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SCIENTIFIC TRANSACTIONS
—OF THE–
Medical Society
—OF—
CITY HOSPITAL ALUMNI
(ST. LOUIS)
FOR THE YEAR 1904.
ST. LOUIS, MO.,
COURIER OF MEDICINE CO.,
1905.
*
CONTENTS.
Retrouterine Hematocele & tº e sº sº dº «-» * *
W. C. Gayler.
Strangulated Hernia, cases that had been operated on for, * , tº tºº
- John Young Brown.
Leukemia s tº tº * { tº- • gºs &º º
J. M. Buchanan.
Acute Osteomyelitis of the Femur sº gº {º * tº gº
C. G. Kirchner.
Ligation of the Common Carotid Artery - tº º wº * > tº a
J. M. Pfeiffenberger.
Recent Therapy in Epilepsy ſº gº º sº gº wº * *
* * Given Campbell.
Treatment of Non-Malignant Diseases of the Skin by the Xray - º
Joseph Grindon.
Cardiac Lesions, Patient with - tº gº º gº * * tº
L. H. Behrens.
Topographical Anatomy of the Thoracic and Abdominal Viscera - tº
Peter Potter.
Use of the Colpeurynter in Obstetric and Gynecologic Practice tº * {
- - George Gellhorn.
Specimen of Aneurism * > sº sº sº wº- sº
E. S. Smith.
Horse-Shoe Kidney, Specimen of, sº wº ge º -: *
Suppurative Appendicitis with Foreign Body, Specimen of, º tº
Complete Calcification of the Coronary Artery, Specimen of, s sº
Complete Calcification of the Aorta to Bifurcation of the Iliac, Specimen of,
Aneurism, Specimen of, * * * tº- tºº sº - . . gº
Exceptional Dilatation of the Ureter, Specimen of, - tº tº
Howard Carter. -
Paralysis of the Deltoid Muscle, Case of, * wº-ºº. * * gº sº
Appendix, Specimen of, Gººg tº *-e sº Eº º tºº
Carcinoma of the Cervix of the Uterus, Specimen of, - s wº sº-
Uterus Bicornis, Specimen of, º • * * tº- *-*. *
Kidneys, Specimens of Diseased, &E's - sº * &ºe tº-
Francis Reder.
Strangulated Hernia, Brief Notes on Three Cases of, , - wº 4-
John Young Brown -
Two Unusual Ovarian Cysts, Report of Cases and Presentation of Specimens,
Appendicitis, Report of Case of, with Specimen, sº tº tºº -->
A. H. Meisenbach. *
Modern Treatment of Prostatic Hypertrophy win Obstruction *
Arthur Tracy Cabot.
Climatology—Its Value to the Student and Practitionel * tº
S. E. Solly
17
I9
26
28
33
57
58
65
88
90
90
9I
9I
9I
9I
9I
92
94
94
95
97
IOI
Io8
I33
W. The Medical Society of
The Surgery of Typhoid Fever - ſº * - gº tº tº I5o
W. W. Keen.
Remarks on the Surgery of Typhoid Fever tº E- tºº |- - 172
Norvelle Wallace Sharpe.
Syncephalus Monoprosopus, Specimen of, tº º £º º 177
J. L. Boehm.
Strangulated Umbilical Hernia—Double Resection of Bowel—Anastomosis
with Murphy Button—Recovery, Case of, wº wº E- - 177
John Young Brown.
Combined Ethyl-Chlorid and Ether Anesthesia by Means of the Bennett Ap-
paratus, with Demonstration, tºº * - &- º tº 181
M. G. Selig. *
The Possible Victory Over the Great White Plague - tº e - 190
S. A. Knopf.
Case of Chronic Seminal Vesicultis—Removal of the Vesicles—Recovery 2I 2
Prostate Stones, Specimens, º º tº º -8 * º 22I
Bransford Lewis. }
Left Hemiplegia s tº tº Eº * $º sº • 222
Horace W. Soper.
The Early Diagnosis of Uterine Cancer - ( * s tº tºº 224
~. George Gellhorn.
The Etiology and Management of Brow Presentations sº sº - 235
F. J. Taussig.
Salivary Calculus, Specimen of, tº sº * - sº tº- {º 252
J G. Moore.
Fallacies, Aims and Methods of Hydrotherapy in Fevers sº * - 253
Simon Baruch.
A Review of Methylene Blue Eosin Blood Stain, a Report of Some Modi-
fications in Method of Preparation Exº º wº. tº- 273
The Ruediger Blood Test for Typhoid tºº tº . * º – 281
George C. Crandall.
INDEX.
Abdominal pain, 94.
section, indications for, Io, I5.
Surgery, I 79.
Abortion, method of inducing, 7o.
Acne necrotica, benefited by xray treatment, 48, 54.
vulgaris, treated by xray, 49, 53, 54.
Alcoholism in tuberculosis, I98.
Anastomosis, I7, 97.
by the Murphy button, 177.
Anatomy of the thoracic and abdominal viscera, 58.
‘Anesthesia, II2.
Bennett apparatus, technic of, 182.
chloroform, a heart depressant, 181.
City Hospital Alumni.
Anesthesia, chloroform and ether, 181.
ether, a pulmonary irritant, 181.
ethyl-chlorid, Bennett apparatus, 181.
morphin, prolongs convalescence, I86.
mortality, 188.
narcotics will produce heart disturbances, 183.
Aneurism, arteriosclerosis as a cause of, 9o.
specimens of, 88, 91.
syphilis as a cause of, 90.
'Appendicitis, IoI.
ice as an anesthetic in, 271.
pseudo, IO4.
specimens, 93.
suppurative, specimens of appendix, 90.
symptoms of, IoI.
unusual symptoms of, 93.
Artery, ligation of, 28.
Atrophy of the skin as a result of xray treatment, 53.
Blastomycosis not benefited by xray, 46.
Blood counts, 23, 25.
Smears, 24.
stains, technic of, 275.
test for typhoid, 281.
Bottinni operation, 125.
Bougie, introduction of, into the uterus, 69.
Bowel, double resection of, 177.
Burns by xray, 55.
Calcification of aorta, specimen of, 91.
of coronary artery, 91.
Calculus, operative treatment for, J24.
salivary, specimen of, 252.
source of infection ot, 124.
Cancer, diagnosis of, 230.
lack of knowledge concerning, 246.
microscopic findings, 228.
mortality, 225.
of the cervix, specimen of, 94.
of the prostate, 126.
of the uterus, case of, 25o.
ulcers of, 233.
uterine, early diagnosis of, 224.
Cardiac lesions, case of, 57.
Carotid artery, ligation of, 28.
Catheterization, dangers of, 130.
in prostatic hypertropy, Io9.
Cervical canal, dilatation of, 66.
Childbirth, instrumental delivery, 236.
Chloroform a heart depressant, 181.
Climate, high altitude, atmosphere charged with positive electricity, 146.
surgery in, I46.
Climatology, 133.
Vi The Medical Society of
Colpeurynter, description and history of, 65.
infection carried by, 84.
in obstetric practice, 65.
should be in every obstetrical bag, 81.
sterilization of, 83.
Coronary artery, calcification of, 91.
Cystitis caused by catheterization, IIo.
Cystotomy, 221.
Cysts, ovarian, 96.
Diagnosis of cancer, 226, 230.
injury to vessels in neck, 31
osteomyelitis, 27.
tuberculosis, 210.
typhoid perforation, 158, 175.
difficulty of making, 165.
Dilatation, bougies, 85.
of the cervical canal, 66.
manual, 84.
Dislocation of the hip, result of typhoid infection, I54.
Dissecting, preparation of body for, 58.
Ectopic pregnancy, cause of retrouterine hematocele, I, 5.
Eczema treated by xray, 55.
Electricity as a tonic, 146.
Epilepsy, bromin treatment does no harm, 43.
not satisfactory, 40.
only palliative, 40,
case of, 36.
early treatment important, 43.
horsenettle as a treatment, 40
recent therapy of, 33.
salt starvation treatment of, 34, 36, 38.
treatments of, in general, 36.
Ether a pulmonary irritant, 181.
as an anesthetic, administered by Bennett apparatus, 181.
Ethyl-chlorid anesthesia, Bennett apparatus, 181.
Extrauterine pregnancy as a cause of hematocele, 2, 5.
Eye, measurement of the pupils, 41, 44.
Femur, osteomyelitis of, 26.
Fevers, hydrotherapy in the treatment of, 254.
Finsen light in the treatment of lupus vulgaris, 45.
Gangrenous conditions, I7.
Gunshot wound, surgery of, I79.
Heart, affected by climatic conditions, 148.
disease of, effect of climate upon, 140.
Heatstroke, hydrotherapy in treatment of, 269.
Hematocele, conservative treatment of, 3, 5, 9, 18.
pelvic, 9.
retrouterine, I.
Hemiplegia. 30, 32, 222.
Hemorrhage, 7, 15, 28.
intraperitoneal, 12, 15
City Hospital Alumni. vii
Hernia, strangulated, 17.
notes on case, 97.
operation for, technic, 178.
treatment of, 18.
umbilical, 177.
Hidradenitis suppurativa, treated by xray, 48.
High altitude, increases red blood corpuscles and hemoglobin, 139.
Hydrotherapy, 253.
in heatstroke, 269.
Hygiene, I34.
in relation to tuberculosis, 197.
Hypertrichosis, treated by xray, 50.
Hypertrophy, prostatic, Io&.
Impotency caused by removal of stone in bladder, 123.
Incisions, I2O.
abdominal, 18O, 214.
for typhoid perforation, 160.
Tnfection of the prºstate, 122.
Keratosis follicularis, not benefited by xray, 46.
Keloid, xray treatment of, 47.
Kidney, diseased, specimen, 95.
affected by climate, I40,
horseshoe, specimen of, 90.
Labor, induced, 81.
premature, 7o.
Laparotomy, 99, IO2.
in treatment of retrouterine hematocele, 3.
Laryngeal complications in typhoid fever, 158.
Leukemia, 19
symptoms of, 21.
pathology of, 19.
Leukocytosis, 23.
Leuoderma, xray treatment of, 51.3
Ligating blood vessels, 7.
Ligation, 28. f
of the common carotid artery, 28.
Locomotor ataxia, diagnosis of, 216.
Lupus vulgaris, 44.
benefited by xray, 45, 52, 54.
case extending over 57 years treated by xray, 44.
treated by Finsen light, 45.
treated by xray, recurrence of lesions, 54.
Murphy button, anastomosis with, 17, 97, 177.
Nephritis, 70.
Nervous irregularities in tuberculosis, 138.
Obstetrics, brow presentations, 235.
use of the colpeurynter in, 65.
instrumental detivery, 72,236.
Operation, Bottinni, 125.
for appendicitis, IO2.
ovarian cysts, 99.
Wiii The Medical Society of
Operation for relief of hemiplegia, 224.
in high altitudes, 149.
ligation of carotid artery, 28.
on the prostate, II.3.
stones in the bladder, 221.
strangulated hernia, technic, 178.
typhoid perforation, 160, 176.
Operative treatment, osteomyelitis, 27.
retrouterine hematocele, 3, 5, 15.
strangulated hernia, 18.
Osteomyelitis, diagnostic points, 27.
of the femur, 26.
operative treatment of, 27.
Ovarian cysts, 98. e
diagnosis of, 99.
Paralysis, 29.
of the deltoid muscle, case of, 91.
Perforation in typhoid bears no relation to severity of fever, 157.
impending, 158.
site of, 157.
of the gall-bladder, complicating typhoid fever, I61.
typhoid, few cases in St. Louis, 170.
difficulty of diagnosis, 165.
Peritonitis, 270.
Prostate, enucleation of, I2O.
indications for removal, 122.
infection of, I22.
specimen of, 221.
Prostatectomy, III.
choosing the best operation, 125.
operative risks, I 17.
perineal operation, 115.
suprapuh ic operation, I I5.
Prostatic abscess from catheterization, I Io.
hypertrophy, IoS.
Surgery, Io9.
Pruritus not benefited by the xray, 51.
Psoriasis benefited by the xray, 51.
Retrouterine hematocele, causes of, I.
Sepsis, 27.
Septic poisoning, 95.
Shock following operation, IoI.
in typhoid perforation, 159.
Skin diseases treated by xray, 44.
Stains, 24.
blood, methylene blue eorin, 273.
preparation of, 274.
eosin solution, preparation of, 274.
methylene azure, 279.
blue, preparation of, 274.
City Hospital Alumni.
Strangulated hernia, treatment of, 17, 97.
Suppuration, I Io.
Surgery affected by altitude, 149.
g abdominal, 179.
of the brain, 224. t
of typhoid fever, 150, 172, 176.
vesiculitis, 212.
Syncephalus monoprosopus, specimen, 177.
Tamponade, 69.
Temperature, abnormal, Ioë.
Therapy (hydro) in fevers, 253.
Thoracic and abdominal viscera, topography of, 58.
Tinea capitas treated by the xray, 50.
Tracheotomy, 156. *
Tubal pregnancy, 2, 4, Io.
treatment of, Io.
Tuberculosis, 191.
altitude as adjunctive treatment, 134.
as affected by climate, 133.
bovine, transmission of to man, 193.
classes of persons who should guard carefully against infection, 195.
communication of, 191.
development of, alcohol as an aid to the bacilli, 198. ſ
diagnosis of. 2 Io.
disposition of spittle, 192.
dress as affecting, 198.
dry air, I34.
duty of lay press in disseminating knowledge, 199.
etiology of, 191.
examination of sputa, 208.
exercise a factor in the treatment of, I49.
importance of diet, 203.
hygiene, 134.
methods of quacks denounced, 2Oo.
moist air detrimental, 134.
necessity of education, 205.
not inheritable, 196.
one of the most curable diseases, 20I.
open air treatment of, 135.
rarified air, effect of, 134.
reduction of mortality, 204.
rest treatment, I48.
suggested rules for prevention of among children, 197.
ventilation, 134.
Tumor as a sequel of typhoid, 164.
Typhoid bacillus, viability of, 151.
fever, complications, 151, 161.
complicated by gangrene, I 52.
effect on the nervous system, 267.
hydrotherapy in treatment of, 257.
impending perforation, I58.
X The Medical Society of
Typhoid fever infection of bones distinguished from pyogenic infection, 154.
joints. I53.
intestinal perforation, 156.
laryngeal complications, 156.
normal saline solution, 268.
perforation bears no relation to severity of, 157.
diagnosis of, 158, 175.
difficulty of, 165.
mortality, I59.
of gall-bladder, 161.
shock, I 59.
site of, 157.
statistics, 175.
surgery of, I5o, I72.
Ruedeger blood test, 281.
tumor as a sequel, 164.
Ureter, specimen showing exceptional dilatation of, 91.
Urine, examination of, 70.
Uterine cancer, early diagnosis of, 224.
(retro) hematocele, 1.
Uterus bicornis, specimen of, 94.
cancer of, 225.
extirpation of, 225.
introduction of bougie into, 69.
prolapse of, replacement, 82.
Vaginal section, indications for, Io, 15.
Vesicles, removal of, 212.
Vesiculitis, 212.
etiology of, 213.
treatment of, 213
Widal reaction in typhoid fever, 283.
Xrays, burns, 55.
have revolutionized the therapy of dermatology, 51.
stimulating effect, 53.
in the treatment of acne necrotica, 48, 54.
vulgaris, 49, 53.
blastomycosis, 46.
eczema, 55.
hypertrichosis, 50.
keratosis follicularis, 46.
skin diseases, 44.
tinea capitas, 50.
leuoderma, 51.
must be administered with care, 54, 56.
not beneficial in pruritis, 51.
production of atrophy, 52.
treatment of hidradenitis suppurativa, 48.
keloid, 47.
lupus vulgaris beneficial, 45, 52, 54.
recurrence of lesions, 54.
used to advantage in psoriasis, 51.
Medical Society
... OF . . .
CITY HOSPITAL ALUMNI.
TRANSACTIONS.–1904.
Meeting of January 21, 1904; Dr. Charles Shattinger,
President, in the Chair.
Retrouterine Hematocele.
By W. C. GAYLER, M.D.,
ST. LOUIS, MO.
HILE in Prof. Döderlein's Frauenklinik in Tübingen,
Germany, it was my good fortune to be permitted to
re-examine thirty-six women who had suffered from
a retrouterine hematocele, and had been treated by the vari-
ous methods. The object of this examination was to find out
what method of treatment permitted of the most rapid recov-
ery, and which method produced the best ultimate results.
The patients, who lived in the surrounding country, were given
railroad fare and expense money, and told that an examina-
tion at the hospital was necessary for their welfare. This was
not true, but was very necessary in order to permit us to carry
on our investigations.
The general consensus of opinion is that almost all retro-
uterine hematoceles are caused by one of the results of an ec-
topic pregnancy. The great majority of cases are caused by
the abortion of the contents of a pregnant Fallopian tube.
2 The Medical Society of
Cases which are caused by the rupture of a tube are compar-
atively rare.
Zweifel’ says that practically all hematoceles are caused
by extrauterine pregnancy. Adding that the idea of a hemat-
ocele caused by a reversed menstrual flow is antiquated. How-
ever, there are reported in the literature many authentic cases
in which a pregnancy of no kind enters as an etiological
factor.
Schambacher” performed laparotomy on fourteen cases,
and found that four of them were not caused by an extrauter-
ine pregnancy.
Kober” reports two cases, one of which was caused by the
lifting of a heavy weight, and the other by a violent coition.
Mundé reports three cases following dilatation of the
cervix, and curettement of the uterus.
I can not understand these three cases and can not help
thinking that the curettement must have been very violently
done.
Thirty-three of our cases were caused by tubal abortion,
two by tubal rupture, and one was, without a doubt, caused by
an escape of menstrual fluid into the abdominal cavity. This
last one was a very beautiful case. A young woman, who
had never conceived, who claimed never to have had sexual
intercourse, and whose hymen was intact, entered the hospital
with a soft tumor in the cul-de-sac. The tumor decreased in
size during the month but when the menstruation came again,
it very appreciably increased in size. This was repeated reg-
ularly for several months.
We all agree that patients who have an uninterrupted ex-
trauterine pregnancy, and those who have an extrauterine
pregnancy which has been violently interrupted, should be
operated upon at once. There are many opinions, however,
as to what the method of procedure should be, when a hemat-
ocele has formed.
I find on looking over the newer literature, for which I am
partly indebted to Drs. Lutz and Ehrenfest, that a more inti-
mate knowledge of the pathology of tubal pregnancy, gained
within the last two years, has changed the opinion in regard
City Hospital Alumni. 3
to the treatment of these cases. It has been found that the
mucous membrane of the tubes is incapable of the rapid hy-
pertrophic changes that take place in the uterine mucous
membrane, immediately after the egg has forced its way into
it. As a result, the chorionic villi force themselves between
the connective tissue fibers and muscular fibers of the tubes
themselves.
Zweifel reported a case in which a small clump of chori-
onic villi pierced the peritoneal covering of the tube, causing
an almost fatal hemorrhage.
Thorn thinks that the villi which force themselves into
the substance of the tubes can not do much damage, as they
must soon die of lack of nutrition.
Shenk" thinks that the anatomical discoveries have not
yet been fortified by clinical experience; insisting, rather, that
the clinical experience points the other way.
Laparotomy was performed in eighteen of our thirty-six
patients. One died of sepsis, fifteen were absolutely well at
the end of four years, and two still complained of pains and
discomfort in the pelvis. The average time until the complete
recovery of the fifteen who did recover was six weeks.
The three who had been operated upon by way of the
vagina were absolutely well. The period of convalescence
was very short, and two again became pregnant.
Only thirteen of the fifteen who were treated conserva-
tively responded to our request to return for re-examination.
Eleven were freed of their complaints and showed no abnorm-
alities upon internal examination. Two still complained of
pain, a feeling of fullness and pressure in the pelvis, and had
a decided resistance in the cul-de-sac upon internal examina-
tion. One of these was the virgin of whom I spoke before.
She refused to submit to an operation. The average time
that these people stayed in the hospital was twenty days, and
the average time until their complete recovery was a little
more than four months.
These observations teach, I think, that these patients
should be given three weeks' trial conservative treatment, in
an institution, where surgical interferance is conveniently at
hand all the time.
4 The Medical Society of
REFERENCES.
*Zweifel.—Muenchener Med. Woch., No. 34, 1903.
*Schambacher.—Centralblatt f. Gynākologie, No. 36, 1903.
*Kober.—Ibid., No. 22, 1903.
*Mundé.-American Journal of Obstetrics, March, 1901.
*Shenk.-Muenchener Med. Woch., No. 16, 1903.
DISCUSSION,
Dr. FRED. TAUSSIG said that this paper had given them informa-
tion that they had long wanted, i.e., the after-results of conservative
treatment of hematocele. In the list of cases mentioned hy Dr.
Gayler, there was one in which the hematocele was attributable to a
cause other than that of tubal pregnancy—the case was that of a
virgin. But there was one thing that made the case less convincing,
namely, the absence of a laparotomy. There must always be a doubt
in our mind when we have not looked into the abdomen to verify the
diagnosis. The apparent hematocele may have been a large prolapsed
ovary; while very probable, the case did not impress him as having
been an absolutely certain one. A case reported at the last Gyneco-
logical Congress by Prof. Treund was very similar, the case of a virgin
with tuberculous disease. Alaparotomy was performed and it was seen
that the mass in the cul-de-sac was old clotted blood from the bleeding
of an old tuberculous pyosalpinx.
Eleven recoveries out of thirteen, as Dr. Gayler reports, was cer-
tainly a very high percentage. Von Dittel reports ninety cases, of
which, over 40 per cent were treated conservatively with good results.
He does not state, however, how long his cases were followed up. Some,
like Winternitz, have maintained that this conservative treatment in-
volved a very long siege of illness, and that some did not recover at
all. In the case of working women who must earn their own living,
operative treatment is preferable. Winternitz found that it was four
to six months before a woman could return to work under conservative
treatment, and the slightly increased risk of operation in such a case
would surely be justified. The speaker said that he had had occasion
to operate on a case at the Female Hospital that illustrated the
dangers of conservative treatment. He emptied the hematocele, but
an infection of the sac took place. At the time of the operation the
City Hospital Alumni. 5
woman had a temperature of Ioa”. Four weeks later another incision
had to be made. At that time it could have been designated as a
pelvic abscess. The woman was at the hospital three months after
the operation and on her departure was far from being in a fit state to
go to work.
Dr. GEORGE GELLHoRN regretted that he had heard only the last
part of the paper, he gathered from the final statements of Dr. Gayler
and from Dr. Taussig's remarks that the essayist indorsed the con-
servative method. In regard to the treatment of retrouterine hemato-
cele and its underlying cause, the ectopic pregnancy, the speaker takes
the stand of Werk, who said: Extrauterine pregnancy must be treated
like a malignant growth viz, operated upon, whenever and in whatever
stage we encounter it. Recent pathologic investigations are apt to
confirm this position. Busse, some years ago, pointed out that the
formation of hematocele may be explained, first, by the fact that the
blood coming from the ruptured tubal sac is not pure but mixed with
other substances and flows into the cul-de-sac in a more or less clotted
condition; second, that the cul de-sac, for the same reasons that so
frequently lead to ectopic gestation, has by previous inflammatory
processes lost its normal facualty of absorption. Therefore the hema-
tocele is either not absorbed at all and may become infected or
necrotic, or is only partially absorbed, resulting in the formation of
thick adhesions.
The peritoneum of the pelvic cavity and especially of the cul-de-
sac, the speaker remembered to have read in a recent article, is in
itself less able to absorb foreign substances than the peritoneum of the
abdominal cavity proper.
While, thus, the cul-de-sac offers unfavorable conditions for com-
plete absorption of a hematocele, the condition of the ectopic tube is
an additional contraindication to non operative treatment. It is gen-
erally known that even after the formation of a hematocele the hemor.
rhage from the ruptured sac may start again or that a new rupture may
take place. Both eventualities may immediately result in the death of
the patient. Futhermore, Opitz has demonstrated that the folds of
the mucous membrane of the ectopic tube grow together in such a
way that a number of blind sacs are formed. This means that if we
6 The Medical Society of
do not remove the diseased tube the ectopic gestation may recur, and
in fact quite a number of such cases have been reported.
The results of conservative treatment as given by Dr. Gayler are
highly interesting. However, only in a well directed clinic may such
risk be taken. In daily practice, radical operation, viz, evacuation of
the hematocele and extirpation of the diseased tube seems the more
prudent course.
Dr. WALTER B. DoRSETT knew of no subject in gynecology that
was of such importance to the gynecologist as well as the general
practitioner as extrauterine pregnancy and hematocele. He questioned
whether these two subjects were to be considered one. While it is
maintained by the great majority of writers on the subject that retro-
uterine hematoceles are due to one cause, i.e., tubal pregnancy, yet
there are occasional cases reported in which there is no doubt of the
Woman not having been impregnated. He had heard a distinguished
surgeon say that all clots of blood in the cul-de-sac of Douglas were
due to extrauterine pregnancy and in many of the operations the fetus
was never found, that it was not necessary to find the fetus in order to
prove that it was a case of extrauterine pregnancy. The fact that
there was a retrouterine hematocele was proof of extrauterine preg-
nancy.
Yet, such cases as the one reported by Dr. Gayler are positive
evidence that it is possible to have hematocele without tubal preg-
nancy. These are probably due to the giving way of some of the
veins from some cause or other. As to whether there are cases of
retrouterine hematocele due to reversed menstruation is a question
that has not been decided. It would seem that the examination of the
contents of the sac would demonstrate that fact, for it would be easy
to decide whether it were menstrual fluid or blood from a ruptured
vein. As to the cases of extrauterine pregnancy, it would seem that
but one conclusion could be arrived at, that there has been some inter-
ference with the tube. In most instances there is a history of sterility
going on for several years in which the woman has suffered with tubu-
lar disease. Strictures may have occurred due to gonorrhoea or
pyosalpinx, or to operation. Another cause is the diverticulum that is
sometimes found. These are congenital conditions. There must be
City Hospital Alumni. 7
sufficient depth to allow the impregnated ovum to fall into them and
then close over them and cut it off so that the fetus develops in this
diverticulum. Now, if it is between the layers of broad ligaments, for
instance, it may grow, into the cellular tissue. Again it may occur so
that the opening may give way near the distal end of the tube, the
tube pressing the ovum into the abdominal cavity. As to operation,
the speaker said he had something to say in the way of criticism, also
as to conservative treatment if that meant nothing was to be done
but keep the patient quiet. He was seriously opposed to opening
these tubes through the vagina; he had done it to regret it. He saw
one very interesting case in which the patient was curetted by the
practitioner who was called to see the woman, whom he thought had
had an abortion. He curetted the uterus, and next day he went back
to see her and found she had, what appeared to be, peritonitis. He
thought he had punctured the uterus and I was called to see the
patient, who was in extremis The speaker said that he intended to
do a laparotomy but almost by accident he found the cul de-sac of
Douglas pushed down and he made an incision. Out gushed a quant-
ity of blood and, later, a fetus. An enormous quantity of blood was
lost. He said that he had operated again through the vagina against
his wish at the request of the patient’s husband, who would not con-
sent to a laparotomy. He had never had so bloody an operation in
his life and the patient died on the fourth day as a result of the great
loss of blood. In case of a rupture of a large blood vessel the only
thing to do is to catch it and ligate it, and it is very much harder to
go through the vagina with the hand and get a bleeding vessel and
ligate it than it is to go in from above. There you come directly to
the gestation sac and it is seized and clamped. From below you can
not tell where the blood is coming from. If there has been a history
of two or three ruptures the attachment of the fetus is a progressive
one, it goes on until there is a large area of attachment, so that in get-
ting in, you can not tell where the bleeding comes from and it is an
active hemorrhage that you can not control.
He had recently been called to see a case in which there was a
history of sterility and extrauterine pregnancy. She had a pulse of
140 and had lost so much blood that it seemed dangerous to move
8 The Medical Society of
her to the hospital, yet it was too dangerous to operate on her in the
room, so that there was nothing to do but wait until the patient be-
came strong enough to take her to the hospital. Nothing could be
told by vaginal or bimanual examination. It was impossible to feel
the ovaries and tubes. The abdomen was distended with free blood,
not clotted blood, so that it was impossible to tell from which side it
came. Most of these are cases of recent origin, i.e., the case is seen
Soon after the rupture has taken place. He had operated upon about
forty and could remember but one which had been recognized before
there was a complete rupture, rupture of the mucosa, not the peri-
toneum. In this case he could feel a sausage-shaped mass, he op-
erated and succeeded in tying it off. (A full description of this case
can be found in the records of the Association of American Gynecol-
ogists.) It was removed without the loss of a drop of blood.
The cases that usually come under the observation of the general
practitioner are those in which the patient is taken suddenly ill, faints,
and a physician is called. He operated not long ago on a young
woman, and the question of pregnancy was entirely foreign to her
physician and himself. She was taken sick down town and lay at
home for seven weeks without anything having been done other than
massage. He operated for tumor and did not know what he was get-
ting into until he found a fetus. There was a tumor without temperature
and no suppuration, an inflammatory condition, apparently in which
there is simply loss of blood, but there is always rapid pulse.
The speaker said that he did not understand Dr. Gellhorn's dis-
tinction between retrouterine hematocele and extrauterine pregnancy,
and that was a question he was very much interested in.
Dr. GELLHORN replied that retrouterine hematocele is usually the
consequence of extrauterine pregnancy. The condition of Fallopian
tube and the pelvic peritoneum both warrant operation because the
operative treatment, on the whole, will give better results than the
non-operative.
Dr. H. S. CROSSEN asked Dr. Gayler what lesions persisted in the
cases classed as not recovered—what conditions were found by ex-
amination after several months? Did the pelvic mass of blood and
exudate remain or were the persisting symptoms due simply to resulting
City Hospital Alumni. 9
adhesions and fixation? How much disability was there in the “not
recovered” cases? He asked also if the essayist had encountered
cases in which the treatment, begun as conservative, had to be
changed to operative.
Dr. GAYLER replied that in the case of those that did not recover,
there was resistance to the finger, pain and pressure. There was not
a very large mass but quite a resistance to the finger and peritoneal
adhesions. The patients were not kept from their work, but consid-
ered themselves invalids. Several of the cases were treated according
to the conservative method for less than two weeks; then, if there
was a distinct increase in the volume of the tumor, an operation was
made.
Dr. CROSSEN said he felt indebted to Dr. Gayler for having given
information of real value on a part of the subject about which there
is a dearth of information—namely, on the conditions present after
several months. There are innumerable reports of cases of hema-
tocele embracing the period of onset and for a short time thereafter,
but as to the ultimate results of the treatment, in a series of cases, he
recalled no exact information other than that given by Dr Gayler.
And a great deal of just such information, obtained by observation of
the cases for several months or a year, is needed to settle the question
as to which is the best treatment for certain of these cases. In this par-
ticular series of non operated cases the ultimate results, which must
be the final guide, were good in a large proportion of the cases—indi-
cating that this treatment is justifiable, and probably preferable, in
many cases of hematocele.
As to the general subject of tubal pregnancy and intra-abdominal
hemorrhage, that is too extensive a subject for proper discussion this
evening, and evidently it was not intended to be brought up by the
essayist. Of course, when there is active hemorrhage into the peri-
toneal cavity there can be no question as to the necessity of operation
nor as to the character of the operation. Such cases, of course,
require abdominal section. But these are not cases of hematocele
and, hence, really not under discussion.
A pelvic hematocele, as he understands that term, is an encapsu-
lated collection of blood in the pelvis; there is no active bleeding and
10 The Medical Society of
the affected area is shut off from the general peritoneal cavity by a
roof of exudate. Such cases of tubal pregnancy are entirely different
from the ones in which there is repeated slight bleeding from a mass
not encapsulated.
He felt that the statement of Dr. Dorsett, that a case of tubal
pregnancy should always be operated on by abdominal section, ought
not to go uncriticized. It seemed to be based on the erroneous idea
that all are cases of active hemorrhage, whereas the majority of cases,
where a well-marked hematocele has formed, are distinctly not so. In
hematocele the bleeding has ceased and the blood is encapsulated and
shut in the pelvic cavity by a roof of exudate. Consequently, the
difficulties of reaching a bleeding tube by the vaginal operation have
no particular bearing on the subject.
In a case with active hemorrhage, or with the mass situated high,
even without active hemorrhage, there is no indication for vaginal
section; the operation should be abdominal section.
On the other hand, in a case which has resulted in a hematocele,
evacuation of the blood-sac by vaginal section is, as a rule, all that is
necessary. And Dr. Gayler had just presented substantial proof that,
in some cases, at least, even this evacuation is not necessary; the
blood and exudate being so far absorbed that the patients become
practically well.
On account of the possibility of hemorrhage as the blood-sac is
being evacuated per vaginam, the abdomen should be prepared so it
can be opened at once if active hemorrhage should occur. The at-
tempt to control active intraperitoneal hemorrhage through the vaginal
wound is to the speaker’s mind a perversion of the vaginal operation.
If free bleeding occurs the case is no longer one of hematocele but of
active hemorrhage, and immediate abdominal section is indicated.
But in the ordinary hematocele the vaginal operation does all that is
necessary (clears out the blood clots) with much less danger to the
patient than abdominal section. The safety and practicability of the
vaginal operation in these cases have been abundantly proven by the
experience of many operators.
The speaker mentioned six cases of pelvic hematocele that had
come under his care. In one the diagnosis was not confirmed by
City Hospital Alumni. 11
evacuation of the blood-clots, but still he felt quite certain of the
nature of the trouble. The patient was brought to the hospital with a
typical history of tubal abortion. There was quite a large tender mass
behind the uterus. He made the diagnosis of probable tubal preg.
nancy with hematocele, but as the patient was doing well he decided
to await developments before advising operation. No more bleeding
occurred. In about three weeks the mass diminished considerably in
size and the tenderness had disappeared and the patient was allowed
to go home.
In another case the symptoms and examination findings were
much the same, but instead of getting better the pain and other dis-
turbances increased. He insisted on operation (vaginal section) but
the patient would not hear to any kind of an operation. The hema-
tocele finally suppurated and ruptured into the vagina.
In still another case of retrouterine hematocele he waited. The
patient was a physician’s wife and her husband was somewhat doubtful
as to the diagnosis so they waited about ten days. The patient was bet
ter for three or four days then the retrouterine mass gradually became
larger and more tender. He then did posterior vaginal section and
cleared out the blood-clots.
In three other cases he did vaginal section as soon as the diag-
nosis was established. In fact, in one case he did the operation before
the diagnosis was established, there being a question before operation.
as to whether the mass was a hematocele or a purely inflammatory
II.12.SS.
These cases all recovered promptly and no particular hemorrhage
was encountered during the operation or afterwards. He regarded
these as cases of hematocele due to early extrauterine pregnancy.
Dr. DoRSETT asked Dr. Crossen if he had found the fetus in these
hematoceles. They might have been some other cause than extrauterine
pregnancy. He always felt it necessary to find the fetus or chorionic
villi before he decided that it was an undoubted case of extrauterine
pregnancy.
Dr. CRosseN asked Dr. Dorsett if he meant to infer that these
were not cases of extrauterine pregnancy.
12 - The Medical Society of
Dr. DoRSETT replied that these cases all got well; his had all died
but one.
Dr. CROSSEN said he thought Dr. Dorsett would agree with him
that about 95 per cent of all cases of retrouterine hematocele are due
to extrauterine pregnancy. For this reason in cases of hematocele it
is justifiable to regard it as extrauterine pregnancy unless there are
symptoms or circumstances indicating decidedly that it is something else.
It is recognized that in these early cases the fetus is absorbed. It is
nearly always possible to find traces of chorionic villi, but it is gener-
ally true that the fetus has been absorbed. For that reason he felt
justified in pronouncing these cases of early extrauterine pregnancy
and so far he had heard nothing that would tend to disprove that
diagnosis. -
As to the stricture placed upon vaginal section by Dr. Dorsett, it
was his conviction that to subject a patient to abdominal section
because she has hematocele is to put the patient in great danger with-
out sufficient cause.
If he had the time at his disposal, he said he would like to discuss
the question of active hemorrhage in the abdomen. He had had
some interesting experiences with that rather familiar class of cases of
extrauterine pregnancy. But there was not time, neither did that
really come within the scope of the evening's subject. There was one
point, however, that he thought could, with propriety, be touched upon
in connection with the subject of hematocele, namely, suspected
hematocele. There are certain cases of tubal pregnancy in which
it is a question whether a well-marked hematocele has formed or not.
If the tube has discharged its contents with resulting hematocele,
vaginal section and evacuation of the blood-sac is the operation of
choice. If, on the other hand, the tube contents have not been dis-
charged or have been only partially discharged and with only frail ad- -
hesions about, abdominal section is the only safe operation. Usually
from the symptoms and the examination findings, especially the loca-
tion of the mass, the differential diagnosis may be made. But occas-
ionally not, and in these doubtful cases abdominal section is the prefer-
able operation. If objection is made to abdominal section on ac-
count of the greater danger and the possibility of it not being neces-
City Hospital Alumni. 13
sary, exploration may be made by vaginal section to determine the
exact condition by direct palpation and the absolute necessity of ab-
dominal section before resorting to it. He had had one such case
only a few weeks ago. It was apparently very much like the one
mentioned by Dr. Dorsett, where the husband objected to abdominal
section. The mass, the size of a small orange, was not low in the
cul de-sac, neither was it very high. It was a question whether it was
simply a hematocele that could be safely evacuated by vaginal section,
or still active trouble in the tube with the probability of dangerous
hemorrhage as soon as frail adhesions were broken. The husband
strongly objected to abdominal section. The speaker stated to the
husband that he would open by vaginal section and if he found a
simple hematocele would evacuate it, but if, on exploring the pelvis
through the vaginal opening, he found the second condition mentioned
he would not attempt to handle it through the vagina but must be
allowed to remove the dangerous mass by abdominal section. The
possible conditions were explained carefully to the husband and then
the speaker stated that he would have nothing to do with the case un-
less he were given permission to open the abdomen if he found it
necessary. This permission was granted. He opened the posterior
cul-de-sac and found the condition not one of hematocele, as he un-
derstands that term. In opening the cul de-sac he opened directly
into the free peritoneal cavity. To the left and extending rather low,
but not occluding the cul-de-sac, was the mass composed of enlarged
tube, ovary and exudate. The condition was one calling for abdom-
inal section. He was careful, in the exploration, not to break the frail
adhesions surrounding the mass, feeling that such action might start
an uncontrollabe hemorrhage. As soon as satified of the condition
he at once opened the abdomen and removed the pregnant
tube in the usual way. The patient recovered without incident,
whereas had he attempted to treat this mass as he would an ordinary
tubal pregnancy hematocele (scooping out of blood clots through the
vaginal opening) there would have been great probability of fatal
hemorrhage.
A close study of the cases of tubal pregnancy will show that
they differ greatly, and the best operation for each case is the opera-
14 The Medical Society of
tion that will, in that particular case, accomplish all that is necessary
with the least danger to the patient.
Dr. DRECHSLER stated that his first case of hematocele was about
1902. He did not know the nature of the case until he saw her at the
hospital. The patient was 26 years old, single, and said that while
she was going to the railroad station at her home in Illinois she had
felt something break in the lower abdomen. She was sent to St. Louis
a distance of 36 miles on a stretcher. She was so weak upon arrival
at the hospital that examination was deferred until the second day.
She was dieted and given stimulants. One cause for her excessive
weakness was that she had been given nothing but Liebig’s beef tea
for six weeks by her physicians. Neither of the physicians who had
seen her had made a vaginal or rectal examination. There was a large,
well-rounded mass in the posterior cul-de sac which he believed to be a
pelvic hematocele. He did not believe it was due to pregnancy. She
was given stimulants for three weeks and carefully watched. There
seemed to be a little improvement in the dimensions of this mass.
The vaginal membrane was more mobile over this mass. The mass
was so large that it seemed impossible that absorption could take
place. An incision was therefore made in the posterior cul-de-sac and
large quantities of blood removed. After three weeks the patient re-
turned to her home. She is not exactly well to day, for she still has
extreme tenderness over the site of the incision. Another case he
saw only a short time ago. The patient, who was 44 years old, was
standing between two seats on a car, and in a collision, was thrown
forward violently. Upon examination a hematocele was found. She
was given rest and vaginal douches and recovered. He mentioned
this case because it was caused by trauma. In the first case he not
believe there was any question of pregnancy. Before opening the
hematocele the temperature was IoI.2° and he was afraid to delay
longer. - -
Dr. TAUSSIG asked Dr. Gayler to state the exact nature of the
conservative treatment that was employed in the eleven cases that re. .
covered and how long this conservative treatment was kept up on the
average.
Dr. DoRSETT said that there was one point he wished to lay special
City Hospital Alumni. 15
stress upon and that was that in most cases the physician is called in
immediately after the rupture. When a surgeon is called to a case in
which there is a loss of blood, the first thing to do, of course, is to stop
the bleeding. This being the case, to get at the bleeding vessel is the
indication, and he would naturally go through the abdomen because
the tubes, being up on the side, are more easily reached than by the
vagina. If the patient has bled for several days, the same thing is
indicated, i.e., securing the bleeding vessel. In going through the cul-
de-sac of Douglas one can not tell where the attachments are. A
large area may be involved in the attachment. He mentioned one
case where a woman had had four ruptures which were unrecognized
by one of the best surgeons in the city. She was accused of hysteria.
The attachments wer so extensive that if he had attempted th empty
this by the vagina the patient would have died the table. There were
attachments to the omentum as high as the umbilicus. The first thing
he got into was fresh blood. As soon as had secured the bleeding
vessel he took out large quantities of blood clot. This had gone on
for four months. She was in the hospital for three weeks before he
dared operate on her. Most of the hematoceles were in the cul de sac
of Douglas. The case operated on through the vagina died from
hemorrhage and he thought that was one thing the surgeon should
have pretty clear ideas about: the advisability of going through the
abdomen or cul de-sac of Douglas. As to the conservative, or what
may be termed let alone treatment, this should never be counten-
anced except in extreme cases. That such cases do arise now and
then in ones practice that should be treated on the conservative plan
there can be be no question—but they are few in number.
