GIFT OF MRS. DOROTHY CHAPMAN TO THE U.C.L.A. LIBRARY
 
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 Surgical Notes from 
 Four Continents and 
 the West Indies : : : 
 
 BY 
 
 NICHOLAS ISENN, M.D., Ph.D.,LL.D. 
 
 Head of the Department of Suri^ery^ Rush Medical Col- 
 lege^ in affiliation with the University of Chicago ; 
 Surg con-in- Chief St. Joseph's Hospital ; Attend- 
 ing Surgeofi Presbyterian Hospital; Surgeon- 
 General of Illinois; Lieut. - Colonel and 
 Chief of Operating Staff with the 
 Anny in the Field during the 
 Spanish-American War
 
 9 
 1305 
 
 PREFACE 
 
 HIS little book is made up of reprints from 
 American Medicine in which appeared my 
 communications sent from many different 
 parts of the world during my travels in 1902-1903. The 
 first journey was made on the occasion of the Seventh 
 Conference of the International Red Cross, which con- 
 vened in St. Petersburg, Russia, May, 1902, which I 
 had the honor to attend as an official delegate of the 
 United States. The next trip was made during my 
 midwinter vacation in .lanuary, 1903, and included a 
 visit to eight islands of the West Indies. The last two 
 articles relate my observations made in Spain as an 
 official delegate of our government to the Madrid 
 International Medical Congress. On all of these travels 
 I spent much of my time in visiting hospitals and 
 clinics and in the study of rare tropical diseases. The 
 '^ Surgical Notes" in this form are intended for my
 
 friends at home and abroad to whom I am so much 
 indebted for the material and information they contain. 
 Owing to my absence from home at the time most of 
 these articles appeared I had no opportunity to read 
 the proof which will account for a few typographical 
 errors which occur. 
 
 X. SEXX. 
 
 Chicago, September, lOOa.
 
 TABLE OF CONTENTS 
 
 1. Medical Paris. 
 
 2. Surgical Observations in Berlin. 
 
 3. Renal Surgery as Practised by Professor James Israel. 
 
 4. Professor Hoffa's Orthopedic Work. 
 
 5. Professor Sonneuburg and His Appendicitis Work at the 
 
 Moabit Hospital. 
 
 6. The Seventh Conference of the International Red Cross. 
 
 7. The Pirogoff Museum, St. Petersburg. 
 
 8. Medical Institutions of St. Petersburg. 
 
 9. Constantinople as a Medical Center. 
 
 10. Medical and Surgical Notes from Asia. 
 
 11. The Hospitals of Jerusalem. 
 
 12. Medical Practice in Cairo and Prevailing Diseases of Egypt. 
 
 13. Professor Nicoladoni's Clinic, Gratz. 
 
 14. The Teaching and Practice of Surgery in the Vienna All- 
 
 geraeine Krankenhaus. 
 
 15. Surgical Work of Professor Von Mosetig-Moorhof in the 
 
 Vienna Allgemeine Krankenhaus. 
 
 16. Medical London in Summer. 
 
 17. Professor John Berg's Surgical Clinic. 
 
 5
 
 18. Present Surgical Methods in the General Hospital, Ham- 
 
 bnrg-Eppendorf. 
 
 19. Hospital Work of Dr. Carl Lauenstein. 
 
 20. Comparison Between Foreign and American Surgery. 
 
 21. Glimpses of the Practice of Medicine and Diseases in the 
 
 West Indies. 
 
 22. Echoes from the Madrid International Medical Congress. 
 
 23. The Medical Institutions of Madrid.
 
 [Reprinted from American Medicine, Vol. Ill, No. 23, pages 965-966, 
 June 4, 1902.1 
 
 MEDICAL PARIS. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 
 of Chicago, 111, 
 
 During the period of the greatest prosperity of France, 
 Paris was the center of medical science of the world. The uni- 
 versity and great hospitals were crowded with practitioners and 
 students from the adjacent and most remote countries. It was 
 generally conceded that medical education could not be finished 
 without a more or less prolonged visit to the great medical 
 institutions of Paris. Nelaton, Velpeau, Malgaigne and Dupuy- 
 tren in surgery ; Louis, Broussais, Trousseau and Broca in 
 medicine, were some of the strongest attractions whose in- 
 fluence molded the teaching and practice of the art and 
 sciencpi of medicine and surgery the world over. Most of 
 the books written by these distinguished celebrities were 
 translated into English, German and other living languages 
 and became the recognized authorities in most of the medical 
 schools. Medical science is deeply indebted to the French 
 investigators who have done so much in eliminating erroneous 
 ideas and in establishing new facts by original research and 
 careful clinical observation. Many of the leading medical 
 men of Paris of recent and present date occupy a well-deserved 
 prominent and influential position as authors, teachers, scien- 
 tists and clinicians. Without a Pasteur, bacteriology might 
 have remained unborn at the present time. Charcot was a 
 profound thinker and a brilliant clinical teacher. Peon and 
 Oilier were recognized masters in laying the foundation of 
 modern surgery. Since the use of the science of medicine 
 in France it has at no time gone into decline. The good work of 
 progress has never come to a standstill, but the influence of the 
 French school has no longer such a firm hold on the medical 
 profession outside of its national limits. The Vienna school, 
 under the leadership of Hyrtl, Rokitansky, Oppolzer, Carl 
 Braun and Billroth, has since enjoyed the greatest popularity 
 and wielded the strongest influence in molding the medical 
 ideas during the middle of the last century. Since the awaken- 
 ing of Germany in 1871, after her victorious conquest against 
 France, the seed of science has flourished upon her soil, 
 and has yielded fruit which in quantity and quality has sur-
 
 passed anything heretofore accomplished in the same space <^f 
 time. With the political victory came a general prosperity which 
 has become the means of erecting and maintaining scientific 
 institutions which in efficiency surpass those of any other 
 country. The universities of Germany, with their model 
 laboratories and hospitals, have become the acknowledged 
 medical centers for the entire world. The current of medical 
 students and graduates seeking additional advantages has l)een 
 recently turned away from Vienna in the direction of Germany. 
 The immense clinical material offered by the hospitals of Paris 
 and the unexcelled facilities for the study of pathology pre- 
 sented by the Allgemeiues Krankenhaus and other large hos- 
 pitals of Vienna are powerless in deviating the course of the 
 present current. How long Germany can hold this supremacy 
 is impossible to predict. It is not so difficult to predict where 
 the next temple of medicine will be erected. In less than 25 
 years the United States will be the Mecca toward which 
 pilgrim medical students from all climes will wend their way. 
 
 Science has been moving westward and will continue to do 
 so in the future. The United States is in its direct pathway and 
 will be reached in due course of time. There can be but very 
 little doubt that when our country has fulfilled its mission the 
 inheritance will next be appropriated by the youngest of civil- 
 ized nations— Japan. The young vigorous private institutions 
 so richly endowed by our public-spirited men of wealth will 
 become the great centers of learning and will meet their exalted 
 future requirements in a way that will astonish the outside 
 world. Paris presents today clinical advantages of far reaching 
 value that are not sufficiently appreciated by those who feel the 
 needs of postgraduate education. Undoubtedly one of the 
 reasons for this is the preference given by our students to the 
 German over the French language when it becomes necessary 
 to acquire another language for the purpose of completing their 
 medical studies. A speaking knowledge of French is prac- 
 tically of l)ut little use to our practitioners, while the large per- 
 centage of German-speaking patients adds much to the desire of 
 mastering this language. Another inducement for obtaining a 
 practical knowledge of the German language is the richness of 
 the German medical literature, which exceeds by far that of any 
 other country. Any one who wants to keep pace with rapid 
 advances of medical knowledge must be familiar with the deep 
 researches of German scientists and the accurate observations 
 of the German clinicians. 
 
 A Forenoon at the ffopital Teyion. — Duving my limited 
 sojourn in Paris I spent one very profitable forenoon at the 
 Hopital Tenon. This is one of the older hospitals in Paris. It 
 is a solid stone building outside of the great business center of
 
 the city and can accommodate 1,000 patients. On that particular 
 day I had the pleasure of familiarizing myself somewhat with 
 the surgical technic of one of the noted surgeons of Paris— 
 Dr. Broca. I was particularly impressed with the simplicity 
 of his details in rendering hands and field of operation aseptic. 
 Hand disinfection is obtained by scrubbing with warm water 
 and soap and by immersion for a short time in a 1 : 2,000 bichlorid 
 solution. The field of operation is disinfected by the same 
 means after the patient is fully under the influence of a general 
 anesthetic. The dressing material consists of plain gauze and 
 absorbent cotton sterilized by dry heat, the former kept ready 
 for use, in tin boxes. Chloroform is the anesthetic used, dropped 
 upon a thin gauze compress held in contact Math the face. 
 Reverdin's needle is used in suturing. Inside of the peritoneal 
 cavity silk is used, outside catgut. The harmonious action 
 between operator and assistant in suturing and ligaturing was 
 a pleasure to observe. Dr. Broca is a very expert operator and 
 his work is the best proof of his familiarity with the technic of 
 the different operations and his vast experience in the operat- 
 ing room. He uses very few instruments and makes free use 
 of his hands in separating and approximating wound surfaces. 
 His movements are quick but deliberate and certain. During 
 the forenoon he performed the following operations: 
 
 Case I. — Appendicitis in a badly nourished boy about 14 
 years of age. First attack ; duration nine days. Clinical symp- 
 toms were mild. There was no swelling in the ileocecal region. 
 Abdomen was flat. An incision three inches in length over the 
 appendix and parallel with the fibers of the external oblique 
 muscle was made. Internal oblique and remaining layers were 
 incised to the same extent. There were adhesions. Appendix 
 was not enlarged, but very vascular. Subserous amputation 
 was done. Mucosa of stump not cauterized, but was buried by 
 two rows of Lembert sutures of fine silk. Peritoneum, internal 
 oblique; external oblique and skin were united separately by 
 continuous catgut suture. 
 
 Case II.— Boy, aged 15. Had multiple enchondroma of 
 metacarpal bones and phalanges of left hand. The tumors 
 varied in size from a hazelnut to a pea. Most of them were 
 central, and near the epiphyseal lines. Operation without elas- 
 tic constriction. Short incision over center of tumor ; removal 
 of tumor by excochleation. Six tumors were removed in this 
 manner, and all of the wounds sutured throughout. 
 
 Case III.— Patient was a girl, aged 12. She was anemic, and 
 the subject of tuberculosis of the lymphatic glands in the 
 submental and left parotid region. Glands were in a state of 
 far advanced caseation, with overlying skin discolored. They 
 were removed by clean excision. In the parotid region a thin 
 mantle of parotid tissue was removed with the caseous 
 glands within the capsule of the parotid. Before draining and 
 suturing, the wounds were touched freely with a 10% solution 
 of zinc chlorid. 
 
 Case IA^. — Boy 10 years of age, operated upon for hypo- 
 spadias. Termination of urethra half way between glans penis
 
 and scrotum. A urethra was made l3y dissecting upon each 
 side a narrow quadrangular flap, Avhich was sutured over a 
 catheter inserted into the bladder. 
 
 The operator was not pleased with the result of this opera- 
 tion, and in all probability next time will make use of the 
 method described by Dr. Carl Beck, of New York, which has 
 yielded such brilliant results in such cases in the hands of this 
 and many other operators.
 
 [ReiDrinted from American Medicine, Vol. IV, No. 2, pages 66-67, 
 July 12, 1902.] 
 
 SURGICAL OBSERVATIONS IN BERLIN. 
 
 BY 
 
 NICHOLAS SEXN, M.D., 
 of Chicago, 111. 
 
 Berlin is today the most profitable center for surgical teach- 
 ing in the world. The vast clinical material is in the hands of 
 men who know how to utilize it in teaching not only the art but 
 also the science of surgery. The German surgeon is a patholo- 
 gist and is guided in his diagnosis and work by his knowledge 
 of the etiology and pathologic conditions which underlie the 
 morbid conditions he is called upon to correct. Berlin is the 
 place above all others for postgraduate instruction. Its rich 
 museums and well-equipped laboratories, the numerous clinics 
 pertaining to all branches of the healing art offer facilities for 
 practical work far superior to those of any other medical center. 
 The young surgeon can prepare himself here for his life work 
 by visiting the clinics of von Bergmann, Konig, Rose, Sonnen- 
 burg, James, Israel and Hahn, men whose names are household 
 words wherever modern surgery is practised. Nowhere is it 
 more apparent than in Berlin that aseptic precautions have 
 recently become very mvich simplified. The greatest stress is 
 laid on the mechanical cleansing of hands by the liberal use of 
 warm water and soap followed by alcohol, with or without a 
 previous ablution with a bichlorid solution. Rubber gloves 
 have been almost entirely discarded. Ether is used more fre- 
 quently than heretofore. Spinal anesthesia has few if any 
 advocates. 
 
 Friedrichshain HospitaL— This is one of the great hos- 
 pitals for the deserving sick poor of Berlin. It is built on the 
 pavilion plan around a large open square. The main entrance 
 is vis a vis with one of the large public parks. The many build- 
 ings are constructed on modern plans, and harmonize as a 
 whole. The operating rooms are equipped with all facilities 
 for aseptic work, and are well supplied with all necessary sur- 
 gical instruments. The institution has a total capacity of 800 
 beds, of which number 250 are set aside for surgical patients.
 
 rrofessor Habn. 
 
 Professor Hahii's ]^o?'^'.— Professor Hahn is well known to 
 the surgical world. He has probaljlj'^ performed more opera- 
 
 'ions upon the stomach than 
 any other surgeon. He is an 
 indefatigable worker, and 
 has done much in the ad- 
 vancement and perfection of 
 surgical techuic. He oper- 
 ates every morning at the 
 Friedrichshain at 10 o'clock. 
 His well-trained nurses and 
 experienced assistants coji- 
 tribute much to facilitate and 
 lighten his arduous daily 
 routine work. The asepsis 
 in his operating room is as 
 nearly perfect as it can be 
 made without any extra dis- 
 play of precautionary meas- 
 ures. No gauze turbans are 
 seen here and no display 
 of white trousers, wooden or golf shoes or rubber boots. 
 Hand disinfection is made by thorough scrubbing with hot 
 water and potash soap, followed by sublimate solution. 
 Gloves are used only in operations for septic conditions, 
 and then only for the purpose of guarding against unnec- 
 essary contamination of the hands. For nine years he has 
 relied on silk exclusively as a suturing and ligature mate- 
 rial. In operations upon the gallbladder he occasionally makes 
 use of catgut. In his practice stitch abscesses very rarely occur. 
 The motto in his operating room is hoJi tcmgere, a warning to 
 nurses and assistants not to touch anything that might contami- 
 nate the hands after they have been rendered aseptic. One nurse 
 threads the needles, another hands the instruments, and the 
 third handles the sponges. One assistant administers the anes- 
 thetic, the second assists the operator, and a third one uses the 
 sponge. Chloroform vapor from the Junker-Kappeler appara- 
 tus is the anesthetic in general use. The visitors permitted to 
 witness his operations do so without being obliged to remove 
 their coats or wear a gown. 
 
 During the most difficult operations the work goes on 
 quietly and deliberately, without any manifestations of impa- 
 tience, showing the hand of a master, ample and careful prepa- 
 rations, and the value of skilled assistants and well-trained, 
 wideawake nurses. It was a source of great pleasure and profit 
 to me to witness the following operations :
 
 Case I. — Gastrogastrostoiny for hour-glass contraction of 
 the stomach : The patient was a woman of about 30 years who 
 had been suffering for several years from indigestion and fre- 
 quent and sometimes profuse hemorrhages from the stomach. 
 The patient was reduced to a skeleton. No positive diagnosis 
 was made between cancer and ulcer of the stomach. The 
 incision was made through the middle of the umbilicus with- 
 out the aid of grasping forceps by lifting up the abdominal wall 
 on each side, incising the fold, including the entire thick- 
 ness of the abdominal wall, when the incision was enlarged up- 
 ward by cutting with scissors. As the vertical incision did not 
 give free access to the stomach a transverse incision including 
 the entire rectus muscle was made on the left side. The stom- 
 ach was found divided into two unequal compartments, the 
 largest one on the cardiac side, by a cicatricial band. The firm 
 adhesions about the smaller curvature made it impossible to 
 deal directly with the ulcer, consequently the proper course to 
 pursue Avas to establish a new and free communication between 
 the pyloric and cardiac compartments of the stomach, this 
 was done by makiog a gastrogastrostomy by suturing. The 
 techuic of this part of the operation was perfection itself. 
 After uniting the serous surfaces with a row of interrupted 
 Lembert stitches in a vertical direction to the extent of three 
 inches the muscular and serous coats were incised on both sides 
 about two lines from the line of suturing and another row of 
 sutures united the serous surfaces accurately, when the mucous 
 membrane on each side was incised and sutured separately 
 w^ith a continuous lockstitch suture. The anterior wound mar- 
 gins were united in the usual manner by Czerny-Lembert 
 sutures. Although the patient was very feeble and the opera- 
 tion consumed 70 minutes symptoms of shock were absent. 
 The abdominal incision was closed by two rows of sutttres, the 
 first including all layers except the skin. Three small capillary 
 drains of gauze were inserted between the external sutures. In 
 applying the external dressing- abdominal compression is 
 guarded against by holding the internal part in place with a 
 number of strips of adhesive plaster which encircle only one- 
 half of the circumference of the body, over whicli a very thick 
 compress of absorbent cotton is applied and held in place by a 
 loose gauze roller. Professor Hahn is of the opinion that firm 
 compression favors the development of bronchial and pulmon- 
 ary complications after abdominal operations. 
 
 Case II.— Perforative appendicitis: Patient a woman of 
 66 years. This was her first attack. The initial symptoms pre- 
 sented nine days ago were comparatively mild. There was no 
 rise in temperature, but there was some vomiting and frequent 
 eructations. Rapidity of pulse was the only grave prognostic 
 symptom. The abdomen was tympanitic, with pain and tender- 
 ness in the right iliac fossa. A muscle splitting incision was 
 made, and as soon as the peritoneal cavity was opened a large 
 quantity of thin fetid pus escaped. The cavity on the side of the 
 small intestines was tamponed at once and the perforated 
 appendix was brought into the incision without any difficulty. 
 A fecal stone escaped Avith the pus and a second one was found 
 in the blind end of the appendix. The perforation through 
 which the liberated stone had escaped was found near the 
 cecum. The first ligature cut its Avay through the softened tis- 
 sues and a second one was applied with less firmness to the 
 stump. No attempt was made to flush the cavity, which was 
 then loosely packed with plain sterile gauze. The operator.
 
 from a very large expfrience, has fonudthat the tampon should 
 remain in place from five to ten days and then be reduced in 
 size gradually, as complete removal at one time, according to 
 his observations, has not infrequently proved harmful. By 
 the gradual removal of the tampon the suppurating cavity is 
 reduced in size as the foreign material is extracted and the 
 danger of damage to the granulating intestinal loops is mini- 
 mized. The copious external dressing is changed as often as 
 indications arise. 
 
 Professor Konig's C/?/?/c.— Professor Konig, the eminent 
 author and present authority on diseases of joints, conducts his 
 clinic at the Charite Hospital every day except Sunday at half- 
 past nine in the forenoon. He is looking forward with well- 
 founded impatience to the completion of the new clinical build- 
 ing, as the present quarters are entirely inadequate for the 
 existing demands. The amphitheater has only 136 seats alto- 
 gether, insulficient for the many students who seek instruction 
 in this clinic. The seats are numbered and assigned to the 
 students who are fortunate enough to receive them by early 
 application. Professor Konig has just celebrated his seventieth 
 birthday. He enjoys robust health and retains the enthusiasm 
 of youth. It does appear sometimes sad to contemplate that great 
 men who have been of such incalculable assistance to science 
 and humanity must eventually succumb to the inevitable senile 
 decrepitude which at last conquers their physical strength 
 and mental activity. Konig has always been an impressive 
 and popular teacher, a reputation he has maintained to the 
 highest degree since he came from Gottingen to Berlin. His 
 language is concise and precise. Like all German teachers he 
 makes pathology the ground floor for his clinical teachings. 
 The details of his aseptic technic are remarkable for their sim- 
 plicity. Hand disinfection consists largely of thorough scrub- 
 bing with hot water and soap supplemented by an ablution 
 with a 1 1000 solution of mercury bichlorid. The field of opera- 
 tion is disinfected in the same manner after the patient is under 
 the influence of the anesthetic. If rubber gloves were ever used 
 they have been discarded. As anesthetics, chloroform and ether 
 are used. I will give a brief description of the material pre- 
 sented and the operations performed during one of his clinics: 
 
 Case I. — Resection of the head of the radius for ankylosis 
 of the eibowjoint following gonorrheal arthritis. 
 
 The patient was a female of 25 years. The forearm was 
 fixed in flexion at an angle of 45° with complete suspension of 
 all rotary movements. The acute symptoms had subsided and 
 as the joint resisted all attempts at immobilization an incom- 
 plete resection was performed a few days ago. On opening the 
 joint on the radial side a bony ankylosis was found between 
 the articular surfaces of the radioulnar joint. The excision of 
 the head of the radius removed the mechanical difficulty and 
 the joiat can now l^e flexed quite freely and pronation and 
 supination of the forearm have been restored. A small iodo-
 
 form gauze drain was removed and the dressing and fixation 
 splint reapplied. It was remarked that in many cases of anky- 
 losis of the elbowjoint arising in the coarse of a gonorrheal 
 arthritis the mechanical difficnity is often to befonnd in a bony 
 ankylosis of the radioulnar joint and that a resection of the 
 head of the radius offers the only chance for restoration of 
 motion. 
 
 Case II. — Fracture of the humerus at the junction of the 
 middle with the lower third, complicated by paralysis of the 
 musculospiral or radial nerve and delayed union. 
 
 In this patient, a robust man of middle age, it was difficult 
 to decide between trauma and callus compression as cause of 
 the paralysis, as the patient's statements in reference to the 
 time when the paralysis appeared were indefinite. Four 
 days before an incision was made over the course of the nerve 
 exposing the seat of the fracture freely. The fragments were 
 found imbedded in a mass of immature callus, and the nerve 
 over it completely severed. The proximal end, as is usually 
 the case, was bulbous. The finding of the distal end was 
 attended by considerable difficulty. Secondary nerve suturing 
 was performed after freely vivifying the nerve ends. Accord- 
 ing to the operator's large experience, restoration of nerve 
 function is often delayed for months after the operation if 
 the operation is performed a long time after the injury. The 
 hope was expressed that the nerve-suturing would hasten the 
 process of bone repair. 
 
 Case III. — Large abscess in left iliac fossa of somewhat 
 doubtful origin ; operation four weeks ago. 
 
 Patient a young man who was attacked suddenly with 
 symptoms of peritonitis. The disease pursued a very rapid 
 course and, in view of the clinical symptoms, appendicitis was 
 suspected as its cause, although the physical signs indicated 
 an accumulation of pus in the left iliac region, extending over 
 the bladder toward the right side. At the time the operation 
 was performed, over four weeks ago, the abdomen was very 
 tympanitic. Almost the entire linea alba was incised but noth- 
 ing abnormal could be found in the peritoneal cavity except 
 distention of the small intestines. The abdominal incision 
 was then closed and a transverse incision made over the pubes 
 and left Poupart's ligament and a large quantity of extremely 
 offensive pus evacuated. The most careful exploration did not 
 reveal a palpable cause for the suppurative inflammation, but 
 it is suspected that an abnormally situated appendix was the 
 starting point of the infection. The large cavity becomes oblit- 
 erated in a remarkably short time by granulations, and the 
 grave symptoms subsided promptly after the operation. The 
 abdominal incision is healed and only a limited granulating 
 field indicates the location of the transverse incision. Gauze 
 was made use of as a drainage material. Attention was called 
 to the comparative harmlessness of fetid pus in dealing with 
 the suppurative inflammation giving rise to this variety of pus. 
 
 Case IV.— Fetid empyema following rupture of an appen- 
 diceal abscess into the left pleural cavity. 
 
 This case was an extremely obscure one. The patient, a 
 young man of 16, when admitted into the hospital presented all 
 the indications of empyema. The early history of the case was 
 obscure. A segment of the seventh rib was excised in the axil- 
 lary line and a large quantity of very fetid pus was liberated. The 
 patient not improving as was expected, the opening in the chest 
 wall was enlarged by resection of the adjacent lower rib. As
 
 6 
 
 the suppuration and septic condition persisted, it Avas finally 
 decided to follow the abscess cavity its entire length in a down- 
 ward direction. The remaining lower ribs were excised and 
 a perforation was found in the diaphragm. The aljscess cavity 
 was followed by extending the incision downward as far as the 
 crest of the ilium. From this time the patient improved 
 rapidly and at the present time the enormous wound is granu- 
 lating satisfactorily and promises to heal in a short time. It is 
 believed that an appendicitis was the cause of abscess forma- 
 tion and that the secondary suppurative pleuritis resulted from 
 the entrance of pus into the pleural cavity through a perfora- 
 tion in the diaphragm. 
 
 Case V.— Diffuse peritonitis following appendicitis ; opera- 
 tion. 
 
 Patient a delicate girl of 10 years. This was her first attack, 
 the duration of the disease being less than two weeks. The 
 symptoms were strong from the beginning, vomiting was a 
 prominent symptom. The abdomen was distended, and the 
 presence of pus in the right iliac fossa was suspected. The per- 
 sistent vomiting, feeble circulation and marked tympanites 
 were regarded as grave symptoms. A long incision was made, 
 and as soon as the peritoneal cavity was opened a large quan- 
 tity of fetid pus escaped. Intraperitoneal palpation proved 
 that the peritonitis was diffuse, with no tendencv to limitation. 
 The incision was then enlarged upward along the crest of the 
 ilium. There was free prolapse of small intestines and cecum. 
 The inflamed appendix came readily into the wound, was 
 ligated and removed. There was no gangrene and no perfora- 
 tion. The stump was buried with a few Lembert stitches. 
 The pus was pushed out by placing the patient on the right side 
 and the wound packed with iodoform and sterile plain gauze. 
 The extent of the disease was mentioned as a contra-indicatiou 
 to irrigation. 
 
 Case VI.— Carcinoma of the posterior wall of the rectum : 
 extirpation. 
 
 This patient was a woman of 66. For twenty years she suf- 
 fered from a rectal difficulty which was regarded to be of a 
 hemorrhoidal nature. The prominent tumor excavated in the 
 center projected from the posterior rectal wall one and one-half 
 inches above the anus. The patient was placed in the lith- 
 otomy position and the anterior rectal wall removed farljeyond 
 the limits of the tumor by the perineal route. The importance 
 of making a careful examination in all cases of rectal disease 
 was emphasized. Like most surgeons. Professor Konig, as 
 the result of experience, has been led to limit more and more 
 the indications for Kraske's sacral resections as a preliminary 
 step to operations for malignant disease of the rectum. 
 Berlin, May 15.
 
 LHeprinted from American Medicine, Vol. IV, No. 3, pages 103-104, 
 July 19, 1902.1 
 
 SURGICAL OBSERVATIONS IN BERLIN. 
 
 Professor Olshausen's Gynecologic Clinic. — The Augusta 
 Hospital. 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 Professor Olshausen occupies today the highest position 
 as a teacher of gynecology. As an operator he is one of the prin- 
 cipal attractions of the medical faculty of the University. He 
 left Halle in 1887, w^hen 50 years of age. His success in Berlin 
 has been phenomenal. The clinical material over which he has 
 complete control is immense. Four laparotomies a day is a 
 small estimate of his daily major operations. Every one of his 
 operations shows the hand of a master. He is never in haste, 
 and yet the operations are performed quickly. The most 
 difficult operations are performed with few instruments. He 
 handles the instruments with an accuracy and dexterity that 
 astonish and charm his audiences. His earnestness and enthu- 
 siasm in the lecture and operating room are impressive. 
 Among his private patients are to be found the names of many 
 of the most prominent families from every country on the con- 
 tinent. His speech and actions are well calculated to inspire 
 patients and pupils with confidence. He begins his operations 
 at 7 o'clock in the morning and seldom finishes his onerous 
 
 task before midday. No time 
 is wasted. He is punctual to 
 the minute. His splendid 
 staff of assistants and well- 
 trained nurses anticipate all of 
 his wants, and the most com- 
 plicated operations are fin- 
 ished without a hitch or a 
 harsh word. 
 
 Chloroform by the drop 
 method is the anesthetic used. 
 Sublimate alcohol catgut is the 
 exclusive suture and ligature 
 material used with one excep- 
 tion, intestinal operations, 
 when silk takes its place. 
 Cathartics are given before 
 Professor Olshausen. abdominal section and three 
 
 days after operation. The day 
 before operation the patient is given a bath, but the disinfection
 
 of the field of operation does not take place until the patient is 
 on the operating table and fully under ihe influence of the gen- 
 eral anesthetic. 
 
 This disinfection, as well as hand disinfection, consists 
 largely in prolonged scrubbing with hot water and soap, fol- 
 lowed by sublimate solution and alcohol. The last antiseptic 
 is now considered the most important in guarding against 
 stitch abscesses. 
 
 The instruments, on a tray, are placed on a stand within easy 
 reach of the operator. One nursie threads and hands the needles. 
 A second nurse hands the sponges and the dressing material in 
 a receptacle, without touching them. The two great rules that 
 should govern the work in every operating room are displayed 
 conspicuously. These rules are : ""Noli tangere'''' and^'Favete 
 Unguis." One assistant assists the operator, a second admin- 
 isters the anesthetic and a third holds the pulse. The leading 
 points in his operative technic will be given in a few of the 
 operations I had an opportunity to witness. 
 
 Case I. — Enucleation of a Myofibroma of the Uterus. The 
 patient was 31 years old; Trendelenburg position. Disinfection 
 of the abdomen was obtained by shaving, scrubbing with 
 warm water and soap, followed by sublimate solution and 
 alcohol. Incision was made through the linea alba. Peri- 
 toneum was opened in the upper angle of the wound so as to 
 avoid injury to the bladder. Incision was enlarged to the 
 extent of five inches with blunt-pointed scissors. Uterus was 
 lifted forward into the wound and a large compress of gauze 
 placed between it and the small intestines. To this large gauze 
 compress a tape was fastened, and to the end of the tape a large 
 hemostatic forceps was applied. These precautions cannot fail 
 to prevent the loss of gauze in the abdominal cavity. The 
 tumor, the size of an orange, involved the summit of the uterus 
 and was interstitial. The mantel of uterine tissue was incised 
 half way between the cornua in an anteroposterior direction, 
 when the tumor was grasped with vulsella forceps and easily 
 removed by enucleation. This part of the operation was done 
 largely by stripping the uterine tissue back with a gauze sponge. 
 The bleeding, which was very slight, was carefully arrested by 
 ligating with catgut. The visceral wound was closed by two 
 rows of continued catgut sutures, the first row including the 
 muscle tissue and the second one approximately the serous sur- 
 faces. The bleeding from the needle punctures was arrested by 
 additional sutures often placed parallel with the line of incision. 
 The peritoneum was sutured separately with a continued catgut 
 suture, the second tier included the fascia, and the third approx- 
 imated the skin. A drying powder was rubbed into the punc- 
 tures of the skin, and the dressing, consisting of a few layers 
 of gauze and a compress of aseptic absorbent cotton, fastened in 
 place by three broad strips of adhesive plaster. Professor 
 Olshausen is of the opinion that ventral hernia after laparotomy 
 only occurs when the fascia, from faulty suturing or suppura- 
 tion, fails to unite. He has no confidence in abdominal sup- 
 porters as preventives of this post-operation complication. 
 
 Case 11.— Multiple Myofibroma of the Uterus: Supra- 
 vaginal Amputation. The patient is a multipara, 47 years old.
 
 The uterus and tumors form a nodular, irregular mass the size 
 of an infant's head. The right ovary is healthy, and the left one 
 cystic. The latter was removed with the uterus. Division of 
 tubes and broad ligaments was made between double catgut 
 ligature. The ovarian arteries were ligated en masse. The 
 uterus was now drawn well forward and upward with traction 
 forceps, the peritoneum incised and reflected largely by pres- 
 sure with gauze sponge. All bleeding points were tied with 
 catgut, after which the uterus was amputated with one 
 sweep of the knife. Projecting bloodless stumps of ovarian 
 arteries were tied sepai-ately. The cut surface of uterine tissue 
 was approximated by continued catgut sutures when the serous 
 surfaces were carefully united by the same kind of suture. 
 Abdominal incision was closed and dressed in the same manner 
 as in the first case. 
 
 Case 111.— Retroversion of Uterus: Alexander's Operation. 
 Professor Olshauseu commenced to perform this operation only 
 three years ago, and is very careful in the selection of cases. He 
 limits the operation to cases of retroversion of a movable 
 uterus which produces symptoms of suflQcient severity to war- 
 rant operative interference. In this case the uterus could be 
 brought into normal position without any difficulty. An 
 incision three inches in length was made from the pubic spine 
 and parallel with Poupart's ligament. After incising the skin 
 and superficial fascia, the lower angle of the inguinal canal 
 where the round ligament expands and is attached was sought 
 for by rubbing with a gauze sponge. The ligament was iso- 
 lated at this point, grasped with hemostatic forceps, divided 
 below the forceps, and then taking the ligament as a guide the 
 inguinal canal was slit open with probe-pointed scissors, the 
 ligament detached and by traction and backward rubbing with 
 a sponge liberated to the extent of about four inches. The 
 ligament was fastened in the canal by four transfixion catgut 
 sutures, the free end excised and the little wound closed by two 
 rows of catgut sutures. Dusting powder and a small aseptic 
 absorbent dressing held in place with roller bandage finished 
 the operation. The operation on the opposite side w^as per- 
 formed in thp same manner. The experience of the operator 
 concerning the remote results of this operation has been very 
 satisfactory. 
 
 The wealth of material of this clinic is shown by the fact 
 that about 700 patients suffering from retroversion of the uterus 
 apply annually for relief. Out of this number only from 35 to 
 40 cases are selected for an Alexander's operation. 
 
 Augusta Hospital.— This institution for the relief of the 
 sick of Berlin has an interesting history. It was founded by the 
 late Empress Augusta and has been a favorite resort for the sick 
 for more than a quarter of a century. It is managed by the 
 Women's Hospital Association, of which the Empress is honor- 
 ary president. It is probably the naost homelike hospital in the 
 world. Its officers and Sisters are selected exclusively from the 
 titled nobility. In a large and beautifully furnished room the 
 Board of Managers holds its meetings, the Empress or her sub- 
 stitute presiding. Here are found portraits of the royal family 
 and a register for distinguished visitors contains the names of
 
 most of the distinguished men and women of the German Em- 
 pire. The hospital, which has a capacity of 190 beds, presents a 
 homelike appearance and is surrounded by ample grounds, made 
 attractive by expert gardeners. The furniture throughout the 
 entire house reminds one of the comforts of a private home. 
 Two of the most distinguished medical men in Berlin are at the 
 head of the medical service. Professor Ewald has charge of the 
 medical and Professor Fedor Krause of the surgical depart- 
 ment. These appointments are made by the Empress and are 
 for life. Professor Krause imbibed his unbounded enthusiasm 
 from his distinguished teacher, the late Professor von Volk- 
 mann. He has written a valuable monograph on tuberculosis 
 of joints, and for a number of years had charge of the surgical 
 work of the Altona Hospital. Recently he has distinguished 
 himself in brain and nerve surgery. He received the present 
 
 Augusta Hospital. 
 
 appointment a year and a half ago, and is now in direct line for 
 early promotion. The care of the sick is in charge of Sisters 
 and nurses who receive their theoretic instructi )n and practical 
 training in the hospital. The Sister Superior receives her 
 appointment from the Empress. Sister von Arnim has served 
 in this capacity since the hospital was opened. All of the 
 Sisters, 20 in number, are of noble birth. The initia- 
 tion of a Sister is an important event, at which the 
 Empress is always present, and presents the Golden 
 Roman Cross she is expected to wear during her service of 
 the balance of her lifetime. The selection of nurses receives 
 the same care. They are young ladies, from 20 to 25 years of 
 age, usually the daughters of clergymen or professors. These 
 nurses very rarely abandon their profession. The nurses must 
 remain m training for two or three years, and during this time
 
 they are instructed in the theoretic part of their profession for 
 three months by tlie senior home physician, who gives two 
 lectures a week. 
 
 The lectures are of the most practical kind. At the expira- 
 tion of the specified time they receive a certificate of proficiency 
 from the Si.ster Superior and are permitted to enter private 
 practice or hospital work in some other institution. The earn- 
 ings of these nurses flow into the treasury of the institution 
 from which they graduated. On the other hand, their alma 
 mater provides at all times for their subsistence and clothing. 
 
 In Germany the loss of a nurse by marriage does not occur 
 as frequeritly as in our own country, where the attractive and 
 most efficient nurses only too often leave their chosen profes- 
 
 5r 
 
 
 
 Augusta Hospital and Garden, 
 
 sion by entering married life, an occurrence which cannot fail 
 in weakening the nursing prof'-ssion. In time of war or 
 other great national calamities, Sisters and nurses are 
 subject to call from the Red Cross Society of Germany, 
 with which this institution is identified. There is perhaps no 
 other hospital in which the sick recei\e better atten- 
 tion. A patient who pays §1.25 a day is entitled to a pri- 
 vate room with two beds, and §2.50 a day a single room 
 including the very best nursing and medical or surgical 
 attendance. The salary of the attending surgeon is less than 
 §400 a year. The income of the mediral profession of Germany 
 is greatly reduced by the questionable custom which prevails 
 in all hospitals throughout the em|»i]-e of rendering fiee medi-
 
 6 
 
 cal service to private patients occupying the most luxurious 
 rooms and by the only too prevalent contract practice among 
 the laboring classes. 
 
 Professor Krause's Work. — Professor Krause belongs to the 
 younger class of progressive surgeons of this city. His present 
 field offers him abundant and very interesting clinical material. 
 In the laboratory connected with the hospital excellent patho- 
 logic work is done. I examined here a large collection of 
 specimens of carcinoma of the pylorus removed by operation. 
 Gastrectomy and gastroenterostomy are frequently performed 
 in this hospital, as Professor Ewald, who has charge of the 
 medical service, refers his cases which require operative inter- 
 ference to the surgical department. Two tumors of the spinal 
 cord were also shown. One of the tumors was a psammoma 
 the size of a hazelnut removed successfully from the dorsal sec- 
 tion of the spinal cord. The symptoms before the oper- 
 ation were so characteristic that the surgeon was able 
 to make an absolute anatomic and pathologic diag- 
 nosis. Paralysis of motion on one side and loss of sensa- 
 tion on the opposite were the most conspicuous clinical 
 features. The cord was freely exposed by resection of three 
 vertebral arches. The dura was incised and the encapsulated 
 tumor removed by enucleation. Nerve function has been 
 restored sufficiently so the patient walks readily with the use of 
 a cane. The other specimen illustrated the diffuse nature of 
 sarcoma of the spinal cord. The tumor had its origin in the 
 Cauda equina and was exposed by an extensive laminectomy 
 and was followed upward sufficiently far to satisfy the operator 
 that the case was hopeless. The patient died. Krause has had 
 a very extensive experience in nerve and brain surgery. In 
 neuralgia of the trifacial nerve he always resorts to peripheral 
 operation first. A beautiful collection of excised nerves was 
 demonstrated. From the point where tbe nerve is attached the 
 main trunk and branches are followed as far as possible 
 so as to make the extracranial excision thorough. If the 
 operation does not prove successful he resorts to his intra- 
 cranial operation for the removal of the Gasserian ganglions. 
 He has performed this operation, up to the present time, on 36 
 patients. Only three of these patients died from the effects of 
 the operation; in those that survived the relief was prompt 
 and permanent except in one, in whom it failed to mitigate the 
 pain. This patient wa,s a physician, who threatened to commit 
 suicide if the operation were refused. The cause of the pain in 
 this patient had a deeper and inaccessible origin.
 
 [Reprinted from American Medicine. Vol. IV, No. 4 page 148, 
 July 26, 1902.] 
 
 RENAL SURGERY AS PRACTISED BY PROFESSOR 
 JAMES ISRAEL. 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 The world admires the work of a master. This applies not 
 only to art, music, science, literature, war and oratory, but also 
 to surgery. The fame of the artist, musician, scientist, littera- 
 teur, warrior and orator spreads worldwide and is immor- 
 talized in prose and song; that of the master surgeon is limited 
 to within the narrow bounds of the profession he represents. 
 To my mind there can be no greater source of satisfaction than 
 to excel in Avork calculated to advance science and bene- 
 fit suffering humanity. The master surgeon occupies such 
 a position. He belongs to the most charitable of all profes- 
 sions. His genius adds to the advancement of science, his 
 art benefits the poor as well as the rich. The surgeon who 
 makes a careful and exhaustive study of the diseases of an im- 
 portant organ and devises new measures of relief merits the 
 admiration and gratitude not only of the members of the pro- 
 
 ^ fession to which he belongs 
 
 but of the entire world. 
 Such a man is Professor 
 James Israel, the master of 
 renal surgery. 
 
 In the preparation of 
 his classic work on the sur- 
 gery of the kidney he has 
 incorporated his vast clin- 
 ical material and has laid 
 down rules of action calcu- 
 lated to secure the best re- 
 sults. 
 
 This book is a veritable 
 mine of information and 
 should be translated at once 
 into the English language. 
 It is safe to state that its 
 author has had more expe- 
 rience in surgery of the 
 kidney than any other surgeon. There are a number of serious 
 and obscure questions pertaining to the surgery of this organ 
 he has definitely settled. He very naturally demands of the 
 
 Professor James Israel.
 
 surgeon an accurate anatomic knowledge of the kidney and its 
 environment. He very correctly asserts, contrary to the 
 opinion generally entertained, that of all kidney operations 
 nephrectomy is the easiest. He strongly advocates conservative 
 operations whenever compatible wath the strnctural changes 
 which have taken place. He emphasizes the importance of 
 exposing the organs freely in all operations, so that the surgeon 
 can make a thorough examination, upon which depends final 
 diagnosis and the te(thnic of the visceral interference. He 
 insists upon catheterization of the ureter in all operations upon 
 the pelvis for the purpose of detecting and removing mechani- 
 cal obstructions. He is satisfied that if this is done urinary 
 fistula never occurs. He does not look upon ether as a danger- 
 ous anesthetic in renal surgery. The local effect of ether on the 
 kidney tissue is of shorter duration than of chloroform. 
 
 It was my pleasure to witness a number of his operations, 
 which I will describe as briefly as their importance permits : 
 
 Case I. — Lithiafiia arid Pyonephrosis^ of Right Kidney: 
 Nephrotoiny. The patient was a woman, aged 35. She had 
 lumbar pain in the right side, and pyuria for several years. 
 Her general health was materially impaired. The right kidney 
 was the size of a cocoanut, freely movable. Diagnosis was doubt- 
 ful. Tuberculosis had been excluded. There were decided symp- 
 toms of stone. Ether narcosis was obtained. Long transverse 
 incision was made revealing first preperiton<-al fat, next retrore- 
 nal fascia, and lastly the kidupy e^nveloped by its adipose cap- 
 sule. The preperitoneal fat and retrorenal capsule were incised 
 vertically toward the spinal side so as to guard against opening 
 the yjeritoneal cavity when these structures were reflected by 
 the use of fingers and sponge pressure until the hilus of the 
 kidney was reached and the ureter was freely exposed. The 
 kidney was very much enlarged and uneven. The space 
 around the kidney was packed firmly with gauze before it was 
 in<;ised. The incision was made on the convex side, from p"le 
 to pole. A. large quantity of fetid pus escaped and a numl)er 
 of faceted stones were removed. Catheterization of the ureter 
 was now made. The operator declared that it is exceedingly 
 dirticult and often impossible to find the ureteral orifice with- 
 out exposure of the ureter. Traction on the ureter causes 
 a dimple like depression on the surface of the pelvis, 
 the deepest portion of which always corresponds Avith 
 the ureteral inlet. The prolje and afterward the ureteral 
 catheter entered the bladder without difficulty. Catheter- 
 ization of the ureter before operation revealed blood and pus 
 corpuscles in the urine from the opposite kidney. The 
 calyxes of th«^ pelvis were freely slit opea with a blunt-pointed 
 bistoury, and after thorough flushing all of the depressions 
 and pelvis wfre packed with iodoform gauze. The margins of 
 rhe visceral incrision were stitched to the lumbar muscles and 
 fascia with caterut. A copious absorbent dressing was applied. 
 It is worthy of note that no safety pins are used. A long, heavy 
 silk thread is tied to the projecting part of each gauze strip. 
 The finding of calculi in the kidney operated upon, points 
 to the existence of a similar affection in the opposite organ. The
 
 precisiou, thoroughness and neatness with which this operation 
 was performed would have pleased the most critical observer. 
 
 Cask II. — Hematuria .- Exploratory Incision. The patient 
 was a woman 32 years of age, anemic and obese. For a number 
 of years she suffered from hematuria of renal origin. Ureteral 
 catheterization loi-ated the disease in the right kidney. Patient 
 appears to be the subject of a hemorrhagic disposition, as all 
 wounds have always bled freely. Ether narcosis was obtained. 
 Long transverse incision was made. Subcutaneous and preperi- 
 toneal fat were found to be very abundant. Kidney not enlarged 
 and very inaccessible. Palpation of pelvis was negative. A 
 hard mass the size of a hazelnut, above the kidney and in close 
 proximity to the large vessels, was discovered. No indications 
 Avere found for a visceral incision. It was surmised that a 
 malignant tumor in the pararenal space might account for the 
 hemorrhage by interfering with venous circulation by com- 
 pression. The incision was closed by deep interrupted sutures. 
 
 Case 111.— Renal Lithiasis: Pyonephrosis; Nephrotomy. The 
 patient was a man, aged 42; premature senility. He has not 
 been well since he was operated upon for stone when a boy. 
 Evidently a cystitis developed after the operation, followed l>y 
 an ascending tireteritis, which culminated in pyelitis and 
 pyonephrosis. There were no symptoms pointing to the exist- 
 ence of a renal calculus. A long transverse incision was made, 
 the kidney was found slightly enlarged and firmly adherent. 
 The intention of the operator was to make a nephrectomy, but 
 the conditions revealed by the incision made such a procedure 
 impossible. When the kidney was incised half a teacupful of 
 fetid pus escaped. Digital exploration of the pelvis of the 
 kidney revealed the presence of a number of small stones, which 
 were removed. Catheterization of the ureter could not be 
 made. Suturing of visceral incisions to lumbar muscles and 
 fascia was done; tubular and gauze drainage. The external 
 wound was diminished in size by a few deep and superficial 
 sutures, and copious dressing of absorbent material completed 
 the operation. 
 
 Case IV.— Chronic Papillomatous Cystitis; Suprapubic Cys- 
 totomy. The patient, a man of 35 years, was well nourished. 
 Twenty years ago he was operated upon for stone in the bladder 
 by crushiag. Symptoms of cystitis were not relieved. Bladder 
 is very small. Two years ago some papillomatous masses were 
 removed per urethra. This operation gave no relief. Tumor of 
 the bladder in the region of one of the ureteral orifices is sus- 
 pected. At no time was there hematuria of any consequence. 
 Urine was loaded with pits. Bladder was inflated with air and 
 patient placed in Trendelenburg's position. Transverse incision 
 severed insertion of recti muscles almost completely. Bladder 
 was brought well forward l3y making traction on two silk liga- 
 tures and incised transversely. Digital exploration revealed a 
 diffuse papillomatous condition of the mucous membrane. 
 Urethral drainage was done by the use of a soft rubber catheter 
 with vesical end, expanded so as to hold the instrument in 
 place. The vesical wound was closed by two rows of catgut 
 sutures, the first one embracing all tissues except mucous mem- 
 brane, when it was covered by a second row. External incision 
 was united by deep silk sutures which brought the divided 
 muscles in accurate approximatiou.
 
 [Reprinted from American Medicine, Vol. IV, No. 5, pages 185-186, 
 August 2, 19Cr2.] 
 
 PROFESSOR HOFFA'S ORTHOPEDIC WORK. 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 Professor Hoffa, although not more than 40 years of age, 
 is well known to the surgical profession by his clinical work and 
 most important literary contributions. His two books on 
 " Orthopedic Surgery " and "Fractures and Dislocations " have 
 been most favorably received and have contributed much toward 
 the advancement of these two distinct branches of surgery. 
 
 Three weeks ago he came 
 
 from Wurz1)urg to till the va- 
 cancy caused by the recent 
 death of Professor Julius 
 Wolff. He did not have to 
 wait long for work. His pub- 
 lic and private clinics are 
 crowded with patients. Some 
 idea may be formed of the 
 amount of his clinical mate- 
 rial by the 50 cases of congen- 
 ital dislocation of the hip- 
 joint which are now under his 
 treatment. I was given an 
 opportunity to see 20 cases in 
 the Polyclinic and to witness 
 two bloodless reductions in 
 the Polyclinic in one after- 
 noon. Thirty cases are under 
 treatment in ambulances. The 
 work in the Polyclinic begins at 2 o'clock and continues 
 incessantly during the entire afternoon. A trained nurse and 
 a staff of physicians render the necessary assistance. Profes- 
 sor Hoffa is an orthopedic surgeon in every sense of the word. 
 His knowledge is not limited to mechanics; he operates when- 
 ever he is satisfied that in doing so the desired result can ])e 
 reached in a shorter time and to a greater degree of perfection 
 than by the exclusive reliance on mechanical contrivances. 
 Every one of his operations demonstrates an intimate knowl- 
 edge of anatomy and sound surgical sense. Chloroform is used 
 by the drop method as an anesthetic and silk as suturing and 
 
 Professor A. Hotfa.
 
 ligature material. Tae silk is sterilize! by boiling in sub- 
 limate solution. Surface disinfection consists in thorough 
 cleansing by mechanical measures, followed by sublimate solu- 
 tion and alcohol. The name of Hoffa came prominently before 
 the profession by the bloody operation he devised for the reduc- 
 tion of congenital dislocation of the hip-joint. A large experi- 
 ence with this method has made him an enthusiastic advocate 
 of the bloodless method as described and practised by Pad. 
 He is, however, of the opinion that in patients more than 8 
 years of age the bloodless method seldom, if ever, proves suc- 
 cessful. In this class of patients he continues to perform his 
 operations with excellent results, as I had abundant oppor- 
 tunity to ascertain. In his private clinic a patient was exhib- 
 ited, operated upon seven years ago, who walked without a 
 limp. This patient was one of the first operated upon by the open 
 method. In children less than 8 years of age he always gives 
 the bloodless method a faithful trial before he resorts to the 
 knife and chisel. Several patients, one among them, a woman of 
 21, recently operated upon, were doing well. The operative 
 work of one afternoon in the Polyclinic included two cases of 
 bloodless reduction of congenital dislocation of the hip-joint 
 and a case of tendoplasty. 
 
 Case I. — Congenital dislocation of left hip-joint : reduction by 
 bloodless method. The patient, a girl, between three and four 
 years, had a congenital dislocation of the left hip-joint with a 
 moderate degree of shortening. When fully under the influence 
 of chloroform the patient was brought into proper position by 
 bringing the pelvis to the margin of the table and resting upon a 
 firm, flat pillow. An assistant fixed the pelvis, and the operator 
 abducted the thigh until it was at a right angle with the pelvis. 
 With the thumb of the right hand, firm pressure was made 
 against the great trochanter, while with the Uft the femur was 
 rotated forcibly outward. These movements were made at short 
 intervals and soon succeeded in lifting the head uponthe margin 
 of the acetabulum, when during the next manipulation it 
 slipped into the depression with an audible snap. The bone was 
 again dislocated and complete reduction effected with the same 
 ease. The limb was then abducted at an angle of 45 degrees, 
 strongly rotated outward and immobilized in a circular plaster- 
 of-paris splint, which included the pelvis and thigh. During 
 the setting of the plaster, firm pressure was made against the 
 great trochanter. In applying the splint, the child was first 
 placed in the ventral position ; the dressing was finished in the 
 dorsal position. If the reduction proves successful, the splint 
 remains for three months. The splint is made more durable 
 and kept clean for this long usage by coating it with water-glass 
 after it has become firm and dry. In this case a perfect result 
 is assured. 
 
 Case II. — Congenitfd dislocation of the hip-joint : bloodless 
 reduction under difficulties. Boy, of "four years, presenting a 
 dislocation of the "left hip-joint with marked shortening. The 
 iipper border of the great trochanter was near the iliac crest. 
 Repeated manipulations failed in effecting reduction. The con-
 
 traded adductor muscles were placed on the stretch and were 
 kneaded to overcome their resistance. Traction force in abduc- 
 tion was then applied on both limbs with an apparatus, the 
 perineum resting against an upright. The persistent strong 
 traction, aided by manual pressure against the great tro- 
 chanter, finally succeeded in reducing the head of the femur 
 into the shallow acetabulum. Fixation dressing the same as in 
 the first case was applied without relaxing the traction, "which 
 was continued until the splint became firm. Between the 
 splint and surface a smooth layer of cotton half an inch in 
 thickness was interspersed. 
 
 Case III.— Tendop I asty for infantile paralysis of exten- 
 sor and supinator muscles of the forearm. This patient 
 was a boy of 12 years. The original spinal affection para- 
 lyzed both limbs on the right side. The muscles of the 
 lower extremity regained function sufficiently so that the 
 boy can walk fairly well. Adductors of thigh contracted 
 with resulting adduction of thigh. Subcutaneous tenotomy, 
 with a small sickel-shaped tenotome, corrected this deformity 
 at once. The operation upon the forearm consisted in utilizing 
 the pronator radii teres. as a substitute for the paralyzed supi- 
 nators, w^hich was accomplished in the following manner: The 
 arm w^as rendered bloodless by elastic constriction. An in- 
 cision Sh inches in length was made over the pronator radii 
 teres on the ulnar side from its point of origin downward and 
 outward. The muscle was then isolated and detached from the 
 internal condyle of the humerus. A second incision about tw^o 
 inches in length was then made over the external condyle, and 
 through the incisions a tunnel was made with blunt instru- 
 ments underneath the flexor muscles, through which the free 
 end of the pronator muscle was drawn and sutured to the 
 external condyle wit*i silk. Hoffa has performed this opera- 
 tion in three similar cases with very satisfactory functional 
 results. The second operation was made for the purpose of 
 making use of the flexor carpi radialis and ulnaris muscles 
 as substitutes for the paralyzed extensor muscles. Through a 
 short incision the tendons of these muscles were isolated and 
 divided immediately above the wrist joints. The tendon 
 ends were at once secured by a ligature. The next step of the 
 operation exposed the extensor tendons by a median dorsal 
 incision above the annular ligament. Through a slit in the 
 tendon sheath the tendon ends, drawn through the subcuta- 
 neous tunnels, w^ere stitched with five silk sutures to the 
 tendons and tendon sheath. All of the wounds were closed 
 with interrupted silk sutures and dressed before the elastic 
 constrictor was removed. The operations were performed 
 with a neatness and accuracy that showed a perfect familiarity 
 with the anatomy and mechanics of the muscles concerned. 
 
