that their ancestors having been free from
syphilis owing to their forced exclusiveness and isola-
tion, from infected surroundings, the present genera-
tion is not immunized from syphilis to such an ex-
tent as other civilized races; hence syphilis, and with
it paretic dementia, when they do occur, present the
more aggravated form of these diseases.
So far as my own personal experience is concerned,
I must say that the Jewish paretics whom I have had
under observation of late years, showed, with few ex-
ceptions, the mild and slowly progressing type of the
disease. A legitimate and pertinent question to ask
at this juncture is: How does the severity of syphilitic
lesions in the Jews compare with those in Gentiles?
Are they severer in proportion to the more intense de-
gree of paretic dementia met with amongst them? As.
for myself, I feel incompetent to answer the question.
CITY HOSPITAL ALUMNI. 47
It seems to be a fact, however, attested to time and
again, that among certain semi-civilized races which,
like the Jews, until comparatively recent times used
to be exempt from syphilis as well as paretic dementia-_-
‘ for instance, some Arabian tribes—the introduction of
the former would be followed by the appearance of
paresis, both being of a grave type.
Many observers think, and my experience tends to
bear out their view, that in order to become a paretic
clement one must be born with or acquire some defect
of the brain. There is, then, such a thing as a con-
genital and an acquired predisposition to paresis. The
acquired diathesis may be due to one or another of
A the infectious diseases, preeminently syphilis, but the
causa nocens may also be toxic in character, alcohol
and tobacco for instance. What in one is the pre-
disposing cause, constitutes in some one else the im-
mediate cause, and vice versa. Again, it is a remark-
able fact, veriﬁed by me in quite a number of in-
stances, that nearly all paretic ,dements of .the classical
type had, even in their well days, extravagant ideas,
and a very favorable opinion of themselves, whereas
those of the dement class were naturally slow of speech
- and somewhat dull of comprehension.
Sometimes it is diﬂicult to make a positive diagnosis
of paresis in a given case in the preparatory or de-
velopmental stages of the disease. There are certain
diseases the symptoms of which closely resemble those
of beginning dementia; the most common is neuras-
thenia in some of its forms. Almost every paretic
dement has at one time or another, antedating the full
development of the disease, been a neurasthenic; and it
is a remarkable fact that generally, as soon as the
clinical picture of paresis becomes clearly deﬁned. all
neurasthenic and hypochondriac symptoms disappear
as if by magic. Some doctors then imagine that they
have effected a wonderful cure of neurasthenia. Such
patients from being weak, irritable, despondent, and
4.8 MEDICAL SOCIETY OF 1
'unable to attend to their duties more or less, suddenly
become seemingly strong and healthy, declare them»
selves well, endure unwonted physical exertion with-
out the feeling of fatigue, and develop an unusual ac-
tivity, which, however, is always misdirected. They
are paretic dements now. ‘ I
Another disease which frequently gives rise to doubt
is polyneuritis, especially that type of the disease
which has been described by Korsakoff as psychosis
polyneuritica. Again, leptomeningitis of speciﬁc
origin, and arterio-sclerosis, but above all certain
forms Of hysteria, in the male, have Often proved
treacherous pitfalls to the reputation of the attending
physician, who, deceived by symptoms pointing to \
paresis, declares that such a person will end in mad-
ness and die in an asylum. Male hysterics, like de-
ments, are on the increase in all civilized countries;
sometimes they exhibit, in addition to Other suspicious
symptoms, even pupillary rigidity, apparently clinch-
ing the diagnosis of paretic dementia. They generally
get well more or less rapidly by some form of sugges-
tion; for instance, faith cure, osteopathy, .Kneipp
cure, and other fakes; sometimes they recover under
the care of scientiﬁc physicians, but not so often as
when treated by impostors.
Paretic dementia, at the present day, may be said to
have become the terrifying spectre of syphilitics._
There is such a disease as paresiphobia, oneof the
many varieties of morbid fear that haunt civilized man
who reads, besides encyclopedias, the current articles
written for the enlightenment of the public and pub-
lished in the secular press; or still more if he takes to
studying medical journals or text-books in order to
arrive at an understanding Of his case, so far as his
prospects of becoming a paretic dement are concerned.
The prognosis in paretic dementia is, as a matter of
course, in every instance and under all conditions un-
favorable. But the cases of the mild type, as already
cs,“ VHOSIPITAL ALUMNI. 49
indicated before, do not die within the conventional
three or four years, as granted by the writers of former
decades, but may live ten or ﬁfteen years; they may
even show decided remissions, some of them being
once more able to attend to their business; they may
seem to have recovered. Hence it is a commendable
plan not to make too rash a prognosis in a slowly pro~
gressing case of paretic dementia, but to hold out the
hope tat the patient may partly and temporarily re-
cover. There are!v cases of recovery on record in the
literature on this subject. The reality of such cases of
true paresis is do’ubted by many. Once in a while I
meet a man who ten years ago was under my treatment
in an institution, for more than a year, with well-
marked Symptoms of paresis. He is apparently in
good physical and mental health now. Was I mis-
taken in the diagnosis?
A few words about the pathological anatomy of the
disease. For many years there have been differences
Of opinion among investigators, some claiming that
the primary seat of the disease is the interstitial tissue,
71. e., the vessels and the neuroglia which, they contend,
proliferates, in Course of time atrophic changes in the
nerve elements resulting therefrom. Another class of
Observers maintain that it is _the nervous elements,
especially the ganglionic cells of the cortex, which un-
dergo atrophic changes ﬁrst, and that the interstitial
' tissues are secondarily affected. Whatever may be the
primary or'secondary lesion, it is a fact accepted on
I all hands'that the more exuberant the connective tis-
sue proliferation, the more profound is the dementia.
I shall now brieﬂy relate two cases illustrative of
the two clinical types of the disease previously alluded
to, with a short statement of the post-mortem ﬁnding.
A microscopic report will be given on another occasion.
Several years ago, a young man about twenty-eight
years of age was brought to me for examination and
professional opinion. He was married and had two-
5O MEDICAL SOCIETY or
children; no clear history of syphilis could be estab-'
lished, although its existence had been suspected on
general principles by the family physician. He had,
about two years previously to my seeing him, become
paretic on the right side, and to a degree aphasic.
'There was at that time no defect of intelligence. notice-
able. He was treated by anti-syphilitic remedies and
recovered from the paralysis and aphasia. A .few
months later he had another attack, was again treated
in the same way, and recovered. At this timefﬂliow-
ever, certain moral ﬂaws, not previously noted and
altogether foreign to the patient, cropped out. .He
had previously been a model husband; now he would
absent himself from 'home in an unseemly manner.
He had, in his well days, been a good musician and a
fair violin player; after the ﬁrst two attacks he had
neglected his instruments owing to physical disability.
On his apparent recovery from his second attack he
had again taken up his musical studies, but played in
an absurd, childlike, discordant manner, thinking all
the while that he performed as well as ever, . At the
same time he was utterly incapable of attending to the
simplest kind of business. He was again treated and
saturated with mercury and the iodides. He again
partly recovered, and went to Germany, and was there
treated in a sanitarium On the same principles as
before. While there he had an epileptiform attack in
which he came near dying. After having recovered
from this, he was pronounced cured by one of the
doctors there and sent home. Soon after arriving he
relapsed into his former condition, became unreason-
able in speech and action but never violent, being of a
placid and doCile disposition throughout his sickness.
But he made foolish expenditures, had no idea of the
value of money, talked about millions, and died ﬁnally
in coma which lasted three or four days. I made a
post-mortem examination and expected to ﬁnd the
classical changes which the books have laid down.
CITY HOSPITAL ALUMNI. 51
There were, however, no macroscopic lesions'nOticeable
in the cortex or meninges. The most obvious patho-
logic change was an hydrocephalus internus of unus-.
ual dimensions, the ﬂuid escaping from the immensely '
dilated ventricles amounting to at least eight-ounces.
There were, on macroscopic inspection, no signs of
chronic meningitisor encephalitis, nor any other coarse
change of the substance of the brain.
The second case was that of a manufacturer about
forty years of age. He had become infected with
syphilis when about twenty years of age; was married
and had healthy children. About one year previous
to my seeing him and to his death he developed symp-
toms Of melancholia, became very sentimental, unnat-
urally affectionate and over-domestic in his habits.
This state of things continued for about six months, ‘
i when, a few days before my visit to him, he became
greatly excited, was abusive to his friends and family,
was sleepless, and rapidly developed exorbitant ideas
of his wealth. ' About this time a characteristic tremor
of the tongue, lips and facial muscles set in, together
with paresis of the members of the right side. Mental
confusion, excitement and physical weakness pro-
gressed at a rapid rate from day to day. On my ﬁrst
visit he was still able to give a fairly correct descrip-'
tion of the course and development of his disease. -
About a week later he talked at random, considered
himself to be in better health than ever, and offered
me a check for $25 000 for my services. Owing to a
rapid decay, both physical and mental, he was taken
to a general hospital. It was to be expected that the
case would take a rapid course and that a fatal issue
was not far Off. I try to avoid commitment to an
asylum of galloping cases like this one, whenever feasi-
ble. I do this in the interest of those who believe that
there is a mortgage on their brains when an ancestor
of theirs has died in~ an insane asylum. . Many a life
has been made utterly miserable by the record of death
52 MEDICAL SOCIETY 013‘
of the father reading: Died in the insane asylum at
; cause of death, paresis. I expected to ﬁnd
in this case, also, the classic changes Of paretic demen-
tia, but I did not. The brain was extremely wet,
about a pint of sero-sanguinolent ﬂuid exuding from its
substance. Microscopically, grave changes in the sub-
stance Of the brain, its vessels, neuroglia, nerve ﬁbres
and ganglionic cells were well marked; there was,
above all, a profound alteration Of the cortical ele-
ments. But macroscopically, edema of the brain would
have constituted the result of a post-mortem examina-
tion. Barring a different distribution of the exuda-
tion, the brain lesions were-in principle the same in -
both patients, but the course of the clinical symptoms
was radically different. In the former it was the
slowly prOgressing, mild form; in the other the
rapidly developing, violent variety, _marked by the
typical form of the delirium of grandeur. _
The symptoms and course of the disease in these
two patients were in conformity with their mental
characteristics in their natural state. The patient last
mentioned had, from his youth up, been aggressive,
boisterous, boastful, visionary and extravagant as to
his future career and possibilities for wealth; the other
had always been a quiet, unassuming, modest young
man. Both of them took their normal mental state in
an exaggerated form into their mental disease.


DISCUSSION. _
DR. GIVEN CAMPBELL concurred with the essayist
in the view that the disease is becoming more frequent
and that the demented type is more general. He
spoke of a case seen at the clinic recently, and' asked
that Dr. Bremer enlighten him in regard to it. The
‘man was about 35 years of age; had. had syphilis ﬁf-
teen years before. He had facial palsy On one side,
apparently complete, with lagophthalmus, paralysis of
the sixth nerve on the other side and Of the sixth and
CITY HOSPITAL ALUMNI. ' ' 53
third on the same with the facial palsy, with ptosis and
immobile pupils, and a great deal of dementia, which
had lasted about a' month. It looked like a case of
syphilis involving the brain, but accompanying the
other symptoms was a weakness of both arms, with
symmetrical wasting of deltoids, biceps, and small
_ muscles of the hand. - He was put on potassium iodide,
and in four weeks the mental condition cleared up;
but what was a little hard for the speaker to under—
stand, the wasted muscles in the shoulder and hand be-
came well and the facial palsy almost completely dis-
appeared. Dr. Campbell said he would hardly class
it as a case of paretic dementia, but he wanted Dr.
Bremer’s opinion as to whether it might not have been
one of those commencing cases. \
DR. BREMER said he thought Dr. Campbell’s case
was simply a speciﬁc disease of the brain and speciﬁc
neuritis, which acted ~well under the treatment. He
would not look upon it as a case Of paretic dementia.
It was this class of cases which simulated paretic
dementia.
DE. BRANSFORD LEWIS said he had been for some
time engaged in compiling statistics relative to the
comparative frequency Of venereal disease, and, inci-
dentally, syphilis among the Hebrews and Gentiles.
As far as he had been able to gather, his impression
was that Jews were not infected proportionately as
frequently as the Gentiles. He said he knew that the
private practice of one physician would, of course, not
furnish much material, but Dr. Llewellyn Williamson
had gone over the records of the City Hospital for ten
years for him, which investigation had disclosed an
enormous disproportion between the Jews and the
Gentiles, and in medical literature he had been im-
pressed the same way. If the ancestors of the J ew-
ish people were SO‘free' from syphilis, he thought the
Jews of the present day ought to Show a more severe
form of syphilis than they do; but his experience had
54 ._ ' MEDICAL SOCIETY OF .
not conﬁrmed this, and he found the Jews did not suf-
fer' from the disease any more severely than others.
He said he was, however, open to instruction on these
_ points, and was still gathering statistics on the sub-
ject, hoping to establish some relative frequency of
the disease in the Jews and Gentiles.
I . DR. BREMER said he only-related the opinions Of
certainEuropean observers on this subject. He did
not give it-as his opinion, that the Jew presented a
more severe type of syphilis than others. He said his
experience, in fact, was that the Jew presented the
mild form of paretic dementia, and not the classical
form.
DR. HENRY J ACOBSON had treated a number of
cases of syphilis in Jews, and, with one exception,
they were all mild cases. Contrary‘to his advice, this
patient married. He had a syphilitic child. Aside
from being nervous, he had no manifestations of the
disease until about two years ago, when he developed
diabetes insipidus. He became very dull, absent-
minded, had aphasia and cOmplained of severe pain in
head at times, and was also troubled with his sight
and heard strange noises, etc. He did not develop
any symptoms Of. grandeur or imagine himself to be a
rich man, but was in' a very bad way. Under mercur-
ial inunction treatment, fresh air and rest from busi-
ness for about ayear, he apparently recovered entirely,
until about. six months ago, when he developed perios-
teal gummata of the frontal bone abTOve the left eye,
and had mucous patches in his mOuth. This was the
most severe case the speaker said he could recall in a
Jewish subject. Another case' mentioned was tuber-
culous dementia. He was a physician, and the ﬁrst .
thing wrong his friends knew was he had several signs
printed after this fashion: “Dr. John Smith, M. D.”
Then he bought a ﬁne turn-out, four-in-hand, costing
him about $800, which he could not afford. Then he
declared he had a patent on a car-coupler, and offered
CITY HOSPITAL ALUMNI. 55
to give Dr. Jacobson many thousand dollars; said he
was going to endow a hospital, etc. He ﬁnally be-
came bed-ridden, developed symptoms of tuberculosis
of the lungs and brain, and died. Dr. Jacobson said
many of the members would recognise the name if it
were mentioned.
" DR. M. A. BLISS said he had been much impressed
with the remarks on dementia occurring in children.
He had seen two cases of paretic dementia in Jews,
both Of which he had seen in the last year and a half.
One developed symptoms about three years ago and '
died about six months ago. He had had syphilis. A
younger brother had developed symptoms of dementia
within the past three months. He contracted syphilis
ten or ﬁfteen years ago, and the speaker said it was
somewhat remarkable that both men should have de-
veloped the disease at the same age; the one now
afﬂicted was, he thought, about three or four years
younger than the other. These, he said, were the only
two instances he had seen in Jews, but he thought
from what information he had that the disease was on
the increase among these people. In reference to the
two cases cited by Dr. Bremer, the speaker said he
would be glad to have a little more detail in the his-
tory of these cases; that is, the clinical features of the
cases. There are many authors who describe a para-
lytic insanity which simulates closely paretic dementia,
but deny that they are true paretic dementia unless
they ﬁnd the classical changes in the brain. The two
cases were very interesting, he said, but he would be
glad to have the clinical features of the ﬁrst case
especially. .
.DR. CI-IAS. SHATTINGER said the sociological aspec
interested him most at present, though he did not
know that this would speak well for his interest in
medicine. He had recently seen a statement averring
that paretic dementia has been known to increase from
decade to decade in Algiers simultaneously with the
56 MEDICAL SOCIETY OF
inroads of syphilis and so-called civilization. When,
he said, such a disease was shown to be on the increase,
when a connection seemed to be established between it
and civilization, and when it was found that this dis-
ease which formerly conﬁned itself to certain ranks in
life was now invading many others, the question arises-
whether the saying of “the survival of the ﬁttest”
was not ~a much-abused dogma? Who are the ﬁttest
surviving under conditions which produce an increased
amount of neurasthenics, paretics, degenerates, klep—
tomaniacs and criminals? It seemed to him that there
must be something wrong with this civilization. It
was very gratifying to him to behold that it was the
doctor who was able to throw so many Side lights upon
it. He said he had recently heard a lecture in a
prominent law school in the city upon responsibility
and crime,-and was surprised to note the difference-
between the views of the up-tO-date neurologist and
the lawyer upon this subject. It was evident to him
and to some of the law students, that the lawyer was
very far behind the doOtor, and that the law in this
particular had lagged behind medicine, as it had
always lagged behind science in general. Leaving
this part of the subject, which was not strictly medi-
cal, Dr. Shattinger said that from the standpoint of
the general practitioner, perhaps the most interesting
part of the subject was the possibility of confounding
paretic dementia with neurasthenia. Dr. Bremer had
already pointed out this difﬁculty. But some thoughts
had suggested themselves to the speaker. The men-
tion Of pupillary symptoms, ocular paralysis and pare—
sis of the limbs, coupled with psychic symptoms, as
clearly distinguishing marks, had already been made.
But these Symptoms were Often absent in the early
stages, and it was in the early stages when the disease
was most difﬁcult to distinguish from neurasthenia.
Headache, inability to conduct one’s affairs as formerly,
a certain slowness of thinking, a slight difficulty in
- CITY HOSPITAL ALUMNI. 57
speech, or perhaps misplacing a word or sentence oc-
casionally, are symptoms from which the inference
would be drawn that these were the signs of paretic
dementia; but the neurasthenic might under emotional
, disturbance (the excitement perhaps of going to a new
consultant) misplace a word or sound occasionally,
though not as often as the beginning paretic. The
neurasthenic might even present symptoms of facial
paralysis—a slight paretic condition about the mouth.
.The neurasthenic might also Show a slight paralysis
connected with the hypoglossus. In neurasthenia, as
he understood, paresis of these two nerves was not an
uncommon occurrence, being sometimes congenital.
If it can be shown that these slight disturbances were
acquired, then the possibility of the case being demen-
tia is strengthened. A symptom which occurred in
paretic dementia very frequently, and an excellent one
to aid in distinguishing it from neurasthenia, although
not infallible, was analgesia or diminution of the sense
of pain. Another symptom that might occasion dif-
ﬁculty in differentiating between the paretic dement
and the neurasthenic was increase of the patellar re-
ﬂex, Sometimes found in the neurasthenic as well as in
the beginning paretic. If it can be shown' that the
exaggeration is unilateral the chances Of it being a
case of dementia are very much improved. Dr. Dre-
mer intimated that it was better for the family, and
that the idea of having it known that an ancestor had
\died in an insane asylum was very much-disliked.
Dr. Shattinger said he thought the physician had a
duty to perform which was not altogether professional
--it was humanitarian. .The‘ physician should have
people understand that it is no stigma to have an ances-
tor die in an asylum. It was most important that it _
be known that diseases of this character were in a
family and that marriages in such families should be
avoided. This could not be accomplished if the phy-
sician abetted the impulse to keep such matters secret.
58 MEDIOAL SOCIETY OF
He said he recognized that the position of the phy-
sician was a difﬁcult one, and that he might become
less popular by pursuing the line of conduct advised,
but he alsorecognized that the medical profession had
never yet failed in any appeal »made to its conscien-
tiousness. -
~ Dr. C. O. MOLz‘ said the cases he had seen at the
Insane Asylum were generally among the lower classes.
Whether this was because those of the better class were
kept at home or in private institutions, as Dr. Bremer
had suggested, he could not say, but thought it
probable. -
DR. BENNO BRIBACH, alluding to the relation of mat-
ter to mind, and of the substratum of the brain to the
mind, said he thought this subject would remain in-_
deﬁnitely in the hands of the neurologist and the
scientist, who would use their own gray matter in labor-
ing to establish these relations which, the speaker
thought, would probably go on for all time with the
same general result. -
DR. FRANCIS REDER said he had always associated
the word dementia with some form of insanity—that
is, the termination of a form of insanity; for instance,
we know of an acute primary dementia and a chronic
primary dementia. Then we have a secondary de-
mentia and a congenital dementia, which is deserving
the name of simple idiocy. The word, he said, had a
peculiar meaning, “ de ” meaning “without” and
“_mens” a “ mind.” This appellation alone Would
hardly do to cover so important a clinical picture. If
he interpreted Dr. Bremer’s remarks correctly, he said -
he would infer that dementia was nothing more than
an outcome of syphilis, and that syphilis was the out-
come of civilization. In only one _case had the.
speaker jumped at the diagnosis of paretic dementia.
That was the case of Dr. Alexander Lee, whom he.
knew quite well. At ten O’clock on the morning of the.-
day when he was overtaken with this sad aﬂ‘liction he.
CITY HOSPITAL ALUMNI. 59
appeared perfectly rational; in the afternoon of that
day Dr. Lee tried to operate on a patient, attempting
' to enucleate a large gland in the neck; the patient
wanted to take an anesthetic, but Dr. Lee told him it
was not necessary. During the operation the patient
became alarmed at the hemorrhage, and feeling that all
" was $101; right, jumped from the table and ran out, Dr.
' Lee following him. He did not catch the man and
' went back to his office. Then he went down town and
seeing a feed store, went in and purchased nearly
everything. he saw. He next bought a lot of furniture
and then visited a jewelry store, where he made ex-
tensive purchases. He was ﬁnally taken and placed
in a cell. When the speaker approached him and
called him by name, he seemed to be the same in every
way, except that he had a vacant stare. Both pupils
were widely dilated. During the conversation the
patient would constantly examine the diamond rings on
his ﬁngers. The prOgress of the disease was very rapid
and he died three or four months later at the Insane
Asylum in Jacksonville. In regard to Dr. Shattinger’s
remarks about neurasthenia, the speaker called atten_
tion to the fact that Erb seemed to place a great deal
of stressupon the pulse wave. He suggested that the
patient ~be placed in the upright position near a chair.
The ﬁnger of the observer was to be placed on the
radial pulse; then the patient was requested to sit in
the. chair; during the act of changing from the erect to
the sitting posture, if the patient is a neurasthenic,
the pulse wave will either slow up or intermit. Dr.
Reder said he had tried this on numerous individuals,
some of whom were apparently healthy, and others
who were suspected as being neurasthenics, and he had
found the pulse wave to vary in several instances. On
closely questioning these individuals, nervous symp_
toms of a pronounced nature were found to be present.
THE PRESIDENT asked Dr. Reder if there any
speciﬁc history in the case he mentioned.
60 . MEDICAL SOCIETY OE
Dr. REDER said there was not. I
DR. R. B. H. GRADWOIIL asked Dr. Bremer to what
he ascribed the bad effects of the iodide of potassium
.__whether to the large doses administered, or to the
drug itself. _
DR. A. H. ME'ISENBACH asked what Dr. Bremer
thought of the propriety of performing a surgical op-
eration in cases Where there was internal pressure sus-
pected or found. In the-ﬁrst case related there had
been found considerable internal hydrocephalus on
post-mortem, and he wanted to know whether lumbar
puncture or trepanation wOuld not be advisable, of
course, however, only as a palliative measure.
DR. J AMES MOORES BALL said he had been very
much interested in the paper and was sorry he had not heard the whole of it. In regard to the relative fre-
quency of syphilis in the Jew and the Gentile, he sug-
gested that the facts could not be arrived at by statis-
tics of general hospitals or charitable institutions,
because it was a well-known fact that the Jews take
good care of their poor, and it rarely happens that a
Jew is found in a poorhouse or city hospital. There-
fore, he'thought, the statistics not only of hospitals
but also those from general private practice should be
secured. -
_ DR. HENRY J AOOBSON asked Dr. Bremer if he had
found any of the so-called Lustgartner’s bacilli of
syphilis in the brains and membranes of the two cases
reported. He said the last Year-Book of Treatment
stated that Dr. Piccunio demonstrated this bacillus
in sections of the membranes and brains of three
out of four patients who had died from paretic de-
mentia.
THE PRESIDENT asked if there was any relation be-
tween a paranoiac condition and paretic dementia;
and, also, in view of the speciﬁc history ascribed to
these cases, what other manifestations of that disease
there were beside the cerebral symptoms. Were there
any active symptoms of the disease?
CITY HOSPITAL ALUMNI. 61
DR. BREMER in closing said, in reply to Dr Bliss’
request for further information of the case reported,
that he did not know the earliest history of the case.
Such patients, as a rule, do not come to the neurolo-
gist in the beginning of their disease, when the clinical
picture is well marked. There is in the preparetic
stage a history of neurasthenia; the symptoms are ill-
deﬁned and impress the casual Observer as being
merely of a generally nervous character. Under such
conditions the patient, as a matter of course, applies to
his family physician for relief; then he goes to the oc—
ulist, aurist, genito-urinary specialist, etc., in fact, he
seeks advice from the peripheralist, as the speaker had
styled this class of practitioners in contradistinction
to the centralist, which means in ,this instance the
neurologist. As a rule, the latter is consulted when
almost anybody can make the diagnosis. In this in-
stance, he had seen the young man when all the symp-
toms admitted of no doubt as to its character. The
only question was, was this dementia simulated‘by
Speciﬁc disease? But he had been treated for syphilis,
pure and simple, and when he improved it was
ascribed to the remedy; when he got worse it was
ascribed to the disease. In regard to the cases occur-
ring in brothers, as related by Dr. Bliss, the speaker
said he could duplicate that. The cases occurred in a
family of ﬁve children—two boys and three girls.
The two boys acquired dementia between 35 and 40
years of age. They were both syphilitics, and it is
reasonable to suppose the girls were not. There was
also a circumstance-worthy of mention: their mother
had a rickety pelvis, and four of her children, includ-_
ing the boys, were delivered by forceps. Here again,
'he referred to the theory Of injury to the brain ac-
quired, perhaps, during intra-uterine life, being a pre
disposing cause. He said it was questionable whether
the forceps delivery did not constitute one of the pre-
disposing causes tO the disease. If there is a latent
62 MEDICAL SOCIETY OF
injury to the brain, either intrauterine or extrauterine,
and syphilis is acquired, followed by unhygienic liv-
ing, anxiety, worry, etc., then, he said, we might ex;
pect paretic dementia to fOllowx That was the case
with the two boys he mentioned. They had both been
treated skillfully and energetically for years for their _
syphilis, and considered themselves well. ‘ Among
those physicians who follOwed up these cases, itwas
a matter of common observation that no matter how
conscientious and thorough the treatment for syphilis
might have been, it had no effect so far as the ultimate
Of paretic dementia was concerned. Dr. Shattinger,
he said, touched a chord that is vibrating throughout
the world—the question as to the survival of the ﬁt-
test and the extermination Of the inferiorities. That, _'
the speaker said, was a sociologic question, very inter-
esting and, perhaps, germane to the subject, but rather
too vast for- him to enter into. He said he believed
Dr. Shattinger had some enthusiastic .ideas on social
reform, etc., but that he was himself inclined to be a
pessimist and did actually believe that the inferiorities
prevailed to-day under the existing economic system,
and that, as someone had put it, the future belonged to
the weaklings and rascals. That the inferiorities did
live and thrive to-day was largely due to our skillful.
hygienists, such as the Society’s worthy president,
who by preventing disease and ameliorating the sur-
roundings of the unﬁt, had not only impoverished the
doctors, but had actually lengthened the lives of the
tubercular, the insane and other inferior persons. As
for keeping these patients out of the insane asylum
_as long as possible, when he was young he shared the
opinion of Dr. Shattinger. Now, however, in the
light of experience in such matters and for the reasons
stated, he acted differently, but only in certain caSes.
When he was called upon to care for a paretic dement
who was harmless, was not a burden to his family,
and the children, if any, were too young to realize the
CITY HOSPITAL ALUMNI. 63
condition of the father, he advocated keeping this
person at home. There was no reason why such a
patient should be in an asylum, especially when the
patient himself had an insight into the nature ofw his
malady, and when there were plenty of means to keep
himsurrounded with proper attendants and the com-
forts and cheerfulness of a home. Such patients fre-
quently know they are of unsound mind and they
dread the asylum. These cases, he thought, should
be kept at home if they can be without damage to the
family. Another class, he said, might be kept at
home if the family so desired it, and if there were
ample means. It was that class that presented the
galloping form Of the disease, and where there were “
indications of a speedy fatal termination. Whenever
there was any possibility of moral contamination, of
danger to the life of attendants or family, and where
there were other reasons why the patient should be
committed to an institution, it was of course a matter
of common sense to act accordingly. The speaker
only desired to emphasize the proposition that there
are certain patients who, under certain conditions and
in certain surroundings, might be kept at home.
In regard to the stigma‘and evil effects upon the
descendants of the insane, generally speaking, com-
mitted to the insane asylum, the speaker said he had
seen so much of that that he was now more than ever
inclined to keep curable patients out Of the insane
asylum. Generally, the children or their relatives Of
the insane are haunted day after day by the fear that
they will share their fate. They feel that they have
the mark on them, and every little symptom of hys-
teria or neurasthenia, creeping, crawling, burning and
other perverted sensations, but particularly the mental
anguish and confusion experienced by the sufferers
from these diseases, are interpreted by them as
approaching mental trouble. Again, if the patient
recovers, it is much better that he be at home where
<64 MEDICAL SOCIETY 015‘
he would have the helping hand and kind attention of
the members of the family to lead him back to the
ordinary routine Of lfe, where his surroundings are the
same as that to which he was formerly accustomed.
For the convalescent period is the most trying and
dangerous for these people. If they recover in an
asylum, there is always doubt about when to discharge.
them, and there-is a time 'of probation in which the-
patient must demonstrate that he is not insane, and
this sometimes exasperates them. If they recover at.
home the way to do so is smoother as a matter of
course. As in every other department of practical
medicine, each case ought to be individualized as a.
matter of course. In regard to the iodides, he said he
ascribed the bad effects to the idiosyncrasies of the in-'-
dividuals. Some persons, neurasthenics above all, when
taking but 4 or 5 grains, will become depressed and even
melancholic, and he had seen patients develop melan-
cholia with suicidal tendencies following the exhibition
of small doses of this drug. Take away the iodide
and the mental depression passes away. In a great.
many people it produced a condition which he liked to
style the “iodide misery,” a'general indeﬁnable feel-
ing of physical and mental wretchedness setting in as.
soon as the iodide is administered, showing that the.
iodide acts as a poisonous substance. Of course, he
said, it was a grand and indispensable remedy in the
practice of medicine, but contraindicated in such
cases as he mentioned. As to lumbar puncture and
trephining, he said these had been resorted to in a.
number of patients. He was sorry that he had not
attempted it in the two cases. The condition of the.
brain in both was such as suggest that surgical inter-
ference might possibly have been the right thing to
have done. It was true the results were so far not.
very promising. Where the punctures had been made
the patients had become rational for about forty-eight.
hours, but this suggested the possibility of perman— ~
CITY HOSPITAL ALUMNI. ‘65
ently beneﬁting by repeated punctures or punctures
Jperformedat the right time in certain cases. In re-
gard tO the syphilis bacillus, he said he did not‘exam-
ine the brain with that point in view, nor did he
examine the blood of the patients with the idea of
ﬁnding this bacillus. As for pain, attacked by the
classical form, when fully developed, such patients
enjoy such a remarkable feeling of well-being that
they do not complain of pain. At certain stages,
especially that of neurasthenia and hypochondriac de-
lusions, they feel and complain of pain, but the typi-
ical paretic dement is either indifferent or he is happy
and declares there is nothing the matter with him.
- Paranoia, Dr. Bremer said, had absolutely nothing
to do with paretic dementia.~ In former times, even as
late as thirty years ago, these two diseases used to be
confounded. In paranoia as well as in dementia the
patient has generally grandiose delusions; there is
‘self-exaltation and self-importance, but there Was a
radical difference between paranoia and paretic de-
mentia. A typical (chronic) paranoiac will talk
logically, coherently and reason correctly, though
from false premises, whereas in general paralysis the
the reasoning may be feebly logical, but generally it is
absurd and ridiculous. The general paretic will
imagine himself to be a great general, a multi-million-
aire, Jesus Christ or God Almighty, but he will act
less in conformity with his self-assumed rOle than the
paranoiac. The paranoiac has an elaborate (as a rule),
well-deﬁned system Of delusions ; the paretic dement
has not. Assuming that that which does not exist,
did exist, viz.: the premises from which he reasons,
the paranoiac would be right in his reasoning ; but the
paretic dement does not reason logically, either from
right or wrong premises. There are, however, cases
where its was rather difficult to say whether a man
was a paranoiac or a paretic. In regard to the activity
of syphilis in these cases of paretic dementia, he said
66 MEDICAL SOCIETY or
that in his opinion syphilitic stage had been passed in
them. It was extremely rare that gummata or dis-
ease of truly tertiary syphilitic character was seen in
them. Asa rule, it was the originally mild cases of
syphilis in whom paresis developed later on_those
which did not need or seek much treatment. In order
to prove that syphillis was really at the bottom of
paretic dementia and that it was nothing but a form
of late syphilis, and that the brain disease was the true
tertiary form, some investigators had inoculated a
number of paretic dements in the last stages, with
secretions of a fresh ulcus and they had found the in-
fection did not take, II. e., they could not be infected
any more. On the other hand, he said he had read of
a case of paretic dementia that had been treated in an _
institution for the insane, had been discharged as
cured, and was returned a few years later with a hard
chancre and the ﬂorid eruption Of syphilis. But, he,
said, it must be remembered that ,there are persons
who contract syphilis comparatively early in life and
are re-infected in later years. One of our greatest
pathologists was infected when he was a little over 20
years of age and died from re-infection when about 50
years Old.

STATED MEETING. THURSDAY EVENING, MARCH 2,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

CYSTOMATA OF THE OVARY.
BY HENRY JACOBSON, M.D., St. Louis.
HE subject of cystomata of the ovaries is so ex-
? tensive that I mention only a few interesting
facts regarding their occurrence and the dan-
gers which arise during their growth and after opera-
tions for their removal.
They may form at any age. Doran found cysts in
fetal ovaries one-sixteenth to one-twelfth of an inch in
diameter. Winckel also reports fetal ovarian cysts.
CITY HOSPITAL ALUMNI. 6'?
According to Olshausen the age of sexual activity,
the age from twenty to ﬁfty years, is an important pre-
disposing factor. _ .
They are very rare before puberty. Margolin re-
ports a large multilocular cystoma in an eleven-year-
Old girl. Wegschuder had a patient twelve yearsv of
age with bilateral ovarian cystoma. Other cases are
reported occurring in girls three, ﬁve and-eight years
Of age. My patient was sixty-two years Old. Pilcher
had a patient sixty-one years old. Duchan collected
reports on ten cases, all over eighty years of age.
Among ,1 686 women having ovarian cysts 1025 were
married and 661 single. Simpson Observed the diseaSe
in three sisters of one family. Rose mentions the dis-
ease in two sisters whose maternal aunt had the same
condition. Olshausen reports the same state 'of' affairs
in three pairsof sisters. Luer refers to seven fatal
cases in one family. '
Dr. L. S. Pilcher I'eports twenty-ﬁve cases of ova-
rian cystomata in the last ten years of his hospital
service. Eleven were monolocular, seven multilocular
adenO-cysts, three papilomatous and four dermoid
cysts. Five deaths in all from the following causes:
two from shock following the operation; one from
hemorrhage, the result of slipping of a ligature; one
case of obstruction of the bowels from angulation
caused by adhesion of knuckle of the ileum to the raw
surface, and one case from tetanus.
The dangers of ovarian cysts are:
1. Hemorrhage into the cysts may come from tOr-
sion of the pedicle.
2. From the superﬁcial vessels of the papillae.
3. From a ruptured vein as a result of puncture by
the surgeon.
Suppuration and gangrene of the cysts follow infec-
tion in different ways, as a result of puncture with
non-sterilized instruments and by reason Of improper
asepsis of the hands and abdomen. It may also be
68 MEDICAL SOCIETY OF
due to complete torsion of the pedicle and passing of
pus-producing germs from the adherent intestinal
walls, or along the lymph or blood.vessels. Obstruc-
tion of the bowels may be partial or complete, caused
by pressure of the heavy tumor on the bowels, or may
be. due to adhesions after the operation, as happened
in Dr. Pilcher’s case. -
Hydronephrosis from pressure on the ureters may
also result. Another complication is rupture of the
cyst wall. The ﬂuid may be unirritating and harmless,
or it may be irritating and set up peritonitis.
If the cyst is suppurating it will cause suppurative
peritonitis. It may adhere to the stomach or intes-
tines and rupture into them. The cyst will disappear
but sometimes the intestinal contents pass into the
peritoneal cavity and cause death.
Ruptures through the vagina, navel or bladder rarely
take place. Rose reports a case in which the pedicle
ligature ulcerated into the bladder and formed the
nucleus of a phosphatic stone, which he took away
three months after removal of the ovarian cyst. He
crushed the stone, and when he withdrew the lithrotrite
he found the pedicle ligature between the blades. He
was very much surprised, because the bladder was not
injured during the ovariotomy and the patient pre-
sented no symptoms of irritation.
The specimen I bring before you I removed from
Mrs. J .; sixty-two years Old, widow, who has had
one child. N 0 history of ovarian growth in the family.
She noticed her abdomen becoming larger, about two
years before she consulted me last August, but she
paid no attention to the increase in size until lately.
Upon examination I found symptoms of mitral in-
sufﬁciency, and the entire abdomen greatly distended
by a ﬂuctuating tumor more prominent on the right
side. Upon deep palpitation, the tumor walls had a
doughy, ﬂumpy feeling. After several'examinations,
I diagnosticated multilocular ovarian cyst, and ad-
CITY HOSPITAL ALUMNI . 69
vised operation. She passed through the operation
without any bad symptoms, in spite of her cardiac
disease; there were no adhesions, and the tumor
weighing about twenty pounds was rapidly removed.
She made an uneventful recovery, and left the hospital
three weeks after the operation. At the end of ﬁve
weeks I allowed her to walk about, and now she is
perfectly well.
DISCUSSION.
DR. F. REDER said that these growths sometimes
have the appearance of being sessile, resting upon the
uterus, frequently ﬁlling out the whole pelvic cavity.
Probably the most important clinical feature about
these tumors was their slow growth, and the patients,
therefore, Often discovered its presence by accident.
All tumors of a multilocular nature were probably
at one time unilocular, and in the course of time
multilocular tumors again become unilocular, on ac-
count of the septa of the various tumors within the
walls of the cyst being perforated by pressure, fol-
lowed by a fatty metamorphosis, absorption and
amalgamation into one large tumor. In the removal
of these tumors it is Often necessary to incise the cap-
sule and with the inserted hand break up inteiyening
septa of the various cysts. This is to be done extra-
peritoneally, if possible. Hemorrhage is sometimes
alarming, The tumor pressing upon the veins and
arteries, causing them to become enlarged, and the ac-
cident Of cutting such a vessel may cause serious
hemorrhage. This hemorrhage is best controlled
by a ﬁrm tampon, unless the bleeding vessel can
be caught and ligated. The unilateral cyst was
sometimes so closely associated with the uterus as to
necessitate the removal of that organ. They not in-
frequently have a tendency to grow downward into the
pelvis, so that the ureter may be placed over and
anterior to the tumor. This is, of course, a little
70 MEDICAL SOCIETY or
unpleasant for the operator, because the ureter, be-
coming empty from pressure, might only be recog-
nized after it is too late.
In the diagnosis of such tumors in the early stage
we usually ﬁnd the tumor posterior, and the uterus
anteverted; in the later stages, however, the tumOr is
anterior and the uterus retroverted. Various forms of
dilatation of the Fallopian tubes, some forms of
cellulitis, ectopic pregnancy, normal pregnancy, and
other pathological conditions in .the pelvis, present
conditions that are rather difﬁcult to differentiate, and
are apt to cloud a clear diagnosis of these tumors.
The specimen was very interesting, inasmuch as one of
the cysts had been perfOrated and the other cysts pre-
served in their entirety.
DR. A. H. MEISENBACH said, from a practical stand-
point, there was no other tumors so clearly outlined as
the ovarian cysts, whether they be multilocular or
unilocular, because the capsule usually presented an
ovoid surface; placing the patient on her back usually
shows the difference between that condition and
ascites. The differential diagnosis between ascites and
an ovarian cyst is made by clearly deﬁned conditions,
namely, in the cyst there is a resonance in the ﬂanks
which does not change; if ascites is present, the ﬂanks
are always dull under percussion. A mistake might
be made, as there are conditions connected with the
peritoneum and the intestinal tract which simulate
ovarian cysts; there might be an agglutination of the
intestines, the peritoneum, the mesentery, and omen-
' tum, and these conditions might simulate a, tumor.
One feature in regard to these tumors at the present
time was the small size of most of them. Before the
day of aseptic surgery these tumors grew to an enor-
mous size. In an old work written about 1600, there
was a picture of a tumor of enormous growth. This
does not occur now, and one passing through the
clinics in Europe will rarely see one of great size, as
CITY HOSPITAL ALUMNI. 71
they are removed earlier than they are in this country.
The operation was perhaps one of the easiest in
abdominal surgery, because most of them have a pedi-
cle, as in the present case. '
The speaker, said, referring to Dr. Beder’s remarks,
that hysterectomy in connection with these cysts was
something new to him; he thought it was rare indeed
that hysterectomy was performed on account of an
ovarian cyst.
DR. REDER said he referred to those forms of cysts
in the broad ligament.
'DR. JOHN GREEN, JR., said he thought it would be
well if Dr. Jacobson would state whether there were
any other signs of cardiac incompetency or whether
the ascites might not have been due to twisting of the
pedicle. He mentioned a case recently under his ob-
servation where the pedicle was twisted and a decided
ascites was present, yet there was no cardiac, renal nor
hepatic involvement.
DR. MARY MCLEAN stated that the largest multiloc-
ular cyst she had ever removed weighed about ﬁfty-two
pounds. It was complicated by a good many adhe-
sions and its contents were colloid; some of the cyst
wells were studded here and there with a malignant
papillomatous growth. One point in technique, which
she considered important in cases where a large pedi-
icle is left, is the covering of all raw surfaces with
peritoneum. She had recently seen a case in which
this precaution had been neglected, with the result
that extensive adhesions to the pedicle had caused
painful recurrent attacks of partial obstruction.
DR. E. S. SMITH said that unless there were other
evidences of failure of compensation and venous
stasis, he could not conceive how there could be as-
cites without a general dropsy. He thought the con-
dition might be accounted for on some other basis.
DR. H. J AOOBSON said the reason the smaller cyst
‘ was not evacuated was because the large cyst demanded
72 MEDICAL SOCIETY OF
quite an extensive incision, and after evacuating that
and removing it the smaller cyst was easily removed
without puncturing. He said he agreed with Dr.
Meisenbach that these cysts rarely attain a great size
now, though Keene reported one of 111 pounds-~84
pounds ﬂuid and 27 pounds solid. He supposed this
case was probably like his own—the patient did not
come under observation until the cyst had grown to a
large size; then again, some of these cases refuse to be
operated on until the cyst had reached a good size.
The question of the removal of ovarian cysts during
pregnancy was one of importance. He considers re-
moval advisable when the tumor reaches the size of a
child‘s head, causing pressure and preventing the rise
of the uterus out Of the pelvis. The cause of the
ascites he did not believe due to the twisting of the
pedicle. In this case he said it was due chieﬂy to the
cardiac lesion. She was cyanotic, had dizzy spells,
heart sounds weak, murmur marked; the pulse was
irregular and thin, ready compensatory hypertrophy of
cardiac muscles had not taken place, and he believed
the ascites, which clouded the diagnosis to some ex-
tent, was partly due to this trouble and partly due to
pressure of the tumor. The tumor was a very large
one and pressed on the different vessels of the abdo-
men and also on the bowels, liver and stomach, and
this pressure interfered with the return ﬂow of the
blood and the lymph, causing ascites. He had gone
over all the points mentioned by Dr. Meisenbach
also; the condition was one combining both troubles,
and made the diagnosis a little more difﬁcult. The
possibility of malignant degeneration was, at her age
also suspected.
CITY HOSPITAL ALUMNI. 73
CEREBRAL HEMORRHAGE WITH TEMPORARY
GLYCOSURIA: REPORT OF CASE.
BY R. B. H. GRADWOHL, M.D., of St. Louis, Mo.
Assistant Physician, St. Louis City Hospital, St. Louis, Mo.
T is but seldom in practice that a case is met
which serves as an object of common interest to
both the experimental physiologist and to the
practical clinician. The case which is here reported
is of this character, and the plea for its recital is that
it is worthy of attention because it performs the dou-
ble function of interesting two diverse classes-the
laboratory worker and the clinical observer. The case
which the writer desires to call to the attention of the
profession is one that came under his care in the Louis 'City Hospital.
One Isaac Lyman, a canvasser, aged i6 years. a
native of New York City, was brought to the institu-
tion at 7.10 A.M., January 29, 1899. The limited
and meager family»history which came with the case
showed that the patient had been the subject of chronic
alcoholism for 20 years or more; that he frequently
went on protracted sprees; that he had suffered with
the usual infantile diseases and that his adolescent
and adult life had been uneventful, so far as the con-
traction Of any serious acute or chronic diseases was
concerned. Nothing was gleaned as to his hereditary
predisposition for apoplectic, syphilitic, nephritic or
diabetic conditions, nor was there a history of direct
syphilitic infection in this individual. So far as his
immediate family knew, he had never suffered with
any of the subjective symptoms of either diabetes
mellitus or chronic Bright’s disease. It was learned
that he had been on a ﬁshing-trip for a week or two
and had returned home on the day before he came to
the hospital. He had appeared to be in his usual
good health when, suddenly, without any apparent
immediate exciting cause in the shape of worry. sud-
74 MEDICAL SOCIETY OF '
den fright or traumatism, he fell over and became
unconscious. He was comatose when he came under
our observation.
He was a man of average build and muscular de-
velopment and his adipose tissue was fairly well re-
tained. He was not emaciated. There were no signs
of dropsy. The face was pale; there was no ﬂoridity
of the countenance and no shortness of the neck, con-
ditions so Often taken as being symptomatic of the
so-called “apoplectic habit.” Respiration was slow
and shallow, but not 'stertorous, likewise was there
no puffed-out appearance of the cheeks. His pupils
were rather small, the left being somewhat larger than
the right; both were irresponsive to either light or
accommodative reﬂexes. There was complete motor-
paralysis of all the voluntary muscles which are ac-
cessible to the ordinary tests, i.€., the upper and
and lower extremities, the tongue, lips, etc. The
deep reﬂexes were wholly absent, but the superﬁcial
reﬂexes such as the cremasteric, etc. , could be elicited.
The pulse was slow, full, and strong, but there was
no appreciable hardening Of the arterial wall. Rectal
temperature was 96° F. Teeth were good and fairly
well kept; tongue was coated. An Odor of coal-oil
emanated from the patient’s mouth. Puncture with
pins, the application of heat, etc., failed to rouse the
patient from his comatose state. N o evidence of car-
diac or pulmonary lesions could be made out.
The urine was immediately withdrawn by means of
a soft rubber catheter and was subjected*to micros-
copic and chemical analysis: 200 cc. of a pale-colored
urine was obtained; speciﬁc gravity 1022; albumins
about 0.1%, demonstrated by nitric-acid contact-test,
potassium ferro-cyanid and picric-acid tests; sugar
present to the amount Of about 3% (Fehling’s, Nyl-
ander’s, fermentation, phenyl-hydrazin tests). No
acetone could be found. The urine was acid in reac-
tion and clear, and after centrifugalization, no sedi-
CITY HOSPITAL ALUMNI. ' 75
ment was obtained. Microscopic examination was
negative. N o casts were present.
To further complete the diagnosis of the existing
diabetic condition, the writer resorted ' to the
blood—test devised and recommended by Dr. Ludwig
Bremer. . This test is made by spreading the blood on
glass slides, beating them for 10 minutes in a hot-air
oven at a temperature 135° C. and then dipping them
in a 1% solution of congo-red or {0%, solution of
methyl-blue. The blood proved refractory to these
stains and remained unstained. a phenomenon which
Dr. Bremer points out as peculiar in all diabetic con-
ditions, providing the specimens are prepared and
and heated properly.
The patient was given 2 drops of croton Oil; his
head was kept elevated. At 11 A.M. no change was
noted in his condition; analysis of 400 cc. of urine
which was now withdrawn gave similar results to the
ﬁrst analysis. -Venesection which was now performed,
did not alter his condition for the better. The tem-
perature had mounted to the normal at 1 P. .\I.; tem-
perature 104° F., pulse 140, respiration 34, at 3 P. M.
The urine now withdrawn, 200 cc.. showed no sugar
reaction but still contained the albumins in the same
quantity. The temperature rose to 106° F. just be-
fore death, which occurred at 6.30 PM. The blood-
test made just before death and just after death
(blood being taken from the median basilic vein) was
negative. Neither albumins nor sugar were found in
the urine withdrawn poSt mortem, 300 cc. in amount.
Post-mortem examination revealed the following:
Slight hypertrophy of the left ventricle; kidneys, liver,
pancreas and stomach normal. The most pronounced
pathologic changes were noted in the cranial cavity;
on opening the brain, it was seen that dark, liquid.
blood ﬁlled the left lateral ventricle and that the re-
mainder of the connecting ventricular system, 2'. e.,
the third, fourth and right lateral ventricles, contained
76 “ MEDICAL SOCIETY OF
a dark blood-clot of good consistency. On washing
off the clot, the source of the hemorrhage was found
to be a ruptured miliary aneurism located on the right
lenticulo-striate artery, the so-called “artery of cere-
bral hemorrhage " or “ Charcot’s branch. ” Rupture
of the aneurism within the internal capsule had caused
a breaking-down of the thin ventricular wall and a
spreading of the blood through the_entire ventricular
system. This frequently happens when a severe hem-
orrhage takes place within the internal capsule. 1 Micro-
scopic examination Of sections of the liver, pancreas,
kidneys and thyroid gland revealed nothing of import-
ance. The arteries at the base of the brain were
atheromatous. The intra-ventricular pressure of the
clot produced a softening of the cortical substance im-
mediately encompassing the ventricles, as demon-
strated both macroscopically and microscopically.
The appearance of sugar in the urine in this case
was due to the pressure exerted by the blood-clot on
the ﬂoor of the fourth ventricle in the area known as
“ Bernard's diabetic center." It was Claude Bernard
who. in the celebrated piqure experiment, ﬁrst produced
an artiﬁcial glycosuria by puncture of the ﬂoor of the
fourth ventricle in the brain of a rabbit.2 This has
been done time and again on rabbits, dogs, cats, etc.,
until now it is accepted as one of the classic laboratory
experiments. The experiment as originally performed
by Bernard was simply the puncture of the ﬂoor of the
fourth ventricle by means of a stylet thrust into the
medulla from above, '5. e., in a direction forward and
downward from the external occipital protuberance.
It has been since modiﬁed, and the glycosuria can be
produced just as readily by ﬁlling the fourth ventricle
with parafﬁn introduced through the needle of a hypo-
dermic syringe which has been thrust through the
cerebellum. The Observation has been frequently
made that in examination post-mortem to diabetes
mellitus, the only pathologic change that could be
'CITY HOSPITAL ALUMNI. 77
found at the autopsy was some lesion of the central
nervous system, particularly lesions in the ﬂoor of the
fourth ventricle, such as tubercles, cysticerci and
sclerosis of the medulla. These ﬁndings, together
with the knowledge Of the experimental production of
diabetes by puncture or pressure on the ﬂoor of the
fourth .ventricle, justly lead us to say that they are
prime etiologic factors in the causation of diabetes
mellitus.
The manner in which disturbances in the ﬂoor of the
fourth ventricle cause an elimination of sugar through
the urine is explicable on the ground that lesions in
that place, i. e., in the diabetic or vasomotor center,
produce a vasomotor paralysis. The question then
suggests itself, what relationship is there between a
vasomotor paralysis and the g'lycogenic function of the
liver? This is still a matter sub judice, but according
to the latest physiologic researches. it is held that im-
pulses travel down the cord from the vasomotor center
to- the fourth dorsal vertebra and thence radiate to the
thoracic ganglia and to the liver. It is sufﬁcient to
say thatthe glycogenic function of the liver is inter-
fered .with- by a vasomotor paralysis, and thereby an
undue'amount Of the sugar which is' normally stored
up in the liver in the form of glycogen is set free in
the blood-stream and this surplus is expressed from
the circulatory system by the agency of the renal ap-
paratus.
The predisposition for hemorrhage in this case was
supplied by the patients long-continued abuse of
alcohol. so that ultimately an atheromatous condition
of the arteries Was brought about. I believe that the
appearance of Sugar in the urine in this case was due
to the direct mechanical pressure exerted by the clot
on Bernard‘s center. In looking over the literature, it
has been noted that frequent observations on tempo~
rary glycosuria in connection with cerebral hemorrhage
have been made by various writers. Notice has al-
78 MEDICAL SOCIETY OF
ready been taken of the observations concerning the
artiﬁcial production of glycosuria by the growth of
tumors in the ﬂoor of the fourth ventricle. Most of
the writers on the subject contend that any increase in
the intra-cranial pressure, such as a hemorrhage,
edema or traumatic injuries, will be followed by a
temporary glycosuria.3 The ﬁrst who probably de-
scribed glycosuria following cerebral hemorrhage was
Leudet.4 Frerichs described 6 cases and Olivier 5,
with autopsies.5 Many reports are fOund in literature.
In the majority of cases the cerebral. hemorrhage is
very severe, but in some cases (very mild cases) a large
amount of sugar may be found.6 Accord-ing to Olivier
the sugar in the urine does not appear until two hours
after the ﬁrst attack. The amount of sugar varies "
much, sometimes disappearing for a time completely
and Often before death it disappears altogether. In
case the apoplexy is not fatal, sugar can be found in
the urine for six days. The amount of sugar varies
from under 1% to 2.9% (Schutz), 4% (FrerichS). A
light grade of polyuria may also be present and very
Often albuminuria.
The seat of the hemorrhage in most of these cases
was in the hemispheres or was intermeningeal and not
so situated that there could be any direct effect on the
fourth ventricle. 'Among these cases, however, were
found a number where the hemorrhage was in the
pons; in only one case did the glycosuria become per-'
manent.7 Naumyss8 and others are inclined to-believe
that the increase in intracranial pressure is the causa-
tive factor in this production of artiﬁcial glycosuria in 7
cases of cerebral hemorrhage. On the other hand,
there are observers who have claimed that direct intra-
ventricularpressure is responsible for the transitory
glycosuria. Morokow9 states that the increase in pres-
sure following these attacks of cerebral hemorrhage
~~causesan increase in the amount of urine excreted,
nd that sugar sometimes "appears in the/urine when
CITY HOSPITAL ALUMNI. 79
the hemorrhage is in the fourth ventricle. He also
states that a passing albumin-uria may be present in
these cases. Oppenheim10 says that sugar may appear
in the urine in cases of cerebral hemorrhage, but not
very often, and then usually not until from twelve to
twenty hours after the onset of the attack. Jaksch11
states that although transitory glycosuria has been re-
ported after apoplexy, he has not been able to ﬁnd a
case among 50 cases of fresh apoplexy within two years.
According to Mills,12 glycosuria is most likely to result
when the lesion is in the fourth ventricle. Loeb13 be-
lieves that in most fatal cases of cerebral hemorrhage,
sugar exists in the urine, but‘that its excretion rarely
continues longer than from twelve to twenty-four hours;
also, that albuminuria is Often present and always lasts
longer than the glycosuria. Robin and Kuss“ make
similar statements. “
It may be well to speak of a case which. Ii. Lépine1-5
_ records. He cites a case where a woman who had a
transitory glycosuria during an apoplectic attack. re-
vealed a hemorrhage in the internal capsule post-Inor-
tem. The hemorrhage in that case, however. was so
slight that we can hardly believe that “the increase-
in-pressure theory” would explain the condition. In
speaking of this particular case, Gould16 justly ques-
tions the value of Observations of that kind and says
“ it may be questioned if records like the above and
the inferences aid much in the diagnosis of Obscure
diseases like diabetes.”
From a review of the preceding references it can
readily be seen that there have been but few cases
where it has deﬁnitely been proved that pressure in the
fourth ventricle produced a transitory glycosuria. The
weight of authority goes to substantiate the theory that
any increase in intracranial pressure would produce
glycosuria by indirectly acting upon the ﬂoor of the
fourth ventricle. In other words there have been but
few, if any, cases analogous to the Bernard piqure ex-
80 MEDICAL SOCIETY OF
periment. I.hold that this case is an example of that
classic experiment. The disappearance '.of sugar from
the urine after a few hours was due to the fact that all
of the glycogen in the body had been transformed into
sugar and had been eliminated; secondly, to the fact
that hyperpyrexia supervened, and it has been estab-
lished that in conditions of hyperpyrexia sugar dis-
appears from the urine. The albuminuria persisted;
this has been noted before by Loeb.17 Dana18 makes
the same statement. It is simply a functional renal
defect and has no signiﬁcance so far as the likelihood
of the- existence of any kind of nephritis is concerned.
The case which I have cited is worthy of attention
because of its clinical and physiologic aspects. Robin
and Kuss19 have ventured the suggestion that we might
make use of the occurrence of transitory glycosuria in
apoplexy as a differential diagnostic test from a condi-
tion of uremic coma, e. 9., eliminating the question of
diabetic coma, if we ﬁnd sugar in the urine Of patient
who is in a coma simulating uremia and apoplexy, we
may decide in favor of apoplexy. Of course, this is
rather a ﬁnely-drawn diagnostic measure, but still it is
worthy of remembrance when we are confronted with
cases of that kind. Cases of this kind are highly in-
teresting, and serve to narrow the gap which separates
the laboratory worker from his colleague in the ﬁeld
of clinical medicine, and, at the same time, make still
more evident the fact that commonplace incidents are
of little moment unless they are well fortiﬁed by the
strong bulwarks of lucid explanation founded on scien-
tiﬁc axioms. .
With the reconciliation of experiment and practice,
with the coincidence of theoretic and accurate practical
Observations, weighed in the balance, and each exactly
balancing the other, another great achievement is
added to this already-memorable epoch of medicine
and another barnacle of empiricism is swept from the
keel of the ship of science. Aside from the satisfac—
CITY HOSPITAL ALUMNI. 81
tion given to those high in point of training in both
experimental and clinical medicine, each demonstra-
tion of this kind lends an air of conﬁdence to the minds
of those who are wavering between the choice of
acceptance of empiricism or truthful, logical medicine,
and forces them'over to the correct side. In short, it
is a source of the greatest pleasure _for the experimenter
to conﬁrm the observation of the clinician, and vice
versa. The laboratory-worker and the practitioner
should strive together, cach to unravel the seemingly
inexplicable problems of the other. _ Then will the
quintessence of investigation, the agreementof theo-
retic teachings with the phenomena Of nature, be at
hand.
. BIBLIOGRAPHY.
11‘yson: Practice of Medicine; Osler: Practice of Medi-
cine; Stengel: Text-Book of Pathology. . ;
2Claude Bernard: Legons dc Physiologic expcrimentale
appliquée la Médecine. Tome I, p. 289.
3Kirk, Stewart, Foster, et al. : Text-Books of Physiology.
4Naumyss: Der diabete Mellitus.
5Leudet: Comptes rendus et mem. Soc. Biologic, 1857.
6Olivier: Etudes sur certaines modiﬁcations dans la secre-
tion urinaire consecutive a l’hemorrhage cerebrale, Gazette
hebdomadaire, No. 11, 1875.
7Schutz: Prag. med. Wochenschrift, 1892.
8Leudet, Olivier: Loc. cit.; Schutz: Loc. cit.; Colby:
Hospital Reports, 1892, vol. xxviii, p. 158; Boa:»Hemor-
rhage des pons, Dissertation, 1877 ; N agel: Ueber diabete
Mellitus mit Hemipleg., Berlin, 1886.
9Naumyss: Loc. cit.
10Morokow: Gehier, Pathologie.
llOppenheim: Lehrbuch der Pathologie.
12Jak<ch, R.v. : Prag. med.Wochenschrift, No.31, 32,1892.
18Mills: The Nervous System and its Diseases, p. 457, 1898.
14Loeb, M.: Prag. med. Wochenschrift, NO. 50. 1864.
15Robin ct Kuss: Apopleme cerebrale et glycosurie.
Med. Modcrne, Rev. Neurologie, No. 6l.
16R. Lepine: Rev. dc Med, October 10, 1897; Gould:
American Year-Book of Medicine and Surgery, 1898.
17Loeb: Loc. cit.
18Dana: Text—Book of Nervous Diseases.
19Robin et Kuss: Loo. cit.
82 MEDICAL SocrETY OF
DISCUSSION. _
DR. ARMAND RAVOLD said that the essayist had
apparently left nothing undone to make his report
complete. His clinical observations were aCute and
carefully recorded; the post-mortem ﬁndings were sur-
prising, but nevertheless in accordance with the clini-
cal observations; the chemic, physiologic, anatomic
and pathologic knowledge displayed showed a wide
and accurate acquaintance with the technique, meth-
ods and literature of these subjects, and the literature
of the whole subject seems to have been carefully and
extensively studied. _
DR. E. S. SMITH said that he agreed with Dr. Ravold.
He did not see that the essayist had left anything to
be said. He had been much interested in the specimen
presented at the last meeting.
THE PRESIDENT said one of the interesting points in
the paper was the corroboration afforded by Dr. Grad-
wohl, in this case, of Dr. Bremer’s researches in the
examination of blood. Dr. Bremer, the speaker said,
ﬁrst presented that subject to this Society, and it seems
clearly to be based on good scientiﬁc foundations. ,
DR. F. REDER said that aneurysmal dilation of cer-
ebral arterioles was interesting because it was the
principal cause of many brain. lesions. In cerebral
hemorrhage, besides the blood pressure, there must be
something else, and it-is here that the pathology of
aneurism of cerebral arterioles must come in, i. e., a
diseased condition of the investing sheath of the arte-
ri‘ole must exist. For instance, there is at ﬁrst a peri-
arteritis beginning in the perivascular lymph sheaths;
this inﬂammation extends to the tunica adventitia, the
muscular coat of the artery dilates, causing an aneur-
ism. After dilatation of the muscular coat has
occurred, the subsequent blood pressure which exists
in the arterioles, and which might be caused by a
mechanical stimulus, such as violent exercise, or by a
medicinal stimulus, may cause rupture to take place.
CITY HOSPITAL ALUMNI. 83
The blood need not conﬁne itself to the place whence
it escaped, but may ﬁnd its way to the surface or into
one of the ventricles, and pass by the iter from the
third to the fourth ventricle. The essayist had ably
demonstrated the morbid process called glycosuria.
Grape sugar and glycogen are both formed in the
healthy organism, but an examination of the secretions
of the healthy body does not disclose to us either
grape sugar or glycogen; therefore, when we ﬁnd
sugar in the urine we look for a diseased condition
somewhere in the brain, possibly somewhere in or near
the medulla oblongata. We expect this diseased con-
dition to cause irritation or pressure upon brain tissue.
This irritation acts as a stimulus to the nerve ﬁlaments
emanating from the medulla. These ﬁlaments ﬁnd
their way down along the cord, as the essayist has i11-
formed us, to the upper dorsal vertebrae, then to join
the gangliated sympathetic, and so ultimately to reach
the liver. The disturbed equilibrium, an alteration of
nerve inﬂuence, causes the sugar to appear in the
urine. In some forms of cerebral hemorrhage the
cause of death is glycosuria; in other forms the cause
is pneumonia. It is of interest to note how this irri-
tation or pressure upon the brain is brought about by
the blood clot. The ﬁbrin collects in the center or at
the periphery of the clot, the corpuscles crowd to-
gether and adhere, the serum is pressed out and ﬁnds
its way into the neighboring cerebral matter. A lim-
ited inﬂammation takes place, and if the blood clot is
near or in the medulla the irritation is suﬂicient to
cause the appearance of sugar. The speaker said
some attention was paid to the pupil during the time
he was at the City Hospital. Autopsies revealed that
in minutely contracted pupils the hemorrhage was
most generally into the pons. In other cases, where
the pupils were unequal, one largely dilated, they found
that the clot was into the lateral ventricle. When
there were seizures of an epiliptiform character it was
84 MEDICAL SOCIETY OF
usually found that hemorrhage was very extensive.
DR. M. A. BLISS said, speaking of the theory that
pressure in, the fourth ventricle caused glycosuria,
that it seemed to him such an effect may come from
internal hydrocephalus. He was not sure that this
observation had been made. The pressure in these
cases was very extensive. He spoke of it merely as a
point to be considered, whether glycosuria does not
occur at _certain times in internal hydrocephalus.
DR. E. S. SMITH said he did not understand why
albumin should appear in the urine.
DR. GRADwoHL said there was only a trace.
DR. SMITH said albumin was often found in cases of
cerebral hemorrhage, but he had never heard .it.
attributed deﬁnitely to the hemorrhage; for instance,
as glycosuria following hemorrhage of the fourth
ventricle. Albuminuria was a part and parcel of gen*
eral sclerosis; as a rule, it is found in cerebral hemor-
rhage, and this general sclerosis extends to the kidney,
predisposing to interstitial conditions which give
albuminuria.
DR. BENNO BRIBACI-I said he thought that the essay-
ist had brought clinical proof to bear out his assertions.
The speaker said he was not aware of anything pub
lished frOm direct clinical observations to prove that
the theory was correct, and he believed that it would
go down in the text-books of that disease as a classical
piece of information. He desired to make a motion,
at this point, that the thanks of the Society be ex-
tended to Dr. Gradwohl for this excellent paper.
DR. GRADWOIIL, in closing, thanked the Society for
the many honors showered upon him and hoped he
would continue to merit them. In regard to glyco-
suria causing death, the speaker said he failed to see-
how glycosuria, per se, could cause death; he supposed
that Dr. Reder meant that this was a concomitant.
symptom of an apoplectic condition, serious enough
to produce death In regard to hydrocephalus caus-
CITY HOSPITAL ALUMNI. 85
ing- glycOsuria, he said he thought there was a case
mentioned where glycosuria was caused by this affec-
tion.

STATED MEETING, THURSDAY EVENING, MARCH 16,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

SANITARY SUPERVISION 0F SCHOOLS.
BY C. SHA'I‘TINGER. M.D., St. Louis, Mo.
ECONOMIC BASIS.
VERY civilized community places upon the
individual two obligations which involve its
very existence. The ﬁrst enjoins each indi-
vidual from, endangering the life and welfare of any
other; the second obliges every member to contribute
to the maintenance of the whole. A civilized com-
munity, by law or prevailing opinion, also expects the
individual not to be a burden, but rather to prove
useful to itself. The community, however, can not
justly impose any\ obligation without incurring the
co-relative responsibility of making fulﬁllment possi-
ble. Put concretely and tersely, the individual is
commanded not to kill, steal or contaminate, but to
pay taxes, earn a livelihood and add to the general
wealth. To meet these obligations, the individual has
the right to demand the necessary ethical, intellectual,
physical and. technical equipment, which means com-
plete health and an ample education.
This principle is recognized more or less consciously,
more or less thoroughly, by the provision of the pub-
lic school. The functions of the school have under-
gone progressive modiﬁcation and enlargement in the
course of time, and are destined to acquire still far
greater comprehensiveness in the future, when the
principle just enunciated will have become more widely
and completely understood. To make of the child a
good citizen, purely from the ethical standpoint, was
presumably the object at a period when very little else
86 ~ MEDICAL SOCIETY OF
than religious instruction was offered. The increasing
demand for intellectual proﬁciency then led to the
constant growth in number and range of mental
studies, to the neglect, it must be acknowledged, of
the development of character and body. _But this,
too, is changing. Manual training is ﬁnding its way
into systems of teaching, and attempts at physical
culture continue to be numerous and persistent. The
well-nigh overlooked body of the child at school is
claiming its share of attention.
HISTORY.
School hygiene in general, and its connection with
visual defects and spinal deformities in particular,
had called forth the labors of medical minds, as well
as engaged the attention of pedagogic journals. and
societies, for some years past. It remained for Dr.
S. H. Durgin, however, to inaugurate at Boston, in
November, 1894, the ﬁrst systematic plan for guarding
the health of children while at school. Chicago se-
cured a similar, though less thorough, service since
September, 1896, while New York adopted the plan
almost in its entirety in March, 1897 . St. Louis was
given a chance to study the system by the volunteer
inspection of ten public schools, made under the aus-
pices and by members of the Medical Society of City
Hospital Alumni, from October 10th to December
25th, 1898.
STATISTICS.
The statistics of sanitary supervision cover too
restricted a period and territory to admit of formulat-
ing positive generalizations. They sufﬁciently dem-
onstrate, however, the value of this work, and point
out its future possibilities. The reports indicate that
about onepupil in every ten has some ailment, and
that from T16 to aS' high as 7,); of those sick should be
dismissed, either because tOo ill themselves or because
a menace to others. To the latter class belong those
affected with any speciﬁc infectious disease. From
CITY HOSPITAL ALUMNI. 87
T86 per cent. to T76 per cent. of the entire attendance
may be expected to come under this head. Acute in-
fectious diseases constituted over 4 per cent. of the
total morbidity in Boston schools during the year
ending November 1, 1895, almost 3 per cent. in 1896,
and 5% per cent. in 1897. During the trial inspection,
lasting 60 school days, the proportion in ten St. Louis
schools was 4% per cent, nearly half of the dismissals
for sickness being on this account. More than ten
percent. of the exclusions from New York schools be-
tween March 29 and July 1, 1897, were made for the
Same reason.
By co-operating with other divisions of a health de-
partment, the aid rendered by sanitary supervision in
ﬁnding and checking sources of infection can easily be
extended beyond the school room. Thus, in Chicago,
during the school year 1896-7, examinations of-pupils
made on the strength of reports of 231 cases of scar-
latina and 7 44 cases of diphtheria among School chil-
dren, led to the disclosure respectively of _745 cases of
the one, and 2, 619 cases of the other disease in homes.
Forty-Six reported cases of measles brought to light an
epidemic in several sections of that city twice during
the same period.
. In judging the degree to which communicable dis-
ease exists in schools, parasitic aﬂ’ections of the head
and body must also be taken into account. Sixty-ﬁve
per cent. of the exclusions from New York schools in
1897 were of this nature. Boston and St. Louis make
a more favorable Showing. The ﬁrst year’s work in the
former city gave a percentage of not quite 2%, but the
latest available tables make it 6 per cent. ; while in the
ten St. Louis schools the proportion found was consid-
erably less than 1 per cent. of 'the total morbidity.
Chicago’s ﬁrst eﬂ‘ort revealed two entire schools liter-
ally infested with lice.
Fraught with less immediate danger than the con-
tagious maladies, yet potent for harm and far larger,
is the contingent of respiratory troubles among chil-
88 MEDICAL SOCIETY OF
dren at school. They may be looked for in 4 to 8 per
cent. of the scholars. Acute catarrhal conditions pre-
dominate, but chronic forms are suﬂ‘iciently conspicu-
ous. Tonsillar and adenoid hypertrophy constitute
from 14 to 18 per cent. of all the respiratory affections.
Regarding eye and ear diseases, the scope of inspec-
tion has so far not been such as to reveal the full quota
of these important disorders. The reported ﬁgures are
nevertheless signiﬁcant. An estimate based upon three
years’ work in Boston indicates that about one pupil
in every 200 had some eye trouble, whereas ear cases
were less than one-sixth as frequent. In St. Louis,
the proportion proved much greater, being about 1 in
27 for eye and 1 in 280 for ear cases. In New York,
during 1897, a triﬂe over 1 per cent. of pupils exam- '
ined showed contagious eye disease, thereby occasion-
ing 17 per cent. of the dismissals. Besides these data,
we possess the valuable and probably more accurate
results of numerous special investigations. Taking
all these together, we learn that in the United States
30 per cent. of the public school pupils are near-
sighted, and that, like in Europe, the proportion rises
with the grade. Four thousand one hundred examina-
tions made by Drs. J. D. Jones and D. B. Smith, in
Cleveland in 1.882, disclosed 8 per cent. More re-
cently, 10 eighth-grade rooms in the same city were
found to contain 13 per cent. of myopes. Twenty-ﬁve
thousand six hundred and ninety-six public school
scholars of Minneapolis, whose eyeswere tested under
the direction of Dr. Frank Allport during the spring
of 1897 , yielded 32 per cent. with defective sight, ex-
clusive of those already wearing satisfactory glasses,
Over 17 per cent. complained of weakened vision after
study.
The school-room affords examples of a variety of
other diseases that do not call for statistical enumera-
tion. Some, like habitual headaches, neuralgia, cho-
rea, epilepsy, spinal curvatures, cervical adenitis,
digestive disorders, anemia, and debility, are rela-
CITY HOSPITAL ALUMNI. 89
tively frequent, and undoubtedly affect the mental
capacity and development of a child.
MEDICAL AND PEDAGOGIC ASPECTS.
The import of the fact that illness exists in schools
to a degree manifest from the preceding exposition
cannot fail to strike the thoughtful. Opportunity of
contagion is the most obvious corollary. The minute-
ness, tenacity of life, and enormous reproductive pow-
ers of the agents of contagion, make the spread of in-
fectious and parasitic diseases within the school possi-
ble, nay certain, in countless ways. The fact that
contagious cases will usually not be at school unless
very mild, or else only before the onset or after the
disappearance of pronounced symptoms, is not dis-
puted. But this actually increases the danger by con-
cealing it. Dr. H. D. Arnold, one of Boston’s inspec-
tors, relates two experiences which may here serve as
instructive illustrations: A boy had scarlatina so light
that the rash vanished in twenty-four hours. He did
not seem ill otherwise and had no medical advice. He
was at school on the afternoon when the rash broke
out; also during another afternoon and the following
morning, after an absence of six days. Twelve cases
of scarlatina among his classmates and one outside the
school were traced to this boy. One developed Bright‘s
disease; another died. Again, diphtheria attacking,
besides the initial case, 13 pupils and four other chil—
dren with two fatalities, followed a case of supposed
=‘ sore throat.” All observers agree in specifying con-
tact at school as the chief factor in the dissemination
of scarlatina and diphtheria. ' i
There, are a number of reasons why the respiratory
organs are so frequently found affected in the school-
room. Their susceptibility during childhood, un-
healthy homes, insufﬁcient or inappropriate clothing.
parental neglect, lack of suitable exercise, faulty
methods of cleaning, heating and ventilating school
buildings have varying shares in the causation. While
9O MEDICAL SOCIETY OF
sanitary supervision alone ~could not eliminate all of
these inﬂuences, it certainly w‘ould indirectly lessen
several. Repeated or continued attacks on the integ-
rity and resistance of the air passages ought not to go
unheeded. Besides immediate evils, they entail fu-v
ture dangers; notably the creation or increase of a dis-
position to contract tuberculosis.
Enlarged tonsils, so common in children, are now
known to be ports of entry for pathogenic germs;
among others, for those producing peritonsillar abscess
(quinsy) and diphtheria. This source of danger is
often not removed, simply because not known to exist.
Adenoid or tonsillar hypertrophy and nasal obstruc—
tions have their pedagogic as well as their hygienic
aspects. Inability to pronounce distinctly or to into-
nate with purity and force can frequently be ascribed
to some such local cause which might be remedied.
Then, too, cerebral activity is intimately dependent
upon respiratory interchange. The idiotic expression
and mental torpidity of the Hmouth-breather” will
often disappear, as if by magic, with the restoration
of normal respiratory channels.
Similar psychic effects are incident to impaired
hearing or vision. Schirmunsky, in investigating the
hearing of 2,221 school children in St. Petersburg,
found the proportion of good to poor scholars to be
4.1 to 1 where acuteness of hearing ranged between
normal and half normal, as 2.6 to 1 where reduced
from 25 to §, and as 1.7 to 1 where below Schmeige-
low found that of , 79 dull scholars, 65 per cent. were
hard of hearing. The writer recalls the case of a boy,
a victim of chronic suppurative disease of the middle
ear, whose wits had been the despair of parents, teach-
ers and employers. _ By effecting a cure, with almost
complete restoration of hearing, he had the satisfac-
tion of witnessing the transformation of a Slovenly,
stupid fellow into a spruce and apt young lad. I
Twenty-six hundred examinations of the eyes of
school children, made ten or eleven years ago under
CITY HOSPITAL ALUMNI. .91
the direction of Dr. S. D. Risley, of Philadelphia,
gave grounds for the declaration that “ many a school
boy, idle only at his books, dull only in the recitation
room, is so because he ﬁnds the continued use of his
eyes a painful task.” An investigation of 2,000 chil-
dren lately conducted by the Philadelphia Teachers‘
Society for Child Study revealed a large percentage
with. defective sight, of such a degree in sOme as to
seriously hamper intellectual development. A majority
were not aware of their condition. The writer once
treated a girl subject to periodic attacks of malaise
and headache followed by convulsive seizures, all of
which necessarily interfered with study and interrupted
attendance at school. Eye strain was discovered, an
error of refraction diagnosticated, and suitable glasses
adjusted, with the result that every symptom disap»
peared at once and never returned.
METHOD.
To realize the full beneﬁts of sanitary supervision
of schools requires the co-ordinated efforts of teachers,
inspecting physicians and bureaus of health. In what
follows will be found an outline of how the work is to
be done in practice. The main features are based upon
the experience gained in Boston and New York, but
the writer is individually responsible for a few minor
suggestions. It is assumed that regulations calling
for report to the local health department of cases of
acute infectious diseases, and providing for the isola-
tion with ﬁnal disinfection of the premises in certain
of them, are already in force. The report of a case
of this special nature ought to be followed within
twenty-four hours by a visit from a medical ofﬁcer of
the department, who directs and controls the measures
taken for isolation, and leaves an explanatory card for
the attending physician. (Exhibit No. 1.) If a report
pertains to a child excluded from school by advice of
the school inspector, this visiting ofﬁcer conﬁrms or
, corrects the inspector’s diagnosis. Inspector and
ofﬁcer may, but preferably should not, be the same
92 y MEDICAL SOCIETY or
person. As soon as release from isolation is requested,
the ofﬁcer again calls to ascertain whether danger is
past and to order disinfection. (Exhibit No. 3.) No
case of diphtheria should be released until a negative
culture has been received by the health department,
and no case of scarlatina, until after desquamation has
entirely ceased, nor earlier than the twenty-ﬁrst day if
absent. Bulletins stating the names, addresses, and
diagnosis of all cases of acute infectious disease re-
ported within the preceding twenty-four hours are sent
in duplicate to each school for the information of the
inspector and teach-ers. The school likewise receives
certiﬁcates permitting the return of scholars dwelling
where such diseases had existed and disinfection has,
taken place. _
A teacher obtaining information regarding the oc-
currence of a case of infectious disease not mentioned
' on the bulletin, communicates the particulars to the
school inspector. If the latter deems an investigation
warranted, he notes them on his daily report to_the
health department. The teacher also informs the in-
spector of the names, addresses, and supposed ailments
of all absent on account of sickness. When she knows.
that a pupil belongs to a family where a case of acute
infectious disease requiring isolation exists, or has
been in contact with such a case, She immediately dis-
misses that pupil from school. The teacher is ex-
pected to carefully observe our charges in order to
select such as seem to have any aural, visual, or
psychic defect; any deformity, oﬂ’ensive physical at-
tribute, or disease of whatever nature. These pupils
are examined by the inspector on his daily visit. Ex-
cepting those instances where a certiﬁcate of release
and disinfection has been received, all returning ab-
sentees are likewise inspected.
Once every year the eyes and ears of all pupils who
can read ought to be tested. This may be done by
their teachers, but better by the inspector where possi-
ble. The method proposed by Dr. Frank Allport is
CITY HOSPITAL ALUMNI. 93
expeditious, and with very few exceptions sufﬁces. to
show whether or not sight and hearing are impaired.
(Exhibit No. 2.)
Every examination must be conducted under scrupu-
lous antiseptic precautions. Wooden tongue depressors,
costing about a tenth of a cent each, and burned after
having been once used, are employed to inspect throats.
Whenever diphtheria is suspected, a culture is taken
for examination and report by the health department.
No treatment is given except in case of emergency.
Every child found to be ill is given a card of explana-
tion signed by the principal and advising its parents
or guardian to consult a physician. (Exhibit No. 4.)
The diagnOsis should be stated on the card in general
and simple, rather than in precise and technical terms.
If the child’s attendance at school would be dangerous
to itself or to others, it is sent home. Cases of conta-
gious disease for which isolation and disinfection are
not enforced are simply told to return when cured.
In a book of which the principal is custodian, the
inspector records the date and time of _his visit, the
number of examinations made, and the name, resi-
dence, age, sex, and diagnosis of each case of sickness
found, indicating which were excluded. A duplicate
record on a blank stating also the district number,
name and location of the school is mailed by him to
the health ofﬁce after having completed his rounds.
(Exhibit No. 5.)
The inspectors should note unsanitary Conditions of
school grounds and buildings, making such recom-
mendations to the boards of health and education as
they deem applicable. They should organize as a
body, meeting once during each school quarter for the
purpose of discussing subjects relating to their func-
tions and to school hygiene in general. This is already
- being done in Boston. The writer holds that the meet-
ings of such an organization ought to be open and the
proceedings published in the daily press, in order to
preserve the responsibility of its members to the pub-
94 MEDICAL SOCIETY OF
lie, and further improve the educational inﬂuence of
their exertions. He is also of the opinion that school
inspectors should receive appointment in virtue of
superiority attained in a competitive examination in-
volving chieﬂy the special knowledge required in their
work. He believes, ﬁnally, that they should be re-
tained in oﬂ‘ice as long as willing to serve and faithful
to duty. An inspector will usually have to be a resi-
dent of his school district. Experience has shown
that one inspector can not attend to more than 1,500
pupils, nor to more than ﬁve schools within easy walk-
ing distance of each other.
COST.
The public schools of St. Louis may be grouped
according to location and attendance in 47 districts,
requiring not less than 51 inspectors. (Exhibit N 0. 6.)
A larger force, up to perhaps 82, would probably
give better results. To be thorough. corporate, pri-
vate, and parochial schools ought to be included in the
system, as is done in New York. Boston employs 50
inspectors at a yearly salary of $200 each; New York,
149 at 8300. Chicago has no special corps, but details
for school supervision a few inspectors engaged in
general work and receiving $75 a month. Ixcepting
in sparsely attended districts, efﬁcient and faithful
service can hardly be expected for less than $50 a
month. Miscellaneous expenses in Boston, so the
writer is informed by letter from the chairman of its ‘
board of health, consume only about $50 per annum.
One thousand cards for testing eyes necessitate an
initial outlay of $7 5. The value of a measure which
saves the lives, preserves the health, and improves the
vigor of our citizens that are and yet to be, is left to
the enlightened reader for reﬂection and decision.
BIBLIOGRAPHY.
Chicago Health Department: Bureau and Division Re-
ports, June, 1897 and 1898.
New York City Health Department: Instructions for
Medical School Inspectors, October, 1897.
CITY HOSPITAL ALUMNI. 95
Boston Health Department: Annual Reports for 1896
and 1897.
Durgin: One Year’s Experience in the Medical Inspec-
tion of Schools; Boston Med. andSurg. Jour., April 9, 1896.
Durgin: Medical Inspection of Schools; Boston, 1897.
Arnold: Some Results of the Medical Inspection of
Schools; Ann. of Gynec. and Pediat, January, 1898.
Homan, Shapleigh and Smiths-7 Medical Inspection of
Public School Children in St. Louis; Medical Review,
January 28, 1899. l '
Baker: Medical Supervision of Schools; Cleveland Med.
Gaz., November, 1897.
Keen: Medical Inspection of Schools; J our. Amer. Med.
Assn., June 18, 1898. , '
Schirmu-nsky: Untersuchungen des Gehoers der Schul-
kinder; Monatschr. f. Ohre'nheilk., H., 1890.
Hippel: Ueber den einﬂuss Hygienischer Massregeln auf
die _Schulmyopie; St. Petersburg Med. Wochschr., I., 1899.
Lorenz: Die Heutige Schulbankfrage; Vienna, 1888.
Allport: Report of Eye Examinations in Minneapolis
Public Schools; Jour. Amer. Med. Assn, January 22, 1898.
Allport: Eyes and Ears of School Children; North Amer.
Pract., June, 1898. _,
Allport: Defective Eyesight in American Children; Re-
view of Reviews, June, 1897. '
Powell: Medical Inspection of Schools; Education,
April, 1898. -
Stewart: Unsanitary Schools and Public Indifference;
Forum, Vol. XX., page 103.
Exhibit No. I.
OFFICE OF BOARD OF HEALTH.
...... ..189....

Doctor .................................................................... ..
' I have just now made an ofﬁcial visit at the house of
your patient....._ ................................. ..at... ....................................... ..
for the Board of Health. It will be my duty to co-operate
with you in maintaining the necessary isolation of the pa-
tient, and on notice from you or the family of the termi-
nation of the disease, to see the patient and certify the
facts required by the Board of Health for its action.
Respectfully,

Agent Board of Health.
Address -

MEDICAL SOCIETY OF
Exhibit No. 2.
P—W


FOR SCHOOLS
VISION CHART
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CITY HOSPITAL ALUMNI. 97
REPRESENTING THE SCHOOL CHART.
A. The portion to be hung on the wall.
B. The line where the two portions are to be separated.
0. The portion containing the teacher’s instructions.

(Please detach by breaking on this line.) -
INSTRUCTIONS FOR THE EXAMINATION OF SCHOOL CHILDREN’S EYES AND
EARS. FOR USE OF PRINCIPALS, TEACHERS, ETC. After the method
proposed by Dr. Frank Allport, of Chicago, Ill.
Donot expose the card except when in Use, as familiarity with its
face leads children to learn the letters “by heart.”
First grade children need not be examined.
The examination should be made privately and singly, in a room
apart from the general school session.
Ascertain if the pupil habitually suffers from inﬂamed lids or eyes.
Children already wearing glasses Should be tested with such glasses
properly adjusted on the face.
Place a card of Snel-len’s Test Types on the wall in a. good light; do
not allow the face of the card to be covered with glass.
The line marked xx (20) should be Seen at twenty feet, therefore
place the pupil twenty feet from the card.
Each eye should be examined separately.
Hold a card over one eye while the other is being examined. Do not
press upon the covered eye, as the pressure might induce an incorrect
examination.
Have the pupil begin at the top of the test card and read aloud down
as far as he can, ﬁrst with one eye and then with the other.
If the pupil does not habitually suffer from inﬂamed lids or eyes,
and can read a MAJORITY of the xx (20) test type with each eye, and
does not, upon inquiry, complain of HAEITUALLY tired and painful
eyes and headache after study, his eyes may be considered satisfac-
tory. But if he habitually suffers from inﬂamed lids or eyes, or cannot
read a MAJORITY of the xx (20) test type with BOTH eyes, or habitually
complains of tired and painful eyes or headache after study, a card of
information shOuld be sent to the parent or guardian.
FACTS To BE ASCERTAINED.
EYES.
1. Does the pupil habitually suffer from inﬂamed lids or eyes?
_ 2. Does the pupil fail to read a majority of the letters in the number
xx (20) line of the Snellen‘s Test Types, with either eye?
3. Do the eyes and head habitually grow weary and painful after
study?
4. Is the pupil probably “ crossed~eyed ?”
EARS -
5. Does the pupil complain of earache in either ear?
6. Does matter (pus) or a foul odor proceed from either ear? I
7. Does the pupil fail to hear an ordinary voice at twenty feet in a
quiet room?
8. Does the pupil fail to hear the tick of a good sized watch at three
feet with either ear _in a quiet room?
9. Does the pupil fall to breathe properly through either nostril?
10. Is the pupil an habitual“ mouth breather?" '
98 MEDICAL SOCIETY OF
Exhibit No. 3.


189 To the Board of Health.
Gentlemen:
I have this day examined . . . . . _ . . . . . . . ..
recently ill with , at N o .................. ..
Street, Ward .......... .., and recom-

mend the disinfection of rooms, removal of card of warning,
and release of patient from isolation, on*
Respectfully,


*Date. Agent Board of Health.
Exhibit No. 4.
189....

Dear Sir, Madam :
Your child, ward
was examined by the medical inspector and showed signs
of .
You are respectfully advised to consult a physician.
Remarks ................. ..


Principal.
School.


Exhibit No. 5.
SANITARY SUPERVISION OF SCHOOLS.
DAILY REPORT.


Name of School . Location
District N 0. Date
Inspector . Time
No. Examined Total Ill
SICK Lrs'r.


Name. Residence. Age Sex. Diagnosis. Excluded. Remarks.


Investigate : ............................ ..


CITY HOSPITAL ALUMNI. 99


INDEX TO MAP.
Daily Average 0
NAME or 2232? 212:2 11121-211222?
ance. District.
Oarondelet ........................ .. 555 555 1
Blow . 964 1
Des Peres .......................... .. 184 1303 2 1 or 2
Delaney .............................. .. 155
Meramec ........................... .. 415
Mt' Plpaﬂant 3 1
(éardenville ..................... .. 40 40 4 1
ravois 179
Grant 577 776 5 1
Garﬁeld ............................. .. 1137 1137 6 1 or 2
Oak Hill and Branch ...... .. 339 339 7 1
Shepard 1176
Froebel 393 1569 8 1 °’ 2
$3.???:"::::"':':"':: Si? 15% 9 1 or 2
Charless ............................ .. 1228 1228 10 1 or 2
p l
31:53:; """"""""""""""""" " 13%? 1232 11 1 or 2
Lafayette ......................... .. ‘ 789
Humboldt .......................... 1074 2472 12 2 or 3
Pestalozzi .......................... .. 609
Madison ........................... 1205 1205 13 1 or 2
Clinton . 1017 1017 14 1 or 2
Peabody ............................ ..* 1009 1009 15 1 or 2
Egg? -----------------------
13?; 1519 16 1 or 2
Chouteau .......................... 784
L’Ouverture ...................... .., 648 1432 17 1 or 2
Adams ................................ ..‘ 780
Rock Springs ................... .. i 338 1386 18 1 or 2
Wheatley ........................ .. 268
J efferson..............................1 1260 1260 19 1 or 2
Pope .................................. ..' 1182
Stoddard ............................ ..| 1101} 3134 20 2 or 3
Lincoln ............................. .. 851
Carr Lane .......................... J 705
Hamilton .......................... I! 496 1201 21 1 or 2
Laclede .............................. .. 521 ..
Sumner High .................... 194 710 22 1
$3252“ -------------------------- "; gig 1450 23 1 or 2
‘Carr l 318
Shields ................................ ..; 763 1081 2* 1 or 2
Mullanphy ........................ ..} 471
Douglas .............................. .. 485} 1205 25 1 or 2
Dessalines ....................... .. 249
5
812151131. ............................ .1 633 1255 26 1 01' 2
Blair 1 1241 1241 27 1 or 2


100 MEDICAL SOCIETY OF


Daily Average _
NAME W 2.22%: 212:2 1421512224?
ance. District.
Ames .................................. .. 1097
Webster .............................. .. 1245 1245 29 1 or 2
Clay 1394 1394 30 1 or 2
Iﬁ'vingk 1287 1387 31 1 or 2
anne er .......................... .. 42
Penrose .............................. .. 629 971 32 1
Bates __ 7 43
Columbia .......................... .. 810 1553 33 1 01' 2
Normal and High .......... .. 1498
Divoll 884} 3256 34 2 01"3
Crow .................................. .. 874
Marquette .......................... .. 965 965 35 1
Riddick .............................. _. 839
Elleardville ...................... .. 906 2087 36 2 or 3
Simmons ............................ .. 342
Cote Brilliante ............... -. 1058 1058 37 1 or 2
Harrison ........................... .. 220 _
Ashland ............................. -. 833 1°53 38 1 0‘ 2
Bryan Hill ....................... .. 1005 1005 39 1 or 2
Lowell ............................... .. 563
Garnett ............................. .. 85 648 40 1
Aldrid e ............................ .. 22
Badeng 135 157 41 1
Walnut Park ................... .. 70 70 42 1
Benton 393
Washington ..................... .. 5:0 } 933 43 1
Arlington ......................... .. 5 7
Belt Avenue ...................... _. 34 601 44 1
Dozier 735 735 45 1
Clifton Heights ............... .. 70 ‘
Gratiot 1 With _
Shaw 481 conveyance.
Vashon .............................. .. 63 J _
Roe 254 556 47 1 Wllh
Longfellow ........................ .. 302 conveyance.
Total ................... .. 55,077 55,077 47 51 to 82


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CITY HOSPITAL ALUMNI. 101.
MUNICIPAL MEDICAL SCHOOL INSPECTION.
BY NORVELLE WALLACE SHARPE, M.D., St. Louis.
INTRODUCTION.
HILE it is true that municipal school inspection
for the detection of disease is the result of
scientiﬁc knowledge and research brought
down to date, yet in a thesis upon such a policy it is,
without doubt, best to view its purpose and advan-
tages from a very simple, practical and utilitarian
standpoint, not emphasizing nor elaborating the scien-
tiﬁc detail which, accumulating through the years, has
ﬁnally in its culmination so equipped the medical man
that he can and does speak authoritatively when he
demands systematic school inspection for the detec-
tion of disease in behalf Of the public weel. It is
worthy Of note that through the ages the Medical
Faculty has been the willing and loyal servant of the
public. The gratuitous service it has rendered to man
is incalculable. In times of national or world-wide
distress. in the peril of contagion. in the daily needs
of the general public, the medical man is. with the
rarest exception. found ready and willing to shoulder
responsibilities and burdens, render skilled aid. and
extend to the careless, indifferent, and Ofttimes ignor-
ant laity the beneﬁcient results Of scientiﬁc research
and knowledge. The logical result of this policy
should be that the dictum Of 'the Faculty, calm. dis-
passionate and scientiﬁc. be received with profound
respect and appreciation, and its recommendations for
the public good be speedily and ﬁrmly established by
legislative bodies, the administration of the resulting
laws being vested in the hands of skilled and conscien-
tious men, not under the control of the professional
politician nor subject to the caprice of any man nor
party who. virtue-like, battens on the state for aggran-
dizement and the gratiﬁcation of purely selﬁsh ends.
Strange to relate, this condition does not in any sense
obtain. Per contra, such a result would be consid-
ered by many worthy citizens, otherwise well inten‘
102 MEDICAL SOCIETY OF
tioned, as a delusion, a medical mirage, the utopean
dream of a theorist or idealist. Note the limited
power Of health boards, the lack Of wise and scientiﬁc
municipal, state and national health laws, the wide-
spread, bland and infantile indiﬁ’erence to the patent
and potential value of a national department of public
health. This excursion may seem to the offhand Ob—
' server not germane to the subject. But to the more
diligent seeker after truth it is borne home that, un-
fortunately, this is a vital as well as a just prelude to
a consideration of municipal medical inspection of
schools. '
1)IFFICUL'I‘IES.
Reﬂection upon the manifold difﬁculties and augean
Obstacles cast in the path Of inspection in other cities
where it has been proposed; the politician, in his pro-
tean guise, ignorant Of the fundamental and basic laws
of health and hygiene, triumphing over the disinter-
ested advice and urgent appeals Of the scientiﬁc medi~
cal man; and the painful, sluggish indifference of the
lay public to such a simple and yet eﬁicient method of
prophylaxis, bids u-s pause and wonder if our vaunted
nineteenth century civilization and culture are what
they are claimed to be. How long shall uninformed
school boards ignore the right Of the child to hygienic
surroundings? How long are the children Of the state,
helpless under the caprice or indifference Of the aver—
age school director, to be exposed to contagion?
PLAN. _
Varying with localcondition's, the plan of munici-
pal medical school inspection comprises a daily inspec—
tion, by an accredited doctor of medicine, of all sick
children of every public school in a given'town. The
inspector to be vested with authority to make compe-
tent examination of the sick child, under favorable
surroundings, and, if necessary, to dismiss the child
from school, with advice to the parents to consult the
family physician and to restrain the child from attend-
ing school until well.
CITY HOSPITAL ALUMNI. 103
RESULTS. <
The practical results from this plan are: (1) Early
detection of sickness in its varied forms. (2) An
earlier institution of treatment in diseased conditions.
(3) A checking of disease in the acute and subacute
stages. (4) A diminution of chronic affections. (5)
A diminished number of days of absence from school.
(6) The limitation, if not actual destruction, of en-
demics and epidemics. (7) Improved health standard
of schools. (8) Improved scholastic attainment of
schools. '
(1) Early detection of sickness in its varied forms.
—That this result would be secured is manifest. Daily,
rigorous inspection by a competent physician of all
ailing or complaining children, and of those who,
through an inherent stoicism or reticence, may only
disclose their need objectively to the teacher, will more ‘
accurately designate diseased states, than can possibly
be secured by any other means.
(2) An earlier institution of treatment in diseased
conditions.—-The inspector should be authorized to
dismiss the sick child from school with a message to
parent or guardian to consult the family physician for
such treatment as may be indicated. Too often a
regime not equipped by medical inspection, a child
will attend school for several days, irritable‘or listless,
fretful or indolent, this status not dependent upon ill-
nature, but upon an actual or oncoming illness. It is
but a bare statement of a fact to mention that an ele-
vated temperature indicative of an indisposition, if not
an actual infection, may often be detected in children
who are perfunctorily sent to school by parents whose
ignorance is their only excuse. Such children should
not be permitted to remain at school, a burden to
themselves, and too often a menace to the health of
the entire community.
(3) Aichecking of disease in acute and subacute
stages.-4Dai1‘y inspection of competent character will
produce this result.
‘ 104 MEDICAL SOCIETY OF
(4) Dim'lnutz'on of chronic aﬁ'ectz'ons will logically
follow from subdivision 3.
(5) Diminished number of days of absence from
school—Early- treatment eﬁ'ecting earlier cures will
abbreviate the daily “ absent record.” Superﬁcially,
it may seem that a child sent home when merely un-
well increases the school “absent from duty” average,
yet this is not so, for the return to duty is hastened.
(6) The limitation, if not actual destruction, of
endemlcs and epidemics, will be secured by isolating
from school at the earliest date (and subsequent insti-
tution of proper home treatment) the fons et 0r'lgo
nalz', the primary case or cases.
(7) Improved health standard of schools. -- Dis-
missal of the actual sick and merely ailing Children
raises the health average of a school.
(8) Improved scholastic attainment of schools.—
By retaining only the healthy child in school higher
efﬁciency in the daily task will be noted. .Mens sana
in corpore sano produces, everything else being equal,
high grade work.
DEMANDS or THE CHILD.
It is also worthy of mention that the sick child de-
mands dismissal from school; the healthful child de-
mands that the sick be dismissed—the ﬁrst on account
of its physical necessities, the second for self-preser-
vation. Our children are justiﬁed in expecting truly
hygienic school surroundings. It is their right. In
no other fashion can this condition be secured than by
Competent daily medical supervision.
REQUISITES. .
Inspection to attain a high degree of efficiency should
be vmade under favorable conditions. The physician
should not be compelled to examine children in the
class-room, halls, or wardrobes; A room of suitable
dimensions, reasonably secure from noise, and prop-
erly equipped, should be provided for him. The
equipment need not be elaborate—an ample ’window,
an argand burner with reﬂector and bull’s eye con-
CITY HOSPITAL ALUMNI. 105
denser, running water and a sink, small table, cotton,
wooden tongue depressers (to be burned after each ex-
amination), gauze, antiseptic tablets and bandages (for
emergencies), and suitable culture tubes and slides
(for the detection of bacterial infections), towels, sta-
tionery, and two or three chairs, would doubtless be
sufﬁcient for all ordinary needs. Arrangements should
be made with the local health board by which inocu-
lated culture media should be promptly received at the
laboratory, and a suitable report returned to the school
and to the inspector, at the earliest opportunity. The
inspector should be informed so that, cognizant of the
revealed condition, he may intelligently control present
and future measures; the principal of the school should
also be made aware of the ﬁndillgs,'that he may keep
an accurate record, which, in the monthly report, will
check the more scientiﬁc record Of the medical man.
Upon the discovery of a communicable disease, the
infected child should be rigidly restrained from at-
tending school, and with the co-operation of the local
health board, adequate fumigating and sterilizing
treatment Of the school should follow, with general
vaccination of the pupils lll case of discovered small-
pox.
. MEAsUREs OF CONTROL. .
The dictum of the medical inspector should be
authoritative and absolute in all schools under his
supervision, in order to secure efﬁcient and tangible
results. In_ extraordinary issues he should be guided
and controlled by a. medical advisory council, to whom,
under all circumstances, he is responsible; said council
itself having general oversight of the entire inspection
system and assuming all responsibilities for thorough
and scientiﬁc results. The personnel of the medical
advisory council would doubtless vary with local con-
ditions, but the acting health commissioner, acting
superintendent of the public schools, and the presiding
officer of the representative medical society of the
town (one lay and two medical members), would con~
106 _ MEDICAL SOCIETY OF
stitute a compact and efﬁcient body, The schools Of
the town should be thrown into districts, each district
to be under the control of an inspector, contiguity of
the 'schools and their individual numerical size to con-
trol district peripheries. A small reserve or alternate
staff of inspectors should be appointed to serve as sub-
stitutes when the regular inspectors are forced by ill-
ness, absence from the city, or an emergency case, to
forego the performance of their daily duty.'*
REMUNERA'I‘ION.
The inspector should be paid for his service from
that portion of the municipal funds designated for
school use and controlled by the board of education.
Remuneration may be furnished in the form of a stated
monthly or yearly salary, or upon a per caplta basis,
the number Of sick children furnished by the princpal
and examined by the inspector to serve as a guide.
The former plan would doubtless be the simpler; the
latter is characterized by the greater equity. Under
either system, monthly bills should be formulated by
the individual inslaectors upon ofﬁcial blanks, and
after endorsement by advisory council, should be paid
by the board of education, or by the constituted proper
authority.
DUTIEs OF THE REPRESEN'I‘A’I‘IVE OF THE SCHOOLS.
Though in the vast majority of cases the presence of
a third party is unnecessary, yet is would probably be
wise to enforce the personal co-operation and presence
of the principal or some accredited representative at
all examinations. He should, upon Ofﬁcial blanks,
furnish the school board a monthly record of the ac-
tion upon and ﬁnal disposition of each case under ob-
servation, said record to serve as a check upon the

*The plan of'having the school inspectors form a body
for the discussion of themes akin to their inspection ser-
vice is in vogue in Boston, and is yielding satisfactory re.-
sults. In view of the fact that such subjects, including
sanitation and general hygiene, are of vital importance to
the public, it'is advisable that the meetings of such a body
be open; and that arrangements be made whereby the pro-
ceedings be accessible to the reading and thinking public.
CITY HOSPITAL ALUMNI. 107
more elaborate and scientiﬁc memoranda furnished to
. the medical advisory council by the inspector.at
RESTRAINTS UPON THE INSPECTION SERVICE.
In order that the interest of the general medical
profession should not be impaired, and that the right-
' of the family to select and employ its own physician
be held inviolable, the inspector should be forbidden
the privilege of treating any case at the school, to
solicit the child or the child’s family to become a mem-
ber of his private clientele, or to suggest or outline any
treatment or plan of treatment in response to the ap-
peals of child, parent or guardian made upon the school
premises. Necessarily such applications for profes-
sional care that are made at the inspector’s private
oﬁice, or in the thousand-and-one avenues of approach
beyond and outside of the limits of the duties of his
inspection service, are not under the supervision of
the medical advisory council; and the inspector would
be justiﬁed in acting independently in these extra-
Oﬁicial capacities. He should, however, be permitted
to serve, yielding temporary medical aid, such acci-
dent Or emergency cases as may arise while he is upon
the school premises engaged in inspection. After the
temporary needs have been met, the child should be
dismissed into the hands of the regular and proper
authorities, no further services from the inspector to
be permitted.
INSPECTION DATA.
The ﬁrst school inspection service performed in this
country was instituted in Boston, November 1, 1894,
after surlllounting incredible Obstacles, and only then
under the stress of a severe epidemic of diphtheria.1

*The usual objections raised by school authorities, that
the principal is already overburdened with work, and can
hardly assume this additional duty, should not be consid-
ered by the public. Adequate and satisfactory arrange-
ments can readily be made; and no such trivial obstacle
should be permitted to act as a bar to the beneﬁcient re-
sults obtained by a proper medical supervision. '
108 ' MEDICAL SOCIETY or
Efﬁciency was manifest from the beginning. Com-
paratively recently the Boston plan has been'copied in
other towns, notably New York City. Reports from
the latter place denote complete satisfaction. The .
only plan of inspection which simulates this method
is in vogue in Brussels, ‘where “school doctors” are
employed, to whom pupils are sent when suspected of
being ill from infectious diseases. Those doctors are
under the control of the bureau of hygiene.2 N In this
city (St. Louis) an inspection service extending over a
period of eleven weeks was instituted by the Medical,
Society of City Hospital Alumni, and carried out un-j
der the sanction and co-operation of the local board
of education. The purpose of this inspectibn was to
demonstrate to said board of education the importance
of establishing an adequate medical inspection service
over the local schools. The following extract from
the report of the Committee 011 Medical Inspection of
the Medical Society of City Hospital Alumni com-
pactly summarizes the results that were secured: _
“ In the plan of organization of this service, after
mature consideration, a number of schools were see
lected which, from their location and other circum-
stances, were deemed fully and fairly representative
of all classes and conditions of pupils to be found in
the local public school population. Schools thus se-
lected were ten in number, and comprised those situ-
ated next north of the line of Washington avenue,
extending from the river to the western city limits,
the school population thus represented embracing all
classes and nationalities, and ranging from those in
the eastern part where the home conditions are of the
worst, to those near the western suburbs where the
home conditions are'of the best. The map submitted
herewith shows the location of those schools and their
relation to the municipal territory, while the ﬁgures
appended hereto show the enrollment of pupils during
the opening week and at the end of the ﬁrst quarter in
November. ”
CITY HOSPITAL ALUMNI. 109


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110 MEDICAL SOCIETY or
Week ending ' Quarter ending


Schools Sept. 9, 1898. N 0v. 11, 1898.
Carr Lane ................................ .. 741 930
Crow ....... ...................... ....... .. 947 1043
Dozier ........... . ....................... .. 854 996
Franklin ................................ .. 608 761
Jefferson ............................... .._ _ 14 l 2 1361
Riddick . . . . _ _ . . . . . .. 992 1162
Shields .................................... .. 839 . 1137
Stoddard .................................. .. 1080 . 1335
Washington ............................ .. 602 700
Dumas (colored) .................. .. 638 1024 y
8713 10449
The work was commenced on October 10th, and
conducted in accordance with the following rules, ‘1
which were ﬁrst submitted to. and approved by the
society, and they were, in all material points, also
concurred in by the school authorities.
1. The two physicians assigned to each school shall
alternate weekly in the service. '
2. The calls shall be made daily at the hour of 10
o’clock, and the principal must be at once notiﬁed of
the presence of the physician.
3. Every pupil found ailing or thought by the
teacher to be indisposed will be brought promptly to
the notice of the physician for inspection—such facili-
ties as the school may afford for the examination in
private being placed at his disposal--and the prin-
cipal, or his or her representative, must be present at
every examination.
4. Cultures shall be taken in every suspicious case
of throat disease for the purpose of bacteriological
tests by the health department.
5. Wooden spatulas shall be used in making ex-
aminations of the throat, and these, when once used,
must be immediately destroyed. ' '
6. No medicine shall be given nor medical treat-
ment extended by the physician to the pupils during
such calls, but every case of illness must be at once
reported to the principal with appropriate suggestions
as to the proper care or disposition of the pupils
CITY HOSPITAL ALUMNI. 111
found ailing; emergency aid may, however, be ren-
dered on request of the principal.
7. N0 inspection of school buildings or premises
on complaint of sanitary defects shall be made by the
physician under any circumstances.
8. Careful records shall be kept by the physician
'of every case examined, which records shall include
the name, age, sex and residence of the pupil, the
principal symptoms observed, the ailment or disease
found or suspected to exist, the action taken and re—
commendation made in each instance.
9. Weekly reports shall be made to the society.
and a monthly synopsis of the returns submitted to
the board of education.
It will be seen from an examination of the table
which accompanies the report, and which gives the
complete ﬁgures for the eleven weeks” service, that a
total of.1565 pupils were examined, and 1601 cases of
ailments and diseases were disclosed, while it was re-
commended that 156 pupils in all be sent home on
account of existing inﬁrmity or disease. deemed dan-
gerous either to the child affected or to his school as-
sociates (10 per cent). - Of the _total morbidity found,
only 76 were of the kinds included in the class termed
Speciﬁc Infectious Diseases, which embraces those
maladies that are most to be feared among the school
population, as diphtheria, scarlet fever, measles,
whooping cough. etc. The cases of diphtheria found
were capable of exact identiﬁcation only by means of
culture tests, the symptoms being mild to a degree
that would not suﬂice to detain the child at- home,
but, nevertheless, were pot-ent for continuous wide-
spread communication of the infection to susceptible
associates. During December. inﬂuenza manifested
itself to a degree unmistakable in a number Of cases.
but in many instances masking its presence behind
catarrhal symptoms of the air passages, or a suﬂ'used
condition of the eyes (coryza). The full intensity of
1 l 2 MEDIOAL SOCIETY OF
this pandemic visitation was probably not felt in the
schools until after the close Of the service on December
23d, and the evil wrought by it is, as yet, incapable of
full estimation. Of the total ailments found, 787, or
more than ~49 per cent. were affections of the oral and-
respiratory tracts, and of these tonsilitis'and pharyn-
gitis lead the list, the number being respectively 261
and 198, both the acute and chronic forms being in-
cluded in these ﬁgures. Next comes 182 cases of
bronchitis in both forms, followed by laryngitis, 51
cases, and rhinitis, 49 cases. These ﬁgures serve to
show how heavily the brunt of morbid inﬂuences falls
upon the anatomical tracts under consideration, and
what an important part they play in the morbidity and
mortality of school life. Diseases of the ear num-
bered 37 cases, catarrhal and suppurative discharges
appearing in 27 cases, while 9 cases of imperfect hear-
ing without visible cause were reported. In affections
of the eye, 382 cases were found, 227 of which were
returned as being imperfect sight without visible
cause. The limitations of the inspection naturally
forbade critical examination to ascertain the causes of
the defects, or to what extent the statements of the
pupils in this respect could be accepted as being trust-
worthy. The other principal ailments found in this
classiﬁcation were coryza, 67, all forms of conjunctivitis,
34, and strabismus, 20. (It is worthy of mention that
many eye cases of a chronic or neglected character
were not referred to the inspectors after they had been
seen once or twice, in order not to burden unneces-
sarily the service with multiple visitations from the
same individuals—N. W. S). Diseases of the skin
numbered 45 cases, some of them being of a communi-
cable nature, as tinea in several forms, pediculosis,
and impetigo contagiosa. In the class MiscellaneOus
Diseases is a total of ‘ 274 cases, many of which
necessarily rest only upon the statement of the child
examined, as headache, neuralgia, gastric, intestinal
CITY HOSPITAL ALUMNI. 113
and urinary diSeaseS, the prescribed scope of the in-
spection not extending either to the determination of
their actuality or cause, if really existent. The prin-
cipal ﬁgures shown here are gastric diseases, 55; head-
ache (habitual) 47; anaemia, 2,1; intestinal diseases,
30; and cervical adenitis, 25. '
In reviewing the results of this work it may not be
amiss to repeat that its fundamental and controlling
purpose was the instant detection of those diseases
capable of being passed from child to child, either
directly from person to person, or indirectly by means
of infected things, -as books, pencils, toys. clothing.
etc. In so far as the medical observation thus exercised
extended, it was found that the physical condition of
the pupils at the inception of the service was reasonably
good, the preceding Summer having been not an
unhealthy one, and notwithstanding the inclement
weather experienced more or less through the fall
months, no. pronounced tendency toward the develope-
ment of the more dangerous diseases was observed in
the schools. Disorders of the throat and air passages
were, however, very generally noted in the course of
the work, which would predispose to and afford favor-
able conditions and soil for the most malignant dis-
eases of child life, provided the efﬁcient agents of those
diseases were introduced. Mention has already been
made of the high percentage which diseases of the. oral
and respiratory tracts hold in the grand total, and in
this fact lies a meaning that must be obvious to every
medical man. The tonsils and associated mucous sur-
faces, when irritated or inﬂamed, constitute a highway
for the entrance of diphtheria, scarlet fever, tubercu-
losis, and probably other infections disorders; and
while such diseases in a severely developed form suf-
ﬁce to detain a child at home, yet there are many cases
so mild in character that school attendance is not in-
terrupted, and it is this class that serves to most
actively and efﬁciently spread the disease, while inno-
114 MEDICAL SOCIETY OF
cent of a knowledge of its dangerous nature; and
these walking cases constitute an obstacle to. the
thorough control of dangerous disorders vastly more
formidable than those that are individually Of a more
severe character. The cases of diphtheria that were -
found were of this kind, and in their detection and ex-
clusion, as well as in the early recognition of other
dangerous ailments, lie the merit and justiﬁcation of
this work as a public health service. The circum-
stance that local conditions did not concur to develop
these maladies to an epidemic intensity, as has been
the case here in some other years, does not weigh
against this contention. The fact must stand unchal-
lenged that in the public schools are assembled daily
the largest numbers of the youthful population any-
where gathered together, comprising all nationalities,
classes and kinds, and that here lies the ﬁeld in which
the most strikingly effective public health work on
preventive lines can be accomplished. A _very con-
siderable proportion of ear diseases, with impaired or
destroyed hearing and impending dangerous complica-
tions, undoubtedly have their origin in disorders of
the throat and air passages attendant upon or conse-
quent to measles, inﬂuenza, scarlet fever or diphtheria.
The results Of the inquiries incidentally made into the
' condition of the eyes and eyesight emphasize the need
for expert skill in _order to decide, in cases of com-
plaint of imperfect sight, the fact of real visual defect
and the proper remedy, or whether the asserted fault
was without good foundation. ' It may, however, be
safely assumed that the number of reported cases of
habitual headache bear a determinate relation to
defective vision among school children; and, indeed,
some other ailments may be found to possess such
relationship. 3
The following method by which the school ins-pec-
tors act in harmony with and are agents 'of the local
health board has been found of service in Boston:
CITY HOSPITAL ALUMNI. 115
“ It should be remembered that the boards of health
'of this State are authorized and required by statute
law to take charge of any case of contagious or infec-
tions disease which may be dangerous to the public
health; and while it is preferred that many cases should
remain at home and be cared for by the family and
i the family physician, their isolation at home must be
satisfactory to the board of health, and so certiﬁed by
a, medical agent of the board. So also is the discharge
of such patients from isolation, the evidence of their
freedom from disease, and the safety of their return
to school or to the public must be satisfactory to the
board of health and come from its medical agent. For
this duty the same medical inspectors are serving as
agents of the board of health in the control of infec-
tious diseases which aretreated at home. We send to
each of the school inspectors every morning a bulletin
of the cases of diphtheria and scarlet fever which have
been reported during the previous twenty-four hours.
Each medical ofﬁcer selects the cases reported in his
district, visits them to see if they are properly isolated,
leaves a card for the attending physician informing
him of the Ofﬁcial visit, and reports his approval or
disapproval of the patient's isolation at once to the
board of health. If the patient is properly isolated.
the inspector places a card. on the door of the room to
indicate the ofﬁcial designation of the room for the
isolation of the patient. If the case is not properly
isolated, and it cannot be commanded at home, he re-
ports the fact to the board of health, and such patient
is taken to the hospital. He makes another visit to
the patient on the question of discharge from isolation,
and again reports to the board of health. If it is a
case of diphtheria a negative report from the labora-
tory to the board of health is necessary, and if it is a
case of scarlet fever, desquamation must have ceased,
and the fact certiﬁed by the agent before such patient
can lawfully be released from isolation. The agent of
1 16 MEDICAL SOCIETY OF
the board is thus held respOnsible for the proper isola-
tion of the patient at home, for recommending the
patient’s removal to the hospital when necessary, and
for the patient’s release from isolation. In other
words, the board of health is provided with trust-
worthy information upon which it can act for the best- ,
protection of the schools and the public against the
spread of infectious diseases. "*
It is hardly necessary to state that the so—called in-_
fectious and contagious diseases, speciﬁc in origin,
are communicated in a variety Of ways; and that
crowded school rooms, common drinking cups, ward=
robes, desks, and water-closets are ready agents in
transferring morbiﬁc material. That these conditions
are existent to-day in our schools is patent; and that
disease is thus transmitted is a logical outcome. What '
scientiﬁc method of disease detection and prophylaxis
is in vogue? To our shame, be it said, there is none.
That infective material, such as diphtheric virus, may
be attached to the ordinary implements and surround-
ings of school life, has been conclusively demonstrated
in the laboratory by Ernst?
KI N DER-G ARTE N D ATA.
If there be any one grade that is by its very envi-'
, ronment and manner of existence more productive of
disease transmission than any other, this grade is with-
out doubt that which is ordinarily termed kinder-
garten. The following reasons sufﬁce to account for
this condition:
1. Large numbers within a comparatively confined.
space. *
2. Educational material used in common.
3. Tables and chairs used in common.
4. Cleansing agents used in common. *
5. Games demanding intimate contact.

*These conditions are also observable in other school
grades.
CITY HOSPITAL ALUMNI. 117
6. Especial susceptibility of the child (at the kinder-
garten age).
(These facts have been derived from personal Ob-
servation in the kindergartens in St. Louis and from '
information secured from competent kindergarten
teachers).
" 1. A number of children disproportionate to the
cubical contents of the room is the rule. One or two
rooms, or one relatively large room divided by arches,
or two smaller rooms connected by door spaces. fre-
quently contain from 75 to 100 children. The air is
noticeably impure, and is kept respirable only by
opening the windows during recess. This is the con-
dition in the more favored schools. In the congested
districts twice as many children may receive instruc-
tion in the sameroom daily, being divided into sec-
tions. Unusual air contamination and double the
amount of incidental personal soil are thus introduced
into the room. It is unfortunately true that in the
congested area the index of personal cleanliness is
markedly low, and the probability of disease growth
and transmission is proportionately greater.
2. The so-called “gift materials (balls, wooden
blocks, beads, sticks, tablets and rings), are used in
common; also. rubber balls covered with wool. These
articles are not characterized by scrupulous cleanli-
ness, sundry wipings by the teachers after school hours
being the only care afforded. Even these spasmodic
cleansings are not Obligatory. The vicious possibili—
ties are apparent. Paste and paste brushes are used
in common; and the brush that today may be moist-
ened in the mouth of a child in the early stage of a
diphtheritic or scarlatinal infection, to-morrow is ab-
sent-mindedly lubricated by an innocent neighbor.
Modeling clay duly moistened (perchance surrepti-
tiously by the saliva of tubercular child or molded
by the ﬁngers of an infant with impetigo contagiosa,
118 , MEDICAL SOCIETY OF
- or one harboring pediCuli), is also common prOperty.*
3. The tables ordinarily supplied are 18 x 36 inches
and are supposed to meet the needs of two children.
These tables are not only common property, but kin-
dergarten teachers are compelled, when the number of
pupils is excessive, to place three or four children at
each table, thus adding the further element of conta-
gion—crowding. I ﬁnd no record that the tables are
ever scrubbedi ' y
4. In some schools the towels are washed every
other day; in some schools a weekly cleansing is
deemed sufﬁcient. ()ne'basin and one towel are passed
from child to child, from ﬁfteen to thirty children be-
ing supplied by the same agents. This is the condi-
tion in the more favored localities and where teachers
voluntarily use some individual caution. In other
schools it is a prevalent practice to wash the children
(total number wrapped in obscurity) upon one damp-
ened towel. Description of the actual condition of
said towel and its possibilities as a disease transmitter
is hardly necessary.
5. The kindergarten system includes various games.
These games require more or less intimate contact
among the children. The so-called “circle work
games" demand clasping of hands, no selection of
neighbors necessarily being possible. In the “pigeon
house "‘ game a small circle (possibly six feet in diame~
ter) is formed Of children. Within this circle two or
more children are placed. All the participants are
required to pack together as closely as possible. In
the “bird’s-nest ” game the same compacting process

*Modeling clay in the St. Louis kindergarten is supplied
in abundance, thus avoiding this source of contagion.—
Superintendent of Kindergarten.
'rLater information shows that the tables are occasion-
ally cleaned by the teachers, not under compulsion. There
is apparently a distaste for scrubbing, on account of injur-
ing the varnished tops.
CITY HOsPITAL ALUMNI. 119
is noticeable, and the parent bird is supposed to. be
feed-ing‘its. young (the child imitating the process by
opening its mouth, and, in fancy, dropping some food
into the open mouths of its playmates), distance be-
tween the two'mouths from one to six inches.
6. That virgin soil, relatively speaking, invites in-
fection is true. And when said soil is infected, that
relative virulence is manifest is also true. Changing
from the abstract to the concrete, it follows that kin-
dergarten pupils, tender in years, comparatively free
from subjection to antedatal contagion, are far more
liable to infection than those Of maturer years, in
whom a phase of resistance, if not immunity, has been
established. That this scientiﬁc fact is recognized
more or less gro'pingly by the laity is shown in the
conventi0nal statements of mothers, that their chil-
dren have had none of the diseases of childhood, “as
they are still too young to be sent to school; but next
year, when we send them to kindergarten, I suppose
that they will catch measles and whooping-cOugh, and
all the rest.” (These facts have been noted by other
Observers. They are not peculiar to St. Louis, but are
characteristic'of the kindergarten system).
N 0 scientiﬁc acumen, nor even unusual intelligence
is needed to realize that this intimate contact, these
compacting methods, common implements and mate-
rials, and careless attention to cleanliness and basic
hygienic measures are proliﬁc sources of contagiouﬁ‘
GENERAL CONDITIONS.
The kindergarten also shares in other unfortunate
conditions common to the higher grade. Common

*It may be noted that our local schools are conducted as
carefully as could be expected, when due allowance is
made for the usual limitations, and that the teachers in
control can hardly be'presumed to be versed in up-to-date
sanitary and hygienic. measures, But in the occasional
school or school-room, where carelessness obtains, lurks
the menace to the child and the general public; and in
these cases inspection is especially demanded.
120 MEDICAL SOCIETY on
drinking cups, water-closets, wardrobes (where cloth-
ing is sometimes hung three or four deep upon the
walls, or piled in large baskets, there to be placed in
contact with all possible unhygienic and contaminating
conditions).* School ﬂoors are scrubbed but rarely
(probably not more than twice or three times yearly,
even under a liberal management). It is considered
suﬂicient to use dust-brushes and pan. And the jani-
tor, mantled and aureoled in clouds of dust, as he-
“ cleans up after school,” is a vivid reminiscence of
school life. Walls and ceilings are practically ignor-
ant of any real cleansing.
It is well known that virulent sputum and infectious
material exhaled from the lungs, or discarded by the
skin (even though in microscopic quantities), are not
only actively infectious at the moment of divorce from
the host, but, favored by lack of suitable cleansing
and other hygienic agents, preserve their malignant
power for weeks—the more resistant bacteria retaining
their power for months. ~
In the light of these well—known facts the pernicious
possibilities of this method of dry cleaning of schools
are apparent. That no vast number of cases has been
absolutely traced in their infection career to an origi‘
nal contact with contaminated dust does not militate-
against the gravity of this cleansing method, or, to be
more accurate, this lack of proper cleansing method;
EXAMPLE OF THE EFFICIENCY OF AN INSPECTION
SERVICE.
“Numerous instances have come under our observa-
tion where a child has been found in school suffering

*Among other school habits provocative of disease trans-
mission, are the interchange of lead-pencils and pens,
transferring of chewing gum from child to child, moisten-
ing the carbon (in the mouth) of the so-called “ lead-pen-
cil,” the use of saliva and sponge for cleaning slates, and
the tendency toward promiscuous embracing and kissin 0‘,
noticeable among girls.
CITY HOSPITAL ALUMNI. 121
f rOm an infectious disease by the medical inspector of
schools and sent home; this case has been followed in
due time by other cases in children whose only dis-
coverable exposure was that which occurred in the
school room. Fresh evidence of such exposure and of
its effect has been brought to my attention within a
few weeks occurring in the service of Dr. Arnold, one
of our school inspectors. An epidemic of diphtheria
occurred in a primary school in which there were forty
pupils, fourteen of whom were attacked with diph-
theria within a period of eighteen days, all from one
room. Of .the fourteen cases, seven were discovered
by the school inspector, and three of these only by
cultures. . All suspicious cases were dismissed from
school May 5th, and recOmmended to the care of their
family physicians. The next morning every pupil was
examined and many cultures were taken. The class
was then dismissed from Thursday to the following
Monday, the room disinfected and cleaned up. For
ten days after their return the throat of all pupils was
examined by the medical inspector when they ﬁrst
assembled in the morning, and no pupil who had been
absent with any suspicious symptoms, was allowed to
return until it was proved by a negative culture that
there cOuld be no danger. As a result of these meas—
ures not a single case of diphtheria resulted beyond
those known to have been infected at the time the
epidemic was discovered. A similar experience with
scarlet fever occurred in the service of the same school
inspector within two weeks, in which eleven cases re-
sulted from the presence in school of one pupil whose
illness had been attributed to German measles. "7
STATISTICS.
The following statistics have been compiled from
the annual reports of the Health Commissioner of the
City of Ski-Louis. Unfortunately, an accurate scar-
latinal record for the ﬁscal year 1888-89 could not be
procured. ‘
22
MEDICAL SOCIETY OF


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CITY HOSPITAL ALUMNI.
123
TABLE II;


SCARLET FEVER.

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TABLE III.
SCARLET FEVER.—NINE YEARS. _l DIPHTHERIA.—TEN YEARS.