Dr. GELLHORN thought that the operation would differ according
to the duration of pregnancy. If rupture occurs after five months of
pregnancy, abdominal section is indicated; if earlier than that, espec-
ially during the first three months, there would seem to be no objec-
tion to operation through the vagina, unless there are insurmountable
difficulties encountered in bringing the tubal sac in view. It has been
done very frequently and in the two cases where the speaker has as-
sisted he was surprised at the ease with which the operation was per-
formed. The vaginal operation can not be objected to on general
principles. -
16 The Medical Society of
Dr. GAYLER, in closing, said that he had found the remarks very
instructive. He had been under the impression that the hematocele
was a mass of encapsulated blood. According to Dr. Gellhorn this
was not necessarily true. In his paper the speaker had meant to
limit himself to adhesions in which there was no free bleeding. He
thought they would all agree with Dr. Dorsett that when there is active
bleeding the thing to do is to enter and tie off the vessel. There are
three kinds of cases to be considered.
1. Those in which the blood escapes into the cul-de-sac, and ad-
hesions then form.
2. The escape of blood into a sac already formed by previous
adhesions, and, }
3. The oozing from the end of the tube, the blood accumulating,
and fresh oozing expanding the mass of blood, all bleeding taking
place in the middle of the mass.
The speaker remarked here that he had seen but little of gonor-
rhea in Tubingen. Most of the women saw but little of the evils of
large cities. He was in the Female Hospital most of the time and
saw not one case of gonorrhea. He considered this noteworthy in
view of Dr. Dorsett’s statement as to the cause of strictures. As to
the conservative treatment, the patients were put to bed, given a light
diet, an enema when needed, no purgatives and no massage, and
warmth applied. After two or three weeks they all wanted to go home,
and it was necessary to exercise a large amount of ingenuity to keep
them in the klinik a little longer. The average length of time of con-
servative treatment was about twenty days. The patient should be
given the benefit of a two or three weeks’ trial of conservative treat-
ment, and if the tumor does not increase in size the speaker thought
the patient was better off without operation. As to the vaginal opera-
tion, they had but three of them, hardly enough to base any definite
conclusions upon. The results were very good in these three cases.
He believed it had been necessary to take out one of the tubes in one
of the vaginal operations. The case mentioned by Dr. Dorsett of a
young woman with bleeding in the pelvis, who had been massaged for
a long time, was not a fair test. He thought if the abdomen had been
left alone that the hematocele would possibly have been absorbed. In
City Hospital Alumni. 17
regard to the case of the virgin whom he had spoken of, they had felt
it was a great misfortune that she would not let them open her ab
domen. They may have been jumping at conclusions in thinking it
was due to reversed menstrual flow but he did believe positively that
it was not due to extrauterine pregnancy. Replying to a question by
Dr. Drechsler he said he knew of but two cases caused by trauma, one
caused by the lifting of a heavy weight, the other due to a violent
coition. Being asked in what instances he would advise conservative
treatment and in what cases operation, the speaker thought it very
hard to make an absolute rule, but very large tumors, of course, had
been operated upon, the smaller ones treated conservatively. In
some of those treated conservatively the tumor felt as large as two
fists.
Meeting of February 4, 1904; Dr. Charles Shattinger,
President, in the Chair.
Dr. John YoUNG BRowN presented two cases that had been
operated on for
Strangulated Hernia.
One was brought into the hospital January 6, at 3:45 p.m. It
was a strangulated femoral hernia on the left side. The neck of the
sac acutely flexed, making it difficult to tell whether the hernia was a
femoral one or not. It had been down thirty-three hours when the
patient was admitted to the hospital. Patient was 54 years of age and
had had hernia for eight years She gave a history of the hernia hav-
ing come down while she was straining at stool; it was parallel with
the inguinal canal but on making the incision it was discovered that it
was a femoral hernia and about eight inches of gangrenous bowel was
found. He made a free incision, resected about ten inches of bowel
and made an anastomosis with the Murphy button; the result of the
operation was perfect. Shortly after this case there came to the hos-
pital a negro laborer 21 years of age, who had had hernia one and a
half years. This presented identically the same symptoms as the
other patient. Upon opening the sac there was found a loop of the
small bowel, partially gangrenous. The favorable results in the first
18 - The Medical Society of
case prompted the same treatment in this one. Through a small in-
cision in the abdomen the bowel was reeched and resected, anastomo .
sis was made with the Murphy button, and he then did the radical
Bossini operation for hernia. He passed his button on the eighth day.
The patient came in with bronchitis and the strangulation in this case
was probably due to the coughing; he then developed pneumonia.
The bowels moved shortly after the operation.
A third case had come to the hospital on February 3. This was
a strangulated inguinal hernia, similar to the others. The doctor
operated, resected twelve inches of bowel, made an anastomosis with
the Murphy button and did a radical Bossini operation. The three
cases were unique. This operation was recommended by Helfing but
it has never been adopted. Senn said that the operation would never
become popular ſor obvious reasons ; the speaker did not know
what these obvious reasons were. In the first case temperature
was Ioo.8°, pulse 84; there wa sno vomiting and the patient
given no morphin. These patients were without nourishment by
the mouth for four or five days, being nourished entirely per rectum.
The speaker stated that he rarely gave an opiate after a laparotomy;
the first twenty-four hours will be stormy and there will be more or less
suffering, but after that time the patient will improve or become ma-
terially worse. The beauty of the operation is that there will not be a
partially denuded gut to put back into the abdomen, which is always
a questionable proceeding. In these three cases the resections were
clean and the buttons passed on time; it is unusual for a button to be
passed in eight days. In one the operation was completed in fifty-five
minutes, in one it was completed in forty minutes and in one, that of
February 3d, the time required was was one one hour and five min-
utes. There were no symptoms of an unusual character. The wound
in the first case is perfectly solid and healed by first intention.
City Hospital Alumni. 19
Leukemia.
By J. M. BUCHANAN, M.D.,
ST. LOUIS, MO.
MONG the diseases of the blood and ductless glands we
find, classed by the authors, that of leukemia, an affec-
tion characterized by a persistent increase in the white
blood cells, associated with hyperplastic changes, either alone
or together, in the spleen, lymphatic glands and bone marrow.
It was described about the same time by Virchow and Ben-
nett, the latter naming it leukocythemia. There are two main
classes—the spleno medullary, or myelogenous, in which the
chief changes are in the spleen and bone marrow ; and the
lymphatic, in which the lymphatic tissues are principally in-
volved. Nothing definite is known as to the cause. It occurs
in all countries, in both sexes at all ages, although more com-
mon in males during middle life. Among predisposing causes
are mentioned heredity, malaria, syphilis, injury and also
pregnancy. Klebs advanced the idea of an infectious origin,
but no single organism has as yet been associated with it.
Pathologically we find the spleen enlarged, increasing in
weight and firmness, as the disease progresses; in the marrow
there seems to be a reversion to embryonal type, the fat being
replaced by lymph cells and nucleated red blood cells in all
stages of development. A true hyperplasia of many chains
of lymph glands. The liver often is enlarged and infiltrated
with leukemic patches. In the blood, in the spleno medullary
variety we find an increase in the larger varieties of leukocytes,
while in the lymphatic we find an abundance of small lymph-
ocytes. -
The case I have to present is one I take to be of the
spleno medullary type, although he has some lymphatic in-
volvement, and gives many of the classical symptoms.
The patient, William Coombs, aged 34 years, single. Na-
tive, New York; in the city I5 years; occupation, bartender.
No hereditary tendencies. He had malaria six years ago and
gonorrhea twice; regular habits; drank beer and used tobacco
moderately; sexually, was rather excessive.
20 * The Medical Society of
2.
67
§§ {\ A&R’ee
S Nº. W
-*S-> N º § §
5, Issºr Sº- jº
\ºj)\ºvº
*.../
sº
*
&
- *s rº
Diagram of Heart, Spleen, Liver and Glands.



City Hospital Alumni. * 21
He noticed a lump in his left hypochrondrium many years
ago but this did not cause any pain or inconvenience, but has
gradually become larger.
Beginning in May, 1903, he suffered from priapism for
eight weeks, since which time he has had no sexual desire.
Other symptoms presented are languor, faintness, dizziness
and weakness, with dyspnea and palpitation on exertion; also
Fundus of Left Eye.
tinnitus aurium, hematemesis and nose bleed. Deafness came
on suddenly during the night, but he hears now with difficulty
in the right ear.
. The patient is of medium size, emaciated, pallor of face,
eyes bright, pupils equal and react to light and accommoda-
tion ; the retinae show engorged and tortious veins, pale fun-
dus, around periphery of which are pigmented areas of vary-
ing size, and in the superior part a more recent hemorrhage.
Lungs normal; heart dullness normal, no murmurs; pulse in-
creased in rate, soft and compressible in character. The lower
intercostal spaces are somewhat bulged and grade off into a
much distended abdomen, presenting dilated superficial veins.
A firm, resisting mass can be felt in the left hypochrondrium,
extending downward and forward to within one inch of the

22 The Medical Society of
median line and to the iliac crest, percussion note is dull over
this area.
The liver extends three fingers below the costal margin,
and there is a moderate ascites.
The legs and feet are edematous and show purpuric areas.
The lymph glands in both groins, also the chain posterior to
the sterno mastoid muscle on the right side are enlarged but
not painful.
The urine contains a trace of albumin. In the blood the
leukocyte count in September, 1903, was 44O,OOO, and in Jan-
uary, I904, 467,OOO, to-day it is 468,750 to the cmm., mostly of
the large variety.
Red cell count to-day 3,200,000; hemaglobin 27 per cent.
Diagnosis: Spleno medullary leukemia.
The treatment has been rest, quiet and liberal feeding,
with two ounces of fresh bone marrow three times a day, and
gradually-increasing doses of Fowler's solution; he is now
receiving 8 minims three times a day.
Dr. H. M. VAN Hook presented the blood specimens from the
above case.
DISCUSSION.
Dr. CARL FISCH said that although cases of leukemia were inter-
esting, there were very few points to be discussed for the reason that
knowledge of leukemia is as yet almost nil. Nothing is known about
the etiology, nothing is known about the pathological process itself ex-
cept what can be microscopically and physically demonstrated. Our
whole knowledge of leukemia consists in the finding of the blood
changes and of the study of the pathologic lesions which are found in
the different organs of the body. There has lately been nothing added
to fill up the lack of knowledge on these points, hence a scientific dis-
cussion is unsatisfactory, almost impossible. When we come to con-
sider what we know about the so-called pathology of leukemia the
point of view that seemed to have been gained during the last ten
years would appear to be incorrect, so that even the great work by
Ehrlich which resulted in the differentiation between two diseases, the
lymphatic and splenomedullary form, is not certain. Ehrlich bases
City Hospital Alumni. 23
his view on the different varieties of white blood corpuscles, not only
on the difference in these cells but on the place of origin. Ehrlich
believed the leukocytes were essentially different from the lymphocytes,
and that all of the polynuclear cells were derived from the bone
Iſlal IOW.
For ten years this conception reigned supreme, but lately doubts
have come up which seem to suggest that Ehrlich's differentiation be-
tween the lympathic and polynuclear element is not to be taken with
the restrictions that Ehrlich put on it. Leukemia is one of those dis-
eases in which a doubt exists since only lately a number of cases have
been reported in which the blood contained not only an excess of bone
marrow cells but at the same time of lymphatic elements. Ehrlich as:
sumed that myelogenous leukemia was a disease of the bone marrow
and that when in lymphatic leukemia the bone marrow was involved
there had taken place a metaplasia. Other observers have stated that
the spleen, although normally in man a producer of lymphocytic ele-
ments can undergo a myelogenic metaplasia. The result of these ob-
servations would make it appear that Ehrlich's division was unjusti-
fied. Clinically leukemia is characterized by an increase of the white
lymphatic or polynuclear elements. It must, however, be emphasized
that this increase or, as it is often expressed, the enormous leucocyto
sis is not the essential point, especially in the myelogenic form, but
the character of the white cells found. In fact, there are cases in
which the number is not increased, say over 60,000 to 80,000 to the
cmm. In such a case there may be present the forms of cells usually
found in the bone marrow, which are not normally found in the circula-
tion and are probably the precursors of the polynuclear cells. In
myelogenous leukemia doubts begin to arise about the difference be-
tween the so-called large mononuclear cells and those cells which are
beginning to show the transition to polynuclear leucocytes. There are
always a number of these in which a few fine granulations may be seen
which otherwise could be called lymphocyte elements. The whole
subject of leukemia is absolutely obscure and it is partly due to the
fact that the conception of the origin and nature of the different
cells met with in the disease are not yet clear and are yet under.
discussion. -
24 The Medical Society of
Dr. MEISENRACH said that there were a number of things that
make the subject an obscure one, as the peculiarities of the blood
picture and the difficulty at times in differentiating one cell from an-
other. For instance, in this case there were cells which have been
described under various terms and there were others resembling them
closely; large lymphocytes whose protoplasm stains with methylen
blue and showing granulations in the majority of cases. It is surpris-
ing to find that there are granules developed and that the protoplasm
still stains blue, again there will be found a basophile alongside an
esoinophile. Again there are the cells described by Turk that, upon
being carefully observed, will show the protoplasmic region becoming
colored and taking on a fine granular appearance. Again there are
the cells in which a sort of granular change appears which might better
be described as a reduction of the protoplasm. These cells are de-
scribed by Nothnagel as types of the large lymphocyte. In relation
to the origin of the two kinds of cells, according to Ehrlich, upon
closely observing the large lymphocytes it will be found that in the -
selfsame cell there may be distinct eosinophile granulations. He had a
number of such cases. He also called attention to the relation between
the so-called pseudoleukemia or Hodgkin's disease and true leukemia,
saying that cases have been observed where the diagnosis was made
intra vitem of leukemia and when the case came to post-mortem the
findings showed Hodgkin’s disease, there being the development of
large foreign white bodies and hypertrophy of the lymph follicles in
the spleen. In some of these cases there was irritation of one part of
the blood-making system and not of another.
Dr BEHRENS said that he had found it almost impossible to get
the satisfactory blood smears between the slides, that the red blood
corpuscles always seemed to fall into a conglomerate mass; he said he
would like to know if this was due to the condition of the cell lining
leukemia. He had found that there appeared to be a tendency toward
a rupture of the red blood corpuscles on slightest pressure; he had
found difficulty in staining even the red blood corpuscles neatly.
Dr. Clarence Loeb said he had examined the fundi and thought
they were not distinctly characteristic of leukemia; the blood vessels .
were not as tortuous nor as distinct in showing the white striations
City Hospital Alumni. 25
usually found on them in leukemia. Far out in the periphery the
fundi had a muddled aspect which might have been caused by a more
or less recent hemorrhage, but resembled rather the lesions of a retino-
choroiditis diffusa. The color of the fundi was redder than normally
fund in leukemia, and the discs were not as pale; the macula area was
not affected, nor were the lids.
Dr. Fisch replied that he did not know what trouble Dr. Behrens
could have had in mounting the specimens, for there was nothing in
the character of the blood to make the smearing of the specimens
different from any other; on the contrary, if the smears are spread out
properly under the cover glass they are invariably beautiful; it is a
general experience that the red blood corpuscles in myelogenous leu.
kemia very often do not undergo any retrogressive changes whatever;
the presence of myelocytes can have no influence.
Dr. MEISENBAcH related his experience in a case where the diag-
nosis lay between Hodgkin’s disease and a severe lymphatic infection
and was dependant upon a blood count; he made the count and found
about 70,000 white blood corpuscles, of these about 70 per cent were
lymphocytes, chiefly of the large type. In the red blood count he
found that the corpuscles had fused ; he had left the blood standing
about 15 minutes and thought that was the cause; then he made
another specimen, took it down immediately and found again that he
was unable to count them, there were groups of four to a dozen cor-
puscles, so fused that he could not count them; he thought he must
have made a mistake in getting his solution, so he had a fresh solution
prepared and in the afternoon made two more attempts, failing each
time. This was a case of acute lymphatic leukemia and the patient
died four or five days later. He had a pulse of 120 to 160, there was
intense weakness, the adenoid tissue of the pharynx somewhat hyper-
trophic, tonsils not particularly enlarged but at the base there was an
increase of the tissue; it has been suggested that perhaps a lytic
process develops in the blood, but this is merely a suggestion.
He said that though Turk has quite a number of such cases in his
clinics, he does not relate any instance of such a condition. Lazarus,
of Berlin, also fails to mention it. The speaker said he had no knowl.
edge of anything bearing on the subject.
26 The Medical Society of
Dr. Fisch remarked that the observation made by the previous
speaker was probably due to the normal agglutination of the corpus-
cles which is common in leukemia; they agglutinate much more readily
than in normal blood. -
Meeting of February 18, 1904; Dr. Charles Shattinger,
President, in the Chair.
Acute Osteomyelitis of the Femur.
By. C. G. KIRCHNER, M.D.,
ST. LOUIS, MO.
DESIRE to present a femur in section which shows the
medullary portion. In the medulla of the shaft there can
be seen a gelatinous substance. The ends of the shaft
are well preserved, as is also the cortical portion. I wish to
call the case to the attention of the Society in connection with
an article which appeared in the Journal of the American
Medical Association, February 13, 1904, in which the subject
was discussed. The patient was treated first for rheumatism.
Both knees were swollen and painful, and the ankle-joints were
also affected. The physician who first saw the case aspirated
the knee-joint. The swelling subsided but abscesses developed
on both thighs and about the hip. There was swelling about
the elbow-joint, and fluctuation being made out, the joint was
aspirated. At first there was only clear fluid, but later pus
was found. A condition of pyemia developed and numerous
abscesses were opened and drained. The abscess on the
left leg and thigh did not heal readily. The sinuses were
followed up and freely opened and the entire knee-joint was
exposed. The patella, lower end of the femur and a por-
tion of the upper end of tibia had become necrotic. The
necrotic tissue was curetted away and the sinuses that had
closed up were re-opened and drained, but the patient did not
improve. The specimen shows how quickly an infectious
process may ascend through the medullary portion of the
bone. º
City Hospital Alumni. 27
Some months ago a case had been received at the hospital
in which the cortex was involved. An x-ray picture was made,
and based upon this picture, an operation was performed and
large slivers of bone were taken from the inside of the shell.
The specimen here could be considered the first step in such a
process. There was present a heart lesion which helped, in
the mind of the attending physician, to confirm the diagnosis
of rheumatism. Just why this acute condition should be pres-
ent could not well be explained, for the condition about the
joint seemed to be a chronic one. The pus was examined and
streptococcus, staphylococcus, etc., found, but the tubercle
bacillus was not found, though it was thought at first that it
was a case of tuberculosis of the joint. In regard to the
pathology of these cases, I must refer to the very interesting
study of these cases, made by Dr. Edward H. Nichols, of
Harvard. He states that in most cases the staphylococcus is
the primary cause but the streptococcus has also been found,
also the typhoid bacillus and the pneumococcus. Often the con-
dition is mistaken for rheumatism. Sometimes it simulates ty-
phoid fever. He goes extensively into the pathology. He states
that suppuration leads to disintegration of the cortex, and later
to sinus Zormation, and that often there is edema and swelling
of the joints and surrounding tissue. The condition of the
bone causes a great deal of pain. Jarring of the limb or per-
cussion of the bone causes pain and this can be taken as one
of the symptoms. Another diagnostic point distinguishing it
from rheumatism is that it affects usually one joint. The
medullary portion of the diaphysis is usually affected and not
the epiphysis. The process may go on through the cortex
and may proceed to the periosteum and the entire periosteum
may be loosened up. The author speaks of the importance of
the periosteum and the endosteum, stating that they have
much to do in the formation of the new bone. Based upon the
integrity of the periosteum he has devised an operation which
would be something like this: If, for instance, the femur was
affected, an extensive incision would be made along the thigh,
the periosteum exposed and loosened up all around the por-
tion of bone involved in this process entirely removed, so that
there would be left only the ends of the bone. The periosteum
28 The Medical Society of
*
then represents a band and this band would be folded upon
itself, fastened with sutures, and making a narrow ribbon,
from the approximated surfaces of which a new shaft would
be produced. In a number of months the bone is regenerated
and the function of the limb can be brought about.
Ligation of the Common Carotid Artery.
By J. M. PFEIFFENBERGER, M.D.,
ST. LOUIS, MO.
was brought to the hospital, suffering with a stab wound
of the left side of the neck about one-half inch below the
angle of the jaw, from which protruded a pair of artery forceps
and a plug of gauze applied by a doctor outside, but was still
bleeding profusely, also a small incised wound of the left wrist,
which severed the extension tendon of the little finger.
The area about the wound in the neck was shaved and
cleaned, the gauze, plug and forceps removed, when there was
a profuse flow of blood from the wound, which was sponged
away, but filled quickly from a spurting located in the depth
of the same. Compression was applied against the common
carotid lower down on the neck, and the hemorrhage partly
controlled, but there was still some bleeding in the upper por-
tion of the wound just below the angle of the jaw, which was
controlled by application of forceps. The wound was next
enlarged downward along the anterior margin of the sterno-
cleidomastoid muscle. The compression was now eased up
from below, and the site of injury to the artery located, which
was at or near the point of bifurcation, and a pair of forceps
applied to same, after which all bleeding was stopped.
The anterior portion of the sterncleidomastoid muscle was
now pulled backward, and the vessel dissected out from its
sheath, just above the omohyoid muscle; the vein, which was
collapsed, lay on the vessel and anterior to it. An aneurism
needle with a ligature was now passed from without inward
hugging the artery closely. After lifting the vessel up with
Jºº. I, I904, the patient, Wm. H., aged 34 years,
City Hospital Alumni. 29
ligature to see that it contained nothing besides the artery,
the same was ligated twice to insure safety against one ligature
breaking. The forceps were now removed, and bleeding from
that point ceased. A ligature was then tied where the forceps
were applied in the upper angle of the wound, and the area
sponged dry, all hemorrhage being controlled. A drain was
placed in the wound, and one stitch taken in the center to hold
the edges together.
- A slight movement of the entire body was noted, and the
patient uttered a slight groan when the carotid was ligated,
could move both feet and legs, and both arms, and talked in-
telligently afterwards, complaining of great thirst; nothing
abnormal was noted about him, except his exsanguinated con-
dition and rapid pulse. He was given an hypodermoclysis of
850 cc. of normal saline solution in the left thigh. The small
wound on his wrist was attended to by suturing the tendon
together with cat gut, and the patient placed in bed. An hour
later he was given another hypodermoclysis of 850 cc. of
normal saline solution in the right thigh. Patient vomited
some about three hours later, and about one hour after vomit-
ing it was observed that he was sweating profusely on the
right side of the body and face, and that he was unable to
move the affected side of his body, with the exception of his
fingers. The Babinsky reflex, the Achilles and patellar reflex
of Westphal were present on the affected side. The tongue
protruded toward the sound side, and he was unable to turn it
toward the affected side. A slight drooping of the angle of
the mouth was also noted on the left side. His pupils
were equal and responded to light and accommodation. There
was some difficulty in speech and in swallowing, and a greater
movement of the left side of chest during respiration. No
sensory symptoms present. He complained of throbbing in
the head and dizziness at times. The next day his condition
was just about the same, his pulse being I 26, respirations 24,
temperature 99° in the morning, and pulse I I4, respirations
22, temperature IoI* in the evening. The third day his pulse
registered 108, respiration 24, temperature 99.2° in the morn-
ing and IOO'” in the evening. Moved his fingers on the paral-
ized side, when asked to, but not without moving the fingers
30 The Medical Society of
of the other hand at the same time. The fourth day, pulse,
temperature and respirations about the same, still moved fin-
gers of both bands, when requested to move fingers on the af-
efcted side. He complained of insomnia, and when he did
sleep was awakened by the slightest noise. The fifth day, his
pulse registered 90, respirations 24, temperature 99.4° could
move fingers of the paralized side, when other hand was closed;
after this the pulse, respiration and temperature gradually
dropped to normal, and remained so. On the eighth day, he
could move his arm slightly, and on the twelfth day, could put
his hand to his mouth and raise the arm from his chest into the
air, but could not move the rest of the right side. The patel-
lar and Babinsky reflex still present, as was the impediment in
speech. On the thirteenth day was transferred to a Medical
Division, and the next day was taken home.
After presenting the symptoms, which followed the liga-
tion, the question naturally arises what caused the same.
First, the transitory sweating of one side; next, the partial
hemiplegia and the deviation of the tongue to the sound side,
followed in a few days by a gradual improvement of the symp-
toms, in a way directly opposite to the usual recovery of a
hemiplegia due to hemorrhage, in that the hand and the arm
were the first to show signs of recovery, they usually being
last.
The disturbance of speech and swallowing may have been
due to injury to descendens noni hypoglossis nerve, as the
same must have been severed, although it may have been due
to the central lesion; next, the transitory hemidrosis could
probably be explained from some injury to the cervical sym-
pathetic, which could have been compressed by the applica-
tion of the forceps, which were applied to the tissue enmasse
by the doctor who first saw the patient.
The partial hemiplegia can be explained by the anemia of
the brain produced by the sudden cutting off the blood supply
to the left side. The stream of blood through that side of the
brain was impeded by the initial injury to the artery, and after
the same was stopped entirely, the blood which was in the
vessels, lay there and probably formed a small clot, which will
gradually become absorbed, as the colateral circulation be-
comes more established.
City Hospital Alumni. - 31
Although the patient lived, and improved, I think, more
conservative surgery could have been done on the case, since
reading up on the results of the ligation of the common ca-
rotid, in that according to several authors, the mortality has
been from 13 per cent, according to Friedlander,’ to 41 per
cent, according to Bryant” and that cerebral lesions followed
in about 32 per cent, according to Piltz”. Jacobson and Stew-
ard* state :
- In incised or punctured wounds, near the angle of the jaw,
a correct diagnosis, as to the vessel, or vessels injured, is by
no means easy when a sharp weapon has passed obliquely and
deeply behind the jaw. By such a wound, either the external
or the internal carotid, or some branches of the former, may
be laid open. A careful dissection alone can clear up the
source of bleeding, and whenever it is possible, this should be
resorted to ; where the circumstances do not admit of this,
the surgeon, relying upon the extreme rarity of injury to the
internal carotid from its protected position will be abundantly
justified in tying the external carotid. Ligature of the com-
mon carotid is less reliable, though, if resorted to on account
of its simplicity, it may be defended by cases like those al-
luded to by Mr. Le Gros Clark,” in which he successfully tied
the common carotid for profuse arterial hemorrhage, due to
stabs near the angle of the jaw.
He reports two cases from stab with a pointed table knife
at the angle of the jaw, in which the carotid was tied, and no
untoward symptoms developed.
In a paper written by Geo. W. Crile" on the “Temporary
Ligation of the Carotid,” he states that he ligated the com-
mon carotid in nineteen dogs temporarily for a length of time
varying from 24 to 48 hours, and that in those vessels where
the pressure produced was only sufficient to close the lumen,
the histologic changes were unimportant, and that in no case
did clotting occur, the compression was made by a specially
devised clamp, of which he gives a cut. -
In the case presented the artery at the sight of permanent
ligation could have been temporarily ligated, and the exact
site of injury determined at which place a permanent ligation
could have been made, and probably evaded the occurrence of
32 - The Medical Society of
the grave symptoms, which followed. But this case was a
patient, who had lost a considerable amount of blood, and was
still losing blood rapidly, necessitating immediate action.
NotE.—April 27, 1904. I heard from the patient's phy-
sician to-day that he now walks to his office with the aid of a
cane and is improving rapidly.
BIBLIOGRAPHY,
*Tillman’s Text-book of Surgery, vol. 2, page 523.
*Bryant's Operative Surgery, vol. I, page 169.
*Pilz, Tillman’s Text-book of Surgery, vol. 2, page 523. r
*Jacobson and Stewart, The Operations of Surgery, vol. I, page 587.
*Ibid.
*G. W. Crile, American Jour. Med. Sciences, 1901.
DISCUSSION.
Dr. HogE said that he could not account for some of the symp-
toms but believed most of them to have been due to the withdrawal
of the blood supply. Hemiplegia is one of the results to be expected
where the common carotid has been ligated; the re-establishment of
the circulation through the circle ot Willis is not immediate, the
respiration is sometimes more vigorous on the paralyzed side.
Dr. CAMPBELL agreed with the essayist in his statement that the
cerebral symptoms were due to the cutting off of the blood supply;
their prominence was probably due to some slight clotting; it would
be interesting to see how the man recovered, whether, as he gradually
improved, the arm and leg became spastic or not; the hemisweating
might have been of a sympathetic character; the absence of aphasia
was interesting, showing possibly not a complete involvement; the
symptoms were probably produced by a mixture of causes; the hemi-
plegia may haveen due merely to the anemia, while some of the more
prominent symptoms may have been due to thrombosis.
Dr. BLISS, referring to Dr. Campbell's remarks relative to the
Babinski reflex, mentioned a case he had seen in the City Hospital
recently ; the man was brought in unconscious; Examination seemed
to reveal the fact that he had a partial hemiplegia; in the post-mortem
no brain lesion was found; they knew that he was uremic, and thought
possibly there had been a hemorrhage in connection with the uremia;
the Babinski reflex was fairly well marked on the right side.
City Hospital Alumni. 33 .
Dr. PFEIFFENBERGER, replying to a question asked by the Presi-
dent, said that he had not noticed any vasomotor phenomena and that
there was no flushing of the face. In reply to a second question by
the President he said that the sweating was on the right side, the
wound on the left. He added that he had recently phoned the physi-
cian now having the case in charge and had been told the patient can
now move the foot and leg, but with some difficulty, and still has
motor paralysis on that side.
The PRESIDENT said that the wound being on the left side and
the sweating on the right, the injury to the sympathetic could hardly be
responsible for it; the more probably, sudden anemia proved, as it
often does to the automatic centers, a temporary stimulus, just as sud-
den suffocation does by shutting off oxygen and paralysis follows later.
This view would seem to fit the case, as it accounts for the fact that
the sweating occurred so early.
Dr. Hoge said that the discussion had reminded him of a case
of paraplegia in which there was profuse sweating of both legs; the
paralysis was both motor and sensory, the latter the more pronounced.
Dr. PFEIFFNBERGER, in closing, said that he not attempted to
know definitely whether or not the hemihidrosis was produced by the
sensory paralysis; he thought, however, that the explanation offered
was a very satisfactory one.
Recent Therapy in Epilepsy.
By GIVEN CAMPBELL, M.D.,
ST. LOUIS, MO.
HE hypochlorinization or salt starvation method of treat-
ing epilepsy is comparatively new. In explaining its
theory we may get clearer ideas of the manner in which
the bromids produce their effect. In considering its practical
application, some help may be extended to those less familiar
with the difficulties of carrying out this treatment and the ad-
vantages of its employment in suitable cases.
As is well known, bromin and chlorin, both members of
34 The Medical Society of
the halogen group, are quite similar elements. There is reason
to believe that in the very early days of life's presence on this
earth, when most living organisms were still inhabitants of the
ocean that bromin did duty for chlorin in may of the
organic combinations of the body. That where human tissues
now contain chlorids often in these earlier days of life's his-
tory bromids were their predecessors. As life came up and
out from the seas the organism was no longer surrounded by
relatively considerable amounts of bromin and vital adaptation
required that its place be taken by the more generally dis-
tributed chlorin, and so through the course of the ages bromin
has ceased to be a normal constituent of higher animal struc-
ture; its very presence in the body exerts a marked effect in
diminishing the activity of the nervous tissues, generally of
certain systems of neurons in particular. But while bromin in
this sense has ceased to be a food, and has become a medicine,
the system still retains more or less of the ability to take it into
those organic combinations from which chlorin long since dis-
placed it. This ability varies with the individual. Some so
strongly retain the ancestral trait that even in the presence of
an abundance of chlorids their tissues will take up sufficient
bromin when moderate doses of a bromid are administered.
With others it is necessary, more or less, to restrict the chlorin
intake and make the tissues, as it were, hungry for halogen
material before they will form proper unions with bromin. -
Experiments on the lower animals have been made, which
prove the foregoing statement. Dogs which have been de-
prived of chlorids and to whose food bromids have been
added, on being killed and the tissues examined have proved
to yield a much larger amount of bromin than other dogs, to
which the same amount of bromids had been administered
without restricting the chlorids.
The salt starvation treatment of epilepsy then consists of
restricting the chlorin intake of such individuals, as without
this aid they do not take up enough bromin to influence their
nervous system, or in doing so require a dose of bromid so
large as to cause troublesome cachexia and acne.
The practical difficulties in the way of carrying this out
are considerable. In the first place such a course means that
City Hospital Alumni. * 35
the patient's food be cooked without salt; another way of say-
ing that it be cooked separate from that of the rest of the
family. When it is remembered that the treatment is a long
one, this inconvenience is seen to be great. Then the patient's
food must be restricted to such articles as contain but a small
amount of natural chlorids. Lastly and most important, when
one is required to eat unsalted food for a long time it becomes
very unpalatable. The appetite wanes and the nutrition falls
off or the patient rebels. To obviate this last difficulty it has
been suggested that sodium bromid, which in taste and season-
ing value can hardly be distinguished from sodium chlorid, be
added to the food while it is being cooked. That the dough
from which the bread is made be thus salted. While this ex-
pedient has much value it has certain disadvantages. The key
to epilepsy's successful management is to accurately adjust the
patient's dose of bromin to his needs. Any treatment which
makes the patient's bromin intake, depend on the variations
of his appetite for food, has in it a vital defect. In attempting
to get around this obstacle I have devised the following
method, which is, as far as known, new.
The food is unsalted in cooking. A considerable part of
his nourishment is made to consist of milk, vegetables, un-
salted bread and butter, eggs, and a limited amount of meat.
To prevent his food from tasting insipid it is salted with sod-
ium bromid, but this is done at the table and care is exercised
that he salts only the portion he intends to eat. His daily
quantity of dry sodium bromid is carefully measured and he is
instructed to dissolve any remaining part in a glass of water
and take it at bed time or just after supper, as circumstances
may require. It will usually be found, however, that the whole
amount of sodium bromid he requires as his dose will be needed
to make his food palatable. This plan lends itself well to the
dose suffuesante method of the French school. It consists in
giving the patient for one week a dose of bromid just large
enough to miss causing bromism; the next week this daily dose
is reduced by 2 grams, to be increased I gram the week fol-
lowing, and given again in the full dose the third week. In
this way the patient is left on an amount of bromid sufficient to
very effectually impress his contex and control his disease for
36 The Medical Society of
one week out of every three. During the other two weeks his
nutrition is spared the full dose and the lessened dose with the
remaining effect of the full dose continues ample to control
his attacks. -
To accomplish this a narrow 2-dram phial is filled with the
requisite amount of dry sodium bromid for each of the three
weeks, and the level of each week's dose is indicated by a
line on the glass, made with a file. The person having the
patient in charge is now given a large bottle of dry sodium
bromid and instructed to fill the measuring phial each morning
to the required mark. A piece of perforated paper is now
fixed over the phial's mouth with a rubber band and it is
used as a salt shaker. Instructions, of course, being given
that if any remains unused after supper it is to be dissolved in
water and taken. -
While the salt starvation treatment would be as effectual
as any other in all cases where bromid is given, with many
patients bromid is so well taken up in the presence of unre-
stricted sodium chlorid that the inconveniences which this
method entails to the patient's family need not be undergone.
It is only where a dose of bromid large enough to disturb the
digestive tract or cause troublesome skin and nutritional dis-
turbances, fails to impress the nervous system that this mtehod
is required.
To speak more specifically, when the high week's daily
dosage is over 7 grams this method is usually required. By
its employment in such cases the daily amount of bromid can
usually be reduced I or 2 grams. º
A number of cases could be cited where the beneficial
effect on the spells and on the patient has been noticeable.
One perhaps will illustrate:
Daisy S., aged II years. Attacks began two years ago;
grand mal; at first two spells a week occurring day and night.
Lately, has forty-eight spells a month. She was put on sodium
bromid in solution, was taken in average dosage of 8 grams a
day for one year. During this time she had one hundred and
four spells, average not quite nine a month, a reduction of
four-fifths. She was then put on salt starvation on which she
has been kept since (July, 1902). Her average dose, even
City Hospital Alumni. 37
with her increasing age, has been 6.5 grams. She has had
sixty-two spells in the last eighteen months, an average of
seven in two months. Her general condition is much im-
proved both physically and mentally and the attacks that still
occur are much lighter. -
In concluding it may be well to state that the hypochlorin-
ization method is of special and not of general applicability in
treating epilepsy. Its use should be reserved for such cases
as do not absorb the bromids well. These are cases that pre-
vious to the introduction of this aid were considered hardly
amenable to the bromid treatment at all. Administered as
here recommended the dose can be as accurately controlled
as by any other method. The appitite keeps good, as the food
is seasoned to the patient's taste, and the objection sometimes
urged against this method in the past, that the patient under
its employment looses in nutrition does not apply.
DISCUSSION.
Dr. SchwAB had expect that essayist would give an account of
the literature on the subject. He stated that he had been much in-
terested in this method it first came to his attention about three years
ago, had recently learned that the salt starvation method was suggested
about thirty years ago. In Gower’s text book there is a suggestion
that salt be taken away but without the suggestion that it be replaced
by sodium bromid; the new thing about this method is that the sodium
bromid is taken with the food. Some of the French investigators
suggest cooking the bromid in the food itself. When the first paper
by Toulonse and Richet came out in 1901, the speaker put a case on
the salt starvation treatment; this patient has been under observation
for about three years. The patient is a boy, age II years and the re-
sults have been enouraging. The speaker said his experience was
limited for the reason that the number of cases to be put on this
method are extremely few. He mentioned the case of a rather anemic
boy whom he had on the salt starvation treatment; in this case the
attacks had been reduced from three or four a week to one or two a
month, but the boy’s physical condition is a great deal worse fman it
ever was ; he tried the treatment for several weeks and then, on ac-
38 The Medical Society of
count of the symptoms manifested, stopped the treatment, gave the
boy milk, etc. The boy was then getting about 40 grains of bromid
a day; the speaker said that he did not then know that the toxic ef-
fect is increased by the withdrawal of salt. The boy at this time was
really suffering from bromid intoxication produced by 4o grains a day;
the dose was reduced to about 15 grains a day, with divided doses, as
suggested by the essayist, and the attacks have practically ceased, but
the physical condition is undoubtedly worse and the mental condition
is practically so. In withdrawing the NaCl there is taken away from
the individual something essential for his metabolism. He mentioned
another case, that of a girl, aged Io years. He had the stomach con-
tents examined after a test breakfast and found no HCl; a second ex-
amination made a few days later showed a marked decrease in the
HCl in the stomach contents. He was not altogether certain that the
HCl was derived the NaCl in the food, but this may account for some
of the pronounced digestive disturbances. Again, the blood needs -
a certain amount of chlorin and when the chlorin is withdrawn it will
possibly affect the physiologic condition of the blood. This method,
in fact, has a great many disadvantages and it is oniy by keeping a
case under watch a long time that one becomes aware of these. The
German investigators take ten or twenty epileptics and put them on
salt starvation treatment for three or four or five weeks, then give them
three or four or five weeks' rest and write up the results. What is
needed is a permanent investigation lasting over a period of two or
three years. There are no reports of a test extending over that period.
It is a strange fact that the men who are considered authorities
on epilepsy in this country, the directors of the colonies for epileptics,
have not taken this up at all. Spratling and the men of that type ap-
parently do not think it of any practicability. He said he had had
about ten cases that he put on the salt starvation treatment and six or
seven had been restricted for six or seven months to two years, and
in all of those cases he had been able to reduce the number of at-
tacks in a remarkable way, but he was not satisfied with the physical
or mental condition. The epileptic attacks seemed to serve a useful
purpose and when the number of attacks were reduced the result was
not what was looked for; if the attacks are due to the toxins in the
City Hospital Alumni. 39
body which lead a certain. explosion, stopping the attacks does not
stop the epilepsy, in other words, these attacks are only a symptom.
He said that the following report was made in some of his cases. They
will say that the patient has gone two or three months without a con-
vulsive attack but has had a light attack that began in the usual way
and then stopped. Now, this is an attack and must be considered as
such, otherwise the report of results will be more optimistic than is
justified. The speaker said that there was now on sale in Paris a
bread called Bromo pan, in which sodium bromid is used in place of
salt; this bread can be bought and prescribed just as diabetic bread
can be bought in ihis country, He had the mother of his patients
prepare a number of loaves of bread in this way, some with sodium
bromid and some without; he had demonstrated this at one of his
clinics and it could not be distinguished from bread prepared in the
usual manner; that without the sodium bromid tastes like Italian
bread. He said that he had adopted practically the same method as
the essayist in his method of administration of sodium bromid, al-
though he had known nothing about Dr. Campbell's method. He had
bought a green salt cellar, in which the sodium bromid will not dele-
quesce, but he believed Dr. Campbell's method was superior, as it
permitted more accurate measurement, and considered the subject one
of tremendous interest. In treating epilepsy one is not treating epi-
lepsy but an epileptic individual; no two are alike, each case must be
handled differently, and for this reason he said that he was rather op-
posed to the catagorical method of method of giving bromid as men-
tioned by the essayist; it can not be given according to any sign or
symptom, as, for instance, the knee-jerk; some one has said that the
only way is to feed the patients on bromid as you would give
them food. The speaker said he had known patients treated in this
way to take as much as a 150 grains a day of potassium bromid and
the results were anything but gratifying, the patients showing the
usual symptons of intoxication, and he had to stop and give smaller
doses; a man must plan his therapy according to his case. As to
pupillary reaction, after reading Dr. Campbell's paper some time ago
he said that he tried it to see what he could get out of it. A patient
would come to him a few hours after having a fit and his pupil would
40 The Medical Society of
"--
not react; in another case the pupils were enturely different following
an attack than at other times and the size of the pupil would seem to
render this method very unsatisfactory. It all comes down to the
purely personal question: What can be done with our epileptics?
Every man who has studied epilepsy has a right to talk of his experi-
ence, but he did believe any set of rules could be made at present;
for instance, a method had been suggested to him by Dr. Fry, who
said that he had used satisfactorily large doses of Solanum carolinense,
the common horse-nettle. He had obtained a quantity of the drug
and at the first opportunity and gave it a patient having three or four
attacks a week; he began with 50 drops and increased the dose to 1
dram three or four times a day; the patient misread the directions and
later went to him complaining of feeling dizzy, having attacks of
vomiting, etc., and said that he had been taking 2 drams four times a
day, yet the drug had not had the slightest effect in reducing the num-
ber of attacks. Most of the remedies so highly praised are tried and
the results are no better than in this case, and the physician must fall
back on the bromids.