 Case TV .—Gonorrheal synovitis of tlie knee-joint : irnrno- 
 bilization of quadratus extensor femoris muscle : tendoplasty. 
 The patient, a female of 25 years, had a gonorrheal synovitis of 
 the left knee which resulted in fibrous ankylosis and functional 
 loss of the extensor femoris muscle. The limb w^as nearly 
 straight, the joint fixed. Several attempts had been made to 
 render the joint movable by hrisement force under a general 
 anesthetic without avail. It was decided to use two of the 
 hamstring muscles as a substitute for the extensor muscle. 
 The biceps and the semitendinous were selected. Each of these 
 tendons was exposed by a short incision and divided near the 
 insertion and sutured to the anterior surface of the patella and
 
 on each side. The implautatiou was done through a small in- 
 cision over the inner and outer borders of the patella. The ten- 
 don ends were brought through a subcutaneous tunnel from 
 their normal location to their new destination. The operation 
 was performed under bloodless constriction and the four 
 wounds sutured without making any provision for drainage. 
 
 The next patients were operated upon in Hoffa's private 
 clinic, 16 Achenbach street, Charlottenburg. The building is 
 new and in a most select part of the great city. It was built 
 recently for this express purpose at an expense of $150,000. The 
 interior in appearance and furnishing resembles a private house. 
 It can accommodate 50 patients, and every bed is occupied. 
 
 A well equipped inechanical department furnishes the 
 apparatuses, most of which are designed by Hoffa. The hall for 
 gymnastic exercise is a revelation to the visitor. Massage and 
 electricity are applied in consonance with modern scientific 
 principles. The discipline throughout the house is faultless. 
 On the day I visited this institution I met Professor Xeuber, of 
 Kiel, who had been studying Hoffa's methods for more than a 
 week. This one circumstance satisfied me that I was in the 
 house of a master. A visit through the private rooms and small 
 wards satisfied me what skill can do to benefit crippled human- 
 ity. Paralyzed extremities were made useful by tendoplasty or 
 by the use of mechanical appliances. Patients that never 
 walked had abandoned all mechanic supports, and were practis- 
 ing muscles that were made to take the place of others that 
 had become useless. 
 
 Case V. — Calcaneo-valgus ; tendoplasty. This patient was 
 a girl of 10 years, with infantile paralysis, which resulted in 
 slight calcaneus and marked valgus deformity. The muscles 
 of the leg were decidedly atrophied. The defective muscles 
 were strengthened or their functional loss was restored by 
 tendoplasty. An incision w^as made over the tendo-Achillis 
 as far as its insertion into the os calcis. The tendon was 
 divided in the center anteroposteriorly and the inner half 
 severed from its insertion. An incision was then made over 
 the tibialis posticus tendon. This tendon was very small and 
 abnormally long. About three inches of this tendon were 
 doubled by a double purse-string suture of fine silk and the 
 base of the duplicated part ligated loosely with the same ma- 
 terial. Through a subcutaneous tunnel \he tibial part of the 
 tendo-Achillis was connected with the shortened tibialis posti- 
 cus or by a number of fine silk sutures. The next step of the 
 operation consisted in utilizing the peroneus brevis to invert 
 the foot. This was done by first making an incision over the 
 peroneal tendons behind the posterior border of the external 
 malleolus. The pei-oneus brevis was severed and the remain- 
 ing peroneal tendon which had become dislocated forward 
 was replaced and fastened in its shallow groove by four fine 
 silk sutures. The internal surface of the os calcis was then ex- 
 posed by a short incision. The cut end of the tendon of the 
 peroneus brevis was then drawn through a tunnel behind what 
 remained of the tendo-Achiliis and sutured to the periosteum
 
 of the internal surface of the os calcis with four tine silk sutures. 
 The uncut part of the tendo-Achillis was then shortened by 
 suturing. All of the wounds were sutured with the same ma- 
 terial and included in the same dressing. 
 
 I was given an opportunity to examine many cases of teu- 
 doplasty for most diverse paralytic affections of the foot, arm 
 and hand with marvelous functional results, cases which but 
 a few years ago would have been pronounced hopeless. In 
 aggravated cases of equinovarus the tendo-Achillis is elongated 
 and the tibialis posticus is used as a substitute for the extensor 
 muscles by implantation of its tendon into the common tendon 
 of the extensors above the ankle-joint. The cut tendon of the 
 tibialis posticus is drawn through a subcutaneous tunnel and 
 securely sutured to the extensor tendons and their sheath. The 
 elongated tendons are shortened at the same time by duplica- 
 tion. Tendoplasty as practised by Professor Hoffa marks a 
 new era in orthopedic surgery and when once fully understood 
 and generally practised by surgeons will become the means of 
 restoring many helpless limbs to usefulness and will become a 
 source of great regret to the mercenary instrument makers. 
 Berlin, May 27.
 
 [Reprinted from American Medicine, Vol. IV, No. 5, pages 186-187, 
 August 2, 1902.] 
 
 PROFESSOR SONNENBURG AND HIS APPENDICITIS 
 WORK AT THE MOABIT HOSPITAL. 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 Every general surgeon sooner or later excels in some 
 special branch of his profession. Nowhere is the truth of this 
 statement more clearly sliown than in Berlin. In brain sur- 
 gery von Bergmann is the acknowledged authority. Konig 
 is the master in diseases of bones and joints. Hahn has no 
 superior in surgery of the gastrointestinal canal. Israel has a 
 w^ell-earned reputation in renal surgery. Krause leads in sur- 
 gery of the nerves, and lastly, Sonnenburg speaks the last and 
 decisive word when the subject of appendicitis is discussed. 
 These are all general surgeons who can and do perform any 
 operation in surgery, but their reputation at home and abroad 
 is largely due to what they have accomplished in the branch of 
 their profession which they have made the subject of special 
 study and investigation. Sonnenburg, the most gifted assistant 
 of the late Professor Luecke, of Strasburg, is one of the busiest 
 men in Berlin. His private clinic is large, and at the Moabit 
 Hospital he is in charge of 350 beds. He is a thorough scholar 
 and speaks several languages fluently. His contributions to 
 surgical literature are numerous, but the climax of his literary 
 
 career was reached with the 
 publication of his book on ap- 
 pendicitis. This classic mono- 
 graph has, in a short time, 
 reached the fourth edition, 
 the best proof of its well- 
 merited popularity. The 
 value of this book is to be 
 found in the manner in which 
 the pathologic conditions of 
 the various forms of appendi- 
 citis are discussed and the logi- 
 cal deductions drawn there- 
 from, as w^ell as in the accuracy 
 with which the complicated 
 cases are described. Last win- 
 ter the number of patients he 
 has operated upon reached 
 
 Professor Sonnenburg. 
 
 1,0(X). The internes in his serv-
 
 ice at the Moabit celebrated this event in an appropriate manner 
 witli their chief. At present tliere are 15 patients in tliis hospital 
 who were recently operated npon for appendicitis. Three opera- 
 tions a day is not an uncommon occnrrence. The entire mortal- 
 ity of the 1,000 cases was 12%, and of the cases operated upon dur- 
 ing the interval only 1%. Grave symptoms during the first 24 
 hours of the attack are looked upon as strongly suggestive of 
 gangrene, and it is in such cases that an operation is performed 
 with the least possible delay. In the absence of positive indica- 
 tions for immediate action, it is deemed advisable to operate dur- 
 ing the interval. In all pus cases the cavity is drained with a 
 Mikulicz tampon and the wound allowed to heal by granulation. 
 The gradual removal of the gauze drain employed in this 
 manner can be done with greater ease and is productive of less 
 pain than when the abscess cavity is packed with separate 
 strips of gauze. In amputating the appendix a transfixion 
 double ligature is used. The mucous membrane of the stump 
 is not cauterized and the stump is buried by two rows of 
 catgut sutures. The first row of sutures embraces all of the 
 coats of the cecum, contrary to the usual practice. Before 
 making the incision an assistant draws the skin two to three 
 inches toward the median line for the purpose of securing for 
 the muscular part of the wound and the subsequent line of 
 union a covering of normal -skin. Whenever practicable the 
 muscle splitting incision is made. If the incision is sutured, as 
 is always done when no pus is found, catgut is used for the peri- 
 toneum, silk for the muscles and fascia, and bronze aluminium 
 wire for the skin. The wire is very flexible and does not irri- 
 tate the tissues. A small absorbent pad held in place by a 
 gauze bandage constitutes the dressing. Irrigation is not used 
 in pus cases. 
 
 The Moabit Hospital accommodates 950 patients. It is made 
 up of a village of 35 pavilions and administrative buildings. 
 The space included by the buildings is a large square beauti- 
 fully laid out, with a macadamized street and walks, and orna- 
 mented with exquisite flowers and blooming shrubs. Two of 
 the pavilions are used exclusively for emergency cases. The 
 two operating rooms are modern and contain the most com- 
 plete outfit of surgical instruments I have ever seen in any 
 hospital. Trained male and female nurses take care of the sick. 
 In the operating room the necessary assistance is rendered by 
 four salaried internes, two orderlies and a female nurse. The 
 orderlies take care of instruments, ligature and suture material ; 
 the female nurse hands the gauze sponges. 
 
 The catgut used in the operations is prepared by Saul's 
 method of sterilization. A large experience has proved this to 
 be reliable.
 
 SAUL'S METHOD OF CATGUT STERILIZATION. 
 
 Immerse and boil the catgut, which has been deprived of 
 all fatty material, in the following solution : 
 
 Absolute alcohol 1,700 parts 
 
 Carbolic acid 100 parts 
 
 Distilled water 200 parts 
 
 Preserve in same solution in sealed bottles of convenient size. 
 
 THREE CASES OF APPENDICITIS. 
 
 Case I. — Perforative appendicitis ; circnimscribed supjinra- 
 tive peritonitis. The patient is a female, aged 56, who is suffer- 
 ing from a first attack. She was taken three days ago with 
 violent initial symptoms. There was vomiting and character- 
 istic pain. Temperature was 102° F., the pulse was 120 and 
 small. Facial expression and muscular rigidity indicated quite 
 extensive peritonitis. There is some dulness in the right iliac 
 fossa beneath the distended cecum. Operation was done by Dr. 
 Hermes, first assistant. The incision was made very close to 
 the crest of the ilium and Poupart's ligament. The perito- 
 neum was reflected and when the posterior surface of the cecum 
 was reached several tablespoonfuls of fetid pus escaped. In the 
 abscess cavity a fecal stone was found. The perforation was in 
 the middle of the appendix, and the distal end was gangrenous. 
 The mesenteriolum was tied in several sections, the appendix 
 ligated at its base and amputated. The stump was buried by 
 two rows of catgut stitches, the first including the entire thick- 
 ness of the cecal wall. The cavity was packed with a Miku- 
 licz drain. 
 
 The day after the operation all of the grave symptoms had 
 subsided, and unless new complications arise a speedy recovery 
 is predicted. 
 
 The Mikulicz drain is always used in pus cases. The 
 wound is left open and heals by granulation. If a hernia de- 
 velops in such cases, as not infrequently happens, a radical 
 operation is performed. 
 
 The next two cases were operated upon by Professor Son- 
 nenburg the same forenoon. 
 
 In making the incision he draws the skin toward the median 
 line so as to cover the muscular wound with normal skin. In 
 doing so the skin sutures and the resulting scar are placed ex- 
 ternal to the anterior superior spinous process of the ilium. In 
 pus cases a free long incision is made ; in relapsing cases with- 
 out abscess formation, the muscle splitting method is employed. 
 In the latter class of cases the patients are confined to bed 
 from two to three weeks. 
 
 Case II. — Relai)sing appendicitis : extensive retrocecal ad- 
 hesions. The patient had three attacks, the first one being most 
 severe. He was a young man who was otherwise in good 
 health. The first attack occurred a year ago, the last one re- 
 cently. Through a comparatively short incision the attached 
 end of the appendix was found. A double catgut ligature was 
 applied and the appendix divided between. The ligature on 
 the appendix was used in carefully dragging the appendix
 
 toward the wouud. The appendix was long and imbedded in 
 its entire length in a mass of adhesions, and much of it had to 
 V)e removed by subserous enucleation. Several other traction 
 ligatures were applied during the process of enucleation. The 
 mesoappendix was ligated in several sections. The stump of 
 the appendix was buried by two rows of sutures, the tirst one 
 including the entire thickness of the cecal wall. Peritoneum 
 was sutured with catgut, muscles and fascia with silk sutures, 
 and the skin Mith bronze aluminium wire. A small absorbent 
 pad constituted the dressing. 
 
 Case III. — Subacute appendicitis; duration of disease two 
 months: operation. The patient was a woman advanced in years. 
 The attack commenced two months ago without any abate- 
 ment of symptoms since. Continuous high temperature, a 
 rapid feeble pulse, pains in the ileocecal region and progressive 
 emaciation were the most prominent symptoms. The abdom- 
 inal wall was relaxed and there was no palpable swelling. The 
 abdomen was opened in the same manner. The appendix was 
 small and there were no adhesions. 
 
 It was explained that there are cases in which the extent of 
 the local disease does not correspond with the gravity of the 
 general symptoms. 
 
 Professor Sonnenburg is a very deliberate, neat and dexter- 
 ous operator and a fluent speaker. He possesses all of the 
 qualifications which make a clear and impressive clinical 
 teacher. During the same forenoon he operated on a patient 
 with carcinoma of the stomach. 
 
 Case IV. — Extensive carcinoma of pylorus with diffuse infil- 
 tration of retroperitoneal glands; gastroenterostomy. The 
 patient was a woman 62 years old. Pyloric obstruction Avas 
 almost complete. Incision was made through the middle of 
 the left rectus muscle. The mesentery of the transverse colon 
 and posterior wall of the stomach near the cardiac side were 
 translixed with a strong silk ligature and after making a button- 
 hole in the latter the stomach was united with the upper part 
 of the jejunum with a large Murphy button. A few Lembert 
 sutures were applied over the margin of the button as an addi- 
 tional security. Sonnenburg thinks well of the Murphy button 
 in performing gastroenterostomy. The whole operation was 
 completed in less than 20 minutes. 
 
 Berlin, May 28.
 
 [Reprinted from American Medicine. Vol. IV, No. 7, page 268, 
 August 16, 1902.] 
 
 THE SEVENTH CONFERENCE OF THE INTERNA- 
 TIONAL RED CROSS 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 
 of Chicago. 
 
 Delegate from the United States. 
 
 The International Red Cross Society has for its principal 
 objects to render war, when it becomes inevitable, more 
 humane and to provide prompt relief in case of great national 
 calamities. The horrors of Sebastopol, Gettysburg, Solferino, 
 Waterloo, Sedan and other great battles during the present cen- 
 tury will have no equal in the future. Ignominious death from 
 cold, starvation and preventable diseases will not figure so 
 conspicuously in the mortuary records of future wars as they 
 have done in the past. Governments 
 and nations are beginning to realize 
 more fully the importance of pro- 
 viding the soldier with food and 
 clothing conducive to the preserva- 
 tion of his health and bringing into 
 effective action sanitary rules and 
 regulations calculated to guard 
 against preventable diseases. The 
 government is not always ready and 
 prepared to meet sudden emergen- 
 cies. The representatives of the Red 
 Cross Societies are. They follow the 
 moving armies, take care of the sick 
 ''?U";'mTn'a!"ffi''^,1i^l"S »<» ^■^"''ded and distribute freely 
 the Red Cross Society of food and drink for the sick and 
 ConfeJenc'l'^ of^lhf ''inte?- ^^'^^^les of comfort not obtainable in 
 national Red Cross. any other way. 
 
 In great epidemics, devastating 
 floods, destructive earthquakes, sweeping conflagrations and 
 burning drouths, they are the first to reach the seat of disaster 
 to provide the unfortunates with shelter, clothing and food. The 
 gospel of humanitarian warfare was conceived by Henry 
 Dunant, of Geneva, Switzerland, during and after the battle of 
 Solferino, and was fully expounded in his now famous pam- 
 phlet, " Souvenir de Solferino." His suggestions to militate the 
 horrors of war laid the foundation for the proceedings of the
 
 Geneva convention, which met April 22, 1864. The International 
 Red Cross Society, the precious fruit of the Geneva convention, 
 has now its representative organizations in all parts of the civil- 
 ized globe, and is the pioneer agency in disposing of the bar- 
 barities and unnecessary cruelties of active warfare, and in 
 bringing prompt aid to the sufferers of great national calami- 
 ties. The growth of this society has been phenomenal. From 
 the transactions during the present conference it is evident 
 that this great international Samaritan is desirous of cultivat- 
 ing closer relationships between National Red Cross 
 Societies and to extend the scope of humanitarian work. 
 The International Red Cross Society meets every five years, 
 and is made up of delegates sent by governments and 
 representatives of Red Cross Societies, the traveling expenses 
 of the official delegates being paid by the respective govern- 
 ments. Some of the Red Cross Societies do the same for their 
 representatives. The delegates appointed by the Russian gov- 
 ernment were all military officers of high rank and important 
 government officials. The only female delegates are from the 
 United States. The names of the delegates embrace 20 different 
 countries and various local organizations. 
 
 All of the meetings are held in the Hall of Xobility, a 
 palatial building used for the entertainment of the nobility. 
 On this occasion it was tastefully decorated with flowers and 
 shrubs. Lieuteuanl-General von Richter presided, and Mr. 
 Odier occupied the desk of the secretary-general. The audience 
 was a brilliant one. The full-dress uniforms of the nobility, 
 military officers and high government officials made an impos- 
 ing and enchanting picture. The weather was in harmony with 
 the objects of the meeting. A few minutes after 2 o'clock the 
 audience rose in a body as Her Majesty, the Empress Dowager 
 Marie Feodorovna entered the hall accompanied by her son, the 
 Grand Duke Heritier Michel Alexandrovitch. As soon as 
 these distinguished members of the royal family had taken 
 their places in the Imperial box the president opened the meet- 
 ing with a short address. The Minister of Justice, Mouravieff, 
 made the principal speech, in which he emphasized the impor- 
 tance of the Red Cross work in the dispensation of charity, and 
 extended a cordial welcome to the delegates. Yon Knesebeck 
 and Schjerning followed with short speeches, and the first 
 meeting was adjourned. 
 
 The program Avas varied and the reports of the numerous 
 committees were very interesting. The discussions were char- 
 acterized by harmony and good feeling. Articles of the Hague 
 Peace Convention were frequently referred to, and from the 
 remarks made it is certain that those two great international 
 organizations will cooperate heartily in maintaining the peace
 
 of the world, and in case of war they will do all in their power to 
 divest it of all unnecessary cruelties and suffering. 
 
 Russian hospitality is almost proverbial. The Moscow 
 International Medical Congress gave the visiting doctors a 
 good insight into what Russians can do when they entertain 
 their guests. If there is any fault to be found with the Seventh 
 Conference of the International Red Cross it is the fact that too 
 
 ralace where Emperor and Empress received the delegates. 
 
 much time was lost in entertaining the delegates. Carriages 
 were placed at the disposal of the delegates from the moment 
 they entered the city, free of expense. The Central Russian 
 Committee looked after the comfort of each delegate. The 
 principal entertainments were : 
 
 1. Informal reunion the first evening. 
 
 2. Banquet at the Tauride Palace, second evening, at which 
 plates were set for 250 guests. 
 
 3. Third evening. Steamer excursions on the Neva, followed 
 by lunch at the Zelaguine Palace. 
 
 4. Reception by the Empress Dowager at the Gatchina Pal- 
 ace, Saturday, May 81. 
 
 5. Monday, June 2. Reception by the Emperor and 
 Empress at the Tzarkoe S61o Palace, followed by lunch. 
 
 6. Sunday evening. Theater and concert. 
 
 7. Monday evening. Reception by the mayor at the City 
 Hall. 
 
 8. At the close of the session, Wednesday, June 4, excur- 
 sion to Moscow. 
 
 The conference was in session a whole week and the meet- 
 ings were well attended. The French language is the official 
 one, although the German and English languages are recog- 
 nized. The transactions are published in French. 
 
 St. Petersburg, June 3.
 
 [Heprinted from American M'^dicine, Vol. IV, No. 8, pages 305-306, 
 August 23, 1902.] 
 
 THE PIROGOFF MUSEUM, ST. PETERSBURG. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago, 
 
 The name of Nicholas Pirogoff stands out preeminently in 
 the medical history of Russia. As a military surgeon he had 
 no superior. He was to General Todleben, of Crimean fame, 
 what Baron Larrey was to Napoleon Bonaparte. Pirogoff's 
 surgical work was fully appreciated by his contemporaries, and 
 his devotion to the sick and wounded of the Crimean war made 
 him the idol of the soldiers and the recipient of the gratitude of 
 a great nation. His vast military experience, his keen powers 
 of observation and his unquenchable thirst for something new 
 and better, placed him in a position to speak and write authori- 
 tatively on everything pertaining to military surgery. His 
 classic work on this subject was translated into nearly all 
 living languages, and is to be found in all medical libraries 
 of any pretension. It can be read with interest and profit 
 by the students and surgeons of today. His- description 
 of hospital gangrene, sepsis, and pyemia as he saw and studied 
 these messengers of death in camp and field make a pen picture 
 perfect in every detail and which, when studied with the nec- 
 essary care, reflects the darkest part of the angry war clouds 
 which hovered over and about Sebastopol during the memor- 
 able years of 1854 and 1855. His accounts of the immediate and 
 remote effects of the large caliber bullets, shrapnel and frag- 
 ments of exploded shells were based on careful observations 
 and a thorough study of an immense clinical material. The 
 conclusions he reached were fully verified by the experiences 
 of our surgeons during the great Civil war. Pirogoff was a pro- 
 gressive surgeon and a true humanitarian. The great personal 
 sacrifices he made for the defenders of his country live in the 
 memory of a grateful nation. His name is a household word 
 throughout Russia. The medical profession reveres and honors 
 his memory. Busts in snow white marble and durable bronze 
 immortalize the thoughtful, kindly face of the distinguished 
 dead in all places where medicine is taught in Russia to remind 
 students of what he did for his country and the science and art 
 of surgery. 
 
 What a pity that a man who spent his whole lifetime in 
 relieving suflfering humanity should die of one of the most 
 cruel of all diseases ! This was the fate of poor Pirogoff. When
 
 advanced in years and when his task on earth was nearly fin- 
 ished, he became the victim of carcinoma of the upper ja\v. 
 The disease pursued a slow course. The unfortunate patient, 
 who had dealt with this disease so often with scalpel and caus- 
 tics, visited Professor Billroth and begged to be given the 
 l)enefits of radical operation. Pirogoff then was 82 years 
 of age. The great surgeon whose services he sought 
 weighed the evidences for and against an operation well 
 and with tears in his eyes revealed to his distinguished col- 
 league the hopelessness of his condition. Pirogoff returned to 
 St. Petersburg discouraged, but resigned to the inevitable. He 
 was met at the station by an enormous crowd of admiring, 
 sympathizing colleagues and friends, and a host of grateful 
 soldiers and patients. Soon after his return death came to his 
 relief, and his noble soul departed from the mould of clay that 
 was disfigured by the relentless disease. St. Petersburg has 
 honored the memory of Pirogoff in a most worthy manner by 
 establishing and maintaining a museum known as the Pirogoff 
 Museum. This is a handsome, solid square building, two 
 stories high, in the immediate vicinity of the Imperial Military 
 Academy, separated from it by a narrow street. The building 
 w^as originally a storehouse for army supplies, and was pre- 
 sented by the War Department to the medical profession of 
 St. Petersburg for this special purpose, a well deserved 
 and gracious recognition on part of the government of 
 the valuable services rendered by the distinguished dead 
 to his country and his profession. The building has been 
 thoroughly renovated and serves at the same time as a meeting 
 place for all of the medical societies of St. Petersburg. On the 
 first floor is a hall with 300 to 400 seats for the general meetings. 
 The next room on the same floor and communicating with the 
 assembly hall is the museum proper. The collection contains 
 some very interesting and rare specimens and historic surgical 
 instruments. The surgical instruments used by Pirogoff dur- 
 ing the Crimean war occupy a very prominent place in the 
 last-named department. A velvet-lined pocket case Avith old- 
 fashioned scalpels, scissors, etc., shows the wear and tear of 
 that memorable campaign. In a separate glass case is exhib- 
 ited a part of the tumor preserved in alcohol and a microscopic 
 section of the same which terminated the life of the famous 
 military surgeon. A fine portrait in oil and a marble bust 
 reminds one of the name of the place they are in and a photo- 
 graph of the deathbed with the lifeless remains shows only too 
 plainly the ravages of the fatal disease. The first floor also con- 
 tains a nucleus for a general medical library. The second floor 
 is devoted to the different specialties in medicine, each of which 
 has its own room and library. For the maintenance of this ideal
 
 Bnedical institution the members of the different medical 
 •societies pay ten rubles (|5.00) annually. The Pirogoff Museum 
 is an ideal home for the medical profession, containing as it 
 does a rich museum, a hall for general meetings, and all that 
 €Ould be desired for the different specialties in medicine, with 
 -general and special libraries. The physicians in Cnicago and 
 in other large cities in -our country have for years labored in 
 vain to establish a somewhat similar institution. Here in St. 
 Petersburg is an object lesson which if applied to our conditions 
 might solve many difficulties we have had to contend with in 
 the past. On my way from Moscow to Constantinople I 
 remained long enough at Sebastopol to visit the battlefields 
 where Pirogoff made his international reputation. Every 
 schoolboy is familiar with the stirring events that made Europe 
 tremble in 1854 and 1855. Only a very few of the participants of 
 that bloody drama remain to relate the sufferings and priva- 
 tions of that eventful campaign so devoid of i)ractical results. 
 
 The valiant charge in the valley of Balaklava and the stub- 
 born struggles on the plains of Inkermanu were events that 
 stand out prominently in the history of the middle of the nine- 
 teenth century. The Russians held the eminence behind the 
 invincible harbor of Sebastopol, and within a thousand yards 
 of their line of battle the English occupied the great Redau 
 (Greenhill) supi)orted by the French on the right and on the 
 left. The plain of Inkermann remains today much the same 
 as it was when the contending forces left it— a series of entrench- 
 ments. A railway track between the headquarters of the Eng- 
 lish army and the city of Inkermann could be used today 
 without much alteration as a roadbed for a modern railway. The 
 English fleet finally landed at Balaklava, and from that little 
 seaport town, nine miles from Sebastopol, the army attacked 
 the Russians on the left flank, with the disastrous result so 
 familiar in history. The battlefield of Balaklava is now cov- 
 ered with fertile vineyards and peaceful happy homes. The 
 large and well-kept Eaglish, French and Russian cemeteries 
 contain the remains or memorial slabs of over 200,000 
 who lost their lives in the defense of the cause they 
 represented. In riding over the stony, sterile plains of 
 Inkermann I found a number of men here and there 
 plying the pickaxe and shovel in search of war relics. For 
 nearly 50 years this strange industry has been a source of con- 
 siderable income and it is by no means exhausted. Cannon- 
 balls, bullets, shrapnel, fragments of exploded shells, buttons, 
 buckles and rusty horseshoes are brought to the surface daily 
 and are sold to the visitors for what they are willing to pay. On 
 the summit of the Redau is a handsome monument erected by 
 the English army to the memory of the fallen heroes. In the
 
 office of the English cemetei-y is a complete list of all the rrames 
 of the British dead, and I noticed it contained the names of an? 
 Hnusually large number of surgeons. This can \ye readily 
 explained by considering the causes of death. It is well knowEs 
 that the great mortality of the allies was due largely to acute- 
 infe^'tious diseases. Cholera, dysentery and camp diarrhea, 
 decimated the ranks rapidly, which in connection with 
 inadequate clothing and food supply, contributed much 
 to the failure of the campaign. Tlie Russian army 
 met a similar fate. Pirogoff saw moi-e a-'tual suffering- 
 than any other militai-y surgeon in the same length of 
 time. He worked night au«d clay on the field and in the hos- 
 pitals in and about Sebastopol in the eare of the sick and 
 wounded. It was AVork of a n:tost discouraging kind. All 
 efforts to arrest the spread of the death-dealing diseases proved 
 futile. The most careful and assiduous treitment only too- 
 often proved powerless in averting death. The most skilful 
 operations proved useless in saving limb and life, for the 
 wounds, as a rule, became infected, and a very large per cent, 
 of tho^ie oi>erated upon died from sepsis, pyemia, erysipelas, 
 hospital gangrene and secondary hemorrhage. It takes courage 
 to follow the course of duty under such trying circumstances. 
 Pirogoff remained at his post as long as his services were 
 required, and performed his onerous duties with an enthusiasm 
 and faithfulness that commanded the respect of his colleagues 
 and won the love and veneration of those who came under his. 
 care. When physicians hear or read of the Siege of Sebastopol the 
 name of Pirogoff invariably suggests itself as the central figure 
 of the noncombatants of that disastrous contlict. The monu- 
 ment that commemorates his deeds in the most worthy 
 and useful manner and that will immortalize his fame is the 
 Pirogoff Museum. The Russians have honored the memory of 
 their most famous surgeon in a manner that merits imitation. 
 Can we say the same of our countrymen ? What have we done 
 for Benjamin Rush, one of the signers of the Declaration of 
 Independence, the eminent physician, the erudite author, the 
 great teacher and the first Surgeon-General of the United States 
 Army? For years the American Medical Association has tried 
 in vain to collect enough money to erect a suitable monument 
 to the memory of the patriot physician in the Capitol city. 
 Why not found and maintain a Benjamin Rush Museum in 
 Chicago, or some other large central city, on the same plan as 
 the Pirogoff Museum, as a permanent home for the American 
 Medical Association and its official organ? Let the medical 
 profession of the United States answer this timely question by 
 word and deed. 
 
 Balaklava, Russia, June 7.
 
 (Reprinted from American Medicine, Vol. IV, No. 10, pages 383-384, 
 September 6, 1902.1 
 
 MEDICAL INSTITUTIONS OF ST. PETERSBURG. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 St. Petersburg is an important medical center. Nearly 
 1,000 medical students are preparing themselves here annually 
 for their lifework. Russian women can now obtain their medi- 
 cal education at home. A medical school has been opened 
 recently for the exclusive use of women. Heretofore most of 
 the female medical students had to travel to Switzerland to 
 reach the goal of their professional ambition. Outside of this 
 school medical teaching is limited to the Imperial Military 
 Academy. This is the only institution in which clinics are 
 conducted. The Military Academy is an immense establish- 
 ment, covering as it does several blocks of ground. It is under 
 military control and every teacher is a commissioned officer. 
 The great solid buildings face the majestic Neva, and from the 
 bridge present a magnificent appearance. The students must 
 study for five years before they are admitted to the final exam- 
 inations. The medical cadets, from 100 to 130, are educated 
 at the expense of the government. The final examination 
 they have to pass is very rigid and requires more than six 
 months. The hospital connected with the Academy has 2,000 
 beds and furnishes all of the practical branches in medicine, 
 with an abundance of clinical material. There is no need here 
 of extramural teaching. The facilities for dissection and lab- 
 oratory work are ample and w^ell calculated to familiarize the 
 student with the fundamental branches of medicine. In this 
 great military institution gynecology and obstetrics are taught 
 in a most thorough manner by a military officer. The nose, 
 throat and ear department, under the supervision of 
 the attending physician of the Empress, is probably the 
 finest institution of its kind in the world. It is a new 
 building, constructed upon most modern and approved ideas 
 and lavishly equipped with all the means for clinical research 
 and scientific investigation. The surgical amphitheater is 
 somewhat unique. It is arranged on the amphitheater plan, 
 and can seat about 200 students. Inside of the amphitheater is 
 a small glass house, on the sides and on top of which are seats
 
 for the students. These are reached by a very steep and narrow 
 staircase made of iron, and from every step the operation can 
 be seen to advantage. The professor first appears outside of 
 this house of glass, explains to the students the nature of the 
 case and the technic of the operation, and then enters the 
 sacred precincts and performs the operation without any further 
 remarks. The students watch his work through the glass Avails 
 and ceiling while the operator performs his task silently, unin- 
 fluenced by the presence of his outside audience. This is a 
 plan that might recommend itself for postgraduate work, but 
 it is. a very questionable one in teaching the young student how 
 to operate. For a student to grasp the essential features of the 
 technic of an operation it becomes necessary for the teacher to 
 explain to him the why and wherefore of every step of what 
 he is doing. One of the important elements in successful 
 teaching in this institution consists in limiting the attend- 
 ance. The hospital as a whole lacks the austere appearance of 
 such an institution. The halls and staircases throughout the 
 building are ornamented by works of art. The products of 
 sculptor and artist are on exhibition everywhere. This orna- 
 mentation does much to divert the mind of the patients in a 
 useful direction, and to fascinate the attention of the visitors. 
 All of the sick of the local military force are treated in this 
 hospital, at the same time adequate provisions are made for 
 the civilian sick poor. Some of the buildings are several hun- 
 dred years old, palatial in architecture, recently renovated and 
 improved to meet all of the modern requirements, including 
 electric light and hot- water heating. The immense clinical 
 material is supplied by the outdoor department or polyclinic. 
 
 PROFESSOR vox WREDEN'S SURGICAL CLIXIC. 
 
 Professor von Wreden is a military officer of high rank. 
 He is in the prime of life, a diligent student and perfectly con- 
 versant with the surgical literature of the present day. He 
 knows no rest between the hours of nine in .he morning and 
 six in the evening. He speaks German and English fluently. 
 He is popular with the students and is the friend of the poor. 
 His calmness and self-control in the operating room charm his 
 audiences and impart confidence in his patients. Surface dis- 
 infection is made by thorough scrubbing with warm water and 
 potash soap followed by alcohol and sublimate solution. The 
 administration of ether is limited to patients the subject of 
 cardiac lesions, in all other cases chloroform by the drop 
 method is employed. Catgut has been entirely abandoned and 
 Its place has been taken by silk and silver wire. Orderlies and 
 female nurses take care of the sick. The latter are furnished
 
 I 
 3 
 
 by the Russian Red Cross and receive a fair salary. The assist- 
 ants are military surgeons of large experience. Professor von 
 Wreden is a warm advocate of local anesthesia. He uses a 1% 
 solution of cocaiu. The average amount of this solution 
 employed is 60 minims. In more than 800 cases he has never 
 observed any serious toxic effects from this drug. I was given 
 an opportunity to witness three operations under this method 
 of local anesthesia. 
 
 Case 1.— Staphylorrhaphy for syphilitic defect of the soft 
 palate; operation under local anesthesia. The patient was a 
 middle-aged woman npon whom a rhinoplasty for syphilitic 
 defect of the nose had been performed a number of weeks ago. 
 The distal phalanx of the left little finger had been successfully 
 implanted and the cosmetic result of the operation was quite 
 satisfactory. A central triangular defect of the soft palate was 
 to be operated upon under cocain anesthesia. With a small 
 hypodermic syringe 60 minims of a 1% solution were injected 
 into the border of the defect and in the lines of incision near 
 the alveolar arch. The pharyngeal mucous membrane was also 
 anesthetized in the same manner. The patient was placed upon 
 a table in a sitting position and the operator stood in front of 
 her. No mouth-gag was used. Hemorrhage was arrested by 
 compression. The Langenbeck method was employed. Three 
 silver wire sutures were introduced with an ordinary well- 
 curved Hagedorn needle. The twisting of the wire was done 
 with Sims' instrument. The index finger was used instead of 
 tissue forceps in using the needles. The whole operation was 
 completed in less than half an hour and evidently without 
 causing much pain. This method of anesthetization is em- 
 ployed in all operations for cleft palate in preference to the use 
 of chloroform or ether. 
 
 Case II. — Relapsing carcinoma of the roof of the mouth ; 
 excision under local anesthesia. The patient was a man ad- 
 vanced in years. On March 5 of this year the left upper 
 maxilla was excised for malignant disease. Recently the 
 carcinoma returned along the border of the defect on the roof 
 of the mouth. The growth was a spongy mass, about the cir- 
 cumference of a silver dollar. A 1% solution of cocain was 
 used in the same manner and quantity as in the first case. 
 Patient was placed in a sitting position upon a table. The soft 
 tissues at a safe distance from the margins of the growth were 
 divided down to the bone with the knife-point of a Paquelin 
 cautery ; with a chisel and hammer the excision of the tumor 
 in one piece was completed. The operation was finished in a 
 few minutes and without any particular complaint on part of 
 the patient. 
 
 Case III. — Central tuberculous osteomyelitis involving the 
 proximal phalanx of the middle fliiger, evidonent under cocain 
 anesthesia. The patient was a pale and somewhat emaciated 
 university student. The disease was of long standing, and had 
 its starting point near the upper epiphyseal line of the proxi- 
 mal phalanx of the right middle finger and had terminated in 
 abscess formation. A fistula led into the interior of the bone. 
 A number of injections were made in a circle around the fistu- 
 lous opening, some of them only into the skin, others into the 
 deep tissues down to the bone. An incision was then made 
 within the limits of the anesthetized area and parallel with the
 
 bone. With a sharp spoon the tuberculous focus was removed 
 and the wound tamponed with iodoform gauze and a small 
 absorbent dressing of sterile wood wool applied. The manner 
 in which the patient behaved showed that the operation was 
 not a very painful one. 
 
 For the purpose of preventing the depressing effects of 
 cocain a liberal dose of port wine is administered immediately 
 before the injections are made. As a wound dressing, sterilized 
 Avood wool made of the fir tree is largely employed. 
 
 RED CROSS HOSPITAL ALEXANDER. 
 
 The Russian Red Cross Society is the wealthiest and most 
 influential in the world. It has the moral and financial sup- 
 port of the Empress Dowager.. It has in its treasury at the 
 present time over $8,000,000. Its organization is perfect and 
 
 Red Cross Hospital Alexander, St. Petersburg. 
 
 reaches the deserving poor throughout the entire vast empire. 
 The best hospitals in St. Petersburg and other large cities are 
 supported and managed by the Red Cross. The Red Cross 
 hospitals in St. Petersburg are the St. George, St. Eugenie, 
 Alexander and Elizabeth, all of them stately buildings and 
 wisely conducted. The Alexander Hospital is one of the finest 
 and best equipped hospitals I have ever visited. It is a solid 
 square building, two and three stories high. The interior is 
 elegant, the furnitiire luxurious. None of the rooms contain 
 more than two or three patients. The halls are ornamented 
 with flowers, shrubs and works of art. Red Cross female 
 nurses take care of the sick. The size of the building is alto- 
 gether out of proportion Avith the number of patients it can 
 accommodate, which is only 50. There are no free beds. The 
 charge for room, board, nursing and treatment is from $5 to $15
 
 per week. The surgeon in charge lives in the institution in a 
 suite of rooms that leave nothing to be desired. 
 
 ASEPSIS OF PROFESSOR PAWLOFF. 
 
 Professor Pawloff, who is in charge of the Alexander Hos- 
 pital, is a firm believer in strict asepsis. He has no use for 
 antiseptics. After each day's work his operating room, which 
 is an excellent one, is disinfected with live steam. The few vis- 
 itors who are permitted to witness his work must appear in 
 sterilized gowns and their heads must be covered with a sterile 
 worsted Red Cross cap. Soap and saline solutions are relied 
 upon in hand and surface disinfection. Linen thread sterilized 
 by boiling is the suturing and ligature material. In approximat- 
 ing the skin he makes use of metallic clamps in place of sutures. 
 These clamps are very quickly applied and readily removed. 
 A number of delegates to the Seventh Conference of the Inter- 
 national Red Cross were present at one of his operations. 
 
 The patient was a man, aged 70, who had a tumor in the 
 right iliac fossa. The anesthesia was commenced with ethyl- 
 bromid and continued with chloroform. An incision along the 
 inner border of the crest of the ilium and Poupart's ligament 
 exposed a soft tumor, which was attached to the inner surface 
 of the ilium. The center of the tumor was cystic and on rup- 
 turing it quite a large quantity of bloody serum escaped. The 
 diagnosis of sarcoma was notdiflicu]t at this stage of the opera- 
 tion. In all probability it was a sarcoma of the iliac fascia 
 which had secondarily implicated the periosteum and ])one as 
 the tumor mass lacked all indications of osteogenesis and the 
 surface of the bone was not extensively affected. With forceps 
 and scissors the tumor was removed piecemeal and with chisel 
 and hammer the affected part of the bone was excised. During 
 the dissection the retroperitoneal fat was freely exposed. The 
 wound was closed with two figure-of-eight deep sutures and, 
 clamps for the skin, leaving enough space for drainage. 
 
 Professor Pawloff resigned from the faculty of the Imperial 
 Military Academy 12 years ago and is now devoting all of his 
 time and energies to the work of the Alexander Red Cross Hos- 
 pital. 
 
 Sebastopol, Russia, June 8,
 
 [Reprinted from American Medicine, Vol. IV, No. 11, pages 427-430, 
 September 13, 1902.1 
 
 CONSTANTINOPLE AS A MEDICAL CENTER. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 Emperor Constantin showed good judgment and a pro- 
 found knowledge of statesmanship and military strategy when 
 he chose for the site of a second empire city on the banks of 
 the Bosphorus, the gateway between the Mediterranean and 
 Black seas, the narrow waterline which defines the limits 
 between two great continents. Constantinople is beautifully 
 situated, scattered, like Rome, over seven hills, reflected upon 
 the restless bosom of the Bosphorus and in view of the bare, 
 rugged mountains of Asia. It has few rivals in military and 
 commercial importance. Nature has made its fortification 
 easy, and it holds the key to the commerce on the great seas 
 which swarm with merchant vessels from all parts of the 
 globe. The city claims at present a population of 1,000,000, 
 to which must be added the several hundred thousand inhabi- 
 tants of its many suburbs and Scutari on the Asiatic side of the 
 Bosphorus. The city has been growing quite rapidly, and 
 shows many signs of recent improvements. It lacks, however, 
 electric street railways and lighting. Telephones are unknown 
 throughout Turkey. The most promising indications of a 
 growing civilization are to be seen in its many medical institu- 
 tions. Constantinople is the great and only medical center in 
 Turkey. 
 
 MEDICAL, EDUCATION. 
 
 The only two medical schools in Turkey are in Constanti- 
 nople, one for civilian the other for military students. Both of 
 these institutions are under strict government control and 
 nearly all of the teachers are military surgeons. The new 
 medical university is located in Scutari near the great Haidar 
 Pacha military hospital. It is supplied with all the modern 
 equipments for the scientific teaching of medicine and its allied 
 branches. The school for the civilian students has 500 matricu- 
 lants, the military 700. The students are required to study six 
 years before they are permitted to apply for the final examina- 
 tions. Tuition is free for the military cadets. After graduation 
 the young officers are required to serve as assistants in one or 
 more of the many military hospitals for a period of two years 
 before they can enter the regular service. If for any reason he
 
 leaves the service before the expiration of 30 years, he must 
 refund the government for the outlay incident to his profes- 
 sional education. After 30 years of continuous service he can 
 be retired on half pension. A full pension is only granted after 
 50 years of service. Ample provision is made for the civilian 
 graduates for interneship after their graduation, under the title 
 of voluntary assistants. Foreign graduates are permitted to 
 practice, but they have no legal rights and cannot hold govern- 
 ment appointments. 
 
 TURKISH MEDICAL LITERATURE. 
 
 Most of the medical books used in the university are trans- 
 lations from French and German textbooks. The books by 
 Turkish authors are few. Among them are works on materia 
 medica, physiology, anatomy and on operative surgery by 
 Djemil Pacha. A number of Turkish medical journals bring 
 short abstracts of foreign medical literature so that the practi- 
 tioners are kept in touch with the advances in medicine and 
 surgery outside of the Ottoman Empire. The government 
 sends annually many of the military and naval medical officers 
 to Paris and Germany for postgraduate work, a movement 
 which has been the principal means of establishing Turkish 
 medical education and medical literature on a scientific basis. 
 The spirit of original research and scientific investigation has 
 taken hold of the rank and file of the Turkish profession, and 
 in a very few years we may look for a rich Ottoman medical 
 literature. 
 
 MEDICAL SOCIETIES. 
 
 Turkey has no national medical society. The vast expanse 
 of the country, the limited means of transportation, render it 
 very difficult to organize the whole profession into one body. 
 Many of the physicians who live in small inland cities and vil- 
 lages are isolated and remain in communication with the out- 
 side world only by mail. Such segregation leads only too often 
 to routine practice and clogs the wheels of progress. Compara- 
 tively few civilian physicians avail themselves of postgraduate 
 work beyond the limits of their own country. It is for this 
 class of physicians that medical societies, large and small, 
 become the most useful postgraduate institutions. A national 
 medical society would be of the greatest utility in stimulating 
 the mass of the profession in this country to united action and 
 could not fail in advancing the cause of medicine and surgery. 
 Constantinople, the great medical center of Turkey, has recently 
 made a good beginning in organizing the profession. It has a 
 medical society with Djemil Pacha as president. The society 
 holds weekly meetings which are well attended and at which 
 the scientific aspects of medicine and surgery receive merited
 
 attention. The euoi'nious clinical material offered by the 
 numerous hospitals of this great city should and will be made 
 available for the outside world through the excellent scientific 
 work of our enthusiastic and energetic Turkish colleagues. 
 
 HOSPITALS. 
 
 Constantinople is well supplied with hospitals. The gov- 
 ernment takes excellent care of its soldiers when disabled by 
 injury or disease and its indigent sick. The city has no less 
 than 30 military hospitals. The largest one, the Haidar Pacha, 
 with 1,500 beds, is located beautifully on a high elevation on the 
 Asiatic side of the Bosphorus. It was in this hospital that 
 Florence Nightingale gained her undying reputation during 
 the Crimean war. It was my privilege during the Greco- 
 Turkish war to visit these hospitals when the wards contained 
 hundreds of wounded soldiers. I shall ever remember with 
 gratitude the many courtesies that were extended to me at that 
 time by the government and the medical officers. To visit any 
 of these hospitals it is necessary to secure a permit. This is 
 received on application through the Minister of the United 
 States, in the case of Americans, when the application is trans- 
 mitted through military channels. On my second visit Mous- 
 tafa Bey, a lieutenant-major at the Yildiz Palace, was detailed 
 as chaperon. How well the preparations were made for the 
 visit became evident when Ave called at the different hospitals 
 and always found the chief surgeon and his staff in full dress 
 uniform awaiting us at the entrance- The whole staff accom- 
 panied us on our tour through the different parts of the build- 
 ings. Coffee and cigarets were invariably served in the office of 
 the chief surgeon at the completion of the visit. I will only 
 refer to three of the larger hospitals visited. 
 
 Yildiz {Star) Hospital.— This hospital, near the Yildi/ 
 Palace, was built during the Greco-Turkish war for the 
 wounded. In less than four weeks barracks for 1,000 patients 
 were in readiness. The buildings remain much the same as 
 during the war. The wounded have all disappeared, some of 
 the barracks are empty and only about 200 patients are cared for 
 at the present time. Brigadier- General Rachid Pacha directs 
 the affairs of this hospital, assisted by a staff of surgeons. The 
 main feature of this hospital at the present time is a large bath- 
 house for Turkish baths. It is noteworthy to make the state- 
 ment, ascertained by a number of inquiries at the different hos- 
 pitals, that venereal diseases are quite uncommon among the 
 soldiers of the Ottoman Army. The principal affections which 
 figure most conspicuously on the hospital register are bron- 
 chitis, pneumonia, typhoid fever, rheumatism, sprains and 
 fractures. Alcoholism is unknown. The operating room is
 
 small, well lighted and supplied with the most necessary con- 
 veniences for aseptic work. In case of another war it is to this 
 hospital the wounded would find their way first, as its location 
 outside the noisy limits of the city and the general arrange- 
 ments of the buildings would recommend it for such special use 
 in preference to the other military hospitals. 
 
 Guniuche-Souyou Hospital.— Thin hospital is located on the 
 north side of the city, and furnishes accommodations for 400 
 patients. The building, a solid two-story structure, is more 
 than 100 years old, and did excellent service during the Crimean 
 war. It is in charge of Colonel Selami Bey, a veteran military 
 surgeon. The halls and wards are at least 20 feet in height and 
 well lighted. This feature of the building, with the wide stone 
 stairs and columns of stone in the front, impart to it a palatial 
 appearance. The iron bedsteads, clean pillows, soft woolen 
 Ijlankets and comfortable mattresses rob the old building of 
 its former austerity. The medical work in all of the military 
 hospitals is classified into surgical and medical. Ophthalmology 
 is the only specialty that is recognized. In this hospital Dr. A. 
 Hazim is the operator, and Dr. H. Sarim the oculist. The con- 
 valescents find a pleasant place for recuperation in the tree-clad 
 garden, beautified with flowers, in the front yard of the hos- 
 pital. A fountain in this garden is now in process of construc- 
 tion. The nursing in all the military hospitals, as well as all 
 housework, is done exclusively by men. The soldiers receive 
 well-cooked, plain, substantial food and wear comfortable 
 hospital clothes from the time they enter until they are dis- 
 charged. During the last year 5,842 patients were treated in 
 this hospital, with only 72 deaths, certainly a most gratifying 
 record. 
 
 The Hamidie Hospital. — This is the finest and most complete 
 hospital in Turkey, and has few, if any equals of its kind in the 
 world. This hospital, the just pride of the Sultan and the local 
 profession, is a memorial to one of his favorite little daughters, 
 who died several years ago. It was built and is maintained at 
 the private expense of the Sultan. The outside world knows 
 little of the work of civilization and deeds of charity of His 
 Imperial Majesty, Abdul Hamid II. He has always manifested 
 a deep interest in the advancement of the science of mediciue 
 and works of charity. A prominent Turkish physician says of 
 him : 
 
 His Majesty, the Sultan, is the greatest and most energetic 
 advocate of medical science in his great empire. 
 
 Before he ascended the throne there were few physicians in 
 Turkey, and science was not as far advanced as at the present 
 time. During the reign of our exalted and kind ruler, medi- 
 cine has so far advanced that we have a number of distinguished 
 surgeons like Djemil Pacha, Haireddin Pacha, Osman
 
 Pacha, Fikry Bey, Noureddiii Bey, Nazim Bey, Hazim Bey, 
 Kudrftt Bey, Halid Bey and Omer Bey. The same can be 
 said of internal medicine. In this field we also have in Turkey 
 distinguished professors, who received their education in 
 France or Germany and who upon their return entered our 
 medical school as teachers. 
 
 That the Sultan has been a much misrepresented man no 
 one who has traveled through Turkey can deny. Here is an 
 institution that serves as a living witness against the unfounded 
 charge of heartlessness and cruelty. An institution in which 
 the very air breathes a spirit of kindness, charity and a deep 
 concern for the proper care of the sick poor that will for all 
 times commemorate the greatest virtues of the present ruler of 
 Turkey. Let the monarchs of more civilized nations cover 
 
 1^ 
 
 -;0 
 
 p^^ 
 
 i^a ■« « 
 
 Hamicli6 Hospital. Main building and pavilion. 
 
 their faces with shame when they visit the Hamidie Hospital 
 in Constantinople. Every man has his faults, and no ruler of 
 nations is perfect, but here is an institution that will always 
 testify to the kindness of heart and liberality to the poor of 
 Abdul Hamid II. The annual expenses of the hospital amount 
 to about §75,000, and they are all paid out of the private purse of 
 the Sultan. The scope of the hospital is limited to the treat- 
 ment of women and children. It is located in Schischli, in 
 Pera, at the northern terminus of the city, on a high hill, from 
 which the city, the Bosphorus, Scutari, and in the distance the 
 Sea of Marmora and the mountains on the Asiatic side can be 
 seen. No more healthful and pleasant location could have been
 
 (> 
 
 selected. A large tract of land around it is being planted 
 with trees and shrubs, and is laid out in parklike fashion. 
 Flower gardens and a fountain add much to the beauty 
 and charms of the place. The main building contains 
 rooms for the director and his assistants, the pharmacy, and 14 
 rooms for the employes, chapel and library. The dwelling 
 rooms are furnished in a most luxurious oriental style. The 
 hospital proper is built on the pavilion plan and can accommo- 
 date 100 patients. The wards are models of cleanliness and 
 comfort. The operating-room is all that money and skill could 
 make it. It is supplied with all conveniences for aseptic work 
 and a complete outfit of surgical instruments. The washhouse, 
 sterilization-room and steam-heating apparatus occupy a sepa- 
 
 Medical staff of the Hamidie Hospital. 
 
 rate building. A military guardhouse is at the entrance to the 
 grounds and a small detachment of soldiers do guard duty. In 
 the well equipped pathologic and bacteriologic laboratory the 
 best scientific work is being done. This department is in 
 charge of Fnad Bey, who qualified himself for this position 
 under Finkler, Kruse, Schulze, Behring, Marmkopf, Muller 
 and Striimpell, all wellknown German scientists. Djevad Bey, 
 also a graduate of a foreign school, is the chemist of the insti- 
 tution and does his work in a separate laboratory furnished 
 with everything necessary for scientific work. Most of the 
 furniture and hospital supplies were bought in Paris and Ger- 
 many regardless of cost. The director's house is furnished in 
 princely style. The present medical staff consists of Colonel
 
 Ibrahim Bey, medical director and physician to H. I. M. the 
 Sultan; Fuad Bey, Yakki Bey, Nonri Bey, Zia-Noumry Bey. 
 
 The greatest defect in all of the Turkish hospitals is the 
 absence of trained female nurses. The high class Turkish 
 women are not obtainable and the low class women do not pos- 
 sess the necessary education and intelligence to fit themselves 
 for the nursing profession. The Hamidie Hospital has found a 
 Avay out of this difficulty. Seven months ago five trained 
 female nurses were engaged in Berlin and after coming here 
 were placed in charge of the sick children and women. This 
 addition to the hospital has wrought wonders in the care of the 
 patients. Their services are highly appreciated. The head 
 nurse receives 70 francs a month, the rest from 40 to 50. These 
 five young women are happy and cheerful in their present 
 situation, although they have as yet made but little progress in 
 acquiring a knowledge of the Turkish language. It is to be 
 hoped that their work and example will set aside the objections 
 of the highborn Turkish women to join their work and open 
 the way to well trained native female nurses. If it were not for 
 the red fez a visit to this hospital would leave the impression 
 that the visitor had passed through one of the most modern and 
 scientific hospitals in Germany. This hospital will furnish the 
 leaven in the further evolution of the science of medicine in 
 Turkey and will become an object lesson in the care of 
 the sick throughout the entire empire. No private hospital 
 offers more comfort, better nursing or more attentive and 
 careful medicaland surgical treatment, and yet it is a rule 
 established by the royal donor that no money should be 
 taken from any of the patients. Children from 1 to 12 years 
 of age embrace the largest number of patients. The gyne- 
 cologic department is well represented. Several pavilions are 
 devoted to acute infectious diseases. Serum treatment of diph- 
 theria is relied upon, and has given the most gratifying results. 
 Last year two children with far-advanced diphtheritiG stenosis 
 of the larynx were admitted. In both instances tracheotomy 
 was immediately performed, and both recovered. Tuberculosis 
 of bones, joints and lymphatic glands is quite a frequent affec- 
 tion among the children. Diseases of the skin and eyes make 
 up a large part of the clinical material. One of the provisions 
 tliis hospital has in view is the care of strangers that might be 
 taken ill in Constantinople. At the Sultan's special request 16 
 beds have been set aside for the treatment of patients that 
 might apply for relief to any of the legations. All that is neces- 
 sary to secure admittance is to apply to any one of the ambas- 
 sadors for a recommendation. I do not know of any other 
 monarchical or republican government that has made a similar 
 arrangement for tlie travelers of other countries in case of
 
 illness— another indication of the Sultan's desire to benefit the 
 sick, regardless of their nationality or religious belief. The 
 question of religion is never raised in admitting patients. In 
 looking over the report for last year, I found that at least 33% of 
 all the patients were Protestants. 
 