VACATION. SCHOOL. VACATION SCHOOL.
(Two MONTHS.) (TEN MONTHS.) (Two MONTHS.) (TEN MONTHS.)
Gases Deaths Cases Deaths Cases Deaths Cases Deaths
Totals 831 67 7168 550 , 1 182 313 11102 2538
Monthly average (in total) ................ .. 415.5 33.5 716 S 55 591 156.5 1110.2 253.8
Excess of a school month (in total)
Over a vacation month (in total),
cases 301.3 . 519.2
Excess of a school month (in total)
Over a vacation month (in total),
deaths 21 .5 97.3
Mortality percentage ............................ .. I 8.06 7.67 26.48 22.86
Excess mortality percentage of vaca- '
over school month, - ‘ .39 - 3.62


CITY HOSPITAL ALUMNI. 125
F'om these two tables the following (Table III),
which is self-explanatory, has been deduced. Atten-
tion is called to the fact that the average school
month produced more cases, and a greater actual
mortality, than the average vacation month. It is of
interest, however, also to note that the average lethal
, percentage is heavier during the vacation month in
both scarlet fever and diphtheria. It would doubt-
less be immature to state that the monthly school
excess over vacation is due entirely to the existing
school session. Yet, that 'the congregation of
large numbers of children in our schools during
ten mOnths of the year is not only a factor, but prob-
ably a very important factor, in disseminating con-
tagion, and thus increasing disease prevalence, can
hardly be controverted.
CONCLUDING STATEMENTS.
Many of the unfortunate conditions herewith noted
merit attention. But it would be absurd to presume
that they would, or in certain instances could, be rec-
tiﬁed, 011 demand, or even after a considerable lapse
of years. “The enrollment of pupils for the past
ﬁscal year was 81,917.”S It is highly improbable
that the municipality would furnish to our public
school youth 81,917 individual wardrobes, drinking
cups, water-closets and toilet requisites; that school
interiors would be daily, or even weekly, scrubbed;
or that the daily physical condition of every child be
certiﬁed by a competent medical man.* These im-

*It is almost gratuitous to observe that no effort is being
made to overthrow the present public school system, nor
to shake the conﬁdence of the public then in. Its
manifold excellencies are manifest.. But like all other
“systems,” it contains factors with vicious possibilities.
Against these do we strive, and toward their amelioration
if not actual removal, are these." suggestions made. At
best, the inspection service, as outlined here, is relatively
inadequate. The public is not yet educated to the plane
126v MEDICAL SOCIETY OE
probable possibilities are necessarily not germane to
the scope of this discussion; they obscure, rather than
clarify, the ﬁeld of investigation. But daily medical
*~'s-upervision will counteract many unfortunatecondi-
tions, will eradicate many more; intelligent and pains-
taking observance Of basic sanitary laws .is both ~ pose
sible and feasible; and the public should not condone
neglectof these simple and wise policies. A The right-
of the child to truly hygienic surroundings physical,-
in all that that implies tO-day, as well as to truly
hygienic surroundings mental, is paramount. A-ny
selﬁsh, partisan, or otherwise narrow-minded act that
militates against full fruition in response to this de—
mand—this right--is a. crime.*
BIBLIOGRAPHY.
1Durgin: Transactions Massachusetts Medical Society, ’97.
2Durgin: Transactions Massachusetts Medical Society, ’97.
3'I‘ransactions Medical Society of City Hospital Alumni,
also Medical Review, Jan. 28, ’99.
4Durgin: Transactions Massachusetts Medical Society, ’97.
5Durgin :, Transactions Massachusetts Medical Society, ’97.
6Durgin: Transactions Massachusetts Medical Society, ’97.
7Durgin: Transactions Massachusetts Medical Society. ’97.
8li‘orty-iourth Annual Report of the Board of Education of
City of St. Louis. .
3505 Franklin Avenue.

that will permit appreciation of up-to-date medical and
sanitary supervision. The excellent work of Francis Gal-
ton in- his anthropometric laboratory in the Kensington
Museum 'foreshadows the possibilities of scientiﬁc medical
control of schools. ' '
*It is self-evident that all these. statements, applicable
to the public schools, are also applicable to other schools,
such as the so-called “private” and parochial. From a.
seientiﬁc standpoint medicalsupervision in these schools
is important in direct proportion to their numerical. size,
and therelative efﬁciency of their sanitary. equipment.
CITY HOSPITAL ALUMNI. 127
DISCUSSION.
DR. M. H. POST asked if these papers were to be
submitted to the board of education. ‘
THE PRESIDENT'said the papers would be made a
part of the scientiﬁc transactions of the society, and
in that way brought to the notice of the board of
education. -
DR. POST said there was a great'deal of informa-
tion contained in the papers which was startling, and
which would be a surprise .to the outside public
and would be a great stimulus to public hygiene.
He thought it very desirable that the _board of educa-.
tion Should be furnished with the facts contained in
the papers. ,
THE PRESIDENT said reprints of the essays would
be furnished the board of education and othersaand
could- be distributed by them.
DR. L. T. RIESMEYER considered the medical in?
spection of school children, as well as the inspec-
tion of the schools and their proper equipment of
the greatest usefulness and importance. He desired
to ask Dr. Shattinger for information in regard to
the real value of bacteriologic examination by the
culture method alone, in so far as the length of the
period of isolation after reconvalescence from diph-
theria was concerned. He said that in exceptional
cases diphtheria bacilli were found in healthy throats,
and he wished to be informed whether hygienists ’ con-
sidered it necessary tokeep patients at home as long
as bacilli were found, irrespective of their virulence.
after clinical convalescence had been completely .es—
tablished, say for a number of months. ,
DR. Cr. C. CRANDALL recalled experience he had
in London some years ago in connection . with G'alton.
Galton had, since 1875-77, been conducting investiga-
tions systematically in his laboratory; children go to‘.
128 MEDICAL SOCIETY OF
' the laboratory about-the time they enter the schools
and are carefully examined. These examinations
cover the sight, hearing and general physical condi-
tion of the individual, and also, in a measure, a men- _
tal test of their capacity. In certain cases, where
defects were discovered, the children were requested
to return for observation, and in some instances they
were taken from school because of defects. It should
be the duty of those in charge of the children in
schools to watch and care for the physical as well as
the mental condition of the children, and where de-
fects are found, to report the fact to the parents.
Ultimately, he said, the capacity of the children will
be advanced by this work. The work undertaken by
the society as Shown by the essays, was just the
beginning of what would ultimately obtain here as it
already exists in other cities. Galton had for years
been endeavoring to obtain such a condition in the
Schools in London. but on account Of' the expense
and the lack of appreciation, up to the last four years
he had not been able to do anything in a public way.
The speaker said he had with him a report such as
was given to each individual by Dr. Galton, and he
thought it might be of value to the committee; the
report, he said, would Show the nature of the physical
and mental examination. ' '
DR. PI-IIL HOFFMANN said he thought the medical
supervision of the schools should not~ be conﬁned alone
to the physical condition of the children, but might
be extended‘to include the school houses and furni-
< ture. He was led to this by the paper read by Dr.
Shattinger. It was undoubtedly true that the furni-
ture, desks and benches, of the ordinary school house
were altogether inadequate for the proper comfort of
the children. Most of us could probably remember
the old desks and benches in use in the schools, and
possibly a great many of these were still in use. It
CITY HOSPITAL ALUMNI. 129
is probable that many of the cases of spinal curvature
originated in the school rooms. He believed the
habit of making the children stand during recitations
was a pernicious one in many cases. Desks, etc.,
Should correspond in some degree to the increased
size of the children as they passed from the lower to
the higher rooms, yet it should not be forgotten that
in a class Or room containing a number of children
there would be all sizes and conditions represented.
THE PRESIDENT said he thought the whole subject
had been well covered by the papers presented. His
own experience was conﬁned to the work done last
fall in one school, and that for colored pupils. The
mortality of the colored population was, as all who
had looked into the matter probably knew. about
double that of white population. It was true, too.
that the fecundity rate was, perhaps, nearly double;
the birth rate is large and the mortality rate large.
- The particular school under his observation would
possibly represent a fair type of the school of the
older kind in construction and arrangement. The
average attendance was about 1000 children of all
ages, except the more advance grades. In the course
of the service there were two things which had at-
tracted his attention casually, because, under the
rules, no sanitary inspection was permitted. The sys-
tem of heating in this school was noticed because the
ﬂue from the furnace opened directly into the center
of the main hallway; if there was any contrivance by
which germs could be more effectually disseminated
he said he did not know it. The inclination among
children and sometimes adults was to use the opening
of the register as a place for expectoration. In cold
weather the children stand over it and warm them-
selves, and mud from their shoes is turned into dust
and carried throughout the building. There could be
no better means, he thought, of disseminating germs
130 MEDICAL SOCIETY OF
through a building, unless it were a power fan in
operation, throwing out dried Sputum. That was one
of the objections found. Whether the same arrange-
ment was existent in many of the schools he did .not
know, but hoped not. Another thing bearing on the
sanitary management of the building was that in this
same school house on Saturdays the blinds were drawn
down and the windows tightly closed; Monday the
windows were opened it was presumed, and the furnace
started up. The speaker said he thought it should
be the invariable rule that on Saturdays every window
should be opened, the Shades thrown up and the
school ﬂooded with light and air even in the cloudiest
weather; he thought this was necessary to a whole- '
some condition. He said he had mentioned the mat-
ter to one of the members of the board of education
but whether it had been remedied he did not know.
It was such a simple thing in the sanitary care of
such a building that he wondered if it had been car-
‘ ried out. It was probably convenient for the janitor
to thus close up the building, but it ought to be an
inﬂexible rule that on Satudays the windows should
be opened, so that all sunlight and fresh air possible
. might enter the rooms.
DE. B. M. HYPES said he had been interested in
the papers as well as in the work of the inspection.
He thought it was an admirable undertaking, and
believed it was appreciated, not only by those inter-
ested in the work, but by many of the citizens both
among the profession and the laity; but he was afraid
much of the beneﬁt to be derived from the work would
be lost unless the society took some action for the
dissemination of the knowledge contained in the papers
read. The speaker was not aware that this plan had
been adopted anywhere else. He made this state-
ment, he said, because he believed the profession was
ignorant of the work done, and therefore thought the
CITY HOSPITAL ALUMNI. 131
society should take some means of distributing these
papers. ' Every member of the medical profession of
St. Louis should receive a copy, and all the members
of the-school board, and all the editors in St. Louis
should also receive copies, so as to arouse interest in
sanitary work and the beneﬁt of medical inspection of
the schools. By attracting the attention Of the public.
and especially the thinking part of the community to
the subject, he believed a great advance would be
made in making the inspection of beneﬁt to the
schools, and in assisting the physicians in carrying
out their plans. The expense, of course, was ob—
viously the great difﬁculty in maturing and carrying
out any plan, and the only way to overcome that
would be by getting at the people—the voters—those
who decide as to the taxes which shall go to the
beneﬁt of our schools, so that the public as well as
the medical profession-Should be in line on this sub-
ject; and, as has been found in political campaigns,
nothing educates the people up to anything like litera-
ture.
DR. A. H. MEISENBACH thought that the general
public would not have an, opportunity of becoming
conversant with the matter unless presented in some
such way; the facts as brought before the society had
been patent to the profession probably, but never were
so cogent as now. The question was of such general
public interest that the committee should be empow-
ered to place these reports at the disposal of the public
press and some means adopted for the publication of
such portions of the papers as would be of interest to
the general public. The speaker said the papers Were
excellent ones, and showed a great deal of work and
thought on the part of their authors. They showed,
too, that this society was a working society and that.
young as it is, it is bound to make its mark.
DR. CHAS. J. ORR recalleda point to which he wished
132 MEDICAL SOCIETY OE
C
to call attention, if it was not presented by the essay--
ist (he had not heard all of Dr. Shattinge'r’s paper).
While engaged in the inspection work he had been im-
pressed with the enthusiasm some of the children
manifested. We are prone to become prejudiced as
we grow old, he said, and hesitate to accept and take
an interest in the progress of affairs in some things.
The fact that the children" took an active interest in
the work and talked with their parents about it out of
school, was potent for good, he thought, because it
would be only a few years until these same children
would themselves become citizens and have a voice in
these matters. He believed the work would be ad-
vanced and interest increased, if the subject could be
brought before the people.
DR. BENNo BRIBACII said he thought this subject
> was one of great interest to every practitioner. Every-
one knows what an important factor the schools are in
the dissemination of disease. There is no doubt that
communicable diseases are increased three and four
times with the opening of the schools, as mentioned in
Dr. Sharpe’s paper. He thought it would be impossi—
ble to have these measures adopted unless the people
became interested, and he believed the only practical
way to do this was to have the matter agitated in the
public prints. He believed it to be a matter of vital
importance to have the system introduced in St. Louis,
and did not believe it could be brought about in any
other way:
DR. FRANCIS REDER said the recent introduction in
the schools of vertical writing was an advance step in
the direction of preventing disease which might come
from a faulty position. It is possible that deformity.
could be largely prevented by the position assumed by
the pupils, especially in the practice of vertical writ-
ing. The continued and prolonged contact of the
chest with the desk would in time Show in the growing
CITY HOSPITAL ALUMNI. 133
child. Another matter, and it was of no little import-
ance, was in a certain book used in the schools, called
the “Health Primer.” During the last four or ﬁve
months it had come to his nOtice that some children
were affected by the study of this book. Two girls,
aged nine and ten years. he had found to have been
suffering from extreme nervousness, and to such an
extent as to compel them to leave school. This
“Health Primer” was of such a kind as to interest
small. susceptible pupils, probably more than was in-
tended. It was possible that the fault may rest to a
r certain extent with the teacher, who may not conﬁne
. himself to what is in the book. but dilate upon the
complications which might arise from such a subject.
The older of these two children complains that-the
blood rushes to her head; she will go to her mother
and say that she has ruptured a blood vessel. In
looking up the matter it was found that this -'- Health -
' Primer " gives instruction upon the bones of the head,
blood vessels, etc. The other girl. who was but nine
years old, one day went to her mother and said she had
cancer of the stomach. The mother. of course, said
she did not, but the child dwelt upon that ailment to
such an extent that she had to go to bed. JIe thought
that as soon as any of these signs were manifest in the
pupil, the child should be excused from any further
recitation on the subject until she was older and could
more easily comprehend the teachings of this book.
DR. G. C». CRANDALI. said he thought nothing could
be accomplished until laws upon the subject could be
made and carried out. The society mightdiscuss the
matter and formulate plans, and yet no result would
be seen unless laws were made to govern the subject.
7 In the East, 'he said, an effort was made to introduce
the system, yet nothing could be done until public
laws were made. That, he said, was the reason why
it failed in London.
134 MEDICAL SOCIETY OF -
DR. SI-IA'I‘TINGER, in closing. replied to the question
as to whether a child should be excluded from school
as long as diphtheria bacilli persisted in the throat,
though perhaps no longer virulent, that he recognized
the fact that the diphtheria bacillus. like other micro-
organisms. may lose its toxicity in whole or in part,
and regain it. He said he supposed the doctor would
agree with him in holding that such non-virulent ba-
cilli in'one throat might regain their toxicity if trans-
ferred to another. Taking cultures until the bacilli
were found absent was the only practical method of
ascertaining when a child might Safely be allowed to
_ return to'school. Should an exceptional case be en-
countered where the bacilli persisted for an unreason—
able length of time. animal inoculation could always
be resorted to as a test- of their virulence. I
There was one point which he had not touched upon
in his paper, and which, he noticed, Dr. Sharpe had
also avoided, and that was when the inspecting physi-
cian should visit the school. The practice here and
elsewhere ':was to make the visit in the morning. The
idea was that by visiting the school as early as possi-
ble, cases would be discovered early and thus do less
harm than, if they had remained in school all day.
But he believed it would perhaps be better to make
the call later in the day, because then those ill would
be more apt to show Symptoms, and the teacher would
have had more time to observe the pupils. We know
fever will be more manifest in the afternoon than in
the morning. He inclined strongly to the opinion that
an afternoon visit would detect- the largest number of
cases of sickness. .
In the German city of Crbttingen they have intro-
duced baths for school children. After a very short
time the children. became very enthusiastic ahout them,
and the parents took greater pains to send them to
school cleaner and better clad, being ashamed to have
their children found dirty or wearing soiled clothing.
CITY HOSPITAL ALUMNI. 135
The question of the inspectors looking after the
hygiene of the schools had been brought up and very
wisely, for he thought it of equal importance to that
of the children themselves. The improved school
furniture found in our newer buildings was an out-
come of the agitation here and in Europe with refer-
ence to preventing near-sightedness and spinal de-
formities among. school children. In this, as in so
many other matters affecting the public welfare, the
medical-profession has just cause to be proud of its
inﬂuence. I
Regarding the legal aspect of medical inspection,
the speaker had obtained information from both the
health commissioner and the city counsellor to the
effect that no special enactment would be necessary if
the service were undertaken by authority of and with
funds controlled by the board of education. An ap-
propriation by the city council, however, could only
be obtained as part of an act establishing and regulat-
ing such service. The principal difﬁculty would be to
secure the means. Paying $50 per month, which the
speaker thought was not one dollar too much. and em-
ploying the minimum number of ﬁfty-one inspectors
would necessitate an annual expense of $25,000 for
salaries. Eighty-two inspectors would bring the amount
up to $41,000. Adding $100 for supplies, etc., the
cost then would be from $25,600 to $41,100. accord-
ing to the extent and efﬁciency of the service. To
obtain this money the speaker said there were three
ways: One, by taking it from the existing funds be-
longing t-o the school board. In order to do this,
Superintendent Soldan says, it would be necessary to
stop building or to curtail the salaries of teachers.
This, of course, could not be done. because we need
‘ more schools, and it would certainly be wrong to re-
‘ duce the salaries of the teachers. This source, there-
fore, is cut off. Another way would be to impose an
additional’tax upon the tax-payers of the city. This
136 MEDICAL SOCIETY or
would have to be done by a general vote of the people.
Whether that could be obtained would depend largely
upon a successful agitation of the issue. The board
of education has repeatedly tried in this way to get
means to erect a library building for the public library
and failed. The speaker thought the daily press was
largely to blame for this. If half the space devoted
to partisan politics were given to the discussion of
questions of vital interest to the people, library build-
ings, sanitary supervision of schools, and much more
would follow. He did not believe that our citizens
were so stingy as to begrudge a small extra tax7 if the
good to be derived therefrom could only be explained
and assured to them. Still, a third way existed7 viz.,
to move the city council to make an appropriation.
To do this it would be necessary to convince its mem-
bers of the need and importance of the measure.
Money is the key to the whole situation. The ques-
tion as to whether sanitary supervision can be secured
for the schools of St. Louis resolves itself into this:
lan the board of education afford the outlay. or can
the city council be prevailed upon to make an appro-
priation, or can the tax-payers be induced to vote an
increase of their rates?
DR. MEISENBACH said he would like to offer a reso-
lution in order to bring the matter in proper shape be-
fore the society—that the gentlemen be authorized to
make an abstract or synopsis of the work done, to be
at the disposal of the committee in charge with the
view of bringing it to the attention of the public press,
both German and English. He thought it necessary
to get the matter before the people, and the necessary
means would be a question for later decision. He said
there were many people among the laity who would
take the matter to heart if it were presented in a proper
manner. -
CITY HOSPITAL ALUMNI. 137
STATED MEETING, THURSDAY EVENING, APRIL 6, 1899,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
DR. GREENFIELD SLUDER exhibited some
Nasal Specimens with Demonstration of Methods
of Preservation.
I present some skulls which show the anatomy of
the nose, prepared after a method of preservation
which is quite as interesting as the specimens them-
selves. While in Vienna two years ago I experienced
difﬁculty in preparing specimens of the nose. These
skulls, which came out of the pathologic institute
there, were taken off the fresh cadaver and hardened _
_in alcohol. At that time I tried to prepare some with-
out decalciﬁcation, but found it almost impossible to
get a skull which would show the ethmoid cells, the
hiatus semilunaris, the infundibulum, without tearing
and spoiling the specimen very much, so I boxed these
skulls up and brought them home, having in mind to
try the scheme of decalcifying. On my arrival I tried
a mixture of 10 per cent. nitric acid with 15 per cent.
of hydrochloric acid, and this is the specimen which
resulted. It is stained with nitric acid in contact with
the soft parts, which makes picric acid, a yellow stain.
I then tried a 15 per cent. solution of hydrochloric
acid and obtained such specimens as these—perfectly
white without being in any way discolored. I found.
however, that the hydrochloric acid 'decalciﬁed very
much more slowly than the other mixture, requiring
about two weeks instead 'of ﬁve days. I then tried an
acid solution in formol to prevent softening. It
worked very well, but added to hydrochloric acid the
mixture made a much ﬁrmer specimen. \ In one of the
specimens it is interesting to note how very small the
frontal cavity is; it is so small as to be absent above
the line of the eyebrow, as shown by the section cut
through at that point. The skull, after such treat-
ment, and after the acid being washed off, cuts just
138 MEDICAL SocIETY or
about like a piece of Swiss cheese. I will now cut
further into this specimen. It remains perfectly ﬁrm
and the cut section shows a perfectly clean surface
without any dislocation of the membrane or bone.
On the line with the eyebrow the frontal cavity is
' absent; it comes in, however, somewhat below on a
level with the cribriform .plate. The section also
shows how extremely thin are the walls of the frontal
cavity next to the orbit and cranium proper. It shows
conclusively how an empyema of the frontal cavity is
most apt to break into the skull; next into the orbit.
This is cut anteriorly to the middle third; probably it
will pass readily through the frontal cavity. This
specimen is not as handsome as others, being dis-
colored for some reason, probably when it was put'into
alcohol. It shows the jaws in contact with each other
and the relation of the epiglottis to the uvula, and
gives a sight of the lingual tonsil. Enlargement of
this tonsil is not uncommon, and we see what might
be mistaken for a reﬂex phenOmenon—the dislocation
of the epiglottis backward in such a fashion as to make
an organic obstruction—the tipping down of the epi—
' glottis causing, dyspnea.
Here is a section that will show the middle turbi-
nated composed entirely of ethmoidal cells, which is
not so uncommon, although not looked for when we
think of the middle turbinated. The entire middle
turbinated is occupied by two ethmoidal cells; it ap—
pears to be an enlargement of the middle turbinated,
the posterior two-thirds being made up by a single
cell; these cells are in direct communication with the
upper cells. This shows what is fairly constant, that
is, whatever may be the deviation of the ethmoid cells
beyond, it is divided primarily into four cells, the
anterior being the bulla. It is divided by three laminae
into four sets of cells, the most anterior often times
extending beyond the uncinate process of the‘ethmoid.
The posterior cell, which is likewise a constant one,
CITY HOSPITAL ALUMNI. 139
open-s. above the middle turbinated, very nicely shown
' in the specimen. The others are not absolutely con-
Stant, but nearly so. The laminae run transversly and
divide the ethmoid into something of a constant
arrangement. -
The diﬁiculty in preparing such sections in bony
skulls, as you can readily imagine, is quite consider-
able and it is almost impossible to avoid tearing.

DR: ROBERT J. TERRY exhibited
Gross Sections of the Human Body.
Let me express my pleasure in accepting an invita-
tion to exhibit my sections which your society has been
good enough to extend to me. I am much gratiﬁed in
knowing that so many are interested in thislwork and
that such preparations are held useful by others than
teachers of anatomy.
Hearing that Dr. Sluder had made some beautiful
specimens by a process Of decalciﬁcation and section-
ing, I went to him and learned his method, for which
I am very much in his debt. I resolved to make use
Of the decalciﬁcation method in preparing sections of
the whole body, believing that if properly manipu-
lated the decalcifying agent would do as well in this
as with the heads which Dr. Sluder used. I chose this
way of preparing the body for section cutting because
the doctor’s results were so good, and because it has, I
think, certain advantages over the freezing and sawing
process. ,
' In the preparation of the sections which you see
here the process was divided into four stages:
(1) Preserving and hardening the subject.
(2) Decalciﬁcation Of the bones.
(3) Embedding.
(4) Sectioning.
1. The whole body was injected (by siphonage into
the femoral artery) with about 1%- gallon of a mixture
of equal parts of formaldehyd and 95% ethyl alcohol.
140 MEDICAL SOCIETY OF
On the day following the injection the body was found to -
be quite ﬁrm and rigid. The limbs and head were then
carefully severed from the trunk by means of a sharp
knife and saw and placed in the decalcifying agent in
large stone jars. The trunk was put into a barrel
which had previously been coated inside with melted
paraﬁne and covered with the decalcifying ﬂuid.
2. I made the decalcifying ﬂuid of hydrochloric acid
and water, mixing one part of the commercial acid
with twelve parts of water. Decalciﬁcation takes place
slowly if the body is whole; removal of the skin hastens
it. Six weeks’ time was required to soften the bones
in this subject and during that time I frequently tested
the condition of the skeleton by running long pins into
the body.
3. When I was able to run a pin through the, bone
in any part of the body I considered the work of the
acid done and at once removed the subject from the
acid bath. It was then washed with water, wiped dry,
and ﬁnally smeared with glycerine; which done, it was
set upright in a strong paper cylinder and embedded
in a stiff glycerine jelly.
4. My macrotome is an imperfect affair, consisting
of a wooden box open at each end and large enough to
hold the paper cylinder. It was fastened upright to a
bench and at such a distance from the ﬂoor as would
allow the movement of a lever up and down. This
raised or lowered a platform within the box upon
which rested the embedded subject. The platform
could be held at any desired level by bracing up the
lever. All space between the cylinder and the sides
of the box was packed with “ excelsior shavings, ”
which prevented the cylinder from rocking during the
sectioning while not interfering with the action of the
platform at other times.
After several trials with different instruments I
found that for my macrotome a knife with a long stiﬁ‘
blade was most suitable, the kind used in hotels and
CITY HOSPITAL ALUMNI. 141
restaurants for slicing large roasts. The blade is
nearly 20 inches long. I should have stated before,
that the upper edge of my macrotome box was made
even and smooth in order to serve as a guide when
cutting the sections; the knife-blade was kept closely
applied to it and made to pass through the body with
a sawing motion.
The sections of the trunk were made by cutting
horizontally through each vertebral body. If you will
examine them you will ﬁnd that the soft parts are well
preserved and not at all injured by the acid. One can
easily ﬁnd the larger nerves, which are white, and you
see that the organs, hardened in Sit“, are not disturbed
in their relative positions; most of the veins are in»
jected with dark red, coagulated blood, and muscles,
tendons and joint structures are quite natural. When
cutting through the abdomen many pieces < of the in-
testine fell out of the section. These I have had little
trouble in replacing properly, since the ﬁxation of the
tissues was so perfect that each fragment bore the im—
press of the one next to it, and the readjusting was
simple and accurate. , _
The bones are in no way damaged as far as the
Shape is concerned; but the color of the cancellous
tissue is changed to a gray or light-brown. The de-
calciﬁed bone resembles cartilage in density and in the
ease of cutting it; it does not lose its shape by bending
or twisting, but when exposed to the air shrinks and
dries to a hard mass.
Decalciﬁcation might with proﬁt be used in the
course of practical anatomy in our medical schools to
facilitate the dissection of parts that are at present
almost inaccessible to the student. I refer to such
important regions as the temporal bone, the nasal
fossae and the air sinuses. These parts can be admira-
bly displayed by the average second-year student with
no other instrument than a scalpel and scissors. And
while speaking of the temporal bone, one advantage
142 MEDICAL SOCIETY OF
which the ‘~' decalciﬁcation and' knife ”' method has
over that of freezing and sawing is in the fact that
with the former process no part is wasted in the cut-
ting, and this is quite an important matter in section-
ingsuch parts as the nasal region and ear.

. - DISCUSSION.
DR. M. A. GOLDSTEIN said that the work of decalci—
fying gross sections of the human body is very valu—
able for the rhinologist, as by this process a good deal
could be accomplished which could not be done in any
other manner. He would be glad to show the Society
at some future time gross sections of the ear decalci~
tied with phloroglucin and hydrochloric acid. It was
a German process, used mainly for microscopic rather
than for macroscopic work. The question of discolor-
ation, which is still a matter of experimentation, as
Dr. Terry suggests, is one which offers much difﬁculty
on account of the decalcifying process. The oculists,
he thought, were far in advance of other anatomical
workers in embedding sections of the eye. He thought
that in the decalcifying process an intense acidity was
produced, which might be responsible for the failure
of the gelatine to act kindly in the embedding process.
He would suggest exposing the acid/to an alkaline
medium until the reaction is absolutely neutral to lit-
mus paper, and then try gelatine. Frozen sections
had one advantage, he thought, in that the spicu-
lee of bone are preserved to a nicety if a out can be
well made. The work can be very cleanly done if the
proper precautions are used in the selection of a saw,
the blade of which is ﬁnely serrated, and where the
section has been carefully and homogeneously frozen.
Another feature of the decalcifying process which he
thought open to improvement was that of discolora-
tion. In many of the specimens the tissues, both hard
and soft, were so colored that it was sometimes difﬁ-
cult to distinguish between the hard and the soft
CITY HOSPITAL ALUMNI. 143
structures, the bone being almost as yellow as the
skin. If the gentlemen would continue in their ef-
forts, however, the speaker thought that all these dif-
ﬁculties would be ﬁnally overcome. One fault of
making a frozen section of a fresh head was that the
skinwas not brought under the inﬂuence of the de-
hydrating process, which shrinks the tissue to a cer-
tain extent.
Du. V. P. BLAIR said he thought the value of the
frozen sections in the study of anatomy was very
great. To the man studying anatomy it would enable
him to make out the absolute relations which might
not otherwise be made out so well; and to the man
teaching anatomy to demonstrate from the dissection
to the frozen section was of great advantage. He had
found it of much service in his work. In this line-
of wOrk he said he had been trying to preserve sec-
tions with the color preserved; while this was nota
matter of great importance it served to attract the
attention of students more closely. In some of the
subjects he had been able to preserve the color of the
liver and kidneys and lungs. His work, however,
was not by any means 'as good as Dr. Terry’s. He
believed the subject of decalcifying the whole body
had originated with Dr. Terry; the mounting of speci-
mens in gelatine had been done before.
DR. CHAS. SHATTINGER said he did not think a con-
troversy as to whether frozen sections or the decalci-
ﬁed body should be used was in place, because the
decalcifying process presented advantages of its own.
It made dissection of difficult regions of the body
very easy, and in that way ﬁlled a want that the
frozen section could not supply, however superior the
latter might be in other respects. This was a subject
new to him, and he felt entirely unable to add any—
thing to the practical features of the work. The
mention of a case which he had recently seen, how-
144 MEDICAL SOCIETY OF
ever, he thought might be of interest in connection
with the nasal specimens presented by ,Dr. Sluder.
DR. SLUDER had called attention to the ease with
which hypertrophic conditions of the glandular tissue
at the base of the tongue might cause dyspnea. The
speaker said he recently had a young man come to
him complaining of attacks of suffocation, as the
patient put it. The patient had feelings in the larynx
of such a nature as to alarm him. _He' was subjected
to a laryngoscope examination, and at the base of the
tongue was found a small growth partly concealed by
the glosso-epiglottic folds. It hung from a pedicle
in a manner to touch the epiglottis during deglutition,
giving the sensation of a foreign body. He removed
it with considerable ease, ﬁnding it not larger than a
small pea and the pedicle perhaps a quarter of an inch
long. After the removal the symptoms disappeared.
DR. SHATTINGER said he knew this was only a sub-
sidary matter, but thought it would emphasize what
might be learned from seeing these specimens.
DR. F. REDER asked if this process of decalciﬁca-
tion possessed superior advantages over freezing in
the making of sections demonstrating various stages
in embryonal life. When Wickersheimer came out
with his ﬂuid some thirty years ago, objects such as
butterﬂies, locusts and humming birds could be pre-
served for an indeﬁnite length of time in the ﬂuid.
The color of objects preserved was not destroyed, nor
were the tissues hardened. He said he would also
like to know to what extent such specimens as are
before us to-night were used in the teaching of an-
atomy in foreign universities.
DR. SLUDER, in closing, said, speaking of the ﬁrst
employment of the decalcifying process, and of Dr.
Goldstein’s statement that it had been employed and
abandoned, though for what reason Dr. Goldstein did
not mention, he recalled that Prof. Politzer had some
ear specimens which, he believed, were decalciﬁed,
CITY HOSPITAL ALUMNI. 145
though he could not be certain of that. He did not
tell much about them, but everyone who saw will
remember their extreme beauty. The specimens were
prepared in closed jars in some sort of medium which
rendered them transparent, probably xylol. There
are a great _many of, these specimens in Vienna; Dr.
_Hyck has some several hundred, but they are all
hard specimens which he had prepared at great cost
and labor. This subject suggested itself to the
speaker in connection with the teaching of anatomy
of the nose. He considered it absolutely essential
that the cavities of the nose be demonstrated to
medical students in order to give any idea of where
nasal suppurations begin. Another advantage is that
it shows the cartilage with the vomer intact, also the
extent to which the former extends backwards; it is
the only way to do so, unless one of these specimens
was outlined in some color. As these specimens are
in more or less constant use for such demonstrations,
they were much handsomer when ﬁrst prepared. He
thought he had never seen just such a condition as
described by Dr. Shattinger, though he had seen
ﬁbromata occurring on the tongue. 'Enlargements of
the lingual tonsil were not at all uncommon and they
seem to tickle the epiglottis. He had seen one case
which seemed purely mechanical; the tonsil was
pushed backwards and seemed to close the larynx.
When acetic acid was applied and the tonsil shrunk,
the dyspnea and cough ceased. On the use of these
specimens in classes he had already spoken. He
added, however, that they were used to demonstrate
the experimental puncture into the antrum. The
puncture is done at the lower border at the junction
of the middle with the lower third. At that point, .
although bony, the wall is thin and the out can be
made Without pain. At the junction of the middle
with the posterior the needle is carried in an outward
direction, the direction being upward, outward and.
146 MEDICAL SOCIETY or
backward. The ﬁxed point at which to bring pres- ‘
sure is the anterior inferior nasal spine. In such a
position a little pressure carries it through. There is
a distance of about 1% inches to the posterior limit of
the antrum. In speaking of this, the suggestion
naturally comes, “ Why does one not go through the
membranous portion of the middle meatus—that
portion made up by membrane alone?” If that por-
tion is selected it may go all right if the antrum is
large; if small it will readily pass upward with a lit-
tle too much pressure into the orbit, and if pressed
still further it goes to the pterygoid fossa.

STATED MEETING, THURSDAY EVENING, APRIL 20, 1899,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

Gonorrhea, lts Complications and Sequelze.
DR. HENRY J ACOBSON: Gonorrhea is far-reaching in
its sequelae and complications. We may ﬁrst take'up
stricture, the common complication or result of fre-
quent attacks of this disease. This stricture may
become tighter and during the act of straining may
cause rupture of the urethra back of it, and sometimes
death, as a result of extravasation, or it may cause a
ﬁstula which will demand a secondary operation.
Sometimes the ﬁstula will open into the bowels, caus-
ing urethro-rectal ﬁstula, which is very annoying;
more frequently a perineal ﬁstula occurs. Another
complication is abscess. The gonococci invade the
urethral follicles and cause an abscess; if it is in the
fore part of the urethra this abscess may burst into
the urethra and the pus passes out, leaving a persistent
discharging ﬁstula, which, besides being troublesome,
keeps up a gleet. The way to treat this is to intro-
duce the endoscope and ﬁnd the discharging point,
and with a ﬁne probe, covered with cotton, apply
campho-phenique, or peroxide of hydrogen, a strong
solution of nitrate of- silver or protargol. Sometimes
CITY HOSPITAL ALUMNI. 147
these suppurating follicles open outside of the penis
and cause a ﬁstula difﬁcult to relieve. Again, they .
occur in more serious situations, such as the prostate,
and cause a prostatic abscess, which may open into
the urethra, or they open into the bladder or back of
the bladder and cause peritonitis and death. Another
complication in this neighborhood is inﬂammation of
the seminal vesicles. The catarrhal inﬂammation of
the seminal vesicles is not so serious, but in many in-
stances causes sexual neurasthenia. The method of
treatment is to strip the vesicles through the rectum.
This is done by having the patient lie on his back,
with his feet drawn up, and, with a rubber ﬁnger-tip
on the ﬁnger, the vesicles are stripped two or three
times a week; improvement is marked in a few treat-
ments. But inﬂammation in the vesicles does not al-
ways terminate favorably. An abscess may form, and
rupture by extension, causing peritonitis. or the infec-
tion may extend to the peritoneal coat of bladder and
endanger life; rarely, an abscess in this situation may
open into, the rectum, and fecal matter passing from
the bowel into this closed cavity may cause toxemia
and death. Another complication, Or result, of stric-
ture is cystitis, due to retained ammoniacal urine back
of the stricture; the bladder soon becomes infected
from instrumentation, blood or from rectum. The
infection may travel to the kidneys and cause a train
of diseases, starting with simple nephritis or catarrhal
pyelitis on to suppurative pyelitis and pyo-nephritis,
which may also cause death, and all due to a primary
gonorrhea. Then again, there are troubles caused by
the gonococci, and not only the gonococci, but by many
thought to be the mixed infection of staphylococci,
streptococci and gonococci, getting into the blood and
passing into the different organs of the body, Gono-
cocci have been found in the joints, in the endocardium,
and in the pleural cavity, causing pleurisy, and we all
know how frequently the gonorrheal infection is trans
'\
148 MEDICAL SOCIETY OF
mitted to the eyes, sometimes to the nose and, some
claim, to the mouth. In hospital experience (I have
seen quite a number of cases of gonorrheal ophthalmia.
Gonorrhea in the female is serious. While connected
with the dispensary for children, I had quite a number
Of cases to deal with in children, some of them due to
rape. Gonorrhea in the young female is also serious,
on account of its effects in after life. It had some-
times been necessary to give chloroform and swab out
the vagina with nitrate of silver solution and after-
wards the introduction of iodoform bougies. ~ At that
time notl‘iing'was known of the newer preparations of
silver, which are probably just as effective and milder.
In women the infection will travel into the tubes
sometimes and leak out into the peritoneum, forming a
closed cavity, and when the woman exerts hereself
more than usual it will burst and cause sudden death,
and unless a pest mortem is made the cause of death
is never known. Besides this serious result there are
often symptoms of dyspepsia, reﬂex pains, etc., which
produce a wretched condition and make a chronic
invalid of the woman. Gonorrhea should be treated
as soon as poSsible after it is discovered and strOng
antiseptics used to prevent extension. In acute cases
protargol is one of the best agents, and also argonin.
When used early it will frequently cause the disap--
pearance of gonococci in the male inside of ten days
or two weeks. After the disappearance of the gono-
cocci some mild astringent should be used.'
DR. M. H. POST said he found cases in ophthalmic
practice which looked suspicious, yet upon close ques-
tioning it was impossible to determine whether the
infection was gonorrheal or not. Recently a married
man, whom he knew quite well, called upon him with
what appeared to be a gonorrheal infection; on exam-
ination the streptococcus, and not the gonococcus, was
found. In ophthalmia neonatOrum 23 cases had been
collected 'where joint infection was noticed shortly
CITY HOSPITAL ALUMNI. ' 149
after the appearance of the ophthalmia. The secre-
tion from some of these joints was examined and the
gonoCocci found, which was along the line mentioned
by the last speaker in noting the presence of the
gonococci in the pleural and endocardial cavities.
Such eases as he had referred to, where there had been
violent inﬂammation, were characterized by staphylo-
coccus and streptococcus and not the gonococcus, and
this fact always made him feel doubtful about reports
of new remedies, unless a microscopical examination
had been carefully made. He said he would like to
hear more about the use of protargol.
DR. J ACOBSON said he used argonin before protar-
gol was brought to his notice. Protargol will keep
longer and can be given to the patient for several days“
use and is -more easily soluble. In many cases pro-
targol was irritating, but argonin also proved irritable.
Some years ago he had suggested that argonin would
' be the remedy inophthalmia, and he noticed it is now
used by oculists for gonorrheal . ophthalmia. Of
course,after the gonococci had infected the deeper
tissues it was useless, Argonin is _a lactate of silver
and prepared in from one-half to 10 per cent. solution.
He prepared the solution by ﬁrst mixing it with cold
water and putting‘a test tube of the mixture in water
over an alcohol lamp, as heat dissolves argonin, and
then drain through a piece of gauze. Protargol is
usually made up by the druggist, or can be readily
prepared by the physician; it can be used in less
strength than the argonin solution. .He thought it
would be a wise thing for obstetricians to use such a
solution, in two to ﬁve per cent, after the birth of the
child in suspected cases; it is harmless and does not
irritate. In the male he uses the protargol solution,
‘ followed by douching the urethra with warm perman-
ganate solution. D
DR. HYPES asked Dr. Post in what per cent. of the
cases of ophthalmia neonatorum coming under the
150 MEDICAL SOCIETY OF '
latter’s care prophylactic treatment had probably been
instituted.
DR. POST said he did not think prophylaxis was
very prevalent. The cases which came to him were
usually those in which no treatment had been at-
tempted. He cited the case of a child recently sent to
him, whose physician stated that he had used Credé’s
method, and yet the disease had developed. The
speaker did not believe that Credé’s method was very
extensively used. Cases of ophthalmia neonatorum
came usually from midwives and those people who do
not even have midwives to attend them, and not from
regular physicians. Occasionally a case was sent by
a regular physician, but he believed that practition-
ers, as a rule, did not use any prophylactic treatment.
The use of Credé’s method always resulted in an in-
ﬂammation of the eyes for several days. While put-
ting a 10 per cent. solution of silver nitrate in the eye
was a rather serious thing, yet it was perfectly justiﬁ-
able where any suspicion of gonorrhea existed. It'
was, nevertheless, a hard thing for the patient to be
subjected to when there could be no thought of any-
thing of. the kind being present. In hospital practice
he considered it very proper to make the,use of Credé’s
method general, but in private practice the physi-
cian is apt to know what he is dealing with, so that
he is not in favor of the universal practice of Credé’s
method, and was far from advocating, as some physi-
cians had done, the enforcement of this method by
legislation. The use of a mild antiseptic could be
made without danger to the eyes of the child, and be
quite as effective. The pus of gonorrhea may be on
the outside of the lids when the child is born, and
when the eyes are opened, especially if carelessly
handled by the nurse, it may be introduced into the
conjunctival sac and allowed to remain there for sev-
eral days; in that case we have a conjunctivitis. Yet
he did not believe that in all cases of conﬁnement the
CITY HOSPITAL ALUMNI. 151
child should be treated with a 10 per cent. solution of
nitrate of silver.
DR. HYPES said the introduction of one or two
drops by the Credé method he had found harmless;
but the use of half-a-dozen drops was hurtful.
In suSpicious cases he used the solution in one
or two-drop doses, and immediately washed it out.
He agreed with Dr. Post that it should be used as
soon as the child was born, because then the eyes were
not open. _‘
DR. POST said he laid most stress upon the careful
cleansing of the eyelids. That is where the infection
comes from, and in his lectures to nurses he empha-
sized this rather than the use of Credé’s methods.
DR. FRANK HINCHEY said he had read the report of
some German physician some time ago who tried to
Show that orchitis or epididymitis was followed by
sterility in the male. From a synopsis of one hundred
cases, the author endeavored to ascertain about what
number of patients who had had double orchitis or
double epididymitis were afterwards sterile. He
found a number of men who had no children, yet he
found many who had children. IVOmen who had suf-
fered from double salpingitis have been known to bear
children afterwards, although we would expect an oc-
clusion there, just as we would in the vas deferens.
For some time past, the speaker said, he had been
making slides of all cases coming to the female clinic
at the Missouri Medical College Clinic, in an eﬁort to
determine the percentage of cases of gonorrheal in-
fection, and in about 70 per cent. he found the gono-
coccus. The majority of these cases were, of course,
from the poorer class of people, and husbands who
had- gonorrhea probably gave it little attention. being
satisfied with three-day cures, etc; but yet he felt
that this was an alarming number, and probably the
great majority of these women were utterly innocent
in the reception of the disease. In most of these cases
152 MEDICAL SOCIETY or
argonin was used in the strength of s} to 2 per cent. so-
lution—even stronger; but it did not seem to accom-
plish more than the ordinary table treatment together
with the home treatment of permanganate and hot
douches. Argonin was not so painful as other measures,
and seemed to relieve the severe burning; but this was
in connection with other treatment, which made it hard
to speak of its especial merit. Some foreign writers.
in speaking of gonorrhea in women, advocate begin-
ning high up in the uterus, and endeavoring to steril-
ize the ﬁeld from above downwards. This the speaker
thought was purely theoreticaland not practical.
DR. H. W. SOPER said Neisser recommends that pro-
targol be retained in the urethra from ten to twenty
minutes. The speaker said he had been using protar-
gol for some time, but found great difﬁculty in having
patients retain it for that length of time, very few
holding it more than ﬁve minutes. He had one pa—
tient who said he retained it ten minutes, and in this
case there was a really rapid and satisfactOry re-
sult, the pus disappearing in ten days. In the treat-
ment of acute gonorrhea he said he would like to have
the opinion of the members on several points. First,
in regard to internal medication. The prevailing
method is to give alkaline diluents, rendering the
urine mildly alkaline. Theoretically the gonococci
develop only in an alkaline medium. If this was true,
then to render the urine alkaline seemed to invite in-
fection backward. Practically he had found the use
of salol and boracic acid usually overcame the ardor
urinae, and rendered the urine sterile and mildly acid.
In the last year or so he had abandoned the use of
local medication in acute posterior urethritis, and gave
boracic acid and salol or urotropin, and he had seen
cases get well on this treatment. He believed the ten-
dency was to avoid instrumentation in all active ure-
thral inﬂammations.
CITY HOSPITAL ALUMNI. 153
DR. HYPES asked if he used salol and boracic acid
in combination, and Dr. Soper said he did.
DR. HYPES then asked if remedies were not recom-
mended under different conditionS—one when the urine
was acid, and another when it was alkaline?
DR. SOPER said the _urine is usually mildly acid.
Ricord observed that normal urine has a mild remedial
effect. The speaker said he believed the urine could
be kept sterile in gonorrhea, and that it should be
kept slighly acid, imitating nature; he thought it
wrong to render the urine alkaline. '
DR. HINCHEY asked Dr. Soper if he would use the
same treatment in chronic posterior urethritis—that is,
where the patient has little or no discharge, and yet,
when he “ goes out” anc “drinks a little beer,” or
has intercourse, he notices in a day or so a little ﬂow,
which, however, subsides in a few days, or, with a
mild injection disappears, to reappear after another
' debauch. Sometimes there is only a mild irritation.
which seems to come after the pus is allowed to pass
from the posterior to the anterior urethra, but the
speaker said he did not understand how the simple
method of rendering the urine. acid would cure a pos-
terior urethritis.
.DR. SOPER said he had reference only to acute pos-
terior urethritis. He had some stubborn cases, which
were treated locally a long time and which cleared up
rapidly after stopping all local treatment and Simply
rendering the urine sterile. He believed local treat-
ment could be kept up too long.
DR. HYPES asked the speaker what his experience
with irrigation had been.
DR. SOPER said he believed the method of irrigation,
if it could be properly carried out, was the best in
acute cases. He had had best results with hot perman-
ganate solution. If begun early and irrigations ad-
ministered twice a day no other treatment was neces-
sary. In these irrigations he made use of a Kietfer
154 ‘ MEDICAL SOCIETY OF
meatus nozzle, one end being attached to an ordinary
fountain syringe; this gave an inﬂow and an outﬂow,
and by determining the amount of pressure so as to
overcome the compressor urethrae muscle, it will ﬂow
in and out and thoroughly cleanse the canal, using
between a pint and a quart.
DR. HYPES asked what was the average duration of
gonorrhea.
DR. SOPER said he had a series of cases treated by
the irrigation method which showed the average to be
ten days, meaning not only the disappearance of the
gonococcus, but disappearance of 'the pus in the
urine. The cases must be selected, however, and
there should be complete abstinence from liquor and
all sexual excitement.
DR. S. DRECHSLER said that when he was an interne
at the Female Hospital a solution of two per cent.
nitrate of silver was used in each conﬁnement case'by
carefully cleansing the lids with sterilized gauze and
everting them, pressing the everted lids together and
having the nurse put on the lids one drop of the solu-
tion. From his experience he cannot see any beneﬁt
derived from the use of nitrate of silver in solution
when comparing six cases delivered by him where the
mother had gonorrhea on entering the hospital; silver
'was used with no bad effects. Out of sixty cases of
conﬁnement with no gonorrhea, eight developed acute
conjunctivitis, with pus formation, after the use of. sil-
ver. The possibility of one infant’seye being infected
from another is excluded. From his experience in
clean cases in the hospital, where patients are isolated
from the class with septic or gonorrheal infection, he
advised cleaning with warm boric acid solution and
drying only. He could not account for pus formation
after use of silver in clean cases and asked Dr. Post
how he explained this.
DR. W. A. BROKAW said he did not think too much
stress should be laid on the gonococcus developing in
CITY HOSPITAL ALUMNI. 15"
‘1
an alkaline medium. The blood serum is the best
medium. His experience was that the sooner the
urine was rendered alkaline the quicker the patient
found relief. There was only a few cases of gonor-
rhea of the mouth'on record, yet the ﬂuids of the
mouth are alkaline. In regard to protargol, he said he
'had used it; in one case he had a patient hold it for
half an hour; this man seemed to have recovered in a
marvelously short time. The gonococcus was found in
the urine, so that he was sure the case was genuine;
notwithstanding this, he was not sure the case was
acute. He said he had worked where hundreds of
cases were treated, yet protargol was not found to be
superior to permanganate of potassium. In the Ger-
man army 5000 cases were treated, some with protar-
gol and some with permanganate, with the result that
protargol was discarded and permanganate substituted.
In acute cases he thought it best to keep hands off.
Instrumentation causes complications. Referring
again to the German army, he said every case there
was put to bed and placed on milk diet; this was con-
sidered the ideal method of treating gonorrhea. But
it was found that keeping the patient in bed and on a
milk diet did not prevent the disease-from running
its course just the same, that is, about six weeks. He
believed that the majority of cases could not be cured-
in less than that time; some might get well sooner,
but his experience was that most of them ran this
course. He thought protargol was a good remedy,
but did not believe it had a speciﬁc action on the
bacillus.
DR. J ACOBSON asked if Dr. Brokaw could say how
many cases of posterior urethritis involving the pros-
tate were cured in Germany during a year.
DR. BROKAW said he could not estimate that, as he
did not keep track of individual cases, but he made it
a point to ask each person under-treatment. and in
156 MEDICAL SOCIETY OF
this way saw that about the same results were gotten
here as in Germany. '
DE. J ACOBSON said he thought many cases of pos-
terior urethritis often pass out of our hands and we
think they have been cured, when they only are dis-
couraged by long and constant treatment. The pros-
tate is so rich in cavities that often the bacilli will get
in there and lie dormant until the person indulges in
drinking or excessive intercourse; then they become
active and the patient thinks he has a new case.
DR. POST said Dr. Hypes departed from the rule in
the application of Credé’s method, as he had never
heard of the use of a mild antiseptic wash immediately
after the application spoken of anywhere.
DR. HYPES said he meant only the cleansing of the
lids.
DR. POST then said he had never seen this method
used at the Female Hospital during seven or eight
months’ service, yet there had not been one case of
ophthalmia neonatorum, and he presumed the same
class of women were treated there then as at the pres-
ent time. There was occasionally a slight conjunc-
tivitis, which disappeared under mild treatment, but
these occurred in the hands of certain nurses, whereas
there was a darky woman there who had charge of the
darky patients and there never had been a case of
sore eyes under her care.

STATED MEETING, THURSDAY EVENING, MAY 4,
THE PRESIDENT, DR. GEo. HOMAN, IN THE CHAIR.

DE. M. F. ENGMAN presented a patient with
Dermatitis Artificialis.
The case was one of indeﬁnite hysteria and was seen
ﬁrst at the clinic at the Marion-Sims Medical College.
The patient was referred to his clinic on account of an
eruption on the body, which she claimed appeared
about a week previously, ﬁrst on the chest. The
CITY HOSPITAL ALUMNI. 157
patient gives a neurotic history and has had “ ﬁts ” at
different times. She has a vicarious menstruation,
sometimes bleeding from the nose during her periods.
'She thinks, she has periods of unconsciousness, in
which she does not know what occurs. Her mother,
so the patient says, states that during these attacks
she is destructive, having once broken a valuable vase.
The eruption is a dermatitis artiﬁcialis, more or less
irregularly distributed, especially on the extremities.
The lesions consist of red blotches, with a brown
areola, ranging from the size of a quarter to the palm
of the hand. Some are more or less round, some ir-
regular in outline, but the spots are characteristic in
being sharply deﬁned and irregular. ()n the shoulder
there is a typical spot. There she had a mole and the
eruption occurred around that; it is sharply deﬁned,
yet it is irregular. ()n the breast there is a more
recent spot. I asked her if she had any spots on the
' nipple, and, strange to say, they have occurred there.
On the leg the spots are characteristic; you will notice
the difference in the spots, some of them being irregu-
lar and some being more or less elliptical in shape.
These spots are painful. ()n the arm there is a char—
acteristic spot; there the reagent used has run down
the arm and penetrated deeper into the skin. Dr.
Schwab has seen the case with me several times, and I
would like to hear his remarks on the neurologic
aspect of the case, which, of course, is the most inter-
esting part of it. I am not in a position to make a
full report of the case, because I did not know all of
the features connected with it.
DR. SIDNEY SCHWAB said: The ﬁrst question we
tried to decide was, whether or not it was a case of
hysteria. After a hasty examination, I could not
say that it was hysteria. The patient was of neurotic
temperament and has some slight areas of anes-
thesia. She had headaches, which were not very
typical, going from temple to temple rather than
158 MEDICAL SOCIETY or
backwards, though the history is not very clear. If
she were hysterical I think it would be fair to say
the headaches were accidental. We have been trying
to get at the motive, and think we are on the
right track. Her mother died some ten years ago and
she now has a step-mother. The father has a violent
temper and exhibits bursts of anger, but no evidence
of violence could be found. One of her motives might
be a desire for sympathy. but she says she has told no
one, so that the question of sympathy is ruled out.
Another interesting feature is, that about ﬁve months
ago she had a quarrel with the man to whom she was
engaged. From that date began those periods of
unconsciousness; though we tried to get some connec-
tion with these attacks and the eruption, we were
unable to do so. Then the question as to whether she
or some one else did it came up. She was very reti-'
cent and gave no answers to our questions. Dr.
Engman then asked her when she did it, and suggested
that she had used carbolic acid; this startled her, and
we felt that we were on the right track. Then, so as
not to make the question too pointed, we suggested
that she did it in one of her attacks. We obtained
nothing very deﬁnite. Then, later, she denied the
whole thing and the case is still a puzzle; two other
points to be considered are exhibitionismus and a
psychopathic sexual condition. Whether this was not
done to regain the sympathy of the man was to be
considered. Probably if this man found out that
it was through his doing that she was afﬂicted in this
way, and had these periods of unconsciousness and
this eruption, he would come back to her.
DR. JOSEPH GEINDoN said these cases of feigned
eruption are of profound interest, on the one, hand
dermatologic and on the other neurologic. The chief
points in the differential diagnosis between these erup-
tions and others similar to them- are: First, that the
lesions are found only upon such portions of the body
CITY HOSPITAL ALUMNI. 159
as are accessible to the patient. In a certain propor-
tion of cases, when the patient is right-handed, the
lesions are located on the left upper extremity, but on
both lower extremities. Secondly, we note the pe-
culiar outline of the lesions; they are angular. While
the general outline of the wound may seem to be cir-
cular, yet a closer examination will show the patch to
be bounded by straight lines, making more or less
obtuse angles with each other. Thirdly, there is
usually something about them which betrays the agent
used, as the linear scratch of a needle or pin, or the
discoloration produced by acids; the mark left by car-
bolic acid is very characteristic to one familiar with
it. Fourthly,together with the above, we must con-
sider the general neurotic constitution of the patient
and the motives which might impel to the act. He
_mentioned a case in which the diagnosis was ﬁnally
proved to all concerned by the nature of one of the
agents used. .The case was that of a young lady in a
female seminary, who was the subject of a very
peculiar eruption. She was somewhat below the aver-
age of intelligence, so that, while tall. she was in a'
class of small girls. Her mother was for a long time
markedly hysterical. and there were evidences of
neurosis in other branches of the family. This girl
had a peculiar eruption, looking much like a weeping
eczema, on each eyelid. The true nature of the
trouble was not suspected at ﬁrst. and as she was suf-
fering from a gastric derangement. this was prescribed
for and a soothing lotion given for the eyelids. She
was seen a few days later and the lesions on the eye-
lids had disappeared, but below them, bounded above
by the inferior margin of the orbit, was on each side
a triangular patch, resembling those which the circus
clown paints. Then he recognized the true nature of
the case. He had learned by experience not to com\
municate such conclusions to relatives until he was
able to prove his diagnosis. He told the girl to use
160 MEDICAL SOCIETY 013‘
the same application to the new patches. A week
later the new patches had almost healed, but at .the
angle of the jaw on each side there was a beautiful
patch. He then asked the attendant to leave the
room and he questioned the girl as to whether she was
happy in the school. She said she was; she loved the
teachers and the girls and had such a nice time. there.
She did not want to go home, and had no idea how
these things came on .her. He told her she brought
them about by handling her face too much, that she
must keep her hands off and they would get well.
A few days later he was sent for and found some
deep lesions extending down to the corium on the
arms, which had become pus-infected. The next time
there 'was large lesions on the legs, as large as a silver
dollar. After one of his visits the doctor called to
see her mother and communicated his diagnosis. She
was very indignant and said it could not be true; that
her daughter was not crazy, and asked if he thought
she wanted to go home. Dr. Grindon said he thought
so. The patient would not~ say so; indeed, she
denied it. Some days later he was again called after
dark, and was told that the girl was bleeding freely
from the spots. When he arrived he found the places
tied up with clothes, which had been smeared with a
red material. One look at this was sufficient to tell
him him it was not blood, but a mineral substance
used in china painting. He asked if china painting
were included in the curriculum, and was told that it
was, and that Miss had a stock of the materials
in her room. The matter was set forth to the mother,
who then recognized that her daughter was feigning.
It was all done evidently with the purpose of being
taken home, which purpose was accomplished. As to
the case before the Society, Dr. Grindon was inclined
to differ from the last speaker, who placed so much
importance on the sexual phase of the question.
Sometimes the mutilation is done for a fraudulent pur-

CITY HOSPITAL ALUMNI. 161
pose. When at the Female Hospital he had a case of
a Woman who burnt her hands with lye in order not to
be put tO work in the laundry. Some years ago he.
had seen a young man, of good family, Of rare intelli-
gence and excellent education; he had had Pott’s
disease of' the spine, and was a distinctly neurotic
subject. A younger brother, to whom he was much
attached, had been drowned some years before.
Althopgh disclaiming any religious belief, he enter-
tained the idea that this brother was suffering in
another state for the sins committed here and that he
might relieve him by some form of vicarious atone-
ment; so, with the lighted end of a cigar, he deliber-
ately burned into his'arm a Latin cross. There were
several steps leading up to it, and these were sur-
mounted by the cross. The purpose may be fraudu-
lent, fanatical, mischievous, insane, to compel
sympathy, or interest or notoriety. The condition is
sometimes seen in hysterical persons. The purpose in
many cases is past ﬁnding out. When we remember
that hysterical subjects often have areas of anesthesia,
it seems likely that these mutilations are practiced on
such areas. He believed there was an element in
-many of these cases besides the inﬂiction of mutila-
tion, whether it be by the use of a needle, or pin, or
a cauterant"; namely, a peculiar vulnerability Of the
' skin. If this condition did exist, as he thought it
did in some cases, a slight degree of violence would
produce a considerable lesion. At the meeting of the
Dermatological Association in 1897 several interesting
papers were read on this subject. Dr. Hyde con-
tended that we should not necessarily consider these
lesions as being intentionally inﬂicted; that the men-
tal constitution of the patient might be such that
self-inﬂiction of the lesion was not intentional.
Nevertheless, motives of jealousy or a desire for sym-
pathy do Often come into play, as in the case of the
Algerian prostitutes, who frequently burn themselves
162- I MEDICAL SOCIETY OF
with lighted cigarettes when deserted by their lovers.
In the case presented, he believed the self-inﬂiction
Was probably unconscious, and also that a peculiar '
Susceptibility of the skin played a considerable rOle.
DR. SCHWAB said he was not inclined to lay special
stress on the sexual element in the casesas a rule,
but he did think it was so in this case.

STATED MEETING, THURSDAY EVENING, MAY 18,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

STRANGULATED HERNIA, COMPLICATED WITH
RETAINED TESTICLE AND INTRA=ABDOM=
lNAL HYDROCELE OF THE CORD.
By JULIUS KOHL, M.D., Belleville, Ill.
B., a young man, eighteen years of age, ﬁne
physique, nearly six feet tall, with ﬁrst-class
family history, was suddenly taken ill.while
at school in Belleville on Friday, suffering from a se-
vere pain in the right inguinal region.
He went to his home at Mascoutah immediately.
Dr. A. J. Fuchs, the family physician, was called and
readily diagnosed an impacted inguinal hernia. TO-
gether withiDr. W. P. Henrich, he tried reduction by
taxis long enough to be convinced that it required
further operative steps to give relief. Saturday
night I was called to assist. The country roads were
in an impassible condition, and there being no fur-
ther trains for Mascoutah that night, I could not
reach the patient until the next Sunday morning,
about forty-eight hours after the ﬁrst symptoms of
pain had appeared. My son, Dr. A. M. Kohl, accom- '
panied me. The following conditions presented:
A tumor about six inches long, four inches wide,
with an elevation in the center of one inch, was sit-
uated obliquely in the right inguinal region, begin-
ning at point about two inches above the middle of
Poupart’s ligament and extending upward. The in-
'CITY HOSPITAL ALUMNI. 163
tegument had assumed a livid appearance. There-
fore any further attempts at taxis were out of ques-
tion.
While preparing the patient for the operation, it
was discovered that the right testicle was missing in
the serotum. An-incision two and“ one-half inches
long was'made through the skin and fascia, and by
careful dissection a dense cyst was reached. It was
black in appearance, distended to its utmost, and
permitted of no manipulation whatever, partly on ac-
count of its immobility, and further because the
walls were in a necrosed condition, which necessi-
tateted careful handling.
A small exploring needle was introduced and a
thick, dark ﬂuid discovered, having a decided fecal
odor. The opening was then enlarged, and over a
pint of ﬂuid withdrawn. The protruding loop of the
bowel and the missing testicle could now readily be
distinguished with the ﬁnger. After a thorough
cleansing Of the parts, and removing as much of the
necrosed sac as possible, an attempt was made to 're-
duce the bowel. But for some reason or other it
could not be done; The internal ring was not tense
and sufﬁciently large to permit the point of the index
ﬁnger to enter.
The testicle was situated just, in front of the ring,
and while making traction on the cord for the pur-
pose of ligating, prior to castration, a small cystic
tumor adherent to the cord slipped out of the abdom-
inal ring. It had the shape of a ﬂattened hickory-
nut of medium size. This tumor internal, and the
' testicle external to the ring, had caused the obstruc-
tion to the reduction of the bowel. The spermatic
vessels were now ligated, and cyst, cord and testicle
removed; so also all of the necrosed tissue of the
sac and inguinal canal within reach. The bowel was
then readily reduced. On account of the great ex-
tent of unhealthy tissue of the inguinal canal, union
164 ‘ MEDICAL SOCIETY OF
by ﬁrst intention could not be expected. On the
other hand it was. desirable to close the wound pretty
ﬁrmly. We therefore concluded to reduce the drain-
age material to a minimum size, and for that purpose
we used heavy double-braided silk in ligating the
spermatic vessels, leaving the ends long enough to
answer for drainage.
The plan proved to be a success. Suppuration-fol-
lowed. By careful management, however, the patient
made a rapid, perfect. and eventless recovery.
Cases like the one described are of rareoccurrenee,
and it is a duty to report them. I am aw'are that the
surgical literature abounds with similar cases. Diupuy-
tren drew attention to them probably as early as any
writer. But more exact data of retained testicle and
their pathologic complications are of more recent
date. The most exhaustive reports have been fun
nished by Kocher.
From my own experience, by continued opportuni-
ties for Observation in hospital and private practice,
I can state that complications as appeared in this
case seldom present themselves.
In the study of this case, the ﬁrSt question present-
ing is: “ How could so much ﬂuid accumulate without
being noticed sooner? ” Undoubtedly, the pathologic
conditions described had existed for a long time. It
was only the dilatation of the internal ring by .the
continued pressure of the accumulating ﬂuid that made
it possible for the bowel to escape._ This occurrence
started the alarm clock and led to the discovery of
the case. The patient’s mother had only a faint
recollection of the congenital imperfection of the son
from the time of his childhood.
The fecal Odor and dark discoloration of the ﬂuid,
which let us suspect an intestinal lesion in the begin-
ning of the Operation, can only be explained by the
theory of osmosis. Encysted hydrocele of the cord
is of more frequent occurrence than is commonly sup-
CITY HOSPITAL ALUMNI. 165
posed. I have often found it in connection with
hydroceie of the testicles. I remember a case where
this» existed on the right side of an elderly gentleman.
He made; a good? recovery after the radical operation.
Several years later the same disease developed on the
left side.
I have found these cases so Often, that for many
years I have discarded every other treatment for
hydrocele, except the radical operation. I have never
met- with a failure, a recurrence of the disease, nor
any other deleterious- resul-ts, while with the old in-
jection methods I have had nothing but disappoint-
ments. It is necessary to look for those additional
cysts of the cord This is rational surgical treatment.

DISCUSSION.
Dn. A. H. MEISENBACH said he was alittle at a loss
to understand both the condition as regards the sac
wall and the ﬂuid contained in the cyst. As he un-
derstood it, Dr. Kohl, in making the incision to the
parts involved, came down on the sac and then
punctured the sac with hypodermic needle so that the
ﬂuid was in the hernial sac proper and pushing for-
ward the sac irrespective of the contained hernia and
of the encysted cord itself. He thought it peculiar that
there should be such a gangrenous condition.
DR. KOEL said he thought this had been produced
by taxis.
DR. MEISEN-BACH asked if the sac was involved.
DR. KOHL said it was: it was in a condition to
break down, though it was not complete gangrene but
a very severe ecchymiosed condition.
DR. MEISENBACE said that with this pathologic con-
dition he agreed with the essayist that unreasonable
taxis had probably been used. For a long time he
said he had followed the practice of trying by gentle
means to reduce the hernia and when this failed he
did not wait but suggested an operation, because there
166 MEDICAL SOCIETY OF
is less danger when the tissues are uninjured than
after ruthless taxis have been tried in order to re-
duce. Retention of the testicle in any case he said,
might be followed by a grave condition, as it might
give rise to an inﬂammatory condition around the
testicle. He believed with the Doctor, that the retained
testicle was the guide which led the bowel into-the
inguinal canal. On the question of drainage he took
‘a decided issue with the essayist. He appreciated
l-fully, he said, the reason why the Doctor drained as
he did, but he was extremely fortunate not to get an
extension of the pathologic process into the peritoneal
cavity itself. The drainage was not along the margin
but extended up quite a distance, and thus might carry
bacteria. He thought gauze drainage better in these
cases. '
DR. KOHL, in closing, said he felt great hesitancy,
but the tumor was there, and he did not believe that
he could go far wrong in aspirating before enlarging
the opening. The puncture was made in a direction,
that if the bowel was near the needle would not strike
it; and by using a very small needle he did not think
that harm could be done. The puncture was made
for diagnostic purposes only, and as soon as the ﬂuid
was demonstrated he did not hesitate any longer. He
agreed with Dr. Meisenbach in regard to taxis in re-
ducing hernia, and thought it ought not be carried
beyond a certain point. He believed that in eight
cases out of ten, the surgeon ought to be able _to re-
duce the tumor by taxis, if called early; but taxis '
should not be kept up too long, especially since in
these days of perfect antiseptic methods, there is little
danger in opening the abdominal cavity. In ligating
he said that he did not include any nerve tissue; he
simply cut the cord and ligated the vessels.

CITY HOSPITAL ALUMNI. 167
DR. GIVEN CAMPBELL presented two' patients in
whom the diagnosis was rather obscure, but he thought
in both there had been an attack Of
Cerebro Spinal Meningitis.
In one Of the children there was a history of
acquired tuburculosis on the father’s side and the
mother now had what appeared to be a broken down
tuberculous‘gland'. This child was well until sixteen
days ago, when it was taken with asevere form of con-
stipation. Was sick for four days 'and complained of
headache, but seemed to make a perfect recovery as
far as physical health was concerned, but after that he
was unable to \. walk. There was no paralysis, but
there was absence of co-ordination. Within four days
after that the hearing was entirely lost. He is abso-
lutely deaf. The bony conduction of sound was also
absent as far as he could test. There are cases which
show signs of destruction of hearing and a similar
destructive process in the retina after acute cerebral
inﬂammation. In this case the eyes appeared to be
normal. Dr. Campbell said he thought the child had
suffered from a slight attack of meningitis—one of
those so-called abortive attacks-and the membrane
lining the internal ear is supposed to be frequently
aﬂfected with the meninges, due supposedly, not to
an involvment Of the auditory nerve but to an invasion
of the internal ear. The other child, aged nine
months, is Syrian by birth. Three months ago he was
' taken with vomiting, constipation, retraction of head,
slight deviation of the eyes, and fever. He was sick
quite a long while and probably had cerebro-spinal
meningitis. There is now paralysis of the head mus-
cles. ' The peculiar point about the case and the only
one Of special interest is that from the time of the
disease, ﬁfteen weeks ago, the child commenced to
have a growth of hair upon its body, which makes the
case most unique.
1-6'8 ' MEDICAL "SOCIETY OF
DISCUSSION.
DR. R. B. H. GRADWOII-L said he had seen one
almost exactly like the ﬁrst case at the City Hospital.
While in the hospital he had undertaken a bacteriologic
examination of the cases seen there and had drawn
a chart Of the main symptoms, whether present or ab-
sent. In one Of the cases which recovered there was
the same condition of complete deafness “on both
sides. In looking over the literature on the subject
he found the explanation was that the trouble extended
along the auditory nerves. He thought Flexner of
Johns Hopkins offered this explanation. '
DR. CAMPBELL asked the speaker if he meant that
the trouble extended along the nerve with involvement
at the terminations of the nerve trunk.
DR. GRADWOHL thought it was the nerve trunk.
He said they described degenerative conditions found
in all the cranial nerves, and that the optic, auditory
fourth, ﬁfth and sixth were most often involved. In'
the cases he had himself examined he had found that
the optic and third and fourth nerves were most often
involved. The chart was self-explanatory in regard
to the clinical aspect of the cases. The mortality.
was 625- per cent.
Asked if he had examined the tympanum, the
speaker said he had and had found trouble in the ears
of ﬁve or six cases, but not in the rest. One case was
that of a woman who had gone to a doctor for ear
trouble for two days, when she suddenly became un-
conscious and the post mortem-showed she had men-
ingitis. In most of the cases he had performed lum-
bar puncture.
DR. LOVE asked if the Sign of Kernig was found in
all cases and Dr. Gradwohl said it was.
DR. JOHN GREEN, JR., asked if in the case which
was believed to have started with otitis media, he had
found the diplococcus intracellularis.
DR. GRADWOHL said he did. He further referred to
CITY HOSPITAL ALUMNI. 169
this case as it was very interesting. The woman was
seven months pregnant, and three days before entering
the hospital, she developed pains in the ear with a
little discharge. She consulted a physician who in-
jected something into the ear. The next day she be-
came unconscious and was brought to the hospital,
where she showed all signs of meningitis. This was
' about eight O’clock in the morning, and during the ex-
amination the fetus was found to be dead. The
woman died about four o’clock in the afternoon and
post mortem, showed that both mother and child had
meningitis; the bacteriologic examination of the ﬂuid
showed the diplococcus intracellularis in both cases,
showing that it, was transmission in utero of the dis-
ease. The ﬂuid from the ears was also examined and
the diplococcus waspdemonstrated, showing that it was
an extension of the disease.
DR. REDER said he noticed that sugar was found
-in two cases and that both had died. He asked-Dr.
Gradwohl if this was always considered symptomatic
of the disease.
DR. GRADwOHL said no. He thought, however,
that it showed some relative involvement of the ventri-
cles. In the case just mentioned where the disease
had been transmitted in utero, the woman had sugar
in her urine and the ventricles contained a good deal
of the exudate. But he did not think it was found
so very often.
DR. MEISENBACII asked if the aspect of the cases
changed any after lumbar puncture had been per-
formed.
DR. GRADWOHLsaid there seemed to be some im-
provement in one case while in another the symptoms
were aggravated apparently; in other cases no change
was observed. The puncture was harmless and ex-
tremely valuable as a diagnostic measure.
DR. I. N. LOVE said the growth of hair on the child
was very rare, yet not surprising. He asked Dr.
170 MEDICAL SOCIETY OF
Campbell if he had not observed other cases of a sim-
ilar increase of the growth of hair in neuroses amOng
women in particular. He said he had heard of several
neurotics where it had developed, although he him-
self had never seen a record of such a case.
DR. M. W. HOGE said that it would have been much
more satisfactory if Dr. Campbell'had seen the ﬁrst
case during its illness and had been able to give a
more deﬁnite history during the acute stage. From
the history obtainable, however, he said he would by no
means be certain that it was a case of meningitis, be-
cause all the symptoms mentioned might be present in
disease of the internal ear, especially if Of an inﬂamma-
tory character. The short duration of the attack and
prompt recovery, with the exception of the hearing,
was rather against meningitis. As to the manner in
which meningitis might produce bilateral deafness he
believed Dr. Campbell’s opinion was the accepted one,
and, as Dr. Gradwohl had explained, also supposed to
be due to an extension of the inﬂammation along the
canal traversed by the auditory nerve and involving
structures of the internal ear. Therefore he thought
the condition now present was, in all probability, due
to an inﬂammation of the labyrinth, and as such in-
ﬂammation might give rise to all the symptoms
described he did not think it at all necessary to sup-
' pose that meningitis existed. Bilateral inﬂammation
of the internal ear—that is, of the labyrinth of both
ears at the same time—is an affection which is not so
extremely rare, though not met with very frequently
in general practice, and the causes are not deﬁnitely
settled.
DR. JOHN GREEN, Jr., asked Dr. Campbell whether
he had noticed in connection with the case any strabis-
mus, ptosis or nystagmus, and ‘whether the fundus of
the eye had been examined by the opthalmoscope,‘ and,
if so, what was found. .
. DR. CAMPBELL, in closing, said his diagnosis of
CITY HOSPITAL ALUMNI. 171
meningitis in both cases was provisional; he- was not
sure that either child had meningitis. In the one with
deafness the Sign of Kernig was still present. In the
other case he agreed with Dr. Hoge that there was con-
siderable doubt. There was a prevalence of the dis-
ease in the city at the time, however. He said he was
aware that there was that acute bilateral disease of the
internal ear which has a predilection for that particular
nerve tissue. The reason he thought there was proba-
bly meningitis and not an inﬂammation of the internal
ear was the presence of vomiting with constipation;
that was a strong indication of acute inﬂammation,
and the fact that the child was unable to walk for two
weeks would point to either one. He thought that the
disease was meningeal deafness, due more to an in-
volvement of the internal ear itself than to the dis-
ease, the loss of function resulting in an involvement
of the nerve trunk. Most cases of meningeal
deafness do not have Visual involvement except in
rare cases, while it is common to have deafness in con-
nection with meningitis and without bony deafness.
In answer to Dr. Green’s question, he said he was sorry
that no examination of the fundus had been made, but
it was not practicable. The child was absolutely deaf,
and no tests cOuld be made, as no communication
could be held with her. It was a sad case, he thought,
because the child had been bright and intelligent, but
was now beginning to pay little attention to persons
and things around her and would soon, he feared, be
a deaf mute. For treatment he had been using the
iodides in both cases, with the idea of hastening reso-
lution Of any exudate if present. In the older child
he was using the syrup of iodide of iron, and the one
with the overgrowth of .hair, the iodide of potassium.
The case with the overgrowth of hair he thought
unique, considering the age of the child. The father
told him that in Syria it was not very uncommon for
children to be born with quite long hair on the entire
17'2 MEDICAL SOCIETY OF
body and especially dOwn the spine. - But it'did not
occur in them unless so born. The speaker thought it
_ pretty certain that the case was not congenital. There
were frequent cases of overgrowth of hair following,
nerve injury, neuritis, etc., and he thought it reasona-
ble to attribute this case to the illness—at least there
was some causative relation, for the growth immedi-
ately followed the illness, and it all came out in the
Course of six or eight weeks.
STATED MEETING, THURSDAY EVENING, JUNE 1,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.

A SPECIMEN 0F CYCLO=CEPHALUS.
BY J. C. FALK, M.D., St. Louis, MO.
HE mother, 27 years Old, had been delivered of
two healthy and normal children, the last about
two years previous. There was no history of
monstrosities on either the maternal and paternal side
of family. The father is of American parentage, in-
telligent, and in gOod physical condition. The mother
is of German descent, delicate in physique, and for
about a year has been failing in health. She is now
suffering from pulmonary tuberculosis, which is mak-
ing rapid onslaught upon her lung tissue.
There is no history obtainable of any maternal im-
pressions which might suggest a causative factor.
There was nothing unusual about the pregnancy ex-
cept that labor set in about six weeks later than the
time the mother had expected.
_ She felt “life” regularly and normally until twelve
days before conﬁnement, when there occurred during
several hours a series of violent fetal movements which
made her sick and caused her to remain in bed for a
day. -
During the following days until labor began she at-
tended to her household duties, but no longer felt any
CITY HOSPITAL ALUMNI. 173
movements of the child. After a somewhat prolonged
labor there was spontaneous delivery of a dead child.
The child was, with the exception of the head, a
normal, well-developed, well-nourished male, weighing
about seven pounds and seemingly at full term.
From the macerated condition of the cuticle, the
history of convulsions twelve days previous to birth
with no subsequent “life” movements, I infer that
death of the fetus took place over a week before its
delivery.


By the exercise of some diplomacyI was enabled to
secure the head of the child which is here presented.
It will be observed that the head is somewhat small
for a seven-pound infant, its general outline being,
however, about normal.
The occiput is illy developed; the cranial bones are
all freely movable upon each other so that the calvaria
may be ﬂattened out in any direction. The ears are
normal in appearance and properly placed. The mouth
is quite small, and inasmuch as the inferior maxilla
17 4 MEDICAL SOCIETY OF
has a limited amount of motion, one Can barely insert
the tip of the little ﬁnger into the buccal'cavity.
In the center of the face, just over the mouth, is a
single orbital cavity containing one eye. To all ap-


a....-.-_.----.
4-..--....-..
--~-~
~--_-u-
a. Blood clot in scalp (caput succedaneum). b. Parietal bone.
0. Frontal bone. d. Dura. e. Conarium. f. Mid. cerebral artery.
g. Cartilage supporting Nasal (?) Rudiment. h. Eye. i.i. Teeth.
j. Mandible k. Basi-occipital. 1. Basi-sphenoid. m. Ant. arch of
Atlas. n. Odontoid process of Axis. 0. Post. arch of Atlas. p. Spinal
cord. q. Occipital bone. r. Bulb. s. Occipital bone. t. Cere-
bellum. u. Torcular Herophili. v. Prosencephalon. w. Dien-
cephalon. x. Naso-pharynx. y. Buccal cavity.
pearances it is a normal eye-ball, pupil, iris, choroid,
and conjunctiva, being like those of a new-born child.
The eye-lids and lashes are well developed. The nose
is a cutaneous proboscis an inch in length situated im-
mediately above the middle of the eye in the center of
the forehead, resembling the penis of an infant. It
appears to be, a purely cutaneous appendage having no
’ CITY HOSPITAL ALUMNI. 175
bony constituents and apparently no attachment to the
skull beneath. At the tip there is a shallow depression
having a minute opening through which a bristle may
be passed along the rudimentary nares for about two
inches. -
The accompanying photograph was taken after the
specimen had been in alcohol for three weeks, hence
the drawn and irregular contour of the face and scalp
shown in the picture. _
, Dr. B. J. Terry, of the Medical Department of the
_Washington University, to whom I submitted the
specimen for dissection, has kindly furnished the
drawing of a mesial section, with a preliminary state-
ment of the ﬁndings from an inspection of cut surfaces.
It was found that the Eustachian tubes are both
present and that all the cranial nerves are in pairs ex-
cept the ﬁrst (Olfactory lobes), which are not discerna-
ble at all, and the second (optic), which is single. '
The cerebrum, it will be noticed, is very small, al-
most rudimentary in its proportions. The pharynx is
not imperforate, as seems to be the case in the ﬁgure;
this is due to the section being to one side of the mid—
dle line.
Dr. Terry promises to make a more minute dissec-
tion Of the cranial contents and present the result in
a subsequent report.
2700 Stoddard Street.

DISCUsSION. '
DR. B. M. ~HYPES: The specimen is not of a simple
character as almost all of these are, but a very perfect
case of the cyclo-cephalic varity, and also, as Dr.
Reder has very properly stated, one of the rhino-
cephalic; they occur separately and together, but more
frequently together. As a rule, there is more or less
variation to be noted in these cases. Although the
eye may he apparently single, it is frequently duplex. I
Dr. Falk should not only preserve the specimen, but
176 'MEDICAL SOCIETY OF
he should have it photographed that it. might be put
on record. Some men in this country have taken the
greatest interest ‘in these cases. Dr. B. C. Hirst has
written an excellent work and given much information
on these forms of monstrosity. There is always an
interesting question comes up in connection with every
form of monstrosity, and that is the old one of “mater-
nal impressions.” The laity almost universally still
. believe that impressions made upon the pregnant woman
are reproduced on the child in utero, and many physi-
cians adhere to the same idea. But little has been
written in later years on the subject. The last article.
of any consequence in later years on the subject was
one published some ten years ago by Dr. Barker, a
prominent New York physician, who expressed hisbelief
in the inﬂuence and effect of maternal impressions. The
profession, however, is drifting away from this belief
of late, especially as embryology became better under-
stood. The prevalent idea as to the cause of cyclo-
cephalus was the premature closing of the medullary
groove, preventing the proper normal development of
part of the skull, especially the nasal bone, which
divides the two eyes. In feeling the specimen it is
found there is a space observable between the nasal
bones. This is the reason why the proboscis was
developed above the eye instead of below it.
DR. R. B. H. GRADWOHL said he had had occasion
to look up the literature on some points in teratology
in connection with an epidemic of cerebro-spinal men-
inigitis transmitted in utero. Ballantyne-divided the
changes occurring in antenatal growth into three parts.
The ﬁrst was germ life, from the time of ovulation to
impregnation; the second from that time to the forma-
tion of the morula-mass, and called embryonic life;
and the third, fetal life, from the formation of the
morula-mass to the full development of the fetus
It is in the third part that these changes occur and
also when disease is transmitted, according to Ballan-
a
-CITY HOSPITAL ALUMNI. 17 7
tyne, and that he thought this was probable in the
case here from the fact that the fetus was fully de-
veloped. He. believed the profession was beginning
to realize that the fetus was subject to the same dis-
eases as seen in infants and adults, and that teratology
is but a single chapter of general pathology.
DR. FALK, in closing the discussion, said that he
has seen recorded two cases of-cyclops born alive, one
living 30 hours and the other 72 hours, but he was
unable to say if they were born at full term as was
this case. These monstrosities are usually acephalic,
hence this variety of teratologic beings is rendered in-
compatible with prolonged life.
~DR. L. DRECHSLER reported a case of
Diphtheritic Vaginitis
in a married woman about 28 years of age.
_ She entered the Female Hospital about Sept. 23,
1897. On the 28th of August previous she gave
birth to twins with no'unusual complication. About
two days previous to entering the hospital had a
severe headache. She gave no history of chill or
fever. Nothing abnormal was found in the heart or
lungs; but she refused a vaginal examination. Men-
tally she seemed to be below the average type of
women who enter that institution. About the second
day she consented to avaginal examination, claiming,
however, that she had no trouble with the genital or-
gans. On this day she had a chill followed by a tem-
perature of 1045-, and the examination revealed a
diphtheritic membrane lining the vagina up to the
inner os. In removing parts of the membrane a de-
nuded surface remained. Two culture tubes. were in-
oculated and sent to the'Board of Health for exami-
nation. Dr. Ravold found the bacilli so virulent that
he asked for cultures for immunizing his horse at
the Poor House. The patient was immediately sent
178 MEDICAL SOCIETY or
to. the isolation ward and given 3000 units of anti-
toxin. There was nothing characteristic about the
temperature except that it reached 104° and 105°, with
the regular form of temperature curve. On the third
day the fever showed no sign of abating, so she Was-
given 1500 units and two days later another injection;
altogether 7500 units of antitoxin were given. The
pulse all the time seemed to be pretty fair, rimning
from 98 to 100 or 110. About the second or third
day she showed a very septic appearance and cough,
and an intrauterine douche of bichloride, 1-5000, was
given. In giving this douche he found he had a very
unfavorable patient to deal with; she seemed. not to
appreciate what was being done for her, even using
force to keep the doctor away. After the douche the
temperature ran up to 105°. The patient suddenly
became irrational. The next mOrning sterilized water
was used and the temperature ran up to 1047}, so he
could not account for the rise of temperature except
as a nervous phenomenon. At the end of four days
another culture was made, and diphtheria bacilli and
streptococci were found present. About the eighth
day only the streptococci were found, and atthat time
the membrane had disappeared. The temperature
had nothing unusual about it except that it persisted
for about three weeks.
In the treatment of the case stimulants were Used,
as whiskey and strychnine and tincture of chloride of
iron.
In answer to a question by the President, Dr.
Drechsler said the woman gave birth to twins on
August 28th, but it was diﬂicult to say how long it was
after gestation that the diphtheria appeared, as the
woman was not an intelligent one and her statement
could not be relied upon.
DR. REDER asked if a diagnosis of diphtheria was
made before the examination of the culture and what
was the condition of the throat. ‘
CITY HOSPITAL ALUMNI. 17 9
DR. DRECHSLER said there was nothing pathologic
in the throat, as cultures were made at different times
and no bacillus found. The diagnosis was made from
the simple inspection of the vagina, for it seemed to
him to be a very plain case of diphtheritic membrane;
but the patient was not isolated until the diagnosis
was conﬁrmed by the Health Department.
DR. HOMAN asked if the source of infection was
known.
DR. DRECHSLER said an effort was made to ﬁnd out,
but nothing could be ascertained. The hygienic sur-
roundings of the patient were very poor.
DR. MARX asked if there was any trouble with the
adnexa.
DR. DRECHSLER said none had been observed.
DR. B. L. SCOTT asked if the temperature fell after
suspension of the douche and if there was any rise
during the next few days. He asked in order to de-
termine whether the rise of temperature was a nervous
one.
DR. DRECHSLER said that was difﬁcult to say in this
case. The patient was a very nervous woman, but
whether the temperature- was due to this or to the
douche he could not say; probably both had some-
thing to do with it.
DR. NORVELLE WALLACE SHARPE said that it was
to be regretted that the case was of such a character
and the reporter was so busy that a more accurate
report could not be made. A true diphtheric growth
in the vagina is rare; he had never seen one, and at
the time did not recall an authenticated case in liter-
ature. It was fortunate that a bacteriologic exami-
nation had been made by a competent man, otherwise
the diagnosis might justly be questioned. It was
worthy of note, too, that if this woman had a diph-
theritic vaginitis she had a remarkably low tempera-
ture; that might be due to oneof two things—a mild
infection, or a very low grade of resistance on the
- 180 MEDICAL SOCIETY OF
part of the host. He was not prepared to agree with
the other gentlemen that the vaginal douche, per se,
caused the rise in temperature; he [could not see why
this should occur in that region and not in others-
for example, as when douching the throat in diph-
theric pharyngeal tonsillitis. He saw very few of
these cases—practically none—and yet he did not
know of any where douching the throat caused a rise
of temperature in a child with diphtheria. He be-
lieved it would have been interesting to have tried
pilocarpin in this case. The use ofthis drug in the
hands of the. staff of the Bethesda Home of this city
had been followed by beneﬁcial effects. The case,
he thought, was rather obscure from an etiologic
standpoint. The only point that was clear was the
bacteriologic examination. It seemed to him un-
usual that the uterine cavity was not infected and
possibly the tubes; also the urethra and rectum.
That the membrane should isolate itself in that man-
ner and give rise to a temperature of only 98° to 100°
was rather extraordinary.
DR. B. L. Soo'r'r said, after the use of the douche in
septic conditions of the uterus, he had never seen the
temperature rise more than a degree or a degree and a
half; that it should rise to 104 and 105 in this case he
thought was evidence that it was purely a nervous
manifestation. He remembered a case in the City
Hospital where a woman on the third day after con-
ﬁnemcnt showed a rise of temperature from 100 to
103, this continuing for three days. He could ﬁnd
no reason for the rise, until on questioning the woman
he found that her parents did not want the child
brought home, desiring that it be given to some insti-
tution, while the woman wanted to keep her child.
This was a constant cause of anxiety. .All visitors
were immediately excluded, even her parents not being
admitted, for a few days; at the same time 15 grains
each of bromide of potassium and choral were given,
CITY HosBrrAL ALUMNI. 181
and the temperature immediately fell; no further rise.
Here was a case that illustrated in a forcible manner
the role played by the nervous system in certain cases
of pyrexia.
DR. 1. N. LOVE said the announcement on the pro-
gram recalled the only case of diphtheria in this
region he had ever had under his care. It was in a
young girl about ten years of age. There had been
diphtheria in the family and attention was ﬁrst called
to the child on account of discomfort, for which he
prescribed without relief. An examination was sug-
gested and~made, and it was found that a pronounctd
membrane existed on the vulvae, including the meatus.
It was clearly diphtheritic; when removal was at-
tempted it clung tenaciously to the surface. This
“was before the days of the Klebs-Loeﬂier bacillus,
but he was sure of the diagnosis. He used benzoate
of soda and bichloride of mercury. In regard to the
use of pilocarpin, he said he had been accustomed to
use “it, but came to the conclusion, after considerable
experimentation, that it was a dangerous drug; it was
very depressing and should always be accompanied
with stimulants. The question of high temperature,
he said, was a very important one. 'Such remarkably
high temperatures as recorded some years ago, rang--
ing from 115 to 116, he had never seen. He did,
however, have a case of a woman, who was tuber-
culous, who after parturition showed a fever of 106 to
108, and only kept down by baths; this condition
existed for weeks,. and the patient was losing
strength, when he thought the possible disturbance of
the nervous system affecting the heat center might be
the cause of the continued rise. He recommended
the removal of the patient to another city, and the
mere'knowledge that she was go‘ng away seemed to
affect her so that her temperature never rose above
1.03 afterwards, though it was many weeks before it
became normal.
182 MEDICAL SOCIETY OF
DR. MARX said it was very possible that the tem-
perature might have been a purely nervous one; but
the douche was not a good procedure, she thought.
Dr. Sharpe’s remarks about the nose and throat she
did not think could hold, because in the uterus, es-
pecially so long post-partum, drainage would not be
perfect as it would be in the nose and throat, and she
did not think any one would dilate. She had asked
about the adnexa because she thought that the trouble
arising after the douche might have been due to their
condition. The most surprising point, she thonght,
was that the patient did not complain of pain in the
vagina. She had never had a case of diphtheritic
vaginitis; but in cases of vaginitis, whether simple or
gonorrheal, pain was a pronounced symptom. She
did not know anything that would bring a patient
more quickly in quest of relief than vaginitis, and
she thought it quite phenomenal that such a condition
should exist without complaint in this regard. In
regard to the treatment she thought the old way of
swabbing would have been appropriate here, or pack-
ing with antiseptic gauze. ~
DR. GEORGE HOMAN said some of the members
present would probably remember a paper read by
Dr. F. A. Glasgow before this society last year on
the subject of septic endometrial diseases. This
point was discussed at that time. In response to an
inquiry as to whether in such cases hot douching was
not only desirable, but necessary to induce contrac-
tion, Dr. Glasgow explained the cause of the rise
of temperature following the contraction of the ute-
rus stimulated by these douches, and, as Dr. Reder
and Dr. Marx intimated, a consequent drawing of ad-
ditional septic material into the circulation. If this
were "the correct view, and it certainly seemed rea—
sonable to the speaker, the nervous system did not
play such an important part as had been Suggested
this evening.
CITY HOSPITAL ALUMNI. 183
I DR. W. G. MARDORF asked if the douches were
given hot. ,
DR. DRECHSLER said they were about 110°.
DR. MARDORF said douchesof hot water stimulated
absorption to a marked degree, and in this case, he
understood, it was only three weeks after the birth of
the child. _At that stage involution is not complete,
liquefaction is going on, and muscular tissue is dis-
appearing and absorption is very active, and any
injection of that sort would be apt to cause a rise of
temperature by absorption Of septic material. These
~ two factors, the tendency of the hot douche to stim-
ulate absorption, and the receptive condition of the
lymphatics and,sys-tem in general, these two things,
he believed, would explain the rise in temperature
without considering the part played by the nervous
system. The difference between the effects of the
douche here and in the throat was because the under-
lying tissues in the latter are not in as favorable con-
dition for absorption, the conditions being more
normal than in this case. He said he had never seen
a case of this kind, his experience being more limited
in so far as the locality of the membrane was con-
cerned. But he believes the fever in this case was
due solely to local causes and the stimulation of
absorption.
DR. B. M. HYPES had but little to add to the discus-
sion which he had heard. He believed the explanation
of the rise of temperature was the absorption of pto-
maines induced by the administration of hot douches.
He added that several times in his experience he had
noticed a rise of temperature following hot douches,
and had avoided a repetition of this by using luke-
warm douches thereafter. He believed if this were
applied to such cases a rise of temperature might be
avoided. He said he had heard a very interesting
paper on Puerperal Septicemia read by Dr. Long-
street of Detroit, two years ago, in which he gave a
184 . MEDICAL SOCIETY OE
history of several cases occurring in his practice in
Detroit and in the hospitals there, which were treated
successfully, by the diphtheritic antitoxin method.
The presence of diphtheritic germs in these cases was
proved by the microscope. *
~DR. CHAS. J. ORR referred to his experience on
one point called up by Dr. Sharpe, and mentioned by
Dr. Love, on the use of pilocarpin as a great elimi-
nator in all these septic conditions, especially in
diphtheria. - Early in his practice he had abandoned
the use of this drug because of the discouraging ef-
fects noticed, but was again enthused by one of the
members of this Society, for whose ability he had the
highest regard, and since that time he had tried it in
two cases, one of diphtheria and one of obscure
diphtheria and scarlet fever, complicated by acute
nephritis. Both were in children. He used it in
doses of a 20th or 25th of a grain, yet, after his ex-
perience with these two cases, he felt that it was a
dangerous remedy. Possibly, he said, he lacked
nerve in its use, but he had observed that it affected
the heart unfavorably, and this was not compensated
by the good work expected in elimination.
DR. DRECHSLER, in closing, explained that for
about three weeks the temperature had been running
up to 104° and 105° in the afternoons, and this
b fore any interference. Pilocarpin was not used in
this case, although there was no counter-indication
for its administration. His experience with that
drug was very favorable, always obtaining very good
results, but in hospital practice, he added, a patient
can be seen as often as desired and watched more
closely than in private practice. In using antitoxin,
he said that no results were noticed until after a
period of from 18 to 24 hours after the injection. In
regard to the symptom of pain, he stated that on
making an examination with the speculum the patient
showed signs of pain, but when questioned about
CITY HOSPITAL ALUMNI. 185
this she declared she felt none; but the speaker
thought this was probably a ruse to have the exam-
ination discontinued.

STATED MEETING, THURSDAY EVENING, JUNE 15,
TE PB-EsIDENT, DR. GEO. HOMAN, IN THE CHAIR.

AN ENDEMIC 0F PEMPHIGUS.
BY ELLA MARX, M.D., St. Louis.
3 ' O rare are epidemics and even endemics of pem-
é phigus neonatorum contagiosa in this country
that Holt, in his book on Diseases of Children,
says he knows of none reported in America. N ever-
theless E. B. Kilham1 in 1889 reported two epidemics
as occurring in the New York Inﬁrmary for Women
‘ and Children in 1887 and 1888 reSpectively; but he
also says he has found no other cases reported in
American or English literature. On the other hand.
‘ in Europe they seem to be not uncommon. Runge,2
whose review of the subject I have found the most
complete, cites twelve authors as reporting epidemics
of some magnitude occurring either in various European
maternities Orin the practice of certain midwives; and
he also cites an epidemic in a London maternity in
1834,. reported by Rigby.
’ The following cases are interesting therefore because
of their rarity in this country and also by reason of
the rapidly fatal issue of the ﬁrst, Kilham reporting
no fatality, and Bunge considering the prognosis in
uncomplicated cases favorable, though admitting the
possibility of fatalities. He quotes Zechmeister’s re-
port Of an epidemic of twenty-six cases in the practice
of a midwife in London, of which six died.
On June 19, 1898, at 5 A.M., I was summoned to
, attend Mrs. J . in her fourth labor, arriving a few mo-
ments after the birth of an apparently healthy girl
baby, _Weighing approximately 7% pounds. The labor
had-been short and easy and no assistance had been
186 MEDIGAL SOCIETY OF
rendered. The cord was still pulsating and after this
ceased it was tied, severed, and dressed with absorbent
cotton. The placenta was delivered spontaneously
after one-half hour.
June 20th. Both mother and child doing well.
June 21st. A small erythematous spot was noticed
over the right parietal bone and in the right inguinal
region, but my attention was not called to them till
the next day, June 22nd, when a vesicle had developed
in both regions, that on the head being the size of an
ordinary varicella vesicle and that on the abdomen
somewhat larger. On this day the cord dropped and
I covered the umbilicus with a collodion dressing for
fear of infection, should the vesicle rupture.
June 23d. The abdominal vesicle has increased to
the size of a silver dOllarand has ruptured. Two more
have appeared in the right groin and one on third ﬁnger
of left hand, and the infant is not nursing well. Move-
ments green; temperature 99.40 F. On investigation,
ﬁnd quantity, of mother’s milk quite insuﬁ'icient; or-
dered cow’s milk, home modiﬁcation.
June 24th. Movements better color; infant less rest-
less; bullae on abdomen and groin extending and fus-
ing, secreting quite profusely.
June 25th. For the past day or two there hasbeen
an eruption on neck resembling prickly-heat, which has
developed into an inﬁnite number of minute blisters.
A bull'a has appeared at external angle of one eye. On
the abdomen epidermis regeneration is progressing.
June 26th. Minute blisters under chin have fused,
and neck in this region' is denuded of epidermis; bulla.
at external angle of second eye.
June 27th. Several vesicles on ﬁngers of right hand;
has had a very restless night; movements have again
been very bad in color; put on Walker-Gordon milk.
._ June 28th. Movements of good color; takes food
well; but on this day the disease began to spread
with tremendous rapidity, the erythema extending-
CITY HOSPITAL ALUMNI. 187
from the edges of the Old bullae and a continuous lift-
ing off of the epidermis following in its wake down the
back and chest and over the face leaving only a small
patch free on either check by 9 P.M. ; temperature 103°.
June 29th. Entire back is denuded and large dark-
blue spots are to be seen; the epidermis hangs in rib-
bons from the hands; has had three watery movements;
‘ urinary secretion continues free. On this day, the
eleventh of its life and the ninth of the disease, death
occurred. '
On the sixth day of the child’s illness the mother,
whose puerperium had been otherwise absolutely nor-
mal, developed pemphigus, the vesicles appearing ﬁrst
on the mammae, then in the groin, and later on scat-
tered here and there on all regions of the body. They
varied in dimensions from the size of a pea to that of
_half a silver dollar; some were tense, others ﬂabby;
some dried down without rupturing. The larger ones
either ruptured spontaneously or the ﬂuid was drawn
off, as it was found that they healed more readily when
so treated.
On the day of the baby’s death it was found that the
nurse had some vesicles on that side of her neck against
which she had been in the habit of holding the child.
She also gradually developed them on various parts of
her body but they were neither so numerous nor so
large as in the mother’s case. The father, who could
not be kept from kissing both the baby and mother,
developed one large vesicle on his forehead, and the
three boys, who had been kept carefully away from
the baby, but probably not later on as carefully from
the mother, all developed mild forms of pemphigus. I
myself had one vesicle on my left forearm, which ap-
peared June 30th and remained visible about a week.
That the infant had pemphigus neonatorum conta-
giosa and that the rest contracted the infection directly
and indirectly from it, is hardly open to doubt, but
the source of the original infection is in this case, as
188 . MEDICAL SOCIETY OF
according to Runge in all reported epidemics, impossi~
ble to determine. There was. no case of it, so far as I
was able to discover, in the neighborhood, and no
member of .the family nor the nurse had ever come in
contact with the disease. -
'In Arcadia, I have heard there was last summer an
epidemic of pemphigus, but there had been no com-
munication with Arcadians.
Most authors believe in the infectious nature of the
disease, though Bohn and Dohrn attribute its origin to
external irritants, such as hot baths and rough hand-
ling of the infant, or injuries due to pressure of for-
ceps, Dohrn3 founding his belief principally upon his
Observation of a midwife in whose practice, despite
careful disinfection, twenty-seven out of sixty-ﬁve in-
fants contracted pemphigus; whereupon she took no
cases for four weeks. Nevertheless on resuming prac-
tice two children out of nine had pemphigus. She
again stopped practicing for four weeks, but, of the
_six children born subsequently under her ministration,
three contracted the disease. Dohrn then had her
come to the Marburg maternity for observation, and
here also three infants in her care had pemphigus,
while four others, not cared for by her, remained free.
Dohrn Observed that she had acquired a certain rapid-
ity and roughness in handling of the infants, and that
it was interesting to see that just the parts most ex-
posed to her manipulations were those ﬁrst attacked.
He believes, therefore, that pemphigus neonatorum is
not a speciﬁc disease, but that mechanical, chemical,
and thermic irritants produce 0 the skin of the new-
; born vesicles whose Contents inoculated upon other
spots cause still further formation.
In this case Of spontaneous delivery there was. not
even the usual pressure on the scalp consequent upon
careful delivery of the head; furthermore, the infant
was quite clean and the primary cleansing necessitated
no violent efforts. The hot bath could not come into
CITY ~HOS-PITAL ALUMNI. 189
consideration, as I do not have a full bath adminis-
tered until after the dropping of the cord, which the
disease antedated.
Faber, according to Runge, reports in 1890 an epi-
demic in the Kopenhagen Maternity which he considers
had its origi in a case of impetigo of one of the puer-
_ pera, and the former believes in the unity of the two
diseases. He thinks that they differ merely in form,
the crusts and scab-formation appearing more fre-
quently in grown children and adults.
Rotch4 also says “ we must remember that on the
delicate skin of infants and young children impetigo
contagiosa may cause the lesion of pemphigus through
the activity ofthe parasite and the great vulnerability
of the skin.” This is, of course, a point which must'
be settled by bacteriologic investigation, which I re-
gret to say was not made; but in none of the seven;
secondary cases "were the lesions such as I associate
with impetigo; crust-formations were rare and when
present thin.
The inception of the disease on the third day is
rather earlier than is recorded by most authors, who
put it at from four to nine days after birth; though
Kilham reports one as beginning on the second day.
While the original case surely showed a high degree
of infectiousness, it would appear that the virulence
of the contagion quickly diminished. Not only did no
new cases result in the entourage of the nurse who left
the house before she was cured, and who, though to
some extent probably exercising care, could not abso-
lutely isolate herself, but I myself discovered the
pemphigus vesicle on my arm while disinfecting for
another obstetrical case. Circumstaces were not such
as to make it possible to send for anyone else to take
» the case, and I merely put an occlusive dressing over
i the vesicle, disinfected as usual, and had no develop.
ment of pemphigus either in this case or one delivered
a few days later.
190 MEDICAL SOCIETY OF
The diagnosis to one seeing the case from the be--
ginning was clear, though in its late stage it closely
resembled the descriptions given of dermatitis exfolia-
tiva contagiosa; that had it not been for the secondary
cases doubt might have arisen as to its identity.
Since the prognosis of pemphigus neonatorum is
considered by most authors as favorable, the insuf-
ﬁcient and unsatisfactory nutrition of the ﬁrst few days
may have had some bearing upon the outcome, as may
' also the fact that the last week of June was one of the
hottest of the summer.
The treatment recommended by all authors, simple
powders}, boracic acid, and zinc ointments, had, accord-
ing to my experience, absolutely no inﬂuence. The
same may be said of ammoniated mercury ointment,
which I tried because of the suggested relation of the
. disease to impetigo; neither did oak-bark baths, recom-,
mended by Soltmann, seem to inﬂuence the course of
the disease. Flaxseed baths, with subsequent wrap-
ping in cotton, added to the comfort of the infant in
the later stages of the disease, but did nothing more;
in fact, like most infections diseases, it seemed to run
its course and then stop of its own accord.
BIBLIOGRAPHY.
1Kilham, E. B., Amer. Jour. of Obstet., Vol. XXIL, No.
10, p. 1039. '
3Runge, Max, “Die Krankheiten der ersten Lebenstage,”
20d edition.
3Dohrn, Archiv. f. Gyn., Vol. X., 1876, p. 589, and Vol.
X[.,1877, p. 567. -
4Rotch, Pediatrics, 1896.
\

DISCUSSION.
DR. B. B. H. GEADWOHL said he had worked on
the micro—organism of pemphigus, a case of which he
had seen last year. He succeeded in separating the
bacillus from one of the bullous lesions, and found it
gave reactions characteristic of the staphylococcus
pyogenes albus; whether this was the speciﬁc cause
CITY HOSPITAL ALUMNI. 191
of the eruption or not he could not say. In looking
Over'th-e literature on the subject he noticed that one
man found the staphylococcus pyogenus aureus,
while another observer, Bumme, found a diplococcus
and had succeeded in inoculating cases. Some of the
cases would go into a typhoid state, and in fatal
_ cases this diplococcus has been found in the urine; it
was a question whether it alone produces general
symptoms of the disease, though this had not been
proven.
DR HOMAN asked if the disease could be produced
in any way except by vesicle rupture, and if a lesion
of the skin was necessary. _
DR.'MARX said she had not studied that phase of
the question. She said there might have been a lesion
on her forearm, produced by the brush while disin-
fecting thoroughly before severing the cord.
DR. HOMAN asked if anyone could tell why the dis-
‘ case was more prevalent and better known in Europe
than in America.
DR. MARX stated that in the fall she had seen a
case in one of the tenement houses, but had no slides
with her, so could get no serum for investigation.
She had inquired whether there were other infants
affected in the house, but there were not. She said
she was much interested in Dr. Gradwoh'l’s remarks,
for she had been unable to ﬁnd any literature on the
subject.
A CASE OF TRAUMATIC RUPTURE OF THE LONG
HEAD OF THE TRICEPS EXTENSOR
cusm.
BY GEO. HOMAN, M.D., St. Louis.
N February 4th, 1899, T. J. W., male, age
about 60 years,of muscular build and good
" habits, came to my oﬁice stating that he had
a few minutes previously slipped and fallen to the
ground and hurt his right arm and shoulder. He
192 MEDIOAL SOCIETY OE
said that The was crossing the street at the "time, the
surface'beingsiheeted with ice, and as he neared the
sidewalk his feet went from under him and he fell
forward, With his right arm partly outstretched,
striking the edge of the curbing with his chest, and
his chin coming down forcibly on the sidewalk. He
wore a heavy overcoat at the time, which “served in
part to break the direct force of the impact ‘On’the
curbing, but notwithstanding this,'th'-e ﬁfth rib'on the
i left side was fractured, as was found upon examina-
tion. 0 .
Abrasionsand bruises of the skin were found under
the chin and in the palm of the right hand, "which
had been shot forward as the weight of the descend-
ing body came more fully upon it.
He complained of much pain in and near the right
shoulder, and the movements of the 'arm on that side
were carefully guarded. _
O-n removing the clothing the injured shoulder
showed no marked differences on inspection from its
fellow, but pain on attempted movement ‘was so great
that nausea ensued.
The seats of pain were respectively at ’a point in-
side and rather behind the upper end of the humerus;
also at the point of the shoulder, near the coracoid
process, and in the left side. He was so well pro-
tected by clothing that no cutaneous bruising Was
found except as already mentioned.
_ As neither fracture nor-dislocation of the bones
constituting the right shoulder could be found, the
patient was sent home, put to bed and made as com-
fortable as possible.
The next day 'a deeply *e‘cc‘hymosed condition was
found to exist at the upper inner posterior aspect'of
the right arm, :and this soon involved the entire inner
and posterior contour of the triceps muscle, extend-
ing even below the elbow. The place where it 'was
ﬁrst observed corresponded closely to the location‘of
CITY HosrrrAL ALUMNI. 193
the painful point in the outer. aspect of the arm-pit,
and wastaken to indicate a rupture of the long, mid-
dle or scapular head of the triceps extensor cubiti.
As declared by the anatomists, a principal function
of the part of the. muscle named is to prevent a
downward and backward displacement Of the head of
the humerus; and it was in the performance of this
function evidently that the traumatism occurred, for
asv the weight of the descending body was received
by the hand instinctively thrown out, the triceps tight-
ened to its work, but the hand slipping forward
threw an immense sudden strain on these particular
ﬁbers, which gave way and would have allowed the
head of the bone to leave the socket had not the edge
of the curbing a moment later prevented its descent,
the line of impact being about middle of the chest.
Such seems to have been the dynamics concerned
in the production of this injury.
pAs treatment progressed it was found that the use
of the right arm, was impaired in attempted back-
ward movements which involved necessary action by
the triceps, but this inhibition gradually passed away
as recovery progressed. I -
The points relied on for the correctness of the .
diagnosis were: 1. The chief site of initial pain high
up in the arm-pit. 2. The development of swelling,
with subcutaneous effusion of blood at the same time
where external bruising was impOssible. 3. The
speciﬁc impairment of function as shown in the
course of treatment.
DISCUSSION.
DR. R. C. HARRIS said" Dr. Homan’s case of rup-
ture of the long head of triceps muscle recalls a case
_ which he had read in a southern med-ical journal some
time ago. The perfOrmer, while springing from one
trapeze to, another, after he had caught the one he
was. springing for, suddenly let go- and fell to the
194 MEDICAL SOCIETY OF
ground. He was picked up unconscious, and exam-
ination revealed a rupture of the tendon, with a com-
plete separation of the muscle from its attachment
to the subglenoid depression, to which this part of
the muscle is attached. Patient died later from the
results of internal injuries. I
DR. F. G. NIFONG said he had never met with a
case of this kind, but he had seen a rupture of the
deltoid. He suppOsed this was due to partial rupture
of the muscle ﬁbres or nerve rupture, producing
atrophy and loss of function. He thought the result
very good.
DR. NORVELLE WALLACE SHARPE said the case was
very interesting and comparatively rare. These
muscle ruptures occur in two classes of people ordi-
narily: in individuals where the rigidity of muscle
ﬁbres is relatively great, as in the aged, or in those
where impairment of muscle tissue exists consequent
upon disease, such as in diabetics, post-typhoidal
cases and syphilitics, less frequently following scar-
let and yellow fever infections. The rectus abdomi-
nis, rectus femoris, adductors of the thigh, muscles
of the calf, psoas and ﬂexors of the forearm, are
those usually ruptured, and in the order named, the
degree of rupture ranging from an almost impercept-
ible stretching with laceration of a few ﬁbres to com-
plete pulpiﬁcation. In a rupture of the ﬁbres such
as suggested by Dr. Nifong the impairment is of
comparatively little import; but a complete rupture
of the triceps, like the one-reported by Dr. Homan,
is a relatively rare occurrence; in this case there was
a distinct separation of the muscle in its continuity.
In the aged, where an individual muscle is of less
value than in the young or in women, where sym:
metrical contour is demanded, it is just as well to
put them to bed and make cold applications, as was
done in this case; but in men who are compelled to
live bythe exercise of their bodies, and in women,
CITY HOSPITAL ALUMNI. 195
where contour is of importance, muscle rupture is
not adequately treated upon that basis, but becomes
a surgical case, where to cut down and unite the mus-
cle and fascial edges by suture would be proper; the
result in such cases is usually very fair. If this is
not done, and function of the part is not restored; we
have then to depend upon scar tissue; this is never
1 strong, and there is almost certain subsequent muscle
atrophy and nerve impairment. This case proceeded
very nicely, but he thought it would be better, as a
rule, to suture the muscle proper and fascial ends to-
gether; after suturing, to extend the arm and fore-
arm and put on a posterior splint, of necessity splint-
ing the arm, forearm and shoulder to the mid-line
anteriorly and posteriorly in plaster of Paris to secure
absolute immobilization in the proper position.
Dr. L. C. BOISLINIERE asked if there was any nerve
involvement, as evidenced by subsequent neuritis.
DR. HOMAN said there was not.
DR. BOISLINIERE then said, referring to Dr. Sharpe’s
remarks in regard to atrophyof the muscle after such
injuries, that this atrophy was usually due to nerve
disturbance or injury, and not to any injury to the
ﬁbres themselves.
DR. SHAnPE’s interpretation of the symptomatology
was that immediately after the injury there is loss of
function dependent upon muscle rupture, but that
subsequent functional impairment is due to imperfect
union of muscle-ﬁbre by elastic scar tissue plus atro-
phy dependent upon nerve involvement. If you
should expect that a ruptured muscle, united only by
fascial edges, to unite, it would be in the scar in the
fascia which envelops the muscle, but the muscle.
itself will not unite perfectly; to secure a good func-
,tional result, muscle ends should be brought together
and held in that position by appropriate sutures, the
edges of the fascia being also united in an adequate
fashion.
196 MEDICAL SOCIETY OF
DR._HOMAN said that he suppOsed the distressing
consequences which might have ensued if the head of ‘
the 'b‘one‘had left the socket involving the muscuIO-
Spiral nerve, had been avoided. He did not think
there had been actual separation of the entire head of
the muscle in its continuity; but judging 'from the
local symptoms, hemorrhage, and seat of pain, and
loss of function, there must have been some giving
way of these ﬁbres. He believed there was also some
strain of the coraco-brachialis, for he had not been
quite able to satisfy himself that there was notmore
or less complete detachment of this muscle frOm its
attachment as there was more or less pain at that site.
As far as he had looked up the subject he found the
relative frequency of rupture of muscles was in the
following order: The muscles attached to the heel-
the tendo Achilles ﬁrst, the quadriceps extensor
femoris second, and the triceps third. He had seen a
case of transverse rupture of the belly of the biceps and
had shown the patient at one of the medical-societies
some years ago. The recovery was incomplete, a
transverse depression across the belly of the muscle
remaining. It might be that if steps such as those
mentioned by Dr. Sharpe had been taken in that case
the function of the muscle would have been more
fully restored, but- he could not say positively. In
the present case he said the man was an intelligent
person and the arm was carried in that position most
favorable to comfort. He had not seen him recently,
but he believed the function .Was pretty nearly re-
stored. After his return to business, during damp
weather the patient complained a great deal of aching
and impairment-of movement, but since warmweather
has set in this has decreased.
CITY HosPITAL ALUMNI. 197
STATED\MEETING, THURSDAY EVENING, SEPTEMBER 21,
THE VICE-PRESIDENT. DR. B. M. HYPES, IN THE CHAIR.
THE- HYGIENE OF PREGNANCY AND‘ PARTURITION.
BY GARLAND BURT, M.D., Newport, Ark.
F we could assume'that all child-bearing women
were, at the time of conception, in good health
and normally developed, their hygienic manage-
ment during pregnancy and parturition would be
greatly simpliﬁed, and would accord so nearly with
that of personal hygiene generally as scarcely to
merit the title of specialty. -
Even if it be assumed that the preparation for
motherhood begins at birth, we shall be obliged to
_ ignore quite an array of hereditary causes which may,
and often do, impede development and impair the
vital energies necessary to normal functioning.
We propose, however, on the present occasion to
study brieﬂy methods for preventing or modifying
the inconveniences, accidents and complications of
pregnancy and parturition as usually met with in-prac-
tice. ‘
The normal or physiologic symptoms of pregnancy
are usually well deﬁned and easily recognized, and
yet the thought has often occurred to me that if we
could have them described to us by a woman thor-
oughly educated in the science of physiology, she be-
ing herself at the time the subject of them, much
new light upon the symptomatology of pregnancy
might be revealed.
It is also probable that much trouble, anxiety and
disease, both in the non-pregnant, as well as those of
the pregnant and parturient states, might be obviated
by a more thorough knowledge of the anatomy and
-' phySiOlOgy of their own systems by women them-
selves, and especially the anatomy and physiology of
their reproductive organs. But care should be taken
that this knowledge is not gained at the expense of
198 MEDICAL SOCIETY OF
the impairment of physical development, and instead
of, being healthful, become a fruitful source of the
pains and perils of child-bearing, the consequence of
' nerve strain and mental overwork.
Recent advances in our knowledge of the nature
and causes of disease have greatly enhanced the im-
portance of preventive medicine, and suggests its
practicability in many forms, but chieﬂy by avoiding
or abating the causes.
It is now generally conceded that most of the in-
fecting causes of disease are from without, and that
a sine qua non of all preventive effort is cleanliness.
A modern writer of popular literature is credited
with having said that the greatest difﬁculty he had
encountered in writing a book was to keep out that
which ought not to go in, and the idea accords well
with professional experience in preventive medicine. '
On the subject of sexual hygiene we might study
with proﬁt the precepts of Levitical law (Lev., xv.,
16 to 33), wherein uncleanness, pollutions, and the
methods for puriﬁcation are deﬁned.
It is, I believe, a generally'recognized fact that
each cavity of the human body is inhabited by germs
or organism's peculiar to itself and normal to it in a
state of health. At the same time they are lia-
ble to be invaded by organisms from without,
and if these should obtain a lodgment, their pres-
ence may prove a source of irritation and interfere
with the normal functioning of the parts. Hence
the importance, especially in gynecology and obstet-
rics, of keeping out that which ought not to go in,
and it suggests that even sexual relations should be
conducted under the most scrupulous sanitary pre-
cautions.
The most disastrous of these invasions from with-
out are the infecting causes of gonorrhea and syphi-
lis, the former frequently invading not only the ure-
thra and vagina, but the bladder, womb, and contig-
CITY HOSPITAL ALUMNI. 199
uous structures, impairinglthe efﬁciency of its vic-
' tims for child-bearing, and often imperiiing their
offspring with blindness; the latter inﬂicts inde-
scribable disaster upon both mother and child, and
the man who would expose an innocent wife to the
contagion of either is unworthy of the relation of
either husband or father.
If gestation is complicated with any form of dis-
ease, either acute or chronic, it should be cured if
possible; but if incurable, the system should be
strengthened and fortiﬁed against its injurious effects.
If the patient is anemic, the cause of the anemia
should be sought and corrected if possible; for it im-
perils the safety of both mother and child, impairing
the strength and vital forces of the former, and re-
tarding the physical development of the latter.
The causes of anemia are various, and may be either
inherent or acquired. Much will depend upon the
success of our efforts to control gastric irritation,
which is sometimes very persistent and distressing.
It is usually of the class of troubles called sympa-
thetic. Some years ago a patient under my care was
so distressed with nausea that an abortion for its re-
lief was seriously contemplated, when some small
granulations on the inner aspect of the cervix uteri
were discovered and destroyed. The vomiting ceased
immediately, and the pregnancy progressed normally.
The quantity as well as the quality of the. blood
should be considered. Hyperemia would in some
cases be quite as inimical to health and comfort as
anemia in others, and requires strict attention to diet
'with reference to both the quantity and quality of the
food taken. Any mild laxative which will reduce the
amount of blood serum will be of serviCe, by reliev-
ing tension and depurating the blood. Our profes-
sional ancestors did not hesitate to bleed ,,in some
cases, not only at the beginning of pregnancy, but in
all its stages, if there were symptoms of plethora,
200 MEDICAL SOCIETY OF
and the results were doubtless beneﬁcial in cases
where the plethora was excessive, preventing head-
aches, abortions and sometimes convulsions.
In the summer of 1856, while I was traveling with
a light escort down the valley of the Humboldt, we
overtook a large train of emigrants, and went into
camp a few rods below them. They proved to be
Mormons, on their way to colonize in Carson Valley,
which was at that time a part of the territory of
Utah. Early the next morning I was called to their
camp to see a young woman in conﬁnement. I found
the patient in an emigrant wagon, and learned that
she had been in labor all night, but without appreci-
able progress. I found by the touch a rigid os,
slightly tumefied, and dilated to the extent perhaps of
an inch in diameter. At the return of a paroxysm,
after the examination, the patient was seized with a
violent convulsion, and then dropped into a state of
coma, out of which she was aroused by the return of
the convulsion every ﬁve or ten minutes. Having
but few medicines with me, and as the patient was
full-habited and ﬂushed, I proposed bleeding; but,
on account of religious objections, the operation was
delayed until the patient’s condition seemed almost'
hopeless—the paroxysms more distressing, the coma
more profound, and the breathing sputtering. She was
bled to the extent of a pint or more, until she began
to look pale around the mouth and drops of sweat
distilled on the upper lip. As the arm was being
dressed the patient dropped off into a natural sleep.
She slept about an hour, and was awakened by a par-
oxysm of natural labor, and was soon safely delivered.
If this bleeding had been done at the beginning of
the labor, or at any stage of it prior to the advent of
the convulsions, they would in all probability have
been prevented.
Pregnancy creates a demand for an increase of nu-
trition, and a corresponding increase of destructive
CITY HosPITAL ALUMNI. 201
- change, while the functions of secretion and elimina-
tion may be more or less impaired through sympathy
with or pressure by the gravid uterus. In preventive
medicine our chief- reliance in such conditions must
consist in regulation of the diet, exercise in the open
air short of fatigue, and frequent bathing. These
often fail, and in some cases all forms of treatment
will prove unavailing.
When the term of gestation is completed a crisis is
reached. The uterus refuses longer to carry its bur-
den, and subordinates the energies of the entire sys- ,
tem in an effort to rid itself of the matured fetus. It
is one of the most interesting of the events of human
life, and though in .the normal state it is a physio-A
logic and natural process, the man who can look on
and not sympathize with the subject of it is a dis-
grace to the mother who bore him and a reproach to
the. species. But while sympathy is due, and is usu-
ally awarded, it is seldom that a woman normally de-
veloped and in good physical condition needs manual
aid in a normal labor. But this does not relieve the
attendant from the duty of watchful care. It de-
volves upon him to ascertain, in the ﬁrst place, if
the labor is normal, which usually requires a careful
physical examination, in the performance of which
he should exercise the utmost vigilance to keep out
that which ought not to go in. He should be careful
not. to infect his patient; and for this reason both
physician and patient should be secured against the
possibility of infection. The history of the past affords
- a sad record of the consequences of a want of cleanli-
ness and antisepsis in obstetric practice. The ob-
stetric toilet should be made with strict reference
to securing the patient against infection. All cloths
necessary to be used in any stage of the labor should
' be thoroughly disinfected. I believe in the belly
band; for while it may not be absolutely necessary,
it affords the patient a sense of support and an assu-
rance that she in not being neglected.
202 MEDICAL SOCIETY OF
During gestation the patient’s clothing should be
adapted to the season, and worn loosely, especially
after the ﬁrst three months. The waistband and the
corset should be laid aside, and a' neatly ﬁtting and
accurately adjusted elastic bandage for the support
of the abdomen will add to the patient’s comfort'and
serenity, especially in the last three months of preg-
nancy and for the ﬁrst few days on rising after con-
ﬁnement.
But in all cases and under all circumstances we
should remember that in preventive medicine "our ﬁrst
and chief aim should be to keep out that which ought
not to _go in.
DISCUSSION.
DR. ELSWORTI-I SMITH said he thought the paper
well worthy of consideration. It was interesting, in
the ﬁrst place, from this standpoint: that it gives the
Observations of a man who has had a long experience,
who has been in the work a number of years, and who
has managed to keep the good of the past and also
keep up with the pace of the present. The essayist
had certainly grasped the situation thoroughly when
he said that the great rule—the great golden rule-_in
obstetrics should be the strict Observance of cleanli-
ness. All the modern idea of asepsis was embraced
in this word. What specially brought the thought
- that Dr. Hurt had retained what was good of the past
and linked it with the present, was his advocacy of
bleeding. Of course we all“ know that bleeding was
greatly abused by our forefathers, greatly overdone; ‘
and experience gradually showed that its uses had to
be much more limited than they had been; but the
‘ speaker said he believed a physician who discarded
bleeding altogether made a great mistake. In the
speaker's experience there were several conditions
where much good would be derived from bleeding.
One such condition was that alluded to by the essayist.
CITY HOSPITAL ALUMNI. 203
He did not agree with Dr. Hurt that plethora alone
would be an indication for bleeding; he understood
the paper as giving this condition as an indication for
bleeding. In his own experience, the speaker said, he
had rarely encountered this condition of plethora,
but he could readily see where bleeding in such cases
would be beneﬁcial. However, in the case of the
young woman in labor, cited in the paper, where con-
vulsions accompanied labor, he did not think the
plethoric condition the cause of the disturbance, but
rather some poison in the blood which ought to have
been eliminated. If the urine of this woman had
been examined a renal lesion would probably have
been found and the convulsions accounted for in
that manner. In other words, she had puerperal‘
eclampsia, which we generally associate with renal
lesions, and which condition we call uremia. In
these conditions of uremia where there were convul-
sions and a tendency to coma, he said he knew of no
better or more efficient treatment, as Dr. Hurt had
cited, than venesection, and he thought it should be
done freely, removing even more than a pint. He had
seen a case come out of profound coma after the
withdrawal of a pint and a half of blood. In this
case the blood was replaced with normal salt solu-
tion; the patient recovered from this attack com-
pletely and lived for several months, but later died
in a similar attack. So he thought these profound
conditions of uremia were most effectively treated by
bleeding and transfusion with normal salt solution.
By removing a quantity of blood and replacing it
with normal salt solution we eliminate a certain
amount of the poison, and not only obviate any dan-
ger from a serious drop in arterial tension, but we
also dilute what remaining poison there may be in the
system.
He alluded to another class of cases in which
venesection was most valuable. These are cases of
204 lVIEDIOAL Socrnrr or,
acute heart strain,especially of the right heart 5 cases in
which we have suddenly developed, especially in full-
habited individuals, some disturbance which throws a
severe strain on the right heart: as in rapid inﬂam-
, matory conditions of the lung, or where a large area
is involved and the circulation disturbed;lwhere the
right heart is laboring 'under a great obstruction
ahead, he had \seen good results follow venesection.
In such cases bleeding alone was done and not fol-
lowed by transfusion, the object being to lower the
tension of the right heart in order to give it a-chance
to regain its tone, as the danger in these cases is
stoppage of the right heart in diastole from over-
distension of the right ventricle; by bleeding in these
cases we make the work easier \on the right heart and
give it time to regain itself, just as any fatigued mus-
cle will do better after a rest, and in such-cases we
may often tide over a very ugly situation by bleeding.
The cases would have to be selected, however, and
only performed in robust individuals in whom the
arterial tension is rather high; where the tension is
low and the pulse small and rapid, we could hardly
expect much from bleeding.
DR. J. (J. MOORE said he agreed with the views of
Dr. Smith. The hygiene of pregnancy was always
an interesting study, and the difficulties met with pos-
sibly made it more interesting than it otherwise
would be, especially the difﬁculties that confronted a
country practitioner. He had been doing an extensive
country practice lately, and often hisingenuity had
been taxed to meet the difﬁculties surrounding some
of his cases. Often-more often in country practice
than in the city—we see the case only when labor has
begun; nothing is heard of the case until the physi-
cian is sent for, or if we hear of it at all it is simply
a word from the huSband that we are expected on a
certain day, perhaps a week or two later. 'In these in-
stances there is no opportunity for observingthe rules
CITY HOSPITAL ALUMNI. 205
of the hygiene of pregnancy. The hygiene of labor,
however, the speaker thought, could be carried out as
well in the country as in the city, possibly better.
In his experience surgical cases had done rather better
in'the country than in the city. ' Other things being
equal, he would rather have a warm farmhouse than
the best hospital in the city. He said he might be
wrong in this statement, but he had seen good results
where the least could have been expected. The coun-
try woman, he said, had the advantage of the city
woman to this extent. In the country puerperal
troubles were rare; but the man who had clean hands
in making his examinations would see little of this
anywhere. He, believed, as Dr. Smith had said, that
cleanliness embraced the whole gospel of midwifery.‘
‘ DR. SMITH. inquired whether it was the practice of
obstetricians generally to make a complete physical
examination of each case of pregnancy before labor,
and whether this included a thorough abdominal and
vaginal examination and measurement of the pelvis.
Was it the custom to do this in every case that was
seen in time?
DR. W. S. BARKER said this particular subject had
been to some extent before the Society last year. The
question of measurement of the pelvis was also before
the Society later, when Dr. Crossen read a paper and
the subject was again discussed, most of the members
confessing that they did very little of that in a scien-
tiﬁc way; a rough measurement with the hand most
of them usually made. In regard to the physical ex-
amination, the speaker said in his work if there were
any suspicious symptoms he had always made an ex-
amination of the urine, and since the meeting referred
to he had. endeavored to do this in all cases; a urinaly-
sis in every case was emphasized at that meeting.
The careful obstetrician, or general practitioner who
did obstetric work, would make a pretty thorough
examination at this time—that is, prior to the oncom-
ing of labor.
206 MiinrcAL SOCIETY OF
DR. SMITH asked if this included a vaginal ex-
amination.
DR. BARKER said yes; healways preferred to make
'a vaginal examination and usually did so- in every
case, and found no difﬁculties in doing so.
DR. JOHN ZAHORSKY said it was not always possi-
ble to make a vaginal examination, especially in
young women. Of course, he said, it ought to be
done in each case, but in some cases the consent of '
the patient could not be obtained, and in these cases
he relied upon, external examination. Measurements,
however, could be taken with the pelvimeter and the
position of the child determined. Urinalysis ought
always to be made in every case, and, if there were
any suspicious symptoms, a vaginal examination in-
sisted upon. In regard to the use of the pelvimeter,
he did not think it was generally used; he thought it
ought to be done, especially in those cases of young
women who have not borne children. In woman who
have borne children without trouble the assumption
could be made that no trouble would ensue; yet by
neglecting these precautions something might arise
which could have been obviated.
DR. B. M. HYPES said that he was delighted to
know that Dr. Hurt was still interested not only in
the subject of obstetrics and in its advances, but in
advanced methods of managing obstetric cases.
The paper itself covered so much ground, he said,
that it would be impossible to discuss it in a general
way and do it justice. It not only included the hy-
giene of pregnancy and labor, but also the disorders
of pregnancy and accidents of labor. The general
ideas of cleanliness in parturition and all hygienic
measures in labor are to be commended and approved.
Prevention (with a big P) of complications and disease
should be the motto of the obstetrician. He said he
felt sorry that so many of 'the gentlemen expressed
the belief, and some seemed to carry it out in prac-
CITY HOSPITAL ALUMNI. 207
tice, that better obstetric work is impracticable.
He thought they were mistaken. Dr. Mardorf had
said he did not think anybody made a practice of
measuring the pelvis previous to or during labor.
Dr. Hypes said he wanted Dr. Mardorf to modify this
belief to some extent at least. During the last three
years the speaker said he had not attended a single
case of labor without having examined the woman
and measured her pelvis, unless she had previously
been examined or measured. He made it a practice
to measure every pelvis, except of course in those
cases where he knew the parts to be normal or he had
previously measured the pelvis; or if the history was
normal, as in the case of the woman having borne
several children naturally; but in all new cases he ex‘-
amined the patient and measured her pelvis. He had
never had objections raised; and when he explained
to the woman that it was a matter of necessity in or-
'der to know that she is properly formed and the
parts are natural so that she may expect a comforta-
ble and easy birth—if there is anything wrong it is
wisdom to know it beforehand so that any emergency
can be met in time—they seem to take reasonably and
sensibly to the matter and acquiesce without any spe-
cial effort on his part whatever. But he did not think
it necessary to go over that ground, as his views had
been expressed in a paper read by him last winter be-
fore this Society. However, he said, the better ob-
stetric work is not only possible but absolutely
proﬁtable, and where the physician takes special pains
and care in directing the woman and measures the
pelvis and looks after her welfare he gets credit for it
afterwards and a better fee. He said he now gets
twice as much for his cases as he did ten years ago.
‘This, he said, is the position taken by advanced mem-
bers of the profession everywhere, as far as he knew_
Every work on obstetrics published in the last ten
years insists upon this general care of the woman
208 MEDICAL SOCIETY OF
l
during pregnancy and labor. At every convention,“
national or international, of Obstetricians these points
are insisted upon, and they go so'far as to blame
physicians fOr not carrying them out. Recently he
had been called in consultation to see a woman in la-
bor. She had been in labor a long time and wasalmost
in articulo mortis. The physician attending her was
a fairly well educated man and had quite a practice,
as the speaker knew, but he had been attending this .1
woman for thirty-six hours and had not measured the
pelvis; whether he had examined the urine he could
not say; he had applied forceps a number of times
and endeavored to deliver an ordinarily sized child
through a pelvic diameter of three inches; it was very
easily measured upon the ﬁnger. In order to deliver
the child, craniotomy had to be performed; the child
was dead at the time Of the Operation and the woman
' died two hours after delivery. This was not a case to
relieve during labor; but if the physician had taken
the pains to investigate beforehand he would have
recognized the condition and the woman could have
been delivered by premature delivery or a suitable
operation during labor. Our obstetric practice
ought to be improved and the welfare of the pregnant
woman more carefully guarded.

:STATED MEETING, THURSDAY EVENING, OCTOBER 5,
THE PRESIDENT, DR. GEORGE HOMAN, IN THE CHAIR.

DR. FRANCIS REDER presented a patient with a
' Gastric Tumor.
That was, at least, the provisional diagnosis, and
he said he'was not satisﬁed with it. Some ﬁve weeks
ago he had seen her at her house, and she then told
him she had a pain in her stomach. No examination
was made at the time, and little attention paid to the
symptom, thinking it a pain due to some digestive
CITY HOSPITAL ALUMNI. 209
disturbance, as She was working about the house dur-
ing the time. He prescribed a remedy which he had
found usually relieved such disturbances. At the
next visit she informed him that the pain was still
there. He then examined the patient, and found a
swelling large enough to take in the entire pit of the
stomach. When questioned the patient said this
lump had been there about six months, but she had
at no time been sick enough to go to bed, but she
would sometimes lie down to rest. The pain is not ag-
gravated by food nor if the stomach is empty. The
character of the pain is of a burning Sensation, not-
lancinating', nOr sharp nor acute. It is dull and
heavy, sometimes feeling as if there was a burning
in the stomach: i Her present weight she j udges to be
about 125 pounds. Two years ago she weighed 140
pounds. Appetite is good, and at times she craves
certain kinds of foods. No febrile disturbance.
‘Occasionally during the afternoon there is a ﬂushing,
something of the hectic nature. The pain is con-
stant, and with it there are frequently signs of nau-
sea. This has never been to such an extent as to
cause vomiting; but there are frequent eructations
and quite a quantity of salty water. Her general
condition is that of a woman in fairly good health.
She has been married ten years, but has never been
pregnant. There is some menstrual trouble, which,
however, he did not think had anything to do with
this condition. His ﬁrst inference of this case was
that it was a' gastric trouble. Now, however, he
felt as though he would like to deviate from that and
say it was hepatic. The patient was then placed on
the table and examined by the members.
‘ DISCUSSION.
Dr. G. BAUMGARTEN said he did not think a diag~
nosis could be made in a case of this kind'from such
an incomplete physiCal examination such as he was
210 MEDICAL SOCIETY OF
able to make to-night. He would want to know a
great deal more about the patient in order to arrive
at a diagnosis, especially in regard to the history.
He said he had hardly any doubt that the tumor was
one of the liver; whether of the parenchyma of the
liver or a new formation, or an outside growth, could
not be determined. He said he had seen a tumor
much like this one, in a negro woman; but he did not,
mean to say that this was such a tumor, but only to
emphasize the necessity of a more thorough history
of the case. This woman was sick enough to go to
bed occasionally when she found it possible to do so,
_and said she thought she had had fever. He had
tried to get at a history of an inﬂammatory trouble.
He was not ready to make any diagnosis of the case.
DR. L. H. BEHRENS said: In regard to eliminating
any gastric trouble after the history of being able to
tolerate any fatty foods, and while there was no vomé
iting, yet there was distress, he believed the contents
of the stomach should be thoroughly examined. This
would probably throw some light on the condition.
He was not satisﬁed that it was conﬁned entirely to
the liver. He had seen a case operated upon recently
with a history similar to this case, and an obstruction
of the pylorus was found due to a tumor in that region.
Such an examination as was possible this evening,
however, could not demonstrate whether in the stom-
ach or connected with the liver substance.
DR. NORVELLE WALLACE SHARPE said the case im-
pressed him as one of the many that doctors fail on.
There are a great many erroneous diagnoses made to-
day upon cases of this obscure type. He agreed with
Dr. Baumgarten in believing that it is quite impos-
sible to make a diagnosis in a case of this type with-
out an anesthetic. He did not feel in accord with
‘ Dr.iBehrens in regard to the exclusion of the stomach
(upon the symptomatology). The ‘slight manipula-
tion he had been .able to make inclined him to believe
CITY HOSPITAL ALUMNI. 211
it. was a hepatic trouble. He thought, too, that he
could distinguish a high-pitched percussion note,
' found in displacement of the colon, which will fre-
quently dissimulate an involvement of the left lobe of
the liver when shielded by colon. I '
DR. J. P. BRYSON said he had watched others make
_ an examination, and his suspicions were in the direc—
tion of a cyst—a cystic condition. He thought prob-
ably all the gastric symptoms might be accounted for -
on the ground of pressure. He asked Dr. Baumgar-
ten whether in the case of a gummatous lesion of the
liver there were febrile disturbances?
DR. BAUMGARTEN said there were in the case to
which he alluded. There had been considerable com-
.plication aggravating the stomach conditions. Th‘e
patient could bear no food. When he ﬁrst saw her
he made the diagnosis from the lesions found, though
he asked her questions and put her on a treatment
_ which he thought would most quickly arrive at the
result, and within several weeks She was able to take
all the food she. wanted in her stomach, in spite of
the mercurials and in spite of the iodids, and she was
perfectly able to digest food, and had no more fever
or other complications of that kind. He could not
just then recall the details of the case.
DR. BRYSON said the reason he asked the question
was to bring out the fact that in these cases 'of gum-
matous lesions, as well as in other tumiform lesions,
the temperature curve is very misleading. He had
seen very large gumma of the liver with very little,
fever, and comparatively small ones with fever, and
he had always been inclined to attribute the fever rise
to a softening of the tumor and as a result of patho-
logic conditions.
DR. JACOBSON asked Dr. Reder if he had used the
electric light. He said this was sometimes a very
good means of making a diagnosis by throwing the
light directly into the stomach.
2'12 MEDICAL SOCIETY OF
DR. REDER said he had not used the electric light.
DR. J. O. MORFIT said the examination had not
been complete; but the case reminded him more of a
cirrhosis of the stomach, if it is a stomach trouble.
He had seen a case of this nature in a woman 25
years of age. From the continuity of the parietes he
would be inclined to consider this an hepatic lesion,
but before deciding he would want to know more
about the size of the stomach. ' This could be ascer-
tained by inﬂation of gas or introduction of water.
DR. ELSWORTH SMITH said he was in the same po-
sition as the other gentlemen. He thought it impos- _
sible to make a diagnosis from such a Superﬁcial
examination as had been possible. The condition
might be one of several lesions, as brought out by the-
difference of opinion in the discussion. He said he
was not altogether satisﬁed that it might not be an
hysterical condition. He asked Dr. Reder if he had
ever noticed any change in the tumor.
DR. REDER said it appeared rather large to him
this evening; that is, it appeared more prominent.
DR. SMITH said the woman gives a historyof loss
of ﬂesh, yet her general condition seemed to be good
for one suffering with a grave lesion. It might be in
the abdominal wall, in the stomach, or the left lobe of
the liver, or, as suggested, in the colon. '_ He thought
Dr. Morﬁt’s suggestion of inﬂating the stomach a good
one. The Size of the stomach Should be known, es-
pecially if the tumor involved the pylorus. Of course
achemical analysis of the contents of the stomach
ought also to be made, before deciding that it is a
stomach lesion. What suggested to him that it might
be in the left lobe of the liver, was-that he thought he
could detect a movement of the liver with respira-
tion, which rather tended to localize the trouble to the
liver. He thought the tube ought to be introduced
into the stomach, of a test meal, and the stomach
nﬂated and outlined. Failing in this he thought it
possibly justiﬁable‘to put the knife in. '
CITY HOSPITAL ALUMNI. 213
DR. KLOKKE said he thought the tumefaction was
connected with the liver. It might be gummatous,
as suggested by Dr. Baum-garten.
DR. REDER said, in conclusion, if we could exclude
the stomach as the initial lesion, and regard the
chronic feature as secondary, he felt strongly inclined
to believe there was a small abscess encapsulated in
the left lobe of the liver. After an examination Of
the contents of the stomach was made and he still
found. symptoms indicative of this, he said he would
make an exploratory incision.
DR. J. C. MORFIT presented a patient—a child-
who, he said, had been sent to him a day or two ago
with a doubtful history of hernia. To all appear-
ances it is a hernia, but only to appearances; not to
a general examination. After a thorough examina-
tion it gives all the cardinal symptoms of hydrocele_
from the tense, elastic, translucent tumor extending
well up into the inguinal canal; no pain, no fever and
nothing but inconvenience of the size of this organ.
The child is ﬁve years old, undergrown, possibly not
as well nourished as it should be, certainly not as
' large. There is no history to lead him to arrive at a
cause of this, and he was puzzled for a long while to
know just what it was. When he put his ear to the
chest of the child he discovered unmistakable heart
sounds, a systolic and possibly a pre-systolic murmur,
and he wondered if this condition of hydrocele could
not be secondary to the heart lesion. He thought if
this could be established it would prove an extraordi-
narily interesting case. We often have edema and
sometimes a gangrenous scrotum due to secondary
‘ heart lesions, but he had never heard of a hydrocele
due to the backing up of the circulation as a result of
mitral regurgitation. The tumor started about three
weeks ago. The swelling began below and extended
upwards. '
214 MEDICAL SOCIETY OF
DISCUSSION.
DR. ELSWORTH SMITH said he thought the case ex-
ceedingly interesting. Whether or not the eﬂ'usion
in the tunica vaginalis is dependent upon the heart
lesion, and, secondarily, just what this heart lesion
is, the examination was not satisfactory because
there was not enough time for it to be So. He
thought the heart lesion was probably congenital.
There is a very loud systolic murmur, with greatest
intensity in the pulmonary area. He said he would
like to know something of the early life of the-child
and its history at birth—whether there were any”
marked disturbances of circulation at that time. As
to whether the heart lesion can account for the ﬂuid
in the tunica vaginalis was something which he had
been puzzled about of late. With heart lesions we
very often see a more or less localized edema. We
often see cases of a general disturbance in compensa-
tion without general anasarca; but there will be a
localized edema somewhere—in the lungs, for in-
stance. He had seen just such a case recently where
there were moist rales in both lungs, but no general
anasarca, though the heart was bad. On the other
hand, there are cases where the heart seems to be
doing its-work and yet we ﬁnd a general anasarca.
These are cases, as far as he had been able to make
out, which had been exposed. If this is true, he
thought it just possible for the eﬁusion in the patient
present. to be due to the heart lesion. Of course, he
knew that we do not have to go that far to explain it.'
If it is true that this effusion is due to the heart
lesion, why do we not have hydrocele in general
anasarca? yet he could not recall a case of general
anasarca injwhich there was effusion into the tunica
vaginalis; it is nearly always in the tissues of the
scrotum. 'He thought this was one of the interesting
questions in the pathology of heart lesions.
DR. L. H. BEHRENS said he heard no rales in this
CITY HOSPITAL ALUMNI. 215
case and he was inclined to regard it as aortic regur-
gitation ,with a mitral lesion. He noticed marked
pulsation in the extremities, and also noticed a very
distinct mitral or systolic sound at the apex and
transmitted to the back. He remarked that he lost '
Sight of the question of the ﬂuid in the tunica, because
the heart condition was so interesting. He did not
believe, however, that the heart lesion had anything
whatever to do with that feature.
DR. J. P. BRYSON said he took it to be a case, from
a very superﬁcial examination, of undescended testi-
cle on the right side with encysted hydrocele on the
left side, but he thought nothing positive could be
determined until the ﬂuid had been drawn off. He
did not believe there was any‘occasion for connectiflg
the. hydrocele with ptherheart lesion. This form of
hydrocele is often seen in children with perfectly good
hearts, and it is Often not- found in children with bad
_ hearts.
DR. G. BAUMGARTEN said he did not think there
were any grounds for connecting the hydrocele with
the heart, nor did he see why a heart lesion should
ever cause a hydrocele; such an edema was not to be
compared in the least with an edema of the lungs.
Hydrocele in children is not a very rare aﬁection,
neither are compensated heart lesions; and he did not
see any reason for supposing that one of these many
children with a compensated heart lesion should have
a hydrocele due to this cause.
DR. MORFIT, in closing, said the coincidence of the
two affections, the heart lesion and the hydrocele,
caused him to wonder if there could be any etiologic
factor between the two, and had brought the case be-
fore the Society merely to get the Opinion of those
men skilled in these affections. Of course he recog-
nized the fact that the two conditions could be inde-
pendent of each other. The history of the case threw
no light on the matter.
216 MEDICAL SOCIETY OF
DR. L. H. BEHRENS read a paper upon
Some Difficulties in the Early Diagnosis of Pneumonia.