Dr. Bliss said that he would like to know the effects of accom.
modation on the pupil whether it would be possible to eliminate the
change produced by the effort at accommodation.
Dr. Hoge said that the subject of epilepsy was always an inter.
esting one from the fact that there is so little known of it and it can
not be expected that the treatment will be wholly satisfactory until
more is known about the pathology than at present. The bromid treat-
ment is the one which has given most satisfactory results, yet it is only.
palliative. About all that can be done is to reduce the number of at-
tacks and get some general improvement, possibly, in the patient’s
general condition. As Dr. Campbell had said, the speaker stated that
the special modification of the treatment was applicable to a particular
class only ; his experience had not been unsatisfactory, however; he
had used it some cases without withholding the sodium chlorid and in
others he thought he got a better effect by withholding NaCl. In with-
holding sodium chlorid, however, he said that he did not deprive the
patient of it altogether; in a mixed diet the patient received about the
amount of salt that he requires. In the cases mentioned by Dr. Schwab
City Hospital Alumni. 41
where the patients did not get along so well, he thought he would look
for some other cause; it has been demonstrated, however, that during
the administration of sodium bromid HCl in the gastric juice may be
partly replaced by hydrobromic acid. The bromid treatment should
be considered as only supplementary and attention should be largely
directed to the general condition of the patient. There is a degenera-
tive and toxic element in the disease and methods that tend to reduce
the toxicity will give good results. In these attacks there also seems
to be a certain degree of habit and the good effect of bromin is parly
due, probably, to its effect in overcoming this force of habit by re-
ducing the number of attacks, thus reducing whatever influence habit
may have in the causation of these attacks.
I)r. GREEN, JR., referring to the pupillometers drawn by Dr.
Campbell on the blackboard, stated that measuremens of the diameter
of the pupil were at best only approximate. A convenientinstrument
and one at the same time measurably accurate consists of a disk of
German silver containing a series of circular apertures ranging from
o. 5 to Io mm. in diameter; the disk is mounted on a dull background,
in order to reproduce as nearly as possible the condition under which
the pupil is normally viewed; and the various openings in the disk are
compared with pupil, and that one selected which corresponds most
nearly to to the pupillary diameter. A point which should always be
borne in mind is that an astigmatism of the cornea of high grade will
produce an oval deformation of the pupil in a meridian corresponding
to the axis of the astigmatism ; under these circumstances a series of
comparative measurements will only be of value if the measurements
are always of the same diameter.
f)r. FALK suggested that possibly a transparent rule could be sat-
isfactorily used in measuring the pupil; for instance, a cover glass
upon which a millimeter scale is engraved would answer the purpose;
this held in front of the eye would not shut off the light nor throw a
shadow against the retina.
The PRESIDENT said that he knew of certain individuals in this
city, not epileptics, who, by reason of peculiar opinions they hold as
to dieting, abstain entirely from salt; these people are vegetarians, and
those who are very strict, also abstain from milk; thus their diet con-
42 The Medical Society of
tains no meat, no milk and no salt other that which is in the food
naturally, and he said that he knew of nothing to indicate that they
were not as healthy as the rest of us. As Dr. Hoge had said, a mixed
diet contains salt enough.
Dr. CAMPBELL, in closing, said that he had done a good deal of
work in the measurement of the pupil; he had tried to get a standard
for the normal pupil; he measured a number of pupils in a dark room
at a fixed distance from the light and he found where the light could
be properly managed that in a normal individual not taking drugs the
pupil will practically be the same at all times for the same individual;
some will run 3 mm., some 2.75 mm., some 4 mm. and some 5 mm.
He found that ordinary drugs did not change the pupil. For a while
he would think he had some definite results and then would note that
all the pupils examined ran too high on some particular day, and it
would develop that on the day in question the gas pressure varied and
the light flickered; the gas light was so unsatisfactory that he tried a
Rochester lamp In order to get a basis for pupillary action it is
necessary to get a fixed light. He said he did not believe it had ever
been investigated as to which end of spectrum most influenced the
pupil; he did not know whether heat rays or the light rich in actinic
rays would have the greater influence; but leaving out of considera
tion the quality, the mere quantity of the light is difficult to control.
When the Rochester failed to give satisfaction he tried an acetylene
burner and the pressure there varied. Finally, he fell back upon day-
light, making the patient look at a distant object on the sky line. This
left much to be desired but was practical if not very exact. In the
dark room he had the light 2 meters distant from the patient when the
experiment was being made, and thus eliminated accommodation ef-
fects in emmetropic eyes. One advantage of the dividers is that they
eliminate the tendency everybody has to guess to the nearest mark.
He said that Dr. Schwab had misunderstood him if he thought that he
considered the pupil sign the only method of determining the full
bromid dose; the only method is to consider the patient, not any one
symptom, but he believed the measurement of the pupil the best single,
symptom. The constitution of the patient, digestive condition, of the
tongue—whether coated or clean, and the presence of hebitude in the
City Hospital Alumni. - 43
patient are all to be considered. The one thing to be avoided in all
cases is routine treatment; the more accurately the patient can be
studied as to his reaction to bromin the more exactly can he be given
just enough, in just that proportion will he receive the benefit that is
his due. More can be done for the patients in the early stages than
for the chronic cases. Where the control of the spasms does not im-
prove the condition of the patient, the mark has been over-shot. If
the doctor is careful enough the bromid will do absolutely no harm
and will, almost always exert a control of the spasms that is, at least,
to the satisfaction of the patient. The treatment can be kept up in-
definitely and the patient’s epilepsy be thus controlled with no impair-
ment of the general condition. The school child who has been unable
to go to school will be enabled to attend school regularly and the man
unable to work will be able to go back to his work. In confirmed
epilepsy probably not much more can be done than to hold down the
attacks; where one has had three or four attacks a week he can usually
be so treated as to have but three or four a year; much more can be
done in the early stages. Epilepsy grows by epilepsy. In one who
has had but few attacks the brain is not nearly so much disturbed ;
every attack renders the brain cortex more vulnerable to succeeding
attacks, so that there is infinitely more chance of curing the cases in
an early stage of the disease. As to putting the bromid into the food
before it is cooked, as in bromo-pan, for instance, there is the disad-
vantage that the patient will eat much more one day and less the next
and it is thus impossible to dose accurately. If the bromid is put on
the food just before the patient eats it, and what is left over is dis-
solved in water, he will get the exact dose intended for him. He said
that this paper reported the results of one limited aspect of the treat-
ment of epilepsy, and he hoped to prove in a paper now in prepara-
tion based upon the entire treatment of epilepsy in fifty or more cases,
that the attacks can be very greatly reduced. He has made a chart
of the symptoms and condition of every patient before the treatment
and another made atter the patient has been under treatment for some
months. In the majority of these patients salt starvation was not
used. He added that he did not believe sodium bromid the only salt
by any means; he had used potassium bromid in some cases and in
44 The Medical Society of
other cases he had found a combination of pótassium bromid and
bromid of magnesia with the tincture of passiflora very satisfactory.
In a general way, when it takes too large a dose of any bromid
to produce bromin effects, salt starvation was indicated; when bromin
effects occurred without a control of the attacks a change of the
bromid was indicated.
Dr. GREEN stated that a serious difficulty in making comparative
pupillary measurements was in obtaining a source of illumination of
uniform candle power; he was under the impression that in Germany
a so-called “standard” candle was to be had which gave a uniform
illumination. In answer to an objection by Dr. Campbell that the
illumination from a single candle would not be sufficient he saw no
reason why a number of standard candles should not be use. He de
sired also to point out that the accommodating may be active even -
when the patient is told to fix his gaze on a distant object, e.g., incor-
rected hyperopia.
Meeting of March 3, 1904; Dr. Charles Shattinger,
President, in the Chair.
Treatment of Non=Malignant Diseases of the
Skin by the X-Ray.
By JOSEPH GRINDON, M.D.,
ST. LOUIS, MO.
LUPUs VULGARIs.
CAN recall but two cases of lupus vulgaris, treated by
me, in Americans of American parentage. The experi-
ence of all American dermatologists accords with mine
in this particular. I now, however, have under observation an
American case of the first magnitude. When we say that lupus
is a disease of youth we mean that it begins in youth. This
case extends over a period of fifty-seven years and began when
the patient was II years of age. It is characteristic—showing
corded, rugous scars, such as exist after a burn of the third
City Hospital Alumni. 45
degree. The soft tissues have disappeared from the nose and
left the skin white, tense and atrophic.
This patient had been under treatment since her I Ith
year, part of the time under the care of general practitioners
and part under an able dermatologist. She says she never
received any benefit She only seemed to grow worse.
Under treatment it would become more acute and ulcerate.
When the patient presented herself, the surface was covered
with crusts and scales. From the first, improvement was ap-
parent. There had been mild subjective sensations but these
disappeared almost immediately. After I had given forty-
eight treatments at the rate of three a week, there was marked
improvement about the nose, lips and cheeks, but little or
none at the sides, for the reason that the tube had been di-
rected to the center of the face. After sixty-four treatments
dermatitis resulted and required suspension for a week. When
this condition was relieved the treatments were resumed, and
twenty-four given, making eighty-eight in all. The patient is
not well, but vastly improved, by the month's treatment, and
this is the first improvement noted in the fifty-seven years
duration of the case.
It is interesting to compare the results obtained by x-rays
with those by the Finsen light. A case that Dr. Engman will re-
member went from here about a year ago to London where
she received the Finsen light treatment and returned vastly
improved, but not cured. Drs. Hyde, Montgomery and
Ormsby, of Chicago, about a year ago reported in the Journal
of the American Medical Association some observations on a
number of cases of lupus in which the x-ray and modified Fin-
sen light were used. In some cases the x-ray was applied to
one side of the face, and the Finsen light to the other for com-
parison. The rate of progress under the two kinds of treat-
ment was about equal.
I have had no exprience with the 1ay in other forms of
cutaneous tuberculosis.
BLASTOMYCosis.
A condition which externally simulates tuberculosis of
the skin, is blastomycosis, an inflammation due to the
46 The Medical Society of
presence of a yeast fungus, It has been described by Gil-
christ, Hyde and others. It is quite common in Chicago.
There are very few cases in other parts of this country and
very few in Europe. Most of these cases occur in people who
are farmers or engaged in the handling of grain. A farmer came
to me recently with a diagnosis of skin cancer. It was evident
that it was not a skin cancer, and a clinical diagnosis of blasto-
mycosis was made and afterwards confirmed by finding
blastomyces in the pus. The patient came for x-ray treat-
ment. I questioned whether it would be of any, benefit, but
on exhibiting the case to some of my dermatological friends
they advised that the x-ray be used, and I tried it. I gave
him thirty-seven treatments with absolutely no effect. I
was keeping the lesion clean, washing it out every day, and
so, of course, it looked better than when he came to me. I
then curetted, scraping down to between the metacarpal bones
and burned out the wound with acid mercuric nitrate; the thing
returned. I curetted again and burned it out and again it re-
turned. After keeping at it until the patient's patience and
mine exhausted, I turned the case over to a surgeon and the
hand was amputated at the wrist. -
KERATOSIS FOLLICULARIs.
One of the very rarest conditions known to medicine is
that which has been called Darier's disease—psorospermosis,
a condition in which we find bodies thought at first to be pro-
tozoa, psorosperms, belonging to the class of coccidia, but
which are now recognized as modified epithelial cells. The
condition was also observed by White, of Harvard, who
termed it keratosis follicularis. As far as I know there have
been only four observed American cases, one in New York,
two in Boston and one here. It is characterized by the forma-
tion of papules, many of which pustulate. About the inguinal
folds and in the natal cleft there occur fungous, cau-
liflower-like excresences from which may be squeezed a
cheesy substance. The pain and discomfort arising from the
excresences in the folds is very great. Ordinary methods of
treatment were of little avail in this case. I used something
to keep the parts clean and lessen the itching, and used the
City Hospital Alumni. X- 47
x-ray, particularly on the papillomatous excresences. After
nine applications, two a week, there was no particular result,
though the patient thought itching was eased. I may say
here that in a variety of diseases, even when there is no ob-
jective improvement, we do generally get some result from the
x-ray in the way of relieving pain. -
KELOID.
Is a condition which in the past has been very difficult of
treatment for the very manifest reason that if we cut out a
keloid it is very likely to return. Electrolysis has sometimes
been of benefit. Injections of thiosinamin have given some
relief. Pusey of Chicago reported a cure of a keloid on
the arm of a boy, by application of the x-ray. The case which
came to me was that of a young, healthy Irish girl. She had
spilled some hot coffee on her chest causing a keloid
which spread over the greater part of both mammae. Not only
was it disfiguring but it was attended with very disagreeable
sensations. Ordinarily, keloid is not painful, but once in a
while it is very sensitive indeed. In this case there was con-
siderable redness and intense itching, so much so that she was
constantly compelled to pull her dress away from her chest to
get relief. The itching was greatly relieved after two sittings.
After twelve more sittings relief from the itching was com-
plete. The cure was very slow. She was very faithful, how-
ever, and came regularly. After sixty-four treatments the
lesion was flatter, paler and smaller. After ninety-six treat-
ments there developed some erythema. I interrupted
the treaments, gave her a mild salicylic ointment, and
told her to return after its subsidence of the redness.
She did not return for a whole month and when she did, to my
distress, I found that the dermatitis had continually grown
worse. There was vesiculation. It looked as if there might
even be superficial sloughing. After twenty days of treatment
the dermatitis disappeared, however, and the lesions flattened
down and disappeared. The last time I saw her there was
only a little redness at the sight of the keloid patches.
48 The Medical Society of
HIDRADENITIs SUPPURATIVA.
An interesting condition is suppuration of the coil or
sweat-glands, called by the French acnitis and folliclis. It is
found about the face, rarely elsewhere, and is characterized by
deeply seated, hard nodules, at first invisible, but appreciable
to the touch, later becoming pink and then a deep red.
Upon making a deep puncture with the lancet we get only a
drop of pus. Where the disease has run its course there is left
a pit something like that of smallpox. The disease is a very
rare one in my experience. A case presented itself recently
and has received nine treatments with the ray, with the result
of some paling of the lesions and some flattening. Mean-
while other lesions have appeared. No method of treatment
has ever given a very satisfactory result, the disease often
continuing for weeks, months or even years.
ACNE NECROTICA.
Among other diseases which have heretofore been but
little benefited by treatment is acne varioliformis, sometimes
called acne frontalis, acne necrotica, etc., the lesions occurring
on the scalp, the middle third of the face, and the anterior
and posterior aspects of the chest along the median line. The
lesions consist of papules which leave a deep pit, hence the
name varioliformis. It is a most rebellious disease. An
extreme case presented itself in November of 1902. The
patient was a young girl. The disease had continued for years
and had been treated by some of the best men here with no
improvement. I treated the case from November, 1902, until
July, 1903, with absolutely no improvement. I think the
patient and I were getting heartily sick of each other. Ap-
plications and medication seemed to give no result at all. It
was absolutely the worst case that I ever saw, covering the
face, with a group here and a group there, making a mass of
swollen tissue. As the inflammation in one group would sub-
side another group would develop. I began treating the case
with the x-ray last July and gave forty sittings in four
months with the very greatest improvement. Instead of the
whole face being involved, only here and there would crop
up a single lesion, so that the patient was very much gratified.
City Hospital Alumni. 49
In the course of three months I gave twelve more sittings.
I have not seen the patient since. The result was a virtual
CU11'6".
Another case of necrotic acne has shown marked improve-
ment after only four applications. *
AcNE VULGARIs.
In acne vulgaris I can say that in a general way the ray
has been most satisfactory. I have not gone to the extent of
Zeisler, of Chicago, who says that he has virtually abandoned
all other modes of treatment. I continue the use of approved
measures, such as local applications, sometimes arsenic, regu-
lations of the bowels and the diet, scaling off and curetting,
which is, of all means, after the x-ray, the most valuable.
However, in the pre-x-ray days I used these methods and did
not get as favorable results as I do now. The results in my
hands have not been as rapid as in the hands of some others.
I do not know why. But although they have been slower they
have been sufficiently rapid to be satisfactory to me and as far
as I have been able to go they seem to show this encouraging
characteristic—there does not seem to be the same tendency
to recurrence, and it looks as the cases were not only relieved
but cured. I believe the action of the ray in acne depends
upon its tendency to inhibit pus formation and bring about
atrophy of the sebaceous glands. When used short of pro-
ducing dermatitis it seems to result in atrophy of the more
highly specialized tissues of the skin and hypertrophy of lower
tissues. For example, while ordinary epithelium and pigment
will hypertrophy, the sebaceous glands, sweat-glands, hair and
nails undergo atrophy. It is chiefly in this way, I believe,
that these cases are helped. Supposing that the ray destroy a
large share of the sebaceous glands in the skin, what will be
the ultimate result? Will it manifest itself in some untoward
manner years later? It is possible. For the present the re-
sult is gratifying. I have not treated a single case without
improvement.
50 The Medical Society of
TINEA CAPITIS
is often difficult to cure. The general practitioner often
undertakes a case with a light heart, but the specialist feels
proud if he cures it within six months. Aldersmith, of Lon-
don, mentions one case he has had under treatment for twelve
years and which is not well. The fungus invades the hair-
follicle. Pulling out the hair is not easy. If the hair shaft is
infiltrated it does not pull out, but breaks off. That is the
difficulty. We could kill the fungus if we could only get at
it. Aldersmith secures the pushing out of the hair by needling
the follicle with croton oil. In the x-ray we have a more ex-
peditious manner of accomplishing the fall of the hair. With
the hair we bring out quantities of the fungus and at the same
time are permitted to get at the disease with medication. One
case which I had treated for seven or eight months without
success was secured after seventeen applications of the ray.
The alopecia which resulted enabled me to use antiparastic
medication successfully. * -
HYPERTRICHOSIs.
Since the x-ray will detach the hair, its use is suggested
in hypertrichosis. The fall of the hair brought about by the
x-ray is not necessarily permanent. I believe it is rarely
permanent unless we choose to make it so. A slight dermati-
tis usually preceeds fall of the hair. If we stop there the hair
will probably return. If we then repeat the process until the
hair fall again, alopecia will probably be permanent. I have
treated several such cases. Where there are only a few coarse
hairs, electrolysis is the method of election. But there is an-
other class of casses. Women, often blondes, sometimes pre-
sent a fuzz of fine hair on the face, a very ugly condition.
Some of these women are wretched. by what they consider as
tanamount to a deformity and seclude themselves from society,
becoming absolutely melancholy and morbid. If there is a
fine down on the face electrolysis is out of the question. It
would be an cmdless job, would be worth seveal hundred dol-
lars and would wear out several pairs of eyes. Depilatories
take off the hair but it comes back again. The x-ray is
especially adapted to these cases. As an example of how
City Hospital Alumni. 51
difficult it is sometimes to bring about alopecia, I may mention a
young woman who came to me with this fine down al lover the
face, I went to work on the case, directing the ray against the
chin. I gave her twenty-six sittings without a sign of effect.
I began with a soft tube, then I tried a hard tube. After
awhile there appeared a slight dermatitis and the hairs fell,
but it required thirty-two sittings in all to effect a cure.
LEUODERMA.
Anyone who has used the x-ray knows how likely it is to
bronze the face, so I thought it would be just the thing in
leucoderma. In a single case I failed utterly to get any return
of pigment in the involved area.
PRURITUS.
Inasmuch as subjective sensations are so often eased by
the x-ray I thought that simple pruritus should yield readily.
I have tried it in several cases of pruritus and without any
effect. - -
These are about all the non-malignant diseases in which
I have used the x-ray. In the majority of diseases, perhaps,
the result was negative. If I were to count all the cases,
swelling the list with a goodly number of acne patients, the
total would be much in favor of the x-ray. It is not a
cure all. It is a great help in some forms of disease, and in a
few will bring about a cure when nothing else will do so.
Other workers have had results is diseases in which I have
never used it. Something like one third of all cases that pre-
sent themselves to the dermatologist are eczema, I am a
little conservative in the treatment of eczema and have been
using the old-fashioned methods under which patient, usually
get well. In psoriasis it has been of great benefit, in the
hands of some. Mycosis fungoides has been much improved
by this treatment, according to report. -
DISCUSSION.
Dr. ENGMAN said that during the last three or four years the x-
ray had almost revolutionized the therapy of dermatology. There are
52 The Medical Society of
so many diseases in dermatology that relapse so frequently, that the
diseases that were formerly incurable, since the x-ray has been used .
have been found amenable to treatment. In lupus he had never had
opportunity to try the ray, but in Chicago, where they have more lupus
than they do here, and especially in the offices of Drs. Pusey and
Zeisler, he had seen cases that seemed to be cured, but he considered
the essayist's case the most remarkable that he had ever seen. He had
treated a case of follicular lupus of the chin which, after a long treat-
ment, had gotten well. He said that he desired particularly to make
a few remarks on the treatment of acne. It has been heretofore a
disease over which the dermatologist has had little control. Some
light has been thrown on the subject by Sabouraud and Gilchrist and
and it is probable that it is a true infectious disease. The speaker
said that he had never seen a case of acne markedly benefited by in-
ternal treatment alone. The patient may get entirely well by going
away in the summer and getting sunburned. The cure may be due to
the action of the actinic rays. It it is always desired to bring about
desguamation. For this purpose resorcin, sulphur, mercury and other
drugs are used for their irritating effect. This is particularly true of
the rapid treatment of Unna or Lassar in which there is a deep scaling
of the skin following which the nodules flatten down or disappear.
The results are very marked, and was a favorite method with the
speaker before the x-ray. There is produced a leukocytosis and all
the marks of inflammation. Possibly there is a destruction of the in-
vading organism. Although this organism may not be the cause of
the disease it is a fact that has to be contended with. One of the ef-
fects of the x ray is to produce a leukocytosis. This is the first effect.
To this action of the x-ray is due the beneficial effects in the treat-
ment of acne.
He said that he had lately been working on this subject of the
treatment of acne with the x-ray, having treated forty-eight cases. In
the last two years he had made some 7,ooo exposures. During that
time he had become thoroughly familiar with his tubes. He used a
stop-watch to mark the time, had a trained attendant with the patient
all of the time during the exposure and a record was kept by this at-
tendant of the distance, etc. It is known that effect of the rays is de-
City Hospital Alumni. 53
pendent upon the distance of the tube and time of exposure, and by
using care the x-ray is an effective remedy in the treatment of acne.
One advantage is that it does not necessitate much treatment on the
part of the patient. They go to the office, take the treatment and
that was all that was necessary.
The speaker said that of course he looked after their general
health, gave them tonics if needed, iron, or whatever might be indi-
cated, and along with the x-ray he gave some mild lotion, prescribed
the use of salicylic acid soap, but in the x ray treatment it is necessary
to avoid any irritation from the application of remedies for then it
would be impossible to tell whether the resulting dermatitis was due
to the x-ray or the irritatiing remedies. At the first appearance of the
least redness he stops the treatment. To get beneficial results it is
not necessary to bring the patient's skin to an active dermatitis. He
had never found it necessary to redden the skin and he secured excel-
lent results by being careful and not bringing the patient to that stage.
Some leading writers, however, advocate bringing the patient to a
slight erythema. There are cases in in which atrophy of the skin has
occurred from active treatment. - t
A case of his had gone to another city and continued the treat-
ments there. When the patient returned to St. Louis the acne had
almost stopped but there was a slight atrophy. He had the treatments
stopped at once and put the patient under a masseurs charge. She
finally recovered. . Although the results are a little slower it is best to
give the treatments in such a way as not to increase the irritation.
Increase the exposure minute by minute. Curetting by the method of
Fox is often of assistance here. On the days he currettes, the speaker
said he did not use the rays, because it has been remarked by several
writers that additional irritation seems to lessen the resistance of the
skin. Another thing that he had noticed was that mild repeated doses
of the ray were stimulating, and in the treatment of acne those
papules on the inside of the circle of the rays would undergo involu-
tion and those where the rays were less intense would rapidly increase.
He felt sure that the x-rays must have a stimulating effect on such tis-
sue. He said he believed the x-ray to be at present the best treat-
ment for that stubborn disease—acne vulgaris. It was refreshing to
54 The Medical Society of
hear Dr. Grindon confess failures, as physicians must and should. The
ray is not a panacea. It is a dangerous remedy when carelessly
handled. All reports of favorable results should contain a warning of
the danger, for it should be handled with the greatest care. He be-
lieved that injuries resulting from the x-ray were due to lack of care in
giving the treatment rather than any idiosyncrasy on the part of the
patient.
Dr. DUNCAN said he had used the x-ray considerably during the
last two or three years, largely in the treatment of malignant disease
of the skin, however. During the last eighteen months he had also
treated a number of cases of non-malignant disease of the skin. He
had not attempted to lead in experimenting on a great many dis-
eases but had simply followed where others had led, and the diseases
he had most experience with were lupus vulgaris, acne, eczema, lupus
erythematous and hypertrichosis. He gave his experience and views
as to the relative value of the rays in such cases. He had used it in
but two cases of lupus vulgaris and he called attention to the stubborn-
ness of the disease. In one case, which yielded to the treatment, after
a year the lesions have returned. In a case of lupus erythematosus
there were no permanent results, the improvement lasting only a few
weeks or a month.
When Zeisler said that he had quit the use of everything except the
ray in the treatment of acne, Dr. Duncan could not understand how
he could talk in that way. Physicians have been taught so long that
acne is largely a manifestation of a general condition that he found it
difficult to understand Dr. Zeisler's position. But when he saw so often
reports of cures of acne he could not but try the ray and of all the
therapeutic methods he found the ray the most efficient. He has had
patients that he treated five years ago with the old methods, with im-
provement and relapse, and he has treated them since with the x-ray
and not only was the improvement great but it was permanent. It
seemed to him that whenever a cure was made with the x ray it was
more permanent, as a rule, than a cure by any other means. If the
patient, after a careful interrogation, seems healthy, not especially
constipated, no especial indigestion, and looks well, he does not diet
as he used to do, gives them nothing, probably internally, but may use
City Hospital Alumni. - 55
some local application. He does not use the curette. He mentioned
the case of a young lady who had been treated here and who later
went to Europe, where she was scaled, but the disease returned. After
she came home Dr. Duncan tried the x ray and she is better than he
has known her to be for five years.
He said he was surprised that neither of the gentlemen had said
anything about eczema. His experience with the x-ray in localized,
infiltrated patches of eczema had been that there was nothing equal to
it. He said he could recall cases of eczema of the palm, of the
back of the hand, of the popliteal space and of the ankle that he had
treated with the x-ray, all showing marked improvement, some result-
ing in a cure. The ray relieves the itching, relieves the infiltration and
cures the eczema. He has a case now that he treated in the old way,
with relapses and improvements. The patient has had eight exposures
and the results are wonderful. Hypertrichosis was the only condition
in which he had ever had a sad experience. In hundreds of cases,
with thousands of sittings he had never had one severe burn. This
lady was the wife of a physician and Dr. Duncan never saw her after
the burn. He treated her for hair on the arm and he understood that
there was a severe burn, so severe that there was sloughing. He had
removed hair from the faces of two other ladies without bad results
before he treated this case. He said he would never again use the x-
ray to remove hairs from the face unless it is an actual deformity. He
was careful with that arm as he had ever been in his life. He timed
exposure by the watch and took special care as to the distance of the
tube and by referring to his record book he can not see where he failed
in carefulness in any particular. Yet it produced a severe burn. In
view of this experience he felt that if there were only a few hairs they
could be removed by the electric needle, or if it were a deformity, he
would use the x ray, but unless it were an actual deformity he would
not run the risk of producing on a woman's face what he had under-
stood he produced on this arm.
He thought the x-ray would be useful in a great many other diseases
of the skin and mentioned a case of blastomycetic dermatitis which
had come to him from the country. The patient was a farmer who
had stuck his hand with a nettle. The disease was all over the hand
and microscopic examination revealed the yeast fungus.
56 - The Medical Society of
Gilchrist reports a case in a negro cured with potassium iodid and
for some reason the doctor who brought this patient to him had had
him on the potassium iodid treatment. The patient felt that he was
improving faster than the doctor thought he was, so he suggested that
he return home and continue the potassium iodid and have the doctor
curette. The man was improving on a medicine that had cured a
case for Gilchrist so the x ray was not used.
The speaker said that he felt the greatest care should be exercised
in the use of the x-ray, not that it is so very dangerous but almost
any man who has has had much work to do will give a history of some
bad result. The x ray is getting somewhat into disrepute from its use
for everything. He said that the more he used the x ray the more he
used it as an adjunct. It can not take the place of surgery by any
means. There is hardly a week that he does not refer back to the
surgeon some patient who has been sent to him. º
Dr. BRANSFORD LEwis said that he would like an expression of
opinion on a case that he had had last fall. He had a patient the
subject of ureter calculus and wanted an x-ray picture. Several ex-
posures were made and he had operated about a week later. The
calculus was gotten rid of and the man made a good recovery and re
turned home. Later his wife wrote to Dr. Lewis about a hollow place
below the rib on the left side. Dr. Lewis said that after hearing the
discussion on the effects of the x-ray, it had occurred to him that pos-
sibly there was more atrophy of the muscle resulting from the x-ray;
so he asked an expression of the essayist on the subject.
Dr. GRINDON, in closing, said that he agreed heartily with Dr.
Engman in what he had said about acne. He felt that the internal
treatment of acne is only of value as is improvement of the general
condition in any other disease. When a patient goes to a dermatolog-
ist, if there is indigestion or constipation he remedies that, for it will
help the patient in a general way. He considered scaling off of de-
cided benefit, and sometimes began treatment by scaling off, believing
that the duration of the case might thus be shortened. When this was
done he did not use the ray until the consequent irritation had sub-
sided. He also agreed with Dr. Engman in considering the disease
City Hospital Alumni. 57
as local. He did not believe that the ordinary pus cocci were the
agents.
Gilchrist thinks he has found an acne bacillus, and believes that
the constipation and dyspepsia which often attend acne are not the
cause but the effect of acne, i.e., by the absorption of the toxins from
the skin the general health is lowered. In only one point did he dis-
agree with Dr. Engman, who seemed to think that idiosyncrasy in the
production of burns had been exagerated. The speaker indeed, had
noticed that a tube that had acted one way on one day would act dif-
ferently on another day, but he had been forced to the conclusion that
there is such a thing as idiosyncrasy. He did not know howelse to ac-
count for Dr. Duncan’s case of a severe burn. There must have been
such an idiosyncrasy in that case. Some people are wonderfully re-
fractory to the rays. In some cases there would be no dermatitis, and
in others in which he used less active tubes, and shorter exposures at
a greater distance, there would yet result dermatitis.
Of three men who go fishing, one will return with a sun dermatitis,
one will be tanned brown and the third will not be affected at all.
Referring to Dr. Duncan’s case of blastomycosis, the speaker
said his case had refused to heal under potassium iodid. The ray
gives rapid results in some cases and utterly fails in others. This case
received a thorough course with no effect, while of Hyde's two cases
one was cured after twelve sittings and one after sixteen.
Replying to Dr. Lewis’ query he said that from everything he had
ever known of the x-rays he could not believe that two short sittings
would bring about a deep atrophy of muscle tissue.
Meeting of March 17, 1904; Dr. Charles Shattinger,
President, in the Chair. -
Dr. L. H. BEHRENs presented a patient with
Cardiac Lesions,
and said that he had seen the patient that day for the first time; he
presented the case because there was present an interesting phenom-
enon though without much interest as regarded the lesion. There
was an aorticlesion with regurgitant pulse and the characteristic throb
58 The Medical Society of
bing of the arteries. At the first sound of the heart on the left side
there was a distinct buzzing that sounded like a factory at work. He
said that the sound was the most intense that he had ever had the
pleasure of listening to, probably due to a buttonholing of the valve,
and he presented the case for this reason.
Topographical Anatomy of the Thoracic and Abdominal
Viscera.
Dr. PETER POTTER.—We are told that anatomy is a closed book
and the man who made the statement is not so far wrong. However,
the statement must be modified on account of the changed conditions
which have arisen during the past few years. There is still a little that
has not been done. Men have not found out all that is to be learned
in several fields and of those fields, I am particularly interested in
gross anatomy.
A body to be of use for dissecting must be left flexible. In pre-
paring a body for section work we use formalin solution, strength 50
per cent, or else equal parts of formaldehyd and water or one part of
formaldehyd and two or three of water. A body injected with 50 per
cent formalin solution becomes firm and very flexible. Every organ
retains its position and exact contour. The formalin is always injected
into the arterial system. The organs are seen in the identical form and
relation they were in when each organ was acting upon all of its
neighbors and being acted upon as well. When an organ was removed
from an unhardened body there was nothing to base the statement on
that that organ retained the shape it was in originally. Most organs
are pliable enough to flatten out when placed on the table. The
liver, for example, when placed on the table assumes an entirely
different shape, and this is true of every other organ to some de-
gree. The brain changes its shape in the same way, but if injected
with the formalin solution it retains its shape and can be handled.
The great gain in the use of formalin solution is the body.becomes
fixed and can be handled, and the organs, when removed show the
outlines and depressions that are normal, thus it is possible to gain an
intricate knowledge of the body it was formerly impossible to attain.
City Hospital Alumni. 59
Formerly the work had to be done in a very few days and it was a race be-
tween the anatomist and the germ as to who would get through with
the organ first, and as the organs did not retain their shape it was not
possible to get an accurate knowledge of their relations. In Gray, for
example, not a single organ was ever given from actual measurements
made upon any single body. The authors and collaborators, after
many dissections and post-mortems, sat down to write a text-book. As
a geologist maps out a country, so must the fme anatomist map out the
surface of the body. Until the anatomist has done this it is impossi-
ble to say that certain organs bear a fixed relation to other organs. If
the measurements of the spleen are made on one body, the kidneys on
... another, there is no possibility of accuracy, for the organs are interde-
pendent. - -
In these maps I have here to-night I have attempted to show the
relation of one organ upon another. I made a set of measurements
upon a body that came into the dissecting room of the University of
Missouri about three years ago. The man was a negro, about 30
years of age, in the bloom of health, weighing 190 or 200 pounds, 6
feet in height, who was suffocated while cleaning out a well. There
was no surplus fat and there were absolutely noblemishes on the outer
surface to indicate that there were any pathological conditions. The
body was injected with 50 per cent formalin solation shortly after
death and was soon firm and rigid and ready for use. The head and
appendages were removed and the trunk cut into twenty-five horizontal
sections. This was the first time I had made sections for myself and
they were not so carefully made as I would make them now if I were
to do the work over again. The sections were made as nearly as possible
the thickness of a vertebra. These sections were drawn as carefully
as I was able to do under the circumstances by laying glass over the
section and tracing it out with India ink, which was used because it
does not spread and a very definite outline can be had. The next
thing was to identify the parts. The section was laid upon a flat sur-
face and the drawing was made and we were then ready to begin the
study of it. The sections were made three years ago and are almost
like shoe leather, as they have been used over and over again. Blue.
prints have been made from the drawings themselves and are more
60 The Medical Society of
easily handled than the drawings. Of course, it was considerable work
to get a complete record of all parts of the body, but that was the
mere beginning. I wished to learn the exact position of every organ
and every part of every organ and its relation to all of its neighbors.
The glass was ruled off in centimeters with a large heavy line in the
middle, with the median line of the plate across the middle of the
section, with the lines crossing different portions of the body with each
organ at that particular level. The sections were then all piled up in
their normal position and measured along the median line. After
measuring all the sections in which the lung appears; for example, all
we have to do is to connect the different parts to get the measurements.
of the lung. Cross lines represent where the section was cut, solid.
lines represent the skeleton; a long, heavy line, the lung; a dash and
dot, the aorta, etc. Looked at when each of the sections are con-
nected it is as the body would appear if it were transparent and you
could look through it. Each organ has been colored differently, e.g.,
the lung is green and can be seen overlapping the liver, which is
yellow.
When I came to make the measurements I found some of my
sections not exactly horizontal, some the sections were lower in front
than behind, and I had to make corrections for every measurement.
To do this I found the exact level of the posterior line, the exact level
of the front line, then, if the difference were 2 cm., I raised the front
1 cm. and lowered the posterior 1 cm. so that the amount of error due
to obliquity was corrected in every case. For every measurement
there has been a correction, though sometimes only a millimeter. The
intention has been to measure as closely to a millimeter as possible
and not a single item was allowed to pass by that would affect the ac-
curacy. It would be a difficult matter to cut the sections absolutely
horitzontal, though I could have taken more pains when I made the
sections. I did not realize the amount of error. The different points
were made on the body, lines were drawn around and the sections cut
with a large knife and saw. I find that decalcification pushes the
parts apart; as it is they have sufficient frame work to hold them to-
gether. I have abandoned it for student work.
In a decalcified body the microtome would be of great value. We
City Hospital Alumni. 61
attempted not long ago to encase a fetus in paraffin, but we found
that the paraffin had retracted from the body. So far we have found
no means of holding the body but by having assistants hold it while
making the sections. If any loose parts were found they were put into
position and stitched there, so that when the drawing was made it was
reasonably certain that the parts were in their normal relation.
DISCUSSION.
Dr. SHARPE said that an enormous amount of work had been
necessary for Dr. Potter to be enabled to bring before the Society these
tangible results. He had been specially interested in the method by
which the sections had been procured and appreciated the difficulties
that had to be encountered. For the purpose of demonstration it is
not a matter of much importance whether the section be a quarter of
an inch thicker posteriorly than it is anteriorly, or the reverse, but
for the purpose of determining definite anatomic relations it is a mat.
terof great import. It is, therefore, necessary that every effort be ex-
pended to get the sections as nearly mathematically exact as possible
Notwithstanding the excellent results already secured, considerable
improvement could be made, and it was an open question whether
that improvement could be better made by sectioning with the body in
horizontal, or in a vertical position. If one felt that he could do bet-
ter work with the body in a vertical posture, it would be advisable to
erect an appropriately slatted frame in which the body could be held
immovably in the original position. In that way it would be possible
to get fairly accurate sections, though he doubted whether it would
ever be possible to get sections mathematically exact. When desired
to make the sections with the body in the horizontal position it should
be placed in a suitably slatted casing of wood or metal, filling around
the body with some mass. If paraffin persists in shrinking, gutta-
percha could be used to advantage, or, fine sawdust or sawdust im.
pregnated with starch or guttapercha. Fe further suggested the use
of moist clay or putty well tamped around the body, sections to be
made before the mass becomes hard. If the mass is permitted to
harden it should be sown through, when the body is reached it may be
replaced by a knife. That would not be at all necessary if the sections
62 The Medical Society of
were to be prepared for class-room demonstration, but accurate data
regarding the size and relation of the viscera is sadly needed and no
effort should be spared in the search. Frrors could be corrected as
they had been in this case, but it entails a perfectly enormous amount
of work, and even then one can not be sure that the corrections them-
selves be correct. -
Dr. Potter’s work was worthy of high praise. It did not seem
to the speaker that the criticism made by Dr. Potter, that a decalcified
body seemed to loose its cohesive power, as evidenced in sectioning
was correct. Even if correct, this relative flabbiness of the sections
would be a serious bar only in class-room demonstration; on the other
hand, it will be found that in gross serial sections made for de-
termining topographic relations where great accuracy is needed, but
the process of sectioning is much easier when a preliminary decalcifi-
cation has taken place. A further advantage lies in the diminished
thickness of the knife-blade needed, owing to destruction of tissue (by
tearing), saws should not be employed in work of this character. In
closing, he alluded to the excellent work of Prof. Terry, much of which
was done with a long-bladed knife, operating over a case in which the
body was controlled.
Dr. KANE said that he regretted that such teaching of anatomy
was not in vogue in his student days. It presented much of interest
from the view point of one going actively into surgery. As to the best
method of correcting the small errors mentioned, he supposed Dr.
Potter was more competent than anyone else. The method suggested
by Dr. Sharpe was only the old carpenter miter-box. If the body
could be imbedded in ordinary potter’s clay and made perfectly secure
and level, accurately measured sections could very easily be cut. With
a compass the body might be marked all round for the purpose of
greater accuracy. - - -
Dr. TALBOTT said that this was certainly a most beautiful illustra-
tion. In this work of Dr. Potter's the study of anatomy had been
made vastly more accurate, it had been made vastly more interesting,
it had been made much more thorough and much easier for the stu-
dent. Like Dr. Kane the speaker wished that especially the process
of hardening and preserving the body had been known when he was
City Hospital Alumni. 63
working in the laboratory. When as a student he went to the dissect-
ing room each evening he shrank from getting his hands into the awful
mess; it was so repulsive and yet so interesting when once begun. He
fancied he could see Dr. Potter's students entering the dissecting room
with eagerness, more earnestness and with the determination to know
something of anatomy. With the speaker's class it had been a ques
tion of how quickly they could get through with it and get away. Now
it is how much they can learn, not how quickly they can get away.
He mentioned as an illustration an experience of his student days.
In the dissecting room were an Assyrian and a German. The As-
syrian had had a year of anatomy, the German had had none, and
they were working together. The Assyrian had removed the skin of
the arm and was very rapidly removing the muscles, very quickly cut-
ting away the biceps and triceps, and was getting around on all sides
when the German called a halt. He wanted to know how soon they
would get down to the “nervous part.” The Assyrian had already re-
moved the skin and muscles down to the bone. He replied to the
German's question that he would tell him about that part to morrow.
He said he had heard most excellent reports of Dr. Potter’s dissecting
room. He felt that the great help, the greatest help, of Dr. Potter's
work and that of others of to-day had been in the method of preserva-
tion. The method of conducting the work is far superior to what it
was. The charts were certainly very fine but the greatest thing about
it all was the method of preservation.
Dr. BRODERICK said that he had been present at a recent meeting
of a medical society when Dr. Potter presented an entire body, sim-
ilarly prepared, with the organs in situ for demonstration and he fully
appreciated the practical worth of the Doctor’s work. He felt that
the specimen brought before the St. Louis Medical Society was of
special value to the surgeon, and suggested a reproduction in papier
mache. It would be lighter in weight, not so hard to handle and the
surgeon could keep it in his office and use it for reference before
undertaking some operation. It would be much handier to keep
such a paper body and not so grewsome to people who happen into
the office. *
64 The Medical Society of
The PRESIDENT said that he noticed that the remarks had hinged
mainly upon the production of absolutely perfect sections. It seemed
to him that marking the body as Dr. Potter had done was the simplest
method of obtaining the sections. The absolutely correct marking
would depend upon getting one level as a standard. All the rest could
be had from that. Some of the instruments used by surveyors might
be of service in getting a point on the anterior and a corresponding
point on the posterior surface; for example, the spine of the dorsal
vertebra could be marked off by a surveyor's telescope, then a corres-
ponding point on the anterior surface could be made, and a circle
drawn around the body.