 Polyclinic of the Hamidie Hospital.— One of the most far 
 reaching charitable institutions of Constantinople is the Poly- 
 clinic connected with the Hamidie Hospital. The average daily 
 attendance is from 125 to 150. Last year 25,000 applied for treat- 
 ment. All patients must pass through the same gate. Inside 
 of the gate is the first examination station. A physician elimi- 
 nates here all cases of acute infectious diseases which are 
 referred at once to the department for the same. Those who are 
 admitted enter the large waiting-room. Another physician 
 
 Polyclinic of Hamidie Hospital. 
 
 classifies the patients and refers them to the department to 
 which they belong. Five physicians, representing surgery, 
 internal medicine, gynecology, ophthalmology and nose and 
 throat diseases in separate rooms are in attendance from 9 a.m. 
 until 2 p.m. All of these rooms are well supplied with instru- 
 ments for diagnosis and treatment. A large dispensary in the 
 same building, presided over by several competent druggist*, 
 supply the medicines free of charge. Ibrahim Bey is the soul 
 of the Hamidie Hospital. He takes great pride in its marvel- 
 ous success. He is a competent bacteriologist, a thorough and 
 earnest student of the German medical literature and passion- 
 ately devoted to the advancement of the science of medicine in 
 its broadest sense. Our visit in this model hospital terminated
 
 with a most excellent dinner given at the special request of the 
 royal founder and patron, H. I. M. the Sultan. 
 
 THE TURK AS A SOLDIER. 
 
 The Turk makes an ideal soldier. He is above average 
 height with a splendid physique, muscular and devoid of super- 
 fluous fat. His simple, temperate habits engender an endurance 
 far beyond that of the soldiers of any other European nation. 
 The Turk can subsist on a minimum of the plainest kind of 
 food without becoming disabled on forced marches continued 
 for many days. The Turkish soldier is content and obedient. 
 His sense of duty is keen and he will follow his leader in the 
 very jaws of death without fear. The Turkish army has become 
 a very formidable one. It is well-drilled and organized and 
 armed with modern weapons. All able-bodied Turks enter the 
 army at the age of 20 and serve for seven years. In Constan- 
 tinople alone there are 17,000 soldiers who live in modern com- 
 fortable barracks. The Turkish cavalry is the finest in the 
 world. The Turkish soldier is a desirable patient. He has 
 faith in his physician and is grateful for his services. Obedi- 
 ence, courage and patience are his greatest virtues. 
 
 THE RED CRESCENT. 
 
 In the Turkish army the Red Crescent is equivalent to the 
 Red Cross. The red crescent on the sleeve and on the white 
 flag means the same practically as the red cross. The Red 
 Crescent Society of Turkey is a very exclusive organization. 
 It is made up almost entirely of military men who have dis- 
 tinguished themselves by meritorious service. Membership 
 in this society, in fact, means government recognition. At the 
 last Conference of the International Red Cross this society was 
 represented by the Turkish Ambassador at St. Petersburg, who 
 attended all of the sessions and manifested a deep interest in its 
 proceedings. 
 
 Constantinople, June 13.
 
 fUeprinted from American Medicine, Vol. IV, No. 12, pages 467-469, 
 iSeptember 20, 1902 1 
 
 MEDICAL AND SURGICAL NOTES FROM ASIA. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 It is a long time since the great continent of Asia was the 
 center of civilization, art, science and Cliristianity. For nearly 
 2,000 years progress has given place to decay. Her treasures of 
 art lie buried under her arid soil or have found their way into 
 the rich museums of distant nations. Her science has been 
 transplanted to a more fertile soil in foreign lands. The light 
 of Christianity kindled in Asia has become almost extinguished 
 by the worshipers of strange gods, and is now illuminating 
 inore brightly Europe, Africa and the two continents that were 
 unknown when it was given to God's chosen people. The dark 
 clouds created by the relentless persecution of the Christian 
 church, the ^reat power of civilization, still hover over the 
 unfortunate contihent and are being only gradually dispersed 
 by the reintroduction of the teachings of Him who selected this 
 land for his soul'-savihg mission on earth. In a land where 
 there is no art and' no science medicine cannot flourish. Super- 
 stition 'and medicine are incompatible neighbors. Science 
 should precede — it certainly must accompany— progressive 
 inodern medicine^ If Hippocrates could return to his birth- 
 place in the island of Kos, near the coast of Asia, he would find 
 kmple indications that the science of medicine which he 
 founded 400 years before the Christian era had found a new 
 l"oothold in many parts of dark Asia. What progress has been 
 made in Asia in the teaching sind practice of medicine during 
 
 (he last half century has been accomplished entirely by outside 
 nfluences. ' The medical missionaries and foreign physicians 
 ^re establishing in many different places institution^ where 
 inodern scientific medicine is taught and prdctis^d and frorn 
 ivhere the good work will gradually but surely extend over thi^ 
 ^utire continent. It is my purpose to speak of A few such med- 
 ical centers in this dommunidation. ' ' " ' 
 
 SMYRNA. 
 
 Smyrna is one of the great commercial ports of Asiatic 
 Turkey. It has a nlix6d population of 125,000 inhabitants. 
 "The Greek's ai^e^well represented knd control mtich df its cofn- 
 ii:ierci'af irfter'^sts. Th^'y oWn and rhaintain a large hospital for 
 the sick of their o^frn nktion'ality. They gained a firm foothold
 
 on this part of the Asiatic soil centuries ago, and have been 
 more successful in business matters than most of the other 
 exotics. The richest men in Smyrna are of Greek origin. 
 
 The Yosharalamhas Hospital. — This institution for the 
 Greek sick poor in Smyrna is a credit to the little nation it rep- 
 resents. It is more than 150 years old and is located in the 
 very heart of the city. It is a solid square building two stories 
 high with a central open court where the patients enjoy the 
 luxuries of a subtropical garden and pleasant walks. The 
 wards are large, well ventilated and supplied with all the com- 
 forts of a modern hospital. The medical staff is composed of 
 young men, graduates of the University of Athens, and most 
 of them have taken postgraduate courses in Paris. Smyrna 
 surgery is French surgery. One operating-room is devoted 
 entirely to aseptic surgery, in the other all the facilities for 
 antiseptic work are at the disposal of the operator. In the 
 aseptic room the appliances for sterilization of instruments, 
 dressings, suturing and ligature material are complete. Like 
 in all Oriental hospitals the absence of trained female nurses is 
 a deplorable feature. Dr. A. N. Psaltoflf is the most distin- 
 guished member of the medical staff of this hospital. He spent 
 several years after his graduation in Paris, and is familiar with 
 French medical literature. He is an able and successful sur- 
 geon, and his example and teachings will contribute much 
 toward disseminating modern surgery in Asia. Other foreign 
 nations in Smyrna own and support their own hospitals, among 
 them the French and Austrian governments. 
 
 Beyrut is the Paris of Syria. It is a city of 75,000 inhabi- 
 tants, located on an eminence which commands a splendid view 
 of the Mediterranean Sea on one side and the Lebanon Moun- 
 tains on the other. Here a new civilization and modern medi- 
 cine have engrafted themselves more firmly than in any other 
 part of Asia, all through the strong influence of the Syrian 
 Protestant College. 
 
 fSyrian Protestant College.— This is an American mission- 
 ary institution founded 36 years ago by the retiring president, 
 Rev. Daniel Bliss, D.D. It is known by the citizens of Beyrut 
 as the American College. The massive stone buildings are 
 distributed over a 36-acre lot located on the shore of the Medi- 
 terranean on one side and shut out from the city by a high 
 stone wall on the other. New buildings are erected as they are 
 needed. At present the great Post Hall is in process of con- 
 struction and when completed will be used as a science hall. 
 The Daniel Bliss Hall is a magnificent college building. The 
 college has an attendance of 600 young men who have come
 
 3 
 
 here to obtain their education from various countries, includ- 
 ing Syria, Turkey in Europe, Greece, Palestine and Egypt. 
 Tlie teaching force is composed of 40 professors and instructors 
 The faculty includes a number of names of former graduates. 
 The college has six departments: preparatory, collegiate, 
 school of commerce, school of biblical archaeology and phi- 
 lology, medicine, and pharmacy. New departments will be 
 added as fast as the finances of this excellent institution will 
 permit. What is much needed is a department of dentistry 
 and agriculture. 
 
 /School of Medicine. — This was organized by Prof. George 
 E. Post in 1867. It has a list of 91 graduates up to the present 
 time. It has more than 100 matriculants and the graduating 
 cjasis for this year numbers 10. The faculty is oompos^ed of eight 
 
 Medical Hall. 
 
 members. Some of these teachers fill several chairs. For 
 instance. Prof. Adams teaches chemistry, materia medica, 
 therapeutics and dermatology, and Prof. Moore gynecology, 
 obstetrics, physiology and hygiene. Recitations constitute a 
 conspicuous feature of all didactic courses. One of the difficul- 
 ties encountered by the college of medicine is the supply of 
 material for the dissecting-room. The cemeteries are the only 
 places where the material can be obtained and the midnight 
 excursions for this particular purpose are attended by great 
 difficulties. The bodies are carefully preserved in alcohol so 
 as to utilize them to the utmost advantage. The college build- 
 ing compares favorably with some of our smaller medical 
 schools. Two amphitheaters serve as lecture-rooms. A 
 museum furnishes ample facilities for the study of compara- 
 tive anatomy, pathology and osteology. The present laboratory
 
 4 
 
 advantages are not what they should be, but a large building 
 now in process of construction will remedy this defect at the 
 beginning of the next session. The tuition is ^0 annually and 
 half of this fee secures admission for graduates of the Syrian 
 Protestant Hospital, Robert College, Central Turkey College, 
 Anatolia College, and of Euphrates College. The requirements 
 for admission specify the minimum age at 17, and a satisfactory 
 examination in English, French or Turkish, geography, arith- 
 metic, elementary physiology, algebra, geometry and physics. 
 After four years' study and after having passed a satisfactory 
 written and oral examination, the students receive a certificate 
 of examination'. This certificate entitles them to apply for 
 "graduation to the imperial Medical School at Constantinople. 
 In Egypt this certiAcate entitles the holder to enter into prac- 
 tice without any further examination. A number of the gradu- 
 ates are now serving as military surgeons in the Egyptian army 
 knd others hold important municipal medical positions. 
 
 The Johanniter Hospital. — This hospital was founded in 
 1867 by the German branch of the Knights of St. John, and 
 receives the warm support and financial aid of this order. It is 
 a two-story stone building, situated on a high bliiff which over- 
 looks the Mediterranean Sea. It contains 70 beds, and is in 
 charge of eight deaconesses from Kaisersworth. These eight 
 well-trained Sisters take excellent care of the patients and are of 
 great assistance to the attending staff. All of the clinical teach- 
 ing of the medical school takes place in this hospital. Professor 
 tost holds his clinics Wednesday and Saturday forenoons each 
 week. The students attend in sections of from 12 to 20. As 
 there are no house physicians in the hospital the students assist 
 in operations ancl attend to most of the dressings. The operat- 
 ing-room is snaall but contains everythiugnecessary for aseptic 
 work. All of the students wear go^vtis. Those who are called 
 \ipon to assist must undergo a most thorough hand disinfection. 
 ^ost is pattial to silk as a suturing material, altliough occasion- 
 ally he makes Use of catgut or silver wire. 
 
 On the day of my visit he operated for congenital inguinal 
 hernia occurring in a man about 35 years old. The opposite 
 side had been operated upon successfully six weeks ago. The 
 operation was performed under cocain anesthesia. 
 
 Post prefers local to general anesthesia in such cases. His 
 experience with this local anesthetic has been quite extensive, 
 and although he has administered in some cases as much as \l 
 grains of the drug in this manner he has never observed any 
 serious after effects. 
 
 In this particular case the patient frequently manifested 
 bain on incising the skin and in making the deep dissection^ 
 The oihentiim ptersisted in protruding on opening the S£lc and i
 
 large part of it was finally amputated below a number of &ti 
 ■masse silk ligatures. This part of the operation appeared to be 
 painless. The hernial opening was very large and conse- 
 quently had to be closed by suturing instead of by a ligature. 
 The spermatic cord was not disturbed and the inguinal canal 
 was closed with a number of silk ligatures. 
 
 The operation was a somewhat tedious one and the two 
 other operations set for the same day, a cystic bronchocele and 
 a relapsing sarcoma of the face, had to be postponed for the 
 next clinic. 
 
 Among the interesting cases exhibited were : Ovariotomy 
 for dermoid cyst, enterectomy for fecal fistula following opera- 
 tion for strangulated hernia, thyroidectomy for parenchyma- 
 tous struma of ri^ht lobe of thyroid, excision of carcinoma of 
 l^reast and a numl;)er of cases of tuberculosis of joints, all of 
 them progressing favorably. 
 
 Professor George E. Post is a most remarkable man. iteis 
 the most popular physician in Syria, respected and honored by 
 
 ;r^ 
 
 
 
 
 
 1 
 
 1 
 
 K^'-i 
 
 r.f^v.<"^j^^|?g^ 
 
 k; S^"*f" 
 
 
 The Johanniter Hospital. 
 
 _all classes of people for what he has done for the country. His 
 students fairly worship him. He is the son of the distinguished 
 Jate Professor Alfred C. Post, of New York. He came to 
 Beyrut soon after his graduation in 1863 and has worked inces- 
 santly ever since. He loves the people and the country of his 
 adoption and his work will be revered and honored by genera- 
 tions to come. The secret of his almost unparalleled success has 
 been work. He has accomplished what he has by systematizing 
 )iis work, and his hours of rest are few, but are taken at a regu- 
 lar time. He has given to the college he loves nearly one-half 
 of his time. Vacation he knows not, work is his recreation. 
 Resides a large and taxing surgical practice he has found time 
 to prepare an Arabic Commentary of the Bible and the Flora 
 f)f Syria, two books that will perpetuate his memory in the 
 history of Syria and in the scientific world. When Emperor 
 IViiliam visited Beyriit and the Johanniter Hospital he was made
 
 aware of what Professor Post had done for the city, the coun- 
 try, and the hospital, and it was a gracious and timely act on 
 his part when he conferred upon the hard- worked, faithful pro- 
 fessor the decoration of the Red Eagle. The famous Emperor 
 never conferred a decoration upon a more worthy man. Pro- 
 fessor Post is a model of what a medical missionary should be. 
 He has acquired a perfect knowledge of the language of the coun- 
 try of his choice. He never fails in delivering every Sunday a 
 sermon in Arabic to the patients of the Johanniter Hospital. 
 Dr. Post has visited the United States only three times since 
 he gave his services to Syria. It is for good reasons that the 
 great hall of science in connection with the Syrian Protestant 
 College should be called the Post Hall, a recognition to which 
 he is entitled by his long and faithful services to the institution 
 that owes so much to his untiring efforts. 
 
 Other Hospitals.— The Catholic College in Beyrut has the 
 same objects in view as the Protestant College, but has not found 
 the same degree of favor with the natives. The French and 
 Greek hospitals take care of the subjects of the respective 
 countries, and will do their share in disseminating modern 
 medicine and surgery in Asia. 
 
 DAMASCUS. 
 
 This is a city that interests every biblical student. It was 
 made famous for all time by the conversion of Saul. The place 
 of his conversion on the road to Jerusalem and the house of 
 Ananias he visited by the Lord's request are the two places 
 every stranger is sure to visit. The city is much the same as 
 when thi-^ incident occurred. Some of the old walls that 
 sheltered it from invading forces at that time still remain. 
 It has now a population of 250,000 inha1)itants, representing 
 Syria and its adjacent countries. Its narrow streets, small 
 shops and the mass of ragged citizens speak only too plainly of 
 its poverty. 
 
 Medical Practice in Damascus. — Damascus is not the place 
 for the physician whose principal desire is to accumulate 
 wealth. The city has 20 licensed practitioners besides the 
 military surgeons stationed here, who are permitted to practise 
 their profession outside their military duties. Ten cents pays 
 for an office consultation, and two to three francs for a visit. A 
 large majority of the people are poor and cannot pay anything 
 for medical services. For this part of the population the many 
 medical dispensaries make provision. For instance, Dr. 
 Alexander Halabi, a physician of Arabian origin, has charge of 
 the Russian Dispensary and cares for 40 patients daily, a service 
 for which he is paid 80 francs monthly. Similar dispensaries 
 supported from other sources do much tOAvard the care of the
 
 sick poor of Damascus. I know of no other city in which the 
 dispensary service does more good than in Damascus. Very 
 few emergency cases apply to dispensaries, as injuries are of 
 very rare occurrence. Smallpox has been stamped out by a 
 strict enforcement of the vaccination laws. Diphtheria is 
 seldom met. Venereal diseases are said to be quite common, 
 and among the natives pursue a mild course. Among the 
 acute diseases typhoid fever, malaria and rheumatism are most 
 prevalent. Tuberculosis of joints, bones and lymphatic glands 
 are common diseases of childhood. 
 
 Damascus Hospitals.— The city of Damascus has only three 
 hospitals, the Municipal or city hospital, the Military, and the 
 A^ictoria Hospital. The Municipal Hospital is a modern build- 
 ing with a capacity for 100 patients and is in charge of military 
 surgeons. Provision is made for a few private patients. The 
 furnishings of the wards are all that could be desired. The small 
 operating-room is supplied with everything necessary for asep- 
 tic work. The absence of trained female nurses in common 
 with most of the public Oriental hospitals is* noticed more by 
 the transient visitor than anything else. The Military Hospi- 
 tal, with 500 beds, is an old building in the very heart of the 
 city, devoid of all modern improvements. 
 
 The VietoHa Hospital. — This is the old Mission Hospital, 
 established and supported by a Scottish missionary society. 
 During the jubilee year of Queen Victoria the British subjects 
 of Syria raised the sum of £160 in honor of the occasion. This 
 sum was later appropriated to the use of the hospital, which 
 then assumed the name of Victoria Hospital. In recognition 
 of this devotion the Queen sent a fine steel engraving of her- 
 self to the institution ; this is now the main attraction in the 
 reception-room. The hospital can take care of 41 patients and 
 is in charge of Dr. Frank Irving Mackinnon, a graduate of the 
 Edinburgh school. Dr. Mackinnon is an enthusiastic mission- 
 ary physician and he has done much and will do still more in 
 disseminating modern medicine and surgery in Asia. 
 
 My next communication will treat of the hospitals in Jeru- 
 salem. The nursing is in charge of two trained Scotch Sisters 
 assisted by native women. A few private rooms are reserved 
 for patients who are able to pay. The hospital was opened five 
 years ago. The surgical patients outnumber the medical. A 
 few days ago the first case of ovarian tumor was operated upon. 
 The large garden with tropical trees and plants is a charming 
 place for the recuperation of convalescents. 
 Damascus, June 24.
 
 IReprinted from American Medicine Vol. IV, No. 13, pages 509-512, 
 September 27, 1902.] 
 
 THE HOSPITALS OF JERUSALEM, 
 
 BY 
 
 N ECHO LAS '^ENX, M,D., 
 of Chicago. 
 
 A brief description of the hos^pital facilities of the ancient 
 historic city of Jerusalem may be of more than passing interest 
 to the medical profession of our country. The very name 
 Jerusalem carries our memory back to our earliest ciiildhood 
 days. The great events which occurred in that city and so 
 vividly described in the Sci-iptures are familiar to every Sun- 
 day-school scholar, and the pictures formed of them in the 
 mind of the child remain as long as memory lasts. It is here 
 where the greatest miracles were performed ; where the Great 
 Physician taught and labored ; where he healed the lepers, 
 made the blind see, the deaf hear, and the lame walk. But 
 Jerusalem of today is not the Jerusalem of those days. The 
 magniticent temple of Solomon, the pride of the Holy Land, is 
 no more. The ruthless hand of time and the destruction 
 wrought by war and fire have left but few reliable landmarks 
 of the proud city of Zion. The descendants of the people who 
 V)uiltand owned it have been reduced to a condition worse than 
 slavery. The Jews of the Bible clamored for the cross ; the 
 Jews of today are held in subjection and are persecuted and 
 humiliated by the crescent. They occupy the narrowest, most 
 crowded, and filthiest streets, conduct the smallest shops, and 
 furnish the largest contingent to the army of shoeblacks. The 
 large group of wailiug Jews that gathers so regularly every Fri- 
 day afternoon outside of what was once the city wall is an object 
 lesson which when once seen will never be forgotten. A mot- 
 ley crowd of men, women and children, with Hebrew Bible in 
 hand, lean against the wall and in pitiable, mournful tones 
 lament their loss and in fervid prayer petition the God of Israel 
 for relief. For nearly 2,000 years these weekly wailings out- 
 side the walls of their former city have taken place with great 
 regularity, but their position in life remains the same. David 
 street is the center of the Jewish settlement and it would be 
 impossible to find a dirtier thoroughfare, less inviting stalls, 
 and more odorous human habitations anywhere. The present 
 number of inhabitants of Jerusalem is 150,000 and of these 
 about one-half are Jews. The lack of sewerage and the scarcity 
 of water account for many of the prevailing diseases. Bathing- 
 is a luxury and not within the reach of the poor. In one of the 
 hospitals I was informed that a patient recently admitted said
 
 that she had not had a bath in ten years and from what I saw 
 in the Jewish quarter of the city and elsewhere I am sure this 
 was by no means an isolated experience. When water has to be 
 bought and paid for out of the lean purse of poverty-stricken 
 people, the supply must necessarily be a limited one. Sewer- 
 age and an ample supply of wholesome water would make Jeru- 
 salem the most healthful city in the Orient, as its geographic 
 location is an excellent one, at an elevation of 2,400 feet above 
 the level of the sea. 
 
 HOSPITALS OF JERUSALEM. 
 
 Jerusalem has for a long time been a center of mission 
 work in w^hich foreign nations and different religious denomi- 
 nations have taken an active interest. The extreme poverty of 
 the great majority of its inhabitants and the unsanitary condi- 
 tion of the city are largely responsible for the unusually large 
 number of sick poor. The different hospitals take care of at 
 least 1,000 outdoor patients every day. It is a great pity that 
 this enormous clinical material is not utilized to greater advan- 
 tage for scientific investigations. The oculist, the dermatolo- 
 gist, and the genitourinary surgeon would find here a rich field 
 for clinical study. The hospitals, some 12 in number, are all 
 small, and none of them makes any pretension to being entirely 
 modern. 
 
 The German or Deaconess Hospital. — This is the best hos- 
 pital in the city. It is one of the many hospitals erected, main- 
 tained and managed by the Sisters of Kaisers werth in Ger- 
 many. This order of German nurses has labored here since 
 1851 in the interest of the sick poor of all nations. The present 
 building is a new one and its doors are wide open to all in need 
 of medical treatment, at the same time ample provisions have 
 been made for private patients. Eight faithful Sisters attend 
 to the needs of the patients and are tireless in securing the 
 necessary funds to carry out the many charitable objects of the 
 institution. During the visit of the German Emperor to Jeru- 
 salem the Empress honored the hospital by a visit. What 
 attracted her attention most was the imperfect supply of instru- 
 ments and facilities for aseptic work in the operating-room. 
 She dictated an order for everything necessary, sent it to Ger- 
 many, and the hospital has now the best equipped operating- 
 room in Palestine, all at her private expense. Visits like these 
 live in the history of any charitable institution. The hospital 
 is located in a quiet part of the city and can accommodate 60 
 patients. The outdoor department is visited by more than 5,000 
 patients every year. The relative proportion of the different 
 nationalities of the inmates for the year 1898 was as follows : 
 Arabs, 698; Armenians, 54; Germans, 45; Greeks, 14; Aus- 
 trians, 12 ; Bulgarians, 3 ; English, Swiss and Spaniards, each, 2 ;
 
 8 
 
 I American and 1 Rnssian. The institution is constantly grow- 
 ing in favor with the natives and its far-reaching influence, as a 
 center of true charity and as a house of refuge for visitors 
 stricken down with disease, cannot be overestimated. 
 
 The Russian IfospitaL—This hospital is supported by the 
 Russian government and a local branch of the Red Cross. It 
 can accommodate 44 patients, and in a separate building there 
 are ten additional beds for patients suffering from acute infec- 
 tious diseases. The arched corridors and rooms correspond 
 in archit cture with many of the more important buildings, 
 public and private, in Jerusalem. The sick are under the care 
 of two Russian Red Cross Sisters. The dispensary is large and 
 in charge of two competent druggists. The small operating- 
 room contains all that is essential for modern surgical work. 
 The outdoor department is popular with the mass of the people, 
 as it WIS visited bv 22,000 patients daring the last year. Dr. 
 
 Gennau Deaconess' Hospital in Jerusalem. 
 
 Severine is the only medical attendant. He is a Greek, studied 
 in Athens and after graduation spent two years in Paris. In his 
 outdoor work he sees many cases of furunculosis, abscess, 
 lymphangitis and erysipelas. In the operating-room he relies 
 on chloroform as an anesthetic, and silk as suture and ligature 
 material. The hospital is open for all deserving sick poor, 
 regardless of nationality or religious faith. During my visit I 
 was shown three cases of empyema recently operated upon by 
 the radical method. In all of these cases the suppurative 
 pleuritis developed in the course of croupous pneumonia. 
 
 The Greek Hospital.— This hospital was established by the 
 Greek Catholic Church in 1865. It has 54 beds, many of which 
 are occupied by pilgrims, who come annually in large numbers 
 to Jerusalem and who are taken ill on the way. Dr. Nicholas 
 Spyridon is the medical director. During the last 10 years he 
 has performed laparotomy for echinococcus cyst twice ; one of 
 the patients died, the other recovered.
 
 Hospital of Saint 7>o?tM.— This hospital Avas built by and is 
 in charge of the Sisters of St. Joseph, who came to Jerusalem 52 
 years ago. The present excellent building is 22 years old and 
 has a capacity of 85 beds. It is a solid stone building two and 
 three stories high, with a large open court in the rear orna- 
 mented with trees, flowering shrubs and flowers. The wards 
 are large, well lighted and scrupulously clean. The comfort- 
 able beds and spotless linen contribute much to the general 
 attractiveness of the sick-rooms. The hospital is in the very 
 heart of the city and is enclosed by a high stone wall. On an 
 average 300 patients call at the outdoor department every day. 
 Two physicians are in charge of the medical and surgical seiv- 
 
 Operating-rooni in Russian Hospital, Jerusalem. 
 
 ice. The Sisters assist in operations and apply many of the 
 dressings. One of the Sisters, a graduate in pharmacy, is in 
 charge of the large dispensary. As all of the patients, indoor 
 and outdoor, are charity cases, it is a source of surprise to the 
 visitor to see the institution in such a flourishing condition. 
 The prayers of these hard-working, unselfish Sisters must find 
 a ready response from somewhere. 
 
 Hospice of the Sisters of Charity, St. Vincent de Paul.— This 
 is not a hospital proper, but a home for the blind, the crippled, 
 the incurables, the aged and the orphans. It is a charitable 
 institution in the widest sense of the word. Seventeen Sisters 
 labor here night and day to render life comfortable, and when 
 it can be done, useful. It contains at present 170 inmates. One
 
 5 
 
 of the Sisters educates the blind children, another takes care of 
 the many infant orphans, a third one conducts a school, while 
 others are engaged in making life endurable for the incurables. 
 Here is a profitable and grateful place for modern surgery. The 
 sight of many of the blind could be restored and many of the 
 crippled limbs could be made useful by surgical intervention. 
 Let ns hope that the Sisters may find the gratuitous services of 
 a competent oculist and surgeon to aid them in their philan- 
 thropic work. 
 
 Baron Rotlischill Hospital.— This charitable establishment 
 was founded 49 years ago by the Rothschild family, and was 
 intended exclusively for the benefit of the Jewish population of 
 the city. The present site M^as selected and the hospital built in 
 1885. The hospital space is limited to 12 beds for men, an equal 
 number for wonien and six for children. Only Jews are 
 admitted into the hospital, while the outdoor clinic is open to 
 all who apply. There are no private rooms, and all expenses 
 are paid from a fund donated by the founders of the institution. 
 Sick mothei'S often bring their infant children with them, and 
 sick children are equally often accompanied by their mothers. 
 The facilities for surgical work are very primitive, as very few 
 operations are performed. Dr. I. G. D. Arbelie is the attending 
 physician and at the same time conducts the outdoor depart- 
 ment, to which not infrequently as many as 325 patients apply a 
 day. The doctor is an Italian by birth and education, but spent 
 several years in Paris after his graduation. He speaks and 
 writes 16 languages, and has use for them all every day in con- 
 versing with his outdoor patients. He is a tireless worker. 
 His professional work often extends beyond the midnight 
 hour. The number of malarial cases he is called upon to treat 
 may be approximately estimated from the statement he made 
 to me that he uses annually no less than 40 kilos of quinin. In 
 severe cases of malaria treated in the hospital he preferred to 
 use this drug by subcutaneous injections ; in the outdoor clinic 
 it is administered in pill or powder form. At the time of my 
 visit nearly all the beds were occupied by malaria patients. 
 Pronounced anemia, enlargement of the spleen and liver and 
 ascites from the last two affections were the most frequent 
 remote malarial complications. In the hospital a small syna- 
 gogue serves as a place of worship for the orthodox Jews. 
 
 Municipal Hosjyital. — Besides the military hospital this is 
 the only government hospital. It was built 15 years ago, has 30 
 beds and is beautifully located on the highest hill in the city. 
 The hospital is well furnished and the little operating-room has 
 been renovated recently and is supplied with all facilities for 
 aseptic work. The question of nationality and religion is not 
 considered in admitting patients. The outdoor clinic of this
 
 hospital, which is a very large one, is in the central and most 
 accessible part of the city. A few years ago a radical change 
 for the better was made in the nursing force by placing the 
 patients in charge of three Sisters of Charity. The initiation of 
 these Sisters into their work in a Turkish government hospital 
 was an important event and the ceremony was attended by the 
 ruling Pacha and military officers of high rank. The Sisters 
 sleep in their own hospice and the only remuneration they 
 receive for their services is 60 piastres (or $8.00) a month, just 
 enough to pay for carriage hire. It is needless to say that the 
 patients appreciate to the fullest extent the kind and skilful 
 nursing of these faithful and devoted. Sisters. Dr. Photios, a 
 Greek physician, has charge of the medical service. He is a 
 man of far more than average intelligence and ability and is 
 devoted to his profession and his patients. 
 
 Jesus-Hilfe.— This is an asylum for the care of lepers. At 
 present the number of lepers in Palestine is estimated at from 
 
 I _«aLjaB!ffi»^ C: LC^'W^^j^/',!^^^-^ -^ I- 
 
 
 Jesus-Hilfe Leper Asylum. 
 
 300 to 400. These unfortunates form a large part of the profes- 
 sional beggars in the streets of Jerusalem. They have formed 
 an organization among themselves with a chief of their own 
 selection at the head for the purpose of making begging more 
 systematic and remunerative. These lepers mix freely with the 
 people in the streets and public places. Most of the lepers are 
 Arabs, the Jews are singularly exempt from this disease. The 
 tubercular and anesthetic forms are about equally represented. 
 Many years ago the Moravian Brotherhood at Herrnhut, Ger- 
 many, conceived the happy idea of taking care of the lepers in 
 Palestine. In 1886 the present building, some two miles from 
 the city limits, was completed. It was found very difficult to 
 induce the lepers to enter and remain in this excellent institu- 
 tion, erected for their special benefit. They hesitated in 
 exchanging their roaming free outdoor life for a pleasant home 
 in the asylum. In many instances they would remain for a 
 short time and then leave suddenly without permission and 
 resume their begging station in the most frequented streets;
 
 8 
 
 when their business did not thrive, when their scanty gar- 
 ments became ragged and finally when hunger tortured them 
 they would return to their former hospitable asylum home and 
 remain long enough to satisfy their immediate wants and then 
 disappear again as suddenly and unceremoniously as before. 
 Gradually, however, the confidence in their benefactors 
 increased and they realized more and more the unselfish benefi- 
 cence of the institution. At present the asylum contains 47 
 inmates. It is conducted in a most economic manner, but the 
 patients are well fed, comfortably clothed and receive the most 
 tender care. The asylum is presided over by Mr. Charles 
 and Mrs. Annie Schubert, and the patients are cared for by 
 Deaconesses Ehrle, Eisner, Miiller and Zimmer. Dr. Einsler, 
 the physician-in-chief of the Deaconess Hospital, directs tlie 
 hygienic and medical treatment. The serum treatment was 
 made use of in a number of cases, but the high fever caused by 
 the injections aggravated the disease and in a few cases hast- 
 ened the fatal termination. Among the 47 inmates of the 
 asylum there is only one Jew. Dr. Einsler, during his long 
 and extensive practice in Jerusalem, has seen only three Jews 
 affected with leprosy, and of these one came from Salonik and 
 the remaining two from Morocco. It seems then that the Jews 
 of Jerusalem have in the course of time acquired an immunity 
 against this disease notwithstanding the increase of poverty 
 and unsanitary surroundings. The Jesus-Hilfe leper asylum 
 of Jerusalem is one of the most deserving charitable institu- 
 tions of Jerusalem and deserves the financial support of all 
 humanitarians. 
 
 British Hospitals,— The English people have done their 
 good share in the alleviation of the suffering poor of Jerusalem. 
 One of these hospitals, the Ophthalmic, is devoted exclusively 
 to the treatment of diseases of the eye; the other is a general 
 hospital. Eye affections are alarmingly common in Jerusalem 
 and throughout Palestine. In no other city are the blind more 
 numerous and inflammatory affections so common. Bulbless 
 sockets and opaque corneas are met every few steps in any of 
 the crowded streets. Specific infection and trachoma are the 
 most frequent causes of blindness. The number of blind 
 infants and young children is astonishing. The Ophthalmic 
 Hospital has 20 endowed beds, which are always in great 
 demand. Three times a week the outdoor department is 
 thronged with men, women and children who apply for relief. 
 This hospital has a Avide range of usefulness in averting blind- 
 ness and in restoring sight in cases adapted for successful 
 operative interference. 
 
 Jerl'salem, July 1.
 
 [Reprinted from American Medicine. Vol. IV, No. 14 pages 550-552. 
 October 4, 1902.] 
 
 MEDICAL PRACTICE IN CAIRO AND PREVAILING 
 DISEASES OF EGYPT. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 
 of Chicago. 
 
 The name of Egypt brings up thoaglits of antiquity. The 
 land of the Rauieses, of the Pharaohs, has a history the begin- 
 ning of which extends back to the dark unknown— Egypt, the 
 most famous of ancient nations, once the center of science, art, 
 literature and commerce and which remains much the same as 
 it was more than two thousand years ago. Tlie Pyramids 
 remain as silent witnesses of the power and ambition of its 
 earliest rulers and the waters of the same lordly Nile continue 
 to irrigate its fertile valleys. In the course of time, science and 
 art fled to foreign countries and the greatest commercial cen- 
 ters have arisen in countries which were unknown when the 
 glory of Egypt was the envy of the world. The Egyptian 
 works of art have found places in the large museums through- 
 out the world. The royal tombs have been robbed and their 
 precious contents are on exhibition in strange lands, strong 
 reminders of the limitation of life and vanity of earthly 
 power. Egypt was the cradle of the healing art. For centuries 
 Alexandria was the mecca for medical students. Its great 
 library attracted the scientific men from far and near. The 
 Arabic medical textbooks were accepted as authoritative every- 
 where and formulated the practice of all pliysicians who made 
 any claim whatever to education. With the gradual decay of 
 Egypt progress in medicine declined, but today the profession 
 of the western medical world is returning to the ancient center 
 of medical education in a new and much improved form what 
 was borrowed centuries ago. So great have been the advance- 
 ments in medicine during that time that the Arabic language, 
 the medical language for many ages, has become utterly inade- 
 quate to express modern medical ideas. Cairo is the door 
 through which scientific medicine is finding its way again into 
 the land where civilization had its dawn. 
 
 CAIRO AS A MEDICAL CENTER. 
 
 Cairo is the largest city in Africa. Its present population is 
 nearly 1,000,000. Located in the fertile valley of the Nile, on
 
 the banks of this great waterway through Egypt and near 
 Alexandria, the great seaport town of the western coast of 
 Africa, it continues to cotnmand an important position in the 
 commercial world. The genial winter climate has made it also 
 a desirable and fashionable health resort. The city has a num- 
 ber of first-class hotels, and daring the winter months is 
 crowded with wealthy visitors from all parts of the world 
 who seek recreation or a climate conducive to their health. 
 Tbe European part of the city has fine residences, beautiful 
 gardens, magnificent streets and boulevards, and is well 
 policed. Begging, the curse of the Palestine cities, does not 
 prevail, and the natives treat the strangers with respect and 
 courtesy. Modern medicine has gained a firm foothold in 
 Cairo and Alexandria. More than 100 European physicians 
 have located here and practice their profession with variable 
 success. 
 
 Medical Pyac</ce.— Egypt does not suffer from a lack of 
 physicians. The country has 10,000,000 inhabitants, and there 
 are from 1,000 to 12,000 physicians in readiness to respond to 
 professional calls. As at least 75% of the patients are unable 
 to pay for medical services, and as the competition in 
 the two large cities, Cairo and Alexandria, is keen, it is a 
 natural consequence that the fees should be small. Few 
 physicians in Cairo receive on an average more than a dollar 
 a visit and 50 cents for an office consultation. Surgical work 
 is better paid for, but $150 is considered a handsome fee for any 
 of the major operations. What makes surgery in Egypt not 
 more remunerative is the inborn aversion of the natives to 
 surgical operations. This aversion amounts almost to absolute 
 refusal among the Mohammedan Avomen. This is the reason 
 why ovariotomy and hysterectomy figure so low in all hospital 
 statistics. The Arabs bear surgical operations well. Shock 
 and accidents from the administration of anesthetics are very 
 i-are. The natives are grateful patients and never forget the 
 services of their physician. Of this I saw an instance in the 
 Municipal Hospital, Cairo. As we were passing through one 
 of the wards a man with a tracheotomy tube in his trachea 
 approached Dr. Wildt, who accompanied me, prostrated him- 
 self and kissed his feet. The doctor explained that the man 
 was a former patient of his at a time when carcinoma of the 
 thyroid gland, which later made the tracheotomy necessary, 
 was still within reach of a successful naedical operation. 
 Excision of the carcinomatous gland was proposed, but was 
 promptly refused. In the meantime experience demonstrated 
 to the patient only too plainly the correctness of his physician's 
 diagnosis and the wisdom of his advice. 
 
 The entrance into practice in Egypt is not difficult, all that
 
 is necessary is to present a diploma from any recognized medi- 
 cal college. The graduates of the medical college in Bey rut are 
 permitted to practise on a certificate from that school. Consid- 
 ering the number of physicians already in the country it would 
 seem advisable and timely to make the laws governing the 
 entrance into practice more stringent. 
 
 Medical Societies.— Y.gyY>i has at present two medical 
 societies, one in Cairo the other in Alexandria. The Cairo 
 Medical Society has a membership of 60, and meetings are held 
 every three weeks during the winter season. At these meet- 
 ings modern surgical and medical topics are discussed and 
 clinical cases and pathologic specimens are exhibited. The 
 Egyptian Medical Congress will be held in Cairo next Decem- 
 ber. This congress is called for the special purpose of discuss- 
 ing tropical diseases, and is international in its scope. Invita- 
 tions have been sent to all countries, and there are fair prospects 
 for a good attendance. 
 
 Dr. H. Wildt will present an exhaustive paper on " The 
 Surgical Aspects of Bilharzia." His immense experience 
 entitles him to speak authoritatively on this subject. Professor 
 Bitter, of the Hygienic Institute, will discuss " Madura Foot." 
 As the professor has made a special study of the parasite of this 
 strange disease for a year and a half the audience may expect to 
 learn all that is known of the etiology and pathology of this rare 
 disease. 
 
 The Egyptian colleagues ought to utilize this opportunity 
 and organize a national society. The annual work of such a 
 society would be of the greatest value in enlightening the medi- 
 cal profession throug.hout the entire world on many of the 
 tropical diseases, the nature of which as yet is but imperfectly 
 understood. 
 
 Cairo Medical College.— This is the only school in Egypt 
 devoted to the study of medicine. It is fairly well equipped, 
 and is attended during the present year by 60 students. Nearly 
 all of the professors are Englishmen, a few natives fill subordi- 
 nate positions. The students must study four years before 
 they are admitted to the linal examinations. The clinical 
 teaching is conducted in the Municipal Hospital by a large 
 staff of professors and instructors, most of them of English 
 birth and education. As the classes are small and the clinical 
 material abundant, this part of instruction is all that could be 
 desired. 
 
 Kasr-el-Ainj/ Hospital. — This is the municipal or govern- 
 ment hospital. It is an old building which has recently been 
 much improved to answer modern requirements. It contains 
 400 beds. All the expenses are paid l)y the government, and 
 admission is free to all sick poor. The wards are large, airy
 
 and well lighted. The hospital furnishings are plain, but com- 
 fortable and sanitary. The two operating-rooms are fairly well 
 equipped. One is used for surgical, the other for gynecologic 
 cases. Here I was given an opportunity to examine an unusu- 
 ally large number of bilharzia cases. In several patients the 
 disease had resulted in the formation of perineal fistula, in 
 others the kidneys had become involved. The ophthalmic ward 
 contained the usual large percentage of eye cases. Among the 
 other tropical diseases I noticed elephantiasis, ankylostoma 
 and a large number of pellagra cases. The latter presented, 
 without exception, the characteristic eruption. In one case the 
 disease was complicated by a partial dementia, but whether 
 
 Deaconess' Victoria Hospital in Cairo. 
 
 this brain defect was a coincidence or the result of the original 
 disease, it was impossible to determine. I was informed that 
 in pellagra cases ankylostoma is very common. All of the 
 pellagra patients showed distinct signs of anemia. The nurs- 
 ing is in the hands of nine trained female nurses from England. 
 This hospital could make itself still more useful to the commu- 
 nity by the establishment of a training school for native women. 
 The Victoria Deaconess^ Ho spi t a L— This is a German hos- 
 pital founded and conducted by Sisters from Kaiserswerth. It 
 is by far the best hospital in Cairo. It was built 20 years ago 
 and can accommodate 100 patients. At present nine Sisters are
 
 on duty. The operating-room is modern and is amply supplied 
 with instruments and appliances for aseptic work. Dr. H. 
 Wildt is in charge of the surgical service and is assisted by the 
 resident physician, a graduate of a German university. All of 
 the patients are expected to pay. They are divided into three 
 classes. The first class pays $2 a day, for which sum they are 
 entitled to a private room. The second class pays ^i a day 
 and live in rooms with two or three beds. The ward patients 
 pay very little and those that are very poor are admitted free. 
 At the time of my visit Dr. Wildt showed me two cases of 
 liver abscess recently operated upon and eight cases of bilharzia 
 presenting the various clinical phenomena of tlie different 
 stages of this disease. 
 
 It is interesting to note the cosmopolitan character of the 
 inmates of this hospital as giveu in a report for last year. 
 
 The nationalities of the patients were as follows : 
 
 Egyptians, 259; British, 140; Greeks, 86; ( Germans, 64; 
 Italians, 46 ; Armenians, 46 ; Austrians, 17 ; Syrians, 18 ; Swiss, 
 14; French, 12; Americans, 7; Berbereens, 7; Russians, 5; 
 Turks, 3; Roumanians, 2 ; Dutch, 2; Indians, 1 ; Soudanese,!; 
 Abyssinians, 1 ; Spaniards, I ; Persians, 1 ; Belgians, 1 ; South 
 Africans, 1. 
 
 PREVAILING DISEASES OF EGYPT. 
 
 The government of Egypt (England, of course) has taken the 
 necessary steps and gone to the requisite expense to establish an 
 institution which is intended to serve the purpose of offering all 
 necessary facilities for the scientific study of infectious diseases, 
 with a special view to more thorough investigation of tropical 
 diseases and of formulating and enforcing effective sanitary 
 measures by building and maintaining the Hygienic Institute. 
 
 The Hygienic l7istitute.— This building is located in the 
 central part of Cairo. The building is a creditable one and is 
 well supplied with all necessary facilities for bacteriologic and 
 pathologic research. It was opened five years ago under the 
 directorship of Professor H. Bitter, a German scientist. Profes- 
 sor Bitter is the right man in the right place. He was a pupil 
 of Koch and other distinguished German bacteriologists, and 
 for several years was privatdocent in the Breslau University. 
 He is well prepared for his manifold duties and commenced his 
 work with an enthusiasm characteristic of the German scien- 
 tists. He possesses all the qualifications for the position he 
 now occupies. He is an expert bacteriologist and pathologist, 
 an artist and skilful photographer. Since he has taken charge 
 of the institute he served as a member of a commission of three 
 appointed by the government to visit Bombay for the purpose 
 of studying the bubonic plague, which was raging in India at 
 the time (1897). He published the results of his far-reaching
 
 observations in a paper entitled " On Haffkine's Preventive 
 Inoculations Against the Plague and on Plague Measures in 
 India." This paper appeared in 1899 and has been very exten- 
 sively noticed in the medical press of Europe and America. He 
 is now engaged in investigating the fungus of madura foot and 
 its effects on the tissues. He makes the final diagnosis in 
 obsure cases in which the use of the microscope is essential in 
 ascertaining the bacterial nature of the disease. He makes 
 thorough investigations of the water supply in various parts of 
 Egypt and locates the source of infection in endemic outbreaks 
 of infectious diseases. He is also professor of hygiene in the 
 Cairo Medical School. 
 
 ACUTE INFECTIOUS DISEASES. 
 
 Bubonic Plagite.~At the present time there are no cases of 
 bubonic plague in Cairo. The disease, however, has infested 
 nine or ten of the surrounding villages and every few days new 
 cases are reported from Alexandria. The Syrian ports enforce 
 quarantine against Alexandria. Active measures are being 
 enforced to arrest further spread of the disease. 
 
 Malaria. — This is very rare in Egypt. In Cairo it is 
 almost unknown and it is very uncommon in the valley of the 
 Xile. The only place in Egypt where malaria is engendered to 
 any considerable extent is along the banks of the Suez Canal 
 and a few other isolated places. Malaria is the prevailing dis- 
 ease throughout Palestine, more especially Jerusalem and its 
 surrounding villages. Professor Bitter explains this on the 
 mosquito theory. He says the mosquito of the Xile valley is 
 the ordinary culex, while the mosquito of the plains and moun- 
 tains of Palestine is the Plasmodium carrier — the anopheles. I 
 had a bitter experience with the latter. In Jerusalem and 
 Damascus they attacked viciously my hands and forearms. 
 Swelling, redness and lymphangitis ensued, which caused an 
 intolerable itching and burning, rendering sleep impossible for 
 several nights. I considered it advisable to take a daily dose of 
 10 grains of quinin to prevent the development of malaria, and 
 so far this prophylactic treatment appears to have been success- 
 ful. I am satisfied that the sting of this kind of mosquito is 
 more virulent than that of the common culex. 
 
 Typhoid i^eyer.— Typhoid fever is the great scourge of Cairo 
 and many other parts of Egypt. In Cairo it is never absent. 
 In the Victoria Hospital 109 cases were treated during the last 
 year, with 12 deaths. The shallow infected wells are the breed- 
 ing places of Bacillus typhosus. 
 
 Other Acute Infectious Diseases. — Dysentery, rheumatism 
 and acute inflammatory affections of the lungs and air passages 
 figure heavily in the hospital records and the case-books of
 
 physicians. Pulmonary tuberculosis and tuberculosis of the 
 lymphatic glands, bones and joints occur with the same fre- 
 quency as in our country. The same can be said of smallpox, 
 scarlatina and diphtheria. 
 
 Bilharzia. — The frequency with which this parasitic disease 
 prevails in Egypt became apparent to me from the number of 
 cases I saw in the Victoria and Municipal Hospitals. The para- 
 site enters through the skin, locates in the radicles of the portal 
 A'ein, in the wall of the rectum or bladder. The ova develop in 
 the submucosa of the rectum or bladder, cause ulceration and 
 
 Madura Foot (after Bitter). 
 
 often the formation of large granulomatous swellings. If the 
 disease invades the bladder the earliest symptom is a slight 
 hemorrhage after urination, followed sooner or later by vesical 
 and urethral irritation. Extensive ulceration of the mucous 
 membrane of the urethra results in periurethral infiltration and 
 the formation of a perineal fistula. Not infrequently the dis- 
 ease ascends along the ureter and ultimately leads to pyelitis 
 and pyonephrosis. The bilharzia cystitis often gives rise to the 
 formation of multiple calculi. Perineal section and suprapubic 
 cystotomy are often made necessary by extensive disease of the
 
 urethra and bladder. In rectal bilharzia perineal abscesses and 
 fistulas are the remote complications. Dr. Wildt has found tur- 
 pentine the most effective remedy for internal medication. 
 
 A nkylostoma Duodenalis. — This parasitic affection of tlie 
 intestinal canal is very common in all parts of Egypt. The 
 most common symptom is a pronounced anemia. In the Kars- 
 el-Ainy Hospital thymol has been found the most effective 
 remedy. This drug is administered in a single dose of two 
 grams followed by a castor-oil purge. After the expulsion of 
 the parasite iron is given to correct the anemia. 
 
 Madura i^oo^— This parasitic disease is quite rare in 
 Egypt. Dr. Wildt has seen only two cases in 23 years. Last 
 year only one case was observed in the Kars-el-Ainy Hospital. 
 The parasite is a ray fungus which morphologically bears a 
 close resemblance to the actinomyces. The swelling of the foot 
 is almost typical. The plantar surface gradually changes from 
 a concave to a convex shape. The nodules in the skin are 
 composed almost exclusively of a pure culture of the fungus. 
 Two varieties occur, the w^hite and the black. In the latter 
 variety the fungus is coal black. The intlammatory swelling 
 consists of granular tissue, which under the microscope might 
 readily be mistaken for a small round-cell sarcoma. 
 
 Abscess of the Liver. — In the tropics this disease is not 
 necessarily preceded by dysentery or any other grave lesions of 
 the intestinal canal. Its bacteriologic origin remains unex- 
 plained. When Professor Koch was in Cairo in 1883 he made a 
 careful bacteriologic study of the contents of a number of 
 abscesses of the liver, but was unable to come to positive con- 
 clusions regarding the essential bacteriologic cause. Xo more 
 definite results have been reached since. I had an opportunity 
 to see two cases of this affection in the Victoria Hospital. The 
 patients were recently operated upon by Dr. Wildt. In one case 
 the abscess was located in the left lobe of the liver. This 
 patient was operated upon by abdominal section, and the oper- 
 ation was completed in one sitting. This is the invariable rule 
 followed by Dr. Wildt. The peritoneal cavity is protected 
 against contamination during the operation and drainage by a 
 gauze pack as long as is required. The same rule is followed 
 when the abscess has to be opened through the free pleural 
 cavity. Dr. Wildt does not fear pulmonary collapse and only 
 in one out of more than 300 cases was the operation the cause of 
 a subsequent empyema. Dr. Wildt has up to the present time 
 operated upon 340 cases of abscess of the liver, with the follow- 
 ing results : Mortality of the first hundred cases, 38% ; the 
 second hundred, 32% : the third hundred, 20%. The statistics 
 prove that like in any other important operations the results 
 improve with increasing experience.
 
 streptococcus Infect ion.— The streptococcus is almost ubiqui- 
 tous, but there are places in which this microbe is rare or 
 entirely absent. It is said by Professor Bitter and others in 
 Cairo that the most careful bacteriologic investigations have 
 shoAvn that it is almost entirely absent in Khartoum, Egypt. 
 In the valley of the Nile this pus microbe appears to be very 
 common. Many patients with furunculosis come to the clinics 
 and into the hospitals. This affection is here called the Nile 
 pustule. It appears in the form of a multiple suppurative affec- 
 tion of the sweat glands. It attack s most frequently the exposed 
 cutaneous surfaces — the face, neck, hands and forearms. The 
 exciting cause in most instances is the streptococcus. Multiple 
 large abscesses are also frequently met, and in many instances 
 it is impossible to find a peripheral, recognizable infection- 
 atrium. I found two such cases in the Victoria Hospital under 
 the care of Dr. Wildt. These abscesses are not without danger 
 to life, particularly in patients suffering from anemia or some 
 other antecedent debilitating disease. 
 
 Cairo, July 5.
 
 [Rejuinted from American Medicine, Vol. IV, No. 15, pages 587-589, 
 October II, 1902. | 
 
 PROFESSOR NICOLADONI'S CLINIC, GRATZ. 
 
 BY 
 
 NICHOLAS SEXN, M.D., 
 of Chicago. 
 
 Gratz is a charming university city, with a happy, contented, 
 peaceful, refined population of 120,000. 
 
 The little city is beautifully located in a green, fertile 
 valley, surrounded by lorest-olad mountains and bisected by a 
 tumultuous tearing stream of the purest, crystal-clear water. 
 Although the city is in the direct line of railway travel from 
 Trieste to Vienna, it is not much frequented by tourists, and 
 the advantages offered by its university have not been suffi- 
 ciently appreciated by those who seek postgraduate education 
 abroad. The University of Gratz recently celebrated its third 
 centennial. The medical department was organized 35 years 
 ago, and has no w an attendance of 300 students. The laboratory 
 facilities are excellent, and the clinical material far beyond 
 requirements. The surgical clinic has 280 beds, and receives 
 much valuable material from the outdoor department. The 
 operating amphitheater has all modern improvements, instru- 
 ments and appliances, is well lighted and can seat from 85 to 100 
 students. 
 