DISCUSSION.
DR. ELSWORTH SMITH said he had an opportunity of
seeing one of the cases in consultation through the
courtesy of Dr. Behrens. He saw the case on two
. occasions, and he said he felt-that it was one of those
anomalous cases of pneumonia which it is almost im-
possible tO make out early in the attack. He ﬁrst
saw the patient aboutthirty-two hours after the-at-
tack, and the history he obtained then pointed dis-
tinctly and directly to angina pectoris. There was no
initial chill; there was no cough, and the picture as
described by Dr. Behrens to him impressed him as
one typical of true angina pectoris. The behavior of
the pain, the sensation of impending dissolution, all
gave the classical symptoms as we would expect to
see them in angina pectoris. Even when the pneu-
monia was developing the only thing which caused
them to hunt the chest was the rise in the tempera-
ture. The patient developed a temperature of 104%,,
which is, of course, very rare in an attack of angina
pectoris; but even with this temperature the patient did
not look like one with a pneumonia. It is not usual
to see a case of pneumonia sitting up in bed; this pa-
tient sat propped up just like a heart case, and lean-
ing forward. He had the expression not of pain,
but a decidedly anxious look; he was not ﬂushed like
a pneumonia case is. He was, in fact, bathed' in a.
clammy sweat when seen by the speaker, and gave
every evidence of a person in severe pain. The ques-
tion might come up as to whether the patient did have
an attack of angina pectoris, but Dr. Smith said
there was nothing to base such an opinion upon.
There were no renal'lesions, and the arteries were
in good condition. He had no cardiac lesion, and
there was no reason to assume a lesion in the coro-
CITY HOSPITAL ALUMNI. 217
'nary arteries. The case was one of those misleading ‘
cases in which there was a late localization of a gen-
eral infection. Instead of ﬁnding crepitation promptly,
as is usual, this was delayed many hours. Another
peculiar feature of the case was that the cough did
not set in until what was taken to be resolution had
begun. On the ninth day the cough commenced; and .
then he found the rales redux, and they felt that
there was an attempt at resolution. The case was
very interesting, and our only safeguard against
making mistakes in' like conditions is to have them
reported.
DR. G. BAUMGARTEN said the cases were certainly
very interesting \because of the anomalous beginnings
of pneumonia. To him they pointed two lessons.‘
First, as to the pain. The case which Dr. Smith just
' referred to suggests this. The speaker said he had
always taught that the seat of the pain is no indica-
tion of the pulmonary lesion; 20 or 30 per Cent. of
pneumonias of the base of the lung at least present
as the initial feature a pain in the pectoral region, and
in such cases it is impossible to judge, from the seat
of the pain, in which lung, the left, or right, the
pneumonia maybe developed. In regard to the ﬁrst
case reported by Dr. Behrens, the speaker said he be-
lieved the pain was really a pain located in the heart.
When Dr. Smith spoke of a true angina the presump-
tion was that he meant areal angina, but not a true an-
gina in the strictest sense; but, notwithstanding, the
whole picture can be called angina pectoris, one of the
nervous kind; it was really the initial pain of pneumo-
nia. Pneumonias in the base of the left lung are
very apt to cause this anomalous pain. The other
‘feature as to the late temperature in the one case is
not uncommon. He had seen several cases develop
with practically no fever-no rise above 99?}. He
had seen one case of repeated attacks, in the course
of which both lungs were involved, develop with no
218 MEDICAL SOCIETY OF
higher temperature than 101. He thought the drop.
from 99%,~ to 98 was really the drop of the crisis.
The PRESIDENT said the experience of the essayist
in the last case reported called to mind a case in
which he had a someWhat similar experience. The
patient was a robust man of about 50 years of age,
who had a chill on Saturday. The following Tuesday
the speaker saw him, and the temperature then was
103. There were no pneumonic symptoms, and noth-
ing to attract attention to the chest, and only by a
physical examination was the presence of the pneu~-'
monia established, consolidation having set in. There
was no cough, nor had there been any -expectoration
About ﬁve or six days after he was ﬁrst seen the rales
redux appeared, and the patient seemed to rest com-
fortably, although the temperature Continued high.
It went as low as 102, however. A fresh infection set
in, and the temperature went up to the original ﬁgure.
The patient complained of no pain, and was quite clear
in his mind except toward the end. In the second
week of treatment the speaker was called out of town,
and left the case in charge Of a consultant; but the
patient died four days later of meningitis. What
variety of organism it was that produced the disease
was not ascertained, whether the streptococcus or the
diplococcus, but there was a very general pneumonia
without any cough or much pain and no reference to
the chest.
CITY ' HOSPITAL A ALUMNI. 2 1 9
STATED MEETING, THURSDAY EvENING, OCTOBER 19,
THE PRESIDENT, DR. GEORGE HOMAN, IN THE CHAIR.

SOME INTERESTING GENITO=URINARY SBECIMENS
BY BRANSFORD LEWIS, M.D., St. Louis,
Professor of Genito-Urinary Surgery in the Marion-Sims College of
Medicine.
COMPLETE DOUBLE URETER.
HE ﬁrst specimen here shown is an anatomic
curiosity. It shows a cOmplete double ureter
from the kidney down to the bladder, with two
separate openings into the bladder. An explanation
of the embryology of this curiosity is not easy; and it
is not frequent in its occurrence. I had never seen
a case before this one, and yet within two days at
the City Hospital this summer two such cases ap—
peared.
Two RIGHT KIDNEYS.
The next specimen is another anatomic pecu-
liarity with reference to the kidney. This is
from a man who had no left kidney, but who had two
right kidneys; that is to say, thefe was a super-
numerary kidney on the right side and nOne on the left.
The upper one was located in its normal position, the
extra. one being on the same side, but lower down
toward the pelvis, lying in the right iliac fossa. It
received its blood supply as follows: the renal artery
from the right common iliac and an extra twig from
the abdominal aorta passing over instead of under the
kidney, and entering the hylum through a ﬁssure at
its loweryedge. The renal vein entered the right
common iliac. The ureteral openings of both these
right kidneys were placed one on each side of the
trigone, at‘the sites of normal ureteral openings.
DILATED KIDNEYS AND BLADDER.
The next specimen is one of dilated kidneys and
bladder, the result of a neglected stricture. The
220 MEDICAL SOCIETY OE
bladder, as the result of the alcohol in which it
has been placed, is at present contracted, smaller than
it was in the fresh state, but even'now you can see
that it is widely dilated; and there is a pronounced
dilatation of both kidneys, the condition of hydro-
nephrosis being approximated. BOth ureters are also
enlarged. This condition, as is readily apparent,
resulted from the continued backward pressure from
neglected strictures in the urethra. The man could
undoubtedly have been relieved by proper treatment,
and his bladder and kidneys retained in a normal
state by' appropriate measures undertaken in time.
GONORRHEAL KIDNEY.
The next specimen is one that I show through the
courtesy of Dr. Nietert, Superintendent of the City
Hospital, and I think is very remarkable. It is a
gonorrheal kidney, and the history of the case is
peculiar in that no history of gonorrhea could be ob-
tained from the patient during life. This patient,
F. F., age 54, Single, a laborer, entered the City-
Hospital July 24, 1899, in a semi-comatOse condi-
tion, which resembled that of uremic intoxication,
and he remained in this condition for the most part
Of the six days that he lived thereafter. AS a re-'
sult, but little deﬁnite and reliable history could be
Obtained from him. He said, however, that he had
never had venereal disease; neither gonorrhea nor
Syphilis. He said that some twelve years ago he had
noticed a heavy pain in the region of the kidneys.
There had been frequency of urination and the
passage of only a small amount each time. Since that
time there had constantly been a sediment in the
urine. Of late years there had been gradual in-
creasing development of lassitude, constant head-
ache, vertigo, failing vision, anemia, indigestion,
sleeplessness, dyspnea on slight exertion, and loss of
ﬂesh. For three weeks before entering the hospital
he had daily chills and fever, and other symptoms
CITY HOSPITAL ALUMNI. 221
that were interpreted by him as malarial. In the
hospital his blood was examined and the plasmodium
malariae was found. Physical examination showed
marked arterio-sclerosis, marked anemia, and lack of
nutrition. There was a limited movement of the
Chest walls, dyspnea, and sunken abdomen; edema of
the lower extremities, especially of the left, and
edema of the lower eyelids. Urine, sp. gr. 1014;
alkaline, yellowish, large amount of albumin; heavy
milk-like deposit, containing epithelial cells under-
going fatty and granular degeneration; epithelial
casts; a few hyaline casts, and a great many leuco-
cytes and crystals (triple phosphate).
Ante—Mortem Diagnosis. — Chronic parenchyma-
tous nephritis and malarial intoxication. Treat-
ment: quinin, stimulants, and diuretics. The patient
gradually grew worse, and died July 30th. Post-
mortem report: heart area about normal; upper lobe
of left lung contains numerous ﬁbromata and tuber-
culous cavities; lower lobe contains much air; right
lung, numerous ﬁbromata throughout, cavities at
apex; marginal emphysema (vicarious); spleen en-
larged, capsule thickened, pulp anemic. The left
kidney showed the following: fatty capsule, about as
usual; tunica propria removed with extreme ease;
the kidney is pale; the remains of a septic infarct
and several cysts are seen on its surface; cortex pale
and cortical markings indistinct. Bight kidney:
ureter immensely thickened; fatty capsule present;
tunic very much thickened, and removed only with
the tearing of the kidney substance. On section it is
seen that the whole of the medullary and cortical
portions are broken down into partly separated cavi-
ties, containing a large quantity of pus and decom-
posed urine, and lined with gangrenous membrane.
A specimen of pus taken from this kidney by Dr.
Gradwohl, Bacteriologist to the Hospital, was ex-
amined microscopically and subjected to culture
222 . MEDICAL SOCIETY OF
experiments. Under the microscope, diplococci were
observed within the pus cells, and they responded to
the Gram test, as do gonococci, being freed from the
stain by washing. Inoculations were made on the a
medium recommended by Young and Hagner (urine
agar), and pure cultures of the same diplococci were
obtained, which also responded to the Gram test.
We know that gonococci wander through the differ-
ent parts of the body producing various gonorrheal
inﬂammations, arthritis, endocarditis, etc., but in-
stances of gonorrheal kidney, such as the specimen
here shown, are, I think, very rare. The ability of
gonorrhea to attack and destroy solid tissues has
been shown by Wertheim, and this is a case well
illustrating that fact. The whole of the secreting and
excreting tissue of the kidney is destroyed in this
instance. No organisms were found other than
those of gonorrhea. Of course, if the patient’s case
had been completely and accurately diagnosed, and
also if his condition had permitted it, he ,might have
been ~relieved of this gonorrheal kidney by nephrec-
tomy; but, aside from the question of diagnosis, his
condition was so low that he could not have been
operated upon at any time during his six days’ stay
at the Hospital before he died.
URINARY, LITHIASIS.
The next case is a whole clinic in itself-'Ohe of
urinary lithiasis. The patient had been in the Hospi-
pital twice during the last year. The ﬁrst time in
the early spring, and the last in July. Previous to
that time he had been under the care of other sur-
geons. In July, when he was in the City Hospital,
and when I saw him, he gave a history of having been
Sick for twenty-six of the twenty-eight years of his
life, so that he really could not remember a day of
health. .When two years old he wasv said to have
Shown the effects of the condition that was after-
wards learned to be connected withtdisease of his
CITY HOSPITAL ALUMNI. 223
kidneys. At the‘ti'me- of his entrance into the HOspi-
.tal he was a mere Skeleton and extremely anemic.
He complained of numerous symptoms connected
with the urinary organs, principal amongv which were
severe pains in the region of the kidneys and urethra,
constant desire to urinate, and there was a frequent
deposit of pus in the urine. Drs. Witherspoon and
Amyx examined his bladder with a cystoscope, and
found there a large amount of inﬂammation of the
mucOus membrane. They also deﬁnitely determined
that the urine came from both ureteral openings. In
view of the post-mortem developments, this ﬁnding ,
is of great importance. As there was a larger
amount of inﬂammation around the left than the
right ureteral opening, and also because the patient
complained more of the left than the right renal region,
it was considered proper to do an exploratory nephro-
tomy on the left _side. This was done through the lum-
bar region by me; a renal and peri-renal abscess was
opened up, and a stone about the size of the end of
the little ﬁnger was removed from the tissue of this
left kidney. Free drainage of the abscess of the kid-
ney was secured, and the patient Was returned to his
bed. His debilitated condition absolutely prevented
the consideration of nephrectomy, which operation, if
it could have been done, would no doubt have secured
him some lasting beneﬁt. It was necessary to per-
form the operation rapidly in Order to get him Off the
table alive. He lived for only a week or ten days
afterward, and then died of exhaustion. It may be
said that the operation of nephrO-lithotomy, and the
drainage that was secured thereby, did him the ser-
vice of relieving him of the continued septic fevers
to which he had been subject a long time before the
operation, On post-mortem the organs were found
to be in the following state, as illustrated by the
specimenswhich I now show you: the left kidney was
tunnelled by an abscess cavity, communicating by
224 . MEDICAL SOCIETY OF
drainage tube with the lumbar wound which I made
in operating. A smaller cavity showed the location
of the stone. The left ureter was very largely thick-
ened, and contained in its channel was the calculus
here shown. It seemed to ﬁll up the ureteral chan-
nel completely; but, as I mentioned, the cystocopic
examination disclosed the fact that urine passed
through it, notwithstanding the presence Of the
stone. The right kidney was even larger than the
left. '
The patient was a sufferer from lithiasis from the
time of his birth. At one time Dr. Senn of Chicago
operated on him by supra-pubic cystotomy, and
maintained drainage for a time, but it gave him no
lasting beneﬁt. '
ADENO-CARCINOMA OF PROSTATE AND BLADDER.
The next case,' which was quite a puzzler, was also
a patient at the City Hospital, and under the care of
Dr. Amyx, Assistant Superintendent. The patient was
54 years Old, and came to the hospital one afternoon
complaining that for twenty-fOur hours he had not
been able to pass any urine at all, following a trip to
the top of the Custom House. On entering, his legs
were swollen with edema, and he was complaining of
the intense pain from complete retention. Dr. Amyx
tried various methods of catheterization, soft cathe-
ters, ﬂexible catheters and metal catheters being
used, but he was unsuccessful in all his attempts, so
he had ﬁnally to resort to the trocar and canula and,
draw off a large quantity of urine. On the same
~evening,'I made similar attempts at catheterization,
but was unable to introduce the catheter further than
the prostatic region. A large mass was noticed in the
rectum, which we supposed to be an enlarged prostate.
In view of our inability to enter the bladder by the
normal route, I made a perineal opening into the
prostatic urethra, and tried to introduce different
forms of catheters or to make my ﬁnger pass to the
CITY HOSPITAL ALUMNI. 225
bladder cavity, but was unsuccessful. The mass was
jammed so closely against the pubis that no instrument
would pass through except by being forced through
thesolid tissue of the growth. It was a remarkable
casein this respect; I have never seen one like it.
We immediately did supra-pubic cystotomy, and then
learned what was the condition inside of the bladder.
With the assistance of the knife, perineal drainage
was effected, together with that through the supra-
pubic route, and the patient was placed back in bed.
Relief from his retention was, of course, secured
thereby, and he was comfortable, but the operation
did not prolong his life, in that he died two days
later. It was only by post-mortem examination that
a complete diagnosis was made. As you can see, a
mass Of hard, so1id tissue has taken the place of the
prostate and posterior wall of the bladder. It has
Obstructed the outﬂow of urine so effectually that the
kidneys have become sacculated, as you see. Dr.
Bartlett, pathologist to the hospital, kindly made a
microscopic investigation of the tumor, and found
it to be adeno-carcinoma. A peculiar feature of the
clinical history of the case is that there had been no
marked complaint of urinary diﬁiculty up to within a
very short time before he died. There had been an
inability to urinate—probably some hindrance to the
outHOW—but the complaint was not Of the degree
that was to be expected in such a condition as found
in post-mortem.
OALOULIIIN THE KIDNEY.
The next specimen is one of the most beautiful
that I have ever seen. It consists of a kidney with
7 or 8 calculi lying in the kidney tissue and one or.
two within the pelvis of the kidney.
URIC ACID STONE.
The next one is a uric acid stone which I removed
from a movable kidney of a woman. She had been
suffering from severe pains in her back since child'-
226 MEDICAL SOCIETY OF
hood and a large number and various kinds of treat-
ment had been applied for years, without relief. The
operation that I did, nephro-lithotomy, to which was
added the anchoring of the kidney into its proper
place, afforded her great relief and restored her to
health which she has been enjoying for years. . '
\
A WILLOW swITCH IN THE BLADDER.
The next specimen was quite'surprising at the time
of the operation: The patient,‘I knew,-had a stone
in the bladder and I operated for the purpose of re-
moving it, but I did not expect to ﬁnd this specimen:
a willow switch about 4 inches lOng, incrusted with
phosphatic material, evidently of from three-fourths to
an inch and a half in thickness. The patient afterward
admitted that he had shoved a willow switch into the
'bladder through the urethra for the purpose, as he
said, of increasing the size of that channel. The
switch had broken Off and remained in the bladder
until the time of the operation. He obtained relief
afterwards. -
URIC ACID STONE.
The next is a small uric acid stone that I removed
from the bladder of a young man 21 years of age,
during last spring. His uric acid tendency was very
marked, so that he required treatment on this ac—
count for some time to relieve the cystitis accom-
panying-it. '
RENAL CALCULUS.
The next is a calculus that came from the kidney.
The renal calculus being nearly always primary, it is '
therefore seldom phosphatic in nature; whatever the
original nucleus of this calculus, it is evident that
the bulk of it is phosphatic; and the pyelitis result-
ing was accompanied with alkaline urine, an excep-
tion to the general rule.
AN ELONGATED PREPUCE.
The next specimen is an oddity in the way of a
prepuce, for which I did circumcision. It is about
one and one-half inch in length.
CITY HOSPITAL ALUMNI. "22.7
. HYPERTROPHIED PROSTATE.
The next three specimens illustrate differing modes
by which hypertrophied prostate causes obstruction
to theurinary outﬂow. They are simply pathologic
specimens, for which no operation was done in life.
OBSTRUCTIVE PROSTATIC HYPERTROPHY.
The next one is a specimen showing Obstructive
prOstatic hypertrophy, and also the effects of the
Bottini operation forthat condition. This specimen
is also from a patient at the City Hospital, and the
whole course of the case was under the direct Obser-
vation of the Superintendent of the Hospital and his
corps of assistants. The patient was a man of 65 -
years Of age. On arriving at the hospital he showed
his feebleness as well as his age by anemia, de-
bility and lack of tone in all respects, besides in-
ability to Uri-nate, which had existed for a considera-
ble but indeﬁnite length Of time. At the time he
entered the hospital, on applying the test for residual
urine, 28 ounces were drawn after he had passed all
- that he could voluntarily. The man had been in the
.habit of urinating from thirty to thirty-ﬁve times in
the twenty-four hours. He had tried the effects of
catheterization without any relief. Involvement of _
the kidneys was shown in the presence of albumin,
casts and pus in the urine. _I performed the Bottini
operation under local anesthesia (cocaine), without
any shock to the patient and without hemorrhage.
The only indication of bleeding was the tingeing of the
solution used for.,irrigating the bladder after the ope-
ration. Usually in this operatiOn three incisions are
made into the prostatic tissue, but because of the
debilitated condition of the patient I considered it,
best to make only one incision, and get him oﬁ“ the
table. That incision was made posteriorily, at what
might be termed the junction of the median with the
right lobe. The patient was kept in bed a few days
after the operation, and it was ten days or more before
228 MEDICAL SOCIETY OF
any deﬁnite evidences of improvement were Observed.
Until the second or third day after the operation the
patient was less able to pass water than he was before
then, so-that one or two catheterizations became neces-
sary. After the tenth day evidences Of improve-
.ment were noticed in the, gradual decrease in the
amount of residual urine corresponding with de-
creased frequency in urination, affording him oppor-
tunity to obtain more sleep. In about three weeks
after the operation he had about 10 to 12 ounces of
residual urine; in about four weeks something like 3
or 4 ounces of residual urine; and after that it came
- down to 1 or 2 ounces. In six weeks after the ope-
ration he was required to urinate only about Seven or
eight times in 24 hours, instead of thirty to thirty-
ﬁve times, as had been the case before the operation.
~He declared himself as vastly beneﬁted. He said
that he could now enjoy a night’s sleep, something he
had not experienced for a number of years, and other
evidences of improvement were correspondingly n0-
ticeable. The patient-"also suffered from a hernia
that was quite extensive, and gave him pain. . I had
in view the idea of presenting him to this society,
and proposed it to him; he consented, but asked that
the presentation be postponed until he could have his
hernia operated upon, and then show himself well in
all respects. I ﬁnally agreed to this, and he was
turned over to the general surgical staff. The result
was not fortunate. The wound became septic; infection
and gangrene of the scrotum and right testicle ensued,
followed by gangrene of the right lung, erysipelas
of the face and gangrene of the bladder. He died
within a week after this operation. The post-mortem
specimen that I show you here illustrates beautifully
the form of hypertrophy that produced the obstruc-
tion to the outﬂow of brine, and likewise shows the
effect of Bottini’s incision that I made. When I
bring the surfaces of the incision together, the collar
CITY HOSPITAL ALUMNI. '229
surrounding the urethral outlet of the bladder is
readily apparent, and it can be seen why there should
have been so much interference with urination (28
ounces of residual urine), and likewise the dilated
condition of the bladder to which it led. 'An eleva-
ted ridge surrounds the opening, and during life
probably acted like a puckering-string might do, fall-
ing together from the pressure of the urine on the
inside,iresulting in a tighter closure the greater the
pressure, up to a certain point. The electrO-incision
made now enables me to separate the wound-surfaces,
showing a marked groove through the prostatic col-
lar alluded to, indicating the channel of freer out-
ﬂow for the urinethat resulted from the operation. '
This specimen also shows the inter-ureteric fold of
the bladder, and elevated fold Of the mucous mem-
brane extending from one ureteral opening to the
other.- The importance of this structure comes from
the fact that it is liable to be burned through in the
Bottini operation unless provision'is made to prevent
it. Freudenberg met with such an accident in one
case, causing suppurative peritonitis and death. To
ward against the possibility of such an occurrence he
then advised the distention of the bladder with boric
acid solution preliminary to doing the operation. For
various reasons not necessary to‘ state here, I sug-
gested the substitution of air for the solution, and
used it satisfaCtorily in several cases. Since then
Freudenberg has adopted the-suggestion, as indicated
in a personal letter to me, printed in the .New York
Medical Record, July 1, 1899. A later communica-
tion said that he had used it in fourteen cases. ‘
COMBINED SUPRA~PUBIO AND PERINEAL PROSTATECTOMY.
The next specimen Consists of the whole of the
right lobe and greater portion of' the left lobe of
a prostate, removed by combined perineal and supra-
pubic incision. The patientwas 79 years old. His
retention of urine, which had been complete for
230 MEDICAL SOCIETY OF
some time before the operation, was relieved by that
procedure, but just about that time the patient died,
in which respect we were disappointed. It is my
opinion—and also that of Dr. Nietert of the City
Hospital—that the only operation that stood any
chance of relieving this patient was the Bottini. I
tried to do this at ﬁrst, but did not succeed in get-
ting the instrument into the bladder, even under an-
esthesia, and was compelled therefore to resort to the
other procedure. Besides his old age and marked
debility, the patient had granular kidneys and was
passing about 120 ounces of urine in 24 hours; he
had been giving evidences of uremic intoxication fOr
more than a month previously. If the BOttini in-
cision could have been made, a groove through the
obstructing prostatic tissue would have allowed of
improved drainage of the bladder without, probably;
adding materially to the debility and shock, since
there would have been two seared, non-bleeding sur-
faces of small extent, instead of large surfaces, open
to infection and tending to bleed, etc.

DISCUSSION .
DR. J. P. BRYSON said there was such a profusion
of riches in what Dr. Lewis had presented that it
would be impossible to cover the ground in an ordi-
nary discussion. Referring to the question of de-
formities of kidneys, the speaker said the case of
gonorrheal kidney was certainly very remarkable. It
was a question whether the gonococcus can reproduce
itself in an acid ﬂuid and attack the mucous mem-
brane of the bladder in such a way as to infect it. If
the condition of this specimen was produced by the
gonococcus and nothing else the kidneys must have
been diseased for a long time, and it would also seem
that the gonococcus had gained acCess to the kidney
by climbing the urethra against a physiologic current,
or reached the kidney by metastasis, as in gonorrheal
CITY HOSPITAL ALUMNI. 231
rheumatism. The demonstration of the gonococcus
seemed to be quite satisfactory; it was a unique spe-
cimen. He did not know of anything in history that
at all corresponded to it, and he thought Dr. Lewis
ought to give it the prominence it deserved and report
it, using it as the topic of a single paper. How the
gonococcus or the tubercle bacillus could climb the
ureter without reproducing itself along the surface of
the mucous membrane (by diffusion) he could not un-
derstand. Gonococci have no power of independent
motion, and the best observers deny the organ-
ism’s pOwer to reproduce in the acid urine. In
regard to. the case in which the Bottini operation
had been performed: in the ﬁrst place he thought the in-
cision with the knife was quite successful, hitting upon
the point aimed at by the operator very satisfactorily;
but it was not an incision which would greatly aid in
evacuating the bladder because it could be seen when
the urethra and vesical outlet were closed, as they
were in life; the edges of the incision were cO-apted,
and unless they had more dila'tability in life than they
appear to have had he did not believe the advantage
gotten from such an incision quite as much as we
would need for the relief of the mechanical obstruC-
tion. In the second place, he can hardly expect from
so limited an incision at the vesical outlet, any con-
siderable atrophy or involution of the hypertrophied
prostate. He attributed the improvement to the
stimulation of the urethra or vesical muscle by the
cautery. He had seen similar improvement follow
the use of silver solution. In the third place, in re-
gard to the circulation: We all know that these pros-
tatics pass urine more frequently at night than in the
day. This seems best explained by changes in the
circulation. Not only is urination obstructed, but the
venous drainage is decidedly obstructed, and will be
as long as the enlarged prostate presses upon the pros-
tatic plexus and the plexus of Santorini. Dr. Bryson
232 MEDICAL SOCIETY OF
said he appreciated the position of Dr. Lewis in re-'
gard to the Bottini operation, and he believed the
operation has a place in surgery, just as vasectomy
has a place in surgery and castration has also a place
in the surgery of hypertrophied prostate. With' the idea
of deciding, of ascertaining just what that place is,
we may differ. The case of deformed ureters shown
was very interesting, especially in connection with
reno-ureteral surgery. We know that all the urinary
organs have been invaded now by the surgeon, and we
deal with ureteral condition as far down as the blad-
der and as far up as the kidney. By modern methods
it is not nearly so difﬁcult to gain access to these 01"-
gans as one, a priori, would suppose. These deformi-
ties, or malformations, as far as the ureters or the kid-
neys and their blood supply are concerned, are much
more frequent than is generally supposed. He believed
too, that this question of deformity of the ureters and
Of the vascular supply has much to do with the mor-
tality in operated cases. He referred to the embry-
ologic development of the urinary organs in connec-
tion with the case of double ureters. The method of
development of the uro-genitalia is complex, yet very
well studied out. The suprarenal bOdies are devel-
oped'not only independently of the. kidney, but their
cortical and medullary parts are formed independ-
ently, one might say, of each other. The medullary
part of the suprarenal body is of the epiblastic layer,
derived from the substance out of which the sympathe-
tic ganglia are formed. The substance of the cortical
part is of mesoblastic origin and begins just above the
kidneys. There are three distinct sets of renal organs
developed in the embryo, two of which are more or
less transitory. First we have the pro-nephros or head-
kidney, high up and behind the heart; second, the
mesonephros or Wolfﬁan body. The pronephros
seems to be entirely transitory. The metanephros is
the permanent kidney, and is developed in the lo’wer
CITY HOSPITAL ALUMNI. 233
part of the Wolfﬁan body, and in such a way as to be
at ﬁrst independent of its duct. The ureter is Often
stated to be the duct of the Wollﬁan body. This is
not true. The ureters are developed as offshoots of
the hinder part of the Wolffian duct, the duct of
Mueller having been formed out of distinct tissue.
.In the male the Wolfﬁan duct becomes the vas defer-
. ens, but disappears in the female. The Wolf'ﬁan duct
and its offshoot, the ureter, and Mueller’s duct all
terminate in the uro-genital sinus. In the beginning
these ducts empty into the uro-genital sinus, but in
the end the Wolfﬁan duct is found emptying into the
prostatic urethra as the vas deferens. The offshoot
from that, the ureter, is found emptying into the
bladder, the \duct of Mueller having undergone
atrophy in its central part. In regard to the case
where the two kidneys were found on autopsy on one
side, he believed one was a misplaced kidney. From
thesketch he had given of the development of the
' ureter as an offshoot of the Wolfﬁan duct, it was
plain that that kidney must have been developed on
one side and then passed over to the other side from
some cause or another, becausev the vesicle termina-
tion of the ureter was in its properlocation.
DR. H. J ACOBSON said Dr. H. Morris had reported
a very interesting case of misplaced kidney with four
ureters and another with three ureters. A case is re-
ported by Dr. Lebau of a kidney with two pelves
and two ureters running down to the bladder. He
thought the specimens of stone in the kidney were
especially interesting. Such a condition often pre-
sents reﬂex symptoms, and not infrequently are mis-
taken for uterine or bladder trouble. Among the aids
to diagnosis which we now have he thought the X-ray
method one especially advantageous. By this means
an Eastern surgeon has claimed to be able to detect
calculi of ,even very small size in the kidney. If
this claim can be conﬁrmed it will mean a great ad-
234 MEDICAL' SOCIETY OF
vancement in kidney surgery. Whenever a stone is
detected in the kidney it ought to be removed. This
statement had been made by our ablest investigator
in renal surgery, Dr. Henry Morris. .
DR. T. C. WITHERSPOON said he had always felt
doubtful about the extension of the gonococcus by
continuity of surface running backward. It would
take weeks for the extension to take place. A period
of some days was necessary for incubation upon each
newly infected portion of mucous membrane. These
inoculations and reinoculatious would require a deal
of time. He believed the lymphatics play theimpor-
tant part in the development of the diseasef It is
primarily a gonorrheal lymphangitis. If observed
closely, he thought there was a distinct connection
between the direction of travel and the lymph cur-
rent, though at times in the opposite direction, as
to the epididymis or kidney, from the deep urethra.
In regard to obstruction from enlarged prostate, he
had never been perfectly satisﬁed why an enlarged
prostate causes urinary retardation. The urethra is
generally much larger, being much like the conditions
of the canal of the uterus in ﬁbroid disease. The
specimens shown, nor does the general enlargement
explain lack of projectile power. Until the explana-
tion be made clearly be felt that we are at a loss to
know how to treat these cases. In 1897 aman about
60 years of age came to him with enlarged prostate
and cystitis; there were casts and pus in the urine
and residual urine, necessitating the use of a catheter
once or twice a day. Excision of a portion of the
vas was performed and the patient kept under ob-
servation for a while with beneﬁt at ﬁrst. The pa-
tient went home and nothing was heard of him until
January last, when it was learned that he was using
the catheter to. draw the urine and could pass none
without its aid. The patient wanted both testicles
removed and this was done under cocain. When he
CITY HOSPITAL ALUMNI. 235
was seen a month ago he did’ not require the use of a
catheter- at all. When ﬁrst seen in January, 1897,
and later at the time of the last operation, the patient
had fever, but now he is free from fever and has
picked up remarkably in ﬂesh. These kidney malfor-
mations, the speaker said, he had usually noticed
wherever he found renal displacement, and thought it
was associated with circulatory abnormalities. When
the origin of the artery is below the normal one, the
location of the kidney has been found low and its
form altered somewhat as a rule, and he would not be
much surprised to know that the relation of the-vas-
cular supply, its direction, amount and association
with other vessels, have much to do with the kidney
and its form.
DR. J. L. BOOGHER said he was especially inter-
ested in the gonorrheal kidney. He had seen an op-
eration for gonorrheal suprarenal abscess. At the
post-mortem it was found that the abscess had de-
Stroyed almost the entire substance of the kidney
and extended down to the bladder and ureteral tract
—quite an unusual occurrence. The catheter had
been used three or four days after, acute urethritis
had developed, showing that carrying the pus up with
the instrument into the bladder had greatly assisted
in spreading the inﬂammation up to the kidney. There
are many reasons why an enlarged prostate closes off
the urethral tract, and among them is allowing urine to
remain too long in the bladder. He said he did not
see how the Bottini operation for infected prostate
could be materially assisted by the use of the cautery,
as it would not destroy germ life. He believed such
cases could be more easily relieved by the injection
of a stimulant, such as nitrate of silver, with massage
of prostate. He had treated a number in this way
' and‘always found it gave relief. He thought more
accurate examinations of the secretions from the pros-
tate should be made before an operation was contem-
plated.
236 MEDICAL SOCIETY OF
DR. R.‘B. H. GRADWOHL said he had made the ex-
amination of the gonococcus in this case. AS there
was no history of gonorrhea, he thought there might
probably have been a slight attack of anterior ure-
thritis, which was not noticed by the patient. People
of that kind do not always notice a slight inﬂamma-
tion. It is well known that the gonococcus can
migrate from the urethra to the heart, meninges and
joints, and he believed that explanation most suitable
for this case. He thought the spread of gonorrhea
was probably along the surfaces. The gonocOccus
develops in media composed of urine, and‘the media
in this case was composed of agar and albuminous
urine, which is one of the most favorable.
DR. H. TALBOTT said the case was under his care
at the City Hospital, though not until after the
Bottini operation had, been done. There was a large
amount of residual urine present which was albumi-
nous, and the patient was in a bad state generally,
being anemic and weak. He urinated frequently,
and was in no condition to undergq any more severe
operation than the Bottini operatiOn at that time.
After the operation the patient gained in weight,
rested better, albumins disappeared from the urine,
and the amount of residual urine was far less, going
down to about one ounce. That was the condition
of patient when he entered the acute surgical ward
for the hernia operation. The wound was infected
from the ﬁrst, however, and showed no tendency to
heal; the scrotum became gangrenous, and the result
was as given by Dr. Lewis.
DR. LEWIS, in closing, said he was grateful for‘ the
full discussion, as it had brought out a number of
points which were obscure to him. Referring to the
extension of the gonococci to the kidney, he said he
had read a paper as long ago as 1893, before the
American Association of Genito-Urinary Surgeons, in
which he took a position radically different from the
CITY HOSPITAL ALUMNI. 237
teachings at that time. He thought at that time that
Finger’s was the latest and most approved book on
gonorrhea- He had taught that the spread of gonor-
rhea from the anterior to the posterior urethra was
by continuity of tissue; that when the posterior ure-
thral inﬂammation did develop it. was usually at the
end of the second or third week of the disease, and
was the result of some predisposing or exciting cause.
Dr. Lewis said he took the position that posterior in-
ﬂammation was one of the ordinary phenomena of
gonorrhea, and not a complication; that this phe-
nomenon occurred in 90 per cent. of the cases; so
that he believed that posterior urethritis was not a
complication. This extension of the inﬂammation
frequently occurred within two or three days, and not
as a result of any predisposing or exciting cause, but
as a direct transposition of the germs through the
' lymphatics. This, he thought, explained the great
frequency and also the reason for considering it an
ordinary phenomenon, and not a complication of the
disease. He did not believe this transference oc-
curred by continuity of tissue along the mucous
membrane of the bladder and ureter, but was carried
through the lymphatics. It was well known that
there was a direct lymphatic communication from the
ureter to the capsule of the kidney, and the infection,
he thought, was carried by this means. He was glad
Dr. Witherspoon had made the point that, even when
7' the lymphatic current was opposed to the germs, it
did not prevent their progress in an opposite direc-
tion. He did not agree with Dr. Bryson that the
Bottini incision in the prostate did not open a better
passage for the urine. The specimens had all been
contracted by being in alcohol for several months.
A groove that is longitudinal would be opened by
ﬁlling up the bladder, by distension of the walls and
urethral sinus; so the groove made by the operation
was open, and stood open ready for the passage of
238 MEDICAL SOCIETY OF
the urine. There had actually been a vast improve-
ment from the operation. He did not have much
faith in massage for reducing a ﬁbroid enlargement
of the prostate. The tissue is often hard as a rock. ~
It is not SO in this instance, but it is Often So. Rest
and nitrate of silver injections are some of the less
serious modes of treatment. We might stimulate a
contraction, but he did not believe these means ever
changed the condition very much where there were
from ten to ﬁfteen ounces of residual urine-fin this
case, twenty-eight ounces. In regard to the expo-
sure of surfaces to infection by the Bottini operation,\
this he thought was one of, the advantages of this
mode of operating. The instrument left a seared
surface wherever it touched, and this surface would
withstand infection. In regard to the scar left by
this incision: that Would not produce obstruction
from future contraction, because it was a longitudi-
nal incision, and the contraction would be longitudi-
nal—therefore not obstructivej His objection to
prostatectomy was the seriousness Of the operation
itself. Ifit were possible to guarantee to the patient ,
that he would live through the operation, it would
probably be the better, as the surgeon can see what
he is doing. Putting the Objections of the one
against the other he believed the objections against
prostatectomy were more serious than those against
the Bottini operation.
The PRESIDENT asked if orchitis in connection
with gonorrhea would be classed as a complication by
Dr. Lewis, or a natural phenomenon.
DR. LEWIS said orchitis was a complication. It
does not occur in 90 per cent. of the cases, nor any
where near that, as does posterior gonorrhea. But
there are cases in which posterior urethritis does not ‘
occur, though they are rare.
DR. SHATTINGER asked on what kind of statistics
the statement that posterior urethritis occurred in 90
per cent. of cases was based. ‘ ‘
CITY HOSPITAL ALUMNI. 239
DR. LEWIS said the statistics were not based upon
his own personal experience only, but were based on
the very extensive experience of the large clinics in
Europe, and he believed it was also so in New York.
However, if he was wrong in this statement he said
he would like Dr. Bryson, who was probably better
posted, to correct him. It was the current teaching
now that this is the percentage. The question might
be asked how are we going to prove that that involve-
ment occurs? To ascertain this the easiest way was
the double glass urine test. When .the patient arises in
the morning, having held his urine all night, allow-
ing the longest time for collection of the pus, he
passes his urine in two glasses. If both glasses are
cloudy the posterior urethra is infected; if only the
ﬁrst is cloudy and the second is clear, that indicates
that only the anterior urethra is infected. When
I there is a posterior urethritis and sufﬁcient time is al—
lowed for pus to get'back into the bladder, all of the
urine is clouded. On the other hand, if the pus is
all produced in the anterior urethra it cannot run back
into the bladder On account of the compressor ure-
thrae muscle, which compels a discharge of the pus.
DR. BRYSON asked what rules applied in the deter-
mination as to a complication of gonorrhea.
DR. LEWIS said he thought a complication was an
extraordinary manifestation of the disease. An epi-
dydimitis would be a complication. It does not oc-
cur in the vast majority of cases.
DR. BRYSON: It is a question of frequency, then?
DR. LEWIS said it was, mainly.
DR. BRYSON: Would call cystitis a complication?
DR. LEWIS said that was unusual and occurred in
the minority of, cases, and he would class it as a
complication.
DR. BRYSON: Is there no obstruction to continuity
in the urethra?
DR. LEWIS said there was. It was claimed for a
240 MEDICAL SOCIETY OF
long time by Guyon that the compresqpr urethrae
muscle prevented the imﬂammation extending back
to the posterior urethra, just as it prevents ﬂuid from
going back, but that was an erroneous claim. The
gonococcus does get back there, notwithstanding the
compressor muscle.
DR. BRYSON said he had a case of per-acute gon-
orrhea, where the entire anterior urethra was involved
probably back as far as the bulb, and the peri-urethral
structures involved as far as the corpora cavernosa,
yet there was no posterior infection. He asked Dr.
Lewis if it were not probable that the infection ought
to have extended backwards rather than being con-
ﬁned to the anterior urethra.
DR. LEWIS said he thought there really ought to be
a posterior infection in that case; but a pathologic
action did not invariably follow any rule. He did
not suppose there could be any rule without its ex-
ceptions. ,,
DR. BRYSON: What is your experience in per-acute
gonorrhea? Is the posterior urethramost frequently
infected?
DR. LEWIS said yes. He had seen it as early as
the third day after a demonstrable discharge,,and had
seen it as late as two weeks.

STATED MEETING, THURSDAY EVENING, NOVEMBER 2,
THE PRESIDENT, DR. GEORGE HOMAN, IN THE CHAIR.

SOME REMARKS ON THE TREATMENT OF PERI=
RECTAL FlSTUL/E, WlTH PRESENTATION
OF SPECIMENS.
BY NORVELLE WALLACE SHARPE, M.D., St. Louis.
N a general way I have looked up the literature
on this subject and the well-known classical
methods. Possibly the ﬁrst procedure was the
introduction of the grooved director, and splitting,
with subsequent packing. Another method advoca-
CITY HOSPITAL ALUMNI. 241
ted by Dittel Courty and Allingham was the use of a
rubber cord, about one-tenth of an inch in diameter,
which was passed down through the ﬁstula and tied
outside, the slack being taken up and the cord re-
tied when necessary. This will gradually, by its
elasticity, bore through the tissues and leave awound
to heal by granulation. The third method, which is
not sound surgery, was by stimulating applications,
and is not advised save when patient refuses the more
radical measures;
In a work which is known as “ Morris’s Lectures on
Appendicitis,” etc., 1895, (1) he suggests an ingeni-
ous scheme applicable to peri-rectal ﬁstulas and opera-
tions for similar conditions, which consists of taking
plaster of Paris rather well impregnated with salt,
and forcing it into the tract, after having cleaned and
dried the canal, and permitting it to harden, the
_ plaster pipe and ﬁstula to be dissected out in toto. It
is a failure if the plaster does not dry, but a success
when this is attained and the plaster hardens. In
the early part of the year I had a casein which I
tried this method, with failure to. secure hardening,
and the following is a brief history:
L. B. G., aged 45, Missouri; general health good.
A year ago he acquired rheumatism, most marked in
the left knee, which is now ankylosed; has been in
poor health during the last year. Four or ﬁve years
ago he had a “pimple” on the” right buttock, which
“ broke” six months after, and now is discharging
pus. There is marked and wide-spread induration
' and tenderness" at that site. Diagnosis, chronic
ischio-rectal abscess. Under an anesthetic the ab-
scess was curetted, the morbid tissue removed and
the cavity packed. No opening into the gut was
found. I make this distinct statement because there
an error occurred. On January 21 I dressed the case,
and found gas escaping through the dressing. Icthyol,
’50 per cent, applied upon the packing, and 25 per
242 MEDICAL SOCIETY OF
cent. on a dressing to the knee. .He was put upon
hot magnesium sulphate solution in the morning
and a milk diet, to correct a gastro-intestinal dys-
pepsia. February 2 the abscess closed, and on this
day a 2-inch peri-rectal ﬁstula was discovered. Gen-
eral condition much better. At this time he had a
very bad attack of intestinal indigestion. On Feb-
ruary 4 ﬁstula was dissected out entire, and walls'
sutured. On February 8 the wound above was uni-
ted, but the wound of mucous surface was not united.
General condition good. The failure to unite in this
case I believe to be due to my carelessness (if you
please). I had ordered the nurse to give me ﬁne
silk, and after running two or three sutures discov-
ered that it was catgut. I did not stop to change
owing to the condition of the patient, who did not
take the anesthetic well. The ultimate result was
thoroughly satisfactory.
The second case occurred in a St. Louis colleague.
The history is rather interesting. The patient has
had three ischio-rectal abscesses, and a half-dozen
indurations, some of which have received, treatment.
He lately discovered a small ﬁstula. It was not tu-
berculous nor due to syphilis nor trauma. The ﬁs-
tula is half an inch to left of the median line; ante-
riorly it apparently branches and approaches the rec-
tal mucous membrane. Sphincter is abnormally irri-
table and rigid. No internal opening found. On
September 5 I dissected out the ﬁstula from the tis-
sues and united by two tiers of silk-worm gut,
failed to ﬁnd the supposed branches. (Possibly the
dilatation was movable). On September 7 I removed
two infected distal stitches. September 9, removed
the remaining superﬁcial tier. Infection along the
stitch holes for about one-quarter of an inch. Incis-
ion otherwise good. Inﬁltration into the perineum,
which is painful and annoying; bowels ordered
opened that day. September 30, a small opening at
CITY HOSPITAL ALUMNI. 243
apex of incision, which is closing. The wound
steadily progressed, but at apex of incision there oc-
curred an area, possibly a half inch in one direction
and three-quarter inch in the other, apparently split-
ting the planes, but it healed after the application of
stimulants and packing, to all practical purpose.
There was still some pain. Because of this there
was supposed to be a stitch infection in the second
tier. September 16, two deep-tier infected sutures
were removed; silk-worm gut was used; it was boiled,
and I don’t think there was any error in technique;
it may be possible that patient was not'scrupulously
scrubbed, as the operation was made at residence.
The infection simulated epidermitis albus type; no bac-
teriologic search was made. In the ﬁrst case I opera-
ted by the Morris method, or rather planned to so do.
The local condition was not good; I could not get the
ﬁstula dry, and the plaster of paris would not hold.
' On the spur of the moment I tried this plan, which I
bring forward for discussion. A director was intro-
duced into the ﬁstula, and the tube was dis
sected out. I have seen no stress laid upon this
in literature, thoughrl have been told that Lange of
New York has so operated several times, and it is
mentioned but casually in several works. I have
sketched off, rather roughly, some diagrams. The
ﬁrst is a rather crude sketch of the sphincter ani,
with indicated muscular action. The sphincter ani,
enveloping the rectum and attached to the coccyx,
pulls from the rectum to the coccyx. The levator
ani taking rise posteriorly is attached anteriorly, and
its pull is anteriorly. To my mind these opposing
pulls not only occasion pain in the rectum, but con-
tinual irritation, which probably foments and in-
creases the disturbance. The second is a diagram of
a ﬁstula in section. Third is tissue split down to the
ﬁstula. Fourth is a transverse section of the third.
Fifth is a partial extirpation. Sixth, extirpation is
244 MnnrcAn SOCIETY OF
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complete, and the ﬁstulous tract lies in the sulcus.
Seventh, the tube of the ﬁstula has been removed.
Eighth,'deep sutures in the wound. Ninth, deep su-
tures tied in lower surface of the wound. Tenth, com-
plete suture plan. In some cases it is necessary to
whip over a third tier of sutures. Eleventh is the
result of operation .
CITY HOSPITAL ALUMNI. 247
The resultant wound by this method is perfectly
clear and clean, and it cannot be secured in any other
way that I am aware. I believe the walls could
be united with silk, and complete union result.
The material for deep sutures in the ﬁrst case was
silk-worm gut, in the second catgut.
At present I am inclined to recommend scrupulous
local cleanliness; deep tier sutures, either silk-worm
gut or catgut chromicized for three weeks; superﬁcial
tier sutures, catgut, or ﬁne silk preferably. Finally,
cleanse with\hot saline solution, or hot bichlorid,
then with peroxid, and rub aristol thoroughly into
operative fluid. Dry dressing.

DISCUSSION.
DR. F. REDER said the essayist, in describing the
reason why a ﬁstula that has been operated upon re-
fuses to heal satisfactorily at times, could well apply
a similar reason as being the cause in the formation
of a ﬁstula. A ﬁstula in ano is, nothing more than an
abscess tract, usually caused by some kind of an irri—
tation, such as a foreign body, severe manipulation
during an examination, or even a hemorrhoidal ulcera-
tion. An abscess develops about the anus, which
may discharge by one or more small oriﬁces, either
upon the buttock or into the gut, or by both surfaces.
In operations about the anal region anatomic strictures
are frequently disregarded. This may Often lead to
a failure in the operation. The reason why an abscess
so readily terminates in a ﬁstula can be explained by
the action of the sphincter and levator ani muscles.
These muscles by acting antagonistically prevent the
approximation of the sides of the abscess, causing
the walls to become thickened and callous, the
oriﬁce to become contracted and indurated. Of
the various operations described by the essayist,
all are applicable, some giving a better result than
others. When a surgeon is called upon to treat a ﬁs-
248 MEDICAL SOCIETY OF
tula in ano his ﬁrst impulse is to lay open the canal.
This would be the most satisfactory procedure were it
not at times that the patient objected to the use of the
knife. Speaking of the rubber tube, he said that such a
ligature had the advantage that it did not require any
subsequent tightening. This we ﬁnd the case to be
with silk. A silk ligature must- be tightened afresh
as soon as it has become loosened. There is a ﬁstula
where the usage of the knife may cause annoying dis-
closures, and where the rubber ligatures may be given
the preference. Such a ﬁstula is usually extensive
and has its inner oriﬁce some two or more inches
above the anal opening. The division of a ﬁstula
having its internal opening so high up in the bowel is
usually attended with considerable hemorrhage, which
is not at all easily controlled. This hemorrhage
comes from the superior hemorrhoidal artery, given oﬁ
direct from the inferior mesenteric. The injection of
gypsum into the ﬁstulous tract, he thought, would al-
ways remain an experiment. The operator who under-
takes to get a cast of the canal is simply trying to
what extent he can succeed. The dissecting art of
the ﬁstulous tract he looked upon more as a reﬁne-
ment, having no bearing upon the ultimate result of a
successful operation. If we can positively ascertain
that the ﬁstula has no ramiﬁcations, a dissection Of
the tube is always a neat piece of work. When he
was assistant to Dr. F. Lange of New York the latter
had on several occasions dissected out ﬁstulous
.tracts and showed them to his audience while the tube
was still upon the probe. It looked well, and clearly
bespoke the skill of the operator. The main difﬁculty
encountered in healing was the proper and thorough
maintaining of asepsis. When the internal opening
of the ﬁstula reaches over an inch above the anal
oriﬁce the placing of sutures becomes difﬁcult. The
mucous membrane should not be included, but the
suture should be so placed in the submucous layer
CITY HOSPITAL D ALUMNI. 249
that a good approximation of the mucous surface can
be accomplished; the rest of the canal is then closed
in tiers. It takes from two to four weeks for such
wounds to heal. Infections cause many failures. A
more radical and safe way would be to lay open the
ﬁstulous tract, curette away the lining membrane and
allow the wound to heal by granulations from the
bottom. He did not think it very appropriate to use
an instrument such as Dr. Jacobson had suggested,
because it was an additional obstacle to cleanliness.
Careful attention to toilet and frequent irrigations was
all that was necessary. Pain usually lasts from four
to six hours after the operation, and is usually
caused by the‘forcible manipulation in dilating the
sphincter. Fistulae, when operated lupon, usually
progress favorably. Some, however, show an unfav-
orable progress. Complications, such as hemorrhoids,
. ﬁssures and ulcerations, contribute much in making a
good recovery sometimes very doubtful. In re-
gard to the second paper, Dr. Reder said he had not
yet felt much of an inclination toward any kind of
serum therapy. He had had one .case in which he
wanted to inject streptococcus serum, but was unable
to obtain it at the time. Calomel was administered,
with a gratifying result. If serum had been injected
the recovery of the patient would have been attributed
to its timely use. From the reports of the American
Gynecological Association, one could almost infer
that serum therapy in its present state possessed lit-
tle, if any, value as a curative agent. We see much
of serum in our journals; positive evidence, however,
as to the cures it has effected is lacking. I can not
believe everything that appears in print. Serum-
therapy, he thought, was still in the experimental
stage, with good prospects for it to remain so for a
long time to come.
DR. CHAS. SHATTINGER said he did not know
whether Dr. Sharpe was aware that the operation of
250‘ , MEDICAL SOOIETY OF
dissecting out a ﬁstula was mentioned by A. G.
Gerster, and a picture of the sutured wound presented
in his book on “ Aseptic and Antiseptic Surgery.”
It is also brieﬂy described. The difﬁculty with which
abscesses and ﬁstulas in this region heal is correctly
ascribed by every one to the anatomic disposition,
but he thought Dr. Sharpe in error in holding an an.-
tagonistic action of the sphincter and levator ani
mainly responsible. He called attention to the fact
that a muscle can act from both ends, either from its
attachment or insertion. The fact remains, however,
that these numerous muscles, with ﬁbres crossing
each other, produce an unusual amount of mobility-
in this region, which is a sufﬁcient explanation. - The ‘
main point of interest in Dr. Sharpe’s paper attaches
to the operation of dissecting out the ﬁstula entire.
He believed that where the ﬁstula is considerably
branched it would, in most instances, be absolutely
impracticable, though he thought, if there were not
too many branches and the ﬁstula did not extend too
high up, it would be possible by careful dissecting to
get out the entire tract. He thought, as Dr. Jacobson
had said, that the duration of illness would not be as
long in a case operated upon in this way as with the
classical operation. Everything depended upon
primary union. If this could be'secured without com-
plications, such a case ought to do well. Can these
dissections be performed and an absolutely aseptic
condition be secured? The close proximity of the
bowels he did not think was the main obstacle. It
should not be forgotten that the ﬁstulous tract is sim-
ply the remains of an abscess—it is a chronic abé
scess, and how far its infection of the tissues extends
outward is something which cannot be determined.
In making a dissection, we have to guess how much
tissue it will be necessary to remove in order to get
away all of the infected tissue. The amount which
can be removed will be limited by the locality, and
CITY HOSPITAL ALUMNI. 251
will necessarily enter into the operation as an element
of chance. He believed it would be proper to ex-
plain this to the patient; to tell him that if primary
union was secured he would be up and about in a
week, but if not it would be longer; yet even then he
would be no worse off than if treated in the classical
way by slitting. He believed the operation had a
legitimate place in the surgery of this region.
DR. R. B. H. GRADWOHI. asked Dr. Sharpe if any
other micro-organisms were found when the pus was
examined.
DR. SHARPE said he believed not.
DR. GRADWOHL said he supposed it was contam-
inated by some other organism when the statement
was made that the culture was “ almost pure.” The
literature upon the subject of antistreptococcus serum
was very extensive. One thing about the reports of
_its use was, that in many cases the serum was in-
jected without any previous bacteriologic examination
of either the blood or pus, and he believed it was
often used where there was absolutely no indication
for it, and this was responsible for. the many bad re-
sults reported and ascribed to the use of this agent.
Some streptococci have a high degree of virulence
and others a medium degree. We must take into
consideration the fact that individual organisms must
be dealt with. A micro-organism with a high degree
of virulence and an established unit system will not
correspond to the unit system of another. - It is ab-
solutely necessary to ﬁnd out in the ﬁrst place that we
are dealing with a streptococcus infection, and to do
that we must have repeated examinations of the blood
and pus. He had in one case made a number of
examinations before ﬁnding the organism; when this
was done the diagnosis was made and serum injected
and the patient’s life prolonged several months. She
ﬁnally died, and the autopsy showed a wide-spread
condition of localized abscesses all over the body.
252 MEDICAL SOCIETY 013‘
This condition existed before the serum was used and
the patient was in an exhausted condition, so that it
was almost impossible to get results in this case. In
order to secure the best results, the remedy should
be used early in the disease, just as in using anti-
toxin for diphtheria. We know that there is some-
thing in the antitoxin treatment of diphtheria, and he
believed there was much in the antistreptococcus
serum, but before using it we must ﬁrst ﬁnd out
whether we are dealing with a streptococcus infection.
That mistake is responsible for many of the so-called
failures attributed to its use, as in the case which Dr.
Green cited this evening. In all probability that was
not due to the streptococcus: it might have been due
to the bacillus coli communis. There are cases on
record of widespread and localized suppuration due to
this germ. _ .
DR. SHARPE, in closing, said he supposed that the
interpretation of the mechanism of infection spread-
ing depended upon the standpoint of the observer.
Ordinarily it was supposed to be due to the action of
the perirectal tissue in contact with septic material
and ﬁstula formation, derived usually from the
bowel, whether the opening was microscopic or ma-
croscopic. Fish bones are said to produce openings
in the rectal wall. He» recognized that ﬁstulas oc-
curred frequently in connectien with ischiorectal ab-
scess. He did not think that any rule could be laid
down as to whether they preceded or followed the
abscess. He did not offer any excuse for failing to
ﬁnd the opening in the ﬁrst case. It was doubtless
there, and it could have been found. He failed,
though he searched for it. He said he had no expe-
rience with silver ointment in puerperal sepsis; nor
did he claim any originality nor priority in this oper-
ation, save that when he did it he had never heard of
its having been performed. In the ﬁrst case that he
tried it, the plaster failing to set (Morris’ operation),
and not caring to delay the operation further, be ex-
CITY HOSPITAL ALUMNI. 253‘
temporized this method, which was successful. _(He
, mentioned in his paper that the method was cited in
various text-books). In regard to Dr. J acobson’s
criticism that cases are delayed in healing, and that
the operatiOn is therefore impracticable, he referred
to his paper and said that there two statements were
outlined which covered his remark. In the ﬁrst case
the wound united in four days, with the exception of
the stitches in the“ rectum; this was due to the error
of using ﬁne catgut; the catgut was absorbed, that is
there was no suture there after the fourth day; but
the wound healed. In the second case, it was stated
the stitches were removed on the third day, and that
union was present on the fourth day. No other op-
erative procedure secures such speedy and cleanly re-
sults. He endorsed Dr. Gradwohl’s remarks thor-I
oughly in regard to error when using antistreptococcus
serum. Both his cases were proved by bacteriologic
examinations. Many specimens when submitted
hardened in alcohol must be taken largely as a matter
of faith. They lose color, and the topOgraphic re-
“ lations are absent. He said he had had good results
with WiCkerSheimer‘S ﬂuid.* The two specimens he
submitted were of good color, well preserved; they
had been in the ﬂuid for some time, and yet they
were reasonably ﬂexible, and the topographic rela-
tions were sufﬁciently manifest. Zenker’s solution is
essentially a hardening solution, and he thought alco-
~hol should be considered in the same category, and
used solely for that purpose, so-Called “preserving
ﬂuids” being used for such specimens as are stored
in gross for demonstration purposes. Dr. Gradwohl
had called his attention to a method consisting Of
three solutions of formal, glycerine and nitrate of
potassium, the specimen to be transferred from one
solution to another. The hardening is not excessive,
the coloring. is preserved, and contraction is not sufﬁ-
cient to injure the specimen. ‘

*Foot note page 166, U. S. Dispensatory, 1889.
254 MEDICAL SOCIETY OF
SOME REMARKS ON ANTI=STREBTOCOCCUS
SERUM, WITH REPORT OF CASES.
BY NORVELLE WALLACE SHARPE, M.D., St. Louis.
N these fragments of the literature on antistrepto-
coccic serum which I present, I have not tried to
make out “ a case ” in its favor. I have looked
over such literature as I had at hand, the statements
pro and con, and submit the following extracts:
In a report of the special committee of the Ameri-
can Gynecological Society, May, 1898, it was stated
that 101 cases had been reported in which a bacter-
iologic examination had been made with 33 deaths, a
mortality of 32.69 per cent.; 251 cases without bac-
teriologic examination with 40 deaths, or a mortality
of 15.85 per cent, a total of 352 cases with 73
deaths, or a mortality of 20.74 per cent. The imme-
diate conclusion was that we are not justiﬁed in pro-
ceeding further with the use of the serum. The re-
port further states that 18 French and German physi-
cians treated 70 cases with bacteriologic examination,
24 deaths; mortality, 34.28 per cent.; 21 English
and American physicians treated 31 cases with nine
deaths, mortality of 29 per cent. Mery, Lowaine,
Courmont, Desse, Van de Velde, claim that a serum
derived from certain streptococci is valuable against
infections by the same streptococci, but may be inert
against infections from other sources. Van de Velde
recommends a serum made from a number of strepto-
cocci. He produced such a serum, calling it “Serum
Polyvalent.” Marmorek, Bullock and Lemoine be—
lieve in a streptococcus unity.
CONCLUSIONS.
First. Clinical observation has shown that the re-
sults Obtained by its employment leave a great deal
to be desired and apparentlyr indicate that it has little,
if any, effect upon the general course of streptococcic
puerperal infection.
Second. The results of laboratory work have been
CITY HOSPITAL ALUMNI. 255
extremely conﬂicting and have cast grave doubts upon
the entire subject. The serum polyvalent of Van
de Velde can not be considered as a satisfactory so-
lution of the difﬁculty, as it is impossible to foretell,
in a given case, whether any of the serums composing
it will be efﬁcient against the particular streptococcus
with which one has to deal.
Third. The only positive fact which has thus far
been satisfactorily demonstrated, is the possibility of
markedly increasing the virulence of streptococci by
appropriate methods.
The results are summed up as follows:
First. A study of the literature shows that 352
cases of puerperal infection have been treated by
many observers with a mortality of 20.74 per cent.;
where streptococci were positively demonstrated the
mortality was 33 per cent.
Second. Marmorek’s claim that his anti-strepto-
coccic serum will cure streptococcic puerperal infec-
tion does not appear to be substantiated by the re-
sults thus far reported.
Third. Experimental work has cast grave doubts
upon the efﬁciency of anti-streptococcic serum in
clinical work, by showing that a serum which is ob-
tained from a given streptococcus may protect an
animal from that organism, but may be absolutely in-
efﬁcient against another streptococcus, and that the
number of serums which may be prepared is limited
only by the number of varieties of streptococci which
may exist.
Fourth. Thus far the only deﬁnite result of Mar-
morek’s work is the development of a method by
which we can increase the virulence of certain strep-
tococci to an almost inconceivable extent, so that one
hundred billionth of a cubic centimeter of a culture
will kill a rabbit.
Fifth. The personal experience of your committee
has shown that the mortality of streptococcus endo-
256 MEDICAL SOCIETY OF
metritis, if not interfered with, is something less than
ﬁve per cent., and that such cases tend to recover if
nature’s work is not undone by too energetic local
treatment.
Sixth. We unhesitatingly condemn curettage and
total hysterectomy in streptococcus infections after
full-term delivery, and attribute a large part of the
excessive mortality in the literature to the former
operation. »
Seventh. In puerperal infection a portion of the
uterine lochia should be removed by D'oderlein’s tube
for bacteriologic examination and _an intrauterine
douche of four to ﬁve litres of sterile salt solution
given just afterward. If the infection be due to
streptococci, the uterus should not be touched again,
and the patient be given very large doses of strychnin
and alcohol if necessary. If the infection be due to
other organisms, repeated douchings and even curet-
tage may be advisable.
Eighth. If the infection extends toward the peri-
toneal cavity, and in gravely septicemic cases, Pryor's
method of isolating the uterus by packing the pelvis
with iodoform gauze may be of service.
Ninth. The experience of one of the members of
the committee with antistreptococcus serum has
shown that it has no deleterious effect upon the pa-
tient, and therefore may be tried if desired; but we
ﬁnd nothing in the clinical or experimental literature
or in our own experience to indicate that its employ-
ment will materially improve the general results in
the treatment of streptococcus puerperal infection.2
Maisey treated a case of puerperal septicemia with
antistreptococcus serum with a recovery. The proba-
ble source of infection was a purulent nasal discharge
on the part of the nurse.3
Rosenthal records four cases of puerperal sepsis
treated with antistreptococcus serum with satisfactory
results.4
CITY HOSPITAL ALUMNI. 257
Mackie reports several cases of generalized septic
infection treated with antistreptococcus serum:
First. A trauma to thumb; staphylococcus and
streptococcus infection. Died.
Second. This case presented no history of trauma,
but became septic, and died. A post-mortem bac-
teriologic examination of the blood and spleen pulp
both showed staphylococcus pyogenes albus.
Third. An acute endocarditis in a culture from the
blood showed staphylococcus. This case died within
twenty-four hours, no effect having been produced.
Fourth. An alcoholic. Subacute pneumonia.
Streptococci and staphylococci found post-mortem.
NO eﬁ"ect produced“.5
Maurice reports a case of septicemia treated with
antistreptococcus serum; injury to head; developed
sepsis. Success.6
Arthur notes a case of puerperal sepsis which be-
came distinctly worse from the third to the eighth
day. The vaginal wall, labiae minorae and majorae
covered with yellowish diphtheritic membrane (in ap-
pearance); the uterus was large and boggy. Nine
injections of antistreptococcus serum were given
within eight days. Recovery. It was found after-
wards that the nurse had a “ sore ” on the right fore-
ﬁnger and thumb.7
P. J. Cotton, Boston, in a paper upon “The Pres-
ent Status of the Antistreptococcic Serum,” after an
exhaustive review of the literature of the subject,
formulates his conclusions as follows:
Probably no one will now contend that the anti-
streptococcic serum is, broadly speaking, effective
against streptococcus infections. Beyond a doubt a
certain degree of passive protection is possible in the
laboratory, and possibly something of the sort is pos-
sible in man. There seems, in view of recent work,
no ground for drawing sharp distinctions between
alleged species of streptococci; and, though it would
258 MEDICAL SOCIETY OF
be a mistake to assume too close a parallel between
the conditions of infections in man and in animals,
yet probably a serum really effective in protecting
rabbits against streptococci would afford some aid to
the human organism in its struggle against a like in-
fection. It is likely enough that this is the explana-
tion of the temporary relief of the symptoms so Often
noted. It does not seem that this represents a strong
action against the infection, but it is something, and
in some cases a very little may turn the tide.
This seems reason enough to give the serum a fur-
ther trial-as a symptomatic treatment, if no more.
There seems to be no good reason against its use.
Urticaria, erythema, joint pains, etc., are of not
uncommon occurrence, but of no great moment. .
Abscesses at the point of injection, sometimes con-
taining streptococci, are not rare, and would indicate
care in using a bacteriologically tested serum. Bué
and Thomson have thought the serum a cause of
albuminuria, but this must be either unusual or slight,
judging by reports.
If the serum is to be used in earnest, it should be
used in considerable doses. Probably in many cases
the dosage has been too small. To protect a rabbit
against a ten times fatal dose needed two-tenths cen-
timetres of Marmorek’s serum; this is one seven~
thousandth the body weight, corresponding to about
ten centimetres in man. The potency of different
makes of serum varies, and they seem to lose notably '
by keeping. Hence, while there are no accurate data
for the dosage in man, yet the problem is not to pro-
tect against infection, but to cope with an infection in
full swing, and that with a serum of doubtful efﬁcacy;
the needed dose will probably be large if anything is
to be accomplished.
The limit of dosage must vary, but the untoward
effects above noted are not frequent, and plenty of
cases have borne twenty-ﬁve cubic centimetre doses.
CITY HOSPITAL ALUMNI. 259‘
In one case a total of 1030 cubic centimetres was
given, though this in a case of some duration; there
were no ill eﬂects beyond a slight erythema.
There seems, then, some reason for continuing the
use of the serum in cases of demonstrated strepto-
coccus infection; care is needful in selecting the
serum to be used; it should be used, if at all, in con—
siderable amount, and, above all, until more evidence
of its power is forthcoming it should be used as an
adjunct only and never to supplant or modify other
treament of the case.8
To these I wish to add two cases that have come
under my charge, treated with antistreptococcus
serum, satisfactory results following.
Mrs. C. W., aged 31, St. Louis, came to me for
menstrual difﬁculty in December, 1898. This condi-
tion had existed for a year or more. Menstruation is
now anticipating ﬁve or six days. Pain is present,
before and after, in both loins and back; headache;
quantity of menstrual ﬂuid average; clots are present.
Has now leucorrhea; bowels are regular; urine abun-
dant; sleep and appetite good; pulse regular. Ex-
amination reveals enlarged uterus and a right lateral
tear; endocervicitis and endometritis. Treatment
consisted of a tonic, with abundance of hot water in-
ternally; local cleansing with peroxid of hydrogen,
ichthyol tampons, etc. Urine 1022, dark amber,
acid, some serum albumins, a few mucous casts, ox-
alate of calcium crystals and pavement epithelium.
Patient improved under treatment; in March, 1899,
transferred to St. Luke’s. The uterus was curetted,
and a one-inch laceration on the right side of the cer-
vix repaired; scar tissue extends well up in the uter-
ine neck and deep resection was necessary; reacted
well from the. operation; general condition good.
March 4th: Doing nicely on hospital diet, salts and
peptonoids. March 15th: has been on Blaud’s pills.
Removed stitches. The lower third of wound not
260 MEDICAL SOCIETY OF
united; and though general condition is good, has
been running a slight temperature with pain in back
and belly. Temperature continues with no assignable
reason, unless la grippe; was given salycilate of
sodium and phenacetine. March 17th: temperature
this morning 99° plus. Seems much better; is now
menstruating. March 18th: temperature ranges from
normal to 101°; general condition fair; vague pains
complained of in sides and anterior of abdomen.
March 19th: urine shows pus mucous, epithelium,
and triple phosphates; bladder is slightly engorged;
urethra and vesical neck inﬂamed; profuse purulent
discharge from uterus (no gonorrhea present); put on
benzoate of Sodium, hot douches, enemata, and vesi-
cal irrigations. March 20th: Bladder and urethra
much improved; inﬂammatory areas found on either
side of uterus, chieﬂy on the right. Temperature now
ranging from 100° to 104°; general condition not
good; streptococci found in discharge from both
uterus and urethra; given antistreptococcus serum
(Fisch), 10 0.0; douches bichlorid 1-10,000. enemata,
quinin and whisky. March 22d: Temperature, pulse,
and general condition steadily improved after injec-
tion of serum; aspect of case radically changed.
March 23rd: Temperature ran up to 103°; pulse 100
to-day; gave 10 0.0 of serum. March 27th: Tem-
perature fell after the last injection; has remained
normal; general condition good; 10 0.0 of serum
were injected to-day, with a view to preventing a
further lighting up of the still indurated periuterine
areas. April 8th: Has been up and is doing nicely;
left pelvis almost clear; in the right there is: still an
area that is fairly sensitive and hard, in and around
the tube. Yesterday 10 c.c. of serum were given.
Patient was collapsed last night; 'no discoverable
cause. To-day there is painful cellulitis in anterior
abdominal wall. Calomel in broken doses was given
and carbolic acid one per cent. poultice applied.
CITY HOSPITAL ALUMNI. 261
April 10th: Practically normal. April 12th: General
condition saticfactory; pelvis seems to have cleared up,
with no resistance palpable; cervix looks well; further
progress of the case was entirely satisfactory; pelvis
remained clear; ultimate union of the wound good.
Mrs. A. W., aged 27 ; Indian Territory; August 13,
1899. Has had trouble in left abdomen for at least a
year and a half, attributed by patient to the after
affects of a bath. During the last three weeks there
has been marked tenderness in the lower abdomen,
followed by evanescent but severe pains. Her men-
struation is regular, ﬁve to six days, and painful dur-
ing the last year; blood clots present; pain most
marked on ﬁrst day. Bowels are temporarily consti-
pated; there is marked pain during defecation, at
times reaching an intense degree; states that urine has
a sediment and is irritating during passage.- There is
a partial prolapse of the uterus noticed by patient to a
greater or less extent for several years. Has had two
children. Menstruation appears early after birth-
ﬁve months after ﬁrst child, six weeks after the sec-
ond. A so-called “boil” appeared in the inguino-
vulvar reg-ion about two months after the birth of the
second child. At times patient notices a yellow mu-
coid vaginal discharge. General health has Steadily
deteriorated during last year and a half until she is
_ now in an exceedingly depressed physical condition.
Is distinctly anemic, with sallow skin, marked lack of
physical force, and suffering at times to such an ex-
cruciating degree that narcotics have been adminis-
tered by her attending physician. Previous treatment
has been of little or no avail, and diagnoses have been
made of the most varied character.
Examination reveals an abdomen sensitive in the
pelvic region, most marked on the left side. Vague
masses, movable, may be made out in both tubal re-
gions. Uterus is quite markedly engorged, retro-
ﬂexed, and in a condition of partial descensus. While
262 MEDICAL SOCIETY OF
both tubal areas are tender, the left is the more
marked of the two; there is a slight bilateral cervical
tear and a perineal tear more marked in its extent
within the vaginal conﬁnes, the external manifestation
of which is but slight. August 14th: Blood examina-
tion; hemoglobin, 30 per cent.; red cells, 4,516,750;
white cells, 20,454. Heart’s action a triﬂe quickened;
no lesions. August 15th: Put on sherry and egg,
Blaud’s pills, strychnin and salts. Urine dark
amber; acid; 1020; no albumin; no sugar; some
urates; red cells; mucous; vaginal epithelium. August
16th: In order to more closely identify the pelvic con-
dition the patient was anesthetized. Even then the
pelvic masses could not be distinctly and positively
differentiated; I am inclined to believe, however, that
both tubes are involved. August 17th: Transferred
to St. Luke’s. General condition as fair as could be
expected under the circumstances. Put upon stimu-
lating treatment, with the usual pre-operative meas-
ures. August 23d: Curetted and drained the uterus
removed both tubes and ovaries; made a ventral ﬁxa-
tion, attaching uterus well up in front of the bladder.
At the operation there was found a double pyosalpinx;
the right cornu of the uterus was so disintegrated that
it had become mushy and was extirpated; the rectum
about three to four inches from the sphincter was en-
circled by a‘ collar of dense inﬂammatory tissue of
about an inch and a half in length, adherent pos-
teriorly to the sacrum; anteriorly to the retroﬂexed
uterus and tubes. Uterus, tubes, ovaries, rectum and
lower coils of the small intestine fused into a common
mass Of adherent structure. The patient stopped
breathing two or three times while on the table and
went into a condition of collapse; she was, however, sat-
isfactorily brought through by the use Of current
methods of resuscitation. She reacted satisfactorily
from the operation. August 24th: Temperature
100.2°; doing nicely. Sept. 3d: Running a low tem-
C-ITY HOSPITAL ALUMNI. 263
perature—100° to 102°. It has been impossible up
.to date to positively determine the causation of tem-
perature owing to conﬂicting physical conditions Of
. long standing, which are here omitted for the sake of
brevity. Sufﬁce it to say that on this date a mass, pal-
pably in the right pelvis, in or around the right broad
ligamentary edge, was discovered. (Owing to the se-
rious condition of the patient on the table the edges
of the ligament were not whipped over with the
sutures.) The general picture presented by patient,
together with the local condition, the character of the
temperature curve, led up to the diagnosis of a proba-
ble or at least possible streptococcal invasion of this
area. It was manifestly impossible to make a culture,
asboth line of incision and vagina were quite clean.
Acting upon the possibility, 5 c.c. of antistreptococeic
serum were given, with moderate doses of quinin at
suitable intervals. Sept. 11th: The temperature con-
tinues in spite of measures adopted. Gave 10 c.c. se-
rum tO-day. Sept, 13th: Examination of line of in-
cision Shows a distinctly inﬁltrated area in the lower
wound angle, which ﬂuctuates. This was opened,
and about a cupful of thick, foul pus evacuated. Bi-
manual examination determines that this abscess
cavity is in all probability connected with the right
pelvic area noted above, but the source and cause of
the condition cannot be determined. The patient
does not look at all well. Streptococci were demon-
strated in the pus by Dr. Fisch. to-day, conﬁrming the
previous opinion. Ten c.c. of serum (Fisch) were ad-
ministered. Sept. 14th: Following the evacuation of
the pus and the injection of the further dose of serum
on 13th, the temperature fell and to—day is almost
normal. Patient is distinctly better. Sept. 15th:
Normal. Sept. 30th: Is up and doing nicely. Oct.
9th: A painful area has again developed in the right
pelvis. This subsided under ordinary treatment of
rest, ieebags, cathartics, etc., and did not go on to
264 MEDICAL SOCIETY OF
suppuration. Oct. 21st: Is out of hospital and
progressing satisfactorily.
RE FERENCES.
1. Morris. Lectures on Appendicitis, etc. 1895.
2. Report Committee American Gynecological Society.
American Journal Obstetrics. Vol. XL., N o. 3.
3. Maisey. Case of Puerperal Septicemia treated with
anti-streptococcus serum. Lancet, 3965.
4. Rosenthal. Philadelphia Medical Journal. Vol.
IV., No. 5.
Mackie. British Medical Journal. 1896.
Maurice. Lancet, 3963.
Arthur. British Medical Journal. No. 2010.
Annals of Surgery. Vol. XXIX. , No. 5.
area
STATED MEETING, THURSDAY EVENING, NOVEMBER 16,
THE PRESIDENT, DR. GEORGE HOMAN, IN THE CHAIR.

SOME REMARKS ON DEMENTIA PARALYTICA,
WlTl'l PRESENTATlON OF PATIENTS.
BY E. C. RUNGE, M.D., St. Louis.
Superintendent, St. Louis Insane Asylum.
PON your invitation I wish to call attention to
this disease as seen in ﬁve patients whom I
have brought from the Insane Asylum.
The general practitioner meets with the disease
even before the specialist in psychiatry; and we
usually see these cases in the later stages of the dis-
ease. Some of these patients are seen in the most
advanced state of the disease, while others are seen
during the remissions of the disease. They do not
come to us in the incipient state of the disease, and
when they are in the maniacal state it would be im-
' possible for me to bring them before the Society.
From a general point of view it is supposed that the
disease is increasing; in fact, organic diseases are on
the increase, but I do not think that insanity in toto
is increasing. I do not intend to go into the ﬁner
differential points in this disease as contrasted with
CITY HOSPITAL ALUMNI. 265
many others, but I shall simply point out the differ-
ences between this disease and neurasthenia. This
is important because the other diseases which simu-
late paralytic dementia are incurable.
The ﬁrst case is a gentleman who had been with us
for ﬁve months. He is 39 years old. (These ﬁve
cases show that the patients develop the disease be-
tween the ages of 35 and 45 years). He is married.
Father was alcoholic; mother living and healthy.
Family history plays less of a ﬁle in paralytic
dementia than in other psychic diseases.
The childhood of the patient was normal; he at-
tended the public schools of the city. Habits: he
was an excessive smoker. He had syphilis sixteen
years ago. About six years ago he began to act
strangely. Having assisted a surgeon in his work,
he imagined he could succeed in surgery. He never
was violent. - ‘
Physical examination was negative. Pupils both
react to light and accommodation. Patellar reﬂexes
normal. Weight was 160 pounds. There was some
incoordination in dancing, in singing, in playing.
He was a fellow who had given much of his time to
playing upon musical instruments. I have been
told by friends of the patient that he really was a
ﬁne violin performer before he became an inmate of
the asylum. He has now no ability to recOgnize the
discords which he produces upon the violin through
the lack of coordination in the ﬁner muscle-groups.
The ﬁrst thing I noticed in another patient at the
asylum, who in his time knew as much about the
use of the microscope as any man in St. Louis,
was his lack of coordination as seen in his inability
to adjust the microscope. Such experiences are
quite frequent with these patients.
With regard to psychic phenomena, there was pro-
found euphoria; for instance, his musical abilities
being exaggerated. When the patient ﬁrst came to
266 MEDICAL SOCIETY OF
the hospital he said that he had been cured of his
mental ailment by four doses of a medicine which
had been prescribed for him by Dr. Bliss at the Mul-
lanphy Hospital. And since that time I have been
anxious to ﬁnd out from Dr. Bliss what this marvel-
ous drug was that cures paralytic dementia in four
doses. ‘
This case has not shown any moral decline; he has
shown considerable attention to some of the pretty at-
tendants at the asylum. The patient’s writing was
fairly good. When this patient ﬁrst came to the
asylum he was possessed of a feeling of well-being,
which had not left him entirely since then. NO mis-
take could be made in the diagnosis of this man’s
trouble. The physician who committed him thought
that there were signs of a nervous break-down. What
.goes against that is the,picture of well-being. The
man had three children at home, a wife dependent
upon him, a mother who comes to the asylum to see
him frequently, at considerable expense and trouble,
and he is perfectly content to remain at the asylum,
not worrying in the least about his family at home.
No neurasthenic could be that way. This man also
had patents at one time that were thought to be
worth something, and yet he is contented here. No
man with these qualities could be satisﬁed at the
asylum. The only thing that worries him is that he
cannot get his “rehearsal” sometimes. There is no
.possibility of nervous prostration being there with
those physical signs, those pupils and exaggerated
reﬂexes. The history of these patients is not com-
plete, because people do not observe all the early
symptoms in these patients. P
The next case is a man who had been at the asylum
two and a half years; 40 years of age; single, and
book-keeper by occupation. Family history is nega-'
tive. Mother died of pneumonia. _His history is
meagre. The patientv states that he lived in Chicago.
CITY HOSPITAL ALUMNI. 267
for eighteen years, which city he considers the
wickedest in’the Union. He says that he contracted
his disease from breathing the contaminated Chicago
atmosphere. He was struck on the head some time
ago. He denies venereal disease. His weight when
admitted was 150 pounds; now it is 130 pounds. Pa-
tellar reﬂexes are exaggerated. Muscle sense is im-
paired. Analgesia is marked. Incoordination is
marked in reading, but not in writing.
Pscyhic phenomena: At ﬁrst he complained of the
“Chicago” disease—euphoria. He can go into a
rage at any time, especially when some of the patients
tease him. The word “rubber-neck ” applied to him
as a sobriqueﬂmakes him very angry. He had no
hallucinations. Hallucinations are rare in dementia
paralytica. Amnesia is very marked. He is very
patriotic. He claims to be a good Republican. He
is also very religious. When he was at the asylum
'one year ago he wanted to be baptized. He never
had any real delusions. Delusions of grandeur at
one time were considered pathognomonic of dementia
paralytica. This is radically wrong; luetics some-
times have these delusions. Cases Of mania also have
delusions of grandeur. Paranoiacs are apt to have
them. There ,is really not a single symptom which is
pathognomonic of dementia paralytica. The thing
which strikes me most forcibly in paralytic dementia
is the general psychic weakening-that “let-down”
which is not easy to misunderstand. It is rather an
inappreciation of their surroundings. In other words,
the patient may talk reasonably, but yet he has that
peculiar wayof not being appreciative of his surround-
ings. These patients have a cautious way of stepping
about, which was particularly marked in this second -
case. Lingual as well as labial ataxia is well marked
in this case. I had the patient'add up a little col-
umn of ﬁgures before he came to the meeting. Al-
though this man had been occupied with keeping
268 MEDICAL SOCIETY OF
books before he was taken tothe asylum, and had
been an accountant, it took him nearly thirty minutes
to add up this little column of three ﬁgures. This
showed lack of attention. And this symptom is
also found in neurasthenia. A neurasthenic fre-
quently complains of not being ready to make up: his
mind about different matters. Another different fea-
ture is that a neurasthenic will intelligently listen
when talked to about his trouble. A paralytic de-
ment will listen, but will not do what he is told to do,
because he does not appreciate it. ‘
Dementia has not progressed far in this second
case; it comes on gradually in these cases. In one
case I could see how dementia gradually crept on the
patient until eventually he became a mere animated
log. I would not call them animals, for I do not like
to insult the noble name of,animal by likening them
to these patients. They are mere animated logs.
The third case was, at the asylum two months. He
is twenty-eight years old, single, machinist by occu-
pation, family history negative, had syphilis thir-
teen years ago. His education is rather meager.
Attended public schools Of the city. He was alWays
bright. Habits: Drinks, indulges in sexual excesses.
His attack began about two months-ago, when he
talked of his immense wealth.
Examination: He has lost in weight ; this loss in weight.
in paralytic dementia is very striking. This is true
until they enter an institution, when they pick up in
I weight. Pupils are equal, and respond to light. Pa-
tellar reﬂexes absent, showing implication of the
posterior column Of the cord. Muscle sense is im-
paired.- There is some analgesia; no Rombergism.
When admitted was maniacal. He was transferred
on the second day of his admittance to the fourth
ward, where he seemed perfectly contented among all
those canvas-suited patients. He said that the house
was palatial, and that the meals were superb. He
CITY HOSPITAL ALUMNI. 269
had amnesia. His mania then began to decline, but
the euphoria remained. He is in possession of con-
siderable wealth, which he cannot deﬁne. He is get-
ting to. be more vague.
This case is well advanced into dementia. The
feeling of well-being is especially well marked. In
his reading the patient slurs over his words.
The nextcase (fourth) shows the dementia more -
marked than the others. There were some severe
traits of ancestral taint in this case. He was always
a fellow who was inclined to be wild. 'He was called
“Happy” 'or “ Wild” Jack. There was the element
of imbecility in this case. There is nothing in the
make-up of an imbecile which will prevent himfrom
getting paralytic dementia. I have received a girl at
the asylum who was an imbecile, and she developed a
progressive paralytic dementia, which ran its typical
course. It was a case of hereditary syphilis. The
fourth patient showed a defective morale before the
development of dementia paralytica. He was at the
asylum eleven months. , He was a cab-driver, which
-was an occupation exceedingly distasteful to his fam-
ily, who are very respectable people. His family his-
tory is bad. An aunt had some form of insanity.
His past history showed that he had had malaria when
a boy. He also had sunstroke once. He was fairly
successful at school. 'He had always been considered
the “black sheep” of a very respectable family.
He afterwards became a cab-driver, much against his
family’s wishes. He was belligerent. He was an
rested for forgery, and was sent to the asylum. I
cannot understand how a man in his condition could
have been mistaken for a sane man, and held for for-
gery. Examination of patient: He weighed 180
pounds when admitted, but at the present time he
weighs 172 pounds. There was no scar on penis.
Pupils: Right larger than left; both react well to
light and accommodation. Muscle sense impaired;
270 MEDICAL SOCIETY OF
patellar reﬂexes exaggerated. There was incoordina-
tion in speaking, reading and writing. He has a rep- .
etition of syllables in his writing which has received
aspecial name when found in speech. There is an
irregular tremor in his writing which is not as marked
in this case as in the next. He showed incoordination '
in dancing. These things are of a transient nature.
In the way of psychic phenomena he has euphoria,
delusions of grandeur. He has almost 'babyish emo-
tionalism. The dementia is unmistakable. This is
the only case of the ﬁve that had hyperesthesia, and
it is the most demented case of the ﬁve. I j
The ﬁfth case is one in which I can bring out the
whole picture ef dementia paralytica because I have _
known him so long. He was 39 years old. He is a
druggist by occupation. Family history showed that '
there was insanity in his'family. He always had good
health. He attended the public schools and after-
wards graduated at the College of Pharmacy. He
afterwards did a great deal of walking, being engaged
in selling patent medicines. He had swelling of the
feet, 71. e., edema. He perspired freely. Habits: He,
drank and smoked to excess. He married a prosti-
tute. He was fond of all kinds of sport. He showed-
a high degree of carelessness on going into business.
He accused customers of owing him money when they
did not owe him anything. He exaggerated about his
winnings at the races. Examination of patient in 1895:
His moral turpitude was such that the speaker had to
reprimand him for keeping disgusting books in his room
at the asylum where he was employed in the capacity
of druggist. The house girls found these books
in his room. He denied to the superintendent that
the books were put there by him. He attended to his
duties fairly well. He played the piccolo fairly
well He was not discharged from his position at the
asylum, but~resigned. During the early part of 1898
he visited the asylum twice while the base-ball game
‘ < CITY HOSPITAL ALUMNI. 271
was in progress. He showed signs of exultation at
that time. ‘ .
Physical examination: Height 5% feet; weight 105
pounds. Temperature normal; inguinal and epi-
trochlear glands enlarged; no scar on penis; pupils
equal and-react to light; muscular power diminished;
slight tremors; reﬂexes normal. During his entire
stay at the asylum he improved physically and no 'dis-
turbance of compensation followed. Subsequent
nervous examination: Right pupil larger than left;
lingual and labial tremors exaggerated; muscular
pOwer impaired; analgesia pronounced; incoordina-
tion pronounced in reading, writing and in playing.
Psychic phenomena: Euphoria. He had marked
delusions of grandeur; he' thought he was very strong.
He was winning money at the races while he still was
at the asylum. He told me that he won money from
the patients at the asylum, and then explained in a
very illogical way why he did not getthe money. This
is different from the neurasthenic who makes logical
statements. Amnesia very pronounced. The quiet
’ of institutional life allays the psychic storm. The
patient wants to make a living for his family. Until
'a few days ago he was never noisy. On that occasiOn
he became very noisy and had to be transferred to an-
other ward. He told me in the presence of Dr.
Greiner about his experience when he was transferred.
The speaker said that he had been given some medi-
cine to quiet him when transferred to the other ward.
The patient afﬁrmed that some men in shrouds had
surrounded him and a kind of mist was thrown over
him by these men. He has been growing more fool-
ish in his actions. In this case it can be seen that
there is a typical picture of the disease, with a gradual
decline in an individual who was rather more disposed
'to a moral decline than the others._ It is important
to recognize these symptoms early. The practi-
tioner who sees these patients early should learn to
recognize these symptoms.
272 ‘ MEDICAL SOCIETY OF
I may mention the case of the Prince'von R., who
spent several hundred thousand dollars in a foolish
way before it was found out that he had this disease.
There are some cases in the city of St. Louis, people
who are well off, who get rid of their money foolishly
before this disease is recognized in them. Thus, men
will be seen to be buying on a declining market, etc.,
showing the initial symptoms of the disease. There
is a ﬁnancial as well as a moral ruin in such cases.
The writing of v the patient showed how the tremor
of his writing is different from that of the senile.
Paresis of the vocal cords could be made out from the
“ goat-like ” character of his voice. At ﬁrst this man
could sing well, but now one could'hearhow badlyhe
sang from his execrable ' rendition of the pretty
ballad, “ Because I Love You.” He has no apprecia-
tion whatsoever of the discords he was producing,
When he ﬁrst came to the asylum this was not so well
marked, but now it is very noticeable.
It is well known that the process in dementia para-
lytica is the. most destructive brain disease, destroy- '
ing the whole cortex of the brain. When the brain
gets into that condition there is no power to evolve a
' delusion. A history of syphilis is obtainable in most
of these cases. There is some relation between the
syphilitic subsoil and disease, like locomotor ataxia
and paralytic dementia. The relationship is .the same
between this syphilitic subsoil and paralytic dementia
as it is between locomotor ataxia and the syphilitic
subsoil. What this relationship exactly is is not
known. ’
I have noted, in a reference to some writer by -
Krafft-Ebing, that some investigator had inoculated
six paralytic dements with the syphilitic, virus, and
none of them developed syphilitic secondaries. It is
interesting to knew that cases of well-marked para-
lytic dementia come to hospitals showing active lesions
of syphilis. Under treatment the active lesion-s dis-
CITY HOSPITAL ALUMNI. 273
appear, while the dementia paralytica progresses.
This shows that there is probably a toxemia following
syphilis'which makes the tissues liable to some pro-
cess like paralytic dementia or locomotor ataxia.
None of theseﬁve cases showed hallucinations. I
' know of a case which is roaming about the country
looking for the person who had his voice. He was
brought to the asylum at ﬁrst in a very weak condi-
tion; so weak that he had to be carried (in. His
physical condition gradually improved, and ﬁnally he
was taken away by his relatives, who thought he waa
well. He came back to see me three times, seek-
ing the person ,who was talking to him. When he
'was sitting in the Superintendent’s ofﬁce he prob-
ably had a revolver with him. He told me that
. if he found that fellow he would kill him. He
thought that the husband of one of his nieces was the
man he wanted, and this rather frightened me, be-
cause he was a dear friend, and I thought that the
friend’s life was in danger from this dement.
_ Another remarkable feature about these cases is
’ their moral nature, which is especially defective.
This is important, because there are patients who
have nothing else to show during the time of their
remissions. I know a patient who is walking the
I streets of St. Louis—a case which cleared up so that
in the period of remission his relatives concluded that
the asylum people were wrong in their diagnosis of
the man’s trouble. I can show letters of this man to
his wife, letters which were very disgusting, and yet
the patient was One of the purest minded of men be-
fore the attack.
Another important feature about these ﬁve cases is
that they had no apoplectiform or epileptiform at-
tacks, which is frequently a great help in the differen-
tial diagnosis between dementia paralytica and neu-
rasthenia. It is perfectly proper to diagnositicate a
condition as dementia paralytica when there is a his-
274 MEDICAL SOCIETY OF
tory of epileptiform or apoplectiform attacks in con-
nection with the other history of that disease. It is
usually a matter of neglect when they get these
attacks, most of the attacks being due to a full stom-
ach, afull bladder, or a full rectum. If there is a
history of a lack of concentration, a pupil which is
inclined to beasluggish or is permanently sluggish in
its reaction, halting in speech, halting in going over
syllables, and a lack of appreciation of the surround-
ings, then the diagnosis of the condition is not diffi-
cult. A melancholic patient remains depressed, while
a dement does not remain so. They can be talked
out of their depression. Any instability of disposi-
tion or instability of any kind in psychoses ought to
make one suspicious of paralytic dementia. Under
such circumstances, I can feel the presence of paresis.
. DISCUSSION.
DR. GEO. HOMAN asked Dr. Bunge whether or not
the last patient whom he had presented retained any
of his skill as a pharmacist.
DR. RUNGE said that he had not retained any such
skill. He had lately shown an inability to account
for some of his simple actions.
DR. HOMAN asked further whether or not the ﬁfth
patient had stood high in his position as druggist at
the asylum, to which Dr. Runge replied that he did
not think so, because the patient had always been un-
tidy, both in his personal appearance and in the man-
ner of taking care of the drug store.
DR. J ACOBSON asked Dr. Runge whether he had
found old syphilitic cases, which had taken regular
treatment for two years, to be subjects of nervous or
mental disease of this kind.
DR. RUNGE said that one of the patients whom he
had presented this evening had had two years’ treat-
ment. He said that most of these cases are very
CITY HOSPITAL ALUMNI. . 27 5
obscure. He said that he thought that cases which
were treated were not so liable to result in this disease.
DR. J ACOBSON said that some authorities say that
every case of tabes is due to syphilis.
DR. SHATTINGER said that he would like to have
Dr. Runge inform him whether he knew of anything
tangible by which it could be shown that.tlie increase
in the number of cases of this disease could be traced
to the social life of the present: '6. e., whether there
was any statistical evidence of any investigators in
literature.
DR. REDER said he wanted to know what the proba-
ble outcome was with patients suffering from paraly-
tic dementia. He asked whether or not it was true
that most of these patients committed suicide. Did
not many of them become violent, while others took a
different turn and dropped into a state of melancholia
and eventually die of exhaustion? He said that he
was very much interested in the life and death of
King Ludwig of Bavaria? Did he not have paralytic
dementia? He said that Dr. Runge had spoken of
the delusions of these patients and their engaging in
enormous enterprises; would this reﬂect upon the
past life of these people? Some of these people
would probably engage in large business ventures,
while the better class would turn their attention to
the Muses. He said that King Ludwig of Bavaria
had a magniﬁcent production of Wagner’s operas pro-
duced upon the Bose Island in the Staarmberger See,
particularly the opera “Lohengrin,” which he had
produced at an enormous expense, in a manner which
probably will never be equalled. It has been said
that to King Ludwig the subsequent success of these
operas was due. There is no doubt but that this dis-
ease in King Ludwig must have taken a violent turn,
for that can be surmised from the violent death of
that monarch by drowning after drowning his physi-
cian. Dr. Reder would like to know from Dr. Bunge
whether that could not have been paralytic dementia.
276 MEDICAL SOCIETY OF
DR. RUNGE, in closing the discussion, said that he
did not believe that there were statistics on this sub-
ject. It is more of a general impression that paralytic
dementia is pre-eminently a “city” disease. This “is
particularly true in the State of Missouri. There are
very few cases of this disease at the State Asylum at
Fulton or Nevada. The asylums close to New York
City are overcrowded with this disease. The anam-
nesis is very meagre in these cases. These patients
are not able to give their histories. When it comes to
mental phenomena, the relatives are usually the last
people to ﬁnd out any facts in that line. The speaker
said that he had called attention, in a recent paper, to
the fact that the weakest point in psychiatry is the
compilation of tables to show the causes of insanity.
Most of the-laity attribute the cause of insanity to the
wrong thing, such as the loss of a lover, a broken
heart, etc. All of those things are incidental. There
is a tendency to produce a general tendency to in-
sanity in the large cities. All of the ﬁve patients pre-
sented before the Society dissipated. This dissipa-
tion is not found in small towns because a man or
woman who does that is soon turned out of the town,
whereas in the larger cities this does not happen.
This is especially true in Europe, where we ﬁnd this
disease increasing. It is increasing among the mili-
tary men, especially among the officers. It has been
observed among the German soldiers. It is not due to
the military profession, but it is due to the excesses
indulged in by the military men. It seems to be a
disease conﬁned almost exclusively to the large cities,
and therefore the life in a large city must have
something to do with it. Otherwise, the farmers who
furnish such a large proportion of the contingent in
the State asylums would show evidences of the dis-
ease more frequently than they do.
In answer to Dr. Reder’s question, Dr. Bunge said
that the paretic clement is entirely devoid of the sui-
CITY HOSPITAL ALUMNI. 27 7


,cidal tendency. He recalled only one case of that
kind among the hundreds which he had seen. He had
harrowing delusions of persecution. Such patients
would never commit suicide, because they are too
happy. They never bother about what is going‘to
happen. They may have delusions of grandeur which
is not characteristic of the disease, but‘the suicidal
tendency in these patients is rare. The general out-
come is very much the same whatever the beginning.
Every author has his classiﬁcation for mental dis-
eases. This disease is divided into four different
types by the latest writer, Kraepelin. These ﬁve pa-
tients will gradually have a loss in memory and a loss
of all appreciation of their surroundings, eventually
coming into the shape of mere animated log. The
vegetative functions go on. The death which is the
'most frequent one with these patients is one of as-
_ thenia. This disease affects not only the brain, but
also the‘spinal cord. Kraepelin adheres to the opinion,
which was propounded at ﬁrst, that almost all bed-
sores are due to neglect. Bed-sores develop some-
times almost instantaneously. A necrotic spot will
appear within an hour. Then the patient is liable to
die of septicemia. The speaker said that he did not
agree with Kraepelin, that the less these patients are
taken care of the more do they die of that cause.
They die of deglutition pneumonia. It is due to
paralysis of the esophageal muscles with a pneumonia
following. The speaker said that. in his impression,
no case ever recovered. Kraepelin says that less than
one per cent.‘ is recoverable. He explains this less
than one per cent. by saying that it might be a case of
remission in the disease or else it might not be paraly—
tic dementia in this small percentage which recOvers.
He said that he did not care to make a diagnosis in
the case of King Ludwig of Bavaria. He was a sex-
ual pervert. He was always to himself, even in his
theater. The same thing is noticed in boys and girls.
278 MEDICAL SOCIETY OF
who masturbate. He did not have the same delusions
as his brother Otto, who had delusions that he was
an animal. He said that the whole family of Bavaria
is tainted. In terminal dementia the process is more
gradual. It isa very slow process. There is not a
disease of the brain in existence which causes such a
complete breakdown of the cortical substance as does
paralytic dementia. They even make that pathog-
nomonic, and if you see a specimen of that kind it
can be said that it is a case of paralytic dementia.
Finally, Dr. Norvelle Wallace Sharpe moved that the
thanks of the Society be extended to Dr. Runge for
his admirable presentation of the subject of paralytic
dementia before the Society ; motion seconded by Dr.
B. B. H. Gradwohl and unanimously carried.

STATED MEETING, THURSDAY EVENING, DECEMBER 7,
THE PRESIDENT, DR. GEO. HOMAN, IN THE CHAIR.
DR. RAVOLD said that, owing to unavoidable inter-
ruptions, he had not been able to prepare a paper for
presentation to the society, but he would try to de-
scribe brieﬁy the methods pursued and the results
Obtained in the
Bacteriologic Examination of the River Water.
On July 20th Dr. Teichman, the City Chemist, and
Dr. Ravold had been ordered by the Health Commis-
sioner, Dr. Max C. Starkloff, to make a chemical and
bacteriologic examination of the waters of the Missis-
sippi, Missouri and Illinois rivers. The necessary
apparatus was purchased, and Mr. Walter Kirchner,
a capable young man, a graduate of Washington Uni-
versity and a medical student now in his third year in
the St. Louis Medical College, was employed to con-
duct the bacteriologic work. All media was prepared
at the City Chemist’s ofﬁce, and the plating and
counting of colonies was carried on in a temporary
laboratory ﬁtted up at the Chain of Rocks pumping
,a
CITY HOSPITAL ALUMNI. 27 9
station. Samples of water were taken daily by Mr.
Kirchner at the Chain of Rocks, and weekly trips
were also made up the riVer in the harbor boat
for the purpose of collecting samples from the
Missouri, Mississippi and Illinois rivers. It was
the intention of Dr. Ravold not only to ascertain
the numbers of bacteria in the river waters, but also
to separate out the different varieties of bacteria
found in the waters, while a special search was to
be constantly made for the bacillus coli communis
and the bacillus typhosns. After two months work
at the intake in counting colonies and in an eﬂort
to separate and identify the different varieties of
bacteria found in the water, for want of time this
part of the work was stopped and the attention con-
centrated upon a search for the colon and typhoid
bacillus. Dr. Ravold here described the different
media used in the plating and also in the search for
the colon bacillus. In the search for the colon bacil-
lus the fermentation tubes of Theobald Smith were
used, not less than three tubes being _inoculated with
one cubic centimeter each from every sample col-
lected. If fermentation occurred in any tube the
growth in it was plated at once and studied for the
colon bacillus. Mr. Kirchner, up to September 30th,
examined eighty-one samples in this way without
ﬁnding the colon bacillus. All of these samples were
also examined independently by Dr. Ravold, with
negative results. About September 1st 50 c.c. of all
samples collected were mixed with 50‘ c.c. of broth
in Erlenmeyer ﬂasks, and then placed in an incubator
at 375° C. At this temperature the colon and ty-
phoid bacilli grow best, while the ordinary water bac-
teria do not. After forty-eight hours in the incuba-
tor the ﬂasks were removed, and the growth in them
plated in gelatine and studied. Fermentation tubes
were also inoculated with 1 to 2 c.c. of the growth in
the Erlenmeyer ﬂasks. In this a constant search was
280 MEDICAL SOCIETY OF
made for the colon and typhoid bacilli. Mr. Kirch-
ner, on account of his medical studies, was compelled
to give up the work on October 1st, when it was
taken up by Dr. Ravold alone. Samples were now
collected twice a week at the Chain of Rocks, and
weekly trips made up the river in a steamboat char-
tered for that purpose. Dr. Ravold exhibited a
chart, and with the aid of a drawing on the black-
board of the Mississippi, Missouri and Illinois rivers
showed where up to date the colon bacillus had been
found in 50 c.c. and also in 1 c.c. samples of the wa-
ter. Throughout the work a constant search had
been made for the discovery of the bacillus typhosus,
but in spite of the most painstaking endeavors, in
which plain gelatine as well as a number of special
media, such as that of Eisner, His, Stoddart, Capaldi,
Piorkovski and others had been used, the bacillus
had not been found up to the present date. Dr.
Ravold insisted that although the typhoid fever bacil-
lus had not been found in the river water, he was con-
vinced from his work up the water that it was never-
theless the cause of the recent outbreak of typhoid
fever in the city, and exhibited a chart showing that
from August 12th to October 26th the river fell nine
feet at the intake. On October 26th the lowest point
was reached; then the river rapidly rose. On this
chart was also recorded the number of cases of
typhoid reported to the Health Department from Au-
gust 1st to December 14th. It was shown that with-
in thirty days after the river reached its lowest stage
there was a great and sudden increase in the number
of cases of typhoid fever reported. The incubation
period of typhoid fever is fourteen days, and it is
fully ten days before the case is reported to the
Health Department. The rise in the typhoid cases
corresponds remarkably with the lowest stage of the
river. Further, at the low stage of the river the fecal
bacteria were found constantly present in even a few
CITY HOSPITAL ALUMNI. 281
drops of water at the intake, proving sewage pollu-
tion. With all these facts taken together, there was
no escaping the conclusion that the river water was
the source of the typhoid epidemic.
DR. CHAS. SHATTINGER said he would ask a ques-
tion that he feared would display gross ignorance of
the subject; but he wondered why so much effort was
made to demonstate that the water was contaminated
with fecal matter, when it certainly must have been
contaminated, considering the towns along the river,
if sewage had discharged into it.
DR. RAVOLD said there was no doubt of this; but
how much reached St. Louis was the important ques-
tion. It is absolutely essential that this be known,
and that he be able to prove it.
DR. SHATTINGER asked if pollution was found in
the Mississippi before the Illinois emptied into it?
DR. RAVOLD said fecal bacteria were found in it
several times.
In answer to a number of questions, he made the
following remarks:
The system of ﬁltration used at Hamburg is sand
ﬁltration.
When asked if the last epidemic of typhoid fever
was really conﬁned to one section of the city, as had
been asserted, Dr. Ravold said that a recent map
prepared for him by Chief Sanitary Ofﬁcer Chas. W.
Francis showed the cases to be pretty well scattered
throughout the city. ‘
In this connection, DR. HYPES said he thought
there was a wrong opinion prevalent in regard to the
localities where the disease showed itself. He knew
that many of his colleagues did not report their ty-
phoid fever cases, and when Observing the chart he
noticed that comparatively few cases were reported
from the southern portion of the city, and he believed
that more than half of those so reported had been
sent in by him. He heard of other physicians treat-
282 MEDICAL SOCIETY OF
ing cases of continued fever, and in families in the
same neighborhood where he was at the same time
treating typhoid fever patients, and yet those other
cases were not reported as typhoid-they were called
malarial or continued fever. From this he judged
that the reports could not be relied upon entirely,
and conclusions from these reports should not be too
deﬁnite.
In answer to Dr. Homan, Dr. RAVOLD said that the
City Chemist was at work upon the river water, and
would undoubtedly answer the questions propounded.
The Illinois River is highly polluted, the Mississippi
is not; by the time the Missouri River is reached both
streams are intimately mixed. When the waters are
high the Missouri and Mississippi do not become
mixed very much before reaching the Chain of Books.
SO that the water pumped at that time is practically
Missouri River water; but when the rivers are low the
mixture of the two waters becomes very intimate be-
fore arriving at the intake, owing undoubtedly to a
number of shallow places, which extend well across
the river between the intake and the mouth of the
Missouri, and which compel the waters to mingle
thoroughly. In the fall and winter months therefore
the water at the intake is a pretty evenly divided
mixture of both streams.
In answer to the question as to the best method of
ﬁltering the city water, Dr. Ravold said that no man
on earth knew what method is the best for purifying
the Mississippi River water at this point, inasmuch
as no investigation of the water worthy of men-
tion had ever been made. The problem is an ex-
ceedingly difﬁcult one, and a conclusion as to the
most efﬁcient and economical method of treating the
water could be reached only after a most careful and
searching investigation, carried on for at least one
year, by highly trained experts.
Dr. Ravold then explained the various methods of
‘k
CITY HOSPITAL ALUMNI. 283
I
purifying water on a large scale, and by a number of
cities in this and foreign countries. The English
sand ﬁlter, as used in England and the principal cities
of the Continent; the modiﬁed English system, the
artiﬁcial sandstone or Wormser ﬁlter, as used in
Worms, Germany, and the American or mechanical
ﬁlters, were described and explained. The question
of a coagulant was also freely discussed.
DR. J. C. FALK said he desired to take issue with
those who claim that a running stream will purify it-
self in a certain distance of ﬂow. If pathogenic
bacteria were always present in water in a state
of ﬁne subdivision, suspended as it were, as solitary
organisms, bare and exposed freely to the destructive
processes of air, light, sedimentation, etc., then we
might concede that a river will practically purify it-
self \in a given number of miles. Unfortunately
pathogenic germs are not always in such a state fa-
vorable for their being rendered innocuous. They
may be enclosed in aggregations in masses of offal,
inside the carcasses of animals, within human bodies,
and under many other conditions is it conceivable for
bacteria to live and propagate for days and weeks
without being exposed to the elements of destruction
associated with a body of moving water. Meanwhile
these pent-up colonies of disease germs can be ﬂoat-
ing onward in their decomposing vessel for possibly
hundreds of miles, and then, reaching the intake of
a city’s pumping station, the rotten container of offal,
carcass or corpse, falls to pieces, liberating its myri-
ads of deadly bacteria directly into the water supply
of a large population He would therefore insist
that it is practically impossible for any sewage-pol-
luted stream to purify itself, or be rendered potable
‘ by running any distance whatever.
DR. CARL FISCH congratulated Dr. Ravold on the
good work done in this direction. He said he
was too well versed in it not to appreciate the
284 - MEDICAL SOCIETY OF
amount of work done and the great care in carrying
out the investigations. As to the vital question—the
contamination Of the water—he would like Dr. Ra-
vold to be a little more explicit; but as it was a sub-
ject allowing of a great variety of opinion he thought
it better, perhaps, to not push that for the'present.
In regard to'the determination of any certain kind of
bacteria in water, he knew this to be a very difﬁcult
task, that becomes more difﬁcult when the investiga-
tor has to deal with outside pathogenic germs in the
water. It is true that the presence of the bacterium
coli commune is,_as a rule, taken to indicate that the
water is contaminated with fecal matter.. With this
opinion the speaker, however, did not quite agree.
He said a number of observers had shown that the
coli commune was not an inhabitant of the intestines .
of mammals, birds and reptiles only. It was known
that a number of plant diseases, as found in plants
growing on the borders of-rivers, were caused by bad--
teria, and in the opinion of reliable observers these -
bacteria did not differ from the coli commune. This
was especially true of plants that grew near the wa-
ter’s edge and along the river banks, and if this was
true the contamination of water with fecal matter
was not proved by ﬁnding the coli bacterium in it.
The table shown by Dr. Ravold showed that the bac-
teria had been deposited in the river at certain points,
or at least in a certain part of the course of the river,
and that, he thought made the matter suspicious.
In regard to the difﬁculty of ﬁnding the typhoid ba-
cillus, the speaker agreed with Dr. Ravold. He said
he would have liked Dr. Ravold to have mentioned
one methOd which will almost certainly demonstrate
the presence of the bacillus in two or three days. He
had been using it of late. He believed that by
changing the method of examining the water much
more reliable results could be Obtained, and by inves-
tigatinga larger amount of water also better results
K
\
CITY HOSPITAL ALUMNI. 285
might be had than by the ordinary method of plating
a small_amount. He agreed with Dr. Ravold that it
was very unlikely that the typhoid bacillus could be
demonstrated in water. It has been done in only a
few cases-only three or four cases in literature.
One point was clear—the doctor’s opinion of the value
of the plating method. The speaker said he had
long since ceased to build any conclusions upon this
method. In this method one fact had been over-
looked, the fact that the bacteria in being transferred
from one medium to another were more or less dam-
aged in vitality. He wondered that Dr. Ravold did
not mention the very reliable method of using the
new peptones (Naehrstoff Heyden).
DR. RAVOLD: That method was mentioned. It was
by this method that so many different opinions were
formed as to the number found; one man might ﬁnd
500 and another man 5,000.
DR. FISCH said he was glad that Dr. Ravold did
not ﬁnd the typhoid bacillus, for had he said he
had found it the speaker would have doubted it.
DR. RAVOLD: I would have proved it.
DR. FISCH said he was afraid he would be inclined
to doubt the proof. He asked Dr. Ravold why he
depended so much upon the fermentation test.
DR. RAVOLD said he had never found a coli bacil-
lus which did not produce fermentation, and when
this took place it was an indication of the presence
of this bacillus.
DR. FISCH- remarked that several pathogenic varie-
ties of the bacterium coli commune were known that
did not produce fermentation.
THE PRESIDENT said the recent occurrence of ty-
phoid fever could hardly be termed an epidemic
either in morbidity or mortality. Considerable im-
portance should be attached, he thought, to the
remarks of Dr. Hypes in regard to the failure of many
286 MEDICAL SOCIETY OF
JR
physicians to report these cases, which by a proper
test would in all probability prove to be typhoid. .
During his term as Health Commissioner, which fol-
lowed the epidemic of 1892, he had occasion to inves-
tigate the sources of the local water supply and the
location of the intakes, and his conclusion was that
it was an instance of municipal self-poisoning, the re-
sponsibility for which could be accurately placed.
In regard to the immediate subject of Dr. Bavold’s
remarks and the latter’s failure to secure a bacterio-
logic index of the speciﬁc germ of typhoid, or of
the coli commune, the speaker said that during his
ofﬁcial term considerable chemical investigation had
been made of the quality of different river waters, and
the chlorid test was at that time considered the most
signiﬁcant, the saline element measuring approxi--
mately the degree of sewage pollution. He asked Dr.
Ravold if any chemical investigation had been made
with reference to that and what importance, if any,was
attached to chlorid as determining the relative fecal
contamination of the rivers concerned—the Illinois, the-
Missouri, and the Mississippi. There are some colored
plates in the Health Department. report for 1894-
which he had caused to be prepared, and by means
of the different colorations the degree of pollution and
amount of chlorid contaminatiOn are indicated, the
chlorids being assumed to have their origin in fecal
contamination. Another very important condition,
which he thought must be very embarrassing to bac-
teriologists, is the amount of suspended inorganic mat-
ter—sand, clay, etc.--in the water. He asked whether
the plating is done with settled water or with ﬁltered
water, and what effect the suspended clay or sand has
upon thevitality of bacteria conveyed in the ordinary
surface or river waters. Another important thing was
the differences in the speciﬁc gravity of the two
waters, i. e., that of the Missouri and the Mississippi.
As is well known, the Missouri River water is heavily
1‘
CITY HOSPITAL ALUMNI. 287
charged with inorganic matter._ Of course suspended
matter, such as sand, clay, and vegetable substances,
has no eﬂ’ect upon the speciﬁc gravity, and the Mis-
sissippi River, carrying also the Illinois River water,
must have a larger amount of chlorids and have a
higher speciﬁc gravity. The natural tendency, he
thought, would be for the Mississippi water to under-
ﬂow that of the Missouri River after they unite and
the former water to reach the intake of the local
waterworks, while on the surface it appeared that only
the Missouri River water followed along the western
bank. This should be fully investigated. There had
been a great advance in knowledge respecting the
processes of ﬁltration. Up to a few years ago it was
thought that ﬁltration was merely a mechanical pro-
cess, but, as Dr. Ravold had shown, it is more than
that—it *is a vital process. It is regarded now by
those who have studied it most not only as avital
process, but they speak of eﬁecting the destruction of
the micro-organisms passing through the ﬁlter by a
burning process—a process of combustion. It had
always been a question with him in regard to dealing
with the muddy waters the local conditions present,
whether the upward system of ﬁltration would not be
preferable to the downward method such as that used
in England and other places where clear waters or
those slightly turbid are dealt with; the advantage
being that sedimentation and ﬁltration would proceed
simultaneously, and a simple reversal of the ﬂow
would automatically cleanse the ﬁlter bed. While we
as physicians, and those who have investigated the
subject, are pretty well satisﬁed that the use of a co-
agulant such as alum may not be injurious to the pub-
lic health, still there is that prejudice existing, and it
has to be dealt with. It may take years to remove
the feeling that alum added to water means an injury
to the stomach, just as the same substance, in combi-
nation with other chemical agents used as a leaven in
288 MEDICAL SOCIETY OE?
bread-making is considered in the public mind to be a
harmful thing, while as a matter of fact alum when
‘ combined with the other agents changes its form and
ceases to be alum in the bread mass. SO it is in the
coagulation process in water ﬁltration, alum ceases to
be alum unless it is used in such quantities that the
desired chemical changes are not effected. In view
of this prejudice in the public mind he thought, it
_worth while to consider whether it would not be
preferable to use the upward process—that is, having
the water pass upward instead of downward. The
cleaning of such a ﬁlter would be an easy matter. He
thought it a great mistake that the necessity of sup-I
plying ﬁltered'water-had not been anticipated and
preparation for it made’by laying a different set of
supply pipes. For street sprinkling, ﬁre department
purposes, etc., ﬁltered water of course would not be
necessary, and by having a separate set of pipes the
problem would be a very simple one, but the cost now
of providing such separated services would be formida-
ble and practically perhaps unattainable, at least for
a number of years.
CITY HOSPITAL ALUMNI. 289
SOME DIFFICULTIES IN THE EARLY DIAGNOSIS
OF PNEUMONIA; CLINICAL REPORT
OF TWO CASES.*
BY L. H. BEHRENS, M.D., St. Louis.
ASE I. August 20th I was called to attend E.
M., aged 45, traveling salesman. He had ar-
rived at the hotel some thirty minutes previous,
and having eaten a light luncheon returned imme-
diately to his foom. When in the room but a few
moments he was seized with paroxysms of sharp, lan-
cinating pains over the pericardium, extending to left
shoulder, darting down arm, and felt over ﬂexor sur-
face Of forearm and ﬁnger ends. He was in the up~
right position, both hands pressed closely over region
of the heart. On his forehead were large drops of
perspiration. His respirations were rapid and shal~
low as if in fright; he had a look of anxiety and ex
pressed fear of impending death.
After several moments the pains began subsiding
and he sank into a chair thoroughly exhausted and
badly frightened, complaining of a numbness in the
left hand and forearm, as well as a sensation of sore—
ness in the shoulder joint and surrounding tissues.
As soon as I had made his condition tolerable for the
time, I succeeded in getting the following history:
Habits: Almost a total abstainer from liquor and
never had been addicted to its use. Smokes a very
mild cigar every second or third day—even then con-
sumes only one-half the cigar. Eats regularly and only
plainest Of foods, and has always slept well.
He had always been an active athlete, however
never overexerting himself. There was no history of
his ever having had any venereal disease, nor could
he recall having ever been conﬁned to bed on account
of sickness norof feeling the least indisposed until

*Read at the meeting held October 5. The copy was
mislaid, and recovered too late for insertion in regular
order.
, 290 MEDICAL SOCIETY OF
about ten days before this attack, since which time
he has had slight headache, poor appetite, sluggish
bowels, and a feeling of general depression. His
conditiOn did not interfere with his work to any de-
gree, as he had been very busy and had come to St.
Louis to take a very active part in a recent conven-‘
tion; and, barring the attack throUgh which he had
just passed, he felt equal to the emergency. His
family his-tory was of the best.
As the soreness and feeling of oppression over the
region» of the heart had not entirely subsided, he be-
came nervous and anxious. After being assured that
all was doing as nicely as could be expected, he
undressed with my assistance and went to bed, assum-
ing the recumbent position slowly, not because of se-
vere pain, but for fear of a renewal of the anginoid
condition from which he had just emerged.
I did not at this time take his temperature, but the
skin was cool; pulse during the attack full and irreg-
ular, varying between 80 and 100 beats per minute,
entirely dependent upon his nervous condition.
Heart valves perfect; heart’s beat at times tumultuous.
Arteries were in good condition.
After about two hours (the last hour being a fairly
comfortable one for him) I left, but had gone only
thirty minutes when I was again hurriedly summoned
by phone.
An attack somewhat similar to the one of an hoirr
and a half before had taken place, but in addition to
the pain in the heart and shoulder violent epigastric
pain was now present. This peculiar sensation would
shift from one region to another, new excruciating in
the heart for a moment, again over the epigastric re-
gion for may be ﬁve minutes, suddenly leaving and
ascending to the shoulder. Thus this siege lasted for
three and a half hours. At the end of this time he
was free from pain and slept possibly two or more
hours and was comfortable ﬁve hours or more.
‘it
CITY HOSPITAL ALUMNI. 291
At 10 A. M. heart and lungs examined with negative
results. Urine at this time could not be obtained, as
I had administered a rather active saline purge.
About 4 P. M. I again called and found temperature
of 103° had developed; pulse 106, respiration 24; but
examination of lungs still negative.
At 9:30 P. M. Dr. S. met me in consultation—26
hours having elapsed since ﬁrst anginoid attack and
about 20 since severe pain had been felt.
On examination at this time distinct moist rales,
edematous in quality, could be heard at lower portion
of both inferior lobes, but most marked on the right
side. Percussion was negative. The pulse was very
weak, readily compressible and 132 per minute.
Temperature 104°.
I succeeded later in obtaining specimen of urine.
s. g. 1020, acid, no albumen, no sugar.
No decided change had taken place until next
evening (48 hours after attack), when right lung was
found to be about as above described; the left how-
ever was thoroughly inﬁllrated, and all the physical
signs of the ﬁrst stage of croupous pneumonia were
present.
I might conclude this case by adding that matters
pI'Ogressed in a rather atypical manner, as accom-
panying temperature table will indicate, the fever
descending to 996° on 29th (9th day) and ascending
rapidly to 104° in consequence of a right side
infection.
Patient did not cough once until the 8th day P. M.,
at which time rales redux were discerned. After this
he expectorated copiously, the sputum being yellow.
Heart seemed exhausted. After rise to 1040 on the
29th, edematous rales could be heard over both lungs
entirely; tracheal rales last. Patient became progres-
sively weaker, dying September 1st, having been per-
fectly lucid throughout.
292 MEDICAL SOCIETY OE


Case No.1. E. M.
TIME ,
DATE TAKEN PULSE RESP. TEMP. REMARKS
Aug. 21 ..... .. PM. ................... -. 103
*~ 22 A.M. 110 ......... .- 104.2
“ 22 .... .- PM. 132 ........ .. 104.4
‘ 23 ..... .. A.M. ................... .. 103.2
‘4 23 ..... .. PM. ................... .. 103.6
“ 24 ..... .. A M. ................... .. 101.6
“ 24 ..... -. PM. .................... -. 101.2
“ 25 .... .. A.M. .................... .. 100.6
“ 25 PM. ................. -. 102
“ 26 A.M. 132 44 100 6
“ 26 .... ._ P.M. 120 40 102 2
“ 27 A.M. .................... .. 100.4
“ 27 .... -. PM. .................. .. 102.2
“ 28 .... -- A.M. .................... -. 101 4
“ 28 ..... -- P M. ................... .. 102.2
‘* 29 .... -. A.M. .................... .. 99 6
“ 29 .... .. PM. .................. -- 104
“ 30 ..... -. A.M. 140 46 103
“ 30 .... .. PM. 134 44 101 8
“ 31 .... -. A M 136 40 103 2
“ 31 .... .- P M 132 42 103 2
Sept 1 .... .- A M 140 50 101 4
“ 1 .... .- PM. 148 56 103
“ 2 .... .- A.M. 160 60 102.4 Died.
"- 2 ..... .. P.M ............................ .-


Treatment: Digitalis, strychnine stimulating.
Case II. I did not have case under my charge
until some twenty-four hours after beginning of at-
tack, but, through the courtesy of my friend Dr. L.,
who had observed him during the severe pains, I am
at liberty to report developments up to the time we
determined the nature of the case confronting us.
W. R, age 52, widower; family history negative;
habits intemperate. Patient had been drinking hard
for one week previous to attack. The night before
was up all night, imbibing more than usual. He
used tobacco moderately, and of late had eaten irreg-
ularly. He never went to bed at any regular time,
consequently his sleep for months had been broken
and disturbed by exciting dreams. His past health
for years had been only fair, and he was of a phleg-
‘3.
CITY HOSPITAL ALUMNI. 293
matic temperament; irritable—as he expressed it,
“never satisﬁed unless partially under the inﬂuence
of liquor.” He was a sufferer from obstinate consti-
pation, and imagined he had most of the diseases of
greater or less import.
Some six weeks before he contracted a so-called
“cold,” which impaired the action of the various
-emunctories. On the 8th of March he suddenly ex-
perienced severe and prolonged pain over region of
the kidneys and extending to the umbilicus, most
marked on the left side. The attack Simulated the
passing of a renal caculus, each advance of the sup-
posed calculus being attended by excruciating pains,
almost causing convulsions.
Morphin sulphate, one grain in the course of thirty
minutes, modiﬁed the pain but little; but later the
patient felt much relieved, yet very nervous, no doubt
mainly due to debauch.
On the following morning early he began vomiting,
and experiencd much soreness over the epigastric re-
gion. Vomitus contained a liberal amount of blood
and mucus. During this time all symptoms seemed
centered in the stomach. The diagnosis was thought
to be acute gastritis (the history would bear out such)
and probable pneumonia of left side, but no attendant
signs were found on examination. Temperature was
normal and had increased but one-half degree up to
this time.
The next morning (32 hours after the severe pains)
~crepitant rales could be discerned low down in inferior
lobe of the left lung, in an area probably three
inches in circumference. Temperature, 98.4; pulse,
‘74, and respiration, 32. He had coughed some dur-
ing the night; sputum was scanty, and slightly
streaked with blood. Patient was free from pain.
The afternoon rise of temperature was about the high-
est recorded, viz., 994°; pulse, 76; respiration, 30.
Deep-seated bronchial respiration could be plainly
294 MEDICAL SooIETY OF
heard over large area, and all other signs and symp-
toms of the second stage of pneumonia were present.
The next morning no perceptible change had taken
place. Patient had passed a restless night. Sputum
was more copious and typically “prune juice.”
Much to my amazement, subcrepitant rales could be
heard over the region described when I examined him
that afternoon, and patient’s' temperature was 98°;
pulse, 62; respiration, 30, the last not returning to
normal until three days later.
In this case occasional moist rales could be heard
for four weeks after above change, and, strange to i
note, active delirium took place eight days after be-
ginning of attack, which I am positive was due to
post-alcoholic condition.
Recovery was very slow.


Case No. 2. W. R. Regular drinker.
a Z Fr] .
DATE Egg 5 % REMARKS.
5" i 04 m a
Mar. 8 PM. 74 32 98.2
“ 9 A.M. 78 32 99 Slept most of night
‘~ 9 PM. 76 34 99.4
“ 10 AM 78 30 99.4 Slept well all night.
“ 10PM. 72 30 98
“ 11 AM. 82 30 98 Slept fairly well.
“ 11 PM. 68 32 98.6
“ 12 AM 78 '24 98.6 Slept nicely.
" 12 PM. 75 26 99
“ 13A.M,8219 98.6 Slept wellall night.
“ l3P,M-3420N01mﬁl
“ 15A M. 80 20 98.2 Slept most of night.
“ 15 RM. 8018 Normal
‘- 16A.M.802O 98
“ 16 P.M. .. .. 982


Delirious all night.