Dr. Potter, in closing, said that as Dr. Sharpe had remarked it
was not necessary in the case of student work that the sections be
absolutely accurate. The relations show just as well.
Several of the suggestions as to imbedding mass he thought would
be very valuable, particularly the sawdust and glue. He had thought
of putty and had also thought of some oil to dilute the paraffin. One
objection to the paraffin was that when it got cold it would break off.
If it could be diluted it might be possible to use it.
As to the method of hardening the body, about 1895, Garrod, a
German, used a 2 per cent formaldehyd soultion injected in the arte-
ries, sectioned the body at once and put it into strong alcohol to
harden. Dr. Jackson, about 1900 or a little earlier, conceived the idea
of injecting a 50 per cent solution. He saw that the lower animals
injected with this solution became rigid and that there was little
danger of drying and no decay. That year he presented it to the
medical world. The credit for all such work should be given to Dr.
Jackson, not that he was the first man to make sections, for even 3oo
years back there is a record of sections being made, but they were of
little value for class work. -
In regard to the papier mache manikin, it would not be grewsome
but that would be its only value. -
Such sections are of value because not only the surface can be
seen but all the parts. If the surface alone is seen it gives certain
relations, but the great value of the work would be lost.
City Hospital Alumni. • 65
Meeting of April 7, 1904; Dr. Charles Shattinger,
President, in the Chair.
The Use of the Colpeurynter in Obstetric and
Gynecologic Practice.
By GEORGE GELLHORN, M.D.,
ST. LOUIS, MO.
HE colpeurynter was brought to the attention of the
profession some fifty years ago, but not until within
rather recent years has a fuller appreciation of its pos-
sibilities been acquired and, as a result, a tangible extension of
the indications for its use been recognized.
The colpeurynter was introduced into obstetrical practice
by Karl Braun in 1851. It represents a simple rubber bag
which terminates in a tube, I5 to 20 cm. in length. As the
name indicates, the colpeurynter originally served only to di-
late the vagina. In 1862, Tarnier and Barnes simultaneously
devised a rubber bag for dilating the cervical canal. Tarnier's
bag (dilatateur intrautérin), however, was too complicated and
not effective enough for general use. Barnes' bag, modified
by Fehling, is well known in this country. It is a fiddle-
shaped rubber bag which is made in three sizes. A long, thin
tube is attached to it.
Systematic intrauterine application of the colpeurynter
was first recommended by Schauta (1883). Maeurer increased
the effect of the intrauterine colpeurynter (metreurynter) by
traction from without. Stanislaus Braun advised the same
procedure independently of Maeurer. Champetier de Ribes
replaced the elastic colpeurynter of Braun by an unelastic
cone-shaped balloon. His bag is also made of rubber, but
has a silk lining to prevent bursting. When distended with
water, it is as hard as a child's head and thus dilates the cervi-
cal canal better. There are a number of modifications of this
bag by Duehrssen, Boissard, Coe, Voorhees and A. Mueller.
These instruments all have the form of a funnel or inverted
cone. The smaller end of the cone is prolonged and bent at
66 The Medical Society of
an oblique angle, so that when thus introduced into the uterus,
it coincides with the axis of the pelvis.
When the colpeuryter is introduced into the vagina, cer-
vix, or uterus respectively, we speak of vaginal application or
colpeurysis, cervical application and intrauterine application
or metreurysis. -
For sterilization, the colpeurynter is filled with hot water
and first cleansed externally with soap and brush. Then, it is
boiled in water or soda solution for five minutes. Previous to
insertion, the contents are permitted to escape and, after intro-
duction, are replaced with a fluid. Distention with air should
be avoided as bursting of the balloon may lead to air embolism
(cases of Delore and Thorn). To fill the balloon, I so far
have used a 1 per cent solution of lysol. I have, however,
shared the experience of others that the lysol gradually mac-
erates the inside of the bag, and I shall, hereafter, use either
boiled water (Strassmann), boric acid solution (Sobestianskij)
or sterilized normal salt solution (Kurrer). The water may be
pumped into the balloon with a large syringe, or may flow into
the bag from a fountain syringe or irrigator under high pres-
sure or else, as Kurrer, Foges and others advise, the colpeu-
rynter may remain in constant connection with an elevated
irrigator. The latter procedure was first recommend by So-
bestianskij. During the labor pain, a part of the fluid is driven
from the balloon into the irrigator, and after the uterine con-
traction has subsided, the water runs back into the balloon.
Thus the uterus is subjected to a constant stimulation resulting
in induction of contractions -
In order to prepare the patient, bladder and rectum should
be emptied. The external genitals and the vagina are cleansed
in the usual way as before all other obstetrical operations.
The patient lies in lithotomy position. The application is very
easy. While one or two fingers of the left hand press the
perineum downward, the colpeurynter rolled upon itself like a
cigar is introduced into the vagina with a dressing forceps or,
better, with a curved clamp with smooth branches.
For the cervical or the intrauterine application, the vagina
is exposed by means of a speculum and a volsellum or muzeux
is placed in the anterior lip. On gentle traction upon the lat-
City Hospital Alumni. 67
ter, the external os may in some cases be pulled down so near
the vaginal entrance that the folded colpeurynter seized with
a long curved dressing forceps can be introduced into the
cervical canal without touching the walls of the vagina.
Should the cervical canal be too narrow, the smaller numbers of
Hegar's dilators or Goodell's instrument may be introduced un-
til the dilatation is deemed sufficient, a procedure which is easily
carried out on account of the soft consistence of the pregnant
uterus. The colpeurynter, then, is slowly passed through
the cervical canal until the larger part of the bag is within the
internal os if a Champetier bag is used, or until the constricted
part, in case of a Barnes colpeurynter, is at the internal os.
Now the dressing forceps is removed, and while the volsellum
is released from the anterior lip, water is pumped into the
balloon. Care should be taken to find out before the opera-
tion how much fluid is needed to distend the bag ad maxi-
mum. In proportion to the size of the balloon, the volume of
fluid ranges from 400 to 750 cc. However, in filling the bal-
loon after introduction, somewhat less water should be pumped
in than in the test examination. Edgar has in two instances
seen rupture of the uterus as proved by autopsy, caused by
intrauterine explosion of overdistended Barnes' bags. After
the colpeurynter within the uterus is sufficiently distended, gen-
tle traction upon the tube having shown its satisfractory posi-
tion, the tube is clamped off or the stop cock closed, and the
speculum is taken out. No definite rules can be given as to
how long the colpeurynter should remain in place. The dura-
tion depends upon the individuality of the case. Biermer is
of the opinion that the colpeurynter may stay in place with
impunity as long as three days, and should only be removed
if rise of temperature and severe pain—except labor pains,
demand its withdrawal. Generally speaking, the effect of the
colpeurynter will have become manifest before that time, in
other words, the bag will be expelled or the cervical canal is
sufficiently dilated so as not to require the further presence of
the balloon.
The effect of the colpeurynter, as mentioned above, is
greatly increased by traction from without. If a slow and
gradual dilatation be desired, a string is fastened to the tube
68 The Medical Society of
or stop. cock. To this string which is stretched across the
foot of the bed, a weight is attached. I usually apply a trac-
tion of from one to two pounds upon Champetier's bag. A.
Mueller successfully used a weight of six pounds.
Should a rapid dilatation be necessary, traction upon the
balloon is exerted by the hand of the operator, and the bag is
pulled through the cervical canal.
The question naturally arises which of these three varieties
of the colpeurynter is preferable in daily practice. The col-
peurynter of Braun, as we shall see later, is most serviceable
in gynecologic work. In obstetrics, both Braun's bag and the
colpeurynter of Barnes suffer from the one great disadvantage
of their elasticity. Traction upon an elastic balloon produces
a stretching and consequently a narrowing of the bag; it at-
tains a more or less sausage-shaped form. It is, then, readily
seen that such a bag is apt to slip out of the uterus before
sufficient dilatation is effected. Furthermore, the possibility of
bursting with all its consequences rather forbids traction upon
the tube of an elastic bag, and yet, as we shall see presently,
traction is almost always an indispensable part of the whole
method. The colpeurynter of Champetier, on the other hand, is
almost entirely free of these disadvantages. Its inelasticity
warrants the constancy of its form after the distention of the
balloon is completed, even though a strong traction be exer-
cised. Its conical form, again, enables us to imitate closely
Nature's method of dilatation. The cervix is dilated from
within outward according to the natural process until the cer-
vix is completely abolished and the external os ad maximum
dilated. Finally, the danger of bursting is considerably re-
duced. For all these reasons, most authors concede the supe-
riority of Champetier's colpeurynter. Edgar comparing the
relative merits of the three forms of colpeuryters says that the
consensus of opinion inclines to the Champetier as being the
most effective, and Bosse emphatically states that “in princi-
ple, the balloon of Champetier is the metreurynter par excel-
lence.” I myself use for intrauterine application exclusively
the Champetier, but also for vaginal use, I regard the latter
as preferable to any other colpeurynter.
The colpeurynter is of service both in obstetric and gyne-
City Hospital Alumni. 69
cologic practice. In obstetrics, the colpeurynter may be used
—first, during pregnancy; second, during labor; third, in the
puerperium.
The principal indication for the use of the colpeurynter
during pregnancy is the induction of premature labor. We
are here not concerned with the indications to interrupt an ex-
istent pregnancy, but have to deal only with the methods of
inducing premature labor. Of the numerous methods recom-
mended to produce uterine contractions, the artificial rupture
of the membranes and the intrauterine injection of water or
glycerin have been abandoned on account of their sometime
grave consequences. As, furthermore, electrization of the
uterus and hot, or alternately hot and cold vaginal douches
are altogether too uncertain in their results, the coipeurynter,
on the whole, competes only with tamponade of the vagina,
cervix and uterus, and Krause's method of catheterization
of the uterus. The former method of tamponade is very
painful and, as a rule, has to be repeated several times. Each
repetition increases the danger of infection and involves great
inconvenience to both patient and physician. Moreover, the
results are by no means encouraging.—(Gaertner).
Krause's method of introducing a bougie into the uterus
is, in my opinion, overrated. The method is not without
danger and does not yield uniformly good results. To select
off hand from the multitude of statistics, both Beuttner and
Lamprecht found that with this method one to eighteen days
elapse before complete dilatation of the os occurs. Biermer,
Kleinhans and Bosse agree that the bougie method accom-
plishes in days what metreurysis accomplishes in as many
hours. My own observations are in accord with the statements
of these last named authors. I shall refrain from giving ex-
tended descriptions of cases, but shall limit myself to a short
consideration of two cases which have come under my care
within the last two years:
The first patient suffered from a myocarditis which in the
previous two deliveries had produced serious complications.
She now desired interruption of the existing third pregnancy.
I first consulted Dr. J. E. Haggard, of Lincoln, Neb., and Dr.
H. C. Buswell, of Buffalo, N. Y., who had attended her previ-
70 The Medical Society of
ously. Since their opinion was in favor of interruption of
pregnancy, I asked Dr. Fischel's advice, who in consideration
of the existing myocarditis also suggested artificial abortion.
February 9, 1902, a bougie was introduced into the uterus and
the method was repeated with two bougies two days after-
wards. In the meantime, tamponade of cervix and vagina
was employed. The fourth day, Braun's colpeurynter was in-
Serted into the vagina. All these attempts of inducing labor
pains having remained futile, Champetier's bag was finally in-
troduced into the uterus on the afternoon of the fifth day.
Three hours later a weight of 3 pounds was attached to
the colpeurynter, and after another hour the weight was
increased by one pound. Labor pains commenced soon
after the first weight was attached and grew continuously in
strength until the fetus was expelled, less than eight hours
after the insertion of the colpeurynter and four and a half hours
after the application of the weight. The prompt action of the
Colpeurynter, as compared with the other two methods ap-
plied in this case, was evident.
The second case was a patient of Dr. Goebel and Dr.
Greiner. She was in the 7th month of her Ioth pregnancy when,
On December 13, Igo3, she was seized with uremic convul-
sions and amaurosis. I saw the patient four days later when
the attack had subsided and the general condition had some-
what improved. There was still a marked anasarca, the urine
contained '/, per cent albumin, and microscopically all varieties
of casts, red blood corpuscles, kidney epithelium and uric
acid crystals. The patient stated that the fetal movements had
not been noticed for the last six days; while fetal heart-beats
had not been found for about five days. We agreed upon in-
duction of premature labor. The indication for interruption
of pregnancy was very clear in this instance. We had to deal
with a case of grave nephritis, with a dead child. As there
were no convulsions at the time, great haste was unnecessary.
Moreover, the accouchement forcé would have necessitated a
general anesthesia which, in its turn, was strongly contraindi-
cated on account Qf the general condition of the patient. We,
therefore, decided to employ metreurysis. The cervix was
easily and rapidly dilated with Goodell's dilator until the bag
City Hospital Alumni. 71
of Champetier could be introduced into the uterus. A weight
of two pounds was attached to the colpeurynter in the manner
above described. Four hours later, the colpeurynter was ex-
pelled, after which strong regular labor pains set in. Nine
hours later, thirteen hours after the insertion of the intrauterine
colpeurynter, the spontaneous birth of a dead fetus in breech
presentation took place. The patient had an entirely
normal lying-in period; the anasarca disappeared rapidly
under appropriate treatment, and a month ago, when last seen
by Dr. Greiner, her subjective condition was very satisfactory.
Of course, she still has her nephritis.
This case well illustrates how serviceable is Champetier's
colpeurynter. In spite of her serious condition interruption
of pregnancy was performed easily and without any inconven-
ience to the patient. There is a remarkable unanimity of
opinion on the usefulness of the colpeurynter. All writers
who have employed the intrauterine colpeurynter agree that of
all methods of induction of labor, metreurysis is the safest,
promptest and superior to all other procedures.
Strassmann fills the intrauterine balloon with water of the
temperature of the body. I believe, however, that by using a
fluid of I Io°F. the mechanical effect of the colpeurynter can
be greatly increased. *
In order to induce premature labor, Baumm combines
metreurysis with intrauterine injection of glycerin. Instead of
using rubber bags, he introduces the ordinary condom (gold-
beater skin) into the uterus and fills it with IOO co. of glycerin.
When this balloon is expelled a few hours afterward, it is
then much larger; it contains from two to three times the orig-
inal volume of fluid (which, however, now consists of but a
very small proportion of glycerin), for an osmotic exchange
between the glycerin within and the aqueous fluid without the
bag has taken place. Labor pains commence, as a rule, from
ten minutes to two hours after insertion. Should they die
away, the diluted glycerin is emptied and new fluid is injected
into the condom. Serious consequences following the intra-
uterine use of glycerin in this manner were not observed by
Bau mm. I do not know whether this method has been applied
by others.
72 The Medical Society of
We have spoken so far of the service rendered by the
colpeurynter in interrupting pregnancy. A still larger field of
usefulness is open to the colpeurynter during labor. In this
connection we have to consider in the first place accouchement
forcé. By forcible delivery or accouchement forcé we under-
stand, according to Edgar, three operations: First, the com-
plete, rapid instrumental or manual dilatation of the cervical
canal; followed, second, by either combined or internal ver-
Sion or the application of the forceps; and third, the immedi-
ate extraction of the child. The principal indication for the
accouchement forcé is furnished by eclampsia. This is not
the occasion to discuss whether, and when, it is necessary to
empty the uterus in eclampsia. The question what course of
treatment to pursue in this dangerous affection is as yet by no
means definitely settled. However, the important fact is gen-
erally conceded that after delivery the eclamptic convulsions,
as a rule, become rarer or may even cease. Quite recently the
dilator of Bossi and its modifications seemed to eliminate all
other methods of forcible delivery such as the classical Ce-
sarean section, the vaginal Cesarean section of Duehrssen, dis-
cission of the external os, high forceps, perforation, etc. But
as experience with Bossi's instrument became more and more
extended, doubts as to its usefulness appeared, and the most re-
cent literature contains quite a number of reports of cases in
which dilatation after Bossi was followed by extensive lacera-
tions of the soft parts and serious hemorrhages. It has es-
caped the attention of the enthusiastic advocates of Bossi's
method that the dilator accomplishes a maximal stretching,
but not a physiologic dilatation of the cervical canal.
Therein lies the disadvantage of instrumental dilatation
as compared with dilatation by rubber bags. The colpeuryn-
ter of Champetier imitating closely the normal mechanism of
the first stage of labor, not only dilates the cervical canal till
the external and internal os are stretched ad maximum and
disappear, but also shortens the cervix itself till it, too, is
abolished. Of course, the advantage of this entirely physi-
ologic dilatation of the cervical canal by means of the colpeu-
rynter would be of doubtful value if it were established : First,
that in eclampsia the greatest possible rapidity is always im-
City Hospital Alumni. 73
perative; second, that the use of the colpeurynter consumes
too much time; and third, that with the methods of rapid and
forcible delivery better results are obtained than with other
methods of delivery.
The first of these three questions whether in eclampsia
delivery should always be hastened as much as possible seems
easy of answer. But the fact that a large number of authori-
ties are strongly opposed to each and every operation, proves
that too rapid a confinement is by no means imperative. Ahl-
feld says that only when labor has progressed far enough to
permit easy termination, without a serious operation, this should
be done. Furthermore, if the soft parts are not yet suffici-
ently dilated, expectant treatment is almost always followed
by good result. Even in those cases in which the convulsions
occur in alarming frequency before labor has begun at all, he
recommends the same expectant treatment. I have observed
in Jena a case of a most severe eclampsia which was success-
fully operated upon by Cesarean section nine hours after the
appearance of the first convulsions and after eight attacks of
the most alarming character had occurred.—(Hillmann). This
case, which is by no means unique, shows convincingly that a
favorable result may be obtained even without great haste.
Regarding the second question whether the use of the
colpeurynter for complete dilatation of the cervix consumes
too much time, I may state that from reports in literature the
duration seems to average from six to eight hours. The con-
ditions in the individual case and the intensity of the traction
exercised naturally produce considerable variance. A few
references may serve to illustrate this point. Boissard con-
demns the colpeurynter of Champetier in that it brings labor
to an end faster than a spontaneous delivery should be, namely,
within eleven hours. Gerich succeeded in extracting the bal.
loon, and thus completely dilating the cervical canal, in four to
seven minutes with a strong colpeurynter and in three-quarters,
one and three hours, respectively, with an elastic colpeurynter,
though the conditions of the cases were otherwise unfavor-
able. Rapidity of dilatation, therefore, can, to a great extent,
be regulated to meet the desire of the physician. Mueller, in
one case, required about ten minutes to dilate the cervix with
74 The Medical Society of
his modification of Champetier's colpeurynter, and L. Meyer,
of Copenhagen, stated at the Ninth Congress of the German
Society for Gynecology in Giessen, 1901, that the complete
dilatation of the os, even when the cervix was still existent, is,
as a rule, accomplished in from six to twenty minutes. How-
ever, it should be borne in mind that such rapidity of
dilatation may, especially in low insertion of the placenta,
lead to lacerations of the cervix as reported by Hink and
Duehrssen. sº
With respect to the third question whether the methods
of forcible delivery obtain better results than other modes of
treatment, I refer to the Transactions of the Congress just
mentioned. During this session the majority of the speakers
on the treatment of eclampsia expressed themselves very de-
cidedly in favor of the colpeurynter. To use the dictum of
Loehlein . By the adoption of metreurysis we have made the
most decided progress in attaining a method for the timely
and appropriate termination of labor.
From the foregoing remarks it is evident that the colpeu-
rynter, especially the one devised by Champetier, occupies a
legitimate position in the treatment of eclampsia. At least,
its application is indispensable as a preparatory method in
order that other obstetrical operations may be facilitated
which otherwise are not to be performed without additional
dangers to the mother.
Also in placenta previa, an extensive use of the colpeu-
rynter of Champetier promises considerably better results for
both mother and child. In these cases, the best method con-
sists in first rupturing the membranes and then introducing the
balloon into the amniotic cavity. In this manner the colpeu-
rynter either accomplishes, directly the delivery or, on the
other hand, prepares the soft parts for version and extraction.
In fact, metreurysis forms the most effective rival to the Brax-
ton-Hicks method of combined version. While the latter is
directed toward saving the life of the mother by checking
hemorrhage, metreurysis considers also the claims of the child.
In metreurysis, the metreurynter, instead of the hips and thigh
of the child in the Baxton-Hicks plan, is used as a pressure
tampon upon the separated portion of the placenta. The col-
City Hospital Alumni. - 75
peurynter method is much the easier; leads, if the necessary
precautions are taken, less frequently to deep lacerations of
the cervix and is not so dangerous to the child. According to
the statistics of Kuestner and Keilmann, 60 to 65 per cent
of living children are delivered.
Again, hemorrhages in the first stage of labor resulting
from premature separation of the placenta can be treated by
the intrauterine colpeurynter. This increase of intrauterine
pressure prevents further hemorrhage from the separated part
of the placenta and hastens delivery.
Vaginal application of the colpeurynter is indicated as a
prophylactic agent against premature rupture of the mem-
branes; or, if the latter has already occurred it serves as a
substitute for the ruptured bag of waters. For the latter
reason, I have applied Champetier's balloon twice within the
last two months. The first case was a primipara, aged 30
years, with very narrow vagina. The child was in breech pre-
sentation, the bag of waters was ruptured, the cervix had al-
most disappeared, the os was of the size of a silver dollar.
The colpeurynter of Champetier was inserted into the vagina
at 8 a.m. and connected with a weight of I*/, pounds. About
four hours later complete dilatation of the os and expulsion of
the balloon together with considerable stretching of the pelvic
outlet took place, and a very large child was delivered without
difficulty and without laceration of the perineum, though both
arms had to be brought down. In the second case the mem-
branes had prematurely ruptured while the cervix would admit
only two fingers. The labor pains though strong and regular
were not effective in dilating the cervix. Champetier's bag
was inserted into the vagina at IO a.m. and a traction of 2
pounds was applied. Two hours later the colpeurynter was
pulled through the vaginal entrance and it was found then, that
the cervix was completely dilated and the head rested upon
the pelvic floor. -
Schauta recommends the vaginal use of the colpeurynter
in prolapse of the umbilical cord and in transverse position in
order to push back the anterior shoulder.
Furthermore, the colpeurynter may be used in uterine
inertia and, finally, in cases of narrow vagina. Especially in
76 The Medical Society of
cases of rigidity of the soft parts in old primiparae, the use of
the colpeurynter and the application of permanent traction
will prevent the otherwise inevitable deep perineal lacerations,
or will, at least, limit their extent.
The contraindications of metreurysis during labor are
surprisingly few. It can not be denied that the possibility ex-
ists of pushing the head sideward by the intrauterine balloon.
I am inclined, however, to believe that this accident can be
prevented by the choice of a colpeurynter of medium size.
Should the head have been deflected, the patient should be
permitted to lie on the side toward which the head will gravi-
tate when it again assumes its normal position coincident with
the withdrawal of the metreurynter. If this automatic cor-
rection should not obtain, internal or external version is indi-
cated. More dangerous is the prolapse of the umbilical cord
after expulsion of the balloon. This can not be prevented,
but in such a case the preceding metreurysis has paved the
way for a successful interference, because the stretched soft
parts afford sufficient room for any operation. In such a case,
version and extraction are immediately to be made. In a few
cases metreurysis has been made use of in internal post-partum
hemorrhages. Notwithstanding the favorable result in Swit-
alski's case, I doubt whether in a complication of this sort
metreurysis is to be recommended. The case of Schwarzen-
bach furnishes a warning example. An excessive speed in
withdrawing the colpeurynter through the cervical canal may
lead to deep lacerations of the cervix, especially if the placenta
has a low insertion, and to the danger of atonic hemorrhages.
In the puerperium, the use of the colpeurynter is limited
to but one condition, which fortunately is not very frequent,
viz, the inversion of the uterus. In cases of fresh puerperal as
well as chronic inversion, our aim is to accomplish reinversion.
In all cases, we should first resort to manual reposition. This
failing colpeurysis is indicated. Special colpeurynters have
been devised for this purpose, for instance, the cone and
funnel-shaped balloon of Kock's, but for ordinary pur-
poses Braun's bag will prove serviceable. Only when blood-
less methods fail, an operative mode of treatment is to be
utilized.
City. Hospital Alumni. 77
So much for the use of the colpeurynter in obstetrical
practice. In gynecology, the colpeurynter has found a wide
field of application, especially in those plans of local treat-
ment which are called “Belastungstherapie” — pressure
weight treatment. In this presence, several years ago, my friend,
Dr. Ehrenfest, spoke in detail on this mode of treatment, and I
follow his description of the general technic. Two colpeuryn-
ters of Braun are connected by means of a stop-cock made of
hard rubber, so that the whole length of the apparatus is about
60 cm. Before connecting this apparatus, one of the colpeu-
rynters is filled with IOoo grams of metallic mercury, while
from the other the air is evacuated by compression of the
bulb. The patient is placed in a comfortable recumbent posi-
tion on a bed or couch, the foot of which is elevated about 50.
to 60 cm. The empty colpeurynter is folded about itself, intro-
duced into the vaginia and placed against the part desired. It
is retained in this position by means of two fingers, while the
filled colpeurynter is elevated with the other hand, allowing
the mercury to flow downward. In the beginning it is advisable
to use not more than 250 to 500 grams, and only after the
patient has become accustomed to this treatment, may we in-
crease the amount until the upper colpeurynter is completely
emptied. The closed valve prevents the return flow of the
mercury. A flat linen bag containing 1,500 to 2,OOO grams of
shot is placed on the lower abdomen.
This form of the mercury colpeurynter as devised by
Funke and improved by Halban is very simple and quite suit-
able for daily practice. There are a number of modifications
which, with exactitude, determine the degree of the intrava-
ginal pressure, and others which combine the pressure of mer-
cury with that of air, but they are somewhat complicated and
consequently not so serviceable for the use of the general
practitioner.
The patient usually remains in the dorsal position, but
should it become necessary to turn the patient upon either
side, the abdominal bag can be kept in position by means of a
bandage. To remove the filled colpeurynter from the vagina,
the patient is permitted to sit upright, when on opening the
valve and lowering the empty colpeurynter, the mercury is
readily transferred from the former to the latter.
78 - The Medical Society of
The mercury colpeurynter was primarily devised for the
treatment of chronic pelvic exudates and, in reality, fulfills all
expectations. In these cases, hot water or hot air treatment -
must be applied first, and when the exudate is somewhat soft-
ened under the influence of the heat, it is crushed, so to speak,
between the weight from above and the pressure from below
and thus absorption is encouraged. In this manner it consti-
tutes a form of forced massage and serves as a substitute, in
many cases, for the laborious manual massage of Thure Brandt.
The mercury colpeurynter may also be used to stretch
and break old and firm adhesions; though I must confess that
my own experience in this field has not been very encouraging.
It has furthermore, been used for the stretching of cicatrices
following cervicovaginal lacerations. In this variety of lesions,
however, I should prefer excision of the scars. &
In the treatment of strongly-adherent retroflexions of the
uterus I follow the lead of Olshausen and resort to operation.
But for the reduction of mobile or but slightly adherent retro-
flexed uteri, the mercury colpeurynter seems to me the ideal
method. I have almost entirely abandoned the manually reposi-
tion of the retroflexed uterus, for the latter, even if successful,
produces annoying and lasting sensitiveness of the abdominal
wall. As a rule, I begin with Kuestner's method (reposition
by means of a vulsellum placed in the anterior lip) and if I do
not succeed at once, I introduce the colpeurynter. For this
purpose, counter-pressure upon the abdomen by the shot bag
is not needed. In Trendelenburg's posture, the mercurial
weight does not press against the sacrum but it exerts its in-
fluence in the direction of the pelvic axis and tends to push the
uterus in the same direction. The uterine body thus forced out of
the lower pelvis, passes the promontory and glides into the ab-
domial cavity. I usually have succeeded the first time in replac- -
ing the uterus. I may add, that since the time I began to make
systematic use of the colpeurynter, the number of irreducible
uteri, in my practice, has surprisingly decreased. Should the
colpeurynter also fail, operation for retroflexion is definitely
indicated.
Under these circumstances it is evident that the colpeu-
rynter is a powerful aid also in replacing the retroflexed preg-
City Hospital Alumni. 79
nant uterus and may often prevent further operative interfer-
ence with this dangerous condition. Finally, there are several
reports in literature of excessive vomiting of pregnancy in
which the mercury colpeurynter relieved the existent con-
dition by pushing the uterus upward, and thus removing
pressure upon the pelvic ganglia.
This, however, is not a complete list of the indications for
the use of the colpeurynter in gynecology. Huppert, for in-
stance, successfully applied the colpeurynter in vaginismus in
order to stretch the entrance of the vagina. He filled the
colpeurynter with gradually increasing quantities of water and
found, after continuing this treatment during several weeks,
that intercourse took place easily and without any pain.
Neugebauer, in laparotomies, inserts a colpeurynter into
the vagina and distents it with water ad maximum. The pel-
vic organs are thus elevated and brought nearer the abdominal
incision so that operative attack upon them is greatly facilitated.
Viertel in examining the bladder, connected his cysto-
scope with a colpeurynter filled with water and intensified the
distention of the bladder whenever necessary.
Such technical detail, however, extends beyond the scope
of my theme. It has been my desire to call attention to this
simple instrument which the general practitioner may use with
the greatest advantage is his daily work.
To sum up, the indications of the colpeurynter in obstet-
rics are:
I. Induction of premature labor.
2. Eclampsia
3. Placenta previa.
4. Hemorrhages in the first stage of labor due to prema-
ture separation of the placenta.
5. Premature rupture of the membranes or as a prophy-
laxis against this accident.
6. Uterine inertia. -
7. Prolapse of the umbilical cord.
8. Transverse position. -
9. To widen the soft parts, especially in old primiparae and,
IO. Inversion of the uterus.
In gynecology, the colpeurynter, mainly in the form of
the pressure weight method, is indicated:
80 The Medical Society of
I. In the treatment of inflammatory exudates and their
residua in the pelvis. -
2. For the reposition of the retroflexed uterus, pregnant
or non-pregnant and,
3. In the treatment of cicatrices following cervicovaginal
lacerations.
In conclusion, permit me to state that it is my belief that
the colpeurynter should be found in the obstetrical bag of every
practitioner and that in the daily gynecologic work the col-
peurynter forms one of our most valuable therapeutic aids.
BIBLIOGRAPHY.
Ahlfeld.—Lehrbuch der Gebutshilfe, 1898.
Haumm.—Graefe’s Sammlung zwangloser Abhandl., Band 4, Heft 7.
Beuttner.—Archiv f. Gyn., Band 47, Heft 2.
Biermer.—Encyclopaedie der Geb. und Gyn., 1900, Band I, p. 508.
Bollenhagen.—Wuerzburger Abhandlungen, Band 3, Heft 4.
Bosse.—Centralblatt f. Gyn., No. 30, 1900.
Delore.—Ibid., 1894, p. 957. -
Edgar.—The Practice of Obstetrics, 1903.
Ehrenfest.—ST. LOUIS Courier of MEDICINE, June, 1901.
Foges.—Centralblatt f. Gyn., 1903, p. 52O.
Gaertner.—Dissertation, 1894, Wuerzburg.
Gehrich.—Centralblatt f. Gyn., No. 6, 1897,
Hillmann.—Monatssch. f. Geb. und Gyn., Band Io, p. 193.
Hink.-Centralblatt f. Gyn., 1896, p. 1250.
Holowko.—Monatssch. f. Geb. und Gyn., Band 16, p. 936.
Huppert.—Centralblatt f. Gyn., No. 32, 1901.
Kurrer.—Ibid., No. 7, 1903.
Lamprecht.—Dissertation, 1894, Goettingen.
Mueller, A.—Monatssch. f. Geb. und Gyn., Band 5, Ergaenzungsheſt.
Mueller, A.—Centralblatt f. Gyn., No. 47, 1902.
Neugebauer—Ibid., No. 5, 1898.
Olshausen.—Transactions German Gyn. Soc., IX, 1897.
Rubeska.-Wiener Med. Presse, Nos. 2–8, 1903.
Sobestianskij.-Cited by Holowko.
Strassmann.—Aseptische Geburtshilfe, Berlin, 1895.
Thorn.—Monatssch. f. Geb. und Gyn., l\), 504.
Verhandlungen der Deutschen Gesellsch. f. Gyn., IX.
Viertel.—Veit’s Handb. f. Gyn., II, 222. -
City Hospital Alumni. 81
DISCUSSION,
Dr. HENRY Schwarz said that the paper was so exhaustive and
so ample that it would be impossible to follow it in every phase in the
time at his disposal but he wished to emphasize a few points that
had especially interested him. He agreed with the essayist that the
colpeurynter ought to form a part of every obstetrical outfit, as it was
most helpful. He also agreed with him that the colpeurynter of the
shape preferred by Gellhorn answered the purpose better in most cases
than other forms of colpeurynter. The dilators of Barnes on proper
occasions answer admirably. It was new to the speaker that the dila-
tor of Barnes which had been handed around was modified by
Fehling. He thought that the Barnes dilator answered better when it
was desired to protect the bag of waters. In a case of slow dilatation
of the cervix in which it is desired to assist dilatation or when the ob-
ject is to protect the bag of waters which seems in danger of rupturing,
the soft Barnes dilator answers better than the Champetier. In all
other cases the Champetier has a much better shape, and on account
of maintaining its shape it answers the purpose much better.
The speaker said that he had never used it until last fall when
attending a case with Dr. Behrens. He was gratified with the excel-
lent work it did in that case and he was inclined to think that in most
cases, especially in placenta previa, it would answer admirably. As to
the use of the instrument for introducing labor, he was not convinced
that it was a good method, and he wanted to say a word in favor of
the old method of using a bougie. He had used that for 20 years and
did not remember a single case in which it failed to start labor, that is,
to produce uterine contractions sufficient to start the dilatation of the
cervix. So far as starting labor was concerned, he thought this method
was a perfectly safe and efficient means Otherwise the colpeurynter
certainly answered an excellent purppose in several obstetrical condi-
tionS.
He did not quite understand Dr. Gellhorn's method of using it in
prolapse of the cord. His practice in these cases had always been to
deliver as quickly as possible because experience shows that in almost
every case the child is lost unless it is delivered at short notice. If if
82 The Medical Society of
were used at all he thought the object would be to get dilatation as
quickly as possible in order to deliver the child without delay. In re-
gard to puerperal eclampsia, the cases vary greatly. If the woman
had no labor pains at all, if she were a primipara, if the cervix was
closed and the patient had convulsions followed by coma, he hardly
thought obstetricians would wait hours to deliver when a few years ago
they were willing to perform Caesarean section under such circum-
stances. He had found that the Bozzi method had enabled him to
deliver a living child within a half hour on two occasions. In one
instance he saved both mother and child, in the second case the mother
was moribund when he was called, but the child was born alive. He
was inclined to think that the injuries attributed to delively with Bozzi’s
dilator were due to placenta previa or to some condition in which the
lower section of the uterus was particularly liable to be torn. With
the cervix in normal condition Bozzi's method seemed to him not to be
so dangerous as to cause him to hesitate to use it when a woman’s life
hung in the balance.
Dr. GEHRUNG said that in the majority of Dr. Gellhorn’s state-
ments he agreed with him. His experience in the use of the instru.
ment had been limited, however, but, had been in the same direction
as those cases reported by the essayist. Undoubtedly the colpeuryn.
ter was a good addition to the armamentarium, but the older means
should not be forgotten. -
What he desired to speak of particularly was the use of the col-
peurynter in the replacement of retroflexed or retroverted womb. It
seemed to be a very useful instrument in some cases, except where
there were adhesions. Where there were no adhesions and where
there was chronic displacement and the womb had been in such a
position for a long time, the colpeurynter was a good thing in the
hands of those not over-well experienced with other means. It will
perform the mechanical action of replacing the uterus to a certain ex-
tent. However, as soon as the colpeurynter is removed in all cases *
where there is a tendency to re-displacement, the womb will fall back
again unless, in the replacement, the fundus has passed beyond the
vertex or danger line. This would hold true of all cases except those
of temporary or accidental displacement. Only in such cases can a
City Hospital Alumni. 83
permanent replacement be effected without other means of support.
For years he has replaced the retroverted and retroflexed uterus by
means of a very simple device of his (Gehrung's repositor consists of a
hard rubber ring, elongated and curved on the flat to suit the pelvic
curve. The repositor is 6 inches long and I"/, wide, ends rounded.
It is, therefore, applicable in most cases). By the introduction of this
and the use of gentle pressure and conjoined manipulation it is possi-
ble to execute the same thing the mercury would do and to carry it
actually and in much less time beyond the point attainable by the
mercury. Whatever means is used must be followed by after-treat-
ment and by putting and maintaining the womb in the opposite posi
tion. The mere replacement will not prevent the womb from falling
back into the old position. After replacemeut it must be kept there
either by surgical or mechanical means, so that the uterus can never
return to or beyond the danger line. Of course, it is not merely a
question of introducing but of scientifically fitting a pessary after the
uterus has been replaced by this or any other means.
Dr. TAUSSIG said that in obstetrical work his experience with the
colpeurynter had been very limited. On one occasion he used a
Barnes bag in a pneumonia patient where delivery had to be hastened,
and his experience was not very satisfactory. The patient was a
primipara and when the Barnes bag was expelled the cervix was
not more than half dilated so that manual dilatation had to be re-
sorted to.
Regarding the more general use of the colpeurynter in this sort of
work, there was still one point to be considered, i.e., the possibility of
infection. In the experience of Dr. Halban of Vienna, the colpeu-
rynter is a dangerous instrument. He noted that infection not infre-
quently occurred though the technic was as careful as was required.
The introduction of an instrument as large as the colpeurynter into
the uterus without touching the external genitalia and thereby carrying
germs into the uterus is not altogether easy. A thorough sterilization
of the instrument is also not a simple. Boiling for five minutes is not
as good as boiling for twenty minutes, and the colpeurynter does not
satisfactorily withstand boiling for that length of time. It has been
suggested to keep the instrument in the fumes of formalin for one to
84 The Medical Society of
two hours. It would be of great importance to have some statistics
as regards the frequency of infection in cases in which the colpeuryn-
ter was used in comparison with cases in which it was not used.
In connection with the question of eclampsia in comparing the
colpeurynter with Bossi's dilator, a third important method of dilata-
ing the cervix should be borne in mind: that of manual dilatation.
The speaker thought it a question whether sooner or later there would
not be a return to that method of dilatation. In his gynecological
practice he had had occasion to use the colpeurynter at the Polyclinic
in about fifteen cases of parametritis and retroflexed uterus. The
cases of parametritis did remarkably well and there were no bad re-
rults. There were five or six of these cases. Treatment was started
by using about 500 grams of mercury for ten minutes, increasing at
each treatment Ioo grams and ten minutes in time until the treatment
extended to Iooo grams for one hour. Even a longer time than that
could be occasionally used. The cases in which the treatment was
used for fixed retroverted uterus were carefully selected. Where mas-
sage was practical it was used. Where the abdominal walls were
rather thick, and fat, or where the patient was sensitive and nervous,
the colpeurynter was used. In some cases the uterus was brought up
from the cul-de-sac and the later so far freed that it could be brought
forward and a pessary introduced. In one case in particular the pa-
tient was very sensitive and after two or three massage treatments
nothing could be effected on account of this sensitiveness. A colpeu-
rynter was used and the uterus lifted out of the pelvis. In that case,
two months after leaving the clinic, the patient returned and, though
for nine years previously she had not been in a family way, she was
then one month pregnant. In another instance, the colpeurynter be-
ing used for a long time without effect, massage was resorted to
and achieved the desired. Where one fails the other may prove
effective.
Dr. REDER said that to the excellent paper he could add only his
opinion. The paper dealing with the advantages of the colpeurynter,
lauded that appliance over other methods used in the past. In ob.
stetrical practice he had had occasion to use the Barnes' bag, which is
an old thing. However, the colpeurynter could not be classed as one
City Hospital Alumni. 85
of the new appliances. Where haste was necessary he thought valu-
able time was lost in the application of the colpeurynter. As Dr.
Schwarz had mentioned, the introduction of a bougie had invariably
resulted in establishing labor pains, aud he had been in the habit of
introducing as many as he could without any danger to the uterine
cavity, sometimes using five or six bougies as thick as the little finger,
and had succeeded in from four to six hours in bringing on the
desired condition. Of course, manual dilatation has also to be re-
sorted to.
In the other conditions mentioned the colpeurynter has a place.
In gynecological practice, however, he thought the colpeurynter a
much over-rated appliance. It had the advantage of showing the
patient that something was being accomplished, but with the old
methods at his disposal the physician could feel very sure of his suc-
cess. A tampon of gauze, for instances, properly placed in the pos-
terior fornix will accomplish as much as the introduction of a colpeu-
rynter. Besides, it is exceedingly difficult to find a patient who will
tolerate that kind of treatment. General massage, the douche and
rest in bed will accomplish, perhaps, a little more.
The speaker said he had also used the colpeurynter in operations
on the perineum. He thought this rubber bag would find a favorable
place and that there were times when its usefulness would manifest
itself to the average patient. -
Dr. HINCHEY said that he had not had much experience with the
colpeurynter, but the bag which Dr. Gellhorn had spoken of and on
which he had laid most stress might be useful, particularly in placenta
previa, yet he did not see how as large a bag as the one shown by the
essayist could be introduced; that is, he did not see how it would be
possible to get the cervix sufficiently open. In a case of placenta
previa (a central implantation) in which he had tried the Barnes' dila-
tor he had found it very difficult to get the os dilated at all. The first
one broke (doing no harm, however, as it was filled with sterilized
water), and the subsequent ones simply dilated the vagina so that
practically nothing was accomplished in securing dilatation of the cer-
vix. It had to be dilated manually and by the use of Goodell dilator,
the speaker and the physician assisting him taking turns. In another
86 The Medical Society of
case the bag ballooned out at the vagina, and where they wanted the
pressure—in the internal os, they got none. In its compressed shape
the colpeurynter shown by Dr Gellhorn looked as if it might be more
easily introduced, but with the placenta in the way he did not see how
enough of the bag could be gotten in to fill up with fluid without com.
pletely detaching the placenta. -
The PRESIDENT said that he would like Dr. Gellhorn to tell him
if the use of this instrument would be applicable to cases where there
is pus in the pelvis. Would pelvic abscess, threatened pelvic abscess
or leaking tubes be a contraindication in its use ?