 Professor Nicoladoni, formerly of Innsbruck, came here in 
 1893 to take the chair of surgery made vacant by the resignation 
 of Professor Wolffier, who accepted a call from Prague. Nico- 
 ladoni is a modest, hardworking, scientific surgeon, and an 
 impressive teacher. His book on scoliosis, which was pub- 
 lished about the time he left Innsbruck, is a masterpiece of 
 careful investigation and sound teaching, and is now being 
 revised by its distinguished author, and will soon make its 
 appearance much enlarged and more fully illustrated. His 
 contributions to surgical literature have been many, and all of 
 them are noted for the originality of the material they contain. 
 His fame as a plastic surgeon has given him an international 
 reputation. He was the first surgeon to practise tendoplasty, a 
 branch of orthopedic surgery which has since been so rapidly 
 developed and practised on such a large scale by Hoffa and 
 others. His most recent innovation in plastic work is the use 
 of cartilage taken from the ribs out of which to make an unyield- 
 ing framework for the frontal flap in rhinoplasty. This opera- 
 tion will be fully described further on. In his clinic he is
 
 assisted by four resident surgeons. The work begins each day 
 at 9.30 a.m., and it is seldom finished before 2 p.m. During 
 this time two and sometimes three operate simultaneously. 
 His first assistant, Dr. Payr, received an assistant professor- 
 ship a few days ago, and the event was appropriately cele- 
 brated. Professor Payr, although a young man, has reached 
 well merited distinction by his original work on the use of 
 magnesium in surgery. In Xicoladoni's clinic, choloroform 
 and the A. C- E. mixture are used as anesthetics. Silk has 
 almost entirely taken the place of catgut. Gloves have been 
 abandoned. Hand disinfection consists of thorough scrubbing 
 with water and marble soap, followed by alcohol and subli- 
 
 Arrows of magnesium in cavernous venous angioma. 
 
 mate solution. Recent wounds, when no drainage is required, 
 are covered with Bruns' airol paste. This paste consists of 
 
 B^lSl alb. I «^ each 20 
 
 Glycerin ss. 
 
 The yellow paste becomes firm in a short time and is easily 
 washed away with warm water. It is claimed that this paste is 
 one of the means to prevent stitch abscesses. 
 
 Magnesium in Surgery.— Dr. Payr has made the effects of 
 magnesium on the tissues a special study for a long time.
 
 3 
 
 Pieces of this metal introduced into the living tissues produce 
 certain definite chemic changes which effect the absorption of 
 the metal. Under its action the watery constituents of the tis- 
 sues are reduced to the original elements, oxygen and hydro- 
 gen. The gases evolved accumulate around the metal, the 
 oxygen combines with it and forms a soluble magnesium oxid. 
 The hydrogen is absorbed. Payr has found the magnesium 
 wire too brittle for suture and ligature material. He has used 
 nails made of this material for direct fixation of fractures and 
 in immobilizing the bone ends after resection. Nails of the 
 thickness of a small lead pencil are absorbed in the course of 
 three to four weeks. He has made many experiments with a 
 small grooved magnesium ring in vmiting severed blood vessels. 
 In uniting a severed artery the ring is slipped over the proximal 
 
 
 3. 
 
 A, B, C, application of magnesium ring. D, Payr's magnesium ring 
 for uniting severed bloodvessels. 
 
 end and after turning the coats of the artery back and over it a 
 ligature is applied over the groove of the ring. (See illustra- 
 tion.) With four fine silk sutures the distal end is drawn over 
 the proximal end, thus bringing intima in contact with intima 
 over a considerable surface, when a second ligature is applied 
 to maintain the invagination. The continuity of the artery is 
 restored in this manner by means of the extra vascular magne- 
 sium ring and two fine silk ligatures. The ring is absorbed in 
 three weeks, and the vessel unites as a rule without the forma- 
 tion of a thrombus. In uniting a severed vein the ring is 
 applied to the distal end, as the invagination must be made in 
 the direction of the blood current. He has resorted to this pro- 
 cedure with success in the case of a wound of the common
 
 femoral vein inflicted accidentally during an operation for the 
 removal of carcinomatous glands in Scarpa's triangle. Four 
 centimeters of the vein were resected, the ends united in the 
 manner described. The patient died three days later and the 
 postmortem established the fact that the union was firm and 
 the lumen of the vein free from thrombus formation. Nicola- 
 doni also suggested the use of magnesium in the case of a large 
 venous angioma of the face. At different times needle-like 
 fragments of the metal were inserted into the tumor through 
 punctures made with a tenotome. At the time of my visit about 
 22 magnesium arrows had been inserted and at different points 
 gaseous crepitation could be elicited around the foreign sub- 
 stances on pressure. The tumor had diminished under this treat- 
 ment more than one-half its size. This new therapeutic agent 
 is entitled to a fair trial in the management of cavernous venous 
 angioma not adapted for a more speedy treatment by excision. 
 
 Clinical Cases. — The following are some of the more im- 
 portant operations that came under my observation during my 
 two visits to Nicoladoni's clinic : 
 
 Case 1.— Rhinoplasty by NicoladonVs method. The patient 
 was a man about 30 years of age. Nearly the entire nose had 
 
 been de5<troyed by 
 syphilitic 'ulcera- 
 tion. There were 
 numerous facial 
 scar s from the 
 same cause. Two 
 months ago the 
 first operation was 
 performed. A 
 number of ribs 
 were exposed by 
 an incision over the 
 costal arch on the 
 right side. With a 
 resection knife a 
 piece of cartilage 
 about four inches 
 in length was ex- 
 cised from the bor- 
 der of one of the 
 ribs. This piece 
 was intended to 
 serve as a support 
 for the bridge of 
 the new nose and 
 the septum ; it was 
 implanted oblique- 
 ly underneath the 
 skin between it and 
 the occipitofron- 
 talis on the left side 
 of the median line of the forehead. A number of fragments of 
 cartilage were inserted at right angles on each side so that the 
 
 Nicoladoni's case of rhinoplasty, showing the 
 subcutaneous Maltese cross of cartilage be- 
 fore second operation.
 
 subcutaneous cartilaginous framework represented somewhat 
 in outline a Maltese cross. The crossbars were intended to 
 serve as supports for the al?e of the new nose. The implanted 
 cartilages could be distinctly seen and felt underneath the skin, 
 and their position and prominence are well shown in the 
 accompanying photograph. A guttapercha model of the nose 
 was made, and over this the paper was cut with which to out- 
 line the frontal flap. Under strict aseptic precautions the 
 rhinoplasty was made. The flap included all of the tissues 
 down to the frontal bone. The free margins of the alse and the 
 septum* were lined by turning the skin in the direction of the 
 nasal cavities and suturing it with fine silk. The immediate 
 cosmetic resultwas excellent. The frontal defect was reduced 
 in size by tension sutures, and will be paved with Thiersch's 
 skin grafts as soon as the surface is covered with granulations. 
 The nasal cavities were not packed with gauze. An external 
 absorbent dressing completed the operation. 
 
 This case will unquestionably prove a great success, and 
 will be reported in full by the operator so soon as the remote 
 cosmetic result can be determined. 
 
 Case II. — Strumectomy for 2)^i'>^6nchymatous struma. 
 Operation performed by Prof. Payr : The patient, a girl, aged 
 20, was the subject of a symmetric struma which recently had 
 commenced to give rise to pressure symptoms. The swelling 
 is smooth, of uniform consistency, and descends somewhat 
 behind the jugulum of the sternum. Patient otherwise is in 
 excellent health. Chloroform was used as an anesthetic. The 
 operation was performed with the patient nearly in a sitting 
 position. Kocher's anterior curved incision was made down to 
 the capsule of the swelling and hemorrhage carefully arrested 
 as the operation proceeded. Some of the larger veins were cut 
 between a double ligature. The left lobe was first removed. 
 The thyroid arteries and veins were ligated separately. The 
 isthmus of the gland was isolated and a vertical linear crush- 
 ing was made with a pair of crushing forceps, and ligated with 
 a silk and a strong catgut ligature when the left lobe was 
 removed. On the right side only the superior thyroid artery 
 and vein were ligated and only a portion of the lobe excised 
 after preliminary en masse ligations with catgut, as advised by 
 Mikulicz. The operation was completed in less than an hour 
 and with the loss of not more than a teaspoonful of blood. The 
 clean anatomic dissection and the careful hemostasis exhibited 
 the work of a master. 
 
 Struma is very prevalent in the mountainous regions of 
 Austria. In the Gratz surgical clinic about 75 strumectomies 
 are performed annually. 
 
 Case III. — Abdominal tumor ; death from the anesthetic. 
 The patient, a multipara, about 35 years of age, was admitted 
 into the clinic a few days ago suffering from an abdominal 
 tumor. The patient's mental faculties were much impaired 
 and her statements concerning the early history of the growth 
 could not be depended upon. Emaciation was marked as well 
 as the anemia. The tumor, the size of a child's head, occupied 
 the right iliac fossa. It was hard, nodulated and not freely 
 movable. For some time she had had symptoms of intestinal 
 obstruction without vomiting. The abdomen was tympanitic,
 
 the muscles, however, were relaxed. Xo temperature or any- 
 other signs of peritonitis. Tuberculosis or malignant disease 
 of the cecum was suspected. From the general appearance of 
 the patient it was evident that the case was almost a hopeless 
 one. The A. C. E. was cautiously administered, the field of 
 operation prepared and the surgeon was in the act of making 
 the first incision when respiration and the heart's action ceased 
 almost simultaneously. Artificial respiration was performed, 
 camphoi -ether injected subcutaneously, but no response fol- 
 lowed. These fruitless efforts were continued for half an hour 
 when the corpse was sent to the morgue for a legal autopsy. 
 
 Case IV. — Carcinoma of the 'mamma; excision. The patient 
 was a woman, somewhat advanced in years, who was at the 
 same time the subject of a large goiter, which, however, caused 
 no inconvenience. Under chloroform anesthesia the entire 
 breast with overlying skin and underlying pectoralis major 
 were removed first, when the axilla was cleared out. The lower 
 part of the wound could not be closed and was left open to heal 
 by granulation. Tubular drainage for the axillary space was 
 instituted and a large absorbent dressing applied. 
 
 Case V. — Right inguinal hei^tiia ; radical operation by Bas- 
 sini's method. The hernia was a small one and a straight 
 incision was made over the inguinal canal. Sac and spermatic 
 cord and vessels were isolated and drawn forward with a strip 
 of iodoform gauze placed underneath them. Isolation of sac, 
 which was excised below the silk ligature applied to its neck. 
 Closure of canal by Bassini's method. The wound was sealed 
 with Bruns' paste, over which a compress of cotton was 
 applied and held in place by a spica bandage. 
 
 Hernia operations are performed in this clinic daily and 
 inguinal hernias always by Bassini's method. The patients are 
 permitted to leave bed in 10 to 14 days. 
 
 In 1,500 patients operated upon, recurrence is said to have 
 followed only in 2%, certainly a result it Avould not be easy to 
 duplicate. 
 
 Case Y1.— Relapsing appendicitis laparotomy; appendix 
 not found. The patient, a young man, had his first and severest 
 attack four years ago, followed by mild attacks nearly every 
 month since. No palpable swelling in the ileocecal region. In 
 making the abdominal incision in the customary place and 
 direction all of the layers were divided. A piece of the great 
 omentum adherent over the cecum was divided between two 
 silk ligatures. Search was now made for the appendix. The 
 posterior surface of the cecum was found firmly attached to the 
 iliac fossa. The adhesions were separated with the greatest care. 
 An enlarged mesenteric gland embedded in the adhesions and 
 first mistaken for the appendix was removed. The operator 
 with the utmost patience and care continued the search for 
 nearly two hours, when the space made behind the cecum 
 caused by separating the adhesions was drained with a long 
 strip of iodoform gauze and the incision, at least six inches in 
 length, was closed with four rows of silk sutures. 
 
 This was evidently one of those trying cases in which dur- 
 ing the first attack a large retrocecal abscess ruptured into the 
 cecum after partial or complete sloughing of the appendix.
 
 Gxi>,TS,Yll.—Scrotal hernia of large size; radical operation 
 by Ba.ssinPs method. This was a good test case for Bassini's 
 operation. The hernia was the size of a cocoanut and the open- 
 ing in the aVjdominal wall large enough to admit three fingers. 
 The patient was a young man otherwise in perfect health. The 
 hernia was located on the right side and had existed for a num- 
 ber of years. No attempt had been made to retain it by truss 
 pressure. The incision was made over the center of the swell- 
 ing and in the direction of the shortened inguinal canal. The 
 sac contained the cecum and several loops of the small intes- 
 tines. The separation of the sac required much time and 
 patience. In the isolation of the sac the operator made frequent 
 use of short chopping strokes with a short-bladed scalpel. The 
 sac was ligated and excis^ed in the usual manner. Six silk 
 sutures were necessary to close the inguinal canal underneath 
 the cord and its vessels. The deep fascia was sutured over the 
 cord with very tine silk sutures and the skin united in a sim- 
 ilar manner. The wound was sealed with Bruns' paste, over 
 which a cotton compress was applied. 
 
 Case VIII. — Faficia sarcoma in right parotid region ; exci- 
 sion. The patient was a woman, aged 35. A swelling over the 
 lower segment of the right parotid gland was noticed first a 
 few months ago. The growth was rather rapid and compara- 
 tively painless. The tumor was the size of a walnut, movable, 
 and the skin over it was normal. Skin was incised vertically 
 and the tumor removed with a zone of apparently healthy tis- 
 sue. The cut surface of the tumor on section presented all of 
 the macroscopic appearances of a fascia sarcoma. The capsule 
 of the parotid gland was intact. Wound was sutured and 
 sealed with Bruns' paste. 
 
 Case IX. — Tuberculosis of lymphatic glands within the cap- 
 sule of the parotid ; removal of tuberculous prodiict with sharp 
 spoon. The patient was a young anemic woman. Development 
 of the swelling, which was the size of a pigeon's egg, was slow 
 and without much discomfort. Under chloroform anesthesia 
 the swelling was incised and cheesy material scraped out with 
 a sharp spoon. The wound was sutured and sealed with Bruns' 
 paste. 
 
 Case ^.—Recurring tuberculosis of glands of right side of 
 neck ; excision of affected glands. The patient, a young anemic 
 woman, was operated upon a few months ago for the same 
 affection. A clean excision was made of all affected glands and 
 fistulous tracts. Partial suturing of.wound was done and iodo- 
 form gauze drainage instituted. 
 
 Case ^l.— Femoral hernia ; radical operation. The patient, 
 a woman, aged 50, had a hernia, size of hen's egg, on her right 
 side. Swelling disappears in the recumbent position. Verti- 
 cal incision, four inches in length, was made over the crural 
 canal. Excision of sac was followed by suturing of Poupart's 
 ligament to the periosteum of the pubes with four silk sutures. 
 External wound Avas sutured and sealed with Bruns' paste. 
 
 Case XII. — Lipoma over upper part of right biceps muscle ; 
 operation under local anesthesia by iSehleich^s infiltration 
 method. The patient was an elderly woman who had a flat, 
 lobulated, movable, subcutaneous tumor the size of a woman's 
 fist, below the shoulder-joint. Schleich's solution was injected 
 into the skin in the line of the purposed incision. The incision 
 was made without causing much pain. The loose connective 
 tissue around the tumor was then infiltrated, but during the
 
 enucleations the patient evinced pain. The wound was sutured 
 and sealed with Bruus' paste. 
 
 The above cases shoAv what is being done daily in the Gratz 
 surgical clinic. Professor Nicoladoni has a splendid staff of 
 assistants who lighten the arduous work of their chief as much 
 as is within their power. They perform nearly all of the minor 
 operations and do not shrink from the most difficult task when 
 the professor makes the request. Nicoladoni stimulates his 
 assistants by example and suggestion to original research, a 
 fact which accounts for the many valuable reports and scien- 
 tific papers which are credited to his clinic by his enthusiastic 
 and devoted assistants. 
 Geatz, July 11.
 
 [Reprinted from American Medicine, Vol. IV, No. 16, pages 627-629, 
 October 18, 1902.] 
 
 THE TEACHING AND PRACTICE OF SURGERY IN 
 THE VIENNA ALLGEMEINE KRANKENHAUS. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 The Vienna Allgemeine Krankenhaus is a little city in itself 
 with a population of more than 3,000 inhabitants. Its present 
 capacity is 2.600 beds. The obstetric department, with 600 beds, 
 has been transferred to another locality, but is under the same 
 management. This hospital is to the sick poor of Vienna what 
 the Charite is to Berlin, only it is much larger. The original hos- 
 pital was built in 1784. The buildings have been repeatedly 
 repaired and improved and new additions have been made as 
 the increasing demand for more space required. The old build- 
 ings are in good condition, and with their new mosaic floors 
 present a modern appearance. The wooden bedsteads and 
 feather beds have disappeared, and have been replaced by iron 
 cots with spring mattresses, snow white linen and comfortable 
 quilts and blankets. The wax candles are only seen in the 
 chapel, as all the wards, operating-rooms and living-rooms are 
 brilliantly illuminated by electricity. Many of the recent 
 improvements are the creation of the present Director Ober- 
 sanitalsrath, Dr. Victor Mucha. The institution has been 
 under his management for eight years, and during that time 
 many useful changes have been made. Dr. Mucha is a man of 
 profound learning, unlimited enthusiasm, and an ideal dis- 
 ciplinarian. He works in harmony with the medical staff, and 
 is respected and loved by all the inmates of the institution. 
 He is ably supported in his arduous duties by his assistant, 
 Dr. Knodl. Dr. Mucha takes a just pride in the new steriliza- 
 tion plant for surgical dressings which has been in successful 
 operation for four years. This was the outcome of a careful 
 personal inspection and study of the different processes of 
 sterilization in all of the principal hospitals of Europe. It is 
 the finest and most complete sterilization plant in the world. 
 The room adjoins the dispensary, and is under the direction of 
 the chief druggist, Adjunct Gmeut. An automatic clockwork 
 connects the two rooms and gives the f^ignals for the functions 
 of the Adjunct with an unfailing precision. Oversteam effects 
 the sterilization and dry heat dries the dressings. All of the
 
 sterilized dressings are subjected to bacteriologic tests and a care- 
 ful record is kept of the results of the sterilization. The dressings 
 for each of the 13 surgical stations are placed in a metallic cylinder 
 and after sterilization the cylinder is locked and a stamp bear- 
 ing the date of sterilization is placed over the keyhole. The 
 only two persons who hold the keys, the chief druggist and the 
 nurse in the operating-room, are the only persons responsible 
 for the ascepticity of the dressings. The chief druggist is now 
 engaged in a series of experiments calculated to solve the prob- 
 lem of speedy and effective sterilization of silk. The M'ork in 
 the Rontgen room is done by an expert. Dr. Oppenheim. Sev- 
 eral hours spent in this department will reveal all of the won- 
 derful results of the present status of the diagnostic and thera- 
 peutic value of the Rontgen ray. The Allgemeine Kranken- 
 haus has been the central figure of the progress in medicine 
 and surgery during the last six decades. During all this time 
 it has been the great center for the diffusion of the knowledge of 
 modern pathology. It has been and is now the mecca for 
 students from all parts of the world who are in search of the 
 basis of rational medicine— a thorough knowledge of gross and 
 microscopic pathology. The great morgue of this hospital was 
 the workshop in which Rokitansky made his international 
 reputation. Here gross and microscopic morbid anatomy are 
 taught today more thoroughly than in any other institution in 
 the world. Here the student can see from 10 to 25 autopsies 
 every day, and here every pathologic lesion is subjected to a 
 most painstaking microscopic examination. The next thing 
 w^hich attracts the attention of students from foreign lands in 
 this institution is clinical diagnosis. Bamberger made this 
 branch of scientific medicine famous and Nothnagel and 
 Kowacs are now the men whose teachings are eagerly sought. 
 It was in this institution that the immortal Billroth reached 
 the climax of his unparalleled reputation as a surgeon. It was 
 the material from the postmortem-room of this, the greatest 
 hospital in the world, that Kyrtl drew his inspiration and 
 became the greatest anatomist the world ever knew. This ven- 
 erable institution remains a source of incalculable benefit to 
 the profession at large and will continue to remain so for cen- 
 turies to come. 
 
 Billroth made it the great school for modern surgery. 
 Many of his pupils and assistants have become distinguished 
 authors and famous teachers. Two of them now occupy the 
 two chairs of surgery in the University. Vienna has not forgot- 
 ten the epoch-making teachings of her Billroth. One of the 
 great thoroughfares of the city is now known as the " Billroth 
 Arcade," and a handsome bust of the profound scholar, the 
 prolific author, and the original surgeon, ornaments one of the
 
 University halls. The number of students attending the 
 University has greatly diminished since the demise of its 
 three greatest lights— Rokitansky, Kyrtl, and Billroth. At 
 present it does not exceed 1,500. The time limit for graduation 
 is five years and about 200 are graduated annually. 
 
 Nursing Force.— One of the apparent great defects of this 
 hospital is the lack of well-trained female nurses. Ninety 
 Catholic Sisters serve in the capacity of nurses, but none of them 
 have had the necessary theoretic and practical training. The 
 same can be said of the orderlies and male nurses. I was 
 informed that in the near future a training school under the 
 direction of Professor von Mosetig-Moorhof will be established, 
 and it is to be hoped that this project will soon be realized, as 
 it would meet one of the most urgent demands of this, the 
 greatest refuge for the sick. 
 
 Professor Freiherr von Eiselsherq'' s Clinic. — Professor 
 Eiselsberg succeeded Professor Albrecht as the chief of the 
 first surgical clinic. He was one of Billroth's most talented 
 and favorite students and taught surgery in a subordinate posi- 
 tion for several years in Vienna, when he was called to Holland 
 and later to Konigsberg, Germany, as professor of surgery. He 
 has not passed beyond the meridian of life and has already 
 attained an enviable reputation as an investigator and surgeon. 
 His present exalted position marks the climax of his academic 
 career. His ambition has been gratified and he has now an 
 opportunity to use his talents in one of the most cosmopolitan 
 clinics in the world. He is well prepared for the task before 
 him. He is a fluent speaker and an expert operator. He takes 
 great delight in performing difficult operations. He is an 
 enthusiast in his profession and has the faculty of imparting 
 this desirable quality of a surgeon to his hearers. In his clin- 
 ical lectures he devotes most of his time to the scientific part of 
 surgery, surgical anatomy, pathology and diagnosis. All of his 
 major operations are performed in a small room, to which stu- 
 dents and practitioners have access in small sections. Those 
 who attend his operations must appear in linen coats and 
 rubber shoes. The aseptic details are very exacting. The 
 operator and his assistants each wear cotton gloves, a white cap 
 and a gauze mask for the face. This mask is an ordinary 
 Esmarch inhaler, to which a spectacle framework is attached. 
 To what extent such a mask can contribute to aseptic precau- 
 tions will be determined only in a very few clinics. The A. C. 
 E. mixture is the anesthetic used. Hand disinfection consists 
 in scrubbing with warm flowing water and potash soap for five 
 minutes, followed by alcohol and sublimate. The field of opera- 
 tion is disinfected in a similar manner after the patient is under 
 the influence of the anesthetic. Silk is the material used for
 
 ligatures and sutures. During tlie clinic I attended the follow- 
 ing operations were performed : 
 
 Case I. — Large hronchocele ; strumectomy. The patient 
 was a country woman, aged 51. The tliyroid gland commenced 
 to enlarge 20 years ago, and for several years the swelling has 
 prod viced pressure symptoms at irregulaV intervals. The entire 
 gland is involved, but the right lobe is much larger than the 
 left. The swelling is nodular and firm, and the right lobe Avith 
 a part of the isthmus is in part retrosternal. It is this part of 
 the swelling that is responsible for the temporary attacks of 
 embarrassment of respiration. Although Eiselsberg prefers 
 to perform strumectomy under local anesthesia, an exception 
 was made in this case at the urgent request of the patient and 
 the A. C, E mixture was administered. The anesthesia at no 
 time gave rise to any serious or even unpleasant symptoms. 
 The head and chest were placed in a slightly elevated position, 
 and the neck rested in extended position upon a circular pillow. 
 A curved incision with the curve extending outward was made 
 over the right lobe of the swelling. Vv^ith quick strokes of the 
 knife the capsule of the tumor was reached and hemorrhage 
 arrested by the use of many hemostatic forceps. All of the 
 bleeding points were then tied with fine silk ligatures. A por- 
 tion of the tumor the size of a walnut at a point where the 
 superior thyroid artery enters the gland was tied off with cat- 
 gut ligatures and severed with the knife. The retrosternal part 
 of the tumor was next liberated by blunt dissection. The 
 inferior thyroid vessels were divided between two ligatures. 
 In separating the tumor from the trachea all of the visible 
 vessels were tied and cut in a similar manner. The isthmus of 
 the gland was subjected to vertical linear crushing before the 
 ligatures were applied, when the mass, as large as a man's fist, 
 was amputated. The trachea w'as found considerably flattened. 
 The left lobe was not removed. A strip of nosopheu gauze 
 was used to establish capillary drainage, and the balance 
 of the wound was closed with silk sutures and the usual aseptic 
 absorbent dressing applied. Cystic and calcareous degenera- 
 tion marked the location of the multiple adenomas imbedded in 
 the miasmatic struma. 
 
 Case II. — Sfruriia complicated by echinococcus cyst: incision 
 and drainage. The patient, a woman, aged 45, had been the 
 subject of an enlargement of the thyroid gland since girlhood. 
 The swelling caused no inconvenience until a number of 
 months ago, when it suddenly increased in size, became painful 
 and tender. Supyjuration ensued, and w^hen the large abscess 
 was incised a large quantity of fetid pus escaped. The acute 
 symptoms subsided but the abscess never healed. A fistulous 
 opening near the sternoclavicular joint leads into the large 
 goiter toward the right side where the swelling is most promi- 
 nent. This sudden attack was taken for an acute suppurative 
 strumitis and it was the intention of the operator to remove the 
 right lobe of the gland with the abscess cavity. The operation 
 "was performed under local anesthesia. The external incision 
 was made in the same manner as in Case I. After the swelling 
 was exposed by reflection of the semilunar skinflap, the fistula 
 was followed into a cavity the size of a small cocoanut which 
 contained a teacupful of the broken-down products of an echi- 
 nococcus cyst. The anterior wall of this cavity was excised, the 
 floor thoroughly scraped out with a sharp spoon and in several 
 places the surface was cauterized with the Paquelin cautery.
 
 The cavity was then packed with a long strip of nosophen 
 gauze and the incision sutured down to the drainage opening. 
 This case is an extremely rare one. The echinococcus cyst 
 developed in the interior of a parenchymatous struma and the 
 suppuration which ensued in its interior simulated in every 
 respect a suppurative strumitis as described by Tavel and 
 others. It was the echinococcus part of the swelling which 
 caused the distressing clinical symptoms and the elimination 
 of this unusual complication by operative interference will be 
 followed by permanent relief. 
 
 Case 111.— Cicatricial stenosis of the esophagus; gastros- 
 tomy ; gastrorrhaphy. A girl, aged 16, had swallowed caustic 
 potash when a child. Symptoms of cicatricial stenosis soon 
 set in and two years ago it became necessary to resort to gas- 
 trostomy to prev^ent death from starvation. The patient was 
 nourished through the fistula until by the use of a gradually 
 tapering soft rubber bougie the stricture was sufficiently 
 dilated to render the artificial opening superfluous. The 
 patient is now able to insert the dilator without any difficulty 
 and can swallow solid food with ease and in sufficient quantity, 
 hence it was decided to close the fistulous opening. The opera- 
 tion was performed under local anesthesia by Schleich's infil- 
 tration method. It was evident from the patient's expression 
 that the operation was not without pain, but she endured the 
 ordeal with patience and fortitude. The fistulous opening was 
 circumscribed by two elliptical incisions, the peritoneal cavity 
 opened, the anterior wall of the stomach drawn forward into 
 the wound in the form of a cone to the base of which a pair of 
 compression forceps were applied. The fistulous opening was 
 closed by a smaller compression forceps and between the two 
 forceps the excision was made which left a small oval visceral 
 wound, this was sutured with two rows of fine silk sutures. 
 Three rows of silk sutures were employed in closing the 
 abdominal incision. 
 
 The outdoor department of Prof. Eiselsberg's clinic is con- 
 ducted in a new building, admirably adapted for the treatment 
 of polyclinic patients. The reception and examination-rooms 
 leave nothing to be desired and the small operating-room is 
 supplied with everything necessary for aseptic work. Here 
 many minor operations are performed by his assistants. 
 
 Professor Gussenhauer's CTmzc— Gussenbauer is Billroth's 
 successor. After the death of the great master discussion was 
 rife among the Austrian and German surgeons as to who would 
 in all probability be called upon to fill the vacancy. It was 
 generally conceded that the choice would naturally fall upon 
 one of his assistants who had won distinction by original 
 scientific work. The final decision ended in the appointment 
 of Gussenbauer, who for many years was professor of surgery 
 in the Prague University. Under Billroth he and Wolffler 
 made the experiments on animals which in their results proved 
 the feasibility of partial gastrectomy for carcinoma and circum- 
 scribed inflammatory diseases and which laid the foundation 
 for gastric surgery. Gussenbauer's experimental studies on 
 the repair of wounds made his name familiar in scientific surgi-
 
 6 
 
 cal literature. His artificial larynx demonstrated his mechani- 
 cal genius. His successful career in Prague recommended him 
 as a worthy successor of his famous teacher. 
 
 The amphitheater in which he gives his clinics remains the 
 same as when Billroth left it. It is a clinic in which more dis- 
 tinguished surgeons have sought postgraduate instruction 
 than in any other. The plain wooden benches, the narrow 
 arena, the low ceiling, the simple instrumentarium remind one 
 of the time Avhen the greatest surgical genius held here the most 
 distinguished clinical audiences spellbound by his matchless 
 work. Gussenbauer is not a Billroth, but he is a great surgeon 
 and a most excellent teacher. His language is short and pre- 
 cise, his diagnostic conclusions accurate, drawn as they always 
 are from the pathologic conditions presented by the case under 
 consideration. His operative technic is well planned and is 
 always carried out with care and deliberation. At the time of 
 my visit he was making preparations to leave the city for his 
 summer vacation and had turned over the operative work to his 
 first assistant. Dr. Salzer, but he was kind enough to show me 
 some of the more important cases operated upon during the last 
 semester. Among these was a case of sarcoma of the brain 
 operated upon by osteoplastic resection of the skull. The focal 
 symptoms left no doubt as to the exact location of the tumor. 
 A gradually appearing hemiplegia on the right side and aphasia 
 pointed to the left motor tract as the seat of the disease. The 
 wound healed by primary intention and the pressure symp- 
 toms were relieved by the operation. A case of obstinate neu- 
 ralgia of thetrigeminous was promptly relieved by removal of 
 the gasserian ganglion. His experience with this operation has 
 been uniformly satisfactory. A number of appendicitis cases 
 were shown, the patients having recently been operated upon; 
 all of them were on the way to a speedy recovery. Several other 
 cases were under observation and under conservative treat- 
 ment. 
 
 Three cases of ununited fracture of the shaft of the long 
 bones had been treated by exposing the seat of fracture and 
 immobilization by direct fixation with Gussenbauer's clamp, 
 and all of the patients were doing well. A case of recurring 
 carcinoma of the orbit made it necessary to resect the frontal 
 bone and the dura mater extensively, and the defect, as large 
 as the palm of the hand, was filled in with a celluloid plate. 
 The large wound healed by primary intention. Gussenbauer 
 makes no display of aseptic precautions in his clinic. Turbans, 
 gloves and masks are not seen, but the hands, instruments and 
 field of operation are prepared with utmost care. Catgut is 
 used only in exceptional cases. Dr. Salzer made an exploratory 
 laparotomy in a case of far advanced carcinoma of the stomach.
 
 Owing to the extent and location of the disease gastroenteros- 
 tomy was not indicated, and a radical operation was out of 
 question. The same forenoon he operated on a case of carci- 
 noma of the bladder. 
 
 The patient, a middle-aged man, had suffered for several 
 months from irritation of the bladder, and recently hematuria. 
 He was anesthetized and placed in Trendelenburg's position. 
 The interior of the bladder was exposed by a median vertical 
 incision. The carcinoma involved the base of the bladder and 
 the vesical end of the left urethra. The entire thickness of the 
 wall of the bladder at a safe distance from the margins of the 
 tumor and half an inch of the vesical end of the urethra were 
 resected. The operation was an exceedingly difficult one and 
 was executed with the utmost care and great skill. Buried 
 sutures of catgut were used in diminishing the size of the 
 cavity behind the resected part of the bladder and in implant- 
 ing the urethra and suturing of the vesical wound. The 
 anterior incision was only sutured in part, leaving a large 
 opening for drainage. The drainage opening in the bladder 
 was sutured to the fascia of the recti muscle with fine silk. 
 The patient was progressing favorably 24 hours after operation. 
 
 Vienna, July 19.
 
 [Reprinted from American Medicine, Vol. IV, No. 18, pages 709-711 
 November 1, 1902.] 
 
 SURGICAL WORK OF PROFESSOR VON MOSETIG- 
 MOORHOF IN THE VIENNA ALLGEMEINE 
 KRANKENHAUS. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 The best surj^ical work is not always done in surgical clinics. 
 The clinical teacher has to contend with many things that 
 divert his attention. He is naturally anxious to build up or 
 maintain the reputation of his clinic and must use his material 
 for the instruction of a critical audience. The surgeon who can 
 give his undivided attention to the work before him can attend 
 to many little details which often escape the notice of the lec- 
 turer, or which, for want of time, must be referred to an assist- 
 ant. The most careful and painstaking operator I saw during 
 my whole trip through three continents was Professor von 
 Mosetig-Moorhof, of Vienna. He is in charge of one of the five 
 surgical services of the AUgemeine Krankenhaus. In the two 
 divisions under von Eiselsberg and Gussenbauer the medical 
 students of the university receive their clinical instruction. 
 The other three services are under the care of Professor von 
 Mosetig-Moorhof, Professor Lang and Professor Hochenegg. 
 Professor Lang's material is made up largely of venereal cases. 
 The curative power of the Finsen light in the treatment of 
 tuberculous affections of the skin is being tested. Experience 
 so far has shown that the treatment requires much time, on an 
 average daily sittings for a year, but if carried out persistently 
 yields good results. Each sitting lasts an hour and costs the 
 hospital $1.20. The apparatus in use furnishes light for four 
 patients at one time. The expert in charge marks the particular 
 spot which is to be subjected to the light treatment, and nurses 
 and patients make the application. Under pressure the tissues 
 to be acted upon by the light are made bloodless so long as the 
 treatment lasts, otherwise the action of the light is useless. In 
 most instances the application results in the formation of a 
 blister. Counter irritation and tissue stimulation are evidently 
 the most important curative effects of the application. In all 
 recent cases a decided reaction in the diseased tissues is always 
 very noticeable. As the disease yields, the tissues become paler 
 and shrink. When ulcerations are present, the defects heal 
 by the formation of a pale, pliable, smooth scar. Reports from 
 other clinics seem to show that relapses after apparent cures are 
 by no means uncommon. I saw several patients with extensive
 
 lupus of the face who were being treated by exposures to the 
 Rontgen ray on one side and the Finsen light on the other. The 
 effects of the Rontgen ray are more pronounced, quicker, and 
 the course of treatment much shorter than that of the Finsen 
 light. Professor Lang is a well-recognized expert in plastic 
 work with Thiersch's skin grafts in covering large skin defects. 
 His cosmetic results are marvelous. Hochenegg has recently 
 been promoted to a professorship and placed in charge of one of 
 the surgical divisions. He is a young surgeon of great promise, 
 whose name has already found a permanent place in surgical 
 literature. His work in abdominal and pelvic surgery is well 
 known and thoroughly appreciated. I now come to the Vienna 
 surgeon whose work I studied with so much interest and profit 
 —Professor von Mosetig-Moorhof. His personal appearance is 
 very striking. He is 64 years of age, tall, erect, with a full 
 flowing, well-trimmed beard. His eyes are blue and reflect the 
 nobleness of his soul. In a crowd of people his appearance 
 would always attract attention. He has been a diligent student 
 since the time of his graduation in 1863 and is familiar with the 
 teachings and practice of all surgical authorities in the world. 
 He is a patient worker, who takes few and but short vacations. 
 His greatest pleasure in life is to be among his patients and to 
 relieve them of their sufferings by his operative skill. His 
 division of 128 beds is always crowded. He is more than sur- 
 geon to his appreciative patients ; he is likewise their friend, 
 who takes more than a scientific interest in their welfare. He 
 visits his wards regularly every morning at 8.30 o'clock, exam- 
 ines all new cases with the utmost care, visits every patient 
 recently operated upon and then begins his operative work, 
 seldom leaving the hospital before the clock in the tower strikes 
 12. He is assisted in his work by a number of faithful Sisters 
 and three resident surgeons. His contributions to surgical 
 literature have been many and of far-reaching importance. His 
 work on operative surgery is very popular and will soon appear 
 in its fifth edition. It is a book that reflects the ripe experience 
 of its author and on every page will be found good, sound 
 advice. The most careful aseptic precautions are observed in 
 the well-equipped and well-lighted operating-room. The few 
 visitors who attend the operations are each required to wear a 
 linen coat. The white aseptic cap is worn by the operator and 
 assistants only during abdominal work. Gloves and masks are 
 not in use. Hand disinfection is made by thorough scrubbing 
 with soap and hot water, followed by marbledust soap, alcohol 
 and sublimate. The field of operation is shaved and disinfected 
 in a similar manner after the patient is fully under the influ- 
 ence of the anesthetic, either chloroform or the A. C. E. mix- 
 ture. The operator wears knit sleeves. Fine silk boiled in 5%
 
 solution of carbolic acid and kept in sublimate alcohol is the 
 favorite material for sutures and ligatures. Before each abdom- 
 inal operation the silk is reboiled. Stitch abscesses are 
 unknown, the best possible proof of the care taken in preparing 
 the silk. 
 
 Directions for Catgut Sterilization.— The following are the 
 directions given for the sterilization of catgut: 
 
 Iodoform plomb, four weeks after resection of the wrist joint. 
 
 1. Immerse the raw material for 24 to 48 hours in sulfuric 
 ether. 
 
 2. Immerse for 8 to 10 days in 96% alcohol and change the 
 fluid frequently so long as it becomes turbid. 
 
 3. Place catgut in a 1% alcoholic solution of mercury bichlo- 
 rid for three days. 
 
 4. Keep for one day in 96% of alcohol. 
 
 5. Preserve in 
 
 Bichlorid of mercury LO 
 
 Glycerin 50.0 
 
 Alcohol 1,000.0
 
 Professor Mosetig-Moorhof is never in a hurry when oper- 
 ating. He makes his plans beforehand deliberately and 
 executes them with the hand of a master. Every motion he 
 makes with knife, needle or spongre is for a distinct purpose. 
 He does not know confusion nor surprise, and when something 
 unexpected arises he is prepared for the emergency. His 
 knowledge of minute anatomy makes the finest dissections a 
 source of delight to him. In doubtful cases he exhausts all 
 modern diagnostic resources before he makes a final diagnosis, 
 and if this cannot be done he relies on the knife to clear up the 
 doubt. His patients, young and old, come to the operating- 
 room without doubt and without fear, with implicit confidence 
 in the man who is to hold their lives in his hands. It is a source 
 of genuine pleasure to accompany this surgeon on his daily 
 visits through the wards. He is greeted everywhere by pleas- 
 ant, smiling faces. There are no indications of mistrust or 
 dissatisfaction, and he has for all a pleasant word or a friendly 
 nod. 
 
 Mosetig-Moorhof s Iodoform Plomh. — For a number of 
 years von Mosetig-Moorhof has made use of a preparation of 
 iodoform in filling bone cavities after operations for tubercu- 
 losis or osteomyelitis. This antibacillary agent is used in the 
 following form : 
 
 lodoformi 40.0 
 
 Cetacei 
 
 01. sesami aa 30.0 
 
 The menstruum is thoroughly sterilized by boiling. The 
 iodoform finely pulverized and sterilized is slowly added to the 
 mixture and agitated constantly until it cools oflt" to ensure a 
 uniform dissemination of the iodoform throughout the mass, 
 which solidifies at an ordinary temperature. After the cavity 
 is prepared the mixture is heated and in a fluid state is poured 
 into it, when it again becomes firm and fills the cavity like 
 dentist's amalgam in a carious tooth. The Rontgen rays 
 show the exact location, size and form of the iodoform plomb 
 in the interior of the bone. The x-ray also shows the process of 
 healing by the gradual disappearance of the iodoform through 
 absorption and substitution of granulations for the absorbable 
 temporary packing. Cavities in the epiphyseal extremities 
 after resection for tuberculosis, treated in this manner heal in 
 the course of a few weeks, and the use of the Rontgen ray at 
 any time will demonstrate their gradual diminution in size and 
 the slow absorption of the iodoform plomb. In extensive oper- 
 ations for necrosis large cavities are filled with this material 
 and, as is often the case, if the cavity is not entirely aseptic the 
 foreign material is gradually discharged in small fragments as 
 the cavity diminishes in size. The greatest benefit from this
 
 method of packing a bone cavity, however, is derived in cases 
 of tuberculous foci in the articular ends of the long bones. I 
 have used for many years with signal success decalcified iodo- 
 formized bone chips in the same class of cases, but from what I 
 
 Iodoform ploinb, five weeks after operation. 
 
 saw in the practice of von Mosetig-Moorhof I am inclined to 
 give his method a faithful trial. 
 
 Tegmm. —Tegmin is a white, aseptic, adhesive substance 
 which is used as a substitute for collodion in sealing small 
 wounds that do not require drainage. It has the great advan- 
 tage over collodion in being absolutely aseptic and can be 
 readily washed away with warm water. 
 
 Stricture of the Esophagus.— 1 was astonished to find so
 
 many strictures of the esophagus in the Allgemeine Krauken- 
 haus. I saw one case in Gussenbauer's clinic, and another in 
 von Eiselsberg's, and three cases in von Mosetig-Moorhof's 
 wards. In all of them the stricture followed the accidental 
 drinking of lye, and in all it became necessary to perform 
 gastrostomy to prevent death from starvation and to prepare 
 the way for successful treatment by gradual dilation. In the 
 last three cases mentioned the gastric fistula had closed or was 
 closed by operation, and the treatment by gradual dilation was 
 progressing satisfactorily. In one case the stricture, a very 
 obstinate one, was finally passed by a socalled gravitation 
 sound. A hollow, tapering, soft rubber esophageal tube was 
 filled with fine shot. It was inserted as far as the stricture, and 
 by its own weight 
 suddenly forced its 
 way through, an oc- 
 currence which was 
 immediately recog- 
 nized and announced 
 by the happy pa- 
 tient. Since then 
 gradual dilation 
 could be made with- 
 o u t encountering 
 any particular diffi- 
 culty. The experi- 
 ence here, like else- 
 where, has been to 
 the eff"ect that the 
 strictures could be 
 passed after gastros- 
 tomy was performed 
 although they ap- 
 peared to be abso- 
 lutely impermeable 
 before operation. I 
 will make brief men- 
 tion of a few opera- 
 tions performed by 
 Professor Mosetig- 
 Moorhof during my 
 visits. 
 
 Resection of 
 Joints for Tubercu- 
 losis.— T\ie number 
 
 of cases of tuberculosis of joints under the care of this surgeon is 
 unusually large. The brilliant results obtained by his thorough 
 
 Iodoform plorab in the lower end of the radius 
 eight weeks after operation for osteomyelitis. '
 
 methods are undoubtedly responsible for this. About 10 cases 
 of resection of the knee and elbow-joint were shown, the 
 patients having been operated upon from a few days to two 
 months ago. In all, the wound healed by primary intention 
 and the limbs were in a useful position. In elbow-joint resec- 
 tions the olecranon process is temporarily detached, and after the 
 resection is completed is united with the shaft of the ulna with 
 aluminum-bronze wire sutures. Several patients who had 
 this joint resected for extensive tuberculous disease were shown 
 who had recovered with useful movable joints. The exter- 
 nal incision is made transversely over the base of the olecranon 
 process. In resection of the knee-joint, Langenbeck's trans- 
 verse incision is the one usually chosen in exposing the interior 
 of the joint. The epiphyseal cartilages are always saved and 
 the tuberculous foci in the articular ends are scraped out from 
 the sawed surface with a sharp spoon, and after thorough 
 cleansing are packed with the iodoform plomb. The greatest 
 stress is laid on complete extirpation of the tuberculous 
 synovial membrane, capsule, and thorough excision of para- 
 articular abscesses and fistulous tracts when they exist. In one 
 case of tuberculosis of the knee-joint with moderate swelling, 
 but marked genu valgum, a tuberculous focus was found in 
 the internal condyle of the femur and one in each tuberosity 
 of the tibia. In excising the capsule the incisions were carried 
 deep enough to expose healthy muscles, tendons and fascia. 
 Particular care was taken in cleaning out the capsule over the 
 popliteal space. In this instance the patella was found exten- 
 sively diseased and was excised. The lower angle of the wound 
 on each side was drained by inserting a folded piece of gutta- 
 percha tissue, a favorite method of drainage with Mosetig- 
 Moorhof. The soft tissues around the resected bone ends, as 
 well as the external wound, were sutured with fine silk. Over 
 the dry, sterile hygroscopic dressing thin strips of beechwood, 
 socalled shoemaker's chips, were applied and held in place 
 with a moist organtine bandage. He never uses plaster-of- 
 paris in immobilizing a limb after resection. The first dressing 
 remains for two to three weeks. When the dressing is changed 
 the little drains and sutures are removed. The line of suturing 
 is kept moist, and the removal of the dressing and sutures 
 made easy by placing over the first part of the dressing, a few 
 layers of iodoform gauze, an impermeable cover of mackintosh 
 or guttapercha. This cover prevents evaporation and inspissa- 
 tion of the primary wound secretion in that part of the dressing. 
 The limb is immobilized in the same manner after the second 
 dressing, Avhichthen remains until, in cases of resection of the 
 knee-joint, firm, bony consolidation has taken place ; that is, 
 about three months. In an aggravated case of tuberculosis at the
 
 8 
 
 base of the thumb in an adult the diseased joint surfaces were 
 exposed by a curved incision with the convexity directed 
 toward the radial side. The tendons and radial artery were 
 carefully held out of the way while the articular end of the 
 proximal phalanx of the thumb and the articular end of the 
 metacarpal bone of the index finger were resected and the 
 multangulum majus was extirpated. The fistulous tracts com- 
 municating with the primary seat of the disease were thoroughly 
 excised and the wound sutured, drained and dressed in the 
 manner described. The thoroughness with which all diseased 
 tissue is removed in all of Mosetig-Moorhof s operations for 
 tuberculosis, and the prolonged iodoformization of the original 
 foci of infection, account satisfactorily for his matchless results. 
 Amputations.— Two amputations I witnessed in this great 
 clinical school for postgraduate instruction demonstrated the 
 technical skill of the operator in this kind of surgical work. 
 
 The first patient was a man, aged 72, the subject of extensive 
 atheromatous arterial degeneration. Two toes adjacent to the 
 big toe were gangrenous. For good reasons it was deemed 
 necessary to make a high amputation. The Gritti supracondy- 
 loid amputation was made. The vivified surface of the pat- 
 ella was brought in accurate contact with the sawed surface of 
 the femur and fixed in position with buried sutures Avhich 
 included the tendon of the patella and the periosteum and 
 paraperiosteal tissues of the posterior margin of the end of 
 the bone. The long oval anterior fiap was sutured in place 
 with silk, leaving the angles of the wound open for the small 
 guttapercha drains. After dressing the stump it was immo- 
 bilized with splints of wood shavings. The next day this 
 patient's condition was much improved and he stated that 
 he had been relieved of all pain since the operation was per- 
 formed. Every step of the operation had been performed with 
 a manual dexterity that charmed the few visitors and yet 
 without any attempt whatever at display. 
 
 In the next case a Chopart amputation was made for exten- 
 sive tuberculosis of the mediometatarsal joint of the foot. 
 The plantar flap extended as far as the base of the toes and 
 when sutured in place covered the amputation wound in an 
 ideal manner. With deep silk stitches the extensor and flexor 
 tendons were brought together in closing the external wound. 
 The heel was well supported with thin wooden splints applied 
 over the absorbent dressing and held in place with a moist 
 organtine bandage. 
 
 Radical Operation for Hernia.— Frote^sov von Mosetig- 
 Moorhof is partial to Bassini's method in operations for the 
 radical cure of inguinal hernia. The inguinal canal is closed 
 underneath the spermatic cord and its accompanying vessels 
 with not more than four aluminum-bronze wire sutures. This 
 material has given great satisfaction in performing this opera- 
 tion. The sutures can be tied with the same ease as silk 
 sutures and remain in the tissues indefinitely without giving 
 rise to irritation. His patients are confined to bed for three
 
 9 
 
 weeks, when they are discharged without any mechanic 
 support. The remote results have been very satisfactory. 
 
 This operation was performed on a woman suffering from a 
 direct inguinal hernia. After resection of the hernial sac the 
 inguinal canal was closed with four aluminum-bronze wire 
 sutures and the skin incision with fine silk. 
 
 Gastroenterostomy . — The patient, an aged emaciated woman, 
 had been suffering from pyloric obstruction for more than a 
 year. Physical examination revealed the presence of marked 
 dilation of the stomach. The incision was made through the 
 right rectus muscle. The disease was confined to the pylorus, 
 and although a number of lymphatic glands were found impli- 
 cated, it was deemed a proper case for a radical operation, which 
 would have been performed if it had not been for the critical 
 general condition of the patient. An anterior gastroenterostomy 
 was made. The position of the intestinal loop which corre- 
 sponded to the junction of the duodenum with the jejunum was 
 reversed and the mesentery of the small intestine was tunneled 
 with hemostatic forceps at two points about four inches apart. 
 Through each slit a heavy silk suture was drawn and tied so 
 as to exclude intestinal contents from the isolated portion 
 during the operation. After suturing the intestinal loop to 
 the stomach, the peritoneum, the length of the purposed 
 anastomosis over the bowel and stomach was incised and with 
 a continuous fine silk suture the parts were united. The 
 mucous membrane was next incised on both sides and 
 united with the same kind of a suture. The anterior 
 margins of the visceral wounds were united in a similar 
 manner. The whole operation was completed in 45 minutes. 
 At no time did the patient manifest the least sign of shock. In 
 this instance the operation was performed under general anes- 
 thesia, at the special request of the patient, although the routine 
 practice is to operate under local anesthesia. For the purpose 
 of preventing flexion of the bowel at the anastomotic opening 
 the proximal part of the loop was sewed to the anterior surface 
 of the stomach to a distance of at least three inches from the 
 anastomotic opening. 
 
 Fluid food is administered by the stomach a few hours after 
 operation, solid food is withheld for four or five days. 
 
 Acute Osteo7nyelitis.— Several cases of acute osteomyelitis 
 were operated upon. 
 
 In one case a girl, aged 5, had been ill only 11 days, and was 
 admitted into the hospital with all the signs and symptoms of 
 extensive involvement of the entire sliaft of the tibia. The leg 
 was enormously swollen, edematous and diffuse fluctuation 
 indicated the existence of a large phlegmonous abscess. Free 
 incisions were made and the greater part of the tibia was found 
 denuded of its periosteum. The immense abscess cavity was 
 washed out with a formalin solution, 5 : 1,000, which is used in 
 preference to any other antiseptic solution in dealing with acute 
 suppurative aftections. The cavity was packed loosely with 
 gauze and a dry absorbent aseptic dressing was applied. 
 
 Laparotomy for Volvulus of the Sigmoid Flexure. — The 
 patient, a woman aged 30, the subject* of a small umbilical 
 hernia, was suddenly taken ill two days ago. She complained 
 of pain in the umbilical region. Abdomen was tympanitic. The 
 sac of the umbilical hernia was empty. There was no vomiting
 
 10 
 
 but complete obstipation. Diagnosis of intestinal obstruction 
 from some mechanical cause was made, but it was impossible 
 to predict the location and nature of the obstruction. Abdomi- 
 nal incision was made through the left rectus muscles. Small 
 intestines were distended and very vascular. The incision was 
 enlarged and rapid eventration made. The prolapsed intesti- 
 nal loops were carefully protected by enveloping them in 
 warm, moist compresses. The large intestine presented the 
 same appearance. A volvulus of the sigmoid flexure was dis- 
 covered as the cause of the obstruction. The malposition was 
 quickly corrected, the intestines reduced and the large abdomi- 
 nal incision closed with three rows of fine silk sutures. The 
 next day this patient was found in excellent condition. An 
 early operation had been the means of preventing textural 
 changes in the twist of the sigmoid flexure which when once 
 ^pveloped render further operative interference almost hope- 
 less. 
 
 Vienna, July 20.
 
 [Keprinted from American Medicine, Vol. IV, No. 19, pages 743-746 
 November 8,1902.1 
 
 MEDICAL LONDON IN SUMMER. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 Summer is not a good time to see medical London at its best, 
 as the teachers and distinguished men in medicine and surgery- 
 take their much-needed vacation about the middle of July. The 
 English doctor knows where and how to spend his days of rest. 
 Many of the ambitious, restless American doctors utilize their 
 vacation in making long journeys, visiting hospitals, labora- 
 tories and libraries, with a view of increasing their store of 
 knowledge, returning to their work in a worse mental and physi- 
 cal condition than when they left it. Not so with the average 
 ICnglish doctor. He knows the necessity of an entire change in 
 thought, surroundings and daily habits of life, and governs him- 
 self accordingly. He seldom crosses the channel, and very 
 rarely undertakes an ocean voyage. The island kingdom is his 
 favorite resting place. In a few hours he is at a safe distance 
 from a noisy city practice in full enjoyment of a comfortable 
 summer home, in a quiet environment that suits his tastes, or 
 at a well-conducted seashore or mountain retreat. Here he 
 remains until the long shadows of the September sun remind 
 him of his duties to his clients and the institutions he repre- 
 sents, when he hastens home with the body revived and the 
 mental activities renewed, and resumes his work with a vigor 
 and enthusiasm that he found flagging at the end of a busy year 
 weeks before his departure. During his absence the most 
 necessary hospital and private work is done by one or more 
 young assistants, but enough material has accumulated upon 
 his return to engage at once his whole time and attention. He 
 finds after his well-spent vacation that work has become a 
 source of pleasure instead of the unavoidable necessary task it 
 was when he left it. With what interest and care the surgeon 
 examines his patients, and how deliberately and skilfully he 
 wields his scalpel, and with what precision he grasps bleeding 
 vessels on his return from his long summer vacation ! His eye- 
 sight is keener, his hands more steady, his step more elastic, 
 his actions more deliberate and his sallow, careworn face is 
 covered with a living mask of ruddy, sunburned skin. It only 
 takes from eight to ten months to wear off what was gained by 
 the much-needed vacation, when in justice to himself, to his
 
 profession aud his patients lie again abandons his rontine 
 work and seeks rest and recreation. Of all learned professions 
 the medical is the one in greatest need and most deserving of a 
 long, free-of-eare annnal vacation. It is hard to make the public 
 understand this, but it is nevertheless true. During the sum- 
 mer months the complicated machinery of the law comes to a 
 standstill, and the lawyers take their vacation Avithout 
 crippling their bank account to any extent. The fashionable 
 churches close their doors when the members of the congrega- 
 tions go to their luxurious summer homes, and the rectors and 
 preachers, with purses well filled with gold by their grateful 
 parishioners for their vacation expenses, leave the great cities 
 and spend their allotted leisure weeks and months where they 
 are sure to find rest, comfort and recreation. It is the doctor 
 who is expected to work from one end of the year to the other. 
 It is the doctor who must pay full rate traveling and hotel 
 expenses when he tears himself away from his work for a short 
 vacation. It is the doctor whose annual income suffers when 
 he leaves his practice for a much-needed outing. It is the 
 doctor who carries away with him the weight of his responsi- 
 bilities to a greater extent than the members of any other pro- 
 fession when away from daily routine work. 
 