For discussion see page 216.
LIST OF MEMBERS RECEIVED DURING YEAR.
Years of Date of
Name. Address. Hospital Election to
Service. Membership.
Abeken, Frederick, City Hospital, 1899-1900....Dec. 7, ’99
Ball, Otho F., 450 Cent. Bldg. 1897-1898....Dec. 7, '99
Bejach, Joseph, City Hospital, 1899-1900....Dec. 7, ’99
Bleyer, Adrien Samuel, “ 1899-1900....Dec. 7, ’99
Boehm, Joseph A., “ 1899-1900....Dec. 7, ’99
Campbell, Oliver Howard, “ 1899-1900....Dec. 7, ’99
Churchill, Roy H., “ 1899-1900....Dec. 7, ’99
Farmer, Percival J ., “ 1899-1900...Dec. 7, '99
Graham, Jno. Randolph, “ 1899-1900...-Dec. 7, ’99
Horine William Henry, “ 1899-1900.--.Dec. 7, ’99
Jelks, Frank W., 7619 S. Broadvi ayJS94-1895... Dec. 7, '99
Kane, Robert Emmett., City Hospital. 1899-1900... Dec. 7, ’99
Koontz, Carl. J., “ 1899-1900....Dec. 7, ‘99
Loeb, Clarence, “ 1899-1900.-..Dec. 7, ’99
Nietert, Herman L. , “ 1899-1900... June 1, ’99
Pettit, Joseph A., “ 1899-1900....Dec. 7, ’99
Phelps, Harlow J ., “ 1899-1900 ...Dec. 7, ’99
Rassieur, Louis, “ 1899-1900... Dec. 7, ’99
Scharﬁ, Eugene A., “ 1898—1900... June 1, ’99
Simon, Frederick Casimir, “ 1899-1900 ...Dec. 7, ‘99
Smith, Harvey S., “ 1899-1900....Dec. 7, ‘99
Spencer, Selden, 2723 Washington Av. 1899-1900....Dec. 7, ’99
Tiedemann,Ernest F.1901 Cleveland Av.1887-1888....Dec. 7, ’99
_
MEMBERS DECEASED.
William Acheson Brokaw ........................................ .. May 9, 1899
Henry Hodgen Mudd. .................. . ................... .. Nov. 20, 1899
INDEX.
Address of president,1.
Adeno-sarcoma of prostrate and bladder, 224.
Amnesia in dementia paralytica, 267.
Angina pectoris, 216, 217.
Angina Ludovici, 27.
Antistreptoooccus serum, 251, 254.
Bacillus coli commune in river water, 279, 284.
of pemphigus, 190. a
typhosus in river water, 279. 284.
Bacteriologic examination of river water, 278.
Bernard’s diabetic center, 76
Bladder—adena-sarcoma of, 224.
willow switch in, 226.
Bottini operation, the, 9, 11, 36.
dangers of, 33.
for hypertrophy of prostrate, 226, 235, 237.
Bremer’s blood test for diabetes, 75.
Burning questions relating to paretic dementia, 39.
Calculi in kidney, 225, 226.
Cerebral hemorrhage with temporary glycosuria, 73.
Oerebi'o-Spinal meningitis, 167.
deafness following, 167, 168.
growth of hair on body after, 167, 171.
in a pregnant woman and fetus in utero, 169, 176.-
lumbar puncture in, 168, 169.
paralysis following. 167.
sign of Kernig, 168, 171.
Chloroform—danger of, 37.
Cyclo-cephalus— specimen of, 172.
Cystomata of the ovary, 66.
dangers of. 67.
diagnosis of, 70.
Deafness following cerebro-spinal meningitis, 167, 168.
Dementia paralytica. 264.
amnesia in, 267.
and hysteria. 48.
and neurasthenia, 45, 56, 59, 268.
and paranoia, 60, 65.
and polyneuritis, 48.
and syphilis, 42, 43, 45, 272.
cause of death, 277.
classical form, 39. 40.
dement variety, 39,40.
diagnosis, 47 , 49.
in the Jew, 45, 46.
in the young, 44, 45.
in women. 41. 44.
iodide of potassium in, 43.
CITY HOSPITAL ALUMNI. 297
pathological anatomy, 49.
report of cases.49, 264.
symptoms, 40, 4|, 42, 267.
Dermatitis artiﬁcialis, 156, 159.
diagnosis, 158.
in Algerian prostitutes, 161.
neurologic aspects, 157, 161, 162.
Diabetes, Bernard’s center, 76.
Bremer’s blood test, 75.
Diagnosis of cystomata of ovary, 70.
dementia paralytica, 47 , 49.
dermatitis artiﬁcialis, 158, 159.
muscle rupture, 193.
pemphigus, 190.
pneumonia, 216, 289.
Difﬁculties of early diagnosis of pneumonia, 289.
Dilated kidneys and bladder, 219.
Diphtheria—pilocarpin in, 180, 181, 184.
Diphtheritic vaginitis, 177.
Ear and throat infection with subsequent involvement of the
neck, 22.
Early stages of prostatic enlargement, 32.
Ether—danger of, 34.
Filtration of river water, 281, 287.
Fistulae—in gonorrhoea, 246. r
peri-rectal, 240.
Gangrene of scrotum, 228.
Gastric tumor, 208.
Genito-urinary specimens, 219.
' ‘ adeno-sar'eoma of prostrate and bladder, 224.
calculi in kidney, 225, 226.
dilated kidneys and bladder, 219.
double ureter. 219.
gonorrhoeal kidney, 220, 230, 235.
hypertrophied prostrate, 227.
. obstructive, 2'27.
prepuce-elongated, 226.
renal calculus, 226.
two right kidneys. 219.
uric acid stone, 226.
urinary lithiasis, 222.
v will-ow switch in bladder, 226.
Glycosuria—cause of, 76, 77 . S4, 85.
tempbrary in cerebral hemorrhage, 73.
Gonococcus—diftusion of. 231, 234, 236.
in joints, 147, 148, 222.
in the endocardium. 147. 222.
in the pleural cavity, 147, 222.
- Gonorrhoea—abscess in , 147 .
complications and sequelae, 146.
ﬁstula in, 146.
in the female. 148, 151.
treatment.149, 152, 153. 155.
Gonhorrhoeal kidney, 220, 230, 235.
298 , MEDICAL SQcrE'rY OF
Gross sections of human body, 139.
u‘rrowth of hair on body, following cerebro-spinal menin-
gitis, 167, 171.
Hernia, 228.
resection of bowel in, 11.
strangulated—with restrained testicle and intra-ab-
dominal hy drocele of the cord, 162. '
taxis in, 165, 166.
ventral—following supra-pubic incision, 9.
History of sanitary supervision of schools, 86.
Human body—gross sections of, 139.
Hydrocephalus—a cause of glycosuria. 84, 85. ‘
Hydrocele—secondary to heart lesion. 213.
Hygiene of pregnancy and parturition, 197.
Hysteria—in the male, 48.
Irrigation treatment of gonorrhoea, 153. '
Kernig’s sign in cerebro-spinal meningitis, 168, 171.
Kidney—calculi in. 225, 226.
dilated, 219.
gonorrhoeal, 220, 230, 235.
two right, 219.
Lumbar puncture in cerebro-spinal meningitis, 168, 169.
Medical inspection of public school children in St. Louis-—
the, 13
Meningitis, 2l8.
cerebro-spinal, 167.
sign of Kernig, 168, 171.
Mississippi river water—puriﬁcation of, 282.
Municipal medical school inspection, 101.
diiﬁculties of, 101.
kindergarten data, 116.
measures of control, 105.
results, 103.
Muscle—rupture of—biceps, 196.
deltoid, 194.
triceps, long head, 193.
relative frequency, 194, 196.
treatment, 194, 195.
Nasal specimens with demonstration of method of preserva-
tion, 137.
Nephritis-chronic parenchymatous with malarial intoxica-
tion, 221.
Nephrotomy, 223.
Novel procedure for facilitating operation for prostatec-
tomy, 3. .
Ophthalmia neonatorum, 150.
Orchitis, 228.
and sterility, 151.
Ovary—cystomata of, 66.
dangers. 67 . ' “a
diagnosis, 70.
CITY HOSPITAL ALUMNI. 299
Pain—seat of pneumonia, 217.
Paresiphobia, 48.
Paralysis—following cerebro-spinal meningitis, 167.
Pemphigus—bacillus of, 190. -
endemic of—an, 185
causes of, 187, 188, 189.
diagnosis, 190.
prognosis, 185, 190.
treatment, 190.
Peri-rectal ﬁstulas—treatment, 240.
Pneumonia—difﬁculties of early diagnosis, 216, 289.
late temperature. 217.
pain—seat of, 217.
rales redux, 217, 218.
Posterior urethritis, 237.
Pregnancy—examination in, 205.
hygiene of, 197.
pelvimeter in, 205, 206. 207.
venesection in, 200, 202.
Prepuce—elongated, 226.
Prostate—hypertrophy of, 327 .
Bottini operation for, 226, 235, 237.
obstructive, 227.
Prostatectomy—combined supra-pubic and perineal, 229.
hemorrhage in, 7.
novel procedure for facilitating operation for, 3.
report of a case, 3. -
report of two cases following electrical incision of
the vesical outlet after the Bottini-Freudenberg
method, with remarks, 28.
suppression of urine after, 37.
Prostatic enlargement—early stages of, 32.
Protargol in gonorrhoea, 149, 152, 155.
Public school children—medical inspection of, 13, 85, 101.
Puriﬁcation of Mississippi river water, 281, 287.
running water, 283.
Quinsy, 27.
Remarks on an ear and throat affection with subsequent in-
volvement of the neck, 22.
Renal calculus, 226.
Report of a casé of prostatectomy, 3. -
Resection of bowel in hernia, 11.
River water—bacteriological examination of, 27 8.
colon and typhoid bacilli in, 279, 284.
ﬁltration of, 281, 287.
Rupture of muscles— biceps, 196.
deltoid, 194.
triceps, long head, 19], 193.
nerve involvement, 195.
relative frequency, 194, 196.
treatment, 194, 195.
Sanitary supervision of schools, 85.
history of, 86.
300 MEDICAL SOCIETY OF
method, 91.
statistics, 86, 87.
Salicylic acid in ear diseases, 25.
Scrotum, gangrene of, 228.
Strangulated-hernia complicated with retained testicle and
intra-abdominal hydrocele of the cord, 162.
Suppression of urine after prostatectomy, 37 .
Syphilis in Jew and Gentile, 53, 60.
Two right kidneys, 219.
Treatment of gonorrhoea, 149, 152, 153, 155.
pemphigus, 190.
muscle rupture, 194, 195.
Triceps extensor cubiti—traumatic rupture of, 191.
Tumor, gastric; 208.
Typhoid bacillus in river water, 279, 284.
Ureter—deformities of, 232.
double, 219.
Urethritis, posterior, 237.
Uric acid stone. 226.
Urinary lithiasis, 222.
Urine—suppression of after prostatectomy, 37.
Uro-genitalia, development of, 232
Vaginitis—diphtheritic, 177, 181.
douches in, 178, 180, 182, 183.
Venesection, 203.
in pregnancy, 200, 202.
Ventral hernia following supra-pubic incision, 9.
Willow switch in bladder, 226.
T a ;.'t;': Mipxﬂ‘
' , ’73 at? We“
SCIENTIFIC TRANSACTIONS
- - -OF THE~ - -
IVIEDICAL SOCIETY
.0F. 0 0
CITY HOSPITAL ALUMNI
(ST. LOUIS.)
FOR THE YEAR 1901.
ST. LOUIS, MO.
COURIER OF MEDICINE CO.
1902.
SCIENTIFIC TRANSACTIONS
- -OF THE- - .
MEDICAL SOCIETY
.OF. C 0
CITY HOSPITAL ALUMNI
(ST. LOUIS.)
'FOR THE YEAR 1901.
ST. LOUIS, MO.
COURIER OF MEDICINE CO.
1902.
CONTENTS.
Remarks of the President on Assuming the Chair, January 3, 1902 - - -
By NORVELLE WALLACE SHARPE, M.D.
Report of a Case of Articular Rheumatism with Fatal Heart Complications in
a Child - - - - — - ~ - - - - - -
By HUDSON TALBOTT, M.D.
Points of Interest Gathered from Eastern Hospitals - - - - -
By FRANK G. N IFONG, M.D.
The New City Hospital - - - - - - - - - -
General Discussion by the Society.
Cerebral Tumor, with Presentation of Patient ~ - — - - -
By GIVEN CAMPBELL, M D.
Our Daily Bread - - - - - - - - - - - -
By GEORGE HOMAN, M.D.
Vaccination - - - - — - - - - - - - -
By JOSEPH GRINDON, M.D.
A Case of Splenectomy, with Remarks - - - - - - - _
By I. P. BRYSON, M.D.
Carcinoma of the Uterus - - - - - - - - - -
By A. H. MEISENBACH, M.D.
A New Non-Surgical Treatment for Inﬂammatory Exudates and their Residua
in the Female Pelvis - - - - - - - - - -
' By HUGO EHRENFEST, M.D.
Duodenal Stenosis Due to Gall-Stones :, Report of a Case - - - -
By ALBERT E. TAUSSIG. M.D.
Report of a Case of Anthrax - - - - - - - - - -
By AMAND RAVOLD, M.D.
Tetanus Neonatorum; Report of a Case that Recovered - - - -
By J. C. FALK, M.D.
Ureter Catheterism in the Male; A New Uretero-Cystoscope \ - - -
By BRANSFORD LEWIs, M.D.
Report of a Case of Obstructive Prostatic Hypertrophy - - - - -
By BRANSFORD LEWIS, M.D.
Specimens Showing Explanation of Non-Suppurative Nasal Headache Refera-
ble to the Middle Meatus of the Nose- - - . - - - - -
By GREENFIELD SLUDER, M.D.
Some Hints on the Management of Laparotomy Cases - - - - -
By FRANK A. GLAscow, M.D.
The Double-Knife in Histo-Pathology - - - - - - - -
By R. B. H. GRADWOHL, M.D.
Report of a Case of Malignant Anthrax Edema - - - - - -
By ELLSWORI‘H SMITH, 111., M.D. and H. G. MUDD, M.D.
Radical Cure for Hernia; Specemen - - - - a; .. _ ..
By A. H. MEISENBADH, M.D.
18
21
53
74
82
93.
95
105
110
115
122
I32
I36
I37
I46
I57
City Hospital Alumni.
i1i
' Surgical Operations on the Aged - - - - - - - - -
ByA. H. MEISENBACH, M .D.
Vesico-Vaginal Fistula; Operation According to the Technique of F reund;
Report of a Case - - y - - - - - .. - - -
By FRANCIS REDER, M.D.
Rupture of the Bladder; Specimen. - - - - - - - -
By A. H. MEISENBACH, M.D.
Spaying of Cows as a Means of Procuring More and Better Milk ~ - v -
By L. F. ABBOTT.
Retained Testicle; With Surgical Features and Microscopic Findings in Three
Cases - - - - - - - - - - - - -
By WILLARD BARTLETT, M.D.
A Case of Appendicitis, with Some Unusual Features - - - — -
By J. G. MOORE, M.D.
Hemorrhagic Infarct of Left Lung; Specimen - - - - - -
- By R. B. H. GRADWOHL, M.D.
Aortic Stenosis; Specimen - - - , - - - - - - _
By R. B. H. GRADWOHL, M.D.
F ibromyomata; Specimen - - - ~ - - - - - _
By CHARLES ]. ORR, M.D.
A Case of Valvular Disease of the Heart - - - - - - -
By ELLSWORTH SMITH, ]R., M.D.
Lipoma; Specimen - - - - - _ - - - _ _
' By F. G. NIFONG, M.D.
Report of Work in Ureteral Catheterization in the City Hospital
Year - - - - - - - - - - - - -
By H. L. NIETERT, M.D.
Case of Recurrent Laryngeal Paralysis, Due to Aortic Aneurysm - — -
By WILLIAM E. SAUER, M.D.
Case of Recurrent Laryngeal Paralysis, Due to Aortic Aneurysm - - -
By L. H. HEMPELMANN, M.D.
A Perforated Uterus; Specimen - - - - - — - - -
A Case of Pus Tubes and Ovaries; Specimen - - - - ~ -
Diaphragmatic Hernia; Specimen - - - - - - ~ - -
Rupture of the Heart; Specimen - ~ - - - — - 3 —
Occlusion of Aorta by Atheromatous Deposits; Specimen - - - -
Severe Gastritis; Specimen - - ~ - - - - - - -
Large Aortic Aneurysm ; Specimen - - - - — — — -
Enlarged Heart, with Extensive Atheromatous Deposits ; Specimen ~ -
Hemorrhagic Infarct of the Kidney; Specimen — — - - — -
By HOWARD CARTER, M.D.
Corneal Ectasia, with Preservation of Central Transparency, Subsequent to
Recurrent Marginal Keratitis - - - -
By JOHN GREEN, ]R., M.D.
A Case of Muscular Atrophy ; A Case of Lingual Hemiatrophy, with Presen-
tation of Patients - - - - - - - - - - -‘
By GIVEN CAMPBELL. M.D.
_ u- - _ -
161
I68
178
I79
186
196
20 I
201
201
202
209
210
213
mg;
219
219
219
220
220
220
220
220
220
224
227
11’ Medical Soclety of
\
Specimen of Mammary Tumor - - - - - - - - - 235
By FRANCIS REDER, M.D.
A Case of Iodoform Poisoning - - - - - - - - ‘ 237
By CHARLES H. DIXONLMD.
Some Personal Observations of Malarial and Blackwater Fever on the West
Coast of Africa - - - - - - - - - - - 241
By VILRAY P. BLAIR, M.D.
Rupture of the Bladder; Specimen - - - - - - ' " 259
By H. L. N IETERT, M.D.
Ectopic Pregnancy; Specimen - - - - - - - - - 260
By H. L. N IETERT, M.D.
Spinal Curvatures; Presentation of Patients - - - , - - - - 264
By T. C. WITHERSPOON, M.D.
Sarcoma of the Testicle; Specimen - - — - - - - ' 27I
By FRANCIS REDER, M.D.
Complete Transposition of Viscera; Report of Three Cases - - - -' 27 5
By W. C. Mardorf, M.D.
Leucocytosis; Demonstration of the Formation - - - ~ - - 278
By LUDWIG BREMER, M.D.
State Sanatorium for Comsumptives - - - - - - - - 281
General Discussion by the : ociety
Gunshot Wound of the Abdomen Inﬁicting Nineteen Perforations Of the In-
testines and Four Lacerations of the Mesentery, with Recovery - - 289
By ROBERT F. AMYx, M.D.

Senile Gangrene of the Right Foot - — - - - - r ' 3OI
By LOUIS I. OATMAN, M.D.
Artefacts of Blood Examinations; Demonstration - — - - - 303
By LUDWIG BREMER, M.D.
Laryngeal Crisis in Locomotor Ataxia; Report of a Case - - - - 309
By CHARLES]. ORR, M.D.
Studies About Agglutinins - - - - - e — - " " 314
By CARL F ISCH, M.D.
Appendicitis ; Specimen - - - - - - - - - - 329
By F RANCIS REDER, M.D.
Three Uteri; Specimens — - - - - ~ - - - “ 33°
By FRANCIS REDER, M D.
INDEX.
Abdomen, gunshot wound of - - - - - - - - - 289
Address OI President - - - - - - _ .. _ - 1
Agglutinins, studies in - - - - - - - _ - - _ 314
Alum baking powders - - - - - -
City Hospital Alumni.
V
Aneurysm, early diagnosis - - - - - -
of aorta - - - - - - _
treatment - - - - .. - -
Anthrax, diagnosis - - - - - - -
malignant edema in - - - - -
report of a case - ~ - - - -
Aorta, aneurysm of - - _ - - - _
occlusion of - - - - - - -
stenosis of - - - _ - _ - -
Appendicitis - - - _ _ _ _ _
case with unusual features
diagnosis - - - - .. _
facial expression in - - - - -
symptoms - - - - _ - ,
Artefacts of blood examinations - - - -
in malaria - - -
Articular rheumatism, with fatal heart complications ~
Atrophy, muscular - - . .. _ - _
Baking powders - ~ - - - - -
chemical substance in -
litigation concerning - - - ~
Bladder, rupture Of -\ - - - - - -
Blood examinations, aitefacts in - - - — -
Bread - - - - - _ - .. _
aerated - - - - .. - _ _
amount of wheat used - - - _ -
baking powders in - - - - - -
chemical substances in -
cost of - - - - - .. - _ -
Scweitzer systen - - - - _ _
Carcinoma Of the breast - - - - - -
uterus - - - _ .. ..
Central ectasia - _ - _ _ - _ _
Cerebral tumor - - _ - _ _ _ -
Constituents of wheat grain - - - - - -
Diagnosis of aneurysm - - - _ _ _
anthrax - - - - _ - -
appendicitis - - - _ - _
ectopic pregnancy - - _ - -
valvular disease Of the heart - ~ -
Diaphragmatic hernia - - - _ _ _ _
Double-knife in histO-pathology - - _ -
Duodenal stenosis due to gall-stones — ~ - -
symptoms - -
Ectasia - - - - _ _ _ .. _
Ectopic pregnancy - - - _ .. - _
diagnosis — - - - - -
Enlarged heart with atheromatous deposits - -
Fever, malarial - - - - _ _ _ -
black water - - - - .. _ _
F ibromyomata - _ - _ - - _ -
- 218
2I8, 220
- 218
115
- 152
110
218, 220
220
- 201
329
- 196
I99
‘ 33°
196
' 303
307
' 9
227
58’ 67
58
- 60
178.259
' 303
35
-
63
..
58
- 64.65.71
236
93’ 33°, 33I
- 224
51
54
218
115
I99
261
205
219,221
I46
- 105
106
224
260
261
220
241.307
241
201
vi Medical Society of
Fistula, vesico-vaginal - - - _ - - - ..
Gangrene, senile - - - - _ - _ _ -
Gastritis - - - _ - - _ - _ - _
Gunshot wound of abdomen with perforation of intestines - -
the pregnant uterus - - - - -
Headache, non-suppurative, referable to middle meatus of nose -
Heart, enlarged - - - - - .. - _ _
rupture of - e - - - - - _ _ -
valvular disease of - - - - - - - -
Hemorrhagic infarct in lung - - - - - - - -
kidney - - - -. _ - -
Hernia, diaphragmatic ~ - - - ~ - - _ -
Hospital commission and reports of, the - - -
Hospital, points of interest in the Boston City - - - —
- Johns Hopkins - - -
Mt. Sinai - - - - -
New York - - - -
Presbyterian - - - -
Roosevelt - - - -
St. Vincent’s - - - -
the new City Hospital (for St, Louis - - - -
plans of - - -
Inﬂammatory exudates in female pelvis - - - - -
new non-surgical treatment
Intestines, perforating gunshot wound of - - - — -
mortality of - - -
operation for - -
drainage in -
suture —
the incision -
Iodoform poisoning - - - - - - _ - _
symptoms — - - - - - -
Keratectasis - - - - - - _ _ - -
Kidney, hemorrhagic infarct 01' - - - - - - -
La; arotomy, abdominal bandage alter - - - - -
after treatment - - - - .. _ ..
drainage in - - - - _ - _ _
ox-gall ﬂushing after - - - - _ _
preparation of the patient - - - - -
rubber gloves in - - - - _ .. -
suture in - ~ _ - - - .. ..
the operation - - - - _ .. _
Laryngeal crises, causes of - - - - _ _ _ _
in locomotol ataxia - - - - _ -
treatment - - - - - _ .. _
Leucocytosis - Q - - - - - - .. _ _.
diagnostic value - - - - _ _ _
Lingual hemiatrophy - - - - -. - _ _
prognosis - - - - _ - -
Lipoma, specimen of - - - - - - . -
Litigation concerning baking powders - - - - - i -
298,
220,
219,
168
301
220
289
299
1 36
220
22 r
202
201
220
221
29,30,31
292,
23 7,
238,239,
I45,
141,
I41,
25
23
22
20
21
I 9
20
27
38
95
95
289
295
293
295
290
292
239
240
224
220
I46
I43
245
I44
139
I44
I39
1 39
312
3°9
313
278
279
233
235
209
60
City Hospital Alumni.
V11
00
Locomotor ataxia, laryngeal crisis in -
Malarial and blackwater fever in the Philippines
on west coast of Africa
Malignant anthrax edema - -
source of infection
symptoms -
Mammary tumor - - _ - _
Muscular atrophy - - - -
etiology - - ~
prognosis - -
treatment - - -
Obstructive prostatic hypertrophy -
Occlusion of aorta by atheromatous deposits
Paralﬂis, laryngeal, recurrent - ~
Perforated uterus - - - - -
Points of interest gathered from Eastern hospitals
Pus tubes and ovaries » - - -
Pregnancy, ectopic - - - -
Prostatic hypertrophy, obstructive - -
I
etiology
mortality -
prophylaxis
symptoms
treatment
Bottini operation for ~ -
Retained tes icle, causes - - -
hereditary inﬂluence
source of danger -
sterility of - - -
surgical features and microscopical ﬁndings
Rheumatism, articular - - ~ -
causes - -
treatment - -
Rupture of the bladder - - - -
heart - - - -
Sanat )rium for consumptives, state -
location
value of
Sarcoma of testicle - - - - -
recurrence of - -
Senile gangrene — - - - -
Spaying of cows, a means of pre’curing more and better milk
\ method - - - -
Spinal curvature - - - - ~
etiology - - - -
treatment - - ~
Splenectomy, a case of - - - -
contraindications for -
indications for - - -
Studies in agglutinins - - - ~
' 309
- 256
- 241
' 2S3
- 2 50
258
251
— 246
— 152
- r 56
I 55
' 23S
- 227
— 23o
- 235
- 231
- 132
- 220
215
221
- 18
- 219
- 26o
- 132
I34 -
186
' I94
- 190
’ 190,193
- 186
' 9
- 14,15,16
178,259
220,221
- 282
284,285
- 283
- 271
' 273
- 301
' I79
- 183
- 264
265,267
- 269
— 82
~
_ ' 314
viii Medical Society of
Sugical operations on the aged - - - - - - - - - 161
after-treatment - - - - - - 164
anesthetic in - - - - ~ - 163
paecautions in - - - - - - 162
some cases - - — - - - - 164
\ when to perform - - - - - - 164 .
Symptoms of anthrax, malignant - - - - - - - - 152
appendicitis — - - - - - - - - - 196
duodenal stenosis - - - - - - - - 106
iodoform poisoning - - - — - - — - 237, 239
malarial and blackwater fever - - - - - 244, 251
tetanus neonatorum - - - - — - — - 116
Syphilis, treatment - - - - - - - — - - - g‘51:;
Testicle, retained - - - - - - - - - - - - 186
sarcoma of - - - ~ - - - - — - “I 271
Tetanus neonatorum - - - - - - - - - - H - 115
antitetanus serum in - — - - - - 118, 119
symntoms - - - - - - - - - 116
treatment - - — - - - - — - 116
Transposition of viscera - - - l - - - - - ~ 275
Treatment of aneurism - - - - - — - - - — 218
inﬂammatory exudates in female pelvis - - - - - 95
malarial and blackwater lever — - - - — - 246
muscular atrophy — - - ~ - - — - - 231
rheumatism, articular — - - - - - — 14, 15, 16
spinal curvature - - - - - - — - - 269
syphilis - - - — - - - — - - 313
tetanus neonatorum - - - - - - - - 116, 119
valvular disease of the heart - - - - - - 20 , 207
vesico-vaginal ﬁstula - - - — - - - - 16 , 172
Tumor, perebral - - - - - - - - - - - 51
mammary - - ' - - - - - — - - - - 235
Ureter, catheterization 0f - — - - - — - - - 122, 210
Uretero-cystoscope, new - - - - - - - - - - 122
Uterus, carcinoma of - — - - - - -' - 93: 330, 331
recurrence of - - - - - - - - 332
perforation of - - - - - - - - - 219, 221
pregnant, gunshot wound of - - - - - - - 298, 299
Vaccinnation - - - - - - - - - - - - 74
spurious form - - - - - - — - - - 77
virus in - - - - - - - - - - 79
Valvular disease of the heart - - — - - - - - - 202
Corrigan pulse - - - - - — 204.a
differential diagnosis - - - -' - - 205
etiological factors — - - - - - 202
prognosis — ‘ - - - - - - 205
treatment - - - - - - 205, 207
Vesico-vaginal ﬁstula - - - - - - - - - - - 168
cause of - - - - - - - - - 168
operation of Freund for - - ~ ‘ - - 168, 173
Reed for - - - - - ,- 176
treatment - - — - - - - 168, 172
Viscera, transposition of - - - - - - - '2 ‘ ' 275
f
Medical Society
...OF...
CITY HOSPITAL ALUMNI.

TRANSACTIONS===190L

Meeting of fammry 3, 1901.
"‘ Remarks of the President, Norvelle Wallace Sharpe, M.D.,
0n Assuming the Chair, January 3, 1901.
Your attention is invited to a statement of the history and work
of the Medical Society of City Hospital Alumni, and the proposed
policy and scope of activity for the year 1901. At 2. called meeting
November 4, 1891, at the Hotel Rozier, forty-two ex-internes of the
St. Louis City Hospital took the necessary steps to form a society
composed of men who had served as interne or superintendent in
that institution.
NAME.— Organization was duly effected under the name “ The
City Hospital Medical Society.” This title obtained until the year
1898 when the name, “ The Medical Society of City Hospital Alumni”
was substituted and to-day remains. For a comparitively extended
period the Society had no ﬁxed place of meeting, but fortunately this
season of migratory sessions has been succeeded by the use of the
quarters of the Board of Education. Renewed appreciation of its
courtesy is herewith tendered.
PURPOSE.——Th€ purpose of this body has been, and is, to bring
into cordial contact, both from the scientiﬁc and social aspects, those
who have undergone the hardships and enjoyed the manifold advant-
ages of a service in the City Hospital. The former purpose has been
2 Medical Society of
elaborated by means of semi-monthly sessions at which papers and dis-
cussions pertaining to medicine and correlated themes have been
demonstrated, and further enriched by clinical and pathological mate-
rial; the latter by a series of informal lunches following the sessions.
REPORTING THE PR00EEn1N0s.-After mature consideration it
was deemed advisable to expend the money consumed in these lunches
in accentuating the scientiﬁc phase of the Society’s function. To that
end the lunch (at the expense of the treasury) was abandoned May ‘
5, 1898, and in its stead was substituted the service of a stenographer.
Since that time the proceedings of the Society have been duly recorded
and published in a journal of suitable character; the same;y_,in bound
volumes furnished to individual members on application to the
Secretary.
It affords pleasure to here bear testimony to the faithful service and
unvarying courtesy of the ofﬁcial stenographer, Dr. Edward ]. Gooden ;
his generous co-operation has extended his service far beyond the limits
of contract and remuneration. The Chair voices the sense of obligation
of the Society. ‘
MEMBER5H1P.—At various times the moot question as to the de
sirability of an active membership consisting of others than internes
of the St. Louis City Hospital has received consideration. The
proposed expansion has invariably failed to, carry. The Society is, as
it was, exclusive. The active membership list at present includes 190
men, of which 148 are resident and 42 are non resident. Owing to the
increased staff of late years in control at the City Hospital, a larger list
of eligible material for assimilation by the Society is annually presented.
To encourage resident internes to become members of the Society, to '
spare them the burden of an annual due, and to stimulate, by this -
gratuitous entry. their contribution to the scientiﬁc work of this body;
resident internes have been exempted from the payment of the annual
due for the currentyear of service. It is a matter of regret that since
this plan was instituted, this concession on the part of the Society has
not been met by a more generous response on the part of the various
Hospital staffs. The yearly increase of the Society, including both
resident internes and colleagues in active practice, approximates 25.
It is worthy of note that voluntary withdrawals from membership are
. I
City Hospital Alumni. 3
notably rare; the hand of Death ordinarily being required to sever a
relation which has proved itself both enjoyable and proﬁtable.
NEOROLO0Y.—-Six members, in good standing, have died since the
birth of this organization, essential data regarding these colleagues have
been recently placed on ﬁle with the Secretary by the Committee on
Revision during the administration of my predecessor in the chair.
NOTICES TO COLLEAGUEs.—The Society furnishes, at present, forty
complimentary copies of the notices of its scientiﬁc work to colleagues
and reputable medical journals. Regret is expressed that a more general
co-operation in the work of this body has not been tendered by those
whom we have thus considered as congenial workers. It is, at this point,
germane to record that though this Society is restricted by Article III.
of the Constitution to a membership exclusive in source, yet the spirit
of the body is notably catholic. We welcome all choice spirits, wheth-
er members of the faculty, or those engaged in search in kindred ﬁelds,
to participate with us. These coworkers are debarred from but the
Society franchise and the payment of dues for current expense. The
Society acknowledges its indebtedness for valuable scientiﬁc contribu-
tions, received, from time to time, from this source.
DEPARTURES FROM PRE0EnENT.-—Though the Society has con-
ﬁned its labors to a rather conventional line of policy, it has, within
the last two years upon three occasions ventured to depart from pre-
cedent. T he first was a gratuitous medical inspection service of cer-
tain selected public schools; and was tendered with appropriate ex-
planations and deductions to the Board of Education, with the hope
that said Board might be convinced of the imperative value of this
method of safeguarding the health of the schools and the public at
large. The Chair notes that this venture of the Society was success~
ful, and that though regret is felt that the Board was unable to insti~
tute so valuable an adjunct to its ﬁeld of activity (on account of lack
of funds), yet a forcible and practical exempliﬁcation of the plan was
made, and future laborers in this ﬁeld may be justiﬁed in erecting a
superstructure upon the substantial foundation thus laid down. The
second was an effort made to check the lawless use of the yearly pit-
tance set aside in the municipal appropriation for the erection of a
new City Hospital; various efforts at that time being made to divert
4 Medical Society of
this fund into extraneous channels. This Society as the initiative
force, acting in harmony with other wings of the body medical, both
in open meetings and before the municipal authorities, was a factor in
checking this disgraceful political scheme. The daily press has at va- ‘
rious times credited this successful operation to the proper sources.
T he last effort was a meeting held for the presentation of the proposed
scheme and plans for the new City Hospital. Members of the pro-
fession were invited to enjoy our hospitality and discuss an elaboration
of the facts as conceived by various municipal ofﬁcers, including the
President of the Board of Public Improvements, the Municipal Archi-
tect, members of the Board of Health, and members of thev’original
Hospital Commission. Action by the Society was not taken owing to
the fact that modiﬁcation of the plans then exhibited was being made.
Attention will be directed to this matter later. It is without doubt
patent that the Society has sustained its high traditions in these de-
partures from its general plan. It is recommended that the same wise
policy of conservatism prevail, sufﬁcient elasticity in control being
permitted to enable this body to be of service to the public weal.
SCIENTIFIC WoRK.-The scientiﬁc work of the Society during the
past year has been healthful, owing largely to the 'unﬁagging zeal of
the members of the Committee on Scientiﬁc Communications. At-
tention is called to the fact that up to date this Committee has been
compelled to employ extraordinary efforts in order to keep on hand
scientiﬁc pabulum sufﬁcient for the consideration of the Society. Rec-
ords show that out of a membership of 190, of which 148 are resident
and 42 are non iesident, but 27 contributed to the scientiﬁc work dur-
ing the year 19c0. It is desirable that, as a body and as individuals,
we should not fail to recognize the importance of the service rendered
us by the Committee on Scientiﬁc Communications; let us, on the
other hand, guard sedulously from the tendency of permitting it to
become either a me‘ndicant or a beast of burden. To, this end cordial
personal co-operation with the Committee is a prime essential.
FINANCE—The ﬁnances of the Society, as shown by the report of
the Treasurer for 1900, are far from what should exist. A deﬁcit of
$2.00 appears ; that this is not greater is due to the generous forbear-
ance of our stenographer, Dr. Gooden, the actual deﬁcit being $ 52.00.
' I
City Hospital Alumni. 5
Admitting the drain upon the treasury induced by recording the pro-
ceedings of the Society, it is held that we are not ready to strengthen
our ﬁnancial standing by elision of this source of expense. The
thoughtful consideration of the members is directed to the patent fact
that our ﬁnancial stringency is due, not to unwise expenditures,-but
rather to delinquency in meeting the payment of the annual dues
by a proportion of the membership in excess of any reasonable num-
ber. Though this has been a vital matter to some, a regretable indif-
ference, upon the part of a major portion of the membership, to this
continued ﬁnancial exigency exists.
THE ANNUAL D1NNER.—-During the latter portion of the year
1899 a plan to institute a society dinner to be known as “The Annual
Dinner,” to occur yearly, the ﬁrst Thursday in january, was discussed
and adopted. The purpose involved being for the members of the
Society to meet upon a purely social basis, thus serving as an admirable
substitute for the lunches formerly in vogue following the semi-monthly
sessions. The price, one dollar per plate (not to include extras), was
adopted for the purpose, not only of simplicity, but that no member
of modest income should be deterred from participating. The ﬁrst
Annual Dinner was held at the St. Nicholas Hotel, January 4, 1900; 55
names appeared upon the subscription list; 39 members and 3 visitors
were present. The affair proved a success and it was generally con-
ceded that the Society would act wisely in encouraging a cordial par-
ticipation by the entire body. During the latter portion of the year
1900, the Committee on Entertainment was authorized to take the
necessary steps toward providing for the celebration of the second in
the series of the Annual Dinners. The same restrictions regarding pay-
ment of plate fee in advance, and the minimum limit of twenty-ﬁve pre-
paid subscribers, which obtained in the preparation of the ﬁrst dinner,
prevailing. It is a matter of no inconsiderable regret that, for various
reasons, unaccountable perchance, a sufﬁcient number of prepaid sub-
scribers was not secured. Automatically, therefore, the failure of the
Dinner of 1901: occurred. Thanks to the ready thought of the Secre-
tary, those having the Dinner in charge made arrangements for a social
gathering with refreshments for the subscribers to the Dinner Fund to
follow the session of january 3, 1901, that so gracious a custom should
v6 Medical Society of
not die a-borning, and that the semblance, if not the actuality, of the
Annual Dinner of 1901 might be preserved.
COMMITTEE DATA.—During the Occupancy of the chair by r
George Homan, the excellent plan 'of providing the standing ‘com-nrit-
tees with books suitable for making note of important committee ~~
work done during the current year, the whole to be compacted and
rendered as a report at the Annual Meeting of the Society, was insti- .
‘ tuted. The plan was but spasmodically executed by the various com-
mittees. The Chair requests that the Chairmen of the standing com-
mittees for 1901, make note of their associates, take .steps toward an
early consultation regarding their special duties for the year, and se-
cure their special committee books, to the end that the Society may,
not only enjoy the beneﬁt of their labors during the year, having
the facts compactly presented at the next Annual Meeting, in the form
of special committee reports, be prepared to offer suggestions and
criticism tending-toward increased committee efﬁciency and the general
welfare of the Society.
STANDING COMMITTEES FOR 1901.—The standing committees for
1901 are as follows:
Executive Committee: Dr. William C. Mardorf, 1888-89, Chair-
man; Dr. Greenﬁeld Sluder, 1888—92, Dr. Hudson Talbott, 1898—99,
Associates.
Committee on Scientiﬁc Communications: Dr. Harry S. Crossen, .
1892—95, Chairman; Dr. J. G. Moore, 1889—90, Dr. H L. Nietert,
Resident Superintendent, Associates.
Committee on Puolicatz'on: Dr. Given Campbell, 1889-90, Chair-
man; Dr. Amand Ravold, 1881-82, Dr. John C. Falk, 1890—91, As-
sociates.
Committee on Entertainment: Dr. William D. Spore, 1861-64,
Chairman; Dr. P. V. Von Phul, 1896-97, Dr. Walter Baumgarten,
1896-97, Associates. 9
The duties of these committees are well known (see Sections VI.,
VII., VIII. and IX. of the Bylaws). Cordial assistance in furthering
their efforts, at the hands of the membership in general, that the
health and work of the Society may be vigorous, is urged.
‘3
City Hospital Alumni. 7
RECOMMENDATIONS—TIE following recommendations from the
Chair are laid before the Society for consideration :
I. That the function of the Executive Committee be increased
so as to include an annual revision of the membership, necrologic, and
mailing lists of the Society; its ﬁndings to be incorporated in its an-
nual report.
2. That no name be added to the mailing list of the Society un-
less having been favorably passed upon by the Executive Committee.
3. That the Committee on Scientiﬁc Communications be author-
ized to promptly take the requisite steps toward securing a meeting at
which appropriate municipal ofﬁcers be invited to present the altered
plans for the new City Hospital buildings, to the end that this Society
may place itself on record as either indorsing or condemning the pro-
posed structures.
4. That the Committee on Publication be authorized to determ—
ine whether the bound copies of the proceedings of the Society for
1898 and 1899 may not be delivered with the proceedings of 1900—-
gratuitously, or at a merely nominal ﬁgure. Attention is directed to
the fact that our contract with the COURIER OF MEDICINE calls for
distribution of copies of proceedings for 1900 to the individual
members.
5. That the Committee on Entertainment be encouraged to cov-
er the failure of its predecessor by bringing to a successful consumma-
tion an Annual Dinner in January, 1902.
6. That a“ Committee on Necrology ” be added to the list of
standing committees.
THE ADVISORY CoUNcn..-The Advisory Council as indicated in
Article VI. of the Constitution, consists of the ex-Presidents of the
Society. Its duties are deﬁned, and Its members exempted from ser-
vice on standing committees. As compensation for the loss of the
service of these valued members as committeemen, the Society is jus-
tiﬁed in expecting council and recommendation of rare merit. W ith~
out consuming time in adverting t0 the labors of this body in previous
years, the following themes are recommended to their attention with
the hope that in the near future the Society may proﬁt by their delib-
erations :
8 Medical Society of
I. The elaboration of a plan, or series of plans, for the increase
of interest in the work of the Society by that wing of the Society that
may be with propriety dubbed the non-active members.
2. The elaboration of a plan f0r placing the Treasury of the
Society upon a substantial basis.
3,. Recommendations regarding the conferring of honorary mem-
bership upon colleagues of acceptable qualiﬁcations, with suggestions
and restrictive safeguards. _
4. The advisability of securing a fund, the interest of which may
serve as an Annual Prize Fund to be awarded to the best thesis pro-
duced in competition ; or suggestions by which the same end may be
secured, other means and methods being utilized.
5. The advisability of increasing the duties of the Advisory
Council so that it may perform the function of a Nominating Com-
mittee.
CLINICAL MEETINcs.—~It seems ﬁtting that the' Secretary be
authorized to communicate in writing to‘ Dr. H. L. Nietert, Superin-
tendent of the City Hospital, the appreciation of the Society for clini-
cal facilities afforded this body during the year 1900; and the accept-
ance by this Society of similar courtesies (as offered to the Committee
on Scientiﬁc Communications, 1900) in 1901.
POLICY FOR 1901.-—In deﬁning the policy of the Chair for the
current year attention is called to the “Duties of the President” as
laid down in Section II. of the By-laws. It will be observed that his
function is largely, if not entirely, executive in character. That, in
addition to this, he may be reasonably expected to perform his share in
all that pertains to the proﬁt of the Society may be, with justice, inferred.
That it should be demanded of him to serve as an inciter of interest, or
to be held responsible for the success of the year’s work is unreasonable.
His value is largely dependent upon his efﬁciency in performing the
duties of the presiding ofﬁcer. Too great stress can not be laid upon
the fact the success of a year’s work as well as the failure of the work
of a year is due not to the Chair but to the individual member. The
dignity of the Chair is not enhanced by expectations tending toward
orientation of the work of the Society, whether in sessions, by being
compelled to call upon individuals for remarks, or in the intervals be-
5‘
City Hospital Alumni. 9
tween meetings, being obliged to assume duties that, of right, fall
within the province of individual or committee. As a general policy of
the Society, in its sessions, the Chair recommends that the members make
special efforts to be present promptly at 8 o’clock, and that they so seat
themselves that they may form a compact body in front of the platform;
that guests be welcomed and conducted to desirable seats; and, further,
that Rule 2, relating to limitation of discussions to ﬁve minutes unless
by unanimous consent otherwise, be more strictly upheld. Appeals
from the decision of the Chair in cases of faulty ruling, are not only
desirable in the interest of right, but will be accepted in the spirit of
courtesy. The success of the work of this Society for the year 1901,
if striven for by the individual member, rather than being left to the
efforts of the ofﬁcers or committemen, may be taken as an assured
fact.

Meeting of jannary I7; 1901; Dr. [Vowel/e Wallace S/zarpe,
President, in the Chair.
Report of a Case of Articular Rheumatism with
Fatal Heart Complications in a Child.
BY HUDSON TALBOTT, M.D.,
ST. LOUIS, MO.,
LECTURER ON EMBRYOLOGY, MARION-SIMS COLLEGE OF MEDICINE.
HILE to-day the nervous system is claiming the atten-
tion of physicians more than ever before, and perhaps
more than any of the other various systems of the
human body, we are none the less excused from treatment and
investigation of other organs, and almost daily do we come
upon interesting, if not, indeed, almost surprising cases.
The circulatory system, I believe, furnishes as many such
cases as any other. Barring one case, which came under my
observation in the City Hospital, I believe the following one is
the most interesting that it has been my fortune or misfortune
to treat:
10 Medical Society of
Lester S.,~ eight years of age, slender build, but strong and healthy
up to March, 1899, when his present trouble began; his home, while
humble, has been fairly comfortable; he ate regularly and of whole-
some food, though rarely of the dainties or so-called luxuries of the
table; no bad habits, but was an obedient child and having no ardu-
ous work to perform. He lived in the country and attended school
but little; was of a very playful disposition. Parents are of German
nativity and are strong and healthy, the father frequently becomes in-
toxicated and uses tobacco, both of which habits he has had for years;
the mother frequently suffers with gall stone colic, otherwise enjoys ex-
cellent health. No history of hereditary disease" in either parents’
family; none of sudden death; all enjoying good health at the present
writing. Patient has one sister and three brothers, all in good health.
On March 21, 1899, he played in the snow all day, running.- a great
deal and became completely tired out at night. On the next day
(22nd), which was his eighth birthday, he felt languid, did not care to
go out with the other children to play, but preferred to lie down most
of the time and ate but little. The following day he complained of
soreness about his knees and pain upon motion. His mother gave
him a tablespoonful of castor oil and swathed his joints in ﬂannel; he
experienced no relief, but steadily grew worse; was able to eat or sleep
but little; the pain became excessive and patient very weak.
One week from the time he was taken I was called. I found my
little patient suffering very much; was quite anemic and thin in ﬂesh;
appetite nil; slight fever; pulse frequent and small; the joints of
hands, wrists. elbows, feet, ankles and knees were swollen, red, hot,
and very painful to the patient. Examination of the heart showed
apex beat in ﬁfth intercostal space and about an inch to the right of
papillary line; no epigastric pulsations noted; chest regular and well
formed; size of heart apparently normal. Auscultation revealed a
distinct endocardial murmur, but no lesion of the valves detected.
Patient complained of his heart ﬂuttering at times. He was placed on
ﬁve-grain doses of sodium salicylate, four times daily, also small doses
of tincture of digitalis. In two days I again saw him ; found his joints
less feverish and painful; also redness and swelling had largely sub-
sided, though the mufﬂed heart murmur was more pronounced. I
informed the father of the child’s condition and the probable termina-
tion In a severe heart disease. The 'kidneys were not acting freely
and were stimulated with diuretics; urine normal in constituency but
rather highly acid. I 1
I saw the patient no more for three weeks,- at which time I was
called to see the daughter, who had pneumonia, and while there ex-
"1
I
City Hospital Alumni. 11
amined the boy, who had complained of some pains about the joints,
also in the region of the heart. He was still quite anemic, appetite
and bowels irregular. Patient lay down most of the time. Examination
of the heart revealed an enlarged area of dullness; apex beat near the
nipple line, and a distinct systolic murmur heard at the apex, in the
axilla, and in the back; pulse was that of mitral regurgitation. He
was again put on sodium salicylate and tincture of digitalis. About
four weeks later I was asked to go to see the patient, who the father
said was suffering greatly. and that something was wrong with his ribs;
he thought they must be broken. I found him breathing rather shal-
low, about 43 per minute; pulse very small, regular, 108 per minute.
Patient retained upright position; epigastric pulsations were marked.
The fourth and ﬁfth ribs bulged very greatly, making a marked angle
midway between sternum and papillary line. Apex beat somewhat
diffused and one-half inch outside nipple line. Dullness extended
three inches to the right of median line, which was near the mammary
line and to the left of the left mammary line. Strychnia and digitalis
were given, with a fatal prognosis, which caused the mother to take
the child to another physician for examination. He conﬁrmed my
prognosis and diagnosis, which brought them back to me. I lost sight
of the case for about two months, at which time they came to me and
the following condition presented:
Patient weak and anemic; respiration shallow, 60 per minute;
pulse small, 120 per minute; epigastric pulsations marked; heart’s
action violent, murmur heard anywhere on the thorax or on following
the abdominal aorta; ribs perhaps not bulged so much as on last ex-
amination, and heart not quite so large, still was twice its normal size ;
liver and spleen seemed to be normal in size and not tender. He
complained of being unable to rest except with his head on a level
with the body. Face would be very much swollen in the morning;
feet and legs swollen at night, for he would not remain in bed. No
edema of the lungs present. Heavy dosage of nux vomica and digi-
talis gave some relief for a short while. I did not see the patient after
this, as he lived in the country, but learned that he died in a couple of
weeks. No post-mortem made.
The interesting points as I see them in this case are: The
rapid fatal course of the disease and the age of the individual;
the abatement of the joint symptoms upon administration of
salicylates, but the steady and rapid progress of heart compli-
cation, which was directly traceable to rheumatism.
12 Medical Society of
While youth is the fruitful age for fatal heart complica-
tions, there are few recorded so young as this individual. It is
one of the trying times when a physician sees the rapid pro-
gress of a disease and must realize the inefﬁciency of his efforts
and the shortcomings of drugs.
While this case, as has many another, proved fatal, I be-
lieve it was because I did not have opportunity to treat him
because of his living in the country several miles from me, and
his home surroundings were not what they should have been,
and, too, the ﬁrst medical attention was one week from the
beginning of the disease, at which time the endocardium was
markedly involved. It is my belief that had the patient had
prompt medical aid and proper home care the result would
have been different.
Another point I would mention is, when lack of heart
compensation ﬁrst showed, the patient could not be induced
to lie down, preferring the upright posture, while later, when it
became more marked, the recumbent position was taken. Of
course, in this position the tax upon the heart is less than in
the upright and it can still perform its task, while in the up-
right it could not. Strange enough, the upright position is
always taken when the heart begins to fail in its task, and often
persisted in to the end, and often permitted or even told to sit
up by the uhthinking physician or less thoughtful nurse.
It is not mine to say whether this condition is a complica-
tion, sequel, or a. part of the disease, there being reasons plen-
tiful for naming it either of the three. Sibson’s observation of
325 cases of rheumatism found 63 which he termed “threat-
ened endocarditis, I3 probable, 107 endocarditis without peri-
carditis, 54 endopericarditis, 6 pericarditis without endocarditis,
3 pericarditis with probable endocarditis. In children 60 to 80
per cent. of rheumatism have endocarditis accompanying it.
Some observers or writers state that it is most apt to accom-
pany rheumatism during the ﬁrst attack, but probably the
majority say that subsequent attacks make the liability to
endocarditis much greater. Certainly there is great reason to
believe the latter to be true. Endocarditis may accompany
mild attacks of rheumatism or severe; it may occur one week
after the rheumatism begins or after the rheumatism has sub-
1‘
City Hospital Alumni. 18
sided, and it has been noticed several days before symptoms
of rheumatism presented. Acute polyarthritis is the disease
which would be most apt to have endocarditis accompany it.
'The ﬁrst valves affected are the mitral, less frequently the
aortic. Rarely the right side is affected._ The pathogenesis,
or what we may call meta-arthritic endocarditis, can not be -
determined so long as our views on rheumatism are so indeﬁnite
as at present.
It is claimed by some that the same organism causing the
rheumatism produces the endocarditis acting as a joint, be-
coming infected by the same organism and responding in a
similar manner. Others claim that it is due to the toxins in
the blood, which, by passing continually over the endocar-
dium, produces an irritation resulting in inﬂammation. Some
observers have found the same organisms in the vegetations
on the valves of the heart, which are found in the joints during
an attack of rheumatism. Again, many researches have failed
to disclose these organisms on the endocardium. We know
that the blood is in an acid state during an attack of rheuma-
tism, and I am inclined to believe that the endocarditis is the
result“ of abnormal conditions of the blood rather than to be-
ing produced directly by organisms.
As to treatment, perhaps the theories are as great in num-
ber as those concerning etiology. Our ofﬁces are ﬁlled with
samples and the profession ﬂooded with literature; speciﬁc
after speciﬁc appears and in rapid succession each is con-
demned and relegated to the forgotten and the f‘ What’s good
for it” still unanswered. First, the patient should be kept in
bed and as .quiet as possible. The salicylates, preferably
sodium salicylate, in large doses, administered. The bowels
should be kept fairly open and a bland diet adhered to—milk
and cereals, gelatin, etc., restricting the meats entirely. Not
until the heart shows signs of weakening in its action do I ad-
minister cardiac stimulants. The endocarditis will usually dis-
appear in a week under the use of salicylates with dietetic and
rest treatments.
14: Medical Society of
DISCUSSION.
DR. F. G. NIFONG believed rheumatism was more frequent in
youthful persons than is generally believed. He thought this affection
in young persons was often attributed to or called " growing pains.”
He had seen quite a number of young persons affected with rheuma-
tism. One in particular was remarkable. It was an infant and the
child had rheumatism in a number of its joints. The mother suffered
with the same trouble to the extent of suppuration in one joint while
pregnant. The infant was but three months old and the trouble readily
yielded under the administration of the salicylates.
DR. GEORGE HOMAN thought the bulging of the ribs described in
the case could be accounted for by an effusion in the pericardium, and
that aspiration might have relieved this condition. ‘Inability to have
the patient under constant observation was, of course, a serious dis-
advantage to an medical attendant. In the treatment of rheumatism
the speaker said that hardly enough attention was given to the action
of the skin. He thought the kidneys must share the irritation with
other organs in this abnormal condition of the blood, and there is
danger of stimulating the kidneys too much and setting up a nephritis.
For this reason we should depend upon the skin as much as possible,
inducing free perspiration and eliminating dangerous materials in that
way and thus taking the burden off of the kidneys.
DR. HENRY JACOBSON agreed with Dr. Homan that tree perspira-
tion should be induced in rheumatism. A case treated with hot air
apparatus readily yielded The patient was given a hot vapor bath
every day. Salophen was given, but the most beneficial results were,
the speaker believed, obtained by the bath. He did not believe the
case under discussion would have terminated differently even had the
Doctor had the child under constant care. The bacterial poisoning
was so severe and the heart affected to such an extent that the child
would have succumbed.
DR. H. S. CROSSEN said this case showed what might happen to
children affected with heart trouble. The general idea is that heart
complications in children are frequent but not serious and usually dis-
appear. The ﬁrst case of heart disease he had seen was in a girl, very
anemic, and the murmurs were unusually loud. He was a? student at
City Hospital Alumni. 15
the time and did not get the murmurs differentiated very well of course
but he remembers very distinctly that he thought the patient would die
right away. Under treatment the trouble disappeared Dr. Talbott’s
case showed that we ought to be careful in prognosis of these troubles
in children. The urine ought to be rendered alkaline and kept so for
some time. He believed the use of alkaline treatment was considered
an important point in preventing cardiac complications in rheumatism.
He thought the mixed treatment (alkaline and salicylates) would have
more effect in preventing heart complications or allaying them when
begun than the salicylates alone.
DR. FRANCIS REDER said it was a singular fact that nothing
deﬁnite was given in this era in the cause of rheumatism. We know
the blood is in a strongly acid condition, and from this we infer that
rendering the blood alkaline combats the disease. Better success has
been observed with this treatment, but it is necessary to push to heroic
doses. The conditions found in the heart are inﬂammatory conditions
about the valve and at the attachments of the valve, and, of course,
the further complication of pericarditis and even the structures of the
heart are sometimes involved. In the treatment of acute and articular
rheumatism much attention should be given the immediate comfort of
the patient. The suffering is intense and they present a deplorable
picture. The hot bath is good but cannot always be applied. Jaborandi
applied to the joints affected gives relief and produces a profuse pers-
piration. The administration of alkalines or the salicylates comes
next. The tincture of the chloride of iron is a superior remedy and
. this ought to be continued after convalescence has been established
for some time.
DR. J. C. FALK believed acute inﬂammatory rheumatism is much
more frequent among children than has been generally supposed. We
often see children or infants having symptoms which can only be ex-
plained on the supposition that it is acute inﬂammatory rheumatism,
articular, or muscular. He thought, too, that heart complications were
frequent in children and that they were more serious and lasting in
. their effects than is usually supposed. The fact that a cardiac murmur
following an attack of acute inﬂammatory rheumatism in a child soon
disappears does not always indicate that the heart has recovered from
16 _ Medical Society of
the damage done, for it is often only temporarily adjusted. The con-
trary may also be true, as serious lesions not infrequently follow rheu-
matic attacks without the cardiac sounds being pronounced. The ~
greater part of these heart lesions following acute inﬂammatory rheu~
matism he considered a permanent injury to the organ—that is, the _
valve never regains a perfect condition; compensation may be estab-
lished and be more or less efﬁcient for a number of years, but sooner
or later an exciting cause will make the damaged part manifest. He
believed the disease was bacterial. He could not account for the clini-
cal picture presented by acute articular rheumatism or. any other hypo-
thesis. In his opinion that variety of rheumatism so frequently seen the different myalgias has not a bacterial etiology, but is phrely a local
manifestation of a constitutional dyscrasia—an obliquity of tissue
metabolism—which, for want of a more descriptive designation, is
called the uric acid diathesis.
DR. JOHN GREEN, JR., said the theory, which the essayist intimated
as his belief—that the cardiac complications were due, perhaps, to the
acid conditions of the blood and not to speciﬁc micro-organic causes,
was strengthened by the statement of Dr. Crossen—that the alkaline
treatment was frequently prophylactic as well as curative.
DR. JAOOBSON did not agree with Dr. Green and Dr. Crossen that.
the alkaline treatment prevented heart complications. In some of the
large hospitals comparison had been made and it was found that a cer-
tain number of cases would have heart trouble whether treated with
the alkaline method or with the sallcylates. The condition of the blood
is disputed, some investigators claiming it is acid, and some that it is
alkaline. -
THE PRESIDENT said that he had hoped to hear some remarks
upon the surgical treatment of acute articular rheumatism. His atten-
tion had been drawn to it favorable some years ago by the researches
of O’Connor, of Buenos Ayres, who had successfully instituted a surgi-
cal treatment of joints with rheumatic infection. The contents of the
joints so treated were invariably found to be turbid and to contain a.
‘micro organism. He also found that the surgical evacuation and
cleansing of the joint with subsequent competent drainage had been
curative. He also found, as a collateral point of interest, a compara- '
City Hospital Alumni 17
tive indifference to infection processes in joints generally. He in-
stanced one map operated on for a rheumatic infection of the knee-
joint. This case,'like the remainder of the series, had been in the
hands of other men, and had been closed with salicylates, iodides,
colchicum and all other drugs in vogue, without avail. When oper-
ated on, foul, purulent contents were evacuated, and a large gauze
drain inserted. When he left the hospital he was walking around
comfortably. Some months after, O’Connor was appalled to see this
man come in and say, “ Doctor, my leg’s leaking ” On examination,
a ﬁstula was found leading into the joint, and discharging synovial
ﬂuid. When asked if it gave him any trouble he said, “ No, that it
was as sound as when he enlisted in the Horse Guards.” This navvy
had been daily engaged in his laborious and uncleanly occupation.
His baths were undoubtedly no more frequent nor thorough than
others in his station of life. He had given no attention to this articu-
lar ﬁstula; and yet no infection had occurred, and in fact shortly after
the tract. spontaneously closed. The speaker felt that we were justi-
ﬁed in expecting much from the surgical treatment of joints infected
by rheumatic processes.
DR. TALBOT, in closing, said he had found a number of cases on
record where there was undisputed history of rheumatism in quite
young persons. The youngest he had found was a child twelve hours
old and there was a speciﬁc history of rheumatism. The mother of
this child had rheumatism and the child presented the evidences of it
and yielded to treatment, the mother’s case continuing some few weeks
afterdelivery when it too yielded. There are several cases of children
affected with rheumatism aged only a few months. He thought Dr.
Falk correct in his statement that many cases of rheumatism in children
were undetected, and he also thought that a good many were called
rheumatism when in fact. they were not. One of the points mentioned
in the essay had been left unanswered; that was, whether the heart
affection is a complication, a sequela, or a part of the disease; is it
due to the micro-organiSm or is it due to a blood dyscrasia, whether _
due to the acid condition of the blood or to toxins, or due to an infec-
tion of the pericardium acting Simply as a joint and becoming infected
as a joint? He supposed this was still an unsolved question and he
1- 8 Medical Society of
had found nothing conclusive on the Subject in the literature consulted,
but believed the cardiac affection due to the constant irritation of the
abnormal blood, which is, as it were, freighted with toxins. The bulg-
ing of the ribs might have been due to pericardial effusion, as sugl;
gested by Dr. Homan, but there were no symptoms of pericarditis or
effusion in the sac other than that of bulging.

Points of Interest Gathered From Eastern
Hospitals.
BY FRANK G. NIFONG, M.D.,
ST. LOUIS, Mo.
T is not my purpose to present a paper or make a co-ordinate
I address on any particular subject, but simply to call atten-
tion to a few points of interest gathered here and there in
some of the best metropolitan hospitals. It is always good for
us to get away from home for a time and see how our neigh-
bors work. If we should have an hypertrophied self-esteem it
may reduce it to the proper size and at the same time ﬁx our
conﬁdence in our own ability to do good work. And if we
should have that rarer trouble of underestimating our capacity, .
it'will cure that also. So many various factors are conducive
to success and more than we realize is due to our environment.
We should measure men, then, not altogether by their achieve-
ments, but more by the difficulties which they overcome.
I have recently had the pleasure and the proﬁt that accrues
to one from a visit to some of the best Eastern hospitals. Iam
indebted to Drs. Weir, McCosh, Bull, Coley, Brown, Brewer,
Elsberg, Willard, White, Halsted, Kelly and various other
gentlemen for courtesy and hospitality. My point of view has
been surgical, as you see. The New York hospitals visited
have been St. Luke’s, St. Vincents’, Presbyterian, Roosevelt,
New York, Ruptured and Crippled, Mt. Sinai; the Presby-
terian, University, and St. Joseph’s in Philadelphia, and Johns
Hopkins in Baltimore.
I can only speak in a general way of the excellence of
these institutions and more speciﬁCally of two or three. Why .
i
City Hospital Alumni. 19
should they not be good when we consider the vast amount of
money that is spent in building and maintaining them: St.
"Luke’s, which is said to have cost two and a half million dol-
‘lars; the Roosevelt with the capital behind it; the Presbyterian
With an anonymous donor of four hundred thousand; the New
York with large real estate holdings from which comes a
princely independent income, and which enables it to build
a newthree hundred thousand dollar addition; the Mt. Sinai
under the patronage of Hebrew wealth will shortly begin the
erection 'of a two million dollar plant; the magniﬁcent St.
Vincents’ backed by the Catholic Church, and all the various
others under the patronage of the different classes of wealth.
After seeing the equally splendid hospitals of Philadelphia
and ﬁnally the magniﬁcent Johns Hopkins, it is with deep
chagrin and shame that a patriotic St. Louisan sees his home
hospitals and other eleemosynary institutions. Why can we
not have at least one splendid hospital that is fully up to the
standard, modern and thoroughly equipped? We, ‘who boast
so much of ﬁnancial solidity, why are we put to shame with
our poorly equipped and poorly endowed institutions—our
"‘ two-bit ” hospitals, and a miserable old barracks for our city
hospital? It is one of the duties of the medical profession to
educate its people and endeavor to improve this condition
of affairs.
_ Now let me tell you of some things I saw at the Roosevelt.
Roosevelt, you know, is intimately connected with the College
of Physicians and Surgeons. Drs. Weir and Bull, with Drs.
Brewer and Blake, operate on alternate days in the magniﬁcent
Syms’ operating amphitheater. I saw them all do good work,
usually before a largeclass of students and visitors. And how
splendidly are they equipped and skillfully assisted; dressed
in a suit of sterilized pajamas and cap, their hands are scrubbed
with sterile soap and water, and rubber gloves are used by op-
erator and all assistants. Dr. Weir did a nephrorrhaphy with-
out gloves, depending on the nascent chlorine method for the
hands, but he usually uses gloves. .The sponges were gauze
rags; a few times I saw sea sponges used. Catgut was pre—
pared by the nurses in the old way of boiling in alcohol, etc.
The dressings and instruments were prepared in the usual way.
20 Medical Society of
\
I submit a sample of new starch bandage material, also a
beautiful new heavy bleached cheese-cloth bandage material
used in the Roosevelt. The surgical service seems very active'
in the Roosevelt. The electric ambulance is a feature here as
it is in most of the hospitals. Each hospital has an ambulance
district and answers all calls within the limit. Police and
undesirable cases are taken to Bellevue Hospital. There ‘
is some arrangement with the city government by which
the private hospitals get a certain amount for each charity pa-
tient cared for. It seems a very admirable plan for so large a
city. '
At the Hospital for the Ruptured and Crippled I saw Drs.
Bull and Coley operating simultaneously as I had seen them
do several years ago—doing the Bassini as they have been do-
ing so well for some years. After operating they showed
numerous cases of non-recurrent hernia that had been done '
from one to ten years previous. Fifteen hundred cases have
been operated on by these men.
The New York Hospital has a very active service. I saw
work in the service of Dr. Bolton and am indebted to Dr. Nes-
bitt, house-surgeon, for courtesies. Their old operating rooms
are passe, but they will soon be in their magniﬁcent new addi-
tion, which is thirteen stories high and contains splendid rooms.
I saw the usual good work here. Being located in central New
York, their service is very active and they have much acute
surgery—accident cases, etc. Most of the dressing was done
in the wards. A new paper bag received old dressing to be
carried out. Here I saw Hodgen splints well adjusted, illus~
trating the Biblical truth, that “A prophet is not without honor
save in his own country.” .
Going still further downthe city we come to the splendid-
St. Vincents’ Hospital. Here they have three or four hundred
patients all the time and much acute surgery. Located near
the Italian and poorer quarters, its ambulance service is very
brisk. They had the ﬁrst auto-ambulance in the city. 'I had
the pleasure of riding on it to an emergency call and it surely
was a rough ride, except over the asphalthum streets. St.
Vincents’ has the usual out-patient department; also equipped
with cells and Turkish baths, for drunks, uremics, etc.
- I"
City Hospital Alumni. ‘ 21
There seems to be a rivalry among hospitals as to which
shall have the best operating rooms. In my judgment the new
rooms at St. Vincents’ easily excel all others. The main room
is very large, beautifully lighted, ceiling thirty feet high,
mosaic ﬂoor, and walls white tiled to the ceiling—not marred
by amphitheater seats. The anesthetizing: sterilizing and
preparation rooms on either side are equally chaste and pretty.
This room is the most beautiful I have ever seen and I do not
see how it can be excelled. '
My admiration of the Presbyterian Hospital may be some-
what exaggerated, but it seems to me—taking it all through—
that it is the best of all these splendid institutions. With build-
ings so complete and beautifully arranged and so thoroughly
equipped in every way; with such an excellent surgical staff,
and the brightest of nurses, it is what these advantages make
it. Through the courtesy of Dr. McCosh and Dr. Mosely,
house-surgeon, I was priviledged to see much excellent
work. Here, also, they have a splendid operating amphitheater
and preparation rooms. The hands were prepared by the
Weir method, but operator, assistants and nurses all wore rub-
-ber gloves. These gloves were sterilized by the wet process
and then again by the dry and placed in sterile talcum powder,
which made them very easy to draw on. The gut was prepared
in the old way, also the dressings. Sea sponges were used,
prepared by theold permanganate and oxalic method. Flat
gauze cloths without cotton were used in abdominal operations
to retain intestines. The nurses attended with sponges, wash-
ing them in sterile water. In order to have the most needed
instruments as close to the operator as possible a hospital bed
table was used bringing the instruments over any part of the
patient. This arrangement I noticed was used by a number of
operators at different hospitals, and although apparently a
small thing, I was struck with its handiness and the time it
saved. It would not be half told of the Presbyterian, if I did
not mention the excellent nurses’ training school. Here we
see the most intelligent and best trained nurses in the country.
These bright young women demonstrate the fact that
'good breeding is of value in any profession and not the least
in that of nursing. Nowhere can you see such beautifully kept
2:, Medical Society of
and orderly wards, such immaculately dressed beds, such per-
fect netes and records. A man is indeed fortunate who falls
under the care of these “ministering angels.”
The Mt. Sinai Hospital is old, but very neat and orderly,
This has been the home of Gerster for the last twenty-ﬁve
years, one of the pioneers in practical asepsis, as you know.
Now Gerster and Lilienthal are the heads of the two surgical
divisions which are always well ﬁlled with interesting cases. I
saw in the wards two hip disarticulations (Wyeth), ﬁve or six
appendectomies, several Bassini hernias, tubercular surgical
cases, several nephrotomies, Proctectomy (Morrison method),
colotomy and colostomy, Estlander’s operation for empyema,
and such like.
I am greatly indebted to Dr. Elsberg of the Mt. Sinai for
courteous treatment and information about Mt. Sinai; also for
his new method of preparing catgut and sea sponges, 'which is
being used with success now at Mt. Sinai. It appears to be a
very rational and withal a simple method. It depends on the
chemical principle that a precipitate or resultant salt cannot
be redissolved in the substance which precipitates it. Many
substances will precipitate albumen and albuminoids and this
precipitate cannot be redissolved by an excess of the substance.
Elsberg found ‘by experimentation that ammonium sulphate
was the best substance to ﬁx the albumen in the gut. The
preparation is simply this : Take crude gut, extract the fat with
one part chloroform and two parts ether by macerating twenty-
four hours; wind on glass spools tightly in single layer and tie
both ends; boil ﬁfteen or twenty minutes in saturated solution
of ammonium sulphate; wash off the salt in sterile water after
boiling andplace in desired media for preservation. The boil-
ing point of saturated ammonium sulphate solution in about
230° F. The gut is wound tightly on the spools to prevent
kinking and becoming brittle at these points. For ofﬁce use
one may keep a saturated solution of ammonium sulphate and 4
prepare his gut as needed. Elsberg recommends the addition
of two per cent. carbolic acid for ofﬁce sterilization, “For
chromicized gut add one per cent. or more of chromic acid to
solution. He is experimenting now to determine the length
of time the different percentages of chromicized gut will last.
i,
City Hospital Alumni. 23
To prepare sea sponges he puts them in eight per cent. HCl
solution for twenty-four hours to remove dirt and sand and
then washes thoroughly; then boil thoroughly in a two per
cent. solution of tannic acid and one per cent. of caustic potash.
Boil any length of time and wash in sterile water to remove the
brown. This method is based on the same principle as that
of preparing the gut. The tannic acid ﬁxes the albuminoid
principle—spongeine in the sponge, and prevents the boiling
from softening and dissolving it. The sponges would be-
come contracted and hard if the potash were not added. The
potash prevents that and leaves the sponge as elastic and ab-
sorbent as new. In many operations it would seem desirable
- to go back to the use of sea sponges if we could feel safe about
them. I hope this method will prove as satisfactory as it
promises.
I did not have the time to see the Philadelphia hospitals
as I would liked to have done. The St. Joseph’s is a well man-
aged hospital of two hundred beds, out-patient department,
training school, and a good pathological laboratory. The
Presbyterian is of the pavilion plan and appears neat and well
equipped. The University Hospital has good operating rooms
and beautiful wards.
Finally, we come to the Johns Hopkins of Baltimore,
which is perhaps of more reputation than any. The buildings
are magniﬁcent and models of architecture, as you know; and
the staff is unexcelled. I think that, perhaps, more original
work comes from the Johns Hopkins than any other institution
in this country. I can not say much for their operating rooms
and amphitheaters, as they are old and out ofdate, and do not
compare in beauty with those of more recently built hospitals.
Good surgery is not dependent on the work-room, however,
and here we see the best in surgery. I enjoyed the courtesy
'of Dr. Halsted and saw him do several difﬁcult operations, one
of them a _cholecystectomy—Dr. Halstead uses silver wire and
silk entirely except in operating near the bladder or pelvis of
kidney; rubber gloves; nascent chlorine method for hands.
Dr. Mitchell, the house-surgeon, has enjoyed a service of
seven years in Johns Hopkins; during my visit he closed a
2t Medical Society of
typhoid perforation at 2A.M., six hours after the ﬁrst symp-
toms appeared.
I also had the pleasure of seeing Dr. Howard Kelly, op-
erate in his private hospital, where he has a beautiful and
thoroughly equipped operating room. He uses cumolized
catgut extensively for ligatures and sutures.
CONCLUSIONS.
I. St. Louis should have better hospitals.
2. St. Louis has good surgeons who are somewhat handi-
capped in their facilities for operating.
3. Pavilion hospitals not necessary in these days of asep-
sis. City hospitals should be high up—sky scrapers. ,
4. These are the days of the most perfect practical asep-
sis and the achievements of surgery are a ﬁtting climax to the
progress of the century.
\
DISCUSSION.
DR. J. C. FALK agreed with the essayist in the statement that for
large cities a hospital built of many stories and compact is superior to
the pavilion plan. He did not think a city of the size of St. Louis
should attempt to build a hospital on the pavilion plan. Provision, of
course, should be made for the isolation of virulent infectious diseases.
The great majority of the patients, however, should be better cared for
in one large building.
DR. HENRY JACOBSON thought there ought always to be erected a
separate building at a distance from the general hospital for the ob-
servance of suspected small-pox cases. There is nothing like a deten-
tion building here at present. During his service at the City Dispen-
sary this was impressed upon him, for in times of small-pox epidemics
there is great difﬁculty the ﬁrst twenty-four hours in pronouncing the
disease such, especially in negroes; and there is danger of sending a
syphilitic to the small pox hospital, and of sending a small pox patient
to the general city hespital. This has occurred not only with syphilis,
but with small-pox, causing great commotion and general vaccination
and exposure to small-pox unnecessarily.
DR. GEORGE HOMAN did not agree with some of the conclusions
of the essayist. The conditions in New York City are exceptional.
"t
City Hospital Alumni. 25
It is situated on a long narrow island, the population is enormous,
land values have reached exorbitant ﬁgures, so that practically the
hospitals in order to meet the demands upon them have no way to
enlarge their capacity except skywards. But while unfavorable local
circumstances compel to this course it does not follow that this bad
example should be imitated where the conditions are different and
ample ground space is available.
The New York people, of course, put the best possible face on
the matter, but to build a warehouse six, eight or ten stories high and
call it a hospital does not make it one—that is, an institution for the
best care and cure of the sick, and that is the sole and dominating
purpose of such an institution.
He thought further that there was too much of a tendency among
hospital men to look upon the patients as mere material—a part of the
hospital mechanism, and not as human beings with tastes and desires
akin .to their own. The instinct of ‘the race in sickness and suffering
turns toward the things of N ature—trees, green ﬁelds, ﬂowers, birds,
etc., and the moral, mental and physical conditions of patients are bet-
teredby an outlook on such scenes rather than views of gravel roofs,
brick walls, smoking chimneys, and the like. It is a serious mistake
to remOve people too far from Mother Earth, for such she is to us in
soberest fact; the “foot on the earth,” as the French say, expresses a
vital necessity.
Where abundant space is available, as found here, he believed
that a hospital building should certainly not exceed three stories in
height. He would be sorry to see the bad example of New York
copied by St. Louis. It is not necessary here, it may be a deplorable
necessity there.
DR. JOHN GREEN, JR., said he had visited the Boston hospitals
two years ago and some points observed there might be interesting in
connection with the New York hospitals. The City Hospital in Boston
had recently added a new surgical addition. It is an immense build-
ing with every facility for handling all sorts of cases. There are sev-
eral small emergency operating rooms for handling unclean cases, and
a separate room where none but clean cases are operated. In one
operating room there are several beds where a patient may be placed,
26 Medical ‘ Society of
if necessary, for the time being after the operation if the condition be
critical. There is a large operating amphitheater illuminated by upper
lights and seating four hundred students. The sterilizing room has
three large sterilizers and everything there is absolutely immaculate.
Adjoining this room is the instrument room containing a half dozen
large instrument cases, one of which is deVoted to abdominal retrac-
tors alone. The instrument cases are examined bacteriologically at
stated intervals. There is a ﬁne medical library open to the internes
and staff of the hospital. The dead-hOuseis very complete, and there
is a splendid pathological laboratory. One interesting feature is the
new “ South Department,” where contagious diseases only—the speaker
thought but three, scarlet fever, measles, and diphtheria—were treated.
The building has three different pavilions connected by bridges. They
are absolutely the most perfect structures for the purpose that could
be imagined; every detail is carried out with the greatest care. In the
diphtheritic pavilion instruments for intubation lie ready for use at all
times so that there may be no delay in operating in urgent cases.
Consumptives are not treated in this hospital. An emergency case
may incidentally be tubercular, but when this is discovered provision
is made for treatment elsewhere.
The Children’s Hospital, presided over surgically by Dr. Brad-
ford whose reputation as an orthopedic surgeon is international, is
rather an old building and contains the operating room where Dr.
Bradford does those remarkable operations ‘in in congenital hip dis-
locations. The room is hung with sterilized sheets from the ceiling to
the floor and these are removed at each operation. There is an ex-
tended sun parlor where convalescent patieots are carried on forms or
wheeled on specially constructed invalid chairs. The speaker agreed
agreed with Dr. Nifong, that the hospital situation in St. Louis was
sufﬁciently heartrendering.
DR. NIFONG said he knew it was necessary for the hospitals in
New York to be built high, but nevertheless he believed they had the
advantage of the horizontal hospitals. He believed it was easier to
heat them and care for them in every way. However, there should be
separate buildings for the different diseases, net one building for all.
There should be. a surgical building, a medical building, one for acute
)7
City Hospital Alumni. , 27
' a infectious diseases, and so on, but no limit as to height. It is very
. pleasant to make such a trip as he had and well repays one.

Special Meeting, jazzuary 31, 1901; Dr. Nowelle Wallace Sharpe,
President, in the Chair.
The New City Hospital.
THE PRESIDENT stated ‘that the hospital as n0w planned was at
best but a makeshift; that the medical profession was justiﬁed in ap-
- proving the excellent work of the original Hospital Commission which
contemplated the erection of a general city hospital in the western
limits of the city on the grounds around the Insane Asylum and Female '
Hospital. This h0spital was to have been erected on the pavilion sys-.
tem, and an emergency hospital (same system) on the old City Hospi-
tal site (to accommodate 400 patients), to be erected and to be used
for the acutely sick, who were to be transferred as soon as they were
convalescent to the general hospital; and ﬁnally, as the city grew, to
duplicate this emergency hospital in the northern portion of the city.
This plan had been abandoned, and the present plan was to erect on
ﬁve acres of ground at the old City Hospital site a pavilion hospital to
accommodate ﬁfty per cent. more than was originally contemplated;
that the “ hospital system ” as suggested by the Hospital Commission
is non-existent, and in its place we have plans for an hospital on the
original ground, this to serve not as an emergency hospital, but as the
City Hospital; for the original general hospital scheme has been
abandoned. ‘
He spoke also of the ﬁnancial phase. St. Louis at present is said
to be handicapped for funds. The law now provides for a certain
amount of money (one per cent. of the revenue) from $50,000 to
$55,000, to be laid aside yearly to be devoted to hospital erection.
There is-about $300,000 on hand; this is to be consumed in the erec-
28 Medical Society of
tion 'of the buildings as now planned. With an increase of $55,000
yearly, it will take twelve years to get the complete hospital, for the
estimated cost is about $1,000,000. In the meantime the city is rent-
ing at a generous ﬁgure a convent abandoned by its former occupants
as untenable. We now have 500 or more patients on. hand, and as the
entire capacity 0f the completed hospital is not to exceed 620 patients, it
is a simple proposition to see where we shall be when the new hospital
is completed; the city will have rented the abandoned convent for '
many years, much money will have been expended, and yet there will
be no more room for the pauper sick twelve years hence than we now
have. And, further, attention is called to the fact that the city hospital,
system—that is, the hospitals under municipal control—will not be re"-’
lieved at all by this proposed handful of buildings on Lafayette Avenue.
For the truth is that the Insane Asylum is so crowded that many hun-
dreds of patients rightfully belonging within its walls are perforce
housed in the Poor House. The Poor House is of necessity packed,
nay overpacked, with inmates; and ﬁnally, that the Female Hospital
' is inadequate in its capacity. The latter title is, patently, a misnomer;
and the hospital itself has no real reason for existence, for the women
there housed should be received, upon a similar basis as men, in prop-
erly equipped emergency and general hospitals. It would be wise to
abandon the so-called “ Female Hospital.”
The question of an hospital for contagious diseases is germane as
a subject of collateral interest. St. Louis has no hospital facilities for
people afflicted with contagious diseases, and nothing is contemplated
in these plans for the care of this class of cases, save a “ contagious
building,” and this is but for the accommodation of contagious dis-
eases arising within the hospital, with a capacity limited to ﬁfty or sixty
beds. Guests of the city may and often are affected with contagious
diseases. There is no place to send them except to the City Hospital;
their reception there is at the option of the superintendent in charge ;
if he sees ﬁt to reject them, they must then be subjected to a painful
and wearisome journey, by inadequate vehicles, to the so'called
“ quarantine hospital” far south of the city. This is a serious problem
not only to the physician in charge, but to the patient, who may be,
and often is, amply able to pay for suitable surroundings. St. Louis
City Hospital Alumni. 29
should be provided with buildings of sufﬁcient size to care for this class
of cases.
There should also be municipal buildings suitable for the care of
the diseases incidental to childhood.
The " municipal hospital situation ” is far-reaching; much farther
than our present city ofﬁcials are inclined to consider or provide for.
The Secretary will now read such ordinances and reports of Hos-
pital Commission. communications, etc., as are pertinent to the topic
up for discussion this evening.
[18’374-1
An ordinance providing for a Hospital Commission, and prescrib-
ing the powers and duties thereof.
Be it ordained hy the Muniez'pal Assembly of the C ity of St. Louis, as
fol/mus :
SECTION 1. A Hospital Commission is hereby created, to be
composed of the Mayor, the Health Commissioner, a member of the
Council—to be appointed by the President thereof, a member of the
House Of Delegates—to be appointed by the Speaker thereof, two phy-
sicians, and one member Of the Boadr Of Commissioners of Charitable
Institutions—the last three to be appointed by the Mayor. Said Com-
mission shall continue for the term Of four years from the date of the
approval of this ordinance. All vacancies by death, resignation, or
Otherwise, shall be ﬁlled by a majority vote of the members of said
Commission at a meeting, of which notice shall have been given ﬁve
days prior thereto. N 0 member of this Commission shall receive any
compensation whatever for his services as such. Said Commission
shall have the power to adopt rules for its own government and regu-
lation, to elect its own Ofﬁcers and committees for such time and with
such powers as may be prescribed bp its rules. Said Commission is
hereby empowered to call upon the heads of the various city depart-
ments to detail such assistance as may be required by the Commission
in the preparation of its report.
SEC. 2. Said Commission is hereby charged with the duty of
formulating a scheme or plan for the construction or reconstruction and
general location, distribution and management of the hospitals belong-
ing to the city, for the purpose of producing a complete, harmonious
system for said institutions, and designate the direction of needed ex-
penditures in construction or remodeling of buildings. Said Commis-
sion shall make reports from time to time, to be forwarded through the
30 Medical Society of
Mayor to the Municipal Assembly, and when they deem necessary they
shall prepare and submit to the Assembly ordinances embracing what
legislation is needed.
Approved March I4, 1896.
From this the Commission did not consider that it had any execu-
tive powers or was called upon to give the details of construction, or
in other words, to get up a set of plans complete. We all know the
general condition of the institutions throughout the city and the pur-
pose set forth was to adjust and correct the deﬁciencies as far as possi-
ble or practicable. The speaker then read the report Of the sub~com-
mittee which had been adopted, which follows:
ST. LOUIS, MO., August 21, 1900.
Honorable Board of Puhlz'e Improvements: I
GENTLEMEN.-—The authenticated copies of report of Committee
of the Hospital Commission and the sketch plans accompanying said
reports designated as Exhibits A, B and C, which have been on ﬁle in
the ofﬁce of the President, should now be transferred to the Board and
become part of its records, for the reason that the plans have been
adopted by Ordinance No. 20,162, and the Board is directed to cause
the hospital to be erected in accordance with said plans. The report
of the Committee is an important part of the records, as it gives a
needed interpretation of the plans, telling what is intended to be ac-
complished and what is excluded. Ordinance 20,162 provides that the
plans be so modiﬁed as to increase the accommodations of the hospi-
tal accommodations ﬁfty per cent. beyond the recommendations of the
Committee, and to this end the isolation ward is to be two stories in
height, and the octagonal ward three stories, instead of one and two
stories, respectively. This modiﬁcation will increase the capacity of
these wards from 121 to 192 patients. This departure from the origi-
nal idea is not entirely consistent with the pavilion plan, but was made
to meet conditions in which the city is placed. Large needs, but small
means.
The completion of the buildings authorized by Ordinance 20,162
will come far short of providing hospital accommodations that will en-
able the temporary City Hospital to be vacated. The Commission in-
tended the hospital 0n this site for the treatment of emergency and
acute cases only, and the Commission’s plan included the concurrent
erection of pavilion wards on the ground on the south of Arsenal Street,
opposite the Female Hospital, to accommodate chronic and convales-
cent cases. '
City Hospital Alumni. 31
In my opinion this part of the Commission’s project must not be
lost sight of. Believing that the present appropriation will complete
the building, whose construction is now authorized, it is possible that
sufﬁcient accommodations for an emergency and acute case hospital
will be sufﬁciently met, and that further appropriation, when made,
should be to provide accommodations for the more numerous class or
cases which the Commission proposed to provide on Arsenal Street.
Respectfully, ROBERT E. McMATH.
[COPY-l
ST. LOUIS, MO., January 29, 1897.
To the Oﬁieers and Members of the Hospital Commission : -
GENTLEMEN.—The members of your Committee appointed to
prepare the preliminary studies, with sketch plans, for the hospital
system Of the city, having made a careful study of the question, report
as follows:
That the site of the old City Hospital affords the most satisfactory
available location for the erection of an emergency and acute case hos-
pital. Your Committee believe that the needs of the city, with its rap-
idly shifting center of population, may be provided for, for many years
by the erection at this point Of an hospital providing accommodation
for 420 patients, if, concurrent with the erection of this structure, there
- may be erected on the ground adjacent to, opposite the building known
as the Female Hospital, semi detached wards which would conform to
the general plans herewith submitted.
The plans accompanying this report and forming a part of the
same are the result of a careful study of the leading hospitals of the
world, and comprise the best points of the various structures examined.
The hospitals studied include not only American, but the great struc-
tures extending over Europe and as far east as Persia. As the result
of this study your Committee believe that a system Of wards, better
known as the pavilion system, would best meet the demands made by
the advanced knowledge of medical science and the hygienic principles
of hospital construction.
In conformity with this conclusion the sketch plans marked Exhibit
A, B and C are herewith submitted, and an elaboration on these lines,
with the careful attention to details necessary to approximate perfec-
tion, would result in an hospital structure at least equal to, and we be-
lieve superior to any now existing, and possessing greater facilities for
the economic and scientiﬁc handling of disease and accident.
. We further recommend that when the growth of the city justiﬁes
it, a similar building be erected in the northern par; of the city to attend
to the growing needs of that section. '
82 Medical Society of
Exhibit A will clearly deﬁne and explain the arrangement believed
to be the best utilization of the space afforded by the site; the accom-
modations provide for the greatest number of patients that is allowed
by the highest possible authorities. This block plan deﬁnes the loca-
tion of the various buildings, their accommodation uses, etc. The
arrangement gives the maximum amount of light, sun, and air to each
ward, with the greatest ease of service and the most economical
arrangement for heating and ventilating. The limit of a little over 400
patients is the greatest number that can be handled successfully in the
space, and this only with the most efﬁcient modern methods of heating
and ventilation. The design contemplates that this hospital shall be ,
equipped with every approved convenience for the reception, prompt
and scientiﬁc treatment of all the acute surgical and medical cases that,
come under the city’s care, excluding only small-pox and contagious”
diseases (except such as originate after admission), also all insane
cases other than those under Observation pending commitment to the
asylum.
To prevent overcrowding and give opportunity for the best results
in treatment, all convalescent and chronic cases are to be provided for
in hospitalibuildings built as elsewhere recommended.
This central hospital is designed to be used for ﬁrst relief in all
cases except contagious and insanity cases, as previously mentioned,
but provision is made for their Observation and for criminal cases. The
situation is central to the denser districts of the city, and with a sys-
tematized ambulance service would be able to care for all emergency
cases that need relief from the city for several years to come.
The hospital pharmacy has in connection with it a dispensary for
outdoor relief, the general arrangement ofwhich will be seen by refer-
ence to the accompanying plans.
The '_Committee are of the opinion that all cases seeking relief
from the city should ﬁrst receive it at this hospital. If this plan is ap-
proved, the present dispensaries should be ambulance stations only,
under the charge of a physician, and equipped for the prompt and safe
removal of emergency and accident cases to the central Or other hos-
pital, or to the home of the victim. _
It has been a long-established custom to permit the use of patients
in the city hospitals for the clinical instruction of students attending
medical lectures in the city. Your Committee considers this a legiti-
mate privilege and one that might be properly enlarged and perpetu-
ated under such regulations as would make it subordinate to the best
interests of the patients. Without specifying, at this time, what are
deemed necessary regulations to this end, the Committee recommends
City Hospital Alumni. 33
in the plans submitted an amphitheater in close relation to a dispen-
sary. From the latter, as well as the hospital walls, material may be
drawn for the purposes of clinical instruction. A pathological and
bacteriological laboratory are recognized as necessaiy in a modern
hospital equipment, and the collecting and placing of specimens in a
properly arranged museum, where they may be accessible for inspection
and study, is also recommended. With this end in view, rooms have
been provided in the plans at points most convenient for the work.
Other features suggested are the Administration Building, to con-
tain Ofﬁces, living rooms, nurses’ home, kitchen block, laundry, dead-
house, and other buildings necessary to the successful administration
of an hospital; in addition to the wards, all have received our careful
attention. An ice machine, located in the power block, is strongly
recommended, not only to supply refrigeration to store-rooms for per-
ishable food and similar uses, but for the manufacture of ice for other
institutions. Facilities for preparing distilled water, in connection With
such a machine, is an obvious advantage to an hospital. The large
annual expenditure for ice for the city institutions has instigated this
suggestion. Steam disinfecting appliances should be provided with
the laundry equipment.
While the foregoing brief outline, in connection with the set of
sketch plans submitted, covers the immediate needs in our hospital
service, in the case of emergency and acute cases we deem it Of equal
importance that the suggestion of erecting wards adjacent to the Female
Hospital, or Poorhouse, be considered and provided for at the same
time. These further accommodations must be furnished in order to
provide for chronic cases and those who are convalescing. Such wards
would form a part of the general hospital buildings, which might, with
the annual income already ﬁxed for hospital work and such appropria-
tions as might be made, be completed within a few years.
Without submitting sketch plans for the extensions suggested,
your Committee recommends that the same general arrangement as
shown in plans for central’hospital be followed, with such modiﬁcations
in construction as the special needs of the various wards and adminis-
trative Offices and rooms make necessary. We further recommend that
the present Poorhouse building be assigned to the use Of the chronic
insane, and be made ﬁreproof so far as may be practicable, and other-
wise remodeled so as to make them suitable for the insane and to form
part of the general hospital buildings, and that other provisions be made
for the pauper charges of the city at the earliest possible date. Your
Committee has given some time to the study of the question of build-
ings and location of these charges, but recognizes that such considera-
3t » Medical Society of
tions were not within the scope of the work assigned to it, so refrains
from discussing the question.
The Committee recommends that, unless legal obstacles exist, the
Female Hospital become incorporated ultimately with the general hos-
pital, losing its identity in its present form, and that the building be
remOved as soon as other accommodations have been prepared. If
this is not feasible, we recommend that it be used only for the class of
patients in the interest of which it was originally intended to be used,
and that all other women and children be provided for in the general
hospital scheme. ~
We recommend that all the old small pox wards of the Quarantine
Hospital be destroyed by ﬁre, and that needed new ones be erected in
accordance with modern ideas, where it will be possible to give the
service that is rightfully expected by the inmates We also recommend
that a more humane method of transportation from the city of this
class of patients than that now in use be provided.
The consideration of the question of management of the hospitals
we deem it best to postpone until after questions of construction and
distribution of buildings have been decided upon. Your Committee
further suggests that immediate steps be taken to clear the site of the
proposed central acute and emergency case hospital of the remains of
the old city hospital structure.
The need of improved and enlarged hospital accommodotions is
so obviously urgent that your Committee feels that the funds available
for such use in the near future are totally inadequate. ’
As greater appropriations can not be made without injurious en-
croachment on revenues needed for other important interests, we
heartily endorse the recommendations of his Honor, Mayor Walbridge,
that steps be taken to secure the necessary authority to increase the
limit of the city’s indebtedness, that these important interests shall not
suffer through the present deﬁciencies in the city’s revenue.
Recognizing the need of legislative provision for the furtherance
of this hospital building scheme. your Committee has now under con-
sideration a form of ordinance which it will submit for your considera-
tion at an early day. Respectfully, .
[Signed] . HALSEY C. IVES, Chairman.
ALBERT MERRELL, M.D.
[True Copy.] MAX C. STARKLOFF, M.D.
Ofﬁcial report ﬁled with the President of the Board of Public Im~
provements.
[Signed] HALSEY C. IVES, Chairman.
City Hospital Alumni. 35
[20,162]
An ordinance to adopt general plans for City Hospital buildings
to be located on city block NO. 1252, and authorizing the construction
of a portion of the buildings, and providing for the preparation of de-
tail plans and supervision of the work of c instruction, and making ap-
propriation to pay the cost thereof.
Be it ordained by the Municipal Assembly of the City of St. Louis. as
follows :
The general plans for City Hospital buildings, to be located on
the property of the city of St. Louis, situated between Carroll Street
and Lafayette Avenue, St. Ange Avenue and Fourteenth Street and
Grattan Street, known as city block NO. 1252, which were prepared by
the City Hospital Commission created by Ordinance No. 18,374, are
hereby approved and adopted. Said plans are designated in the re-
port to said Hospital Commission of a subcommittee, dated January
29, I897, as Exhibits A, B, and C, of which blue-print copies are on'
ﬁle in the ofﬁce of the President of the Board of Public Improvements
and are endorsed: “Filed with President Board of Public Improve
ments Ofﬁcial Drawing Hospital Commission, three sheets Exhibit A,
B, and C, Halsey C. Ives, Chairman.” Provided, however, that said
general plans are hereby directed to be modiﬁed so as to increase the
capacity of the hospital when fully completed from 411 to 620 beds.
SECTION 2. The Hospital shall be designed and conducted upon
the pavilion plan._ The several buildings shall be constructed of granite,
stone, brick, iron and wood, so as to be ﬁreproof as nearly as possible.
The foundations shall be concrete and piles where found necessary.
The total cost of the hospital buildings and complete equipment of
' boilers, machinery and appliances required for heating, ventilation,
laundry, kitchen and other service appropriate to a hospital, together
with cost of plans and superintendence, shall not exceed $1,000,000.
SEC. 3. The Board of Public Improvements is hereby authorized
and directed to cause the following-named buildings to be erected and
‘ equipped: Isolating ward, two stories high; octagonal wards, three
stories high; connecting wards, one story high; laundry block, one
story high; kitchen block, three stories high, and boiler house, one
story high. Said buildings shall be built in accordance with plans and
speciﬁcations prepared by the Commissioner of Public Buildings, and
approved by the Board of Public Improvements, and the said Commis-
sioner of Public Buildings shall supervise and superintend the erection
of said Hospital buildings subject to the direction and control of the
Board Of Public Improvements.
36 Medical Society of
SEC- 4. The Commissioner of Public Buildings, with the approval
of the President of the Board of Public Improvements, may employ for
the preparation of necessary plans and drawings and for supervision of
work, one principal draftsman at a salary of $125 per month, one.
draftsman at a salary of $90 per month, and one superintendent at ﬁve
dollars per day of actual service. Tne wages of such employes shall
be paid out of the fund appropriated by this ordinance, and,shall be
charged as part of the cost of the buildings.
SEC. 4. The cost of the above described work shall be paid by
the city of St. Louis, and the sum of $258,000 is hereby appropriated
from fund “Erection of Hospital Buildings” to pay the cost thereof.-
Approved August 15, 1900.
[20,212.]
An ordinance to amend Ordinance N 0. 20,162, approved August
15, 1900, entitled, “An ordinance to adopt general plans for City Hos-
pital buildings, to be located on city block No. 1252, and authorizing
the construction of a portion of the buildings, and providing for the
preparation of detail plans and supervision of the work of construction,
and making appropriation to pay the cost thereof.”
Be it ordained by the Municipal Assembly of the City of St. Louis, as
follows : /
SECTION 1. Ordinance No. (20,162, approved August 15, 1900, '
entitled, “An ordinance to adopt general plans for City Hospital build-
ings to be located on city block No. 1,252, and authorizing the con-
struction of a portion of the buildings, and providing for the prepara-
tion of detail plans and supervision of the work of construction, and
making appropriation to pay the cost thereof,” is hereby amended by
striking out Section 3 of said Ordinance No 20,162, and inserting in
lieu thereof the following :
SECTION 3. The Board of Public Improvements is hereby author-
ized and directed to cause the following named buildings to be erected
and equipped, namely: Isolated ward, two stories high, with base-
ment; octagonal wards, three stories high, with basement; connecting
corridors, one story high; laundry and boiler block, one story high,
with basement, in which boilers and appurtenances shall be placed;
kitchen block, three stories high, with basement; surgical building,
one story high, with basement. Said building shall be located, as
shown, on the modiﬁed block plan of New City Hos-pital, approved by
the Board of Public Improvements on November 2 3, 1900. Said
buildings shall be built in accordance with plans and speciﬁcations
prepared-by the Commissioner of Public Improvements, and the said
City Hospital ’ Alumni. 37
1
Commissioner of Public Buildings shall supervise and superintend the
erection of said hospital buildings, subject to the direction and control
of the President of the Board of Public Improvements.
Approved January 15, 1901.
After the reading of these memoranda and ordinances bearing
upon the hospital situation, the President, in laying the matter before
the Society and its guests for discussion, mentioned that it was a mat-
ter of vital interest to the tax-paying public why this hospital scheme
should have been permitted to lie dormant for so many years; the
dates of the various memoranda extending back as far as 1896. NO
adequate reason had ever been advanced why St. Louis, in her poverty,
unable to build suitable hospitals for the care of her sick poor, should
not have accepted the propositions tendered by syndicates to erect
buildings, to be rented by the inunicipality,-with the option of purchase
at the expiration of a stated number of years ; there surely exists a ﬁeld
for wealthy philanthropists to build and present to the City of St. Louis .
wards conformable to modern knowledge and adequate to the demands
of an ever-enlarging number. of sick poor.
MR. LONCFELLOW, Commissioner of Public Buildings, said the
impression that the scheme as laid out by the Hospital Commission
‘ had been abandoned, was erroneous. The intention is to keep within
this scheme. It is realized that 4% acres of ground at the Old City
Hospital site is insufficient for hospital accommodations adequate to
the needs of a city the size of St. Louis, but it is the only site available
on which we can place two-story buildings to accommodate 400 pa-
tients, or three-story buildings to accommodate 600 patients, and thus
make a beginning of a hospital system. The hospital for convales-
I cents, recommended by the Commission, should be built as soon as
the ﬁnances of the city will permit, and a duplicate of the plan pro-
posed fOr the present site should also be erected in the northern section
of the city as soon as the money can be had.
The changes from the plans as submitted by the Hospital Com-
mission are: The removal Of the nurses’ building from the site, with
the expectation of buying ground, before the completion of the hospi-
tal, adjacent to the hospital, for the nurses’ building. The stable has
been removed from the site with the expectation that the 'city would
38 Medical Society of
provide for this building across the street. The boiler house and
laundry have been combined into one building. The clinical building
and dispensary have been put under one roof. -
In this manner the ground has been cleared up and more space is
available for the wards than was contained in the original plans. Aside
from these changes there is little difference in the two sets of plans.
The kitchen has been changed from Carroll Street to a place within the
grounds. The octagonal wards were originally shown joined end to
end; a study of the plans seemed to show it would be better to separ-
ate them and place them as shown in the new plan. These are the
principal departures from the original scheme of the Hospital Com-
mission. _ .
The prospect is, he said, that it will be a great many years before
we see the completion of these buildings, unless the 'city ﬁnds meansto
provide money, which do not now exist; or some of our wealthy and
generous citizens donate the money.
He thought this was a fair ﬁeld for the medical fraternity to induce
their wealthy friends to donate wards for the city hospital which the city
is not able now to build.
The city has now about $250,000 for the purpose; about $52,000
will be added to this sum next spring, and about the same each year,
but the money on hand now is not sufﬁcient to complete the buildings
already authorized. The buildings now authorized by ordinance are
the isolation ward, the octagonal wards, the surgical building, power
house, laundry, and kitchen. Temporary arrangements will be pro-
vided to overcome the difﬁculty of having no administration building.
DR. ALBERT MERRELL regretted the departure from the original
plans of the Hospital Commission. which contemplated erecting an
acute hospital on the old City Hospital grounds, to be followed by a
similar building in the northern portion of the city, and building a gen-
eral hospital further out. The general Outline is practically the same
as in the original plan, except that the octagonal ward is three stories,
and the isolation ward two stories instead of one. The internal
arrangement is alterated, but in some' respects for the better. The
basement addition is an improvement on the original plans, which were,
however, only sketch plans and not intended to arrange details. ' It is
City Hospital Alumni. 39
likely that the hospital needs will be unsolved for many years to come.
He was glad to see this much of the hospital begun, however, as the
present quarters are a disgrace to the city. The work accomplished
there he considered remarkable under the circumstance, but remarked
that ..“ patients will sometimes get well in spite of the doctor” and that
may explain favorable results with our hospital conditions.
DR. L. NEWMAN thanked the Society for the courtesy extended
him and the Society which he represented. St. Louis, he said, is noto-
rious in being slow to advance. It was years before the city ofﬁcials
got out of the old barn on Eleventh and Market Streets, and years be-
fore the building, now the new City Hall, was in shape to be occupied.
It is .now something like six years since the tornado, and the hospital
has been forced from one lot of sheds to a worse. It is to be hoped
that the action of the Society to-night and in the past will bear fruit by
getting not only the medical men but the progressive business men of
the city together and in that way possibly hasten the work which is
probably the most worthy work any community can erter into and cer
tainly the most worthy any community needs. The hospital facilities
are so poor that we dare not take Visiting medical friends there, and it
is to be hoped that at no distant date we shall see a consummation of
the plans now urged. _
MR. LONGFELLOW, at the request of the members, explained the
plans of the two octagonal wards.
Each ward is an octagonal room 62 feet in diameter containing 24
beds. It has light on all sides and a sun room on the southwest and
southeast. In the center is a ventilating shaft carrying air from the
wards. The buildings are connected by a corridor near the center of
the rectangle. There are two rooms next the wards for linen and the
patients’ clothes, toilet-rooms and nurses’s closets; there is on one side
a stairway and an elevator; on the other side is the serving room and
elevator for bringing up fuel, etc. The serving room is ﬁtted up with
steam tables, gas stoves, sink, refrigerator, and china cases. Next to
the serving room is the dining room. Beyond this is a dressing room
for dress-ing wounds and for minor operations. On the other side are
two isolation wards—small rooms with two beds in each—for the sep-
aration of patients from the general wards. The octagonal wards are
\-
40 Medical Society of
three-story buildings; the connecting corridor is one story high; the
roof of the corridor connects with the second story and forms a prom-
enade; the third story does not connect with this corridor, but in its
place there are balconies where patients can get the sun in pleasant
weather. The ventilation of this and all the other wards is to be with
air warmed by steam by the indirect method. Air is admitted under
the window and taken out from the center of the room. The air is
warmed on steam coils in the basement and conveyed to the rooms
and drawn out of the rooms in the center by means of fans driven by
electric motors. The distance between the beds in the ward is 3 feet.
'DR. W. E. FISCHEL objected to the ﬂue in the center of the room,
saying it would obstruct the view of the nurses and they would riot be
able to see all the patients. _
MR. LONGFELLOW acknowledged this, but said it was the nearest
approach to perfect ventilation.
DR. FISCHEL asked Mr. Longfellow if he considered the arrange-
ment in the Childrens’ Hospital of Boston a good one. I
MR. LONGFELLOW said he did not know what that was.
DR. FISCHEL said the system there was a very excellent one. He
had not given a great deal of time to the study of ventilation, but he
knew the wards in the Childrens’ Hospital of Boston were as sweet as
could be. There are from 20 to 40 children in a ward there and noth-
ing could be more delightful than to visit the institution. In the wards
there is an unobstructed view of all the patients. This ought to be
considered. It is true of all the wards of all the hospitals that he had
visited; it is so abroad, and in the Presbyterian Hospital in New York
the system is especially good.
MR. LONGFELLOW said the ventilation in the Presbyterian Hospital
is good. It is a forced ventilation, the air being forced into the rooms
and drawn out by fans. '
Continuing the explanation of the plans, Mr. Longfellow said the
isolation building, which occupies the space on plan indicated by letter
A, has a small ward in the south end in the form of a half octagon.
There is apace for nine beds. On one side is the linen room, on the
other side is the serving room. There are toilet and bath rooms, and
a room for two nurses. There is a corridor separating this portion
City Hospital Alumni. 41
from the remainder of the building. The remainder of the building
contains ten rooms for patients, with two beds in each ; two rooms for
nurses each with two beds, toilet rooms, linen room, a serving room,
and an operating room. These patients’ rooms are each provided with
a water closets and ﬁre-place. This building is detached from the
others. The method of ventilation is similar to that of the octagonal
ward. The air is admitted below the window and drawn out from the
center of the room. In two of the rooms it is intended to provide a ‘
place for portable tubs supplied with hot and cold water, so that a pa-
tient may be kept in water as long as desired. The building is two
stories high. In the basement is arranged a waiting room for visitors
with facilities for changing the clothing if desired. The small ward has
the same ventilating arrangement as already described—the center
ﬂue. He believed this the best way to secure perfect ventilation,
though he was sensible of the objection raised to it. .
MR. ITTNER said he was interested, as all citizens should be, in
the City Hospital situation. The fact that we can not build a million-
dollar hospital outright should not discourage us if we can make a good
beginning. We know that all large undertakings on the continent are
not the work of a year or two years, but sometimes the work of a quar-
ter of a century; but the work is all laid out in the beginning and care-
fully planned, and though it may be added to year by year, it is ﬁnally
completed in the spirit of the original plans. We are told that the
original Hospital Commission laid out an elaborate scheme and he
was happy to hear Mr. Longfellow say there had been no radical de-
parture from that scheme. He was glad also to hear Dr. Merrell, who
had examined these plans, say they did not differ materially from the
original scheme.
DR. MERRELL said the difference in the scheme was radical, though
the plans were not materially altered, except that _the capacity was in-
creased ﬁfty per cent. on the same space of ground.
MR. ITTNER said we should not feel altogether disappointed. We
are about to make a beginning in the erection of a city hospital, and
he believed some of us would live to see the scheme as originally laid
down fully accomplished. He had talked with Mr. Longfellow on the
subject of heating and ventilating. He thought it would be better to
42 Medical Society of
5
have the ducts conveying the hot air to the rooms placed in the inner
walls. His experience in building schools had proved that ducts in
outer walls become chilled and retard the flow of air, except in cases
where the air is forced into the rooms by mechanical means. He be-
lieved in the mechanical system of heating and ventilating—the air is
heated in the basement‘and driven to the rooms by means of fans.
MR. MONTROSE P. McARoLE said he was not an expert on heating
and ventilating, though he had studied the system in use in our public
schools and he thought this a most satisfactory method. He thought
the ventilating shaft in the center of the room ought to be omitted, as
it was unsightlv and obstructed a full view of the room. One objection
to taking air from the outside and passing over coils to be heated, was
that the air is full of dust and soot and especially so here six months
of the year. This air should be ﬁltered by being passed over a ﬁlter
surface composed of wool with glycerine and water which takes up the
soot and dirt and delivers the air comparatively pure and clean. He
called attention to the fact that Mr. Longfellow was not a free agent
in this matter and that the conditions under which he labors make it
difﬁcult for him to do anything at all, his position as Commissioner of
Public Buildings taking up practically all of his time and making it im-
possible for him to study the matter as it should be. What he has
done he has done at times snatched from his own leisure. He deserved
great praise and credit for what he had accomplished,and the speaker
hoped that he might not be supplanted in his position with the chang-
ing of the administration, believing the matter could not be in better
hands.
MR. H. WILLIAM KIRCHNER thought it was not so much a ques-
tion of ventilation as one of doing. If the city intends to spend a
million dollars on a hospital he thought it should be built in such a way
as to leave no room for criticism. The entire result, however, he said
depended upon the physicians of the city and not upon the architects.
When a patient is placed in charge of a physician that physician is re-
sponsible for the patient, and if a hospital is to be built he thought the
physicians ought to be responsible for the building of it. He thought
it would be a serious mistake to erect a number of buildings on so
small a lot, or spend a million dollars on a hospital that would be a
City Hospital Alumni. 43
failure. One of the most difﬁcult things to accomplish, even with the
greatest care a physician can take, is asepsis, and to crowd a surgical
ward and a dead house to within 25 feet of one another he considered
criminal. If the physicians would get together and prescribe the medi-
cine the members of the City Council ought to take in this matter he
thought they would take that medicine. The plans as now projected
ought not to be carried out, and the physicians ought to get together
and plan a hospital as it ought to be built and he believed they would
get it.
DR. R. M. FUNKHOUSER said a mistake was being made in this
question, but he could not see the remedy. There is not a city in the
United States where the facilities are so poor, where accommodations
are criminal, where life is at such an imminent risk as in the present
instance. Many will recall that in the early part of last year a number
of physicians waited on the City Council and it looked at that time as
if we would get no money for a city hospital and that the money
already put aside for this purpose would be turned into another chan-
nel. He ﬁrmly believed the protest of the physicians at that time pre-
vented the Council from using this money for other purposes. The
Assistant Counsellor had said there was no other way to obtain money
to defray expenses except the use of this fund, set apart for a hospital,
but it was not so used, and he believed if the physicians would take a
stand and unite and work together they would accomplish something.
He called attention to the recent meeting called in regard to the new
amendments to which the representative. citizens from the different
walks of life were invited and said not a single physician, to his knowl-
edge, had been invited to give his opinion on the needs and necessi-
ties of the city. He considered this a shame.
A number of physicians, himself among the number, went to the
Mayor and asked permission to look over the plans and speciﬁcations.
They met several times and looked over the plans and a number of
improvements suggested. As a body and as individuals the physicians
protested against the completion of the plans as now intended, in the
manner intended, and on the ground intended. What kind of a show-
ing will St. Louis make when the World’s Fair opens with the claptrap
and inadequate new hospital built on the old grounds for 600 patients?
44 Medical Society 01
Would it be sufﬁcient if we have a World’s Fair? It is claimed that
one of the main objects in having a World’s Fair is to erect structures
that will be permanent. If we could get the men of wealth and inﬂu-
ence in the World’s Fair project interested to the extent that they
would agree to direct or use their inﬂuence to have some of these
buildings put up in an accessible place, permanently and subsequently
used as hospital buildings, it might be a partial solution of this question.
DR. .W. E. FISCHEL thought it would be a mistake to erect a hos-
pital to meet the needs of the city for ﬁve or ten years only. His ideas
in this respect were in accord with Mr. Kirchner’s. He believed a
permanent structure large enough to accommodate the city’s wards a
quarter of a century hence should be erected. He had been privileged
to become familiar with the plans as conceived by the original Hospital
Commission and he thought he knew all that Was in the minds of those
gentlemen. A tremendous amount of time was consumed in the
preparation of these plans and most stress was laid upon the construc-
tion upon the old City Hospital site a hospital for emergency cases
only, and that the general hospital _should be built further out in the
western part of the city near the other eleemosynary institutions where
there were to be a complex of buildings to answer all needs. He had
visited some of the best hospitals in the East and he knew they had
built not for present needs only, but had planned to have their institu-
tions answer the needs of the cities for a long period in the future. The
city, of course, is handicapped with a lack of money, but like Mr.
Kirchner, he wanted to see a beginning ~ Let us do just as much as
can be done, but in this beginning let us plan for the future. It has
taken centuries to build the cathedrals of the world. He believed we
could have a hospital started now, keeping always the needs of the
future in view, and he hoped to see it begun, but he hoped it would
not be with the idea that $250,000 or $500,000 would erect a structure
such as is needed. The details of the building should be left to men
trained in work of that kind.
PROFEssoR WILLIAM TRELEASE said that though neither an archi-
tect nor a physician, he had imbibed enough knowledge of both archi-
tecture and medicine from the discussion to believe that he saw the
difference between an emergency hospital and a temporary hospital,
City Hospital Alumni. 45
and that while the original plans of the Hospital Commission had pro-
vided for an emergency hospital in the heart of the city and a suitable
hospital removed from the dirt and noise, the proposition for the con-
struction of a city hospital now under discussion seemed to refer to a
temporary hospital in the city, rather than either of these ' He thought
it might we well to dismiss for the present the hope of securing the
' general hospital desired, and recognizing that what is now about to be
constructed is a temporary hospital, to make it as complete as possible
for general use, but in such a way as not tointerfere with its ultimate
utilization as an emergency hospital when the general hospital should
later be provided on a larger area and in a better place. If a million
dollars Or more are to be expended in installments, he agreed with
others who had spokon, that it would be well to use this money as it
became available—in the proper construction of parts of the hospital—
so that after theexpenditure of the entire sum a hospital worthy of the
city and adapted to the purposes for which it is intended would have
been secured. He did not favor the putting of so many buildings on
so small a space of ground for anything but the needs of emergency
construction, and especially he did not believe in having the dead-
house within 25 feet of the other buildings and particularly close to the
surgical wards. Ventilation of a hospital such as is about to be built
would be a most difﬁcult matter, as the air would be laden with in-
organic as well as organic living and dead particles, and these would
be a menace to life. While with proper planning and detail construc-
tion the grounds that it is proposed to use would be suitable for an
emergency hospital, he thought the fact should never be lost sight of
that the general hospital needed for the city ought to be constructed
without unnecessary delay further out, where pure air and clean hospi-
tal conditions were possible. While looking toward the welfare of the
poor fellow who has to go to the hospital, and giving him pure air to
breathe, good nursing and medical attention, he thought we should go
a little farther and think of the effect that beautiful surroundings have
upon everybody, so that this strong adjunct to the service of the physi-
cian and the nurse might be available in .building up the shattered
health of the patient. He said, in conclusion, that he was not criti-
cizing the work of the gentlemen who had made the present plans, nor
46 . Medical Society of
had he the slightest disposition to criticize them, as he understood that
the plans were very g00d, but he did criticize and seriously protest
against the building together of the buildings as now contemplated,
unless this arrangement were distinctly understood to be the provision
of a rather more ample emergency hospital than the original Commis-
sion had contemplated, with the equally distinct understanding that the
physicians of the city would not rest until the necessary general hospi-
tal further out should have been secured. .
MR. L. C. BULKLEY thought it would be necessary to change the
- ordinance under which the Building Commissioner was working, if the
change suggested were to be carried out. The amended ordinance
should provide for the construction of certain hospital buildings and
appropriate money for that purpose, leaving the arrangement to the
Building Commissioner and such experts as he would employ. He
thought Mr. Longfellow was to be complimented on the showing he
had made, as the ordinance had burdened him with cOnditions which
made it a wonder that anything had been accomplished. He agreed
with the other gentlemen who had spoken, that it would be a mistake
to build the general hospital down town; it should be out where there
is plenty of space and can be added to as funds were available. In
regard to hospital construction, he said we should use as little material
of a porous nature as possible. Clay products, glazed glass, and such
material should be used; avoiding marbles, plaster, and such porous
material, for the reason that they take up matter injurious to the health.
DR. GEORGE HOMAN shared the general regret that the scheme as
proposed by the Hospital Commission should be departed from. He
favored the two-story ward building, though the addition of a story to
each of the surgical wards was perhaps not a very grave departure
from right principles, and the addition of a single story to the isolation
building need not be deplored. The objection to the shaft in the 'cen-
ter of the wards in the octagonal buildings he thought a vital one; this
should be avoided, if possible, and he believed it could be dispensed
with and all the beneﬁts of the ventilating shaft retained. He did not
see the advantage of an octagonal ward except as a show feature. The
Johns Hopkins Hospital had derived much advertisement from this
feature, as everyone who visited the hospital was ready to speak of the
City Hospital Alumni. 4:7
octagonal wards. If that is of surpassng importance it goes without
saying that it should be retained. However, be doubted the utility of
that form of ward; necessarily, the heads of the beds would diverge
and thelower extremities brought together, and with an unavoidable
tendency to overcrowding the lower ends of the beds would have to be
swung from side to side to allow access to the patients’ heads. This
could only be remedied by arranging the beds with heads towards the
center, and having a corridor along the outer wall. The square form
of ward would subserve all purposes, with the center free, and the nurse
would thus have an unobstructed view of the entire interior. There
would be difﬁculty in securing an equable temperature and proper
ventilation of a rotunda ward without drafts. This was commented
_ upon very recently by some of those in charge of Johns Hopkins Hos-
pital. Cross currents and drafts occur in spite of arrangements made
for opposite purposes. In regard to taking air from the outside near
the ground level, the objection urged that this would be laden with
impurities is very weighty. He thought it would be better to hive the
intake at the top of the buildings rather than in the basement, espe-
cially where the buildings are grouped so near together and in an insti-
tution of this character. Straining the air is, of course, desirable.
The attitude of the profession in this hospital business should be
one of grim determination; we should give the city authorities no rest,
but insist upon having the means not only to carry to completion these
projected buildir. gs but the supplemental or general hospital adjacent
to the other institutions in the suburbs, and the isolation hospital for
infectious and communicable diseases.
As a matter of detail he had suggested to Mr. Longfellow the
general substitution of rain baths for the stationary bath-tubs. The
advantage of this would be economy of space, means. and time, and it
would avoid the possible communication of cutaneous and exanthema-
tous disease by carelessness in cleansing the tubs.
If _the proposed scheme of erecting a state hospital should be car-
ried through and a location secured near the city, he thought it might
be. well to go on with the construction of the emergency buildings, as
now contemplated, and that the city should send its convalescent pa~
tients to the state hospital and pay for their care if the general hospital
48 ' Medical Society of
recommended as a necessary complement to the emergency hospital
can not be provided for at this time or in the near future.
DR. AMAND RAVOLD said a number of vital points had been
brought out in the discussion. When looking over the plans a second
time he saw the infection ward was placed right against the surgical
ward and on the other side was the dead-house. This ought not to be.
The original plan called for a two-story building to accommodate 420
patients, with a convalescent hospital in the suburbs. Somebody is
guilty of inereasing the number of beds from 420 to 620. A hospital
is a place for a sick person to get well, and this is not going to obtain
when a lot is overcrowded with buildings and the buildings over-
crowded with patients. That, he said, is what these plans contem-
plated. Somebody in the Board of Public Improvements was guilty of
this condition by altering the plans. If these plans are carried out and
a hospital for 620 patients is erected, three stories high, we will have,
when completed, a hospital resembling the Edinburg Hospital, which,
as he had said before, is the worst institution of its kind in the world ;
we are imiiating that structure—that is, we are going to build a hospi~
tal exactly like the worst one in the world. We expect to spend a large
. sum of money and why not get the best the world affords and even ﬁnd
improvements on whst has been done. He thought the physicians
should organize and try to have that ordinance repealed. This infec-
tion ward ought to be done away with. We all come in contact with
infectious diseases and what is done? The case is reported and imme-
diately the house is placarded The patient has no escape; if he lives
in a hotel, or if the business is carried on in the same building—like a
grocery—the business is almost irreparably injured, and the city re-
quires the placard With a hospital for infectious diseases these peo-
ple could be sent there and no harm done their business. This ward
proposed provides for 56 patients. There is fully that number of in-
fectious diseases in the city every day, so that this is nothing but a
makeshift. It will take from twelve to ﬁfteen years to build a hospital
with the present rate of increase in funds and all that time the city will
occupy the abandoned convent spending $t2,000 annually, whereas, if
could take $200,000 we could put up a very ﬁne one-story building for
the chronic and convalescents out in the neighborhood of the Poor
City Hospital Alumni. 49
House. The City Charter is now too small for this city and it should
be amended so that we could raise money on bonds or some feasible
‘ way. As it is now we are powerless to raise any funds for this purpose.
MR. LONGFELLOW said he was much impressed with what had
been said by the gentlemen present. The statement,made that We
were about to build a hospital which would be one of the worst in the
world was not encouraging. If this is so he thought now is the time
for the President of the Board of Public Improvements and the Build-
ing Commissioner to be furnished with information as to what would
be the most suitable building for that site. T he work of clearing the
site and excavating for some of the buildings is now in progress and if
the plan adopted is not a good plan the work should be stopped im-
mediately and the ofﬁcers furnished with information for the erection
of a suitable building. However, he thought there was a misappre-
hension on the part of some of the gentleman as to the change in the
character of the institution from that contemplated by the Hospital
Commission. His understanding of the situation is and has been since
the work began, that this hospital will eventually become the emer-
gency hospital, but that until a general hospital can be built this will
have to serve as the City Hospital; when it becomes possible to erect
the general hospital further out, this Will be used only as an emergency
hospital. The question of the height of the buildings—if the merit of
the plans depend on that—is still open to revision where not ﬁxed by
ordinance. The isolation building is ﬁxed by ordinance at two stories,
the octagonal wards three sthories, kitchen building three stories,
laundry and boiler house one story, and surgical operating building
one story. It there is any mistake in the height of these buildings the
President of the Board of Public Improvements should be so informed
at once. As to future construction of buildings, it will be far in the
future at the the present rate of providing the funds, and it will be
probably several years before the rectangular wards are built. He said
he came to the meeting for information and he would be glad if any-
one who had deﬁnite ideas as to what the city ought to have would
formulate his ideas and present them to the President of the Board of
I Public Improvementsiand to him. He was anxious that the city should
have a creditable hospital and one that is as good as can be had. He
50 Medical Society of
had but one thought in the matter and that was to provide an institu-
tion as perfect as could be made withxthe money furnished.
DR. HOMAN said there was one point not brought out in the dis-
cussion and that was the fact that the octagonal Ward is planned for
four stories, with a certain class of patients to be placed on the fourth
ﬂoonrl
MR. LONGFELLOW said this was true. The rectangular portion of
the octagonal building has a fourth story added in which are ten cells
for the detention of patients. There is also a room for the attendant,
a linen room, and toilet room. This is reached by stairs and elevator.
MR. E. G. RUSSELL said that in view of the fact that one of thew~
principal changes from the original scheme as'laid out by the Hospital
Commission is the increase in the story heights and the crowding to-
gether of the buildings, and considering that the plan is practically
completed and part of the work contracted for, something might be
done by rearranging the grouping of the buildings in such a way as to
overcome many of the objections raised. He thought the dead house
could be removed and this would decrease the total number of build-
ings on the site. The present buildings might be placed further apart
at no great expense and he believed the Board of Public Improvements
and the Building Commissioner would be very glad to enter into any-
thing of that sort, while if the scheme is condemned in toto it might
result in all objections being ignored. He suggested that a committee
be appointed which should take the plans and rearrange the buildings
in a suitable way and thought much might be accomplished by this
means. ' '
MR. McARDLE said the physicians could depend upon the archi-
tects for any assistance they could give in this matter.
DR. NEWMAN, President of the St. Louis Medical Society, said the
society he represented voiced the same sentiments and would co oper
ate with the Medical Society of City Hospital Alumni to the fullest
extent.
City Hospital Alumni. 51
Meeting of Feéruary 7, 1901; Dr. Narz/elle Wallace Sharpe,
'Presi'dent, in the Chair.
Cerebral Tumor.
DR. GIVEN CAMPBELL presented a case which he diagnosed as
cerebral tumor. The patient had had a mole on the side of her nose
all her life. Two and a half years ago this mole became inﬂamed and
ulcerated, and was operated upon but recurred. A few months later
another operation was performed. The soft parts on the side of the
I nose were thoroughly removed and skin was grafted from the shoulder,
since this time there has been no local return. From the physician
doing the operation Dr. Campbell ascertained that the microscope
showed the growth to be an epithelioma. A few weeks ago She came
to the clinic for treatment, stating that she had noticed since last Feb-
ruary that two ﬁngers other right hand were gradually becoming weak;
the weakness was present in both ﬂexion and extension, though slightly
more pronounced in extension, and has gradually progressed ever
since. Anesthesia involved the whole of the ring and little ﬁnger as
would be the case if the 8th cervical root were involved, but not ex-
tending along the middle of ring ﬁnger or the other ﬁngers and further
-on up the arm as would be the case with the ulnar nerve involved.
The entire hand is somewhat weak. Grasp of right hand is 40 pounds
. of the left 60 pounds. The arm also, even the shoulder muscles are
somewhat involved. The right pupil is a triﬂe more dilated than the
lett. The condition looked to him like aperipheral nerve lesion except
that the reﬂexes in the arm are distinctly increased. This, he said,
pointed very strongly to an involvement of the upper motor neuron.
The distribution of the anesthesia and the muscular paralysis probably
indicated the seat of the lesion in the cortex and the question arose
whether it was a cerebral neoplasm or not. There had been at no
time vomiting, headache, virtigo or visual disturbances. The fundus
of each is normal. 7
DISCUSSION.
DR. M. A. BLISS said the case was very interesting and presented
some peculiar features. .The distribution of the paralysis indicated a
52 Medical ' Society of
.peripheral neuritis but all other symptoms of this were absent. The
ﬁngers have a slightly glossy 'appearance but not sufﬁcient to call
characteristic, and the reﬂexes throughout the arm are increased, con-
trary to what is found in a neuritis. He did not think it probable that
the lesion was located in the cord. If the seat of the trouble is in the
cortex we should expect to have more irritative symptoms in the be-
ginning or during the progress of the disease than have been. mani-
fested. He thought the lesion was cerebral and sub~cortical.
‘ DR. M. W.'HOGE had seen the patient on a previous occasion
with Dr. Campbell at which time he had made a more thorough exam-i
ination than this evening. Taking all the symptoms into considera- ,
tion he thought we were almost obliged to pronounce the condition I];
due to a lesion in or near the cortex, as Dr. Bliss had said, because the
symptoms are not compatible with a lesion situated lower d0wn in the
motor tract. The reﬂexes are increased not only in the arm but also
in the leg on the same side which would not be the case if due to a
peripheral lesion or to one situated in the cord in the region of the 8th
cervical nerve ; nor could the lesion be in the neighborhood of the in-
ternal capsule and be so limited and at the same time involve both the
motor and sensory tracts. The sensory area of the cortex is not so
well mapped out as the motor area but they seem to be situated in
about the same region, the sensory area being somewhat more extens-
ive than the motor.
He did not think the irritation symptoms mentioned need neces-
sarily be present in a Slowly-growing tumor. We might have a neo-
plasm of considerable size not only Without any irritation symptoms,
but with few symptoms of any sort until the motor area was actually
encroached upon. I
DR. CAMPBELL, in closing, said he was glad the patient had been
presented as he felt that he had been enlightened in regard to it. The
absence of irritating symptoms had caused him to doubt the involve-
ment of the cortex, yet he could not understand how the motor and
sensory symptoms could be present unless the cortex was involved, or
at least approached. He was glad to know the suggestions of Drs.
Hoge and Blis corresponded with his view. He was inclined to think
the neoplasm was of the same nature as that for which the operation
City Hospital Alumni. 53
had been performed on the nose and had by metastasis involved the
brain. ' '

Our Daily Bread.
Bv- GEORGE HOMAN, M.D.,
ST. LOUIS, MO.
follows: An article of food made of the ﬂour or meal
of grain, mixed with water or milk and salt, to which
yeast, baking powder, or the like is commonly added to pro-
duce fermentation and rising, lightness, or sponginess, the
mixture being kneaded and baked in loaves or as biscuits,
rolls, etc.1
It is stated that the most primitive way of bread making
was to soak the grain in water, press it and then subject it to
heat. This was improved upon by pounding or braying the
grain in a mortar or between two. stones before wetting and
heating, and some etymologists would derive the word bread
from this braying operation.
The development and reﬁnement of this process may be
said to constitute one of the chief marks of advancing civili-
xation, and in no particular has the cooking of food received
more attention than in the preparation of bread. The need of
this form of aliment is so pronounced in peoples who have
emerged from the savage state that the name has stood since
the earliest records as a synonym for food in general, the ad-
herents of the Christian religion, for example, being enjoined
to pray that they may be given day by day their daily bread;
and as such it typiﬁes the fundimentals of animal life meeting
some of the primary physiological demands of the body al-
though not in itself a complete food.
In all the more advanced nations the ﬂour of wheat is
used in the making of bread, and the proper milling of the
grain is necessary for the two-fold purpose of reducing it to a
powder and of excluding the coarser and indigestible parts.
While the richness in quality of the grain in the world’s
wheat-growing regions increases toward the equator still after
A COMPREHENSIVE deﬁnition of bread is worded as
54 Medical Society or
the evaporation of the contained water the mean composition
of an average quality of wheat may be stated in percentages
as follows:
Gluten and albumen . . . . . . . . . . . . . . . . . . . . . . . . .. 13.5
Starch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54.5
Gum, sugar, oil and ﬁber . . . . . . . . . . . . . . . . . . . . . . 30.
Saline matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.
Taking the weight of one hundred kernels of wheat as
3.87 grams the Chief of the Division of Chemistry, Depart-
ment of Agriculture, has recently stated the constituents of
that quantity of grain in the following form :
PER CENT. ,
Moisture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 10.62
Proteids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12.23
Ether extract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.77
Crude ﬁber . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.36
Ash . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.82
Starch and sugars . . . . . . . . . . . , . . . . . . . . . . . . . . . 71.20
As mentioned in the deﬁnition of bread given above the
three absolute requisites for the making of good bread are (I)
ﬂour or meal, (2) yeast or leaven. and (3) water containing
salt—the ﬁrst furnishes the important food constituents, pro-
teids, starches and ash; the second by gaseous evolution dis-
tending or raising the dough and thus enabling the applied
heat to act more efﬁciently; while the water and salt are nec-
essary to form the dough mass and impart savor to the ﬁnished
product.
The mere assembling and mixing of these materials even
though of the best quality does not assure a wholesome arti-
cle of bread for besides the requisite skill for preparing the
dough its proper baking is an equally important factor, and is,
perhaps, the least well understood of the two.
The means or agents employed to leaven the dough are
of prime importance and their relation to the desired end
should be clearly comprehended.
Yeast or leaven is a ferment known from earliest times
and is added to give a start to the fermentative process through
the action of its enzymes on the gluten, starch and sugar of
City Hospital Alumni. 55
the ﬂour thereby supplying carbon dioxide which imparts a
spongy texture to the bread.
Yeast consists of microscopic vegetable organisms, which,
when placed in _a suitable medium, grow rapidly, producing
alcohol and carbonic acid gas. The evolved gas, in attempting
to rise, becomes entangled in the meshes of the dough, dis-
tending it and making it light. After the dough has risen
sufﬁciently, it is placed in a hot oven to bake. The heat de-
stroys the yeast plant, and thus prevents further fermentation.
If the growth of the yeast be allowed to continue for too long
a time, acetic, lactic, and butyric acids are formed, and such
dough makes “sour bread.” 2
The minimum temperature of an oven for bread baking is
placed at 320°F., and the maximum may reach 570°F. The
action of the heat dissipates much of the water from the dough,
v distends the air spaces more fully, steams or boils the starch
and gluten in the dOugh, develops some gum from the starch,
and when yeast has been used, as before mentioned, destroys
the yeast plant. _
However high the temperature of the oven may rise that
of the interior of the loaf can not be much if any above 212°F.,
so that essentially the cooking of all but the crust of the loaf
is the effect of the action of moist rather than dry heat, and
the baking process must be continued for such length of time
as may be required to accomplish the transformation of the
raw starch, etc., into a form fully acceptable to the human di-
gestive functions, and this implies a period depending, of
course, upon the size of the loaf and the temperature of the
oven,—-the formation of dextrine being a very important part
of the process.
The following is a correct description of the general qual-
ities of good bread“: Good bread has a thick, fragile crust,
which is not burnt, and which forms from twenty to thirty per
cent of the weight of the loaf. The crumb is white and ﬁlled
with cavities, the partitions between which are easily broken
down. These cavities should be distributed through every
part of the crumb ; otherwise the bread is sodden and heavy,
and decomposes quickly. The bread should be of a pleasant
odor and taste.3
56 Medical Society of
Besides the use of yeast for raising bread other substances
are'employed which by chemical action set free carbon diox-
ide and thus distend the mass; and their convenience of use
and rapidity of action have contributed largely to replace
yeast for this purpose in domestic use at .the present time in
the preparation of the more quickly extemporized forms of
bread. ‘
The employment of saleratus with buttermilk, or other
acidulous milk, ‘was the forerunner of the baking powder whiCh
now plays such an important part in the commercial world, as
well as in the economy of the domestic menage. They were
ﬁrst used in this country, perhaps, forty years ago, and the
practical development of the idea involved in their I prepara‘é
tion' was due to American enterprise. While there are several
different substances and combinations used by baking powder
manufacturers the object sought is identical, that is by the re—
action of bicarbonate of soda and an acid salt mixture in the
ﬂour to generate carbonic acid gas by the addition of water
and thus quickly inﬂate the mass, this process being aided by
the heat of the oven. 44 '
Domestic experience had gradually developed the butter-
milk-saleratus combination for raising biscuits, rolls, etc., but
the difﬁculty always confronting the cook was to correctly
proportion the two ingredients as the weak lactic acid of the
milk did not always neutralize the amount of alkali presented,
and the result was a product with an interior of a saffron hue
mottled with dark spots and of a more or less soapy, alkaline
or bitter taste.
Curiously enough the conﬁrmed digestive derangements
often attending the eating of such forms of bread were attrib-
uted to the fact that they were consumed while hot, and even
to this day some physicians may be found who inveigh against
the use of hot rolls or bread, as if the mere temperature was
the cause of offending rather than the faulty making or im-
perfect baking—these inducing in the partaker, fermentation,
ﬂatulence, gastric distress and other unpleasant symptoms. A
compacted bolus of such bread when swallowed presents to
the digestive power of the stomach a serious task as it can be
acted on but slowly and disintegrated with difﬁculty thus giv-
City Hospital Al umni. 57
ing rise to pyrosis', eructations, and other manifestations of la-
borious and imperfect digestion, and if the baking alone be at
fault this holds true of bread made with any kind of leavening
whatever.
It was with the object of furnishing an agent that could
be kept on hand ready for immediate domestic use that the
baking powder industry came into existence, and that a popu-
lar want has been met would appear to be proved by the mag-
nitude of this branch of trade at the present time. Therefore
it becomes necessary to consider the inﬂuence of these pro-
ducts in the preparation of an article of food so important as
‘ bread, and to inquire into their possible or actual ill effects on
i the health of those who use bread into the making of which
this form of leavening enters.
As already indicated the only object sought in using leav-
ening agents is the inﬂation of the dough-mass; and this end
is attained with (I) yeast as the result of a vital process; (2)
with certain substances as a result of their mutual chemical
action; and (3) it may be reached by mixing the ﬂour with
water charged with carbonic acid gas, or by inﬂation of the
dough by some simple mechanical agent, as a pair of bellows
for example,—the means to be adopted in the average kitchen
depending on facility of use, relative inexpensiveness, efﬁciency
of action and satisfactoriness of result in appearance, palata-
bility, wholesomeness, etc. In the ordinary domestic menage
baking powders appear to offer these advantages in a superior
degree, and therefore the substances which enter into their
composition and the method of their manufacture claim public
as well as professional attention in view of the vast develop-
ment of the busines within the last twenty years.
There are three principal combinations of chemical sub-
' stances used in the manufacture of baking powders, these be-
ing known to the trade as straight alum powders, phosphate
alum powders, and cream of tartar powders, and the average
composition of these several products may be stated with ap-
proximate accuracy, omitting fractions, as follows:
58 Medical Society of
STRAIGHT ALUM POWDERS.
PER CENT.
Soda-alum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Soda bicarbonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Corn starch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
PHOSPHATE ALUM POWDERS.
Calcium phosphate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Soda-alum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Soda bicarbonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Magnesia carbonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Corn starch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
CREAM OF TARTAR PownERs.
Cream of tartar . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . .. 55
Soda bicarbonate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Corn starch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
It may be explained here that in all of these formulas the
starch is added simply for the purpose of separating the active
ingredients thus insuring the good keeping quality of the pow-
ders and favoring their more equable reaction when used. In
trade language it is termed a “ﬁller.”
In the last two formulas a small percentage of albumen is
added to increase the glutinous quality of the dough, and thus
favor the action of the liberated gas.
It being borne in mind that the sole purpose of these sev-
eral combinations is the lightening of dough by means of the
freshly evolved carbon deoxide, and as it is not charged that
this gas is injurious to health when employed in the prepara-
tion of food, it remains to be seen whether there are any by-
products or secondary combinations against which such a
charge may fairly be lodged.
In the ﬁrst two formulas alum holds a leading place, the
variety stated to be preferred and used for this purpose being
soda-alum, as distinguished from the other kinds known as
ammonia-alum and potassa alum. The alum used in these two
combinations is alumen exsiccatum or alum from which the
water of crystallization has been driven by heat, thus losing
nearly half of its weight and appearing as an opaque white
powder somewhat resistant to the action of cold water.
City HOspital Alumni. '59
The obvious aim of the manufacturer in order to secure a
satisfactory product must be to so proportion the amount of
alum and bicarbonate of soda that they will both disappear as
the result of the reaction which takes place when used in
bread-making, for upon success in this respect must depend to
a very considerable extent his ability to please his customers,
in short to do a successful business.
The combining proportions of soda-alum and pure soda
bicarbonate are as 48 to 50, and no residue will be left, but as
found commercially these substances usually contain some
impurities and this fact must always be taken into consid-
eration.
Soda-alum being a double sulphate of sodium and alumi-
num the evident secondary combinations possible in the case
of the ﬁrst and second formulas, failinga correct proportioning
of the constituents, would be sulphate of soda (Glauber salts)
and aluminumhydroxide, the. acid element for the production
of carbon dioxide being furnished by the aluminum sulphate.
But in the case of the third formula the reaction of the acid and
alkali constituents would secondarily produce sodium potassi-
um tartrate (Rochelle salts), and in both instances if these
combinations were present in any quantity in the bread the
well-known bitter taste of these two familiar salts would give
sufﬁcient warning to the consumer, and as a matter of fact
such ﬂavoring was not uncommonly met with in biscuits and
rolls made with the saleratus-buttermilk combination; indeed,
it is sometimes encountered now in forms of bread made with
any kind of baking powder. While such a taste is, of course,
foreign to good bread and must be pronounced most objec-
tionable, still the substances responsible for it could hardly be
considered harmful as at most they would be unlikely to have
more than a slight aperient effect on those consuming such
bread. ' '
The combination known as aluminum hydroxide or hy-
drate or ter-hydrate, possible when alum baking powders are
used, is described as a light, amorphous powder, devoid of
odor or taste, insoluble in water or in alcohol, but soluble in
solutions of the acids and the alkalies. It is a mild astringent
and dessicant, and, when freshly precipitated, clariﬁes the
60 Medical Society of
liquid in which it is contained by withdrawing from it dissolved
matter both organic and inorganic.‘ .
Litigation, in the course of which the chemistry of baking
powders was exhaustively gone into by scientiﬁc experts with
special reference to the question of the effects of alum on the
human system, was begun in St. Louis late in 1899 as an out-
come of legislation enacted by the General Assembly of Mis-
souri the same year which prohibited “any person or corpora~
tion doing busines in this State to manufacture, sell or offer to
sell, any article, compound or preparation for the purpose of
being used or which is intended to be used in the preparation
of food, in which article, compound or preparation, there is,
any arsenic, calomel, bismuth, ammonia or alum,”—the mini-
mum penalty being ﬁxed at one hundred dollars.
While the inﬂuences that procured this legislation were
not publicly evident at the time of its enactment the interests
controlling and owning the cream of tartar baking powders
business appeared conspicuously in the prosecution of the ﬁrst
case instituted under the law, and they spared no pains or ex-
pense in order to secure a conviction, the reputed inroads on
their business by their competitors presumably prompting this
course as the market price of the alum powders is about one-
third that of the cream of tartar powders.
The style of the case was State of Missouri, plaintiff, 715.
Whitney Layton, defendant, and the fact that the defendant
was engaged in the manufacture and sale of alum baking pow-
ders was not denied, the defense resting on the asserted un-
constitutionality of the law and the harmlessness of alum
baking powders. In the course of the trial a great amount of
expert and ex parle testimony was heard—chemical, medical,
physiological, etc—many of the most eminent chemiSts in this
country being present, the efforts of the prosecution being
vigorously exerted to show either that free alum was present
in the bread or that harmful aluminum compounds were formed
when alum baking powder was used, the substance called
aluminum hydroxide being especially pointed out as of that
character.
Without undertaking to review the great body of testi-
mony offered and bearing on these points it will be sufﬁcient
CIty Hospital Alumni. 6L
to quote from the decision of the trial court in giving judg-
ment in the case. After commenting on the contention of the
prosecution that hydroxide of aluminum was deleterious and
the testimony offered by eminent experts as to its theoretical
effects, attention was called to the fact that but one witness
presented any report of experiments (which were performed
upon himself) and these showed that a single dose of not less
than twenty grains were required to produce any appreciable
effect. The testimony of all other experts who testiﬁed for
the prosecution rested purely on a theoretical basis, and though
it appeared that hydroxide of aluminum was a substance eas-
ily accessible and which could have been made the subject of
practical experiments by the various eminent scientists yet
they were without a single practical test except the one men-
‘tioned,' and were without a basis of actual determination upon
which to found their theory. The Court continues:
“Upon cross-examination the experts testifying for the prosecution
admitted that in all their reading and information they possessed on
the subject they had never themselves come in contact with, nor could
they obtain any information or any knowledge of any recorded in-
stances in which functional disorders or disease or impairment of the
digestion and general health had resulted to any human being from the
use of alum baking powders as an ingredient in the preparation of
food. In the mind of the Court this fact, considering the enormous
proportions to which the alum baking powder industry has _grown in
this country, and the length of time in which such baking powders
have been used stands as a stone wall against the deductions of the
most eminent scientists who presented their theories on the part of the
prosecution. I am unable to ﬁnd in the evidence presented in this
case any just ground for a ruling that alum baking powders, of them-
selves, when used in the preparation of food are in any way less
wholesome than any other variety of baking powders.”
There can be no doubt of the fact that a strong public
prejudice exists against the use of alum in bread-making, but
this prejudice originated in times when bread stuffs were much
clearer than now, and when alum was deliberately employed
for the purpose of whitening the loaf, thereby enabling an in~
ferior flour to be used, as well as to increase its weight in con-
62 Medical Society of
tained moisture, thus perpetrating a double commercial fraud
which very properly was the object of restrictive legislation.
A dietary cheat also attended this misuse inasmuch as the
phosphates of the ﬂour were rendered less soluble, if not in-
soluble in the stomach. _
The fundamental distinction between this fraudulent use
of alum, and the purpose of its presence in baking powders
to-day will be obvious from what has already been said; but
that the justly grounded prejudice arising in other days has
been shrewdly taken advantage of by the cream of tartar bak-
ing powders. people to discredit the product of their business
rivals can not be doubted, and in the legislation obtained? in
furtherance of their ends no small degree of craftiness was
displayed in putting arsenic as the leader and alum as the
wheeler in the tandem driving of alleged statutory poisons.
Ancient history tells that a certain king was wroth against
two of his ofﬁcers, the chief of the butlers and the chief of the
bakers, and threw them both into prison where they lay for
three days, after which the king restored the butler to his
honors, but he hanged the chief baker. The counts in the
indictment against this offender are not given in the narrative,
and while commentators may differ it must be evident to med-
ical men who may read between the lines that incompetency
or negligence in his work must have been the crime which
outraged the stomach and roused the dyspeptic wrath of his
master; and it is not too late even now to pay a deserved
tribute to the worth of one who was no mean man nor incon-
siderable ruler for his action clearly showed that he possessed
the quality of penetrative sagacity to discOver the cause of the
mischief, and the courage to ﬁt the penalty to the crime.
Should we ever happen upon the mummy of this Pharaoh let
us not withold a tear to his memory and indulge the hope that
emulators of the example set by this kingly soul mayf-arise
even in these degenerate days. For who of us when cori-
fronted at table with sour, leathery, sodden or tasteless traves-
ties on bread has not hanged the baker—in his mind—but we
have not dared to go any further than that.
As already pointed out even if all the elements of bread
be of the best quality and .the mixing also be without fault
City Hospital Alumni. 63
still if the baking be not equally perfect as to stage of leaven-
ing and time of exposure failure must ensue. Doubtless much
of the gastric distress and fermentation with acid eructations,
heartburn, etc., 'in persons of weak digestion may be traced to
the eating of breads not baked sufficiently to kill the saccha-
romyces where yeast leaven has been used; and a long train
of evils may with equal truth be ascribed to the unchanged
starches consumed in forms of breads where heat at a proper
temperature has not been permitted to have its full ripening
effect upon the loaf. ‘
The custom, perhaps, in the average kitchen is to hurry
the pans into the oven and whisk them out almost as soon as
some singeing or scorching is apparent, the usual fault being
a too high temperature with insufﬁcient time of exposure for
penetration of the heat throughout the interior, which is abso-
lutely necessary to secure transformation of the starch with
the formation of dextrine on which the savor and aroma of
bread depends and which adds so greatly to its palatability
and digestibility. In fact, true paniﬁcation is impossible oth-
erwise.
It is, therefore, incumbent upon those who denounce alum
baking powders as being hurtful to point out clinically recog—
nizable disease caused by such powders and at the same time
to be careful not to confound therewith forms of gastric ail-
ments which existed long before such powders were known.
A recent writer5 has directed attention to several points
in connection with bread and bread~making that are of inter-
est and importance. As to the extent of this business he says
that during the twelve months ending June 30, 1899, 268,868,-
281 bushels of wheat were used in the United States for bread-
making, this amount equalling 16,I32,096,860 pounds. The
waste in milling wheat (bran, etc.) is replaced in bread by wa-
ter so that practically a pound of bread equals a pound of
wheat. The actual cost of this bread, placed upon the table,
not to speak of the proﬁts of the baker, is about three cents a
pound; making the total value of the bread consumed in the
period of twelve months in the United States $483,962,90580.
Now this vast sum of money ought to command a better
article 0f bread than that commonly offered to consumers and
64 Medical Society of
Prof. Wiley calls attention to the Schweitzer system, as he ob-
served its operation in France. By this system ﬂour is used
from freshly ground wheat milled in a way to cause it to be
more than doubly rich in phosphates and nuclein which are
largely destroyed in the roller process of grinding, and the fact
of this vital difference between the two ﬂours has been demon-
strated by means of actinographs.
Flour is subject to oxidization by exposure to air and thus
suffers impairment in its nutritive value this being evidenced in
part by the loss of its golden tint which is one of the marks of
a good article of ﬂour.
The nitrogenous principles of wheat are composed chieﬂy
of glutenin and gliadin which with water form the gluten or
tenacious element of dough. In the Schweitzer ﬂour, which
is of a marked golden tint and granular, these principles are
preserved and the bread which is also yellowish in color is so
palatable, nutritious and so aromatic that no other kind is de-
sired. The writer above-mentioned says:
“In view of the enormous economic importance of the bread in- I
dustry, it is not unreasonable to desire to see the quality of our bread
improved It is not at all an exaggeration to say that scarcely 25 per
cent of the enormous quantity of bread mentioned above is properly
prepared or properly baked. The nutritive properties of the other 75
per cent are diminished, its palatability decreased, and its value less-
ened bv improper paniﬁcation—not to speak of the dyspepsia and
other digestive disorders attending the use of poor bread. In the in-
terest of health, ecomomy, and good living a reform in our bread-
making process is urgently demanded.”
He add that the domestic baking of bread is to be de-
plored, that bread badly made has not a leg on which to stand,
and that an earnest effort should be made to relegate domestic
bread-making to the past, and to substitute in every commu-
nity bakeries under competent control offering the best bread
at the lowest prices.
From what has gone before it may be not unfair to con-
clude that bread-mixing and bread-baking have not in this
country, as yet, been generally perfected; that much of the
nutritive value of ﬂour is dissipated and lost in bread as ordi-
narily presented; that while the leavening of bread is an im-
‘City Hospital Alumni. 65
portant part of its wholesome production the particular agent
to be selected for this purpose—whether of vital, chemical or
mechanical nature—must be largely discretionary with the
baker; that serious dyspeptic consequences may attend the
use of yeast raised bread, as well as that made with any other
kind of leavening; that the efﬁciency of baking powders as
respects the purpose for which they are intended is unques-
tioned, while it has not been shown by medical experience or
expert testimony that more harmful results follow from the use
' of the alum powders than from other forms of baking pow-
ders ; that a great conservation of economic and nutritive
value seems possible from a better understanding of the art of
milling grain, the care and! treatment of ﬂour thus produced,
and the proper preparation and baking of bread from such
ﬂours as evidenced by foreign experiment and extended ex-
perience.
LITERATURE.
1Standard Dictionary.
’Vaughan.—-Lomb Prize Essays, Am. Public Health Association.
3Healthy Foods, Am. Public Health Association.
4Encyclopedic Medical Dictionary.
5H. W. Wiley—“Forum,” November, 1900.