Dr. GELLHORN, in closing, said that he was greatly gratified by the
discussion and was glad to notice that the majority of the speakers
agreed with the points in his paper in regard to the usefulness of the
colpeurynter He took up several points on which he had made notes.
The colpeurynter which goes under the name of the Barnes' bag, was
modified by Fehling; just as Braun's bag in its present form is, in
reality, a modification by Grehser. In prolapse of the umbilical cord,
he had had no personal experience with the colpeurynter, but Schauta
recommends in such a case the placing of a colpeurynter in the vagina,
in this way pushing the cord upward and at the same time exercising 3.
counter pressure upon the uterus, which hastens delivery. After the
colpeurynter has been in place some time, the os is sufficiently dilated
to perform such operations as are necessary to save the child. There-
fore, in this instance, the colpeurynter is not a distinct mode of treat-
ment, but is a preparatory method to enable the obstetrician to term-
inate delivery and to save the child.
He fully agreed with Dr. Gehrung that in the replacement of the
uterus the use of the mercury colpeurynter is only a preliminary step:
it only serves to bring the organ into the right position; to keep it
there it is always necessary to resort to a pessary. He thought the
simple device of Dr. Gehrung seemed admirably adapted to the work
and he would not fail to make use of it the next time he had an op-
portunity. & -
He thought Dr. Taussig rather over-estimated the danger of in-
fection. Infection threatens much more on the part of the physician
who does not clean himself sufficiently or does not observe the neces-
City Hospital Alumni. 87
sary precautions in introducing instruments than from the part of the
instruments. The colpeurynter can be thoroughly sterilized. If boil-
ing for five minute should prove insufficient, he would boil the bag ten
minutes or until it is thoroughly sterilized.
Economy of material in medicine is not a good method, and he
preferred to sacrifice one or two colpeurynters to running the risk of
sacrificing the patient's health through lack of proper sterilization.
But he was not sure that boiling for five minutes was not sufficient to
sterilize a colpeurynter. He refered to an article written recently on
the sterilization of rubber gloves. The authors sterilized their rubber
gloves by merely brushing them with soap and water for two minutes
and a half and afterwards dipping them in bichlorid solution. Their
researches proved that the sterilization of the gloves was perfect, and
if such a simple mechanical cleansing of the rubber gloves was suffici-
ent to bring about asepsis it would seem that five minutes boiling
would be sufficient. Without the statistics spoken of by Dr. Taussig
it is impossible to make a positive statement, but Biermer, who has
written the most exhaustive and extensive essay on the colpeurynter,
states emphatically that the morbidity after its use is very low.
The speaker had folded a Champetier colpeuryner while Dr.
Hinchey was speaking and now called attention to the fact that the
space required was not very large. Before introducing it into the cervix
which is as yet not sufficiently open, it is necessary to dilate the cervix.
The dilators of Hegar or Goodell will dilate the soft cervix wide enough
to permit the passage of the colpeurynter into the canal. In placenta
previa the best method is to push the colpeurynter through the mem-
brane or, in the case of a placenta previa centralis, through the pla-
centar tissue itself into the amniotic cavity, then to release and fill it.
Then, by pulling slightly on this instrument, it is evident that it will
push the placenta against the uterine wall so that no further hemor-
rhage is possible. Simultaneously the delivery will be hastened. The
reports in literature regarding this procedure are very encouraging and
contrast favorably with other methods of treatment.
The dilatation of the cervix sufficiently to introduce the colpeu-
rynter takes about five minutes, after that the colpeurynter is inserted
and the weight attached. It all depends upon the individual case as
88 The Medical Society of
to how long a time will be require for complete dilatation to take
place. As stated in the paper, the time can be more or less regulated
by the obstetrician and ranges from a few minutes to several hours.
If properly placed and pulled through with sufficient force, the non-
elastic colpeurynter of Champetier takes from four to twenty minutes,
so that the time required for dilatation is not longer than the time re-
quired by the use of the Bossi dilator. The speaker's experience
with the Bossi dilator was limited to one case, in which good result
was obtained, but the case was not a full-term pregnancy.
To respond to the question of the President, the colpeurynter is
never applied in any acute or subacute infection conditions. The
presence of pus is always a centaindication to its use. The applica-
tion of the colpeurynter in such cases would be likely to lead to an
exacerbation of the inflammatory condition.
Dr. E. S. SMITH, presented a
Specimen of Aneurism.
This specimen is from a man aged 56 years. The family history
was negative. Previous history showed syphilitic infection a number
of years before with insufficient treatment. His habits were bad; he
was an alcoholic, also addicted to excesses in nicotine and venereal.
About nine weeks before he entered Mullanphy Hospital he began to
have thoracic pain, which gradually increased. It was shifting in
character and there was a gnawing, boring sensation. There was also
disturbance of voice. Dysphagia then developed and when he en-
tered the hospital February 15, 1904, he could only swallow liquids.
On entering the hospital he showed a good deal of evidence of
tracheal trouble, there was much loss of weight and the general con-
dition was bad but there was no marked cachexia. The history showed
nothing pointing to any previous growth of any sort in any region of
the body. Physical examination showed no enlarged lymphatics either
about the clavicle, in the axilla or the groin. The chest showed dull-
ness in the right scapular region. The heart appeared normal. There
was absolutely no bruit in the chest. At the first examination I could
detect no pulsation, no tracheal tug and no bruit. We thought we
could make out some slight difference in the pulse, the tension being
City Hospital Alumni. 89
lower in the left radial. There was paralysis of the left vocal cord.
At that time it was impossible to distinguish between a mediastinal
growth and an aneurismal tumor. There was some evidence of pres-
sure on the left bronchus. The patient, on the night of February 21st,
in the early morning was suddenly seized with a severe attack of
dyspnea and went into collapse. My assistant found that there was
complete loss of respiratory murmur over the left lung and vicarious
breathing over the right. I was then for the first time able to make
out a repetition of the heart sounds over the dull area. There was still
no bruit present, no other change in the situation. Diagnosis was
then made of aneurism. The patient gradually grew worse, never
fully recoved from this attack, and finally expired on the 23d.
The autopsy showed a specimen of interest, flrst, because it veri-
fies every physical sign and, in the second place, it verifies the import-
ance of some signs in diagnosis of aneurism and the comparatively
little importance of some other signs. We have here a small heart,
the aortic opening with no lesion, then a pouch just beginning at the
junction of the transverse. Following he aorta we find a tremendous
sac and at the junction of the ascending aorta we find Nature’s effort
to remedy by the formation of a large clot. Here we have the recur-
rent laryngeal wound right over tumor. The left bronchus is adherent
to the under surface of the tumor. The esophagus shows why he
could not swallow, the tumor jumping into the anterior wall of the
esophagus, so that food had a very narrow place. Another symptom
was persistent nausea—not so much vomiting as nausea, probably due
to involvement of the pneumogastric. The interesting phase of the
specimen is that it goes to prove the great importance of Da Costa's
old sign of aneurism —repetition of heart sounds over the dull area. He
said the bruit amounted to nothing, but one of the most important
signs was being able to establish two points of pulsation in the chest
and the two heart sounds. This case shows the little value of the
bruit. We had no suggestion of any bruit at all. We have a normal
aorta opening. The more I see of these cases the more I am con-
vinced that the bruit in aneurism comes from the aortic opening. I
do not believe I can recall a case, either in the City Hospital or out
90 The Medical Society of
side, where there was a bruit with the aneurism that there was not in.
volvement of the aorta.
DISCUSSION.
Dr. JACOBSON said that this case illustrated the great frequency
of aneurism in syphilitic cases. It shows that such cases ought to be
treated energetically in the early stages and there will be less likelihood
of aneurism occurring later. The next most frequent cause is arterio.
sclerosis. Of course, in this condition we have hyalin fatty degenera-
tions and of calcarious ulcerations deposits and later the blood cur-
rent flows through the walls of the artery. The number of aneurisms
that occur are surprising. *
Dr. SMITH, in closing, said he had recently had a case under ob-
servation which contrasted very nicely with this case. The left kidney
been removed for a carcinoma and later the patient developed evi-
dence of mediastinal growth which gradually increased. This case
did not come to autopsy but there was no question as to the correct-
ness of the diagnosis, there was pronounced cachexia, etc. There
was a most distinct bruit in the chest upon pressure.
Meeting of April 21, 1904; Dr. Charles Shattinger,
President, in the Chair.
Dr. HowARD CARTER presented specimens of
Horse-Shoe Kidney.
This specimen I have already exhibited before the St. Louis Medi-
cal Society. These are rarely seen and the two specimens are perfect
in type. They are evidently complete functionating kidneys. The ure-
ters are about normal and the kidneys have no special clinical signifi-
cance. They were in about the average position of the kidney.
Suppurative Appendicitis With Foreign Body.
The appendix was dilated until it was about as large as my two
fingers. The lumen of the appendix was small and contained a foreign
body as large as a medium-sized olive and had suppurated through.
City Hospital Alumni. 3. 91
It is possible that it may have been a small body originally and its
size was due to concretions. In all my autopsies I have only encoun-
tered two cases of foreign body in the appendix, and so far as I have
been able to learn from my conversations with other physicians, but
two other cases have been noted by these gentlemen.
Complete Calcification of the Coronary Artery.
The cause of death in this case I can not state. He was found
dead and probably suffered from angina pectoris. There was an athe-
romatous condition of the arch of the aorta.
Complete Calcification of the Aorta to Bifurcation of
the Iliac.
The whole arterial system was in a state of degeneration. The
smaller arteries were also involved and both kidneys had suffered from
the process. One was little more than a mass of cysts and the other
was cirrhotic, probably the result of faulty circulation. This specimen
was from a woman and she ought to have been dead ten years sooner.
She was probably 65 years old, and died from some other trouble—the
result of shock, having been run into by a cart.
Aneurism.
This aneurism was situated both above and below the diaphragm.
The patient entered the hospital with what appeared to be gastritis
and died within twenty-four hours.
Exceptional Dilatation of Ureter.
The patient died from hemorrhage due to cancer of the uterus.
When the body was opened I saw what appeared to be a loop of small
intestine going directly into the abdominal cavity but found it was an
enormously dilated ureter. It seemed to have been occluded, proba-
bly by a retroflexed uterus. The vessel was probably one and a half
fingers in diameter. One of the kidneys was atrophied.
Dr. FRANCIS REDER presented a patient with -
Paralysis of the Deltoid Muscle.
The history of the case in brief is this: The man was taken sick
92 The Medical Society of
in October with typhoid fever and during his convalescence in Decem-
ber fell from the porch and struck his shoulder against a shed. There
appears to have been a dislocation which was reduced. There is a
free motion of the arm forward and backward but when he attempts
to elevate his arm he is unable to do so. It was at first impossible to
carry the arm backward but he can now do so after some practice ;
there is a flatness of the shoulder and an abnormal prominence of the
acromion process. The head of the humerus is in the glenoid cavity.
During the last two months the condition of the arm has somewhat
improved, but the patient is a laboring man and the arm in its present
condition is of very little use to him. The condition seems to be one
of paralysis of the deltoid muscle possibly due to an injury of the
circumflex nerve which supplies the posterior surface of the deltoid and
gives that nerve its mobility.
DISCUSSION.
Dr. LIPPE said he believed that Dr. Reder’s diagnosis was correct
and that it was a paralytic condition, yet the presence of Dugass’
symptom —the inability to place the hand on the opposite shoulder
with elbow at the same time touching the chest, puzzled him; he did
not feel competent to say whether that was a symptom of a paralytic
condition. Possibly Dr. Reder could tell them whether that condition
was ever found in an affection of the circumflex nerve, and he asked
the doctor if he had made any electrical test.
Dr. DRECHSLER said that it seemed the head was in the glenoid
cavity and the doctor had demonstrated that by raising the arm it pro-
duced prominence of the acromion process so he believed that there
was some disturbance of the nerve.
Dr. REDER, in closing, said he did not see the man at the time
of the accident; he saw him two or three months later. From numer-
ous observations of this condition the only inference he could draw
was that, the from the debilitated condition of the man from the
typhoid ſever, injury, small as it was, affected the circumflex nerve and
the brachial plexus. The anatomical conditions were normal; the
mobility of the joint was normal; the only lack of motion was in the
elevation of the arm, showing that the function of the deltoid was to
some extent impaired. As the man had always been in good health
City Hospital Alumni. 93
and there was no constitutional trouble, the only inference to be drawn
was that his condition was due to the injury. There had been some
improvement during the last six months and he believed that in time
the arm would be useful, but it never would be a strong arm.
Dr. FRANCIS REDER also presented specimens of
Appendix.
There is nothing abnormal about this appendix; it is a perfectly
healthy. It is the history that is abnormal and that led to its removal.
The patient was a girl, 13 years old, who had had numerous attacks of
pain in the right iliac fossa; the last attack of pain was of unusual
severity. When he saw her later both temperature and pulse were
normal; the only abnormality was pain due to pressure over Mc-
Burney’s point. He saw her every five or six hours for five days and
there was no change; on the morning of the sixth day there was no
change but in the afternoon the pulse ran up to a 13o, temperature to
99°. The pain had been constant and was only relieved a little by
ice applications; heat was not tolerated. Inasmuch as this little
patient had had a number of attacks, he advised operation and it was
accepted. In inserting the finger he was not able to locate the appen-
dix. Enlarging the incision he found the ileum and cecum but could
not see the appendix, but found a hardened place and thought it was
the base of the appendix, then following it up and making traction he
pulled out the appendix; it was filled with fluid and was about as large
as one’s little finger. It was amputated, the wound closed and in a
week the girl left the hospital. This appendix had slipped into the
mesocolon. We know the mesocolon invests the anterior two-thirds
of the larger bowel and diverges posteriorly leaving a space filled with
fat, and in this little space the appendix had hidden itself; when it
was withdrawn there was a suction sound.
In connection with this he cited another case, which shows how
much weight should be given to pain in the abdomen. A young
man, aged 23 years, had pain in the hypochondriac region, but there
was no acceleration of the pulse an no rise in temperature, and he
remained at work. He treated him for tape-worm, and it did no good,
he was then taken to the hospital and given a colon flush, and it did
94 The Medical Society of
no good. At first he thought he was a hypochondriac. He brought
the case up in the German Medical Society here and their opinion was
that he was suffering from “hunger pain.” He was made to eat about
every fifteen minutes during, the day; for a time he seemed somewhat
relieved, but the pain came back again and he insisted there was
something wrong in his belly and he wanted me to cut it open. After
arguing with him for three weeks the patient said if he would not cut
him open he would go to someone who would. So, in view of the
continuous pain, he decided to operate. He made an incision and
found everything normal; the gall-bladder was normal; the ureters
were normal. He went down in the region of the appendix and with-
drew one unusually long, and on account of its length he amputated it.
The patient left the hospital in about two weeks and has not had pain
since. That was about two years ago.
Carcinoma of the Cervix of the Uterus.
Two years ago this woman placed herself in the hands of a sur-
geon here in St. Louis, an able man, who knew the condition of the
patient, who was an intelligent woman willing to do anything the doctor
suggested, and he curetted her. She was losing blood frequently and
a large quantity at a time; the curretting checked the hemorrhage for
about five months; she was then losing only a little blood at a time
but often. She consulted me and he found this cancerous condition.
The speaker suggested removal of the uterus and she accepted. This
shows how useless it is to curette for a cancerous condition. We
should bear in mind that an early operation does more good than a
later and more extensive one.
Specimen of Uterus Bicornis.
The woman was about 25 years of age and suffered from a large
pelvic abscess. He saw her about three years ago and she then had
this pelvic abscess; the removal of the uterus was advised and refused,
but some two months ago she came to me and said that she could not
live any longer in such a condition and asked me to give her relief.
He found the cul-de-sac of Douglas was full of exudate. Not caring
to make a vaginal puncture the tube was removed, and getting his
finger into the cul-de-sac discovered a similar condition of what he
City Hospital Alumni. 95
thought was an enlarged tube on the right side, which was also re-
moved. When he got down to it and found a hardened condition, he
began to think of a cyst, but thought awhile and concluded it was a
uterus bicornis. The woman was septic and died three weeks later of
uremic coma. This woman had given birth to three children and
during her pregnancies she menstruated regularly. We know that the
uterus is formed by fusion and junction of the ducts of Muller. If we
have no junction of the ducts we have a uterus didelphys. Further-
more, one of Muller's ducts may develop properly and the other may
not, giving a uterus unicornis. When he curetted this uterus he got
into the cavity very well with the curette but when he got ready to
wash it out he found it impossible to do so.
Diseased Kidneys.
He showed the kidney in connection with this uterus. The patient
had two uremic convulsions. He brought her out of the first one by
the use of copious saline solution but in the second she died.
DISCUSSION.
Dr. JACOBSON considered the specimens of fused kidney very
beautiful. Frequently these kidneys are found situated lower than the
normal position of the kidney in front of the sacrolumbar vertebrae
and they then give rise to trouble, especially in women during confine.
ment. There may ensue rupture of the kidney as result of pressure
endangering the life of the patient. This type of kidney is supposed
to be due to embryonic changes. In the specimens presented the
upper extremities were united while in the majority of such cases the
fusion is at the lower extremity.
Dr. ORR said he did not wish to attempt a discussion of the speci-
mens but he wished to ask Dr. Reder how he accounted for the relief
of the pain in the abdomen when that long appendix was removed.
Had he found any other abnormal condition, such as an enlarged
stomach, or did he believe that if he had removed a part of the omen-
tum, or if he had simply retired after opening the abdomen, that the
patient would in any case have been relieved from the pain 3
Dr. BUCHANAN said that in regard to the long appendix which
Dr. Reder had told about; he had had the pleasure a few days before
96 The Medical Society of
of removing, post-mortem, an appendix which extended up and was
attached by adhesions to the liver and measured 17 cm. in length.
The man died of pneumonia, but his previous history of abdominal
pain was similar to Dr. Reder’s case. The base of the appendix was
found in normal position.
Dr. SHARPE said that the Society was really embarrassed by a
surplus of good things. He desired to take exception to Dr. Reder's
statement, as understood by him, that the appendix was found in the
mesocolon It appeared to him, from the discription, that the ap-
pendix was found in a pouch or cul-de sac posterior to the colon or
mesocolon, but not in the mesocolon.
Dr. DRECHSLER thought that the Coroner’s Office no doubt af.
forded many interesting specimens. He had noticed that the cases
seem to run in droves. He had seen in one week as many as five
cases of aneurism in which the subjects had died on the street. He
was sometimes astonished at the size of the aneurisms. It was sur-
prising to what an extent they would grow and the man still be able to
attend to his business.
The kidney specimen was a very pretty one, and the calcification
of the coronary artery was also interesting, though they are frequently
found in post-mortems.
Dr. REDER, in closing, said that Dr. Orr had asked a question
that he could almost answer positively. He believed that though the
appendix was not diseased and only about one-quarter of an inch was
in a congested state, that its removal had given the relief the man ex
perienced. He could understand how it caused the disturbance. It
was lying upward and he thought when the intestines were filled that
it pressed upon some of the ganglia. He did certainly believe that
the appendix was at fault. The patient was very sensible man
otherwise.
City Hospital Alumni. 97
Brief Notes on Three Cases of Strangulated
Hernia.
By JOHN YOUNG BROWN, M D.,
Superintendent of the City Hospital.
HE first was a woman, aged 54 years, who had had a
femoral hernia for eight years. When admitted to the
Hospital the hernia had been down for thirty-five hours.
The patient was vomiting, pulse bad. Examination showed a
tumor well above Poupart's ligament, the neck of the sac be-
ing acutely flexed, making it difficult to tell whether the her-
nia was an inguinal or a femoral one. She was immediately
prepared for operation. On opening the sac, a loop of small
bowel was found, tightly constricted, the constriction being at
the neck of sac ; the bowel was black, necrotic in spots and
denuded and did not respond to hot saline solution, and resec-
tion was deemed advisable. A supplementary median incision
was quickly made, the bowel was pulled through this incision
and ten inches of the gut resected, an anastamosis being made
with a Murphy button. The median wound was closed and a
radical operation was done at the hernial site, after the method
of Bassini.
The operation was done in forty minutes. Both wounds
healed by primary union. The button was passed on the
twentieth day.
The second case was similar to the first. The patient, a
negro, aged 31 years, was admitted to the Hospital with a
strangulated inguinal hernia of the right side. He had suf-
fered from hernia for a year and a half, and the hernia had
been down for eight hours. This case presented identically
the same symptoms as the first case. On opening the sac, a
loop of small bowel, black and necrotic, was found. As in
the first case, a median incision was made, the bowel drawn
out and twelve inches of gut resected, the anastamosis being
made with the Murphy button. The median incision was
closed, followed by a radical Bassini operation. The operation
was done in forty-five minutes. The wound healed by first
9S The Medical Society of
intention the button was passed on the eighth day, and conva-
lescence was uneventful.
The third case was operated on four days ago; I can not
bring him out into the clinic, but, will say that he is in good
shape and out of danger. The case was a right side strangu-
lated inguinal hernia, down nine hours. The conditions on
opening the sac were practically the same as in the case. The
same procedure was gone through with, viz, resection through
supplementary median incision, followed by radical operation.
Time of operation one hour aud five minutes.
I hope in the near future to discuss these three cases
fully, in a paper. The cases are unique and the results are
exceptional, as the mortality following primary resection is
from 30 to 40 per cent.
Meeting of May 5, 1904; Dr. Charles Shattinger,
President, in the Chair.
Two Unusual Ovarian Cysts.
Report of Cases and Presentation of Specimens.
By A. H. MEISENBACH, M.D.,
ST. LOUIS, MO.
Tº: specimens which I present are unusual from the
fact that both patients have undergone a second lapa-
rotomy. The first specimen is unusual on account of
its size. It is not often we find an ovarian cyst of that size,
because ordinarily the diagnosis is made earlier and the cyst
removed. I never saw one that approximated this in size.
The patient from whom this cyst was removed was 38
years of age at the time of its removal. About eight years ago
I operated upon this woman, who was then single. I operated
then for hematoma on the right side. There was nothing ex-
traordinary about the case, though the exact nature of the
hematoma could hardly be determined at the time of the op-
eration. I saw her again about the first of February. She
had been married about seven months at the time of coming
City Hospital Alumni. 99
to me. Her husband was very much exercised on account of
the condition because it placed him in an embarrassing light.
She was sparely built, weight about 130 pounds and was about
5 feet 7 inches tall. Her appearance was very striking. She
said she had been treated for a year for varicose veins, that
they were better but still gave a great deal of trouble. Her
husband, who had been married before, said he noticed some-
thing unusual about his bride although he offered no solution
of the condition. A month before coming to me she was ex-
amined and the statement made that it was possibly preg-
nancy. To this the husband, of course, took decided objec-
tion. Finally they drifted to me because of her having had my
services before.
The woman's appearance made a decided impression on
me because her contour, even with the clothes on, was not that
of a pregnancy. After taking an anterior, posterior and lat-
eral view I decided it was not pregnancy. The abdomen was
immensely distended and the contour was full, not flattened
out. The surface of the abdomen was domeshaped and did
not sag or tend to sag in the middle. That is a distinct differ-
ence between an ascites and a cystic tumor. There was dull-
ness over the anterior of the abdomen extending to the margin
of this tumor. The flank and iliac regions were tympanitic.
This could be distinctly and carefully outlined so we could
outline the tumor, especially by percussion. The vaginal ex-
amination clinched the case. I found a retroverted uterus of
the infantile type, so by exclusion I could arrive at no other
diagnosis than that of a very large ovarian cyst, but it was
hard to determine from which side it came. I gave them my
opinion and told the woman the only thing to do was to un-
dergo an operation. She had had an operation before and a
woman who has undergone one laparotomy is not easy to get
on the table again. But she was becoming more emaciated,
her appetite became less and she was gradually losing ground
and she sudmitted to the operation, which was done on Febru-
ary 18th.
There was nothing unusual about the operation. The in-
cision did not exceed three inches in length. The moment I
entered the abdomen this tumor presented itself and by the
100 The Medical Society of
use of an ordinary trocar I was able to empty and remove it.
The pedicle was long and there were no adhesions anywhere.
There were two cysts, the fluid escaping from the anterior one
was like coffee grounds, with no odor and a little thicker than
the ordinary fluid. I then went in with my finger and found
the other cyst, which I emptied, and after both had been thor-
oughly emptied it was easy to remove them. The pedicle was
ligated in three sections and the woman made an uneventful
recovery. - -
She was in my office last week and the varicose veins had
disappeared. This cyst was on the left side. The uterus
showed no evidence of having been impregnated. The cyst
was 16 inches in its long diameter, I I inches in its transverse
diameter, 8 inches in depth and weighed about 30 pounds
when filled with fluid. *
The second case was unusual, first, because it was the
second operation this patient had within about a year, and then
because of the character of the tumor removed. The patient
wat 68 years of age. A year ago last October she was op-
erated upon in Davenport, Iowa, for presumably an ovarian
cyst. A letter from the surgeon stated that there was nothing
unusual about it. This woman after the operation went to
Eureka Springs and spent the time intervening until about the
middle of February at Eureka Springs. She was much
emaciated and the abdomen was much distended. At Eureka
Springs she had the misfortune to fall into the hands of a
quack, a woman at that, who tried all means to relieve her of
this “water on the womb,” as she termed it. I sent her to
the hospital to buoy her up somewhat, but her respiration be-
came so impeded that I found it necessary to operate at once.
This case presented many similar features to the first one but
there was not that clear definition of the tumor. In this case
also there was dullness in the flanks, so it seemed as if there
must be some other condition along with that of ovarian
growth. We did not get the clear shaped outline on percussion.
Another thing was the peculiar condition of the cul-de-sac. I
found a hard mass with a notch or depression, as if formed of
two fingers. It was perfectly hard. This woman was inclined
to be sallow and had the peculiar facial expression often seen
in people with abdominal tumors.
City Hospital Alumni. 101
The moment I made an incision a dark straw-colored
fluid shot out which proved to be ascitic fluid. So I thought
at first I had made an error and was dealing with ascites rather
than a cyst. The fluid was very carefully withdrawn, her
peculiar circulation not allowing of too rapid escape. I have
seen patients collapse and die from tapping the abdomen.
After the abdomen had been emptied and I had enlarged my
incision, I found the suspicion I had was correct. The peri-
toneum was thickened, nodular, the intestines dotted with
small nodes, and looming out from the pelvis was a cystic
tumor. I succeeded in ligating the pedicle and getting the
patient off of the table alive and that was about all. For an
hour or two she was in a most precarious condition and I had
to resort to the means usually employed in such cases.
The appearance of the tumor led me to believe that I had
to do with a cancerous condition, which the microscope showed
to be the case. The case is peculiar because in the first opera-
tion there was nothing suspicious shown, and then this growth
following which is of malignant character. What relation this
may have borne to the first operation I can not say. This
woman did not do well and it was an up-hill tug from the time of
the operation until she was able to leave hospital and return
to her home. I expect a return of the ascites and the
cachexia that usually follows. The microscope showed an
ovarian cyst with carcinomatous degeneration. This is com-
paratively rare and in all my operative work I have found but
few such cases.
Dr. A. H. MEISENBACH also also reported on a case of
Appendicitis, With Presentation of the Appendix.
This specimen I removed yesterday. It was taken from a young
man 20 years of age. I saw him Monday evening, in consultation
with a doctor from Carondelet. The patient was taken ill on Thurs-
day. Friday he complained of pain in the abdomen and there was
some vomiting; there was a passage from the bowel Saturday morning,
none since then ; he vomited continuously but it was not of fecal
character. I found the boy a well-developed muscular fellow, almost
| O2 The Medical Society of
six feet tall. He had a temperature of Io.2°, pulse of 120, and was
not suffering very much. Upon making an examination of the ab-
domen it was comparatively soft, but the most decided feature was the
presence of pain and this pain was always in a positive and circum- .
scribed area, at McBurney’s point. There was no dullness in the
right iliac region. The physician in attendance was inclined to be-
lieve there was some kind of obstruction, but from Monday until
Friday there was no distention and taking the circumscribed area of
pain into consideration, I made up my mind that this boy was suffer-
ing from appendicitis. In determining the painful spot instead of
using the hand it is best to use the finger; by tapping the finger you
can locate the point after the manner of an anesthesiometer. By
letting the patient do that themselves they will always touch the
right spot; this boy invariably stopped about McBurney’s point. The
doctor had been giving something to control the vomiting. I advised
a pack, and if there resulted no improvement, an operation.
Tuesday morning he was sent to the hospital, but Dr. Aufgerheide
was inclined to wait. We gave him castor oil and waited twenty-four
hours, at the end of which time he had a stool. His temperature was
Ioo 4°, pulse 86, and there was still that painful spot. His father was
there and I told him I thought the best thing to do was to open the
abdomen. I operated at Ic:30 Wednesday morning. When I opened
up the abdomen, making the incision we usually do for appendicitis, I
found that the omentum blocked the way into the cavity and obstructed
the view, I tore through the omentum to get a good view; in spread-
ing the wound apart the omentum gave way and there, well up, was
quite a little pus; this came from where the cecum lies against the
iliac fossa; none got into the abdominal cavity for I turned the pa-
tient squarely upon the side and protected the abdominal cavity with
gauze pads After it had been thoroughly evacuated I washed out
the cavity with salt solution, then packed with gauze ; I then turned
him over partly on the side to search for the appendix and found it
lying upward; alongside the iliac peritoneum; it was very much en-
larged, and I had no difficulty in freeing the appendix and bringing it
down to the wound so that I could easily excise it. Usually a big ap-
pendix is so bound down or so disorganized that is not easily found.
City Hospital Alumni. - 103
The operation was easily done and after the excision of the appendix,
in the location of the abscess cavity I packed with iodoform gauze and
inserted a tube; the gauze was packed in all directions, shutting off
this area that had been involved.
This was one of those cases which are on the borderland, where
it is hard to tell what to do—whether to operate or to wait. It was
one of those cases in which a man might have waited and the question
is whether or not he might have waited to advantage. The adhesions
were not tough and the cecum very easily came into the abdominal
wound. After the operation I placed the patient in bed with the head
elevated and body at an angle of about 23°. With a temperature of
99.6° and pulse still above Ioo, he complained of no pain and was in
fairly good condition, so I have good hopes for him, but he is not out
of the woods yet. In these cases, until the third or fourth day is
passed we can not say that the patient is out of danger.
DISCUSSION.
Dr. DEUTsch thought the ovarian cases interesting. They were:
out of the ordinary because so large a cyst is rarely seen now. While
he felt that the first patient was exceedingly lucky in getting into Dr.
Meisenbach’s hands, yet he felt that it was almost unpardonable to
make a mistake between ovarian cyst of such size and pregnancy and
he thought the examining physician could not have been well trained
in diagnosis.
The second case was also highly interesting, and while the prog-
nosis in such a case is always grave, because of the metastases, yet,
there was only one thing for the Doctor to do, that was to remove the
growth he found. So far as the appendix case was concerned, he be-
lieved the Doctor was right in saying that he would have to wait a few
days before saying that his patient was out of danger, for it is always
a little dangerous to remove an appendix from a pus sac. It was one
of those cases which taxes the judgment of both the surgeon and the
general practitioner - -
Dr. KANE considered this the most interesting specimen of ovar-
ian cyst he had ever seen. The Doctor was fortunate in having to
deal with a cyst of that size that there were so few adhesions. It was
104 The Medical Society of
a splendid specimen. He had never had to deal with any large ovar-
ian cysts; those that he had to operate on were small but with a good
many adhesions. He had seen an interesting case while he was as-
sistant to Dr. Bryson. The patient was a young woman who had re-
cently been married; she had always been healthy and when well
weighed about 8o pounds. He saw her eight months after her marriage
and found the abdomen much enlarged; she had noticed it about a
month after her marriage and it had increased rapidly during the sec-
ond and third months. A general practitioner was called to see her
on account an attack of shortness of breath. The patient was turned
over to Dr. Bryson, who operated next day. There was found a par-
ovarian tumor with fetus of about five months’ development; there
were removed a number of cysts from the ovary on the right side;
the uterus was one mass of fibromata and showed cystic degeneration.
The mass removed weighed about 35 pounds. The woman made an
uneventful and perfect recovery.
As regards the specimen of appendix, Dr. Kane hoped he would
be pardoned for bringing up a case of pseudoappendicitis he had re-
cently seen. He was called by a general practitioner to see a young
girl, of highly strung nervous temperament, about 17 years of age.
She gave a history of having had an attack of appendicitis about a
year ago, and said she had been attended by Dr. Murphy, of Chicago,
who had made a diagnosis of appendicitis, and whose fee, she said,
was $250. She had a temperature of IoI.5° for two days before Dr.
Kane saw the case; there were no obstructive symptoms no gastric
symptoms, the knees were not flexed and she did not give the symp
toms of one suffering from appendicitis giving such a temperature.
He made a diagnosis of autointoxication from the intestines. One
evening he received a message that she had a temperature of 106°
and he was telephoned by the nurse fifteen minutes later that the girl
had a temperature of 114°. He hurried to the case and found the
girl lying perfectly conscious with a temperature of 98°. He decided
the nurse had put the thermometer under the hot-water bag or held it
under the hot water spiggot. He told her if it occurred again to let
him know immediately and she very kindly did so about 12 o'clock
that night. He lost no time in reaching his patient and found her
City Hospital Alumni. 205
pulse between 7o and 8o, she did not complain of thirst or of any of
the symptoms of fever, but the mercury went to the top of the glass
tube.
He wrote the people at Notre I ame, where she had been in
school, and found that Dr. Murphy had never seen the girl and had
never charged a fee of $250 for an examination. Her only symptoms
are the high temperature and pain in the region of McBurney's point.
She has been perfectly miserable for about three weeks, but she will
get over the pain, get up and go out and engage in a game of basket
ball, then her temperature will run up to 11o to 1 14°. He had looked
up the question of high temperature and found recorded a temperature
of 174. The case shows how hysteria will simulate anything. -
Another that had interested him was the care with which the
Doctor had opened up the abdomen on account of the danger of col-
lapse. He had known of two cases where the abdomen had not been
carefully opened and the patient had died of collapse. Not long be-
fore he had operated upon an old lady with a very large abdomen and
as soon as the least fluid was allowed to run out her pulse would
go down. When he cut into the abdomen he found cancer of the
liver and cancer of the ovary. He filled the abdomen with salt
solution and was very much surprised to see how the fluid was
taken up. - -
Dr. SOPER said he was very much interested in all the cases of Dr.
Meisenbach, especially the appendicitis case. In all probability the
pus the Doctor found was under the cecum; very likely it belonged
to that class of cases in which rupture takes place into the cecum
eventually. All physicians see cases in which they hesitate to decide
whether to operate or not and then some morning they find their pa-
tient without ſever and practically well, the pus sack having ruptured
into the cecum and the pus drained off in that way. The speaker
mentioned a case of a patient who had been in bed two weeks with
rather high fever, recovery taking place in this manner; in this
case, also, no tumor could be palpated. The pus was found in
the stools. -
In case of high temperature, he said he would like very much to
see that temperature recorded. He and Dr. Falk had attended a case
106 The Medical Society of
of heat stroke in which the temperature was Io9', the highest temper-
ature they had ever seen recorded by the thermometer; this patient,
too, had recovered. -
Dr. DEUTSCH suggested that Dr. Kane's case was not one of
pseudoappendicitis but rather of pseudothermometer.
Dr. KANE added that he had used every means in his power to
to exclude the possibility of error. He had taken the temperature
with three different Hicks’ thermometers and he was not the only one
who had made the observation. One physician had noted a tempera-
ture of Iobº. The temperature would go up in half a minute. Some-
one had suggested that the temperature was due to friction of the
tongue and Dr. Kane said he would hate to try to wiggle his tongue
fast enough to carry the temperature up 114°. He was williing to
confess that he had been skeptical, he was from Missouri and had to
be shown—and he was shown. He had purchased a volume by Ould
and Pyle for the sole purpose of looking up the question of high tem-
peratures, and compared with some of the temperatures recorded his
temperature looked like a temperature in the arctic regions. He had
found a record of one temperature of 174°. He had observed this
temperature not once but many times and had seen the mercury go
up to 110° and over—as far as the glass tube would permſt. There
was no hot-water bag, and there was an ice pack over the seat of the
pain.
Replying to a question by Dr. Falk he said the skin was not hot
and the pulse varied from 70 to 80. The girl had been in the habit of
carrying a thermometer and taking her own temperature. He would
ask her if she felt hot and she would reply that she felt about 99°. He
- would talk to her for half an hour and her temperature wauld drop to
normal, and he did not think his talk had the effect of a sponge bath, -
either. The girl was sent home to her mother and the family physician
requested to communicate his observations to Dr. Kane. When he
does so he will be pleased to let the Society know that somebody else
has found that temperature besides himself.
Dr. MEISENBAcH, in closing took up the points mentioned by Dr.
Deutsch. As to the case of differentiation between pregnancy and
cyst, it has happened that many good operators have opened the ab-
City Hospital Alumni. 107
domen expecting to find a tumor in the ovarian region, or possibly,
the literine, and have found it was a pregnant uterus. He added that
he had a young woman under his observation who shows a complexity
of symptoms that makes him hesitate to formulate a diagnosis. He
has examined her time and time again, and still he hesitates. He
wished to emphasize the statement so often made, that it is impossible
to say what is in the abdomen until the abdomen is opened.
Replying to Dr. Deutsch s remark that he had qualified his state-
ment with the words, “an ovarian cyst of this size,” Dr. Meisenbach
said that he agreed with Dr. Deutsch that a cyst of such proportions
should not have been mistaken for pregnancy, for certainly all the ear-
marks of pregnancy were lacking. Of course, all diagnosis was a
comparative affair. One man would see and hear what another man
would not.
In the appendix case, he stated that he did not, as a rule, remove
the appendix in a pus sac; in this case he had been governed by the
circumstances, and would not have removed it had it not come easily
into view and had he not been in entire command of the abdominal
cavity. That was the weak point in all cases of appendicitis, but
where there is pus sac, if the appendix comes readily into view, if
other conditions are favorable, he removes the appendix. Appendix
operations are still sub judice. The principle underlying all the tech-
nical work should be — always be prepared to wall off the abdominal
cavity. He had seen a patient who had an attack of appendicitis in
November, and who had a second attack the first of March; he saw
the patient on March. Ioth. From the inferior iliac spine midway to
tle median line, an area the size of the hand, was dull. Ex-
pecting to get into a pus sac, he made the incision a little nearer the
spine of iliac than usual. Uusually before getting down to the pus
sac there will be found an edema of the wall of the abdomen, but in
this instance such was not the case and he found that he had cut di-
rectly into the peritoneal cavity. He walled off carefully and reached
the pus cavity, only to find merely the remains of an old cavity the
dullness was due to an exceedingly thickened wall. In this case he
did not look for the appendix but merely mopped out the cavity and
closed the wound. Whenever he entered the peritoneal cavity and
1 O8 The Medical Society of
found an abdominal abscess, he walled off the abdomen from the site
under consideration, liberated the pus, put in a drainage tube, closed
the wound and left the rest to Nature. If, on the other hand, the ap-
pendix came easily into view, he removed it. In the majority of cases
it was impossible to locate the appendix and he thought it was fool-
hardy to attempt to remove it under those conditions. Formerly it
was thought every appendix must sought for and removed. Another
thing was that the case was one of these borderline cases in which,
possibly, it would have been better surgery to wait until those ad-
hesions had formed and the abscess cavity walled off. The tempera-
ture might have dropped down to normal ; high temperature is not
always indicative of pus. The position that Ochsner now takes is that
in doubtful cases it is better to wait
Several years ago surgeons operated during the height of the in-
flammatory condition; this is not good surgery. In those cases that
run from two to ten days, in which there is a decided walling off, it
would be the better plan to wait, but it is impossible to know that
there will be that walling off. What led to the operation in this case
was the persistent pain and vomiting.
Dr. EUTsch said that he would like to state for the benefit of
Dr. Meisenbach that the surgeons in the East are of entirely different
opinion. They cut out every appendix. In Moumt Sinai Hospital
he saw twenty five appendices cut out in one week. The best inen
there take out great big strings of appendices, every one of which
has come out of a cavity filled with pus, and they claim they get
good results.
Meeting of May 19, 1904; Dr. Charles Shattinger,
President, in the Chair.
The Modern Treatment of Prostatic Hypertro-
phy with Obstruction.
By ARTHUR TRACY CABOT, A.M., M.D.,
BOSTON, MASS.
HE search for the best method of relief for prostatic
obstruction has been one of the most interesting prob-
lems in surgery. It has been distinctly a modern ques-
tion and those of us whose surgical activity began in the sev-
City Hospital Alumni. 109
enties have lived through the period of this surgical experi-
mentation. We have seen various mothods brought forward,
severely tested and then laid aside or partially adopted into
accepted practice.
It is because I feel that we are just now reaching sounder
ground upon which we can stand more securely, that I have
selected this hackneyed subject to present to you.
I do not propose to go into a detailed description of
methods, but to sketch briefly the steps which have led for-
ward to our present position in prostatic surgery, and then to
examine somewhat more in detail what that present position is.
Such a study of the subject and such an attempt to define
the position now occupied by advanced surgical practice must
necessarily be considerably affected by the personal inclina-
tions and opinions of the writer. I offer here, then, my pres-
ent creed with a description of the road by which I have
reached it.
The following table presents a list of procedures that have
been resorted to by surgeons endeavoring to overcome pros-
tatic obstruction.
Catheterization.
Perineal,
Prostatotomy | Per Urethram,
Suprapubic.
Prostatectomy—
º Perineal,
Partial { Suprapubic.
Suprapubic,
Complete { Perimeal,
Combined.
Orchidectomy.
Vasectomy.
CATHETERIZATION.
Of these various methods catheterization has been used
probably for the permanent treatment of more cases than have
been treated in all the other ways put together.