 The public must be made to understand that medical men 
 are entitled above any other profession or class of men to an 
 annual vacation, and that such vacation, properly spent, will 
 bring to patients better service, and will be one of the most 
 important factors in promoting the science of medicine, public 
 hygiene and sanitation. In London, like in all large cities in 
 Great Britain and on the Continent, most of the clinical work 
 during the months of July and August is done by the working 
 assistants, whose teachings and operations are usually credit- 
 able reflections of the practice of their chiefs. In many of the 
 surgical clinics, for instance, the first assistant operates as well 
 and in some instances better than his master. The visiting 
 doctor, however, is always desirous of witnessing the work of 
 men whose names have become famous in medical or surgical 
 literature, hence he is often disappointed in visiting clinics 
 during vacation months. For profitable laboratory study and 
 clinical instruction in small classes, under competent assist- 
 ants, the summer months offer many inducements to students 
 and physicians from foreign countries. The rich anatomic and 
 pathologic museums of the College of Physicians and Surgeons, 
 and of the numerous hospitals in London, alone would furnish 
 rare object studies for an entire summer to students desirous of 
 becoming thoroughly grounded in the two most important 
 fundamental branches of medicine and surgery — anatomy and 
 pathology. Anatomy is taught more thoroughly in England
 
 8 
 
 than in any other couutry. Vienna leads in pathology and 
 Berlin in bacteriology and clinical instruction. There are too 
 many hospitals and medical colleges in London. The govern- 
 ment does little or nothing toward the support of medical edu- 
 cation, and the hospitals have to rely largely for their support 
 on private contributions. It is not unusual to tind in any of the 
 great daily papers an appeal to the public from a number of 
 hospitals for support, showing their pressing need of financial 
 aid to meet current expenses. With the exception of St. 
 Thomas', most of the hospitals are small, and as nearly all of 
 them have their own college, it is easy to see that the clinical 
 material is inadequate, and that the necessary improvements 
 are not made as promptly as the increasing demands require. 
 If London had one large, general hospital under the control of, 
 and supported by the government, and in connection with a 
 great medical school, the cause of medical education and post- 
 graduate instruction in England would be materially advanced. 
 All of the existing medical schools do excellent work, and their 
 graduates compare favorably with those of the continental uni- 
 versities, but the practical training could be conducted in a 
 much more satisfactory and efficient manner in a school in con- 
 nection with a large, general hospital under government 
 control. 
 
 The British Medical Association is the largest organization 
 of medical men in the world. It has reached the mature age of 
 70 and embraces the majority of the practitioners of the island 
 kingdom and of its numerous colonies. It owns a central home 
 on the Strand in the very heart of London, which has been 
 acquired at an enormous expense. The official organ of the 
 association. The British Medical Journal, has the largest circu- 
 lation of any similar publication in the world. Through the 
 able business-like management of Mr. Ernest Hart, its late 
 editor, the journal has become a source of income instead of a 
 financial burden to the association. The income from legitimate 
 advertisements last year amounted to ^97,H75. Good manage- 
 ment of the business atfairs of the association has placed it upon 
 a sound financial basis. Last year |1,875 was voted for scientific 
 research and ^3,250 for scientific research scholarships. Since 1874 
 the association has appropriated out of its funds for scientific 
 research $85,115. This is an example worthy of imitation by the 
 American Medical Association. So long as the governments and 
 the public in England and America take so little interest in medi- 
 cal scientific research it becomes the duty of the profession not 
 only to do the work gratuitously but also to contribute the neces- 
 sary means to advance the science of medicine. The present mem- 
 bership of the association is 18,758. Much of the scientific work 
 is done in the many branches of the association in the island
 
 kingdom and its c't)lonial possessions throughout the civilized 
 world. The annual meeting is devoted largely to social func- 
 tions and entertainments of all kinds. The working hours are 
 from 10 a.m. until 1 p.m. The English physicians enjoy such 
 diversions. These entertainments include many out^door amuse- 
 ments. What is expected of the visitors in a social way may be 
 learned by a glance at the following social program furnished 
 this year : 
 
 1. Official opening of the Annual Museum and Exhibition. 
 
 2. Garden Party by Mr. and Mrs. Edward Donner. 
 
 3. Soiree at the Owen College by the President and Local 
 Executive Committee. 
 
 4. Excursion to Blackpool. 
 
 5. Garden Party by Dr. and Mrs. Mould. 
 
 6. Garden Party by Mr. and Mrs. H. H. Smith-Carrington. 
 
 7. Reception and Fete in Whitworth Park by the President 
 and Local Executive Committee. 
 
 8. Garden Party ])y Mrs. Rylands. 
 
 9. Annual Dinner of the Association. 
 
 10. Ladies' Reception and a Variety Entertainment at the 
 Princess Theatre. 
 
 11. Garden Party by the Council of Owen College and the 
 President of the Manchester Medical Society. 
 
 12. Garden Party by the Mayor of Salford. 
 
 13. Lord Mayor of Manchester's Conversazione in the Town 
 Hall. 
 
 14. Ball, given by the President and Local Executive Com- 
 jnittee. 
 
 15. Visit to Crewe Works. 
 
 16. Excursion to Bury. 
 
 17. Excursion to Northwich. 
 
 18. Excursion to Southport. 
 
 19. Excursion to Windermere. 
 
 20. Excursion to Lancaster. 
 
 21. Excursion to Chester and North Wales. 
 
 22. Excursion to Colwyn Bay and Conway. 
 
 23. Excursion to Llambevis, Snowden, etc. 
 
 24. Excursion to Haddon Hall and Chatsworth. 
 
 25. Excursion to Lake District. 
 
 The effect of so many entertainments was made manifest in 
 the general and section meetings, many of which were scantily 
 attended. During the midst of a meeting of the Gynecologic 
 and Obstetric Section I counted 30 members in attendance and 
 in the Surgical Section there were seldom more than 100 present 
 at any one time. The Manchester meeting was presided over 
 by Mr. Walter Whitehead, F.R.C.S. (Edin.), F.R.S.E., a sur- 
 geon of great repute. It is one of the customs of the British 
 Medical Association to select its president, orators and chair- 
 men of the different sections from the local profession of the 
 city in which the meeting is held. This plan has much to 
 recommend it as it gives the local physicians a recognition 
 which they as well as the public appreciate and limits the 
 honors of the association to the men who have to do the hard
 
 work to make the meetiDg a success. Tlie president's address 
 as well as the addresses in medicine by Sir Thomas Barlow and 
 in obstetrics by Professor W. Japp Sinclair were well received. 
 The subjects for the work of the diflterent sections were selected 
 and arranged with care. The discussions were characterized 
 by harmony and brought out much valuable pathologic and 
 clinical information from the varied and extensive experiences 
 and observations of the different speakers. Tuberculosis of the 
 genitourinary organs, prostatectomy and the palliative treat- 
 ment of carcinoma were the principal subjects discussed in the 
 Surgical Section. 
 
 Drs. Alexander and Parker Syms, of New York, took a 
 leading part in the discussion of prostatectomy, and their 
 remarks made a deep and favorable impression. 
 
 Coro7iation Honors for Medical J/e«.— The King has no 
 more loyal subjects in his vast empire than the physicians. 
 When the South African war broke out the most distinguished 
 surgeons with princely incomes, moved by the purest patriotic 
 feelings, offered their services to their country. Sir William 
 MacCormac, Sir William Stokes, Mr. Frederick Treves, Mr. 
 Thomas Jones, and many others took the field regardless of 
 many unavoidable privations and a hostile climate, and in a 
 most unselfish manner gave their services to the sick and 
 wounded. Their unselfish, patriotic deeds cannot be estimated 
 in money value. They risked their lives, and Sir William 
 Stokes, Mr. Thomas Jones, and many others found an honor- 
 able soldier's grave. His Majesty has recognized the patriotism 
 and valor of his medical subjects and has been liberal in the 
 distribution of honors. The council of the British Medical 
 Association has this to say on the subject in their report for this 
 year: 
 
 " The council has noted with much satisfaction the honors 
 conferred upon members of the association by the King in con- 
 nection with his coronation. More especially are congratula- 
 tions tendered to Sir Victor Horsley, whose work in connection 
 with the association the council is glad to acknowledge." 
 
 Of the knighthood recently bestowed upon Scotland's most 
 distinguished surgeon, William Macewen, the Edinhiirgh 
 Medical Journal says : 
 
 "Sir William Macewen, professor of surgery in the Tiiiver- 
 sity of Glasgow, has achieved by his contributions to surgical 
 science such a reputation that his clinic has become a Mecca to 
 which pilgrims are drawn from all parts of the world." 
 
 The successful operation performed upon His Majesty by 
 Sir Frederick Treves for appendicitis has made for tJiis eminent 
 surgeon a lasting reputation, and his grateful royal patient will 
 know best how to remunerate him for his skilful life-saving 
 service. The King has had a personal experience with what
 
 modern surgery can do in averting death and alleviating pain, 
 and in view of his speedy and satisfactory recovery by opera- 
 tive intervention from a dangerous disease, we may expect in 
 the near future a perfect shower of honors upon deserving 
 medical men outside of those wh<^ are in immediate charge of 
 the nation's patient. 
 
 Two Interesting Surgical Operations by Sir Victor Horsley. 
 —Victor Horsley is continuing his scientific researches on brain 
 localization. He is a tireless and systematic investigator. As 
 an intracranial surgeon he has no superior. As a diagnostician 
 of brain lesions he has no equal. His knowledge of the minute 
 anatomy of the brain and the functions performed by its 
 various parts, and the disturbance of these functions by definite 
 pathologic processes, enable him to recognize and locate affec- 
 tions anienal)le to successful surgical operations. He is a 
 cautious, expert operator. I.ike most English surgeons, he 
 combines asepsis Avith antisepsis. As an irrigation fluid a 
 solution of bichlorid of mercury, 1 : 10,000, is employed. Xo 
 gloves are used. After thorough cleansing of the hands and 
 field of operation with warm water and soap, turpentine and 
 bichlorid solutions follow as chemical disinfectants. Chloro- 
 form is vised as an anesthetic. He has never vised spinal anes- 
 thesia, and is averse to this procedure, as he considers it more 
 dangerous than the administration of anesthetics by inhalation. 
 As a dressing moist cyanid of mercury gauze is given the 
 preference over dry antiseptic dressing material. 
 
 I had an opportunity to witness two of his operations at the 
 University College Hospital. 
 
 Case I. — HartJeii-Kraase operation for neuralgia of the 
 trigeminus. The patient was a man advanced in years, who had 
 suffered for a long time from excruciating pain in the course 
 of the first and second branches of the trifacial nerve. Medical 
 treatment afforded no pernvanent relief. His general health 
 Avas not seriously impaired. The entire scalp was shaved and 
 tlioroughly prepared l)y scrubbing with hot "water and soap, 
 followed by turpentine, and after removing the turpentine 
 with a similar scrubbing the surface was washed and scrul)bed 
 repeatedly with a 1 : 500 solution of bichlorid of mercury. After 
 the patient was fully under the influence of chloroform the 
 temporal region was freely exposed by making a horseshoe- 
 shaped incision, with the base directed downward, and l)y 
 reflecting two flaps, the first one including the skin and the 
 deep one ail of the soft structures down to the bone. The skull 
 was opened by removing a disc of bone with a large trephine, 
 tlie opening was then enlarged in tlie direction of the base of 
 the skull with strong bone-cutting forceps. The sharp-pointed 
 triangular blades manipulated by the expert operator accom- 
 plished the task quickly and well. With the operator's dural 
 reflector the envelopes of the brain were carefully separated 
 over the extent of the cranial resection. The size of the skull 
 defect before the intracranial operation was commenced 
 amounted to at least o inches in the transverse and 2.^ inches in
 
 the vertical diameter. It was in the exposure aud excision of 
 the gasserian ganglion that the great skill of the operator 
 became most apparent. With a broad retractor of silver the 
 brain and its envelopes were lifted away from the base of the 
 skull, which was followed largely by the use of dull instru- 
 ments uutil the ganglion was reached. The isolation of the 
 ganglion proved to be the most difficult part of the operation. 
 This was finally accomplished by the cautious use of a very 
 small scalpel and the dural reflector. Capillary and venous 
 hemorrhage was quite free and was kept under control by 
 making compression with a small gauze sponge held in the 
 grasp of a forceps. 
 
 The ganglion was excised with as much of the proximal 
 side of the nerves as could be reached with safety. As some 
 hemorrhage continued, the space occupied by the excised gang- 
 lion was packed with a strip of gauze which was brought out 
 at one of the angles of the wound. The two flaps were sutured 
 separately with fine silkwormgut. This is at present Hors- 
 ley's favorite suture and ligature material. Catgut is seldom 
 eiiiployed in his practice. A large, moist compress of cyanid 
 of mercury gauze constituted the dressing. The next day the 
 patient stated that he was free from pain. The gauze tampon 
 was removed and a similar dressing applied. 
 
 Professor Horsley has performed this operation Go times 
 with four deaths. In the patients that recovered the result was 
 satisfactory. As a precaution against ophthalmic complica- 
 tions, the eyelids are sutured together with three or four silk- 
 wormgut sutures, which are not removed for three or four 
 days. 
 
 Case II. — Retnovo,! of a large sarcoma of the cerebellum. In 
 this case the diagnostic acuity of Professor Horsley was fully 
 confirmed by the findings revealed during the operation. A 
 little boy, about 6 years of age, had been suffering for several 
 months with symptoms which pointed to the cerebellum as 
 the probable seat of the disease. Among the prominent symp- 
 toms were hemiparesis in the right side, the characteristic 
 pupillary changes and pain in the occipital region with moder- 
 ate retraction and fixation of the head. From these and other 
 minor symptoms the conclusion was reached that the tumor 
 was located in the cerebellum on the right side. The same 
 preparations were made as in the foregoing case. The patient's 
 head and chest were slightly elevated and turned well toward 
 the left side. The occipital bone on the right side was exposed 
 by reflecting a slightly oval flap with the convexity upward. 
 Somewhat profuse hemorrhage from several large openings in 
 the bone occurred, and was promptly checked by rubbing into 
 the bleeding places aseptic wax. From the promptness with 
 which hemorrhage was arrested from this source it was evident 
 that this material is of great value in arresting hemorrhage 
 from bone. With cutting forceps, an oval opening was made in 
 the occipital bone, about two by three inches, with the long 
 diameter in the transverse direction. The pulseless dura at 
 once bulged into the opening. Between two delicate, grasping 
 forceps the dura was nicked, when a small amount of cerebro- 
 spinal fluid escaped. A small, grooved director was inserted 
 into the slit, and upon it the dura was incised in a vertical 
 direction to the extent of about two inches. The brain now pro-
 
 traded into thedural opening. With a probe the operator tore 
 a small opening in the center of the protruding mass, when iu 
 consequence of the intense intracranial pressure the rent greatly 
 increased in size, and a large tumor made its appearance in the 
 tear of the mantle of brain-tissue which covered it. The tvimor 
 was firmer and more vascular than the surrounding brain- 
 tissue. The operator remarked that he considered it dangerous 
 to complete the operation, as he had lost some cases from cerebral 
 edema which followed the immediate removal of large tumors 
 of the brain. The wound was drained with gauze and sutured. 
 The dressing consisted of a large, moist compress of cyanid of 
 mercury gauze. The child showed no untoward symptoms dur- 
 ing or after the operation. The next day the stitches were 
 removed, the skin-flap reflected and the tumor, nearly the size 
 of a hen's egg, was found on the surface of the cerebellum, and 
 was removed without the slightest difficulty. The intracranial 
 pressure had effected almost complete spontaneous enucleation. 
 
 The idea of removing large tumors of the brain in two 
 stages is a most excellent one, and this method will undoubtedly 
 be the means of materially reducing the mortality of such 
 operations. Professor Horsley is a brilliant scientist and a 
 remarkable surgeon, and when the King knighted him he per- 
 formed an act which met a hearty approval of the profession 
 throughout England. 
 
 Two Cases of Hysterectomy for Nontnalignant Disease of the 
 Uterus by Professor W. Japp Sinclair. — During my attendance 
 on the meetings of the British Medical Association I had the 
 pleasure of witnessing the surgical technic of Professor W, 
 Japp Sinclair, of Owen College, Manchester. As an eminent 
 author and successful clinical teacher he is well known in the 
 medical world. He is a sturdy hardworking Scotchman, a 
 graduate of the University of Aberdeen, and has taught obstet- 
 rics and gynecology in Owen College for 12 years. By ability 
 and hard work he has come in possession of a large and 
 lucrative private practice. He is a firm believer in asepsis in 
 surgery, but his methods in accomplishing the desired object 
 are of the simplest kind. In his hospital work two assistants 
 and four trained female nurses render the necessary assistance. 
 He is a bold and yet a conservative operator. When he sees the 
 indications clear for an operation he proceeds without hesitation 
 and performs it on plans well mapped out. He has performed 
 cesarean section 18 times and saved 1() mothers and their chil- 
 dren. In one of the two fatal cases death ensued from remote 
 causes. His address on obstetrics before the British Medical 
 Association was a scholarly product full of good sound teaching 
 and was highly appreciated by his large and attentive audience. 
 He is a deep thinker and a fluent speaker. He is a strong advo- 
 cate of Schuchardt's method of vaginal hysterectomy. The 
 operation is described as follows by Schuchardt, and quoted Ity 
 Sinclair :
 
 While the perfected vaginal method of extirpation of 
 the uterus is characterized by careful protection of the vaginal 
 canal and of the external genital organs by means of specula in 
 order to keep the passage to the portio open, etc., the first object 
 of the paravaginal method is to obtain free access, consistently 
 Avith surgical principles, to the diseased organs. Xo attention 
 is paid to the conventional sparing of the external genitals ; the 
 left labium is completely split, and with it the whole vaginal 
 tube, with the vaginal vault, the paravaginal and pararectal 
 tissues, the levator ani and coccygeal muscles, the cellular 
 tissue of the ischiorectal fossa, as well as the skin of the peri- 
 neum and of the lateral anal region down to the sacrum. 
 Incisions hitherto employed produced only a dilation of the 
 lower portion of the vagina, the paravaginal incision causes a 
 complete gaping of the vagina and vaginal vault. The para- 
 vaginal incision begins on the left labium, and divides the 
 vaginal wall on the left side, but in its deeper parts it is essen- 
 tially a median incision. Superficially the wound is situated to 
 the left only so far that the rectum and sphincter ani are not 
 injured. The skin incision is situated in the vicinity of the 
 anas, distant only about a finger's breadth from it; it then 
 turns round it in a circle behind the anus to tbe middle line. In 
 this essentially median position of the wound, which yet permits 
 it to be deepened as far as to the ligamentum sacro-spinosum 
 if necessary, lies the peculiarity and the chief advantage 
 of the paravaginal incision. . . . If the paravaginal incision 
 is ettected in the manner described, then the parametrium on 
 both sides becomes equally accessible and a second incision on 
 the right side is unnecessary. . . . Only when there is 
 occasion to remove a portion of cancerous rectum with the 
 cancerous vaginal wall does an incision on the right side 
 become necessary. The two incisions then enclose between 
 them the diseased portion of the vagina and rectum, and meet 
 behind in the middle line. 
 
 Sinclair has performed the paravaginal operation 14 times 
 and is well pleased with the technic of the operation and its 
 results. 
 
 Case I. — The patient was a nullipara, aged 35, married, but 
 uever pregnant. For three years she has suffered from menor- 
 rhagia and pelvic distress, has not been benefited by repeated 
 curetings and general treatment. Uterus was enlarged, para- 
 metrium free. The operation was performed in the manner 
 described. The slitting of the vulva and vaginal wall gave 
 rise to free hemorrhage, which was at once arrested by the 
 application of hemostatic forceps and ligation. The deep, gap- 
 ing wound rendered the access to the uterus and adnexa very 
 easy. The operation was completed in less than an hour, as 
 the uterus was movable and yielded readily to traction. The 
 operator's large curved needle was used in applying the deep 
 silk ligatures. The vaginal vault was sutured and the culde- 
 sac drained with a soft rubber tube, to which a strong silk liga- 
 ture was tied for its easy extraction. The vaginal cut and the 
 ischiorectal wound were sutured likewise with silk. The 
 vagina was lightly tamponed with iodoform gauze and iodo- 
 form was freely sprinkled between the layers of the gauze. 
 Retractors were only used in lifting the anterior vaginal wall 
 forward. The extirpated uterus was enlarged, succulent, and 
 the mucosa granular.
 
 10 
 
 Case II. — The patient was a married wouiau, aged 52, who 
 had given birth to several children and had reached her meno- 
 pause at the age of 50. Recently she has suffered repeated uter- 
 ine hemorrhage and profuse leukorrheal discharge. Vaginal 
 examination revealed a fixed uterus with a hard mass on the 
 right side. The suspicion of malignancy was a strong one and 
 hysterectomy was recommended and eagerly accepted by the 
 patient. In this case the operation proved a very difficult one, 
 owing to the numerous firm parametric adhesions, and the 
 paravaginal incisions did not give any too much room for the 
 extirpation of the uterus. The right ovary was cystic and 
 embedded in a mass of adhesions. The operation required 
 much patience and perseverance, but was completed without 
 any mishap. The wound was closed in a similar manner as in 
 the first case. 
 
 The paravaginal operation is to be recommened, particu- 
 larly in cases in which the vagina is narrow and unyielding, 
 and when the uterus is fixed in a high position, and finally 
 when carcinoma has involved the tissues around the vaginal 
 portion of the uterus. 
 
 London, August 2.
 
 [Reprinted from A^nerican Medicine, Vol. IV, No. 20, pages 786-788, 
 November 15, 1902.] 
 
 PROFESSOR JOHN BERG'S SURGICAL CLINIC. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 Sweden has three universities, located in the cities of Stock- 
 holm, XJpsala and Lund ; each of these universities has a 
 medical department. The largest medical school is the Caroline 
 Medico-Chirurgical Institute, connected with the University of 
 Stockholm. This institution has an attendance of from 250 to 
 300 students, and graduates from 20 to 50 every year. The 
 medical course extends over seven to nine years, according to 
 the natural ability and application of the student. The long 
 course of study, the small classes, the abundance of clinical 
 material and the well-equipped laboratories afford the students 
 all necessary facilities to obtain a thorough theoretic and prac- 
 tical knowledge of medicine and surgery. 
 
 For the last 15 years women have been admitted to the 
 medical school, and have made an enviable record as earnest, 
 diligent students. Professor Berg informed me that they rank 
 among the first in the different classes, more especially in the 
 theoretic courses. In the audience of about 30 in the surgical 
 clinic I attended there were three women, and I noticed how 
 intently they followed the remarks of the lecturer and every 
 step of the operative work, and they were the last to leave the 
 clinical theater. There are now 25 female physicians in Stock- 
 holm engaged in practising their profession and in honorable 
 contest with their more numerous male competitors. So long 
 as women insist on studying and practising medicine they 
 should be given the best opportunities to satisfy their desire 
 and ambition, and this can only be done by coordinate educa- 
 tion. Female physicians have secured a permanent foothold in 
 the medical profession, but it would be to their interest and 
 advantage if they would devote their time and talents to gyne- 
 cology, obstetrics, diseases of children, diseases of the eye, ear, 
 nose and throat, and dentistry. Nature has endowed them with 
 qualities well calculated to practise these specialties with sue-
 
 Professor John Berg. 
 
 cess and a good prospect of an independent, comfortable exist- 
 ence. The clinical teaching of the Caroline Medico-Chirurgical 
 Institute is conducted in the Serafrim 
 Hospital. 
 
 Serafrim Hospital.— This institu- 
 tion is supported by the government, 
 and has a capacity of 400 beds. The 
 members of the faculty compose the 
 medical staff. The surgical depart- 
 ment has 140 beds and is located in the 
 old part of the building. The surgical 
 clinics are conducted by Professor 
 John Berg and Professor J. H. Aker- 
 man. Professor Berg is the head pro- 
 fessor. The surgical cases of the large 
 Poliklinik are in charge of the same 
 men. The clinical service alternates 
 between the two professors every 
 four months. The clinical amphithe- 
 ater can seat about 50 students. Most 
 of the major operations are per- 
 formed in an adjoining operating-room, to which only a few 
 students, wearing linen gowns, are admitted. Both operating- 
 rooms are supplied with all necessary instruments and facilities 
 for asepsis. In the operating-rooms there is no unnecessary 
 display in making preparations for an operation. No gloves and 
 no caps. The fact is fully recognized here that clean hands, 
 sterile instruments, ligature, suture and dressing material and 
 a carefully disinfected operative field are the essential pre- 
 requisites to procure asepsis. Hand and surface disinfection 
 are made by scrubbing for a sufficient length of time wnth warm 
 water and potash soap, followed by 1:1,000 bichlorid of mer- 
 cury solution and a 2% solution of creolin. Chloroform by the 
 drop method is the favorite anesthetic, but ether is used in 
 cases in which it is deemed safer than chloroform. Two house 
 surgeons assist the operator. A trained female nurse handles 
 the instruments, ligatures and needles, and a second one takes 
 care of the gauze, sponges and dressing material. Catgut is pre- 
 pared according to von Bergmann's directions, and instruments 
 and silk are sterilized by boiling. In the abdominal cavity 
 silk is used almost exclusively, catgut for buried sutures. In 
 the clinical amphitheater much of the time is spent in diagnosis 
 instruction, the operative work being limited to emergency 
 cases, minor operations and infected cases. 
 
 Professor Berg, the successor to the late Professor Ross- 
 ander, is the head professor of surgery and senior sur- 
 geon to the Serafrim Hospital. He is in the prime of life, above
 
 average height, with a noble, dignified bearing that at once 
 betokens the gentleman and scholar. Modesty is one of the 
 most reliable indications of genuine greatness, and this is one of 
 the many virtues that characterize the life and work of Profes- 
 sor Berg. He is a great favorite among his students and a 
 friend to his patients. He is careful in the selection of his cases 
 for operation, and his clinical teaching is noted for the con- 
 servative spirit which predominates, something which cannot 
 be said of all of the clinics on the Continent. He recognizes the 
 limits of the art of surgery, and takes great pains in emphasizing 
 them in his teachings. He is a fluent and forcible speaker who 
 has no difficulty in commanding the attention of his class and 
 of imparting his earnestness and enthusiasm to every one of 
 his listeners. A very important feature of his clinic is the 
 assigning of a case to one of the candidates for graduation. 
 The student must write a full history of the case, which is read 
 by the professor when the case is presented, and he must be 
 prepared to defend his diagnosis, witness the operation and 
 visit and report upon the progress of the case daily thereafter. 
 This kind of clinical instruction is a method of teaching best 
 calculated to make the student a good diagnostician and a 
 thinking, safe practitioner. Sweden has an excellent system of 
 preparing young physicians for hospital work. Throughout 
 the kingdom hospitals are being built in all of the larger 
 villages, but restrictions are placed on the candidates who 
 make application for the medical service. It is an inflexible 
 rule that such candidates must present a certificate showing 
 that they have served satisfactorily as an assistant in one of the 
 large clinics for a period of at least three years. This is a most 
 excellent plan, as it assures for the most remote parts of the 
 country excellent medical and surgical skill. 
 
 Limitation of hospital practice is surely needed in our 
 country, and it would be well for our profession, and still 
 better for serious cases remote from medical centers if the 
 same regulations could be enforced which have been in such 
 successful operation in Sweden for a number of years. 
 
 Operations.— Frofessor Berg is a very careful and skilful 
 operator. He makes no attempt at display of his manual dex- 
 terity. He operates upon his clinical cases with the same care 
 and consideration as upon his private patients. He never for- 
 gets that he is not only an operator but also a teacher. He is 
 keenly conscious of his responsibilities to his students, who, 
 as is generally the case, will imitate the example of their teacher. 
 He teaches his students not only how to operate but also where 
 and when not to operate. His clinical lectures are devoted 
 largely to diagnosis and a comprehensive study of the patho- 
 logic conditions presented by the case under consideration.
 
 The furor operativus has found no foothold in his clinic. He 
 is familiar with what is going on in the surgical world but is 
 slow in adopting new doubtful procedures. He regards spinal 
 anesthesia with mistrust and has never given it a trial. He is 
 not willing to abandon well-tried reliable methods for innova- 
 tions of doubtful value simply because they are something new. 
 On the day of iny visit to his clinic two very rare and extremely 
 interesting cases furnished the text for his clinical lecture. 
 
 Case 1.— Retention cyst {?) of the frontal sinus ; operation. 
 The patient was a man, aged 25, the subject of an orbital swell- 
 ing. The swelling involved the right orbital cavity and was 
 first noticed seven years ago. There was no pain nor tender- 
 ness. There was slight exophthalmos and outward deviation of 
 the eye. Nasal cavities w^ere normal. Distinct fluctuation 
 elicited on palpation led to the information that the swelling 
 was in part covered by a thin plate of bone. The swelling 
 occupied the inner upper quadrant of the orbital cavity. 
 Eyesight was unimpaired. The case was thoroughly dis- 
 cussed from a diagnostic point of view. The obscurity of 
 the nature of the swelling was emphasized. Osteoma of the 
 orbit, dermoid cyst, inflammatory diseases of the frontal sinus 
 and ethmoidal cells and malignant tumors were all mentioned, 
 but the final diagnosis was left for the operation to reveal. The 
 patient was prepared, anesthetized and the operation com- 
 menced by making an incision along the orbital arch down to 
 the frontal bone. With an elevator the periosteum was reflected 
 in the direction of the swelling. As soon as the orbital cavity 
 was reached a yellowish white gelatinous material escaped and 
 the opening led into a large cavity— the distended frontal sinus. 
 This cavity contained at least three ounces of the same kind of 
 material. The communicating opening between the frontal 
 sinus and the nasal cavity was found without any particular 
 difficulty with the probe. With a chisel and hammer part of 
 the orbital margin was removed to aff'ord freer access to the 
 cavity which was then thoroughly cleansed of its contents and . 
 the lining membrane excised with forceps and curved scissors. 
 The opening between the sinus and nasal cavity was enlarged 
 until the tip of the index finger could be inserted. The cavity 
 was then packed with a Mikulicz drain and the external inci- 
 sion reduced in length by suturing with silk. A small 
 absorbent dressing finished the operation. The nature of the 
 cyst contents, the absence of all inflammatory indications, leave 
 but little doubt that the case was one of retention cyst or 
 myxoma of the frontal sinus. 
 
 Case II. — Ulcer of duodenum; gastroenterostomy. The 
 patient was a woman of 40, who for 20 years had suffered from 
 symptoms indicative of a faulty digestion. Pain and distress 
 was not aggravated by the quantity and quality of the food. 
 There were repeated attacks of hematemesis and discharge of 
 altered blood through the intestinal canal. An enlargement 
 could be palpated in the region of the pylorus. Patient was 
 somewhat emaciated and anemic. Heart's action was weak, 
 circulation feeble. Probable diagnosis of ulcer of duodenum 
 was made by exclusion. Owing to the weak action of the 
 heart ether was used as an anesthetic. The skin in the line of 
 abdominal incision was infiltrated with Schleich's solution for 
 the purpose of reducing the amount of the anesthetic to a min-
 
 imuni and to shorten the time required for operation. The 
 operator decided to perform a gastroenterostomy with a view of 
 securing rest for the ulcerated part of the intestinal tract by 
 excluding it from the active process of digestion. A median 
 incision was made extending from the tip of the ensiform car- 
 tilage to the umbilicus. The stomach and duodenum presented 
 no visible or palpable evidences of disease. From this it was 
 evident that the ulcer of the duodenum, which was unquestion- 
 ably present, had not penetrated deep enough to involve the 
 peritoneal coat. The head of the pancreas was enlarged, but 
 retained its form and consistency. Professor Berg is in favor 
 of posterior gastroenterostomy, but in this case the anterior 
 operation had to be performed because the mesocolon was too 
 short for the posterior. The anastomosis was made near the 
 pylorus and the large curvature of the stomach. Doyen's long 
 clamps for the stomach and intestinal clamps for the jejunum 
 were used to exclude stomach and intestinal contents from the 
 seat of operation. A loop of the upper part of the jejunum 
 was sutured with silk to the anterior surface of the stomach in 
 its long axis at the point indicated to the extent of three inches. 
 The peritoneal coat of the stomach and duodenum was incised 
 two lines from the row of Lembert stitches, over which another 
 row of serous stitches was applied. The visceral wound on 
 each side was next completed, the mucous membrane all 
 around united, and the anterior stitches buried under two rows 
 of Lembert stitches. The sewing was done exclusively by con- 
 tinuous silk sutures. A flap of the omentum was now drawn 
 from the pyloric side and laid over the line of suturing 
 anteriorly and fixed in place with three serous sutures. The 
 abdominal incision was closed with three rows of silk sutures. 
 The wound was covered with a small absorbent dressing. The 
 whole operation was completed in less than an hour and was 
 executed with a delicacy and skill as pleasing to the audience 
 as it must have been satisfactory to the operator. 
 
 Other Stockholm Hospitals.— ^iodkhoVm. has made ample 
 provision for its sick poor. It is well supplied with well-man- 
 aged hospitals and charitable institutions for the insane, the 
 aged, the poor, and the orphans. 
 
 Sophia Hospital.— This magnificent hospital, with its park- 
 like grounds, is the creation of the Queen of Sweden. It con- 
 tains 80 beds and is managed by the Sisters of Sophia. The 
 material for this order of Sisters is selected from the best families 
 in Sweden. The Sisters are in training in this, the mother house, 
 for 2^ years, and after their graduation they are expected to 
 serve the rich and the poor without expectation of a financial 
 reward, as their earnings go into the general fund of the sister- 
 hood. The nursing in this hospital is therefore of the highest 
 order. The wards and private rooms are elegantly furnished. 
 The two new operating-rooms are models of their kind and a 
 glance at them would inspire every surgeon with confidence so 
 far as the facilities for aseptic precautions are concerned. One 
 of the features of these rooms is the electric lighting. The 
 electric lamps over the operating table are covered with glass 
 and a convex glass between the lamps directs the rays of light
 
 6 
 
 m such a manner that no shadows are cast upon the field of 
 operation. For the best private rooms a charge of seven kronen 
 is made. The hospital expenses of the poor are often paid by 
 the congregations to which they belong. The Queen is a liberal 
 contributor to the annual expenses and is a frequent visitor at 
 the hospital. 
 
 Crown Princess Louisa Hospital.— This hospital is devoted 
 to the care of sick children and is under the patronage of Crown 
 Princess Louisa. The buildings are two and three stories high 
 and are surrounded by an attractive flower garden. It has a 
 capacity of 120 beds. The medical side is in charge of Prof. 
 Jonas Waern, the surgical department is presided over by 
 Docent Dr. Bjorn Floderus, and Dr. Oscar Gibson is chief of the 
 polyclinic. The operating-room is small, but is well supplied 
 with instruments and all facilities for aseptic work. The 
 expenses for indigent children are paid by the districts from 
 which they are sent. Last year a bazaar under the patronage 
 of Princess Louisa netted 86,068 kronen. Of this amount James 
 Carnegie contributed 20,000 kronen. The receipts from pay 
 patients during the same time amounted to 6,547.25 kronen, 
 while the total running expenses for the year reached the sum 
 of 110,434 kronen. Last year 244 operations were performed, 
 with 234 recoveries, five improvements, and only five deaths, a 
 good record considering that many of the operations were per- 
 formed for far advanced tuberculous affections of joints, bones, 
 lymphatic glands, and skin. In the polyclinic 435 minor opera- 
 tions were made with no mortality. 
 
 Deaconess Hospital.— This hospital, with 80 beds and a 
 home for the aged, is beautifully located on a high embank- 
 ment facing the harbor of Stockholm. It is in charge of an 
 order of Sisters and has an excellent training school, where 
 Sisters are prepared for their life work. Dr. Hugo Toll, who 
 practised his profession for a number of years in Minneapolis, 
 Minn., is the surgeon-in-chief. His skill as an operator is 
 highly appreciated by the hospital authorities, the Sisters and 
 his patients. He keeps pace with the rapid progress of surgery, 
 and his results would compare favorably with those of any 
 other hospital. Space does not permit to describe the remaining 
 hospitals of Stockholm, but it can be said with credit to this 
 Venice of the North that it has made excellent and wise pro- 
 vision for patients of means as well as its deserving sick poor. 
 
 Stockholm, August 10.
 
 (Reprinted from American Medicine, Vol. IV, No. 24, pages 942-946 
 December 13, 1902.] 
 
 PRESENT SURGICAL METHODS IN THE GENERAL 
 HOSPITAL HAMBURG-EPPENDORF. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 The new Allgemeine Krankenhaus Hamburg-Eppendorf 
 accommodates 2,000 patients. It is built on the barrack plan, 
 and is spread out over several acres of g^round. The different 
 buildings are numbered and the streets and sidewalks inter- 
 secting them are laid otit in the form of a miniature city. All 
 of the buildings are constructed upon modern plans, and are 
 heated by steam and lighted by electricity. The four operating- 
 rooms which are in use at the present time are furnished with 
 «very possible convenience for aseptic work. Many of the 
 little aids to perfect aseptic precautions are the inventions of 
 Dr. Kiimmell, who has spent much time and thought in sim- 
 plifying and rendering more effective the aseptic precautions 
 now in general use. Among these are the ingenious applica- 
 tion of a rubber cork for bottles containing saline and antiseptic 
 solutions, a fountain alcohol dropper worked by compressing 
 a rubber bulb with the foot, and bottles in which catgut and 
 silk are preserved for immediate use. The instrument supply 
 in each of the operating-rooms is complete and in charge of a 
 well-trained orderly (Oberwarter), who is held responsible for 
 their perfect and sterile condition and proper arrangement on 
 the instrument table. Two house surgeons assist the operator 
 and a third administers the anesthetic, which at present consists 
 of a definite mixture of chloroform and oxygen gas. Two 
 trained female nurses attend to the gauze, sponges, and dress- 
 ings. 
 
 This hospital contains a larger number of surgical patients 
 than any other hospital in the world, the number ranging from 
 500 to 750. It is a great pity that this immense material cannot
 
 be utilized for clinical instruction on a greater scale. Hamburg 
 should have a university, and the general hospital is the proper 
 place for the medical department. There are some indications 
 that this desire will be realized in the near future. An oper- 
 ating-theater with a seating capacity for 120 is now in process of 
 construction, and university instruction is now given by emi- 
 nent scientists in nearly all studies given in university courses. 
 These lectures are given gratuitously. Hamburg is the most 
 beautiful of all European cities, a great seaport in close touch 
 with all parts of the world, and all it needs to make it an ideal 
 city is a great university. The creation of a live, efficient med- 
 ical school would meet no difficulties, as the present clinical and 
 teaching force would constitute a strong faculty, and the 
 immense clinical and anatomic material, with the existing 
 laboratories and museums, would answer all the immediate 
 requirements as a teaching material. The surgical department 
 of the general hospital has won an enviable reputation 
 throughout the entire medical world. It is not uncommon to 
 find in the little audience of six to twelve which gathers around 
 the operating tables every day, eager to see the most recent 
 innovations in surgery and to witness the most difficult things 
 in operative skill, clinical teachers from as many medical 
 schools and countries. I know of no other place where a man 
 can see and learn more in the same space of time. The only 
 regret of the visitor is that he cannot witness all of the operations 
 going on at the same time. He is never idle. When an opera- 
 tion is completed all he has to do is to step into the next room, 
 where another operator is at work, and when he has finished 
 the visitor can retrace his steps and find another patient is on 
 the table ready for operation. 
 
 Surgical Service.— ^iuQe Schede left the hospital in 1893 to 
 accept the professorship at Bonn the surgical service is 
 divided equally between Dr. Hermann Kiimmell, first chief 
 surgeon, and Dr. Sick, second chief surgeon. From 10 to 14 
 new cases are received daily. The infected ones are assigned 
 at once to the wards where they belong ; all other patients enter 
 the receiving pavilion, where they are given a bath and are fur- 
 nished with the hospital garb. Dr. Kiimmell attends to the 
 receiving ward four days in the week and Dr. Sick three days, 
 but for the purpose of equalizing the material all children 
 under 12 years are assigned to Dr. Sick. In the receiving-room 
 the patients are examined and after the diagnosis is made are- 
 sent to their appropriate wards. In this way the clinical 
 material is systematized and properly distributed. 
 
 Surgical Work of Dr. Eilnimell.—'' Yrsesente segroto Tac- 
 eunt colloquia, Effugiat visus Decus omnia dominat morbus." 
 This is a warning printed in large type which stares the visitor
 
 8 
 
 Dr. Hermann Kiimmell. 
 
 in the face from the wall he is 
 likely to face in every operat- 
 ing-room. Every visitor is re- 
 quested to remove his coat and 
 wear a linen gown. Dr. Kiim- 
 mell was well prepared for the 
 present position when he be- 
 came the succei?sor to Schede. 
 His scientific investigations 
 which led to the introduction 
 of bichlorid of mercury as an 
 antiseptic brought him at once 
 into prominence. His clinical 
 observations on intestinal ob- 
 struction and appendicitis are 
 closely interwoven with the 
 progress of modern surgery. He is a diligent student and an 
 enthusiastic, deliberate and careful operator. He is not what 
 some are fond of being called, "a lightning operator," but his 
 vast experience, his thorough knowledge of anatomy, and his 
 familiarity with the changes wrought by pathologic processes 
 place him in a position to proceed with his work without hesi- 
 tation. He has reached the age of greatest usefulness and we 
 may look to him with confidence for many scientific and clinical 
 literary productions, the fruit of his labors in his present fertile 
 clinical field. When the opportunity presents itself he will 
 occupy the front rank as a clinical teacher, as he is in possession 
 of all the desirable qualifications for such a position. 
 
 Dr. KiimmelVs Methods in Abdominal Operations. — There 
 is no gynecologic department in the Hamburg General Hos- 
 pital. Gynecology is here a part of general surgery. From one 
 to four abdominal and pelvic operations are made here almost 
 every day. Dr. Kiimmell has contributed much by writing 
 and example to the perfection of abdominal surgery. He can 
 speak on this subject with authority. I will give a brief outline 
 of the methods now in use as practised by him and his colleague, 
 Dr. Sick. 
 
 Preparation of Patient.— In very weak patients a roborant 
 and nutritive course of treatment is resorted to for a few days 
 before the operation. Subcutaneous injections of sterilized 
 olive oil (Leube), nutrient enemas and intravenous infusion of 
 physiologic solutions of salt have been found most useful in 
 increasing the resisting power of the patient sufficiently to war- 
 rant surgical interference. Two quarts of saline solution are 
 infused twice or thrice a day for several days preceding opera- 
 tion. The bowels are moved thoroughly the day before the 
 operation. Prolonged or repeated catharsis is warned against
 
 in most emphatic terms. If the stomach is not empty it is 
 evacuated by siphonage before the anesthetic is commenced . On 
 the evening before the operation the abdomen is thoroughly 
 cleansed with sulfuric ether, shaved and scrubbed with soap in 
 the cleansing bath. The abdomen is then covered with a com- 
 press wrung out of a bichlorid of mercury solution 1 : 2,000, 
 which is kept moist by applying over it some waterproof 
 material. 
 
 Anesthesia.— Fifteen minutes before the anesthetic is com- 
 menced, 0.01 gram morphia with atropin is injected subcutane- 
 ously. Male patients addicted to the use of spirits are given a 
 wineglassful of cognac. 
 
 In the narcosis-room absolute quietness is enforced ; no one 
 but the anesthetizer and a Sister are admitted. Chloroform is 
 the anesthetic in use, ether in only exceptional cases when the 
 patient is very weak or the subject of heart disease, or finally in 
 continuing the chloroform narcosis in operations of long dura- 
 tion. 
 
 The drop method was employed exclusively until the intro- 
 duction of the oxygen (Wohlgemuth) admixture. The apparatus 
 now in use registers wath accuracy the quantity of oxygen and 
 chloroform inhaled. A deep narcosis is essential in all opera- 
 tions in the Trendelenburg position, as the slightest muscular 
 contractions force the intestines forward into the w^ound, thus 
 obscuring the pelvic view. Local anesthesia by Schleich's 
 infiltration method is resorted to when the general xiondition of 
 the patient contraindicates the administration of a general anes- 
 thetic. Spinal anesthesia was tried in ten cases, but the results 
 w^ere such that it has been permanently abandoned. 
 
 Disinfection of the Patient. — After the patient is completely 
 under the influence of the anesthetic the disinfection is com- 
 pleted before he is transferred to the operating table. After 
 removal of the sublimate compress, one of the assistants, prop- 
 erly prepared, scrubs the abdomen wath marbledustsoap with a 
 bunch of sterilized wood fibers. The softened epithelial cells 
 are rubbed off so far as this can be done. This mechanic 
 cleansing is regarded as the most important part of the entire 
 process of surface disinfection. After removal of the soap with 
 a sterile towel the surface is scrubbed with alcohol, applied 
 W'ith a gauze sponge, followed by rubbing wdth ether. The 
 use of the ether is continued until the white sponges 
 are no longer stained. When the white gauze is no longer 
 discolored the best proof is furnished that the mechanio 
 cleansing is as complete as it can be made. Alcohol is 
 then used again, and lastly rubbing off with a bichlorid solu- 
 tion, 1 : 1,000, completes the disinfection of the field of operation.
 
 The abdomen is then covered with a sterile cloth and the 
 patient placed upon the operating table. 
 
 Prepa7'ation of the Surgeon and Assistants. — Contamination 
 of hands with septic material must be avoided for at least 24 
 hours before the operation. If during that time it becomes 
 necessary to operate on septic cases, rubber gloves must be 
 worn. If visits to the postmortem-room are made, a change of 
 clothing and a bath are insisted upon. The operator and assist- 
 ants wear a white cap to avoid the entrance into the abdominal 
 cavity of hair and other infectious material, should, as some- 
 times happens, their heads come in contact during the opera- 
 tion. Linen gowns are worn by all in the operating-room. 
 Gloves, face and head masks are considered superfluous pre- 
 cautions. 
 
 Much stress is placed upon the importance of proper care of 
 the hands, as smooth skin can be more easily disinfected than 
 rough skin. Lanolin and glycerin are recommended. The 
 statement is made and emphasized that the hands with smooth, 
 healthy skin, after a thorough mechanic cleansing are practi- 
 cally free from bacteria, with or without the subsequent use of 
 alcohol. The best remedy for the cleansing of the hands is the 
 prolonged and thorough cleansing with flowing warm water 
 and soap. 
 
 Kiimmell has used marbledust soap for 11 years, but 
 recommends Schleich's marble soap, which is prepared in the 
 pharmacy of the hospital, as the soap sold in the market is not 
 what it should be. 
 
 The hands are washed in running hot water for ten minutes, 
 during which time the finger nails receive careful attention, and 
 the aseptic brush is used with vigor. The hands are then 
 rubbed v»^ith gauze sponges saturated first with alcohol and 
 lastly with ether. Immediately before the operation is com- 
 menced the hands are once more rubbed with alcohol and 
 bichlorid of mercury solution. 
 
 Preparation of Dressing Mateinal and Instruinents. — The 
 sterilization-room, separated from the operating-room by a glass 
 door, is supplied with all modern means of sterilization. Every- 
 thing that is to be brought in contact with the wound is ren- 
 dered aseptic by boiling or steam sterilization before it is 
 brought into the operating-room. The orderly arranges needles 
 and instruments and places them in pans filled with sterile 
 water on a table within easy reach of the operator. The instru- 
 ments are wrapped in a linen cloth and are sterilized in a 
 Lautenschlager apparatus, and the wrapper is not removed 
 until they are to be used. 
 
 Silk is sterilized by boiling in bichlorid of mercury solu- 
 tion, 1 : 1,000.
 
 Catgut is boiled in a saturated solution of ammonium sul- 
 fate, according to the method of Elsherg. 
 
 Preparation of Ammonium Sulfate Catgut. — Selection of 
 good raw material is important. The catgut is wound upon a 
 square glass plate with projecting margins, in order to expose 
 the threads fully to the boiling solution, as they touch the plate 
 only at four points. The boiling is done in an enameled pot 
 and is continued for half an hour, when the plate is removed 
 with a pair of sterilized forceps and rinsed in sterilized Water. 
 
 For a short time the catgut is immersed in alcohol to harden 
 it, when it is placed in sterilized oil of juniper ready for use. 
 Catgut and silk are kept in bottles with a wide neck securely 
 closed with a glass cork, which is removed when the material 
 is needed and a nickel cover sterilized by boiling substituted. 
 Through a central perforation in this cover the threads are 
 brought out. From the time the sterilization is completed no 
 one touches the silk or catgut except the operator, who threads 
 his own needles. The one who sterilizes the material and the 
 operator are the only two persons responsible for the asepticity 
 of the suturing material. The catgut prepared by this method 
 is firm, ties easily and securely, and remains in the tissues for 
 three to four weeks and more. Dr. Sick had recently an oppor- 
 tunity to examine a buried suture four weeks after the opera- 
 tion, and found the material softened but retaining its hold on 
 the tissues. Catgut is used almost exclusively for buried 
 sutures, and a large experience has shown the superiority of 
 the ammonium sulfate over catgut prepared by any other 
 method. 
 
 Elsberg's method of catgut sterilization is so simple and so 
 sure in its results that it soon will find its way into all hospitals, 
 and it cannot be recommended in too strong terms for general 
 adoption in private practice. 
 
 Incision.— T>T. Kiimmell is in favor of a small incision. 
 Even in operations for intestinal obstruction he does not make 
 the incision as long as he advised a number of years ago. With 
 increasing experience the incisions are made smaller. A 
 median incision is made in all operations upon the stomach, 
 pancreas and in all gynecologic operations. In appendix opera- 
 tions all muscular layers are incised to the requisite extent. 
 If the uterine adnexa are involved the incision is made in pref- 
 erence along the outer border of the rectus muscle. In opera- 
 tions upon the gallbladder a vertical incision is made, begin- 
 ning at the costal arch. All abdominal incisions are made 
 quickly. With one stroke of the knife all tissues are divided 
 down to the peritoneum. The peritoneum is incised separately 
 and the incision enlarged with blunt-pointed scissors. With 
 small vulsellum forceps the peritoneum and skin are grasped
 
 at bleeding points, rendering the use of hemostatic forceps 
 unnecessary. This manner of dealing with the abdominal 
 incision is noteworthy, and deserves imitation by all abdom- 
 inal surgeons. Drainage of the peritoneal cavity is seldom 
 resorted to. The abdominal cavity is never flushed. Blood and 
 other fluids are removed and the surfaces dried with gauze 
 sponges. 
 
 The incision is closed with four rows of sutures ; the first 
 embraces the peritoneum, the second the muscular layers, the 
 third the fascia and the fourth, of silk, the skin and deep fascia. 
 The wound is covered with a sterile compress, held in place by 
 strips of perforated adhesive plaster. The silk sutures are 
 removed on the seventh or eighth day. 
 
 After-treatment. — As a rule the fate of the abdominal cavity 
 is decided after suturing of the incision. In case of collapse an 
 intravenous infusion of a liter of saline solution is made at once 
 and if necessary is repeated in a few hours. This expedient is 
 resorted to in all cases when the pulse exceeds 120. Pain is 
 subdued by the administration of morphia. Vomiting should 
 be prevented by withholding all food and fluids by the stomach. 
 If no vomiting takes place coffee and tea are given in small 
 quantities 24 hours after the operation. Ice is never given. 
 The sense of thirst is relieved by rinsing the mouth with 
 acidulated fluids. If vomiting persists for more than 48 hours 
 peritonitis must be suspected. A diffuse pronounced perito- 
 nitis results in death and all efibrts to prevent a fatal termina- 
 tion are useless. Laxatives after laparotomy for the pre- 
 vention of peritonitis have been abandoned. The rectal tube and 
 injection are relied upon in relieving tympanites and in securing 
 action of the intestines. If glycerin injections prov^ fruitless, 
 syrup and milk seldom fail. If rectal alimentation becomes 
 necessary three injections of sugar, salt, yolk of egg, and 
 cognac are given every 24 hours. Forced nutrition advised by 
 Leube consists in the subcutaneous injection of sterilized olive 
 oil underneath the fascia of the thigh in quantities varying 
 from 40 to 60 grams. If the patient requires energetic stimula- 
 tion camphor is added to the oil. It will be seen from the 
 foregoing that the after-treatment in many respects differs from 
 that in general use elsewhere. As the changes made are based 
 upon an enormous experience the advice given deserves the 
 serious consideration of all surgeons. 
 
 Dr. KmmnelPs Operations.— I was fortunate enough to find 
 Dr. Kiimmell at his post after his return from his summer 
 vacation and to witness a number of operations, which I will 
 describe briefly : 
 
 Case I. — Carcinoma of cardiac orifice of stotnach ; gastros- 
 toTny. The patient was an old man, emaciated almost to a
 
 skeleton and very anemic. Cardiac obstruction was almost 
 complete. After the necessary preparatory treatment gastros- 
 tomy was performed under the influence of the chloroform- 
 oxygen mixture. An incision two fingers breadth below and 
 parallel with the left costal arch, which divided the rectus 
 muscle almost completely, was made. Stomach was very 
 small and atrophic and there was extensive malignant disease. 
 A small incision was made in the stomach as near as possible 
 to the cardiac orfice and a Xelaton catheter the size of a large 
 lead pencil was inserted and fastened in its position with 
 two stitches of fine silk. Two inches of the catheter were then 
 sewed over according to Witzel's method. The anterior wall 
 of the stomach around the catheter was sutured to the parietal 
 peritoneum in the upper angle of the wound and the incision 
 closed with three rows of continuous catgut sutures and one of 
 silk for the skin and deep fascia. Two ounces of port wine 
 were at once poured into the stomach through the catheter. 
 