NOTE—The following description of the Schweitzer method of
milling wheat and the production of bread is taken from a consular
report to the United States Government, published Ianuary 29, 1900.
This report says that the ﬂour is ground only in quantities sufﬁcient to
meet the daily needs of the bakery, and that the wheat when received
is carried by an elevator to the top of the mill and turned into the
different cleaning and separating machines. The report continues :
“After all the foreign substances have been removed and the
grains of wheat have undergone a thorough brushing and washing,
they are clean and shiny; but the grooves of the wheat sometimes
retain a little dust. This is completely eliminated by a Schweitzer
appliance, which, seizing, each grain lengthwise, splits it exactly in the
groove.
“The wheat thus cleaned passes into the mill, composed of ﬂat,
circular steel grinders, grooved in such a manner that they accom-
plish the decortication of the kernel and its granulation into meal at
_ the same time. These grinders are movable, but do not touch; so
that, instead of crushing the wheat and producing a ﬂour in which the
66 Medical Society of
starch only is retained, the outer and harder portion of the wheat, con
taining gluten and other nutritive properties, is retained in the ﬂour.
The bran alone is expelled.
“Attached to the mill are the works for kneading the meal, water
and yeast into bread. All this is done mechanically, the works being
separated into three stories. Special yeastvis prepared in the upper
story in rooms heated in summer and cooled in summer. The yeast,
ﬂour, and the salted and ﬁltered water are carried down by machinery
into kneaders in the form of half cylindrical tubs, rotating on' two
pivots placed in the axis of the kneading troughs, so that the tubs
may be placed at a lower or higher angle in order to accelerate or re-
tard the kneading.
“One person can attend to two Schweitzer kneaders, regulating
the distribution of the dough, and thus the kneading of 2000 kilo-
grams (4409 pounds) of dough per hour is accomplished.
“The steel arms of the mixing and kneading machinery, some of
which are stationary and others mobile, stretch and work the dough
much better than hand power.
“The ﬂour, salted water and yeast automatically enter one end of
the tub, and dough in an endless skein of pale yellow issues from the
opposite end. This dough ﬁnally falls on tables on the ground ﬂoor,
where it is weighed and made into bread of every shape and dimen-
sion. Small wagons are charged with the shapes, which then go to the
raising room. Each ﬂoor has a fermenting room kept at an even
temperature.
“The dough, after raising, is carried by wagons into the baking
room, where it is placed in Schweitzer ovens heated by gas from retorts
arranged in such a manner that the gas does not exter the oven, and
the heat is so regulated that the baking operation goes on auto-
matically.
1 “In connection with this model establishment is a laboratory for
the chemical examination of the samples of wheat submitted for pur—
chase. These are, upon their arrival, ground and passed through a
seive by a small hand-bolting mill, * * * which determines immediately
the nutritive volume of the grain in gluten and nitrogeneus matter.”
This report also states that there are mills, ovens, and kneaders
of various dimensions that may be worked 'by machinery or hand-
power. The latter system enables the farmer to grind his own wheat
and make his bread from an unadulterated and wholesome product
and mentions that family bread produced by this system is retailed in
France at the rate of about two cents per pound, which is really. one
cent less than the usual price. ‘
City Hospital - Alumni. 67
DISCUSSION.
"DR. ALBERT MERRELL said in regard to the changes taking place
. in baking dough to make bread we should keep clearly in mind the
changes that take place in the starch. The statement of the essayist
that the temperature of the interior of ~the loaf does not much exceed
that of boiling water is probably true. At that temperature the starch
granules are burst and the product partakes more of the character
of ordinary boiled starch in which form it is readily appropriated in the
alimentary canal. The formation of dextrine is not obtained until
submitted to a very high temperature. What is known as British gum
is a form of dextrine manufactured by the action of high temperature
alone ; a temperature of 4oo°F. converts starch into a soluble form of
dextrine and the external part of the loaf alone is thus acted upon in
the oven.
The cellular condition is an important feature and he thought it
very desirable to bring it about without the introduction of foreign
substances for the purpose of giving off carbonic acid gas.
He took exception to one point in the paper,—-that was the
statement that domestic bread making should be abandoned. In his
experience the best bread he had seen was baked in his own kitchen,
or that of some one who had an equally good cook. The ordinary
baker’s bread he thought could not compare with the home made arti-
cle properly cooked.
Of the mechanical means for distending the loaf, the cream of
tartar and bicarbonate of soda baking powder was the orignal powder
and was for years made in private kitchens. It immediately followed
the old sour milk and buttermilk process. In the latter the uncertainty
in the proportions of bicarbonate of soda and salt and lactic acid often
resulted in an excess of alkali, seriously retarding digestion and thus
caused the abandonment of this proces.
Alum baking powders were ﬁrst heard of a great many years ago,
but not in the present form. A party in Ohio made an alum powder,
using raw or unburnt alum, and it had a very extended sale because it
was cheap. Later, burnt alum, the so-called dessicated or dehydrated
alum was used. There are three types of alum—soda alum, potash
68 Medical Society of
alum and ammonia alum. The soda alum is not frequently found on
the market but is used in chemistry. Crystallized alum contains twenty-
four molecules of water of combination which is expelled at a high
temperature leaving a dehydratedalum which is insoluble in cold water.
He spoke of this in explanation of the marvelous sale of alum baking
powders and their extensive use. Most of the cheap hotels and some
of the dearer onces, use it. and wherever hot bread is served it is al-
most always prepared by one of the soda and alum combinations. The
reason why the mixture indicated under the head “ straight alum ”
powders is made of dehydrated alum is that when mixed with bicarb-
onate of soda and placed in the ﬂour to make a dough and cold water
added the gas is not given off while the mass is cold, but as soon as
placed in the oven and the heat applied evolution of carbonic acid
gas occurs and, of course, the dough rises and becomes more and
more cellular in texture. This is done in the large restaurants where
a half barrel of ﬂour may be mixed at one time and placed on a table,
and the last biscuit made from this ﬂour is as good as the ﬁrst.
In the cream of tartar powder the activity of the constituents is
so great even in the presence of cold water, that it is necessary to
hasten the dough into the oven and then have its temperature just
right. i
“Alum phosphate powders ” originated in an attempt to improve
the baking powder, the theory being that if calcium phosphate is
brought in contact with bicarbonate of soda and alum is also present
there will be a reaction ﬁrst in the presence of cold water between the
phosphoric acid and the soda, causing a prompt evolution of gas and _
when placed in the oven the heat would cause a further reaction be-
tween the balance of the acid and the mass become very light.
The bitterness of Glauber salts, alluded in the paper, is prevented
by using a certain proportion of alum. But calcium phosphate is hy-
groscopic and it makes no difference how dry the powder is when the
can is opened it will absorb moisture from the atmosphere and the
powder will ﬁnally lose its leavening power. Mixture with a certain
proportion of dried or burnt alum corrects this tendency of a mixture
of soda and calcium phosphate to lose its leavening power, and this
explains the mixture known as alum phosphate powders.
City Hospital Alumni. 69
DR. JOHN ZAHORSKY was glad to see the stand taken that alumi-
num hydrate was harmless and that the prejudice against alum baking
powders should not exist. He had read some of the testimony in the
trial referred to by the essayist and was impressed with the positive
manner in which assertions were made at that time for which there
were no grounds except prejudice. Since this investigation clinical
tests have been made on the gastric secretions after the use of alum
bread and it was shown to have no effect
A point but slightly touched upon was that in brown bread the
gluten of the wheat is retained and some authorities urge this as an
advantage because of the increased proteids. It is known, however,
that the vegetable albumin is not as easily digested as the animal pro-
teids and the gluten casein particularly, is not equal to meat proteids
or the casein obtained from milk. Children, he said, suffer a great-
deal from indigestion when beginning to eat bread and he believed this
could often be accounted for on the theory of badly cooked bread; it
is frequently vomited after a while in large masses somewhat resembs
ling curds of milk.
The preparation of the yeast for bread baking deserves mole sci-
entiﬁc study than it has bad. There are often other bacteria beside
the saccharomyces, which ought to be eliminated. These may cause
slight changes in the proteids, and the yeast of the future ought to be
a pure product. The bacteria on the outside of the loaf are killed by
the heat of the oven but many may remain in the center which are not
so acted upon; these often cause nausea, and induce fermentation in
the stomach and intestines. Therefore, he thought the subject of
yeast for bread making, from a commercial standpoint and more partic-
ularly from a hygienic standpoint, should receive more attention than
it has had in the past.
DR. JOHN GREEN, ]R., said there were a large number of restau-
rants in London belonging to the so-called “Aerated Bread Company.”
Dr. Merrell had alluded to the process of introducing atmospheric air
into the dough, and the speaker wondered if the bread served in these
restaurants were actually aerated in this mechanical way. It was cer-
tainly an excellent bread as far as the taste and appearance was con-
cerned.
70 Medical Society of
It has been said that whole wheat bread has a decided advantage
in conditions of constipation because of the mechanical irritation of
the indigestible constituents, thus conducing to a restoration of the
normal tone of the bowel. The speaker had also heard this denied.
He asked Dr. Homan to give his opinion on this point.
DR. W. S. BARKER did not hear the paper read and could not
discuss it. He asked, however, if anything had been said about clean-
liness in the handling and delivering of bread to the people. This he
considered a matter of great importance. Some one had suggested
at one time that bread be delivered in paper boxes or cartons similar
to the manner in which crackers are handled. Some method ought to
be devised and generally adopted. We know how the bread is at
present hauled about in wagons and dragged out over the steps by the
driver and mingled with all sorts of bacterial ﬁlth—a defect which is
certainly remediable.
DR. AMAND RAVOLD expressed regret at not having arrived in
time to hear the paper of Dr. Homan. Some years ago, following the
publication in a monthly magazine of the statement of a New York
physician that baker’s bread contained bacteria in large numbers, he
had carried out a series of experiments to ascertain the truth of the
statement. The conclusions reached were, that the high heat—over
5oo°F., to which the bread was exposed in the oven, and the length of
time necessary to bake the loaf practically destroyed all the bacteria
in baker’s bread. He had found the center of the smaller loaves ster-
ile, but some of the larger loves, so-called “home made” bread occa-
sionally showed growths of bacteria from the center of the loaf. The
bacteria belonged to the spore-bearing group, the bacillus subtilis be-
ing most frequently found. No growth of the saccharomyces “yeast
cells” were ever obtained.
The aerated bread spoken of was at one time, about 1876, made
and sold in this city. He had enjoyed eating it in boyhood, and on
inquiry some years later, was told by a member of the ﬁrm who man-
ufactured it, that when ﬁrst introduced here it was sold in large quan-
tities, but after a time it seemed to pall upon the appetite, and the
ﬁrm gave up its manufacture, because people were tired of it.
In regard to baking powders, Dr. Merrell in his very able sum-
City Hospital Alumni. _71
mary of the chemistry of baking powders failed to state whether or not
a‘nyJof the alum remained in the bread after baking, and if so whether
or not it was harmful in the minute quantites that might possibly re-
main. Alum, in his opinion, is not a cumulative drug, and in order to
produce deleterious results with it the dose must be very large.
He further expressed much amusement occasioned by the pro-
found knowledge (sic) of chemistry displayed by a number of local
physicians who testiﬁed in the recent baking powder litigation in this
city.
DR. HOMAN read the following extract from the paper of Prof. H.
W. Wiley:
“Among all the exhibits of bread and bread-making at the Paris
Exposition the one which interested me most was a system of milling
and baking combined. This system has a double purpose: (I) To
make the ﬂour more palatable and more nutritious than that made by
the ordinary roller mill; and (2) to make it immediately before baking,
so as to secure for the loaf a flour which is absolutely fresh. It is well
known that all food substances when ground to a ﬁne powder have a
tendency to become oxidized. As is the case with coffee, which is
best when freshly roasted and freshly ground, so it is with cereal ﬂour,
which is never so aromatic, so palatable, or so nutritious as at the mo-
ment when it is ﬁrst made. '
“The Schweitzer system of milling and bread making secures the
two points mentioned above. In Paris a mill and attached bakery, on
a somewhat large scale, illustrated the method which is employed in
supplying bread to a populous community. So perfect is the milling
system employed that the smallest mill, intended for use on a farm, and
driven by hand, as a coffee mill would be run, makes ﬂour identical in
composition with that made by the largest machine. The Schweitzer
system, in regard to the milling operations, is a return to the old sys-
tem of mill-stones, with the exception that corrugated steel grinders
take the place of the millstones of the olden days. These grinders are
so accurately adjusted as to admit of the making of the ﬁnest ﬂour,
while avoiding actual contact of the two grinding surfaces. The sim-
plicity of the apparatus, its cheapness, and the ease with which it can
be installed commends this system particularly for domestic use and
for the supply of villages and small communities. Nevertheless, it is
capable of being operated on an extensive scale, as is demonstrated by
the large establishment at La Villette, Paris, where more than 100,000
72 - Medical Society of
pounds of bread are made per day from ﬂour not more than twenty-
four hours old. _ i
“This system of milling also retains in the ﬂour many of the nu-
tritive elements which which the roller system eliminates. The germ
and many of the gluten cells, especially those situated near the outside
of the grain, in the aleurone layer, become ﬂattened on passing be-
tween the rollers, and their particles are not able to pass through the
bolting cloths ; hence they do not appear in the ﬂour. For this rea-
son the ﬂour made with the roller process is extremely white and very
smooth to the touch; its whiteness being due to the preponderance of
starch, and its smoothness to the crushing of the starchy particles by
the mill rollers. On the other hand, the ﬂour produced by the
Schweitzer system has a marked yellow tint and is granular, because
the particles composing it have never been crushed, but have been
simply separated and torn by the grinding surfaces. _
“The ﬂour produced by this grinding process contains especially
the phosphatic elements of nourishment, which are so abundant in
wheat, particularly in the nuclein of the embryo, and which are largely
eliminated by the ordinary roller process of milling. This difference
in the two ﬂours is beautifully shown by means of skiagraphy, in other
words, in actinographs made by the use of the Rontgen rays. If the
two kinds of ﬂour be placed side by side on a sensitized plate and
subjected to the action of the Rontgen rays, it will be seen that the
ﬂour made by the ordinary milling process produces a very faint image,
while that made by the Schweitzer system produces a much darker
shade. This is due to the fact that the phosphatic elements tend to
retard the passage of the Rdntgen rays, while the starchy elements
permit them to pass with but little obstruction. Chemical analyses
show that the ﬂour made according to the Schweitzer system has more
than twice as much phosphatic materials as that made by the ordinary _
roller process. The importance of this fact in respect to nutrition
should not be lost sight of, and we must admit that nutrition, not
whiteness of color, is the principalobject of bread-making.”
In answer to questions and statements of other speakers he said
he quoted from the Forum article in regard to the baking of bread in
private kitchens and that Dr. Merrell took issue with Prof. Wiley and
not with himself on this subject. Dr. Homan did not doubt that a
competent cook with proper material and that essential, properly
ground ﬂour in a fresh state, could make good bread. But the ﬂour
on the market is often old and stale especially when prepared by the
City Hospital Alumni. ‘ 73
roller process and the cook is at a disadvantage in this respect.
He said he should feel rewarded if he had done something to put
one absurd notion in its grave, and that was in regard to the alleged
unwholesomeness of eating .hot bread. There can be no objection
from a dietetic standpoint to hot bread, but he believed all who had
had any experience in the profession would agree with him, however,
that this false idea was still prevalent. The idea that the temperature
and not the quality of the bread was the objectionable feature indica-
ted an entire misapprehension of the conditions.
Dr. Merrell mentioned the excellent quality of bread made in his
own kitchen and the speaker did not question the statement. While
in New Mexico last year, in a town of a few hundred inhabitants, he
had met a native Mexican woman who produced the best domestic
bread he had ever tasted. It was the most perfect example of the def-
inition of good bread quoted by him, and conformed to the description
in every particular—pourousness, lightness, thickness and friability of
the crust, development of dextrine, in short, every feature of good
bread was present.
He thought one of the reasons why our bread is so—execrable,
he could almost say—was the departure fronrthe old style of baking,
the so-called Dutch oven method; that is by heating the oven by
burning hard wood in it and after the bricks of the oven were thoroughly
heated, raking out the coals and putting in the pans; the temperature,
high at ﬁrst, gradually declined and thorough penetration of the heat
throughout the loaf was obtained.
Aerated bread to be successfully produced requires the invest-
ment of considerable capital and suitable machinery. Such bread, of
course, can not be prepared in the domestic kitchen.
He shared thoroughly the view expressed by Dr. Barker in regard
to the uncleanly conditions often attending the delivery of bakers’ bread.
He had seen the bread wagon, at the place where he sometimes took his
meals, drive into the alley and the driver with dirty ﬁsts toss the bread
from the open wagon "to the cook; if a loaf fell on the ground it was
picked up and thrown in as the others were. For this reason he had
insisted that bread served to him there should be re-baked. I He sug-
gested too, that bakers generally be required either to enclose each
74 Medical Society. of
loaf in a paper bag so as to protect the bread while being hauled
through the streets, or that a canvas bag, similar to the postal mail
bag be provided, with lock and key and have the loaves put in this
bag at the baker’s, the bag then locked and remain thus until it
reaches the place of delivery. In this way there would be no contam-
ination between the bakery and the place where the bread was to be
delivered. ' i
In regard to alum, it. is simply used to produce carbon dioxid,
and after combining with the bicarbonate of soda its work is ended.
As he had said in the paper the competitors of the alum baking pow-
ders people took a shrewd advantage of the public prejudice against
alum which was aroused by attempts many years ago to use alum for
the purpose of enabling an inferior article of ﬂour to be used, thus
making the loaf white, and also increasing its weight, and these frauds
were properly made the subject of legislation, being declared felonies
by English law.

Meeting of February 21, 1901; Dr. Norvelle Wallace Sharpe,
President, 2'12 the Chair.
Vaccination.
By JOSEPH GRINDON, M D.,
ST. LOUIS, MO.
NE might imagine that in this, the ﬁrst year of the
O Twentieth Century, there would be little excuse for
writing a paper on vaccination. _lenner’s discovery is
more than a hundred years old and, its value was acknowledged
from the ﬁrst by all the best minds of the profession. True,
testimony to its value is constantly accumulating and some
new facts concerning it—symptomatic, pathologic and histO-
logic, have from time to time come to light, but I shall have
_ nothing to offer to-night which is not already accessible to
you all. _- \ ' I '
What then is my excuse for choosing this subject? First,
City Hospital Alumni. f 75
that the repetition of the best-known truths is not useless, and
that it is Well to be occasionally reminded of the reasons for
the faith that is in us.
Second, that among that larger audience which I may
hope to reach through you, there, are still some who do not
appreciate the value of this, among the greatest blessings
vouchsafed to humanity. Proof of this assertion is easily
furnished by the fact that during this and last winter, small-
pox has been rife throughout the United States, whereas a
century ago it seemed probable that it would soon be stamped
out from the face of the civilized world. Every pitted face is
a reproach to civilization.
Third, because even among medical men the science and
art of vaccination are but ill understood. Pus infections and
other spurious inoculations still occasionally pass for vaccina-
tions, leaving their recipients worse off than before, because
in fancied and unreal security. Even true vaccinations are in
large proportions imperfect and insufﬁcient, and thus unde-
served doubt is thrown upon the efﬁcacy of the procedure.
The records of all small-pox hospitals show a certain propor-
tion of patients bearing one or more vaccine scars. This
should not be, and would not he, did all vaccinators thoroughly
understand their business.
The course of vaccinia in the human subject presents a
close parallel to that of variola, which is not surprising when
we remember that in fact it is variola, modiﬁed by its passage
through the organism of the cow.
Usually at the close of the third day after vaccination a
slight elevation of the abraded surface may be seen; this is
better marked the next day. By the ﬁfth day the epidermis.
begins to be pushed up by a ﬂacid accumulation beneath, and
on the sixth day a distinct, multilocular, bluish-White vesicle
has been formed, with raised edges and a saucer-like central
depression. The vesicle continues to spread at its periphery
for two days more, when, that is on the eighth day, a speciﬁc
inﬂammation, marked by a red circumferential area, the are-
ola, makes its appearance. The vesicle and areola now pre-
sent the appearance beautifully described by jenner as “the
pearl on the rose.” It is the formation of this areola which
76 Medical Society of
signalizes the event of systemic intoxication. It is the index
of immunity. From that moment, and not before, its the indi- I
' .vidual vaccinated. For two days more and until the tenth
day both vesicle and areola enlarge, the latter may now be
two inches or more in width, and is of a dusky hue. The arm
is hot, swollen and tender; the inﬂammation has extended to
the neighboring subcutaneous connective tissue. Contiguous
lymphatic glands may be implicated; there is more or less
systemic disturbance, fever, anorexia, restlessness, etc.
After the tenth or eleventh day, the pustule, for such it
has now become, begins to dry in the center, the areola grows
narrower and the local and constitutional symptoms begin to
abate. By the fourteenth or ﬁfteenth day a dark mahogany
colored scab has formed which falls off between the seventeenth
and twenty-ﬁfth day.
The course of events may vary somewhat from what has
just been stated; the variation may be either in the way of
acceleration, as when long-humanized virus is used, or in the
way of retardation, as is likely to be the case with bovine
virus. '
This retardation may occur, (1) during incubation; this
may occur with any dry lymph, but more particularly the
bovine, owing to its insolubility. (’2) during dessication and
desquamation, the scab, in fact, occasionally remains attached
for many weeks. i
The resulting cicatrix is at ﬁrst vascular but soon becomes
white, and should present a foveated and somewhat radiated
appearance. '
The test for vaccination which has received the name of
Bryce consists in re-inserting the virus on the fourth, ﬁfth or
sixth day after primary vaccination, when, if the ﬁrst have been
successful, the vesicles of the second insertion are hurried for-
ward so that all come to maturity on the same day. The vesi-
cles and areola of the second insertion are much smaller than
those of the ﬁrst. If there be no acceleration of the second
lot, the ﬁrst is supposed to have failed, and then the second is
to be regarded as the initial vaccination and to be tested by a
third, and so on. . -
It is important that one should be informed as to the ex-
City Hospital Alumni. 77
istence and clinical characters of the several forms of spurious
vaccinia recognized and described. It is unnecessary to dwell
upon the possible sinister effects of an error of diagnosis here,
through which an individual may suppose himself protected
when in reality his susceptibility to small-pox is as great as
ever. The various forms are:
1. Red tubercles, the size of peas, which afterward sup-
puratc. This form was very common in St. Louis some years
ago and has been observed by me within the last year. The
little tumors may persist for weeks. _ -
2. A non~umbilicated, but acuminated or conoidal vesicle,
cemmencing with much irritation and itching, containing straw-
colored or opaque, instead of clear, lymph. The areola is
completed on the ﬁfth or sixth day, begining to decline on the
eighth day and the scab falls off by the tenth.
3. Instead of the usual vesicle, a bleb sometimes forms, '
followed by troublesome ulceration.
4. A crop of herpetic vesicles, preceded by shivering and
accompanied by intolerable itching and enlargement of axil-
lary glands. The bursting of the vesicles is followed by an
eczematous inﬂammation.
5. Occasionally vesicles which have apparently run a
normal course up to the eighth or tenth day, suddenly rupture
and are followed by ulceration which extends both in depth
and peripherally; three such casesI observed recently. These
cause much local and constitutional disturbance. Of course,
any of these events calls for revaccination.
Among the possible complications are inﬂammation and
suppuration of neighboring and even of distant lymphatic
ganglia. My personal opinion is that this is always due to a
ﬁlthy vaccination. ,
Various cutaneous manifestations may accompany the
constitutional disturbance incident to vaccinia. The most
common of these is a roseola identical in appearance with that
at times accompanying dentition. Papular eruptions, urticaria,
erythema multiforme, purpura and zoster have also been re-
corded. Vesicular and bullous eruptions may occur, at times
eXactly copying the vesicular and bullous types of dermatitis
78 Medical Society of
herpetiformis. A number of such cases were reported to the
American Dermatological Association at its meeting in 1900-
by Drs. Bowen, of Boston; Pusey, of Chicago; Dyer, 'of New
Orleans; myself, and others. In my two cases the eruption
appeared—as seemed the rule—about four weeks after vaccin-
ation. Large tense blebs arranged in groups and circles were
scattered over the general body surface in a symmetrical fash—
ion. Some of the Boston cases had existed for a year or
more when reported. Still graver are the cases reported by
Hutchinson and Stokes under the name of vaccinia gangrenosa.
There appeared purpuric spots which later became gangrenous.
Fatalities have been known.
Serious as these well-established cases, are they are so few
as to sink into insignificance when compared to the immense
number beneﬁtted by vaccination.
Vaccination may determine the appearance of eczema in
those predisposed to it, or aggravate it When it already exists.
For this reason it may be well to defer the operation in some
cases, provided, of course, that there has been no exposure to
small-pox. ~
When one of the continued fevers makes it appearance
before the eighth day of vaccination, that is, before the appear-
ance of the areola, it will sometimes happen that the progress
of the vaccinia will be arrested until the subsidence of the
more important disease, when it will take up the thread of its
tale where it was dropped. At other times the two diseases
will go on together. Of the relations of this sort existing be-
tween vaccinia and variola I shall speak later.
Revaccination is second in importance only to primary
vaccination. Its course departs more or less from that of vac-
cination. The vesicles may reach their acme by the ﬁfth,
fourth or third day, sometimes the process does not go beyond
papulation.
The question is frequently asked, how often should one
be revaccinated? We may ﬁrst observe that it seems to be a
fact that any vaccinal impress may wear out in time. In what
time, depends upon the nature of the ﬁrst vaccination, the
time of life at which it was done, and individual peculiarity.
I obtained a record of the date of last vaccination in 555
City Hospital Alumni. 7 9
cases of small-pox observed by myself, with the following
result:
CASES. DEATHS. PER CENT.


Never vaccinated . . . . . . . . . . . . . . . . . 314 146 46.5
Vaccinated over 15 years . . . . . . . . .. 123 29 23'5
Vaccinated between to and r 5 years. 2 3 6 26.0
Vaccinated between 5 and IQ years. 27 5 18.5
Vaccinated within 5 years . . . . . . . . . 68 1 r 16.0
Totals . . . . . . . . . . . . . . . . . . . . . . 555 197 35.7
This table shows not only the protecting inﬂuence of vac-
cination but its power in mitigating the severity of the
disease.
As to the time of life, puberty and the changes incident
thereto lessen the potency of the vaccinal impress received at
an earlier date. For that reason vaccination should be again
resorted to soon after.
The following table, taken from Corry, shows the gradual
effacement of the vaccinal impress, at the present day, and
also how, without vaccination, small-pox is eminently a disease
of early life as are the other exanthemas, and for the same
reason.

Percentages of Deal/z from Small-pox at Various Ages.
Under Over
5 5—20 20—40 40—60 60—80 80
Pre vaccination times. . . . 83.15 15.79 1.16 o o 0
Present . . . . . . . . . . . . . . . . 3.07 16.34 58.41 18.61 3.24 .32
__ m ..__.__. _ _..____ _ r..- .. _. _
Trousseau’s rule, that one should be vaccinated every ﬁve
years, while probably an excess of precaution, is a good one.
At all events, one should revaccinate whenever there is danger
of infection.
Superiority of Bovine Virus—Now, as to the kind of virus
one should use. There are certain facts which should guide
us in our choice. Virus many removes distant from its foun-
tain head, that is which has been often transmitted since ﬁrst
80 Medical Society of
taken from the cow, has lost much of its prophylactic power.
Four years after jenner had given his discovery to the
world, a committee of the House of Commons, appointed for
the purpose, could ﬁnd only two cases of post-vaccinal small-
pox. In Copenhagen, at the time, a city of 100,000 souls,
where vaccination was rigidly enforced, not a single fatal case
of small-pox occurred during the thirteen years ending with
1823. At Annspach, Bavaria, a place of 300,000 inhabitants,
nota fatal case occurred during the nine years ending with
1818. Of over 500,000 vaccinated in France between 1804
and 1813, only seven are known to have taken small-pox.
Soon, however, it began to be apparent that the beneﬁcent
inﬂuence of the discovery was on the wane. In France, he-
tWeen 1819 and 1835, there were 5,467 cases of post-vaccinal
small-pox, of which 51 were fatal. In Copenhagen, there were
several epidemics between 1825 and 1835, in which there were
3,093 post-vaccinal cases and 66 deaths.
There is, however, a place for the use of humanized virus,
namely, in cases showing relative insusceptibility to vaccinia.
Facts seem to show that failures are rarer when humanized virus
is used than when bovine. Thus Corry reports in his own
practice failures in 3II ﬁrst vaccinations with bovine and one
in 1,140 with humanized virus, using in both instances the fresh
unstored lymph, that is, arm to arm or calf to arm.
The formula of insusceptibility is expressed as follows:
Let X represent the number of primary vaccinations yielding
one failure. Now, if the probability of success was the same
for a second or a third vaccination as for the ﬁrst the ratio of
failures for third attempts would be I to The ﬁfth and
sixth volumes of “Reports of the New York State Board of
Heath,” however, show that failures are more frequent than I
to X3. That is, that one in whom a vaccination has failed is
less likely to have a success than one never vaccinated, the
3
ratio of failure being Say that the ratio of failure for ﬁrst
z(27,ooo,ooo)
9
Selection of the Suoject.——Cutaneous and intestinal affec-
tions contraindicate vaccination; chronic diseases—such as
attempt is I to 300, then :6’OOQ’OOO_
City Hospital Alumni. ' ' 81
syphilis and struma—offer no impediment, neither does preg-
nancy. Of course, in the face of exposure to small-pox all
ordinary rules should be set aside and the individual rendered
as nearly immune as possible-with the least loss of .time.
The best age at which to vaccinate is three months, that
is before the commencement of the troubles incident to denti-
tion. Of course, when small-pox prevails, the child should be
vaccinated at birth. I have seen a child sicken with small-pox
on the tenth day of its life; the mother was well ; it must have
inhaled the germ almost with the ﬁrst lung-full of air. This
may serve to impress the moral of early vaccination. .
The question may be asked: Is theie any use in vaccin—
ating persons who have been exposed to small-pox for a day
or more? Idesire to give an answer in no uncertain voice.
Yes, of course, and without the loss of a single precious mo-
ment. ‘First, because you ‘can not tell when the germ enters;
one may resist the infection to-day and receive it to-morrow.
‘ Second, because even though one be already infected, it may
still be in time to save health, or if not that, perhaps life. The
average duration of incubation of small-p0x may be called
thirteen days. The areola of vaccination marking the recep-
tion of the systemic impress occurs on the eighth or ninth day.
This gives us three days or so in which to work out the salva-
tion of the threatened individual. If not in time to prevent
the disease altogether, it may be in,time to mitigate it.
Marson states the matter as follows: Suppose an unvac-
cinated person to inhale the germ of variola on a Monday, if
he be vaccinated as late as the following Wednesday the vac-
cination will be in time to prevent small-pox being developed,
if it be put off until Thursday the small-pox will appear, but
will be modiﬁed, if the vaccination be delayed until Friday, it
will be of no use, it will not have had time to reach the stage
of areola, the index of safety, before the illness of small-pox
begins. 8
~
82 - Medical Society of
A Case of Splenectomy, With Remarks.
BY. 1. P. BRYSON, M.D.,"
ST. LOUIS, MO.
SPLENECTO .VlY is still a sufﬁciently rare operation to
justify the report of a single case, allthe more so when
the patient is the subject of leucemia, a condition dis—
tinctly contraindicating surgical intervention, except for the
most urgent reasons. I
The patient, jane McK.,aged 27 years, American, single, without
occupation on account of her disease, residing in Vienna, M0., was
seen September 25, 1900, on account of what was supposed to have
been an enlarged and ﬂoating kidney. Physical examination quite
easily demonstrated that the large tumor occupying the left side of the
abdomen and extending from. above the lower border of the rib to and
into the pelvis, was not a kidney at all but a very much enlarged and
freely movable spleen. I quote now from the hospital records:
Family History—Father living and healthy at the age of 70
years, mother 61 years of age. Five brothers and one sister. ' ~
Past 1Yistory.-—Usual diseases of childhood; mumps at 8 years,
pneumonia at 14 years. Menstruation began at 17 years; has always
had dysmenorrhagia. Her present trouble began in early girlhood
with pains of a dull, heavy character in the left side, most severe in the
left inguinal region. For a long time she had periods of perfect com-
fort but about one year ago pains become more severe, recurred more
frequently, lasting two'or three days, with, intermissions of the same
duration ; she had occasional hot ﬂushes, vertigo and persistent
cephalgia. '
For the last three years her feet and legs, as far as the knees, be-
came much swollen, blue, and even black, painful to the touch, pitting
on pressure ; no varicose veins.
Examination showed a large tumor on the left side, extending ~
from beneath the ribs down into the bony pelvis. The tumoriis quite
movable, changing position with the patient’s movements, not painful
on manipulation, quite ﬁrm, round and smooth. No glandular en-
largement and no enlargement of the superﬁcial veins. I
Urinalysis—S. G. 1020, dark amber, clear, acid, no albumin, no"
sugar, no bile, no excess of indican; microscopically, negative.
v City Hospital Alumni. ' 83
October 12 Operation. An incision eleven and a half inches in
length was made from the free margin ‘of the ribs in a straight line
parallel with and two inches to the left of the median line; exposed a
spleen- enormously, enlarged, capsule smooth and mottled, showing
the thickening of an old perisplenitis, quite dark and congested.
The pedicle was long enough to permit of delivery of the organ.
The splenic artery was large, the vein greatly distended, admitting the
tips of three ﬁngers on section. The pedicle was tied off in sections ;
twelve ligatures of No. 9 braided silk being used, the distal end was
clamped and the organ removed. Atthe time of the removal the organ
weighed ﬁve pounds and two ounces. The wound was closed and
the patient put to bed; she rallied well; saline enemata administered;
no shock. .
October 13. Comfortable, except for gaseous distension; sleeps
well. 5
,, October 17’. Superﬁcial sutures removed, wound healing; blood
examination for plasmodia, negative; leucocytes and eosinophiles in
creased; yeast fungi and mould present.
October 18. Epistaxis and bleeding from the gums. Anterior
nares plugged.
October 20. All sutures removed.
October 24. Temperature has gradually risen to 103°F. Diar-
rhea. Blood again examined -— no plasmodiae found; leucocytes
still increased in proportion to red cells. Urine for 24 hours seventeen
and a half ounces. -
October 25. Urinalysis: S. G. 1030, faintly acid, 2 per cent
of albumin, no sugar; some epithelial and mucous cells, urates in
excess, yeast fungi and moulds and granular casts; few red blood
cells.
OCtober 26. Urinalysis : S. G. 1020. acid, dark amber, slightly
cloudy, 1/, per cent of albumin, no sugar, mucous and ﬂat epithelial
cells, few red blood cells; calcium oxalate crystals, yeast moulds and
some granular casts.
October 28. Urinalysis: S. G. 1010, faintly acid, amber, clear,
3/4 per cent of albumin, no sugar, many bacteria, yeast moulds and a
few faintly granular casts. Diarrhea continues.
November 1. The patient very comfortable. Diarrhea has ceased.
November 12. Blood examination: Leucocytes still increased
but not as largely as before; eosinophile more abundant, no plas-
modia. ,
November 15. Urinalysis: S. G. 1020, clear, acid, no albu-
84 Medical Society of
min, no sugar, some mucous cells, calcium oxalate crystals and a few
bacteria. ‘
November 19. Discharged from the hospital.
November .23. Blood examined: No plasmodia, very few eosin-
ophiles, white cells not as numerous as before. The patient appears
well. No enlargementqof the thyroid or lymphatic glands. '
RESUME.
A large, well-developed woman, aged 27 years, with good
family and personal history, but presenting evidences of con-
genital ﬂoating spleen which had become hypertrophied,
gradually developed symptoms of obstruction, anemia, dys-
menorrhea and intermittent amenorrhea. Within the past
year crises of acute pain and shock, becoming more and more
severe and frequent, referable to axial rotation of the enlarged
spleen, have developed. Absence of lymphatic involvement.
Splenectomy followed by neither shock nor hemorrhage. On
the sixth day epistaxis and bleeding from the gums which was
quickly followed by pyrexia, anorexia, diarrhea and acute
nephritis, all of which subsided within twelve days. Recovery
is complete and the anemia is distinctly improved two months
after operation. During convalescence no enlargement of the
lymphatic tissues is demonstable.
As may be seen. there is an unfortunate hiatus in the rec-
ord, viz., the absence of a competent blood examination be-
fore operation. On September 25th, when the urinalysis was
made at my ofﬁce, the blood was, as I recall, also examined,
and I got the impression from a verbal report that, while there
was a high grade of anemia, there was not a true leucemia.
Even in the face of such contraindications there was urgent
need for relief, which could only come from operation. The
case seemed to be one of congenital wandering spleen, enorm-
ously enlarged, and developing symptoms due to displacement,
obstruction, pressure, dragging on certain viscera and crises
referable to axial rotation. Only after the occurrence of two
such crises, causing dangerous symptoms of collapse, was it
determined to face the risk of splenectony. .
Both of these crises appeared to be due to rotation of the enlarged organ, the lower border of which slipped over be-
City Hospital Alumni. 85
yond the median line,at the same time that it greatly increased
in size and became tender to pressure. Quickly there followed
nausea, emesis, a heavy dragging feeling in the epigastrium,
rapid pulse, cool clammy skin and great pallor. Under such
conditions one may be justiﬁed in taking considerable risks as
when splenectomy is done in those cases of acute anemia due
to lacerations and internal hemorrhage with collapse. More-
over, the pressure symptoms manifested by edema and hyper--
esthesia of the lower extremities and symptoms of obstructive
constipation, were not only increasing but seemed to account,
_ in a measure at least, for the anemia.
Leaving aside the barbarous practice alluded to by Dionis
(1733) as unmilting, and the operations for disease said to have
been done by Zaccarilli in 1549, and by Ferrerius in 1711,
both of which have been discredited, it seems that in late
years surgeons have done splenectomy for the following con-.
ditions: First,-. leucocythemia; second, injury or prolapse;
third, certain cases of movable spleen; fourth, simple hyper-
trophy with or without cirrhosis; ﬁfth, sarcoma or lympho-
sarcoma; sixth, cysts; seventh, hydatid disease.
The operation for leucocythemia is now considered un—
justiﬁable because of its high mortality (over 90 per cent).
Writing in [896, the late Mr. Greig Smith was able to col-
lect the following summary of tables: Collins, 89 cases, I3
for diseases not associated with. leucocythemia; of these 8
recovered. So far there appears to have been done only one
successful operation for leucoCythemic spleen—that of Franz-
olini, of Turin, and this is doubtful.1 Ashurst, 43 for disease,
with 31 deaths; 21 for injury or prolapse, all successful.2 Nuss-
baum, 26v cases for traumatic causes, with 16 recoveries. Gil-
son, 18 operations for injury, all recovered; 37 for disease,
with 29 deaths and 8 recoveries.3 Podrez and Kharkoff esti-
mate the total mortality at'73 per cent. Mollieret, 28 cases
for disease and II for wounds, with same results as above.‘
9
1Med. Woch , No. 20, 1883. ,
’International Encyclopedia of Surgery, Vol. V.
8Rev. de Surg., April 10, 1885
4LDiction. enc. des Sc. Med. 1883.
86 I Medical Society of
Wright, of Manchester, England, tabulated 62 cases; 22 for
leucemia, all fatal; 23 simple hypertrophies; with 15 deaths;
7 for malaria, with 2 deaths; 3 for cystic disease, all recovered;5
Asch, 90 cases, 51 successful (14 for wandering spleen).6 .Dr.
M. Howard Fussell, of the University of Pennsylvania, col-
lected statistics up to 1890, showing a total of 105, with 57
recoveries and 48 deaths; 28 were for simple hypertrophy,
with 19 deaths; 24 for leucemia, with 23 deaths; 26 for acci-
dent, with 1 death; 16 for ﬂoating spleen, with 1 death; 5 for
cyst of spleen, with I death. The rest for rupture, suppura-
tion, pernicious anemia and sarcoma. Spanton has collected
25 cases for leucemia, with 24 deaths ;_ 75 for non-leucocythem-
ic spleen, with 28 deaths.7 Dr Richard Douglas, 194 cases—-
For leucocythemic spleen 36 splenectomies, with 31 deaths;
simple hypertrophy 59 operations, with 25 deaths; for neo-
plasm 5 operations, with 3 deaths; for hydatids 6 operations,
with 2 deaths; for wounds 43 operations, with 11 deaths.8
Summing up, Greig Smith9 says: “Operations for leuco-
cythemic spleen are unjustiﬁable; operations for traumatic
lesions are justiﬁable and safe. For movable spleen excision
ought not to be carried out till less severe measures, such as
mechanical support or operative ﬁxation have been tried and
found ineffectual. For cysts, the spleen may be removed with
a fair chance of success, but puncture or incision with drain-
age ought to have a trial ﬁrst. In the early stage of malig-
nant disease the operation is justiﬁable. In the rare cases of
primary hypertrophy the operation is permissable if the dis-
ease is attended with danger or serious discomfort.”
In the case Of cysts, abscess and certain cases of wander- -
ing spleen, the trend of opinion seems to be toward splenec-
tomy rather than splenopexy, or incision and drainage. In this,
surgical opinion seems to run parallel with that in regard to

5Med. Chron., December, 1888.
6Inter. journ. of Med Sci., November, 1888.
7Brit. Med. ]our., November 2 and 9, 1895..
8journ. of the Amer. Med. Ass’n, April 25, 1896.
9Abdominal Surgery, Vol. II, page 1093.
City Hospital Alumni. 87
nephrectomy as related to nephrotomy and nephropexy in
certain conditions.
Plucker10 estimates the mortality of splenectomy for cer-
tain' conditions, as follows: Leucemia, over 90 pen cent; es-
sential hypertrophy, 57 per cent; malarial hypertrophy, 55
per cent; hydatids, 40 per cent; sarcoma, 30 per cent.
So far as I have been able to see, the estimates Of mor-
tality have been based on the ﬁgures given above, but it is en-
couraging to note that Burtz has demonstrated that the mor-
tality frOm splenectomy has, in recent years, been diminished,
which he thinks may be attributed to improved technique,
asepsis and a proper restriction Of the cases in which it should
be done.
Up to this time only a few splenectomies for ﬂoating
spleen associated with twisted pedicle causing pain and. shock,
have been recorded. One such case by Dr. Isaac Scott
Stone may be found reported in the Annals of Surgery, Vol.
XXX, page 321, 1899. So far as I have been able to ascer-
tain no splenectomy has been done in such cases associated
with splenic leucemia.
The report of the pathologist which follows, demonstrates
that the leuceinia in the case reported here was not myeloge-
nous or lymphatic, but splenic. While sufﬁcient time has not
elapsed to determine the ultimate result, the case may assist
in modifying somewhat the sweeping generalization against
splenectomy in cases associated with leucocythemia because
of the high mortality, as well as in explaining the few success-
ful operations done in such cases, operations which have been
discredited, perhaps, unjustly.
MICROSCOPICAL REPORT OF DR. T. Konis.
The microscopic examination of the spleen shows great
changes in the structure of the tissue. The follicles are ab-
sent and the pulp is replaced by connective tissue and blood-
vessels. The section has a great quantity' of large vessels
with round dilatations on the end. Their wall is very thin and
covered by endothelia and in some places by spindle-shaped '

loDeutch. Med. Woch., August 12, 1897..
88 ~ Medical Society of
cells. These round and oval dilatations at the blood-vessels
are Thoma’s ampullae. The connective tissue is very much in-
creased over the normal quantity; we see between its ﬁbers a
great many round cells with characteristics of large 1ympho~
cytes. The eosinophile cells and myelocytes, the same cells
we ﬁnd in capsules of the spleen and‘in the trabeculi.
Such changes inthe tissue of the spleen might be present
in the following pathological conditions: First, primary meg-
alospleny; second, chronic stagnation of the blood, as in cir-
rhosis of the liver, and in heart and lung diseases;ithird, in
malaria; fourth, in chronic leucemia. The primary megalos-
pleny shows large cells inside the dilated vessels and-in the
walls of them. We do not see any such cells in our speci-
men. The stagnation of the blood and malaria'is excluded by
the absence of the corresponding clinical symptoms and by
lack of deposit of pigment which is always present in Old
cases of malaria. The inﬁltration of the connective tissue and I
of the capsule by lymphocytes show that we have to do here
with an old case of leucemia where the hypertrophic condi-
tions of the adenoid tissue disappear and the connective tissue
becomes hypertrophied. '

NOTE—The patient presented herself at my Ofﬁce June 7,
1901. Five weeks before she had been thrown from a horse
sustaining a severe contusion of the right shoulder which was
also dislocated. _Her health had been excellent and she ap-
peared strong and well except for some stiffening and thick-
ening about the shoulder. There was nothing in her general
appearance to indicate that she had ever been the subject Of
leucemia.
At my request Dr. Given Campbell made an examination
of the blood. The report follows.
BLOOD EXAMINATION REPORT OF DR. GIVEN CAMPBELL.
The patient was seen June 7, 1901, and her blood exam-
ined; result Of examination was as follows: Blood normal in
color but seems a triﬂe thin in consistence. At. the point of
puncture the blood ﬂowed unusually profusely. HemOglobin
estimated, by Hammerschlag’s method, reveals 80 per cent,
City Hospital Alumni. 89
which is very little, if any, lower than is normal for the average
American woman. Erythrocites are normal in size and shape
and show no neuclcated corpuscles. A study ofithe white
cells shows no increase of either large or small lymphocytes.
Polyneuclear neutrophiles are normal in number but the neu-
clei Of these contain some peculiar granules which take the
same color as the chromatin but stain more diffusely; they
have been present in several specimens of blood, one of
which was taken as early as twelve days after operation. The
eosinophiles are present in increased numbers, constituting
about 10 per cent Of the total leucocytes; they are all of the
polyneuclear variety. ‘A careful examination fails to reveal
the presence of any myelocytes, 'nor does the blood now
show any signs of leucemia.
DISCUSSION.
DR. A. H. MEISENBACH was requested to open the discussion.
American surgeons and investigators, he said, were the ﬁrst to remove
the spleen, at least experimentally. In 1871, the speaker saw the
spleen removed from a dog in the Rush Medical College, in Chicago.
The dog was shown as a curiosity among the students. The animal
was as frisky and sleek and full of pugnacity as other dogs, and it was
evident that the removal of the organ had had no detrimental effect.
The case reported by the essayist was fortunate in that it had a
long pedicle ; this is not always the case. A number of years ago the
speaker had seen Dr. Dalton remove the spleen but the pedicle was
short and there was much diﬂiculty in locating it. Secondary hemor-
rhage also occurred.
All who have been in practice a number of years have seen large
spleens due to malarial causes, and especially in the Mississippi river
bottoms. He had seen one or two cases where the spleen ﬁlled the
whole abdominal cavity. In the early days of his practice the treat-
ment consisted of large doses of iron and many did well.
It had never been his fortune—or misfortune—to meet a case re-
quiring removalof the spleen. However, he would not hesitate under
proper conditions, though he would feel that he was attacking a very
grave condition. The liability of hemorrhage from the pedicle is a
surgical hindrance. ‘
90 Medical» Society of
He asked Dr. Bryson why he would not use the clamp. The
speaker could see no material difference in a pedicle of a spleen and
that of any other abominal organ, such as the ovary, with a pedicle.
He thought the clamp could be used in a case of this kind without
serious effect, just as it would be used in a nephrectomy where we have
a large pedicle and necessarily leave the clamp in situ. He did not
understand whether the pedicle had been dropped intraperitoneally or
in the wound, but presumed it was in the former. He asked what the
present condition of the patient was as he did not hear this stated; .
from the history he thought her general health should be improved.
Dr. Bryson covered the ground so completely that there is very little
to say regarding the surgical aspect, and Dr. Kodis had thoroughly
covered the pathological ﬁeld. '
He congratulated Dr. Bryson on the Outcome of the case in the
face of the high mortality shown by statistics. In this, however, as in
all other surgical operations, he believed the statistics were becoming
better because of improved technique and asepsis. Aseptic surgery
has been the turning point in operative procedures and many opera-
tions formerly considered unjustiﬁable and impossible are now ac-
complished.
Dr. F. REDER said surgery of the spleen is still in its experimental
stage as can be seen from the statistics quoted. He mentioned one
operator, jonnesco, of Bucharest, who has had brilliant results in
splenectomy. When. he gave out his statistics he had something like
twelve cases and three deaths. These splenectomies were performed
for what is known as malarial spleen, one case being a hydatid disease.
The essayist mentioned leukemia or leucocythemia as a contraindica-
tion for removal Of the spleen. Other contraindications are—adhe-
sions, great size of the organ, profound cachexia. The indications for
removal would probably be failure of medical treatment to reduce the
size of the organ and to relieve the pain, also beginning cachexia.
The case cited by the essayist was a fortunate one in not having a long
pedicle and there being no adhesions; such conditions complicate an
operation very much. '
The speaker had been present at three splenectOmies--on'e here I
and two in the East. The two in the East were” performed for hyper-
City Hospital Alumni. 91
trophied spleen of malaria. In the case in this city he could not re-
member if the cause of enlargement had been determined, to all ap
pearances the. case was one of malarial spleen. 'The patient died from
b secondary hemorrhage. The other two cases were compliéated with
extensive adhesions and the operator took great precautions so that
_ the rupture of the adhesions was made at the expense of the abdomi-
.nal walls. The adhesions were separated between double ligatures.
The pedical was broad and composed chieﬂy of blood-vessels, section
of the vessels of the pedicle was made between the ligatures; com-
plete hemostasis was secured before closure of the abdomen. The '
abdomen was tightly bandaged.
The speaker said he did not understand Dr. Kodis’ remarks about
' malarial spleen—whether it was considered a contraindication for non-
interference. Dr. jonnesco claims that such a spleen ought to be re-
moved,,especially if there was a tendency to malarial cachexia. Such
patients gain rapidlyin bodily weight and assume a more normal ap-
pearance of the skin. However, since we do not know the function
I of the spleen there ought toibe great hesitancy in removing that organ.
. Dr'. Bryson spoke of the rise of temperature following the operation.
The speaker thought this would invariably follow such an operation
because of the impoverished condition of the blood, and it was to this
condition more than to the operation itself, that the great mortality was
‘ most likely due to. _
DR. H. W. SOPER was specially interested in this case in view of
the fact that he has had a patient under Observation for the past four
pears who has an enlarged movable spleen. The patient is a neuras-
thenic and the enlarged spleen was discovered while making an exam-
ination for some gastricpain. The spleen was down in the iliac fossa.
After it was discovered she complained of great pain and discomfort
in the region Of the spleen, though she stated that she was not aware
of the tumor and it had caused her no inconvenience. Dr. H. H.
Mudd was consulted and he veriﬁed the diagnosis of enlarged and
‘movable, and, perhaps, malarial spleen, It was decided not to oper-
ate and efforts were directed toward relieving her of the neurasthenic
symptoms, which succeeded quite well. " Since that time, three years
ago, the patient has not complained of the spleen.
92 Medical Society of
The spleen lies commonly in the iliac fossa and does not displace
the stomach, as would be expected. Inﬂation shows the stomach to
be normal as to size and position; the abdominal walls are lax and the
organ can be freely moved form the normal position to the iliac fossa
and back again without discomfort.
DR. BRYSON, in closing, said he did not mean to convey the idea
that he would not use the clamp in certain cases. The clamp in this
case was not applied until the pedicle was ligated, for the reason of
its interference with the securing of the vessel by putting the pedicle
in state of tension. The gastro-splenic omentum was thin' and
not difﬁcult to detach though it dragged on the stomach; there was,
however, no enlargement or dilatation of that organ. The number of
ligatures he thOught exceeded 12. The pedicle was held on the ﬁnger
of the left hand, the aneurysm needle was passed from above down-
ward, the several ligatures placed and tied; then the clamp was
ﬁrmly' applied between the spleen and the ligatures, and the pedicle
divided between the clamp and ligatmres.
About a year ago he had made an exploratory incision, in the case
of a young lady with hypertrophied spleen, but found the adhesions so i
great that removal was not attempted. The gastro-splenic omentum was
divided, however, between ligatures, thinking that possibly the stretch-
ing upon this band had something to do with the hematemesis. This
recurred, however, within two months. Malaria was suspected as the
cause of the hypertrophy, but the plasmodium was never found in the
blood.
In regard to the systemic disturbances after removal he thought
these were to be expected, and probably one of the most marked phe-
nomena is this rise of blood-pressure, this might have caused the epis-
taxis. In the literature consulted he could ﬁnd no mention of this
occurrence following splenectomy. The dangers of the operations are
principally from hemorrhage and shock, and the hemorrhage may take
hours after the operation. Hemorrhage is most apt to occur in the
leucemic cases because, it is said, the veins are very thin and friable
in these cases.
The recurrence of the crises, increased frequency of the pressure
symptom, anorexia and nausea, rendered it necessary to do something"
City Hospital Alumni. 93
or the patient would have died. Since the operation she has been
perfectly well.
The patient had been shown before the Society at a previous
meeting, and attention was called to the fact that though fully devel-
oped sexually, there was almost complete absence of hair on the pubis
and in the axillae.
The patient pleaded for an operation. She had sought employ-
menf as a servant but no one would take her because of her peculiar
shape. Following the operation there was no enlargement Of the
lymphatics nor was there before the operation. She had no sign of
the enormous appetite which is supposed to follow splenectomy.
The case referred to by Dr. Reder, the speaker thought, was the
case reported at the Moscow Congress by jonnesco. Dr. Ionnesco
urges operation in what he calls the malarial spleen. He believes the
spleen is not a poison destroyer but simply retains and holds the micro-
organism. The speaker was inclined to think this quite probable in
view, of the great difﬁculty we have in curing malaria. Had he been
willing to prolong the paper he would have said something about this
and even gone so far as to suggest an analogy between malaria and
syphilis. He had seen a number of cases where the malarial micro-
organism after having been driven from the blood by quinine reappear
again and again following the exhibition of ergot, which is supposed to
cause contraction'of the splenic blood-vessels. May not this obser-
vation throw some light on the recurring stages of syphilis. In the
present state of our knowledge he would be unwilling to operate upon
a patient for malarial spleen. The rate of mortality is too high and
the undertaking too serious in this condition.

Meeting of Marc/z 7, 1901; Dr. Norz/elle W'allace Slzarpe,
President, in the Chair.
Carcinoma of the Uterus.
DR. A. H MEISENBACH presented a specimen of carcinoma of the
uterus. It was of interest because it was fresh and showed macro-
scopically the carcinoma of the cervix. The specimen was taken from
94 Medical Society of
a woman, 55 years of age, ante-mortem. Dr. Meisenbach had seen
her for the ﬁrst time about two weeks previously, being called in
consultation by Dr. Toeppen as the patient was supposed to be suffer-
ing from an attack of appendicitis. She showed the ravages of long
suffering, and the lower part of the abdomen was very tender to pal-
pation and percussion. Five years ago she had a similar attack and
since that time at intervals. The tenderness was exquisite and a
thorough examination of the abdomen impossible. From the examin-
ation he was able to make, however, he was led to believe that there
was no appendicitis but that the trouble arose from some pelvic dis-
turbance. Examination of the vagina showed a markedly hardened
os. Dr. Toeppen mentiOned this and expressed a suspicion of carci-
noma, and after digital examination, Dr. Meisenbach agreed with him.
In the anterior cul‘de-sac he found what seemed to be an anteverted
uterus; it was very tender and a thorough examination could not be
made.. The patient was sent to the hospital and kept under observa-
tion for a week. The temperature varied from 996° to 101°F. One
feature about the case was the condition of the digestive tract. The
appetite was very poor and denoted a condition seen in patients who
After she had been in the
hospital a week the abdomen was opened and a conglomeration of
have suffered from a long_continued sepsis.
conditions was found. ~ Everything seemed to be centered in the me-
dian line. He found a well marked urachus and the extremity where
it was attached to the bladder'was bifurcated. The omentum, anterior
part of the abdominal parietes, small intestines, tubes and bladder all
matted together in one indescribable and indeﬁnable mass. By a
careful separation of the adhesions he worked gradually downward
and broke into an abscess cavity. He had taken the precaution to
carefully wall off the peritoneal cavity with pads. He succeeded in
separating the organs and the conditions disclosed what he had sus-
pected—a pyosalpinx.
He stated here that a section of the os had been examined micro-
scopically and was pronounced carcinoma. Then the question arose
whether it would be better to stop the operation or go on with it. He
decided to take the greater risk and continue the operation. All pre-
cautions were taken to avoid shock by injecting salt solution, etc., pre-
City Hospital Alumni. 95
vious to the operation. The hysterectomy was comparatively simple, but
the patient did not withstand the operation, living only eighteen hours
after. A little tumor was found within the body of the uterus which
seemed to be a small ﬁbroma. The cervix showed marked inﬁltration.
one peculiarity about the case was that a woman could have such a
condition and yet there be no vsymtomatic signs of carcinoma. The
case showed practically two pathological conditions, a chronic pelvic
inﬂammation involving the right tube—suppurative pyosalpinx, and
carcinoma of the cervix. Dr. Meisenbach demonstrated microscopi-
cally sections taken from the cervix, and stated that the reason for
bringing the specimen was that it was fresh and showed the pathologf
ical condition so beautifully.
In reply to Dr. Reder’s question as to the cause of death and if
drainage had been established, stated that the cause of death was
shock, and that drainage had been made through the vagina.

A New Non=5urgical Treatment for lnflamma=
tory Exudates and Their Residua in
the Female Pelvis.
Bv HUGO EHRENFEST, MD.,
sr. LOUIS, MO.,
CONSULTING GYNECOLOGIS'I‘ TO THE CITY HOSPITAL.
URING the last few years much stress has been laid on
the attempt to treat acute and chronic inﬂammatory con-
ditions of the female pelvis and their residua by methods
of a less radical nature. While panhysterectomy continues to
be the O nly resource in certain cases, it was proven on the other
hand, that some conservative measures give equally as good
and, in some cases, even better results. These conservative
methods are both operative and non-operative. The operative
methods attempt to remove only the diseased portion of the
genital organs, thereby preserving (should such be possible)
the function Of menstruation and the possibility of pregnancy.
These conservative, operative procedures are mainly recom-
96 Medical Society 01
mended and employed by American gynecologists. In some
contradiction to them, German authors are attaching more
value to the conservative, non-operative methods. It seems to
me that these methods do not get the appreciation in Amer-
ica which they merit. -
A review on the new book of Professor Macnaughton-
]ones, of London, in the New York Medical Record, December
22, 1900, p. 990, contains the following sentence: -“ The last
chapter, which includes the subject Of ‘ Massage,’ would better
have been Omitted, since mechanical treatment is tO-day hardly
looked upon- by us as a justiﬁable, let alone a legitimate aid to I
the cure of diseases peculiar to women.” .
According to my own experience and the results given by
a great many trustworthy authors this view is not-justiﬁed and
in many respects dangerous. The value of some conservative,
non surgical procedures is at present, without doubt, estab-
lished. To this class belong—gynecological massage, hot-
water douches, the treatment with the thermophor, etc. With
this paper I wish to call your attention to a new procedure,
comparatively young and unknown. Being well acquainted
with all the above-mentioned methods, I think this new one
offers some remarkable advantages. Very favorable results
which I have experienced by employing it justify me in recom—
mending the same. In brief, allow me to give you the origin
of this new procedure. .
Professor W. A. Freund, of Strassburg, inaugurated a
method of treatment of pelvic exudates by “ pressure-weight,”
and presented a paper on this subject at the “ Naturforscher-
Versammlung,” at Braunschweig, in 18,7. The pressure is _
produced by placing a bag ﬁlled with bird-shot on the abdo-
men, and at the same time inserting into the vagina a rubber
condom also ﬁlled with shot.
Funke1L reported a series Of cases from Freund’s clinic, in
which excellent results followed this treatment, and gave in
this report the indications for the use of this method. Before i
the above was published, Pincus2 used and recommended a

1Hegar’s Beitraege, Bd. 1, p. 264. V
2Zeitschrift f. Geb. und Gyn, Bd. 39, p. 13.
City Hospital Alumni. '" 97
similar'treatment, to which he gave the name of “pressure-
posture.” His method consists of placing the patient in the
Trendelenburg position with a bag of shot on the abdomen,
and nothing in the vagina save a. colpeurynter ﬁlled with'ai-r,
its Object being to support the uterus.3 '
The many successful cas'es following the use Of these
methods induced my former chief, Professor Schauta, Of Vi-
enna, to try them in his clinic. Schauta did not limit himself
to the use of either method but utilized a combination of both,
which consisted in placing a shot bag on the abdomen and at
the'same time introducing a colpeurynter ﬁlled with metallic
mercury into the vagina, the patient being placed in the Tren-
delenburg position. .
, The most satisfactory results with this method were pub-
lished by Halban.‘ Later, Funke5 advised some changes in the
technique, Which I have adopted; and I ﬁnd them of great
practical value.
I will now give you a short account Of the rationale, the
indications and the technique of this procedure:
The shot bag placed on the lower part of the abdomen
compresses the pelvic exudations, while counter-pressure is
produced by the vaginal colpeurynter ﬁlled with mercury; the
latter exerts the same inﬂuence in the reversed direction, with
the addition, that the uterus is forced out from the lower pel—
vis, thereby stretching all adhesions and hands, if any exist.
For this particular purpo’se the Trendelenburg posture is the
most effective. In this posture the mercurial weight does not,
as in the horizontal dorsal position, press against the sacrum,
_ but it exerts its inﬂuence in the direction Of the pelvic axis
and'tends to press the uterus in the same direction.
In the case of a retroﬂected uterus, pregnant or non-
pregnant, the colpeurynter placed into the posterior fornix
will push the uterus directly out of the cul-de-sac and cause it
to assume an anteverted position, the patient being in the ele-

3This method is spoken of by john C. Clark, Am. Gynecol. and
Obstet. ]ourn., April, 1900. ‘ A
4Monatschrift f. Geb. und Gyn., February, 1899.
5Centralblatt f. Gyn., N O. 8, 1900.
98 Medical SOciety of
vated dorsal posture. By changing the position of the patient
to either side we can produce the pressure in any direction
desired. Such treatment further'assists the absorption of ex-
udates by improving the pelvic circulation. I
The indications for the use of thisrnethod are found in
cases of chronic inﬂammatory conditions of the pelvic organs
or their results, and in malpositions of the uterus.
Naturally we may eXpect the most favorable results in
lesions situated in the lowest part of the pelvis, for instance,
cicatrices following cervico-vaginal lacerations, hard exudates
as the result of chronic parametritis, deep~seated adhesions
and hands after perimetritis, as well as shortening of the sacro-
uterine ligaments. In adhesive bands of the fundus uteri the
effect is not so manifest, though in“ such cases we often succeed
in materially relieving the subjective symptoms- due to the
stretching of these bands. In the treatment Of retroversion
of the uterus, where the ﬁxations are low down in the pelvis,
‘ the results of this method are surprisingly good. In cases of
incarceration of the pregnant uterus, even a single introduc-
tion Of the vaginal colpeurynter (ﬁlled with mercury) was fol-
lowed by the correction of this abnormal condition (as reported
by Halban and Funke).
The principal contraindications of the use of this method
are all acute inﬂammatory conditions of the pelvic contents.
In some cases of sub-acute conditions we may use this treat-
ment, but only with the greatest caution, in order to avoid a
recurrence of acute symptoms, particularly in cases of pyosal-
pinx. In such cases, when the tubes and their exudates are
located in the cul de-sac, we Often get good results, if the
proper precautions are observed. Care must be taken that in
these cases the weight of the mercury in the vaginal colpeu-
rynter is between 200 and 400 grams, and the treatment must
be immediately stopped as soon as thepatient complains of
severe pain. Should the patient have an elevation of temper- ,
ature, this method must not be repeated.
- The general tec/cniqne of this method is as follows:
. Two vaginal colpeurynters are connected by means Of a
stOp-cock made of hard rubber, so that the whole length of
the apparatus is about 60 cm. Before cOnnecting this appa-
City Hospital Alumni. 99
ratus, one of the colpeurynters is ﬁlled with 1,000 grams Of
‘metallic mercury, while from the other the air is evacuated by
compression Of the bulb.
The patient is placed in a comfortable recumbent posi-
On a bed or couch, the foot end of which is elevated about 50
to 60 cm. '
The empty colpeurynter is folded, introduced into the
vagina and placed against the part desired. / It is retained in
this position by means of two ﬁngers, while the ﬁlled colpeu-
rynter is elevated with the other hand, allowing the mercury
to ﬂow downward. In the beginning Of the Course Of this
treatment it is advisable not to use more than between 250 to
500 grams, and only after the patient has become accustomed
to this treatment, we may increase the amount until the upper
colpeurynter is completely emptied. The closed valve then
prevents the return ﬂow of the mercury. A ﬂat linen bag,
containing 1,500 t0_-2,000 grams of shot is placed on the lower
abdomen.
The patient usually remains in the dorsal position, but
should it be necessary to turn the patient on either side, the
abdominal bag can be kept in position by means of a bandage.
To remove the ﬁlled colpeurynter from the vagina, the patient
is allowed to sit up, and by opening the valve and lowering
the empty colpeurynter, the metal ﬂows out readily.
The apparatus should be cleaned and kept in an antisep-
tic solution. .
At the beginning of the treatmentthe procedure must
not consume more than 15 minutes; yet, I have found that
patients become speedily accustomed to it, and it is by no
means uncommon that patients remain in the Trendelenburg
position with the pressure of 1,000 grams in the vagina for
four or ﬁve hours with very little inconvenience. Usually I
leave the colpeurynter in place .for one to two hours every sec-
ond day. As mentioned before, the treatment must be inter-
rupted should the patient complain of pain, and in a few days
it may be attempted again, but in the event of elevation Of
temperature this method must be given up, as this condition
contraindicates its use.
The pressure treatment is a form of forced massage, but
D
100 A Medical SOciety of
it does not exclude manual massage according to Thur-e
Brandt’s method. 8 i
We can treat more successfully the adhesions which are
situated higher up in the pelvis by means .Of manual massage,
after we have removed the exudates and adhesions below by
pressure weight. My experience, as mentioned before, justi—
ﬁes me to strongly recommend this treatment. If applied
according to the directions suggested in this paper, it will be
followed by good, sometimes by even surprising results.
DISCUSSION.
DR. HENRY _IAOOBSON thought this method of treating exudates
would be followed by good results. However, he had seen very ex-
cellent results from very large douches of hot water—three or four
gallons at a time, and afterwards the application .of a 25 per cent gly-
cerine and ichthyol tampon. He considered ichthyol a very excellent
remedy and used it on tampons,and lately had been giving it internally.
DR. MEISENBACH said it had been insinuated that American phy
sicians had made a “carpenter Shop” of the female vagina, that he
was in the habit of tinkering with the vagina and introducing all sorts
of instruments therein for relief. The speaker was glad to learn our
friends from across the water were following in the footsteps of the so
called American tinkerer.
In 1890 T hure Brand’s massage came in vogue. He was not a
physician, only a Swedish masseur who introduced massaging the pel-
vic organs. The treatment never received thorough recognition on
the part of the better class of German physicians. In the German
text-boOks on gynecology the methods are spoken of in the same
manner as generally quoted by American authors on gynecology. The
reasons why the method is not in vogue are many. The speaker did
not believe that from a moral or scientiﬁc standpoint that a woman
would be beneﬁtted by the massage treatment and he thought it was
Often carried on tO-day in a manner that would not stand the light of -
investigation. A
For the removal of these exudates he did not know of anything
superior to hot water with proper applicatiOn of ichthyol. and glycerine.
, The method outlined to-night appealed to the mechanical instincts of
City Hospital Alumni. 101
‘many but that it would do a great deal for the relief of patients he was
in great doubt. He did not think we could thus release a uterus bound
down by adhesions without serious after-effects. He did not think it
a safe procedure to lift a bound down uterus in that manner just as he
did not think it was wise to introduce a pessary into the vagina and
raise the uterus in that way; therefore, he thought it safer to do an
abdominal or vaginal section than attempt to work in the dark.
There are certain cycles in medicine and surgery—the methods
have their day, are used a while then cast Off. He was inclined to be
conservative and not operate on all cases; each should be studied
with regard toéits peculiar conditions. He failed to see how the bag
of shot Would be of beneﬁt when applied to the abdomen; if applied
in many cases he felt it would do more harm than good.
In treating patients in hospital and private practice we treat two
different classes of people ; iu the hospitals they are under our control,
and this is especially true of hospitals in Germany where patients are
looked upon as so- much material. In this country in private practice,
or even in the hospitals, patients can nOt be handled as they are in the
hospitals of Europe, therefore, many of the methods Of treating dis-
eases in vogue across the water can not be applied here.
DR. CHAS. SHATTINGER thought there ought to be no feeling or
antagonism between those who advocate surgical and those who adve-
cate mechanical means of treating these cases. We should try to es-
timate the relative value of the two kinds of treatment. All will agree
that it would be foolhardy to use the shot and mercury treatment in a
case of pyosalpinx, a case of encysted pus collection in the pelvis, or
purulent infection of the ovary. The indications here are as unequiv-
ocal as in case of a felon.
Surgeons are very apt to forget that when they take out an organ
or part of organ, instead of triumphantly declaring what they have
accomplished, they should feel humiliated. The ablation of an organ
is not a triumph of medical science, but an acknowledgment of the
failure of medical science. It is the acknowledgment that in order to
give relief "to a sufferer, it was necessary to mutilate him. However
by this he did not mean to say- that a diseased organ should be left in
the body when it can not be remedied. There is a difference, too, as
102 ' Medical Society of
to who the patient is. It may be a poor, working woman with little
time and less money to spend in attempting to secure relief in a round-
about way. It may be neccessary for her to make a sacriﬁce of some
part of her anatomy in order to get the organism into working condi-
tion. Even though the same results could be attained in some other
way, it might be right in such a case to take a short cut by resorting
to the knife. As there is no occasion for enmity between the advocate
of mechanical means and the surgeon, just so there should be no ref-
erence to difference in treatment according to nationality. German,
French and English treat the same as we do. Surgery is the same in
Berlin as in New York or St. Louis. But it may be said that Europe-
ans, having been accustomed to a more careful and more elaborate
training in medicine, approach the treatment of disease with greater
reference to physiology and pathology than the American physician,
which has led to the invention and use of certain methods less known
here. That has nothing to do with nationality, but with habit of
thought. In this connection he desired to refute the statement of Dr.
Meisenbach, namely, that T hure Brand’s treatment was not adopted
by the more reputable physicians. It is true that Brand was a layman,
and that his treatment met with great Opposition. That recognition
was refused so stubbornly by so-called reputable physicians was, in the
speaker’s Opinion, simply an indication that these men were not broad-
niinded enough to investigate the merits of something which came
fromia layman. Thure Brand ﬁnally succeeded in getting one man to
try his method in a gynecological clinic and, much to the surprise 'of
this gentleman, excellent results were obtained. An extravagant en-
thusiasm followed this trial, which carried its advocates too far. In the
course of time its limitations were discovered and it now occupies a
legitimate ﬁeld. .
The'criticism of immorality should not be laid to its door and the
speaker said he personally refuted this statement. He uses the method,
and knows he uses it with clean hands and that his patients receive it
with clean sentiments. He had only lately had. occasion to treat a
lady who had been in the hands of physicians off and on for ten years .
Among her medical advisers were some _of the most eminent,men of
our city, and several of our best surgeons. Almost without exception,
City“ Hospital Alumni. 103
they advocated an ovariotomy. She came to the speaker for general
treatment. Incidentally to his examination, he discovered a pelvic
trouble. He found a cystic and prolapsed ovary, the pathological
condition being so marked that he, too, advised an operation. He told her that her general condition, though not entirely dependent
upon the local trouble, would probably become much better if the
ovaries were removed, and that general treatment would promise more
afterwards than if the organs were allowed to remain. She positively
refused an operation and desired him to do all that was in his power
without resorting to surgical means. He promised to do so with the
distinct understanding that he would not be responsible for results. In
connection with other means of treatment he used the constant current
and massage for a number of weeks. The patient still has a cystic
ovary, but it is not prolapsed, and she is free from local symptoms and
almost free of general disturbance. She declares she is glad she has
fought against operative interference for so many years, feeling all the
time that some day she would be relieved without an operation. He
did not relate this case with a boastful mind or to indorse the views of
the lady in oppositiOn to the Opinion of the able medical men she had
consulted, but to show that he, himself, had in this instance been made
a convert. Every day taught him new possibilities in the way of me-
chanical therapeutics.
The treatment advocated by this evening’s paper is a form of
' massage, and the main effect is probably upon the circulation. The
bag of mercury will no doubt produce a certain amount of local ane-
mia during the time it is in place, especially when, coupled with eleva-
tion of the hips, while its removal will be followed by a reactive
hyperemia. .
DR. F. REDER doubted very much if a patient would tolerate the
treatment mentioned by the essayist for any length of time. He did
not think there was anything new about it except the appliance and he 1
did not think it was a superior method. He could not be convinced
that anything was superior to the human hand. The exudations in
pelvic conditions are almost exclusively pus formations and many do
yield to massage treatment, but the massage is manual, by introducing
the ﬁnger into the vagina with a boring motion about the walls as long
104 ~ Medical Society 01
as the patient will tolerate it; this could be carried on two or three
times a week. He did not believe a patient would assume the Tren-
delenburg position with a weight on her abdomen and remain so for
any length of time.
DR. JOHN GREEN, ]R., asked in what direction the shot bag exer-
cised pressure with the patient in the Trendelenburg position. If the
position were extreme he thought pressure would be toward the dia-
phragm and not toward the pelvis.
DR. EHRENFEST, in closing, said that this treatment does not ex-
clude other kinds of treatment. It is usually combined by him with
hot water douches and ichthyol tampons. He would add, however,
that Professor Schauta, of Vienna, had been one of the ﬁrst to recog-
nize the value of gynecological massage, if properly applied. Schauta
states that he cures one third of his patients suffering from chronic
pelvic exudates and their residua, by means of massage. The value
of this treatment has been repeatedly acknowledged by men like
Chrobak or B. S. Schultze.
The speaker called the attention of Drs. Meisenbach and Reder
to the reports_of F unke and Halban. The latter contains detailed
histories of thirty-ﬁve cases. The speaker had, himself, treated many
cases with “pressure weight” and he could assure Dr. Reder that the
patients, with the exception of a few had “tolerated” this treatment
without complaint. The position assumed is not the extremeiTrendel-
enburg position, as the foot end of the bed or couch is raised only 50
60 centimeters, just enough to give the weight of the mercury in the
vagina a better direction. For this special purpose a pillow placed
under the buttock proves advantageouly.
The treatment is called in the .German language “Belastungs ‘
Therapie,” and not as Dr. Reder said, “_Belaestigungs Therapie.”
The speaker repeated, what was stated in the paper, that all acute
'inﬂammations of the pelvic contents strictly contraindicate this treat-
ment. In cases, in a subacute state, it may be tried, but only with
the greatest precautions.
City Hospital Alumni. 105
, Meeting of ﬁlare/z 21, 1901; Dr. Nerr/elle Wallace Sharpe,
President, 2'12 the Chair.
Duodenal Stenosis Due to Gall=Stonesz Report
of a Case.
BY ALBERT E. TAUSSIG, M.D ,
s'r. LOUIS, MO.
HE great majority of gall-stones that pass down through
the common duct into the duodenum pass through the
intestine without hindrance and are excreted with the
stool. Such stones are rarely larger than a small hazelnut.
When the stones are larger, however, their elimination is not
so simple. Such stones can not enter the cystic duct, still less
can. the pass the sphincter that separates the common duct
from the duodenum. They usually, sooner or later, become
adherent to the wall of the gall-bladder or imbedded in it.
' This may be followed by an inﬂammation about them; adhe-
sions.form between the inﬂamed gall bladder and other organs
or the parietes, and the stone burrowing it way through the
ﬁbrous mass escapes from the'gall-bladder. Such stones may
penetrate the bowels, stomach, pelvis of the kidney, ureter,
bladder, uterus, vagina, pleura, liver, portal vein, and the ab-
dominal wall. They have been vomited from the stomach,
coughed from the lung, passed from the bladder, and expelled
from the uterus during childbirth. Porges relates a case of
apparently incurable ﬁstula in the right thigh that was sup-
posed to be tubercular or syphilitic and that resisted all treat-
ment. On opening up the ﬁstuious tract, he found near the
right trochanter a large gall-stone that had wandered down,‘
retroperitoneally from the gall-bladder. ,
Of all the abdominal viscera, the one most apt to be pierced
by an ulceratin-g gall-stone is the intestine. The ileum, on ac-
count of its mobility, is but rarely perforated. The colon and
duodenum are more frequently affected. In its normal posi—
tion the fundus of the gall-bladder lies against these portions
106 Medical Society of
of the intestinal tract; if it lies rather towards the median line,
the stone will perforate into the pylorus or the ﬁrst part of the
duodenum; if it lies more to the right, into the colon or the
second portion of the duodenum. If the stone has penetrated
the colon, it rarely causes much trouble, but is passed uncon-
sciously. If it enters the duodenum, it usually passes down~
wards into the ileum, and there or even in the jejunum may
cause intestinal obstruction. A large number of cases of ileus,
often ending fatally and due to the impaction lower in the gut,
of stones that had ulcerated into the duodenum, have been re-
ported. Much less frequent are the cases in which the stones
have perforated the stomach. Here pyloric stenosis may re-
sult, leading to stagnation of the stomach contents. If the
stone has actually penetrated the gastric cavity and lies loose
within it, it may act as a ball-valve. Osler has reported a num-
ber of such cases in which such a stone caused paroxysmal
pyloric stenosis separated by intervals of comfort; the obstruc—
tion occurred whenever the stone happened to be in front of
the pyloric oriﬁce.
More frequently we have a pyloric or duodenal stenosis
caused by adhesions of the pylorus to the inﬂamed gall-blad-
der, or by an inﬂammatory thickening of the pylorus and
duodenum, or by the perforation into the lumen of the pylorus
or duodenum of a stone so large as to occlude it. In such cases
we usually.have paroxysmal attacks of gastralgia, due to vio-
lent peristaltic contraction of the gastric muscularis; later dila-
tation with fermentation of the gastric contents ensues. The
diagnosis is apt to be that of an ulcus scar at the pylorus, or if
the stone can be felt, even of carcinoma—until the detection
of a stone in the stool or vomit clears up the diagnosis. Occa-
sionally, as in a number of cases cited by Gaillard, the stones
have even been obtained by means of the stomach tube.
Sometimes stones that have penetrated the lower duode-
num do not pass down into the jejunum and ileum without
further disturbance, but remain in the duodenum and cause
trouble there. A number of such cases of obstruction near the
lower end of the duodenum are on record. They have a very
deﬁnite symptomatology—persistent vomiting of large amounts
of bile and absence of meteorism and fecal vomiting. Both
City Hospital Alumni. 107
symptoms—positive and negative, prove that while there is in-
testinal obstruction, the seat of the stenosis can neither be in
the lower part of the gut (owing to absence of ileus), nor proxi-
mal to the mouth of the common duct (owing to biliary vomit).
The stomach contents in such cases should contain pancreatic
juice in addition to the bile, though I do not know that this
has ever been looked for.
Cases in which the stones perforate the duodenum be-
tween the pylorus and the mouth of the common duct and re-
maining there cause a stenosis at this point, must be very rare.
Indeed, in the literature at my command, I have not been able
to ﬁnd the report of a case. It would not seem possible, clin-
ically, to differentiate such a condition’ from that of pyloric
stenosis. The following case, observed at the medical clinic
of the Washington University Polyclinic, illustrates this con~
dition:
Edith B., 31 years of age, midwife, came to the clinic for treat-
ment March 9,1900. Her family history was good, and except as
follows she had never been ill. Has borne two healthy children, the
younger six years old. N o venereal history ascertainable.
Six years ago she was awakened one night by a severe colicky
pain in the epigastrium lasting several hours. Three years ago she
had a similar attack, and one year ago a third. The third attack was
followed by icterus, the ﬁrst two were not. She had never had typhoid
fever; in fact had always enjoyed the best of health.
Four months before coming to the clinic she had an attack some-
what resembling the previous ones, but characterized less by pain than
by what she calls “an uneasy, smothering feeling ” in the epigastrium,
accompanied by a sensation of gastric distention. The distress was
relieved by the application of heat; but instead of soon being replaced
by a condition of well-being, as had been the case before, it had re-
curred at frequent intervals and had entirely incapacitated her for work.
She soon began to vomit, usually from one-half to two hours after eat-
ing, and sometime before coming to the clinic had retained practically
nothing. Solids had been retained longer than liquids, and all food
had been retained better when she was in the recumbent position.
Oddly enough, castor oil and other drugs had been retained better
than food. The vomit had never been large in quantity, had a sour
taste, and had only once been blood-streaked. Appetite good, but
capricious, thirst excessive, bowels habitually costive.
108 Medical Society of
Patient was pale and thin; she said she had lost thirty-ﬁve pounds
in four months.
The thoracic viscera were apparently normal. On inspection, the
stomach could be made out as a smooth, rounded tumor ﬁlling the
epigastrium. A series of vigorous peristaltic waves could be seen
traversing it from left to right. The stomach tube was introduced and
contents expressed; this was two hours after an Ewald breakfast.
There were obtained 160 c.c. bread and water, fairly well macerated
and digested. A few ﬂakes of bile-stained mucus were present, but
none of the milk ingested the day before. The stomach contents
showed no sign of putrefaction or unusual fermentation. Total acidity
0.18 per cent, free HCl (Congo) 0.09 per cent, no lactic acrd present.
The stomach was then inﬂated; laterally its borders extended to the
edge of the epigastric region, inferiorly did not quite reach the umbili-
cus. N o tumor could be felt. After the expulsion of the air, the ab-
domen was very ﬂaccid and the edge of the liver could be felt extend-
ing one and one-half inches below the costal margin. The other ab-
dominal viscera were normal.
Repeated examinations of the abdomen and of the stomach con-
tents gave the same results, excepting that on one occasion a hard,
smooth mass about the size of a walnut and very tender and not mov
ing with respiration couldbe felt in the epigastrium. This was never
again found.
Urine, rozo—normal. Blood, hemoglobin 60 per cent, histologi-
cally normal, no leucocytosis.
A provisional diagnosis of benignant pyloric stenosis, due to an
ulcus scar, was made, and the patient kept in bed on a mild diet and
with regular lavage.
For several weeks she did well under this treatment, but then went
from bad to worse, and ﬁnally consented to an exploratory laparotomy.
The operation was performed by Dr. Tupper in the amphitheater
of the Polyclimc. On opening the abdomen the stomach was found of
the normal size, and the pylorus too, when brought into view, showed
externally no abnermality. The gall-bladder was distended with bile
and apparently normal. A small incision was made'into the anterior
wall of the stomach near its pyloric end; the surgeon’s ﬁngers, inserted
into the pylorus, found no stenosis. On being pressed down farther
into the duodenum, however, a hard mass could be felt just beyond
the pylorus, and after some effort seventeen faceted gall-stones were
brought into view and extracted. The gastric and abdominal wounds
were then sutured. The patient made a nearly uninterrupted recovery
City Hospital Alumni. 109
and for several months was relieved from all her previous distress.
Since then she has dropped out of sight.
This case is of interest for several reasons besides its rarity.
The comparative frequéncy of pyloric stenosis, due to an ulcus
scar, led us to interpret the patient’s previous attacks of colic
as due to an ulcus, when an unprejudiced consideration of the
history should have led us to the correct diagnosis. The mass
of stones had evidently ulcerated from, the gall-bladder into
the wall of the duodenum and remaining there had caused a
partial stenosis. It seems rather strange that while the stones
were easily dislodged by the operaior’s ﬁngers the violent
peristaltic efforts of the stomach should have failed to dislodge
them.
In my case the patient was observed and operated upon a
comparatively short time after the formation of the stenosis, so
that we found a great hypertrophy of the gastric walls without
dilatation and with frequent vomiting. If the case had gone on
without interference, we should next have had a dilatation with
less frequent but more profuse vomit that would have shown a
greater and greater degree of fermentation and decomposition.
Finally, when then the dilatation had reached its maximum,
the vomiting, as in excessive dilatation- from other causes,
would have ceased, we might even have had a lactic acid fer-
mentation and the case might have closely resembled one of
malignant pyloric stenosis.
BIBLIOGRAPHY.
Galliard, Amer. jour. Med. Sci., XI, p. 98, On pyloric Obstruction
due to Gall-Stones.
Twentieth Century Practice, IX, pp. 765, 768, a general discus-
sion of the subject.
Nothnagel, Darm und Peritoneum, II, pp. 278-281, Intestinal
Obstruction due to Gall-Stones.
Nothnagel, Kr. der Leber, esp. pp. 238, 239, also pp. 208, 209,
216,235.
Herz, Deutsche med. Woch., r896, Nos. 2 3 and 24, On Duodenal
Stenosis.
Robt. Porges, Wiener klin. Woch., 1900, N o. 26, On Wandering
Gall-Stones.
110 Medical Society of
E. C. Davidson, N .Y. Med. ]our., january 20, 1900, On Perforat-
ing Gall-Stones.
]. B. Bradbury, Amer. Year Book, 1899, p. 298; Brit. Med. ]our.,
September 2 5, 1897, A Case of Gall-Stone Stenosis.
F. F. Ward, Amer. Year Book, 1899, p'. 202; Med. Rec , Ianuary
22, 1898, a similar case.
Wilkinson and Aeria, Amer. Year Book, r898, p. 189, Cases of
Gall-Stone Ileus.
Lycett, Amer. jour. Med. Sci., CVII, p. 84; Brit. Med. Jour ,
1893, No. 1706, A Case of Pyloric Stenosis, Hematemesis, large stone
vomited.
Castqer, Virch. Yahrsb., 1894, II, p 22 3, Gall-Stone Ileus.
N. Reichmann, Berl. klin. Woch., 1897, No. 3 3, Pyloric Stenosis
due to Gall-Stones.
Nasse, Ibid., 1894, p. 899, Gall-Stone Ileus due to Perforation
into Duodenum.
A. Schuele, Ibid., 1894, p. 1015, Duodenal Stenosis due to Gall-
Stone.
Pozzi, Bull. de la Soc. de Chirurgie, 1894, p. 630, Duodenal
Stenosis due to Gall-Stone.
C. Liebermeister, Krankheiten der Unterleibsoréane, p. 284 ff.
Wood and Fitz, The Practice of Medicine, pp. 940, 943.
H. Elsner, Med. News, LXXII, p. 172, Wandering Gall-Stones.
See this article for much additional bibliography.

Meeting of April 4, 1901; Dr. Nornelle Wallace Sharpe,
President, in the Chair.
Report of a Case of Anthrax.
BY AMAND RAVOLD, M.D.,
ST. LOUIS, MO.
HE patient, Mrs. Z., age 38 years, white, married, mother of two
children, has suffered for some years with chronic nephritis; is
fairly well nourished but anemic. September 29, while scrub-
bing- a slate drainage board attached to one side of her kitchen sink,
ran a small splinter of slate into the outer surface of the ﬁrst—phalanx
of the little ﬁnger of her right hand; the splinter was a small one and
City Hospital Alumni. 111
broke off even with the surface of the skin ; she dug out the splinter '
with a pin which she ‘heated in a gas ﬂame before using; the splinter
was very friable and she experienced a good deal of trouble in remov-
ing it, but afterwards continued at work. That night the wound
pained enough to interfere somewhat with sleep, and by noon the next
day, twenty-four hours after the injury, the pain, now of a throbbing
character, was so severe that she came to me for relief.
The site of the splinter could be made out distinctly by a dark
line, about 7 millimeters in length, beneath the skin; it seemed to me
a very trivial wound to be the source of so much suffering, neverthe-
less I open it up with a sharp bistoury. The small amount of debris
along the line made by the splinter was carefully cleaned out, and the
wound washed out with a solution made up of 5 per cent carbolic acid,
to which is added corrosive sublimate sufﬁcient to make 1Am, and
hydrochloric acid .5 per cent. This is a strong and penetrating disin-
fectant. The solution was rubbed into the wound and kept in it for
about ﬁve minutes; the ﬁnger was then washed in sterile water,
wrapped in corrosive sublimate gauze covered with rubber tissue and a
bandage. Patient left with the pain very much relieved.
October 3, she came to my ofﬁce and said that up until that
morning she had been free from pain in the wound, but that now it
was of a throbbing character and as severe as when I ﬁrst saw her.
She certainly had the appearance of one suffering severe pain. In-
spection shows a slightly inﬂamed wound with a small drop of pus in
its depth. This was cleaned out, the wound again disinfected with the
carbolic acid and corrosive sublimate solution, dressed as before and
the patient left practically free from pain, with instructions to wash the
wound every morning with a 1/2000 solution of corrosive sublimate, and
to dress it with gauze and rubber tissue, of which I gave her enough
to last several days.
October 8, ﬁve days later, she again came to my ofﬁce complain-
ing of a throbbing pain in the wound which had begun in the night.
I found the ﬁnger much swollen and indurated. The wound was
nearly healed, with no pus in it, but a vesicle had formed about it and
extended across the upper surface of the ﬁnger, between the nail and
joint, then down along the inner surface of the ﬁnger as far as the
second joint. I split open the vesicle, washed it out with a 1/mo solu—
tion of corrosive sublimate, and dressed it with powdered boracic acid,
gauze, rubber tissue and bandage. I requested her to return the next
day, for I feared that I had poisoned her with the carbolic acid and
corrosive sublimate solution, and had another case to add to the long
list of dermal poisoning with carbolic acid.
112 Medical Society of
I did not hear from her until early on the morning of October I r ,
when I was called to the patient’s home, and found her in bed recov-
ering from an hysterical attack brought on, she said, the night before
by the throbbing pain in the little ﬁnger, and in which she had been
attended by Drs. ]. M Grant and S. Klein. She now complained of
intense pain in the wound; I removed the dressing which she had
about the ﬁnger and hand, and found the ﬁnger, hand and forearm
much swollen, with the glands in the axilla tender but not perceptibly
enlarged; a hemorrhagic vesicle had formed in the area of the ﬁrst
vesicle and the skin about the edges of the vesicle was black and
necrotic looking; the vesicle was incised and from the dark bloody
ﬂuid which discharged, a swab culture was made on Loefﬂer’s medium,
a tube of which I fortunately had in my valise; I also snipped out a
small piece of the necrotic area, which after dressing the wound I took
to my laboratory; the small piece of necrotic tissue was stirred about
in melted agar, plated in Petri dishes and put in an incubator at 37°C.
That afternoon the patient was much easier, temperature 101°F., pulse
110, urine contained .5 per cent of albumin and a large number of
small and large hyaline, epithelial and granular casts.
October 12, agar plate showed a number of characteristic anthrax
colonies; cover‘ glass preparations were made from several of the col-
onies and from the growth in the culture tube; all showed a large,
thick bacillus with squared ends, which stained easily, but no spores
could be demonstrated in the bacilli. The diagnosis was now clear,
my patient was suffering with anthrax (malignant carbuncle); I hur-
ried to her home and found her suffering with increased pain, very
nervous, temperature 102.2°F., pulse 108, and had slept very little
during the night; wound showed necrotic tissue in all of the area 00-
cupied by the hemorrhagic vesicle, but no new vesicles had formed;
wound was anesthetized with 5 per cent cocaine solution and the en-
tire necrotic area thoroughly curretted, then cauterized with pure car-
bolic acid, washed in sterile water and dressed with sublimate gauze.
Temperature returned to the normal on the third day; swelling of
hand and arm soon disappeared, but the wound on the ﬁnger healed
slowly. '
Patient made an uninterrupted recovery.
The puzzling question in this case is, where did _the infec-
tious material come from P Was it conveyed to the wound by
the splinter, the pin, the brush, the knife with which the wound
was cleansed, or in some other way P
The drainage board from which the splinter came, is
City Hospital Alumni. 113
of slate,‘ with grooves cut in it which deepen as they approach
the sink. Meat, when it comes from the butcher, is sometimes
placed on the drainage board, and it is within the range of
possibility that anthrax bacilli were sown into it from a piece
of diseased meat. However, cultures made from scrapings of
the board failed to show the anthrax bacillus. The pin was
ﬂamed before being used to dig out the splinter. The scrub-
bing-brush was a new one, having been purchased that morn-
ing, and its bristle were not of animal, but of some kind of
vegetable ﬁbre. The knife with which the wound was scraped
was ﬁrst dipped in alcohol,'and the alcohol burned off before
using, which insures sterilization.
Anthrax is very rare among cattle in this region. In
1895, however, quite a number of cases of the disease were
discovered among the diary cattle of the city, but it was
quickly suppressed by the energetic action of Health Commis-
sioner Dr. Max C. Starkloff, who quarantined all infected
stables and destroyed and incinerated all diseased animals.
To the knowledge of the health authorities, no case of the
disease has occurred among cattle in this vicinity since that
date. A case of the disease in man was reported from St'
Louis county in june, 1900, by Drs. Elsworth Smith and H.
G. Mudd. The origin of the infection in this case is unknown,
which must also be declared of my case.
The bacteriologic examination of bacillus found in ne-
crotic tissue from Mrs. Z., was as follows:
Bacillus, square ends, 3 to 5 m. in length. Isolated and
in chain. Nonniotile. Forms spores in center of rod.
Stains easily with watery solutions of the basic aniline
dyes. Decolorizes slowly when stained according to Gram.
Spores stain with Ziehls’ carbolic fuchsin.
It grows freely on broth, forming a thick white granular
deposit, with small ﬂocculent masses clinging to side of tube.
Gelatine plate, after six days at 20°C. shows small and
large colonies, nearly all showing small amount of liquefac-
tion; colonies under low power of microscope show ﬁnely,
granular center with wavy threads extending out at some
length from center, giving the so-called Medusa head appear-
ance.
\
114 Medical Society of
Gelatine cultures show a yellowish white growth along
the thrust, with small spiculae of growth extending but at
right angles from it, giving a root-like appearance.
Glucose gelatine, slowly liqueﬁed but no gas produced.
Milk, coagulated and casein liquiﬁed.
Potato, thick smeary yellowish brown growth.
Guinea pig weighing 465 grammes, injected subcuta-
neously into abdominal wall with I cc. of 48-hour old broth
culture. Died in 60 hours.
On post-mortem, made the same day, the abdomen was
found to be swollen, the swelling extending to chest wall.
Subcutaneously tissue, semi-ﬂuid and gelatinous, with ecchy-
motic spots scattered through it. Lungs pale. Heart cavi-
ties distended with blood. Liver somewhat enlarged, with
cloudy swelling. Spleen very much enlarged, dark, soft,
friable. Kidneys congested.
Bacillus found in smear cover glass preparations made
from heart blood and spleen pulp.
Diagonsis.--Bacillus anthracis.
DISCUSSION.
DR. GRAnwor-IL said it seemed to be a clear case of anthrax in-
fection. It is a disease of cattle and seldom affects man except those
who handle wool and hides. It is rather common in Russia and Ger-
many among those who handle wool and hides ; he had seen one fatal
case in Germany. The disease is practically extinct in France, where
the vaccine method was instituted among the lambs and sheep ; it was
formerly very common there. In Russia the disease also affects horses
and men engaged in handling the hair of horses’ tails _-which is an
industry—suffer from the disease. '
In this connection he spoke of the recent work of two men in
Vienna on anthrax in which it was endeavored to show that symtom-
atic anthrax was rather common in rag-pickers. The speaker thought
this was not the real anthrax bacillus but another which resembles it
closely morphologically and‘pathologically. These men tried to show
that there was no such thing as anthrax. Dr. Gradwohl felt convinced
that the bacillus which they described was nothing but the bacillus
aerogenes capsulatus which Welch, of Johns Hopkins, had already
City Hospital Alumni. 115
discovered. It seemed to him another instance of European investi-
gators neglecting to look up the literature and failing to see the work
of Americans.
DR. RAVOLD, answering several inquiries, said that no one was
justiﬁed in making a diagnosis of anthrax, unless the case was well
advanced, without the aid of the microscope and culture tubes. He
had hoped that some one would have discussed the question as to
how the bacillus got into the wound ; as for himself, although he had
made diligent inquiry, he could not account for it. As to whether
dipping agknife into alcohol and then burning it off would sterilize the
blade without injury to the temper, he knew positively that the proced-
ure would insure sterilization, but as to injuring the temper and dulling
the edge he was not so certain; he would not treat a delicate instru-
ment in that way. He wished to emphacize the fact that in this case
he was certain that he was dealing with a case of carbolic acid necro-
sis and was very greatly surprised and alarmed at the bacteriological
evidence. Hereafter, he would not only have recourse to bacteriolog- -
ical'aid early in such cases, but would use pure carbolic acid in all
suspicious wounds, because the pure acid penetrates deeply and
destroys spores of anthrax and tetanus in a very short while.

Tetanus Neonatorum: Report of a Case
That Recovered.
BY 1. c. FALK, M.D.,
ST. LOUIS, MO.
HE child, male. was born October 21, 1900, the attendant being
T a competent physician of this city. I was informed by the
family that it was necessary to use the forceps in delivery ; no
especial difﬁculty seemed to have attended the birth, and there was only
a slight abrasion on one side of the infant’s head from the use of the
forceps. The child was subsequently taken care of by an old lady, a
relative, who dressed the navel daily with absorbent cotton and petro-
latum. The navel separated on the ﬁfth day.
Nothing out of the ordinary was noticed until the eighth day-
116 Medical Society of
October 29th, when in the forenoon the mother observed that the child
could not nurse; thinking its mouth was sore she used some household
remedies, but the condition growing worse, I was called in during that
evening.
On my arrival I found the infant normally developed and fairly
well nourished; it cried intermittently, the jaws were closed so as to
admit only with some force the tip of my little ﬁnger; about every
ﬁfteen minutes he had spasms, during which the ﬁsts were tightly
clenched, hands ﬂexed on the forearms, forearms on the arms and
the latter drawn ﬁrmly against the chest; the lower limbs were
similarly drawn together, the thighs being pulled up on the abdomen.
I noticed no opisthotonos, although the family claimed to have seen
the body straighten out and the head drawn back during some of the
convulsive attacks; I noticed a marked emprosthotonos several times.
During the spasms the child cried hard through the the partly-closed
mouth, the jaws at such times being noticeably pulled tighter and the
angles of the mouth drawn out.
The extraneous surface was cool and moist, axillary temperature
98°F, pulse 160 and regular. Deglutition was almost impossible,
ﬂuids being sucked into the respiratory tract at every attempt. There
was some suppuration at the navel but nothing unusual in its appear-
ance. I gave one grain of calomel by the mouth, and ordered chloral,
two grains, and potassium bromide, four grains, per rectum, every two
hours, and left instructions for rectal feeding.
On the following day, October 30'h, his temperature was 100°F.
and spasms recurred every half hour. I increased the doses of chloral
to four grains and the potassium bromide to eight grains every two
hours.
October 31th, the temperature was ror°F., his condition the same
as on the previous day, but the spasm seemed to be a little milder.
November rst, rectal temperature 99°F, general condition about
as yesterday; paroxysms still recur about every half hour. At 8 RM.
10 cc. of antitetanic serum was injected at one time, the injection be-
ing made deep into the buttocks. The administration of the chloral
and bromide was continued.
November 2d, rectal temperature normal. Mother says baby had
a much better night; spasms are not coming so often (about every
hour), the child having slept all of the intervals between attacks. An-
other 10 cc. of the serum was injected at 10 o’clock in the morning;
the chloral and bromide being given per rectum every three hours.
November 3d, rectal temperature normal morning and evening;
improvement marked; slept two hours at one time last night and three
City Hospital Alumm. 117
hours at another. He is now being fed with breast-milk from a spoon;
swallowing is still difﬁcult;'opens mouth better and cramps are less
severe, recurring at intervals of one to two hours. Injected 5 cc. of
the serum at 10 o’clock in the morning and the same amount at 6
o’clock in the evening. ‘
November 4th and 5th, slight improvement noticeable each day.
November 6th, rectal temperature 99°F. Swallows fairly well,
but is still unable to nurse at the breast. Convulsive movements have
ceased, there being only a slight stiffening of the muscles of mastica-
tion and occasional mild rigidity of the arms and legs. Gastro-intes-
tinal disturbances (vomiting and diarrhea) having appeared the chloral
and bromide were discontinued and bismuth subnitrate administered.
November 8th, the baby sleeps well at times but whines and is
restless the greater part of the day and night; rectal temperature
100°F.; spasms and rigidity of the muscles have ceased entirely. A
bromine acne has developed on the face and upper part of the body.
November 10th, the child slept six hours at one time last night;
vomiting and diarrhea have ceased; now nurses at the breast; tem-
perature normal.
December 20th, the baby is gaining rapidly in weight and is in all
respects a normal infant. This was evidently a case of tetanus of
moderate severity, as on the second day there were already signs of
improvement noticeable; the change for the better was much more
marked after the serum had been administered and recovery subse-
quently progressed steadily.
It will be observed that the ﬁrst two injections of serum were full
ordinary adult doses of IO cc. each.
DISCUSSION.
DR. H. S. CROSSEN thought that the serum treatment was not
used as frequently as it ought to be, not only in this class of cases, but
in all forms of tetanus. He said he would like to hear from Dr. Ravold
what effect had been obtained recently in the treatment of tetanus by
serum. He was particularly interested in the report read this evening,
because he had treated a case of tetanus not long ago. It was that of
a small boy who had received a wound of the foot and several days
after began to have trouble in masticating his food. The family sup-
posed it was sore throat and paid no attention to the symptom. A day
or two later, however, in the middle of the night, the child had a chok-
ng spell, and the speaker was telephoned for. He found a clear case
118 Medical Society of
of tetanus. The wound was almost healed. He excised, the granulat-
ing area and the inﬁltrated tissue down to the healthy tissue, and in
the morning used the serum; in all he gave the boy three or four in-
jections. He also used morphine, chloral, and the bromides, but at-
tributed his success very largely to the use of the serum. The attack
was not very severe. He had, however, seen cases in such a stage
progress and become very severe.
DR. F. G. N IFONG was an ardent advocate of serum therapeutics.
Hts experience was limited to the use of diphtheria antitoxin and anti-
streptococcus serum and on the use of the former he had made some
reports to this Society. He thought that even a limited number of
favorable reports on the use of antitetanus serum would greatly
strengthen the position of the serum therapeutist. In a condition so
uniformly fatal some good reports would make unanswerable argument.
DR. N. SAENGER spoke of the case of a boy who had received a
gunshot wound of the hand. The patient was not seen by him until
about ten days later. The symptoms of tetanus had then commenced.
He immediately dressed the wound antiseptically, though it did not
show much inﬂammation, and administered the antiseptic serum; in
all, three or four bottles were used. On the third day the patient died.
He believed there might have been a different result had the serum
been used early in this case. He felt conﬁdent that it is of great value
when used early, but in neglected casesrit does not seem to be of
much beneﬁt.
DR. R. B. H GRADWOHL said the result in this case was en-
couraging. The cases he had seen in the City Hospital were nearly
all failures. He had also seen the serum used in one case, very early
in the attack, in Germany, which also failed. The experience of most
men in that country was that the serum was not as much of a success
as it had been hoped it would be In France the best results had been
achieved with serum-therapy. Beyond question the serum, to be of
beneﬁt, must be used early in the disease. The toxin is so virulent
that no relief can be hoped for if the injection is delayed. In the case
reported this evening the medication afforded some relief, as there was
some betterment before the serum was injected. He thought that the
intracranial injection of the serum was too heroic a measure to be
useful. '
City Hospital Alumni. 119
DR. H. W. SOPER thought the case a very mild one. A case re-
ported by Dr. Runge some years ago was treated with large doses of
chloral and bromide—to almost a toxic degree. Very soon after that
report the speaker saw a case of tetanus and adopted the same method
of treatment. It was a mild case, running much the same course as
that described by Dr. Falk, and the child recovered in about the same
way. He would not say whether the serum had much effect or not.
Dr. Falk compelled his patient to rest as much as possible, but in his
case the speaker said this was not possible. Nourishment was given
in frequent doses of small amounts of milk and this had been adminis-
tered a few drops at a time so that it trickled down the esophagus.
Another case was seen at the City Hospital. A boy had his foot badly
crushed by a car. Two weeks later he developed tetanus and had
violent convulsions every day. Everything was tried, including large
‘doses of arsenic, but the patient ﬁnally died. The temperature ranged
from 103° to 106° F.
DR. AMAND RAVOLD was very much interested in the case re-
ported by Dr. Falk, and was of the opinion that Dr. ]. Friedman had
reported one or two cases of the disease in infants, which had recov-
ered with antitoxin treatment. In regard to the bacillus, he felt certain
that it had been established beyond a shadow of a doubt that the teta-
nus bacillus is the etiological factor in the causation of the disease,
and that without the tetanus bacillus, no true tetanus. In the discus-
sion the fact seems to have been lost sight of—that there are all de-
grees of virulence in the bacillus, as well as there are varying degrees
of susceptibility in the individual; the child possessing less resistance
than the adult. In his opinion the disease might be divided into three
classes:
First, cases in which the period of incubation is of long duration
(over nine days) before trismus occurred and in which the symptoms
were mild, the jaws but slightly locked, and the spasms and convul-
sions wide apart. Cases of this class almost invariably recover without
treatment.
Secondly. cases in which the period of incubation is less than
eight days with a rapid onset of the symptoms, or those of a long
.period of incubation and a very rapid onset of symptoms. Cases of
120 Medical Society of
this class are beneﬁted by any treatment which assures sleep (for there
are are no convulsions during sleep) and causes long intervals be-
tween the convulsions. Here cleansing of the wound, quiet, hygienic
measures, and such drugs as chloral, bromides, morphine, arsenic and
antimony save fully ﬁfty per cent of the cases, while recent statistics
seem to show a decided improvement in this class of cases when anti-
toxin is used in conjunction with other drugs.
The third class of cases have a short period of incubation, less
than four days, with a frightfully rapid onset of symptoms. This class
of cases are hopeless under any treatment and invariably die within
forty-eight hours after the ﬁrst symptoms occur.
The reason why tetanus antitoxin is of so little value in the dis-
ease is that it is administered too late, and this is on account of the
nature of the disease, as a diagnosis of it can not be made until the
spasms and convulsions characteristic of the malady occur, and the
interval of time during which the tetanus toxins have been poisonous
—the cells of the central nervous system——is so great that they are
injured beyond repair. The real value of tetanus antitoxin is as a pro-
phylactic remedy, administered to patients who have received grave
surgical injuries in which dirt has been driven into the wound, and in
penetrating wounds made with unclean weapons. In this class of cases
tetanus antitoxin will immunize patients apainst the disease with almost
absolute certainty, and as it is a harmless remedy, should be fearlessly
administered when indications demand it.
The tissues about the wound should always be excised, otherwise
the bacilli in the wound would continue to manufacturing toxins which
would ﬂoat in the blood-stream and injure additional nerve cells,
The dosage should not be less than 25 cc. (preferably 50 cc.) of
antitoxin of the highest potency. Intracranial injections had been in-
troduced as the results of Roux’s experiments upon animals, and so
far as the literature was available of its use in man, the results were
not very satisfactory.
DR. P. ]. HEUER said the intracranial method had been tried in
several cases in St. Louis with fatal results in all. The injections were
made after trephining and large doses were given but without apparent
effect.
City Hospital Alumni. 121
DR. F. REDER said that the success of the toxin lay in its early
use. He spoke of the case of a man who stepped on a nail. The nail
entered the heel of the left foot about half an inch. Three hours later
he came to the speaker complaining of inability to open his mouth.
He also complained of feeling sick. The speaker incised the wound
freely and put on a moist dressing. By morning all the disagreeable
symptoms had subsided. He believed tetanus would have developed
in this case had not the incisions been made.
DR. RAVOLD, in answer to a number of questions, said that it took
quite a number of hours for tetanus bacilli when sown into a wound to
produce toxins, and secondly, some hours would elapse before symp-
toms of the poisoning manifested themselves. For instance, the deadly
mineral poisons, when administered in lethal doses to an animal, kill it
rapidly‘ and dramatically, but tetanus toxin, when injected into an ani-
mal, acted differently. The animal after receiving the injections re-
mains apparently uninjured for from twelve to twenty-four hours, when
gradually the spasms begin and the animal dies in convulsions. The
toxin is none the less deadly, but slower in its action; in fact, tetanus
toxin is the most deadly poison known to man. It is, therefore, so ab-
solutely essential that in all cases of tetanus the wound be thoroughly
curetted and disinfected with powerful disinfectants. He asked Dr.
Reder if the man treated by him was not hysterical.
DR. REDER said that he was not certain that this was an attack of
tetanus but feared it might develop.
DR. FALK, in closing, said this was the third case of tetanus
neonatorum he had seen, the two other cases resulting fatally. In
none of the cases was he the attendant during conﬁnement, nor had he
seen the patients previous to the development of tetanus.
As to the time intervening between the administration of the ﬁrst
dose of antitoxin and signs of improvement, he stated in the paper that
there were evidences of mitigation of the symptoms before the anti-
toxin was given. While the symptoms of tetanus were unmistakable,
they were mild. Fairly good doses of bromide of potassium and chloral
were given from the beginning. The ﬁrst symptoms were noticed in
the forenoon of the eighth day of the child’s life. Within eight hours
of that time he saw the child for the ﬁrst time and he gave the bro-
122 Medical Society of
mide and chloral per rectum at once. The symptoms continued ‘about
the same until the next day, when the dose of this medicine was
doubled. This was continued until the following morning; then the
ﬁrst dose of serum was given, but the symptoms had already dimin-
ished in severity. He gave a full dose of the antitoxin-10 cc.; about .
twelve or fourteen hours later he gave the second dose of the same
amount, and on the third day the child received 10 cc. in two injec-
tions.
His object in reporting the case was not to make claim of a case
of tetanus having recovered because of the use of the antitoxin, but
simply to report a case of tetanus in the new-born that did recover.
He agreed with Dr. Ravold, that where there is an infecting focus
in tetanus, that focus ought to be removed if possible; the wound
should be incised and thoroughly cleansed. This is the point where
the germs and toxins are developed, and while some may have en-
tered the circulation, we can prevent further absorption of the supply
,by cutting off the source. ‘

Meeting of .May 2, 1901; Dr. Norvelle Wallace Sharpe,
President, in the Chair.
Ureter Catheterism in the Male: A New
Ureter= Cystoscope.
BY BRANSFORD LEWIS, M.D.,
ST. LOUIS, MO.,
PROFESSOR OF GENITO-URINARY SURGERY, MARION SIMS-BEAUMONT
MEDICAL COLLEGE, ETC.
HE following case, quoted from a recent issue of the
Zeitschrift fiZr Klinische llledicinische, Band 38, Heft
5, and the Philadelphia Medical journal, _Iune 2 3, 1900,
illustrates not only the desirability of possessing some means
of avoiding such an unfortunate result as depicted, but also
the embarrassing position in which the surgeon ﬁnds himself
in certain cases when deprived of such a means:
City Hospital Alumni. 123
“A girl, 21: years of age, was subjected to laparotomy because of
the absence of the vagina and the presence of a tumor in the pelvis,
which was thought to be a hematometra, and an artiﬁcial vagina
could not be made. The operation was undertaken in order to re-
move the ovaries and prevent further menstruation. The left ovary
was readily found and removed. The tumor was incised and found to
be a sac containing a hard body and a mass consisting chieﬂy of dark
blood-clots. When the operator advanced to the removal of the tu-
mor he found connecting with it a cord running downward, which
made him suspect the possibility that the tumor was a kidney. It
proved to be a kidney, with marked fetal lobulations and portions
which were markedly hypertrophic and others equally atrophic. The
patient passed no urine after the operation and became nauseated.
She was given packs and sweat-baths, which gave some relief, but the
weakness increased. She became apathetic; the left parotid swelled,
and the swelling became so great as to ﬁnally interfere with breathing.
.She grew restless, the pulse became small, and strength was lost rap-
idly. Seven days after the operation she was somnolent, the pupils
were contracted and unresponsive to light, and she died, with temper-
ature subnormal. On postmortem there was no sign of peritonitis.
The uterus and vagina were absent, likewise the right kidney and its
ureter, and the right ovary. The tumor that had been removed was
the only kidney.”
Under such conditions, of course, uremia and death were
inevitable. This diagnosis was not made by an amateur, but
by one of the masters of the surgical art in Germany, and
such a happening is not by any means unique with him; the
same thing has been done a number of times by others, and
the records of operative work on the kidney, so brilliant in
other directions for the last thirty years, have been greatly
marred in this respect, through lack of completeness in diag-
nosis, either preliminary to, or during an operation. Dejong’s
statistics of 197 nephrectomies with St deaths, records 2 of
them (2.5 per cent) as depending on the fact that the other
kidney was absent; and there were 9 others in which the pa-
”tients died because the other kidney was so diseased as to be
unable to carry on the functions of a kidney. This makes [1
cases, or 13.5 per cent, in this series alone, in which death was
contributed to by the operation.
124 Medical Society of
-
That the profession of the world has appreciated this un-
fortunate defect in renal surgery and has tried its utmost to
remedy it, is indicated by the persistent endeavor it has made
in various directions to accomplish a more reﬁned and com-
plete diagnosis of kidney conditions before any such radical
operation is undertaken. For this purpose, such heroic meas-
ures have been advocated as suprapubic cystotomy for ureteral
catheterization (Harrison, Guyon), or exploratory laparotomy
for the purpose of palpating both kidneys (Knowsley Thorn-
ton). It is evident that the latter procedure could not indi-
cate more than the mere presence of two kidneys, not furnish-
ing any information as to health or disease of one or the
other.
Of late years, more useful and less radical means have
come into vogue, the endeavor being to secure the two urines
separately by means of devices for catheterism or suppression
of one ureter at a time. The ureter-catheterizing cystoscopes
of Nitze, Brenner, Casper, and Albarran, and the urine segre-
gator of Harris have been most favored by the profession.
The cystoscopes mentioned have all been based on the
plans of the previous cystoscopes of Nitze and Leiter,
with telescope lenses, hot electric lamps, and the addition of
tubes for the conduction of small ureteral catheters. Theo-
retically, or when used in the phantom (artiﬁcial) bladder,
ﬁlled with clear ﬂuid that does not become opaque, these in-
struments seem to work beautifully. The artiﬁcial ureteral
openings can be plainly seen and penetrated with the catheter,
and everything works charmingly; but usually, when we come
to make practical use of them on a patient, affected, for ins-
tance, with hematuria or some obscure urinary lesion, our
troubles begin; we ﬁnd that, both on account of the compli-
cated nature of the instruments themselves, with their tele-
scope-lenses, refractors and magniﬁers, and hot electric lamps,
all of which must be perfect and perfectly adjusted in order to
give service; or, on account of the conditions under which it
is necessary to use the instruments (clear ﬂuid is required, not
too cold nor too hot, and in sufﬁcient quantity to afford work-
ing-space for the instrument), difﬁculties rapidly accumulate,
and, in a large proportion of cases to a degree that makes the
City Hospital Alumni 125
operation impossible, even in the hands of skillful and prac-
ticed surgeons. In a series of 26 attempted ureteral catheri-
zations in the male, reported by Dr. Tilden Brown (Annals of
Surgery, December, 1899), there were 7 failures, or 25 per
cent. There can be no gainsaying the fact that this is too
large a percentage of failures for a surgical procedure to be
satisfactorily reliable. And this series represents the efforts
of those most accustomed to the work and presumably, most
skillful in its execution. Attempts by unskilled hands will
undoubtedly give a much larger percentage of failures.
If such .be the case, the instruments for ureteral catherism
in the male hitherto in use fall far short of affording satisfac-
tion, to say the least.
This is likewise true, in my opinion, of the Harris segre-
gator. It not only causes an unbearable amount of pain in a
number of cases, even after the generous use of cocaine, but
its results are erratic and unreliable. I have reached this con-
clusion not only from my own efforts with the instrument, but
have had equally unfavorable experiences reported to me by
several of my friends in the profession. It may drain from
one side and not the other for a time, and later, stop draining
from the ﬁrst and begin to drain from the second; or bloody
urine may come from both sides when it should come from
only one. An enlarged prostate is apt to compromise the efﬁ-
cacy and reliability of this instrument at all times.
My inability to satisfactorily use the instruments for urine
differentiation in the male has been the incentive for the con-
struction of the ureter-cystoscope herewith presented. _
Its fundamental object is the catheterization of the ureters
in the male, but it may be used also in the female, although
this has been so well provided for by the Pawlik-Kelly
method.
I may say that I have succeeded in easily catheterizing
the male ureters with this cystoscope a number of times when
I had been unable to successfully use the older forms (Albar-
ran’s, Casper’s, Nitze’s), aud I believe that with practice and
the full development of its possibilities it will give far better
and more certain service than any of the others.
It consists of a tube, which carries in its upper wall a
126 Medical Society of
smaller tube for the conduction of the wires that connect with
the electric lamp, and in its lower wall another small tube for
the conduction of the silk-web ureteral catheter, and for guid-
ing and controlling its inner extremity after it reaches the
bladder cavity. The light from the lamp emerges through a
glass window, sealed in the roof the main tube. The lamp,
when burnt out, is removable by unscrewing the tip and pull-
ing it out.
@ - ‘—


WINDOW


OBTURATOR. is
To facilitate the introduction of the cystoscope, an obtu-
rator is furnished, which closes the distal oriﬁce and prevents
scraping of the membrane against the edges of the opening;
but, at the same time, these edges are so rounded that they
may be brought in contact with the membrane without injury
to the latter; so that the instrument, if withdrawn from the
bladder into the prostatic urethra, may be pushed back into
the bladder without re-inserting the obturator.
A glass-covered cap may be placed over the ocular end
to enable the operator to forcibly distend the bladder with air
when that condition is not effected by posture. The inﬂation
is made by a rubber bulb attached to a stop-cock.
The ureteral catheter which I employ is the same as that
furnished with the Casper cystoscope. The lamp made use of
is the small mignon lamp but lately introduced by the makers,
City Hospital Alumni. 127
and possesses the remarkable attributes of much light and lit-
tle heat; though affording a brilliant glow, it radiates so little
heat that it may be held within a quarter-inch of live tissue
for an indeﬁnite period and without discomfort, to say nothing
of pain. It is really this property of the electric lamp that
makes this instrument feasible. A hot lamp requires the
shield and protection of ﬂuid before it can be introduced into
the bladder; whereas this can be used with perfect safety and
comfort, so far as heat is concerned, in the empty bladder.
Thus the use’of ﬂuid is eliminated, together with its several
disadvantages, such as rapid clouding by in-ﬂowing pus or
blood, etc. _
From the brief description given, is evident that the in-
strument is extremely simple, which, I believe, is one of its
chief advantages. Its freedom from complexity relieves it of
many of the sources of difﬁculty encountered in the use of
the older forms. 'It has no lenses to intervene between the
eye and the object of investigation. Lenses must be perfect
in order to be of any service whatever, and perfection in them
is both expensive and CIIH‘ICUlt of attainment; and after per-
fection has been attained, the usefulness of the instrument
may be destroyed in an instant by the displacement of the
lenses in the slightest degree or the clouding of the cement
that secures them. Sometime ago my Leiter cystoscope suf-
fered in this way, and it required a trip to Europe and six
months’ time to replace it in my hands for use again.
"The Window in this instrument is so placed that should it
become smeared with pus or blood it may be cleansed by a
cotton swab without removal from the bladder. “The lamp is
brought within a half-inch of the membrane undergoing search
for the ureteral opening, and the closeness and directness of
the illumination thus produced is of large advantage in facili-
tating its discovery. It is well known by those who have
studied this subject that the ﬁnding ofa ureteral opening _
under the most favorable conditions, for instance, with the
i bladder laid open before the eyes, is often a difﬁcult matter,
so that every point that favors its exhibition should be secured.
It is doubtless true that no instrument will ever make the op-
eration of ureteral catheterization so easy that it may be in-
128 _ Medical Society of '
variably accomplished by those unaccustomed to the work.
A difﬁculty to which attention is called by Dr. Tilden
Brown (Mid), is that met with when the bladder is so con-
tracted that only two ounces or less of ﬂuid can beretained
in it. This small amount does not afford enough working-
‘ space for the instruments mentioned, with the exception of the
Brenner, and it can not work in less space than that given, by
the amount mentioned. In using the present instrument no
ﬂuid is used at all; on the contrary, the bladder is emptied as
much as possible beforehand, and it is not desirable to have it
distended to any marked degree, even with air. The absence
of ﬂuid prevents the clouding of the ﬁeld of view by in-ﬂow-
ing or pus blood. Indeed, the emerging of bloody ﬂuid from
a ureteral opening would assist in the discovery of the latter
by marking its location. ,
Sterilization—It is well known that the cystoscopes in
the market are not sterilizable by the ordinary means ‘of dry
or steam heat, because of the delicacy of their construction
and the presence of the cemented lenses. Before using this
cystoscope it may be placed in a steam sterilizer as long as is
desired. .
In a recent paper on a subject allied to this, Dr. Lilien-
thal (journal of Cutaneous and Genito- Urinary Diseases, March,
1900), has this to say: “In by far the greater number of cases
in which catheterization of the healthy ureter is practiced, _
disease of the other kidney or of the bladder is present, and
the region about the ureteral oriﬁce, not to mention the
ureteral mucous membrane, is anything but sterile. Efforts
at disinfection are, of necessity, incomplete; ﬁrst, because it
is not possible actually to disinfect mucous membranes; and,
again, because there is constant soiling from the other ureter.
The danger is, theoretically, and perhaps practically, minim-
ized when the catheterization is done by the dry method of
Kelly, in which the ureteral catheter need not touch any tissue
except that at the mouth of the ureter itself.” I
I The same advantage isaffOrded by this cystoscope, which
employs the “dry method.” The inner walls of both cysto-
scope and catheter-carrier are sterilized, as mentioned, so they
do not contribute any organisms to the sterilized catheter; and
City Hospital Alumni. 12.9
the catheter emerges from the inner extremety of its carrier
to pass directly into the ureteral opening, without touching
either ﬂuid or mucous membrane, save that of the ureter
itself.
I have not attempted to make any especial provision ,for
catheterizing both ureters at the same time, but there are two
ways in which double catheterization may be accomplished:
By making the catheterizations of the two ureters at success-
ive séances, or successively at the same séance; or, after the
ureter-catheter is introduced into one ureter, a small soft rub-
ber catheter is introduced into the bladder through the main
tube; both catheters are allowed to remain in their positions
as the cystoscope is withdrawn; one of them drains directly
from the ureter, the other from the bladder-cavity, which, of
course, is collecting the urine from the other ureter. As to
whether this maneuver is perfectly reliable, avoiding any
chance for a mixing of the two urines through the escape of
some of the urine along side of the ureteral catheter, there is
a question. -However that may be, some operators depend on
it, notably, Guyon. If the catheter ﬁts in the ureter tightly,
_ it will probably not allow of any escape; but if it is a loose ﬁt
from patency of the opening, one should not rely on this
method, but resort to successive catheterization.
Technigae.—-At ﬁrst, in studying the use of this instru-
ment, I‘made use of the knee-chest posture, in which position,
when the cystoscope was introduced and the obturator with-
drawn, allowing the entrance of air into the bladder, the trac-
tion of the abdominal contents on the fundus of the bladder
would result in wide distention of the organ, even without any
forcible pumping of air into it. But although the mucous
membrane could then be plainly seen, I was disappointed
in many cases in the fact that the ureteral openings did
not come within sight; they seemed be located just “ around
the corner” of the projecting vesical neck. While this was
not true in all cases, it was too frequent an occurrence to make
the procedure reliable; so that I had to resort to the dorsal
decubitus, and have found it to be very much better adapted
to the easy discovery of the ureteral openings; and by pro- -
v-iding a semi-Trendelenburg pose to further gravitation of the
130 ~ Medical Society of
in-ﬂowing urine toward the vesical fundus, and at the 'same
time causing moderate forcible distention of the organ through
the air-cock of the instrument, the interference of accumu-
lating ﬂuid is done away with. That is the gist of my present
plan.
In the female, placed in the dorsal position with the hips
well elevated, when the obturator is withdrawn from the cys-
toscope, permitting of the in-rush of' air, the bladder almost
invariably dilates in the manner described as occurring in the
male placed in the knee-chest position; but with the male in
the dorsal position this is not the case; passive dilatation does
not take place, and forcible distention with the air-pump is
necessary. I have noticed that whereas no damage is done
to the bladder by injecting air into it, and no danger can come
from its possible ascent into the ureters (see the report of my
experimentation on the subject, “Air-Inﬂation of the Bladder
in Connection with the Bottini Operation,” the Medical
Record), it is a disagreeable fact that air is not well borne
by the sensitive patient; it \seems to cause a more painful
sensation than a similar amount of water. I have not yet
evolved a technique for anesthetizing the bladder only, that
has proved satisfactory, and have hitherto worked with chlo-
roform anesthesia—although I believe that with thorough co-
cainizing of the posterior urethra and vesical neck, and the
injection of some sedative solution, such as antipyrine, into
the bladder, this difﬁculty will be overcome.
Preliminary irrigation and emptying of the bladder and
'urethra having been carried out, sterilization of the cystoscope
and accessories accomplished, the patient is put under anes-
thesia and brought into the lithotomy position with the hips
elevated. The cystoscope is introduced in the manner of or-
dinary catheterization. On taking out the obturator there
may be some spurting of urine that has been left in after the
irrigation, or that has accumulated since then. I have had a
pump constructed with which to remove this balance effectu-
ally. It is inserted directly through the cystoscope and then
works automatically. Next, the ocular window is placed in
position, air is pumped into the bladder to the degree of mod-
erate distention, and the electric current is turned on. By
City Hospital Alumni. 131
moving theinner end of the instrument in various directions,
a panoramic view of the interior of the bladder is obtained.
If one is 'trying only for ureteral catheterization he immedi-
ately seeks one of the upper angles of the trigone. He sees
a small, slanting slit or opening in the membrane, from which,
if he watch closely, he will observe the emergence of a little
spurt of urine at intervals. The silk-web ureteral catheter has
already been in position for manipulation, lying within its
proper tube of the cystoscope even before we introduced the
latter into the bladder; so it is now readily shoved forward
toward the,ureteral opening which it easily penetrates and
passes on up the channel, its ﬂexibility enabling it to adapt
itself to the natural curve of the ureter. While in this posi- -
tion, the penetration of the ureter by the cathether can be
perfectly demonstrated to any spectator present. If it is de-
sired to drain that ureter for a time, the catheter is pushed well
up into the ureter and co-incidentally the cystoscope is with-
drawn from the bladder and urethra. The ureter catheter is
sufﬁciently long to permit of this. Air is prevented from es-
caping from the bladder through the ureter-catheter tube by
the close hugging of both tube and catheter at their junction
by a small tube. After the operation it is best to empty the
bladder of the air by passing in a soft rubber catheter, or
allowing it to escape through the cystoscope at the time of
removing it. The patient is liable to experience grewsome
thoughts if, later, he ejects air from his bladder.
While I at ﬁrst did not expect very much from this in-
strument as a cystoscope, per se, its object being primarily the
catheterization of the ureters, the view it affords of the interior
of the bladder should not be underestimated. It is similar to
the picture presented by the Kelly cystoscope in the female
bladder; which, in certain respects, is far superior to that pre-
sented by the lens cystoscopes. Aside from the disadvant-
ages of a ﬂuid medium, already mentioned, these instruments
with lenses give an inverted image; and, corresponding to the
magniﬁcation of the ﬁeld there is contraction of its area. In
other words, there are these several modiﬁcations of the image
before it getsto the eye of the observer. He may or may
not be able to interpret and judge them correctly. But with
132 Medical Society of _
the cystoscope under discussion, there is absolutely nothing
to intervene the object and the eye, so that what is seen, is
seen without any modiﬁcation whatever. Moreover, to the
sense of sight may be added that of touch, by means of the
probe; so that when one is in doubt as to what he sees, he
can add the testimany of the probe on the subject. A
With the older forms of cystoscopes I have never been
able to get a satisfactory view of the part of the bladder con-
stituting the so-called neck—that part formed by the base of
the prostate; with them I never have been able to clearly see
the conﬁguration of prostatic o-utgrowths or _obstructing
masses, occurring in hypertrophy of that organ. With the
present instrument this maneuver can be accomplished in
exactly the same manner that an endoscopic view is obtained,
viz., by successive changes of its position, either in turning it
or gradually withdrawing or reintroducing it. This, I believe,
will prove a very valuable property in connection with this
cystoscope.
The ﬁeld of direct therapy to bladder, ureters and kid-
ney-pelves will be materially broadened, I am conﬁdent, by
making use of the direct access afforded by this instrument.
Applications can be made to the vesical membrane by the
cotton-tipped swab, as is done with the urethroscope; and
successive antiseptic irrigations for urete-rsor kidney-pelves
are no more impracticable than the catheterization itself.