The discomforts of this method are obvious. The diffi-
culties of obtaining opportunity for aseptic instrumentation
110 The Medical Society of
or, indeed, for any comfortable catheterization as often as the
call to urinate is felt have made the last years of many men
miserable.
Besides the discomforts, the catheter patient is exposed to
many real dangers directly due to his constant use of the in-
Strument.
Epididymitis is a frequent happening to these patients,
often attacking the same victim many times, and not infre-
quently leading to suppuration.
Prostatic abscess I have seen many times and, doubtless,
in some of these cases the suppuration starts in the seminal
vesicles. I have seen at least one case in which this was prob-
ably the condition.
Cystitis is an almost constant condition in patients using
a catheter. Even when the urine appears quite clear and there
are no symptoms of irritation the microscope will show the
presence of pus in the urine. This condition of chronic in-
flammation is liable to sudden and often unavoidable exacer-
bations. A slight chilling of the surface of the body, a too
long retention of urine, or an unusually dirty catheter, are the
usual exciting causes of these “attacks of cystitis.”
In these bladders, often sacculated, and with thickened
walls, such attacks are no slight matter, and they keep the
sufferer for a considerable part of the time incapable of work
or pleasure.
Even more serious are those cases in which the inflamma-
tion creeps up from the bladder to the kidneys. This is quite
sure to happen sooner or later and in most patients dying as
a result of prostatic obstruction pyelonephritis is the finally
lethal condition.
After reciting these disadvantages attaching to the treat-
ment by catheter, it must still be remembered that many pa-
tients live from ten to twenty-five years after they are obliged
to void every drop of their water through a catheter. They
have these occasional inflammatory accidents and are able to
overcome them with such success that the fatal issue is de-
ferred until they have reached a good old age.
Why has this method of treatment, with so much incon-
venience and with danger not inconsiderable, so long held its
City Hospital Alumni. 1 11
position as the method of choice in the treatment of prosta-
titis P
As I understand the answer to this question, it is because,
up to a recent time, the dangers of the other methods of treat-
ment were considerable and the relief by them of the urinary
difficulty was by no means certain.
The remote risks of catheterization seemed slight com-
pared to the immediate risks of operation, and it has always
been a human failing to overestimate the dangers near at hand
and to leave out of consideration those which are more re-
mote, though, perhaps, equally real.
Let us now brieflv review the steps that have been taken
in the effort to so improve the technic of the operations on
the prostate as to enable the operator to confidently expect a
lasting relief of the urinary obstruction.
ARTIFICIAL OPENINGs.
The idea of avoiding the prostate altogether and conduct-
ing the urine away by a false route was early given a trial; and
the suprapubic fistula or false urethra of Hunter McGuire had
some vogue.
The difficulty of preventing leakage at the fistula and the
impossibility of thorough cleanliness prevented this method
from ever becoming popular.
The patient's care of himself was quite as difficult as the
management of catheterization, so that the method was, at
best, only applicable to those cases in which some exceptiona-
ble obstruction made the use of the catheter difficult, or to
patients who could not procure proper catheters.
PROSTATOTOMY.
Prostatotomy was first done through the urethra and dates
from the time of Mercier. At first this operation made but
little progress owing in considerable part to the timidity with
which it was done. The incisions in the prostate were limited
in extent and few in number. Then, perineal prostatotomy
was given a trial. The operation was an easy one, consisting
of a median urethrotomy through which the prostatic urethra
was explored with the finger, which served as a guide to a
1 2 The Medical Society of
knife which incised the obstructing bar or lobe. A large drain-
age tube, with later the passage of a sound, were relied upon
to keep whatever gain the incision had afforded.
In this way a few cases were somewhat benefited, but
the improvement did not prove to be sufficiently sure or last-
ing to enable us to offer this operation to our patients with any
enthusiasm. -
Presently, in the last ten years, internal prostatotomy has
been revived with the Bottini galvanocautery knife, and this
being used with some boldness and thoroughness, has achieved
better results than ever before; better results even than peri-
neal prostatotomy had accomplished. This operation can be
done under cocain anesthesia and is consequently, applicable
to old and feeble patients, in whom general anesthesia and ex-
tensive cutting carry more than ordinary risk. t
To add to the precision of this operation the distance to
the prostate has been shortened by introducing the instrument
through a median urethrotomy (Chetwood), and for this method
the additional advantage of drainage of the bladder is claimed.
This modification, however, makes the procedure more of an
operation requiring anesthesia and so enhances the risk to old,
broken men to whom, as I have said, the operation is especi-
ally applicable.
If a cutting operation is to be done the perineal enuclea-
tion of the prostate would, in most cases, add but little to the
shock, and would considerably increase the chance of a good
functional result.
PROsTATECTOMY.
The early prostatectomies were partial operations. Dur-
ing a lateral lithotomy a lobe of the prostate was wholly or in
part shelled out, or an operator opening the bladder suprapu-
bically found a projecting and ulcerated third lobe which he
cut away, often with the result of restoring the power of urin-
ation to a very satisfactory degree. Then this partial opera-
tion was systematically undertaken for the relief of obstruc-
tion and considerable portions of the prostate were cut away
with rongeur forceps.
The functional results of this operation when applied in-
City Hospital Alumni. 113
discriminately to enlarged prostates was often not good and
added but little to the comfort of the patient. The operation
was also by no means devoid of risk. Its mortality has been
variously reckoned as from Io to 16 per cent.
Operators soon found that the enlargements of the lateral
lobes and their pressure on the urethra were responsible for
this failure to get good functional results, and we owe to Bel-
field and McGill the first systematic attempts to remove the
whole prostate. In carrying this out Belfield devised the plan
of combining a perineal with a suprapubic incision, thus af-
fording access to the gland from both sides.
Although Dittel had previously shown by dissection that
the prostate was quite accessible by the perineal route, after
depressing the rectum, to Belfield belongs the credit of first
seriously using the perineal route, and advising it as a regular
method of reaching the prostate gland.
The various steps of the perineal operation have been so
fully and well described (Alexander, Pye, Nicoll, Delbet and
Proust, Adenot, Albarran, Young and others) that I will here
only speak of their salient features and their points of differ-
en Ce.
Alexander made a very thorough study of the subject,
and satisfied himself that the prostate could be enucleated
with safety by the perineum, and that this could be accom-
plished without injury to the bladder from below. In order
to facilitate the operation, Alexander advised combining it
with suprapubic lithotomy which should allow one hand to
steady the prostate from above and press it down against the
finger which was doing the enucleation in the perineum
through a median incision. A skilled operator like Alexander
could remove the gland with great precision in this way. The
capsule of the gland was torn through from the urethral side,
this tear being started at the apex of the prostate, and being
extended far enough to afford room for the enucleation. This
tear was necessarily irregular, extending as it did in the di-
rection of least resistance. Owing to the uncertainties that
the varying resistance of tissues introduced, certain accidents
occasionally accompanied this operation even in the most
skillful hands. Considerable portions, and sometimes indeed,
114 The Medical Society of
the whole prostatic urethra were unintentionally torn away
with the gland. In a comparatively small number of cases
the rectum was torn, and this proved usually to be a serious
complication, leading often to the death of the patient.
This method has been variously modified by other opera-
tors seeking to avoid opening the bladder above. They have
opened down to the bladder wall, and then with pressure ap-
plied through the opening into the space of Retzius have
pushed the prostate downward. Others have accomplished
this without any wound above, simply by suprapubic pressure
over the abdominal wall.
The ground was now prepared for the purely perineal op-
eration and surgeons planning for this adopted various meth-
ods for bringing the prostate down as near the perineum as
possible.
A rubber balloon attached to the end of a stout rubber
tube which could be introduced into the bladder through an
opening into the membranous urethra was one of the first of
these devices (Sims). The balloon, after introduction into the
bladder, was blown up so as to give a firm hold within the
bladder, and the rubber tube then served as a handle by which
strong downward traction could be exerted.
Various rigid instruments were used for the same pur-
pose. An instrument with a beak, set almost at right angles,
like a lithotrite, would serve as a hook to draw the prostate
down. &
Delbet devised an instrument, the beak of which could
be bent at right angles to the shaft after introduction.
In other instruments, two beaks can be projected from
opposite sides of the shaft (DePezzer), thus giving the best
possible hold within the neck of the bladder. Dr. Young's
tractor is an excellent instrument of this sort. It is strong,
simple in construction and manipulation. This is the instru-
ment that I use and find extremely helpful.
The effort toward a greater precision of technic led to the
adoption of a crescentic incision in front of and partly encirc-
ling the same, which gives a somewhat wider field of opera-
tion, and by alowing of a more complete survey of the ana-
to mical structures, enables the operator to avoid injuring im-
City Hospital Alumni. 115
portant parts and give better opportunity to repair with su-
tures the perineal structures that are divided. In one of my
operations, the retractor with which an assistant was depress-
ing the rectum tore a hole in its wall. This rent, though in
the deeper part of the wound, on a level with the prostate, was
easily brought into view and accurately sutured by a double
row of continuous chromic catgut and healed perfectly with-
out in any way complicating the case.
This fortunate escape from any evil consequence of an
accident that had proved so serious in the earlier perineal
prostatectomies, argues for the wide opening afforded by a
transverse incision.
If the rectal wall is protected by a gauze sponge beneath
the retractor such an accident should not occur.
When the prostate is reached the French operators (Al-
barran, Delbet, Proust and Adenot) split the prostatic urethra
along its floor and then attach one lateral lobe after the other.
Young, seeking to avoid injury of the seminal ducts,
makes an incision through the capsule over each lateral lobe
in turn. These incisions allow of a complete removal of the
gland with usually but slight injury of the floor of the urethra
and they avoid the posterior part of the capsule through which
the ejaculatory ducts run.
Dr. Young wrote to me that among the patients operated
upon by him in this method he has found that of those men
who up to that time had retained their sexual vigor, 70 per
cent kept it unimpaired after operation.
Describing the evolution of prostatectomy, I have follow-
ed the line directly from Belfield's combined operation through
Alexander's operation to the simple perineal operation.
While these steps were being taken, other operators de-
veloping the suprapubic operation, showed that the whole
gland could be shelled out from above, and that, although the
prostatic urethra was often wholly removed in this way, still
good functional results were usually obtained.
This operation is still strongly clung to by some surgeons,
especially by those who had a hand in introducing it. It has,
however, several distinct disadvantages.
First, the vascular ring at the neck of the bladder is lia-
116 The Medical Society of
ble to injury and the hemorrhage when started is hard to stop
except by packing. This adds to the pain and shock follow-
ing the operation and also increases considerably the danger
of sepsis. The packing in the neck of the bladder is so close
to the orifices of the ureters that there is danger that its pres-
sure may hinder the flow of urine through them and thus add
to the chance of uremia which is the greatest menace to these
operations.
The injury to the prostatic urethra is lightly spoken of by
the advocates of suprapubic prostatectomy, some of whom re-
gard the removal of this part of the canal as of little con-
sequence.
In seeking a decision between two operations, however,
the one which does the least amount of injury will always be
preferred if it is equally efficacious.
The perimeal operation seems to give more surely good
functional results than the suprapubic. It is still too early to
know what the final verdict will be as to restoration of func-
tion, and it is possible that some cases at first rated as bril-
liantly successful will show a return of obstruction. We must
wait for further information in regard to this permanence of
functional results before we are in a position to accurately
judge of the claims of either of these operations.
The evidence we now have shows that the complete re-
moval of the gland by either method gives a surer and more
lasting relief than any partial operation.
Lastly, the mortality of the suprapubic operation is greater
than that of the perineal, and surgeons who have had experi-
ence with both operations feel that the perineal operation is
decidedly the safer.
Albarran characterizes it as “an operation which is not
grave and which gives brilliant therapeutic results.” He re-
ports 42 cases without a death fairly to be attributed to the
operation. One of his cases already seriously infected died
thirty-eight days later. This seems to have been a case that
the operation failed to save, rather than one in which it caused
death.
Young tells me in a personal communication that he has
done perineal prostatectomy after his method on 50 patients
City Hospital Alumni. 117
and but two of these patients have succumbed. One died of
pulmonary embolism two weeks after operation, and one of
asthenia of old age five weeks after operation. This latter
patient was a feeble man 84 years of age.
I have had 13 cases without a death, but 2 of these are
too recent to be as yet counted.
These IoA cases with but 3 deaths, while too few in num-
ber to establish any fixed mortality rate for the operation,
show at least that it is a procedure well borne by old men with
impaired organs.
After this brief review of the nature and effectiveness of
the various operative measures for enlarged prostate, we are in
a position to consider how we shall apply them to the varying
needs and conditions of our patients.
No single method can be applied indiscriminately to all
cases We must not only take account of the form of ob-
struction with which we are dealing, but we must also carefully
study the general condition of our patient. We must inform
ourselves as to the action of the heart and blood vessels. ES-
pecially must we study the state of the kidneys. It is not
sufficient to satisfy ourselves that the urine is free from casts
and contains no albumin, we must learn what the functional
activity of the kidneys is; whether the urine is carrying off
the excreta in sufficient amount. We shall often find that
kidneys that show signs of considerable irritation evidenced
by casts and albumin in the urine are in a better functional
condition and are doing their work more efficiently than others
which are evidently free from any inflammatory condition.
All of this must be carefully considered before we can
rightly judge what operative risks may be safely taken. While
making the study, we shall often find that by a little judicious
treatment, the capacity of the kidneys may be very greatly
increased and a power of excretion wholly inefficient for the
needs of the body may be so improved that the patient will
bear with impunity an operation which would in his earlier
state have been almost certainly fatal. -
Until recently, I considered that the catheter should be
the method of choice in the treatment of prostatic patients,
provided they were intelligent and cleanly enough to observe
&
118 . . The Medical Society of
reasonable precautions in its use. That is, I felt that operative
methods with a mortality of Io to 16 per cent could not justly
be urged upon patients able to manage the catheter, and I
found that a frank statement of the risks and chances of cure
offered by operation usually led patients to adhere to the
catheter. * . .
It remained for the modern perineal operation to change
this point of view.
The certainty of the technic and the possibility of remov-
ing the whole obstructing gland by an incision which avoided
important structures and was well placed for drainage and for
proper wound treatment, attracted me strongly to this method,
and I soon found that I could propose to my patients with a
fair statement of its dangers and probable success with a good
chance of their accepting the proposition in preference to the
catheter life. - -
I am in the habit now of telling patients for whom the
operation seems appropriate that its mortality risk is some-
what less than 5 per cent and that the chance of failure is less
than 15 per cent.
The statistics that are coming in day by day show that
these figures are, if anything, too high.
In patients with small prostates there is considerable
chance of a partial failure in restoration of function, but in men
with large prostates in which lateral pressure is responsible for
the obstruction, the chance for good functional result is at
least 90 per cent, and probably better.
Assaming this modern position to be justified, let us now
consider the conditions under which a resort to the catheter
may still seem preferable to an operation for the removal of
obstruction. - .
It happens, not infrequently, that the disease runs an in-
siduous course and is first discovered when the kidneys, and
perhaps the heart and vessels, too, are already seriously af-
fected. Under these conditions the dangers of an operation
are enhanced, and if the patient is made reasonably comfor-
table with the catheter, it may be better to temporize in this
way for the short time remaining to him of life. Even in
these cases, however, it is often possible to do a Bottini oper-
sº
City Hospital Alumni. - 119
ation under cocain anesthesia and thus restore a reasonable
power of urination with a minimum of operative risk. When
these advanced prostatics have already reached a degree of
renal insufficiency so great as to have led to a decided state of
uremia, evidenced by nausea, vomiting, somnolence or great
restlessness, they are not in a condition to bear operative in-
terference. Such patients may be greatly benefited by the
judicious use of the catheter.
In a recent paper I have shown that by constant drainage
through an in-lying catheter, the function of the kidneys al-
ready seriously disabled may be restored, and patients in a
pronounced uremic condition may be brought back to a state
of health in which they can safely undergo operations which
would have been almost certainly fatal if done during the ex-
istence of uremia.
In very fat men with large prostrates, the depth of the
perineum and the suprapubic approach add greatly to the
difficulties of the operation; and as such patients do not bear
operations well, it may be the part of good judgment to in-
troduce them to the catheter life, rather than to subject them
to the unusual operative risk that their condition entails.
Even these seemingly unfavorable conditions may, how-
ever, be overcome by judicious management, as the following
case well shows:
E. L., aged 72 years. A stout, flabby and pale old man,
entered the Massachusetts General Hospital, April 22, 1904.
He had noticed progressively increasing frequency of urina-
tion for the past six months. Two weeks ago he was seized
with pain in the abdomen. He had been constipated and was
taking laxatives at the time; the bowels then became loose
with tenesmus. He worked at shoemaking until eleven days
ago. Five days ago he began to vomit; the vomitus was
black in color but not fecal.
At the time of entrance he was vomiting profusely the
same black material and had a large loose movement also
black in color. -
Lungs emphysematous with rāles in the bases.
Bladder distended to above the umbillicus.
The catheter drew 83 ounces of urine, clear and light in
120 The Medical Society of
color—specific gravity, IoI2. The catheter was tied in. Af-
ter this the daily amount of urine varied from 60 to 80 ounces
and contained hyalin and granular casts which gradually di-
minished in number. -
The temperature at first ranged between 102 and 103°F.
The condition of the lungs (hypostatic congestion) was
thought to partly account for this.
The vomiting ceased immediately after drainage of the
bladder was established and never reappeared.
April 24th (two days after entrance) the 24-hours' amount
of urea was 9.8 grams.
May 7th, urea was 27.7 grams. º
May 16th, perineal prostatectomy was done without caus
ing any interference with the action of the kidneys. In fact,
on the second day after operation the quantity of urine rose
to I3O ounces for that single 24 hours. - -
This case is not yet finished and the functional result is
still in doubt, but it serves as an illustration of the manner in
which a uremic patient with greatly distended bladder may be
prepared for serious operative interference.
Finally, there will be a certain number of patients with
hemorrhagic diathesis, with diabetes, or with some other com-
plicating disease that prohibits any operation that can possi-
bly be avoided, and in which we shall fall back upon the cath-
eter as a pis aller.
The catheter will also continue to play an important rôle
in the immediate relief of cases of sudden completes obstruc-
tion. To the majority of other prostatic patients we may
properly, I think, recommend a consideration of operative
treatment. -
Lastly, a few words as to the applicability of these oper-
ations to different forms of prostatic hypertrophy. -
If the prostate is large, it is usually easy to enucleate
through the perineal incision. If it is small and tough, at-
tached to its capsule so that it does not strip readily, it may
be gnawed out piecemeal with rongeur forceps and scissors.
In one such case I cut away, bit by bit, a tough bar at the
neck of the bladder until only soft mucous membrane was
left.
City Hospital Alumni. 121
Sessile third lobes, large or small, may be pulled down
and removed through the opening left after the removal of the
lateral lobes. - - -
Pedunculated lobes may be drawn down in a similar way
unless the pedicle is small. In two such cases I have pulled
the lobe out through the urethra and cut it off, with excellent
result.
Occasionally we meet cases in which the third lobe forms
a large pedunculated tumor which is difficult of approach from
below, but which can be easily removed through a suprapubic
incision. Moreover, these polypoid growths usually stop the
urine by acting as a ball-valves and their removal often re-
stores the power of urination without the necessity of remov-
ing the whole gland. Such an operation has but little risk,
and these are the patients for whom a suprapubic incision
should be chosen.
When other conditions exist, such as a large or sacculated
stone which requires a suprapubic cystotomy, if a peduncu-
lated third lobe is found, it can be easily removed without add-
ing to the severity of the operation, and such removal has a
very fair chance of restoring the power of urination.
CoNCLUSION.
I. I consider a perineal prostatectomy the method of
choice for the treatment of prostates causing obstruction so
great as to require the constant use of the catheter.
2. In patients too old or enfeebled to safely bear this op-
eration, a Bottini operation under cocain may ofter be safely
done, or if even this seems too severe, the catheter life may be
entered on. -
3. It is still too early to be sure that all of the good re-
sults reported soon after the operation will show themselves to
be lasting. -
4 The cases in which functional failure seems most prob-
able are those with small contracting prostate and with dis-
tended atonic bladders.
[I MARLBorough ST.]
122 The Medical Society of
DISCUSSION. -
Dr. FERGUSON, of Chicago, regretted that he had not had an op-
portunity to look over the data of some of his cases or to clothe his
ideas in the language best suited to the importance of the occasion.
He referred first to two indications for removal of the prostate gland,
chronic inflammation and malignancy. In the first results are always
good, in the latter they are always bad. In regard to chronic infection
of the prostate gland, one case was referred to as an example. A
physician, aged 29 years, had a streptococcic infection of the prostate
gland. He went from Canada to England for treatment and then re-
turned to Chicago. Upon examination he found no streptococci, but
did find the colon bacillus. So painful was his trouble that he became a
morphin fiend. He hesitated to remove the prostate in so young a man,
thinking the inflammation would subside and that as the infection
cleared away he would get better. The case finally came to operation,
however, and since, the removal of the prostate he has had no pain,
uses no morphin, has no impotency and the frequent urination has
subsided. * -
Another indication is hypertrophy of the prostate gland. First,
in regard to the size of the prostate, simply because it is enlarged is
no indication for its removal. In the case of Senator Girard the pros-
tate was about as large as a cricket ball. A physician passed a dirty
catheter which infected him and from which he died. A recent case
referred to the speaker was an acute infection of the prostate gland.
So large it was that it obstructed the rectum by pressure and he was
called upon to do a prostatotomy, as it was thought to contain a large
abscess. He did not believe there was any pus there, so left it alone.
The enlargement subsided and the patient is now quite comfortable.
. Such conditions, of course, are rare. * - - -
In illustration of the conditions that give rise to obstruction of the
urinary flow, Dr. Ferguson presented plates from an old work by
Maelise, who devoted his life to surgical anatomy, especially deformi-
ties of the prostate gland. The speaker thought that these plates
would be of interest. . . . . .
An uncommon condition is an overhanging portion of the pros-
tatic tissue. Dr Ferguson had had three such cases. In meeting
City Hospital Alumni. 123
with a case of obstruction to the urinary flow one of the first things to
be considered is the age of the of the patient—whether it is a contra-
indication to operation or not. He had operated upon them at dif-
ferent ages, from the young man he had mentioned to a man aged 83
years. At one time he had had three cases over 80 years of age, and
each made a good recovery. So the age is not a contraindication,
other things being equal. The sexual function of the patient has to
be taken into consideration. He has now under his care an attorney
of 55 years of age, who has residual urine of from four to twelve
ounces. The sexual function is unimpaired. It is a question whether
it would be wise to remove his prostate until catheter life begins.
It is a matter of history that removal of stone from the bladder is
sometimes followed by impotency. A friend of the speaker came near
being sued for malpractice because the removal of a stone had thus
impaired the patient. Had the prostate been removed at the same time
with a similar sexual result he might have had some support in the
profession. So the catheter, in Dr. Ferguson’s opinion, has only a
limited field of usefulness. The continuation of the catheter life
through months and years of suffering, can not be too heartily con.
demned. To take a patient who has no knowledge of medicine or
asepsis and put a catheter in his hands is a mistake. The prostate
ought to be treated at the proper time Time is an element in the
treatment of the prostate in the saving of life. The condition of the
bladder also should be taken into consideration. If the bladder is very
much enlarged and atony has taken place, by removing the prostate
and giving the bladder the proper drainage, it recovers the power of
empting itself without leaving any residual urine. If the bladder has
been inflamed a long time and still the enlarged prostate is there
what shall be done? Operate, of course. That thickened, inflamed
bladder should be given a chance to empty itself. Shall the prostate
be removed when there are found two or three or more diverticula ;
sometimes there are a great number of small diverticula, what shall be
done then 3 The prostate should be removed by all means. It is
known tha' ' se diverticula will contract once they have found their
way out Ö. " : ladder muscles but the abdomen can be opened and
these clº 6 y:h comparative impunity. The speaker mentioned one
124 The Medical Society of
case in which the prostate was removed with the knowledge that
there were two diverticula, one quite large. The patient is able to
urinate properly and empties the bladder excepting what remains in
those diverticula. Dr. Ferguson expects to open above the bladder
and cut those off.
If there are stones loose in the bladder, and are quite loose and
the surgeon can be very sure of it, it is better to remove them supra-
pubically and, that being done, the prostate can be removed afterward
through the perineum. A reason for removing them suprapubically is
that it gives an opportunity to get rid of infection. If they are en-
cysted, treat the bladder as an abscess, drain the perineum without re-
moving the prostate at the same sitting. The least amount of surgery
with the maximum amount of good is as true of the bladder as of any
other part of the body. The encysted stones can be removed after
the patient has gotten over the infection.
In complications of the kidney, pyonephrosis, it is a question what
shall be done? If pus is coming down into the bladder and the blad.
der is not properly drained on account of the enlarged prostated, what
shall be done? The part to attack first is one or both kidneys. The
speaker recalled several cases in which even catheterization had
brought on acute pyelonephritis that carried them off His own ex-
perience with prostatic surgery had been limited, as he had had but 52
cases operated on by the perineal route and 24 suprapubically, Dr.
Murphy had had 51, Ochsner well up to that number, Drs. Senn, Mc-
Arthur, Bevan, Steele and others have had many cases, so that they
can count in Chicago alone some two or three hundred cases, with the
mortality just as Dr. Cabot had stated. The wonder is that surgeons
did not get onto it sooner. The first man to remove the entire pros-
tate through the perineum was Dr. Goodfellow, of San Francisco, who
reported 75 cases without a death. He uses simply a median incision,
if he has not room he extends the incision. The edges of the wound
will retract and give as good a view, and the parts fall together after-
ward better than in a transverse or any other incision. Dr. Ferguson,
after using several incisions, now has returned to the median. The
tractors and prostatic depressors are many, the principal thing is to
put something inside the bladder. Dr. Pyle, of Toledo, Ohio, was
City Hospital Alumni. 125
the second to remove the entire prostate through the perineum. The
great good that comes from the perineal operation is remarkable.
Gross said, “no man yet has had the temerity to remove the prostate
gland,” and he added that he hoped no man would ever be so foolish
as to try to do it; and this was only a few years ago. London surgeons
removed the entire prostatic urethra with it and a number of men here
have done the same thing. Extensive operations upon the prostate
are now done successfully, whereas it was thought a few years ago that
it could not be touched.
Dr. LEONARD FREEMAN, of Denver, said, that in discussing such
a subject before a society of this kind one should be prepared, and he
was not prepared, but there were a few things of which he would
speak. A most important question, in those cases that need operation,
is, what operation shall be performed ? One class of writers say
that the Bottinin operation is the operation of choice, while an-
other set of writers say that it should never be done, that it is not
surgical, that one can not see what one is doing. There is a place for
the Bottini operation, however, and a place for prostatectomy, and
there is also a place for catheterization. Dr. Ferguson was right in
saying that where it is contemplated putting a catheter into the hands
of a man who will infect himself, the physician should hesitate. But
there are cases where a man has used a catheter for years and is al-
ready infected ; his kidneys may not be sound ; his other organs may
not be sound and his condition not good. Is it not sometimes better
to let him go on ? Dr. Freeman stated that he had done between
twenty and thirty Bottini operations, and perhaps, fifteen prostatecto-
mies and had had successes and failures in both. When he first began
to use the Bottini operation he attempted to use it in all sorts of cases,
and had some unpleasant experiences in consequence. The Bottini
should be used in those cases in which the disease is in its insipiency.
The surgeon hesitates, when the prostate is small, to remove it because
of the seriousness of the operation, because, also, of the difficulty
with which a small prostate is sometimes enucleated. It is in these
cases, where a man is beginning to use a catheter, that the Bottini
gives the best results. It is of value in cases where the heart or kid-
neys are unsound. Again, there is a third class of patients where it
126 The Medical Society of
may be useful, those who refuse to have the perineum opened, fearing
an operation of that kind too much, There is a good chance for many
of these men in the Bottini operation. But nevertheless in suitable
cases a prostatectomy is the operation of choice. Surgeons are told
that in prostates having one configuration they should do one operation
and in a prostate with another configuration they should do a different
operation. But a man can not always tell. Only a few days before,
the speaker had thought he had every indication of a valvular third
lobe and found that it was simply an enlargement of the lateral lobes.
He had no doubt that by some men the cystoscope could be so handled
that they could tell all about the configuration but most operators
could not do this. It should be remembered that as soon as the cys-
toscope is inserted into the bladder many of the finer configurations
are pushed aside and escape the observer.
During the past year Dr. Freeman operated upon four cases of
cancer of the prostate in which the symptoms of cancer of the pros-
tate seemed to fail. This makes him think, that perhaps, it is more
common than is usually supposed. In one case he opened the peri-
neum and found a small, hard, smooth prostate. There had been no
bleeding. Nothing but the symptoms of obstruction. Prostatic can.
cers sometimes remain latent for long periods or else develop in
cases of ordinary hypertrophy. Dr. Freeman had followed a case for
two years as an ordinary prostatic hypertrophy and when he operated,
though it had not developed any other symptoms, the prostate was
C2. In CôIOUIS.
l)r. JAMES BELL, of Montreal, Canada, had listened with great
pleasure to Dr. Cabot’s paper although his attitude was more consev-
ative than r. Cabot’s. It is sometimes diffiult to decide what to do
with these patients. In many cases the condition is such that it is
clear what to do, but in the case of a man in good health who has some
residual urine, it is a question what to do. The history of results is
not sufficiently clear to enable one to decide. It is certainly a great
responsibility to advise a man in good health, say under 60 years of
age, who has not begun to use a catheter, to undergo an operation.
At one time a few years ago one would have thought from the reports
of many of these prostatic operations that the questions was settled.
City Hospital Alumni. 127
The complications referred to by Dr. Ferguson all have
their indications for treatment, but the great question is, whether
to resort to the habitual use of the catheter or not? When the profes-
sion is better educated as to asepsis, many patients will be able to use
the catheter safely. As Dr. Freeman has said, many patients are al-
ready infected before consulting the surgeon, having used the catheter
indiscriminately for a long time, and some of those get along fairly
well. Whether these men should be advised to undergo an operation
under such circumstances is questionable. They can be assured of
much less danger in the operation at the present day, but patients are
still obliged to use the catheter after the operation. The residual urine
would disappear for a time, but later they would be obliged to use the
catheter. For this reason Dr. Bell said he would like very much to
know the remote history of these cases which have been operated
upon, for he was in a most unsettled frame of mind. There was no
question surgery where he felt less certain of the ground, that is, speak-
ing of the cases in general. Of course, in many cases the indications
are quite clear.
Dr. BRANSFORD LEwis said an interchange of views on a great
topic such as the one under discussion was desirable. He never heard
a genitourinary surgeon talk on the subject without learning some-
thing. After the addresses of the evening he felt more hopeful about
prostatic hypertrophy subject than ever, not because he believed any
discovery had been made, but because study of the subject was going
forward in a definite, searching, scientific way, rather than in an em-
pirical manner. Each problem is being solved progressively. A few
years ago, at a meeting of the Genitourinary Association at Atlantic
City, Dr. Lewis had appealed to the profession not to go off on a
tangent and say that any one operation was the one, and all others to
be condemned. Since that time he had received dozens of letters
from men in the profession saying that the position was well taken; that
the profession should look at it more broadly and liberally. He be-
lieved in the views, as given by Dr. Freeman, of the advantage of the
several operations; and because the profession is beginning to look at
it in that way he had hope for great results,
One of the problems mentioned was in reference to a choice of
128 The Medical Society of
operations. One can not say, here is a man aged 60 years, he deserves
such an operation, and here is a man aged 50 years, who deserves an-
other operation. There must be taken into consideration the general
condition of the patient, and, more important still, the shape and con-
firmation of prostatic outgrowth. The different forms of prostatic
hypertrophy make indications for choice between operations. Dr.
Lewis presented models in clay of actual specimens in his pos-
session.
The condition of the hypertrophied prostate is a large determin-
ing factor, the age, another determining factor. Patients, aged 52 or
53 years, are sometimes considerably older in general debility than
others aged 65 years. At one time he had under his care two men from
Mississippi, one aged 56 and the other 73 years, and the man of 56
appeared 20 years older than his neighbor of 73 years.
As an illustration of the remark that hypertrophy of the prostate
is not always an indication, Dr. Lewis presented a specimen of pros-
tate which was removed through the perineum by another surgeon and
the patient was not relieved a particle. After being operated upon he
had to use a catheter. Dr. Lewis then attempted a Bottini operation
which also did not give any relief. He then made a suprapubic in-
cision into the bladder and removed the intravesical outgrowth and the
man has been well and able to urinate for two years. A perineal pros-
tatectomy had been done by a capable surgeon without any result.
Another was that of an old patient who saw Dr. Lewis in I)ecember.
Specific gravity of the urine was 1 oog. He had two big stones in the
bladder, was debilitated to the last degree and anesthesia wou'd have
put him in his grave. Yet, he was suffering such tortures that some
thing had to be done. If he had done the operation which is so gen-
erally applauded (perineal prostatectomy) Dr. Lewis believes he would
have died. He made under local anesthesia, a supra pubic incision
and removed the stones, looking after the urinary secretion He then
made a deep groove through the posterior prostatic bar, with the
Freudenberg incisor, which has enabled the patient to pass the urine
satisfactorily. This patient is now perfectly well, after having been
apparently in an inextricable condition. He has another case that was
entirely relieved by the Bottini operation. In other cases because of
City Hospital Alumni. 129
the conditions present it was impossible to do a Bottini operation or
do the perineal operation, so suprapubic incisions were made. The
moral is to select the operation for the individual case.
In reference to the Bottini being applied only to cases in their in-
cipiency, he did not know whether that was a point well taken or not.
Since perfecting his examining cystoscope (retrograde view) he had
been enabled to look backward into the bladder, presenting a new
phase. Within the last three or four months he had had cases that
puzzled him until this cystoscope cleared the matter up. A finger was
placed in the rectum and no enlargement of the prostate could be felt,
but when the cystoscope was put in there could be seen big knuckles
of the prostate projecting into the bladder. Whether that could be
called an incipient state or not he did not know. It was early, so far
as general indications would go, but there was enough obstruction not
to be removed by the Bottini. If one divides a knuckle of the pros-
tate he gets two lobes instead of one and that does not relieve the
passage any. As to the perfection of results, he could not tell. He
has operated upon something like fifteen cases by the Bottini method
and has done over twenty prostatectomies, and is so much gratified by
the result that he is a thorough believer. He believes that greater
danger comes from not operating and using the catheter than from
operating, for the present methods of operating are attended with so
small a degree of mortality, and followed by such a large degree of
success.
Dr. JAMES E. MooRE, of Minneapolis, after having attended the
meeting of the Surgical Association in the morning and walking through
the Fair in the afternoon, had not thought of attending the meet-
ing of the Society in the evening until he learned that Dr. Cabot would
be the speaker. It was an agreeable surprise to find that the paper
was read before a body of young medical men. They would find from
what Dr. Cabot and the others had said that they had not solved this
problem, and these young men expected to take it up, for the speaker
doubted if it would be solved during the life of the older members of
the profession. Those present were to be congratulated on hearing so
conservative a paper. By the term conservative was not meant one
who does nothing, but one who does the most good under given con-
130 The Medical Society of
ditions. The question before them was, “What are you going to do
for these old men?” and next, “How are you going to do it?” Person-
ally, it was the speaker's belief that the catheter had killed more men
than it had ever cured. The prostatic's real danger begins when he is
introduced to catheter life. He hoped to see the day when the surgeon
could say to a man even at an early age: “We can relieve you safely
and surely.” Prostatectomy of some form will be the operation of the
future. At the present time Dr. Moore rather prefers the perineal
prostatectomy, altough he admits he may, change his opinion. He
hoped he would die before he got too old to change his views. He
had been very much pleased with the paper by Dr. Young, of Balti-
more, and his hearers were recommended to watch Dr. Young’s work.
Dr. Young has operated fifty times with but two deaths. His opera-
tion is to remove enough of the prostate to restore the parts to their
natural condition and at the same time restore, the functions. It should
be remembered that the prostate is a gland and important and what it
does is not known. Prostatectomy now is usually followed by impo-
tence and it can not be held out to men in early life without promising
them something more than is possible now. Operations upon the pros
tate are not so easy as they have been pictured. Of course, it is as
easy to pull out the prostate as to pull out a tooth, but to take it out
without doing harm is what the surgeon tries to do and what the
speaker hoped the young men present would learn to do.
Dr. HARRY McC. JoHNSON said, in response to Dr. Cabot’s inquiry
as to Dr. Bryson's method of operating, that a description of it ap-
peared in the Annals of Surgery over a year ago. Dr. Bryson had
gone through the evolution Dr Cabot had mentioned; first doing the
suprapubic operation, then the Alexander operation, then he made a
suprapubic incision down to the bladder for the purpose of shoving
the prostate down for perineal enucleation. Later, he simply used the
perineal route. He made a perineal urethrotomy, introduced the finger
until it struck the obstruction, and then with some blunt instrument,
made a hole in the prostatic capsule, introduced the finger and shelled
out the prostate, of course, tearing the floor of the prostatic urethra.
He had operated on more than a hundred cases, many by this method,
and in not a single case was there a puncture of the rectum. That
City Hospital Alumni. 131
complication did not seem to arise, but if it did, it could be dealt with
by making the two incisions, separating the rectum as in the Young
operation and proceeding as Dr. Cabot had in his case. This opera-
tion appealed to the speaker as the ideal perineal operation, better than
pushing the rectum back. There is not so large a hole, the prostate
is readily removed and the patient makes a more speedy recovery.
We do a dangerous thing when we put a catheter into a prostatic's
hands. It is practically impossible for him to maintain an aseptic
bladder, and thus we have a septic condition added to what is often
an already inefficient kidney.
We should rather take into consideration, when we are deciding
the expediency of operation, the general condition of the patient. A
prostatectomy on a man otherwise healthy is not a dangerous opera-
tion, but it becomes so the more the patient’s condition is deteriorated
through the agency of these two factors — sepsis or uremia. Indeed,
it is sepsis, or uremia, or both, which finally terminate the patient’s
life. So that it seems that the ideal time to operate is whenever it
becomes necessary to put a catheter into the patient’s hands, and be-
fore he reaches that condition in which sepsis and uremia play such an
important rôle.
Dr. HENRY JACOBson, referring to the cases in which the Bottini
instrument is used, the essayist stating the surgeon has to work in the
dark, said that objection was overcome by a dial attachment to the
cystoscope and to the Bottini instrument; I have one with my instru-
ments which I showed to the Society two years ago. So we now see
where the channel is forming, and the objection that one is working
in the dark will not hold good. He added that he preferred prosta-
tectomy in the majority of cases, but thought that the kind of obstruc
tion and health of patient must govern the choice of the method to
be used.
Dr. R. E. KANE thanked Dr. Cabot for the tribute he had paid
Dr. Bryson. Dr. Johnson had very well covered Dr. Bryson’s opera-
tion. As to Dr. Cabot’s impression that an instrument had been used
by Dr. Bryson, Dr. Kane stated that Dr. Bryson depended entirely
upon his finger and in a few instances where he had to do with fatty
subjects he made a prevesicular incision. Referring to the case of Dr
132 The Medical Society of
Ferguson in which the diverticulum was large enough to introduce two
fingers, a similar case was operated upon by Dr. Bryson. The prostate
was removed with some brief benefit, but at the end of about two
months the patient got worse than he was in the first place and a year
later it was necessary to no a suprapubic operation. The diverticulum
was very nearly as large as the bladder proper. Relative to the put-
ting of a dirty catheter into the hands of dirty people, Dr. Bryson
used to tell a story of a man who had gone to his office for examina-
tion. Dr. Bryson was preparing to catherize the patient who inter
rupted the proceedings, pulled a dirty catheter out of his pocket, spat
upon his hands and introduced the catheter and drew off the clearest
urine the doctor had ever seen drawn from a prostatic.
Dr. CABOT, in closing, said that he thought the removal of the
prostate for chronic inflammation an excellent operation. It seemed
the only logical way of treating the old intractable prostatics. He said
Dr. Ferguson had spoken on a subject a little aside from the discussion,
but one of great importance, viz., the treatment of stone behind an
enlarged prostate. Dr. Ferguson thought it should be removed supra-
pubically. Dr Cabot said that he had removed stones in cases of 125
prostatic patients by crushing and pumping them out with 5 deaths.
As the suprapubic operation has a much higher mortality than this, it
is plainly better in those patients where it is wise to get rid of the stone
first to select the crushing operation rather than the suprapubic.
The essayist said that Goodfellow is reported to have had but two
deaths, but he understood that at least one other patient was admitted
to have died from some other cause than the operation within a short
time thereafter. Of Dr. Young’s cases, one died of pulmonary embo-
lism and another of asthenia. They certainly did not die of the op-
eration, per se, but in charging up the mortality of these procedures,
which are employed in the effort to save life, it seems plain that if this
effort fails, the case must be counted against the operation selected.
In a case of death from pulmonary embolism, or of a death from
asthenia, after a perineal prostatectomy, we must doubt whether a
Bottini done under cocain anesthesia would not have pulled these pa-
tients through.
A plain statement of the facts enables each observer to interpret
the statistics according to his best judgment.
City Hospital Alumni. - 138
In his operations he had found cancer of the prostate to be more
common than was generally supposed.
Meeting of June 16, 1904; Dr. Charles Shattinger,
President, in the Chair.
Climatology: Its Value to the Student and
Practitioner of Medicine.
By S. E. SOLLY, M.D.,
COLORADO SPRINGS, COL.
[T IS not my purpose to give you an exposition of the
| details of medical climatology, but to call your attention
to its general and relative importance.
The value of climatic influences in the treatment of dis-
ease was formerly overestimated, to-day it is underestimated.
The reason for this is because of the welcome but belated rec-
ognition by the profession at large of the paramount import-
ance of hygiene in the cure of pulmonary tuberculosis.
As an overwhelming majority of the invalids who resort
to change of climate are victims of tuberculosis, it is mainly
in this connection that I propose to discuss the subject.
For a long time the physicians whose chief concern has
been with tuberculous patients, have preached to their breth-
ren upon the importance of hygiene, especially in the regula-
tion of exercise, diet and daily life, as well as the due consid-
eration of individual peculiarities and the value of a suitable
change of air. They have also furnished statistics demons-
trating the practical benefits arising therefrom. Moreover, for
many years the methods and success, first of the consumptive
hospitals of England and later the sanatoria of Germany and
Switzerland in the treatment of tuberculosis have stood an
object lesson for the profession to learn by. In spite of all
these teachings they would not learn but trusted to the use of
minor weapons, such as creosote and cod-liver oil, to win with
in the fight against tuberculosis, ignoring hygiene, permitting
134 - The Medical Society of
re-infection and closing windows in their exaggerated fear of
drafts.