 Case II. — Retroversion of the iiterus ; shortening of the 
 round ligaments by the A lexander method. Dr. Kiimmell has per- 
 formed this operation 150 times, and is very much pleased with 
 the immediate and remote results. In a number of cases the 
 patients became subsequently pregnant, and experienced no 
 inconvenience before and after delivery. He follows the advice 
 of Dr. Goldspohn and opens the peritoneal cavity on both sides 
 a modification of the typical extraperitoneal method of Alex 
 ander, which he believes presents many advantages, as it per 
 mits the insertion of the index finger, with which adhesions 
 can be separated, the exact position of the uterus ascertained 
 and with which reposition of the dislocated uterus can be made 
 Incision was made over the entire length of the inguinal canal 
 Round ligament was found and isolated in the upper part of the 
 canal. The ligament was followed in a downward direction 
 and torn from its insertion. By making traction on the liga- 
 ment, the parietal peritoneum was drawn forward in the form 
 of a funnel and was incised with scissors above the ligament. 
 With the index finger introduced through the slit in the 
 peritoneum the necessary exploration was made, and by traction 
 on the ligament and pressure against the posterior surface of 
 the uterus complete reposition of the displaced organ effected. 
 With two catgut sutures the pillars of the canal and ligament 
 were transfixed. The free end of the ligament was then used 
 as a living suture, using for this purpose a large, short, flat, 
 curved needle with which three stitches were made, including 
 the firm fascia of the external oblique. The ligament was 
 fastened to this fascia with two catgut sutures and the project- 
 ing part cut off even with the muscular layer. Suturing of small 
 superficial wound was done with silk. The same operation was 
 done on the opposite side. 
 
 Case III. — Inoperable carcinoma of the rectum ; left iliac 
 sigmoidostomy. Under general anesthesia an incision was made 
 through all abdominal layers, three inches in length two fingers' 
 breadth above and parallel with Poupart's ligament. The dis- 
 tended sigmoid flexure was readily found and brought forward 
 into the wound. The surface of the bowel was sutured first to 
 the peritoneum, then the muscular layer, next fascia and finally 
 the skin with continuous catgut sutures. Visceral incision 
 will be made 24 hours later without an anesthetic. 
 
 Case IV. — Genn valgum; transverse linear osteotomy. 
 The patient was a baker, aged 19. Right limb was affected, 
 deformity being far advanced Under general anesthesia
 
 an incision was made down to the bone an inch in length at a 
 point corresponding with the upper margin and internal 
 border of the patella. With an osteotome S inch in width 
 the bone was incised transversely until the fracture could be 
 completed by manual force. The bone was very dense and the 
 chisel had to be reinserted three times before it was possible to 
 fracture the remaining part of the bone. No sutures. The 
 wound was covered with a small sterile dressing. After correc- 
 tion of the malposition the limb was immobilized upon a well 
 padded posterior splint. In a few days a plaster-of-paris dress- 
 ing will be applied and will remain until bony consolidation is 
 complete. 
 
 Case V. — Relapsing appendicitis ; appenclicectomy . The 
 patient, a young man, had six attacks within as many months. 
 Last attack occurred 13 days ago. Acute symptoms subsided 
 a few days ago. There was no temperature, no swelling. 
 Oblique incision was made in line of McBurney's point, dividing 
 all of the layers of the abdominal wall. Appendix was imbedded 
 in a mass of adhesions behind the cecum. There was a small 
 abscess around the tip of the appendix in communication with 
 perforation. Meseuteriolum clamped in sections and tied after 
 removal of appendix. Appendix was ligated at the base with 
 fine silk. Mucous membrane of stump was excised with curved 
 scissors and raw surfaces sutured together separately. Stump 
 was buried by sewing over it the adjoining serous surfaces. 
 Pus was carefully wiped from abscess cavity, which was packed 
 with a strip of eophen gauze which was brought out at the 
 upper angle of the wound. Incision was closed with etagen 
 continuous catgut sutures. Skin was sutured separately with 
 silk. A small absorbent dressing was held in place with strips 
 of perforated adhesive plaster. 
 
 Case YI.— Intestinal obstriiction ; laparotomy. The pa- 
 tient was a woman, aged 30. For several months she had 
 repeated attacks, which from the symptoms resembled in 
 many respects relapsing appendicitis. Tympanites was well 
 marked, especially in the upper segment of the abdomi- 
 nal cavity. No swelling could be detected in the ileo- 
 cecal region. Temperature 38° C. There was constipation 
 and occasional attacks of vomiting. Considering the uncer- 
 tainty of the diagnosis, the incision was made along the 
 outer border of the right rectus muscle. Patient in Tren- 
 delenburg position. Appendix was small and presented no 
 macroscopic lesions. Appendectomy. A cystic right ovary 
 was removed. Tube was removed separately. Upper part of 
 small intestine was distended and very vascular. Lower 
 part of ileum was pale and collapsed. Eventration and careful 
 examination failed to demonstrate the existence of a mechanic 
 obstruction. Cecum was also distended and vascular. Reduc- 
 tion of intestines was facilitated by lifting the margins of the 
 abdominal incision with short vulsellum forceps, and by cover- 
 ing the intestines with an artificial peritoneum of gauze over 
 which uniform, gentle, manual pressure was made. Suturing 
 of abdominal incision was done in the customary manner. The 
 operation relieved the symptoms of obstruction, and the patient 
 was progressing favorably four days later. (Was this a case of 
 adynamic obstruction caused by intestinal sepsis?) Toward 
 the completion of the operation the patient became somewhat 
 collapsed, and an assistant resorted promptly to intravenous 
 infusion of one liter of saline solution. The pulse and general 
 appearance improved visibly in a short time after the infusion.
 
 10 
 
 Case YII. — Renal tuberculosis; nephrotomy; freezing 
 point of the blood as a diagnostic and prognostic resource 
 in renal affections. This was a case of unusual interest, 
 as it gave an opportunity for the operator to give a compre- 
 hensive account of the diagnostic and prognostic value of the 
 freezing point of the blood in affections of the kidneys and renal 
 surgery. Dr. Kiimmell has made a very thorough study of 
 this subject, and he has found this test reliable in all cases in 
 which it was applied. The test is a very simple one. All that 
 is required is a C. thermometer, a large test-tube and a freezing 
 mixture of ice and salt in a glass bottle with a wide neck. Two 
 ounces of blood are drawn from the median basilic vein with a 
 cannula into the glass tube. Coagulation must be prevented by 
 constant agitation. The glass tube is immersed in the freezing 
 mixture — also the thermometer. The column of mercury falls 
 until the freezing point is reached, when it rises. The observa- 
 tions are made at this time and the result recorded. As a con- 
 trol experiment, the freezing point of distilled water is subse- 
 quently ascertained for comparison. The freezing point of nor- 
 mal blood is 0.56° C. In renal insufficiency the freezing point 
 is lower, and falls with the accumulation of solid material in 
 the blood. These facts were first pointed out by Koranyi. Dr. 
 Kiimmell has applied this test in more than 265 cases, and has 
 always found it reliable. He has formulated from his experi- 
 ences the following rules : 
 
 1. A freezing point of 0.58° does not contraindicate an oper- 
 ation. 
 
 2. A freezing point of 0.59° demands caution. 
 
 3. A freezing point of 0.60° and below is a positive contra- 
 indication to any operative interference on the kidney. 
 
 In Case VII this test showed a low freezing point of the blood, 
 but still within the range of a justifiable operative attempt short 
 of nephrectomy. 
 
 The patient was a boy, aged 14. He had lupus of the face of 
 long standing. For several months there had been renal symp- 
 toms. Numerous bacilli were found in the urine. Right kidney 
 was much enlarged. Chloroform-oxygen general anesthesia. 
 Right kidney was exposed by large transverse extraperitoneal 
 incision. The operator introduced his whole right hand 
 behind the kidney, liberated the upper pole and in a few min- 
 utes brought the organ forward into the wound. Kidney was 
 lobulated, pale, soft, and at least eight inches in length. From 
 the convex surface the kidney was incised from pole to pole, 
 laying open freely the distended pelvis and calices. Paren- 
 chyma was pale and edematous. There was very little hemor- 
 rhage. The immense visceral wound, pelvis, and calices Avere 
 tamponed with eophen gauze and after the kidney was replaced 
 the external wound was tamponed with the same material. If 
 after this operation the freezing point of the blood improves 
 nephrectomy will be performed. A few days after the opera- 
 tion the patient was doing well. 
 
 Case YIll.— Catheterization of ureter in male. Dr. Kum- 
 mel is an expert in catheterization of the ureter in the male. 
 He says the operation is much easier in the male than in the 
 female. He makes use of the urethral cystoscope manufac- 
 tured by Remiger, Gebbel and Schalle, Berlin. The illumina- 
 tion of the bladder with this instrument is perfect. So soon as 
 the ureteral orifice is in sight the tip of the ureteral catheter is 
 bent in that direction by a spring, when the catheter is advanced 
 and finds its way into the ureter without any difficulty. The
 
 11 
 
 case occurred in a man advanced in years who came into the 
 hospital to be treated for cystitis. Ureteral catheterization was 
 made as one of the important diagnostic resources. To obtain 
 the urine from each kidney separately it is only necessary to 
 insert the catheter a few lines beyond the ureteral orifice. 
 Catheterization of the left ureter was made in a few minutes 
 with very little discomfort to the patient. 
 
 Case l^.— Primary carcinoma of liver ; exploratory lap- 
 arotomy. Progressive marasmus and repeated attacks of vom- 
 iting suggested the existence of malignant disease of the 
 pyloric end of the stomach. The patient was a man between 60 
 and 70 years. Incision was made a little to the left of the 
 median line. Liver was enlarged, hard, uneven, and under- 
 neath the capsule numerous carcinomatous nodules could be 
 seen and felt. The stomach was small and atrophied. The 
 abdominal incision was sutured in the usual manner. 
 
 Case X. — Radical operation for iyiguiyial hernia by a modified 
 Bassini-Kocher operation. Dr. Kiimmell treats the sac accord- 
 ing to Kocher, and modifies the Bassini method of obliterating 
 the inguinal canal by placing the cord over instead of underneath 
 the fascia of the external oblique muscle. He has performed 
 this operation in several hundred cases and is well satisfied 
 with the results. Relapse of the hernia is almost unknown, 
 and he has never observed atrophy of the testicle as a remote 
 complication. General anesthesia. Hernia right side. Incis- 
 ion was made over entire length of canal. Sac, cord and ves- 
 sels were isolated and lifted away from the inguinal canal with 
 a strip of iodoform gauze. The sac was opened and tip of left 
 index finger inserted and employed as a guide in separating 
 the sac from the cord and its accompanying vessels. Separa- 
 tion of sac was done as far as the internal inguinal ring. A 
 pair of closed hemostatic forceps passed into the canal from 
 below, and with it the tissues were tunneled from within 
 outward over the neck of the sac. Through this tunnel forceps 
 were inserted from without inward and the sac grasped and 
 drawn tight. The neck of the sack was securely stitched to 
 the firm fibers of the external oblique muscle and the sac 
 amputated close to the sutures. The inguinal canal was closed 
 with a continuous catgut suture, which included also the 
 external oblique muscle. The subcutaneous fat and fascia were 
 sutured separately over the cord with catgut and skin with fine 
 silk. This operation appeared to be perfect in every detail and 
 was executed with the skill of a master. 
 
 Case ^il.— Radical operation for inguinal hernia. Same 
 operation. 
 
 Case J^ll.— Congenital dislocation of hip-joint; bloodless 
 reduction. The patient was a girl of 4^ years. Three 
 months ago it was taken for granted that the bloodless reduc- 
 tion had succeeded, and the limb was immobilized in a plaster- 
 of-paris dressing. On removing the dressing a few days ago 
 the head of the femur was found outside of the acetabulum. 
 According to the experience of Dr. Kiimmel such failures are 
 by no means of rare occurrence. In repeating the attempt 
 reduction was effected and the limb was at once immobilized in 
 a plaster-of-paris dressing at a right angle to the pelvis and 
 forcible rotation outward with knee flexed. The fixation 
 dressing will remain undisturbed for three months. 
 
 Case XIII. — Myomatous uterus; abdominal hysterectomy. 
 The patient was a multipara, aged 30. Trendelenburg position. 
 Subserous myofibroma the size of a billiard ball detached in
 
 12 
 
 briDgiDgthe uterus forward into the wound. Fundus of uterus 
 was enlarged by an intramural tumor of the same size. One of 
 the ovaries was saved. Broad ligament and uterine arteries 
 were tied with silk. Vaginal opening was carefully closed 
 with a continuous suture. Abdominal incision was sutured in 
 the customary manner. 
 
 Case XIV. — Salpingitis ; salpingostomy ; oophorectomy. 
 The patient was a multipara, aged 32. A few years ago a ventro- 
 fixation was made. Anterior uterine mural adhesion drawn 
 out into a string at least four inches in length. The inflamed 
 right ovary was removed. Right tube was enlarged, tortuous 
 and fimbriated, extremity closed by adhesions. About an inch 
 of the distal end of the tube was excised, and as the lumen of 
 the remaining part was open the mucosa was stitched to the 
 peritoneal coat with fine silk sutures \\\i\x the expectation of 
 restoring the functional utility of the tube. 
 
 Dr. SicTc's Surgical Work.— Dr. Sick is the second chief 
 surgeon to the hospital. He is a very quiet, modest man, who 
 finds his greatest satisfaction in the museum, laboratory, 
 morgue and operating-room. I doubt if he ever enjoys a vaca- 
 tion, as he is happiest w^hen at work. He is a man of few words, 
 but knows how to interest his visitors in his operative work. 
 He is a cool, deliberate and dextrous operator. He makes his 
 plans carefully and executes them w^ithout hesitation and with- 
 out unnecessary haste. Every move he makes is for a definite 
 purpose, and accomplishes its object. Everyone w^ho witnesses 
 his operations is impressed with the idea that he is in the pres- 
 ence of a surgeon of unusual experience. Dr. Sick approaches 
 the most difficult task with the same ease of mind and body as 
 though he were called upon to perform the most insignificant 
 minor operation. He takes a justifiable pride in many of the 
 interesting specimens in his collection. He has made a special 
 study of acute osteomyelitis of the sternum, and his anatomic 
 and pathologic specimens illustrating this subject throw a flood 
 of light on this somewhat rare affection. He is now investi- 
 gating the anatomic changes which take place in the neck 
 of the femur after amputation of the thigh. The angle of the 
 neck in the course of time is greatly diminished, undoubtedly 
 in consequence of traction made by the weight of the stump. 
 A skull is shown in which, years before death, a piece of bone 
 nearly the size of the palm of the hand of an adult was removed 
 and reimplanted. The outline of this enormous disc is well 
 shown in the specimen, proving conclusively that the bone 
 temporarily removed retained its vitality and took an active 
 part in the restoration of the continuity of the skull. The 
 inner surface of the skull is perfectly smooth, while the 
 external table of the implanted bone is slightly atrophied. A 
 number of skulls show what takes place after the Wagner- 
 Wolff temporary resection of the skull for the removal of 
 malignant tumors of the brain. The bone at the base of the
 
 18 
 
 flap always united by bony union, while the upper part was 
 always liftedaway from the marg^in of the cranial defect by the 
 gradually increasing intracranial pressure, leaving a gaping 
 cleft for the expansion of the intracranial mass. A large col- 
 lection of ivory braces and screws for direct fixation of com- 
 pound and ununited fractures show the different stages of 
 absorption. 
 
 A stomach is exhibited taken from a patient operated upon 
 for ulcer of the stomach ten years before death from an acute 
 pulmonary affection. A gastroenterostomy was made. The 
 patient improved rapidly after the operation and digestion 
 remained unimpaired. The specimen tells an interesting story. 
 The communication between the stomach and upper part of the 
 jejunum is large enough to admit two fingers. Near the 
 pylorus and extending along the lesser curvature of the stomach 
 is a large, smooth scar, corresponding with the location and 
 approximate size of the hourglass-shaped ulcer for which the 
 operation was made. Dr. Sick has had an unusually large 
 experience in gynecologic, abdominal and pelvic operations, 
 and I was greatly pleased to witness his skill in this depart- 
 ment of surgery. I will describe very briefly two of his 
 operations : 
 
 Case I.—Myojibroynas of the uterus; abdominal hysterec- 
 tomy. The patient was a woman, aged 33, mother of two 
 children. She had uterine hemorrhages for more than a year. 
 Intrauterine myoma the size of a small cocoanut projects into 
 the vagina and was first removed. Laparotomy in Trendelen- 
 burg position. Quick median incision. Margins of incision 
 grasped with small vulsellum forceps at bleeding points. A 
 splendid view of pelvic cavity and contents was obtained. The 
 uterus, the size of an adult's fist, was studded with subserous 
 tumors. Right ovary, tube and uterus were removed. Dr. 
 Sick makes exclusive use of catgut as ligature and suturing 
 material. Broad ligament was tied in sections. After tying 
 uterine arteries, the uterus was excised rapidly with blunt- 
 pointed, curved scissors. Vaginal opening was hemmed with 
 continuous catgut suture, which checked all hemorrhage. The 
 opening was then accurately closed with peritoneal catgut 
 sutures. Abdominal incision sutured with four tiers of con- 
 tinuous catgut sutures. Small absorbent dressing held in place 
 by strips of perforated adhesive plaster finished the opera- 
 tion. 
 
 Case 11.— Appendicitis simulatirig salpingitis ; appendec- 
 tomy. Patient was a married woman, aged 30. Four years ago she 
 had a severe attack of what was considered at the time pelvic 
 peritonitis. Four weeks ago she was delivered of a child. She 
 has never been free from pain in the right iliac region since the 
 first attack. Probable diagnosis, pyosalpinx on right side. 
 Bimanual palpation under anesthesia detected a hard swelling 
 in the region of the right fallopian tube. Trendelenburg posi- 
 tion. Rapid median incision. A coil of small intestine was 
 found adherent to the parietal peritoneum in the right iliac 
 fossa. In separating the firm adhesions with finger and blunt
 
 14 
 
 instruments, a fecal stone the size of a large bean escaped. In 
 the small cavity in which the stone was lodged the open termi- 
 nal end of the appendix was discovered. Excision of walls of 
 abscess-cavity and perforated appendix. The raw surfaces on 
 the intestine and parietal peritoneum were carefully covered 
 with healthy peritoneum by suturing with catgut. Adhesions 
 extended to the fundus of the subinvoluted uterus. Abdominal 
 incision was closed wath four rows of continuous catgut 
 sutures. No drainage. 
 
 A visit to the general hospital Hamburg- Eppendorf should 
 include inspection of the bath-house, gymnasium, massage- 
 room, orthopedic department, and morgue. The bath-house, 
 a model of its kind, is in charge of competent orderlies 
 and trained nurses. The gymnasium has a complete outfit 
 of Zander mechanical apparatus for passive and active exer- 
 cise of every muscle and joint of the body. This outfit was 
 purchased at an expense of 30,000 marks. Instruction in mas- 
 sage, theoretic and practical, is given free of expense. After 
 three months the candidates for this kind of hospital and pri- 
 vate work are examined and if found competent receive a cer- 
 tificate of proficiency from the orthopedic department. Corsets 
 and apparatus of all kinds are made by skilled workmen. 
 From five to twelve necropsies are made daily in the morgue 
 by men who are familiar with that kind of work and experts in 
 gross and microscopic anatomy. From w^hat I have seen in 
 various places on this trip I have come to the conclusion that the 
 practitioner can see and learn more in one day in the general 
 hospital Hamburg-Eppendorf than in any other place on the 
 Continent or anywhere else. 
 Hamburg, August 15.
 
 fKeprinted from American Medicine, Vol. V, No. 2, pages 6«-68, 
 January 10, 1903.] 
 
 HOSPITAL WORK OF DR. CARL LAUENSTEIN. 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 One of the best known names in the medical and social 
 circles of Hamburg is that of Dr. Carl Lauensteiu. As a sur- 
 geon his name is familiar wherever surgery is practised. His 
 contributions to surgical literature have been many and of great 
 scientific and practical value. His voice is heard at every 
 annual meeting of the German Sur- 
 gical Society, and never fails to 
 command earnest attention. Nearly 
 every volume of the transactions 
 of this society contains an account 
 of his activity as a surgeon and 
 scientist. He speaks French and 
 English fluently, and is well versed 
 in everything pertaining to foreign 
 medical literature. His personality 
 is a striking one. He stands six 
 feet four in his stockings, erect as 
 the fir tree of his native home, and 
 is endowed with the physical 
 strength of a giant. A man of ordi- 
 nary size standing or walking aside 
 of him experiences a keen sense of 
 his physical insignificance under 
 the shadow of his towering height. 
 He is a typical blonde, and his 
 large azure-blue eyes reflect the 
 nobility of his soul. He has reached 
 the fifty-second milestone of his 
 busy, useful life. The son of a cler- 
 gyman, he received the most care- 
 ful training from early child- 
 hood for the profession of his 
 choice. He studied medicine at 
 the University of Gottingen, and 
 
 was the favorite pupil of the late Professor William Baum. 
 Lauenstein respected and loved his teacher of surgery. The 
 
 Carl Lauenstein and his 
 smaller brother as privates 
 during the Franco-Prussian 
 war.
 
 genuine piety, profound learning and honest convictions which 
 characterized the life and work of Professor Baum made a deep 
 and lasting impression on hi% pupil, and undoubtedly had 
 much to do in molding his subsequent professional career. 
 Lauenstein loves to relate little incidents in the life of his 
 master. Many of these little storiettes reflect the surgical 
 practice of those days. On one occasion an assistant had used a 
 probe in exploring a foul abscess ; the professor, who wished to 
 examine a recent wound, called for the instrument, and wishing 
 to impress his assistants with the importance of surgical clean- 
 liness, wiped the probe between his lips and then with a clean 
 and easy conscience used it upon his patient. Lauenstein's 
 early student days were eventful. At the outbreak of the 
 Franco-Prussian war he was a medical student at Gottingen. 
 He, like most of the university students, promptly volunteered 
 and entered the military service as a private of a musketeer 
 regiment. During the short, historic military career he w^rote 
 one and often two letters every day to his anxious, devoted, 
 affectionate parents. These letters were preserved, and in 1895 
 he published them in book form and presented this souvenir of 
 the war to his mother on Christmas day. How his aged mother 
 appreciated this gift only a mother can describe who has passed 
 through the same bitter experience. Lauenstein was a faith- 
 ful, heroic soldier. He was in action eleven times, and had 
 many narrow escapes, but Providence deviated the bullets 
 aimed at him. His patriotism and sense of duty knew no 
 tK)unds. On his return home one of his friends furnished the 
 explanation why he escaped uninjured. He said that during 
 one of the battles a Frenchman drew his bead on him at close 
 range, the next moment he dropped his musket lower, fully con- 
 vinced that other comrades had selected the same conspicuous 
 target, and not wishing to waste ammunition, fired at a man of 
 ordinary size. In one of his letters to his parents he said that if 
 he were permitted to return home alive he would never return 
 to France, where he experienced all the privations meted out 
 to the private soldier during a forced campaign under the most 
 distressing climatic conditions. He failed to keep this promise. 
 He recently made a bicycle tour through France with his 
 oldest son, a law student, and visited all of the familiar battle- 
 fields where he served his country so well 32 years before. Such 
 men should be rewarded with a jeweled cross of gold instead 
 of one of iron. Dr. Lauenstein's opportunities for making prac- 
 tical use of his surgical knowledge and skill have been 
 immense. He is surgeon-in-chief to two of the Hamburg hos- 
 pitals and at the same time enjoys a lucrative private practice. 
 Bethesda Hospital. — This is a private hospital in charge of 
 -deaconesses. It contains 100 beds, of which 50 are occupied l)y
 
 3 
 
 surgical patients. Lauenstein is the very soul of this institu- 
 tion. It is here where his surgical methods can be studied to 
 greatest advantage. A new addition is nearly completed and 
 will afford the necessary additional room for the increasing 
 demands on the hospital. The patients are divided into three 
 classes. The first class patients pay eight marks a day, the sec- 
 ond five. Many of the third class are received as charity cases. 
 The wealthy citizens contribute liberally toward the improve- 
 ments and running expenses of this excellent institution. The 
 operating-room is small, unpretentious, but the plain, simple 
 facilities for asepsis are utilized in such a practical manner that 
 the visitor becomes convinced that the patients who are oper- 
 ated upon have received all the essential prophylactic care that 
 modern surgery can offer against infection. Lauenstein places- 
 more weight on air infection than most surgeons. One of his^ 
 requirements in entering the operating-room is careful wiping 
 of the shoes, a task which is performed in a most conscientious 
 manner by a male servant. Gloves are used in operations upon 
 septic cases, and then only for the purpose of protecting the 
 hands against contamination. Instead of a mask the hair and 
 beard are washed and are kept moist with an antiseptic solu- 
 tion. The operator is assisted by the house surgeon and three 
 Sisters. One of the Sisters administers the anesthetic, usually 
 chloroform, by the drop method ; another has charge of the 
 instruments, and the third one handles the gauze, sponges and 
 dressing material. 
 
 Lauenstein' s Method of Hand Disinfection. — Lauenstein has 
 made disinfection of the skin a special study for several years. 
 Some three years ago he reported upon the results of his scien- 
 tific investigations on this subject. He made use of all then 
 known methods of disinfection and then removed a small 
 particle of skin from the disinfected surface and under strict 
 aseptic precautions transferred it to a nutrient medium. 
 Without exception microbes developed, which led him to the 
 conclusion that absolute asepsis cannot be obtained by any of 
 the methods so far employed. These observations taught him 
 the necessity of combining aseptic with antiseptic measures. 
 He irrigates wounds with a 2% solution of lysol. His direc- 
 tions for hand disinfection are the following: 
 
 1. Softening and washing of the hands without brush in 
 warm water with soap, frequently changed until the water 
 remains clean. 
 
 2. Cleansing and trimming of finger nails. 
 
 3. Renewed washing in warm water without brush. 
 
 4. Final cleansing in warm water and soap with use of sterile 
 brush. 
 
 5. Drying with sterile towel.
 
 6. Thorough immersion and scrubbing of fingers and hands 
 Avith 96% alcohol with use of sterile gauze sponges with special 
 reference to finger nails and subungual spaces continued for three 
 minutes. The field of operation is prepared the evening before 
 operation and the surface covered with a compress saturated 
 with a solution of salicylic acid. Before the operation the final 
 disinfection is made. 
 
 Lauenstein's Method of Catgut Sterilization. — Lauenstein 
 has given the different methods of catgut sterilization a fair 
 trial and after finding them unsatisfactory has adopted the fol- 
 lowing method : 
 
 The catgut, free from fat and sterilized by dry heat, is 
 immersed for eight days in 50% creolin-vasogen. In this very 
 active bactericide the catgut softens and swells and is sat- 
 urated with the creolin-vasogen throughout. It is then placed 
 in 2% salicyl- alcohol to which 10% of glycerin is added. In this 
 solution the threads are often turned over and in this solution 
 it regains its firmness and tensile strength. Before use it is 
 immersed in .5% formalin-alcohol. He has used catgut pre- 
 pared by this method for six 
 years with perfect satisfac- 
 tion. The bacteriologic ex- 
 aminations of this catgut 
 made frequently by Profes- 
 sor Dunbar have always 
 proved its absolute sterility. 
 Silk used for superficial su- 
 tures is sterilized by boiling. 
 Dr. Lauenstein regards reli- 
 able catgut as the ideal ma- 
 terial for ligatures and bur- 
 ied sutures. He has in his 
 service a large gynecologic 
 material. One day he exam- 
 ined three patients under 
 anesthesia and dictated the 
 following diagnoses: Sub- 
 serous myofibroma, solid 
 
 tumor of ovary, large ovarian cyst. All of these patients were 
 operated upon three days later. On the day of my visit to this 
 hospital he performed the first operation after his return from 
 his summer vacation. 
 
 Dr. Carl Lauenstein. 
 
 Tuberculosis of the Knee-joint : Amputation of Thigh After 
 Resection of Joint had Failed. — The patient was a woman, 
 aged 56, who entered the hospital two months ago, suffering 
 from advanced tuberculosis of the left knee-joint. Typical 
 resection was made with faint expectation of a successful result
 
 owing to her advanced age and the extent of the disease. The 
 wound healed only in part and the extensive recurrence left no 
 doubt concerning the propriety of resorting to a mutilating 
 operation. Patient was anemic and considerably emaciated ; 
 chloroform anesthesia ; elastic constriction at base of thigh ; 
 long anterior and short posterior cutaneous flaps ; remaining 
 soft tissues were divided down to the bone with one sweep of 
 the knife; soft tissues were retracted with two folded gauze 
 bandages. After reflection of periosteum with elevator cross 
 section of bone with a bow saw, the femoral artery and vein 
 were isolated separately and tied with catgut. Careful search 
 was made for the intramuscular branches, which were seized 
 with hemostatic forceps. So thoroughly was this done that 
 when the constrictor was removed no further use of the forceps 
 became necessary. The flaps were united with silk sutures 
 leaving both angles of the wound open for gauze drainage. 
 The wound was thoroughly flushed with a 2% solution of lysol 
 before and after suturing. A few layers of loose sterile gauze, 
 next a thick layer of aseptic absorbent cotton, a cushion of 
 wood wool and a second layer of cotton held in place with a 
 gauze roller, which also included the pelvis, constituted the 
 dressing. 
 
 In the absence of unfavorable symptoms the first dressing 
 is not disturbed for two weeks. With the methods he now 
 employs Dr. Lauenstein looks with confidence to his results. 
 
 Harbor Hospital.— This is a government hospital built and 
 supported by the city of Hamburg. Dr. Lauenstein is the 
 surgeou-in-chief, assisted by four salaried resident physicians. 
 The hospital is intended for emergency cases, and its interior 
 construction corresponds with this purpose. The wards are 
 well furnished, well lighted, and well ventilated. It contains a 
 motley population, as it is likewise the refuge for the sick and 
 injured sailors of all nations who frequent the great mercantile 
 harbor of Hamburg. 
 
 This is the place in Hamburg to make a practical study of 
 accidental surgery. Among the injuries brought here almost 
 daily are fractures, dislocations, sprains and burns ; stab and 
 gunshot wounds are comparatively rare. 
 
 The dressing and operating-rooms are constructed upon the 
 most improved plans, and are splendidly equipped. With all 
 such conveniences it must be a source of gratification and 
 pleasure to practise emergency surgery. The Rontgen appa- 
 ratus and rooms are in constant use, and in charge of an expert. 
 A complete outfit for photography turns out daily the most 
 interesting illustrations of fractures, dislocations, and other 
 injuries. Dr. Lauenstein is now making a special study of 
 spiral fractures. He has the requisite material at his disposal 
 to elucidate this subject from a scientific as well as a practical 
 standpoint. Much has been said and written concerning this 
 particular anatomic form of fractures, but more light is needed 
 to comprehend fully the mechanism of their production. A
 
 Q 
 
 number of beautiful Rontgen illustrations were shown of spiral 
 fracture of the tibia and fibula. In fracture of both bones» 
 the seat of the injury involv^ed the lower part of the tibia, while 
 the fibula yielded near the upper extremity. Reduction and 
 retention by proper means of fixation offer no particular diffi- 
 culties, and the results are usually very satisfactory. Dr. Lau- 
 enstein intends to present the paper he is preparing on the 
 nature and treatment of this fracture on the occasion of the 
 eightieth birthday of his Excellency Professor von Esmarch^ 
 which will be celebrated in the birthplace of that distinguished 
 surgeon next .January. The paper will be profusely illustrated » 
 and will be looked for with interest by the profession, as it will 
 clear up a number of doubtful points in the etiology of spiral 
 fractures. The nursing in this hospital in the male wards is 
 done exclusively by trained male nurses. The scrupulous clean- 
 liness throughout the entire institution reflects credit upon the 
 director as well as upon the efficient and well-organized nurs- 
 ing force. 
 
 The city morgue is located in the hospital grounds. Here 
 is a good place to make a practical study of legal medicine, as 
 a number of postmortems are made daily by an expert, and the 
 causes of death, accidental and otherwise, are investigated with 
 a view of satisfying all legal requirements. 
 
 The detention department is an interesting part of the hos- 
 pital. This serves as a temporary asylum for cases of acute 
 insanity, delirium tremens, etc. Violent patients are confined 
 in single rooms having an iron door, which is locked. The 
 room contains nothing but a leather-covered mattress for a bed» 
 About six cells are always occupied by delirium tremens 
 patients. Tn one cell we found a man in shirt sleeves facing 
 the rear wall reaching with trembling hands for red currants 
 which he saw distinctly on the bare white wall but always 
 eluding his greedy grasp. Lauenstein has abandoned the use of 
 alcoholic stimulants in the treatment of delirium tremens after 
 a trial of over 20 years. He has become satisfied and firmly 
 convinced that recovery takes places more speedily without 
 than with alcohol. He looks upon the disease as an intoxica- 
 tion and reasons very properly that the sooner the cause is 
 removed the more sure and prompt will be the recovery. So 
 long as the patients are violent they are confined in a cell. 
 Small doses of morphia and chloral hydrate are given to pro^ 
 cure sleep. Much stress is laid on the administration of con- 
 centrated fluid nourishment. If on admission of the patient 
 there is reason to believe that the stomach contains alcohol it is. 
 evacuated by siphonage. The acute symptoms usually subside 
 in three or four days, when the patient is transferred to an 
 adjoining ward, where with other conv^alescents he receives the
 
 appropriate after-treatment and where he remains until recovery 
 is complete. It is said that most of these patients return about 
 every six months with the same disease and pass through the 
 same course of treatment. In Germany, like elsewhere, 
 delirium tremens is caused by the excessive use of spirits ; beer 
 drinkers seldom succumb to this disease. 
 
 The medical tourist visiting Hamburg should not neglect to 
 make a visit to the Harbor Hospital, as he will be sure to find 
 here many things of the utmost scientific and practical interest 
 and will always meet a cordial reception by its genial medical 
 director, Dr. Carl Lauenstein. 
 
 On board S. S. " Blucher," August 25.
 
 (Reprinted from American Medicine, Vol, V, No. 3. pages 105-108 
 January 17, 1903.] ' 
 
 A COMPARISON BETWEEN FOREIGN AND AMERI- 
 CAN SURGERY. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 The average physician seldom sees more than the hospitals 
 of his own country. It is a great privilege and a rich experi- 
 ence to have an opportunity to visit the hospitals of four conti- 
 nents in succession, and to study their facilities, scope of work, 
 and methods pursued in the treatment and care of the sick. 
 Such an unusual opportunity presented itself to me on my 
 recent mission to St. Petersburg and long journey to the Orient. 
 This trip was not one purely of pleasure or recreation. It 
 included many hardships, as the journey through Asia and 
 Egypt was made in midsummer, when the heat was greatest and 
 the pestiferous insects most numerous and in best fighting con- 
 dition. After the adjournment of the Seventh Conference of 
 the International Red Cross the main object of my tour was to 
 familiarize myself with the present surgical methods in the dif- 
 ferent hospitals of the countries through which I traveled. My 
 observations were made in France, Germany, Russia, Turkey, 
 Syria, Palestine, Egypt, Austria, England, Sweden, and 
 America, and have been briefly described in the pages 
 of this journal. I found everywhere satisfactory proof 
 that our profession is a truly international one, bound 
 together without regard to color, religion, or politics 
 by a strong tie of a common desire to advance science 
 and benefit humanity. I have become more convinced 
 than ever that this bond of union is stronger in the medi- 
 cal than any other of the learned professions. The desire 
 and genuine willingness to learn and to instruct are more pro- 
 nounced among medical men than any other class. I also 
 became satisfied that modern progress in medicine and surgery 
 has no geographic limits. The medical men throughout the 
 entire civilized world are all engaged in doing their share 
 toward the advancement of science, and make their contribu- 
 tions according to surroundings, opportunities and facilities for 
 work. It is not difficult to accomplish great results in a well- 
 equipped institution with adequate financial resources. I 
 admired particularly the scientific work in some of the small 
 laboratories in the distant Orient, where many investigations of
 
 far-reaching value have been made under the greatest dif- 
 ficulties. It is work of this kind that is entitled to full recogni- 
 tion. The progress of medicine has penetrated the most remote 
 countries that have any claim on civilization. The dawn of the 
 light of original thought and research is visible everywhere, 
 and is rapidly forcing out of existence routine practice. The 
 science of medicine is rapidly retracing its steps from whence 
 it came. The newest and best in medicine in Asia and Africa 
 comes from Europe, more especially from Germany. The 
 missionary physicians have been the pioneers in disseminating 
 modern medicine throughout the distant East, and in establish- 
 ing outposts for scientific research. In many of the small labora- 
 tories of the missionary hospitals, original work is being done 
 w^hich would be creditable to larger and better equipped insti- 
 tutions. The spirit of awakening has taken a firm foothold 
 upon the soil of Asia and the Dark Continent, and will soon 
 bring about changes in the care of the sick and in the preven- 
 tion of disease that will be a source of gratification to those 
 who called it into existence. The universities and hospitals of 
 Russia would compare favorably with those of any other 
 country. The medical profession of England enjoys the respect 
 of the government and the public, and is exceptionally well 
 qualified to cope most successfully with the prevention and 
 treatment of disease. The lethargy in medical matters which 
 prevailed in France for a considerable length of time has disap- 
 peared and has given place to an energetic and enthusiastic 
 search for the unknown in the science of medicine. Germany 
 and Austria have done more for the advancement of scientific 
 medicine during the last half century than all of the other 
 European countries combined. Germany is today the Mecca to 
 which medical students and practitioners make pilgrimages 
 from all parts of the world for the purpose of obtaining the 
 material for a firm foundation upon which to build the super- 
 structure of rational medicine. Surgery in all of these countries 
 has attained a high degree of perfection. Some of the hospitals, 
 more especially those supported by the different governments, 
 are palaces for the sick, and are supplied with all conceivable 
 means and appliances for asepsis. 
 
 It is a great privilege to serve the sick in such an insti- 
 tution, as more than one-half of the battle with disease and acci- 
 dents is fought by the well trained nurses and the staff of 
 assistants with long service and large experience. It is in less 
 favored hospitals that the surgeon assumes greater responsibili- 
 ties, and it is the results he records that are withiu reach of the 
 general practitioner and which represent the achievements of 
 the mass of the profession. All of the European physicians are 
 well-educated men, as the entrance to their medical education
 
 is well guarded, for medical colleges are gradualjy recognizing 
 the importance of an adequate preliminary education as an 
 essential requirement for the successful study and training of 
 the medical student, but the change from a medium to the 
 highest standard is slower than the present conditions demand. 
 On the other hand, I believe we can claim, without fear of 
 contradiction, that our students apply themselves more closely 
 to their studies than those of any of the European schools, and 
 that more of the mass of our profession keep pace with medi- 
 cal progress after graduation than the physicians abroad. The 
 keen competition and the inborn activeness and desire to 
 succeed that characterize the average American physician 
 make him a diligent student and a tireless practitioner. There 
 is no country in the world where so many medical journals are 
 read as in America, and where postgraduate education is more 
 keenly appreciated. Our active, well-attended, numerous 
 medical societies, local and national, keep up the scientific 
 interest of the rank and file of our profession, and are the most 
 important agents in stimulating and furthering postgraduate 
 education. 
 
 The vast clinical material of the large European hospitals is 
 utilized to greater advantage than the clinical material here. 
 Autopsies are more frequently made and with greater thor- 
 oughness. All hospitals of any size issue an annual report in 
 which will be found a concise retrospect of the medical and 
 surgical work for the year. These publications are valuable 
 literary contributions and are eagerly looked for and liberally 
 quoted by authors. Politics and church influence do not cripple 
 hospital management as much in Europe as in America. The 
 university professors are sure of their hospital appointment 
 until their retiring age reminds them of the limitation of their 
 career as teachers. The esteem and respect for medical men 
 abroad is much keener than here and they occupy a higher 
 position in the social world and political circles. From a prac- 
 tical standpoint the American doctor compares well with his 
 colleagues abroad. His natural aptitude, his education and train- 
 ing harmonize in making him self-reliant and in making the 
 best use of his knowledge at the bedside. The American doc- 
 tor is impartial in the selection of his reading material. He has 
 no national prejudices. He absorbs knowledge from all avail- 
 able sources. All new innovations and discoveries are given a 
 prompt and fair trial. Many of our physicians and surgeons 
 make frequent visits abroad and return with new ideas which 
 enlarge their knowledge of disease and open new fields for 
 their practice and surgical activity. It is safe to make the 
 statemeilt that the gigantic progress in American medicine and 
 surgery which has been made during the last quarter of a cen-
 
 tury is due largrely to what our students and practitioners have 
 borrowed in Europe and the seed thus introduced has found 
 here a fertile soil and has yielded fruit a hundredfold. From a 
 medical and surgical standpoint no country is independent, and 
 we have reached a stage in the growth of medical science which 
 brings us up nearly to the same level with any of the foreign 
 countries. We have every reason to look with a justifiable 
 pride on the part America has taken in the rapid development 
 of modern surgery. The teachings of Lister were eagerly 
 grasped and promptly applied in practice. Some of the coun- 
 tries on the continent were slow in adopting the new views, 
 America never hesitated. From what I have seen on three 
 continents I can say without hesitation that the aseptic pre- 
 -cautions which are in use by our surgeons are applied as thor- 
 oughly here as anywhere else. The average American surgeon 
 is resourceful. He may not have the same broad preliminary 
 and professional education as his European colleagues, but he 
 ds quick and determined in the selection and use of appropriate 
 therapeutic resources. The American surgeon is eminently 
 practical. He is peculiarly well fitted for emergency work. 
 He performs the most difficult task with the simplest means 
 :and appliances. American ingenuity, recognized the world 
 over, is well represented in the medical profession. A visit to 
 'Europe, Asia, and Africa, with a view of ascertaining the 
 present status of surgery in difl*erent countries, awakens a new 
 interest in the science and art of medicine as they exist in our 
 own country. On my return from Europe I remained two days 
 An Xew York for the purpose of visiting a few of the most 
 ^prominent hospitals to obtain the necessary material upon 
 which I could base a practical comparison between foreign and 
 American surgery. 
 
 Midsummer is not a good time to see surgical New York, 
 as most of the prominent surgeons are enjoying their much- 
 .needed rest and recreation at that time. I was fortunate to 
 ■find a few of the men I was anxious to see at home and at 
 work. 
 
 Xew York has four medical schools, all of them in excellent 
 repute. Among these the College of Physicians and Surgeons 
 is the one that is entitled to first place, by virtue of age and the 
 elaborate facilities it can extend to its students in its theoretic 
 ^nd practical courses. Most of the clinical teaching of this 
 college is conducted in the 
 
 ROOSEVELT HOSPITAL. 
 
 The Roosevelt is one of the best, if not the best, private 
 hospitals in New York. The name of this institution com- 
 memorates the philanthropy of a grand-uncle of our present 
 
 i
 
 Chief Executive, who donated |1,400,000 for the erection and 
 maintenance of the hospital. The pride of this hospital is the 
 W. J. Syms operating-room, built at an expense of $250,000, the 
 gift of the man whose name it bears, and which was opened 
 for clinical teaching in 1892. It is the most costly and prob- 
 ably the most perfect operating theater in the world. The con- 
 struction of the interior of the room, as well as everything 
 within it, are such as to adapt them for perfect aseptic work. 
 The teacher of clinical surgery who visits this part of the hos- 
 pital, and who has been less fortunate in his svirroundings, is 
 perfectly amazed at the conveniences which are at the disposal 
 of his more favored colleagues here. In the amphitheater th& 
 large college clinics are held. Professors Weir and Bull give 
 each one clinic a week. Drs. Brewer and Blake give each 
 three clinics to small classes of 20 every week. The students 
 of this college have every opportunity to acquire the necessary- 
 surgical skill that a large material and effective teaching caiii 
 offer. In a small side room, equally well equipped, the more 
 serious operations, and operations upon private patients, are 
 performed. Another room is devoted to septic cases, and in it 
 will be found every possible convenience for antisepsis. The 
 McLean operating-room is another very luxurious part of the 
 hospital, and is used exclusively for gynecologic operations. 
 The students attend this clinic in small sections. Two anes- 
 thesia rooms are within easy reach of the main operating-room. 
 The hospital has 250 beds. Two rooms, with two beds each, 
 near the main operating theater, are reserved for patients wha 
 have undergone a serious operation, and there they remain 
 until they recover from its immediate effects, when they are 
 assigned to the wards where they belong. The disinfection- 
 room and two rooms for the preparation of the dressing mate- 
 rial are all that money and skill could make them. The hos- 
 pital is well supplied with trained female nurses. The training- 
 school connected with it has 60 pupils. The nurses are not over- 
 worked, as is the case in many other hospitals. The wards, 
 with 36 beds, are attended to by five nurses. The course of 
 study and training for the nurses is three years. During this 
 time they are given an opportunity to perfect themselves in, 
 the nursing of a great variety of patients. Eight internes are 
 employed for the surgical side alone, perhaps more internes to 
 the number of patients than in most hospitals. The outdoor 
 department is very large, and two automobile ambulances are 
 seldom at rest. Ether is the anesthetic in general use. 
 
 Weir''s Method of Hand Dismfect ion.— This method is virtu- 
 ally the one relied upon by all of the surgeons connected with 
 the Roosevelt Hospital, and might well be termed the Roose- 
 velt method. It is as follows :
 
 Thorough scrubbing of hands with flowing, warm, sterile 
 water and potash soap. About a tablespoouful of small crystals 
 of sodium carbonate are then placed in the palm of one hand, to 
 which is added about one-third as much of chlorid of lime. The 
 hands are thoroughly rubbed with this mixture for some length 
 of time, when they are rubbed dry with a sterile towel and are 
 then rinsed in sterile water. Professor Weir places much stress 
 on the penetrating power of chlorin gas, which reaches 
 microbes in the appendages of the skin and in the layers of the 
 epidermis inaccessible to many of the antiseptic solutions. 
 
 The finger-nails ref^eive proper attention in the mechanical 
 treatment of the hands. After the chlorid disinfection sub- 
 limate solution is used in the usual way as an additional safe- 
 guard. Alcohol is occasionally used, but is not considered 
 essential in completing the hand disinfection. 
 
 Professor-, Weir has proved the reliability of this method of 
 hand disinfection by numerous bacteriologic examinations, 
 which invariably demonstrated the absolute sterility of the sur- 
 face thus treated. Weir only makes use of rubber gloves in 
 aseptic cases \vhen he has to operate upon joints and the abdo- 
 men. Dr. Brewer uses gloves in all of his operations. Catgut, 
 silk, silkwormgut, and horsehair are used for suture material. 
 For buried sutures catgut is usually employed. 
 
 Roosevelt Method of Catgut Sterilization.— Immerse in juni- 
 per oil for 4 days; immerse in sulfuric ether for 14 days; 
 immerse in benzine for 14 days. Boil in alcohol for half an hour 
 to an hour, according to the size of the catgut. Keep in alcohol 
 ready for use. 
 
 The iron-stained silkwormgut is a favorite material for 
 superficial sutures. 
 
 The anesthetic is administered in the anesthesia-room by 
 one of the internes. Two internes and two trained nurses assist 
 the operator. The patient is prepared the evening before the 
 operation and the final disinfection is made after the patient is 
 fully under the influence of the anesthetic. 
 
 Professor Weir has had a long and varied surgical exper- 
 ience. He entered the regular army in 1861, soon after his 
 graduation, and did most creditable service during the Civil 
 war. He is well remembered by his army colleagues. During 
 his recent all-around-the-world trip he visited the Philippine 
 Islands. Here he found many of his old army friends, who did 
 all in their power to make that part of his journey pleasant and 
 profitable. Weir's name is intimately associated with the 
 surgical literature of America. He has been an earnest student, 
 a successful surgeon, an impressive teacher, and a prolific 
 writer. He finds it difficult to cut loose from his professional 
 work, as this brings to him more satisfaction than idle recrea- 
 tion. During my stay in New York he came to the city for a 
 few days from his vacation to perform a number of operations 
 on private patients.
 
 The patient operated upou the day of uiy visit to the hospital 
 was a very interesting one. 
 
 The man was about 50, and the subject of a somewhat 
 obscure affection involving the floor of the mouth and the 
 submental and submaxillary regions. A number of weeks 
 ago while taking outdoor exercise in the country he sud- 
 denly experienced a sensation near the base and lower surface 
 of the tongue as though some sharp foreign substance had 
 entered the tissues. A violent inflammation followed, which 
 involved the submental and submaxillary regions. This in- 
 flammation terminated in the formation of an acute abscess. 
 The swelling subsided only in part after the abscess was incised 
 and a fistulous opening remained. A hard mass remained and 
 resisted all treatment. A positive differential diagnosis 
 between an inflammatory affection and malignant disease could 
 not be made. Under ether anesthesia a horseshoe-shaped incis- 
 ion was made along the lower border of the inferior maxilla. 
 The flap was reflected as far as the hyoid bone. At this stage of 
 the operation a piece of the indurated tissue was excised and 
 the pathologist of the hospital, who was present, made a frozen 
 section and examined it under the microscope. This examina- 
 tion demonstrated the inflammatory nature of the affection. By 
 a careful and somewhat difficult dissection all of the infected 
 glands and indurated tissues were thoroughly excised. A large 
 rent in the mucous membrane of the floor of the mouth was 
 made. A Penrose drain was inserted into one angle of the 
 wound and the external incision closed with fine iron-dyed 
 silkwormgut sutures. The oval wound was tamponed with a 
 strip of iodoform gauze saturated with compound tincture of 
 benzoin. An external absorbent dressing finished the opera- 
 tion. 
 
 The Penrose drain is a most excellent one for capillary 
 drainage. It consists of a tube of very fine soft rubber loosely 
 filled with absorbent gauze. 
 
 Weir has made a very fine collection of appendicitis speci- 
 mens. The specimens are fastened on one side of a narrow 
 strip of white cardboard, and on the other side is a drawing 
 and the legend. The specimens are preserved in cylindric 
 glasses containing a formalin solution. It is hoped that this 
 valuable collection of pathologic specimens will be utilized 
 for the benefit of the general profession in illustrating the 
 pathologic condition of thi^ as yet somewhat obscure disease. 
 
 Dr. Brewer is one of the attending surgeons to Roosevelt 
 Hospital, and also clinical instructor in the College of Physi- 
 cians and Surgeons. He is a young surgeon full of promise, in 
 fact, as Professor Weir informed me, " one of the coming men." 
 During Weir's absence he does most of the operative work. It 
 was a source of pleasure and profit to me to witness a few of his 
 operations. 
 
 Case I. — Left inguinal hernia, radical, by Bassini\s 
 tnethod. Left inguinal hernia of many years' standing, for 
 which truss was worn for a long time. Patient was a man of 
 30, otherwise in excellent health. Ether anesthesia was
 
 employed. Final disinfection was done before operation. 
 Hand disinfection by Weir's method. Incision was made over 
 entire length of inguinal canal. Partial isolation of sac, when 
 it was grasped with two dissecting forceps, between which it 
 was opened with scissors. Omental part of hernial contents 
 adherent to the sac. The omentum was separated, tied with 
 catgut, and amputated at a safe distance below the ligature. 
 After complete isolation of the sac it was transfixed at the neck 
 with needle covered with catgut and tied and cut off below the 
 ligatures. The cord and accompanying vessels were now iso- 
 lated and lifted out of the canal with a folded strip of iodoform 
 gauze. The inguinal canal was closed with chromicized catgut 
 sutures, the material always employed in performing this part 
 of Bassini's typical operation. Next the fascia of the external 
 oblique muscle was sutured over the cord with a continuous 
 suture of ordinary catgut sterilized by the Roosevelt method. 
 Iron-dyed silkwormgut interrupted suture was employed for 
 the skin. The dressing Avas sterile loose gauze and absorbent 
 sterile cotton held in place by strips of adhesive plaster and an 
 abdominal bandage with two perineal straps. It is routine 
 practice here to drain such wounds with a folded piece of sterile 
 guttapercha tissue. The wound is frequently douched with 
 warui physiologic solution of sodium chlorid. 
 
 Case II. — FiMula folloiving operation for acute appendicitis ; 
 laparotomy; suturing of cecal perforation. The patient, a 
 young man, was operated upon by Dr. Brewer two months ago 
 for acute appendicitis. The wound healed by primary inten- 
 tion, but a small fistula remained which failed to heal. There 
 was a very scanty seropurulent discharge at times. It was sup- 
 posed that this fistula was caused and was maintained by an 
 infected silk ligature. The fistulous opening was enlarged by 
 incising the scar tissue in both directions. The fistula led into 
 the abdominal cavity and the incision had to be enlarged. The 
 great omentum and cecum came into view and in following the 
 fistulous tract a minute perforation in the cecum was found 
 where the appendix was ligated at the first operation. The 
 perforation was thoroughly disinfected with hydrogen dioxid 
 and was closed with a continuous Lembert suture of very fine 
 catgut. The external incision was sutured with two tiers of 
 buried catgut sutures and superficial iron-dyed silkwormgut 
 sutures. A guttapercha strip drain was placed in the lower 
 angle of the wound. Dry hygroscopic sterile dressing was 
 applied. 
 
 NEW YORK HOSPITAL. 
 
 This is probably the most elaborate and best equipped 
 private hospital in New York. It is well endowed and it is 
 said that it takes more money to take care of a patient in this 
 than in any other hospital. The number of patients corresponds 
 with that of the Roosevelt. A new wing wath 50 beds is for 
 private patients and has a separate staff of internes and nursing 
 force. The rooms are luxuriously furnished. Some of them 
 have a bath-room and closet conveniences. The ward patients 
 pay $2 a day, while the private rooms command from $30 
 to $75 per week. A small but beautiful separate operating- 
 room is connected with this department of the hospital. It is 
 in this room that Dr. Charles McBurney performs most of
 
 his operations. The training-school of this liospital is attended 
 by 80 pupils, who are required to take a course of three years 
 before they are permitted to apply for final examination. 
 The lectures are given by members of the attending staff. 
 The general operating-room seats 75 students. No fee is 
 charged for clinical instruction. Students from all of the four 
 medical schools take advantage of the excellent clinical teach- 
 ing given here by the large staff of attending physicians and 
 surgeons. The students of the Cornell Medical School take 
 private courses, for which they pay a small fee. The surgical 
 staff includes the wellknown names of L. A. Stimson, Francis 
 W. Murray, A. B. Johnson, Frank Hartley, and P. R. Bolton. 
 These men keep up the high standard of clinical surgery of this, 
 one of the best known of the New York hospitals. Ether is 
 the anesthetic of choice. The catgut is sterilized by Saul's 
 method. Sulfate of ammonium catgut after a fair trial has been 
 abandoned, as it was found too brittle in tying the ligatures and 
 sutures. Silk and iron-dyed silkwormgut are used for super- 
 ficial sutures. Hand disinfection with chlorid of lime is in 
 general use. 
 