Report (if a Case of Obstructive Prostatic
Hypertrophy. _
BY BRANSFORD LEWIS, M.D.,
sr. LOUIS, MO.,
PROFESSOR OF GENITO-URINARY SURGERY, MARI-ON SIMS-BEAUMONT
MEDICAL COLLEGE, ETC. -
PATIENT, C. W. T., 51 years of age, American, farmer, was
brought to me by my friend, “Dr. John H. Britts, of Clinton,
' Mo., on April 5, 1901. For the past two or three winters the
patient has been compelled to arise from two to four times at night _-
City Hospital Alumni. 133
to urinate ;, but during the summer he has not been troubled in this
respect. There has never been any venereal infection, or any. trouble
with the genito-urinary organs until within the past year; last fall the
patient began to notice interference with urination, greater frequency,
with increasing indications of bladder irritation, which culminated in
February, this year, in an attack of complete retention, Dr. Britts
drawing off something like two quarts of urine on two or three occa-
sions. In'November, 1.900, a severe attack of sciatica (right) laid the
patient up, and he has suffered from this more or less ever since, to
such a degree that he is now unable to walk.
At my ﬁrst interview, April 5th,. the patient appeared to be in a
very bad condition generally, as well as locally; the yellow, cachectic
hue was presumptive evidence of the implication of the kidneys, which
was conﬁrmed by ﬁnding albumin in the urine, lessened urea excre-
tion (1.4 per CEBU, and lessened 24-hour quantity. Catheterism was
difﬁcult; a soft rubber cateter could be introduced at times without
much trouble, but at others it required much painful and prolonged
effort; and of the metal instruments, only one with a long prostatic
curve could be made to enter. On this account I was unable to make
use of the cystoscope for further diagnostic aid.
Because of the several unfavorable conditions present, I deemed
it advisable to improve his condition as much as possible before at-
tempting any operation, and even questioned the possibility of doing
any operation on him at all, lest he might not survive it; but because
of the complete inability to pass any urine without the aid of the
catheter and at the same time the great difﬁculty and pain incident to
the use of this instrument each time, it was evident that something
had to be done even if it only gave temporary relief.
I therefore left a soft rubber catheter in the bladder, giving con-
tinuous drainage for a week, at the end of which time there was no
improvement in his ability to pass water; there was still complete re-
tention Moreover, there was marked decrease in urinary secretion—-
practically almost suppression on April 10th, when only eight ounces
were drained in 24 hours; and various evidences of uremia appearing,
we gave him transfusion of normal salt solution which, with the addi-
tion of diuretin, stimulated the urinary ﬂow to about forty ounces.
Continuous drainage was kept up for another week, when the patient
desired that operative measures be undertaken, saying that he would
rather run the risk of dying than continue in his state of suffering as
he then was.
The Bottini operation, with three incisions, and air inﬂation, was
134 ' Medical Society of
done on April 17th; local anesthesia; very little if any shock; mod-
erate amount of pain (although the patient is extremely sensitive). On
the same night, without trying to see if urine could be passed volun-
tarily, my assistant catheterized once; biit since that time no catheter
has been required; the patient has urinated voluntarily as he desired,
beginning with the morning following the operation. He passes a
good, full stream continously until the bladder is quite empty, and
gives the ﬁnal spurts that indicate the ejection of the last teaspoonful
or so. This is repeated as often as the bladder is reﬁlled with antsep-
tic solution, used tor irrigation. While there has been considerable
a burning sensation at the neck of the bladder, the result of the
cauterizing, naturally, the general condition (excepting ‘the sciatica)
has improved exceedingly. The albumin has decreased to only a
trace, the urea has gone up to normal, likewise the quantity of urine;
the appetite is excellent and strength increasing. There was no hem-
orrhage, only a little coloring of the urine for the ﬁrst three or four
days. One chill, with a temperature of ro4°F., occuring on the next
day after the operation, but there was subsidence and prompt disap-
pearance of this feature. Eleven days after the operation two sloughs
came away, after which the stream was much freer.
I should have been glad to present the patient here, as I in-
tended to do had his sciatica permitted his walking well enough“ to get
around.
DISCUSSION.
DR. H. W. SOPER thought Dr. Lewis could claim many points of
originality in the instrument shown, which commended itself for its
simplicity and practicability. .
DR. E. W. LEE has never been able to catheterize the male ureter
successfully. He had experimented with the various known for this
purpose but \without success. The instrument shown by Dr. Lewis
gave positive proof of the catheter entering the ureter, and the intro-
duction of a catheter into the bladder with the ureter-cystoscope in
place, would draw the urine from the other ureter ; this he considered
very important. The instrument he thought was ideal.
In the case operated on by the Bottini method he thought the
proper course had been pursued ; he thought this operation indicated, -
wherever there was a chronic enlargement or engargement of the
prostatic gland. Where there is a pedunculated condition of the .
middle lobe the Bottini operation is not indicated; in such cases the
City Hospital Alumni. 135
operation should be performed through the peritoneum or by the
suprapubic method.
DR. P. I. HEUER had seen Drs. Bryson and Carson operate with
the best instruments known and the success of each was practically a
failure in all their ureteral operations on the male subject.
The speaker felt that Dr. Lewis had accomplished something en-
tirely new and was to be congratulated. The work done by detailed
by Dr. Lewis might be accepted as showing the practicability of the
instrument.
DR. 10s. L. BOEHM had been personally interested in Dr. Lewis’
achievement and knew that every statement made in regard to the
work accomplished with the instrument was borne out by facts. He
had been present at several cases where the urete’rs had been success-
fully catheterized. He had previously seen good surgeons attempt the
catheterization of the ureters with the various instruments on the
market but in all cases their attempts had been practical failures.
With Dr. Lewis’ instrument success was readily accomplished.
The Bottini operation described was a remarkable success. He
assisted Dr. Lewis at several of these operations, and felt that this op-
eration should establish the superiority of the Bottini operation over
other methods for certain cases of hypertrophied prostates. Dr.
Freudenberg, of Berlin, before the International Congress of Surgeons,
in Berlin, April, 1900, said the method of air-inﬂation of the bladder
was popularized by Bransford Lewis. Had it not been for this method
he hardly thought the Bottini operation could be performed'so success-
fully as it is.
DR. LEWIS, in closing, said he greatly appreciated the cordial re-
ception given his demonstration. He regretted the absence of the
patient operated upon, but an attack of sciatica prevented his being
present. While he believed in the Bottini operation for“ certain cases,
yet he did not think it would answer in all cases of hypertrophied
prostrate. Early in its career he performed this operation in a certain
case; there was some improvement but he felt that it was a failure.
He asked the patient to allow him to do a prostatectomy but the man
had seen this operation done during his stay at the hospital and de-
clined; later, however, he did permit another surgeon in the city to
136 Medical Society of
perform this operation by the suprapubic route. A pedunculated ob-
struction was found which was removed and entire relief fel'lowed'.
But the Bottini operation is indicated sometimes. If the case reported
had been given chloroform he felt that the patient would have died in»
twenty-four hours. If the operation had been performed through the
suprapubic route he thought death would have occurred in two or
three days.
DR. GREENFIELD SLUDER demonstrated
Specimens Showing Explanation of Non=Suppurative Nasal
Headache Referable to the Middle Meatus of the Nose.
DR. JOHN GREEN, ]R., said these cases are especially interesting
to the ophthalmic surgeon because it is to him' that these patients come
‘or are referred by the general practitioner after the latter has exhausted
his efforts at relief. He had the history of a case which had been
handled conjointly by Dr. Green and Dr. Sluder, and the speaker had '
been able to observe the case throughout.
The patient was a young married woman giving the following
history :' About eighteen menths ago, during the last months of preg-
nancy, she found difﬁculty in reading; she had never been troubled
previously. There was a “feeling of strain” on attempting close work.
Since then the eyes had pained continuously and there was a “heavy
feeling” in the head especially in the frontal region; the sensation was
described as a “tension.” Visual tests showed a slight degree of
manifest hypertropia, R.E. Hm. I, V. 16/15; LE. Hm. .5, V. 16/1,,.
Various tests failed to reveal any astigmatism. Maddox test disclosed
a trace of homonymous diplopia and slight vertical diplopia image of
the left eye about one inch above that of the right eye. Correction
of the refractive defect failed to give relief.
She had been in charge of a competent ophthalmic surgeon, of
Nashville, Tenn, who told her “one eye was higher than the other”
and advised an operation—presumably the division of one of the
recti muscles. It was then discovered that she had marked tender-
ness of the orbit in the region of the pulley of the superior oblique ;.
this seemed about equal on the two sides, which is unusual, as in these
City Hospital Alumni. 137
cases the tenderness is more marked on one side than on: the other.
The case was then referred to Dr. Sluder, who discovered a clos-
ure in» each mid‘dle meatus. Topical applications with a view to
shrinking the membrane were instituted. Almost immediately the
patient found relief; the feeling of tension disappeared, the constant
pain in the top of the head became less severe. The improvement
has been continuous and uninterrupted, and the patient free from pain
in the eyes or headache.
Many of the cases show an insufﬁciency of one or other of the
recti muscles and are compelled to use prisms in order that they may
be able to: use the eyes at all. After nasal treatment the prisms can
be discarded and the ability to use the eyes is very markedly increased.
9

Some Hints on the Management of
Laparotomy Cases.
BY FRANK A. GLASGOW, A.B, M.D.,
ST. LOUIS, MO.,
HE non-surgical portion of the profession and even many
of those performing surgical operations seem to be of
the opinion that after a laparotomy has been properly
performed any average physician is capable of looking after
the case. No greater mistake could possibly be made. I have
seen some cases and I have heard of many others that were
lost from lack of the attention which only the operator could
give.
I do not hesitate to say that the after-treatment of a difﬁ-
cult, complicated case requires more knowledge, skill and good
judgment than it does to perform the operation.
In this paper I propose merely to state what I have found
it advisable to do in laparotomy cases and also to warn against
mistakes which I believe are too often made.
In the preparation of a patient for the operation a course
of medicine, I believe, is seldom necessary. If the patient has
been using morphine regularly I would advise strongly that it
138 Medical Society 01
be continued; it has become a necessity for the nervous sys-
tem, and besides, this is not the proper time to break up the
habit. I have heard of cases where this sudden deprivation
of morphine has contributed to fatal result. I have in former
years often heard it said that a morphine habitue is a bad sub-
ject for operation; this was due to following the rule—“avoid
morphine after abdominal operation.” This excellent rule is
not applicable to morphine cases. The condition of the kid-
neys should be investigated in every case; if there is any evi-
dence of disease of these organs we should avoid ether. Often
we ﬁnd that the urine is of a high speciﬁc gravity and deﬁcient
in quantity; in this case, if there is no urgency for' the opera-
tion, we should give plenty of distilled water. The only med-
icin'es whichI would give are weak tea, infusion of digitalis
or ﬂuid extract stigmata maydis, as diuretics. A saline laxative
should be given in small doses to' clean out the intestinal tract.
I have found a mixture of magnesia sulphate, two ounces;
sodium sulphate, three drams; sodium bicarbonate, one-half
ounce; sodium chloride, three drams, to be a very good laxa-
ative; given in teaspoonful or dessertspoonful doses in a half
glass of water every two or three hours, it acts-very efﬁciently
and does not seem to leave the patient constipated as does
sulphate of magnesia alone. An enema should also be used
before the operation.
I do not believe in starving a patient for several days
prior to an operation. We know how weak, both in bodyand
spirit, a healthy man gets when very hungry, we also know
that a weak, despondent mental condition is antagnonistic to
prompt recovery. The patient should have a moderate quan-
tity of liquid or soft food up to day of operation. I have my
doubts about milk being the best food for it undoubtedly
leaves much fecal material; probably broths and gruels are
better. I have very little use for the liquid prepared extracts
of beef; the freshly-extracted juice from rare steak is far su-
perior. The day of the operation the patient should receive
some tea or coffee for breakfast, nothing more.
As for the preparation of the patient—a large vaginal
douch of I to 2000 bichlorid of mercury solution should be .
given the night before and again the morning of the opera-
City Hospital Alumni. 139
tion; this is for fear that it may be necessary to open the va-
gina; of course, if this occurs, the vagina should be scrubbed
with'soap and water, and again douched. The hair on the
abdomen, mons and about the vulva should be shaved the day
before and a thorough scrubbing given with soap and water,
applied by means of a stiff brush; do not overdo this and
cause abrasion of the skin; follow this with an alcohol wash
and then, if you please, with bichloride—4 to 2000.
Years ago, in my zeal to get off all of the superﬁcial
epithelia containing microbes, I applied soft soap over the
whole abdomen and left it on all night. The next day I found
a very extensive raw surface and had to wait until this had
healed before I could remove the ovarian tumor. With anti-
septics, if too strong, you may cause a redness, which is a
mild inﬂammation; this is detrimental as it lowers the vitality
of the skin and makes the edges of the cut more liable to be
attacked by any stray microbe.
At the time of the operation the abdomen should again be
washed with water and alcohol. Washing at this time with
turpentine is of advantage, not for its antiseptic effect, but be-
cause it leaves a thin pellicle on the surface and seals in all the
germs in the surface epithelia; do not wash it off with alcohol
but merely wipe off with clean cotton.
During the operation, of course, every antiseptic or asep-
tic precaution should be taken. I can not recommend too
highly the wearing of gauze over the hair. The practice of
allowing the nurse or doctor who attends to the sponges to
hold them in the hand is bad. It is not necessary and it is
adding a chance of infection. Let them pick up the sponges
by means of forceps, and never touch them with the hands.
The fewer who handle a wound or articles which come into
contact with a wound the less danger there is of infection.
You can not be certain of any one but yourself, and not al-
ways of yourself. I always consider it a favor if anyone calls
my attention to the fact that my hands have touched anything
not absolutely sterile. You may possibly do this and not no-
tice it. ._
For suture material, for some years, I have used almost
exclusively catgut, and do not get suppuration. The catgut I
140 _ Medical Society of
buy ready prepared in alcohol in sealed tubes; these tubes are
placed in with my instruments when they are boiled, this will
destroy any germs. which may have hatched since their prep-
aration and also cleanses the outside.
The subcuticular suture for closing the abdomen is a Y
great improvement on any suture passing through. the skin,
andI can heartily recommend it. We should cover every-
raw surface with peritoneum or cauterize it in order to pre-
vent adhesions of the guts to it. We should stop all bleeding
before closing the abdomen. In cases where you must drain,
be sure that the gauze is not compressed where. it comes
through the abdominal wall. A long tube may cause death
from pressure on a gut or, at least, a fecal ﬁstula. I have
never had such a case, but was present at an operation where
it subsequently happened. If a long tube is used, see that the
dressings are wrapped ﬁrmly around the outside so that it can
not be pressed inward. I prefer to use a long continuous
piece for packing, often in conjunction with a Mikulicz bag;
when using several pieces, on removal, we dften get hold of
one of the undermost ﬁrst, and only after using some force do
we ﬁnd out our mistake. A short glass tube ﬁrst passed
through the abdominal wall will protect the gauze from com-
pression.
I would warn you against washing out the cavity from
which you have removed the gauze; either the general cavity
is not completely sealed off as soon as we expect or we have
broken the seal in removing the gauze. I have had very se-
vere abdominal pain ensue from attempting to wash out such
a cavity—when using a double uterine canula, allowed to enter
by gravity alone. I have seen the same thing happen when
washing out after a vaginal hysterectomy, even a number of
days after the operation.
If one should notice a rise of temperature and some sen-
sitiveness over the line of incision, remove the dressing and
feel the line of incision; if there is a thick hard place here;-
open down to it by separating the healed wound; wash out
and drain, and it may not keep your patient in bed a. day
longer than otherwise would be the case. I have not seen
such cases for several years.
City Hospital Alumni. 141
If you have had to pack the abdomen get the gauze out
the second or third day, taking every aseptic precaution. I
generally put in a narrow short strip of gauze for a day or so,
then a spiral silver drainage tube, long enough to pass through
the abdominal.wall, and let it stay a few days. These cases
need not be conﬁned to bed any longer than those where there
has been no drainage.
After a laparOtomy I am afraid that we are apt to err on
the side of starving a patient rather than giving too much. If
the patient is very weak we should give nourishing enemata
from the start; peptonized milk is one of the best. When this
is Prepared with pancreatin it decomposes very quickly in
the bowel and what remains becomes very offensive. This
certainly must be deleterious and can be easily prevented by
adding one grain of salicylic acid to each dose of the pre-
pared milk. Some nourishment can be rubbed in through the
skin, as for example, peptonized milk or oil; in this way we
can save the stomach very much.
One thing which troubles patients more than anything
else after laparotomy is thirst; they call for ice or ice-water.
In my opinion they should never be allowed either; neither
ice or ice-water quenches the thirst, but on the contrary, in-
creases it; the stomach ﬁlls up with cold water, which is not
absorbed, but is later on rejected. Give tablespoonfuls doses
of hot water; give occasional enemata of cool water or normal
saline solution in quantities of one-half to one pint; this Wlll
be retained and absorbed, and thirst will not be a prominent
symptom. We never feel that a patient is safe until there has
been a free action or a passage of ﬂatus from the bowels. The
stomach is often so irritable that no medicine except calomel
. will be retained; if ten or ﬁfteen grains of calomel fail, we
may give one or two ounces of sulphate of magnesia by high
enema, give it in about six or eight ounces of water; in three
hours follow with an enema of suds and turpentine. In giving
high enemata I would by all means urge that you give them
yourself; the soft tube which is generally used almost invaria-
bly coils up in the lower ractum; you can only determine this
by feeling with your ﬁnger; with your ﬁnger you can guide
0
142 ‘ Medical Society of
the end of the tube up into the colon and only in this way be
certain of giving a high enema.
One of my patients from whom I had removed a large
cystic tumor vomited for three days. Intestines could be felt
down in the pelvis. She was put in the knee-chest position,
the intestines pushed up and an enema given while in this po-
sition. The result was very satisfactory, although previously
even the high enema had failed; an enema given in the knee-
chest position is as efﬁcient as one given with a long tube.
Sometimes the vomiting is due to the packing pressing on a
gut; when you remove your gauze the vomiting will cease.
I remember a case some years ago: The patient seemed to
be doomed; about 4 o’clock in the morning, assisted by the
night nurse, I removed all of the gauze, the vomiting ceased
and the patient recovered.
I would suggest that you never put in any packing except
between your two ﬁngers, so that you may be certain that you
do not get gut mixed with your gauze. The patient should
not be allowed to rise from the bed for at least’two weeks. I
generally take my ﬁrst dressing off at this time, and have her
measured for a bandage: as soon as she gets this I let her up.
This bandage should ﬁt well, but should not be tight; it should
have little or no elastic in it; it should be loose enough to
allow the hand to be introduced under it when the patient is
lying down. The bandage should be held down by means of
two rubber bands or tubes passing between the thighs.
Ican not work well with rubber gloves and do not use
them unless I have soiled my hand shortly before the opera-
tion. Scrubbing the hands well with soap and water, then
rubbing with chlorinated lime and carbonate of soda, with a
subsequent dipping in I to 2000 bichloride solution, I ﬁnd to
be allsufﬁcient. The lime remains under the nails and in the
crevices about the nails and seals in .or destroys germs in
these localities. Of course, very much depends on your
assistants. ~
City Hospital Alumni. ‘ 148
Meeting of April 18, 1901; Dr. Nowelle Wallace Sharpe,
‘ President, in tlze Chair.
DR. FRANK A. GLASGOW read a paper on the
Management of Laparotomy Cases.
DISCUSSION.
DR. CHAS. SHATTINGER had used the sulphate of magnesia hypo-
dermatically. He found that in using 5-grain doses would result in
one'passage, but even this could not be relied upon with certainty.
DR. A. H. MEISENBACH said that one of the draw-backs to opera-
tive work was the after-care of the patient by one unaccustomed to
operative work. The after-treatment is often of as'great import as the
operation itself as far as the patient is concerned. The more thorough
the preperation the better for the patient. In emergency surgical
work a careful preparation of the patient is often prevented by the
urgency of the case, both as regards the gastro-intestinal tract and
a the external surface of the body. He thought, too, that many patients
were over-prepared and often over-starved, as stated by the essayist.
He did nob-favor the extensive purging and dieting for a week before
the operation. If the patient is thoroughly cleansed out the day be-
fore the operation and the rectum thoroughly empted the morning of
the operation, he thought all conditions had been fulﬁlled. Patients
recover when operated upon in emergency and when all the usual pre-
cautions of aseptic work have not been thoroughly carried out. He
mentioned an instance in which he believed that he had lost the
patient through starvation. He thought, too, that scrubbing of the
abdomen could be overdone. His method of preparation of the pa-
tient is to give a full bath, preferably warm, in the morning. The
pubes are then shaved and the abdomen thoroughly scrubbed, then a
“pack of soft soap or bichloride; then when the patient is on the table,
going over again with bichloride and lastly with alcohol. The use of
turpentine he considered beneﬁcial. It not only is an antiseptic but
forms a coating on the skin such as had been described. Lawson-
Tate had brought this practice into prominence. He applied alcohol
144 Medical Society of
not only to the abdomen of the patient but also to his own hands,
especially the ﬁnger nails. The remark made by Keen was-very strik-
ing when he said that surgeons when they had nothing else to do
should rub their hands with alcohol, using gauge saturated with the
alcohol. He did not use rubber gloves and had heard with astonish-
ment a statement made by a surgeon that he used rubber gloves, but
cut out thumb and ﬁnger so as to have the tactile touch. The speaker
thought this destroyed any value the rubber glove might otherwise
have. When operating on a pus case and having a sterile case im-
mediately following he thought the rubber glove might be of value,
though even this is unnecessary if the statement of the Scotch surgeon,
Cheyne, is true, that he can go out of the operating room, cleanse his
hands and do surgical work without infecting the patient. He thought
it important that the surgeon should not allow clotted blood to dry on
his ﬁngers during the operation. To prevent this he had three or four
basins with bichloride in one, distilled water in another and formol so-
lution in another. The ﬂushing of wounds with liquids he thought in
advisable. Sponges dipped in a saline solution, wrung out, and then
the ﬂuids dipped up, was better. In regard to the sutures he had
always been a great admirer of catgut and used it extensively with
average success. Lately he had operated on several cases --for radical
cure of hernia and in three cases used catgut. Suppuration followed in
every case. He used the chromacised catgut from sealed tubes arid
thought the suppuration due to the suture material because all pre
caution had been taken. During this time he operated on two cases
in the country for strangulated hernia and used catgut. One of these
patients died though the other recovered without incident. In the
last few cases for hernia he had used silk prepared by boiling and the
wounds healed by primary union.
DR. HENRY JACOBSON said that in high colon ﬂushing ox gall was
of advantage when there was a tendency to bowel obstruction, used
with a Wales’ bougie, which would not bend upon itself when it
reached the sacrum. He did not think much nutritive effect could be
had from inunctions of milk, especially in adults. It is best to wear
gauze on the head over the beard. When the surgeon is suffering
from a cold he did not think he should operate.
City Hospital Alumni. 145
DR. F. REDER said he was becoming skeptical about giving
patients water after operations, especially since a patient operated
upon lately had emptied a pitcher of water with no ill effects. He had
been allowing his patients a little water, such as moistening the lips or
tongue, or placing a moist cloth to the mouth, or even giving a half
ounce every two or three hours.
In regard to the drainage of the abdominal cavity he believed the
old method by the tube is still preferable when drainage is necessary
and as the incision is in the median line, and Dr. Glasgow’s method of
introducing the drain is admirable. In a cavity where there is
oozing it should be introduced in a way to check that oozing. The in-
cision should be externally large enough to allow inspection of the
wound so that the dressing can be carried down to the bottom.
The use of the ice bag is very grateful to patients and that to-
gether with the elevation of the bed give good results.
DR. SHATTINGER objected to the practice of a large number of
surgeons in urging upon their patients the wearing of an abdominal
bandage after operations for either a very long time, or, worse, for the
rest of their lives. The usefulness of a propef support for a reasona-
ble period after abdominal operation he thoroughly appreciated, but
the continued use for a long period of time or through life he thought
a grievous mistake. The abdominal muscles are undoubtedly weak-
ened thereby, and the resultant relaxation predisposes to hernia. A
muscle that is in normal condition and can carry out normal pressure
against the abdominal contents shall be the best safeguard against
hernia. Aside from any consideration of hernia, however, this long
continued use of a support predisposes these patients to various mal-
positions of the abdominal viscera. He had had cases of gastroptoses,
for instance, to treat, which, if not due to this advice on the part of
the surgeon, were at least agrivated thereby.
DR. GLASGOW, in closing, said he objected to the use of formol on
the hands for the reason that when there was blood on the hands it
stained a dark brown. He said he should have mentioned one class
of patients in his paper which was that of those addicted to the use Of
morphine. He thought it inadvisable to take away this stimulant from
the patient just before an operation. When they came to him under
0
146 Medical Society of
such circumstances. he always kept them on their stimulant. The
practice of giving morphine just before an operation he did not ap-
prove, unless the surgeon knew his patient’s disposition toward the
drug, as they frequently vomit for some time after its use. As to
sponges, he thought they ought to be dry and used just out of the
sterilizer. As to catgut, he thought it ought to be be boiled in order
to destroy the germs on the outside of the tube. The catgut in tubes
may be sterilized while in the tubes but become infected when taken
out. There is no trouble in boiling the catgut in tubes. He usually
put the tubes in the sterilizer with the instruments. The tubes do not
break and they are sterile when taken out. He always uses gauge
covering on his head and he thought this ought to be extended down
under the chin so as to catch the perspiration. In regard to wearing
a bandage after the operation he agreed with Dr. Shattinger that much
harm might follow the extended use of the support. He usually di-
rected his patients to wear the support a year, but rarely longer than
that. He objected to elastic bandages and did not use them.

Meeting of May 16, 1901; Dr. Norr/elle Wallace Sharpe,
President, in the Chair.
The Double=Knife in Histo=Pathology.
BY R. B. H. GRADWOHL, M.D.,
ST. LOUIS.
Y intention primarily in the writing of this paper was
merely to give a few points on the technique of the
double knife which I am using in the study of micro-
scopic pathologic conditions, but in this connection I deem it
advisable to say something on the study of fresh pathologic
specimens in general. While working with Prof. Langerhans,
of Berlin, I was impressed with the skill shown by him in the
study of fresh unstained pathologic sections. It seems that
Rudolf Virchow many years ago laid great stress on the im-
portance of this study. As a matter of fact, some of the best
City Hospital Alumni I 147
work ofthis master of pathologic anatomy was done with
crude instruments, with a few reagents in the shape Ofa bottle
of iodine and acetic acid and a simple microscope. Virchow
described many changes for the ﬁrst time in specimens which
were cut with arazor and with little or no staining. To my
mind, the greatness of the man, lies not only in what he has
done for pathology but mainly in how he has done it, i. e., with
cindefacilities and with no previous authentic records or liter-
ature to guide him. In short, he opens up new ﬁelds and laid
down dicta in a- scientiﬁc way where, before, all had been e."-
roneous and irrational. It was Virchow who ﬁrst laid empha-
sis On the importance of studying. changes in the organs as
they exist, before they are placed in ﬁxing and hardening
ﬂuids. In Short, it was his idea to see cellular elements as
they existed, or as near as possible as they, exist in life. It
goes without saying that ordinarily, as we study pathologic
specimens, we see things in death, and not in life. The near-
est approach to Studying the living changed cells of the or-
ganism is by fresh examination of a piece of tissue removed
from the living body. The “new era” of pathology will come,
I predict, when we can by some manner or means look
through our lenses at the living tissues Of the body, not at the
dead, as we now see it.
I say again, then, that Rudolf Virchow, long time ago,
emphasized this point. For years it has been lost sight of,
but we are coming back to it, with the swing of the pendulum
of reason. Dead tissues have been described and changes
accurately noted, yet can we say with certainty that this is the
condition of the cellular elements as they exist before life is
extinct? I claim that we must approach as closely as possible
to a study of conditions as they exist and not as they are after
death. To this end, Virchow has used, in addition to his sim-
ple razor, an instrument called by him the “doppel-Messer”
or double knife. This instrument consists of two blades placed
side by side, arranged on a metal handle. The shape of the
knife is that commonly called the “Heidelberg ' blade,” 2‘ e.,
plane on one side and concave on the other. The knives,
being held in a parallel direction, can be pushed close togeth-
er by a screw arrangement on the handle, while the distance
148 Medical Society of
between the blades is regulated by this wedge, worked on a
screw at the end of the handle.
The technique of its use consists in arranging theIbladeS
at a suitable distance, dipping the knife into water so as to se-
cure a ﬁlm of water between and over them, holding the knife
perpendicularly to the surface of the obtect to be cut, bringing
. it ﬁrmly down on the organ, imitating the bow-string move-
ment of the violinist, then swerving the instrument from side
to side so as to release the specimen; again dip the blades in
water and the specimen ﬂoats out. It can then be mounted
in some indifferent ﬂuid, preferably normal saline solution.
The examination of fresh specimens ineans quick work
and an insight into conditions as near as possible as they exist
in nature. It is. of course, self-evident that with ﬁrst work in
this branch of microscopy, there is great difﬁculty in recogniz-
ing the conditions, even in recognizing the elementary struct-
ures of tissue. This is, however, acquired by practice. A
point which urges me to insist on the study of fresh pathologic
\Specimens is that we see some changes in such specimens
which can never be seen in a ﬁxed, hardened and’stained spec-
imen. For instance, cloudy swelling, hydropic, fatty or slimy
' degeneration are conditions only to be seen in fresh speci-
mens, never in stained specimens. This examination must
take place in an indifferent solution. Physiologic salt solution
from 0.6 per cent to 0.75 per cent is probably the best medi—
um. In order to hold the medium ﬂuid, it is necessary at
times toiring the specimen with vaselin or melted parafﬁn.
We know, too, that some information can be gained from
the fresh specimen by simply making what is called by the
Germans an “Abstrichpraparate” which consists in running
the sharp edge ofa knife over the surface, for instance, Ofa
tumor and bringing off some of the characeristic cells. But
this is not comparable with the use of the double-knife. It is
especially in conjunction with autopsy work that the advanta-
ges ofthe double-knife are to be seen. We know that the
pathologist can fairly well make out with the naked eye ap-
pearances most of the gross changes of tissue, but he is posi-
tively at a loss to diagnosticate some conditions at the autopsy
table which would be of supreme importance to him in mak-'
City Hospital Alumni. 149
ing up his anatomical diagnosis. It is to often the case that
conditions of neprhitis are diagnosticated from the naked eye
picture where microscopic study afterwards revealed a different
tale. I myself have seen conditions diagnosticated “interstitial
change” or “fatty change” at autopsy where later examination
Showed the error ofit all. By the use of the double-knife in
all doubtful cases, a positive idea of the condition can be as-
certained. Neoplasmns at the post mortem table are Often
difficult to correctly diagnose. Here again a fresh cut will
clear up the condition. Aside from the use of this instrument
at the autopsy, it can be utilized as a substitute for the freez-
ing microtome in the diagnosis of tumors during the course of
a surgical operation.
In order to bring out special parts ofa section, various
chemicals have been utilized by Virchow and his followers.
One reagent after another can be applied to the same prepara-
tion, and in this way: On one side of the cover~glass place
a small piece of ﬁlter paper which will absorb most of the
ﬂuid by which the Object is surrounded and then drop the next
ﬂuid at the other edge, when by capillary attraction, it ﬂows
into the preparation. This can in turn be absorbed and the
next ﬂuid used. Of all the ﬂuids used in conjunctlon with
fresh pathologic work, acetic acid is probably the most im-
portant. The action ofacetic acid on fresh tissue is to cause
the connective tissue and protoplasm to become more trans-
parent and to cause the nuclear structures shrink, thereby
bringing them out more sharply. Mucus is dissolved. Acetic
acid is, therefore, utalized when we wish to quickly look at the
form, arrangment and number ofnuclei. Of greatest importance
is acetic acid when we wish to differentiate between an albumin-
ous (parenchymatous) and a fatty degeneration; albumin is
disolved and fat changes are brought out more clearly by
acetic acid. Elastic elements of tissue, together with various
organisms found in tissue are brought out sharply by it. It
can be used either in concentrated form, as glacial acetic acid,
or in solution of 2 to 5 per cent. Acetate of potassium solu-
tion is also used in bringing out nuclei strongly. Where there
is a calcareous change suspected, we use hydrochloric acid in 3
per cent solution, whereby gas bubbles are produced (C02).
150 Medical Society of
One part of Lugol’s‘ solution in four- parts of water is an excel-
lent means of making out amyloid changes. Glycogen-con-
taining bodies of amyloid substances are stained black. An-
other means Of detecting amyloid change is by putting the
fresh section in a solution of gentian violet; amyloidparts are
stained deep red while the other parts are stained violet.
Summing up the reasons why we should use this method
of examination, I will go over the processes which can be seen
in the ﬁrst section:
I. Where there has been a hemorrhage into tissue, we
can see it best in the fresh specimen, getting a better idea of
the age or the hemorrhage. Hematoidin crystals can be
made out, also amorphous yellow hemosiderin. '
2. Necrotic changes can well be investigated in the fresh
specimen. .
3. Atrophy is easily made out. Should we want to ex-
amine muscles and nerves in atrophy, then the use of macera—
tion ﬂuids are necessary. ~
4. Cloudy swelling; parenchymatous degencratoin. These
changes which can only be seen in the fresh specimen. To dif-
ferentiate this condition from fatty changes, as we have. said
before, use acetic acid, whereby the intracellular nuclei are
dissolved, while fat is sharply deﬁned.
5. Fatty changes: To detect fat use acetic acid, as be-
fore explained. Again, use a solution Of either and chloro-
form which rapidly dissolved fat in tissue. Another excellent
means of detecting fat is the osmic acid staining.
6. Hyaline and colloid degeneration can well be studied
in this way.
7. Amyloid degeneration has already been alluded to.
The micro-chemistry of this substance can best be solved in
the fresh specimen.
8. Inﬂamation of tissue in general can well be studied in
the fresh specimen unstained. Should staining be deemed
expedient, dip the specimen in methyl green and good pict-
ures will be forthcoming.
9. Tumors of various sorts, if of good consistence can be
diagnosticated in this way. a
I have thus laid down good reason, I think, for the patho- '
City Hospital Alumni. 151
logist, especially the autopsy physician, to take up the study
of fresh specimens. I have seen its workings under a master,
my teacher, Prof. Langerhans, and I cannot commend it too
warmly. I am supervising the autopsy work in our City Hos-
pital and am using my double knife in the dead house with
excellent results and in what I hope is a scientiﬁc manner of
completing my anatomical diagnoses.
I havelbirought with me two specimens or lesions of the
liver which I propose to cut before you and show you the
microscopic picture. In the one, the fatty change is quite
marked. In the other it is fnot so well established. In this
ﬁrst specimen, there is a condition of fatty degeneration and
inﬁltration, with central atrophy of the cells, a condition of
hepa muschatum mixed with fatty degeneration. In this con-
dition we- have a fatty inﬁltration, the fatty' globules being
around the veno centralis. Cyanotic atrophy of the lesser
cells leading to the secondary disturbances.
DISCUSSION.
DR. A. H. MEISENBACH said the instrument shown by the essay-
ist was not new but a modiﬁcation of the Valentine knife, though on a
larger scale. Ten years ago he used the Valentine knife under in-
struction of Drs. Israel and Jurgens, in Virchow’s laboratory and did
the same work Dr. Gradwohl is doing now. ‘
He hoped the younger members of the profession would use
this means of diagnosis for it is very valuable especially in demon-
strating the changes taking place in the tissues. The use of this
knife in the operating room ought to be of value. It would, of course,
necessitate the presencs of someone qualiﬁed to use the microscope
because the surgeon- generally has his hands full with the operation.
The use of the instrument at an operation would be a means of indi-
cating to what extent further operative work would be necessary.
DR. CHAS. SHATTINGER thought the instrument should be made
the subject of class instruction. There is too much staining; too
much artiﬁcial preparation in the college work by the students. The
students fail to appreciate the appearance of tissues in their natural
state, or the state which approaches the normal as nearly as possible
152 Medical Society of
in class work. He always, in his class work, laid great stress on using
- tissues as nearly as possible to their appearance in life. This does
not receive a hearty response on the part of students. They like to
see the tissues stained, losing sight of the fact that they are stocking
their mind with artiﬁcialities. It is very [necessary to get down to ﬁrst
principles in this kind of work and how better do so than to see the
cells, not as we make them appear, but as they really are?
DR. GRADWOHL, in 'closing, in answer to questions, that this
method had no special advantage over the freezing microtome except
that it is much easier to handle and especially did this apply to its use
in the autopsy room. The results would be the same in both cases.
DR. JOHN GREEN, ]R., suggested that freezing might .produce art-
ifacts whereas the method described by Dr. Gradwohl was free from
this objection.
DR. GRADWOHL said he had not met with that condition. The
freezing would of course, subject the tissues to some change whereas
the knife as shown cuts the tissue while it is fresh and unchanged, but
whether artifacts would be produced by the ,freezing he could not
say.

Report of a Case of Malignant Anthrax
Edema.
BY ELSWORTH SMITH, ]R., M.D. AND H. G. MUDD, M.D ,
ST. LOUIS, MO.,
N June 6, 1900, through the courtesy of Dr. H. G. Mudd,
0 there came under my observation Mr. L., American,
aged 55 years, a retired business man, whose history
was as follows : No deﬁnite hereditary predisposition to dis-
ease; he had always enjoyed good health with the exception
of dyspepsia for the past two years; more or less excessive
indulgence in alcohol for the past year or two; previous to
this time he had partaken of stimulants in moderation.
Sunday, june 3d, as was his custom, he spent at his coun-
try home in his usual health, until the early afternoon, when
City Hospital Alumni. 153
he began to experience a feeling of malaise, with chilliness
. and feverishness. He returned to his home in the city that
same evening and from then on to the time of my ﬁrst visit on
Wednesday, june 6th, he continued to have chilly sensations
with fever and some abdominal pains with diarrhea. There de-
veloped also during that period (the exact date of which was
not obtainable) pain and swelling in the region of the lower
third of the right leg.
I When ﬁrst seen the temperature was 104°F., pulse 100,
respiration 24. There was quite severe pain in the right leg
which was swollen and edematous to the knee, suggestive
more of a severe and extensive cellulitis than anything else,
except that there was less tension in the inﬂamed structures
than is usually present in ordinary cellulitis.
The story of the case from this date (june 6th) to that of
his death, nine days later, was that of a rapidly-spreading and
deep-going infective inﬂammation which involved ﬁnally not
only the thigh but even the region of the buttock and sacrum.
The virulence of the process was so great that wide and deep
incisions made into the involved tissues from time to time
showed a rapidly-developing gangrene resulting, not from ten-
sion. of the parts, which at no time was high, but due simply
to the virulence of the toxins.
The general symptoms were those of a violent septicemia,
the temperature remaining between 101° and 103°F., pulse 90
to 120, respiration 22 to 40. On june 14th, the day before
death, at5 o’clock in' the evening, the temperature went to
IO6.2°F. Nausea, vomiting, diarrhea, profuse sweating and
delirium, all the symptoms in fact which go to make up the
picture of profound sepsis were also present.
Agar tubes inoculated with secretion from the inﬂamed
limb were sent to Dr. Amand Ravold, on which he very kindly
made the following report:
DR. AMAND RAVOLD’s REPORT.
DR. ELSWORTH SMITH, ]R:
I send you herewith a report of the results of the examination or
the agar tubes inoculated by you and delivered to me. The tubes
were placed in an incubator at 37°C. and the growth which had formed
154 Medical Society of
on the medium was studied the next day. I found a thick yellowish-
white growth all over the medium in both tubes. Stained cover-glass
preparations showed an apparently pure culture of a large thick bacil-
lus with squared ends, some isolated, but the greater number in short
and in long chains. There were no spores to be made out, the bacilli
being stained uniformly throughout. The growth in the tubes was
plated in both agar and gelatine, and the following culture media inoc-
ulated, broth, milk, plain and glucose gelatine, potato and Loefﬂer’s
medium. The original agar tubes and the agar plates were placed in
an incubator at 37°C. and the other tubes and plates in an incubator
at about 20°C. On the morning of the 17th the agar plates were
studied with a' microscope and showed the characteristic Medusa head
like colonies of the bacillus anthracis. Cover-glass preparations of
the growth in the original tubes showed spores in many of the bacilli.
Upon this evidence I reported to you that I was certain that the micro-
organism found in the tubes was bacillus anthracis, but that I would
complete the examination and report to you later.
All cultures were examined on the twelfth day excepting thev gela-
tine which were studied on the sixth day.
GELATINE.
Plates on the sixth day showed small and large colonies of the
Medusa head like colonies, some colonies showing a small amount of
liquefaction. Tubes showed a yellowish-white growth along the inoc-
ulation thrust with small spike-like growths radiating out of it. giving
it a root-like or arborescent appearance. The medium for a short
distance along the thrust was liqueﬁed in all tubes. No gas was
formed in the glucose gelatine. '
BROTH.
Showed a granular deposity in the medium and ﬂocculent masses
clinging to the sides of the tubes. Milk was coagulated and pepto-
nized. Potato, a grayish-white layer, somewhat dry looking. Loefﬂer’s
medium, liqueﬁed.
PATHOGENESIS.
Guinea-pig, male, weighing 584 grammes. inoculated subcutane-
ously into the abdominal wall with 1 cc. of 48-hour old broth culture,-
died on the fourth day. Post-mortem same day; abdomen and part
of the thorax edematous; subcutaneous tissue distended with a gelat-
inous, semi-fluid exudate and scattered through this tissue were many
small ecchymotic areas; liver enlarged; lungs pale, red in color;
City Hospital Alumni. 155
spleen much enlarged, dark in color and very soft andfriable. Smear
preparations from spleen pulp and blood from heart cavities showed a
large bacillus in great numbers. Inoculations were mades from spleen
into culture media and the bacillus anthracis was again obtained in
pure culture. '
I am convinced from the above examinations.that the micro-
organism found in the culture tubes inoculated by you is the bacillus
anthracis.
Aside from anthrax being in itself a rare disease, the
above case, it seems to me, should be of interest in exempli-
fying especially the difﬁculty of arriving at a diagnosis in
many ,of these cases.
Anthrax manifests itself usually in three forms: First,
externally, or that of a malignant pustule, where there is a
typical initial ' lesion which renders the reizognition of the
trouble comparatively easy; second, the internal form (thora-
cic or intestinal mycosis); third, that of anthrax edema, where
the process assumes the form of an extensive and deep-going
edema without any apparent initial lesion, and to this latter
variety, the case in question belongs.
It is wellnigh impossible to make a diagnosis of these two
last forms without ﬁrst having one’s suspicions aroused by
either the presence of some evident etiological factor or the
- 'anomolous behavior of the symptoms and physical signs in the
case. The presence of either one of which set of data lead-
ing to a bacteriological examination and a recognition thereby
of the true nature of the affection.
In the case just cited it was evident from the ﬁrst that a
virulent infection was present, originating in the leg, causing
an extensive and rapidly-spreading edema with resulting
gangrene and a secondary profound general sepsis, and it was
further noted that the death of the involved tissues of the
limb did not result from tension of the parts but evidently
directly from the poisonous effects of the toxins in which the
structures were inundated.
It was then‘ the presence of this rapidly-occurring and
extensive gangrene with absence of any great tension, so con-
siderably present as the cause of necrosis in the ordinary form
156 Medical Society of
of cellulitis that aroused suspicion as to the character of the
pathological process and led to the bacteriological examina-
tion and thereby to a correct appreciation of the malady des-
pite the absence in the involved limb of anything even sug-
gestive of the initial anthrax pustule.
The above two signs, therefore, viz., gangrene without
marked tension should prove of great value in the correct in-
terpretation of such cases.
Once the presence of anthrax was determined, search was,
of course, at once instituted to ascertain the source of the in-
fection and the result thereof forms another interesting phase
of the case.
As a rule, we know that in external anthrax the inocula-
tion generally occurs on exposed surfaces—as the hand, fore-
arm, neck, etc.; here, though, the infection evidently started in
the leg, a part, as a rule, protected with clothing;
After much inquiry the following story was elicited, which
furnishes the most probable mode of invasion of the disease.
During the afternoon of the day the patient spent at his coun-
try home (viz., Sunday, june 3d) he engaged for some time in
a game of quoits, using old horseshoes in the place of the reg-
ular articles devised for the game. After taking to his bed ill
that evening and without having washed his hands after the
game of quoits he remembered having scratched very vigor-
ously with his ﬁnger nails his right leg and associated the dis--
turbance arrising thereafter in the limb with the trauma thus
self-inﬂicted. '
Now with the complete absence of any other apparent
etiological factor and with the well-known fact of susceptibility
to this disease being greatest in the herbivorous animals it
seems most plausible to conclude that the infective agency
was conveyed from the horseshoes used in the game to the
abrasion on the leg, through the medium' most probably of
the patient’s ﬁnger nails, even though such a mode be certainly
a very unique one. The disturbance of which the patient
complained on the afternoon of june 3d, was, of course, in all
probability quite foreign to the farmore grave affection which
developed later, and served only as a predisposing factor to
the subsequent onset of the attack of anthrax. '
City Hospital Alumni. 157
The surgical phase of the case I will leave to Dr. Mudd.
DR. HARVEY G. MUDD’s REPORT.
I saw the case for the ﬁrst time on Wednesday morning.
At that time therewas a little abrasion surrounded by an area
which looked like cellulitis simulating erysipelas; so closely
did it resemble an erysipelatous infection that I did not feel
safe in handling the case, and asked Dr. Smith to take charge
i of it. Some days after this I saw the case with Dr. Smith and
found that the trouble had spread rapidly and that the larger
part of the leg was edematous though not more so than is or-
dinarily found in a rapidly-spreading gangrene. There were
no large blebs or blisters such as are ordinarily seen in cases
of gangrene. The color of the leg was very dark and the idea
that it was malignant edema occurred to us long before we
thought of anthrax; only toward the close-10f the case was
anthrax thought of and cultures taken.
Incisions were made in the leg with the hope of limiting
the spread of the gangrene, though with little hope of saving
the patient. The incisions were long and free and deep.
There was not much tension. On cutting through the skin
and tissues and muscles there was very little gaping and little
tension shown. It was a case in which to make a diagnosis was
difﬁcult. I have never seen a case of the kind nor heard of a
report of a case of anthrax edema as masked as this was.
When I saw the patient the second time the leg was af-
fected up to the groin and buttocks and had already passed
the stage where an amputation would do good. When ﬁrst
'seen at the time the inﬁltration was in the lower leg, amputa-
tion might have offered some hope, but no one at that time
would have recommended it, and the patient and family would
not have permitted it.
_ DR. A. H. MEISENBACH presented a specimen 01
Radical Cure For Hernia.
The patient was a man 64 year of age. He had been treated for
hernia by the injection method by one of the hernia specialists in town,
without result. The patient weighed about 260 pounds and the adi-
] 58 Medical Society of
pose tissue of the abdomen was three inches thick. On section it was
found that all the anatomical landmarks had been obliterated; the
cord and superﬁcial fascia and sac being one mass and the point
which ought to have been attacked by the hernia-specialist was avoid-
ed. This was probably due to the thickness of the abdominal walls
and the specialist was not willing to thrust his needle to the proper
point evidently fearing to go to deep. The adhesions about the cord '
were so great that it was determined to take away the cord, testicle
and everything on that side. The specimen was brought to show
what the pathological conditions were which gave rise to the hernia.
The patient had been known to the essayist for the past twenty years.
After going to the specialist for 22 months without relief he became
disgusted, and again wore his truss. In the light of our present knowl-
edge in regard to hernias he thought if it was ever safe to guarantee a
result, we might do so in a case of an uncomplicated hernia. Of
course, he never guaranteed a result in any surgical operation, but
this operation offered a better outlook than any other. The death
rate is less‘ than 9/10 of I per cent and the reccurences less than.3 per
cent. '
The sac in this case is very adherent and thick on all sides. Silk
was used in the deep sutures, and aluminum bronze wire in the skin.
This was done because he believed they would have to remain much
longer than is usual. He said he felt justiﬁed, too, in taking out the
entire contents of scrotum on that side because of the massing of the
organs and tissues. The vas was hypertrophied to the size of a goose
quill. I
DISCUSSION.
DR. H. JACOBSON asked Dr. Meisenbach if that old man had a
stricture, which was answered in the negative. The speaker, continu-
ing, said, even if he had no stricture he believed that, under the cir-
cumstances, the false passage would indicate an external urethroiomy
combined with the usual Alexander‘operation suprapubic opening of -
bladder above, making a through and through drain because a false
passage had been made probably with extravasation of urine as a re-
sult. If the false passage had not been made he would then have pre-
City Hospital Alumni. 159
ferred the‘modiﬁed Alexander operation—having an assistant press the
bladder down. He thought Dr. Meisenbach perfectly justiﬁed in
leaving the catheter in as long as he did, though usually it is not nec-
essary to allow it to remain that length of time. He took exception
to the statement that the mortality was 9/1, per cent in all cases. He
believed it should be about 8 per cent in old men with double large
scrotal hernia, opening the sacs of these herniae we ﬁnd adherions;
they contain several feet of the colon and small intestines which are ex.
ceedingly difﬁcult to reduce. The precautions of a warm room, stim-
ulents and heat before and after the operation, etc., might reduce the
mortality but he thought it much greater than 9/10 per cent.
DR. F. REDER said this was undoubtedly a time when the opera-
tions enumerated by Dr. Meisenbach was very dangerous procedure,
not only in the old but in the young. This was in the pre-antiseptic
period. He agreed with Dr. Meisenbach that there is no operation
which cannot be performed on the aged as well as upon the young
though in the former probably greater precaution must be used. One
thing, however, that an aged person can not withstand well is suppur-
ative processes.
When the organs are in a comparatively fair condition he thought
almost any kind of an operation might be performed even if a cardiac
lesion existed but which was not pronounced. With a renal lesion it
is almost as dangerous in the young as in the in the old to perform any
sort of operation requiring an anesthetic. Another condition of the
aged which would make one hesitate to perform an operation is that
of arcus senilis. His attention had been called to this and the out-
come was veriﬁed by the death of the patient in several instances.
The operations enumerated by the essayist are all capital oper-
ations. Of the other operations, such as hernia, varicose veins, ﬁstula
and operations necessary for the relief of cancerous conditions, he
thought no surgeon would hesitate in giving the patient relief. The
difference might be called simply an echo of days gone by. The laity
at that time were averse to an operation because they feared it would
be immediately fatal and they were willing to bear the pain and live a
little longer,
About six weeks ago he operated upon a lady nearly eighty years
160 Medical Society of
of age for intestinal obstruction. He talked to her rather heroically,
telling her he would simply make an opening and allow the escape of
the fecal matter. The operation was performed and the patient is
now in good health gaining in weight, and feels very grateful.
The saying that a man is as old as he feels and a woman as old
as she looks, has a bearing on operative cases. If the statistics were
closely examined he believed it would be found that old men bear
operative procedures more successfully that old women.
DR. MEISENBACH, in closing, said he agreed with Dr. jacobson
that an external urethrotomy is the operation indicated in these cases
as a rule, but in this case it could not be well performed. A number
of years ago be operated on a patient with torn and lacerated urethra
in the membranous portion. The patient fell while walking over a
joist and straddling the joist tore the urethra. He saw the patient two
days after the accident. A country surgeon had attempted external
urethrotomy but had only cut down through the perineum, not com-
pleting the operation. In this case he simply enlarged the
opening already made and resected both ends of the urethra and
also two thirds of the cavernous portion. A portion of the prepuce
was taken and cut so that when the tissues contracted 1t would ﬁt into
this gap. The patient recovered.
One reason why he did not perform external urethrotomy on the
patient mentioned in the paper was because he could not ﬁnd the
opening into the bladder—he hunted for this opening for half an
houn
He agreed with Dr. jacobson that the percentage of recoveries is
probably not as low as stated. These are not the class of cases ﬁt for
radical operation because we have the contraction of the abdominal
cavity to contend with and the scrotum is ﬁlled with the contents of
the abdominal cavity and there the peritoneal cavity is much con-
tracted.
Dr. Reder’s statement was correct in regard to suppuration in the
old. Fortunately this case had the advantage of a perfect aseptic
conditions. The operations we perform on young and old today
would have been dangerous before the aseptic period. He had been
astonished to see with what facility wounds heal in the aged. A case
City Hospital Alumm. 161
was related in the Medical Record, illustrating this. A surgeon re-
sected the pylorus in a patient 72 years of age with complete success.
Therefore he thought the position taken in his paper was justiﬁed; that
age itself, providing there was good condition of the heart and kidneys
and lungs, was no bar to operative interference. With grave lesions
in any of these organs, however, operations of course become more or
less dangerous.
Surgical Operations on the Aged.
BY. A. H. MEISENBACH, M.D.
ST. LOUIS. MO.
HE aged like the middle aged and the young are amen-
able to the various surgical diseases that the latter are,
hence the surgeon is often called upon to operate on
them. It is a general belief, among the laity at least, that surgical
operations on the aged are dangerous or unjustiﬁable. How
often do we hear the remark, that, “he or she is too old
to operate on; that they will not withstand the shock of oper-
ation.”
To this belief we cannot give consent. We do not believe
that age, per se, is a bar to surgical operation. Surgeons well
know that people who are inclined to be delicate and quasi
invalid will often withstand the shock of surgical operation
better than those who are robust and lead an active life.
In the former the invalidism has inured them to conﬁne-
\ment and rest, and makes them bear the effect ofsurgical con-
ﬁnement with greater ease and less fretting, than the robust,
who, when forced to be conﬁned in a given position for a
length of time worry and fret—a condition unfavorable to
recovery.
In the aged we ﬁnd that Nature has made provision for
a greater equipoise of the various functions — their
lives are more regulated—there is an absence of the turmoil
and restless energy of middle life which in itself is a factor
of self destruction.
162 Medical Society of
Furthermore the individuals who have reached an ad-
vanced period of life do so by virtue of an inherited good con-
stitution, which stand them good at this period of life.
In these patients we ﬁnd the organs yet (most of them) in a
wonderful state of preservation.
The main consideration, of course, in the question of sur-
gical operations in the aged is that there are no grave lesions
of the vital organs, heart, lungs and kidneys especially.
These being ina satisfactory condition, we can undertake
quite extensive operations on the aged, keeping, however,
certain facts in view.
Asa rule, the aged do not bear well—ﬁrst, the abstrac-
tion of heat; second, the loss of blood; so that in our oper-
ative work these factors should be borne in mind. In oper-
ating, the conservation 1 of the animal heat especially
should be looked after, notably is this the case when the
abdomen is opened.
To this end the heating of the operating room should be
so constructed that it can be quickly run up, say to 90 or 100
degrees. An operating room where abdominal work is done
should never be below 80°F. The room should be warm,
even at the expense of the comfort of the operator, assistants
and nurses. The patient should be well protected by flannel
blankets or, better still, by a blanket suit as suggested by
Homans, of Boston. This suit consists of closed leggins, ex-
tending onto the body, and a jacket with long sleeves extend-
ing over the hands and closed at the ends. The material
used is heavy white blanketing. A table constructed so as to
have it kept warm by hot water canal, or other means, is valu‘
able; especially, also, after the operation, should the patient
be well protected. I fear from what I have seen at times that
this is not fully appreciated, having seen patients taken from
warm operating rooms through chilly corridors, the patient
not properly covered. The room and surroundings of the
patient should be rather warmer than for younger patients.
All operations should be as bloodless as possible. The
parts should be rendered so if operating on an extremity by
Esmarch’s tourriiquet; elsewhere the careful use of hames-
tatic forceps or by ligature should be indulged in. The use
City Hospital Alumni 163
of mumal salt salution under the skin should always be em-
ployed whenever indications of a lowered blood tension
suggests itself.
Alzestkez‘z'cs.—-“The less of any anesthetic any patient
gets the better for the patient.” This doctrine applies equally
as well to the aged. The anesthetic I use is chloroform and I
often anticipate its use by ahypodermic ofmorphia and a good
“horn” of whisky. I have found that this miminizes the
amount of chloroform necessary during the operation. IO to
20 grains of chloreton one-half hour before operation have
also been suggested, the effect claimed being nerve tranquil-
ity, less amount of anesthetic used and less liklihood to post-
operative nausea and vomiting. I have tried this several
times on young subject with apparent good results. Local
anesthesia should be employed if any contraindication to a
general anesthetic exists.
Several years ago I operated on a woman past 65‘ years
of age who, the attending physician stated, had a heart lesion,
and was afraid of a general anesthetic. The woman was suf-
fering from a strangulated femoral hernia. In this case I used
a IO per cent cocaine solution with good results. The bowel
was gangrenous so that a resection was necessary. Approx-
imately (end to end) was done with a Murphy button. The
only pain the woman complained of during operation was
when pulling sharply on the messentory. She made a good
recovery from the operation but died a few weeks after on
account of inanition produced by an intestional ﬁcal ﬁstula.
The button had produced a slough on one side of its approxi-
mation.
I have found that the mental equation is a decided factor
in surgical operations on the old as well as the young. Those
patients always doing better who had “their nerve” with them,
than those who were inclined to be pessimistic. If there is
opportunity for preparatory preparation of the patient it
should be carefully carried out, taking care, however, not to
deplete the system too much by over purging and low diet
before the operation.
On general principles, I am inclined to believe that even
164 Medical Society of
in younger subjects we are apt to over-do the preparatory
treatment, especially as to purging.
The after-treatment should also be carefully attended to.
As soon as the stomach will permit after operation, alcoholic
stimulants should be given; if not exhibited per 0.9, the rectum
should be utilized; also by hypodermic syringe.
As to the class of operations I shall cite in illustration in
this paper, I will state that they area few of the number I
have operated on. They are all capital operations and go to
illustrate that operation should not be refused on account of
age. The determining facts being as in the younger.
I. Is the operation necessary,
a. To save life;
5. To prolong life;
a. To add to the comfort of the patient for the rest of
the alloted years.
If these questibns can be answered in the afﬁrmative the
patient should have the beneﬁt cf our surgical skill.
Under all circumstances, in every case, the patients and
friends should be fully appraised of the import of a surgical
operation.
CASE I.—GANGRENE OF RIGHT LEG.
Mrs. H, female, aged 63 years. Saw patient November 23,
I893, eleven years ago, had paralysis of right leg. Four weeks pre-
vious had an attack of " grippe. ” this was followed by swelling and
gangrene of the foot. Gangrene of a dry nature; slow progress.
Amputated leg at Rebekah hospital December 19th. Amputation
bloodless, lower third of the femur. The wound healed nicely and
the patient left the hospstal January 4th.
CAsE II.——GorrER, UNILATERAL, RIGHT SIDE.
Mrs. B., female, aged 61 years, well nourished. The patient had
had a goiter for a number of years, but it did not trouble her very
much until the last year, when she began to develope symptoms of
dysponea and nervious tremours which became more marked and
come on oftener lately, sometimes havmg as many as four or more
attacts daily. The goiter was not very large but very ﬁrm (parenchy-
matus variety), pressing backwords on the trachea and on the pneu-
City Hospital Alumni. 165
mogastric nerve. Operated December II, 1903; usual operation for
goiter—leaving in part of the gland so as to escape the developement
of myxedema. The patient recovered nicely from the operation and
left the hospital December 28th, improved in health.
CASE III.-—VENTR0FIXATION; RETROVERSION OF THE UTERUS.
The previous patient also had a marked prolapsed and retroverted
uterus which caused her much distress; pelvic pains, backache and
bearing-down pains. Having recovered from the previous operation
she again entered the hospital. I performed a ventroﬁxation, with
good results, notwithstanding the fact that she had an attack of inter-
current bronchitis, so that in her coughing spells I was afraid that she
would burst the abdominal wound. She made a complete recovery,
CASE lV.—GALL-5T0NEs; CHOLECYSTOTOMY; CHOLEDOCHOTOMY.
Mrs. B., aged 70 years, was brought to my notice in the latter part
of August, 1900, by Dr. Volker, of Carondelet. She had been a suf-
ferer for a number of years from stomach cramps; several physicians
had seen her and a diagnosis of gall-stones had been made. A few
weeks previous to my seeing her she had been under observation in a
private hospital; operation was not done, for what reason I do not
know. I found the patient an intelligent woman, of wiry built (very
weak, however) and strong will-power; she was very sallow; pain and
tenderness over right hypochondrium; fever of an intermittent type,
accentuated when paroxysms of pain came on; temperature 99° to
100°F. Pressure over the gall-bladder caused pain. Diagnosis, gall-
stones.
The patient was very determined, and said: “Doctor, I don’t
want to live this way any longer, I want to get well or die.” I told her
an operation was the only hope and to this she consented.
She was taken to the Lutheran Hospital and the preparatory
treatment was strychnia, 1],,0 gr., hypodermically, three or four times a
day; stimulants, alcohol baths. I operated September 3; anesthetic,
chloroform; sulphate of morphine. 1/, gr , before anesthesia. Vertical
incision at the border of the rectus; when the belly was opened gall-
stones in the gall bladder were revealed, also one in the common duct.
The gall-bladder was opened and stitched to the abdominal parietes;
the common duct was opened, the stone removed and the duct left
open ; a rubber drain was carried down to it, fastened by one stitch of
ﬁne catgut and iodoform gauze packed around it, both tube and gauze
were carried out of the abdominal wound at the side of the gall‘blad-
166 Medical Society _ of
der. The rubber drain in the gall bladder rests in the wound which
was closed with silkworm gut. She reacted well from the operation,
which lasted one hour and forty minutes. The temperature never
exceeded 99.2°F. She left the hospital at the end of October, the
convalescence being prolonged on account of the double drainage of
the peritoneal cavny and the gall bladder. ‘
The last I heard of her, some months since, was that she was in
good health, skin clear and had gotten fat.
Ckoledoc/zoz‘omy is one of the most difﬁcult operations in
gall system surgery; difﬁcult on account of the deep seated-
ness of the ﬁeld of operateration and also on account of the
technical difﬁculties as to incision and getting out the stones.
Nevertheless the patient recovered; thanks to_ a naturally
good constitution and a determined will. Without operation
this patient would have, in a short time, been gathered to the
great majority. The result well repaid the operative risk.
CASE V.-—ENLARGED PROSTATE; VIOLENT CATHETERIZATION;
FALSE PASSAGE; RETENTION OF URINE.
Mr. D., aged 84 years. Operation, suprapubic cystotomy, pros-
tatectomy, retrogressive catheterization. I was called to see the
patient, an inmate of the Memorial Home; a day or two before he
could not pass his water. An aged M.D., also an inmate of the Home,
tried to pass a stiff No. X silver catheter, he did not succeed but got
blood instead of urine. When I saw the patient his bladder was over-
distended—nearly up to his navel, I tried to get into the bladder with
soft rubber catheters, ﬂexible metal prostatic beak and ﬁliform bougies
but did not succeed. I aspirated the bladder above the pubis and
again tried to get in with instruments per m'am naturalem but again
failed. After three aspirations and repeated attempts at introduction
of instruments I had the patient sent to the hospital where I opened
the bladder suprapubically, resected the middle lobe of the prostate,
and did a retrogression catheterization, leaving the catheter in for three
weeks. The patient recovered from the operation without any unusual
symptoms, except a threatened pneumonia, which rapidly subsided-
under treatment. The patient, with the exception of, a small ﬁstula, is
in good health.
This case is also interesting on account, ﬁrst, of age;
second, of the previous “violent catheterization” ’which may be
City Hospital Alumni. 167
very serious false passages leading to infection and urenary
fever; third, the combined operation of suprapubic systotomy
and prostotecting.
CASE VI.—-STRANGULATED FEMORAL HERNIA; HERNIOTOMY;
RAnIcAL OPERATION.
I was called to see Mrs. E., aged 65 years, who since the earlier
part of the night before had been suffering from a rightsided femoral
hernia. The patient is a spare-built woman, intelligent, with strong
willpower; she was not suffering much. There was a tumor in the
right femoral region the size of a hen’s egg. Attempts at reduction
had been made but without success. I advised operation as the
safest means of dealing with the case; she assented and was trans-
ferred to St. Anthony’s Hospital for immediate Operation, which was
performed at II o’clock that morning; chloroform anesthesia, with 1/,
gr. morphine. I found a hernia chieﬂy composed of omentum, the
knuckle of bowel being very small; the bowel was dark and congested,
but the epithelium was not destroyed. I deligated the greater part
of the omentum in the sac and cut it away. Having satisﬁed‘ myself
that the bowel was all right it was dropped into the abdomen. The
various steps of the radical operations were then carried out; the pa-
tient recovered from shock, was not sick and on the tent or twelfth
day was out of bed completely well.
The above related cases illustrate a wide range of cap-
ital surgical operations on the aged. This list might be ex-
tended but would be of no material interest, nor would it help
to further elucidate the object of this paper,ie., to demon-
strate the feasibility and safety in operating on patients
advanced in years.
From the above cases we are justiﬁed, we believe, in draw-
ing the following conclusions:
I. The aged bear capital operations relatively well.
2. Age, per se, is no drawback to surgical operation,
everything else being equal. ‘
3. The aged, under proper conditions, should be given
the beneﬁt of our skill in surgical work.
4.. We must bear in mind thaf the aged do not bear well
the loss of heat and blood.
5. In our surgical work the foregoing must be kept in
mind and proper means employed to prevent the same.
168 Medical Society of
Vesico=Vaginal Fistula; Operation According to
Techniqe of Freund; Report of Case.
BY FRANCIS REDER, M.D.,
ST. LOUIS. MO.
I—TE relative position of the bladder to the vagina is such
that when the vitality of the immediate tissues becomes
impaired, a slough or an ulceration may result, causing
a direct communication between these parts through which
urine will escape into the vagina. Such a condition is known
as a vesico-vaginal ﬁstula. '
The most frequent cause Of a vesico-vaginal ﬁstula is a trau-
matism resulting from a tedious and difﬁcult labOr, caused by
an impaction of the child’s head in a narrow pelvis, or a neglect
of the condition of the bladder during labor. A vesico-vaginal
ﬁstula may also be caused, exclusive of operation (vaginal
hysterectomy) and cancerous disease, by the improper use of
instruments or from the presence of foreign bodies in the blad-
der or vagina.
If the ﬁstula is the result of labor we may usually look
for a transverse opening. If, however, the ﬁstula has been ex-
cited by the action of instruments the opening is more apt to
be longitudinal. .
The evils resulting from the existence of a vesico-vaginal
ﬁstula, as well as the difﬁculties of the cure, will depend in a
great measure on the position, size and condition of the open-
. ing, these evils and difﬁculties being greater in proportion to
the proximity of the ﬁstula to the bas-fond of the bladder,
and least when it is in or near the anterior portion of the
urethra. »
In considering the treatment for vesico-vaginal ﬁstula the
more recent advances made in the operatiVe technique since
the antiseptic era have given us a reasonably certain amount
of success that we may look upon the treatment as a curative
one. .
Like any wound, the course of a ﬁstula of this character
City Hospital Alumni. 169
uninterfered with is toward closure. This closure may take
place by primary union or by granulation. A small ﬁstula
elosing without operative assistance will do so in a few weeks.


Iii;
~r~tlllllitii
I
FIG. I.--Classical Operation for Vesico-vaginal Fistula. In a vistula
permitting the Classical Operation little or no loss of tissue has
occurred; sutures in place, but not tied.
An opening in the vesico-vaginal wall that has not closed after
several months will, from the time of the accident, unless
aided by an operative procedure, become an intractable af-
fection.
170 Medical Society of
In the cure of vesico-vaginal ﬁstula the treatment prepar-
atory to the operation is of the greatest importance. It be-
comes peremptory that the general condition of the patient
be brought into the best favorable state. A vesico-vaginal


FIG. 2.—Vesico-vaginal Fistula showing the loss of tissue sustained i‘
by repeated efforts to effect a closure. ‘
City Hospital Alumni. 171
ﬁstula is not a “hurry-up” case and it is well that the patient
be informed of this at the very beginning of the treatment.
Special attention should be paid to the excoriated and
edematous condition of the external organs of generation
caused by the irritation of the urine. Frequently an eczema
extends over the nates and upper part of the thighs. The
mucous membrane of the vagina is not infrequently swollen
ills-.4)
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. __,\~—~
/
_m
. A."
P'II,
_ ,j._
\ m.
s...
'2‘-.
4 ' -:
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‘u\|
v a
.
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FIG. 3.—Freund’s Operation. The uterus is brought into the vagina
and is used as a plug in the opening of the bladder; it is sutured
to the freshened edged of the ﬁstula.
and reddened, Often containing sloughing necrotic tissue,
while the edges of the ﬁstula are covered with sabulous and
offensive phosphatic deposits. The urine is almost always
phosphatic and should be kept in an acid condition or there
will be no local improvement. These conditions must be cor-
rected before the ﬁstula is subjected to an operative proced-
ure. It may require weeks before the proper conditions are
brought about and may cause some dissatisfaction on part of
the patient, however, the preparatory treatment is a matter
essential to success. Without it the most skilfully performed
operation will most certainly fail.
172 Medical Society of
For the treatment of vesico-vaginal ﬁstula the operative
treatment is the only one to be considered. In the milder
cases success is invaribly‘certain by simply freshening the
wound margins and bringing them together with sutures, while
in the graver cases a more extensive operation becomes im-
perative. '
The difﬁculties attending a cure of vesico-vaginal ﬁstula
have led surgeons to suggest the use of different instruments
and to recommend various modes of operating. Among the
methods in vogue the most successful and most frequently
performed is the one known as the classical. This method
consists in simply denuding in a funnel shape, the margins on
the vaginal surface, leaving the vesical mucosa untouched.
The neat and accurate apposition of the parts with suture
completes the operation.
By another method the defect is covered by flaps trans-
planted from the contiguous vaginal wall.
Opening the ahdomeh and cutting through the vesico-
uterine peritoneum, thus detaching the bladder from the ﬁstula,
sewing up the bladder wound and then uniting the peritoneum
and closing the abdomen, is another method. I
Demedaz‘z'oh on the vesical mucosa from one side of the
ﬁstula around to the other and uniting this surface to the
freshened anterior part of the ﬁstula, has been successfully
performed.
Another method consists in dissecting the bladder loose
from the vagina and sewing up the vesical wound separately.
The anterior face of the uterus is used to close the vaginal
defect.
A method occasionally resorted to consists in freeing the
bladder around the posterior two-thirds of the ﬁstula,
bringing it forward and uniting it to the anterior third, which
is freshened on its vaginal surface.
Prohahly the most heroic method consists in the opening of
the posterior fornix Of the vagina, bringing forward the body of
the uterus and attaching it with its posterior surface to the edges
of the ﬁstula on all sides, thereby closing the ﬁstula, using the
body of the uterus as a plug. .
It is plainly evident that a certain degree of dexterity
City Hospital Alumni. ' l73
and skill must be necessary to execute the technique of any
of the methods enumerated to insure success.
I have had occasion to operate upon a sufﬁcient number
of vesico~vaginal ﬁstulas to fully appreciate the gravity and
difﬁculty of such an operation
Exclusive of the classical method all other methods pre-
sent their individual Obstacles which are sometimes extremely
difﬁcult to overcome.
The ﬁstula best suited for the classical method are those
where the parts present a healthy condition, where we ﬁnd an
absence of hypertrophy and induration of the edges of the
ﬁstula, where no previous attempt at closure has been made
and where time has'not been given the opportunity to form
the cicatricial bands and scar tissue which so frequently com-
plicate an otherwise simple operation. For the classical op-
eration the time offering the best advantages for an operation
would be six to eight weeks after labor. The tissues then will
be found soft, vascular, with the normal laxity not yet de-
stroyed by ﬁxation and atrophy. The classical operation per—
formed under such conditions would with much certainty cure
the ﬁstula—be it small or large.
In performingthe operation it is well to have a goodly
amount of loose tissue at your disposal. ‘ If such tissue is nOt
forthcoming it becomes advisable to resort to surgical meas-
ures upon the adjacent tissues in the hope of relieving the
tension caused by the scar tissue. It is always well to have
a deﬁnite idea as to how the denuded margins Of a ﬁstula will
allow of approximation before the true condition will be re-
vealed by pulling upon the stitches. It is at this stage of the
operation where usually the greatest disappointment takes
place.
Like in all plastic work good judgment, skill and dexter-
ity on part of the operator is necessary to success. The
surgeon feels very keenly a failure in a plastic operation. He
feels the loss of valuable tissue and deplores the increasing
difﬁculties in effecting a cure usually arising out of such a
failure.
Two years ago a case Of vesico-vaginal ﬁstula came under
my care that presented anything but an encouraging outlook
17 4 ‘ Medical Society of
for a cure. The patient was 40 years of age and clearly
showed the mental anguish and distress this intractable condi-
tion had wrought upon her. She had been subjected to oper-
ation for the cure of this ﬁstula ﬁve times within two and a
half years with no improvement in her condition. In fact, her
condition was worse. The condition of this woman dated
back to the birth of her third and last child, ﬁve and a half
years ago. The labor was a very tedious and difﬁcult one,
delivery being eventually accomplished with instruments.
The conditions as they presented themselves upon exam-
' ination were as follows: Labia majora and minora excoriated
D and swollen; an ecZema about the external gentalia and inner
side of the thighs. The mucous membrane was covered with
an offensive phosphatic deposit.
An opening with smooth and atrophic margins in the
vesico-vaginal septum large enough to readily admit two ﬁn-
gers permitted the much congested bladder mucosa to pro-
trude. This ﬁstulous opening began about one half-inch back
Of the introitus and extended up to a cicatricial mass that par-
tially imbedded the cervix. On the right‘ side of the ﬁstula
there was a marked cicatricial band. ’
After a three weeks’ preparatory treatment consisting of
boric acid douches, sitz baths, nitrate of silver applications to
the eczematous'area, internal administration of benzoic acid
and tonics, the patient’s condition appeared favorable for op-
eration.
During the three weeks of preparatory treatment the
method of operation that would give a reasonable amount of
success was almost my constant thought. I determined upon
a method devised by Freund, and felt assured that ifI did not
meet too great a difﬁculty in bringing the uterus into the vagina
the defect could most likely be greatly improved if not cured.
The operation was performed in the extreme lithotomy posi-
tion with hips well elevated. Posterior and lateral retractors
exposed the ﬁeld. Douglas’ cul-de-sac was opened and the
uterus was drawn out into the vagina. This was done with
some difﬁculty. Silk ligatures passed through the body of the
uterus had to be substituted for the tenaculum on account of
the easy manner in which the uterine tissue could be torn.
.City Hospital Alumni. 17 5
After considerable manipulation the posterior wall of the
uterus was brought into the opening of the bladder. The
edges of the ﬁstula having been freshened in the usual way,
the posterior surface of the uterus was next scariﬁed and
scraped on both Sides in front of the broad ligament and su-
tured to’the freshened edges of the ﬁstula with a continuous
catgut suture, using a small curved needle. This part of the
operation proved the most difﬁcult. After the suturing had
been completed, sterilized milk introduced into the bladder
gave no evidence of leakage. The opening into Douglas’ cul-
de-sac was loosly packed with strips of gauze; the vagina was
also loosly packed.
No permanent catheter was introduced. The bladder,
however, was relieved every three hours by catheter. Three
days following the operation the urine showed evidence Of
blood. It eleared on the fourth day and remained clear. One
week after the operation the packing in the vagina was re-
moved and an opening was made in the fundus ofthe uteriis-
to afford an exit for any menstrual bltiod. The packing in the
cul-de-sac was also removed and fresh gauze introduced. The
patient was alowed to pass urine without assistance and did
so without any inconvenience one week after the operation.
Two weeks after the operation a leakage became evident.
Examination disclosed a small opening on the left side near
the cervix. The edges about the opening were freshened and
closed with catgut suture. Secure union followed. Six weeks
after the operation the patient was discharged as cured.
A year later I had occasion to see this patient and found
her in excellent health. Examination revealed a marked atro-
phy of the uterus and considerable shortening of the vagina -
caused by the serosa of the uterus and the mucosa of the pos-
terior vaginal wall uniting through inﬂammatory deposits.
Menstruation occurred four times after the operation and
then ceased. On the fourth day after the operation the tem-
perature rose from 995° to IOO.6°F., pulse beat ran from 90
to 104. A saline cathartic brought temperature and pulse
back into an acceptable range.
17 6 Medical Society of
DISCUSSION.
DR. HUGO EHRENFEST said he could ﬁnd but little to say in
addition to Dr. Reder’s excellent paper. He had seen this operation
performed by Schauta with perfect success. One question which
might arise is, what would become of a myoma if developed in an
uterus ﬁxed in that position. SO far as he knew that condition had
never been Observed.
Another operation, called kolpokleisis, not mentioned by the es-
sayist had been advised for this condition, that in the enlarging of the
ﬁstula between the bladder and vagina end sewing up the latter so
that the vagina becomes a part of the bladder. He had seen two
cases operated upon in this way with perfect success.
Dr. A. H. MEISENBAcH said he had never had a caSe of vesico-
vaginal ﬁstula during all his experience. One method of operating
not mentioned illustrated the efﬁciency of the Trendelenburg table.
Trendelenburg operated on one case of high ﬁstula by Opening the
bladder and stitching the ﬁstula through that organ and then closing
the bladder. The speaker did not see the operation but did see a hy-
drostatic test ten days after the operation, which proved the suc-
cess of the operation.
DR E. MARX said she had been unable to follow the details of the
operation, but she thought it a serious matter to produce so marked a
mal-position of the uterus in a women not past the menopause.
Could the ﬁstula not have been closed by seperating the bladder more
thoroughly from its peritoneal connections; possibly through an ab-
dominal? If this were not possible, it would certainly be preferable to
do even this operation rather than allow the ﬁstula to remain.
DR. R. C. HARRIS asked whether the Reed method as admitted
by Charles Reed had been considered. In some respect this opera-
tion resembled that practiced by the essayist. Brieﬂy it consisted of
the following: Both margins of the ﬁstula are split, then with a sharp
pointed scissors curved on the ﬂat, the vaginal mucosa is separated also
the vesical, the former is folded outward and approximated and the
latter inward and appproximated. A curved needle with a handle
specially made is then inserted just beneath the vaginal mucous mem-
brane dipping deeply into the cellular tissue and brought out just be-
City Hospltal Alumni. 177
neath the vesical mucosa, It is then crossed over and inserted beneath
the vesical mucosa through the cellular tissue and brought out again
just beneath the vaginal mucosa, it is then threaded with silk worm
gut and withdrawn; other sutures are passed in the same manner,
drawn together, the wound approximated and the sutures tied. The
buried or hidden sutures may also be used in the manner advanced by
Martin, of Berlin. T sokna, of Athens, Greece, after closing the ﬁstula
with interrupted silk worm gut permits his patient to get up and go
about shortly after the operation, claiming that the upright posture
favors natural drainage of the bladder and tends to hold parts in state
of proximation. Reed’s method of treating this variety of ﬁstula is il
lustrated very explicitly in his new work on gynecology.
DR. REDER, in closing, said he had attended a medical congress
in Berlin in 189r and while there heard mentioned the operation
alluded to by Dr. Ehrenfest. The technique was also described on a
patient. However, the speaker thought the technique and subsequ‘ent
treatment were so complicated that the operation would hardly do. It
is one that would not be practiced to-day when there are other methods
which were almost sure to give more positive results.
The objection to the Trendelenburg operation is the stitching of
the mucosa. Why this objection should exist he could not say but it
presents some complications. The surgeon does not resort to stitch-
ing the mucosa. prefering to come in contact with the freshened edges
of the vagina of the wound. The secret for all operations for vesico-
vaginal ﬁstula is to have sufﬁcient laxity of tissue to bring together the
margins of the wound. A surgeon who does not exercise care in this
matter tears off the edges and puts in his sutures but he can hardly
bring them together and when he does so there is so much tension on
the sutures that the operation is practically a failure. From the nu-
merous operations performed on the case reported he had to deal with
simply a hole, there was no available tissue that could be utilized in
bringing the margins of this opening together. The Operation described
bv Dr. Harris he thought well of, especially in allowing the freedom to
the patient to walk about after the operation.
178 Medical Society of
Meeting of fame 6, 1901; Dr. Norvelle Wallace Sharpe,
President, in the Chair.
DR. A. H. MEISENBACH presented a specimen of
Rupture of the Bladder.
This specimen is the bladder removed from a gentleman 84 years
of age upon whom the speaker did a suprapubic cystotomy for Oh-
struction due to enlarged prostate. The case was reported at a pre-
vious meeting of the Society. The patient was improving steadily and
yesterday seemed in such good condition that he was told a few more
days would complete the cure. About two O’clock this morning the
patient had a fainting spell and died in about‘an hour.
On May 14th a secondary operation was made necessary in order
to freshen the edges of the ﬁstula and bring them together. This was
a very simple operation and was done without an anesthetic. This
second operation, however, seemed to have a debilitating effect upon
the old gentleman and while he did not complain, it was evident that
he was not in as good condition as before.
On opening the bladder post mortem no special changes were
seen. The attachment to the abdominal wall was ﬁrm. This brings
up the important question of the return of functionation of the bladder.
It seems reasonable to suppose that return to functionation will be
slower where the organ is attached out of its normal anatomical po-
sition. One thing noticable is the size of the prostratic sinus. The
ﬁnger can be passed into the sinus and the middle lobe does not in-
fringe upon the prostratic urethra. He demonstrated the ease with
which the capsule could be enucleated and called attention to the im-
portance of this feature in doing the peroneal operation and enucleat-
ing the prostate from below. He thought this the coming operation
and superior to the suprapubic operation where the conditions would
admit it. A small calculus was found in one of the seminal ducts.
City Hospital Alumni. 179
Spaying of Cows as a Means of Procuring
More and Better Milk.
BY L. F. ABBOTT,
ST. LOUIS, MO.
N 1872 I engaged in the milk business in Boston, Mass,
I all of my milk being shipped into the city on cars, and,
in common with other dealers, I did not see a cow from
one year’s end to another. In 1879 I had built up a large
trade, supplying four hundred and ﬁfty families. At this time
I was forced to buy a cow to supply milk for an infant, or lose
some good customers. In a short time this cow was nearly
dry and I had to buy another. As I was then in the cow bus-
iness I wished to know something about them. In the course
of my inquiries I found an article copied from a French dairy
work advocating the spaying of cows and giving some reasons
for doing so. I took this matter up and upon careful investi-
gation found the following to be the usual conditions under
which milk is produced.
Starting with a fresh cow, there is a time when her milk
is not considered ﬁt for use, this time is variously estimated at
from one to ten days. Commencing with about three weeks
after coming in a cow is in a state of sexual heat, this occurs
quite regularly every three weeks until she is with calf again.
At such times her whole system is in a state of fever; She will
not give nearly so much milk, often falling off one half, this
usually effects three milkings. This milk will not keep sweet
nearly so long as the milk at other times.
The “ United States Agricultural Reports,” 1863, page
390, Mr. Willard, in reply to an inquiry on this point, writes as
follows: The milk of cows in heat does sometimes play
queer pranks with cheese. I have had it occur in my own
dairy when several cows were in heat at the same time. Milk
at such times is feverish and akin to a mass of putridity, not
infrequently a fetid or very offensive odor is emitted from the
whey and curd if used for cheese making; such milk will no
180 Medical Society of
more produce solid curd than it will give health and nourish-
ment to a calf when taken into the stomach, and what is dan-
gerous to a calf should be carefully withheld from a delicate
infant or person in feeble health. Such milk is unﬁt for dairy
purposes as well as for direct use as food.
When the cow becomes pregnant these conditions cease,
but we are now confronted with a new difﬁculty. It is gener-
ally conceded that the ﬁrst sign of pregnancy in a woman, who
is nursing a child, is that her milk disagrees with the child and
She is compelled to wean it on that account; itis reasonable to
suppose that like causes will produce the same effect in both
the human and animal systems. In further support of this we
have the testimony of dairymen who are making a high grade
of butter and cheese, that milk produced by cows in this con-
dition is unﬁt for their use, that after a time the bad conditions
seem to wear away, but will return again some time before
coming in fresh again, some cows being more effected by these
conditions than others. There are some cows that will go
dry four, and even ﬁve months before coming in fresh, while
there are others that can not be dried at all. This remark is
Often made by the farmer: “This cow never goes dry, we
have to milk her right up to the time of calving, but her milk
is not ﬁt for use and we throw it away.” ‘
The question here arises—éhow long has it been that the
milk was wholly unﬁt for use, and how good was it for a time
before that if affected by the ﬁrst stages of pregnancy and
wholly unﬁt for use in the last stages, at what time between
has it not been more or less affected P
The State has a law, with a heavy penalty, against killing
a cow for beef, I think, for sixty days before she is to come in
fresh, as the meat is not considered ﬁt for use. How much
better is her milk, which is a direct issue of pregnancy?
We ﬁnd another serious difﬁculty among dairy cows, and
that is abortion, sometimes caused by accident but more likely
to occur when cows are too highly fed; it sometimes seems to
be an epidemic, going through the entire stable. A cow com-
ing in in this way is a long time in getting right and even then
will not give nearly so much milk as though she had gone her
full time.
City Hospital Alumni. 181
As a safeguard against these conditions I advocate the
spaying of cows while fresh as a means of producing more
and better milk. When I ﬁrst commenced to seriously con-
sider this subject I applied to veterinary surgeons and found
that they knew very little about it; I received all sorts of dis-
couraging theories by people who usually ended in acknowl-
edging that they knew nothing about it. The only reliable
encouragement I received was from Honorable Josiah Quinsy,
father of President Cleveland’s Assistant Secretary of State, he
informed me that about twenty years before he had some cows
spayed that he kept no record of, but his recollection was that
they gave a large quantity of milk for a long time, and that he
was so favorably impressed that he thought of writing an arti-
cle for publication on the subject.
My experiments were conducted under the direction and
with the assistance of my family physician and personal friends
who were doctors. Ihave found that this subject has never
failed to interest physicians. The principal interest of phy-
sicians and consumers in this operation is that it removes frOm
the system all of the disturbing elements incident to a cow
coming in fresh; there being no other tax or drain upon the
system the milk is always of the same pure and even quality,
the product escapes the waste of material and energy, as well
as risk and loss of time in bringing his cows in fresh again.
As the cow has no other drain upon her system her entire en-
ergies are devoted to producing milk or growing fat. By
selecting cows of a dairy temperament and properly feeding
them, fully 50 per cent more milk can be had in a year than
under the usual conditions, and when the cow has passed her
age or season of usefulness as a milker, she will make better
beef. It is a well-known fact that all animals, both male and
female, deprived of their reproductive organs make better
meat; why should they not make better milk P
The ﬁrst question that is usually asked in regard to this
operation is, will the cow give any milk afterwards? By this
operation we remove the disturbing elements which cause her
to go dry, and she becomes a constant milker.
It is not a dangerous operation in the hands of one who
fully understands the technique, the risk is comparatively ml,
and should not exceed one-quarter to one per cent.


DAY. A.M. P.M. TOTAL. DAY. A.M. RM. TOTAL. DAY. A.M. P.M. TOTAL.
I 13.4 10.1 23.5 1 12 9.13 21.13 I 7.2 5.8 12.10
2 11.8 9.7 20.15 2 11.12 8.11 20.7 2 7.1 5.5 12.6
3 12.10 10.11 23 5 3 10 9.8 19.8 3 7 6.8 13.8
4 13 7 20 4 10 9.14 19.14 4 7.8 6.6 13.14
5 11.8 7.2 18.10 5 11.12 5.4 17 5 8 5.4 13 4
6 7 6.6 13.6 6 1.8 O 1.8 6 4.2 4.10 8.12
7 12.14 6.14 19.12 7 7.12 5 12.12 7 6.12 6.4 13
8 10.6 8.14 19.4 8 7.12 7.8 1 5.4 8 8.4 6.14 15.2
9 11.4 8 12 20 9 7.6 7.14 15.4 9 8.2 6 2 14.4
10 11.10 8.4 19.14 10 8.14 7.8 16.6 10 8.6 6.2 14.8
11 11.10 9.8 21.2 11 9.6 7.14 17.4 11 8.4 6 14 4
12 11.8 8.8 20 12 9.12 7.12 17.8 12 9 6.2 15.2
13 13.2 7.10 2012 13 104 7 17.4 13 9 5.10 14.10
14 11 8.8 19.8 14 10 3 8.2 18.5 14 8.12 6.5 15.1
15 12.2 9.12 21.14 15 10.4' 8.6 18.10 15 9.8 7.6 16.14


ZSI
Io Kaeioog Ieotpew
City Hospital Alumni. 183
In my ﬁrst experience with this operation I decided to
use ether. I employed a veterinary surgeon to administer the
anesthetic and it took about four or ﬁve minutes to produce
profound anesthesia—she was smothered, as the ether was given
on a sponge. We opened her belly, however, for the experi-
ment, and as she lay on her side I discovered that the intes-
tines were crowded over on that side, therefore I performed
the next operation with the animal standing. In this opera- -
tion we cut a small artery in her side and she bled to death.
This was not very encouraging to begin with—the two cows
cost me $95.00, so I decided to take cheaper stock for the
next operations.
Dr. Chadwick, of Boston, was present when I attempted
to operate on the next two cows. He feared the animals
would bleed to death and thought we had better wait. I said
no, if the animals should die it would be evident that the op-
eration Is a dangerpus one, so I~ proceeded with the work.
Both operations were successful. The next day the cows gaye
no milk. In two or three days, however, both returned to the
uSual quantity of milk, and in a Irionth from the time of oper-
ation they were giving Six quarts where only four had been
obtained previously.
In this operation the cow must be ﬁrmly ﬁxed so that she
can not move and do herself or those about her harm. When
so ﬁxed a sharp-pointed knife is used to cut through the skin;
this is done in the hollow between the back and the hip and
at one cut._ We then cut carefully through the ﬂeshy parts,
and this is where’the most danger iarises from hemorrhage.
After getting into the cavity we reach in ﬁnd the ovaries, they
are about the size of the end of the thumb, sometimes smaller.
They are cut off with the thumb nail and drawn out, the side
is then sewn up and the operation is completed. To one
familiar with it, it is very Simple. The cow gives a better
quality of milk after the operation and she gives milk more
constantly.
The accompanying table gives a ﬁfteen day’s record of
three cows (in pounds and ounces of milk) after spaying, also
the following average for three months:
First cow—March, 20.7; April, 21.6; May, 25.7.
Second cow—March, 24.9; April, 16.15; May, 27.4.
Third cow.——March, ﬁve day, 10.6; April, 17.6; May, 218.
184 Medical Society of
DISCUSSION.
DR. E. M. NELSON, speaking on this subject, said he thought all
of us had seen children showing signs of ill health, gastric disturbance,
etc., which could only be explained by the fact that the mother
was menstruating at this time. Those who have had much experience
in the care of children realize that this same condition takes place
when a cow from whose milk the child is fed is in heat. Milk fur-
nished by such a cow is feverish, and disagrees with the child, some-
times causing a serious illness. About seventeen years ago he read in
the Boston Medical and Surgical journal, some articles in regard to
the use of milk procured from spayed cows. It interested him at the
time, but he had not seen or heard anything more on the subject since
then. A few days ago a gentleman called at his ofﬁce who proved to
be the person who wrote the articles referred to. He considered the
subject an interesting and important one and had decided to ask Mr.
Abbott to present the subject here. Dr. Nelson then introduced Mr.
Abbott who read the paper. ,
\ DR. jos. GRINDON said it had always been a matter of wonder to
him that with methods so crude the results should be so good. Mr.
Abbott had said the mortality ought not to exceed ‘/, of I per cent.
This the speaker thought, would be considered good statistics any-
where. He asked what aseptic precautions were taken. He would
have thought that a spayed cow would cease to give milk.
DR. MEISENBACH said the idea was novel but from a scientiﬁc
standpoint he did not see much in the subject as presented to discuss.
The practical question as to what value this milk would be to the in-
fant was not well brought out. Nothing had been said about the an-
alysis of this milk and no statistics as to whether the child fed on this
milk was better nourished. From a scientiﬁc standpoint he thought
we should have some data as to the analysis and component parts of
this milk showing wherein it differs or is superior to other milk.
The question of the surgical procedure is not a difﬁcult matter.
Arteries are not tied off as in the human, but are twisted and torn and
hemorrhage is controlled by this torsion process.
DR. CHARLES SHATTINGER said the bulk of milk analyses given us
City Hospital Alumni. 185
have been practically worthless. These analyses have consisted in a
statement of the amount of proteids, carbohydrates, fat, etc., com-
parisons between the milk of different animals, or of the same animal
at different times, and between human milk and animal milk. By such
analyses and comparisons an attempt has been made to establish the
relative value of different milks and to ﬁnd a substitute for human
milk. As physiological chemisty is becoming more advanced we are
beginning to realize that something more is needed than these analy-
ses have afforded.
These analyses give us information of the nutritive value of milk
the same as they do of the nutritive value of any other food, but they
do not establish that in which we are most interested, namely, the
effect the milk will have upon the child, and the effect it may have in
causing disease. It would seem that the effect of milk in these partic-
ulars depends upon constituents which have heretofore escaped analy-
ses. What these constituents are, we do not as yet know. They are
not deﬁnable by the grosser processes of chemistry, but will have to
be approved by the more delicate methods of biological research, such
as are being used in the investigation of cytotoxines.
MR. ABBOTT, in closing, said a spray of carbolic acid was used
before operating and the hands washed with the same solution. He
has operated upon 15 cows and lost one in the Operation. This was
lost through severing an artery and the cow bled to death. In another
case an artery was cut but by twisting with forceps the bleeding was
stopped and there was no serious results.
He read the following extract from the Boston [Medical and Sur-
gical journal, April, 10, 1884, page 353:
“ Dr. E. W. Cushing stated that there is always an infant in his
house. He has used the milk from a spayed cow for more than a
year and ﬁnds it to be a good product and of uniform quality. New
milk (after calving) is not good for children, and the milk during
menstruation is not wholesome for an infant. Cows and woman are
much alike in this respect. The milk taken from a pregnant cow is
unwholesome for a delicate person, and no mother thinks of nursing
her child after she has again become with child. Milk as we obtain
it is often neither natural nor healthy, for no animal in a natural con-
dition gives milk while she is carrying her young.”
186 Medical Society of
Retained Testicle; With the Surgical Features
and Microscopic Findings in
Three Cases.
BY WILLARD BARTLETT, M.D.,
ST. LOUIS, MO.
S there exists a more or less general misuse of the terms
A which are applicable in describing this afﬂiction, I may
be pardoned for calling attention in my opening lines
to the deﬁnitions of an undisputed authority. Prof. Koenig1
reserves the name cryptorchism for double retention and refers
on all occasions to a Similar unilateral affection as monor-
chism, which I shall do in my treatment of the subject.
Retention is, as Kaufmann2 puts it, very commonly seen
in children, the late Prof. Gross3 having noted its occurrence
in several members of the same family. It is one of the de-
velopemntal errors which can by no means be regarded as
pecular to the human species, for Kuennemann4 recognizes its
existence among horSes,icattle, hogs, sheep and dogs.
The right side is said by I)aCosta5 to be the more fre-
quently affected in monorchism, but this statementis not sup-
ported by the statistic of Marshall6 who found, in examining
10,800 men, cryptorchism once, left monorchism six times,
and a like anomaly on the right side but ﬁve times.
_ Strange as it may seem, these apparently undesirable
conditions have several times been simulated with various de~
grees of success; it being reported by Galin7 that a number of
young Russians, in the desire to present a physical defect
which ’will insure them exemption from military service, have
pushed the testicle up into the inguinal region and by the use
of irritating bandages and injections succeeded pretty well in
keeping it there.
From the earliest times writers have attempted to explain
retention by a congenital defect in the attachments of the
gland or by some early inﬂamation of neighboring structures
through the effect of which it became ﬁrmly adherent in what
should have been merely a temporary resting place. It was
not until recently that the idea was advanced by Finotti,8 as a
result of extensive investigation, that cryptorchism and mon-
orchism are the expression of mal-development of the organ
City Hospital Alumni. 187
itself; and in accordance with this teaching, a normal testicle
is never stopped on the way to its usual destination.
CASE 1.—The patient is a strong manly fellow of 18, the subject
of right monorchism, his retained gland lying just within the internal
ring but having been, according to his account, at different times pal
pable beneath the skin. It now feels slightly smaller than its mate,
the consistence is as usual in this organ, and the appearance of the
cut section after excision differs in no way from the ordinary. The
thick tunica albuginea is intimately connected with the parenchyma
and the corpus Highmori bears the expected proportion to the rest of
the testicle. Uncommonly heavy and irregular septa divide the sec-
tion into lobules, and instead of growing more slender as they ap-
proach the periphery, some of these trabeculae spread into ﬁbrous
patches of no regular outline, imbedded within which are a few scatter-
ing gland tubules. In many of the pyramidal compartments the inter-
stitial element is decidedly increased over what is usually found in a
healthy youth of eighteen; the tubules being widely separated in con-
sequence This anomalous connective tissues shows no recent em-
bryonic cell collections, but consists of ﬁne wavy ﬁbers and few con-
nective tissue cells. The normal trabeculae present, on the other hand,
ﬁbers which are decidedly heavier, straighter and more easily stained.
The membrana propria surrounding a few of the tubules which
are contiguous to these scars, is considerably thickened; with the rare
exceptions mentioned, the tubuli contorti are possessed of ﬁne base-
ment membranes and their epithelium consists of several layers of
cells, each containing an oval nucleus with one nucleolus. As far as
the shape and size of these epithelial elements are concerned, it is im-
possible to make any division into parietal, mother and daughter cells.
Nuclear ﬁgures do not appear at all, but it must be added that the
specimen was not ﬁxed for a few hours after its removal. The usual
granular mass ﬁlls most of the lumina, but I have been unable to ﬁnd
one complete spermatozoon. The tubulirecti contain the usual single
layer of columnar cells but no villi can be made out, nor do sperma-
tO‘Zoa appear in the lumina.
The groups of interstitial cells scattered here and there present
nothing unusual, either as far as appearance or number are concerned.
CASE 2.—F or the specimen here considered, I am indebted to Dr.
M. B. Clopton. The imperfectly descended organ is from the right
side of an individual of the virile class, 23 years old; it lay just out-
side the external ring, while its mate—as in my ﬁrst case—was in the
usual position.
i The septa are, many of them, thickened to irregular massess of
188 _ Medical Society of
scar tissue toward the periphery, these being continuous with exten-
sive patches of similar nature which lie well within the pyramids. The
interstitium separating the individual tubules is also quite generally in-
creased, there being many small areas __of round-cell inﬁltration, an
evidence of thefact that the process is, in so far at least. recent and
progressive.
Gf decided interest also is the condition of the convoluted tubules.
Every membrana propria is distinctly thickened, some more so than
others, and the diameter of the tubule is in every instance de-
creased in proportion to the amount of thickening. In some of these
gland units, epithelium has been completely displaced and they now
constitute, as the last stage of the change, mere ﬁbrous cords. Others
give a beautiful exposition of the fact that the infantile character has
been retained. In most of these tubules however there is seen a
multiple layer of epithelium, each cell posessed ofa large round or
oval nucleus with one nucleolus. The lumen is generally apparent and
contains the usual granular mass, but nowhere are spermatazoa in
evidence. Indeed this parynchyma presents none of the characteris-
tics which are seen in healthy individuals of this man’s age.
The tubulae rectae are of unusually small size, have their 'tunicae pro-
priae thickened, retain their epithelium and show in their lumina a
small amount of granular detritus.
Interstitial cells are seen in clusters situated in all parts of the
specimen; appearing in somewhat greater proportion than in Case 1.
CASE 3. The organ from which this specimen was taken was
kindly placed at my disposal by Dr. A. H. Meisenbach. It was a case
of cryptorchism, in a man of 35 of the virile type. His left testicle,
which I examined, lay just within the inner inguinal ring.
My sections which I intended for transverse, show nothing of a
trabecular arrangement, but the interstitium is the seat of changes
which are in the highest degree remarkable. First and foremost is the
universal increase in the number of interstitial cells; not only are there
immense clusters of them in various parts of the specimen, but every-
where else are the individual tubules dissected apart by single rows.
' The cells are of the most varying sizes and shape, no doubt as a result
of the counter-pressure of one another. Some are degenerate as is
evinced by the faulty staining qualities of their nuclei, while in a few
ﬁelds are seen a number of Reinke’s crystaloids, undoubtedly pro-
ducts of retrogressive metamorphoses in the interstitial cell.
The number and width of the stuffed capillaries which penetrate
the masses of interstitial cells is truly wonderful. In some ﬁelds these
City Hospital Alumni. 189
channels gain cavernous proportions and entirely displace the cells, or
at least divide large groups into numerous smaller ones.


SPECIMEN No. 3.—Vasi Increase of Interstitial Cells.
On most of the tubules, evidences of pressure atrophy are appar-
ent; a very few contain several rows of fairly well preserved epithe-
lium and open lumina, but the greater number present almost any
other appearance that can be imagined. In some instances, but a few
epithelial cells lie in confusion within a distorted membrana propria;
in others, there is a single layer. the row from one side touching that
of the other in the complete collapse of the tubule which has been in
troduced.
No distinction can be made between straight and convoluted tu-
bules; the membrana: propriae exhibit the greatest variety in the matter
of thickness, while a number of the granular units have undergone
complete hyaline transformation, The ﬁner retrogressive changes
which have attacked the epithelial elements, are evinced, in part at
least, by the varying intensity with which the nuclei stain. It is hardly
necessary to remark that spermatazoa are nowhere to be seen.
To recapitulate, these three specimens show that the an-
tomical picture in this condition, is by no means uniform.
190 Medical Society of
Case I deviates from the normal chieﬂy in that there is a rela-
tively large amount of connective tissue, the presence of which
is explained by the imperfect development of the glandular ele-
ment which, in the healthy male of 18, has to a far greater ex—
tent displaced the same. In Case 2, there is an absolute con-
nective tissue increase in addition to mal-development of the
tubules; while Case 3 is the subject of intense interstitial cell
growth, vascularization and pressure atrophy 0f epithelial
structures.
For practical purposes we must, however, disregard ana-'
tomical differences to some extent, as the ﬁner distinctions can
not be made until the organ is examined microscopically.
Among those who have devoted themselves to a minute study
' of these cases, Minervini and Rolando9 with one such, as well
as Finottilo with seven, found what Ribbert11 refers to broadly
as atrophy of the testicle, meaning a condition in which the
tubules are insufﬁcient and the connective tissue is increased.
But this so-called atrophy is, according to Finotti,l2 not the re-
sult of retention; just the reverse, it, like the retention as pre-
viously mentioned, is to be traced back originally to mal-de-
velopment of the organ.
The actual value of such organs to their possessors can be
quite, easily shown by the following. Spermatogenesis is
always late and has in fact been very rarely observed at an,“ so
the productive power is of little value for purposes of argu—
ment. But Smith,13 Minervini and Rolando,14 Pick,15 and Fi-
notti16 have noted, as in my three cases, that 'these men though
childless, are of the virile type and of unimpaired sexual po-
tence. The last two assertions can certainly not be made re-
- specting men who were castrated while babies, so Finotti very
logically concludes that the testicles, even though retained
and atrophic, are responsible for the manly type and the sex-
ual appetite as well as power. Can they then be considered
and treated as useless, up to the time when a man has gained
his majority? By no means.
Whatever their worth to the possessor, it can not be dis-
puted that these abnormal glands constitute a source of ser-
ious danger as well. Orth17 makes the broad assertion that
they are prone to become the seat of tumor formation, and it
has been the experience of Koenig,18 Kocher19 and Tillmanns20
City Hospital Alumni. 191
that cancer is the form of growth most frequently met with.
On the other hand Cuneo and Lecene21 assert that the organ
in its normal position, is more likely to undergo carcinoma-
tous degeneration, but that the retained organ more frequent-
ly gives rise to sarcoma, which is then directly traceable to
the increase in interstitial cells, which is frequently seen in the
gland whose desent has been impeded. These same cells are
considered by Hansemann22 to be responsible for at least that
form to which the name alveolar sarcoma, has been applied.
Among the others who report the malignant connective tissue
tumors complicating monorchism are Krompecher23 Schmidt,“
Riedelfs Kayserz6 and Kaber;27 the last named writer having
found that eighteen out of one hundred and fourteen glands
thus affected, had never descended. Further reasons for the
retained testicle becoming the subject of surgical treatment
are that it induces incarceration, torsion, hydocele, hernia, and
hypochondria, as mentioned by Koenig,28 Parona29 and Zie-
bert.30
There are in these cases two essentially different sets of
operative indications, viz., those which arise from clinical sym—
toms of disease already present in the gland, and those which
we deduce from considerations of a physiological and patho-
logical nature. In regard to the ﬁrst class, it must be appar-
ent that no one should hesitate to remove organs, in either
monorchism or cryptorchism, which threaten the patient’s life
or health in one of the ways above mentioned.
But with respect to the second class of indications, there
is decidedly more room for argument; for example, when a per-
fectly quiescent retained testicle is encountered—in the course
ofa hernia or other inguinal operation—what shall be done
with it? Clearly, in monorchism, possible future danger is
averted by excision, and the loss is compensated by the organ
on the other side. But in disposing of a double retention,
under similar circumstances, the principal consideration must be
of the patz'elzt’s age. As stated above the retained atrophic tes-
ticle has, in its inﬂuence on the development of the virile type,
practically its only value. Consequently, if we disregard cos-
metic considerations, a man above 21 is no loser, when one or
both of the offending structures are excised; but on the other
hand, he gains a priceless immunity from future dangers.
192 Medical Society of
However, up to the time when development is complete,
an effort must be made, in cryptorchism, to forcibly bring
down one gland, at least, as has been‘done by Casati,81 Boyer32
and others, or spontaneous desent must be favored by a
proper transposition of the tissues as Sargi83 and Trombetta
have proposed.
BIBLIOGRAPHY.
1Lehrbuch der speciellen Chirurgie, 1899, II, 827.
’Lehrbuch der speciellen pathologischen Anatomie, 1896, 652.
8System of Surgery, 1864, II, 782.
‘Ergebnisse der allgemeinen Pathologie und pathologischen Anat-
omie, 1898, II, 436.
5Modern Surgery, 1900, 1031.
6Koenig’s Lehrhuch der speciellen Chirurgie, 1899, II, 82.
7Chirurgia, Bd. V., 130.
8Archiv f. klinische Chirurgie, Bd LV., Hft. I.
9Morgagni, 1900, No. I.
l°Archiv f. klinische Chirurgie, Bd. LV, Hft. I.
1'Lehrbuch der pathologischen Histologie, 1896, 382.
1’Archiv f. klinische Chirurgie, Bd. LV, Hft. I.
13Guy’s Hospital Reports,‘Vol. L111, 215.
14Morgagni, 1900, No. I.
15Surgery, 1899, 1021.
16Archiv f. klinische Chirurgie, Bd. LV, Hft. 1.
"Pathologisch-anatomische Diagnostic, I894, 401.
18Lehrbuch der speciellen Chirurgie, 1899, II, 828.
19Ibid, (quoted by Koenig).
20Lehrbuch der speciellen Chirurgie, II, 1898, 364.
2‘Revue de Chirurgie, 1900, No. 7.
22Virchow’s Archiv, Bd. CXLII, S. 538,
2"’Virchow’s Archiv, Bd. CLI, Suppl-Hft.
24Sitzung der deutschen pat010gischen Gesellschaft, September, ’98.
’5Beilage zum Centralblatt f. Chirurgie, 1896, No, 3!.
26Mittheilungen aus den hamburgischen Staatskrankenanstalten,
1899. ‘
"American journal of the Medical Sciences, May, 1899.
28Lehrbuch der speciellen Chirurgie, 1899, II, 827.
’9Pohc1inico,]uly I, 1897.
80Beitraege zur klinische Chirurgie, Bd. XXI, Hft. 2. ~
3‘Communicazione fatta all’ Academia della scienza mediche e
naturali di Ferara ll giorno, December 8. 1895
37Centralblatt t. Kinderheilkunde, 1896, No. 2.
a'Morgagni, 1897, No. 6.
City Hospital Alumni. 193
!
DISCUSSION.
DR. BRANSFORD LEWIS said it is a fairly well-founded belief of the
profession that individuals suffering with cryptorchism or monorchism
are sterile and this is true in a large majority of cases. In monorchism
the retained testicle is lacking in impregnating elements and in cryp-
torchism both testicles are sterile. It is not ornamental to have the
testicles hangin g in this unusual way and some patients will ask advice
about their removal. The speaker did not think the simple fact that
spermatozoa were absent and that there was likelihood of malignant de-
generation sufﬁcient reason for removing the testicles. It is well
known that old men who have no practical use for their testicles, and
who have been deprived of them for the purpose of curing prostatic
obstruction, have become very morose as a result of the loss, and
cases of actual insanity have developed in persons unsuspected of any
such tendency, following castration. The impression is very great on
the mentality of even an old man and it is liable to be very much
more so on a younger individual. They have been replaced by cellu-
loid ‘* testicles,” but the posession of one’s own testicles, even though
they be of little use, has a good moral effect.
The theory that the condition is a lack of development rather
than simple malposition, is very plausable; it is a lack of physiologi-
cal and anatomical development, and this explains why there are no
spermatazoa. The speaker mentioned a case quoted in the Phila-
delphia Medical journal in which the writer was satisﬁed that there
wes positive proof that a cryptorchid was the father of a child.
The speaker said he had watched two cases for eight or ten years.
He told them he would be willing to take out the abnormal testicle
provided the necessity became evident but as yet no occasion had
arisen for doing so, As a result of gonnorhea in one case there was
an epididymitis in the retained testicle which subsided in the course of
a few days. That was about four years ago and he has had no trouble
since. In the other case there never has been any trouble of this
kind.
He asked the essayist to give his opinion as to whether it would
be advisable to remove an undescended testicle to avoid ~a possible
developement of sarcoma or carcinoma?
194 Medical Society of
DR. MEISENBACH said the testicle gived Dr. Bartlett by him was
from a young man 33 years of age who had undescended testicles on
both sides. The cause for operation was an inguinal hernia on each
side. The testicle on the right side was located about the linea pecti-
nea over the pubic bone. This was very painful at times and conﬁned
the patient to his bed. The other testicle had never given any
trouble. This was closely attached to the hernial sac and when freed
was not recognized at ﬁrst as a testicle—it looked very much like a re-
tention cyst. After examining it closely it was seen to be an undevel-
oped testicle. The virile power of this patient the speaker did not
know. He was well developed and had a full beard but was bald
headed. In another case he removed an undescended testicle on the
right side on account of inguinal hernia in a young man of 18 years.
He was above the average height for his age, below normal in weight
and inclined to be delicate.
The speaker thought these undescended testicles are, in many in-
stances, the causative factors in inguinal hernia.
As to the virility or these men the essay throws important light
on the subject. It may be that there are other causes for the virile
power of the man and this power may lie in the prostate as an acces-
sory organ. We know that some eunochs are virile even after their
testicles have been removed. From an operative standpoint he be-
lieved the patients would be better off without these undeveloped, de-
fective organs. They are liable to carcinomatous or sarcomatous de-
generation, which is always a menace.
DR. W. D. HAGGARD, ]R., of Nashvrlle, said he had occasion to
operate upon one case which was the result of traumatism.
He thought it might be advisable to insert a celluloid testicle for cos-
metic purposes.
DR. GEpRcE I—IoMAN said he had had the pleasure of presenting
some facts to the Society on this subject in November, 1898. The
main feature of this case was that the gentleman presenting this
peculiarity stated that it had been present in ﬁve generations, except
one in which there was no male issue, always on the left side, and in
collateral lives the same defect was noticed. It would seem from this
that heredity exercises an important inﬂuence upon this condition.
City Hospital Alumni. 195.
This gentleman is the father of two sons by different mothers both of
whom showed the same peculiarity. In connection with this subject
he spoke of horses with one or both testicles retained and said that
country people counted them as being of rather vicious temper and
rather below the normal in sexual appetite. It is well known that
some rodents periodically experience a physiological atrophy and re-
cession of the testes into the inguinal canal. He asked Dr. Bartlett if
he had examined the testis of the squirrel, for example, when in this
condition and whether it presented any resemblance, histologically, to
the human undescended testis.
DR. MEISENBACH, answering Dr. Lewis’- question, said an undes-
cended testicle if not giving trouble and the patient’s mind was not
abnormally attracted to it, might be left. If, however, it became the
seat of trouble or a hernia takes place he would remove it.
DR. BARTLETT, in closing, said he was unacquainted with the con-
dition in animals ‘other than those mentioned.
Replying to Dr. Blair?s question he said the so-called sexual edu-
' cation of these persons is not influenced by the removal of the testis
after they have attained 'full manhood.
The question of removing the testis to preventft-lie" possible de-
velopment of malignant trouble, he would divide ‘ias lli'e 1klrd in the
paper. , If the undescended testicle was encountered. in 'cOurse of
another operation and on account of its position


future trouble, he would remove it, provided the if." _ However, as Dr. Meisenbach has said, there was no to take it
out unless it was causing trouble or was encountered in the course of
another inguinal operation.
196" Medical Society of I
A Case 'of Appendicitis With Some
_. Unusual Features.
BY J. MOORE, M.D.,
ST. LOUIS, MO.
AM enabled to report the following case by the courtesy
of Dr. H. C. Dalton, in whose practice it occured and who
has furnished me with most of the history.
B. T. M., a printer; family tubercular. Six years ago the patient
had typhoid fever and made a fairly good recovery. One year later he;
had a cough and lost ﬂesh. Tubercle bacilli were found in the spu-
tum and he went to Colorado, where he remained two 'yf'ears and re-
turned, apparently cured. He remained well until the present attack.
Dr. Dalton was called on the evening of November 19, 1899, and
found him complaining of severe pain in the lower abdomen, more
acute on the left side, but not distinctly located. The patient stated
that he was compelled to pass urine frequently and that urina-
tion was exceedingy painful, the most severe pain being in the glans
penis ' _re acute toward the end of the urination. He had
been suffering several hours when Dr. Dalton ﬁrst saw him, and
that the i;n'-theg=,fhead of penis was the ﬁrst symptom noticed and
this was 1 ed by pain and cramping in the lower part of ab-'
domen. oélwijfrptoms suggested a renal colic but examination of
abdomen a" >o‘iifiurine failed to throw any light upon it. At this time
his temperature was 99°F and pulse 8 5. There was no distention of
belly and no localized tenderness, but the whole lower abdomen was
sensitive, especially on the left side.
He Was given saline purgatives and cold applications and D!
Dalton saw him several times in the next thirty-six hours. There was
but little change in his condition except a slight but continuous'in -
crease in tenderness in the abdomen. On the morning of the 21st Dr.
Dalton asked me to see him and the condition was then as follows:
Temperature 99.5°F., pulse 90. His temperature had not gone
above 100.5°F. and his pulse had ranged from 85 to 100 during the at
tack. He still had rather frequent desire to void urine but pain upon
urination was not now severe. The abdomen was slightly disturbed
and was resonant upon percussion except a small area to left of the


City Hospital Alumni. 197
median line, about midway between the umbilicus and pubes, where
there was comparative dullness. The right iliac region, espec-
ially, was noted as being free from dullness and distinctly less tender
than the same region on the left side. The muscles of this region
were distinctly less rigid than on the left side, though he did not bear '
presSure well on any portion of abdomen below the umbilicus. An
indistinct “ doughy” resistance was found on palpation in the region
of the dullness mentioned above, Except for the gradual and slow in-
crease in the area of tenderness and the appearance of the indistinct
tumor the patient seemed to be in an excellent condition, but we both
were convinced that there was serious trouble and renewed the recom-,
mendation that Dr Dalton had already made, that the abdomen be
opened. This was absolutely declined by the patient and his family,
and the treatment continued as before.
I saw him again on the 22d and 23d and there was little appre
ciable change in his condition except that on the morning of the 22d,
after seVeral copious stools he expressed the belief that he was better;
he was free from pain and felt well; his temperature was 99°F, pulse
90 and his expression vastly improved; but the pain returned with
greater severity in the afternoon and on the morning of the 24th his
temperature was ror.5\°F., his pulse 1 IO, and his whole belly somewhat
disturbed and quite tender, while his face had acquired the pinched,
anxious and apprehensive expression which has been so aptly called
the faez'es abdomz'rzalir. The tumor in the left side was now distinct
and the patient evidently failing rapidly. Operation was now ac-
cepted by the patient and family with the distinct assurance that it
was a last resort.
Operation by Dr. Dalton, assisted by Dr. Roland Hill and myself.
Incision in median line opposite site of the tumor. Upon opening the
abdomen, the inflamed anddistended head of the colon presented;
intestines‘were somewhat distended, vessels engorged, and the visible
peritoneum inﬂamed and covered in many places by patches of adher-
ent lymph, while a thin, foul pus oozed up between the coils of the
smallbowel. The tumor which had been felt“on the left side con-
sisted of several coils of inflamed bowel, matted together in a mass as
large as a cocoanut. These were easily seperated and in the midst of
the mass was found _a very long and much inﬂamed appendix, its per-
forated tip ﬁrmly adherent to the fundus of the bladder on the left
side. A fecal concretion protruded from the perforation.
The appendix was ligated and removed, all adhesions separated
and abdominal cavity washed out and a careful peritoneal tailet made.
The most intense inﬂammation and the sole site of adhesions, was in
198 Medical Society Of
the immediate neighborhood of the appendix. The pelvis was fairly
well ﬁlled with pus and the Whole peritoneum was more or leSs iri-
vOlved in the inﬂammatory process. Strips of iodoform gauze were
carried in various directiOns between. the coils' of intestines and into
the pelvis and ﬂanks, and brought out at 10wer angle of wound. The
patient bore the operation well and rallied nicely from its effects but
died on second day from peritonitis.
The interest ofthis case, I think, is in the anomalous po-
sition of the head of the colon and appendix, and the conse-
quent confusing clinical picture presented.
Early operation might have saved the patient, but was de-
clined. If we could have made a positive diagnosis of appen-
dicitis, no doubt they might have consented, but, though ap-
pendicitis was discussed among other conditions, no positive
diagnosis of any sort was made nor do I think that was pos-
srble to arrive at any deﬁnite conclusion. -I shall not try to
explain the malpositio-n of the appendix but will say that after
the removal of the appendix and separation of the adhesions
the caput coli seemed to fall very naturally into its proper po-
sition in the right iliac fossa.
The Whole progress of the disease was slow and insidious.
At the operation it was apparent that perforation of the _ap-
pendix and infection of the general cavity must have occured
in the early days of the attack, yet his condition remained
good up to the morning of the operation. \
DISCUSSION.
DR. W. D. HAGGARD, JR, said the record of this case was exceed—
ingly valuable as it presented several interesting phenomena. We are
not accustomed to see pain reﬂected along the nerves and glands
except in'the absence of pressure and tenderness, and pain on the left
side are not looked for in appendicitis, although they may be found in ,
the region of the stomach. He felt that the diagnostic value of Mc-
Burney’s point is questionable, for in the absence of pain on pressure
at this site we are doubtful of the diagnosis. We are often puzzled as --
to the best time to open the abdomen. We are not prepared to urge
an operation with the same assurance that we would if certain of the
City Hospital Alumni. 199
diagnosis and often the time for operation will pass. So far the speak-
er’s views have passed through about three transition periods. His
early belief was that operation should be performed as soon as the di-
agnosis was made. This is a good rule if you can make a diagnosis,
but in many cases this can not be done immediately or we do not see
the patient until he has reached a dangerous border line. Then he
switched to Operating when operation seemed indicated, but this plan
prQVed worse than the other, for the reason that when the operation
seenied to be necessary there was usually a perforated peritonitis and
death in about twenty-two per cent. At present his attitude is, in a
well-marked case that is not getting better within twelve to forty-eight
hours, to operate. We never regret having operated too early but we
often realize that the operation was put off too long. Some surgeons
want to ﬁnd the appendix and take it out in every case. The speaker
did not think this was always the part of wisdom. When an abcess is
present we shOuld deal with this and not try to ﬁnd the appendix.
Later, when the patient had fully recovered, the appendix can be re-
moved without danger. In removing the appendix he leaves no
stump. This is thought simple and safe. In draining the cavity he did
not trust gauze, especially iodoform gauze. The gauze does not drain
and iodoform has been followed by urinary symptoms and toxemia.
DR. MEISENBACH agreed with Dr. Haggard that McBurney’s
point is not always a safe or certain guide in all cases as indicative of
the seat 'of trouble, but relatively speaking it is a good guide. It has
been established by several surgeons that the position of the appendix
varies, sometimes pointing downward, sometimes upwards and some
times crosswise. Where the pain is to the left of the median line the
appendix has been found to point crosswise. He mentioned a case
upon which he recently operated. He was called by the physician
in attendance and found an area of tenderness and dullness from the
middle of pubis to the right ‘illiac spine. There was no deﬁnite point
of excessive pain but a general tenderness. He agreed in the diagno-
sis of appendicitis and the patient was sent to the hospital for opera-
tion. The ordinary incision abong the border of the rectus was made
but the appearance of the contents of the belly was not what he ex-
pected to ﬁnd. There was no inﬁltration but the small intestines were
200 _ lMedical Society or
very red and in a massed condition and he thought there was an ob-
struction in the region of the ileum. He extended the incision and
gradually eviscerated the bowels and came upon a mass in the ileum
which seemed to be sloughed connective tissue in a gangrenous state.
This was separated and removed. Upon examining this mass he
found it was the sloughed appendix completely separated from all an-
atomical landmarks. The side of the mass was perforated and lying
in the perforation was a hard body which seemed to be an incarcer
ated grape skin. The cavity was washed out with salt water solution
and drain instituted but the patient died in forty-eight hours. He
thought this anomalous condition was caused by the mesentery folding
itself about the grape skin and was walled off by an inﬂamatory pro-
cess which produced a local peritonitis. He thought it was best to
open the belly in the median line when the exact site of the trouble is
not made out. By doing this we can explore both side; of the cavity.
He was glad to hear Dr. Haggard take such a positive position
in regard to hunting for the appendix in every case. Very often it is
far better to leave the appendix alone and treat only the abscess. He
mentioned the case of a boy who was sent to the hospital for opera-
tion but other work interfering the operation was postponed for a day.
In the meantime the bowels moved. The next day the patient showed
a septic curve and he prepared to operate but the parents refused to
allow it. The boy was sent home and about a week later there was
dullness in the inguinal region and up to the liver. The parents were
told the boy might die unless operated upon but they still refused.
About two weeks later the abscess evacuated itself in the median line.
Under chloroform the cavity was found to extend from the lower
border of the liver down into the pelvis, and walled off by plastic
lymph exudate. It was practically an extraperitoneal abscess and the
boy recovered.
DR. MOORE, in closing, said it was his practice to open the ab-
scesses in these cases, and let the appendix alone. If later, the ap-
' pendix gave trouble it could be removed but this procedure was not
done as a routine thing. He agreed with Dr. Haggard’s remarks on
the removal of the appendix. In this case there was no pain over Mc-
Burney’s point and the reason for this was that the head of the colon
City Hospital Alumni l 201
had been forced over to the median line while the abscess and appen-
dix was on the left side of the man’s belly. The site for the incision
was chosen deliberately in the median line. The symptoms were un-
certain and all referred to the left side, yet he always felt that we have
an inﬂammatory condition of the abdomen and are unable to make out
just what it is, it is apt to be appendicitis. He has seen a number of
obscure cases which, on operation or autopsy, proved to be appendi-
eltis.

l
Meeting of fame 20, 1901; Dr. Noroelle Wallace S/zarpe,
President, in the Chair.
DR. R. B. H. GRADWOHL presented a specimen showing a
Hemmorrhagic Infarct in Left Lung
in a patient W1th mitral insufﬁciency. The case was that of a patient
55 years of age and the kidneys showed senile atrophy. He also
showed a nutmeg liver taken from the same patient. Dr. Gradwohl
also exhibited a specimen of
Aortic Stenosis
in which the valves were perfectly rigid.
DR. CHARLES J. ORR exhibited specimens of
Fibromyomata
taken from the nares of a boy ten years of age. The growth seemed
to be a ﬁbromyomata but no microscopical examination had been
made.
These growths are very common, he said, but this one is of rather
unusual size in a child of this age. It apparently developed from the
superior portion of the middle turbinate posteriorly involving the for-
nix. The larger mass removed from the posterior nares on the left
side. The tumor pushed the soft palate aside and pushed over the
septum causing complete obstruction on one side and a good deal of
obstruction on the other side. It was removed under complete anes
thesia with the cold wire snare.
202 Medical Society of
A Case of Valvular Disease of the Heart.
DR. ELLSWORTH SMITH presented a patient giving the following
history: Patient is 29 years of age, laborer. entered the hospital on
June 4, Igor. Smokes but does not chew tobacco. Has drunk a
pint of beer every day fOr six or seven years. In cold weather takes
two drinks of whisky in the morning. Father is dead, cause not
known. Mother is living; she has suffered from rheumatism since
childhood until a few years -' ago when she. was cured. Patient has
had nearly all the diseases usual to childhood. Had malaria in last
several months. Had syphilis about twelve years ago. Had rheuma-
tism at twelve and has since then had an attack every winter. On in;
quiring into the rheumatic symptoms Dr. Smith said this consisted
only of pain without any swelling or fever. It was not an inﬂammatory
rheumatic trouble. In November, 1901, patient had a burning pain
in his chest which lasted all night. It was found that this pain was not
limited to this time but had been present before and since. He also
suffered from shortness of breath especially on exertion. Two weeks
i ago the feet and ankles began to swell. Urine 1025, with albumin
present.
This history calls attention to the probable source of the trouble.
There are several etiological factors of cardiac disturbance it.
There is syphilis which we know, is very prone to cause disease of the
vascular apparatus. Then there are more or less alcohol and a cer-
tain amount of strain on the vascular system in his occupation. His
age is of course rather against a cardiac disturbance involving the
aortic opening. The other etiological factors, however, are such as
would cause a disturbance of the aortic opening, especially syphilis.
There is no probable source here for the mitral lesion because the
rheumatic history is indistinct. ‘
On inspection we see quite considerable pulsations of the vessels
in the neck; also a good deal of impulse in the cardiac region. The
apex beat is found 1n the seventh interspace and fully two inches to
the left of the mammillary line. On percussion we ﬁnd a corresponding
increase of dulness to the left, both relative and complete. There is
also some slight enlargement to the right. On auscultation we hear a
City ‘Hospital Alumni. 203
diastolic bruit down the sternum and loudest about the fourth costal
cartilage; There is also a systolic bruit heard up in the vessels. Over
the apex there is another systolic bruit which extends up into the
axilla. The examination of the mediastinum fails to reveal anything
except a bruit which is carried up into the vessels. There is no dul-
ness in the course of the aorta. No dullness over the~descending
aorta, and none over the lungs. There is no evidence of ﬂuid in the
pleural sacs, and no ascites. There is quite a little edema of the lower
extremities.
The ﬁrst thing that attracts our attention is the enlargement of
the heart. It is what we call a “bullock’s heart.” The enlargement of
the left ventricle taken with the diastolic bruit makes the diagnosis of
aortic regurgitationpretty clear. It is the primary lesion in this case.
When we get the sounds in the vessels as we ﬁnd them here with puls-
ation of the vessels and diastolic bruit down the sternum, which takes
up the second sound of the heart, we have the characteristic signs of
this trouble. The only thing that might be confounded with it is a
regurgitation at the pulmonary oriﬁce. If this were the case, however,
and the aortic 0riﬁe'"were not involved, we could distinguish the two
conditionsiby the absence of enlargement of the left side of the heart.
While we are not apt to mistake this aortic regurgitation for some
other condition, we may overlook another condition that is often as-
sociated with aortic regurgitation, that is thoracic aneurysm. There-
fore inthese cases of aortic regurgitation we should always look for
aneurysm.
The phenomena in the vessels is important in the making of the
diagnosis of aortic regurgitation. These phenomena are almost path-
ognomnoic of aortic regurgitation for they do not occur in the thor-
acic aorta unless aortic regurgitation is present. In all cases of aortic
regurgitation we see this undue pulsation in the vessels. Here there
is a distinct thud over the aorta. This is produced by the lesion in the
aorta. This is produced in the following manner: At every systole
the ventricle throws the normal amount of blood into the aorta which
raises the blood pressure in the arteries suddenly and causes the jumpy,
upward movement of the artery. When diastole takes place there is
a sudden leaping backward which causes the sudden drop in blood
204: Medical Society or
pressure and the artery recedes. This produces the Corrigan pulse.
The reason for this peculiar pulse is that the blood regurgitates into
an almost empty ventricle and there is more or less of a suction action,
while in aneurysm the blood ﬂows back more gradually and encounters
a sac already nearly full of blood. It is not possible to have a Corri-
gan pulse without aortic regurgitation.
There are other lesions present in this case. There is a certain
amount of narrowing of the aortic opening. This statement is based
on the systolic murmur heard in the aortic area which is carried into
the vessels, and on the presence of a thrill in the great vessels of the
neck—a systolic thrill. The principal reason for this diagnosis is,
however, that the symptoms of regurgitation are somewhat modiﬁed _
by the stenosis. With a heart the size of this and with the amount of
edema and disturbance present, we should liaver‘niore disturbance in
the vessels, more pronounced phenomena in the Corrigan pulse, than
we have here. This is not a complete Corrigan phenomena and that
is due to certain amount of aortic stenosis.
This, he said, is also another important element in the diag-
nosis ofaortic stenosis. He did not believe that aortic stenosis can
be diagnosed unless there are some modiﬁcation of the vessel phenom-
enon. The thrill and systolic murmur in the aortic area is not sufﬁ-
cient upon which to base a diagnosis of aortic stenosis. If there is no
regurgitation with modiﬁcation of the vessel phenomena, then we must
have other symptoms in order to make a diagnosis of aortic stenosis,
especially a diminution and sometimes complete absence of the second
sound. This is due to the complete obstruction of the aortic opening
which prevents the aorta from ﬁlling completely and therefore the
sound in diastole is limited. In all cases of aortic stenosis we must
have this diminution, lessening, or obliteration before we can make a
diagnosis of aortic stenosis.
The mitral lesion in this case, he thought, was a relative insufﬁc-
iency. There is present no deﬁnitite etiological factor for the disturb-
ance in the mitral valve. We know too, that in aortic stenosis we
have at some stage a disturbance of the mitral opening and this is
evidenced in this case by the dyspnea and edema. This then, is a
-City Hospital Alumni. 205
case of aortic regurgitation, with a certain amount of aortic narrowing
and a relative mitral insufﬁciency.
The prognosis, of course, should be guarded where there is such
a break in compensation as is seen here. The prognosis in aortic re-
gurgitation before the break comes is usually good. The prognosis
is gravest in mitral stenosis, less so in mitral regurgitation and in aortic
stenosis it is good except for the possibility of acute dilation in over-
Straining. If the patient can guard against overstraining the outlook
is good. There is the possibility of an anginous attack, ofcourse. and
the patient’s death from angina pectoris.
The differential diagnosis is not always easy. There must be pres-
ent a good many phenomena before the diagnosis can be made and
even then in may be confounded with other conditions. There are
two things, however, which will aid us. We must remember that in
aortic stenosis we always have a lessening of the second sound of the
heart, and, secondly, we do not have the disturbance in the pulse in
other lesions that is seen in aortic stenosis.
T reatment.—Our mainstay when there is a break in the compen-
sation is digitalis. “Whether the case is mitral or aortic we use this
drug. The old idea that we will kill a patient with aortic regurgitation
by giving digitalis is exploded. Even if digitalis does slow the pulse
the beneﬁt derived 1n strengthening the ventricle counterbalances any
trouble we might have from an acute dilatation. We know that these
cases of aortic stenosis become practically mitral cases when compen-
sation breaks, and we deal with them as we would with mitral cases.
In giving digitalis he preferred the freshly prepared infusion. With
such a patient as the one before the Society he would begin with a
teaspoonful and increase the dose until its full effect was seen. A
practical point in the administration of digitalis is to watch the amount
of urine for the twenty-four hours. Whenever there is a drop in the
amount of urine passed, especially if the heart is slowing and there is
increased tension in the arteries, it is time to diminish the dose or
cease giving the drug. for these are usually signs of a disturbance in
the heart due to overdoseage of digitalis. If digitalis fails, or you want
a'prompt effect, or the stomach will not tolerate the digitalis, stroph-
anthus is the next best drug. If it is desired to get a special effect
206 . -Medical Society of
on the kidneys the addition of citrate of caffein will produce this. For
the dropsy as seen in this case, of course as compensation is're-estab-
lished, this will disappear. If it persists, however, and the patient’s
condition willjaermit it, we might drain through the bowel either by
the epsom salts method of Hay, or elaterium. He had found elate-
rium acts very well and has had no depression from its use. He gives
it in 1/6 to ‘/, grain dosesrepeated as necessary. A dry diet is help-
ful in some cases. If the edema is extreme, puncturing the limbs
will drain and helps the circulation. This can be done with aseptic
precautions and without danger of erysipelas and tends to restore the 4
balance in circulation. For the dyspnea when severe, and especially to
give the patient rest, there is nothing better than morphine and this
can be given freely. In extreme cases venesection should be prac-
ticed. He mentioned a case that had actually been snatched from the
jaws of death by venesection. He took a pint of blood from-this pa-
tient. Where the right heart is overloaded this gives the patient a
chance to regain tone. Pepper records a case where the auricle itself
was punctured and the patient saved. When all remedies fail we
should try the Schott bath treatment and a certain proportion of these
cases are tided over for quite a while by this treatment. One case so
treated who was practically moribund when the treatment began, has
been doing well for two or three years. ‘
He said he would accentuate two points, namely, that aneurysm
can not produce the Corrigan phenomena in the vessels unless there is
aortic regurgitation present. Second, the danger of making a diagno-
sis of aortic stenosis unless there is deﬁnite data present and espec-
ially if aortic regurgitation is present without a modiﬁcation of these
_ vascular phenomena.
DISCUSSION.
DR. P. V. VON PHUL said he was particularly glad to hear Dr.
Smith’s remarks on the treatment of these lesions. He was anxious
to hear more of the Schott method and whether he thought the treat-
ment indicated in a case like the one present. If not, he asked Dr.
Smith to say when the treatment is indicated. - He also asked about
capillary pulse as a diagnostic feature.
City Hospital Alumni. 207
DR. HUDSON TALBOTT said the subject was of great interest to
him. He was specially glad to hear the remarks about aortic stenosis.
‘ The treatment of these cases is very important for we all have cases _in
which all treatment seems to fail utterly. He said he had had the
pleasure of treating several cases with Dr. Smith by the Schott method
in the City Hospital. He was not favorably impressed with the
method. Helthought that perhaps the method was deferred too long
and that possibly _we might get more results if we did not wait until all
other methods had failed. Puncturing had been used with beneﬁt in
the cases referred to. I
DR. GEORGE M. TUTTLE thought rest in connection with un-
compensated heart leisions is very important. The beneﬁcial results
are quickly seen in hospital patients . who are accustomed to hardship
and privations. The rest they obtain in the hospital in connection
with good food often enables the patient to leave the hospital perfectly
well so far as he is aware. He thought it important to keep the pa-
tient ﬂat on his back and thus prevent the heart from doing any extra
werk- ..
DR. SMITH, in closing, said the Schott method, as far as we are to
"see at present, does nothing but restore compensation in a certain
number of cases, but we have no evidence that it accomplishes this
better than other methods. Therefore he did not resort to the Schott
method when other means would give results. It is irksome and difﬁ-
cult to carry out and hard to gain the patient’s consent for any length
of time. He relied upon the older methods until he saw that they had
all failed and then he tried the Schott baths. In a limited number of
cases this method is useful. Dr. Talbott’s experience was discourag-
ing because they had taken patients in the last stages of broken com-
pensation. He favored puncturing early in these cases, or whenever
the tension in the arteries became great. N o harm results from the
procedure as under aseptic precautions there is no inﬂamatory trouble
or erysipelas following. It certainly makes the patient more comfort-
able, especially where the genitals are distended.
The matter of rest is a question often hard to decide, but in cases
of acute failure of compensation rest is indicated. In chronic cases,
208 \ Medical Society of
however, he would doubt the propriety of absolute rest. A part of
the Schott treatment is graduated exercise, that is training the heart
gradually to do more work. This is the object sought in mountain
climbing. In chronic cases systematic exercise is beneﬁcial. He had
gotten some good results from the Schott method. A young girl With
a mitral insufﬁciency and failure of compensation was in such an ex-
treme condition it was a question whether she could be handled with-i
out dying and they did give up all hope. In her case it was astonish-
ing how she improved under the treatment. After the second bath
she could rest well. Still he did not believe that compensation ef-'
fected by the Schott _method was any better than when secured by the
older methods. While it will restore compensation in a certain pro-
portion of cases, yet he did not think the number was great enough]
to justify its employment in preference to the older methods and begin
the treatment early. A counter indication for the Schott treatment
is extensive renal disease. He used cardiac tonics in connection with
the Schott treatment tn a certain proportion of cases. The Schott
method will assist other methods and reaches some cases which do
not respond to other treatment.
City Hospital Alumni. _ 209
~Meeiz'ng of Septeméer 5, 1901; Dr. Nowelle Wallace Sharpe,
‘ President, in the Chair. '
Specimen of Lipoma.
.DR. F. G. NIFONG presented a specimen of a lipoma removed
from Mrs. D., aged 58 years, married. Family history: Two brothers
died of consumption, father had malaria and mother heart disease.
~ The patient had never had any serious illness; her only trouble was
at childbirth; she bore six children. At 15 she began to menstruate
» and between that and her 16th year she had a severe “spell” of ab-
dominal p_ain,_‘.a swelling in the abdominal wall and a rupture of the
wall between the umbilicus and the pubis; this discharged a glairy,
- white ﬂuid for‘six months before it healed up. After this she enjoyed
good health until three years ago when she began to have pain in the
abdomen ; she was also attacked with what seemed to be an epileptoid
convulsion; the ﬁrst attack came on about four o’clock in the morn-~
_ ing; this happened several times. iShe manifested also some bladder
' trouble; the severe abdOminal pains continued; the last attack was
about ten days ago, when she came to St. Louis. On examination a -
tumor was-found in the lower portion of the abdomen; the speaker
thought this tumor might be attached to the bladder, as there were
bladder symptoms, with pus in the urine, but no casts or sugar. The
bladder would not hold more than ﬁve or six ounces; the pain was
quite severe The tumor was removed to-day from the abdominal
wall;ithe tumor was found to be continuous with an omental hernia
passing through a ring the' size of a silver dollar. The omentum was
tied off and dropped back into the cavity and the ring closed.
_ The question is, was. thls tumor of omental origin in the ﬁrst place,
and not, where did it originate? It is a rather unusual place for a
) lipoma, although, of course, they may be found wherever there is
connective tissue; its intimate connection with the omentum seems to
point to omental origin. You will notice, though, that the tumor’s
consistence is quite different from omental tissue—being ﬁrmer, more
‘ ﬁbrous, lessrvascular, etc. ~ ‘ '
DR. H. S. CROSSEN asked if the tumor was nearer the pubis than
\
210 Medical Society of
the umbilicus; did it seem connected with the peritoneal cavity; was
there any evidence of a peritoneal covering inside the sac?
DR. NIFONG replying, said it was nearer the pubis; it was sep-
arated from the cavity by a distinct thick hernial ring ; it was imbed-
ded in the abdominal wall; was outside of the peritoneum and was
peeled out like a typical lipoma until the hernial opening was reached,
here I found it continuous with the omentum. Whether the omentum
was simply a hernia under the tumor, which had adhered, I am not
prepared to say. I think that, perhaps, the beginning of the trouble
was a cyst which became inﬂamed—adhered to the abdominal wall
and ﬁnally ruptured. This weakened the wall and afterwards an
omental hernia developed and from this the lipoma; this tumor has
been noticed for forty years but gave no trouble during the childbear-
ing period—only during the last few years has she suffered severely.
The intense pain was probably due to the partial strangulation of the
omentocele.
Report of Work in Ureteral Catheterization in
the City Hospital the Past Year.
BY. H. L. NIETERT, M.D.,
ST. LOUIS, MO.,
SUPERINTENDENT ST. LOUIS CITY HOSPITAL.
URING the past year about twenty-ﬁve cystoscopic ex-
aminations and catheterizations of the ureters in females
were made at the City Hospital. The examinations
were in each case made with a Kelly-Pawlic cystoscope under
general anesthetic. The dorsal position with elevation of
hips about ten inches above the rest of the body was employ-
ed. This elevation in all but one case answered the purpose
of producing distention of bladder sufﬁciently to inspect the
mucous membrane and catheterize the ureters. It was ob—
served that drawing down the perineum, by means of the ﬁnger
introduced into the vagina, and allowing the posterior walls
of the bladder to drop down, greatly facilitated its distention.
‘ -City Hospital Alumni. I 211
After introduction of the cystoscope into the bladder to al-
most its full length, it has been the practice to introduce (the
indexﬁnger into the vagina, gently pressing the bladder-wall
against the end of the instrument. Then with the mucous
membrane of the bladder under constant observation, the in:-
strument was slowly withdrawn until the interureteric folds of
mucous membrane was reached. The moment the end 'Of the
instrument fell upon this fold it would spring prominently be-
~ fore the opening. The fold once demonstrated it is usually an
easy matter to ﬁnd the ureters, which are located on the top of
~ the folds and about three-fourth inch to. either side of median
line. - '
The operations were usually performed with little difﬁ-
culty, until recently when an attempt was made to catherter-
izé' a very large and ﬂeshy woman. Here the slight elevation
proved insufﬁcient to properly dilate the bladder. The tense
and heavy abdominal wall pressed too ﬁrmly upon the organ to
permit of any inﬂation. After repeated attemps to ﬁnd the
ureters in this contracted state of the bladder, the search was.
abandoned. The patient was too large and heavy to place in
the knee'chest position practiced by Kelly. The idea then oc-
curred that Iv might be successful if the pelvis were elevated to
"almost a vertical position. This was accomplished by elevat-
ing the'end of the table to the extreme Trendelenburg and
" strongly ﬂexing the thighs upon the abdomen, thus producing
a combined Trendelenburg and lithotomy position as shown in
accompanying illustration. It was necessary, of course, to
change my position from the end (if the table to the side of the
patient, with the’instrument directed almost horizontally back-
ward. In this position I was able to thoroughly inspect the
bladder. The distention Was perfect as all pressure had been
removed. The intestines and uterus had fallen away from
that organ, allowing a perfect inﬂation. I was able to cathe-
terige the ureters without any further difficulty.
I believe the distention of the bladder by this method is
i more perfect than that of the knee-chest position and is less
uncomfortable to the patient.
The male ureters were catheterized six times with the
Lewis cystoscope and all under his directions. The ﬁrst cath-
212 Medical Society of
eterization was performed~ about one year ago with an old
model of the present instrument, which did not provide for the
inﬂation of the bladder. The patient was placed in the knee-
chest position and the examination was made under a general
anesthetic.


i 3
The combined Lithotomy and Trendelenburg Position for Catheter-
izing the Ureters.
The last ﬁve catheterizations were performed about two
months ago with the modiﬁed instrument presented here this
evening.
The time required in catheterizing the male ureters is
about the same as that required in the female with the Kelly
instrument, namely about one-half to one minute.
Thus far we have not had an opportunity to try the cys-
City Hospital Alumni. 213
toscope for females devised by Dr. Lewis, but after a careful
examinatidn of the same I can see quite an advantage, in his
1 instrument over the Kelly-Pawlic cystoscope. First, with the
Lewis instrument the bladder-wall can be perfectly ﬁxed by
the inﬂation of the organs and thus a perfect view of the mu-
cous menbrane obtained. Second, by the distention of the
. bladder with air, the wall is carried farther from the end of the
instrument, giving the operator a view of a large area at one
time and facilitating the ﬁnding of the ureters. Third, the il-
lumination from the small lamp in the end of the instrument is
more satisfactory than the indirect light from a mirror. Fourth,
,the instrument has a carrier, so that a ﬂexible catheter can
easily be used if it is desired to wash out the pelvis of the kid—
ney. \V _
In conclusion I Wish to state in reference to Dr. Lewis’
cystoscope for the male, that it possesses marked advantages
over most of the other designs, inasmuch as it enables the
operator: ﬁrst, to ﬁx the bladder wall with air instead of water,
secondly, to catheterize the ureters by direct light.