The early symptoms of the disease were unrecognized
and the doctors did not awaken to the peril of a tuberculosis
until phthisis was well established. Many physicians from
ignorance or greed kept their patients with them, seeing them
slowly die while sowing a fresh crop of tuberculosis among
the inmates of their unclean, ill-ventilated homes. Other
physicians rather than their clients should die upon their hands
hastily shipped them to another climate, the place ill-chosen
and the hour too late.
While climatic change was recognized by the specialists
as valuable, up to 35 years ago, they were at fault in its appli-
cation; being influenced by the fear of cold for their patients,
they sent them to warm climates, and noting the soothing ef-
fects of dampness upon the cough and general nervous irrita-
bility, they chose a moist in preference to a dry air. These
were the days when euthanasia was practiced by sending off
patients to die peacefully in the soothing lethal chambers of
Madeira and Florida, or they were exposed to the vicissitudes
of weather and the dangers of ill-ventilated cabins upon long
sea voyages. In these latter experiments the hardy ones fared
better than those who were condemned to the enervating cul-
ture medium of moist heat on shore, but the route and season
were not wisely considered, nor the individual, as to the prob-
able effects upon him of the monotony of life and diet.
Next came the use of altitude, and when Lavos Platz was
first opened there was an uplift of the voice in favor of high
climates, and from London, Paris and Berlin patients were sent
to the mountains of Switzerland, Italy and later to the far
Andes and the high plateaux of Colorado, but alas, while the
remedy was a good one, too often it was forgotten that its
value lay in its appropriate application. Thus many were sent
who had scarcely strength to reach their destination, and oth-
ers to whom a rarefied air was almost a poison, died the quick-
er from the change.
Later came the recognition of the value of hygiene and
the open air treatment as valuable apart from the use of cli-
mate. It was a matter of great surprise to many of the pro-
City Hospital Alumni. 135
fession to find that patients in an indifferent climate did well
with the open air treatment and rest. The fact that patients
can get well of tuberculosis in such climates as England, the
Eastern States and Europe has led to the idea that all that is
wanted is quantity of air without respect to its quality. It is
an undoubted fact that hygiene is of the first importance. Dr.
Burney Yeo said truly that “a bad climate with good care was
better than a good climate without care.” Therefore, the first
essential is the care of the patient. The reason that so many
have gotten well without marked climatic change is because
of the early recognition of the disease and the fact that tuber-
culosis is a curable disease in a large percentage of cases.
Post-mortem examinations reveal that a large number of
persons have been spontaneously cured in whom had been ob-
served no symptoms of tuberculosis during life. It is, there-
fore, not surprising that a great many patients should get well
even in an indifferent climate. Nevertheless, there is a large
margin of cases in whom the chances are less and in whom
not only the quantity but the quality of air is important.
The influence of a mere change of locality upon the mind
of the patient is quite marked and an important consideration.
While a change of surroundings is usually beneficial to all in-
valids, it is particularly so to the tuberculous. When a patient
is informed that he has tuberculosis he nearly always wants to
get away to something different. Change of climate, fortu-
nately, generally results in obtaining a purer, even if not an
air different in quality. - *
Many physicians have said that a climate with plenty of
sunshine, because an outdoor life can be readily indulged in,
is all that is wanted. There is, however, to be reckoned with
the amount and intensity of sunshine. The good effect of
sunlight upon tuberculosis is undoubtedly something more than
the result of the mere ability to sit out of doors; there is
something in the influence of the rays of the sun with their
light and heat. We know the power of light upon disease, as
shown in the use of the Finsen rays, x-rays and radium. Also
the beneficial effects of heat upon many diseases. To secure
the influence of sunlight in the highest degree, dryness of air
is necessary. Sunlight has to be gradually accustomed to,
136 The Medical Society of
especially by fair people. Sunlight, moreover, is at all times
too stimulating and very irritating to some persons. This ex-
plains the remark of the Englishman who, landing at Liver-
pool in a fog upon his return from Colorado, said, “thank God,
I am out of that beastly sunshine.” In what scantiness of
sunshine the English dwell and how it seems entirely absent
to the dwellers of dry sunny lands is illustrated by the story
of the bishop in England saying to a visiting Parsee, “I can
not understand how an intelligent man like yourself can wor-
ship an inanimate object such as is the sun.” To this replied
the Parsee, “Ah, my lord bishop, but you should see the sun,
what a glorious thing it is.” .
Dryness of air in a climate does not necessarily mean also
a scanty precipitation. For the air may be almost constantly
humid with a moderate annual rainfall because of the frequency
of light showers, dews and fogs and the little evaporation
owing to a clay soil or the absence of drying winds. There
may be a large number of rainy days and a small rainfall or a
heavy rainfall and few rainy days. Again, there is a differ-
ence in the rain falling from an upper stratum of clouds
through a dry or through a humid air. A gentleman in Colo-
rado was talking to a visitor from the East and remarked, “In
the Adirondacks it is always training,” to which the visitor re-
plied, “I notice it is raining here.” “Yes, but you see here it
is dry between the drops.” It is not merely the rainfall that
should be taken into consideration, but the number of rainy
days and the humidity. If you want sunshine without humid-
ity you must get away from the coast.
For years patients have been sent to Egypt and Algeria,
but the Arizona lowlands are just as good and in some respects
better. In these lands we find great dryness and great heat
in summer, and in winter genial warmth. Immense benefit is
derived in many cases from winter residence and in a few by
residence through the summer. I myself recovered my health
in Egypt, but later work in London broke me down again and
I went to Colorado for permanent residence with a successful
result. The heat of desert climates is almost insupportable
in the summer to most people, and to certain others the cli-
mate is rather irritating even in the winter. On account of
City Hospital Alumn. 137
heat and dust, and absence of rarefied air, it is not as bracing
as the high altitudes. These remarks apply to the lowlands
of Arizona, on the uplands there is a fine mountain air with
less cold than in Colorado.
There was and still is a pet delusion that equability is
necessary in a good climate for phthisis. The fact being that
real equability does not exist without constant humidity, and
this element is inimical to most consumptives, though there
are exceptions to this, as to all rules, and in some cases the
other advantages, chiefly non-climatic, may enable them to get
well in spite of the dampness.
Equability involves both humidity and temperature. The
most perfect examples of equable climates are found on sea
islands in high latitudes during summer weather. For instance,
the Bahamas in winter, and Nantucket in summer, are typical-
ly good climates of this class.
Sea shores come next, the most equable being those
where the shore is shut off by hills from the drier land breezes,
but owing to their high humidity and their lack of ventilation,
they are most enervating, while those on which the winds blow
freely from both land and sea are more bracing but at the same
time less equable and more treacherous.
On ship board while the patient is under the influence of
constant equability of humidity there is necessarily during
most voyages and seasons, great variations of temperature and
wind pressure, while these factors may be healthfully stimulat-
ing, yet they cause sea voyages to be less beneficial than res-
idence on sea islands, for those persons for whom a constant
equability is desirable.
On a sea shore precipitation may be light and the humid-
ity high, as in Southern California, with its morning and even-
ing fog. On the Riviera there is less fog and more rain.
The fact that cold rather than heat is beneficial to tuber-
culosis has been proven the world over. There are exceptions
to this rule and some cases are more benefited in a warm cli-
mate than in a cold one, but cold nights and warm days give
the desirable climate for most. The arresting effect of intense
cold has been shown in cases of persons with tuberculosis who
went to the Arctic regions. The good effects of cold have
138 The Medical Society of
been dwelt upon by Hirsch and many others. We all know
the benefit of arousing the nervous system. Lying beneath
almost every case of tuberculosis are nervous irregularities.
If you will investigate the history of most cases you will find
they originated in a condition of nerve-tire. If you can re-
lieve this condition you remove the predisposing cause of the
disease. Place one of these individuals in a warm, damp cli-
mate and the effect upon him is very marked indeed. He does
not care whether he gets well or not. But put him in a cold,
invigorating climate and you will have him fighting for his life
and he will do it well. That the cold air is better than the
warm air has been well illustrated at the Massachusetts State
Sanatorium at Rutland. It is surprising the benefit there de-
rived from the cold air. Some of the patients have their beds
arranged on a slide so that they can be made to slide out of
the window exposing the head and throat, while their bodies
remain protected in the room. Of course, there are excep-
tions, owing to some condition of the disease peculiar to the
individual. For instance, in advanced cases, the patients being
left with limited lung capacity, are usually better off in a
warm than in a cold climate, though in either case dryness is
also desirable. Nevertheless, a still more limited number live
longer in a moist equable climate of moderate temperature.
As you go higher, as the air becomes dryer, you have cool
nights, cool shade and hot sunshine. It is no exaggeration to
say that in Colorado in the winter you can lie on a dry moun-
tain side and put your bottle of wine near you in a snowbank
while you are warm and comfortable in the sunshine. It would
appear to many to be a dangerous thing to encounter such
differences between sunshine and shade, but on the contrary,
it is a beneficial thing for most consumptives, for they receive
cold dry air into their lungs while sunheat and light is on their
bodies. Sunstroke is due to the length of the spells of heat
rather than to the intensity of the heat for a day or two, so
that the heat of the sun is actually beneficial to many, espec-
ially in connection with dryness of the air and cool nights.
There are blood changes that result from change to a high
altitude, which I believe to be real and permanent, although
there are a few others who believe that they are only apparent
City Hospital Alumni. 139
and temporary. Undoubtedly the first increase of red cells is
due to the mechanical effect of alternating pressure, but this
increase persists, and in the deeper vessels of animals resident
in high climates the same condition has been found and, more-
over, the hemoglobin is also increased. Even granting these
changes are only compensatory, apparent and temporary, why
should they not stimulate the individual to real blood regener-
ation, the same as does massage, cold baths and iron. While
iron is of great value in curing anemia, yet it is difficult to tell
how the result takes place, but it is reasonable to believe that
if the iron is supplied for a time, the blood is fortified, thus it
begins once more to absorb it from the food, and so it may be
with the raising of the standard of the blood by residence in
high altitudes.
After a prolonged residence, however, particularly if there
occurs some depression of health from disease or overwork,
the blood begins to deteriorate again and then the patient is
benefited by a change, for a time, even to a worse climate. It
is the duty of the physician to recognize when the patient shall
need a high altitude and for how long. These blood changes
are practically completed in a month, and the same time
is taken in reducing them when a person goes down from an
altitude to sea level. A month's absence, for this reason, is
often of great value, while an absence of six or eight weeks is
not beneficial. It is, therefore, usually best to let the patients
go away for not longer than a month the first time and if they
they return improved and keep improving, permit them later
to make a longer visit.
No one climate is suitable to all cases. Tuberculosis attacks
all sorts of people and under all sorts of circumstances, there-
fore, all sorts of climates are needed. With some, it is better
not to send them away from home at all, because the better
care at home more than offsets the advantages of the change
of climate. Physicians often treat the subject of climatic
change too lightly, when called upon to consider whether their
patients shall remain at home or change their climate. The pa-
tient also is not sufficiently impressed with the importance of
the question or does not give the physician time enough to
properly weigh the matter. Again, the consultant, in the
140 The Medical Society of
brief time he sees the patient, does not learn to know him as
an individual, to recognize and allow for his mental, moral and
social qualifications for making a change of climate. The
pulling of patients up by the roots and sending them traveling
without due consideration is often a great wrong and the out-
, come disastrous, though the fatal termination may be so long
postponed that the initial cause, viz, the doctor's mistake, is
often forgotten.
To appreciate what a climate is, it is necessary to know
its meteorology as well as its topography and resources. The
meteorological conditions are now being very well recorded
by the United States Bureau and by volunteer observers,
though much is yet to be desired. In selecting a place for
your patients, you want to study these records, do not send
them to a place simply on the statements in the literature sent
out by the hotels and railroads, though these often contain
valuable facts. Climatology is a science and if you have the
data you can build up a climate for yourself. It is useless to
tell you that it is dry if the records prove that it is damp.
Take Southern California, for example, for years it was called
a dry climate, but it is not a dry climate in the way in which
it is claimed. There is fog morning and evening. The hu-
midity is low during midday but it is high during the rest of
the twenty-four hours. Southern California is an extremely
valuable climate for many people, even for some cases of tu-
berculosis, though in most of these it does more harm than
good. The residents are now beginning to recognize this and
are trying to push the tuberculous patients away from the
coast. Inland California is very much better for them, as has
been said. If you wish to send your patients into a sea air,
they are generally more benefited on the islands than on the
seashore.
Of other diseases besides tuberculosis, many are greatly
benefited by a change of climate. Kidney diseases are some-
times cured and often greatly relieved. Many get well in Col-
orado, but more do well in Arizona.
In heart disease you are told that a high climate is bad,
that such patients should be sent to the sea level. It is true
of many but not of all cases. It appears that in those cases
City Hospital Alumni. - 141
that are benefited, the good result is due to the diminished
blood pressure. -
Chronic rheumatism is often greatly benefited and certain
nervous diseases are often much improved in the altitudes.
How are you going to learn about climate P I am raising
this question at the American Climatological Association at
Philadelphia in a few weeks. I wrote to nearly all of the med-
ical colleges asking the question, if they gave any instrution
in Climatology. Many replied that the professor of the prac-
tice of medicine touched upon the subject, but no books were
recommended and there was no course of lectures devoted to it.
In fact, the subject is at most entirely ignored in the schools.
Of course there is a very powerful plea against its being in-
serted in the curriculum because the students have too much
to leain now in the time, and they would have to cut out
something else in order to put this in. It might be a little like
the story of the old peasant whose wife was killed by the train
while driving home their cow. A sympathetic visitor calling
upon the old man expressed her grief at the loss of his wife,
but he did not seem greatly concerned. He remarked, “It
might have been worse—it might have been the cow.” So, in
the opinion of the professors to place Climatology in the cur-
riculum, some more valuable study must be omitted. But I
do not believe this is necessary. It would suffice to give stu-
dents a foundation of knowledge so that they could intelli-
gently investigate the matter of climatic change when occasion
required in the future. This modicum could be given in three
or four lectures and some of the time saved by giving up the
present desultory talks upon climate. Further, in order to in-
sure that the students paid proper attention to these lectures,
one or two questions upon Climatology should be set in the
examination papers.
DISCUSSION.
Dr. CRANDALL had thoroughly enjoyed the discussion on climatol-
ogy and fully agreed with the speaker on points, especially the last,
that there is not enough attention paid to the subject in our schools.
Undoubtedly all mention the subject in lectures on medicine and
chest diseases, but as to the discussion of the subject in the abstract,
142 The Medical Society of
but few schools take the matter up in that way. Another point
well taken referred to the restricting of the number of patients sent
away, that all patients should not be sent regardless of the conditions.
The speaker had in years past occasionally sent patients to a different
climate only to regret it. He does not make it a custom now to send all
cases but considers everything bearing on the subject before deciding.
It is useless to send a patient unless it is possible for the patient to go
with a contented mind. Of course, as Dr. Solly had said, it is often
encouraging to the patient to make a change and in that case it is
beneficial. But if they are homesick, if the conditions are bad, if they
do not know how to take care of themselves, or know how to clothe
themselves and are lacking in the comfort they would have at home,
it is no benefit but rather an injury to send them away. When a pa-
tient is sent away he should be given a letter to some physician in the
vicinity so that he may have some one to consult. They should be
given special instructions in regard to the climate to which they are sent.
If they are simply sent to a hotel or boarding house with no instructions,
they do not get the full benefit of the climate. If the patients can be
sent to a location where they may carry on their occupation, it is a good
thing for them. He had very recently been consulted by a patient who
did not know whether to go to Colorado or to Arizona. The patient
volunteered the information that he had a position offered him in Col.
orado where he could continue his work, and the speaker sent him to
Colorado. There is a great deal of benefit in occupation for those
who are able. They should be instructed not to associate with tuber-
culous patients. A patient had better live in a tent than in the most
perfectly equipped boarding house with other patients. All those
things should be taken into careful consideration and, among the cli-
mates adapted to the patient, they should choose in a measure where
they shall go. The Adirondacks are especially to be recommended
for the reason that the patients are instructed very carefully in regard
to the care of themselves, and they have devoted especial attention to
this in all their little colonies. The speaker also frequently sent pa-
tients to Colorado. The physicians there are teaching their patients
now how to live with tuberculosis. He makes it a rule to tell patients
that they may continue to have some trace of the disease, that it may
City Hospital Alumni. 143
become latent, but that they may still be tuberculous and that there is
a possibility that under some acute condition it may again become
active, and they are instructed how to protect both themselves and
others. '. -
Dr. BoISLINIERE was particularly pleased with Dr. Solly’s state-
ment that no climate is adapted to all forms of tuberculosis, and again,
that many patients will do better to return again for a short period.
The climate sometimes is too dry for them. He mentioned a patient
whom he had sent to Arizona eight years ago with an immense dis-
turbance of the lung, a tremendous cavity, who every two years has to
leave Arizona for a time and always returns greatly benefitted. Her
apparent wellbeing with that tremendous cavity in the lung is simply
astonishing. The general trend of thought seems to be that one climate
is just as good as another. The speaker held that to be false. What-
ever can be accomplished in climate like St. Louis can be accomplished
with better results in a climate like Colorado or Arizona. He had
lived for several years in New Mexico, where there are many cases of
imported consumption, and many do very well in that climate. One
man of his acquaintance was a deputy sheriff. He had an enormous
cavity in the lung; he was in the saddle constantly, riding a hundred
miles at times without leaving the saddle, and had done that for ten
years. It was doubtful whether a man in that condition could have
attended to his duties anywhere except under the influence of that
beautiful climate. He saw but two cases originate there. One was
miliary tuberculosis which ran a rapid course. He saw no cases
among the Mexicans. In their language there is no word for the con-
dition. -
Dr. Elsworth SMITH said that he had for sometime been very
intimately acquainted with Dr. Solly’s very able book and had listened
with great pleasure to his talk. He hoped that Dr. Solly in his closing
remarks would tell them something in reference to the point he made
about the patients improving for a time in a high climate and then
coming to a standstill and doing better for being sent away. The
question that vexes the clinician is how long a patient should be kept
in a climate. A great many think that if once a patient is sent away
from home he should remain away permanently. Dr. Smith wished
144 The Medical Society of
to know whether Dr. Solly thought the patient should be allowed to
return home, or whether he should merely be transferred to another
climate.
The point made as to a consultant was an excellent one, and an-
other point was that the average medical man and medical student is
not sufficiently instructed in this branch. If they were adequately in-
structed not so much responsibility would be thrown upon the con-
sultant. He should be called upon to decide the matter of diagnosis,
perhaps, in obscure cases, but he thought it was a difficult matter for
the consultant to determine the question of personal equation of the
patient If the subject were more generally understood then each man
could pass on that matter himself.
As to the effect of high climate on heart disease, he hoped the
doctor would enlighten them more fully. It had always seemed to the
speaker that in diseases of that kind it was a question of the blood
pressure in the given case; in cases where there is a high arterial ten-
sion, as in arterio sclerosis, he had always thought they should do well
in a high climate. In cases of low blood pressure, as in valvular
lesion, he advised against a high altitude.
Dr. BEHRENS regretted exceedingly to have come in so late that
he had missed much of Dr. Solly's talk, which no doubt was very in-
teresting and instructive. Physicians are too prone to send their pa-
tients to a different climate without instructions They are sent to El
Paso or Albuquerque, going into a community where they can not make
a living and where they have no friends and under such surroundings
they do not get the benefits which should accrue from a change of
climate. In the matter of sending patients to a consultant Dr. Behrens
felt that he had been very remiss. When a patient goes to one of
these health resorts after awhile he becomes dissatisfied and takes no
care of himself. If he recovers it is a matter of good fortune, if he
does not recover his physician has iost all interest in him. He had
made it a point to visit some of these health resorts, Colorado Springs,
for instance. He had sent patients to Dr. Solly's city, Colorado
Springs, with much benefit in many cases. He had also sent patients
to San Antonio and various other Texas health resorts. San Antonio
has an altitude of only several hundred feet, with very peculiar condi-
City Hospital Alumni. 145
tions, a little creek running through the place, and used as a sewer, so
he understood. His patients did not do as well as when sent to some
similar place with better conditions. As to the matter of keeping tu-
bercular patients congregated, the best results are not obtained, he
thought. The method practiced throughout the country is productive
of but little good. Sunshine will not help these unfortunates if they
are congregated and allowed to discuss their condition.
Dr. GARCIA wished Dr. Solly would take up the question of the
difference between the tuberculous patient going away, who leads an
active life and he who leads a sedentary life. Those who can afford
to go away often lead a too sedentary life. He had a patient who had
typical incipient (verified by microscopical examination) tubercu-
losis who went away and came back much better. This man got a
position as fireman on a mountain line where he had much active
work. Dr. Garcia said that he had a tentative diagnosis made on him-
self in 1893, but after a long course of vigorous athletics all symptoms
disappeared and he now believes these symptomn were merely delayed
pneumonic results.
Dr. HILL said that he had been very pleased to hear Dr. Solly's
views in reference to sending patients to a high altitude. He was
afraid that he had been guilty of sending two patients to Colorado in
the past year whose conditions had become so bad as to almost pre-
clude the probability of improvement. Both of them had high
temperatures in St. Louis and both of them went down rapidly in
Colorado. The way the high altitude acted in these cases brought to
mind the remark of Dr. Smith relative to the effect of high altitude
upon a weakened heart. Both of these patients had swelling of the
feet. Dr. Hill believes it is unwise to send patients to a high
altitude after the heart has been weakened by tubercular trouble. He
had had a patient brought to him from a place higher than Colorado
Springs a few years ago. She was a girl fifteen years of age who had
heart trouble. She was swollen so that her features were almost un-
recognizable. One pleural cavity was full of fluid and one partly full and
she was gasping for breath. To-day she feels perfectly well and is not
conscious of the valvular lesion. He also wished that Dr. Solly
146 The Medical Society of
would tell them something of his ideas regarding the rest treatment in
consumption.
Dr. HINCHEY asked Dr. Solly if he entirely approved the plan of
an absolute outdoor life for all classes of consumptives. He had been
told by physicians about Denver that there are camps where the pa-
tients sleep out of doors in all weather, both men and women, robust
and delicate patients. He thought this was going to extremes.
Dr. SHARPE said that he had seen some very interesting articles,
at different times, by physicians in high altitudes on blood pressure,
and the relative mortality of high altitude operations compared with
those of the lowlands. Dr. Sharpe wished to know, if patients from
an high altitude came to the lowlands needing surgical intervention,
whether, in Dr. Solly's opinion, they required any modification of
usual methods of preoperative preparation, and whether any special
care should be instituted during the period of anesthesia. Are we
justified in anticipating ordinary postoperative reaction?
Dr. SHATTINGER called attention to a fact not mentioned, that in
high altitudes the atmosphere is generally charged very highly with
positive electricity. Just what effect that would have it would be hard
to say except that it would have a tonic influence, but that there is
more behind it is shown by observations made recently in a German
laboratory. They took sterile whey and passed an electric current
through it. The portion of whey into which they dipped the anode,
may be designated “positive” whey, the portion into which they dipped
the cathode, “negative whey,” and the portion between, neutral whey;
the term “neutral” referring to the electrical condition and not the
reaction. The “positive ’’ whey gave an acid reaction, the “negative”
an alkaline reaction, and the “neutral” a reaction leaning to either one
or the other. If the two portions of the whey that have been changed
chemically be exactly neutralized so that the three portions of the
whey have exactly the same chemical reaction they had before, it is
found that the “neutral” whey behaves toward bacteria just as sterile
whey. The “negative ’’ whey favors the development of bacteria,
whereas the “positive ’’ has a distinctly inhibitory effect, which lasts
from twenty four to thirty-six hours. By means of the “ultra-apparatus,”
an instrument that is thought to indicate the molecular structure of
City Hospital Alumni. 147
bodies, a difference in the appearance of the three kinds of whey can
be seen. This is interesting in connection with the study of electrical
conditions in the mountains.
Dr. Solly, in closing, expressed his appreciation of the interest
shown in the subject and only regretted that he would be unable to
answer all the questions fully unless he stayed to breakfast.
'Taking up first the matter of atmospheric electricity, but little is
known about it although certain effects have been observed in certain
people. The dry Chinook winds very frequently produce hemorrhage
and nervous disturbances, particularly in women. The electrical dis-
tubances are very strong and they do probably play an important part
in nervous diseases. Persons who are inherently nervous, as women
compared with men, are not so generally benefited, as the climate is
too stimulating.
As to the effect of altitude on the heart in connection with tuber-
culosis, cases of mitral insufficiency usually do well, and if properly
cared for compensation is soon established. Most cases of mitral
stenosis and aortic valvular disease do badly. The heart in young per-
sons or in any persons in the early stages of consumption is usually
benefited, because the muscles of the heart are strengthened just as
the muscles of the body. If they have a lung which is solid with tu-
berculous pneumonic processes and which, if it is removed, will prob-
ably be removed with cavity, dragging the heart out of place, they are
not likely to do well. In advanced fibrosis they are not benefited as
regard the heart, but in all these cases, of course, it is necessary to
balance the good with the evil. The physician is apt to parcel diseases
out as being of this organ or of that, and they forget how dependent
these organs are each upon the others. In tuberculosis one of the
most important questions is, why did that person become tuberculous?
It is often difficult to tell why, and it is the underlying cause that must
be attacked.
It is rare that physicians examining cases of heart disease do not
examine the urine, not only the chemical test but as to the quantity.
It is quite an important matter to know about that. It throws light
upon your case. He had lately been investigating the indican in -
urine. It is not thought of much importance and it is not of import
148 The Medical Society of
ance as it indicates directly the condition of the intestinal tract. It
represents the amount of absorption from the intestines through insuf-
ficient evacuations of the bowels. As a properly acting digestive pro-
cess is one of the means of getting people well, this little point is of
great importance.
As to the matter of when patients should go away from a climate,
that going away which is, of course, only temporary, the patients only
going away for a certain time. There are patients who never can go
away, you can not risk them at all. That is illustrated in the climate
of Arizona. Dr Solly has sent patients from Colorado to Arizona
who would have died in Colorado and who have lived for years in
Arizona, the heat and dryness being just what they needed. But there
are a large number of cases that can go back to their own climate.
The far most important point is, what they are going to do after they
go back. If you are going to shut up a man in a store in Colorado
he may live, but under the same conditions here or in Boston he will
die. He will not have the fresh air, he will not have the exercise, he
will not have the benefit of even those brief moments going to and
from his house, and the pure night air that he will get in Colorado he
can not get here. But if he can be placed under different conditions,
if here he can get a position as street car conductor or can do the work
of a farmer or a driver, he may live here here though he would
die in a store. Persons of means often do well in their own climate.
A great many more can go back than we think, if they will live under
hygienic conditions. Some of these patients are sleeping out of doors
even in New York. As to whether this open air treatment is not carried
too far, it is true that everybody can not stand it, but many more can
stand it than we think. They do not get catarrh, for instance, if they
live out of doors all the time. Those who are exposed day and night
can stand it in a remarkable way. Patients will go through attacks of
pneumonia lying out of doors and they beg to be allowed to remain
outside. There is something about this that is not understood. The
open air of the porch or outdoors is a very different thing from the
air in a room with every window open.
As to the question of exercise or rest, a large body of men be-
lieve entirely in rest, another equally large believe entirely in exercise.
City Hospital Alumni. 149
One may say that when there is fever the patients should rest. How
absolute the rest is depends upon the case. In going to a high alti-
tude there is no question about the necessity for rest. Patients, as a
rule, exercise too much at first and too little after they have heen there
for a while. If there is a great cavity the patients are often benefit.
ed by considerable slow exercise. Many cases put on the rest cure in
Germany would have done better if they had gone out and exercised
and coughed and expectorated, thus expanding the healthy lung. Ex-
ercise is necessary for the healthy portion of the lung, rest for the dis-
eased portion. Those having an evening temperature should be quiet
in the afternoon and exercise in the morning. Exercise should not be
violent, constant or extreme. Patients often sustain serious injury from
mountain climbing. They will go to Colorado Springs and carry their
valise up the hill from the station to their lodgings, sometimes sustain-
ing serious injury. They should not attempt the walk from the station
and should see a physician as soon as possible. They are very apt to
overdo in the first few hours. Dr. Solly urged his hearers to send
their patients to some physician in whom they had confidence and
have them see this physician as soon as possible atter their arrival.
Taking up the subject of surgery at high altitudes, Dr. Soily said
that he did not now do any surgery. He believed that Dr. Powers, of
Denver, had investigated the matter. At first it was thought that
surgical shock was more extreme at a high altitude but the fact
was there was not sufficient care being taken in the operations
The patients did not have the attention they should have. It was a
matter of keeping them warm. All of the important operations have
been done in Colorado and where done by men of skill they are as
successful as elsewhere. But there are patients, as very nervous wo-
men, who are better in a low altititude. As to recovery, the healing of
the wound is remarkable. Dr. Solly had gone to Colorado from Lon-
don, where he had done surgical work in the hospitals, and he was
perfectly astonished at the rapid healing of wounds in Colorado.
There is no doubt that in convalescense there is considerable advan-
tage in being in high altitudes. It is the opinion of surgeons that in
the case of those leaving a high altitude and going to a lower one, it
is better for them to wait a week or two before submitting to an opera
tion, so that they may may get acclimated.
150 The Medical Society of
Replying to a question by Dr. Boisliniere, Dr. Solly said that
extrapneumonic tubercular lesions do remarkably well in Colorado,
but there are very few of them seen. What used to be called scrofu-
lous joints are more apt to be benefited at the sea level, but there are
now in use remedies that make them almost independent of climate
He urged his hearers to see to the matter of climatology in the schools
and to do what they could to get accurate climatological data so that
they would not be compelled to depend upon the statements of hotel
keepers, adding that he had once seen himself quoted on the subject
of the dryness of a place where the humidity was about 8o.
Meeting of June 30, 1904; Dr. Charles Shattinger,
President, in the Chair.
The Surgery of Typhoid Fever.
By W. W. KEEN, M D.,
PHILADELPHIA, PA.
R. PRESIDENT AND GENTLEMEN:—When you
M kindly invited me to address you I was obliged to
excuse myself on account of numerous other existing
engagements, and when you still pressed the request I accepted
with the statement that it would be impossible for me to take
time to prepare a carefully written paper, but if you thought
a few ea: tempore remarks upon the Surgery of Typhoid Fever,
would be useful, I would gladly meet your wishes. I must ask,
therefore, for your indulgence if both in matter and manner I
fall far short of what I would wish. I have not had time to
tabulate the many cases reported since my book on “The
Surgical Complications and Sequels of Typhoid Fever” was
published early in 1898, and, therefore, have had to quote sta-
tistics of that date except in a few cases. Saving, however,
in typhoid perforation, I suspect that while numbers might
vary, the percentages would be much the same.
My attention was called to this subject as early as 1874
by some cases I had had. In my Toner Lecture, in 1876,
City Hospital Alumni. 151
I gave a brief résumé of our then existing knowledge on the
subject. Afterward, in 1898, as already stated, I published a
little monograph on the Surgery of Typhoid, covering the
ground more completely. It is a striking fact that in the
years that have elapsed since 1897 there should have been so
many cases reported compared with the number previously
reported. My book published in 1898 covers practically the
records of typhoid surgery for about fifty years. The number
of cases in that period was 17oo. I think since 1898 I have
notes of perhaps IOOO additional cases.
One must remember that there are many more deaths
from the complications of typhoid than from the fever itself.
Hölscher, in a study of 2000 fatal cases, found that 24 per
cent died of the fever and 76 per cent of the complications
and sequels. -
In 1876 when my Toner Lecture was delivered, the bacil-
lus was not known. Moreover, even in 1898 the pyogenic fac-
ulty of the typhoid bacillus was still in doubt, though now it
is a well-recognized fact. The viability of the bacillus in
the body is something extraordinary, especially in the bone
marrow, the spleen and the bile. Thus, Sultan found the ty-
phoid bacillus in an open sinus from the clavicle after six
years; Buschke, in the rib, after seven years; von Dungern, in
the bile, after fourteen and a half years; Droba, in the bile,
after seventeen years, and Hunner, in the bile, eighteen years
after the attack of typhoid, all in pure culture.
Not seldom the bacilli are found in many organs in the
same patient, showing their very wide distribution. Thus, in
one of his patients, Flexner found them in the mesenteric
glands, the spleen, the liver, the bile, the kidneys, the lungs,
the bone marrow and the blood of the heart. As a matter of
fact, I advocated in 1898 the view that these wide-spread in-
fections indicated'unerringly the diffusion through the blood,
although I could show then but few cases in which the bacilli
had been cultivated from the blood. In the past few years
the bacilli have been found in many cases, in the blood in 80
per cent of the cases examined, especially in the early stages.
This, therefore, may prove to be one of the very earliest means
of diagnosticating typhoid fever as well as of explaining its
152 The Medical Society of
multiple invasions. Moreover, as in cases of abortion, the ty-
phoid bacillus has been found in the placenta and the fetus, L
no other means of such infection could be imagined than by .
the blood.
One of the most important complications to be considered
is gangrene, the result of thrombosis. It is generally a late
complication or early sequel, arising usually from the second
week to the seventh, chiefly in the second and third weeks.
The cause of the thrombosis is not only the weakened heart
and the weakened and sluggish circulation, but the bacilli
themselves existing in the blood, the heart and the walls of
the arteries and veins. If a thrombus forms in an artery it
causes a dry gangrene through cutting off of the blood supply;
if in a vein moist gangrene through damming up the blood
supply.
Occasionally the gangrene is bilateral. It is far more fre-
quent in the lower parts of the body than in the upper, i.e.,
where the force of the circulation is the least. Out of 214
cases it appeared I46 times in the genitals and the legs. The
same preponderance is seen in the joints in the proportion of
70 to 17, and in the bones I 12 cases in the lower extremities
to 4I in the upper.
Curiously enough Ricketts has shown in his recent paper
that it is much more common in men (IOO cases) than in wo-
men (34 cases).
The most remarkable case of gangrene I ever saw I will
describe briefly, because it is of more than usual interest, in-
asmuch as it shows the possibility of using the rectum for
many years as a common cloaca. A woman, aged 34 years,
in March, 1872, was ill of typhoid following prolonged nursing
of her husband who died of typhoid. Gangrene of the vagi-
na caused both rectovaginal and vesicovaginal fistulae, which
a colleague had not been able to close. I, in turn, was equally
unsuccessful in my efforts to close them. After thirteen op-
erations by him and myself, covering about two years, the
woman was cured in this way: After the operation and con-
sequences had been fully explained to her and her ready as-
sent given, the urethra was excised and the vulva entirely
closed. All the urine, all the menstrual discharge—which
City Hospital Alumni. 153
continued for a few years after the thirteenth operation (a
lucky number for her), and also all the feces, were passed per
rectum. In December, 1888, twelve years after the opera-
tion, she came to me for the first time, complaining of diffi-
culty in urination. I found that a little round calculus had
formed in the vagina and was acting as a ball-valve and caus-
ing retention of the urine. On crushing and removing this
through the rectovaginal opening she was entirely relieved. I
saw her last in November, 1898. For twenty-two years the
rectum had served as a common cloaca without irritation of
the rectum or infection of the kidneys. She told me that she
rose only once or twice during the night to urinate and that
she had been perfectly clean and comfortable ail these years.
As to the prevention of typhoid gangrene, it is practically
impossible either to foresee or to forestall it. When it occurs
all we can do is to keep the parts as clean as possible and,
finally, after the line of demarcation has formed, to amputate
the extremity or excise the slough. Here I would suggest
neural infiltration in preference to general anesthesia, especi-
ally if the operation has to be done during the course of the
fever. Ricketts' statistics seem to show that operation is im-
perative, for in 87 cases operated upon there were 22 deaths,
a mortality of 25 per cent, while in 35 cases not operated
upon there were 34 deaths, a mortality of 97 per cent—a most
startling contrast. But I suspect it is somewhat misleading in
one respect. In many of the cases not operated upon the
gangrene was doubtless so extensive and the patient's condi-
tion so grave as to forbid any operation whatever. In the re-
maining suitable cases the results are so encouraging that in
doubtful cases we should give the patient the benefit of the
doubt. *
In every case of typhoid infection of the joints, let me
urge especially that you take the opportunity to examine the
fluid bacteriologically. With modern, methods I hope we
shall be able to detect the typhoid bacillus in pure culture;
but there has been no case up to the present time, so far as I
remember, in which the typhoid bacillus has been proved to
exist in the joints, though unquestionably the post-typhoidal
joint infection must be the result of the bacillus.
| 54 The Medical Society of
The most unexpected result of the joint affections of
typhoid is dislocation of the hip, due to distention of the cap-
sule with fluid. I have seen personally three cases of this
lesion but unfortunately long after the fever, when it was too
late to do anything. It is distinctly a complication of child-
hood and early youth. Of 38 cases 35 were under the age of
20 years. Most of these cases have only been discovered by
the doctor after they have occurred, since, as a rule, no pre-
monitory symptoms have been observed. The child has ty.
phoid and is lifted by the doctor or the nurse from the bed
when suddenly one of the hips is dislocated; or the child may
complain of pain, and upon examination the hip is found al-
ready dislocated—no one knows when or how.
The lesson is clear. Examine the hips in young patients
with care, especially if there is the least complaint of pain.
I say the least complaint of pain, because in most of these
typhoid patients their apathy and indifference to any except
considerable pain may very possibly make the physician dis-
regard slight complaints, only to find later the grave error into
which he has fallen by want of attention to such slight com-
plaints. If a dislocation occurs, immediately replace it and
guard against its recurrence.
Affections of the bones are, as a rule, a late sequel rather
than a complication; they are relatively frequent. I found on
record up to 1898, 237 cases. The bacillus of typhoid has
been found in pure culture many times, not only in the long
bones but in the diffused marrow of the spongy bones, be-
cause in the bone marrow the infection is the most frequent
and lasts the longest after the fever has passed. In fact, it is
probable that the marrow of most of the bones, including even
the vertebrae, is infected at one time or another during most
cases of typhoid.
There is a marked difference between a typhoid infection
and an ordinary pyogenic infection of the bones. When there
is a pyogenic infection the patient is distinctly sick, often, in-
deed, very ill. He has high fever and complains of severe
pain. These symptoms are absent or slight, as a rule, in ty-
phoid infection. In many cases there is little or no fever, and
only at the point of infection may there be tenderness. An-
City Hospital Alumni. 155
other thing which sharply differentiates typhoid bone disease
from similar pyogenic diseases is the fluctuations in the local
manifestations. A lump will appear, be a little red and tender
and then will subside, only to reappear at a later period. I
have known such a rise and subsidence to occur five or six
times in the same case." Moreover, typhoid infections of the
bones are apt to continue for years and to attack successively
different bones. In one case I had under my care the attacks
covered a period of eight years, and may have continued much
longer for I then lost sight of him. In this patient's case his
occupation required hammering with a large sledge hammer,
and in consequence he had multiple attacks in the arm, fore-
arm, leg and thigh, especially on the right side, on which came
the strain of his occupation. The most frequent results of
such an affection are a periostitis or an osteomyelitis, the lat-
ter being on the whole, I think, the most frequent.
The osseous lesions of typhoid as we would naturally ex-
pect are very widely distributed but preponderate in the lower
extremities. In the head there were 14 cases, in the trunk 49,
in the upper extremities 41, in all IO4; whereas, in the lower
extremities, there were 112 cases, more than in all the other
parts of the body combined. Sir James Paget long ago called
attention to typhoid periostitis (osteomyelitis, I believe, almost
invariably) of the ribs and sternum. The date at which the in-
fection occurred will show you that it is a late sequel. The dis-
ease arose in 16 cases in the first two weeks, from three to five
weeks in 66 cases, from months to years after the fever in IO4
CalSCS.
The treatment is very clear and simple, namely, removal
of all the diseased tissue. You will find in a great number of
cases, especially in your earlier cases, before you are taught
by disagreeable experience, that you will fail to cure your pa-
tients by the first operation because you do not go wide enough.
If the infection is in a rib, for instance, we must take out the
entire thickness of the rib and go far from the disease forward
and backward. I have had to do two, three or four operations
in some of my early cases because I did not remove enough.
Considering the origin and extent of the operation it is not a
very dangerous one—only II out of 168 cases proved fatal.
156 The Medical Society of
When the infection invades the laryna it is most frequently
during convalescence, usually from the fourth to the eighth
week (83 out of 143 cases). I found 22 I cases up to 1898. I
well remember during the Civil War two cases of typhoid in
which within forty-eight hours of each other I had to do
instantaneous tracheotomy, but unfortunately without saving
the life of either patient. The age is important, the patients
are chiefly from 15 to 25 years of age (109 to 56
for all other age). After the age of 25 years, laryn-
geal complications are rare; before the age of 15 years,
they are very rare. Very frequently the laryngeal symptoms
will be slight, but if you find in any typhoid patient that there
is even a slight hoarseness or dyspnea, instant and close atten-
tion should be given to the case, for there may be a sudden
change for the worse, a livid face, bloody expectoration and
almost instantaneous suffocation. Of 98 cases not operated
upon, 77 died and only 2 I recovered, a mortality of 78.6 per
cent, while of 99 cases operated upon, 55 died and 44 recov-
ered, a mortality of only 55.5 per cent. The most dangerous
of all forms of laryngeal typhoid disease is necrosis of the
laryngeal cartilages. In these cases death followed in 95 per
cent of all the cases. -
The only treatment is early tracheotomy, and in many
cases an instantaneous one. Tracheotomy is the operation
not only of choice but of necessity. Intubation is not to be
considered. -
I now come to a complication of the greatest interest both
medically and surgically, which will appeal to all of you,
namely, intestimal perforatton. Operation in these cases was
first advocated by Dr. James C. Wilson. I remember the first
case he had in which, though we did not operate, we were
ready to do so. He asked me late in the afternoon to go and
see a patient with him. This was in 1886, two years after
Mikulicz's first, and up to that time, the only operation, which,
however, had not then been published. We could not quite
make up our minds that there was a perforation, and so finally
decided to wait until the next day. She was then a little bet-
ter, and each following day there was some improvement un-
til she finally recovered without operation. But this case soon
City Hospital Alumni. 157
led to the first published plea by Prof. Wilson for operation in
case of perforation. - -
Perforation bears no relation to the severity of the fever,
and, in fact, it is not uncommon in the ambulant type of the
disease. Taylor states, that based upon the Census and the
Marine Hospital Reports on the frequency of typhoid in the
United States, we have about 500,000 cases a year with a mor-
tality of about 50,000. Osler attributes about 30 per cent of
the mortality to perforation. If this is so, there are annually
about 15,000 deaths in this country due to perforation. On
an average we can now save 30 per cent of these cases of per-
foration, which would mean 4,500 lives saved annually. In
their recent paper, Harte and Ashhurst collected from Janua-
ry, 1898, to December 31, 1903 (the six years following my
monograph), only 201 cases operated upon the world over.