 Rubber gloves and caps are worn constantly by operators 
 and assistants. Two internes and two trained female nurses 
 assist the operator. A third interne administers the anesthetic. 
 I was fortunate enough to find Dr. Alexander B. Johnson at 
 work. He is professor of surgery in the Cornell Medical 
 College, and one of the most careful and skilful operators in 
 New York. On the day of my visit he had to deal with two 
 very rare cases. 
 
 Case I.— Ulcer of stomach ; laparotomy. The patient was a 
 young man, who was admitted into the hospital for hemor- 
 rhage from the stomach. The general condition of the patient 
 was fair. No special distress after eating and no vomiting, 
 excepting during the bleeding attacks. On two occasions he 
 vomited a large quantity of blood, and decomposed blood 
 passed per rectum. A median incision was made. The stomach 
 was unusual in size and appearance. The pylorus was incised 
 transversely. Near the pylorus and the small curvature of the 
 stomach two bleeding points were found in the course of a vein 
 of considerable size. Visceral incision was enlarged and 
 mucous membrane of the stomach freely everted for inspec- 
 tion. The remaining part of the interior surface of the stomach 
 was inspected through a bivalve rectal speculum and with the 
 aid of reflected light, but no additional lesions could be dis- 
 covered. Hemorrhage from the two bleeding points was 
 arrested with two purse-string sutures of catgut. 
 
 Visceral incision closed with continuous catgut suture for 
 mucosa and mattress catgut Lembert sutures. In closing the 
 external incision, catgut was used for the peritoneum, muscu- 
 lar layer, fascia, and iron-dyed silkwormgut and fine silk for 
 the skin. Guttapercha strip drainage was employed, the drain 
 to be removed in 48 hours. A small, dry dressing for the
 
 10 
 
 external woiiud, held iu place with strips of adhesive plaster, 
 and abdominal bandage. Although no distinct ulceration 
 could be discovered, there must have been minute erosions that 
 caused the venous hemorrhage, and the treatment resorted to 
 undoubtedly succeeded iu preventing recurring attacks. 
 
 Case II. — Late fever complicating appendicitis ; operationy 
 exploratory laparotomy . A young man was operated upon by 
 Dr. Johnson four weeks ago for gangrenous appendicitis. 
 Early operation. Appendix was removed, and the wound 
 healed by primary intention. Xo untoward symptoms until a 
 few days ago a high temperature developed which ranged 
 between 104° to 105° F. Other general symptoms confirmed the 
 suspicion of the existence of a retrocolic, hfpatic, or subphrenic 
 abscess. Liver was enlarged. Xo palpable swelling in the 
 ileocecal region. Ether anesthesia was employed. Incision 
 was made four inches in length below and parallel with the 
 right costal arch. Liver was found enlarged, but no indica- 
 tions of the existence of an abscess within, above, or beneath it. 
 The incision was enlarged sufficiently for the insertion of the 
 hand which was employed in making the necessary intra- 
 abdominal palpation for the detection of a suppurating focus, 
 but nothing was found that could explain the remote post- 
 operative fever. The abdominal incision was closed with 
 buried and superficial sutures in the usual manner. The 
 operator came to the conclusion that in all probability the 
 remote septic complication was the result of a thrombo phle- 
 bitis, which had its origin at or near the primary seat of infec- 
 tion. 
 
 BELLEVUE HOSPITAL. 
 
 This is the wellknown, large, general charity hospital of 
 Xew York. It is an old institution, but improvements have 
 been made from time to time so that it serves its present pur- 
 pose well. Its present capacity is 1,000 beds. The emergency 
 department is the largest of any hospital in Xew York. Four 
 ambulanees are in use all the time, and 18 horses are always in 
 readiness for this service. The automobile ambulances have 
 been abandoned, as not infrequently something would go 
 wrong when speed was most required. The attending staff is 
 made up largely of members of the faculties of the four medical 
 colleges. It is the great center of clinical teaching for students 
 and practitioners. Surgical clinics are given daily in the two 
 large operating-rooms. The training-school for female nurses 
 is attended by 80 pupils, and the school for male nurses by 90. 
 The course of training is three years. Forty-five internes assist 
 the attending staff in taking care of the vast clinical material. 
 It is estimated that 24,000 patients enter this hospital every year. 
 The morgue is one of the finest in the country. The mortality 
 in this hospital is for obvious reasons very high, as many acci- 
 dent cases are brought to its doors with patients in a dying con- 
 dition. The number of postmortem examinations made 
 annually sums up into many thousands. The morgue is a 
 great school for the study of gross pathology. The surgical 
 practice in this hospital is not uniform, as many of the
 
 11 
 
 operators pursue methods of their own. Dr. Gill Wylie is one 
 of the attending gynecologists. His aseptic precautions are 
 very simple, and yet efacient. He scrubs his hands with warm 
 water and ethereal solution of soap, cleanses the finger-nails 
 thoroughly, and then resorts to chemical disinfection by 
 immersion for a few minutes in a solution of bichlorid 1 : 8,000 
 to which three parts of tartaric acid are added. He performs his 
 operations in a small room connected with his ward. On the 
 day of my visit he was absent from the city, and his patients 
 were in charge of his assistant. Dr. Lee. An Alexander opera- 
 tion was performed for retroversion of the uterus with skill 
 that would have done credit to his clinical teacher. The 
 delirium tremens ward and detention wing are well w^orth a 
 prolonged visit, as they contain an abundance of the most 
 valuable clinical material, interesting and profitable alike to the 
 alienist and general practitioner. 
 
 This completes a description of my surgical observations 
 during the last four months, and I return to my private 
 practice and college work fully satisfied that from a surgical 
 standpoint America compares well with any of the foreign 
 countries I had an opportunity to visit. In conclusion, I desire 
 to thank all of my colleagues, near and far, for the many 
 courtesies extended to me on my long and highly-interesting 
 and profitable journey. 
 
 New York, August 29.
 
 1 Reprinted from American Medicine, Vol. V, No. 13, pages 503-506, 
 March 28, 1903. i 
 
 GLIMPSES OF THE PRACTICE OF MEDICINE AND 
 DISEASES IN THE WEST INDIES. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 Recent political events of far reaching significance have 
 awakened our interest in and brought us in closer touch with 
 the beautiful tropical West Indies. Before the war with Spain 
 our nation knew little of the mountain peaks of the lost 
 Atalanta, but since the fortunes of war have placed us in 
 possession of one of these, and destiny gave us an opportunity 
 to liberate another one from foreign rule, our eyes are turned 
 in the direction of these landmarks which divide the great 
 Atlantic Ocean from the blue waters of the Caribbean Sea. The 
 West Indies offer so many inducements for the midwinter 
 tourists and chronic invalids from the North that a brief 
 description of my recent three weeks' tour may interest the 
 many readers of American Medicine. It is a strange but pleas- 
 ing experience to leave icebound Chicago and in less than a 
 week find yourself in a new country, among strange people 
 and surrounded by the luxviriance of a tropical climate. It is 
 on an occasion like this that we are reminded of our school- 
 boy days when we were made to study geography and stock 
 our youthful imaginative minds with the location of distant 
 countries, their people, their climate, products of the soil,., 
 manufactories, and workshops. It is a source of great gratifi-- 
 cation to look at the dizzy height of the gigantic palms, to pick.; 
 from the shrubby nutmeg tree its aromatic fruit of the color of 
 gold, and from the pepper vine the grape-like clusters of 
 pungent green-yellow berries, and to attack the bark of the 
 cinnamon tree with a pocket-knife to satisfy yourself that you 
 have found the real article remembered so well by many as one 
 of the ingredients of the favorite delicate dishes of childhood 
 days. Spend a short midwinter vacation in the West Indies, 
 as I did, and you will experience the same delight, 
 and will return to your arduous duties, as I did, with pleasant, 
 dreams of what the special senses enjoyed and in a better- 
 humor to bear the burdens of the daily routine toil. Besides; 
 admiring nature's exquisite beauties which only a tropical soil;^ 
 can build and a tropical sun can paint the medical visitor to>
 
 the West Indies is most interested in the shady side- of life in 
 the tropics— tropical diseases. With our present methods of 
 rapid navigation a physician living east of the Rocky Moun- 
 tains can visit the most interesting and important islands of 
 the West Indies and obtain a fair knowledge of their people, 
 natural resources and prevailing diseases and return in four 
 weeks well satisfied with w^hat he has seen and learned. The 
 trip during which the following observations were made 
 extended from January 15 to February 5, 1903, with New York 
 and the island of Martinique as opposite points. The passen- 
 gers on the " Kaiserin Maria Theresa," of the North German 
 Lloyd, left New York wrapped in furs and the heaviest over- 
 coats, and many demands were made of the stewards for addi- 
 tional blankets to fight the cold in the chilly staterooms when 
 the shivering passengers retired for the night. This source of 
 discomfort did not last long as the great ship under full steam 
 made a bee line for the equator, evidently anxious to relieve 
 her human freight of the cumbersome winter clothing. On the 
 third day out a general overhauling of the contents of the 
 steamer trunks in search for lighter clothing became the main 
 occupation of the passengers. Silk and linen took the place of 
 wool and fur, and white and yellow became strong rivals of 
 the sombre black, brown and gray of the wearing apparel, a 
 change from which caps, hats and shoes were not exempt. 
 In a very few days the dome of gray threatening clouds disap- 
 peared as by magic, and the lifting of this heavy impenetrable 
 curtain by invisible hands exposed to the unobstructed vision 
 the azure blue boundless sky of the tropics, decorated during 
 the day by the warm sun of the South which approached nearer 
 every day with ever increasing fervor, and by night by the 
 pale crescent-shaped moon and countless luminous stars. 
 Before we were aware of the distance we had traveled land was 
 sighted, and on the morning of January 19 we reached our first 
 destination, the harbor of Charlotte Amalie. 
 
 m. Thomas.— This is one of the three islands in the West 
 Indies belonging to Denmark. It is an important coaling 
 station for merchant vessels from the most remote parts of 
 the world. More than half of its small population live in 
 Charlotte Amalie, the seat of the colonial government. A small 
 military force is located here. The principal revenue is derived 
 from the export of bayrum, which is noted for its superior 
 quality and cheapness. The soil is unproductive and the negro 
 population miserably poor. The government oflicials, the 
 military, and a few business men make up the small body of 
 white inhabitants. Two Danish doctors attend to the needs of 
 the sick. The government is obliged to do what it can for the 
 sick poor.
 
 JCommune Hospitalet. — This hospital can accommodate 115 
 patients when it is taxed to its utmost capacity. It is arranged 
 in the form of an open square, and consists of one-story barracks 
 divided into small wards for six to eight patients ; all of these 
 wards open on the square. On the left at the entrance of the 
 square is the building for men, on the right for women, and in 
 the rear is a one story frame building for the insane. The hos- 
 pital is furnished in a most primitive way, and the filth 
 appeals both to the eye and nose. We found here the usual 
 varietyof diseases which ordinarily prevail here, syphilis, rheu- 
 matism, ulcer of leg, bronchitis, endocarditis, and myocarditis, 
 and a number of cases of elephantiasis. Only one of the insane 
 was locked in his room, the remaining patients were either in 
 their open rooms or wandering about in the yard. I was inter- 
 ested to ascertain who was responsible for the filthy condition 
 of the institution. After a somewhat prolonged search we found 
 the female nurse who had charge of the patients who belonged 
 to her sex. She was a colored woman of doubtful age, clad in a 
 dirty calico dress, her dusky face made more so under the 
 shadow of a large straw hat with drooping broad rim that evi- 
 dently had done service for many a season. To the inquiry 
 where she had received her training, she made no direct reply. 
 The only argument she made as to her proficiency as a nurse 
 was that she was the mother of seven children and thought 
 that that kind of practical training ought to suffice to prepare 
 her for her vocation in life. With this kind of training she 
 entered the institution 17 years ago and has held her place ever 
 since. She was particularly anxious to impress upon us the 
 wonderful results of her extensive obstetric work. The con- 
 valescent women give her assistance in the performance of the 
 more arduous and menial part of her work. The nursing on 
 the opposite side of the square made no better showing. A 
 negro, who looked like an ordinary day laborer, served in the 
 same capacity here. A vest that once was white and a clumsy 
 pair of cowhide shoes distinguished him from his subordinates, 
 so far as external appearances were concerned. The doctor who 
 is in charge of this hospital is said to be a very busy man, but 
 he never fails to take his siesta between high noon and 3 p.m., 
 a time he claims for himself, and during which when called 
 upon he sends his compliments by a dark-skinned bonne of the 
 island, that is if she can muster enough courage to disturb her 
 master's nap by conveying a message to him during that time 
 of the day. The poverty of the island may offer a partial 
 excuse for the way in which this hospital is conducted, but it 
 is high time that the general government, so long as it persists 
 in holding it as a colony, should look into this part of the man- 
 agement of its black subjects.
 
 'St. Kitts, a small speck in the mighty ocean, is one of the 
 numberless colonies of England, as well as one of its oldest. It 
 is reached from St. Thomas in a few hours by steamer. It does 
 not take long for the visitor to learn that he is on British soil. 
 English is the language of this island. The native policemen 
 are splendid specimens of the colored race, well uniformed and 
 disciplined, clean, courteous, and faithful in the execution of 
 their duties. The clean streets and splendid country roads are 
 a good evidence of a modern progressive government. St. Kitts 
 has a population of about 30,000, of which the negroes furnish 
 the bulk. Basse Terre is the only city of any size. It is the 
 seat of the local government and important charitable institu- 
 tions. Like nearly all of the West Indies, the interior of the 
 island is mountainous. Our country is represented here by 
 Consul Dr. Haven, a graduate of Rush Medical College, who 
 practised his profession for many years with great success in 
 Chicago, and who accepted his present position to recuperate his 
 health by a change of climate. To him we are indebted for 
 many courtesies. 
 
 Lazaretto or Leper Asylum.— l^e-prof^j is found in all of 
 the West Indies, but is quite prevalent in St. Kitts. The Laza- 
 retto is located on a high elevation by the seashore and near the 
 base of Brimstone Hill, with the remains of an old fortifica- 
 tion upon it, which was abandoned 36 years ago. The Lazaretto 
 is connected with the city by a magnificent macadamized road 
 which follows the seashore and passes through a number of 
 quaint negro villages, the landmarks of former large sugar 
 plantations. The asylum buildings are well adapted for the 
 purpose for which they were intended. An open space between 
 them has been transformed into a charming flower garden, 
 intersected by beautiful gravel walks. A tract of several acres 
 of land belongs to the institution, but the soil is so poor that 
 nothing has been done in the way of cultivating it. The colony 
 was founded 10 years ago, and has been managed ever since by 
 Dr. John Foreman, who takes a deep interest in its welfare. 
 Absolute segregation does not exist in any of the islands. In 
 St. Kitts and the rest of the West Indian British colonies 
 ample provision is made for the indigent lepers. The law 
 requires that lepers should not pursue any vocation 
 which would be likely to spread the disease, such as the hand- 
 ling of foodstuff and clothing. If a leper is found begging or 
 engaged in a business or trade calculated to disseminate the 
 disease he is arrested, convicted and sent to the asylum for 
 treatment and isolation. At present there are 72 lepers in the 
 Lazaretto, the youngest a little bey of 6. The macular and 
 tuberculous variety are about equally represented, as well as 
 the sexes. All of the i)atients are negroes, with the exception
 
 of two Portuguese women. The treatment is palliative and 
 symptomatic. 
 
 Cunningham ITospitn I. —This is the government hospital of 
 the city of St. Kitts and commemorates the name of a former 
 
 Acute exfoliative dermatitis (St. John' 
 
 Governor of the island. It has a capacity for about 100 patients. 
 The buildings are two-story barracks, the lower of solid 
 masonry, the upper of wood. The wards are well lighted and 
 plainly but comfortably furnished. Dr. W. J. Brauch is the 
 medical officer in charge. He is assisted by two graduate col-
 
 6 
 
 ored pharmacists. I found here two cases of amputation of the 
 leg for elephantiasis, the operation having been made necessary 
 by extensive ulceration. The patients were doing well, but the 
 wounds failed to heal by primary intention. The colored 
 female nurses under the direction of a trained English nurse 
 take care of the sick, and the general cleanliness which prevailed 
 here spoke well for their efficiency and industry. 
 
 ,St. Joh7is—We landed at Antigua, St. Johns, January 21, 
 and lost no time in looking up the medical aspects of the island 
 city. A visit to the ancient cathedral reminded us that the 
 public is sometimes appreciative of the services of physicians 
 after they have completed their unselfish career and have gone 
 to their reward. On a marble tablet on the wall on the right 
 side of the main entrance I found the following inscription: 
 
 To 
 
 The Memory of 
 
 Robert Peddie, 
 
 Surgeon, 
 
 Native of Kelso in Roxburghshire, N. B., 
 
 Who died in this island 
 
 On the XVI of November, A.D. MDCCCXLI, 
 
 At the age of XLI years. 
 
 This Tablet 
 
 Is consecrated by the sympathies of 
 
 A few of his friends. 
 
 In life they esteemed him 
 
 As well for 
 
 His faithful discharge of his duties 
 
 As a member of the Legislature 
 
 As for 
 
 Exemplary conduct in all the Relations 
 
 Of Professional and Domestic Intercourse. 
 
 And now that he is departed, 
 
 They desire to record their feelings 
 
 Of sorrow and respect 
 
 That these may not pass away with 
 
 Their own fleeting existence. 
 
 The wording of the above tribute reflects the feelings of 
 esteem and veneration for the life work of an exemplary mem- 
 ber of the medical profession. 
 
 St. Johns has been impoverished since the depression of the 
 sugar-cane industry. The streets of Antigua, the capital, are 
 thronged with beggars w^ho are noted for their aggressiveness 
 when visitors make their appearance. Outstretched black 
 hands and the plaintive " give me a penny " constantly menace 
 the peace of mind of the stranger on the streets. If the hungry 
 
 i
 
 crowd becomes too large it is sometimes necessary to look for 
 a policeman for relief or enter or seek peace and rest in some 
 public establishment. Malaria is quite common in St. Johns. 
 On the other hand, typhoid is quite rare. 
 
 Vaccination is enforced by the Board of Health, conse- 
 quently the mass of the people is protected against smallpox. 
 The entire population is saturated with syphilis. The disease 
 has existed for such a long time, and is so common, that it has 
 lost much of its virulence. Some idea may be formed of the 
 prevalence of this scourge of the colored race from the fact that 
 150 pounds of potassium iodid are consumed in the hospital 
 annually. Tuberculosis here, like elsewhere in the West 
 Indies, has a firm hold on the black race. The insane asylum 
 is located on an island in the harbor, formerly a strong forti- 
 fication. The leper colony is located on a high ridge overlook- 
 ing the harbor, and numbers at the present time 40 inmates, 
 all colored. 
 
 Holderton Hospital. — This is the only hospital on the island, 
 and can accommodate 200 patients. It bears the name of a 
 deceased rector of the ancient cathedral. It is in charge of Dr. 
 Frederick L. Norris, a young and most capable physician. The 
 wards are airy, neat and fairly well furnished. The buildings 
 occupy the eminence of a hill behind the city, and the ample 
 grounds are well laid out and ornamented with tropical trees, 
 shrubs and flowering plants. From here a beautiful view of 
 the city and harbor, as well as distant mountains, can be 
 obtained. 
 
 Elephayitiasis in /St. Johns, — The visitor need not go to the 
 hospital to see this disease, it is constantly seen in all its stages 
 in the streets. The bare legs displayed by men, women and 
 children make it possible to study this disease in the streets 
 any time of the day. Through the courtesy of Dr. Norris I had 
 an opportunity to examine 72 cases of elephantiasis. 20 in the 
 hospital and 52 in the poorhouse. Among this number were 
 two cases of scrotal elephantiasis. In one of them a negro, aged 
 about 30, the disease involved first the right leg, and two years 
 ago it extended to the scrotum, which at the present time has 
 reached the size of the head of an adult and is complicated by 
 enormous enlargement of the penis. In the second case, an old 
 negro, the disease was limited to the scrotum and had reached 
 about the same dimensions. In the poorhouse, 50% of the 
 inmates were disabled by this disease. Dr. Norris is averse to 
 operative interference in such cases, as the disease as a rule has 
 impaired the general health of the patients to an extent as to 
 interfere seriously with the satisfactory healing of wounds and 
 subsequent restoration of the general health of the patient. 
 The vulva is very seldom affected by this disease, otherwise
 
 women are as susceptible to it as men. The nursing here, like 
 in all the British possessions of the West Indies, is in charge of 
 a graduate English nurse, who at the same time serves as 
 matron. Colored girls of desirable age enter the hospital and 
 without any special instruction or training begin their work. 
 They become very useful hospital servants but lack the high 
 qualifications of our nurses. They receive from four to eight 
 dollars a month for their services, according to the degree of 
 efficiency and experience in their work. The poorhouse and 
 prison are near the hospital, the former on the same grounds. 
 
 An Innocent Prisoner.— XJnder the guidance of the prison 
 captain.aud Dr. Norris we visited the prison. The prisons in 
 all English colonies are models of their kind, and the Antigua 
 prison proved no exception. The discipline is perfect, and the 
 prisoners are made to pay the penalty of their offense against 
 the law by hard manual labor that requires no skill, princi- 
 pally crushing stone. In one part of the prison rough coffins 
 are made for the Vjurial of the poor. The execution chamber in 
 the prison building has been idle for more than two years, but 
 the machinery for hanging is kept in good repair. Corporal 
 punishment is only resorted to in the most obstinate and 
 refractory casas, and consists usually in the use of the lash or 
 four hours in the treadmill. The women contingent is larger 
 here than in most prisons. Washing is their principal employ- 
 ment. In the female department we found a coal-black baby 
 boy only a few days old curled up on a floor-mat on the stone 
 floor. This little convict was certainly incarcerated without 
 any cause for which he could be held legally responsible. His 
 mother was serving her sentence for a petty ofl"ense, and before 
 her time expired one more inmate was added to the prison roll. 
 This instance illustrates well that the innocent have often to 
 sufter the crimes of the guilty. May this infant prisoner never 
 know where he was born ! 
 
 Hospitals of the West Indies as Postgraduate Institutions 
 for the Study of Tropical Diseases. — It is a great pity that the 
 medical officers of the hospitals of the West Indies have neither 
 the time nor the appliances for the scientific investigation of 
 the many as yet obscure tropical diseases they are called upon 
 to treat. The material is simply enormous, and could be readily 
 made available by our young graduates in medicine and by 
 prospective health officers. These are the places to which the 
 attention of our foremost medical schools should be directed. 
 Some of the scholarships should be devoted to the study of 
 tropical diseases in these colonies. I am sure every hospital 
 would throw open its doors widely to students, provided the 
 investigations would be made without increasing the financial 
 outlay. "I became so deeply impressed with the great oppor-
 
 9 
 
 tunities that I determined to use all my influence to have 
 Rush Medical College take an initiative step in this direction, 
 with the hope that other institutions would follow the example, 
 so that in a few years a competent bacteriologist might be found 
 in all of the hospitals. There is no better place for the study of 
 elephantiasis than St. John's ; St. Vincent, for ankylostoma 
 duodeualis, and St. Kitts for leprosy, and all of these islands for 
 acute and chronic intestinal diseases. 
 
 Mar ti7iique.— This island, under French rule, was the prin- 
 cipal objective point of my short midwinter vacation. It is the 
 most picturesque of all the West Indies, and the most widely 
 known since the last eruption of Mount Pelee, which com- 
 pletely destroyed St. Pierre and nearly one-third of the entire 
 population of the island. This island was discovered by 
 Columbus, June 15, 1502. He landed at Corbet, near the present 
 ruins of the illfated city, St. Pierre. 
 
 Fort de France is the capital of Martinique and has at 
 present a population of nearly 40,000. Very few of the original 
 race, the Caribs, remain. Like all primitive peoples they have 
 disappeared by the ravages of the diseases brought to their 
 beautiful island by the invaders. They struggled long and 
 fiercely for their rightful possession but finally had to yield to 
 the inevitable. The negroes have increased to an alarming 
 extent, and since the sugar industry has been waning the 
 government is seriously taxed in taking care of the poor. The 
 city is well drained and lighted and has excellent streets. The 
 whites are few and by no means in a cheerful mood owing to 
 financial reverses which have occurred in the past and which 
 are in store for them in the future. Most of the houses show 
 indications of decay and very few buildings are in process of 
 erection. The hotels are primitive and the table still more so. 
 Meat is poor and scarce. Fish is plentiful and in great variety, 
 but cannot compare in quality with those of our northern 
 waters. The negroes subsist largely on bread fruit, guavas, 
 mangoes, cocoanuts, bananas, plantains and other cheap trop- 
 ical fruits. A small military force occupies the garrison. The 
 policemen are negroes under command of French officers. 
 The prevailing language is French, which by the lower class of 
 people has been changed into a patois unintelligible to the 
 Parisian. The military hospital is an elegant red brick struc- 
 ture, well equipped, a credit to the military branch of the gov- 
 ernment. 
 
 Hopital Civil.— This is the general hospital, open to the 
 sick from the entire island. It is situated outside of the city 
 limits on a mountain side several hundred feet above the level 
 of the sea. It was built five years ago at great expense and has 
 room for 250 patients. The ample grounds are artistically laid out
 
 10 
 
 and beautified in a way only possible in a tropical country. 
 Pure water is supplied from mountain springs in abundance 
 and all of the buildings are lighted by electricity. Seven two- 
 story pavilions face the valley in a straight line, all of these 
 connected by excellent sidewalks. The lower stories are made 
 of solid stone walls, the upper of wood painted white. The red 
 roofs of tiling furnish a pleasing contrast with the exquisite 
 verdure of the mountain side behind and snowy whiteness of 
 the walls beneath. The nursing is in charge of nine Sisters of 
 Charity, which in itself would account satisfactorily for the 
 scrupulous cleanliness inside and outside of the buildings. The 
 operating-room is a separate frame building octagonal in shape. 
 The instrument supply is a very limited one, which means that 
 no unnecessary operations are performed^ I found here again 
 many cases of elephantiasis ; the affected leg of one of the 
 patients must have weighed at least 75 pounds. The enormous 
 weight of the limb required much effort on the part of the 
 patient when he attempted to walk. Dr. Bouvier is the 
 medical director. He is assisted by a resident interne. 
 
 The Ruins of St. Pierre. — The former city of St. Pierre, now 
 in ruins, is by the coast line 20 miles distant from Fort de 
 France. Before its destruction by the volcanic eruption of Mount 
 Pelee it was a thriving city of about 36,000 inhabitants. Mount 
 Pelee is 4,500 feet high, and separated from the ruins by a low 
 mountain ridge and a small river. The destruction of the city 
 was as sudden as it w^as complete. The terrible catastrophe 
 occurred at 5.30a.m., May 8, 1902. The eruption was in reality an 
 explosion of the most terrible kind. Before the explosion the 
 water from the little lake which occupied the basin of the 
 extinct crater disappeared. It is claimed that the entrance of 
 such a large volume of water into the subterranean furnace was 
 the principal cause of the explosion ; at any rate it is certain that 
 the hydrogen gas which escaped when the explosion occurred 
 filled the entire valley occupied by the city, ignited and 
 destroyed everything living and ignitable within reach. The 
 explosion tore open the mountain below the crater on the side 
 of the city and the gas escaped with such tremendous force that 
 the largest trees were uprooted and the most substantial build- 
 ings torn down. The positions of the prostrate trees and the 
 torn down walls are everywhere the same — away from the 
 mountain. The death of the people and the destruction of the 
 city came with an awful suddenness. In less than five minutes 
 the furious mountain had accomplished its deadly work. Not 
 a house remains, and of the nearly 40,000 people only one Avas 
 saved. What was formerly the rival of Fort de France is 
 wiped out of existence. The recent ruins present today an awe- 
 inspiring picture. Many of the houses are leveled to the
 
 11 
 
 ground. The stately churches are mere piles of brick and 
 stone. The giants of the forests, charred and mangled, obstruct 
 the vacant streets. All signs of animal life have disappeared. 
 The ruins are really a great cemetery in which more than 
 30,000 bodies remain. More than 6,000 bodies have been found, 
 and were either buried or cremated ; the others are buried under- 
 neath the debris of the ruins and a layer of lava mud of varying 
 thicknesses. It is said that no man is so wicked as to be 
 entirely devoid of virtue. The same may be said of Mount 
 Pelee. What she did in a rage of anger she did quickly. 
 Probably not a single one of the victims svifFered the pangs of 
 death for more than five minutes. The deadly gases, the burn- 
 ing atmosphere and the force of the explosion killed almost 
 instantly every living thing within reach. Then the volcano 
 undertook the task of the undertaker by throwing out a rain of 
 soft mud until most of the corpses were out of sight. The 
 former city is now a deserted ruin. Not a soul lives there. At 
 the time of our visit a number of negro women were picking 
 up tiles along the beach. A few negroes were busy here and 
 there with picks and spades in search for buried treasures and 
 relics of the disaster. Bones and whole skeletons are being 
 uncovered daily by the drenching rains washing away the 
 thin layer of mud under which at first they were buried. Not 
 a roof remains, and many of the narrow streets are com- 
 pletely obstructed by the debris of the ruins and the volcanic 
 mud. St. Pierre will live in history, but will never be rebuilt 
 on its present site. On the day of our visit the summit of 
 Mount Pelee was wrapped in mourning, but through the 
 dense veil of clouds ascending columns of steam could be seen, 
 a warning that the volcano so far has refused to rest. The next 
 day an explosion blew off the top of the mountain. The force 
 of the explosion and the fire which destroyed the city extended 
 far beyond the limits of the city. In the direction of the explo- 
 sion not a single living tree could be seen. It was in the neigh- 
 borhood of the destroyed city, near the limits of the sea of fire, 
 that many people were injured and suffered from more or less 
 extensive burns. Of these, 250 were sent to the Civil Hospital 
 at Fort de France. I had an opportunity to examine a few of 
 these patients that remained at the time of my visit, recovering 
 slowly from the effects of burns. 
 
 A MiraculouH Mscape.— Only one of the inhabitants of St. 
 Pierre escaped. He was a prisoner, and was not discovered in 
 his prison cell until four days after the disaster. All the 
 remaining prisoners were killed. The prisoner who found his 
 freedom in such a miraculous way is a negro aged about 35. 
 He has suddenly risen in distinction. He is now a successful 
 beggar in Fort de France. I met him in a little cigar store and
 
 12 
 
 was successfully appealed to for a small contribution, in con- 
 sideration of which he willingly exhibited large scars over the 
 left shoulder and same side of chest, following the healing of an 
 extensive burn. Later he came on board the ship for exhibi- 
 tion and realized ^20, probably more money than he ever 
 handled before. 
 
 St. Vince7it.—This little island possession of England has 
 come into notoriety by the volcanic eruption of its highest 
 volcanic mountain (3,000 feet), La Souffri^re, which became 
 active at the same time with the distant Mount Pelee. Two 
 thousand lives were lost and a whole village destroyed. Ashes 
 were blown as far as Barbados, over 100 miles away. Kings- 
 town is the capital city. It has 9,000 inhabitants, with few 
 exceptions negroes. The botanical garden is one of the finest 
 in the world. It was established in 1764, the first in the West 
 Indies. The visitor will find here the greatest variety of palm 
 trees, indigenous and from foreign tropical countries, cacao, 
 cinnamon and nutmeg trees, and the pepper vine. 
 
 ColonioA Hospital.— This is the principal hospital of the 
 island and has room for 80 patients. The grounds upon which 
 the hospital is built present a truly tropical appearance. The 
 tov;ering gigantic palms, floAvering shrubs and ferns, make a 
 most attractive foreground. Like all of the West Indian hos- 
 pitals it is built on the barrack plan. The pavilions are two 
 stories high, the lower of stone, the upper of wood. The upper 
 story projects about eight feet beyond the lower. The furni- 
 ture is of the plainest kind but answers all of the existing 
 requirements. The wards are kept clean and in excellent 
 order. An English trained nurse is the matron and super- 
 vises the work of the colored nurses. Dr. C. W. Branch is the 
 attending physician. He is a graduate of Edinburgh and is an 
 earnest, enthusiastic and progressive man. He and another 
 physician take care of all the sick in the city and surrounding 
 country. 
 
 Ankylostoma Duodenalis in St. Fmcen^.— Uncinariasis 
 (Ankylostomiasis) is very common in all the West Indies, 
 but particularly so in St. Vincent. Dr. Brauch believes that 
 at least one-third of the entire population is affected by this 
 disease. The principal symptom is a gradually increasing 
 anemia. Ultimately fatty degeneration of the liver invariably 
 takes place. During the early stages of the parasitic invasion 
 the disease is often overlooked. Careful examination of the 
 stools must be relied upon in making a positive diagnosis. 
 In one year Dr. Brauch treated 120 patients. His treatment 
 consists in the administration of large doses of thymol. To 
 an adult he never administers less than 8 grams (120 grains) 
 of the drug divided in four equal parts, which are adminis-
 
 18 
 
 tered in capsules one hour apart, beginning early in the 
 morning. In tlie evening following castor-oil is given in 
 sufficiently large doses to produce free catharsis. The reputa- 
 tion of thymol in the treatment of this disease has been well 
 established, not only here but in many other hospitals in 
 the tropics. Sometimes the treatment has to be repeated. 
 Toxic symptoms are not often observed, but should they 
 appear speedy elimination of the thymol by early and free 
 catharsis will soon relieve the unpleasant symptoms. 
 
 Kingstown, St. Vincent, January 24, 1903.
 
 3 
 
 and counterirritations by the use of the actual cautery. The 
 entire number of patients for the year amounted to 3,799. 
 Among the most noteworthy diseases were typhoid, malaria, 
 tuberculosis, and venereal affections, and their complications. 
 The report alludes to the typhoid fever patients as follows: 
 " There were 28 cases of this disease admitted with 12 
 deaths, a very high deathi-ate no doubt; but nearly all of the 
 fatal cases were admitted in a very advanced stage of the dis- 
 ease, indeed little or nothing could be done for them." Malarial 
 fever was most prevalent daring the last five months of the 
 year. The mortality from this disease was very small. Of 
 1,226 cases 18 proved fatal. The venereal cases numbered 206 
 and were classified as follow : Syphilis, 33 ; gonorrhea, 90 ; 
 chancroid, 83. The hope is expressed that the disease is on the 
 decline. The five cases of tetanus proved fatal without an 
 exception. Only one case of yellow fever is recorded and this 
 patient died. In two amputations for elephantiasis of the leg 
 the patients recovered. Elephantiasis and ankylostoma are 
 rare affections here as compared with some of the islands 
 further east and south. 
 
 Cuba.— The war with Spain has made us more familiar with 
 Cuba than any other island in the West Indies. This event has 
 given us ample opportunity to become better acquainted with 
 its people and the diseases which afflict them. Our invading 
 army reached the island at a time when the climate was most 
 dangerous and the acute infectious diseases most prevalent. In 
 a few weeks we lost nearly one-half of the fighting force by dis- 
 ease. The number killed outright by bullets was small compared 
 with the loss from disease. The Spaniards passed through the 
 same trying experience. It is well known that the Spanish army 
 lost 50% of its fighting strength from the same cause in two 
 months after landing in Cuba. The Spanish surgeon I met 
 inside of the lines of the enemy, a few days before the surrender 
 of Santiago, where we delivered to him, under a flag of truce, 16 
 wounded Spanish prisoners, informed us that when his part of 
 the army reached Cuba the men were all in good health, and 
 that then many were sick, and none well. He drew a sad 
 picture of how their ranks were decimated by yellow fever, 
 malaria, and dysentery. During the entire insurrection Cuba 
 was at no time entirely free from yellow fever, and malaria is 
 present more or less in most of the valleys and lowlands of the 
 coast. Many of our soldiers were infected with typhoid fever 
 in the home camps before they left for Cuba, and here all of the 
 conditions were present for its rapid spread among the troops. 
 Malaria, typhoid fever, and dysentery rapidly thinned out the 
 ranks and file of our army, and when the troops returned 
 every transport was a veritable hospital. American inter ven-
 
 tion has gained for Cuba not only the long-wished-for independ- 
 ence, bat it has also brought another and perhaps greater bless- 
 ing — almost complete eradication of yellow fever from this pest- 
 stricken island. The wonderful results of modern sanitary 
 methods are seen nowhere to better advantage than in the city 
 made famous by the war. 
 
 Santiago is the oldest city in America, founded by Velas- 
 quez in 1514. Its present population is 40,000. It has now direct 
 railway communication with Havana. Before and during the 
 Spanish-American war Santiago was noted for its filth and 
 pestilential air. The nearby Siboney, the base of our opera- 
 tions during the war, was shunned even by the coast fishermen, 
 as it had gained an unenviable reputation as a neverfail- 
 ing focus of yellow fever infection. The moment the Americans 
 took possession of Santiago a vigorous warfare against this dis- 
 ease was initiated and prosecuted without a let-up until this pest- 
 hole was converted into one of the healthiest cities on the island. 
 Dr. Leonard Wood proved himself not only a brave soldier 
 but also a sanitarian of the highest merits. His sanitary meas- 
 ures have done more of permanent value for the Cubans in the 
 city of Santiago and elsewhere than his bravery in the gallant 
 charge on San Juan Hill. We arrived at Santiago Thursday, 
 January 29. As we passed the famous Morro Castle the Cuban 
 flag, a single star in the center of a red triangle, and the white 
 and blue stripes, was displayed side by side with the familiar 
 star-spangled banner, signifying that the single star owed its 
 existence to and claimed the protection of the star-bedecked 
 emblem of the great sister republic so near by. Any one who has 
 not seen Santiago since 1898 would hardly recognize it today. 
 The magnificent asphalt paved streets, the clean gutters and 
 utmost cleanliness everywhere are in strong contrast with the 
 conditions found here after the surrender in 1898. No such radical 
 changes would have taken place in the same length of time had 
 the Cubans succeeded in gaining their independence without 
 outside assistance. Santiago is now a healthy city, made so 
 entirely through the energetic efforts of the Americans during 
 the few years of their occupation and rule of the island. Even 
 now the odor of carbolic acid pervades the air in many parts of 
 the city where disease had formerly its stronghold. A moun- 
 tain stream supplies the city with an abundance of pure water. 
 Business has improved, new industries are being established, 
 and a general awakening is apparent everywhere. 
 
 Will the Cubans ever appreciate to the fullest extent what 
 has been done for them by a modern form of government, the 
 direct outcome of American intervention? Will the object 
 lessons in practical sanitation witnessed by them during the 
 last five years yield the expected fruit in the future? The
 
 future can only decide. To me the most interesting place in 
 Santiago was the Civil Hospital. 
 
 Civil Hospital.— This, the only hospital for civilians, was 
 formerly the Spanish Military Hospital. Material improve- 
 ments and changes have been made to fit it for its present pur- 
 pose. It is a very large, square, one-story brick building with 
 a large open plaza or court inside for a number of large wards 
 and ample space for the convalescents. The rooms of the outer 
 or wall part of the building are largely devoted to the adminis- 
 trative part of the institution, offices, pharmacy, operating and 
 dressing-rooms and a number of small wards. Here are also 
 found those suffering from mental diseases. These patients are 
 brought here for observation for a period of 30 days when, if 
 found insane, they are sent to the Insane Asylum at Havana for 
 treatment and further safekeeping. The medical staff consists 
 of four attending physicians and two resident internes. An 
 American trained nurse is at the head of the training-school for 
 nurses. The training of the native nurses consists iu lectures 
 by the attending physicians and recitations and demonstrations 
 by the head nurse. They are required to pursue their training 
 and studies for three years ; at the end of this time they are 
 subjected to a rigid examination and if found qualified receive 
 a certificate to this effect. 
 
 It is the expectation of the managers of the school that a 
 sufficient number of trained nurses can soon be supplied to the 
 well-to-do patients in the hospital and private homes. Pro- 
 vision is made in the hospital for private patients at the rate of 
 $1.25 a day. There are at present 252 patients in the hospital. 
 During the last year it cared for more than 4,000 patients and 
 520 operations were performed. The operating-room is large, 
 well lighted and equipped with all necessary appliances for 
 modern surgical work. We were fortunate in finding Dr. 
 Ramon Neyra, a member of the attending staff, on duty. He 
 is a graduate of Bellevue Hospital Medical College, New York, 
 and until recently practised his profession at Panama. He is a 
 progressive man and takes a deep interest in the success of this 
 new institution and the welfare and comfort of his patients. 
 The scrupulous cleanliness throughout the institution speaks 
 well for the industry and intelligence of the foreign and native 
 female nurses. Among the more interesting cases shown was a 
 case of chronic tetanus. The patient was treated by antitetanic 
 serum and chloral hydrate and was on the way to recovery 
 after an illness of more than six weeks. Second, a case of 
 gunshot wound of the neck. In this case a 30-caliber bullet 
 entered the mouth, penetrated the tongue near the tip and was 
 extracted the day before our visit through an incision in the 
 posterior part of the neck. Also a number of radical operations
 
 for hernia and several cases of laparotomy for different indi- 
 cations were shown. 
 
 Havana. — The tourist who visited Havana before the 
 Spanish-American war will be astonished and pleased 
 at the remarkable changes which have taken place since. 
 I saw Havana two years before the American army lauded 
 on Cuban soil. The Spanish flag then waved over Morro 
 Castle and Spanish troops paraded the streets of the city. 
 A guerrilla warfare was then in progress with the discontented, 
 oppressed Cubans. Business was dull, and the merchants 
 looked with apprehension into the uncertain dark future. The 
 harbor reeked with filth, the streets were dirty, all improve- 
 ments at a standstill. The water supply was contaminated, and 
 sewerage was either entirely lacking, or at any rate very defec- 
 tive. Yellow fever had a firm and permanent foothold on the 
 soil and in the many unsanitary dwellings of the poor. I 
 visited the Spanish Military Hospital at that time. It was an 
 immense ancient pile of stone and cement, without any indi- 
 cations of w^hat modern surgery had accomplished. It con- 
 tained a number of yellow fever patients, some of them in a 
 dying condition. In the surgical wards I found a large num- 
 ber of wounded. All wounds were suppurating. Erysipelas, 
 phlegmonous inflammation, osteomyelitis and necrosis were 
 the rule in gunshot wounds of the bones. The surgeons who 
 made their rounds used the same probe in examining the 
 wounds, as they proceeded from ward to ward, without even 
 taking the pains of subjecting it to ordinary cleansing, to say 
 nothing of disinfection. Hands were washed when the work 
 was done. What I saw at that time was the surgery of half a 
 century ago. It is remarkable what changes have taken place 
 since the American troops took possession of the city. The 
 Spanish colors have disappeared from the flagstaff of Morro 
 Castle, and its place has been taken by the flag of the new- 
 born republic of Cuba. Back of Morro Castle, on an eminence 
 rising from the sea, the Stars and Stripes wave over the camp 
 of several companies of our soldiers who still remain to pro- 
 tect the interests of our country. 
 
 • The wreck of the " Maine" sleeps in the clear water of the 
 harbor as a .silent reminder of the immediate cause which 
 provoked the final struggle of the island for liberty and inde- 
 pendence, Havana is now a prosperous, progressive city with 
 250,000 inhabitants. The well paved streets are models of clean- 
 liness, the sewerage and water supply are the best in the world. 
 Business is thriving and a general air of prosperity is notice- 
 able on every side. Old buildings are being renovated and 
 naany new ones are in process of construction. Yellow fever 
 no longer hangs over the city like a threatening cloud. A
 
 vigorous battle against its bacterial cause, inaugurated and 
 prosecuted with unremitting energy by American sanita- 
 rians, has wiped out of existence this scourge from this part 
 of the island. The Spanish Arsenal has been converted into a 
 modern university, and the Spanish Military Hospital is now 
 the General Hospital for the poor of the city, greatly improved 
 and well managed. The " General Wood Laboratory " is a 
 scientific institution of which a much older country might well 
 be proud. Old Havana has discarded its ancient dress and 
 has taken a place in an entirely new attire, well to the front 
 in the ranks of the healthiest, most interesting and progressive 
 cities of the present day. The inarvelous changes which this 
 city has undergone have been as radical as they have been 
 speedy. Five years is a short time for a stagnant old city to pass 
 through such a complete renaissance. All of this has been 
 accotnplished largely by American assistance, American intel- 
 ligence, and by American energy and enterprise. It remains 
 now for the Cubans to take up the work of maintaining what 
 they have gained, and now and in the future to imitate the 
 example of their well-meaning strong ally, to whom their grati- 
 tude should be sincere and lasting. 
 
 Centra A.sfiiriano Hospital.— To the medical visitor the hos- 
 pital facilities of Havana offer the greatest interest. The city is 
 well provided with hospitals, private and public, nine in all. 
 In all of the places we had visited before during the cruise 
 among the West Indies, none of the hospitals had desirable 
 accommodations for private patients. In a few, pay patients 
 were received, but none of them had private rooms. In 
 Havana there are two public hospitals devoted to the care of 
 the sick poor, the rest are private hospitals established and 
 maintained by mutual aid societies. Of these the Centro Asturi- 
 ano is decidedly the largest and the best. After visiting the 
 Santiago Public Hospital, a most excellent institution, I was pre- 
 pared to find a still better one in Havana. A visit to the Centro 
 Asturiano, however, was a complete surprise — a revelation. I 
 found here a model hospital eqiiipped with all known modern 
 improvements, a hospital which has no equal anywhere, except- 
 ing perhaps the Hamidie at Constantinople. We have many 
 splendid hospitals in our country, public and private, but not 
 one of them can compare with this magnificent structure in the 
 infant Cuban republic. It is the property of the Central 
 Asturian Society, an organization to which Cubans and 
 Spaniards are eligible alike, all of the members of which pay 
 |1.50 a month, for which consideration they are entitled to free 
 medical treatment at the dispensary and hospital. The branch 
 of the society which built and supports this hospital numbers 
 14,000 members, and has therefore an annual income of |252,000.
 
 The present capacity of the hospital is 250 beds, and the 
 number of patients 178. It is next to impossible to give 
 a description of this hospital that will do it justice. The 
 uninitiated visitor finds something new and novel with every 
 step he takes. In the first place the site of the hospital is a well 
 chosen one. It is situated on a tract of land which comprises 
 no less than 100 acres, near the southern limits of the city, 
 
 ^, 
 
 Fig. I.— Administrative building. Centre Asturiano Hospital. Fig. II. 
 —Operating pavilion, Centre Asturiano Hospital, front view. 
 
 made readily accessible by an electric tramway. The hospital 
 occupies the highest point of the hill, but is hidden out of 
 sight by tall trees which line the avenue leading from the 
 entrance to the buildings. As one enters the arched, artistic 
 gate, he finds himself in a beautiful park with indigenous trees, 
 shrubs, and a great variety of tropical flowers. Near the center 
 of the park is an artificial lake, spanned at one end by an
 
 9 
 
 arched bridge of exquisite architectural design. Eighteen 
 pavilions make the present group of buildings, arranged 
 around a large park-like court. All of the buildings are one- 
 story structures with solid stone walls of roughly hewn stone 
 coated on both sides with cement, painted on the outside a faint 
 blue and salmon color, and all of the door frames azure blue, 
 which adds much to their attractive, pleasing appearance. The 
 inside walls and ceilings are frescoed, the details of which 
 exhibit the good taste and great skill of the artist. All of the 
 wards have a broad open space or passageway the entire length 
 of the room with the comfortable cozy little private rooms with 
 one and two beds on each side opening into it. The inner wall 
 of the rooms is a frame partition with a space of at least five feet 
 between it and the high ceiling, thus affording every facility 
 for free ventilation of every room, or rather compartment. 
 The wide central hall or passageway is furnished with chairs 
 and small round tables. Here the patients who are not confined 
 to bed take their meals, from one to four at each table. All of 
 the floors are made of tiling. 
 
 At the time of our visit the principal meal of the day was 
 served. The table ware was as good as in any first-class res- 
 taurant. The dinner consisted of roast beef, stewed Spanish 
 peas, excellent white bread, vegetables, and a glass of Spanish 
 claret. The operating pavilion is a study in itself. From a 
 central passageway doors lead into the sterilization, disinfect- 
 ing, instrument and anesthesia rooms. The large operating- 
 room is reserved for aseptic cases exclusively and is faultless 
 in its construction. The collection of instruments, all of them 
 imported from Paris, contains everything the surgeon will ever 
 need in performing any operation and much to spare. The 
 instrumeutarium alone represents the cash value of a small 
 fortune. The sterilization-room is perfection itself. It is cer- 
 tainly a great privilege to operate under such perfect condi- 
 tions and it is not difficult to understand why the results should 
 not be within the range of all that is attainable in this age of 
 successful surgery. One large pavilion is used as a storehouse, 
 another for the reception of patients and sterilization of cloth- 
 ing and bedding. The kitchen is a separate building, equipped 
 with every possible convenience. The washhouse contains the 
 most modern machinery. The pride of the institution, how- 
 ever, will be the bathhouse that is nearing completion. All 
 around the central, porcelain-lined swimming bath are bath- 
 rooms for special baths, such as Turkish, Russian, douche, 
 electric and medicated baths. It is impossible to conceive of a 
 more perfect bathing establishment than this, and it is doubt- 
 ful if it has an equal anywhere. A Chicago firm was the suc- 
 cessful bidder for the construction of this part of the hospital, 
 and the firm needs no better recommendation than the work
 
 10 
 
 done here. It would require too much space to describe in 
 detail the many unique features of this wonderful institution 
 for the sick, it must be seen to be understood and appreciated. 
 Not a dollar has been foolishly expended, everything is simple 
 and yet elegant and eminently practical. It will be for a long 
 time an object lesson for all architects who are to prepare plans 
 for new hospitals in our as well as more distant countries. The 
 society employs three physicians at salaries ranging from |150 
 to ^300 per month, and two resident internes. The number of 
 female patients so far has been very small and these are cared 
 for by a trained female nurse ; the remaining nurses are males, 
 most of whom received their training in the Spanish and Cuban 
 armies. A corps of well-trained female nurses is all this hospital 
 requires to place it at the very head of all institutions of its 
 kind. The hospital on the present large scale was commenced 
 six years ago, and new buildings are being added as the 
 demands upon it increase. A few interesting points concern- 
 ing the surgical work, I have taken from a report published in 
 1901. The chief operator is Dr. Manuel V. Bango. The statis- 
 tics embrace all operations performed from March, 1897, to 
 July, 1901. The number of operations was 2,066. Of these 
 2,057 patients recovered and only 9 died. This is certainly a 
 record it would be impossible to duplicate elsewhere. The 
 results undoubtedly are unexcelled, but it must not be forgotten 
 that among the operations we find furuncle mentioned 152 
 times ; cold abscess, 237 ; felon, 51 ; hemorrhoids, 39 ; enuclea- 
 tion of inguinal glands, 168; hydrocele operations by injection 
 and incision, 327; fistula in ano, 29; gradual dilation of the 
 urethra in stricture, 62 ; and many other minor surgical proce- 
 dures which should not be attended by any mortality. Of the 
 120 Bassini operations for hernia 1 patient died : of 2 lapar- 
 otomies for gunshot wound 1 patient died, and of 3 opera- 
 tions for strangulated hernia 2 patients died. During the same 
 period of time the number of patients was 18,435. Of these 
 18,073 recovered and 362 died, a total mortality of 1.96%. 
 
 Real Hospital de San Lazarus.— The Royal Hospital of St. 
 Lazarus is the asylum for lepers. It is an old two-story square 
 stone and cement building, divided in the middle by a connect- 
 ing wing which separates the open square or court into two 
 spaces of equal size and which separates the male from the female 
 patients. It has been the home for this unfortunate class of 
 patients since the founding of the institution 50 years ago. Its 
 inmates are under the watchful, tender care of the Sisters of 
 Charity St. Vincent de Paul. 
 
 At present seven Sisters, with a long and trying experience, 
 remain faithful at their post. Their willing hands and cheerful 
 faces have done much in modifying the gloom that necessarily
 
 11 
 
 hangs over the inmates of such a home where there is so little 
 hope of recovery or escape. The present number of lepers is 
 117. A second asylum for lepers, with 40 inmates, is located at 
 Santiago. The laws of Cuba make segregation compulsory. A 
 person suspected of having the disease is examined by a com- 
 mission of three physicians, and if declared a leper is sent to 
 one of the two asylums, where he is held until he dies or 
 recovers. The Sister Superior made the statement that during 
 the last three years two or three patients were discharged cured. 
 In these cases it would be well to place an interrogation mark 
 behind the diagnosis in the records of the hospitals. The 
 youngest patient in the hospital is a boy of 12. One of the 
 inmates, a Cuban by birth, claims he contracted the disease 
 during a prolonged residence at Key West. He said he was 
 covered with boils all over the body. His skin is now clear 
 and he presents no evidences of being atfected with the macu- 
 lar form of the disease. Visitors, relatives and friends are per- 
 mitted to enter the hospital at any time of the day, but the 
 patients are strictly confined. They are well cared for and 
 appear to be as contented with their unhappy lot as circum- 
 stances will permit. The building is situated on the seashore 
 drive, where the patients receive the benefits of the cool, 
 refreshing ocean breeze. 
 
 Neio Providence. — New Providence is one of the Bahama 
 group of islands, and is well known as a popular winter resort for 
 tourists and invalids from the north. The number of inhabitants 
 does not exceed 15,000. The little island is flat but is very attrac- 
 tive with its tropical foliage, graceful palms, ciba, cedar, silk cot- 
 ton and tamarind trees, and luxuriant vegetation. Nassau is the 
 seat of the English colony of the Bahamas. The Colonial Hotel, 
 an American enterprise, is an immense and beautiful building 
 facing the harbor. During the three winter months it is open 
 to the public. For a midwinter rest it would be difficult to find 
 a more soothing climate than Nassau and a more comfortable 
 hotel than t]ie Colonial. Dr. W. E. Bullard, a wellknown New 
 York physician, spends his winter vacations here and attends 
 to the medical needs of the patrons of the hotel. His genial 
 disposition and medical skill have earned for him a well 
 merited reputation as a successful physician here and in New 
 York. The city itself is quiet and orderly, and during the 
 winter months the climate is delightful. The many beautiful 
 drives, the sea bathing and yachting, the wonders of the unique 
 sea garden, and the mysterious fascination of the " Lake of 
 Fire," afford pleasing attractions for recreation and mental 
 diversion and rest. 
 