Since reading this paper before the Hospital Alumni As-
sociation an article appeared in the journal of the American
Medical Association of October 26, 1901, describing a new
gynecological position, used by F. _Iayle. The article was
copied from the British Medical fonrnal. Jayle uses the po-
sition I described in my report for a great number of his sur-
gical operations on the bladder and vagina and uses it espec-
ially for operations for vaginal ﬁstula.
Case of Recurrent Laryngeal Paralysis Due to
Aortic Aneurysm.
BY WILLIAM E. SAUER, M.D.,
ST. LOUIS, MO.
i'
HE patient, Mr. _I. C., aged 42 years; ﬁrst consulted me
on June 3, 1901, being referred by Dr. A. C. Bernays.
He states that in the early part of November, 1900,
214.~ Medical Society of .
he suddenly became speechless—that is, could not speak
above a whisper, but after a few minutes his voice returned
and he could speak as well as ever. About a week later he
again lost his voice, but this time he was speechless for about
ten days, after which his voice returned but he was very
hoarse and remained so up to the present time.
Three years ago while writing on a blackboard in a pool-
room, he was suddenly seized with a sharp pain in the chest,
radiating to back and down left arm with a tingling sensation
in ﬁngers; since then he has been troubled with a hacking.
He has been treated for rheumatism, tuberculosis, grip, and
many other afﬂictions, until March of this year, when the case
was diagnosed as syphilis, and he sent to Hot Springs where
he remained seven weeks, receiving the usual inunctions and
hot baths; having taken some forty ﬁve in all. The pain in
his chest was greatly relieved, but he began to have attacks of
shortness of breath, with wheezing in the chest, and during
the past few weeks he could sleep but little and lost greatly in
weight.
Family history is good. Previous history: *There has
existed since childhood a mild ear trouble; he has had some
ﬁve or six attacks of gonorrhea, and two suppurating bubos
ﬁfteen years ago. I could not elicit any syphilitic history.
Up to ﬁfteen years ago he had been employed as an express-
man, doing heavy work, since then he has been a clerk in a
cigar store and pool-room.
On examining the patient I found his voice hoarse and
harsh in character; his respirations were somewhat rapid. In
the larynx I found a typical recurrent laryngeal paralysis,
that is, during respiration the left cord was immovable
in a position mid way between adduction and abduction; dur-
ing efforts of'phonation the right cord caused the median line
to meet its fellow on the opposite side. Suspecting' an aortic
aneurism as the cause of the paralysis I next examined his
chest and found distinctly visible pulsation over the upper por-
tion of sternum as well as marked pulsation in the carotids;
on palpating this region a dictinct systolic impulse with a
marked diastolic shock was felt.
Percussion revealed an area of dulness extending just be-
City Hospital Alumni. 215
yond the outer edge of the sternum on the right, and about an
inch and a half beyond the left margin of the sternum; above
on a line with the upper margin of the second rib and below
blending into those of the heart dulness. \
On auscultation, a faint systolic murmer with a loud ringing
second-sound could be heard, and all over the chest numerous
sonorous rales could be heard. The heart did not seem to be
displaced or enlarged, arid save for the markedly accentuated
second-sound nothing abnormal could be detected. I could
not make out any difference between the two radial pulses.
Tracheal tugging was well marked.
He was was put on increasing doses of potassium iodide,
and after a week had elapsed he began to breath very much
easier and could sleep very much better.
On june 15th, he went to Detroit where he remained
until July 16th, and on his return felt very much better in
every way, he could sleep without interruption and had gained
some ten pounds in weight. I again examined him, but could
not made out any changes in his larynx or chest. He had
been taking up to 30 drops of the saturated potassium iodide
solution; this was gradually reduced to 15 drops three times
daily, which he has been taking continuously since July 22d;
Since this time I have examined him repeatedly, and during
the past few weeks, thought I could notice a decrease in the
force of the pulsations, and that the area of dulness does not
appear to be quite as large as it was. In the larynx I found
no change.
Case of Recurrent Laryngeal Paralysis Due to
Aortic Aneurysm.
BY L. H. HEMPLEMANN, M.D.,
ST. LOUIS, Mo..
ATIENT, james 1., aged 45 years. Family history:
Cause of father’s death unknown; mother, two sisters
and one brother alive and healthy,
Previous history: Two years ago he injured his ankle in
jumping off a moving train, otherwise always healthy. Has
I 5
216 - Medical Society of
had gonorrhea several times; had sore on penis about ten years
ago and again six years ago; no history of secondary symp-
toms or of any speciﬁc treatment.


Is a moulder by trade and has been in the habit of carry-
ing ladles of molted iron. Was a prize ﬁghter from 1878 to
1884; fought I3 battles with bare ﬁsts’; has always used alco-
holic liquors to excess; drank beer mainly, but also a great
City Hospital Alumni. 217
deal of whiskey; drank continually and went on sprees.
Present trouble began, as patient says, about a year ago,
at which time he noticed pains in precordium and in left arm,
they came on periodically, sometimes every day; he has suf-
fered from cough and dyspnea for past four months; he can not
lie on his'right side because of the dyspnea; he worked up to
July“ of this year.
Urine 1020, no albumen or sugar. -
Physical examination: The patient is a very muscular,
well-nourished man. The pupils are equal, the pulsation is
distinct over the upper part of the sternum, the whole ster-
num seeming to rise at each systole; there are no dilated
veins; no thrill can be felt over the chest or in the suprasternal
notch, the apex beat is in the ﬁfth interspace in the mammary
line; it is not very heaving; the radials and carotids are syn-
chronous.
Dulness as per diagram. Normal sounds are heard at
the apex over the second right intercostal space, a fairly clear
ﬁrst-sound is heard and a faint diastolic murmur. [Over the
third left intercostal space and more plainly in the second is
heard a faint ﬁrst—sound and a plain blowing diastolic murmur.
His voice is hoarse and he has the brassy cough so character-
istic of recurrent paralysis. I have been unable to see the
vocal chords as the patient is an alcoholic and has a very irri-
table pharyngeal reﬂex.
There is no dislocation and apparently but little hypertro-
phy of the heart. There is a horizontal pulsation of the
trachea when the head is extended, which I take to be trans-
mitted from the carotids rather than a “tracheal tug.” He is
quite dysp_neic; there has never been any difﬁculty in degluti-
tion nor any asthmatic or neuralgic attacks.
DISCUSSION.
DR. L H. BEHRENS said both these cases were very interesting.
In the case of Dr. Sauer’s patient he was surprised that the existence
of an aneurysm had escaped notice even as long as three years ago;
the early recognition of aneurysm he had frequently discussed and
thought it of great importance. He referred to an article (mentioned
218 Medical Society of
by him at previous meetings of this Society) in the 1V. Y. Medical
journal, which was taken from the West Indian Medical journal, in
which several famous London diagnosticians called attention to cer-
tain early symptoms of aneurysm, such as a sudden suffocation when
thrown suddenly back in a barber’s chair. One of the patients pre-
sented this evening states that he felt this sensation; the other case
did not recall having such symptom but he had cervico-brachial neu-
ralgia. Whenever there is a recurrent laryngeal paralysis we almost
intuitively auscultate the chest to see if there is any pressure due to an
aneurysm, because this is the most frequent cause of throat trouble
such as we have here; the other symptoms in both cases are such as
we usually ﬁnd; the left pulse in one case is smaller than the right;
in the other case there is no difference in the pulsation. We are often
led to believe that we hear all kinds of murmurs and sounds in these
conditions; it is more often that we do not hear anything typical of
aneurysm and it is very difﬁcult to make an early diagnosis of aneu-
rysm unless we take into conmderation the peculiar symptoms men-
tioned.
The treatment in these cases is very unsatisfactory; he recalled
ﬁve cases seen in the City Hospital of aueurysm of the ascending and
descending, and two in private practice last year, and no improvement
was seen in any of them. i x
One case of aneurysm of the arch with symptoms similar to one
of the cases shown this evening was given iodide until he was taking
seventy drops three times a day and showed a marked degree of iod-
ism ; there resulted a slowing of the circulation, a relief of the pain-
ful symptoms, but the aneurysm continued to grow slowly and by pres-
sure on the bronchi dissolution rapidly took place ; there was no rup-
ture, just a gradual suffocation. He had seen gelatin injected in sev-
eral cases but no marked degree of ﬁbrination took place; there is lit-
tle to do but wait. If possible we should keep the patient in bed and
away from all excitement; the diet should be modiﬁed so there will
be no digestive disturbances and follow out the oft-repeated rules ; in
this way we may, at least, prolong life somewhat and make the patient
fairly comfortable. Some cases are on record as having lived I 5 to
20 years after ﬁrst symptoms were observed.
City Hospital Alumni. 219
DR. SAUER said he hardly believed the prOgnosis was quite as
bad as Dr. Behrens had pictured, as there are cases recorded even
’with marked symptoms, that have lived 18 and 20 years.
DR. HEMPELMANN said the average duration given by Eichhorst
was 16 months after recognition, though cases were cited that lived as
long as 18 years. ' '
The gelatine injections seem to do good in some cases and the
patient seems to feel better. Where the iodide is followed by im-
provement, however, he did not think there was any indication for
other treatment.
He mentioned that the patient shown by him this evening was an
inmate of the Mullanphy Hospital, and Dr. Senseney had seen the case
with him. , '
DR. HOWARD CARTER exhibited some specimens taken from Cor-
oner’s cases. The clinical history of these cases was, of course, un-
obtainable as they were all post-mortem examinations. The ﬁrst
specimen exhibited was 4“
A Perforated Uterus.
This was a case of abortion which came through the hands of a
midwife. Th'e uterus was shown to have been pregnant about three
months; there was a general peritonitis with a perforation through the
neck of the uterus and into the cavity of the peritoneum; there were
two openings into the peritoneal cavity.
A Case of Pus 'Tubes and Ovaries.
This specimen was evidently taken from a prostitute. It showed
a chronic pelvic peritonitis; the uterus had never been pregnant.
Diaphragmatic Hernia.
' This is arather unusual case. The patient was set upon by a
number of boys and punched and kicked in the stomach. The her-
nial mass contains the transverse colon and nearly all of the large
omentum. The rent in the diaphragm is small and strong adhesions
had formed on each side. All the viscera were misplaced—the stdm-
' ach and heart being forced over to the right side. The incarcerated
colon contained fecal matter; there was no pus, but a large amount
220 Medical Society of
of ﬂuid was present in the left pleural cavity into which the hernia had
taken place. The patient lived three or four days.
Rupture of the Heart.
This is a very interesting specimen, The patient gave a history
of feeling ill for several days, and went to his room in the hotel and
died there. The pericardial sac was found ﬁlled with blood; along
the septum was seen a scar; this really consisted of a number of mi-
nute holes entering the left ventricle; the heart was not opened. It
is a very unusual condition; it is unquestionably a case of “broken
heart ;” there was some fatty change in the muscle. The deceased
was an old man who did little or no physical work.
Occlusion of Aorta by Atheromatous Deposits.
The heart is considerably enlarged and somewhat dilated; the
amount of fat around it is greater than usual; the valves on the right
side are comparatively normal; the mitral valve is practically normal ;
the aorta, however, is almost completely occluded by calcareous de-
posits; the entrance to the coronary arteries is, in some instances, oc-
cluded but the arteries themselves are not atheromatous.
The next specimen from the same patient, showed a
Severe Gastritis.
The next specimen showed a case of ‘~
Large Aortic Aneurysm.
This was probably a ‘case of very long standing. The sack is
ﬁlled with laminated clots of various size, of the consistency of shoe
leather and varying in color from white to dark brown.
The next specimen was an
Enlarged Heart with Extensive Atheromatous Patches
extending into the abdominal aorta.
The next specimen was a
Hemorrhagic Infarct of the Kidney
from the same case.
DR. MORFIT was most interested in the specimens of ruptured
heart and diaphragmatic hernia. The calcareous condition of the
City Hospital Alumni. 221
arterial trunks and coronary arteries, no doubt, were a strong factor in
predisposing the heart to give away along the course of the coronary
vessels. Nothing in the history of the case would lead one to dis-
cover the mechanical cause, whatsoever it may have been. He had
been impressed lately by coming in contact with several traumatic
cases of ruptured viscera where the external surface injury was little
more than a slight bruise. Within the last few weeks Dr. Carter had
done an autopsy on a coroner’s case and found the small intestine torn
square off a few inches above its junction with the duodenum. He
recalled one recent case in which there was scarcely any injury to the
integument, biit blood in the urine led to the discovery, at operation,
of a right kidney badly lacerated and fractured into several parts
The hernia was the second one of that variety he had seen. Dr.
Carter’s case was evidently acquired through injury. The ﬁrst case
he had seen was of long standing, as evidenced by, the thick edge of
the ring in the left side of the diaphragm near the outer border of
the central tendon. About twelve feet of small intestine with part of
the colon was found in the thoracic side of the diaphragm and having
been distended with gas gave rise to a resonant percussion note,
which enabled the diagnosis to be made beforehand. In other re-
spects a strangulated hernia through the diaphragm gives the same
symptoms as a similar condition in other locations.
DR. R; B. H. GRADWOHL said the case of ruptured heart was es-
pecially interesting. The cause of the rupture might be determined
by opening thedorgan and examining the wall; it might be due to a
thrombosis of the coronary artery. The case of diaphragmatic her-
nia was also interesting; the solution of its nature would also be likely
determined by a more careful examination. as to the existence of a
congenital ring, etc. Acase of this sort has been recently operated
upon with success by Miculicz. ~
DR. JOHN GREEN, ]R., asked if it was known what character of
instrument was used in a case of perforated uterus.
DR. CARTER said he did not know. The midwife said she had
not used an instrument ; she said the fetus had been dead for several
days when the patient ﬁrst came to her; she said, however, she would
have used instruments if she had known how to do so and had had
\
222 Medical Society of
them. The speaker said he did not mean to assert that the midwife
used an instrument but that an 1nstrument was used is unquestionable
though by whom could not be ascertained.
DR. NIFONG mentioned a case of ruptured uterus seen in con-
nection with his father. The woman had produced abortion upon her-
self by using some sort of instrument. The fetus was supposed to be
dead as she was having hemorrhages, and they proceeded to curette;
they soon took hold of what they supposed to be the cord and pulled
on it, having getten away a small fetus about three months old; after
pulling on the supposed cord they found it to be intestine. In this
quandry the uterus was cleaned out thoroughly, the intestine replaced
as best they could through the opening in the uterus. There was
profound shock and they expected the patient to die, but she rallied
and went on to complete recovery.
DR. Jos. L. BOEHM mentioned three cases of ruptured uterus,
seen while he was interne at the city hospital. All the cases occurred
in the practice of a certain midwife, who has since been sentenced to
a term in the penitentiary. Dr. Nietert was present at the post'mor-
tem examinations. The perforations in the three cases were always
in the fundus, which led to the belief thata blunt curette had been
used. He thought this similarity in the location of the perforation a
peculiar coincidence and asked if this was usual and what had been
the experience of other members in this respect.
DR. H. S. CROSSEN said he recalled a case of rupture of the
uterus but was not cErtain that it followed aa attempt at abortion. The
patient was brought in the hospital about I I o’clock at night, with her
intestines hanging out between the thighs. She gave a history of hav-
ing fallen from a wagon a day or two before and was attended by a
midwife who supposed the patient was about to abort. The midwife
found something but did not know what it was, and called a physi-
cian; the physician found the intestines in the vagina ahd sent the
patient to the hospital. On examination the speaker found a large
amount‘of the intestine outside of the vagina and without the mesen-
tery; the mesentery had been stripped off and it appeared to him that
considerable force must have been used in pulling down the intestine.
He supposed, though he was not sure this is correct, that the midwife
City Hospital Alumni. 223
had pulled and kept on pulling on the intestine until she had gotten
out quite a number of feet. In this way he accounted for the mesen
tery being stripped off; that, however, is a question. As the mesen-
tei'y had been torn off and there was internal hemorrhage, he opened
the abdomen and removed thirteen feet of small intestine and a large
amount of the mesentery and did an end-to-end anastonosis of the
several portions of intestines; the rupture was in the interior part of
the uterus, just above the interal os; it looked very much as if a di-
lator had been forced through the anterior wall of the uterus because
the opening was quite large; a small sharp curette would hardly
make an opening large enough for this amount of intestine to escape.
The patient did well for about ﬁve days, but developed peritonitis and
died later. Post-mortem it was found the intestines had healed nicely
—there was no leakage—but a small part of the mesentery sloughed,
causing late peritonitis.
This case was reported in 1898; he simply mentioned it now in
connection with the subject of ruptured uteri.
DR. L. DRECHSLER thought we shouﬁl be careful about receiving
ante-mortem statements of patients under these conditions. He men-
tioned a case seen in a private hospital where the patient stated that
she had attempted an abortion upon herself. Post-mortem showed
that she had a peritonitis, due to a ruptured extrauterine pregnancy,
the peritonitis not originating from the uterus itself—there was no le-
sion in the uterus.
224 _ Medical Society of
Meeting of September 19, 1901; Dr. Noroelle Wallace Sharpe,
President, in the Chair.
Corneal Ectasia with Preservation of Central
Transparency Subsequent to Recurrent
Marginal Keratitis.
BY JOHN GREEN, JR., M.D.,
ST. LOUIS, MO.
I : ERATECTASIA as a sequel to inﬂammatory changes
in the cornea is in general characterized by (a) serious
impairment, or even total loss, of vision; (at) the ectatic
portion is formed of cicatricial tissue and is, hence, opaque.
The following case differs from the classical type in that (a)
vision (with appropriate glasses), is still fairly acute; (e) the
ectasia is formed by normal tissue and is transparent.
J. M., male, German, aged 61 years, came under observa-
tion July 13, 1901. Family history' good. He served as a
cavalryman in the Confederate army 186I-65, and underwent
considerable hardship, but was not seriously ill during this pe-
riod. He believes he contracted syphilis in 1864, and was
under irregular treatment two months. ‘
Ocular history—In 1894, following an attack of grip, the
patient began to have attacks of redness of the eyes, with pain,
lachrymation and photophobia; each attack lasting from two
to seven days. He would remain free from symptoms for
thirty to sixty days, when a precisely similar attack would oc-
cur; the recurrences continued four years.
Three years ago the patient noticed that a point oflight
“looked like a star,” and that occasionally distant objects ap-
peared double. His friends noticed a “staring” appEarance of
the left eye. On experimenting, vision was found moderately
impaired in right eye, markedly impaired in left eye. Vision
is thought to have grown progressively worse up to a year
ago, since which time no change has taken place either in
vision or appearance.
City Hospital Alumni. - 225
Status przsens.—-Right eye: Inspection reveals an
annular sulcus involving the upper half of the corneal
periphery; the sulcus is semicircular' in proﬁle and runs
parallel to and one'and one half mm. from the sclero-corneal
junction. Minute blood vessels run beneath the trough ‘of
the sulcus and terminate in delicate points of opacity. A
pterygial growth pervades the cornea at the inner lower quad-
rant. Viewed laterally, the cornea is obviously ectatic and has
the appearance of a sharply beveled watch glass. The ante-
rior chamber is a little deep; the pupil is circular, reacts ac-
tively to light and accomodation.
Left eye: Centrally the transparent cornea is pushed
forward so that the apex of the ectasia lies four mm. above the
transvere sclero-corneal plane. Above it is bordered by a
broad and shallow sulcus presenting the same general char~
acteristics as the excavation of the fellow eye. A pterygial
growth invades the cornea at the lower inner quadrant. The
anterior chamber is very deep, the pupil is circular and reacts
to light and accomodation.
Ophthalmoscopic examination shows in both eyes clear
media and normal eye-grounds.
The ophthalmometer (Javal-Schidtz) shows greatly in-
creased curvative and high grade of astigmation in both eyes.
An accurate measurement is impossible owing to the interfer-
ence with the reﬂection of the mires by the pterygia.
Visual tests:
Right eye, V. 15/150, without correction.
Left eye, V. 3/15(,, without correction.
The best measurement of the refraction was found to be
Right eye M. 3, Am. IO, M0 horizontal V. "119+.
Left eye, M. IO, Am. IO, M°+45°, V. “738+.
The initial process was probably an attack of marginal
keratitis. In view of the formation of pseudo-pterygia and
the tendency of the disease to pass through periods of “remis-
sion alternating with relapses” the diagnosis of keratitis mar-
ginalis superﬁcialis (Fuchs) may fairly be made. Each suc-
ceeding exacerbation produced a greater and greater thinning
of the corneal periphery until the atenuated tissues could no
longer withstand the intraocular pressure. What, then, took
226 . Medical Society of
place? The intraocular pressure, acting as a vis a tergo
against Descemet’s membrane, gradually stretched the weak-
ened periphery thus carrying forward the apex of the cornea.
The increased curvature is to be accounted for partly by the
radial tension of the scar tissue, partly by the annular con-
striction at the periphery.
DISCUSSION.
DR. M. WIENER said the case was exceedingly interesting He
had never seen one just like it; the marginal inﬂammation, as ex-
plained by Dr. Green, had probably caused the stiffening, and the
resulting contraction of the periphery of the cornea.
DR W. E. FISCHER said he had never seen a case of this kind and
was very glad to have an opportunity of examining it. It reminded
him of peripheral corneal atrophy, though it certainly did not be
long to that class, as the cornea remains clear; the literature is very
scant on the subject.
DR. J. H. CROSS said the case looked to be, at ﬁrst sight, a case
of keratoconus or keratoglobus, where the cornea is enlarged, but a
more careful examination showed it was not of this character.
DR. GREEN said he would like to have the opinion of the gentle-
men in regard to the advisability of operating on the pterygium of the
right eye. As the latter is the one that will give the patient the great-
est service, the question of removal of the growth before it seriously
encroached on the pupillary area must be considered. The speaker
believed that the inﬂammatory process had come to a standstill, and
that in all probability the pterygium had reached the limit of invasion.
DR. WEINER thought operative interference would produce more
scar tissue and, hence, a contraction, and as the contraction is in
the upper part of the cornea, and inner and lower portion of the lens,
he thought it would be just as well to let it alone. He feared that an
operation with its resulting scar tissue might choke off some nourish-
ment from the clear cornea.
DR. FISCHER agreed with Dr. Wiener. As the pterygium is
very thin and doesn’t seem to advance, he thought it best to leave the
case as it is; aside from the question of nourishment, there would cer
City Hospital Alumni. 227
l
tainly be scar tissue and he believed this would rather aggravate the
trouble.
DR. CROSS was also of the opinion that it would be better to let it
alone. He did not think it wise to use operative interference on a
cornea in the condition seen here tonight.
DR. GREEN said the case, at ﬁrst sight, seemed to be a rather
anomalous case of keratoconus b'ut' careful inspection at once dis-
proved this. The case was seen in consultation by Dr. A. E Ewing,
who suggested stimulating applications of tincture iodine. This treat-
ment had been faithfully pursued for about six weeks and had re-
sulted in the formation of a certain amount of new tissue, as shown by
a partial ﬁlling up of the peripheral excavation.
A Case'of Muscular Atrophy: A Case of Lin=
gual Hemiatrophy, with Presentation
of Patients.
BY GIVEN CAMPBELL, JR., M.D.,
ST. LOUIS, MO.
/
HE modern tendency towards simplifying our classiﬁca-
T tion of the muscular atrophies, renders a résumé of our
knowlege of these conditions advisable before present-
ing this case.
In 1850, Duchenne, and a little later, Aran, brought into
prominence a disease producing wasting of the muscles unac-
companied by sensory changes, commencing in the small mus-
cles of the hands, involving the shoulder girdle later and de-
veloping in adult life. Pathological research subsequently
proved in these cases that the condition was accompanied by
degenerative changes in the cell bodies in the anterior horn of
the spinal cord and in the axones of the pyramidal tract cells.
Later study developed the fact that certain cases of muscular
atrophy commenced in infancy or youth; that in these cases
the atrophy affected the roots of the extremities rather than
their distal ends. Reaction of degeneration was not found, al-
228 Medical Society of
though often present in the ﬁrst-mentioned cases; true and
pseudo-hypertrophy were often observed. In these cases the
hereditary tendency (absent in the cases ﬁrst described) was
strongly present: autopsies showed no changes in the central
or peripheral nervous system, the muscles alone appearing
to be affected.


Progressive Muscular Atrophy, showing characteristic axillary fold and
projection of scapula into into the supraclavicular space on the
right side. .
There were thus formed two classes of progressive muscu-
lar atrophy: The spinal form or progressive amyotrophy, and
City Hospital Alumni. 229
the essentially muscular form or progressive muscular dystro-
phy, or as it is commonly called, dystrophy.
It is to the latter class of cases that our patient belongs,
and on the subdivisions of which a few more words will be
said. Until quite recently there has been a tendency to make
deﬁnite classes of the dystrophies according as they affected
. ﬂ, ' ' .' iii?

‘ .133 I
w r 1
. - p _.,
- r g
A
i
i .


Progressive Muscular Dystrophy, showing especially well the tilting of
the right scapula. The patient is pressing his hands forcibly
together.
different groups ofmuscles, as to whether pseudo-hypertrophy
was a prominent symptom and as to the age at which the at-
rophy ﬁrst appeared. To each of these types the name of its
230 Medical Society 0t
discoverer was given and a cumbersome nomenclature was
built up; but as time has passed and cases have accumulated,
the distinctness ofthese types has faded. It is seen that the
dystrophies merge one into the other; that even the pseudo-
hypertrophic form does not always keep to its type; that
pseudo-hypertrophy frequently occurs in certain muscles in the
juvenile type, and what is more important, that in families
where dystrophy is present one brother will suffer from pseu-
do-hypertrophy, while another will develope the juvenile or,
perhaps, the so-called “hereditary” type of muscular‘atrophy.
We now, therefore, reﬁne much less in our classiﬁcation of
the dystrophies, but still consider them as entirely separate,
clinically at least, from the spinal muscular atrophies or amyo—
trophies. The essential difference between the two conditions
lies probably in that in the amyotrophies the muscular" wast-
ing is secondary to an atrophy of the motor cells of the anter-
ior horn of the spinal cord, this atrophy being usually accom-
panied by degeneration of the lateral columns of the cord.
The muscles directly connected with the anterior horn cells
that have been destroyed atrophy as do all/muscles Whose
lower motor neurone has perished; while in the dystrophies
there is reason to believe that the muscular wasting is due to
some developmental deﬁciency. Recent investigation shows
that new-born animals possess many more muscle ﬁbers than
adults, and it has been suggested that this natural disappear-
ance of muscle ﬁbers may, from some cause, exceed physiolog-
ical limits and produce dystrophy. The appearance of dys-
trophy in several members of the same family, or in several
members of succeeding generations; its propogation by the
females; its appearance during active growth, and at develop-
mental epochs, stamp it as a developmental disease.
The history ofthe patient before us is as follows:
Parents healthy; no brothers; mother’s brother had a
paralysis of the shoulders, similar to that from which the pa-
tient is suffering; infancy and childhood uneventful. He lived
on a farm and did the active work ofa farm boy up to six
months ago; for the past ﬁve years, however, he has com-
plained ofa weakness in his back and shoulders, which has
progressively increased.
Cit y Hospital Alumni. 231
Aspect, as seen in photographs, presents the typical appear-
ance of muscular dystrophy. The apparent increase in the
length ofneck is due to the falling of the shoulders; the clavi-
cle sloping outward and downward where it should nor-
mally slope outward and upward; the marked muscular
belly on the deltoid well below the point of the shoulder; the
peculiar axillary fold, due to the absence of the pectoral mus-
cles; the striking displacement ofthe scapulae, owing to which
the superior internal angle appears in the supraclavicular
' space in front (shown in front-view photograph by cross); the
atrophy ofthe upper-arm and exemption of the forearm and
hand; the pseudo-hypertrophy of the supra- and infraspinate
muscles; all illustrated strikingly the picture of muscular dys-
trophy which we had'been accustomed to designate as of the
juvenile or scapulo-humeral type, or type of Erb.
The displacement of the scapula, especially on the
right, is more extreme than is usually seen in these conditions.
The bone pushes up the line from head to point of shoulder
and gives the appearance of an unusual development of the
trapezius. ~
Another striking feature of the case and one very well
shown in the photographs, is the remarkable good develop-
ments of the muscles not involved in the disease, notably on
the lower limbs. The thigh muscles are those of an athlete in
strength as well as in appearance. A history of how this
development was brought about is no less interesting
than instructive; the patient states that as his back in
the course of the disease, became gradually weak, he
found that in doing his work it became easier in lifting
things to squat down and raise himself by means of his
thighs than to use his back. He thus saved his back at the
expense of an added strength to his thigh, and right here is a
valuable lesson in the management of these diseases. Keep
such patients on their feet and keep them active. The pro-
gress of the disease is very slow and uniform, and there is
ample time for other muscles to hypertrophy and compensate
for those that are diseased. Avoid food that will make such
patients overly fat, and if contractures occur resort early to
tenotomy. Drugs are of little avail in treating dystrophy;
232 Medical Society of
thyroid feeding may be tried ; persistent electrotherapy, mas--
sage, hydrotherapy, and, above all, a carefully prescribed and
directed course of muscular exercise, such as can be given
with a Whiteley exerciser offers the best hope.


Lingual Hemiatrophy.
Perseverance in these measures will keep such patients
active and useful long after others in the treatment of whom
these measures have been neglected, have become bedridden.
The writer would suggest the following conclusions: (I)
Spinal muscular atrophy and muscular dystrophy are still to
be regarded as separate diseases; the one a disease of the
spinal cord, probably in the broadest sense toxic in nature, and
in which the muscular atrophy is a secondary process; the
other a disease primary in the muscles and due to a develop-
mental defect in the genesis of muscular tissue. (2) That the
attempt to divide the dystrophies into distinct classes is not
justiﬁed by our present knowledge and (3) that in treating
dystrophy more can be accomplished through measures that
City Hospital Alumni. 233
stimulate a compensatory hypertrophy of the muscles spared
by the disease than by any other method, and that the success
following such efforts amply justiﬁes the undertaking.

The subject of this report of lingual hemiatrophy rep-
resents in a very typical manner a condition interesting be-
cause of its rarity.*
The accompanying illustration shows the deformity in a
very satisfactory manner. The atrophy was discovered acci—
dentally. The patient here present was ﬁrst seen by me Sep-
tember I4, 1900.; she came to the clinic for treatment of a
facial spasm, and on causing her to show her tongue the con-
dition we now see was discovered. She does not know how
long her tongue has been in this condition; in fact, she did
not know that her tongue was ‘in any way different from other
peoples’ tongues; she was able to use it in eating in an entirely
satisfactory manner, and the deformity did not interfere with
speech. She shows, in addition to the lingual hemaitrophy,
an atrophy of the sternomastoid of the same side and a motor
paralysis of the same side of the larynx.

*Photographs were takeniby Mr. G. T. Dougherty, of No. 1902
O’Fallon street.
After presenting patient he said, I might mention, in speaking of
the clinical history of this patient (case of Muscular Dystrophy) that
up to ﬁve or six years ago he was perfectly well. About that time he
sprained his shoulder, as he expressed it; then he sprained his back.
In neither case was the sprain the result of any special injury—rather
coming of itself. Since then the shoulder and back have become pro-
gressively weaker. On applying for treatment, a week or so ago, he
presented the typical deformity seen in dystrophy of the type of Erb,
or the brachial-humeral type; in this type of dystrophy the disease
coinmences about the time of puberty, or a triﬂe earlier, involving the
muscles of the shoulder, the pectoral muscles, latissmus dorsi, rhom-
boids‘and serratus. The most marked deformity is often that which
is called the “loose shoulder.” At this point (indicated by a cross in
trout-view photograph) you will notice a protuberance, that is, the su-
\
234. Medical Society of
perior internal angle of the ‘scapula—-a rather unusual place for the
scapula. In attempting to lift the patient by the shoulders you will
notice.that the shoulders are raised and the body not lifted ; the upper
ﬁbers of the pectoral muscle are quite good on the left side, less so on
the right side; there is quite a prominent lordosis; the muscles not
affected by the dystrophy are unusually well developed. He has an“
~
uncle who has some weakness of his shoulders.
DISCUSSION.
DR. W. E. SAUER said in regard to the case of lingual hemiatro-
phy, that the inferior largyngeal nerve was the one involved, though
the superior laryngeal nerve on the other side appears to be involved.
There was also some involvement of the soft palate and he believed
the lesion must be central as the spinal accessory showed some involv-
ment ; he said the text books described a condition in which one side
of the tongue, the soft palate, the vocal cord, the sternocleido-mas-
toid and the trapezius were involved ; he had not examined the con
dition of the ear very closely, simply making an ocular inspection
which showed a catarrhal condition to be present. _
In this case the sensory nerves are intact in the larynx and he be-
lieved this had a bearing on the mooted question of the origin of these
nerves. He thought it showed that the motor nerves come from the
spinal accessory. 5
DR. M. A. BLISS said there still existed a great deal of confusion
in regard to these cases and he felt very grateful to Dr. Campbell for
showing these cases tonight. It was quite a long time before any very
clear idea of the pathology of the various types becameknown and until
recent times no very close differentiation was made4 The custom of
naming the types after the men who described them only served to
make the confusion greater; the various“ eases described have not
been distinct clinical pictures. There has been a tendency recently to
divide the types into spinal and muscular atrophy; he believed that
nearly all of these belonged to the family groups. Friedreich’s ataxia
belong in the same class. Frequently we see cases of atrophy occur-
ring in one member of a family and hypertrophyrin another member,
and yet the essential pathological features may be the same; the pseu-
City Hospital Alumni. 235
do-hypertrophies are eventually followed by atrophy and loss of motor
power. The case shown this evening he thought the most striking he
had yet seen and the photographs brought out its well marked features
very clearly.
DR. CAMPBELL, in closing, said the prognosis in the case of lin-
gual hemiatrophy was bad for recovery of the use of that side of the
tongue. The case is interesting as showing that a patient may use
one-half of the tongue about as well as another person would the en-
tire organ, as this this patient does. She is able to turn the tongue
in either direction and uses it in eating and talking with perfect free-
dom; the muscular tissue in the left half of the tongue is entirely
gone; there is no response to faradism or galvanism.
The prognosis in the dystrophy case, he said, depends very
largely upon the extent to which we can keep the patient on his feet.
If allpwed to remain inactive he will go down hill fast; if he is kept
occupied in such things as will give the other muscles a chance to hy-
pertrophy and act as a compensation for the diseased muscles, the pa-
tient will get along surprisingly well. The prognosis is better in pro-
portion as the disease begins late in life; the juvenile type presents
the best prognosis of all the dystrophies, although he had seen cases
of pseudo/hypertrophy which remained stationary for a long time. In
such cases there should be systematic exercise, prescribed by a physi-
cian ; the physician should direct just how much and what kind of ex-
ercise should be given and all the details should be regulated with the
view to get the maximum amount of nutrition to the muscles with the
minimum of injury to the diseased muscles by over-exertion; in this
way a great deal can be done for such cases.

Meeting of Oez‘oéer 3, 1901; Dr. NorveZZe Wallace Sharpe,
“ _ President, 2'12 the Chair.
Specimen of Mammary Tumor.
DR. FRANCIS REDER presented this specimen. It was taken from
a woman about 37 years of age, who had always enjoyed good health
and looked the picture of perfect womanhood at the time of operation.
236 Medical Society of
The history she gave was, that about three months ago she noticed a
nodule, not painful; she did not mention it to her husband and hoped
it would pass away, but she felt somewhat alarmed. About four
weeks later she noticed a sharp pain radiating from the right breast up
into the'neck ; she then mentioned the matter to her husband, who
asked her to consult a physician. I was called to see her, I examined
the breast and found the couture normal, but in the axillary segment I
found a nodule. The woman weighed about 165 pounds and the tu-
mor was about the size of a walnut. I thought I felt ﬂuctuation but
on account of the amount of adipose tissue I could not be sure of
that, I told the patient what I thought the growth might be; I was
judging from the fact that 9 or 10 per cent of such growths are sus-
picious, though I did not mention this to the patient. She was given
iodide of soda, but the pain rapidly grew worse and at the expiration
of a week I was satisﬁed that the breast ought to be removed. I con-
versed with her in a way to alleviate her anguish, but she did not then
give her consent to the operation. Two weeks later, however, she
consented, and the operation was performed. The breast was re-
moved, and the axillary space thoroughly cleared of all glands and adi-
pose tissue. After amputating the breast and looking at it 'closely I
thought I might possibly have erred in my diagnosis. When it was
incised a grayish liquid ran out and a cyst was revealed which looked
like a multilocular cyst It was submitted to a microscopical examin-
ation, and the physician who examined it wrote to me two ‘days later,
saying he hoped I had performed a radical operation, as the condition
was found to be cancerous. The seat of the growth was in the upper
part of the outer quadrant of the breast, which is a favorable seat for
carcinoma of the breast.
Thereare two kinds of carcinoma with which we have to deal in
this region: Carcinoma ﬁbrosa, or scirrhus, and the medullary, or en-
cephaloid carcinoma. It can readily be seen that the growth here
belongs to the medullary type because the ﬁbroid condition-is alto-
gether wanting. In the scirrhous form it is rare to ﬁnd the whole
breast involved. There has been no adherence of the skin in this
case to the growth nor has the nipple retracted to the growth.
City Hospital Alumni. 237
The wound healed by primary union, and two weeks after the
operation the patient was able to leave the hospital.
During the preantiseptic era the mortality from breast amputation
was as large as from amputation of limbs; the mortality has now been
greatly reduced. The matter _of recurrences may be due t0‘the phy-
sician who has charge of the case, or to the patient herself who will not
give her consent to an operation in time to prevent recurrence. Hal-
stead has gathered some interestingstatistics, probably the least num
ber of recurrences were in those cases where extreme radical opera-
tions were performed. He had gone so far as to remove nearly all of
the pectoralis major and the fascia of the pectoralis minor, and, in se-
vere cases, severed the clavicle. His dissections are very clean and
smooth. In one operation I saw, the veins had been stripped for
about two inches, and in one case he went so far as to expose the axil-
lary artery, something that is not often done.
During the last ﬁve years I have removed about twenty cancerous
breasts. Of these, four died from acute diseases; two have had re-
currences, and one woman operated on three years ago shows suspic
ious signs internally, yet I can not ﬁnd any induration about the cica-
trix. Another case came under my observation after an operation by
another physician. Three months after the operation a tumor formed
in the aXIllary space and under the scapula, and it was then she ﬁrst
consulted me. I told her there was nothing to do but institute treat-
ment, using the toxin ef erysipelas, and this did furnish some relief of
pain, but she died of exhaustion. The other cases, the‘ last of which
was seen a year and a half ago, I think are in_good health.
A Case of", Iodoform Poisoning.
BY CHARLES H. DIXON. M.D.,
ST. LOUIS, MO.
~
RS. 5., aged 20 years, in March, 1900, was septic from
M an osteomyelitis of the right tibia; a year before she
had been treated for an arthritis of the right knee,
which at the time was thought to be tubercular. About six
238 Medical Society 'of
weeks or two months before I saw her, she was operated on
for some growth in the joint, and a short time after this the
joint became septic. She ran a high .temperature and had in-
tense pain, so severe that she was kept constantly under the
influence of opiates, taking three-quarter grain of morphine,
hypodermically, several times a day. The heart and lungs
were normal; the urine was normal as regards frequency,
amount and ingredients. She was of a decidedly nervous,
temperament. '
On March 7th, she was operated on and a large part of
the Shaft of the tibia removed, leaving above only the articu-
lar surface and the outer shell of the upper two-thirds of the
_bone; it was dressed and next day the temperature dropped
to.near normal, and morphine was rapidly diminished, although
She craved the drug continually. On March 14th, the dressing
was changed from a bichloride gauze to one ofigauze moist-
ened in a 10 per cent iodoform and glycerine emulsion and
packed into the cavity. Three days later, when the dressing was
changed,,she was exceedingly nervous, calling for morphine
incessantly and imagining that she saw objects on the ceiling.
Her temperature was not over 99.5°F. No chills or sweating,
tongue moist, pulse quick and weak. The wound was dressed
as before and about a dram of the emulsion poured over the
gauze after it was packed into the cavity. The following day
the condition of her mind was worse; she became almost
wild, force being required to keep her in bed, she was' raving
constantly, at times there was a low muttering delirium. Her
urine was now scanty and high-colored, while just before She
was passing a normal quantity; it showed epithelial casts, al-
bumin and iodine, but no blood. The dressings were changed
immediately, the parts thoroughly cleansed of all particles of
iodoform, and bichloride gauze substituted. The condition
began to improve at once, and in a few days all symptoms had
disappeared.
The iodoform used in this emulsion was the crystallized
and not the powdered.
Ihave seen several cases of iodoform poisoning and all
occurred when the emulsion had been used, with one excep-
tion, and in that case the powder had been rubbed into the
surface.
City Hospital Al umni. 239
DISCUSSION.
DR. REDER thought iodoform unquestionably a dangerous drug
when applied to large surfaces. During his term of service in the
City Hospital, iodoform was used in quantity. After amputations it
was applied to the stump and dusted on and rubbed in until there was
a regular paste formed. In a number of cases the patients had deliri-
um and afterwards died, death being attributed to shock, though oc-
curring sometimes from three to six days after the operation. Since
the toxic effects of the drug have become more thoroughly understood
it can be readily,seen that iodoform poisoning was probably the cause
of death in these cases. The most characteristic symptom of iodo-
form poisoning, he thought, Was the tongue; this organ becomes dry
and a peculiar discoloration appears on its surface, this is followed by
nervousness and delirium.
DR. GREENFIELD SLUDER mentioned a case following operation.
Laparotomy had been performed and the result seemed successful; a
little later there‘was an erysipelatous blush, followed by wild delirium
and death, which was atrributed at that time to iodoform poisoning. It
was not an uncommon thing during his term in the City Hospital to
see more or less disturbance following the use of iod'oform. It was
rubbe'd into the wound, dusted on the surface and used on a pack.
Oftentimes it was used with the idea of closing the wound next day
by aseptic granulation. Such manifestations as iodoform eczema were
of almost daily occurrence. In the past two years he had used a good
deal of iodoform in the nose, and it is a habit now to dress all wounds
with iodoform, though patients will sometimes object. He always
uses It at the time of operation, if not afterwards; it forms an insolu-
ble coat and remains in the granulation tissue until healing takes
place. He had one case during this time which he thought showed
some symptoms of iodoform poisoning; there was an eczema. a high
degree of swelling, redness and some temperature. All these symp-
toms subsided on discontinuing the use of the iodoform.
DR. J. C. MORFIT mentioned a peculiar case of iodoform poison-
ing. It was different from the case described by the essayist, as the
orm of iodoform used was a IO per cent iodoform gauze used as a
240 Medical “Society of
pack ; the pack was used following a vaginal hysterectomy for adeno
carcinoma. The patient showed symptoms of restlessness, but the
most prominent symptom was a metallic taste, she complained of this
even at times when she took food or drink. The operation was per
formed on january 2 5, 1897, and from then to the 27th, her tempera-
ture gradually went up until it reached 101°F. The iodoform gauze
was discontinued and the temperature dropped to 99 5°F. The gauze
was reapplied and the metallic taste was not noticed until about the
ﬁfth day ; the iodoform gauze was again removed but the temperature
rose to 101°F. This occurred about three times, and bismuth gauze
was substituted; after this the temperature never rose above Ioo°F.
The most striking symptom was the pulse—it was rapid and irregular,
and the improvement in the pu1se,_was more noticeable after the re-
moval of the iodoform gauze than the improvement—in the temperature.
DR. JOSEPH L. BOEHM spoke of a case of hydrocele in which the
tunica vaginalis testis had been opened and the cavity packed with 10
per cent iodoform gauze; this was done _for about a week, and about
the ninth day the patient complained of intense headache and a cop-
pery taste. The patient was subject to nephirits, but on examination
of the urine no urinary symptoms of iodoform poisoning were found.
On withdrawing the iodoform gauze all the symptoms subsided, and
plain gauze was used.
In the City Hospital he S&W' a case of ~chronic empyema which
had, for three months previously, a purulent discharge. At the sug-
gestion of the Superintendent he used an iodoform emulsion, about an
ounce every day for a week, in the pleural cavity. The patient then
complained of a metallic taste, to which little attention 'was given.
However the emulsion was discontinued and the powder substituted;
about a dram was dusted into the wound on alternate mornings. After
using the powder four days the patient complained of headache of a
severe character; the powder was withdrawn, and ﬁve days later the
patient said his headache had- disappeared.
The hydrocele case he thought a little peculiar andattributed the
absorption to impaired vitality of the patient, who was subject to
nephritis, and was a strong alcoholic.
City Hospital Alumni. 24:1
DR. DIXON, in closing, said the tongue in this patient was not dry
at any time during the attack nor was there any coating. In regard to
the moist gauze and the iodoform emulsion, he thought the two were
identical. The gauze is made from an emulsion of iodoform and is
kept moist by means of glycerin. Of course, if it is made fresh it
might add to the strength of the gauze.
Some Personal Observations of Malarial and
Blackwater Fever on the West
- Coast of Africa.
BY VILRAY P. BLAIR, M. D.,
ST. LOUIS. MO.
LATE SURGEON IN AFRICAN ROYAL MAIL S. S. CO., OF LONDON, ENG.
HAD not been at sea a month before my curiosity was
I permanently piqued by the partly fabled, partly true tales
of the wealth, the dismal forests, the great rivers, the
savagery, the mahogany, the gold and the curios of the surf2
bound, fever-stricken west coast of Africa, which has fur-
nished gold, ivory, and slaves to the civilized world from time
immemorial; the Phoenicians traded beads for gold, and the
Portuguese and Dutch swapped ﬁre-locks for human ﬂesh.
It is not surprising, then, after listening to these tales for
several months, that I should, within three days of my return
to Liverpool have signed ‘on the “ Biafra,” an African Royal
mail liner, for a three months’ cruise to the “white man’s
graveyard.” -
I had not only the curiosity of an ordinary traveler, but
my opportunities of observation of the fevers of the _Iavery,
yellow-jack, and beri-beri in the Brazils and leprosy in the
islands, had taught me that there were advantages in studying
endemic diseases in their native habitat, which could never be
had under the artiﬁcial surroundings of the highly-civilized
temperate zone. The “Biafra” offered exceptional opportu-
nities for my purpose. She was a model ship of 5,000 tons
242 Medical Society of
burden, which had once been selected as worthy of entertain-
ing the King of Belgium. Besides passengers, she carried a
full cargo, and after depositing her tourists at the islands, was
to strike directly from the Canaries to Sierra Leone; then
coast down the Liberian, the Kroo, the Gold, the Slave
and the Ivory coasts, and then cruise up the Niger delta, and
spend two week in the river. Then coast up the Sierra Leone
and the Ilesde Los, gathering a cargo of oil, mahogany, rub-
ber, and returning invalids, before starting on the two weeks’
run to Liverpool. In my anticipation of opportunities of
observation, I was not disappointed, as in the proportion of
fever we had aboard, we quite broke the record of several
years.
To render this coast totally unﬁt for human habitation,
devoid of gray-haired negros, where all government ofﬁcials
are employed for one year’s service, with six months’ vacation
between services; where seven years of such service is suf-
ﬁcient to earn for a government servant a life pension—if he
lives to gain it—and to earn for it, next to Panama, the title of
the deadliest of all fever-stricken coasts,I believe that two
factors co-operate with each other in perfect harmony. These
are the malarial infection and the climate. With the former
you are familiar. Of the latter, I will, at the risk of imposing
on good nature, say a few words.
The term “ West Coast” ordinarily applies to that portion
of Western Africa extending from Senagambia on the north
to somewhere about Wauﬁsh Bay in German, Southwest
Africa on the south. It is surf-bound throughout its entire
extent, gives exit to the Niger and the Congo, besides smaller
rivers, and presents a variety of scenery. The high verdure—
covered mountains of the Sierra Leone give place to the low
hills and ﬂats of the Liberian and Gold coasts. The delta of
the Niger, except by the creeks, is an impenetrable mangrove-
swamp; While to the south, is a desert as sandy and as arid as
Sahara. In places, great salt marshes poison the air with a
most sickening stench, while its tracts of dark forests are
primeval. In spite of this variety, it presents such an unvary-
ing picture of death and desolation as to bring it all under the
one generic term. Throughout its whole extent it is tropical
City Hospltal Alumni. 2L3
and, except in the desert portion, the year is divided into a
very short dry, and a prolonged wet season. During the
latter there is great rainfall, sometimes continuing incessantly
for days at a time, and whether in rain or shine having a
damp, depressing atmosphere which tends to render one
exceedingly irritable and morose, and to foster a constant
desire, I might say in some a need, for at least mild alcoholic
stimulation. In all parts, food has to be imported. Cattle
can live in but few places, and do not remember to have seen
a horse in the nine weeks I was there. Goats and chickens
can be had in most places, while in a few ﬁsh are abundant.
The white residents live either in stone or mud houses, in
the towns in the older settlements; or in elevated corrugated
iron bungalows, in the newer. Where possible, these are
placed on elevated ground and from the edge of the clear-
ings, but in many places they abut on the jungle, or are sur-
rounded by scarcely sufﬁcient solid dry ground for domestic
and commercial purposes, having the connecting paths of
ofﬁces, bungalows and factory, formed by throwing up mounds
of earth. In most places the effort is made to get the water
supply from rain collected in sectional cast iron cisterns. In
all stations of but even a few years’ existence, the graveyard
is a prominent record of the past, while the isolated bungalow
that has not one or more white crosses in its miniature garden
is a rare exception. Ordinary avocations require long trips to
be made into the interior by hammock or canoe, and nights
and weeks must be spent in natives huts on the rivers, in the
jungle or in the mahogany camps. When Iwas there, the
Ashanti war, with its forced march to Cumassi, entailed hard-
ships that were past endurance by many a sturdy Briton.
The fever is of the estivo-autumnal variety, rarely tertian,
usually quotidian,1 occurring most frequently in june, _Iuly
and August, disappearing entirely in the very dry season of
December. I was on the coast in September, October and
November, 1900, but as the rainy season had been unusually
protracted, fevers were common.
The usual history of a newcomer is, that a man under
thirty-ﬁve years of age, who has passed a physical examination
in Europe, lands ﬁrst for .about three days at Sierra
24.-I Medical Society of
Leone. This is a mountainous coast, rising abruptly from the
water, some peaks reaching an elevation of nearly 2,000 feet.
Viewed on a clear day, with its open hillsides, its palm groves,
its picturesque settlement, and its green terraces, it looks like
one of Nature’s health resorts—but it isn’t. After two
weeks of seasickness, overfeeding and want of exercise, the
opportunity for hammock excursions on the shoulders of the
bearers, and the novel sights of Freetown, tempt the novice to
unwanton activity during the stay, and incidentally to expose
himself to infections of several kinds. Then three weeks’
coasting. of the nature of a more or less continuous sightsee~
ing picnic, brings him to the rivers, and after visiting several
stations, his immediate destination is reached. Here he
either takes up the duties of his newly-chosen life, or proceeds
farther inland, with possibly having the plasmodia already
multiplying in his veins. He is warned against going in the
sun without a pith helmet, exposure to chill of the night
air, the dangers of constipation, overexertion, etc., but proba-
bly the thing he notices most is the change of food; and in
the wet season, the continual rain. It is not long, as a rule,
before the depression of the climate begins to show, and
usually before three months, there is a chill and a sharp rise
of temperature, repeated for several days, till quinine takes
effect. This usually recurs from three to twelve times in the
ﬁrst year, with more or less chronic poisoning between times,
till the patient is carried off by blackwater fever, is invalid at
home, or acquires a more or less immunity. The patient
seldom dies from the ﬁrst attack of uncomplicated fever, nor
can he ever be sure that his immunization is complete; any
wetting, exposure to the sun, or indiscretion at any time may
bring on an acute exacerbation, and it is in the older residents
that fever in itself is most dangerous. While on the coast, or
exposed to the stimulating sea air on the trip home, or even
months after arriving in Europe, there may be an acute ex-
plosion, hyperpyrexia, and death within a few hours. These
cases are sufﬁciently uncommon to be noticeable, but I have
the authority of government surgeons that two such cases
occurred in Sierra Leone within a month, while I was on the
coast. One victim was the guest, the other, was the host at
~ City Hospital Alumni. 245
Q
suppers, and in both cases they were dead before 6 am. Such
occurrences in apparently healthy individuals in Europe and
also on board the ship en route are on record. The majority
of residents have a sallow complexion, and it is seldom that
you see the healthy bronze that should come from exposure.
‘ Early in October, we crossed the bar and entered the
Forcades river, one of the mouths of the Niger, and spent
two weeks in the narrow channels of the delta which is inter-
esting and as evil a place as there is on the coast, and it will
be principally observations made here and after leaving that I
shall present.9 In between one and ten days after leaving
Forcades river, seventeen of the crew, including myself, were
taken with the fever. Its distribution seemed to be in pro-
portion to the exposure of the individual to the sun. The
engineers and ﬁremen, though subject to dysentery, neural-
gias, diarrhea and heat apoplexy, were, without exception,
exempt. Among stewards, whose duties were between decks,
‘there were no cases. Of the seamen, who worked on deck
cleaning, chipping and painting, all, with the exception of one
prentice, were taken down, while the quartermasters, who
worked under the cover of awnings, escaped. Of the stewards,
whose duty required exposure on deck, several were attacked.
One of the four mates had fever, while I, who had exposed
myself to both sun and the cold of the night, felt the ﬁrst
symptoms when my duties required me to spend a consider-
able time in the hot forecastle. I saw two cases in which there
was a chill, a sharp rise of temperature and’sweating, with no
return during the voyage. These were old coasters, and
afterwards both had severe attacks in England, one being
carried from the ship unconscious. There was one case of
a continued, irregular fever, lasting four weeks, that seemed
little inﬂuenced by quinine. I must mention, in this case the
quinine was given only by mouth. All the others, except my
own, were more typical cases of estivo-autumnal fever. After
twenty-four hours malaise there would be a hard chill, lasting
an hour or so, followed by a rise of temperature of 104 to
106°F., with vomiting, headache, great pain in the back and
back of the thighs and legs, tenderness over the liver and
spleen. Bilious vomiting was constant, and sometimes so per-
2I6 Medical Society of ~
sistent as to preclude feeding and medication by mouth. Con-
stipation was present in all cases. During this stage the
urine was scanty, the skin dry and hot, the eyes glazed and
staring, and the Whole picture was one of extreme discomfort
and a deadly illness. Under proper treatment the fever
declined to about 102°F., and in most cases, in which there was
not a recurrence of the chill, convalescence was established
within a week. In the treatment of these cases, quinine at
the proper time is essential; phenacetin, properly used, is
useful, but must be handled with care on account of its
depressing effects and the poor reaction in that climate. I
saw a severe collapse, lasting two days, after ﬁve grains of
antipyrin, in which I though I would lose the patient. The
proper treatment, as learned from Government doctors on the
coast, and practiced with good results myself, is during the
hot stage to cover the patient with a number of blankets, and
administer hot drinks with the view of producing a sweating.
At this time ﬁve grains of phenacetin may be given, but it is
not considered the best routine practice. During this time
the temperature must be carefully watched, but as long as it
is not above 106°F. there is no indication for changing the
treatment. After a time a most profuse sweating is estab-
lished, which, unless there is an exacerbation of the fever,
continues from one to several days. The patient relaxes, and,
though weak, is comfortable. Quinine is administered in large
‘doses, and the patient recovers. If the temperature con-
tinues to rise OVPA‘ﬂIOOOF. and sweating does not occur, then
other means must be tried, usually cold baths with ice, if
obtainable. Here the prognosis is extremely grave, and it is
these cases that succumb to pyrexia, with locked secretions.
Personally, ifI had such a case, I would try hypodermoclysis
and pilocarpin, but I could ﬁnd no record of such being used.
I once tried antipyrin, with the aforementioned result. Dur-
ing the hot stage, despite the pain, the greatest discomfort is
an internal feeling of pressure and heat, and the relief which
comes with the sweating is most grateful. Though bringing
relief, the sweating produces a discomfort of its own. It is
of an exceedingly irritating character, and when ﬁrst starts
gives the sensation of ﬁre, and after twelve hours often so irri-
City Hospital Alumni. 2 I 7
tates the sweat glands as to cause a dark conﬂuent eruption
on the back, thighs and arms. There were some cases in
which there was a great tendency to drying of the skin, with
recurrence of moderately high temperature, necessitating
repeated sweatings. It was not until I learned the use of
bimuriate of quinine hypodermatically that these cases fol-
lowed the same satisfactory course. I believe this to be the
only proper way to give quinine there, as absorption from the
stomach is very doubtful. I took from one to two grams a
day for three weeks, without noticing a single evidence of its
absorption. I learned this from Dr. G. N. Taylor, a Govern-
ment ofﬁcial, and a passenger to whom I was much indebted
both for his kind ofﬁces and his profound knowledge in
handling these cases. Dr. Taylor was a typical West-coast
invalid. He had been sixteen months at Quitta, where he
had had repeated attacks of fever, but had not been relieved
from duty. He had been carried to the surf boat, and had
occupied a couch on the deck. He assured me he needed no
other attention but sea air and food, and as I had all I could
attend to, I- left him, having gained the impression that he was
a very sick man of ﬁfty or sixty years of age. Two weeks
later, when I was obliged to request him to attend the crew
and myself, I found a marked change, and when he left us at
Teneriffe, he was a splendidly-built athlete of thirty-three
years of age. Such are the opposing effects of continuous
malarial poisoning and sea air.
With the white residents on the coast, malarial fever is
regarded very much inthe same light as the teething of in-
fants in civilized countries—something .that must be gone
through with, and it is the character and intensity of the mani-
festations that interest them. Few escape, and the instances
are notable. Among the natives of the coast, fever is almost
unknown, though .I saw a black in Liberia, who, after a resi-
dence of some years in the states, had several attacks on his
return. ~ The Camaroons coming from the interior to work on
the coast are subject to it,8 as are the Chinese laborers on the
Congo railroad.6 Fortunately, I had no deaths aboard the
ship, but here deaths are rare, except among returning in-
valids; their time of greatest danger is the ﬁrst contact with
248 Medical Society of
the cold air. In the case of Belgian laborers coming from
the Congo, who are rather addicted to absinthe the ﬁrst few
days at sea, often brings an enormous mortality. I might
mention that among the Belgians on the Congo is the only
instance I know, of the employment of White labor on the
coast where exertion and exposure to the sun are distinctly
dangerous. In the early days, in the ’20s and ’30s, before the
intelligent use of quinine, as we understand it, and the aboli~
tion of salivation and bleeding, the death rate in the garrisons
at Sierra Leone ranged from 50 to 70, and even 75 per cent a
year, while at Cape Coast Castle it ranged from two-thirds to
the whole of its mean strength.26 Old sailing masters have
told me that in vessels lying in the Niger creek, it sometimes
reached ‘100 per cent in a few months. I have been unable to
obtain authentic ﬁgures of the death rate amongst the Whites
at present. I can mention those that were given to me by
residents in different places which I visited, and I had no rea-
son at the time to disbelieve my informant. If you wish you
can make allowances for exaggeration. In the Ilse de Los,
out of 157 white residents 34 died in the wet season of 1900._
At Sapelli, a new station high up in the Niger delta, well’si-tu-
ated on a clay bank at an elevation of about ﬁfteen feet above
the creeks in a clearing a mile square, seven of the thirteen
whites who had been stationed there had died. At Arkassa,
which boasts twelve white residents, I counted over twenty
graves. Allowing for almost any exaggeration, when you
consider that these deaths are amongst men who have passed
a medical examination, and are more or less constantly under
medical observation, with the privilege of being invalid at
home at any time it is necessary, these ﬁgures are at least
suggestive. The difﬁculty of transporting instruments, and
the fact that medical ofﬁcers are, as a rule, more or less de-
bilitated by sickness and overwork, blood examinations are
not as constant as could he wished, in fact, are rather neg-
lected; but from the blood slides11 and the post-mortem speci-
mens sent to Europe, and from the work of the more ener-
getic on the coast, there is no doubt that this fever is identical
in its etiology with the estivo-autumnal fever of Italy and
other places.
City Hospital Alumni. 249
To me the subject of prophylaxis by general sanitation-
looks almost hopeless. The deltas can not be drained, and
the death rate in the older towns and cleared uplands and in.
the Sierra Leone mountains is, after making allowances for
better care, received no less than that in the jungle. Enlarge-
ment of clearings, the extension of commerce, the opening
'Of gold mines, the execution of drainage, where possible, may
improve these general conditions; but, until these changes are
of such magnitude as to effect the atmosphere, I believe that
little will be accomplished in this line, and that the resident
will have to depend upon proyhylactic measures of a purely
local and personal nature.25 One of the greatest helps to
this end has been, and will continue to be, the African Royal
Mail Steamship Company. These enterprising people send
vessels to every point along the_coast and up the creeks,
where a stick of mahogany or a puncheon of oil can be ob-
tained ; and, though its primary object is commerce, it brings
food, the comforts of life, the means of execution, the services
of its surgeons, and safe transportation to the whites that
love of gain or adventure have tempted into this death-dealing
wilderness. It is most liberal in its policy, and it will be
many years before any of the newer lines will be able to show
a record of equal good accomplished. The prophylaxis by
the individual must be worked out on two distinct lines.
First, the avoidance of infection, and secondly, the preven-
tion of its development, after inoculation has occurred. As
to the ﬁrst, I take it for granted that the bite of an infected
mosquito, of the variety of the anopheles, is the only known
mode. By following the rules given by the Liverpool Society
of Tropical Medicine, properly located bungalows may be
freed from mosquitos of all kinds, and most easily of the
anopheles, but still, though some hold to the contrary, I do not
believe it possible for people following ordinary avocations in
the tropical bush to absolutely avoid being bitten. Besides
this, there is another element of danger which, no matter how
imperfectly understood, has been too constantly and univer-
sally observed in malarial countries as having a causative
relation to, if not a direct cause, of infection, to be disre-
garded. This is the disturbing of the earth either for agri-
250 Medical Society of
'cultural or building purposes. This fact is so forcibly demon-
strated by the history of the occurrence of fever on the West
coast, that in Sierra Leone excavation for building purposes
is regulated by legislations to certain seasons, and on the
upper Niger, where large coffee plantations are being opened,
and where fevers are not as rife as on- the coast, outbreaks of
malarial and blackwater fever have at times been conﬁned to
those engaged in tilling the soil. On one plantation- three
gardeners in succession died of blackwater fever,6 and unless,
as Fisch .has suggested, this is due to the fact that the uneven-
ness resulting from digging furnish an extra number of con-
genial breeding places to the anopheles, we have a totally
unintelligible source of danger, which accentuates the import-
ance of the second consideration in prophylaxis, the retarding
of the development of the invading organism. I believe the
most rational means is the regular administration of quinine.
This is advised by Plehn in the Camaroon, who has _seen good
results among government servants, where it is compulsory,
though he warns of the special danger in that country of its
exhibition being followed by blackwater; and Koch expresses
the hope that by this means malarial and blackwater fever
will be stamped out of existence. Beyond this the ordinary
rules of hygiene, with special reference to the peculiarities of
the climate, should be followed.
If. in the presentation of my subject I have di/velt too'
long upon environment, I beg to offer as excuse that anyone
who has observed diseases in this country, must be impressed
with the fact, that though speciﬁc infection is necessary, the
majority of the manifestations are inﬂuenced by, if not due to
climatic peculiarities.
_ No mention of fevers of this country, no matter how
terse, would be complete without more than a passing notice
of the blackwater " fever, which, by most observers, is con-
ceded to be a complication of malaria, and which is respon-
sible for more deaths than all other diseases of the coast com-
bined.‘*"7 Its mortality is variously estimated from 20 to 60
per cent. In 167 cases of sickness occurring in the Camaroon
in 1897, reported by A. Plehn, 138 of which were malaria, 12
were blackwater fever, and 17 from other causes; there were
City Hospital Alumni. I 251
8 deaths, 5 of which weredue to blackwater fever. The ﬁrst
attack rarely occurs before a six months’ residence, usually
after several attacks of simple malaria, and never after three
years, though once having had it a person is subject to fresh
attacks at any time. Crosse reports one primary case, occur-
ing in England in a returned coaster.
It commences with a chill, a sharp rise of temperature,
and within twenty-four hours the urine is of a color varying
from claret to porter. At the appearance of the hemoglobin
in the urine, the fever subsides; there is always a pronounced
icterus, and a green bilious vomit is always constant and dis-
tressing,6-“13 though there is never bile in the urine. In favor-
able cases the symptoms subside, the urine resumes its normal
color, and recovery takes place in a few days. Relapses are'
frequent, and though apparently of a milder form, are more
often fatal. In fatal cases the symptoms all persist, the pulse
becomes rapid, hiccoughing ensues, patient becomes heavy or
comatose, the urine scanty or suppressed, and vomiting con-
tinues. Death results from exhaustion or uremia. Diagnosis
is based upon previous attacks of malaria, the chill, the green
vomit, the icterus and°the black water, the absence of bile in
the urine and the rapidity of the pulse. It has been con-
founded with yellow fever, but in the blackwater fever the
icterus is more pronounced and the pulse rate increases; there
is no black vomit and no irritation of the skin, which accom-
panies true icterus12 of the yellow fever. In blackwater fever
the vomit is always green, while in early stages of yellow fever
it is light-colored. Its morbid anatomy seems to be fairly
constant. Large quantities of erythrocytes are destroyed in
the capillaries of the liver and spleen; the liver, kidney, and
spleen are enlarged, and less pigmented than in ordinary
malaria;2 the kidneys are hyperemic, cortical substances pale
and yellow, pyramids brown-streaked, and tubules affected by
cloudy swelling; the collecting tubules are ﬁlled with pig-
ments and cells,2 and are degenerated. - Suppression, accord-
ing to Sambon, is due to degeneration and blocking. The
principal change in the blood is due to the rapid destruction
of the red-blood corpuscle, which fall to one-third the normal
in twenty-four hours, rapidly degenerating with nucleated red-
252 Medical Society of p '
cells5 and corpuscles of various sizes. The urine is acid and
of a high speciﬁc gravity with deposits, which Sambon regards
as broken-down. corpuscles, and Crosse ascribes to kidney
cells. It rarely contains bile ;12 albumin is always present, and
the color is due to metahemoglobin, never to red-cells.5~‘°
The parasite of malaria has been found in the blood by many
observers, and more often in the brain and spleen, when not
observed in the peripheral circulation. It is a well-known
fact' that in typical estivo-autumnal fever the parasites are often
absent from the peripheral circulation, when present in the
larger vessels and the viscera. There is also a rapid destruc-
tion of the parasites at the appearance of the blackwater, and
in most cases quinine has already been given, so that not ﬁnd-
ing the plasmodia in all cases does not signify that they are
not malaria. Plehn found the parasite in seventeen out of
forty cases,‘ recognized it as identical with that of ’estiv0-
autumnal fever, and states that they are not neCessarily pres-
ent in the peripheral circulation. Mannaberg17 warns against
looking for the parasite afterquinine has been given, and late
in the disease. Koch ~has found it in a fair percentage of
cases, and F. Plehn23 states that it will always be found if the
blood is examined early before the blackwater fever occurs.
These ﬁndings have been substantiated by most obServers,
though some have found the parasite in a very low percentage
of cases.22 The most satisfactory and complete work? on the
subject of the parasites and other evidences in the blood has
been done by Stephens.21 After stating that negative results
as to the ﬁnding of the parasite does not mean the absence of
malaria, in which he is substantiated by Turk, he notes
numerous cases of malarial'fever in which a few were found
only after most prolonged search. 'He states that the pres-
ence to the amount of 20 per cent or over of large mono-
nuclear leucocytes means malarial infection, and that the pres-
ence of large and small pigmented leucocytes are important
the diagnosis. He then gives a tabulated list of sixteen cases
of blackwater fever which, clinically-and from the presenceof
either the parasite, pigmented leucocytes, or the percentage of
large monocucler leucocytes or of the' pigmentation of the
organs were undoubtedly malarial; but in only three of these
City Hospital Alumni. 253
were the parasite found, and one had been examined early
before the black water supervened. I have mentionedthese
ﬁndings at length on a_ccount of the disagreement among
observers as to the etiology of blackwater fever, and we will
now take up the most plausible theories. These are :
1st. A malarial complication.
2nd. Quinine poisoning.
3rd. That it is a speciﬁc disease.
The malarial theory can rest with the evidence already
adduced. Sambon is the most weighty champion of the
theory of a speciﬁc disease, and bases his belief ﬁrst upon its
geographical distribution, which has lately been disproved,16
and on the occurrence of a hemoglobinuric fever in sheep,
cattle and goats, which is due to a parasite, and concludes
that the same is the case of the disease in man. Want of
space prevents the from citing all the evidence that can be
brought to bear against this, but the lack of positive evidence
of such a speciﬁc organism, and the overwhelming evidence
in favor of the other two theories, I believe justify the dis-
. missal of Sambon’s explanation. '
The quinine theory was ﬁrst suggested by Veretos, in
1858, and has received support from the Greeks, Tomaselli,
and Koch3 and the other German observers; and all bring
forth a formidable array of ﬁgures 'to their support but Koch
always, and Plehn"t lately, its most staunch advocates, will not
say that quinine in ordinary doses can produce blackwater
fever, without previous malarial infection, and though Plehn‘
and Crosse5 and other English physicians have recorded cases
where no quinine had been previously given, still all of the
English practitioners I met on the coast had observed an
apparently more than accidental relationship between the
administration in large and small doses and the development
of blackwater fever. During a malarial paroxysm there is an
enormous destruction of red-blood corpuscles, and it has been
demonstrated that hemaglobinuria can be produced in dogs
by the administration of quinine. To anyone who has ob-
served a very severe malarial paroxysm on the coast in the
dry stage, when all the secretions are checked and where
there is every evidence of a most acute intoxication, it would
254 I - Medical Society of,
not take a stretch of the imagination to see how the adding
of the extra poison of quinine at this time might develop
serious damageof the blood and kidneys, and I believe that
Stephens has struck the keynote in his conclusion that black-
water fever is essentially malarial disease, in which quinine is
the most common immediate determining cause of intoxica-
tion; and that protection from malaria will protect from the
blackwater fever.
NOTES AND BIBLIOGRAPHY .
1Uncomplicated estivo-autumnal fever of the gold coast—Albert
]. Chambers, Lancet, Nov. 3, I900.
2The parasite of malaria in the tissues in a fatal case of black-
water fever—George Thine, M.D., B.M., June 13, 1899.
3Koch in Reise Berichte.
4Plehn in Kamerun Kiiste. .
6A case of blackwater fever, complicated by dysentery—A, T.
Wooldridge, L P.C.P._. London, M.R.C.S., L.S.A., Lancet, March 18,
I899. _ V
6Blackwater fever—W. H. Crosse, M.R.C.S., Lancet, Vol. I, ’99.
p. 82!.
"Das schwarzwasser ﬁeber—Koch, Arbeiten aus der Kaiserlichen
gesundheitsamte, 1898, Bd. XIV, s. 304. _
' SStudien zur klimatologie, physiologic und pathologic in den
tropics—F. Plehn, 1898. ‘ '
9Lancet, March 25, 1899, p. 823.
10Lectures on malarial fever—Sydney Henry Thayre.
11Parks and Howard, Journal of tropical Diseases, February,1899.
12Copeman, Allbritght’s System of Medicine, Vol. II, p. 747.
13Fischer, Guy’s Hospital Gazette, 1897.
1‘Egles, in Malarial Fever as met with on the Gold Coast, p. II.
“Dickson, in Hygiene and Disease in Warm Climates, p. 181.
16Powel, journal of Tropical Medicine, 1898, p. 117.
1IMannaberg, in Die Malaria Krankheiten, 1899, s. 225.
18McGregor, Guy’s Hospital Gazette, Jan, 21, 1899.
19Dr. Moffat, in British Medical journal, Sept. 24, 1898, p. 926.
20Robson, in Two years in West Africa (15221.), Oct. 22, 1898.
2‘Stephens and Cantab, Lancet, Igor, Vol. I, No. 12, p. 848.
22Zumann, in Centralblatt fiir Baktiriologie, states that the severity
of the attack bears no relation to the number of parasites.
1“F. Plehn, in Die Kamerun Kiiste. .
i
City Hospital Alumni. 255
“Klima und gesundheitsverh'atnisse des schutzgebietes Kamerun
in der zeit vom 1. July, 1897 bis den 30. juni, 1898.
25In the sand desert surrounding Wauﬁsh Bay in German South-
west Africa there is a dry river bed, the Swokob, which is ﬂooded once
about each ten years. For about seven years previous to this event
fever was unknown in this region, but for about three years afterwards
there was a growth of of wild grass in the river bed, and fever is rife.
28Johnson on Tropical Climates, p. 433.
Reports of Major Tulloch.
21W. A. Bryson, Lancet, Sept. 4, 1847.
28Dr. Frank Fry, of St' Louis. tells me that he has seen a genuine
case of hemaglobinuria coming on during the use of chlorotone in a
neurasthenic, which was relieved upon discontinuing the drug.
[3603 LINDELL BOULEVARD.]
DISCUSSION.
DR. R. B. H. GRADWOHL voiced the sentiment of the Society in
thanking Dr. Blair for his admirable paper. The latter part of the
paper the speaker considered especially interesting in relation to the
etiology of blackwater fever. Dr. Bransford Lewis had collected a
number of cases of hemoglobinuria in the South, where it was a com-
'mon experience after the administration of quinine. In Italy, at the
last Congress, in searching for the malarial germ and the pathology of
blackwater fever and hemoglobinuria of malaria of that region, it was
stated that this was due to actual blocking of the glomeruli vessels by
the malarial parasite,'and sections were offered in proof of the state-
ment. He mentioned that several years ago he had seen it suggested
in the Brz'tz's/z Medical journal that blackwater fever be treated by
inunctions of creosote, and that favorable results had been reported.
He asked in what proportion of cases had quinine been used as a
prophylactic measure, and with what success, and also if there were
any statistics on the subject.
DR. W. S. BARKER thought the injection of quinine hypodermatic-
ally a most desirable method in certain cases where the usual method
of administration was not effective, and deplored its neglect,in urgent
cases. In quite a number of cases, perhaps a score, especially among
children, he had injected the hydrochlorate of quinine hypodermatic-
256 - -' Medical Society of
ally and obtained results which would hardly haye been obtained with
the ordinary method of administration, owing to the fact that the
stomach repeatedly rejected it, or that there was but a slight degree of
assimilation of the drug in the alimentary canal.
DR. FRANK WINTER (Captain and Assistant Surgeon, United
States Army) said he had made some observations of the occurrence
of these fevers, during the last few years, in the Phillipine Islands. The
essayist’s mention of the relationship between an active, energetic life
in the sun in the tropics and the occurrence of these fevers, he thought
very important. There can be no question about the occurrence of
these fevers being in direct proportion to the extent of exposure to the
sun. In this connection he said that in a volunteer regiment to which
he was attached during part of an active campaign when the men were
exposed to the sun the sick list reached 33 to 35 per cent of the
strength of the {regiment ; as soon as the active campaign was susj-
pended the list fell to 8 or IO per cent.;“ Another point is the anemia
following the use of quinine. Quinine is given as a prophylactic even
when the men are not sick, and it is found that the blood-count is ma-
terially diminished in red blood corpuscles. The results of his obser
vation as an army surgeon in Manilla and vicinity had been to demon-
strate that quinine had a deleterious effect on account of the anemia
following its use, consequently he is not an advocate of its use; it is
still given, though not nearly to the same extent as formerly. The
principal measures of prophylaxis followed, are avoidance of exposure
to night air and the consumption of sterilized watei". That the night air
5 deleterious and harmful is shown by the fact that the Spaniard and
Philipino always close their houses as tight as they can at night; as
soon as the sun goes down the windows and doors are closed. Their
houses, too, are built above the level of the dew point, and usually on
bamboo sticks, six feet above the level of the ground. A Spaniard or
Philipino would rather sleep in a tree than on the ground. The water
supply is of much importance ’and efforts are made to boil this for
drinking purposes. The soldiers are often placed in such a position
that it is impossible to boil their drinking water, so that any deductions
made of the invasion of malarial intoxication, as concomitant with
certain forms of water consumption are, of course, erroneous. Beyond
City Hospital Alumni. '257
these things he did not recall any measures instituted fof the especial
prevention of malaria.
DR. H. W. SOPER asked if the administration of quinine hypo-
dermatically had been followed by abscesses. In a patient seen in the
hospital, several abscesses had formed after the subcutaneous use of
bimuriate of quinine.
DR. BLAIR, in closing, said he believed the attacks of fever seen
on board ship were more severe, as a rule, than those seen ashore, the
greater stimulus of sea air bringing on a more pronounced reaction.
Except. in the color of the vomit, the absence of methemoglobin in
the urine, the clinical picture of these cases differ little from that of
non-fatal blackwater fever. Many observers call attention to the im-
perfect absorption of quinine when the mucous membranes are con-
gested during the acute attack. I saw several cases where the vomit-
ing, high temperature and dry skin continued almost uninterruptedly
for several days and did not yield to other treatment, but which
straightened out after two to ﬁve seven grain doses of bimuriate of
quinine administered hypodermatically. No attempt was made at an-
tisepsis or asepsis but there were no abscesses or local inﬂammation.
The local sequelae are rather hard nodules, somewhat anesthetic, last-
ing several months. The bimuriate causes little pain, and is soluble
in about double its weight of water. Surgeon McGregor gave, in
three cases of blackwater fever, from three to ﬁve grams of quinine,
with recovery. Dr. Moffat, P.M.Q, of Uganda Protectorate, and
Robson, of Birmingham, reports groups of unselected cases in which
those receiving one to two drains of quinine early in the attack re-
recovered, while those who received none, or received it late, suc-
cumbed. ‘
All dwellers in the tropics, whether foreigners or natives, are im-
pressed with the dangers of night air. That they have tradition and
all precedent to support their belief, I grant; that it is an unqualiﬁed
evil, I doubt. The coast blacks on the shore sleep in huts, but, among
the hundred or so deck passengers and Kroo boys we had on board,
who, rain or dry, slept on deck, with rather insufﬁcient covering, I
never saw any evil results, that I could attribute to exposure at night.
258 _”Medical Society of
It is rather stimulating, and if one is protected from chill by woolen
covering, I do not see why, in itself, it should be so bad. It may, by
its very stimulation, have the effect of bringing on an attack of fever
similar to those produced by contact with sea air, but we know, that,
within ordinary limits, pyrexia itself is not an evil, and that a person
often feels better after an attack of fever than before. It seems to
come within “the range of my mental vision to see how a persOn can
be in a better physical condition when breathing in, and having the
face and possibly the hands and feet in contact with the cemparatively ’
refreshing night air, and with occasional sharp attacks of fever, than
the one who is continuously on the dead level of climatic depression
and chronic malarial intoxication. I believe it is the latter class that
furnish the chronic invalids, the tropical wrecks, and the subjects for
blackwater fever. I know the latter often follows exposure, but there
is such a thing as acquiring tolerance to exposure. , '—
' A. Bryson says that, in 1844, twenty men and an ofﬁcer went
from the “ North Star” to do boat duty at Sierra Leone. The men
all took wine and bark ; the ofﬁcer did not, and he was the only one
who suffered from an attack of fever. That two boats in the same
year were detached from the “Hydra,” to examine the Sherebro river ;
the men in one boat took wine and bark, and were exempt ; while all
the men in in the other boat, who took no bark, were, wjth the excep-
tion of the captain, after an exposure of only two days, attacked with
fever of a dangerous character. _
As to the results of quinine prophylaxis, he could not give accu-
rate ﬁgures. There seems to be a general "impression among workers
on the coast that the good results from the use of ﬁve grains of the
drug morning and evening, or ﬁfteen grains once a week, outweighs
the evil of continuous quinine stimulation, andthe danger to the red-
blood corpuscles. However, A. Plehn, who is a champion of its use,
warns against large doses in the Camaroon, on account of the liability
in that country of blackwater fever. He recommends one-half gram
each ﬁve days, to be carefully increased, if needed. Some say its use
should be limited to those who are to make a stay of a few months or a
year.
City Hospital Alumni. ' 259
I
Meeting of Oetoéer 17, 1pc]; Dr. Noraelle Wallace Sharpe,
' President, in the Chair.
Rupture of the Bladder.
DR' H. L._NiETERT presented a specimen of ruptured bladder
removed from a patient, post-mortem. The rupture was one and one-
half inches in length, and extended through the entire thickness of the
bladder wall. The patient entered the hospital in a semiconscious
condition. The history obtained was that he had been sick for three
weeks, and complained of tenderness over the abdomen; there was
slight distension of the abdomen, no vomiting, pulse good, temper-
ature 101°F. There was constipation, but after saline catharsis, the
bowels moved. The patient died the day after entering the hospital.
Post-mortem, the peritoneal cavity was found to contain a large
amount of urine, the peritoneum highly injected, and the bladder
ruptured.
Not being satisﬁed with the history he had been able to elicit, he
sent for the relatives of the man, and they gave a history entirely dif_
ferent from that secured from the patient. It was stated that the
patient had been drinking, and on October rrth he was very much in-
toxicated, during which time he fell on the pavement and struck on
his abdomen. _He got up, complaining of pain in his abdomen, and
went home to bed' i The pain grew worse, and he was sent to the
hospital.
The specimen is interesting, as it shows that a very serious
damage may be done an important organ from a seemingly triﬂing in-
jury, and without external signs of injury. Looking at the mucous
membrane, it appears perfectly normal; there is evidence of a con-
tusion, however, on the posterior wall. The highly injected condition
of the peritoneum, without other signs of peritonitis, is interesting.
There was no pus, no agglutination of the peritoneum, showing that
the urine in this case was perfectly sterile. In several other cases of
ruptured bladder, due to external violence, he had noticed the highly
injected condition of the peritoneum, the absence of pus, agglutina-
tion of the peritoneum, or lymph.
260 Medical Society of
Ectopic Pregnancy.
He also exhibited a specimen showing an extrauterine pregnancy.
The patient gave a history of having trouble for some time with her
ovaries and tubes, and was treated for “along time. The day before
entering the hospital she was seized with a fainting spell, and became
very weak. When she entered the hospital she was very weak and
complained of a severe pain in the abdomen. On examination, a
large mass was discovered in the cul-de-sac, extending to the right
iliac region. After several examinations, a diagnosis of extrauterine
pregnancy was made. The uterus was curetted, and a portion of the
endometrium was obtained, which was submitted to microscopical ex-
amination. This showed the- mucous membrane was covered with
normal epithelial tissue; there was some proliferation of the gland-
ular element, but no deciduous cells were present. When thisreport
was received, it threw a doubt upon the diagnosis, and he thought
that instead of an ectopic pregnancy, he had to do with a pelvic ab-
scess. The patient was prepared for laparotomy, and also for an
operation through the vagina. The latter was performed, and the
cul-de-sac opened. A large amount of clotted blood was discovered,
and thisconvinced him that the diagnosis of extrauterine pregnancy
was correct. Laparotomy was then performed, and the tumor shown
was taken out. i
From this case, it would seem, that we can not always depend
upon scrapings from the uterus, to make a diagnosis of extrauterine
pregnancy. I
orscussron.
DR. HUGO EHRENFEST said he had seen the case of extrauterine
pregnancy two days before the operationrand two days after the pa-
tient entered the hospital. At this time shedid not show any symp-
toms of shock, and was not in a bad condition, such as we see in
cases of ruptured ectopic pregnancy. This, he thought, probably due
to the comparatively small amount of free blood in the abdominal
cavity. At the ﬁrst examination, he stated, that from the form and
consistency of the tumor, he thought it was a case of ectopic preg-
nancy’. Notwithstanding that the introduction of any instrument into
City Hospital Alumni. ' 261
8
the cavity of the uterus is strictly contraindicated in case of suspected
ectopic pregnancy, he suggested that a slight curettement be made, in
order to obtain a portion of the endometrium.
The patient being in the hospital, and under constant observa-
tion, he felt that, if acute hemorrhage should follow the curettement,
she would have immediate attention, and an examination of the endo-
metrium would established the proper diagnosis. Dr. Fisch ex-
amined the scrapings, and reported that he found no sign of formation
of decidua. This seemed to exclude the diagnosis of extrauterine
pregnancy, and the speaker was, therefore, surprised, when, on open-
ing the abdomen, it was found that the clinical diagnosis was right.
This made the case very interesting, as the text-books everywhere
state that the endometrium always forms decidua in cases of ectopic
pregnancy. He had started a histological examination of the removed
tube, but did not have time to complete it. One section showed some
large cells, with large nuclei, cells which looked like decidua, but he
was not prepared to say they were decidua. He intends to complete‘
the examination, and endeavor to ﬁnd villi, which, of course, would
establish the diagnosis of ettopic pregnancy.
In connection with this case, he showed a specimen of ectopic
pregnancy, taken from a patient a year ago. The pregnancy was
about the middle of the fourth month, and rupture did not occur until
during the operation of laparotomy. _The woman had only the symp-'
toms of a simple abortion, and was treated for that by another physi-
cian, when he discovered the tumor and called the speaker in consul-
tation. The diagnosis of ectopic pregnancy was made, and the tube
containing an embryo of about 12 centimeter length extirpated.
DR. CARL FISCH said this case was very instructive to him, inas-
much as the microscopical examination had not borne out the clinical
condition. In regard to the report made on the ﬁndings, he had
nothing to retract. There had one point been raised as questionable,
andihe was glad to be able to fortify his assertions, .by Dr. Gellhorn
coinciding with his opinion, that is, that the specimen taken from this
case did not show any decidual changes. The question raised was
the possibility of these scrapings coming not from the uterine mucosa,
‘ 262 Medical Society bf
but from the cervix. He asked Dr. Nietert if there was any question
about this point. -
NR. N IETERT said he felt sure he obtained the scrapings from the
uterus; he went into the cavity almost an inch.
DR. Frscn said it never occurred to him that the scrapings could
be other than uterine. He brought the matter up, however, at the
suggestion of Dr. Gellhorn. Personally, he had had never aidoubt
that he was dealing with uterine mucosa, and had to continue to stick
to the tenor of his report. This uterine mucosa was perfectly normal.
The superﬁcial epithelium eonsists normally of columnar cells, which
change early in pregnancy to a ﬂat form. There was not the slighest
change'in these cells. There was congestion, but no change in the
glandular structure and in the interstitial cells. The specimen
showed nothing to indicate that an extrauterine pregnancy existed.
The text-books tell us that peculiar decidual changes take place,’but
to his knowledge there were no reports extant in which the mucosa
was examined at a'very early stage of extrauterine pregnancy. Since
it was supposed that this case was more than three or four weeks old,
we might presume that the reaction in the mucosa had not yet taken
place; the changes are always seen, if curetteing _is done at a later
period of ‘ extrauterine pregnancy.
DR. NIETERT asked if only one piece of the scrapings was ex-
amined.
DR. FISCH said he examined every piece; he did this in all exam-
inations of uterine scrapings submitted to him. In addition, he would \
mention another point against the theory of the scrapings being from
cervix, that was, the great thickness of the removed portions. The
mucosa of the cervix is very thin, and even in a hypertrophid condi-
tion, would not be as thickas these specimens. '
DR. Geo. GELLHORN said he wanted to explain why he suggested
that the scrapings might have come from the cervix. When he saw‘
one of the sections, prepared by Dr. Fisch, he fully agreed with him
that the mucous membrane did not show any changes characteristic
for pregnancy' .He noticed, however, that thenuclei of the epithe-
lium cells were arranged on the basis. This arrangement is typical
for the epithelium cells of the mucous membrane of the cervix. In
City Hospital Alumni} ' 263 _
contradistinction, the nuclei of the epithelium cells of the endomet.
rium are located in the middle of those cells. Therefore, he was not
surprised not to ﬁnd decidual changes, as the latter only take place in
mucous membrane of the body of the uterus. _
For the lack of the decidual changes in other sections which,
according to Dr. Fisch’s view, certainly come from the endometrium,
another explanation suggests itself. We know that decidual changes
in the uterus progress as long as the ectopic pregnancy advances.
After interruption of the pregnancy, the uterine decidua undergoes a
retrograde involution. ‘ Since, in this case the ectopic pregnancy was
only of short duration, and 1nterruption might have occurred some
time ago, we can- presume that at the time of the curettement, the de-
cidiial changes had already disappeared, and the normal state was
re-established. ’
DR. FISCH said that in the examination of the uterine scrapings,
we had avery distinct and characteristic staining reaction on the one
side of the cervical, and on the other side the uterine glands. The
cells of the cervical glands produce mucus; therefore, in specimens
stained with hematox'ylin and eosin, their inner two thirds appear in
i a bluish hue, or remain entirely unstained; while in the cells of the
uterine glandular structures. these portions retain the ordinary proto-
plasmic ,character, and are stained deeply with the eosin. In the
present case, not a single cell exhibited the ﬁrst picture, all of them
took_ the eosin. The fact, that in some places their nuclei appeared
less characteristically situated, than in the normal uterine glands was
explained by the hypertrophic condition of the glands, where the pro-
liferation of the epithelial cells exceeds the given space, and the cells
appear somewhat irregularly arranged.
DR. HENRY JACOBSON said it was unfortunate that the history of
the case of ruptured bladder was not obtainable, and a diagnosis made
antemortem. If this could have been pbtained, the man’s life might
have been saved, as suturing of ruptured bladder walls, with drainage
early in these cases, usually results in recovery, with modern methods
and technique. The absence of blood. in the urine and his voiding
several ounces of urine, was misleading. In the female, rupture of the
_bladdemarely occurs, except during labor. And then into the vagina
264 ' Medical Society of
where there is no peritoneum and the walls are thinnest. The mortality
in these cases is almost all. When rupture of the bladdei occurs in
persons who drink a great deal of alcoholic stimulants, the urine not i
only escapes into the abdominal cavity, but there is usually "an inter-
stitial nephritis, which plays an important part in causing _the death of
the patient.
DR. WM. S. DEUTSCH said he saw a case a few days ago ’of a man
who fell from a height of eight or ten feet. He fell in such a way that,
he struck with his perineum against the edge of a washtub, tearing
the urethra through and sustaining also a rupture of the bladder. The
unusual feature of the injury is in the fact that the bladder was ruptured,
although the blow was not received directly over the bladder. The
rupture in the bladder was not at ﬁrst detected, on account of the torn
urethra, and because the distension of the bladder seemed to contra- '
indicate .a torn bladder. It was afterwards found that the bladder had
been torn, and the patient died from this injury, no doubt.
Spinal Curvatures—Presentation of Patients.
BY T. c. WITHERSPOON, M.D.,
ST. LOUIS, MO.
WISH to present three patients who have spinal curva-
I tures, typical of the three classes of ﬂexures seen in the
‘ column. -The ﬁrst is a small patient, with a tubercular
process now going on in the dorsal region. There is, as you
can readily see, a process limited to the interspace between
two of the vertebrae, or an involvment of the~body of one
alone. The deformity is an angular kyphosis, ’or better, a
gibbus. This case presents the'typical curvatures of a col-
lapsing of the bodies of the vertebae in a limited area. This
is so characteristic of tuberculosis, that I need not dwell upon
it further.
The next case is one of early spinal rickets. The kypho- - I
sis commenced in his sixth year, and increased gradually dur-
ing the next few years. The curve is a pure kyphosis. It is
City Hospital Alumni. ' ~ 265
regular, involving the dorsal region, and telescoping the ribs
into the/pelvis. This is a typical curve of rickets, showing
the effect of the superincumbent weight upon softening ver-
tebae. When a lateral curvature becomes a part of such a
deformity, the child is Usually older, that is, at the growing
period, when the scoliosis becomes apparent. The lateral
change depends upon other mechanical factors than a simple
softening of the bodies of the vertebra.
In these two cases I simply wish to show the typical
tubercular and rachitic spine. They both illustrate the result
of a diseased condition of the bodies, and the giving away of
them upon pressure from above. In the one case it occurs at
a point, in the other, throughout the entire column.
The third case is. one of scoliosis in a young negro, 15
years _of age, who comes to the hospital for an injury to the
forearm. As you see, he is a strong, healthy-looking fellow,
and on questioning him, I elicit no noteworthy history of past
sickness. Here you see the typical picture of the scoliosis of
adolescence. The dorsal region presents a ﬂexure to the right
and the lumbar to the left. The right scapula is elevated and
on a line posterior toxthe left. The inner'border of the scapu-
la is very prominent, while that'of the left is scarcely visible.
This depends upon torsion of the column, which is a
necessary accompaniment of lateral ﬂexure. A number of ex-
periments upon the dead body have been performed, in which
it is shown that a bending to the side produces torsion con-
comitantly. This is explained by the necessary mechanical
relation of the vertebrae, bound, as these are, by tense liga-
ments. The articular processes may be considered the base
of a triangular_ﬁgure, while the front of the body of the ver-
tebra is its apex. The articular processes are allowed a
limited amount of movement, but in the dorsal region this is
very small, on account of the ribs and their strong ligamen-
tous attachments. In the articular zone, then, it is clear that
the attachments of the vertebrae are quite broad, extending
from side to side of each vertebra, while in front it is rela-
tively narrow, represented by one ligament, the anterior com-
mon. A bending of this column of triangular-shaped bodies,
in a direction parallel with their bases, all of which are at the
266 - ' ’ Medical Society of
same time bound together by strong ligaments, will cause
torsion to take place, the apex swinging toward the convex or
toward the concave side of the ﬂexure, as the apex or end of
base ligaments give the most. In the case of the vertebral
columns, the base is strongly bound together across the entire
lengh by the articular, the posterior common, the subﬂava and
the inter and interspinous ligaments. The apex is held by the
anterior common ligament, and between this and the base, at
the side of the vertebrae, there is no ligamentous resistance.
On this account the antero-lateral side will ﬁrst yield under
the strain. _ I
Another factor in the mechanics of torsion is the soft in-
tervertebral substance. This substance allows the edges of
the vertebra to approach the closer on-the concave side, while
the bulk of it slips to the convexity. The interspace between
the base and the apex, not being so tightly held by ligaments,
is the part to give. Into this territory the intervertebral sub-
stance slips and it becomes the convex side of the curve,
swinging, therefore, from an antero-lateral to a lateral posi-
tion. In the dorsal region, where the anterior common liga-
ment lies to the left side, as a rule, the marked torsion appear-
‘ing so clearly, is readily _accouhted for. These cases of scolio-
sis may present a double curve or a single one. As a rule, it
is double, with a right dorsal and a left lumbar convexity.
Chisholm Williams records 500 cases of this trouble, 257
of which were right dorsal and left lumbar, 84 the reverse, 90
total right, and 64 total left. The remaining cases showed a
triple curve. Since the direction taken by the curve is in
each instance not the same, there must be some mechanical
difference in the anatomic construction of the different spines,
which will account for the direction taken. In this regard, I
have been doing some work which, while it is at yet too lim~
ited in amount, nevertheless points a way of solution. I ﬁnd
the anterior common ligament is not uniformly in the center
of the bodies of the vertebra, but is often to be found to one
side. The commonest situation is to the left of the median
line in the dorsal region. veering over somewhat to’the right in
the lumbar. In several cases I found a difference in the
amount of ligament to the left side, as compared with the
City Hospital Alumni. 267
right, about 3 or 4 to I. This was in the dorsal region, where
, the aorta and intercostal arteries determine the develop-
ment of the ligaments. The lumbar region shows very
slight differences. In the dorsal region, the right intercostal
arteries being given off to the left of the median line pass
behind the vena cava, clinging closely to the bodies of the
vertebrae, and preventing by pressure the same development
of the ligament on the right side. “
Scoliosis is observed between the ages of ten and ﬁfteen,
at that time of life when the child begins to rapidly increase
stature. It is a mistake to consider every case weak and rather
below the normal in health. I have at the present time several
robust girls under my care for scoliosis, one in particular is very
athletic and is out of doors the major part of the time, yet she
presents a well-developed sigmoid curvature. Girls are affected
four times as often as boys. Looking over the various pieces
of literature at my disposal, which bear upon this subject, I
'ﬁnd a unison in the chief cause to which it is attributable.
Barwell says it is due to the habit of bad position while trying
to write in school. Clark emphasizes the same cause. Wil-
son (Philadelphia), says: “Without entering upon the large
subject of theoretic etiology, it may be concisely stated that
idiopathic rotary-lateral curvature of the spine is produced or
inﬂuenced by two factors, namely, constitutional debility or
enfeebleness, and prolonged maintenance of an altered rela-
tionship normally existing between the shoulders and hips.
Position in conjunction with rickets, debility, muscular irregu-
larities, etc., is the chief factor in causing the deformity.
Heredity does seem to play a part.”
It does seem to me that these causes must play a secon-
‘ dary role in scoliosis. The very mechanics of the deformity
demand another explanation. In the ﬁrst place, position
might give rise to a bending of the lumbar area, but it could
not well inﬂuence the dorsal to the extent observed. Then,
too, the dorsal area is the very ﬁrst to show the deformity.
Faulty position is always accompanied by a forward bending
and would lead to a kyphosis with scoliosis. Kyphosis is not
observed in the typical scoliosis of adolescents, but rather, a
tendency to lordosis. Again, a curvature from position re-
268 I Medical Society of “
quires the consideration of the superimposed weight of the
head and upper extremities, and a giving away on the body
side of the vertebra. This would cause the same deformity
seen in early rickets, namely, a kyphosis, and, therefore, every
scoliosis from this cause would be one of kypho-scoliosis.
The lordosis, seen especially in the lumbar, can only be ac-
counted for by an increase in the length of the column in
which the bodies of the vertebra and intervertebral substance
grow more rapidly than the posterior or base ligaments.
Otherwise lordosis is impossible.
In contemplating the changes which characterize this
affection, no reasonable explanation, it seems to me, can be
offered in either of the two general classes of causes which I
referred to as coming from men who are to be regarded as
authorities, namely, position and weakness. From a mechan-
ical point of view, an explanation is better found in those
changes, which are almost the reverse of these, namely, rapid
growth and the development of unequal pressure within the
bony-intervertebral substance column itself. An unequal
growth between the ligaments and the column would lead to
those changes which characterize this trouble. The increased
tension in the column would ﬁnd relief by a displacement of
the soft intervertebral substance in an antero-lateral direction
with the curves resulting. The more closely-bound dorsal
region would be the ﬁrst region to indicate the presence of
such a condition. The looser cervical and lumbar regions
would be the last to show the change, and at all times would
\ show less. The greater the weight from, above, the more
marked the curvature, because of the relatively increased ten-
sion in the column, therefore, the lumbar shows more curva-
ture on standing than the cervical vertebra. The rotation of
the pelvis is but the same thing seen higher up in the column,
that is, a torsion seen in the lower end of the column continu-
ous with that which occurs throughout the entire lot of ver-
tebrae. I am sorry I can not present some ﬁndings of a post-
mortem kind to substantiate that which I here have offered,
but in the near future I promise this proof. The direction
taken by the curve would be inﬂuenced by the position of the
anterior common ligament, and, as far as I have been able to
City Hospital Alumni. 269
M
discover, the post-mortem ﬁndings bear a direct relationship
to the statistics in this regard.
As to treament, I would suggest using the lever power of
the ribs. If the convex posterior side, which is usually the
right in the dorsal, be bound down by adhesive straps encir-
cling the half of the chest, the left ribs alone become active in
respiration. The ribs act as levers of the ﬁrst class, in which
the bodies of the vertebrae are loads, the transverse processes
are fulcrums, and the respiratory muscles are the motive
means. The ribs of either side acting alone, tend to curve the
column to that side. Respiratory exercises, while lying on
the back, are very advantageous, as is also leg and arm move-
ments. I am able to obtain much more rapid improvement
in this deformity by strapping the convex side of the chest
than by any other means at my command. Let me recom-
mend it.
I suppose there is no subject presenting itself to the doctor that
causes him to feel his helplessness more thoroughly than that of
scoliosis. In the last year I have had two ﬁne, strapping, strong girls
come to my ofﬁce with scoliosis. I looked up everything on the sub-
ject, and could ﬁnd nothing to help me, so I was awakened to an un-
usual interest to explain scoliosis--upon what basis does this lesion
rest? How is scoliosis possible? Upon looking through a few author-
ities, I found that most of them agreed in this one particular, that one
cause of scoliosis of adolescence is positional. Scoliosis is due to the
fact that at that time of life children go to school, sitting at their desks,
becoming fatigued with the long hours, leaning over to one side, hold-
ing their shoulder as steady as they can, they swing the pelvis and
hold it at a faulty angle; there is a shortening through the column, and
ﬁnally, a twisting of the pelvis and at the time a curvature of the
column. Such authorities as Barwell, Clark, H. A. Wilson, Noble
Smith, all ascribe the cause largely due to position. I have mentioned
some things, which have occurred to my mind that might help to throw
some light on the subject.
He then presented a patient, a boy, and called attention to the
fact that the rotation was less below than above, showing the thoracic
210 Medical Society of
point where the ligaments bind the greatest, that is, were most
ﬁrm; in the lumbar region, where they were not so ﬁrm, there was
more play between the vetebrae, and less curvature.- When standing,
the patient showed less lordosis, which is explained by the fact that
we have an articular surface, with a possible shifting position up and
down. We have here a typical condition following tubercular trouble
in the bodies of the vertebrae. We have a kyphosis, showing one
vertebra giving way to the disease locally, and collapsing at one point.
He called attention to the small amount of curvature latterly seen in
this case.
The next patient presented was a man, giving a history of trouble
dating from his third year and stopping at his eighth year. He showed
this case, to call attention to a rachitic rather then a,tubercular condi-
tion. The characteristic curvature seen, looked like rickets, but it
might not be due to that. It shows at no point an angle, as though it
were one complete round curve. Every time the patient breathes, the
ribs swing up in front, and at the side. Being articulated with
the body of the vertebrae and the transverse processes they raise the
vertebrae. At one point the ribs are more at alright angle that at
another.
He then demonstrated his manner of treating this condition, by
strapping the part with adhesive straps in such a manner as to hold the
ribs, ﬁxed on one side so that with every inspiration the oppositb side
is raised, but the strapped side is at rest, thus tending to straighten
the column. The strap should be carried well over to the median
line. When the one side is held ﬁrmly strapped, the opposite be-
comes markedly expansive. He said he had two patients whom he
was treating in this manner, except that the straps are made of cloth,
and worked into a shape resembling a corset; each morning it is
tightened, and can be kept in that state. This governs the respiratory
movements, and produces a decided expansion of the opposite side.
This, in connection with exercise, was his usual treatment in these
cases.
He said scoliosis is seldom seen in adults, but very common’in
children. This is probably due to the bony changes taking place be-
tween the ages of 16 to 24 years, accompanied by a steady increase in
City Hospital Alumni. 271
the ligamentous lengthening, and, he thought. many of these patients
get well without any treatment.
M
DISCUSSION.
DR. L. DRECHSLER said he had several cases under observation.
One, a young man, 24 years of age; says his curvature was due to an
injury received while playing with a younger brother. Another pa-
tient knew nothing of the curvature being present until he came up for
an insurance examination in some fraternal society. In each case the
speaker recommended exercise, especially the routine exercise ob-
tained in some of the German turn societies. He also recommended
that a bar be suspended, by means of rings and hooks from top of a
door frame between two adjoining rooms at home, and every time the
patients went through they should swing themselves ; he believed that
the exercises practiced on a horizontal bar, in which the body weight
was suspended by the hands. was the most beneﬁcial.

Meeting of November 7, 1901; Dr. Norvelle Wallace Sharpe,
President, in the Chair.
DR F. REDER presented a specimen of
Sarcoma of the Testicle.
The growth, he said, presented none of the characteristics of
malignant tumors, the principal features entering into diagnosis of
malignancy being the age of the patient and the rapid growth of the
tumor. The patient was 72 years of age and had always enjoyed good
health, nor was he sick at the time the growth manifested itself; it was
discovered accidentally when he was bathing. His general health
continued good and he refused to consult a physician. It was a growth
that might have been considered tubercular or syphilitic, but both of
these factors were eliminated. The patient ﬁnally consented to an
operation, and the testicle was removed; it is the left testicle. On
microscopical examination it was found to be a small round-celled
sarcoma. The cord was about the size of the wrist.
On cutting into the substance the ﬁrst time it_resembled the mot-
272 Medical Society of
tled appearance of cheese ; in some places it was white, in others
mottled and in other places it was dark. The section for microscopi-
cal examination was taken from the mottled portion, and revealed the
. small round cells of sarcoma. The patient experienced no pain at
any time. He was very reluctant, when I gave my opinion that it was
a malignant tumor, to have it removed and only consented because of
the size of the organ. It made its ﬁrst appearance in May, or at least it
was then that he discovered it, and by October had assumed its present
size, though it is now considerably shrunk from being in the solution.
This I considered quite a rapid growthf' it was ovoidal in shape. At
ﬁrst I thought I could discover some ﬂuctuation but the introduction
of the needle failed to ﬁnd anything of a ﬂuid nature. On making an
incision about the tunica vaginalis a spoonful of ﬂuid escaped, but I
presume it could not be considered cystic because such ﬂuid is found
in inﬂammatory conditions of this membrane.
The rectal condition was normal; there was anodulated condition
at the internal ring which plugged up the oriﬁce so that there was con-
siderable of the growth in the abdominal cavity. The prognosis, of
course, was very unfavorable and the man will evidently die before
long from exhaustion. One week before the operation he became very
weak and took to his bed so that when I saw him he could talk little
above a whisper.
The speaker, in answer to Dr. Bryson’s query as to how much of
the cord was excised, said he went as far as the internal abdominal
ring and when he had severed and ligated the cord it retracted into
the cavity. However, he did not open the abdomen.
DISCUSSION.
DR. ]. P. BRYsoN said he presumed there was some reason for
not going further because the excision of a growth of that extent with
involvement of the cord would be of no particular service except to
relieve the patient of the presence of the tumor; recurrence would
take place and we could expect the patient to succumb in a few
months. The absence of pain is rather unusual. Some years ago
he had an interesting case under observation: He had operated on the
mother of the patient some months before for a malignant growth in
City Hospital Alumni. 273
9
the breast, and the young man presented himself three years afterward
with an enlarged testicle. Both syphilis and tuberculosis were ex-
cluded and there was no doubt of the malignancy of the growth. He
removed the growth, going far up, and thought he had removed the
entire growth; he also followed down the vas deferens along the blad-
der; this was found to be healthy. The patient returned and asked
for another examination. Quite a large fusiform mass was found on
the left side extending well up into the lumbar region. The patient
passed into the hands of another physician who made a different diag-
nosis, and operated. The patient, after suffering great pain, died; it
was on account of this pain that he had consulted the speaker.
The specimen seems much shrunken but he thought there was no
question about the diagnosis even from the clinical aspects of the case.
He said it was well to follow the rule whenever we see a growth
as large as the ﬁst to cut it out; we should, in fact, remove even
simple granulating growths undergoing degeneration and metastases.
Very few of these growths are single.
Several years ago he saw a rather interesting case in a physician ;
he was syphilitic and had an enlarged testicle. The patient said that
three years after the initial lesion his testicle swelled considerably but he
paid little attention to it. After a time it, as well as the tunica vaginalis,
began to shrink, until there remained nothing but a small, ﬁbrous lump.
He consulted the speaker and it was not difﬁcult to make a diagnosis
of syphilitic testicle with complete atrophy from neglect. The lump
had grown to be a large mass when he was last seen and removal was
advised. This was done, the dissection being made up the peritoneum
for quite a distance toward the kidney. Since then he has remained
perfectly well.
DR. R. B. H. GRADWOHL said he saw a case with Dr. Bransford
Lewis on which he made a microscopical examination. It was in a
boy, aged 18 years, and was found to be a small round-celled sarcoma;
the tumor was not large and did not extend up the cord. Dr. Lewis
dissected high up and apparently removed the entire growth, but four
months later’the patient had a recurrence in the stomach.
DR. V. P. BLAIR asked if it was not common for sarcomata in this
region to recur by metastases through the lymphatic system. He
‘274 '_ ‘ Medical Society of
#
thought it easy enough to explain a metastasisin the stomach or lungs
where the infection is carried through the circulation but he did not
know that it was common for it to extend through the lymphatic
system.
THE PRESIDENT suggested that probably all had seen cases of
sarcoma that were practically painless. He asked if Dr. Bryson con-
sidered it to be a rule that pain is present in sarcomatous growths in
this region; is this pain due to tension on the tunica? Does the Doctor
observe the pain to be exaggerated in recurrence?
DR. BRYSON said as far as the ﬁrst case mentioned was concerned
it would be a question whether it occurred by metastasis through the
lymphatics. He believed that sarcoma does occur along the line of
the lymphatics and thought the occurrence this case was through
this channel. Of course, metastasis through the blood channels might
occur anywhere and so he was astonished to learn, after having seen
two cases, that it was not so uncommon in the “lungs. Cancerous
growths—epithelial—might occur anywhere, but the fact is well under-
stood that new growths, even cartilaginous, the apparently benign or
non-malignant, and neoplasms of all kinds, should ,be removed, be-_
cause of the danger of infection through _the associated lymphatics,
and metastasis will occur even in cartilagenous growth. The fact is,
we do not often see any growth, even of this size, to be a simple sin-
gle growth; the great majority are mixed growths.
In regard to pain in sarcoma, he said that was a question of the
parts affected. We are very apt to have pain in all growths and swell-
ings in the lymphatic glands. A growth, however, is not always the
kind that destroys the nerves. We are all familiar with growths on the
kidney, which are so commonly painless, and also growths on the tes-
ticle, especially sarcoma, but a growth upon or an enlargement of the
post-peritoneal lymphatics, he thought, were particularly apt to be
painful. In the case mentioned above pain was the cause of the
patient complaining; the swelling was not at ﬁrst manifest. The pain
was very severe and'nocturnal like syphilitic pains.
City Hospital Alumni. 275
Complete Transposition of Viscera: A Report
of Three Cases.
BY W. C. MARDORF, M.D.,
sr. LOUIS, MO.
HE case which led to this report was that ofayoung
man, aged 22 years, small of stature, but well de-
veloped, weighing 130 pounds, whom I was called to
see at II o’clock a.m., October 3d of this year. I was told
his bowels had not moved for ﬁve days, during which time he
had pains in the lower abdomen, at ﬁrst slight, and afterwards
increasing and spreading over the entire abdomen. He had
been vomiting during this time, but the vomitus was simply
what he had taken into the stomach, and occasionally bile.
He had been seen by a physician the day before, who en-
deavored to move the bowels with heroic doses of castor oil
and other purgatives, and failing in the attempt, relinquished
the case with a fatal prognosis. On examination of the ab-
domen, I found it distended and tympanitic, with a somewhat
mufﬂed percussion note and slight though plainly perceptible
thickening or increased resistance in the left inguinal region.
Examination was painful, but not extraordinarily so.
Assuming that the case was one of peritonitis of unknown
origin, but most probably caused by some obstructive trouble
‘ of the intestine, located in the left lower quadrant, such as a
volvulus or the like (I could not satisfy myself as to the con-
dition), I took up his general condition, and found it so bad
as almost to contraindicate operative interference. A pulse of
I30 and poor, and a temperature of 96.8°F., breathing rapid
and shallow, together with a pinched, anxious face and cold
grayish skin, all warned that if anything was to be done, it
must be done soon. Postponing further examination, I ad—
vised his removal to the City Hospital for operation, which
was agreed to. He was immediately taken there, and at 4
pm. laparotomy was performed, Dr. Nietert operating. On
incision the abdominal walls were edematous, and the cavity,
276 Medical Society of
on being opened, revealed a severe general peritonitis of some
days’ standing, with some pus in the dependent portions, and
adhesions between the coils of intestine, which were covered in
places by a thick, ﬁbro-purulent exudation. There were
necrotic patches along the small intestine, where the inﬂam-
mation was most severe, but the source of the trouble was
ﬁnally located in a necrotic and leaking appendix, which was
found in the left iliac fossa, and not walled off by adhesions
from the general peritoneal cavity, but hanging free.
Further examination showed the sigmoid ﬂexure and
descending colon to be on right side, the pylorus on the left,
and the esophageal oriﬁce to the right side. The greater lobe
of the liver was to the left, in fact, all the non-symmetrical
org'ans within reach were found transposed. The appendix
was removed and stump inverted, the cavity cleansed as well
as possible; the patient’s condition had failed during the
operation, and in spite of all efforts no reaction occurred after-
wards. Death took place about six hours after operation. A
post-mortem examination was held, at which I was not pres-
ent, when it was found that all the nonsymmetrical viscera,
such as heart, lungs, liver, spleen, pancreas, stomach, and in-
testines were regularly transposed, but otherwise perfectly
formed. The specimen is here for inspection. ‘
I also take the occasion to present a little girl, aged II
years, with a like condition, whom I have had under observa-
tion for some years, and who is here for examination. She
has had a cough since her birth, being never free from it, with
recurring attacks of bronchitis in winter, and considerable
anemia. Within the last two years her general condition has
improved. She seems fairly well-nourished, as you can see,
and the cough is occasional and slight, but still present. I
can not connect the transposition of the organs with any ill
health she has had, even wrth the cough she has had all her
life; it would be difﬁcult to trace the connection. In this case
the position of the heart, liver, and spleen can be readily
outlined.
I am sorry that I can not present another subject of the
same variation from the ordinary, whom I saw some three years
ago, but of whom I have lost all trace. It was a strOng boy,
City Hospital Alumni. 277
aged I 7 years, who came to me for treatment of an accidental
injury. He seemed to be in good health, and assured me he
had never been very sick, though somewhat weakly in his
early years; what attracted my attention most was the slightly
greenish tint of a very dark skin. He said he had always had
this color, and there were no symptoms of illness connected
with it. I could not detect any abnormality of the heart or liver,
save for the transposition, though the former organ was probably
responsible; both seemed to be functionating properly, and I
wish I could have presented him to this society, as much be-
cause of the color of the skin as of the displaCed viscera.
The literature that I have found bearing on the etiology
of this condition has been very scant, and with reason, for not
only is this deviation a comparatively rare occurrence, but it
is undoubtedly caused by forces or inﬂuences operating in the
earliest development of the embryo, a ﬁeld of research which
is extremely difﬁcult and almost closed to investigation, be-
cause the means thereto are at present lacking.
When we ask why all the non-symmetrical organs are
transposed in these cases, we are ﬁrst forced to inquire why it
is that these viscera, such as heart, liver, lungs, and others are
placed as they normally are; why the heart and spleen to the
left, the liver to the right? Why not evenly balanced?
A difﬁcult stumbling-block! We can only say that the
ordinary condition is normal, and any other abnormal,
though not necessarily prejudicial to health, if regular. Sev-
eral theories have been put forward, and, among others, von
_ Baer quoted by Fisher, in Woods’ “Handbook,” offers the
following as a part of his theory’: “The embryo of a bird
during the ﬁrst 36 hours lies with its abdominal surface down-
wards; but in the course of the third day of incubation in the
egg ‘of the common fowl a change of position occurs, so that
the left side of the embryo comes to be laid on the adjacent
surface of the yolk.” In rare instances, von Baer, having no-
ticed in the eggs-of birds and in the ovum of the pig, the
embryo lying with its right side to the yolk, he was led to
believe this to be the explanation of transpositions of the
viscera. “Ingenious as this hypothesis is,” comments Fisher,
“it is unfortunately wanting in proof, and does not appear to
278 Medical Soclety of
t
explain the absolute reversion, or right and left symmetry,
such as we see in the double organs; as in the hands and feet,
the hemispheres of the brain, and other parts.”
Of the several hundred cases of transposition on record,
it is probable that many were not complete, but were rather
malformations, and due to arrests of development.
Among the cases cited by Fisher, the following are the
more remarkable:
Baillie’s case, a man, aged 40 years (in dissecting room),
complete transposition of thoracic and abdominal viscera. In
this case six distinct spleens were found, all supplied by
branches of the splenic artery.
Young’s case of complete transposition, a lady who lived
to the age of 85 years. ~
Hickman’s case lived to the age of six weeks. “The
lungs, liver, stomach, and spleen were all completely trans—
posed.” “The heart, though to all intents and purposes
transposed, yet actually occupied its usual position and direc-
tion in the thorax.”
Hickman’s case, a woman, aged 22 years, diagnosis con-
ﬁrmed by autopsy. Heart, aorta, and stomach to right, liver
to left; nine small spleens.

Meeting of Novemaer 21, 1901; Dr. Noraelle Wallace Sharpe,
President, in the Chair.
DR. LUDWIG BBEMER demonstrated the formation of
‘3
Leucocytosis.
Leucocytosis in appendicitis is a fact. I believe that the unrelia-
ble study of leucocytosis which takes place after ingestion, will be
abandoned and attention will be called to the character of the leuco-
cytes. We know that a leucocyte and a pus corpuscle are said to be
the same thing where blood corpuscles constitute,the elements of pus.
This is true and is not true in the sense that a pus corpuscle is a
changed leucocyte. The pathological change in a leucocyte can be
demonstated by proper re-agents and by proper preparation of the
specimen. I believe the time will come when it will be demonstrated
City Hospital Alumni. 279
that certain leucocytes are not leucocytes proper, but pus corpuscles
in the blood. I do not say that I am able to demonstrate this, but I
know this, that I have seen diseased conditions of the leucocytes in
cases of appendicitis, though these cases had, unfortunately, pro-
gressed so far that there was a. peritonitis and a large pus sac.
He then demonstrated by chart the transition of the blood con;
stituents into leucocytes and pus cells, and showed a typical leuco-
cyte on the chart and called'attention to the central portion from which
radiated the various tracks of granulations, in the one pointed out
there being four. He then explained how it was possible to demons-
trate certain conditions in a case of appendicitis. Whenever we ﬁnd
pus corpuscles—corpuscles that have been changed and passed from
the normal state to a diseased condition—taking other symptoms en-
tering into the case, I believe we will be able to diagnose a case of
appendicitis. The corpuscles have their typical arrangement altered;
we do not ﬁnd the wbll-circumscribed arrangement or the truncated
appearance but we ﬁnd bundles. The 'nuclei have become more or
less diffused. This is from a case of appendicitis and you can see
how the arrangement of the granulations has been changed; it is not
only changed in color but also in arrangement, and whereas the gran-
ulations are very ﬁne here, there they are clung together on account
of the degenerative process and appear much larger, and on account
of their largeness and discoloration I would pronounce this a pus cor-
puscle. I do not say that in every case we could make a diagnosis,
and I must say that I have never yet made a diagnosis, but in two
“cases I have been able to see the pus corpuscles by means of the
proper staining. Whether we will ever be able in every case to diag-
nose pus and thus settle questions of the greatest importance, of
course, I am unable to say.
In cancer we have not been able to discover any decided change
as far as the red blood corpuscle is concerned; As a rule, there is a
high degree of anemia and the red blood corpuscles present the ap-
pearance characteristic of anemia. I do not think there is anything
characteristic of cancer iii the blood upon which we can base a
diagnosis.
280 Medical Society 01
DISCUSSION.
DR. DEUTSCH asked if any change would be expected before the
patient became septic. ‘ ‘
DR. BREMER said not until the pus made its appearance.
DR. DEUTSCH.—-So there would be no beneﬁt derived from blood
Examination in the initial stage.
DR. BREMER.—No. I think not; however, when it is found it is
positive evidence that there is suppuration somewhere, and if the
physical signs are present I think the diagnosis is clinched.
DR. HOMAN asked how the presence in the blood of these bodies
was accounted for and if there was a re-absorption of the white blood
corpuscles.
DR. BREMER pointed out a drawing on the chart which he said
was from a case in which there had been an initial chill; but the ques-
tion was it a chill due to malaria, as the patiént had been suffering
from malaria—or was it a chill of 'pyemia? The plasmodiumswas not
present, but changes were found which enabled me to conclude that
there was a pus formation somewhere in the body andthe clinical
signs soon bore out this conclusion.
DR. JACOBSON asked if the streptococci were found.
DR. BREMER.-No, not in the blood. l
DR. H. W. SOPER said he had seen a statement that small doses
of pilocarpin given to a healthy person would cause an increase of the
leucocytes in the blood. About the same time he saw another state-
ment that in pneumonia it was observed that leucocytosis developed
in those cases in which recovery occurred. Taking these two state-
ments together he decided that he would try this method in the next
case of pneumonia. The opportunity soon came and he administered
pilocarpin in small doses, not employing any other remedy; the blood
showed a very marked increase of leucocytes and the patient made a
good recovery from the pneumonia. but a week or so later developed
a very large empyema... Dr. Baumgarten had seen the case in consul-
tation. The question he wanted answered was whether the'production
of so many leucocytes hadanything to do with the formation of the
O
empyema ?
City Hospital Alumni. 281
DR. BREMER thought Dr. Soper should not reproach himself for
having injected the pilocorpin and .believed he could absolve himself
from being instrumental in‘ causing the empyema. He did not think
the pilocarpin had anything to do with the production of the
empyema.
State Sanatorium for Consumptives.
The special order of business of this meeting was the considera-
tion of the following resolution offered at the “meeting of November
7,1901.
WHEREAS, The provision by State Government of Sanatoria
for the reception and care of tuberculous persons has become an ac;-
knowledged ‘necessity for the better protection of the public against
tuberculosis in its various forms ; and, I
WHEREAS, Several states already possess such sanatoria while
Missouri, although the ﬁfth state in the Union in order of population,
has taken no step toward providing for the establishment of such an
institution. therefore be it
Resolved, that the Soéciety of City Hospital Alumni recognize the
urgent necessity for an adequate institution designed for the exclusive
care and treatment, both hygienic and medical, of tuberculous persons
in the State of Missouri, the said institution to be erected and main-
tained by the State government.
2. That this Society shall at once, by correspondence and other-
wise, seek to enlist the active co operation of other medical societies
and bodies, and of the public press throughout Missouri to the end
that a sanatorium, commensurate with the importance of the object
sought, be authorized by legislative action, the same to be erected in
some suitable location in the mountainous part of the State.
3. That copies of these resolutions be transmitted to all other
medical societies in the State, to medical colleges, to the medical press
and the local daily press, to the Governor, and members of the Gen-
eral Assembly; and that a persistent agitation of this. subject he
maintained in order that public opinion may be so inﬂuenced as to
secure favofable action by the next legislature toward the effectual
282 Medical Society _of
prevention and control by approved methods of one of the destructive
diseases to which mankind is liable.
DISCUSSION.
DR. GEORGE HOMAN said the purpose in bringing this matter be-
fore the Society was, if possible, to start a movement in the direction
indicated. We have a large tuberculous population, and it seems to
be the drift of medical and sanitary opinion that some institutions,
hardly a hospital in character, should be provided for tuberculous pa-
tients who can not také proper care of themselves, and who are in
more or less indigent circumstances. The term sanatorium is used
rather than hospital, the prevailing idea being an open air or out-door
treatment. This scheme has taken shape in a number of the Eastern
states—Massachusetts having established one, also New York, and
Pennsylvania is moving in that direction. The United States Govern-
ment is also carrying out this idea, in having established in New
Mexico a sanatorium at Ft. Stanton, a former military reservation. At
this place all persons in the army, navy and marine hospital services
may receive this form of treatment. It is practically open-air treat-
ment in a salubrous climate. , i
As far as the speaker has been able to gather information, the in-
stitutions in New York, Massachusetts, and Pennsylvania have been, '
or will be situated at a considerable elevation. That in New York, will
be in the Adirondacks; the Massachusetts institution will be about a
thousand feet above the sea level, the highest point in that State, be-
ing about 1,200 feet. The Pennsylvania institution will be in the
mountains. He had not been able to obtain the plans of working of
the institutions, but he supposed they would be large institutions,
built for the use of those persons who are not yet bed-fast, and who
can do out-door work. such as the strength of the different patients
will permit. All varieties of lighter employment will be followed, such
as gardening, farming, dairying, and that sort of work.
He thought this State would be very soon in good position
ﬁnancially to undertake this work, as the outlook is favorable for
Missouri to be practically out of debt by the time the next legislature
meets, and if this scheme meets with general favor in the medical pro-
City Hospital Alumni. 283
fession, he believed it could be carried through. It is certainly
worthy of discussion as one of the means of combating tuberculosis,
as this is a matter that is now uppermost in medical thought as well
as in the public mind. I
DR. BREMER heartily indorsed all the resolutions. He said that
a number of years ago, a Dr. Brehmer, of New York, established the
ﬁrst sanatorium for the, exclusive treatment of tuberculous patients.
At that time doubt was expressed as to the efﬁcacy of such treatment,
but the brilliant results obtained convinced the medical profession and
the public that sanatorium treatment was the right treatment for this
form of disease. He did not think there was any particular selection
of the cases, the advanced cases were admitted with the mild ones and
of all the cases received, one-third were completely, cured, one~third
were improved to such an extent that they could go back to work, and
one-third died. That is certainly a very good showing—two-thirds
improved and one-third deaths. It shows what can be done by
rational treatment. A former assistant of Dr. Brehmer entered the
sanatorium 40 years ago as a consumptive. When it became possible
0 make the diagnosis of consumption by demonstration of the tuber-
cle bacillus, his was one of the ﬁrst cases that showed the bacillus.
That man is still living, and afterwards carried out the ideas of his
master, and perfected them. _
i The consumptive must have a proper education along certain
lines in order that he may not go home and spread the disease. One
of the principal objects of a sanatorium for the care of consumptives
is the hygienic education given these persons. In this way the disease,
if not prevented, can at least be restricted. There has been a marked
decrease in all parts of the civilized world. In Germany and England
there has been a remarkable decrease in these cases, due to the edu-
cation of these patients, the result of their sojourn in sanatoria of this
character.
DR. DEUTSCH mentioned an institution, managed by Dr. Bonny, of
_ Denver, who practiced in Denver, and gave ‘special attention to tuber-
culous cases. This gentleman established a hospital in Denver, and
also a sanatorium in the wild regions of Colorado for the care of
consumptives, known as the Estes Park region. The speaker knew of
_284 I --Medical Society of
one case that-had been under the Doctor’s care for ten years, and was
now, to all intents and purposes, well. "
The Denver institution is a beautiful place, and arranged accord-
ing to the latest scientiﬁc methods. The blankets, mattresses, and
bed cloths are sterilized in large sterilizers built for that purpose, as
soon as the patients leave them. As soon as the weather permits, he
takes all the patients to a little town Called Lyons, near Denver, and
begins from that point to place the patients at various elevations iii the
mountains, suited to each case. He has camps at different pbints,
each with trained nurses in attendance, and the Doctor goes out twice
a week to the different camps. He claims wonderful results. They
sleep out doors and don’t really know what a closed house is until the
winter gets very severe. When the weather becomes too severe, he
takes them back to the sanatorium in Denver. p
DR. JACOBSON mentioned that Dr. Wm. Porter had» charge of a
hospital on the bluffs of Carondelet for the treatment of consump-
tives. The institution would accomodate probably 300 or 400 per-
sons, embracing late methods of treatment. He thought the best
place, probably, for such an institution would be in the Ozark
mountains. %
DR. L. H. BEHRENS said it was probably in the clinics where we
saw that class of cases of consumption which would be most bene
ﬁtted by a sanatorium, such as suggested by Dr. Homan. In clinical
work, which is principally amongst the very poor, he had found many
cases of phthisis pulmonalis in its very incipient stages. The patient
is given instructions in hygiene, and the beneﬁt of home treatment,
but usually the case goes through the various gradationsto a fatal
termination. The treatment is very unsatisfactory in the city, and it
for no other purpose than to get the patients in the open air, a great
deal will be accomplished by having them in a sanatorium. Time and
time again do we see the beneﬁt derived by sending these people to
such places as Arizona, New Mexico, Southern Texas, with an eleva-
tion of 3,000 feet and upwards. The very poor must remain in the
city, where the treatment is very unsatisfactory. If they could be
educated, not only the poor but the better class of patients, in the
proper care of themselves and observe the rules laid down as regards
City Hospital Alumni. ' 285
promiscuous expectoration, there would be some mitigation of this
awful condition. 1
He hoped the agitation would be continued. If we have no ideal
place for the establishment of such an institution, we certainly have
many palces that are much better situated for the treatment of this
disease than in the city. '
DR. H. S. CROSSEN asked if it would be the more advisable to
agitate the building of such an institution in this State, or the creating
of a fund for sending these patients to some other State, where there
were better conditions for their treatment. He recognized that this
suggestion was a new departure and thought it would be difﬁcult to
accomplish, as the establishment of the hospital in this State would
give employment to a large number of persons, and is always a matter
of importance.
DR. HOMAN said Arizona, New Mexico,. and Texas possess un-
doubted advantages for this class of cases, and generally the Strtes in
the Rockies and along their southern slopes, but he thought the ﬁrst
thing to do, was to make the move in the direction indicated in the
resolutions. The next step might be to send patients somewhere else,
or there might be branch institutions established. That would be a
matter for future consideration. He believed we have in this State
sites equal perhaps to those of any of the States that have instituted
this method of treatment. He did not know the maximum elevation
of the Ozarks, but thought it was a thousand feet or more. and the
conditions ought to be very favorable, as the mountains are covered
with pine, cedar and hardwood. An extreme elevation, of course, is
not desired, and the character of the soil, the surroundings, mean
temperature. amount of sunshine, rainfall, etc., should be considered.
DR. BREMER said the institution established in the Adirondacks is
not at a great elevation. In the City of Berlin excellent results have
been obtained by the sanatorium treatment, which is, in a way, a
notorious consumptive breeder. By strict attention to hygiene they
have excellent results, and in 100 cases there has been but one case
developed in a number of years. This would show that the disease
is not, as claimed, strictly infectious; that is, one where the germ
286 . Medical Society of
is carried by means of the clothes or other articles to persons who
inhale the pathological germs, and develop the disease.
In regard to the spread of tuberculosis, we are still much in the
dark. All experiments made are laboratory experiments, and can not
imitate the natural state fairly. It is a remarkable fact that in the big
Berlin hospital for all lung cases, inclusive of tuberculosis, there has
not been one case contracted by contagion. What we know is that,
under proper hygienic treatment, not excluding drugs, but the wise
employment of drugs, a great deal is done in restricting the spread of
tuberculosis.
Where is the money to come from? The State is nat inclined to
further undertakings of this kind. In many of the European countries
we see a great deal of charity in this line. It is not only the patient
who must be educated, but the rich man should be taught the wisdom
of giving liberally to such institutions. The State alone is powerless.
He thought the capitalist should be educated to give some of his
money to institutions devoted to the cure of diseases, and giving a
man a good body. Much of the beneﬁcence of the rich man is ill-
placed.
DR. DRECHSLER said that he believed that there were good loca-
tions in the Ozarks for such an institution, and that it was nottneces-
sary to put up a large building, but a number of buildings on the
cottage plan, on a large piece of ground, say one thousand acres or
more. These cottages to be built of yellow pine, without paint on the
interior, but may be given a coat of whitewash on the exterior.
Those able to work could be given employment about the place, so as
to make the home almost self~sustaining. While he was in Louisiana
a number of years ago, in the pine regions of St. Tammany Parish,
about 34 miles from the coast, he visited a health resort where he
found several consumptives who were improving rapidly; here he found
this cottage plan. It seems that the atmosphere among the pines
is a good stimulant, and is beneﬁcial in its effect upon the lungs.
DR. BEHRENS said the altitude of the institution in Albany, N.Y.,
referred to by Dr. Bremer, is 1200 feet. Sunshine is what we have to
depend upon in out-door treatment, and exercise. Patients sent South
do not receive much medicine but are out of doors most of the time.
City Hospital Alumni. 287
The speaker has observed a great deal more than he of
the ‘infectiousness of consumption, but he could not but be-
lieve it is infectious. He mentioned. the case of a family in South
St. Louis in which consumption developed. The father and mother
gave a good history, the mother being about 52 years of age and the
father about 60 years of age, and died recently of valvular heart dis-
ease. There was no history of consumption on either side and both
were healthy-looking people. Their son was 16 years of age when he
was stricken with phthisis ; he did not know how he became affected.
A brother who slept with him died in about three months of consump-
tion. A sister, who worked in one of the laundries of the city, about
22 years of age, contracted a cold and in three‘l months she developed
phthisis and died, and another sister at the end of a year died of the
same disease. He believed this was a case of infection being carried
from one to the other. The carpet in their one room must have been
impregnated with the bacteria as they spat on it constantly.
In the City Hospital several years ago two nurses died within one
year of consumption ; they were in the consumptive ward and neither
gave a history of consumption in their families, so I was informed.
The treatment of these cases in .the clinic is a failure for the reason
that no adequate measures are taken to prevent its spread in the case
of the very poor.
DR. BREMER said there is no question that the tubercle bacillus is
the cause of consumption, but the point is, and it is of vast importance,
that back of the bacillus there must be a condition favorable to the
production of the disease Our crowded tenement houses—from two to
four persons living in one room—alcoholism and depression, these are
the things that produce tuberculosis and the bacillus only steps in and
ﬁnishes the job. In the old country it has been observed that placing
a tuberculous and a healthy person together has never resulted in the
transmission of the disease from the one to the other, and these men
have paid special attention to the matter.
On the other hand, those who have communion with each other do
not transmit or become attacked by the disease. It is a disease asso-
ciated with misery, though this does not prevent rich persons from
contracting it, and where the best hygienic conditions prevail we have
288 _‘ Medical Society of
seen consumption develop. There is a peculiar. mental condition
manifested in the tuberculous patient; they disregard all rules yet' _
seem unconscious of it; they will. spit on the floor and maintain that
they have not done so; they will cough in the face of a person and
declare they did not. The speaker had seen this in his hospital prac-
tice. If tuberculosis were really such an infectious disease everybody
would have it. It 'is well known that the miserable hygienic and social
conditions of the people play an important part in the spread of
' tuberculosis.
He agreed with Dr. Behrens that the surroundings described, -
especially in tenement houses and alleys where there is a great con- .
gregation of people and where no attention is given to cleanliness,
infection takes place, but otherwise this infection is of minimum im-
portance. The tubercle bacillus is triturated and ﬂoats in the atmos-
phere and if the disease were really so infectious we'would all die,
because we all inhale the bacillus every day.
Be the infection, however, ever so great and deadly, the curability
of sanatorium treatment is established. The Ozark Mountains are in
all respects suitable, there is splendid water and good air and the
country is free from malaria. judging from the remarkable results
obtained elsewhere he thought our State as well adapted for the treat-
ment of consumptives by this method as any in the country.
DR. V. P. BLAIR said the great ends attained in sanatoria for
consumptives, especially for the poor, would be proper food, segrega-
tion and a more hygienic life. He thought the matter of elevation for
a sanatorium for consumptives desirable but not absolutely necessary.
In Funchal, Madeira, there is a sanatorium for the treatment of con-
sumptives, founded by the late Emperor of Brazil. In this institution
are found a great many consumptives from Brazil. It is located not
over 100 feet above the sea level and the climate is rather damp ; the
amount of sunshine is not great as the sky is always more or less over-
cast with clouds, yet the results obtained'are very good. The'men in
charge are scientiﬁc people and their methods are entirely modern.
In the Canaries the climate closely resembles that of the Arizona
plateau. Great numbers of English tubercular patients go to these
islands and many live but a few feet above the sea level, though at
City Hospital Alumni, 289
Teneriffe they can obtain an elevation, of 12,000 feet. Englishmen
who go to sea for their health generally go to a bad climate, but the
great majority do well. On‘the ships they have good food and when
in the, tropics they can sleep on deck. There are places in southern
England where they have enormous sanatoria for the treatment of
consumptives. It is claimed that they can live out of doors and that,
is about all that can be said of them ; it is a damp, miserable climate,
yet they have good results in their sanatoria.
He thought the moving of patients from this State to others in
order to get the beneﬁt of sanatorium treatment would be very expens-
ive. He had been in Colorado, New Mexico and Arizona for ten
months. The air is dry and stimulating in these states and the patients
are able to sleep out of doors; it is this out of door life that, he
thought, is the greatest beneﬁt to these people. The climate in west-
ern Missouri somewhat resembles that of Colorado The air is brac-
ing, the sun is warm and there are a great number of sunny days, so
that he though all along the western- border of Missouri a somewhat
similar effect could be obtained as that in Colorado or the elevations
of Arizona.
A Gunshot Wound of the Abdornen lnﬂicting
Nineteen Perforation of the Intestines and
Four Lacerations of the _v Mesentery,
With Recovery.
BY ROBERT F. AMYX, M D.,
ST. LOUIS, MO.
HE patient was received at the St. Louis City Hospital
at 7:10 p.m., December 11, 1900. _Iohn_Walker, col-
ored, aged 21 years; nativity, Mississippi; occupation,
laborer; social condition, single. Present condition:_ The
patient received a gunshot wound of _the abdomen about one
hour before coming to the hospital. Examination revealed a
wound of the right iliac region just above McBurney’s point.
290 Medical Society 01
The patient was immediately prepared for operation, the usual
antiseptic and aseptic precautions being observed. After
thoroughly washing and antisepticizing our hands—this pro-
cedure requiring about twenty—ﬁve minutes, the patient was
placed on the operating table and anesthetized, chloroform
being used. At 8:15 p.m., an incision ﬁve inches in length was
made at McBurney’s point. On attempting to palpate the in-
testines, after entering the peritoneal cavity, I was surprised
to ﬁnd the intestines walled off by ﬁrm adhesions; the latter
were between the omentum, ascending colon and cecum. The
adhesions were torn and an entrance made in order to reach
the small intestines. It was then found that the omentum was
attached to the entire right side of the peritoneal cavity,
dividing this cavity into two closed spaces, the one above con—'
taining no intestines, while the under one contained the small
intestines and the sigmoid ﬂexure. ,
The small intestines were delivered through the rent in
the adhesions and examined. The perforations found were as
follows: Twojust above the cecum in the ascending colon,
one about three inches from the cecum in the ileum, two in the
ileum about three feet from the cecum, twelve were in the
lower portion of the jejunum, these were distributed very
closely within eleven inches of the intestines, the latter were
very badly contused and lacerated; ﬁnally, two more perfora-
tions were found in the sigmoid ﬂexure. The two perforations
just above the cecum and in the ascending colon were sepa~
rated by a mere band of intestinal tissue; this was cut away
and the edges of the wound enlarged so that all of the con—
tused and lacerated tissue was removed, and when the perfor-
ations were closed normal tissue was approximated instead of
devitilized contused tissue as would have been the case if the
edges of the Perforations had not been cut away.
The Czerny-Lembert suture was used in closing the per~
forations; seven separate perforations were closed in this man-
ner, whilethat portion of the jejunum which contained the
twelve perforations was resected, and an anastomosis of the
intestine was made with Murphy’s button. In addition to the .
perforations in the intestines there were four rents in the mes-
entery; two of the rents were in that portion of the mesen-
City Hospital Alumni. 291
tery immediately below the gut in which the twelve perfora-
tions were situated. These were removed when making the
resection of the gut; the other two rents were sutured, as the
blood supply to the gut beyond these points was not disturbed.
The procedure which caused the greatest difﬁculty was in
suturing the perforations in the sigmoid ﬂexure; the adhesions
were so ﬁrm at this point that it was very difﬁcult to deliver
the gut through the opening in the right iliac region.
The abdominal wound was enlarged downward until a
better ﬁeld for work was secured. The perforation in the an-
terior wall of the gut was comparatively small, while that in
the posterior wall was about one and a half inches long, the
bullet having passed through obliquely.
After inspecting the entire length of the gut for further
wounds and satisfying ourselves that there were no more, the
peritoneal cavity was ﬂushed out with normal saline solution ;
twelve gauze drains were inserted in the various recesses of
the peritoneal cayity, viz., above the omentum, below the
omentum, above and below the mesentery, into the pelvis and
up toward the liver so that drainage was established above and
below the liver.
This procedure has been practiced at the City Hospital
for the past two years with gratifying results in gunshot
wounds ofthe abdomen. After placing the drains the abdom-
inal wound was sutured and reduced to a small size so that
the drain could not be forced out by the straining efforts of
the patient. An abdominal pack of bichloride of mercury was
applied and the patient placed in bed; the head of the bed
being elevated about ﬁfteen inches so as to facilitate drainage
in the direction of the abdominal wound and toward the pel-
vis. The time occupied in performing the operation was three
hours. The patient stood the long, tedious operation very
well. The pulse was I20, respiration 36, temperature IOOOF.
The course and after treatment“ were as follows:
December 12.—Slight tympanites present, no distinct
signs of peritonitis. One-tenth grain doses of calomel were
given every hour until one grain had been taken; this pro-
duced one small action from the bowels. The patient vomited
on several occasions. Three drops of carbolic acid were given
292 Medical Society of
twice during the day; the vomiting disturbed the patient con-
siderably, and I decided to give him a seidlitz powder, this
was alowed to effervesce so that most of the carbon dioxid
was discharged before giving it to the patient, with this three
drops of carbolic acid were giVen; there was cessation of the
vomiting after this. _
The patient’s condition remained unchanged up to De-
cember 17th, when there was a decided change for the better.
During this period six to eight drops of carbolic acid with a
seidlitz powder were given daily; there was a free movement
of the bowels daily, and the patient did not complain of any
discomfort. The tympanites which existed immediately after
the operation had subsided.
His condition continued to improve. On the tenth day
after the operation Murphy’s button was passed; for several
days previous to this date the patient had complained of pain
in the left gluteal region; examination revealed a tumefaction
with ﬂuctuation at this point; the parts were antisepticized,
cocainized, and an incision was made, about half a pint of pus
escaped. On inserting my ﬁnger into the pus cavity Ifelt
the bullet imbedded in the tissues; it was extracted and found
to be of 44 caliber. After this the temperature, which ,had
been increasing, began to decline. On the third day after the
pus and bullet were removed his temperature was IOOOF. His
condition continued to improve steadily, and he was discharged
from the hospital March 4th, having completely recovered.
During the ﬁrst ﬁfteen days the patient was nourished by
liquid diet only, no solid food of any kind was given until his
temperature began to decline; a semiﬂuid diet was then
substituted, such as custard, icecream, whey and peptonized
milks, so that the approach to the solid diet was gradual.
I wish to call attention to the manner in which the drains
were removed. Instead of removing the entire drain at one
time, only a portion was removed each time, so that drainage
could continue along each tract made by the individual drain,
until the tract closed behind the drainage material; this pro-
cedure was carried out with each drain.
Some criticism may be made of the site selected for the
abdominal incision. The reason the incision was made at
City Hospital Alumni. 293
McBurney’s point was that it was at a point where the bullet
when passing through the peritoneal cavity, would most likely
injure the cecum or the ascending colon. When this incision
was made it was decided that a median one would also be
made if theconditions present should justify such a procedure;
this was unnecessary, as it so happened that all of the injured-
viscera could be examined through the primary incision. The
points I wish to emphasize are as follows :
I. The edge of each perforation was cut away in order to get
into normal tissue, 2'. 2., tissue which was not contused; so that
when the edges of the wound were brought together, repairing
process would be more rapid and certain than it would have
been if the contused edges of each perforation had been
' turned in. There 'can be no doubt that contuse'd tissue around
perforations'made by bullets often break down; this process
going to and often beyond the sutures. This condition has
been demonstrated in post-mortems. From this observation I
believe all perforations produced by a bullet should have their
contused edges cut away before closing them.
2. Whenever we are dealing with gunshot wounds of the
abdomen with perfOration of the intestines by a bullet, drain-
age should be instituted. It’is impossible to estimate how
much infectious substance is carried into the peritoneal cavity
by the bullet from outside of the cavity. When the bullet
passes through the intestine it carries with it the contents of
the organ. Besides this, the contents of theiintestine will also
pass through the perforations into the peritoneal cavity, so that
there is a certainty of a Wide-spread infection; one that is not
removed by the ﬂushing of the peritoneal cavity, in a degree,
thorough enough to satisfy one that the peritoneum can take
care of itself afterwards.
3. The infectious substance is not the only factor to deal
with. The manipulation of the abdominal viscera always pro-
duces a slight degree of contusion so that the momentary
lowering of the vitality of the peritoneum in the presence of
infectious media, in many instances, terminates in a peritonitis
of a varying degree. '
4. The drains should not be disturbed before the ﬁfth or
sixth. day, and then only a small portion should be withdrawn
294 Medical Society of
at a time. This manner of withdrawing the drains allows a
better drainage than by an immediate removal of the entire
length of the drain.
5. The diet in the above case was a liquid one up to the
ﬁfteenth day; after this period a gradual increase to a solid
one, covering a period of one week.
6. The number of perforations made by the bullet was
remarkable. The number of perforations in the gut which was
removed, 2'. e., twelve in eleven inches of intestines.
I have with me the resected portion of the intestine which
can be inspected. I am unable to present the patient as he
was convicted of manslaughter after recovering and is now
serving a two years’ sentence in the penitentiary. At some
future time I may have the opportunity of presenting him
to you.
DISCUSSION.
DR. E. A. SCHARFF said the result in the case reported by the es-
sayist was particularly interesting because of the fact that during the
speaker’s stay at the City Hospital he saw from twenty to thirty Mur
phy buttons used without a single good result—all were removed at
the dead house. i
DR. HENRY jAcossoN said the use of carbolic acid with seidlitz
powder was something new to him. We would naturally suppose that
with the systemic shock from the insult to the peritoneum and bowels
the heart would also suffer as carbolic acid is a decided heart depress
ant; the two acting together would diminish the chances of recovery;
it was a good feature, however, in being anesthetic and thereby pre-
venting vomiting. We usually depend upon salines or the antiseptic
and laxative effect of calomel. He mentioned the new analgesic,
chloretone; he had given this to patients before the administration of
chloroform, to prevent vomiting, with good resu‘ts, and believed it
could be used in this class of cases. He asked if the intestinal con-
tents escaped into the peritoneal cavity, and if so, were they mopped
out or irrigated by saline douches.
DR. REDER said he was much pleased to hear the essayist lay
special stress upon drainage of abdominal wounds caused by bullets.
City Hospital Alumni. 295
He asked if there was anything on the drain after its removal that
would lead to the belief that the case would have progressed favorably
without drainage. With these injuries to the abdominal cavity, even
if we take the greatest precautions in cleansing and ﬁnd nothing to
drain, we do not know the future development of the case. The hu-
man economy is very peculiar in that respect, and in three to six days
after the injury is inﬂicted there might be something which requires
drainage. We depend much upon the microscope, but the microscope
does not give us the most positive assurance; there is still something
further than the microscope reveals to us to day with all the great de-
velopments secured by that instrument. The number of perforations
sustained by this man and the recovery following operation makes
the case very remarkable. It is really fortunate' that the Doctor dis-
covered all the perforations; it was fortunate for the individual that no
important vessel was in the path of the bullet, He asked if nutritive
enemata were given, and if so, what was the character of them.
THE PRESIDENT said that with indulgence of the Society he would
speak briefly on the paper under discussion. He thought that Dr.
Amyx deserved rather unusual praise. Such a grave case rarely re-
covers, and the favorable outcome speaks highly, not only for the
attending skill, but also for the extraordinary resisting powers of the
patient.
Without doubt, the policy of performing abdominal section for
perforating abdominal wounds occurring in civil practice is a conserv-
ative procedure. The development of military surgery has, however,
moulded a line of action which is quite at variance with the thought
of non military operators. Time will not permit anything like a criti-
cal survey of the growth of military surgery, even in the comparatively
limited ﬁeld of abdominal work. Sufﬁce it to say that during the
Crimean war the mortality of the English troops with perforative ab
dominal wounds was 92.5 per cent; of the French 91.3 per cent.
During the American Civrl war gunshot wounds of the intestines pro-
duced a mortality of 90 per cent, during Kitchener’s invasion of the
Soudan, 5 abdominal wounds received operation, 5 died, mortality 100
per cent. Senn reports during the Cuban campaign 4 abdominal sec-
tions with 4 deaths, mortality 100 per cent. United States Army Re-
D
296 Medical Society of
ports show during the Hispano American war 116 cases of perforating
wounds of the abdomen, of which 8: died, mortality 70 per cent; a
group of 10 cases which received operation of which 9 died, mortality
90 per cent.
The extreme exigencies prevailing in the South African, Cuban,
and Phillippine campaigns presenting abdominal sections (attended
by modern precautions) have produced a class of cases which have
received practically nothing beyond stimulation, surface cleansing and
rest; the results as a whole have been surprisingly gratifying. Many
cases, though handicapped by most serious and extensive lesions, have
recovered, and that, too, frequently without complications, and in a
comparatively smooth, uneventful fashion.
Robinson reports from the Philippine campaign records a group
of 45 cases in which the mortality was 48.9 per cent, and another of
30 cases, not operated upon, in which 10 died, mortality 33 1-3 per
cent. This. he claims includes wounds of the intestine, liver, bladder
and stomach, and that the recoveries were unusually uneventful. The
English, too, in their African campaign have been repeatedly aston-
ished at the remarkable results accruing from a non operative policy in
abdominal work. Many factors contribute, among others, the relative
emptiness of the stomach and bowel of the soldier in action, the vigor
incidental to an out-of-door life, the comparative cleanliness of the
bullet, its smooth surface, small caliber, high velocity (with the various
wound peculiarities resulting therefrom), the collapse of the walls of
this small bullet wound, satisfactory and sufﬁcient lymph exudative
processes, the quick sealing of the external wound by coagulated blood
(in dry climates) and, ﬁnally, the use of the ﬁrst-aid packages. It
requires but a moment’s reﬂection to observe that abdominal wounds
of civil life are not of these characteristics. Are we to anticipate that
conservative civil surgery of this region will markedly change its plan
of attack? Hardly; for while in military surgery the soldier as a pa
tient has the advantage of the civilian; in civil surgery the advantage
of surgical equipment and surroundings is incomparable. The greater
gravity of the condition of the civil patient. per se, must therefore be
met and overcome by our more complete surgical equipment. Yet it
is well for us to give our patients the beneﬁt of the doubt, abdominal
'3
City Hospital Alumni. 297
section should not be made the unvaryingly rigid mode of procedure.
Selected cases, without doubt, may be counted upon to recover under
the waiting policy.
The speaker added that he had had a limited experience with
chloretone both upon animals and man. During operative work upon
animals the results varied widely. At times. a most attractive anesthe-
sia was produced; yet, on the other hand, without apparent cause, the
result would be highly unsatisfactory. Dogs have been encountered
that would require two or three times their proper and usual dose and
yet from a half to three-quarters of an hour would be needed to pro-
duce unconsciousness sufﬁcient for surgical manipulations. One un-
doubted advantage lies in its prolonged period of lethargy, frequently
lasting from 24 to 36 hours. He considered it not an unvaryingly
reliable preparation. He did not indorse the statement that carbolic
acid was a cardiac depressant sufﬁcient to demand watchfulness; he
considered it compratively inoccuous in doses indicated in combating
nausea.
DR. HUGO EHRENFEST said that when Sir Wm. MacCormac, the
well-known surgeon, returned from the Transvaal he made the state-
ment that all _cases of perforative abdominal wounds operated upon,
died, and that all cases not operated upon, recovered. This statement,
of course, created quite a sensation and was 'apt to overthrow the
routine treatment of perforating abdominal wounds. A German sur-
geon, who was in the Transvaal with the German Red Cross Expedi-
tion, wrote an elaborate paper in which he tried to show that
the rules which experience made necessary in the Boer war were not
.applicable‘to perforating abdominal wounds inﬂicted during times of
peace. He brings up three points to show the difference between
wounds suffered in war and those inﬂicted during a quarrel between
individuals. The ﬁrst thing he mentions is the bullet itself. In war,
steel bullets, while in ordinary times lead bullets are used; these pro-
duce quite a different wound from the steel bullet. Second, in war-
times wounds are inﬂicted usually at a time when the intestinal tract
of the soldier is more or less empty. That makes a great difference
and this German surgeon emphasizes this point and said that the Eng-
lish soldiers, as a rule, were in a bad plight and could hardly get any-
298 Medical Society of
thing to eat before going into battle so that their intestines were really
entirely empty. He made reference to the old rule in France, that
before a man goes to meet another person in a pistol duel he always
takes a dose of castor oil. He asked Dr. Amyx if he could say at
what time of the day, or how long after eating, had the wound been
inﬂicted in the case reported. The third point brought out by the
German surgeon was that operation, as a rule, was performed under
most unfavorable circumstances. He stated that he was present at a
laparotomy performed in one English hospital, and said there were so
many ﬂies in the operating room that the moment the gut was pulled
out of the wound it became black with ﬂies. Of course, under such
conditions we would not expect good results. In conclusion, he states
that the rules given for practice in war are not applicable to wounds
inflicted in time of peace.
DR. GRADWOHL, in corroboration of Dr. Ehrenfest’s remarks, said
he read this paper some time ago, which was very interesting, and
goes far to show that the conservatism spoken of by the 'President
should be observed even in some cases in private practice. He
thought it would be wise in cases where the shock is slight and the
intestinal contents had not escaped, that the surgeon should keep his
hands off at least forqa day. The exudative material thrown out will
go a long way toward repairing perforations from bullets of striall
caliber. The attempt of Nature to close up these perforations is fur-
ther facilitated by exudation.
DR. GELLHORN referred to an article on gunshot wounds of the
pregnant uterus recently published by him. One of the cases which
was operated upon by Albarran, of Paris, resembles somewhat the
extraordinary case reported by Dr. Amyx. The intestines in Albarran’s
patient showed four wounds in the superior part of the ileum,lying two
by two and each pair 20 cm. distant from each other. Albarran re-
sected the whole injured portion of the intestines and sutured a ﬁfth
wound in another intestinal loop. In the anterior wall of the uterus
there was found a bullet hole through which a loop of the umbilical
cord was hanging. The wound of exit was found low down in the
posterior wall or the uterus. Albarran resected the protruded loop or
the umbilical cord. replaced the stump and closed the two openings in
City Hospital Alumni. 299
the uterus; 24 hours after the operation the patient expelled the fetus.
Recovery was undisturbed and perfect.
i DR. SCHARFF mentioned an interesting case seen at the City Hos-
pital. A woman, six months pregnant, shot herself through the abdo-
men the bullet penetrating the uterus and also passing through the
arm of the fetus. She was operated on three-quarters of an hour after
the injury, Cesarean section being performed. The child lived about
eight hours, but the woman made a perfect recovery.
DR. V. P. BLAIR asked why the bichloride pack had been used for
eight days after the operation. The German surgeons of the present
day. he said, use a strong solution of alcohol to produce a hyperemia
of the abdominal wall in cases of peritonitis. Some even go to the
extent of returning to the old method of blood-letting. Leaving the
bichloride pack on the abdomen for eight days], the speaker thought,
there might be danger of poisoning by absorption. If the abdomen
was made perfectly clean before the operation, and it is legitimate to
suppose that all the organisms were not killed, a pack applied for 12
hours afterwards would have accomplished everything desired. He
did not wish to be understood as criticising the method but wanted to
know the object of such continued application.
DR. AMYx, in closing, said the object of leaving the pack on so
long was to obviate the inﬂuence of any material that might have got-
ten on the abdominal wall while it was exposed to the air in chang-
ing the dressings. The discharge from the wound through the drains
was of a bloody character for the ﬁrst few days or so. The drains
were not removed for ﬁve or six days ; by that time the substance on
the drain from the peritoneal cavity was slightly purulent; this contin-
ued until the drains were removed permanently.
N o nutritive enemata were given because of the perforation in the
sigmoid ﬂexure. He was nourished wholly per os, using sometimes
albumin water and milk, and lime water and milk. There was some
intestinal contents in the peritoneal cavity, but only a little. He asked
the patient if he had eaten supper and he replied that he had not
taken food since 12 o’clock noon, so that the intestines were practically
empty, except the sigmoid ﬂexure, where there were several large
pieces of fecal matter; it was the presence of these lumps that led to
300 Medical Society of
investigation of the sigmoid ﬂexure and the discovery of the perfora-
tion. He gave one-tenth of a grain of calomel every hour until one
grain had been taken.
The pack, as stated, was not applied for the purpose of a counter-
irritant. The Hospital, as we all know, is not altogether favorable for
operative work, so he adopted the rule of always applying a bichloride
pack.
In reference to gunshot and knife wounds of the abdomen, for
six years at the City Hospital, up to 1899, he had collected 110 cases,
which he submitted to Dr. Matas, of New Orleans Of these, 35 were
simple penetrations without perforation; in these but few operations
were performed. In most instances the wounds were enlarged in order
to remove the foreign material from the track of the bullet and a drain
instituted, which was left from three to ﬁve days, then removed.
Of these cases 95 per cent recovered. Of the 110 cases, in
which there was perforation, 8 were of the stomach only; 2 recovered,
and 6 died. All were operated on. There were 67 cases of perfor-
ated intestines, stomach, or some one of the solid viscera, with one or
other of the hollow viscera. Of these 2 3.5 per cent recovered. Most
of the wounds inﬂicted were made by bullets from the ordinary pistol,
and in these cases the bullets were soft material, so that there was a
great deal of laceration and contusion. There were but few cases
that did not show marked signs of shock.
The bullets used in a Mauser riﬂe are steel covered bullets, and
have a greater velocity than the ordinary pistol balls, so that the
wounds inﬂicted by these guns are of a very different character to the ‘
wounds produced by a soft bullet, with less velocity. The treatment
is, therefore, entirely different. There should always be positive evi-
dence that an organ is wounded, before it is reported as such.
He mentioned the case of a saloonkeeper who was stabbed in
the left lumbar region. On examination the spleen was found to be
injured, and the upper portion of the kidney was cut. Palpation of
the peritoneal cavity did not reveal perforation in the splenic ﬂexure of
the colon. He put in-a drain and waited until the next day. He
then found that there had been bloody stools, so the patient was re-
moved to the hospital, the cavity opened at the original site, and the
City Hospital Alumni. 301
splenic ﬂexure investigated. Nothing was found, however, but a
simple contusion of the parts, from which blood was oozing, this caus-
ing the bloody stools. The patient recovered without further opera-
tive procedure. The manner of cleaning the peritoneal cavity of in-
testinal contents in the case reported this evening was as follows :
After closing all the perforations and making the anastomosis, the
intestines were wiped with a piece of gauze. All of the foreign mate
rial that could be seen was removed in this way.
The course of the bullet through the abdominal cavity being a
long one, I decided to ﬂush the cavity with normal saline solution.
After doing'this, the drains were placed and the abdominal wound
practically closed. The reason for using the carbolic acid in the above
case was to relieve the excessive vomiting, and at the same time offer
a means to lessen the fermentation that so often exists in such a case.
Five to eight drops in 24 hours did not produce any depressing effect
on the heart. Other cases having wounds of the intestines and other
viscera were given carbolic acid, with no apparent depressing effect on
the heart or respiration.

Meeting of December 5, 1901; Dr. Norvelle Wallace Sharpe,
President, in the Chair.
Senile Gangrene of the Right Foot.
' , Bv LOUIS J. OATMAN, M.D..
ST. LOUIS, MO.
ATIENT, Mr. William S., 8.) years of age, native of
France, farmer, married. Family history good. Pre-
vious history—claims never to have been sick in his
life as far as he knows. His present trouble began in August,
1900. While loading a wagon a box fell, striking his great
toe, the surface was abraded about the size of the toe-nail and
just below the nail; this remained in about the same condition,
refusing to heal for a month, then he noticed the toe turning
blue and also that he was loosing the sense of feeling in it.
302 Medical society of
This condition gradually extended to the ﬁrst metatarsal joint,
when a physician was called to see him. He diagnosed gan-
grene and advised amputation, which he performed. Up to
the time of operation there had been no suppuration and no
moisture. Immediately following amputation (which was done
at the ﬁrst metatarsal joint) the whole foot began to swell and
a slow inﬂammation set in. At this time I was called to see
the case and found moist gangrene, foot swollen, metatarsal
bones protruding, and suppuration with marked ‘odor. Tem-
perature 100°F., pulse 95. The patient was in bed, weak and
complaining of constant pain. Physical examination showed
general arterio-sclerosis and chronic bronchitis. A bichloride
poultice was applied and the case was treated in an antiseptic
manner; several abscesses formed and' were opened. In four
months from the time I ﬁrst saw the case the line of demarca-
tion began to form at the ankle-joint. The patient’s temper-
ature had never been above IOO°F., pulse 95 to 100. He sat
up most of the time and complained very little of pain.
As soon as the line of demarcation was well defined, I
advised amputation; he consented, and after the usual prepara-
tions he was given chloroform and the leg amputated at the
middle third; the tissues looked fairly well, the vessels very
hard and brittle. The wound was closed and a moist carbolic
dressing applied. The patient stood the anesthetic very well,
suffering very little afterwards. The wound healed by ﬁrst
intention and the patient sat up in one week.
This has been six months ago, and the patient made an
uninterrupted recovery. He now walks on an artiﬁcial foot.,
DISCUSSION.
DR. HOWARD CARTER asked if any member could suggest why
such an excellent result should follow in the case reported, where the
condition of anterio-sclerosis was so pronounced. He said it was a
remarkable recovery. The speaker thought these cases, as arule,
were inoperable.
DR. 1. C. MORFIT said the result in this case was certainly very
ﬂattering. He complimented the essayist for giving ample time for
the line of demarcation to appear. He thought the reason why the.
City Hospital Alumni. 303
primary operation at the metatarsal joint was not successful was prob-
ably because it was not done aseptically. The later operation must
have been perfectly aseptic, because union took place by ﬁrst inten-
tion, even though the vitality of the patient must have bern consider-
ably lowered. Then, too, in all probability the leg was at its best, as
regards nourishment from the blood supply; because, no doubt, suf-
ﬁcient time had elapsed before operation for the collateral circulation
to establish itself. In other words, nature had accomplished every-
thing toward amputation, except the mechanical removal of the dis-
eased limb.
DR. OATMAN said the only reason for reporting the case was the
Surprising result. It is now seven months since the operation. He
advised against an artiﬁcial foot, but the patient insisted upon having
this, and has been walking on it now for four or ﬁve months. The
patient is in good health at present. When the leg was amputated, it
was found that the vessels were so brittle that they could be tied only
with great difﬁculty. It is one of those cases where it is difﬁcult to
explain the prompt healing.
DR. L. BREMER demonstrated
Artefacts of Blood Examinations.
The nature of the subject would exclude the possibility of pre-
senting it in the form of a paper, and what you see is nothing but the
reproduction of pictures, as they were found under the microscope.
The present state of hematology is in a chaotic condition. A
great deal ‘of this confusion and chaos is due to the fact that the man
who is the most competent to speak on a subject like this, the man
who is called the father of modern hematology, has gone out of this
work, at least so far as the micro-chemical and pathological phase of
it—I mean Ehrlich.
What do we understand by an artefact? An artefact in a micro-
scopic preparation is one that will impose itself on the mind of the
observer as being something speciﬁc and characteristic, but which is
found, after repeated examinations, to be the product of certain cir-
cumstances or agents which temporarily have their effect. These
_304 Medical Society of
\
artefacts play a great part in modern publications on blood. All sorts
of things seen' in the blood have been described as characteristic of
this or that disease, especially as far as the micro-chemistry and mor-
phology of the red-blood corpuscle is concerned.
Ordinarily we ﬁnd the red blood corpuscle is represented as a
disc with a central depression. If fhat disc should present a frontal
aspect, we would see a different. shape. ' A common artefact is a cir- _
cumscribed ring inﬁthe center of the corpuscle containing no hemo-
globin. Some artefacts are due _to the manner of spreading the blood.
The method of spreading blood generally recommended is to
take two glasses, drop theblood on one and cover with the cover-
glass, and then separate the two glasses. I claim that this is a very.
fruitful source of artefacts because‘that drop, if it is too small, will
causela powerful adhesion between the two glasses, and y0u will have
great difﬁculty in separating, so great that it i is almost impossible to
do. There is an immense amount of pressure in consequence of the
adhesion between the two glasses. On the other hand, if the drop is too
large we get a very unsightly preparation, which at one point will be
very thick, at another not noticeable. To avoid this condition, I have
devised a wave-like fashion on the drop. This will allow astudy of
the red blood-corpuscle in all sorts of conditions which manipulationis
will produce, and also in conditions where manipulation has not been
at work. The drop is placed on a slide, and then the upper slide is
moved in a wave-like fashion, thereby producing hills and dales. Of
course, it must be done in such a manner that the destruction of the
red blood-corpuscle is as insigniﬁcant as possible. By this method, in
the several layers, the corpuscles will be formed in a variety of posi-'
tions and shapes. The uncolored part of the red blood-corpuscles is
the nucleus without a chromosome. 1 p
In the valleys of these smears there is little serum and in conse-
quence of this rapid drying process theIhem-oglobin is forced into the
nucleus. The characteristic morphological aspect is preserved in the
parts of the smear that contain more serum and do not dry so rapidly.
When the red blood corpuscle is looked upon vertically it will present
projections on either side. This is probably the central vesicle. It is
City... Hospital Alumni. 305
not an artefact but a real constituent. The mulberry and thorn-apple
forms are familiar artefacts.
Certain physicians have found nuclei in some red blood corpus-
cles; it is mostly hemoglobin squeezed into the central vesicle. In
some red blood-corpuscles a peg projecting from the circumference to
the center is found; it is the result of the spreading process and all
point in one direction. It is the inherent property of the hemoglobin
to assume the spheroidal shape, hence many small globules are seen
when red blood-corpuscles are destroyed. Red blood-corpuscles very
rarely contain chromosomes.
By the process of compressing in preparation various forms are
produced. The hemOglobin may be squeezed out of the red blood-cor-
puscles and it assumes a variety of forms. The vulnerability of the
corpuscles varies in different conditions. Sometimes a trabecular
formation is found; it is most commonly a nucleus.
Folding of the corpuscles produces a peculiar shape. Occasionally
a perforated corpuscle is observed; pieces of hemoglobin may be
torn off.
Another constituent of the blood are the platelets; they have been
variously interpreted ; they are not artiﬁcial bodies; they have a nuclear
center and stain differently from the red blood-corpuscles. These
bodies contain chromosomes, which the speaker had discovered several
years ago; but the central part is white and unstainable; this is a
minute globule. Several years ago the speaker had demonstrated that
the platelets were nuclei which are in a rudimentary form in normal red
blood-corpuscles, but which resume their former activity on the death
of the cell. The common picture of several platelets attached to a
cell does not signify that all come from this cell; one platelet only
arises from one cell.
The speaker demonstrated the various stages in the life history of
the platelets.
Leucocytes also change their shape and appearance if an alkaline
or neutral stain is used; in the former case the nuclei are very prom-
ment.
306 . Medical Society of
DISCUSSION.
DR. CHAS. SHATTINGER said his attention was attracted immedi-
ately by the corpuscles in the second chart with the spot of hemoglobin
in the center, which Dr. Bremer had explained as due to the pressing
in of the detached globule of hemoglobin. He had seen just such a
condition exempliﬁed in a case, about a year ago, of a girl who had
chlorosis. He had subjected specimen after specimen to an examina-
tion and in every instance this appearance was present and it had
puzzled him. He used the different dyes but soon convinced himself
that this central body was unstainable by the neutral dyes and took on
the acid stains. He then became suspicions that he was dealing with
an artiﬁcial product and set about studying the matter. He exam-
ined the ﬁrst specimen which had been previously prepared and was
surprised to ﬁnd this same globule in the center. ~
Another specimen of blood was taken with the utmost care and
examined for this spot, and in every specimen taken from this patient,
whether stained or examined unstained, he invariably found a number
of corpuscles with this appearance. Under these circumstances the
logical conclusion seemed that he was not dealing with an artiﬁcial
product; he could not think the hemoglobin had been pressed in, he
did not see how this could have been done in so many specimens, or
even in any of them where practically no pressure had be iised. The
matter remained inexplicable to him, and when he saw the picture he
felt that some explanation was promised, but he was still in doubt, and
he asked Dr. Bremer for his opinion of the condition mentioned, bear-
ing in mind that the condition was found in a so-called fresh prepara-
tion as well as in so many instances.
He also asked Dr. Bremer’s opinion of the examination of blood
in liquid vaselin. This method had been recommended and the speaker
had tried it on a number of occasions. The method does not permit
of staining but has the advantage of examining the blood in a condi-
tion nearly akin to what it is when ﬂowing in the blood-vessel. The
ﬁrst time he tried this method it required extra care in catching the
drop exactly in the center of the vaselin and covering it with another
drop of the liquid vaselin without having come in contact with any-
thing else. He was astonished at the appearance of the blood—the
City Hospital Alumni. 307
softness and pliability and the extreme ease with which the corpuscles
could ﬂoat in that medium; it seemed even SLIPBI'IH' to what is seen
when the blood is examined in the web of the frog, or in the blood-
vessels themselves He had since resorted to this method with enthu-
siasm, not as a means of clearing up the details of morphology but as
a means of noting the different appearances of the blood.
DR. HOWARD CARTER said he had observed in fresh specimens the
condition shown in the ﬁrst picture; he was familiar with this particu-
lar specimen but he had almost always failed to, ﬁnd it in the fresh
specimen and never in the vertical position. He had found another
artefact in the blood of a patient on several occasions which took on
this form, but his experience was not the same as Dr. Bremer’s, that
all pointed in the same direction, because in his case there was formed
a complete cross as though four or ﬁve corpuscles had coalesced This
particular form he had seen in the blood of one patient on several
occasions and he did not believe it was due to the manner of smearing.
He had modiﬁed the method of smearing suggested by Dr. Bremer
as he does not use a cover glass in smearing. He uses a spatula
made from celluloid and gets the drop of blood along the edge
of the spatula and without exerting any pressure on the under
side he gets an almost uniform smear with exceedingly few artefacts.
He said there was an article published in a recent number of American
Ma’z'ez'ne, which was, if nothing else, at least amusing. The writer
had been deceived by crenated corpuscles and described them as
germs.
We all fall in the error of mistaking these artefacts for something
signiﬁcant. He had examined hundreds of specimens and had himself
fallen into this error, particularly in examining blood for malaria. His
notion of the frequency of malaria has been badly shattered by these
examinations; he had examined the blood of nearly every patient giv-
ing a history of chill and fever, and the plasmodium was seen in a very
small percentage of the cases, but artefacts were found in abundance.
DR BREMER, in closing, said he had been in the same position in
regard to the central knobs, as Dr. Shattinger. He had seen thou-
sands and thousands of these ﬁlms, and concluded they must have
some clinical signiﬁcance, but when he looked at a distinct part of the
308 Medical Society of
specimen he could not ﬁnd them. That is whereithe rub comes. , We
may see these things with regularity in certain areas and think they
mean something. For a long time he believed they had a morpho-
logical and pathological signiﬁcance, but when he paid closer atten-
tion to them and looked for the other side, he ﬁnally concluded they
must be artefacts. He said there is a possibility that, in consequence
of mechanical injury, certain forms are more readily injured than the
blood of the healthy, and we do see this formation in the blood of dis-
eased persons when it is not fOund in healthy blood, but in the fresh
specimen he had been unable to discover it, unless it was after air had
acted on the specimen.
The corpuscles are extremely delicate structures, and can be dis-
arranged, injured and disﬁgured by a breath of air, and more so by
mechanical injury. He said he was not familiar with the liquid vase-
lin preparation, so he could not speak of that method. The celluloid
spatula he considered a good thing, and had employed it, but it can
not be cleaned readily.
Malaria, he thought, comparatively scarce. Out of ten cases of
pronounced malarial conditions, he believed there would be demon-
strated but one case of real malaria. Some years ago he read a paper
on the abuse of the term malaria, and the habit of giving enormous
doses of quinine. He protested at that time against the indiscriminate
use of quinine, there being many conditions with chills and fever that
are not malarial, and are now called autoinfection, and some cases,
where the history of the case shows the attacks, come with the regu-
larity and periodicity of malaria. In these cases he has hunted for
the plasmodium, and been astonished at his failure to ﬁnd it, so that
he came to the conclusion that malaria is almost a myth in this part
of the country. He had even visited the City Hospital and examined
the many patients giving this history, and the cases had been
diagnosed malaria, without; ﬁnding one true case of malaria. This is
very strange, and does not seem to agree with the present idea of the
transference of malaria by the mosquito.
The artefacts found in supposed malarial blood, spoken of by Dr.
Carter, the speaker had often seen. Some very remarkable specimens
have been sent him by out-of-town physicians to demonstrate the
City Hospital Alumni. 309
presence of plasmodium, and often the place where the plasmodium
could be found was marked. Some most incredible things were seen
under these circumstances, even down to a piece of dirt, which had
been looked upon as the plasmodium.
Laryngeal Crisis in Locomotor Ataxia: Report
of a Case. 1
BY CHARLES ]. ORR, M.D.,
ST. LOUIS, MO.
HIS particular symptom of tabes dorsalis occurs in but
a small per cent of the cases observed and reported.
Coming, as it does early in the disease, before the gen-
eral group of symptoms appear, it is quite often misleading,
causing error in diagnosis, failure in treatment, and humilia-
tion to the attending physician.
Frequently laryngeal crisis is accompanied by paralysis,
though not always, as the case reported hereafter will show.
The common laryngeal crisis resembles an attack of whoop-
ing-cough; the sensation of tickling or choking usually pre-
cedes the attack, yet the spasm may develop very suddenly;
then we have the very severe attacks, in which ’there is suffo-
cation, loss of consciousness, or even an alarming convulsion.
The patient will struggle laboriously to breathe and give long,
noisy respirations, and as this becomes more difﬁcult his face
gets ﬁrst pale then cyanosed and, ﬁnally, an epileptic paroxysm
may ensue. Usually the process does not go to the extreme;
after a few seconds or minutes at most, the contraction of the
glottis relaxes and the patient quickly recovers. Death, how-
ever, may occur in one of these attacks.
The different forms of laryngeal crises may occur in the
same patient ;, he may suffer for a long time with the lighter
attacks and become a victim of the severe ones; they may
vary greatly in the frequency of their occurrence, sometimes
coming so often as to almost preclude the patient’s sleeping,
and, again, not a single attack for days; sometimes the slight-
810 Medical Society of
est cause may bring on a violent attack; frequently no cause
for the particular spasm can be detected.
If there is no laryngeal paralysis present the local exam-
ination may reveal nothing abnormal or only a hyperemic
mucous membrane which is very sensitive. The paralysis
(usually the abductors) frequently is revealed at the ﬁrst ex-
amination and if not present may be expected later; if uni-
lateral it may cause little or no trouble. It is more often bi-
lateral and this causes difﬁculty in breathing, which becomes
yery noticeable if the patient makes any extra physical effort,
such as walking rapidly, climbing stairs, etc. The voice re-
mains clear but tires quickly. When the paralysis is present
the attacks seem to be more severe in character. Rarely we
ﬁnd a condition of anesthesia in the larynx instead of hyper-
esthesia, which is the more common one. The paralyses when
found are usually persistent and rarely show much im-
provement.
Iam sorryI am unable to present the patient..for your
personal inspection for I feel sure he is a victim of that relent~
less disease—locomotor ataxia, though the presence of three
cardinal symptoms, as yet, can not be demonstrated. I wish
to conﬁrm the statement which is not made by all authors on
this subject, that this laryngeal crisis, when present, is an early
symptom of locomotor ataxia. I have heard, or read some-
where, the opinion that laryngeal crises occur only in individ—
uals whose nerve resistance is weak, in my limited observation
I have found this true.
CASE—Mr. ]. ]., American, white, aged 28 years, height
5 feet 7 3-4 inches, weight 125 pounds; married; nervous
temperament. Father and three sisters living and in good
health, all similar in height and comparative weight; mother
died at the age of about 35 years of accident. The patient
had the usual diseases of childhood, and though always rather
slender in ﬁgure usually enjoyed excellent health. Six years
ago he contracted syphilis and was treated rather constantly
for about two years in the usual way, and thought he was
cured. About three years ago he had seemingly a severe
attack of la grippe, from which he recovered promptly in
City Hospital Alumni. 311
two weeks, except severe pains in the back lumbar region;
these persisted for about three months; he especially suffered
after sitting and when attempting to rise, or after lying in
bed all night and trying to get up and dress. These ﬁnally
disappeared and for months he was quite well. He was mar-
ried about this time, two and a half years ago. Has one child
one year old; both wife and baby are in perfect health.
In _Iuly, 1900(17 months ago), while riding in an open
summer car he was taken suddenly with a violent cough and
choking spell, it lasted only a few moments but alarmed him
greatly, his impression was that a gnat or something of that
kind had suddenly ,been sucked into the larynx. In a few
days afterwards another attack occurred while he was eating,
and at this time the cause was thought to be a bread-crumb.
About this time he consulted me; I examined his nose, throat
and larynx and observed several abnormalities but nothing to
whichI could assign the true cause of laryngeal spasm. I
discovered the larynx very sensitive to any application, and
frequently followed by a spasm. During the next three or
four months I saw him occasionally and learned that these at-
tacks continued to occur with varying frequency. I prescribed
proto iodid and gave various local applications, but with little
or no beneﬁt
In March, 1901, he was attacked again with what seemed
to be an acute muscular rheumatism, having some fever rang-
ing from 100° to 102°F., intense pain over the entire body but
especially in the back and thighs. Examination at this time
revealed marked anesthesia of the skin over the lower limbs,
especially over the legs; sharp pins could be thrust through
the deep layers with no unpleasant feeling to the patient.
Sensation was seemingly normal over the plantar surface.
The pupils reacted promptly to light. There was very slight
unsteadyness on standing erect with eyes closed. Patellar
reﬂex was, perhaps, slightly diminished. No ataxia was
observed.
Dr. Fry saw the patient several different times and a pro-
visional diagnosis of locomotor ataxia was made. After about
one month’s illness he recovered entirely from the acute symp-
toms. He has been more or less under my observation and
312 Medical Society of
treatment ever since. The laryngeal crises continue, not so
frequent, however, and not so severe. During the past six
months he has been free of all muscular pains, has gained ﬁve
pounds in weight, looks and feels well, excepting the occasional
laryngeal spasms, which are to him always alarming.
Present Condition—Marked anesthesia of the skin and
deeper tissues over the legs and the same condition, only not
so marked, over the thighs; acute sensation over arms and
body; knee-jerks less responsive; temperature sense acute,
especially for cold; some anesthesia, at times, of the bladder,
as evidenced by tardy ﬂow and straining necessitated to void
it; no uretheral obstruction; retains his urine longer but
empties the bladder perfectly. No double vision; no ataxia,
except slight inability to stand on one foot and put the other
heel to the knee; can easily walk a line and is conscious of no
misstep or unusual sensation in walking' in the dark or when
barefooted. The patient is very much inclined to constipation,
and has observed no loss of sexual powers.
DISCUSSION.
DR. W. E. SAUER congratulated Dr. Orr on making this diagnosrs
so early. While it is true that in the adult, one of the ﬁrst causes of
laryngeal spasm is given as tabes, there are many other causes, and a
diagnosis of tabes is made only after a long observation of the patient.
We often see laryngeal spasm in perfectly healthy persons. Among
other causes are hysteria and neurasthenia, especially in women. He
had seen tracheotomy performed in a severe case in order to save the
life of the patient. Gower states that laryngeal spasm is next in fre-
quency in tabes to gastric disturbances. In 100 cases of tabes the
larynx was involved in 14. Gerhart reports 122 cases of tabes with
involvement of larynx in 17. It is exceedingly difﬁcult to make a diag-
nosis of tabes in these cases, especially in the beginning, and then only
by exclusion, unless, of course, other tabetic symptoms are pronounced.
In this case there was nothing but the cough and history of lues.
DR. BREMER thought the case really one of tabes. The signs
may be there in their incipiency. in an abortive state, but we are una-
ble to perceive them. He thought that when one has heard the pecu-
City Hospital Alumni. 313
liar cough, so characteristic of laryngeal crisis, it is never forgotten,
and he knew of nothing to compare with it. He thought this peculiar
affection was more often found in juvenile tabetics than in older ones,
that is, in persons with a syphilitic infection, dating back not more
than four or ﬁve years; where the infection is ﬁfteen to twenty-ﬁve
yearg old, this is not so. Referring to the usual treatment of syphilis,
namely, the use of iodid of potassium, as mentioned by the essayist,
the speaker did not think the iodid of potassium treatment the
proper treatment. There may be conditions simulating tabes, but
which in reality are due to the syphilitic infection, such as a neu-
ritis, or the formation of gummata or inﬂammations of various kinds,
when the antisyphilitic treatment is in order. He doubted, however,
that any real beneﬁt would be derived from the use of iodid of potas-
sium or soda, or other salts, in an ordinary case of tabes, that is, where
the sclerotic and degenerative changes are already in process. He
rather thought they would do harm. This, he thought, is often seen
in patients who have returned from Hot Springs, even where the m-
jurious effect of the hot-air baths have been sustained. The patient
is put on a thorough course of iodid of potassium, and when he re-
turns he is worse than ever, or soon afterwards he shows the ill effects
of the treatment, and sometimes the condition is even grave. The
iodid in these cases is a destructive poison, and the outlook for the
patient is not nearly as good as if he had been let alone. This is the
result of his observation during many years, and after watching a
great many tabetics. His conviction is that the iodid of potassium is
a deadly drug for the tabetic. except in such cases where the charac-
ter-istic lesions of syphilis of the spinal cord or brain give rise to the
picture without there being tabes. These remarks, however, were not
by any means in the nature of a criticism upon the treatment of the
case mentioned by the essayist—merely an exchange of experiences.
DR. ORR, in closing, said his experience in the treatment of ta-
betics was limited. Dr. Bremer stated that in cases in which there
has been true degeneration, the iodid not only does no good, but
is harmful. This, the speaker admitted, but the best writers on the
treatment of locomotor ataxia whom he had consulted, based upon
these facts, namely, that the majority, if not all, cases of locomotor
314 Medical Society of
ataxia follow upon syphilitic infection, that when degeneration has
taken place nothing avails, but where a syphilitic condition exists,
either in the restoration of tissues where degeneration has not taken
place, or in tissues proceeding to a degeneration, the iodid does pre-
vail, and that is the position he took. In this particular case he said
it might be taken for granted that a limited degeneration had taken
place, but a restoration with only a partial destruction or a prevention
of the spread of the degenerative process, is the object to be attained.

Meeting of Deeeméer 19, 1901; Dr. [Vowel/e Wallace Sharpe,
President, in the Chair.
Studies About Agglutinins.
BY CARL FISCH, M.D.,
ST. LOUIS, MO.
ABOUT a year ago I had the pleasure of reporting to you
the result of some experiments,1 which, for the ﬁrst time
demonstrated, that the several forms of proteins—I had
especial reference to the casein—found in different animals
were not identical with each other, but that the homologous
proteins, although chemically not distinguishable, could biolog-
ically, distinctly be differentiated from each other. As you
perhaps remember, I obtained this evidence by immunizing or
injecting animals with milk from various sources. Thus I ob-
tained sera that, in a peculiar way, reacted on the milk, by
the injection of which they were produced—I mean the pre-
cipitation of the casein of this milk by its homologous serum.
This reaction was so speciﬁc, that the serum of an animal im-
munized with goat’s milk did not affect the casein of woman’s
milk or of cows’ milk, and vice versa. My observations have
been fully conﬁrmed a little later by Wasserman and Schiitze,
and from them evolved a great number of investigations in
the same line, that now enable us, to prove the fact that all
chemically homologous proteins of different animals are
City Hospital Alumni.
Q0
15
different from each other. A practical result of these~investi~
gations we possess already in an elegant method of determin-
ing the presence or absence of human blood in suspected
material, a method which, as to exactness and delicacy, leaves
all the methods hitherto in use far behind.
What I demonstrated, was the production of a coagulin,
a substance that in its qualities could be further characterized
by its neutralization by an artiﬁcially prepared antienzym. I
have since continued my work on some other coagulins, the
so-called bacterial agglutinins, an instance of which is known
to all of you, from the Widal reaction. The trend of my ex-
periments would, however, escape you, if I would not, before
detailing them, give in a few words the relation they have to
Ehrlich’s side-chain theory. As you know, Ehrlich considers
the reaction taking place between toxin and antitoxin as a
simple chemical one, a factor that he can well be proud to
have established by an enormous amount of work of the most
unobjectionable character. You know, furthermore, that the
antitoxin to Ehrlich is nothing but certain protoplasmic
groups of various cells, which, by combining with the toxin,
are eliminated from the household of the cell. Since they
are necessary to the integrity of the latter, they are repro-
duced, and since reproduction always means a hyperproduc-
tion, they are reproduced in number too great for the need of
the cell. Subsequently, then, they are detached, and now ap-
pear as antitoxin in the body ﬂuids. We have long known of
substances assimilable to the protoplasm, forming ﬁrm com-
pounds with it. But our notion about these substances has
been restricted to nutritive substances, while Ehrlich widens
it and extends it to all organic substances, having the proper
chemic afﬁnity to the above-named protoplasmic groups. The
phenomenon of intoxication thus ranges itself among the
normal physiologic processes of cell life. Ehrlich calls these
protoplasmic groups or side-chains, receptors; in the case
where only ferments, cell secretions, or toxins are the combin-
ing substances, that means, comparatively simple compounds,
nothing else is present, and there this form of receptors is
called the one of the ﬁrst order. Wherever the combination
with high-molecular albuminoids or even the dealing with a
316 Medical Society of
whole gell is concerned, a more complicated mechanism is
necessary. There the ﬁxation of such a giant-molecule is
merely the eondz'tz'o sine qua um, and it can be utilized for the
nutritive functions of the cell only through fragmentation, by
means of fermentative processes.
This can be achieved in two ways. It may be that the
receptor besides the group, which secures the ﬁxation of the
molecule, possesses itself of another active group of enzymotic
properties; like, for instance, the tentacles of the sundew,
serve at the same time to the catching of insects and to the
secretion of ferments for their digestion. Receptors of this
kind are those of the second order. But it has been found
that the main functions in cell life are performed by a still
more complex mechanism, by the receptors of the third order
or the amboceptors. In these the receptor is provided with
two “catching” groups, in the way of tentacles, of which one
attaches itself to and ﬁxes the molecule or cell to be mastered,
while the other attracts from the surrounding medium the
normally present fermentative substances. It is one of the
most gratifying tasks to follow Ehrlich in the positive estab-
lishment of these facts, which, to an occasional intruder into
this subject, appear more like phantadms. By innumerable
painstaking investigations, Ehrlich and his associates, were
able to lay clear the course of these processes, and especially
the so-called hemolysis (that means the destruction of the red
corpuscles of an animal by the serum of another animal) has
now been bared of much mystery.
Another very startling fact that was _found during these
researches, was the great number of different speciﬁc receptors
that are present in any animal organism, a fact which, with the
innumerable variations and combinations that it offers, has
shed a great light on many so far unexplained phenomena in
regard to immunity. The term speciﬁcity must not be
widened, but rather narrowed; there is not one speciﬁc re-
ceptor corresponding to each substance, with which the cell
protoplasm may happen to come in contact, but the latter
may ﬁt with greater or less ease into different receptors, or, as
it is expressed, its chemical afﬁnity for various receptors may
be of different degree. It is one of Ehrlich’s most ingenious
City Hospital Alurnnl. 317
feats to have positively established this fact for a number of
hemolytic substances. He lays a great stress on this point,
although it extends the realms of investigation almost to
nebulous distances.
So far, only for receptors of the third order, this fact has
been clearly proved, or more strictly, for hemolysins. It
would be of the utmost interest, to attempt to do so for other
forms of receptors, perhaps of the second order, that means
for protoplasmic groups, which, in addition to the catching
mechanism, if we may call it so, are provided themselves with
an active fermentative constituent.
The Widal reaction, which, to 'the majority is only known
as a diagnostic aid, offers such a chance. In a great number
of immunizing processes, with varying material, one of the
results is that the immune serum, when brought together with.
the immunizing substance, produces precipitation (like in the
before mentioned test for blood), or, if these substances are
cells, that it causes the cells to agglutinate. The most differ-
ent theories have been advanced to explain this curious phe-
nomenon; none is satisfactory, and the best we can say is,
that we have to deal in it with a physical process. I shall ex-
plain that later.
To the great degree, in which practically the Widal reac-
tion is used, it is due that we have become acquainted with
certain discrepancies in its results, which mainly has had the
effect to evoke discussions about the practical value of the
reaction. You know, that in some typical cases of typhoid
fever the reaction will totally fail, that in others of intense
severity it will be weak, as it is called, and that very light
cases sometimes give a very strong reaction. Although a
great number of explanations could rationally be advanced
for these occurrences, none would be conclusive, since it could
not be proved by direct experiment. This is different in ani-
mal experimentation, where, with the factors in the case
known or determinable, the results ought to be constant.
However, this is not the case. It has often been observed,
that the serum of animals immunized with typhoid cultures
behaved very differently sometimes to cultures of the typhoid
bacillus from different sources. As the potency of the im-
318 Medical Society, of
mune serum for the agglutinativeiproperties is measured by
the dilution, in which it will clump together the bacilli of a
standard suspension, it was found, that while an immune
serum always aggutinated the bacilli, by which it was pro-
duced in the same dilution, its agglutinative power was higher
or lower for other cultures. How can that be explained, if we
assume that a typhoid bacillus is always one and the same
thing? Durham,2 in his remarkable treatise on agglutinating
sera, encountered especially these differences; and he, in a
hypothetic way, assumed that the partial and mutual reactions
were due to the fact that the agglutinin was not a single sub-
stance, but composed of a number of constituents, of which
each one must ﬁt into the corresponding bacillus, to bring
about the complete reaction. He found that agglutination by
typhoid sera occurred even with bacteria of other species, only
in a much less active and pronounced way, than with the
homologous bacilli, and vice versa.
In the beginning of this year my attention was especially
called to this phenomenon by the serum of a rabbit that I had
highly immunized by means of a typhoid culture for years
kept and transplanted in my laboratory. I do not remember
its source. This serum agglutinated the bacilli at a dilution
of I to 5,000. When tried on a bacillus isolated from the
spleen of a typhoid fever patient, the reaction was only ob—
tained at a dilution of I to 500, while serum of another rabbit
immunized with this latter bacillus agglutinated it at I to 2,000
and the former bacillus at about the same dilution. To learn
more of this perplexing experience, I started on a series of
experiments, of which in the following I can give only a
résumé, since the details would be trying to your patience.
I experimented With four different cultures of typhoid
bacilli (one, the old culture, and three (2, 3 and 4) isolated
from different typhoid fever _cases, coming to autopsy at the
City Hospital); to these were added a culture (5) of a bacil-
lus, that I shall call, for the want of a better name, coli com-
mune, and which was obtained from a case of cystitis. In
order to make the results more easily appreciated and under-
stood, I must say some words about the methods used in
them. The immunization of the animals was obtained by
City Hospital Alumni. 319
intraperitoneal injections of emulsions of agar cultures twenty-
four hours old, grown at 37°C., given at intervals of about a
week. These emulsions were increased in density, ﬁrst by
the number of loopfuls (always the same loop was used), sus-
pended in a certain amount of salt solution, afterwards by
quarter, half, whole, etc., cultures. Before injection the emul-
sions were heated to 60°C., for three-quarters of an hour. All
of the rabbits were treated this way; a goat received the in-
jections subcutaneously. After a certain period some blood
was drawn from an auricular vein and tested, and if found
agglutinating to a sufﬁcient degree, the animal bled to death.
The serum was preserved under toluol, in tightly stoppered
bottles. Its potency keeps this way unaltered almost in-
deﬁnitely (at least for six months).
For the testing of agglutinating power, only twenty-four
hours’ agar cultures were used. One loopful of the growth
was taken and suspended in 2 cc. of physiologic salt solution,
the diluted serum added, and the contents ﬁlled up to 5 cc.,
with salt solution. The test tubes were kept in an incubator
at 37°C. for two hours and the result noted. The reaction
was considered complete, when, after this time, the ﬂuid in the
tube appeared clear. In doubtful cases centrifugation ensued
and to the decanted ﬂuid some fresh emulsion was again
added: Since the term, complete reaction in these tests is
much more arbitrary, than, for instance, in experiments with
blood corppscles, every experimenter must form his standard,
or accept exactly the one of another author. I found that
my method was satisfactory, and yielded good results.
The results of the direct experiments are contained in the
appended table, the number given to the different sera corre-
sponds to the number of the culture, with which the rabbits
were immunized; an additional letter a and e indicating that
two rabbits were injected. The goat was immunized with the
culture I.
320 Medical Society of


T1. T2. T3. T4. C5.
Ser. Goat . . . . . . . . . . . . . . l : IOOOO r: 2500i : 5000 r : 5000 I : IOO
Ser. I . . . . . . . . . . . . . . .. 1:5000 1:500 1230001:25001:100
Ser. 2a . . . . . . . . . . . . . . .. I : 2000 1_: 2000 r : 500 r z 500 0
Ser. 26 . . . . . . . . . . . . . . .. r : 4000 I : 7000 I : 1000 r : i250 0
Ser. 3 . . . . . . . . . . . . . . . .. 125000 1:5ooor : 7500 1: 7000 I : 500
Ser. 4 . . . . . . . . . . . . . . . ..‘1:5ooo I : 2500 I : 7000 I : 7000 I : 75o
Ser. Col. 5 . . . . . . . . . . . . . o o l 500 500 I : 4500

A closer study of this table shows certain regularities, in
spite of the seemingly lawless appearance of the ﬁgures. The
ﬁrst impression gathered from it is the great difference of ac-
tivity of the sera towards various races of bacilli. On the
other side, while certainly typhoid bacilli I and 2 represent
widely distant types of these bacilli, the bacilli 3 and 4 are
very much alike, as is also expressed in the behavior of their
sera. Still, here, too, a great difference is'noticed in compar-
ing the activity of their sera towards TI and T2. Since all
the observations were made under absolutely the same condi-
tions, and since the differences are so marked, an error is ex
cluded.
The question now arises, how, on the basis of the side-
chain theory, all of these facts can be accounted for? The
agglutination is due to the combined action of a speciﬁc por-
tion of bacillary protoplasm, and of another substance fur-
nished by the immunization of the animal. We must agree
that the receptors of the serum attach themselves to the pro-
toplasmic portions of the bacillus, to which they have a
speciﬁc afﬁnity. Now, it would be,highly illogic to assume
that each bacillus had only one of these particular groups,
just as little as each ganglion cell, must be supposed to be
fatally intoxicated by the combination of one antitoxin gi'oup
with one toxin molecule or micella. We know rather that
every animal cell is' the bearer of a great number of such re-
ceptors, which are either all alike or differ in their stereo-
chemic constitution more or less, and, thereforefin their chemi-
cal afﬁnity for the substances, with which they come in contact.
For certain bactericidal substances this has been directly dem-
onstrated by Neisser and Wechsberg, and in this lies the reason,
why bactericidal sera in certain doses rather kill the infected
City Hospital Alumni. 321
animal than protect it. It is only a logic consequence that we
assume that the speciﬁc groups of a bacillus or another cell
are not all of them identical, and that the immune bodies pro-
duced by them during immunization are not all of them of
the same kind. As well as the hemolytic substances can be
proved to be different in character in one and the same
animal, we have a right to apply the same reasoning to the
agglutinins. If this is the case, if we can prove that one and
the same typhoid bacillus produces in an animal not one agglu-
tinin, but different varieties of it, varieties that in their
afﬁnity for bacillary protoplasm vary, and that, therefore,
agglutinate one race of bacilli better than another, we have
only to look for the method to show it. This method is given
by what Ehrlich calls the “partial absorption experiments.”
I have applied them to the agglutinins, and have come to the
following results, which are the résumé ofa great number of
single experiments.
As appears from what has been said about the action of
the receptors of all orders, they are, during the process of
neutralizing the corresponding groups, used up and made
inert. If we add blood-corpuscles to hemolytic serum as long
as they are dissolved, we come to a point where hemolytic ac-
tion of this serum can not be demonstrated any more. The same
obtains for the agglutinins. An agglutinating serum, to which
bacteria have been added to saturation, that means, to the limit
of its agglutinating power, becomes inert. By rapid centri-
fuging, it is easy to separate the serum from the bacilli and to
obtain a clear ﬂuid, to which now a fresh bacillary suspension
can be mixed without the slightest trace of clumping appear-
ing. In this way I tested my sera. A common centrifuge,
which gives 3 to 4000 revolutions, and into which small test
tubes are ﬁtted, does good service. It is not absolutely neces-
sary to get rid of all of the bacilli in such a suspension, as
microscopic examination is always used for control.
The exact agglutinating power, according to my method,
being known, it was only necessary to add a slight surplus of
bacteria to the serum. The quantity of ﬂuid was always as
much as possible kept near 5 cc.
With serum No. I of the goat, and the same serum No. I
322 Medical Society of
of a rabbit, the result always was that after separation with
Typh. No. 1, none of the other bacilli were agglutinated, when
added to the clean centrifugate. The same was true for serum
2 and 2a. Serum 3 and 4, when treated in the same way with
Bac. I, behaved differently; here T2 was not agglutinated,
but a distinct reaction appeared when the centrifugate was
mixed with emulsions of T3 and T4. On the other hand,
when serum 3 or 4 were exhausted by their homologous
bacilli, there was no agglutinin left for TI or T2. And
again, Serum I could not be deprived of all of its agglutinin
by clumping in it T3 or T4; on addition of TI to the centri-
fugated mixture, distinct and typical agglutination occurred.
As to the race of coli used, in no case could any agglutination
be observed, after the sera had been deagglutinized by their
homologous bacilli.
Other experiments were made to exhaust the agglutinin
supply of a serum by a heterologous bacillus; so, for instance,
was added to Serum 2a the typhoid bacillus No. 3, until no
more clumping would occur; after centrifugalizing to different
portions of the ﬂuid TI and T2 were given, and a copious
clustering occurred. Several more experiments gave similar
results, which, it would tire you, to describe more in detail.
This observation is of especial importance, since it shows we
really have to deal here with distinctly different substances.
It is proved by what has been said, that the agglutinins
of immune sera act differently on different races of the same
bacillus. It is proved that immunization with one bacillus
produces receptors of various kinds, some very similar,to each
other in their chemical afﬁnity, others widely different, and,
therefore, unable to act on other races of the same species of
bacterium. We are justiﬁed to say that the multiplicity of
receptors obtains, too, for the agglutinins. I can not here
enter into the theoretic possibilities that this fact opens up.
So far we have only dealt with the morphologic phenom-
enon of agglutination, as the expression of a process that
takes place when an immune serum acts on the bacterium, by
which this serum was produced. But this does not explain
the process of agglutination, the observation that the bacteria
under these circumstances are forced to clump together in
City Hospital Alumni. 323
larger and smaller masses, without being impaired in their
vitality. For we see that if we leave a clump of these bac-
teria alone, they begin to multiply and to produce new gen-
erations, as long as the nutritive material supplied lasts. I do
not mention the impairment of mobility, because we see
typical clumping reactionsjust as well in immotile cells and
immotile bacteria. That all of the explanations offered do
not satisfy the observed facts, I have already mentioned. Cer-
tainly it is not mere combination of the agglutinin of serum
with the susceptible substance of the bacterium, which causes
agglutination. If we subject the serum as well as the suspen-
sion of typhoid bacilli to dialyzation, until the water ﬂowing
from the dialyzator shows no trace of chlorine, the mixture of
these two ﬂuids does not bring about the clumping reaction.
If the slightest amount of sodium chloride is added, the reac-
tion sets in immediately. That here the salt has nothing to
do with the binding of the agglutinin to the bacterial sub-
stance, can easily be shown; Let us centrifugate the mixture
before the addition of salt, pour off the clear ﬂuid and sus-
pend the precipitate of bacteria in distilled water, eventually
centrifugate again and suspend again, to wash away the last
trace of the adhering primary ﬂuid. Now we add to the clear
centrifugate a culture of bacteria suspended in salt solution,
no agglutination will occur. We add to the suspended bac-
teria on the other side a little salt, and instantaneously the
clumping will begin.
We see thus that binding of agglutinin to the bacteria
does not cause directly agglutination, but that the interference
of other chemical substances is necessary for the latter. I
will say, in addition, that the dialyzation does not lessen in
any way the vitality of the bacteria, as they appearjust as
active and motile in such a suspension as in physiologic
solution. Dialyzation can be most conveniently obtained in
small collodion sacs, made over the end of a test tube.
Some other substance causes the same process that makes
the bacteria cluster together. ]'oos3 and Friedberger‘ have
published beautiful experiments on this phenomenon and
found that not sodium chloride need to be this substance.
Other salts, and even some colloid substances, like glucose
324 Medical Society of
asparagin, act in the same way, and some of them more ener-
getically than Na Cl.
I have repeated these experiments and modiﬁed them in
various ways; in all points I could conﬁrm the results of those
authors. The salt concentration to which the mixture of
dialyzed serum and bacillary suspension has to be brought, is
very low. A sodium chloride addition to make the whole contain
about 0.0467 g. mol p. liter, that means 2.7 per m., will cause
agglutination immediately. In this respect I differ especially
from Friedberger, who maintains that even lower percentages
produce the phenomena. With increasing height of the per-
centage of salt no differences are observed. In 30 per cent up
to saturated solutions no agglutination occurs, as I found. For
other salts the ﬁgures are a little different, but show the
same range. It has been asserted by loos that the action of
the salts is chemic, that a combination between it and the
agglutinins takes place. The evidence that he brings to
strengthen this supposition, is, however, not conclusive, and
can be omitted here. It is much more likely that the salt acts
merely by the setting in force of physical phenomena, like we
observe them in coagulation processes. And here I can not
refrain from directing your attention to the recent work, that,
especially by Posternak,5 has been done on the physical prop-
erties of the micellae of proteids.
While so far our knowledge of the properties of proteids
and particularly their classiﬁcation has been based on chemi-
cal reactions, to which coagulation and precipitation also were
added, it can be shown that many of these chemical charac-
teristics have nothing to do with chemical energy, but are
merely the expression of the play of physical forces acting on
these substances. We owe it to the advances of physical
chemistry that many mysterious corners of organic chemistry
begin to be elucidated. Forgetting the colloid nature of
proteids and not knowing very much about colloid substances,
we classiﬁed the proteids merely as chemical bodies and re-
ferred all of their so-called chemical characteristics to their
molecular structure. Thus, it came about that mere changes
of their physical properties were attributed to chemical differ-
ence and that on mere physical phenomena the farthest-reach-
City Hospital Alumni. 325
ing speculations about the molecular texture were built. What
we know about albumins, globulins, nucleo albumins, etc., is
merely physical, and nevertheless we utilize this knowledge
chemically.
The solution of a colloid body is not impermeable to cer-
tain membranes, because the molecules of the dissolved sub-
stance are too large to pass the pores of this membrane, but
because the molecules of these colloids behave differently
to the dissociating action of the solvent. We know too much '
about crystals in inorganic chemistry to assume that in the
solid substance the molecules are, as it were, isolated; we
know, that here too, they appear in the form of distinctly
grouped and arranged complexes, but for which the dissocia-
ting power of water is so great that in it they separate into
the single molecules. Colloids are merely substances for
which this power is not so disintegrating, colloids differ only
in this from other substances that the water or another sol-
vent does not dissociate their micellar grouping to the degree
to which the simple chemical compounds are disintegrated.
Colloids remain in solution as long as the equilibrium between
the size and elasticity of their micelles and the degree
of dissociating power is maintained. As the elasticity of the
micellae may be considered constant, it is mainly their size,
which can be inﬂuenced by various moments, for instance, the
temperature. We are, however, more interested here in the
change of forces in the dissolving ﬂuid.
If we take a proteid soluble in a certain ﬂuid and thus
disintegrate it to a certain size of its micellae, we can by intro-
ducing certain factors into this ﬂuid act on the size of these
micellze. Posternak has made a great series of fascinating
attempts in this line; to sketch them appropriately would go
much too far for our purposes, but one point I have to mention
with a few words, because it touches, as you will see, the sub-
ject under discussion.
If we dissolve in, let us say, a slightly alkaline or acid
water some proteid, we can by gradually adding small amounts
of sodium chloride, ﬁnally produce a complete precipitation of
the proteid. What occurs by the dissolving of the salt? You
know that we not simply obtain a solution of Na Cl molecules
326 Medical Society of
in water, but that a certain proportion of these molecules is
dissociated into the two ions Na and Cl. This proportion in-
creases and decreases with the greater or lower molecular
concentration of the ﬂuid, so that we well can imagine a solu-
tion in which not a single molecule of Na Cl exists as such,
but where all of the molecules are disintegrated into the elec-
tropositive cation Na and the electronegative anion Cl. It
was found by the author mentioned that under similar condi-
tions the precipitation began'always at a certain and constant
concentration, that means at a time when the relation of the
number of free ions to the nondissociated molecules reached
a certain proportion. This varied when different salts were
used, but was always constant, and the variations are fully ac-
counted for by the difference of the mobility, electric conduct-
ibility, etc., of the different ions, a point which I can only
mention.
We must conclude from these experiments that there is a
battle going on between the ions and the intact molecules for
the possession of the proteid micellae, for which the latter have
a speciﬁc adhesive, but not chemical afﬁnity. The former have
a tendency to decrease the size of the micellae, while the latter
increase it to the point of in_solubility or precipitation.
I am sorry that what I say here must appear more or less
phantastic, but it would take many hours to prove that the
picture I used is really merely a humanized paraphrase of the
processes going on in such a solution. The reason why I had
to enter into the subject altogether, was that from it could be
derived a rational explanation of the phenomenon of bacterial
and cellular agglutination. I made especial eXperiments to
ﬁnd out how much salt could be added without producing in a
mixture of dialyzed serum and dialyzed suspension of bacilli
the actual agglutination. I found that for Na C1 the lowest
limit was a solution of 2.73 per m. (0.0467 g. mol p. liter), in
which the coefﬁcient of dissociation is equal to 2.
Solutions more diluted than that leave these mixtures in-
tact and the single bacilli as isolated and motile as they were
before. In other words, here also everything points to the fact
that as the number of intact salt molecules increases, the co-
agulable substance formed by the union 'of the agglutinins and
City Hospital Alumni. 327
the susceptible protoplasm of the bacillus is precipitated; and,
perhaps, Kraus is right when he brings it into analogy with
the precipitates produced in a ﬁltrated culture by immune
serum. .
If we return to our starting point, when we said that the
agglutinins were receptors of the second order and contained
besides the one haptophorous or catching group, a group
which directly was able to act on the prey, a fermentative
group, we may state the process thus: After the attachment
of the agglutinin receptor to the protoplasm of the bacillus
the fermentative group of the former begins to exert its action
on this protoplasm. The resulting substance is soluble in the
ﬂuids of the protoplasm, but coagulates as soon as the bacil-
lus is, by osmosis, invaded with a solution exceeding a certain
molecular concentration. The fact that the bacilli are not
destroyed, but continue to live in spite of the agglutination,
may be due to the presence of the susceptible substance only
in the external layer of the bacillary protoplasmic body, _
which at the same time would account for the sticking together
of bacilli coming into contact with one another.
LITERATURE.
1Studies about Lactoserum, St. Louis COURIER, February, 1901.
2Durham, Jour. Exp. Med., Vol. V'
3Zeitschr. f. Hygiene u. Inf. Krankh., Vol. 36 (joos).
4Centralbl. f. Bacteriol., Vol. 30, No. 8.
5Annales de l’Inst. Pasteur, Igor (Posternak).
DISCUSSION.
DR. GIVEN CAMPBELL said the Society was to be congratulated in
having heard this very able paper. Work along these lines is becom-
ing so specialized that one not engaged in this kind of work is hardly
capable of discussing the details of such a paper.
DR. R. B. H. GRADWOHL seconded Dr. Campbell’s statement that
the paper had been enjoyed by the Society, and felt that it was an im-
portant contribution on this subject, and conﬁrms Ehrlich in the theo-
retical explanation of animal immunity. Of special interest were the
328 Medical Society of
different cultures of the typhoid bacillus, and the behavior of animals
treated with one culture toward another.
DR. H. EHRENFEST asked how, by the Ehrlich side-chain theory,
the acquired immunity was explained. This point had not been ex-
plained in the paper, and the speaker would feel personally obliged for
more light on it. He also wanted to know whether cultures of typhoid
bacillus if taken out of Cultures Nos I or 2 would immunize different
animals—whether that serum would show the same qualities—chemi-
cal and physiological. 0
DR. FISCH, in closing the discussion, said he felt that he had im-
posed upon the members of the Society by reading a paper on such a
subject, as it could not be expected they should be able to thoroughly
discuss it.
In regard to Dr Ehrenfest’s question about the existence of an
acquired immunity there had been as yet no other theory advanced
which will satisfactorily explain it. Ehrlich’s side chain theory is to
the effect that the activity of extraneous substances is only possible by
the presence of these side-chains, that is, by the existence of groups
chemically constructed so as to combine with those substances intro-
duced into the animal organism. If they are introduced, these sub-
stances affect their activity, because they follow the same chem
cal lines and combine with those groups. It follows that where
groups are present such a substance as a toxin must exert some action.
But it is not necessary that these groups should always be present.
There may be certain species which grow up, and that is really the
case, and their existence has been proved by Ehrlich. The speaker
had himself made experiments in this direction. He had taken a
rabbit and immunized it with the blood of another rabbit when he
got a serum which, if mixed with the blood corpuscles of the rabbit
which furnished the blood for the injection, it destroyed these corpus-
cles, that is, the blood of one rabbit destroys the corpuscles of an-
other rabbit. But if carefully immunized, he could take the blood of
one rabbit and, after deﬁbrination, inject this blood into the same
rabbit afterwards, using the same serum in the same rabbit, and there
will be no reaction. That means that this rabbit does not contain
City Hospltal Alumni. 329
anything susceptible to its own toxin. This proves that such a condi-
tion of the lack of certain receptors is a fact.
In regard to the question of the behavior of certain sera in dif-
ferent animals, Dr. Ehrenfest had inadvertently touched upon a very
interesting and important subject. There is a difference in the strength
of the sera, and we can get, by continued injections and increasing
doses, any strength of agglutinin we want He was a little surprised
in his experiment, in the case of two animals -a goat and a rabbit——
to get the same typhoid bacillus effect. It is especially emphasized _
by Ehrlich that we have no right to assume that the means are the
same, and, practically speaking, perhaps in our time we may produce
an antitoxin which will contain all the positively obtainable immune
bodies which can be made acceptable —typhoid or whatever it is.
DR. F. REDER presented several anatomical specimens. The ﬁrst
specimen was from a case of
Appendicitis.
The speaker said he could always feel deeply for anyone suffering
with appendicitis, as he had himself some years ago, when the disease
was far less understood than it is to-day, and the operative technique
not advanced to the perfection of the present time, submitted to a'.
median laparotomy.
The case from which the specimen exhibited had been taken was
interesting, as perforation had taken place within 48 hours after the
attack. The patient was a young man, aged 26 years, who had always
enjoyed good health. The attack began three weeks ago, when the
patient was apparently in perfect health. He awoke one morning
about 2 o’clock with a severe pain. During the day the pain ceased,
but that night returned, and the next forenoon it was so severe that he
begged his brother to kill him in order to relieve him of his pain. He
was brought to the city and sent to the hospital, where the speaker
saw him that evening. His temperature was 102°F., pulse 140. There
had been no vomiting or nausea—nothing in the history but the pain.
This pain was diffused over the entire abdomen. On palpation the
seat of the most intense pain was found to be in the right iliac region.
The abdomen presented the characteristic signs, but the diagnosis of
330 Medical Society of
appendicitis was based principally upon facial expression. This was
very characteristic. He had aged perceptibly, the features being
drawn, the color of ashes, and the eyes sunken. The exhausted
condition of the patient precluded operation that night, so ice bags
were placed and a saline enema given. The next morning the facial
expression was worse, and operation was performed at 9 o’clock. He
found a perforation and three ounces of pus in the cavity. The intes-
tines and omentum were much congested. The temperature dropped
to normal and remained so. The cavity was ﬂushed with saline solu-
tion, and a rubber drain as thick as the thumb introduced. This was
changed on the fourth day, and a simple gauze drain substituted. The
cavity was not again disturbed by solutions, and the gauze drain was
removed on the twelfth day, with the wound almost granulated. This
appendix contains a perforation, and the speaker thought that was due
rather to pressure than to imﬂammatory conditions. The appendix
was large and much congested.
Three Uteri.
This is an interesting specimen, removed ﬁve weeks ago i The
, woman was 56 years old. On palpation the uterus was found enlarged,
reaching to the umbilicus. When the ﬁnger was introduced into the
vagina the cervix was found widely open, and passing the ﬁnger about
it, there was found a growth. This growth was ﬁrm. At the time he
advised a curettement, which was refused. The patient would not
permit anything to be done, so he advised morphin to allay the pain.
Some four or ﬁve months later he was again asked to see the woman.
The condition had changed. She had been having hemorrhages, and
was more or less emaciated. On examination the vaginal canal was
found to be full of a mass. On severe pressure the mass would pro-
trude. The pains were those of a. woman in parturition when the
uterus was trying to expel the growth. The exposed part of the
growth was necrotic, and the odor was very strong. I asked that I be
permitted to remove this growth in the vagina, and promised that the
pains would cease. She consented to this. In removing this growth
‘he did not use any instruments, using his ﬁnger. It was readily
broken up. The upper segment of the cervix appeared as If it had
City Hospital Alumni. 331
been afﬂicted with cancer—appeared ragged. ‘In this. however, he
was deceived. He cleaned out the canal, and in two weeks again saw
the patient and found the cervix normal. Having in mind the nature
of the growth, he asked that the organ be removed. To this she con-
sented, and two weeks later the organ was taken out. He was then
glad that he had not curetted, which he had been considering pre-
viously, because the character of the tumor was such that a curette
would not have accomplished much. Dr. Gradwohl had examined the
growth, and the speaker was much relieved when it was pronounced a
simple ﬁbroma.
The next specimen was from a woman, aged 46 years. He was
asked in this case to perform trachelorrhaphy. She was bleeding,
though there was no odor. On examination he found cauliﬂower
excrescences, which looked like carcinoma, and he asked to be allowed
to remove the organ. This was done eight months ago, and the
woman is today in perfect health.
The other specimen was removed from a woman, aged 50 years.
He thought at one time that he could not afford to remove 1t, but he
could see no way out of it. It was a case of dysmenorrhea, exceeda
ingly painful. The speaker had seen her in one attack, and the
attending physician had to administer chloroform in order to give her
relief. She had taken to the use of morphine. The only relief seemed
to be in removal of the organ. This was done by the abdominal
route. The introitus was very narrow, and had he attempted to
extirpate through the vagina he would have encountered much difﬁculty.
DR. G. GELLHORN was especially interested in the second uterus
shown—the one with the intrauterine growth which protruded into the
vagina. The uterus still shows signs of muscular hypertrophy pro-
duced by the primary dilatation of the uterus and the efforts of the
\uterus to expel the. growth. A tumor of that kind will act like a
foreign body in the uterus, and the organ will try to get rid of it.
Therefore, the tumor appeared in the vagina, and if medical assistance
had not been obtained, it is probable it would ultimately have pro-
truded from the vulva. QIn some cases even an inverted uterus might
follow, as in several instances, reported about ﬁve years ago. A tumor
of this kind was born into a vagina, turned down with forceps, and
332 Medical Society of
Si
the pedicle cut off with the Pacquelin cautery. In this procedure the
inverted uterine wall'had been torn through and total extirpation was
immediately made, because it was impossible to repair the hole in the
uterine wall.
Formerly these tumors were dissected off as nearly as possible to
the base, and the rest uf the tissues left.
It seems peculiar that the pedicle in the tumor shown this evening,
which is considered a ﬁbroma, should be so very soft, even after a
hardening process of ﬁve weeks.
In the second case, the carcinoma of the vaginal wall, the oper-
ation shows a splendid result, and he thought Dr. Reder should be con-
gratulated by the absence of recurrence for over eight months,
especially as the carcinomatous growth appears to extend to the line
of excision. In 77 per cent of cases of carcinoma of the neck of the
womb, recurrence takes place within six months after the operation.
This is mostly due to a contamination, he believed, of the incision
with particles of the cancerous growths, or with instruments or ﬁngers
touched with the eroded cervix. ,
Of the third case little can be said, as the condition of the
patient seemed to demand. such heroic measures. He supposed all
other methods for relieving the patient had been futile.
THE MEDICAL SOCIETY OF
CITY HOSPITAL ALUMNI
SAINT LOUIS.
18591—1901.
CONSTITUTION, BY=LAWS,
ROSTER OF OFFICERS AND
STANDING COMMITTEES
WITH LIST OF I‘IEFIBERS.
ST. Lours, Mo.
COURIER OF MEDICINE CO.
1902.
ORGANIZATION FOR 1901.
OFFICERS.
President - - - - NORVELLE WALLACE SHARPE.
Wee-President - - - FRANCIS L. REDER.
Secretary - - - - JOHN GREEN, JR.
Treasurer - - - - HORACE W. SOPER.
THE ADVISORY COUNCIL:
CHARLES J. ORR, Chairman, WILLIAM S. BARKER,
ELSWORTH S. SMITH, JOHN B. SHAPLEIGH.
JOSEPH GRINDON, GEORGE HOMAN.
STANDING COMMITTEES.
The Executive Committee:
WILLIAM C. MARDORF, Chairman,
GREENFIELD SLUDER, Associate, HUDSON TALBOTT, Associate.
Committee on Scientific Communications:
, HARRY S. CROSSEN. Chairman,
JOSIAH G. MOORE, Associate, HERMAN L. NIETERT, Associate.
Committee on Publication:
GIVEN CAMPBELL. JR., Chairman,
AMAND N. RAVOLD, Associate, JOHN C. FALK, Associate.
Committee on Entertainment:
WILLIAM D. SPORE, Chairman,*
PHILIP V. von PHUL, Associate, WALTER BAUMGARTEN, Associate.
*Resigned on becoming a non-resident member. Philip V. von Phul appointed
Chairman, and Rutherford B. H. Gradwohl second associate, October 3, Igor.
-
CONSTITUTION.
ARTICLE I.
NAME.*
The name of this body shall be The Medical SOciety of City
Hospital Alumni.
ARTICLE II.
OBJECTS.
The objects of this body shall be the scientiﬁc investigation and
discussion of medical and allied subjects, and the drawing of the
members into more intimate scientiﬁc and social relations.
ARTICLE III.
MEMBERSHIP.
Only physicians who have served in the City Hospital as assistant
or superintendent, and who are Of reputable SOCIal and professional
standing, shall be eligible for membership.
Honorary membership may be conferred on Alumni of the City
Hospital.
ARTICLE IV.
ELECTIONS.
Election of members shall be by ballot. A majority vote of the
members present shall be required for election, but one third of the
members present voting in the negative shall reject.
ARTICLE V.
OFFICERS .
The Ofﬁcers of the Society shall be: President, Vice-President,
Secretary, and Treasurer; to be elected by ballot at the last meeting
of each year. and to hold ofﬁce until their successors are elected and
quahﬁed.
ARTICLE VI.
THE ADVISORY COUNCIL.
The ex-Presidents shall constitute an Advisory Council, of which
the retiring President shall become the Chairman. The object of the
Council shall be to promote the general welfare of the Society by

*The Society was organized under the name of The City Hospital Medical
Society. The present name, The Medical Society of City Hospital Alumni, was
assumed March 3, I898.
4c The Medical Society of
suggestions or recommendations in matters of policy, or scientiﬁc
work. The Advisory Council; acting as A Nominating Committee, shall
present candidates for the several ofﬁces of the Society on, or before,
the date of election. The members of the Council shall be exempt
from service on the Standing Committees.
ARTICLE VII.
COMMITTEES.
There shall be four Standing Committees, of three members each,
appointed annually, of which Committees the President shall appoint
two members, and the Vice-President one. These Committees shall
be known as The Executive Committee, Committee on Scientiﬁc
Communications, Committee on Publication, and Committee on Enter-
tainment. ‘
ARTICLE VIII.
QUORUM.
Six members shall constitute A Quorum for the transaction of
ordinary business, and ﬁfteen for the election of Ofﬁcers and members.
ARTICLE IX.
MEETINGS.
Stated meetings of the Society shall be held on the ﬁrst and third
Thursday of each month (except July and August), at 8 o’clock P.M.
ARTICLE X.
AMENDMENTS.
The Constitution may be amended by a two-thirds vote of the
members present at any stated meeting, but in making amendments
the following form of procedure shall be observed. Every proposition
to amend the Constitution, or any part thereof, shall be submitted in
writing, at stated meetings only, signed by at least two members, and
shall lie over for at least one stated meeting exclusive of the date of
presentation. When called up for action, it shall be the duty of The
Executive Committee to make a written report on the advisability of
modifying, adopting, or rejecting the proposed amendment. All
members of the Society shall be duly notiﬁed of all such proposed
amendments.
BY= LAWS.
SECTION I.
ORDER OF BUSINESS.
. Action on Minutes of Previous Meeting.
Reports of Committees.
Miscellaneous Business.
. Elections.
. Presentation of Patients and Anatomical Specimens.
. Reading and Discussion of Papers.
Unannounced Specrmens and Cases.
. Adjournment.
The Scientiﬁc Program shall be The Special Order of Business
at 9 o’clock.
°°r' @m-P‘TPH
SECTION II.
DUTIES OF THE PRESIDENT.
It Shall be the duty of the President to preside at all meetings,
appoint all Committees, unless otherwise provided for, and to perform
such other duties as the Constitution and By-Laws prescribe.
SECTION III.
0 DUTIES OF THE VICE-PRESIDENT.
It shall be the duty of the Vice-President to perform the duties of
the President in the absence of the latter.
SECTION IV.
DUTIES OF THE SECRETARY.
It shall be the duty of the Secretary to record and preserve an
accurate account of the proceedings of each meeting; to keep a
corrected register of the members, the dates of their service in the
Hospital, and their addresses; to conduct the correspondence of the
Society, and to perform all other duties pertaining to his ofﬁce assigned
to him by the Society. He shall preserve in his records a complete
necrologic list of members of the Society. He shall submit a report
at The Annual Meeting, which shall give in detail the work of the
Society for the year. In said report suitable reference shall be made
to members of the Society who have died during the current year.
He shall be exempt from the payment of Dues.
6 The Medical Society of
SECTION V.
DUTIES OF THE TREASURER.
It shall be the duty of the Treasurer to collect and take charge of
the Funds of the Society. He shall make disbursements only when
authorized by the President and the Chairman of The Executive
Committee.
He shall submit annually, or when required by the Society, an
itemIzed statement of receipts and expenditures, and a list of delin-
quent members. He shall be exempt from the payment of Dues, and
shall furnish annually a satisfactory bond, in the sum of Five Hundred
Dollars, at the expense of the Society.
SECTION VI.
DUTIES OF THE-EXECUTIVE COMMITTEE.
The Executive Committee shall conduct the business affairs of the
Society. It shall authorize expenditures, and, by its Chairman, order
the payment of accounts ; and it shall also act as An Auditing
Committee.
The Executive Committee shall also investigate and report upon
the names of candidates for membership, and shall perform such other
duties as are prescribed for it by the By-Laws.
SECTION VII.
DUTIES OF COMMITTEE ON SCIENTIFIC COMMUNICATIONS.
The Committee on Scientiﬁc Communications shall provide
suitable scientiﬁc material to engage the Society at each stated meeting,
and it shall send a program to the members at least two. days in
advance of such meetings.
Non members may present papers or other communications to
the Society, on invitation from the Committee on Scientiﬁc Communi-
cations, with the approval of The Advisory Council.
SECTION VIII.
DUTIES OF COMMITTEE ON PUBLICATION.
The Committee on Publication shall provide for the recording and
preservation of the Proceedings of the Society.
SECTION IX.
DUTIES OF COMMITTEE ON ENTERTAINMENT.
It shall be the duty of The Committee on Entertainment to
provide a suitable place for the meetings of the Society, and to take
charge of such entertainments as shall be desired by the Society.
City Hospital Alumnl. 7
SECTION X. .
ANNUAL DUES.
The Dues from each active member shall be $3.00 annually,
beginning the ﬁrst of January nearest the date of his election to
membership. Dues from members of the City Hospital Corps joining
the Society during their year of Junior Service, shall begin the ﬁrst of
January following the expiration of their term of Junior Service.
Honorary Members shall be exempt from the payment of Dues.
Members exempt from the payment of Dues shall not be permitted the
privilege of voting.
SECTION XI.
DELINQUENT MEMBERS.
Members in arrears for two years’ Dues, who fail to pay same,
after due notice. from the Treasurer of arrearage and penalty, shall
forfeit membership. Three notiﬁcations shall constitute due notice.
SECTION XII.
EXPULSION OF MEMBERS.
Members accused of improper Conduct against whom charges
have been preferred by a fellow-member and sustained by The
Executive Committee, after due trial may be expelled by a two-thirds
vote of the members present, all the members having been previously
notiﬁed of the proposed action.
SECTION XIII.
AMENDMENNS.
These By-Laws may be amended by a majority vote at any stated
meeting, previous notice of such proposed action having been given
to all the members.
SECTION XIV.
PARLIAMENTARY PROCEDURE.
The proceedings of the Society shall be conducted in accordance
with “ Roberts’ Rules of Order.”
8 The Medical Society of ’
GENERAL RULES.
I. Annual Dinner. — The Committee on Entertainment is authorized to
provide a Dinner on the evening of January 4, 1900. Said Dinner to be repeated
yearly on the evening of the ﬁrst regular meeting of the society, thereby constituting
The Annual Dinner of the Society.
I. The price per plate shall be limited to One Dollar. Wine, cigars, etc., to be
ordered and paid for, by the individual over and above this stated sum.
2. Members desiring to share in this Dinner must forward name, address, and
One Dollar to the Chairman of the Committee on Entertainment, who
will assign them seats.
3. Only members of the Society shall participate in this Dinner; with the
exception that invitations may be extended by the Society as a whole,
to suitable individuals, to be guests of the Society; the expense incurred
for these guests to be paid by the Treasurer, upon presentation of the
audited bill.
4. Desirability of an individual as a guest to be passed upon by the Society;
and invitations to such individuals to be forwarded them in writing,
signed by the President and Secretary. All proposals for guests are to
be made at The Annual Meeting of the Society.
5. The Dinner is not to be given as The Annual Dinner of the Society unless
at least twenty-ﬁve members comply with Section 2.
II. All names proposed as additions to The Mailing List must be referred to
The Executive Committee.
III. The Lommittee on Scientiﬁc Communications shall furnish to those
opening a formal discussion of a paper an adequate abstract of said paper.
IV. Remarks of members In discussion shall be limited to ﬁve minutes each,
unless by unanimous consent otherwise, and no member shall speak a second time
on the same subject until all others, so desiring, shall have been heard.
V. The privileges of the ﬂoor in scientiﬁc discussions may be extended to
guests and visitors.
VI. These General Rules may be suspended at any meeting on motion without
previous notice.
ROSTER OF
OFFICERS AND STANDING COMMITTEES*
FROM DATE OF ORGANIZATION,
November 4th, I89I.
1891
Organization Committee:
BRANSFORD LEWIS.
FRANK R. FRY, ALBERT H. MEISENBACH.
1 89 l -1 89 2
Secretary - - - - - - - ELSWORTH S. SMITH.
Treasurer - - - - - - WILLIAM C. MARDORF.
The Executive Committee:
BRANSFORD LEWIS,
HENRY H. MUDD, ALBERT H. MEISENBACH
Committee on Scientiﬁc Communications:
CHARLEs F. HERSMAN,
HENRY C. DALTON. JOHN B. SHAPLEIGH.
Committee on Publication:
FRANK R. FRY,
NORVELLE WALLACE SHARPE, GEORGE HOMAN.
Committee on Entertainment:
ISAAC N. LOVE,
LOUIS C. BOISLINIERE, JOSEPHUS R. LEMEN.
1893
Secretary - - ~ - - - - ELSWORTH S. SMITH.
Treasurer - - - - - - , - WILLIAM C. MARDORF.
The Executive Committee:
BRANSFORD LEWIS,
WILLIAM N. BEGGS, ALBERT .H. MEISENBACH.
Committee on Scientiﬁc Communications:
LUDWIG BREMER,
JOSEPH GRINDON, GEORGE HOMAN.
Committee on PublicatIon:
HENRY JACOBSON,
HENRY C. DALTON, ELSWORTH S. SMITH.
Committee on Entertainment:
ISAAC N. LOVE,
JOHN C. FALK, JOSEPHUS R. LEMEN

*During the years 1891, 1892 and 1893 the ofﬁces of President and Vice-President
w ere non-existent. A Chairman was chosen to serve for each stated meeting.
The Medical Society of
1894
President - - - - - - - WILLIAM S. BARKER.
Vice-President - - - - - LUDWIG BREMER.
Secretary - - - - - - - LOUIS C. BOISLINIERE.
Treasurer - - - - - - _ WILLIAM C. MARDORF.
The Executive Committee:
BRANSFORD LEWIS,
WILLIAM N. BEGGS, ALBERT H. MEISENBACH.
Committee on Scientiﬁc Communications:
ELSWORTH S. SMITH,
JOHN B. SHAPLEIGH, FRANK R. FRY.
Committee on Publication:
JOSEPH GRINDON,
GIVEN CAMPBELL, JR., HARRY M. PIERCE.
Committee on Entertainment:
ISAAC N. LOVE,
LUTHER M. PERKINS, CHARLES F. HERSMAN.
1895
President - - - - - - - ELSWORTH S. SMITH.
Vice-President - - - - - JOHN B. SHAPLEIGH.
Secretary - - - ~ - - - LOUIS C. BOISLINIERE.
Treasurer — - - - - - WILLIAM C. MARDORF.
The Executive Committee:
CHARLES H. DIXON,
FRANK G. NIFONG, WILLIAM N. BEGGS.
Committee on Scientiﬁc Communications:
T. CASEY WITHERSPOON,
MAx A. GOLDSTEIN, ULVUS L. RUSSELL.
Committee on Publication:
WILLIAM S. BARKER,
ALBERT H. MEISENBACH, JOHN C. FALK.
Committee on Entertainment:
BRANSFORD LEWIS,
HENRY JACOBSON, JOSEPHUS R. LEMEN,
City Hospital Alumni. 11
1896
President - - - - - - - JOHN B. SHAPLEIGH
Vice-President - - - - - - HENRY C. DALTON.
Secretary - - - - - - - JOSIAH G. MOORE.
Treasurer - - - - - - - WILLIAM C. MARDORF.
The Executive Committee:
ELSWORTH S. SMITH,
GEORGE HOMAN, WILLIAM S. BARKER,
Committee on Scientiﬁc Communications:
CHARLES H. DIXON,
WILLIS HALL, FRANCIS L. REDER.
Committee on Publication:
HARRY M. PIERCE,
JACOB FRIEDMAN, GREENFIELD SLUDER.
Committee on Entertainment:
DAVID R. NOWLIN,
BENJAMIN M. HYPES, HERMAN FRUMSON.
President - - - - ' - - - JOSEPH GRINDON.
Vice-.President - - - - - LOUIS C. BOISLINIERE.
Secretary - - - - - - — HORACE W. SOPER.
Treasurer - - - - - - WILLIAM C. MARDORF.
The Executive Committee:
JOHN B. SHAPLEIGH,
LUDWIG BREMER, FRANK A. GLASGOW.
Committee on Scientiﬁc Communications:
T. CASEY WITHERSPOON,
WALTER B. DORSETT, JOHN MCH. DEAN.
Committee on Publication:
HARRY S. CROSSEN,
HARRY M. PIERCE, WILLIAM S. BARKER.
Committee on Entertainment:
BENJAMIN M. HYPES,
HOWARD CARTER, FRANK G. NIFONG.
12 The Medical Society 01
1898
President - - - - - - - GEORGE HOMAN.
Vice-President - - - - - - FRANK R. FRY.
Secretary - - - - ,- - — HORACE W. SOPER.
Treasurer - - - - - - - WILLIAM C. MARDORF.
The Advisory Council :*
JOSEPH GRINDON, Chairman, WILLIAM S. BARKER,
ELSWORTH S. SMITH, JOHN B. SHAPLEIGH.
The Executive Committee:
H. WHEELER BOND,
AMAND N. RAVOLD, JOHN MCH. DEAN.
Committee on Scientiﬁc Communications:
N ORVELLE WALLACE SHARPE,
OTTO SUTTER, GREENFIELD SLUDER.
Committee on Publication:
LUDWIG BREMER,
CHARLES J. ORR, M. GEORGE GORIN,
Committee on Entertainment:
ERNST MUELLER,
LOUIS H. BEHRENS, ALBERT E. TAUSSIG.
President - - - - - - - GEORGE HOMAN.
Vice-President - - - - - - BENJAMIN M HYPES.
Secretary - - - - - - - WILLIAM A. BROKAW.
Treasurer - - - - - - - WILLIAM C. MARDORF.
The Advisory Council: ,
GEORGE HOMAN, Chairman, WILLIAM S. BARKER,
ELSWORTH S. SMITH, JOHN B. SHAPLEIGH, JOSEPH GRINDON,
The Executive Committee:
H. WHEELER BOND,
AMAND N. RAVOLD, HARRY R. HALL.
!
Committee on Scientiﬁc Communications:
FRANCIS L. REDER,
JOHN MCH. DEAN, . PHILIP J. HEUER,
Committee on Publication:
CHARLES J. ORR,
RUTHERFORD B. H. GRADWOHL, CHARLES SHATTINGER.
Committee on Enterta'nment:
NORVELLE WALLACE SHARPE,
ERNEST H. COLE, HORACE W. SOPER.

*Created March 3, I898, on the occasion of the Revision of the Constitution.
City Hospital Alumni. ' 13
1900
President - - - - - - CHARLES J. ORR. ,
Vice-President - - - - N OR~ ELLE WALLACE SHARPE.
Secretary - - - - - JOHN GREEN, JR.
Treasurer - - ~ - - HORACE W. SOPER.
' The Advisory Council:
GEORGE HOMAN, Chairman, WILLIAM S. BARKER,
ELSWORTH S. SMITH, JOHN B. SHAPLEIGH, JOSEPH GRINDON.
The Executive Committee:
FRANCIS L. REDER,
HARVEY G. MUDD, M. HAYWARD POST.
Committee on Scientiﬁc Communications:
CHARLES SHATTINGER,
RUTHERFORD B. H. GRADWOHL, JOSIAH G. MOORE.
Committee on Publication:
GIVEN CAMPBELL, JR.,
AMAND N. RAVOLD, JOHN C. FALK.
Committee on Entertainment:
FRANK R. FRY,
JOHN P. BRYSON, ERNEST H. COLE.
LIST OF MEMBERS.
C. M Denotes Charter Member.
Years of Hospi- Date of Admis-
Name. Address. tal Serviee. sion 10 Society.
Abeken, Frederick, Poor House. 1899-00. Dec. 7, 1899.
Adelsberger, L., Waterloo, Ill. 1884-85. C. M.
Amyx, Robert F., 1943 N. Eleventh st. I897.— Nov. 4, I897.
Babler, Edmund A., 618 Euclid av. 1898-99. Nov. I7, 1898.
Ball, Otho F., Commercial bldg. 1897.-— Dec. 7, I899.
Ball, W. F., Batesville, Ark. 1897-98. Nov. 4, I897.
Banks, Harry L., Hannibal, MO. 1890-9I. May 5, 1898.
Barker, William,S.,1 IIOI Tyler st. I890-9I. C. M.
Barnes, William 8., Pilot Grove, MO. IQOI-OZ. June 20, 1901.
Baumgarten, Walter, 109 Broadway, Baltimore. 1896-97. Dec. I7, 1896.
Bechtold, Louis J., Belleville, 111. 1870-71. C. M.
Beggs, William N ., Denver, Colo. 1886-87. C. M.
Behrens, Louis H., 5 S. Broadway. 1894-95. Feb. 18, 1895.
Bell, John H., Pine Bluff, Ark. I89I.— C. M.
Benway, William H., City Hospital. I90I-Oz. June 20, 1901.
Boehm, Joseph L., 800 Morgan st. 1899-00. Dec. 7, I899.
Bohn, Julius C., City Hospital. Igor-oz. June 20, IgOI.
Bleyer, Adrian, S., ' 445: Washington boul. 1899-00. Dec. 7, I899.
Boisliniere, Louis C.,? 3509 Olive st. 1882-83. C. M.
Bond, H. Wheeler, Linmar bldg. 1890-92. C. M.
Bradley, T. L., Warrensburg, Mo. 1896-97. Dec I7, 1896.
Brady, Jules M., Poor House. 1898-99. Nov. 17, 1898.
Bremer, Ludwig,8 3723 West Pine st. 1870.-— C. M.
Bribach, Benno, 7608 Michigan av. 1879-80. April 18, I895.
Broderick, J. K., Europe. IgOO-OI. Oct. 4, 1900.
Bryson, John P., 209 N. Garrison av. 1868-69. C. M.
Campbell, Given, Jr. 3429 Morgan st. I88 9-90. Oct. 12, I893.
Campbell, 0. H ., 2603 Washington av. 1899-00. Dec. 7, 1899.
Campbell, R. L., City Hospital. 1900-02. Oct. 4, 1900.
Cass, W. E., U. S. Army. IgOO-OI. Oct. 4, 1900.
Carter, Howard, Webster Groves, MO. 1894-95. Feb. 6, 1896.
Christian, Charles H., New Bloomﬁeld, MO. 1890-91. Mar. 21, IgOI.
Churchill, R., Peoria, 111. 1899-00. Dec. 7, 1899.
Cole, Ernest H., 4305 West Pine boul. 1885-86. April II, 1892-
Coleman, H. T., Pattonville, MO. 1895-96. Feb. 6, 1896.
Coughlin, W. T., CiIy Hospital. IQOI-Oz. June 20, 1901.
Crossen. Harry S., 4055 Olive st. 1892-95. Sept. I 5, I894.
Currie, Dtnald H., Marine Hosp. Washington, D.C. 1897-98.
Nov. 4, I897.

1 President, I 894.
2Vice-President, I897.
3Vice-President, 1894.
' City Hospital
15
Alumni.
Name.
Curtin, Henry W.,
Dalton, Henry C.,1
Davis, H. W.,
Dean, John MCH.,
Dempsey, William H.,
Denby, J. P.,
Deutsch, William S.,
Dice, Henry F.,
Dillon, W. A.,
Dixon, Charles H.,
Dorsett, Walter B.,
Doyle, William J.,
Drace, Charles C. ,
Drake, James E.,
Drechsler, Louis,
Ehrlich, Louis W,,
Epstein, Jacob M.,
Evans, Ellis, A.,
Eyermann, Edward H.,
Fahnestock, C. L.,
F alk, John C.,
Farmer, Percy J.,
Farrar, J. O’Fallon,
Farrell, John J.,
Fischer, Oscar H.,
F lippen, J. Hart,
Forbes, H. B.,
Forder, W. Carver,
Friedman, Jacob,
Fries, William A.,
Frumson, Herman,
Fry, Frank R.,2
Gallagher, Joseph C.,
Garcia, Felix W.,
Gaylor, Wenzel C.,
Gehrung, Julius A.,
Ghiselin, A. H.,
Glasgow, Frank A.,
Goebel, Arthur,
Goldstein, Max A.,
Gorin, M. George,
Years of Hospi- Date of Admis-
Address. I
3233 Easton av.
3536 Easton av.
Alton, 111.
319 N. Grand av.
Alton, Ill.
Carlinville, Ill.
3135 Washington av.
739 Euclid av.
City Hospital.
3345 Morgan st.
3941 West Belle Place.
City Hospital.
3201 Lawton av.
City Hospital.
2701 Blair av.
I823 S. Ninth st.
905 N. Eleventh st.
Steeleville, MO.
1711 S. Broadway.
MCCOOk, Nebraska,
2702 Stoddard st.
5329 Vernon av.
3538 Easton av.
City Hospital.
2711 Washington av.
Perry, 0. T.
Ogden, Utah.
Female Hospital.
2804 Clark av.
1544 S. Broadway.
904 N. Broaoway.
3133 PIne st.
City Hospital.
2926 Gravois av.
2917 Hemietta st.
Female HospItal.
Webster Groves, MO.
3894 Washington av.
3508 Manchester av.
3738 Westminster Place.
4200 West Belle Place.
Gradwohl, Rutherford B.H. Commercial bldg.
Graham, John R., 181 W. 75th st., New York City.
Grant, John M ,
Green, John, Jr.,
4132 Easton av.
2670 Washington av.
tal Service.
1895.—
1872-75.
I887-9I.
1900-'01.
1996-99-
1898-99.
1898-99.
1891-92.
1897-98.
Igor-02.
1878-79.
1878 79.
190102.
1901-02.
190I-02.
1896-97.
1893-95-
1893-94-
Igor-02.
1898-99.
1896-97.
I890-91.
1899-00.
I896~97.
‘ 1901—02.
1899.-—
1898-99.
1898-99.
1901-02.
1878-79.
1883-84.
I889-9O.
1879-80.
1901-02.
1893.—
IgOI-Oz.
I901-02.
1897-98.
1878-79.
1880-81.
1892-93.
1895-9%
1898-99.
1899-00.
1889 91.
1898-99
sion to S 0eiety.
Mar. 17, 1898.
C. M.
Oct. 4, 1900.
Dec. I7, I896.
Nov. I7, 1898.
Nov. I7, I898.
Sept. 19, Igor.
Nov. 4, 1897.
June 20, 1901.
C. M.
C. M.
June 20, 1901.
June 20, 1901.
June 20, 1901.
Dec. 17, 1896.
Feb. 14, 1895.
Jan. 21, 1897.
June 20, 1901.
Nov. 17, 1898.
Dec. I7, 1896.
C. M.
Dec. 7, 1899.
Dec. I7, 1896.
June 20, 1901.
Mar. I, 1900.
Nov. 17, 1898.
Nov. 17, 1898.
June 20, 1901.
C. M.
C. M.
C. M.
C. M.
June 20, 190I.
Mar. 17. 1898.
June 20, 1901.
June 20, 1901.
Nov. 4, 1897.
Oct. 12, 1893.
ApIil 21, 1898.
Jan. 12, 1893
Feb. 6. 1896.
Nov. 17, 1898.
Dec. 7, 1899.
C. M.
Nov. 17. I898.

1Vice-President, 1896.
2Vice-President, 1 898.
16 The Medical Society of
Years of Hospi- Date of Admis-
Address.
3506 Manchester av.
614 N. Compton av.
3894 Washington,
Name.
Greiner, Theodore,
Grim, Ezra C.,
Grindon, Joseph,1
Hall, Harry R., 925 Goodfellow av.
Hall, Willis, 2332 Washington av.
Htmel, George F., M0. Pac. Hoso. Kansas City, MO.
Hardy, William F., ' City Hospital.
Harris, Rufus C., 1303 N. Garrison av.
Haase, Moses E., 4263 West Pine st.
Hempelmann, L. H., 1107 N Grand av.
Henke, August F., 2210 Howard st.
Hess. J. D., Holcomb, MO.
Heuer, Philip J., 303 N. Grand av.
Hinchey, Frank, 2330 Washington av.
Holland, Thomas E., Hot Springs, Ark.
Homan, George,2 Odd Fellows bldg.
Horine, William H., Haleyville, I. T.
Hurt, Garland, Newport, Ark.
Hypes, Benjamin M.,3 2005 Victor st.
Jacobson, Henry, 4392 Laclede av.
Jelks, Frank W., 7619 S. Broadway.
Kane, Robert E., 1117 N. Grand av.
Kirchner, W. C. G., City Hospital.
Kohl, Julius, Belleville, Ill.
Koontz, Carl J., Galesburg, lll.
Krenning, William G., City Hospital.
Levy, Aaron, Olivia bldg.
Lewis, Bransford, Century bldg.
4321 Bell av.
East St. Louis, Ill.
East St. Louis, Ill.
Lippe, Meyer J.,
Little, E. H.,
Little, H. M.,
Loeb. Clarence, Europe.
Loew, Edward C., 1419 S. Broadway.
Love, Isaac N ., N .Y. Post-Grad. School, N.Y. City,
Luedde, W. H., 2670 Washington av.
Luedeking, Robert, 1837 Lafayette av.
Mardorf, William C., 1 111 Chouteau av.
Matlack, James A., Prairie City, 111.
Mayes, J. W., Dalton City, 111.
McCandless, William A. 3857 Westminster Place.
McElroy, R. L., Louisiana, MO.
Meier, Christian,
Meisenbach, Albert H.,
Miller, A. B.,
Miller, Herman B.,
City Hospital.
2229 S. Broadway. ' r
3559 Olive st.
City Hospital.
tal S erm'ce.
I 897-98.
1 901 -02.
1 879-80.
1 89 5-96.
1881.—
1 888-89.
1901-02.
1898-99.
1882-8 3.
1896-97.
1896-97.
1900-01.
189 5-96.
1894.—
1874-75-
1373-74-
1 899-00.
I876-77.
1872-7 3.
1886-88.
1894-95-
1899-00.
1901 -02.
I 8 58-60.
1899-00.
1901-02.
1897-98.
1884.—
1897-98.
I 900-01.
1900-01.
1899-00.
1898-99.
1 872-74.
1900-01.
1885.—
1888-89.
1900-01.
1898-99.
1873~75-
1896-97.
1991-02.
1876-77.
1900-01.
1901-02.
sion to Society.
Nov. 4. 1897.
June 20, 1901.
C. M.
Feb. 6, 1896.
C. M.
Oct. 12, 1893.
June 20, 1901.
Nov. 17, 1898.
Nov. 7, 1901.
Dec. 17, 1896.
Dec. 17, 1896.
Oct. 4, 1900.
Feb. 6, 1896.
April 17, 1898.
Aug. II, 1892.
C. M.
Dec. 7, 1899.
C. M.
C. M.
C. M.
Dec. 7, 1899.
Dec. 7, 1899.
June 20, 1901.
C. M.
Dec. 7, 1899.
June 20, 1901.
Nov. 4, 189 7.
C. M.
Jan. 6, 1898.
Oct. 4, 1900.
Oct. 4, 1900.
Dec. 7, 1899.
Nov. 17, 1898.
C. M.
Oct. 4, 1900.
Mar. 17, I898.
C. M.
Oct. 4, 1900.
Nov. 17,1898.
Feb. 18, 1897.
Dec. 17, 1896.
June 20, 1901.
C. M.
Oct. 4, 1900.
June 20, 1901.

1President, 1897.
3Vice-President, 1899.
2President, 1898; President, 1899.
City Hospital Alumni. 17
Years of Hospi- Date of Admis-
Name. Address. tal Service. sion to Society.
Moberg, A., Pittsburg, Kansas. 1897-98. Nov. 4. 1897.
Molz, Charles 0., Bedford, Ind. 1898-99. Nov. 17, 1898.
Montague, Herbert L., 2604 Locust st. 1896-97. Dec. 17, I896.
MOOk, W. H., Quarantine Hospital. 1900-01. Oct. 4, 1900.
Moore, Josiah G., 5259 Page av. 1889-90. C. M.
Morse, F. L., Colorado. 1900 01. Oct. 4, 1900.
Mudd, Harvey G., 2604 Locust st. 1881-82. C. M.
Mueller, Ernst, 3236 California av. 1884-8 5. C. M.
Murrell, C. P., City Hospital. 1900-OI. Oct. 4, I900.
Nelson, William L., City Hospital. 1901-02. June 20, 1901.
Nietert, Herman L., City Hospital. 1899-02. June I, 1899.
Nifong. Frank G., 704 N. Kingshighway. 1889-91. C. M.
North, E. P., Mo. Pac. Ry. Hospital. 1900 01. Oct. 4, 1900.
Norvell, B. P., U. S. Army. 1900-01. Oct. 4, 1900.
Nowlin, David, Montgomery City, MO. 1890-92. C. M.
Oatman, Louis J., 4245 Olive st. 1893-94. April 17, 1898.
Orr, Charles J.,l 701 N. Channing av. 1891-92. Aug. 11, 1892.
Pauley, William H., 3203 Easton av. 1896-97. Dec. 17, 1896.
Perkins, Luther M., Farmington, MO. 1886-88. C. M.
Pettit, Joseph, 919 Belmont st., Portland, Ore. 1899-00. Dec. 7, 1899.
Pfeffer, Francis J., 1800 S. Eleventh st. 1895-96. Feb. 6, 1896.
Phelps, H. L., Phoenix, Ariz. 1899-co. Dec. 7, 1899.
Pierce, Harry M., 4046 N. Grand av. 1887-89. C. M.
Pinkerton, B. J., Beirout, Syria. 1900-OI. Oct. 4. 1900.
Pitman, John B , Kirkwood, M0. 1901-02. June 20, 1901.
Post, M. Hayward, 2670 Washington av. 1877-78. Jan. 12, 1893.
Printz, Felix C. W., 1019 Russell av. 1898—99. Nov. 17 1898.
Prouty, S. B., Union Trust bldg. 1900-OI. Oct. 4, 1900.
Rassieur, Louis, City Hospital. 1899-02. Dec. 7, 1899.
Ravold, Amand N., 2806 Morgan st. 1881-82. May 16, 1895.
Raymond, Raymond O., 3862 Olive st. 1900 01. May 3, 1900.
Reder, Francis L.,2 4629 Cook av. 1884-85. C. M.
Reder, A. Ralph, C.B.Q. R R.,Chicago, Ill. 1894-96. Feb. 28, 1895.
Richards, E. E., TarkIO, MO. 1898-99. Nov. 17, 1898.
Rowland, W. P., Bevier, MO. 1888-89. C. M.
Rush, William, H., City Hospital. 1901 02. June 20, 1901.
Russell, Ulvus L , Oklahoma City, O. T. 1893-95. Sept. 14, 1894.
Saenger, Nathaniel, 241 l N. Twenty-Second st. 1895-96. Feb. 6, 1896.
Sauer, William E., 3862 Olive st. 1897-98. Nov. 4, I897.
Schleifiarth, E. L., 8 S. Broadway. 1881-82. C. M.
Schlossstein, Adolph G., 3153 Longfellow boul. 1894-95. Nov. 5, 1894.
Schuchat, W. L., 2200 Chouteau av. 1896-97. Dec. 17, 1896.
Scharff, E. A., 4967 West Pine st. 1898-00. June I, 1899.
Scott, B. L , 913 Austin av., Waco, Tex. 1897 98. Nov. 4, 1897.
Seibold, John F., New Haven, Conn. 1891-92. C. M.
Semple, Nathaniel W., 2670 Washington av. 1897-98. Nov. 17, 1898.
Shanahan, Nicholas C., 1121 Cass av. 1894-95. Mar. 18 1897.

lPresident, 1900.
2Vice-President, 1901.
18 ' The Medical Society of
Years of Hospi Date of Admis-
Name. Address. tal Service. sion to Society.
Shapleigh, John B.,1 2608 Locust st. 1881-82. C. M.
Sharpe, N orvelle Wallace,2 3505 Franklin av. 1890 91. C. M.
Shattinger, Charles, 2924 S. Grand av. 1886-87. C. M.
Simon, Frederick C. 1833 Cass av. 1899-00. Dec. 7, 1899.
Simpson, Bernard S., 4246 Olive st. 1897-98. Nov. 4, 1897.
Skrainka, Philip, 701 N. Charming av. 1884-85. Mar. 17,1892.
Slusher, R. L., Phoenix, Ariz. 1900-01. Oct. 4. 1900.
Sluder, Greenﬁeld, 2647 Washington av. 1888-92. C. M.
Smith, Elsworth S.,3 116 N. Grand av. 1887-90. C. M.
Smith, H. G., Tuscola, Ill. 1899-00. Dec. 7, 1899.
Smith, Owen A., Maplewood, M0. 1892-93. Oct. 3, 1901.
Smith, U. S., Desloge, Mo. 1898-99. Nov. 17, 1898.
Smith, W. F., Springﬁeld, Mo. 1898 99. Nov. 17, 1898.
Soper, Horace W., 813 N. Eighteenth st. 1894-95. Sept. 13, 1894.
Spencer Selden, 2723 Washington av. 1899-00. Dec. 7, 1899.
Spore, William D., Mut. Life Ins ‘co., Mexico City. 1861-64. C. M.
Stewart, S. S., MO. Pac. Ry. Hosp.,LiIt1e Rock, Ark. 1898-99. Nov. 17, 1898.
Sutter, Otto, 2310 N. Fourteenth st. 1895-98. Dec. 5, 1895.
Talbott, Hudson, 3151 Laclede av. 1898-99. Nov. 17, 1898.
T aussig. Albert E., 2647 Washington av. 1894-95. Feb. 14, 1895.
Taylor, T. B., Festus, MO. 1876-77. C. M.
Tiedeman, E. F., 3901 Cleveland av. 1887.— Dec. 7, 1899.
Thierry, Charles W., Jr., Grand and Lindell avs. 1898-99 Nov. 17, 1898.
Thompson, Edgar, U. S. Navy. 1894.— Mar. 7, 1898.
Thompson, Joseph A., Vlrden, 111. 1897-98 Nov. 4, 1897.
Townsend, J. A., Unionville, M0. 1900-01 Oct. 4, 1900.
Vallé, Jules F., 3303 Washington av. I885 86 C. M.
Von der Au, O. L., 1309 Geyer av. 1892-93 Feb. 6, 1896.
von Phul, Philip V., Linmar bldg. 1896 97 Dec. 17, 1896.
Weiner, Meyer, Linmar bldg. 1896-97 Dec. 17, 1896.
Weinsberg, Herbert A., City Hospital. 1901-02 June 20, 1901.
Welch, Thomas, St. Petersburg, Fla. 1897-98 Dec. 4. 1897.
Werth, Duncan S., 4126 Easton av. 1897-98 Nov. 4, 1897.
Wessels, R. H., Vandeventer and F inney avs. 1900-01 Oct. 4, 1900.
West, Washington, Jr., Belleville, Ill. 1897—98 Nov. 4. 1897.
Williamson, Lewellyn, U. S. Army. 1897-98 Nov. 4, 1897.
Wills, William J., CottondBelt Hosp, Little Rock, Ark. 1901 02 June 20, 1901.
Winter, Francis A., U.S.Army (Jeﬁerson Barracks). 1889-91 Dec. 5, 1901.
Witherspoon. T. Casey, 4318 Olive st. ' 1889-90 Sept. 4, 1894.
Wolfort, Louis J , 7081/2 Pine st. 1895-96 Feb. 6, 1896.
Zimlick, A. J., Philadelphia, Pa. 1895-96 Feb. 6, 1896.
Zimn ermann, C. A. W., Fast St. Louis, Ill. 1897-98 Nov. 4, 1897.

1Vice-President, 1895: President, 1896.
2Vice-President, 1900; President, 1901.
3President, 1895.
N ECROLOGY.
Years of Hospi- Date of Admis-
Name. tal Service. sion to Society.
Alvord, George Edgerton, 1890—91. C. M.
Bejach, Joseph, 1899-00. Dec. 7, 1899.
Brokaw, William Acheson, 1896-97. Dec. 17, 1896.
Dean, Dexter V., 1877-86. C. M.
Hersman, Charles Finley, 1888-90. C. M.
Lane, George H., 1895-96. Feb. 6, 1896.
Mudd, Henry Hodgen, 1865-66. C. M.
Smith, Elsworth Fayssoux, 1848-49. C. M.
Stack, John P., 1891-93. C. M.
Tali, Samuel M., 1900-OI. Oct. 4, 1900.

Date of Death.
April 26, 1897.
June 9, 1900.
May 9, 1899.
Aug. 26, 1900.
Oct. 11, 1895.
Mar. 17, 1902.
Nov. 20, 1899.
Aug. 19, 1896.
Feb. 10, 1902.
Mar. 30, 1901.