 Neto Providence Asylum. — The Colonial Government of the 
 Bahamas has to deal with a somewhat mixed method of taking
 
 12 
 
 care of its sick and poor. The New Providence Asylum, Nas- 
 sau, is the only public institution for the dispensation of public 
 charity. It is situated near the center of the little city on 
 ample grounds, which have been improved only in part. It 
 hardly deserves the distinction of a hospital. It was founded 
 in 1832 and was at first intended as a home for the poor. In the 
 course of time provision had to be made for the insane and 
 lepers, so that by a gradual process of evolution it has become a 
 combination of poorhouse, insane asylum, hospital, and lepro- 
 sery, retaining, however, its original purpose as the preponderat- 
 ing feature. This complex and certainly very unique institution 
 is in charge of Dr. L. D. Parsons, a charming personality. Dr. 
 Parsons is a graduate of Edinburgh and has been at the head 
 of the management of the asylum for a year. He has already 
 made many important changes, and has in contemplation many 
 more calculated to bring the asylum up to the standard of 
 present requirements. The possibilities in this direction are 
 great and we wish our colleague the very best success in his 
 humane endeavors. The buildings are all two-story stone and 
 cement pavilions. The one that serves as a hospital has 40 
 beds. A trained English nurse with three colored helpers is in 
 charge of all of the inmates of the asylum. The young colored 
 women do not take kindly to nursing, as they do not look upon 
 the occupation of a nurse as a profession. The greatest diffi- 
 culty is encountered in securing the material, as the women 
 prefer housework to hospital work. As soon as a probationer has 
 been instructed in the performance of her simplest duties she 
 is apt to leave as soon as a prospect of a more congenial employ- 
 ment presents itself. The nursing in all of the West India hos- 
 pitals is very unsatisfactory, and will remain so until the col- 
 ored women can be made to understand and realize the dignity 
 and high standing of the profession of nursing. The last Eng- 
 lish nurse here held out for three years, when her health broke 
 down from overwork, and the same fate awaits the one who 
 has taken her position. 
 
 The poorhouse proper is the best building on the grounds, 
 and Dr. Parsons has taken the necessary steps to convert it 
 into a hospital and remove the inmates to the present hospital 
 building, a most desirable change. The insane asylum in the 
 same enclosure occupies the top of the hill, and has at present 
 40 inmates. A number of the male patients were engaged in 
 chopping wood under the supervision of a guard. The lepers, 
 14 in number, live in a separate building, but are allowed to 
 mingle freely with the other inmates of the asylum, and are per- 
 mitted to leave and enter the asylum during the daytime when 
 they choose to do so. There is no compulsory segregation in 
 the colony of the Bahamas.
 
 13 
 
 There are few abdoniinal sections performed, as the colored 
 women suffering from myofibroma and ovarian tumors who 
 occasionally enter the hospital invariably refuse to be operated 
 upon. New Providence appears to be out of range of the trop- 
 ical diseases we found so common in the more southern of the 
 West India islands. Elephantiasis as an indigenous disease is 
 almost unknown, and ankylostoma and abscess of the liver 
 very rare. The most common disease is tuberculosis. Malaria 
 of a mild type and its complications make up a large part of 
 the statistics of the diseases of the islands. The water supply is 
 cistern and well water, and although Nassau has no sewerage 
 its soil is free from typhoid infection. 
 
 On board " Kaiserin Maria Theresa," Harbor of New York, Feb- 
 ruary 6, 1903,
 
 [Reprinted from A?nerican Medicine, Vol. V, No. 24, pages 964-967, 
 June 13, 1903.1 
 
 ECHOES FROM THE MADRID INTERNATIONAL 
 MEDICAL CONGRESS. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 The Madrid International Medical Congress has passed 
 into history. The members who attended will relate their 
 experiences and observations in their respective medical 
 circles in near and remote parts of the world, and the profes- 
 sion at large will pass final judgment upon its scientific merits 
 after perusal and study of its published transactions. Like in all 
 similar events praise will not be unmingled with criticism. 
 The attendance was larger than was expected. The register 
 contained the names of 6,961 members, of which number 3,53Q 
 were credited to Spain, and 3,431 to foreign countries. The 
 foreigners were represented by the following countries : Ger- 
 many, 776 ; Australia, 7 ; Argentine Republic, 45 ; Austria, 258 ; 
 United States of Colombia, 2 ; Cuba, 13 ; Denmark, 35 ; Belgium, 
 98; Bosnia, 3; Brazil, 252; Bulgaria, 4; Egypt, 12; United 
 States, 195; France, 826; England, 238; Greece, 9; Hayti, 1; 
 Italy, 238; Japan, 4 ; Luxemburg, 4 ; Mexico, 25 ; Norway, 51 ; 
 Holland, 16; Peru, 4; Portugal, 33 ; Roumania, 21 ; Russia, 
 297; San Domingo, 2 ; Servia, 9; Sweden, 21; Switzerland, 35 ; 
 Turkey, 11 ; Uruguay, 3 ; Venezuela, 18. The government, or 
 as they were designated here, official delegates, numbered 474. 
 Many of the members who registered by mail did not attend. 
 The tedious railway travel in Spain and the limited hotel 
 accommodations of Madrid did their share in limiting the 
 attendance; the many places of great historic events and 
 the boundless treasures of art in which the country abounds 
 attracted others who were not prompted by a sense of hunger or 
 thirst for additional medical knowledge. The figures quoted 
 above indicate plainly that the Congress was overwhelmingly 
 Latin in its make-up. The euphonious Latin languages — 
 Spanish, Portuguese, and Italian— were most in use in conver- 
 sation, reading of papers and discussions. The French occupied 
 the second place in the scale of frequency. The average 
 Spaniard has but little desire to acquire foreign languages. 
 Nearly all of the educated classes speak French, very few Eng- 
 lish or German. Among the medical men German is a rare
 
 accomplishment and only a limited nvimber of naval surgeons 
 have acquired a speaking knowledge of English. In the section 
 meetings English was seldom heard and German even less 
 frequently. A fair estimate of the number of delegates in 
 actual attendance would be about 5,000. The delegates were 
 divided into three classes : (1) Official or government delegates, 
 who received a gold badge with a ribbon of the national colors ; 
 (2) delegates from medical societies or scientific institutions, 
 who wore a silver badge with ribbon; and (3) members of the 
 Congress by subscription, who were labeled with a plain gold 
 badge. These badges played an important role in the selection 
 for a number of the most important social features, the official 
 delegates being shown a decided preference. 
 
 Opening Exercises. — Long before the time set for the open- 
 ing of the Congress, at 3 p.m. Thursday, April 23, the Royal 
 Opera House was packed with a brilliant audience. On the 
 floor every inch of available standing room was occupied by a 
 seething mass of humanity. The boxes were filled by distin- 
 guished government officials, prominent citizens, military and 
 naval officers in full-dress uniforms, and invited guests. When 
 the young King entered the royal box accompanied by his 
 mother. Infanta Maria Theresa, and Infanta Isabel, the 
 immense audience rose as a body and the band playei the 
 royal march. The royal party was not cheered so vociferously 
 as is the case when one of our Presidents makes his appear- 
 ance on a similar occasion, but the greeting was a well-meant 
 one, and was participated in heartily by the foreign delegates 
 from all parts of the world. The youthful potentate and his 
 august mother made a very favorable impression upon every 
 one present. The King listened attentively for two hours to the 
 addresses of welcome and the numerous long and short 
 responses. An incident occurred here which excited some 
 newspaper and public comment. When our country was 
 called upon to respond a profound and at the time a painful 
 silence was the only reply. The call was repeated with the 
 same result. What was interpreted by some as an intentional 
 slight to Spain on part of our delegation was simply due to a 
 lack of organization of our delegates at this as well as subse- 
 quent occasions, for which no individual delegate was to blame, 
 but something which should be studiously avoided in the 
 future. As it was no one felt authorized to respond, when our 
 country was called upon, through its scattered delegates. The 
 matter was subsequently explained to the proper authorities, 
 and on leaving Madrid I was informed by a Spanish naval 
 officer of high rank that this incident created rather a favorable 
 impression than otherwise among his countrymen. The King 
 wore the uniform of a field marshal. He did not speak. I was
 
 informed that " in public the King never speaks." The Royal 
 Theater is a large and magnificent structure, but its interior 
 proved entirely inadequate to afford even standing room for 
 the immense throng desirous of witnessing the opening cere- 
 monies, the most attractive feature of every International Med- 
 ical Congress. 
 
 General Sessions.— The\9.^i session of the Congress was held 
 in the large amphitheater of the Central University. At this 
 meeting it was announced that the Moscow and Paris prizes for 
 the best scientific work had been awarded to Grassi, of Rome, 
 and Metschnikoff, of Paris, and that Lisbon, Portugal, had 
 been selected for the next place of meeting. 
 
 By what motives and manner of reasoning the committee 
 on nominations decided upon Lisbon as the next place for the 
 
 Fig. 1.— Royal Palace. 
 
 Congress is difficult to comprehend. This action necessarily 
 means two consecutive Latin congresses and will inevitably cut 
 down the attendance to a minimum. Lisbon is a much smaller 
 city than Madrid, its hotel accommodations more limited, and 
 it is also less accessible; all serious objections against this 
 selection, to say nothing of the fact that the Latin languages 
 will again rule the deliberations of the Congress. Portugal is 
 an interesting country to visit. Lisbon is a charming little 
 city, but the next Congress should have met in a more central 
 place and in a large city with ample hotel accommodations and 
 in a country where the English and German languages carry 
 more weight. If a general criticism of the Congress just 
 ended is permissible it is the fact that the hotel facilities of
 
 Madrid were inadequate to the requirements of so large an 
 attendance, and this difficulty will be greatly increased at the 
 next place of meeting. I am confident the United States will 
 send the usual large contingent of delegates, who will repre- 
 sent in a creditable manner the scientific work of our profession 
 notwithstanding the inconveniences they will meet in finding 
 accommodations, and the difficulties they will have to encoun- 
 ter in making themselves understood. 
 
 During the intervening days the general sessions were held 
 in the aula of the San Carlos College of Medicine. Sixteen 
 speakers were on the program, among them Dr. Howard A. 
 Kelly. The title of the address of this speaker was a signifi- 
 cant one: " The Passing of a Specialty." The time of the gen- 
 eral sessions, called here conferences, interfered seriously with 
 the work of the sections, and it was probably for this reason 
 that the attendance was small. Among the more distinguished 
 speakers may be mentioned Waldeyer, of Germany ; Politzer, 
 of Austria; Arthur Thomson, of Oxford; Brouardel and 
 Robin, of Paris ; Maragliano, of Italy, and Pawloff, of Russia. 
 
 Section Work. — There was at this as well as all previous 
 meetings of the International Medical Congress no lack of 
 papers for all of the sections. The furore of the pen of the 
 present generation of medical men is made obvious at all gath- 
 erings from the smallest county and city medical societies up to 
 the International Medical Congress. The average attendant is 
 no longer content to listen and learn; he is imbued with a 
 sense of duty that compels him to produce, to write, to teach. 
 The result of such a crowded program was here the same as 
 elsewhere on similar occasions. The limited time allotted to 
 each paper made the reader anxious to go over as much ground 
 as possible, hence he felt it his duty to read rapidly, which only 
 too often meant unintelligibly, followed, if by any, a short and 
 imperfect discussion of the subject presented. The scientific 
 work of such a large assemblage of medical men must of neces- 
 sity be done in the different sections. The section program of 
 the Madrid Congress was an unusually prolific one, comprising 
 the titles of nearly 2,000 papers on every possible subject per- 
 taining to medicine and surgery and allied sciences. These 
 papers were distributed among 16 sections and several sub- 
 sections. Many of the authors of papers announced on the pro- 
 gram were conspicuous for their absence, an evil by no means 
 limited to the International Congress and one which should 
 receive the earnest attention of the committee on program. It 
 is not at all unusual for authors to send in the titles of papers 
 they never intended to prepare, much less to present them in 
 person. Such deception deserves censure and should be made 
 impossible by more stringent regulations. Another quite
 
 noticeable irregularity is the presentation of papers after they 
 have done service at some previous medical society meeting and 
 after they have found space in some medical journal months and 
 years before their resurrection on such an important occasion. 
 In looking over the general program I had no difficulty in 
 detecting a number of very familiar titles. The friendly spirit 
 of the Spaniards toward the Americans became manifest when 
 it came to the distribution of section honors. The following 
 delegates were made honorary presidents of sections: Dr. 
 Howard A. Kelly, Gynecology; Professor Stuart, Chicago, 
 Physiology ; Dr. Reginald Sayre, Diseases of Children ; Dr. C. 
 H. Hughes, Neurology ; Dr. R. H. Reed, General Surgery ; Dr. 
 Harlan, Dentistry; Surgeon-General O'Reilly and Dr. N. Senn, 
 Military Surgery. All of the sections held their meetings in the 
 
 Fig. 2.— National Museum and Gallei-y of Modern Art. 
 
 National Art Gallery and Museum, a spacious and imposing 
 structure, a lasting monument to Spain's perpetual interest in 
 the preservation and promulgation of art. This centralization 
 of section work had many advantages, but was not without 
 objection. This magnificent building is centrally located and 
 easily accessible, but the proximity of the sections and the 
 many priceless art treasures afforded too many diversions from 
 continuous hard section work. The ^^ congi^essiste" could not 
 resist the temptation in passing through the building to note 
 what was going on in the different sections and to study and 
 admire the wonderful paintings, illustrating modern Spanish 
 art. Then, too, the picture galleries were open to the public, a 
 circumstance which contributed its share in aggravating the 
 confusion. The section meetings were held from 9 o'clock a.m.
 
 6 
 
 until noon and often the time was extended for another hour or 
 two. As a rule, the man who spoke loudest and was most lib- 
 eral in making gesticulations enjoyed the largest attendance. 
 As indicated by the titles of the papers presented, most of the 
 modern subjects which are at this time agitating the progressive 
 professional minds were ably presented and thoroughly dis- 
 cussed. Some of the most valuable papers were presented by 
 Spanish authors. The Spaniards are fluent speakers and 
 delight in debate. Spain is keeping pace with her European 
 neighbors in the advancement of the science and art of medicine. 
 The forthcoming transactions of the Congress will bear ample 
 testimony to the correctness and force of this statement. We 
 must come in closer touch with Spanish medical literature if we 
 wish to keep apace with the newest and some of the best work 
 that is being done in unraveling the mysteries of disease and 
 in search of new and more effective therapeutic resources. 
 
 Spain can no longer afford to hide what she has done toward 
 the advancement of modern medicine within her own bound- 
 aries ; her excellent work in this direction must become com- 
 mon property wherever scientific medicine is taught and 
 practised. One of the striking defects of the section w^ork in 
 most, if not all, of the sections was the limited number of 
 demonstrations— the teaching by the kindergarten method. 
 This lack of practical demonstration was keenly felt by those 
 who were not familiar with the languages in most common 
 use. The too numerous and often quite lengthy papers 
 undoubtedly constituted a bar to more satisfactory and extended 
 demonstrative teaching and if so this obstruction should be 
 eliminated at the next meeting of the Congress. What the 
 seeker for knowledge on an occasion like this desires most and 
 looks for are ocular demonstrations illustrative of the ideas the 
 speaker desires to convey to his audience. The section meet- 
 ings were not so well attended as one would expect after look- 
 ing over the subjects scheduled in the general program. Too 
 many of the delegates had come with the intention of doing 
 sightseeing instead of attending to the legitimate duties of the 
 mission on which they had been sent. This kind of dereliction 
 of a voluntarily assumed duty is only too common, and merits, 
 to say the least, a sharp criticism. The confusion of languages 
 that prevailed throughout the entire Congress found its way 
 into the general program. I will give only a few instances of 
 title mutilation as it appeared in the general program for the 
 authors who presented papers in English and German. 
 
 My friend, Dr. C. H. Hughes, of St. Louis, was announced to 
 read a paper in the Neurological Section on " Eew Vievos of the 
 Virile Reffiese." I wonder what Lindsay Steven, of Glasgow, 
 thought when he saw printed under his name "A Case of Ocute
 
 Lympatic Leukalmia urt Minde vous Lympatic Medules in 
 the Skin." Dr. R. H. Harvey Reed, of de Rock Springo Hugo, 
 was expected to discuss " Metral d'implantation duto the 
 Rectum." I was registered in the Military Section, and drew a 
 long breath when called upon to present my paper on " The 
 First Dirping en the Battlefired." 
 
 The German language fared no better than the English in 
 the program. 
 
 lam sure the patriotic feelings of Korbitz, of Berlin, received 
 a shock when he saw his name coupled with the title of his 
 paper on " Das Schmelzen des leichtflussigen Forzellans una 
 cin hener electrisher ofen." I do not know the fate of the 
 paper by Grunmach, of Berlin, in the Section of Internal Medi- 
 cine, but the title as printed was certainly a strange one — 
 
 Fig. 3.— Dr. Calleja, President of the 
 Congress. 
 
 Fig. 4.— Dr. Care, Secretary or 
 the Congress. 
 
 " Uibu dis Fortschritte in des Diagnostik dirrili dis X Strah- 
 len." 
 
 It would certainly not be in good taste to criticise too 
 severely the orthography of the English and German language 
 in a product of the Spanish press, and I have quoted these 
 illustrations only as a hint to the committee on program for 
 the next meeting of the Congress, to which I desire to add the 
 well-meant suggestion to consult some one who has a fair 
 knowledge of the two languages, which are too widespread and 
 important to be ignored, before they deliver the program to the 
 printer, and then engage the services of a competent proof- 
 reader. 
 
 Exhibits.— One of the great attractions at the meetings of the 
 American Medical Association is the exhibition hall. It is
 
 8 
 
 here where the country and village practitioners replenish 
 their stock of proprietary medicines without depleting their 
 hank accounts and collect current medical literature for their 
 libraries without diminishing the contents of their pocket- 
 hooks. It is here where he can quench his thirst with spark- 
 ling waters of all kinds and satisfy his sense of hunger with 
 predigested bread, milk and meat without augmenting the size 
 of his boarding-house bill. If he is so inclined he can satisfy 
 his desire for alcoholic stimulants without invading the pre- 
 cincts of saloons on his way to and from the meetings, and all 
 that is asked by the exhibitors for his Indulgences is the good- 
 will of the patrons after their return to their respective fields 
 of activity. It is here where he can learn the names and uses of 
 new instruments, apparatuses and splints minutely described 
 and illustrated in catalogs which are distributed with a liber- 
 ality bordering on actual extravagance. If any of the delegates 
 came to Madrid with any such expectations and intentions 
 they were certainly disappointed. The Madrid merchants and 
 manufacturers either failed to grasp the opportunity or per- 
 sisted in conducting their business in the usual everyday 
 routine manner notwithstanding the streets of the city were 
 thronged with 5,000 strange doctors from all parts of the world. 
 The only exhibits and efforts at advertisement that I saw were 
 by a Paris firm which dispensed Vichy water and distributed 
 literature pertaining to its health-preserving and health-restor- 
 ing qualities with laudable liberality, and a small stand where 
 a sorrowful looking individual distributed circulars of a de 
 luxe edition of Don Quixote. No books, no instruments, no 
 proprietary medicines in sight. In speaking of the section 
 work I emphasized the fact that demonstration teaching was 
 not done to the extent it deserves. I must refer here to an 
 exhibit in the surgical section of plaster models by Doctors 
 Bockenheimer and Frohse, of Berlin, which represented the 
 dififerent steps of Bassini's operation for inguinal hernia as 
 performed in Professor von Bergmann's clinic. A study of 
 these models imparted a full and detailed knowledge of the 
 technic of the operation and demonstrated clearly the value of 
 such object lessons in the teaching of operative surgery. Let 
 me express the hope that this kind of section work will attain 
 greater popularity at future meetings of medical societies, large 
 and small, and more especially of the International Medical 
 Congress. 
 
 Social Entertainments.— Spanish hospitality has become 
 almost proverbial throughout the entire world. This national 
 virtue is characteristic of all classes of society— high and low, 
 rich and poor, educated and ignorant. The hospitality practised 
 is of a charming kind, it is not a hospitality of the head but of
 
 the heart. The Spaniard makes you feel that the hoase you 
 visit is your own, that the things you enjoy are furnished by 
 you, in fact that you are the host and he the guest. The Spaniard 
 is an ideal entertainer, a polished gentleman, refined in man- 
 ners, whose pleasure it is to serve his friends. The spirit of 
 the knighthood days lives in spite of time and great national 
 and family reverses. It makes itself felt on the streets, in the 
 mansions of the rich and the hovels of the poor, in places of 
 public amusement, the market, shops, and especially in educa- 
 tional and charitable institutions. The members of the Con- 
 gress regardless of nationality were made to feel that they 
 were the guests of the nation. The royal family made its 
 appearance on three different occasions for the benefit of the 
 
 Fig. 5. 
 
 -Grand Amphitheater of the Faculty of Medicine of San Carlos 
 College. 
 
 visitors. FeM^ if any, crowned heads would condescend to 
 receive in their own palace several thousand people in one after- 
 noon as was done by King Alfonso. The reception at the palace 
 at three o'clock in the afternoon on the second day was a bril- 
 liant affair. The military men appeared in gala uniform, the 
 ambassadors in court and citizens in full dress. At the entrance 
 to the palace the visitors had to show the card of invitation. 
 The delegates were grouped in different rooms according to 
 nationality. The Americans were assigned to the dining-room, 
 where they were met by Minister Hardy, who introduced the 
 King to a number of delegates who occupied the front row, at 
 the head of which stood Surgeon-General O'Reilly. The King 
 was followed by his mother and Infanta Maria Theresa, both of 
 them dressed in black, while the King wore a handsome
 
 10 
 
 uniform. He as well as his mother speaks English and German 
 fluently, and conversed in these languages with the members 
 of the American delegation. We were all deeply impressed 
 with the modest and genial manners of the young ruler of the 
 old nation that has played such an important role in the drama 
 of the Old World and made it possible for Columbus to find the 
 new one. We Americans must never forget what Spain has 
 done for us, we must ever keep in mind the jewels of Isabella, 
 the Catholic. After the reception we were invited to visit dif- 
 ferent apartments and look at the wonderful collection of tap- 
 estry. In the afternoon at 4 o'clock, Wednesday, April 29, 
 all of the delegates and ladies in attendance were given a gar- 
 de"n party by the royal family. The spacious garden behind 
 the palace was at its best. The soft green of the well-kept 
 lawns, the new headdress of the giants of the forest, the flowers 
 in all colors, the many fountains in action and the throng of at 
 least 5,000 people in their best attire, made a picture that time 
 will never efface from the memories of those who were privi- 
 leged to witness it. Six bands stationed in different parts of the 
 park-like garden played alternately while the people strolled 
 about leisurely in the full enjoyment of a lovely spring day, 
 made memorable by the environments and the hospitality of 
 the King that prompted the occasion. The King entered the 
 garden in a carriage accompanied by his mother and the two 
 infantas. After leaving the carriage the royal party made its 
 w^ay through the dense crowd, addressing a few words to those 
 standing near by as they passed along the principal avenues of 
 the garden. 
 
 A splendid buffet lunch, including champagne, was served at 
 a long table, around which several hundred people could be 
 seated and help themselves at the same time. This garden 
 party was one of the most pleasing features of the Congress and 
 I am sure that every one who was present will remember with 
 gratitude the royal host who, by his dignified manner and 
 charming hospitality, added so much to the success and pleas- 
 ures of the Congress. Of the section entertainments I can only 
 speak of the military section. The afternoon was devoted to the 
 visiting of government institutions, notably the Military 
 Hospital and the Laboratory of the Army and Navy. These 
 visits always ended with a most excellent lunch, including the 
 native wines and champagne. The section dinner was given 
 in one of the dining-rooms of the Ingleterra Hotel. The Minis- 
 ter of War and a number of military and naval ofl&cers of the 
 highest rank were present. The dinner was one which it 
 would be difficult to duplicate in America. The parting 
 speeches were numerous, in many languages, and most of them 
 eloquent. Contrary to what we were made to believe before w
 
 11 
 
 entered Spain, after ample experience we had to come to the 
 conclusion that the Spanish kitchen is a most excellent one. 
 The rooms in the hotels are large and the beds not only com- 
 fortable but luxurious. Receptions by the mayor of the city and 
 the Minister of the Interior and an opera party completed the 
 list of entertainments. 
 
 The Committee on Entertainments very wisely excluded 
 from the program the national sport— bullfighting. It is needless 
 to say, however, that most of the delegates, including their 
 wives, secured admission tickets in time and were in their 
 seats at 4 o'clock Sunday afternoon when the first bull made 
 his attack on the poor blindfolded horses, who looked in vain 
 for protection from their stupid riders. The bull in turn was 
 teased, worried and tired out when the gaudily dressed bull- 
 fighter (butcher) entered the ring to put an end to the misery 
 of the half dead brute. This brutal sport was repeated six 
 times before the program was finished. The Madrid bullfight 
 is a tame affair compared with that of the City of Mexico, and 
 it is safe to say that no foreign " congressiste" will ever care to 
 witness another one. The royal family neither attends nor 
 encourages this sport. For years repeated efforts have been 
 made to suppress it and its days are evidently numbered. It is 
 a relic of former days and so far as brutality is concerned it is 
 no worse than the cockfights and football games so well pat- 
 ronized in our own country. 
 
 Reflections.— It is much easier to criticise mistakes than to 
 avoid them. The local committees of the Congress did much 
 creditable, hard work. The medical profession of Madrid and 
 Spain at large was anxious to make the Congress a great suc- 
 cess. In many things the efforts succeeded, in others they fell 
 short of expectations. The government officials from the King 
 down to the employes of the lowest grade did their duty. The 
 railroads and steamship companies ofifered sufficient induce- 
 ments by reduction of rates to secure a large attendance. Look- 
 ing backward, it is not difficult to ascertain where better 
 arrangements could have been made. The system of registra- 
 tion was very defective. No reliable bureau of information. 
 Only two persons were in charge of the mail ; it required both 
 patience and perseverance to call for letters. The " Bureau de 
 logement " assumed a difficult task when it undertook to secure 
 desirable accommodations for the visitors. Many bitter com- 
 plaints were made by members who were assigned to quarters 
 outside of the hotels. The hotel guests had no reason for well- 
 grounded dissatisfaction. The general program did not give 
 the desired information. The titles of the papers for the sec- 
 tions were thrown together without any reference to the time 
 when the papers were to be presented in the respective sections.
 
 12 
 
 The Diario OJicial., under the editorship of Dr. Enrique 
 Salcedo, contributed something toward the remedying of this 
 defect, but failed in doing away entirely with the existing 
 confusion. The Suplemento Diario OJicial, containing the 
 names and local addresses of the members, made its appearance 
 on the day the Congress adjourned. Hence there was no way by 
 which we could ascertain the addresses of friends we w^ere 
 anxious to meet and visit. Nine numbers of the Diario 
 were issued, the last number the day after the Congress 
 adjourned. The foregoing are'some of the shortcomings of the 
 Arrangement and Program Committees which should be 
 remembered, and, if possible, avoided by those who will be 
 placed in charge of the management of the next Congress. On 
 the whole, however, we fared much better than we had reason 
 to anticipate. The merits of the Congress overshadow the 
 demerits ; the pleasures, the disappointments. We can say with 
 the editor of the Diario Oficial (NumeroS): "Le lien n'est 
 pas opportun pour parler des fruits du Congres, ils sont con- 
 signes dans les Actes qui seront comme un livre d'or, dans le 
 vaste champ des sciences medicales, mais nous pouvons bien 
 dire que le XIY*'"^ Congres de Medecine, continue la glorieuse 
 tradition des anterieurs et qu' il est I'honneur de notre 
 Facuite." 
 
 Two evils threaten the future successes of the International 
 Medical Congress. They are : 1. Too great laxity in the admis- 
 sion to membership. 2. Too large attendance. The elimination 
 of the first evil will correct the second. The Congress should 
 be strictly a delegated body. The appointment or selection of 
 delegates should be restricted so that at no time the attendance 
 would exceed 2,000. The selection of the delegates should be 
 made by a committee of the National Medical Association of 
 the countries seeking for representation, or in the absence of 
 such by the governments. The doors of the Congress should be 
 closed to laymen so far as membership is concerned. So far 
 each Congress has had its full share of camp followers, who 
 take advantage of reduced transportation rates, crowd the 
 hotels, and never fail in taking in all the entertainments which 
 are always given as a compliment to the doctors in attendance ; 
 as the present requirements for membership in the Congress 
 are such that any one, professional and layman, who pays the 
 stated subscription fee is admitted and is entitled to all the 
 privileges accorded the delegates. There are few cities large 
 enough to secure desirable accommodations for more than 2,000 
 to 3,000, hence the desirability of restricting the attendance. A 
 change in this direction cannot be made too soon, and it is 
 hoped that the authorities of the next Congress will consider 
 this matter and formulate the regulations accordingly, inas-
 
 13 
 
 much as the hotel accommodations of Lisbon are greatly inferior 
 to those of Madrid and the other cities in which the Cougress 
 has met in the past. 
 
 The delegates returning from Madrid have much to be 
 grateful for. We have seen Spain, her antiquities and works of 
 art. We have seen her rugged mountains and fertile plains. 
 We have seen the royal family, and have come in touch with 
 her chivalrous, hospitable people. We have become familiar 
 with her excellent charitable institutions, her schools and uni- 
 versities, and more than all this, we have established, I trust, a 
 bond of permanent friendship between the Spanish and Ameri- 
 can medical profession. 
 
 In conclusion, I desire to extend my sincere thanks to Cap- 
 tain Juan Redondo, of the Spanish Navy, who was my constant 
 companion from the time I arrived at Madrid until my depart- 
 ure, and through whose influence I received many courtesies 
 and much valuable information, which, without his friendly 
 intervention, would not have been obtainable. 
 
 Madrid, April 30, 1903.
 
 [Reprinted from American Medicirie, Vol. VI, No. 1, pages 30-33, 
 July 4, 1903.] 
 
 THE MEDICAL INSTITUTIONS OF MADRID. 
 
 BY 
 
 NICHOLAS SENN, M.D., 
 of Chicago. 
 
 The American physician in search of rest or knowledge; 
 beyond the Atlantic Ocean usually pursues the well-trodden 
 paths through Germany, France, and England. The peninsula 
 of Spain is not often frequented by medical tourists. Modern 
 Spanish medical literature is not abundant, and does not tiud 
 its way into the current of the world's medical literature 
 to the extent it should. The medical institutions of Spain 
 are not sufficiently known to the outside world to be 
 estimated correctly in the scale of modern advanced 
 requirements. The fourteenth International Medical Con- 
 gress recently held in Madrid will do much to bring the 
 scientific work of the Spanish practitioners and investi- 
 gators to the notice of their colleagues in the remaining 
 countries in Europe aud far beyond the seas. A wrong impres- 
 sion prevails not only in our country, but elsewhere, to the effect 
 that Spanish medicine is at a standstill. The forthcoming 
 volumes of the Transactions of the Madrid International Medi- 
 cal Congress will prove the contrary. The spirit of the present 
 age has animated the Spanish profession and makes itself evi- 
 dent in all of its medical institutions and medical literature. 
 Progress and investigations are rife everywhere, and have 
 wrought results well calculated to astonish visitors. 1 am con- 
 fident every one who attended the Congress at Madrid will 
 return with a more favorable opinion of the part Spain is taking 
 in the advancement of the science and art of medicine if he 
 utilized his time to advantage in visiting and studying its medi- 
 cal institutions. The present Spanish medical literature is not 
 extensive, but highly creditable. I will cite only two instances 
 showing its character. The best current medical publication is 
 undoubtedly the Revista Ibero-Americayia de Ciencias Medicas, 
 a quarterly journal founded by the late Professor Federico 
 Rubio y Gali. It is a credit to medical journalism, the 300 
 pages of each issue being the newest and the best in the field of 
 recent medical progress. The illustrations, colored and half- 
 tone, are numerous and artistic. Under the first heading it 
 brings valuable clinical contributions; then follow original sci- 
 entific articles, aud finally review of reviews, bibliography,
 
 and varieties. Another among the many recent publications is 
 the " El Laboratorio Central de Sanidad Militar." This book 
 of 322 pages, profusely illustrated with excellent photographic 
 reproductions, gives the history and minute description of the 
 laboratory of the medical departments of the army and navy. 
 I have alluded to these publications only to indicate the type 
 and character of the Spanish medical literature of the present 
 day in order to show that the profession is wide awake, and con- 
 tributes its full share to the scientitic work of the age we live in. 
 Central University. —Spa,in has probably more universities 
 to the number of its inhabitants than any other country. The 
 one in Madrid is called the Central University to distinguish it 
 from the rival institutions inanumber of the smaller provincial 
 cities. The ancient Universite d' Alcala de Henares was abol- 
 ished in 1836, and in its place the University of Madrid was 
 created, with the faculties of law and canon law. The present 
 
 
 
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 InMM 
 
 mi 
 
 
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 Perspective of a street. 
 
 name of the University was adopted in 1850, and at that time 
 the faculties of law, philosophy and letters, sciences, medicine, 
 and pharmacy were installed. Later the medical and pharma- 
 ceutical departments were assigned new quarters. The corps of 
 professors and instructors is a very large one, and the different 
 courses long and thorough. The library is large and contains 
 some very rare books, among them a copy of the " Bible Com- 
 pluteuse," the only one in Spain, and many remarkable manu- 
 scripts. Among these should be mentioned the Testament and 
 Codicil of Cardinal de Villanueva and a Hebrew Bible. 
 
 San Carlos College of Medicine.— This is the medical depart- 
 ment of the Central University. The school was founded in 
 1780 by Charles III, and occupies at present an ancient building 
 in Atocha street, 104-106. Professor Julian Calleja y Sanchez is 
 dean. The professors, assistant professors, and instructors 
 number 61. The course of study extends over seven years. 
 The anatomic museum contains a very extensive collection of
 
 8 
 
 models, skeletons, bones, and dried specimens from the dissect- 
 ing-room, splendid object lessons for the students of anatomy. 
 The dissecting-room is large, well lighted, clean, and amply 
 supplied with material on marble slabs of the most practical 
 design. The pathologic museum has a rich collection of speci- 
 mens illustrating all phases of disease, and so arranged that 
 they can be studied to advantage with the least possible amount 
 of handling. In the obstetric department I took particular 
 notice of a series of models in plaster descriptive of the differ- 
 ent stages of labor, a material which must be a great aid in 
 teaching this part of the healing art. The physiologic depart- 
 ment is well supplied with animals for experimental purposes, 
 and a splendid assortment of the most modern instruments for 
 teaching and scientific research. The wooden benches in the 
 lecture-room would be objected to by our more fastidious stu- 
 dents, but they have done service here for a long time, and so 
 far they have not been made the cause at any time of any of the 
 student demonstrations so common here. I visited the college 
 on a Sunday forenoon, and found the assistant professor of his- 
 tology hard at work in his laboratory. Valuable original 
 research is in progress here, and the work is carried on with 
 much enthusiasm by teachers and students. The bacteriologic 
 laboratory is up to date, and this part of the curriculum is in 
 high favor with the students. The number of students who are 
 in attendance now does not exceed 400. The library contains 
 50,000 volumes, among them many rare parchments and manu- 
 scripts. Beside this one there are seven other medical colleges 
 in Spain, but the power to grant diplomas is limited to the San 
 Carlos. If a licentiate of any other college is desirous to acquire 
 the title M.D., he must attend another year the instructions at 
 the San Carlos before he can come up for the final examination 
 for the degree. Licentiates of any of the schools are privileged 
 to practise, but are not permitted to make use of the title M.I). 
 It is estimated that the present number of medical students in 
 the different colleges is somewhere in the neighborhood of 
 2,000. 
 
 Practice of Medicine in Spain. — Like most of the civilized 
 countries Spain is well supplied with doctors. The pay received 
 by medical officers of the army and navy is a fair indication of 
 the average income of the general practitioner. This basis is 
 very low in Spain. One of my friends in the navy has served 
 his country for 23 years, has reached the rank of captain and is 
 paid only ^60 a mouth. His duties are so exacting that he has 
 little opportunity to increase his income by private practice, so 
 he has to figure on his salary to support himself and his family, 
 consisting of wife and four children. From one to two dollars 
 is the average charge for a professional visit in Madrid, and the
 
 fees for obstetric service and surgical ojDerations are correspond- 
 ingly small. Twenty thousand dollars a year is considered a 
 princely income enjoyed only by one or two practitioners of 
 great repute in Madrid, and from §1,000 to .$5,000 a year is 
 the limit of a busy practitioner. The social standing of the 
 Spanish physicians is not so high as in Germany and England, 
 but compares favorably with that of the American doctor. 
 
 Charitable Institutions.— H ihe civilization of a nation is to 
 be measured by the number of charitable institutions then 
 Spain heads the list. The Spaniard has often been represented 
 as being fierce and cruel. From what I have seen I am satisfied 
 there is more cruelty practised in Chicago on man and beast in 
 one day than in Madrid in a month. The family ties in Spain 
 are more tender than with us. Unprovoked violence and 
 cruelty are rare. The sense of humanity is keen and active. 
 The nobility of the character of the Spanish people is best 
 shown by the many charitable institutions for the poor, the sick, 
 the orphans, the homeless, and the aged. The street beggar in 
 this city has no excuse for practising his nefarious trade. If he 
 is deserving of charity he will find it in one of the many institu- 
 tions established and maintained for this purpose. Our well 
 meaning charitably disposed people can learn many a practical 
 lesson by looking into the manner in which the government 
 and the people of Spain take care of their deserving poor. The 
 Sisters of Charity, St. Vincent de Paul, the oldest and best order 
 of the Catholic Church, are present everywhere in Spain and in 
 large numbers. They are in charge of nearly all of the hospitals, 
 take care of the orphans and aged, and educate the children. 
 The influence of this order is in evidence in nearly all of the 
 charitable institutions. The cornet, the headdress of the 
 Sisters of Charity, is an emblem of charity of the noblest 
 kind, honored and respected by all nations. In Madrid 
 alone there are 11 asylums, 2 hospices, 2 institutes, and 
 5 houses of refuge for the benefit of orphans, the aged, widows, 
 the crippled, and helpless. Many of these noble institutions 
 have been founded and are maintained by Avealthy citizens and 
 aid-societies. The Institute for Epileptics is a good indication of 
 the concern of the government for its unfortunates. Where is 
 the city that can make the same showing of the wise distribu- 
 tion of needed charity ? What has Chicago done for its imbeciles 
 and epileptics? Let those who charge the Spaniards with 
 cruelty come here and see, and if they can leave prejudice at 
 home they will comprehend what true charity means. 
 
 JTospiYa/.s.— Madrid may well pride itself on its hospital 
 facilities for the army and the sick poor. The well-to-do 
 families are opposed to hospital treatment ; the consequence is 
 that there are no elegant private hospitals such as we find in
 
 our country in nearly every city of sufficient size to support 
 such an enterprise. It is not long since the same prejudice 
 against hospitals existed in our country. The objections have 
 been overcome by the establishment of home-like private hos- 
 pitals and by the trained female nurse. The trained female 
 nurse must be created first and then private hospitals will fol- 
 low as a necessary sequence. The greatest fault of the Spanish 
 hospitals is not to be found in the buildings but in the absence 
 of the trained female nurse. Nearly all of the nursing in the 
 hospitals is done by the Sisters of Charity. They are a noble 
 band of intelligent, willing, self-sacrificing women, but lack the 
 necessary training in the care of the sick and as helpmates in 
 the operating-room. In our country the Sisters have recog- 
 nized the necessity of such training, have received the requisite 
 instruction, and are now managing the best training schools 
 for lay nurses. Let the Sisters in Spain follow their example 
 and better nursing and private hospitals for the wealthy will 
 follow in rapid succession. 
 
 Military ffospiYa^.— The Military Hospital (Hospital Mili- 
 tar de Madrid en Carabanchel Bajo) was built eight years ago 
 
 General view of Military Hospital. 
 
 near the city limits. A narrow railway and electric tramway 
 furnish ready transportation to and from the city. The build- 
 ings or pavilions, 24 in number, are solid brick structures of 
 one and two stories, communicating with each other by glass 
 walled galleries. The general in command and medical 
 officers occupy the two elegantly furnished pavilions near the 
 entrance to the grounds. The two surgical pavilions communi- 
 cate with the operating-room. The preparation, anesthesia, 
 instrument and operating-rooms are in a separate pavilion of 
 modern design. All of the buildings are lighted by electricity,
 
 the sewerage is perfect, and ample provisions have been made for 
 bathing. All the buildings are heated by hot air. The wards 
 are well lighted and ventilated and kept scrupulously clean. 
 The institution has a well-equipped bacteriologic laboratory 
 and a museum rich in pathologic specimens and a large collec- 
 tion of plaster models illustrating many pathologic conditions, 
 more particularly diseases of the skin and syphilitic lesions 
 in all stages of the disease. The food is plain but nourishing 
 and healthful. The waterworks supply the institution with 
 345 cubic meters of pure water every day, being 690 liters for 
 each patient. Isolation pavilions make adequate provision for 
 infectious and mental diseases. The hospital is intended to 
 
 Operating paviliou. 
 
 furnish room for 400 patients, but in case of need can accommo- 
 date twice that number. The storeroom for medical supplies, 
 the depot for amljulances, the stables for the horses, the disin- 
 fection-room, aud the steam laundry are all constructed upon 
 plans calculated to yield the best results upon an economic 
 basis. From 10 to 12 surgeons are daily in attendance. Only 
 the surgeon-in-chief resides in the hospital. The sick are cared 
 for by 20 Sisters of Charity and a sufficient number of men from 
 the sanitary corps. The interior of the operating-room, the 
 make-up of the instrumentarium, the dressing material, and all 
 the facilities for asepsis are sufficient guarantee that modern 
 surgery has found its way into this hospital. The institution 
 is one of which the military surgeons of Spain may well feel
 
 proud. The surgeons on duty can spend their leisure time in a 
 large, elegantly furnished room in which the members of the 
 Military Section at the close of their visit to the hospital were 
 served a most enjoyable lunch. 
 
 Clinical Hospital.— The Clinical Hospital (Hopital Clinique 
 de la Faculte de Medecine) is an old somewhat dingy building 
 adjacent to the San Carlos College. It has a capacity of 240 beds. 
 The faculty of the college has exclusive control of the manage- 
 ment of the hospital and all of the clinical instruction is con- 
 ducted here. The wards have from 10 to 24 beds. Professor 
 San Martin is the chief surgeon. 
 
 The operating-room is small and is separated from the still 
 smaller auditorium occupied by the students by a glass parti- 
 tion. Professor San Martin is evidently a firm believer in 
 asepsis. On the day of my visit he operated on a patient with 
 inoperable carcinoma of the rectum and demonstrated his new 
 operation for the formation of an artificial anus. 
 
 The patient was anesthetized by the introduction of chloro- 
 form vapor through two rubber tubes inserted into the nares. 
 The abdomen was opened in the left iliac region in the usual 
 manner. A transverse incision two to three inches in length was 
 then made through the skin and fascia lata two inches below 
 the iliac crest and a little behind a vertical line from the ante- 
 rior superior spine of the ilium. After making a short cross cut 
 through the fascia a tunnel was made with hemostatic forceps 
 underneath the sartorius muscle into the iliac fossa and the 
 sigmoid flexure was then drawn into this submuscular passage 
 until the apex of the loop was on a level with the skin of the 
 external incision, in which position it was fixed with sutures 
 embracing the mesosigmoid. The abdominal incision was 
 closed with buried continuous catgut sutures. The bowel will 
 be opened after it has become securely adherent. 
 
 The operator calls this operation the valve method, and 
 maintains that the muscles surrounding the loop of intestine 
 act as an efficient sphincter, which prevents leakage between 
 the bowel movements. The clinical material of this hospital is 
 utilized to the best advantage for the students. Two to three 
 students are assigned to each important case. They are 
 required to write up a complete history of the case, make a 
 thorough examination, and visit the patient regularly. This 
 method of clinical instruction has certainly much to recom- 
 mend it to the attention and for the consideration of clinical 
 teachers. It would, however, be difficult if not impossible to 
 secure such liberties with patients in any part of our country. 
 
 Provincial Hospital —This, hospital (Hopital Provincial) 
 is more than 200 years old. It was founded in 1587 by Philip II, 
 under the name of La Encarnacion y San Roque. It is an 
 immense square building with a central court. The windows 
 are small, the solid stone walls six or more feet in thick-
 
 8 
 
 ness, features -which impart to the building a fortress-like 
 appearance. The wide corridors all around the open court are 
 protected against cold, wind and rain by a siding of window- 
 glass. The court has been converted into a beautiful flower 
 garden. The wards are large, with high ceilings, and all the 
 floors are made of tiling. The furnishings of the wards, includ- 
 ing the beds, are plain, but comfortable. Sixty Sisters of 
 Charity take care of the patients — never less than 1,000. The 
 professors of San Carlos College give their gratuitous services 
 to this institution, but so far have not been permitted to give 
 clinical instruction. A movement is now on foot to secure this 
 privilege, and it is hoped that the request will be granted. 
 The clinical material here is simply immense, and its utiliza- 
 tion for clinical teaching would be a great acquisition to the 
 teaching facilities of the college and would open up a rich mine 
 for scientific clinical work. The hospital has two operating- 
 rooms : the new one in a separate pavilion meets all the require- 
 ments for modern aseptic surgery. Sunday is the visiting day. 
 I happened to visit the hospital on that day and found wards, 
 halls and corridors crowded with relatives and friends of the 
 patients. Loud talking, laughing and smoking gave the hos- 
 pital the appearance of a public market, rather than a place for 
 the injured and sick. Corpses were being carried out, new 
 patients were brought in, all of which made a scene that could 
 not be reproduced in any of our hospitals. The Provincial Hos- 
 pital is for the sick poor of Madrid what the Bellevueis for Xew 
 York, the Charity Hospital for New Orleans, and Cook County 
 Hospital for Chicago. The expenses of the hospital are paid 
 out of the public funds of the Province, as no provision what- 
 ever is made for pay patients. 
 
 Princess Hospital.— The Princess Hospital (Hospital de la 
 Princesa) is another great public charity in the very heart of 
 the city. It was founded in 1852 by Queen Isabella II in com- 
 memoration of the birth of the Princess of Asturia. The three- 
 story brick pavilions with inside glass-protected corridors face 
 a capacious open court beautified by subtropical trees and 
 shrubs, flower beds, fountains and winding paths. It can 
 accommodate 225 patients. The only requirements for admis- 
 sion are poverty and illness. The wainscoting of the rooms 
 and halls, as well as the floors, are in glazed tiling. The oper- 
 ating-room is small but well adapted for aseptic work. The 
 care of the sick is in charge of 30 Sisters of Charity. I found 
 here a number of trained orderlies, who assist in the nursing 
 and in the operating-room and apply many of the dressings. 
 These men receive their training in the San Carlos College, 
 where they attend lectures and receive practical instruction for 
 two years. At the end of that time and after having passed a
 
 satisfactory examination they receive a certificate which entitles 
 them to serve as assistants to physicians. The training and 
 scope of work corresponds with those of the barber surgeons of 
 Russia and other European countries. One of these orderlies 
 
 Princess Hospital. 
 
 is the anesthetizer of the hospital. The anesthetic in general 
 use in Spain is chloroform. The instruments and dressing 
 materials are kept in a separate room near the operating-room. 
 Suture and ligature material is purchased already prepared and 
 
 Court of Princess Hospital. 
 
 is kept ready for use in hermetically sealed glass bottles. The 
 attending staff is composed of seven physicians and surgeons 
 who receive their appointment by concour. They are assisted 
 by 26 agreges and 85 assistant physicians. Drs. Cospedal and
 
 10 
 
 Ustaris are the principal operating surgeons. In this as well as 
 in most of the hospitals in Spain there are no permanent 
 internes. The young doctors who serve in place of our internes 
 are appointed by competitive examination and hold their 
 positions until they are advanced and become members of the 
 stati'. This hospital has three such internes, who serve alter- 
 nately for 24 hours. They are the only members of the medical 
 corps who receive a small salary. Two days out of three they 
 attend to their private practice. Three priests serve the spiritual 
 needs of the inmates in the same manner, occupying the same 
 room every third day. A small clinical laboratory and a 
 pathologic museum represent the scientilic aspects of this hos- 
 pital. The polyclinic attached to this hospital is nearing com- 
 pletion. Sixteen physicians are in attendance at different 
 times, all of whom render their services gratuitously. In Spain, 
 like in our country, the medical profession is expected to give 
 to the hospitals their time and labor free of charge. 
 
 The arrangements of the interior of the new polyclinic are 
 very practical, which enables the attending staff to dispose 
 of the large clientele quickly and in a most satisfactory 
 manner. The specialties that receive recognition here are dis- 
 eases of the urinary organs, nervous system, larynx, eye, ear, 
 digestive tract, gynecology, and diseases of children. The 
 annual expense of the polyclinic alone amounts to 138,320 
 pesetas. Dr. Jose Ustaris is chief of the attending staff. 
 
 Riibio Institute.— The " Institut de Therapeutique Opera- 
 toire" is universally known under the name Rubio Institute, 
 in memory of the late Professor Federico Rubio y Gali, its 
 founder. It is the only hospital in Madrid devoted exclusively to 
 surgical cases. The cornerstone was laid by the Queen Regent 
 in July, 1895, and its doors opened to the sick poor in need of 
 surgical treatment on the first day of October, 1896. Professor 
 Rubio was the most eminent surgeon that Spain produced 
 during the latter part of the nineteenth century. He was 
 highly esteemed not only by his colleagues and students, but 
 also by the entire population of Madrid. He contributed 
 liberally toward the building and support of the hospital. He 
 died at an advanced age June 28, 1902. He remained at his post 
 of duty until the day before his death. At his request he was 
 buried in the small chapel on the hospital grounds, where a 
 marble slab in the floor in front of the altar with suita])le 
 inscription on a silver plate marks the place where his remains 
 are at rest. The principal motive that induced Professor Rubio 
 to found this hospital was to establish a postgraduate school 
 for the study of surgery. The pupils, graduate physicians, on 
 payment of 250 pesetas have the privilege to attend operations 
 and receive instruction for two consecutive years. The hos-
 
 u 
 
 pital is situated upon a high bluff at the northern boundary of 
 the city, in full view of the Ijeautifnl Moncloa valley, watered 
 by the Manzares river. The grounds are park-like, shaded by 
 groves of young eucalyptus trees. The brick and stucco pavil- 
 ions are one-story high, and the two main wards, with 24 beds 
 each, are connected with the operating-room by galleries. The 
 operating-room leaves nothing to be desired, and is supplied 
 with all possible facilities for aseptic operations. The hospital 
 is lighted by electricity and heated by steam. The closets and 
 bathrooms compare well with those of our best hospitals. Up 
 to date 30 beds have been endowed by the payment of 12,700 
 pesetas for each by friends of the deceased founder. Upon an 
 oval silver plate on the wall above the bed the name of the 
 donor is inscribed. An isolation pavilion with six beds in as 
 many rooms is set aside for infected cases. Above the entrance 
 door and in the vestibule of this building will be found the 
 
 Ruble Institute. 
 
 names of the teachers of Rubio. A separate two-story building 
 is vised as polyclinic for outdoor patients. The institution is 
 managed by a board of directors, of which the Queen is honor- 
 ary president. 
 
 The Rubio Institute is the best hospital in Madrid, and the 
 patients, although all of them are cases of charity, receive the 
 same care and attention as in any of our best private hospitals. 
 It is the only hospital in the city that has a training school for 
 female nurses. Tlie present number of pupils in the school is 
 12. The training consists of lectures given by the members of 
 the staff, demonstrations, and practical instruction. At the end 
 of three years they are examined, and if found qualified, receive 
 a certificate which entitles tliem to follow their profession out- 
 side of the institution. The headdress of these nurses is a very 
 unique one. It consists of a hood rather than a cap which 
 leaves only the face part of the head exposed. The outside of 
 this hood is blue, the inside lining orange yellow. The hospital
 
 12 
 
 is to be congratulated upon this radical change in the nursing 
 of its inmates. It has become a pioneer in Spain in the impor- 
 tant matter of nursing. The example it has established can- 
 not fail in inducing other institutions to do the same, and when 
 I visit Spain again I hope to find that all of the Sisters of 
 Charity serving in hospitals will have become trained nurses, 
 and that every large hospital will have its own training school 
 for lay female nurses. With the realization of such a radical 
 change in the care of the sick, the hospitals of Madrid and 
 throughout Spain Avill come in line with those of any other 
 country, old and new, I have made brief allusion only to a 
 few of the largest hospitals of Madrid. The number of hospitals 
 is simply astonishing, considering the size of the city — 17 in all, 
 beside the many asylums, hospices, homes, and institutes. 
 The hospital for children has 200 beds, the smaller ones from 
 12 to 50. The hospital for the insane is an ideal institution 
 with a branch at the seaside, Villajoyosa, where the inmates 
 spend the summer months. Music, dancing, theaters, are 
 only some of the diversions regularly furnished for the unfor- 
 tunate patients. Madrid has also, strange to say, a homeopathic 
 hospital. The Institute Homeopathique et Hopital de San .lose 
 owes its origin to the liberality of Marquis de Nunez. The four 
 chairs for the elucidation of the homeopathic doctrine and 
 practice were founded by the Marquis, and since his death 
 have been supported by the government. Fifteen thousand 
 patients have been treated in this institution since its founda- 
 tion in 1878. The French and Italian residents have made pro- 
 vision for their poor sick countrymen by the establishment 
 and maintenance of hospitals of their own, the former with 20 
 beds. 
 
 Among the many societies formed with the object of diffus- 
 ing and popularizing humanity in all its phases, I will only 
 mention the Red Cross Society and the Society for the Protec- 
 tion of Infants. 
 
 The Red Cross Society of Spain is well organized for effective 
 work in peace as well as in war when it is called upon to exer- 
 cise its humane functions. Its loyalty to the intent and regula- 
 tions of the Geneva Convention was amply demonstrated dur- 
 ing the Spanish-American war. Its activity in relieving suffer- 
 ing and distress in sudden emergencies at home is well known. 
 Of the objects of the "Societe Protectrice des Enfants " the 
 following is said : " Cette Societe humanitaire a pour objet de 
 sauvegarder la vie des enfants par tous les moyens possibles, 
 depuis leur naissance, contre tous les dangers auxquels les 
 expose leur faibless, de les proteger, quelle quesoit leur classe 
 ou conditions contre 1' abandon, la misere, les mauvais traite- 
 ments, et les exemple immoraux, et de rendre populaires les
 
 13 
 
 preceptes les plus utiles de V Hygiene et de la Morale, eu union 
 des preceptes religieux." Let those who live far away from 
 Spain and who have heard of the barbarity of its people come to 
 Madrid and see its magnificent works of art, its splendid 
 schools, its excellent hospitals, its many homes and asylums 
 for all classes of unfortunates, and its humane societies. To all 
 of these I say, reserve your judgment until you " come and 
 see." 
 
 On board S. S. " Princess Irene." harbor;of New, York, May 14, 1903.
 
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