Yet, it would seem that in these six years in the United States
alone 90,000 patients died from typhoid perforation, nearly all
of whom should have been operated upon and about 27,OOO
lives saved. Have I not reason then to select the topic of the
evening when it is so evident—so painfully evident, that the
profession at large have not even begun to appreciate the need
for operation in typhoid perforation ? It is especially the fam-
ily physician; the one who attends typhoid fever, rather than
the surgeon, who needs to be taught that perforation means
operation, as a rule, just as he has painfully learned that, as a
rule, appendicitis means operation. Iteration and reiteration
are needful, here a little and there a great deal, and in time the
profession will be convinced, but only, I fear, after the loss of
many valuable lives.
The site of perforation is most commonly in the ileum,
though it appears also in the appendix and cecum, and in the
opposite iliac fossa, in the sigmoid. Moreover, there are some-
times two, three or even four perforations or impending per-
forations which later may go on successively to complete per-
foration. Hence the need in every case in which operation is
done is to examine several feet of the intestine for other
impending perforations to see that they are closed and sealed
up in advance of perforation. There are on record a number
of cases in which the patients have been operated upon for
158 The Medical Society of
perforation and in full tide of recovery who have died of a
later perforation. Most of these could have been prevented
had the impending perforation been sealed by a few sutures.
As to diagnosis, the symptoms are sometimes sudden and
severe. There may be marked shock and pain. On the other
hand, there is slight or no shock in most cases. There is al-
most always pain, but often not so severe as to produce any
shock. There will sometimes be nausea and vomiting. Rigid-
ity of the abdominal wall is sometime present but not always.
There is sometimes a slight fall in temperature. Hepatic dull-
ness rarely disappears. The perforations are not usually so
large as to allow of the escape of gas in large quantities into
the peritoneal cavity. Leukocytosis I believe to be of great
value. During the fever itself there is, as a rule, no leukocy-
tosis, sometimes even in perforation there is none. But if
there is pain, a fall in temperature, a rise in leukocytes to I5,-
OOO, 20,000 and sometimes even 50,000, then you ought to
conclude that there is perforation and that operation should
be undertaken as quickly as possible. When perforation
has gone on long enough to give rise to peritonitis, then you
will have also a rise in the blood pressure and there will be a
hard, quick pulse.
When I wrote my monograph in 1897, I took a much less
hopeful view of operation in these cases than I do now. Up to
that time I could collect only 83 cases, with a mortality of
80.7 per cent. In view of the disease, itself a most serious and
dangerous malady, and of the high mortality, I was of the
opinion that the outlook was rather gloomy. But cases since
reported by Finney, Cushing and others have shown that such
patients bear operation unexpectedly well. .
In 1898 and 1899 I collected 73 additional cases of oper-
ation and the mortality had fallen from nearly 81 to 72 per cent.
Harte and Ashhurst have recently collected 362 cases to the
end of 1903. Arranged by periods of five years there were:
From 1884 to 1888, IO cases, with a mortality of 90 %.
From 1889 to 1893, 16 cases, with a mortality of 87.5%.
From 1894 to 1898, IOO cases, with a mortality of 72 %.
From 1899 to 1903, IOG cases, with a mortality of 69.2%.
This progressive fall in the mortality from 90 per cent to
City Hospital Alumni. - 159
69.2 per cent is most encouraging. Instead of 30.8 per cent
of recoveries which is the average result for all surgeons, in-
dividual operators, under exceptional hospital advantages, have
had a much higher rate of recovery. But surgeons, as a rule,
should anticipate for the future recovery in at least one case out
of three, and I believe it will gradually rise to 40 or 45 and pos-
sibly to 50 per cent, though from saving one in three to saving
one in two is a long step. Undoubtly, also, the published cases
do not fairly represent the actual cases, for many unfavorable
cases slumber—and very possibly always will slumber, in sealed
case-books or unpublished memories.
The time at which operation is done after perforation is
of great importance. In the first twelve hours, according to
Harte and Ashhurst's recorded cases, the mortality is 73 per
cent, during the second twelve hours it is 73.8 per cent, while
in the third twelve hours it rises to 93.5 per cent. The fact
that after this time there is a fall in the mortality to 67.2 per
cent is no argument for postponing the operation, because most
of the patients would be dead before you could operate on
them. These later statistics confirm those published in my
book. My position in that publication has been misunder-
stood. It has even been said that I preferred to wait until the
second twelve hours, an utterly untenable position in the face
of a spreading infection. What I stated was that so far as we
could judge by the statistics then available (1897), the second
twelve hours showed a less mortality than the first twelve
hours. The later and fuller statistics of Harte and Ashhurst
show that the mortality of the first and that of the second
twelve hours are now practically the same. Moreover, in my
book I urged as prompt operation as possible with two pro-
visos: First, as advised by Abbe, that we should not so hasten
operation as to be handicapped by want of suitable provision
for light, means of flushing and sufficient assistants; and sec-
ondly, that if profound shock were present we should wait a
reasonable time to see whether it would pass off.
Of course, I refer here only to any primary shock that
may immediately follow the perforation and, therefore, be due
very largely to severe pain and not to the later-delayed shock
which may arise from absorption and infection. The latter
160 The Medical Society of
form of shock could not occur immediately after operation,
and therefore could not be taken into consideration when de-
ciding whether operation should be done immediately.
Happily the spread of modern hospitals even in small
towns provides for the first condition in a large number of cases.
As to the second, I must still adhere to the view which is the
admitted rule of practice in other surgical cases. When a
limb is smashed in a railway accident, if there be little or no
shock, immediate operation is proper. But if there be pro-
found shock, a cold, clammy skin, a hardly-perceptible pulse,
a sighing respiration, where is the wise, sensible surgeon who
would not delay operation for a reasonable time in spite of the
danger, here also, of an hourly increasing infection? If after a
while it is evident that the patient's condition is not improving,
then in spite of the shock he must operate. So in typhoid
perforation, if there is little or no shock—as is the rule in the
majority of cases, then the earlier the operation can be done the
better, as I said in 1898. But if there be profound shock, I
still believe that a judicious surgeon will wait but only for a
reasonable time. The increasing infection in this short space
of time will be more than counterbalanced, in my opinion, in
the majority of cases by the decreasing danger from operating
during severe shock, if it exists. Were this not so, the second
twelve hours, as we may conclude now from 362 cases, should.
show a large increase in its mortality instead of an increase of
only 8/IO of I per cent over the first twelve hour period.
As to the technic of the operation my judgment is that in
most cases a general anesthetic will be required. Patients
frequently complain severely of pain upon opening the abdo-
men under a local anesthetic. The incision should be long
enough not to embarrass the surgeon, yet so short that he can
close it quickly and leave no chance of hernia. -
If the perforation is a small one it should be closed, with-
out trimming the edges, with Lembert sutures. If it is very
large your choice must lie between a resection with an end-to-
end anastomosis, and an artificial anus. The artificial anus is
so much more safely and quickly made that this should be the
operation of choice in most cases. This will of itself diminish
largely the future mortality rate. When the patient recovers
City Hospital Alumni. 161
a secondary operation to re-establish the continuity of the in-
testine may be performed. In all such cases a search should
be made to discover impending perforations and to prevent
them by Lembert sutures.
Perforation of the gall-bladder is not a frequent complica-
tion. Up to 1898 there had been reported only four perfora-
tions of the gall-bladder treated by abdominal section result-
ing in the cure of three of the cases—a recovery rate of 75
per cent.
I have not time to consider the other complications of
typhoid, but can only mention the brain, eye, ear, thyroid,
gland and a few cases of stricture of the esophagus. Pleurisy
and empyema are not at all uncommon. Perforation of the
stomach occasionally takes place. There is occasionally in-
flammation of the spleen, softening of the mesenteric glands,
which may resemble perforation. Suppuration of an existing
ovarian dermoid is infrequent, but five or six cases have been
reported, and a pure culture of typhoid bacillus has been found.
Abortion is not uncommon, the placenta and the fetus both
showing the bacillus in pure culture. The male genitourinary
organs are occasionally affected, most frequently with orchitis
and occasionally a cystitis. Abscesses of the muscles are not
uncommon. Scarcely an organ of the body escapes the
malign influence of the fever.
Now that we are awakened to the wide spread and fre-
quent surgical dangers that may arise in nearly every organ
and portion of the body—dangers which can be discovered
and mitigated, or sometimes even averted by timely means—
the future should show far better results, especially in intestinal
perforation, than the past.
'[NOTE.-After this address was delivered, during my sum-
mer holiday, I saw in consultation with Dr. C. P. Thomas, in
Spokane, a very unusual case which illustrates exactly the
points here made. The peculiar symptomatology enabled us
to reach a correct etiology and diagnosis. Although the case
was not one of affection of the bone, as at first thought prob-
able, the same peculiarities of late typhoid infection were well
illustrated.
162 The Medical Society of
A woman, aged 34 years, about January I, Igo4, began
to complain of pain in the region of the sacro-iliac joint. The
pain was never severe, and came and went. About April 1st,
a swelling appeared in the same region. This also came and
went, increased and decreased, almost to the point of disap-
pearance. Finally, by July it increased considerably in size,
became red and at last ruptured, discharging considerable pus.
Meantime there had been no fever, no loss of appetite or sleep,
and, therefore, no loss of weight.
In view of this peculiar history and the absence of sys-
temic symptoms, which would have been very marked if it had
been an ordinary pyogenic abscess, I asked the woman if she
had ever had typhoid ſever. She immediately stated that she
had had a prolonged attack in the preceding September and
October.
On examination I found two openings nearly in the crease
between the buttocks over the lower part of the sacrum. A
probe showed that the skin was separated from the underlying
tissues down to the tip of the coccyx and upward and to the
right as far as the middle of the crest of the ilium. I pre-
sumed that there was probably diseased bone at the bottom of
the trouble. On operation, however, I found that the external
abscess communicated with the interior of the pelvis through
the great sacrosciatic foramen, and on investigation of the in-
terior of the pelvis, I found that there was no diseased bone,
but that a large abscess had formed in the connective tissue
between the anterior surface of the sacrum and coccyx and
the rectum. Instead of discharging through either the rec-
tum, vagina or bladder, as would ordinarily have been the
case, it had made its egress through the great sacrosciatic for-
amen and finally ulcerated its way through the skin. Of
course, there may have been a typhoid periostitis or osteomy-
elitis and any fragment of bone have been discharged when
the abscess ruptured, but I was not able to discover any evi-
dence of such osseous disease. Moreover, the prompt recov-
ery of the patient after thorough curetting and temporary
packing with iodoform gauze seems to indicate that the dis-
ease did not involve the bone.
The sharp contrast between the mild constitutional course
City Hospital Alumni. 163
of such a typhoid infection and the severe constitutional symp-
toms which would have attended an ordinary pyogenic infec-
tion, and the increase and decrease in swelling and pain were
most instructive features of the case.]
DISCUSSION.
Dr. FRANK J. LUTz said that if he were to respond he would be
limited to a recital of his personal experiences. Dr. Keen, the origi-
nator of the operation for typhoid perforation so far as the English
speaking world is concerned, brought the matter before the profession
in a monograph with which all are familiar. All, occasionally see cases
of perforation which have not been operated upon. Those in general
practice can no doubt recall many cases which the autopsy proved
should have been operated upon- The speaker had seen one case of
hip joint dislocation in a child who, after some months of suffering,
was subjected to a reduction and made a fair recovery. This girl had
as an additional complication two abscesses, one above and the other
below the elbow, from which there was successfully cultivated the ty-
phoid bacillus. At the time he did not understand the relation of the
typhoid infection to the dislocation. He thought it due to trauma,
although assured by the mother and nurse, both intelligent women,
that no trauma had occurred. He had also seen one case of gangrene
of the intestine in the course of typhoid fever, and he did not under-
stand the relation between the typhoid infection and gangrenous in.
testine. He had seen five cases of empyema following typhoid perfor
ation. It had been a great pleasure to have a verbal explanation of
Dr. Keen's monograph, which the doctor plans to bring up to the
present status of the subject. Dr. Keen's address had been not only
highly entertaining but very instructive.
Dr. HERMAN TUHOLSKE thought that to attempt to discuss the
paper read by Dr. Keen would be like carrying coals to Newcastle.
All that could be said had already been said by him who is the teacher
of the work on typhoid fever. It had been the most instructive medi-
cal evening he had ever lived. He had enjoyed hearing from Dr.
Keen's lips all that he has taught by his writings for many years. He
had seen one of the rarer forms of typhoid sequels. An account o
164 The Medical Society of
the case was published in the first number of the Bulletin of the
Washington University. It was a dermoid tumor of the ovary, re-
ported by Dr. Jonas. There was found a large tumor containing pus.
There were no adhesions, there had been no intestinal disturbance.
Dr. Fisch found the bacillus and established beyond doubt the exist-
ence of the typhoid bacillus in this tumor. The patient had had ty-
phoid fever six years before. It is therefore one of the interesting,
rare cases of which so few have been reported. A second form which
is exceedingly rare is that of muscular abscess in no way connected
with the bone or periosteum. This case was on the upper arm, in the
triceps muscle. There were none of the symptoms of an inflamma-
tion present. It was of a chronic type, the center of it almost fluctu-
ated Gumma was suspected but the history was not there. Finding
it not to be a gumma it was incised and in the pus it contained there
was demonstrated the typhoid bacillus. A third case seen by him
is not so rare, for next to the perforations in the ileum those in the
adjacent parts are less rare. There were two large perforations in the
cecum. Undoubtedly there was considerable necrosis in that part.
There was a large fecal fistula and the finger introduced into it,
after being partly withdrawn it could be passed into a second
opening. The patient had gone through all the peculiarities, the
abscess breaking, and finally forming a fecal fistula. An incision
was made, a fairly good sized piece taken out, and the patient made a
good recovery.
So far as his operations for typhoid perforation were concerned,
Dr. Tuholske felt that he had not been very successful. In his first
case, although he sewed over one that he thought to be an impending
perforation, the patient died. In a second case the typhoid perfora-
tion was found and sewed over, but that patient died also. He has
had individually no recovery, but is not at all discouraged, and stated
that he believed the urgent appeal of Dr. Keen's to the profession
would do a lot of good and that the profession will one day save a fair
proportion of such cases, He added that he wanted to be one of Dr.
Keen's humble disciples in this matter.
Dr. M. G. SEELIG stated that in Mt. Sinai Hospital, New York,
he had had a great deal more experience with typhoid perforation than
City Hospital Alumni. 165
with the other surgical complications of typhoid; he would, therefore,
limit himself to a discussion of intestinal perforation. His experience
had been limited entirely to cases under his care during 1902 and 1903
while senior and house surgeon at the Mt. Sinai Hospital. During
1902 there were admitted Io'ſ cases of typhoid. There occurred
among these 9 perforations; 8 were operated upon with a mortality of
88.5 per cent, i.e., I case recovered. In 1903 there were Io9 cases of
typhoid admitted; Io perforations occurred, 8 were operated upon,
with a mortality of only 50 per cent. The improved mortality rate is
to be attributed to the fact that the cases were more appreciatively
studied and operative interference earlier instituted. In every case
where a diagnosis of perforation was made the perforation was found.
The house physician on his daily rounds made a careful physical ex
amination of every typhoid patient. The importance of this daily ex-
amination has been brought out by Dr. Keen. Any sudden change in
the condition of the patient was called to the attention of the house
physician, who then called in the house surgeon and if it were deemed
necessary, the attending surgeon was then sent for. If a diagnosis of
perforation was made, operation instituted immediately or as soon as
the consent of the relatives could be obtained. The one clear and
concise fact resulting from this study was the variation in the symptom
complex of typhoid perforation. The clinical picture varied in every
case and to such a degree as to make a diagnosis always difficult and
at times extremely uncertain. Abdominal pain was found to be the
most constant symptom. No reliance could be placed on the pulse,
the temperature, the leucocyte count or the facies. Practically, the
sheet anchor of diagnosis was the careful consideration of the general
condition as compared with the patient’s condition while under the in-
ternist's observation. The speaker was compelled never to draw de-
ductions from any one symptom, until he had ascertained how long
that symptom had been present. The pulse might have been high
from the beginning, or the leucocyte count might have been 12,000 to
18, ooo from the beginning of the fever, or meteorism might have been
so extensive that liver dullness was obliterated from the sixth day on,
or the facies might have been distinctly Hippocratic, yet the diagnosis
of perforation was not assured. In one of these cases, the internist
166 The Medical Society of
reported that the suspicious symptom had existed from the be:
ginning of the disease. The surgeon, though called early, must be
largely dependent upon the internist, who influences disagnosis and
his whole course of action.
Dr. N. B. CARSoN has had some little experience with the sequels
of typhoid. None of the tissues escape. That which is of most in-
terest is the involvement of the intestinal canal. He, though having
seen a number of these cases in which he wanted to operate, up to the
present time has never been accorded that privilege. Usually the
family objected and the patients have most of them gone to their grave
in consequence. He had seen cases, however, where he thought there
was perforation and the patient got well. His sister had typhoid and
was recovering when apparently there occurred a perforation and they
expected a fatal result; much to his surprise she got well. Only re
cently a brother of a friend of the speaker had all the symptoms of
typhoid perforation. An operation was not done and the patient re-
covered; yet the symptoms were all those of perforation. Now, how
is it possible to distinguish? Year before last he saw two cases oper-
ated upon at Roosevelt Hospital. One was operated upon within
twenty-four hours after perforation had occurred; the patient died.
The next day another patient was operated upon, having all the symp-
toms of perioration; a perforation had not occurred, although all the
coats except the peritoneal coat were perforated. The speaker heard
later that this patient also died. He added his urgent plea to physi-
cians in cases of suspected perforation to call in a surgeon early and
let him judge whether operation is to be done, for if success is ex-
pected the operation must be done early. He believes less harm will
be done in those cases where operation is done and no perforation
found than in those cases where they are left to take their chances. -
Montcalm, of Montreal, urges operation immediately without regard
to shock. Dr. Carson stated that he could not agree with him in this,
although he favors early operation. In a case that occurred at the City
Hospital within the last year he had advised against operation on ac-
count of extreme shock; he was sure the patient would have
died on the table from the shock; but there are other cases where
it is possible to operate and save the patient thereby.
City Hospital Alumni. 167
Dr. WILLARD BARTLETT said that Dr. Keen had mentioned one
point that could not be passed over lightly — the method of surgical
treatment of the intestine after perforation has occurred. The custom
is and has been to sew up the perforation. Just on this point he wished
to lay stress on an article by Escher, of Triest, who advocated the
suture of the intestine to the abdominal wall, letting a fecal fistula form.
He gave a report of four cases treated by this method, with three re-
coveries. After reading an account of these operations he was called upon
to operate upon a young man twenty hours after perforation had oc-
curred. Four inches from the ileocecal valve the perforation was
found, he simply fastened the intestine to the abdominal wall with two
sutures and the man recovered. In three months the fecal fistula
closed, Escher found that out of eight cases four recovered. Of
course, such small statistics do not count for very much. One great
advantage in this operation is the saving of time, his operation requir-
ing just thirteen minutes.
Dr. PAUL Y. TUPPER expressed his appreciation of Dr. Keen’s
scholarly address His own experience had been limited, dating back
to his observation of typhoid as a general practitioner, he could recall
many complications which at that time were thought to be simply in-
cident to the generally depressed condition of the patient; it is now
known that these are directly the result of the typhoid infection. He
had seen a number of cases of abscess, notably of the parotid gland,
and he could see no reason why that gland especially should be affected,
but it does occur frequently. Stiff joints are a common sequel. Re-
ferring to intestinal complication, he had seen no case where he had
the opportunity of operating, but he had made up his mind to act
promptly and finish as quickly as possible whatever had to be done.
There would seem to be no reason why the simple attaching of the
perforated intestine to the abdominal wall, or the putting in of a drain,
should depress the patient markedly—the mortality from operative in-
terference would be very small if there were simply put in a drain,
rather than anything attempted in the way of a prolonged operation.
Dr. A. E. MEISENBACH felt that all had received additional impetus
, r \he surgery of typhoid fever. One of the first complications he
had ever seen was necrosis of the upper jaw, he removed the necrotic
168 The Medical Society of
bone and the diseased part; he sees the young man every now and
then and with exception of having an angle of the mouth drawn up-
ward he has entirely recovered. He had a case last December show.
ing the difficulties that confront one making a diagnosis. The patient
was between 15 and 16 years of age; for a month he had been treated
by a physician for malarial fever. On December 22d he came into
the hands of a college of his, on the 26th the temperature raised and
he complained of epigastric pain, on the 27th his temperature became
subnormal. He saw the case with the physician twelve hours after the
supposed lesion had occurred; during the night the patient had felt
uncomfortable, but there was nothing to lead to a diagnosis of perfor-
ation, there was some absence of liver dullness, there was no pain and
the facies were not characteristic of intestinal involvement; he did not
advise operation because there did not seem any indication for opera-
tion—that night the patient died. Upon opening the bowel the cavity
was found full of fecal matter and within two inches of the ileocecal
valve there was a perforation. - -
Dr. H. C. DALTON was particularly pleased that Dr. Keen had
called attuention to the necessity for examining the intestine for other
perforations, or impending perforations. In one case where he had
found a perforation about a foot from the ileocecal valve, the patient
died and at the autopsy he found another perforation about two feet
higher up. In a second case upon which he operated the patient re-
covered from the operation and died two weeks later from the fever,
the post mortem showing the operation had been a perfect success.
He expressed himself as being extremely pleased to have been present
and hear Dr. Keen’s address, and felt that he had been greatly bene-
fited and instructed.
Dr. FRANCIS REDER most heartily thanked Dr. Keen for his very
valuable paper and congratulated the members of the Society upon
having Dr. Keen with them. He could not imagine anything more
elevating or more stimulating than to listen to such a man. Aseptic
surgery has placed the young doctor and the old doctor almost on an
equal basis, but it is the diagnosis and the practice what brings out the
difference. There is something about an old doctor, an atmosphere
of truth and love and confidence that inspires the younger members of
City Hospital Alumni. 169 .
the profession with a feeling of modesty and respect toward him. The
members of the Society were all very glad to have Dr. Keen with them
and hoped he would come again.
Dr. F. G. NIFong felt that it would be mere presumption for
him, a juvenile in surgery, to discuss the paper of Dr. Keen, a nestor,
but he did wish to ask a question: It is the difficulty of diagnosis
that has given him trouble; he had seen one of the cases mentioned
by Dr. Carson, a case that recovered though there were all the classi-
cal symptoms of perforation; operation was not done, they simply
paralyzed the bowel with opium and the patient recovered. He had
seen two cases of typhoid in which thrombosis of the vein of the lower
extremity was ushered in by rigor and rise in temperature. Would it
not be possible to have the classical symptoms with thrombosis of the
mesenteric veins and think it was a perforation ?
Dr. Robert LUEDEKING said that he could not report anything
that touched upon the burning subject of perforation in children, this
being a rare complication in the young. With perforation in patients
of older age he has had some experience. After reading the classical
writings of Keen and Osler on the complications of typhoid fever; he
has been very alert in his watch for such complication. Four cases of
perforation have occurred in his practice. Only one came to opera-
tion. In this case perforation took place early in the morning, and opera-
tion was proceeded with at 11 o’clock. The patient was in fairly good
condition, but it was found that a tremendous serous exudation had
taken place; there was an enormous quantity of fluid in the abdomen.
The patient died. In the other cases the proposed operation was re-
fused and the diagnosis was confirmed at the post mortem. In one
interesting case the patient was a young woman about 24 years of age.
Typhoid was fully established. She was reported one morning as hav-
ing had a drop in temperature, there was found a changed condition
of the pulse, there was but little distension of the abdomen and a
perforation was assumed. The leukocyte count, however, was nega-
tive and operation was refused. The patient rallied and lived for two
weeks. There arose a tremendous distension of the abdomen and
absolute refusal on the part of the bowels to move. At the post-
mortem, on opening up the peritoneal cavity, there was an escapement
170 The Medical Society of
of gas and collapse of the abdominal wall. It was found that the bowel
was collapsed and the gas accumulation had been in the free cavity.
Nothing was found in the ileum of an ulcerative process; in the head
of the colon, however, there were a few small defects in coats. The
mesentery, particularly of the colon, was found emphysematous. The
bowel was not distended with gas. Culture and examination showed
the bacillus aerogenes. There was present a partial perforation and
the bacillus aerogenes was the cause of the death, which an operation
would have averted. He added, that he would like to ask Dr. Keen
one question: In his student days many of the patients showed
Zenker's muscular degeneration and had rupture of the pectoralis
major or biceps of the abdominal muscles. He has not seen in his
practice here a single case of rupture of muscle, he wished an explan-
ation of this. - - - -
l)r. W. E. FischEL, replying to a question put by Dr. Carson as
to whether the percentage of perforations in typhoid here was not very -
small, replied that that was the only point on which he felt that
had a right to say anything. He thought that Dr. Keen ought to
know that the reason why the surgeons who had been called upon to
discuss the paper had not had a larger experience in operative work in
typhoid perioration was not due to the fact that physicians in St. Louis
do not recognize typhoid perforations, but that they do not often oc-
cur. In his experience at the City Hospital not more than two per-
forations a year from typhoid ulcers are recorded, and that too, from a
class of patients poorly nourished offering the least resistance to enteric
fever. That being true in the City Hospital it would be true even in an
exaggerated degree in private practice. During 1903 there were a
tremendous number of cases of typhoid, yet Dr. Fischel never saw a
single case of perforation. Dr. Keen had expressed the hope that the
goal which might be reached in the treatment of typhoid perforation
was that at least 50 per cent of the cases might be saved. He, as a
physician, knowing nothing of surgery, hoped for a better goal in ty-
phoid, viz., that the day might come soon when, as in diphtheria, ty-
phoid would be controlled, so that the surgeon’s services would be re-
quired as seldom as they are now for the relief of laryngeal diphtheria.
When the perforation is of thirty-six hours duration before the surgeon
\
City Hospital Alumni. z- 171
proceeds to operate, the percentage of recoveries has been quite
large. He asked Dr. Keen what, in his judgment, would have been
the result cases if they had not been operated upon.
Dr. Elsworth SMITH simply wanted wanted to reiterate what Dr.
Fischel had said. He had been in practice since 1887 and, except his
stay of three years at the City Hospital, he had never seen a case of
perforation although he had seen quite a number of intestinal hemor-
- rhages. He thanked Dr. Keen for the interesting lesson that had been
given them, adding that he was going home to study it.
Dr. KEEN, in closing, said that he was not surprised that Dr.
Lutz did not understand the typhoid dislocation of the hip. He re-
membered very well his own surprise at the first case he found reported
thinking that it was a far-fetched idea to connnect it with the fever and
there must be some mistake. But he soon found another, and another,
and still others, until he learned that dislocation does occur in typhoid.
He was glad to find the discussion bearing especially upon typhoid
perforation. That is the point now chiefly under debate.
He had been glad to hear the remarks of Dr. Seelig as to the im
portance of pain as symptom of perforation. Pain is one of the most
prominent symptoms. Disappearance of liver dullness due to tym-
pany was not what he had referred to, but the fact that the perforation,
as a rule, would be large enough to permit the escape of gas to such
an extent as to cause the disappearance of the liver dullness by free
gas in the peritoneal cavity. The method adopted at Mt Sinai Hos-
pital can not be too highly commended, that is, the thorough daily
inspection of the patients in order that typhoid perforation or other
complication may be discovered. It is the only way in which we shall
be successful. -
As stated by Dr. Carson, it is better to do an occasional useless
operation than to neglect to do necessary operations through hesitancy.
Fewer lives will be lost by needless operations than by neglected
operations.
Dr. Bartlett referred to the speed in operating as an important
factor, Dr. Keen said it was precisely for that reason that he had dis-
couraged a resection of the bowel and urged the formation of an arti-
ficial anus. -
172 - The Medical Society of
He had been very much struck during the debate at the small
number of operations that had been done in St. Louis and had intended
asking why, but Dr. Fischel had answered that question by stating
in his remarks that a perforation rarely occurred. Happy St. Louis
where the Folk(s) are of such a character that they don’t have perfor-
ation and where they catch all their boodlers :
As to the large percentage of recoveries in operations done after
the first thirty-six hours, it is probably due to the fact that patients
who have able to live that length of time in spite of the perforation
possess such vitality and resistance that when operated they can with-
stand both fever and operation much better than most other patients.
If, however, surgeons left all their cases of perforation until after the
first thirty-six hours before operating, there would be a holocaust of
early deaths without operation.
Fe stated that he had seen three cases of rupture of the muscles.
Whether it has escaped the notice of later observers he did not know,
but it is certain that rupture is not reported as frequently as it used to
be. He added that he could not express his appreciation of the re-
ception tendered his very imperfect presentation of this matter. If he
had done anything to arouse the attention of the profession—of the
internists, for they are the men who see these cases and must recognize
the perforation, the speaker felt amply repaid for his efforts.
Remarks on the Surgery of Typhoid Fever.
By NORVELLE WALLACE SHARPE, M.D.,
ST. LOUIS, MO.
DESIRE to call the attention of the Chair to the fact
I that in a comparison with the experience of the essayist
of the evening, the experience of any operator in the
West is of but relatively little value. For without question the
surgery of typhoid in the South and West has not been permit-
ted to develop to the degree that it has in the East. We are
hardly justified in drawing definite conclusions from the experi-
ence of any one man. There still exists a peculiar indifference on
City Hospital Alumni. 173
the part of the majority of internists in that cases of typhoid fe-
ver are not more freely handled in conjunction with a surgical
colleague, nor referred, when necessary,for surgical intervention.
This is due to one of three conditions, either surgical lesions
(particularly perforations of the bowel) do not occur, or if oc-
curring are not referred to a surgical colleague, or on the other
hand are not discovered by the physician in charge.
Consideration of a digest of the literature of the subject,
even though incomplete, may serve to indicate why the surgi–
cal world demands surgical intervention, in the interest of the
patient, in certain typhoid complications.
McCrae and Mitchell have reported a series of 275 cases,
covering a period of 3 years, in the service of the Johns Hopkins
Hospital. The following surgical complications were noted.
Furunculosis, I 3 (pyogenic cocci); abscess, 2 (pyogenic cocci);
otitis media, I (pyogenic cocci); periostitis, 2 (in both cases
the clavicle); perichondritis, I (thyroid cartilage); cervical
adenitis with tonsilitis, I ; mastitis, 3; abscess of the liver I,
(practically negative cultures were found, case ended in recov-
ery); suspected cholecystitis, 5 [Keen reported 21 cases of
liver abscess prior to 1898. Da Costa reported 22 cases of liver
abscess in 1898, Perthes, in 1902, notes one case of liver ab-
scess occurring during convalescence]; appendicitis, probable,
4; intestinal perforation, 8 (7 were operated upon, 2 recovered,
a third dying from toxemia a week later); intestinal perforation
with hemorrhage, 2. - -
Gall-bladder.—1829, Louis recognized the possibility of
cholecystitis complicating typhoid.
I887, it was first known that Eberth's bacillus could pro-
duce a suppurative inflammation; Fraenckel found same, in
pure culture, in an encapsulated peritoneal abscess.
I890, Gilbert and Girode first demonstrated the presence
of typhoid bacillus in a suppurative cholecystitis
I897, occurred the important monographs of Osler and
Mason. - -
- Quincke, in the “Nothnagel System,” indorses Louis’
original statement (1829) “that changes in the bile and gall-
bladder are much more frequent in the course of typhoid fever
than in any other acute disease.”
174 - The Medical Society Of
Osler states that Flexner found the bacillus of typhoid in
the bile in seven out of fourteen cases. -
In the records of the Boston City Hospital the bacil-
lus was found in 21 out of 30 autopsies on typhoid fever
patients. . - -
Chiari found the bacillus of typhoid in 19 out of 22 pa-
tients brought to autopsy. - -
Miller found the bacillus in a case of cholecystitis, 7 years
after the attack. - -
von Dungern found the bacillus fourteen years after an
attack. - -
Droba found the bacillus 17 years after the attack, while
Hunner found it 18 years after the attack (as has been just
alluded to by Dr. Keen). & -
It is well known that biliary stagnation favors bacillary
invasion while a free flow of bile is inimical. Cushing reports
that after having introduced within the gall bladder of a dog
typhoid bacilli, they were absent, when the bladder was opened,
twenty-four hours later.
Gall-stones.—Naunyn, in 1891, enunciated his famous
dictum that “gall-stones due to a catarrhal inflammation are
induced by micro-organisms.” - - -
Richardson, in 1897, suggested the similarity which exists
between the bacillary clumping in the bile and a gigantic
Widal reaction within the gall-bladder; further, that there was
a possibility that these clumps were the foci of subsequent
calculi. &
Burley, in 1903, reports a case, and records six others, of
suppurative cholecystitis, in which the bacillus of typhoid was
found, none of which had ever had typhoid.
Stewart, in American Medicine, of June 25th, adds a simi-
lar case. 4 -
Jntestinal Perforation.—By far the most interesting of all
the surgical complications of typhoid are perforations which
occur through the walls of the bowel. r
I884, Leyden recommended surgical repair as the only
rational procedure. - - -
1884, von Mikulicz reported three personal cases and re-
viewed the literature.
City Hospital Alumni. 175
1886, J. C. Wilson indorsed operation “as the only alterna-
tive to the patient's death.”
Cushing reports a mortality in unoperated cases of 95
per gent. -
Keen, a mortality in operated cases of 80.64 per cent.
Finney, operated cases, 73.78 per cent. Monod, mortality in
operated cases 88 per cent.
1898, Westcott reported 83 cases, covering a period of
ten years, operated upon, with a recovery 19.3 per cent.
1899, Keen reported 75 operated cases, recovery, 28 %.
1901, Cushing “ I3 & 4 & & 4 & 46. I 7%.
1903, Escher “ 4. & 4 “ & 4 75 %.
Perforation occurs in 3 per cent of all typhoid cases, ac-
cording to Osler, Fitz and Murchison. Finney finds perfor-
tion of the ileum present in 80 per cent of all perforations; of
the large intestine I2 per cent, of the appendix 5 per cent. It
is generally conceded that a pre-existing appendicitis favors
recurrence during typhoid.
Shattuck, Warren and Cobb, found hemorrhage from the
bowel associated with perforation, in more than one-third of
their cases.
Gesselewitsch and Wanach, 1898, show that IO per cent
of the fatalities in typhoid are due to perforative peritonitis.
Stewart quotes Taylor (1903), “that probably over
16,OOO cases perish from perforation, annually, in the United
States.” - -
Osler, “of deaths from typhoid 50 per cent are due to
asthenia, or of the poison, or of both; 30 per cent to perfor.
ation; 20 per cent to hemorrhage and other accidents.”
The appendix is found perforated in 9.6 per cent of all
perforation cases (Cushing); in 3 per cent (Fitz); in 7 per cent
(Hopfenhausen).
Diagnosis.-The clinical picture presented in perforation
during typhoid has been variously interpreted, largely accord-
ing to the personal equation of the several clinicians. We
are safe, however, in considering the following to be the signs
and symptoms which are ordinarily most worthy of reliance:
Abdominal pain, nausea, vomiting, circumscribed flatness and
rigidity, localized tenderness, increasing distention, elevation
176 The Medical Society of
of temperature, leukocytosis—of these, pain is usually the
most important. Crile finds that increased blood pressure is
of great value in diagnosis. In those cases characterized by
a vicious infection or an enormous outflow of bowel content,
or a low degree of subjective resistance, we may find a falling
leukocytosis. This is of the gravest prognostic value.
Any of the above-named symptoms may be absent. Murphy
interprets collapse as “a late symptom due to peritoneal
change with absorption of the products of infection.” The
diagnostic scheme advocated by Connell, is not to be counten-
anced. Escher (1903), in that remarkable series of four cases,
in which no attempt to suture the perforated bowel was made,
but an enterostomy or colostomy was performed with the
greatest possible speed, secured a recovery rate of 75 per
cent. McClagen advises a colostomy, for the purpose of
drainage, in cases characterized by a partial paralysis of the
bowel, with stagnation of bowel content, and autointoxication;
and supplements this by placing his patient, when returned to
bed, in a reversed Trendelenburg position. It may be briefly
said that in operating, the patient should be stimulated when
necessary, the body heat conserved while on the table, and all
surgical methods of a time-saving character compatible with
thorough work and safety should be followed. The claim of
Escher that it is poor surgery to attempt to suture perforations
in a fragile, or at times, a rotting bowel, is worthy of profound
consideration; and the Escher enterostomy, without doubt,
demands the serious thought of all surgeons brought in con-
tact with these cases. -
I wish to call attention to the words of two of the master
in medicine : -
Osler: “What is essential in every serious case is the
watchful care of a man who will be quick to grasp changes in
the patient's condition, and who in such cases, is in hourly col-
lusion with his surgical colleague.”
von Mikulicz (1884): “If suspicious of a perforation,
one should not wait for an exact diagnosis and peritonitis to
reach a pronounced degree, but on the contrary one should
immediately proceed to an exploratory operation which in any
case is free from danger.” -
City Hospital Alumni. - 177
I would further suggest that on all frank cases of perfor-
ation operation should promptly be made, and when in reason-
able doubt,-eaplore. We should not be deterred by formid-
able complications,—as witness the case reported by Cushing
in which recovery occurred after a second and later a third
perforation had received surgical treatment.
The attention of those interested is called to an excellent
article in the May issue of the American Journal of Medical
Sciences, by Baer, on the “Distribution of Ulcers in Typhoid
Fever.”
Dr. J. L. BoEHM presented a specimen of
Syncephalus Monoprosopus.
This specimen is believed to have been mummified for fifty years
and came from Columbia, South America. It belongs to the class
Syncephalus Monoprosopus. It has two distinct heads, two bodies
and one face. These are not rare, there being about eighty known
instances among mammals and eighteen among birds. Piersol and
Hirst report one case. The method of embalming is a secret of the
natives of the country. The specimen belongs to a physician from
Columbia who will present it in Paris.
Meeting of September 1, 1904; Dr. Charles Shattinger,
President, in the Chair.
Dr. John YoUNG BROWN presented a patient upon whom he had
operated for
Strangulated Umbilical Hernia. Double Resection of Bowel.
Anastomosis With Murphy Button. Recovery.
The patient I present tonight is one which presented a very un-
usual condition. She was brought into the hospital on March 7, 1904,
with a strangulated umbilical hernia. She had had this hernia for
fourteen years and during that time had had ten children. She was
brought here in a very bad condition. The hernia, which was large,
178 The Medical Society of
had been strangulated for fourteen hours. The usual efforts—taxis,
hot applications, etc., had been applied. Elliptical incisions were
made, it being my intention to do the radical operation of Mayo iſ
conditions permitted. On opening the hernial sac I found in the sac
a small portion of ileum, the cecum, appendix, ascending colon and
transverse colon gangrenous. Primary resection was out of the ques-
tion, I, therefore, determined to make an artificial anus; this was done
by simply incising the cecum, as the gut was adherent to the sac about
the ring. I was careful not to loosen the adhesions but split the
aponeurosis externally to the sac. The patient was in a wretched con
dition, and I put her to bed to die. For some mysterous reason she
did not die, and the artificial anus worked perfectly. She discharged
her fecal matter through this anus for ten weeks, and the question
came up of restoring the continuity of the bowel. After a very careful
and deliberate examination I did not think it would be wise to attempt
an end-to end anastomosis at the site of the hernia. I concluded to
open the abdomen below the umbilicus (she was a very fat woman)
and resect the ileum close up and invaginate the stump and then re-
sect the colon. I also purse stringed the distal end of the colon, leav-
ing these two blind pouches of bowel (illustrating on blackboard), and
then I anastomosed the ileum with the sigmoid, leaving her practically
without the large bowel except the sigmoid. The anastomosis was
made with the Murphy button, reinforced with Lembert sutures. The
bowels moved in twenty-four hours after the anastomosis and she
passed the button in nineteen days. Recently, in a third operation, I
caught the bottom of the blind gut with a clamp, inverted it and
clamped it off and there is now left only a small amount of mucosa
which I will dissect off or burn off with the cautery. I was exceed-
ingly careful to make the abdominal closure secure. In closing the
peritoneum I used catgut for the muscle and fascia and horse-hair for
the skin; it held well. Her functions are normal, digestion excellent
and she will go out in excellent shape. The remarkable feature of this
case was that she ever recovered sufficiently from the gangrenous con-
dition found, to ever come to a secondary operation. I do not be.
lieve an artificial anus should ever be made except as a last resort. I
have had large experience with strangulated hernia, have done four
City Hospital Alumni. 179
primary resections all made through a supplementary abdominal in-
cision, all recovered. Since that time I have had one death, but the
patient's condition was exceedingly bad. I attribute the four consec-
utive successful cases largely to luck—quick work and a careful tech-
nic, we do have a great deal of luck in such cases.
As to anastomosis I have had a large experience in resection
work. In strangulated hernia and gunshot work I think the ideal
method of making a resection is the Murphy button. I know of no
method that makes the beautiful approximation that the button does.
In one case my assistant, Dr. Kirchner did a beautiful double resec-
tion, for perforating gunshot wound of the small bone, using the Con-
nell suture and the Murphy button used above the Connell suture; the
button passed on the fourteen day, the man dying after complete re-
covery from operation, from hemorrhage of the lungs. At the autopsy
the button union was so perfect it was almost impossible to find where
the anastomosis had been made.
As to time, in strangulated hernia and gunshot work, it is fre-
quently necessary to work fast. Such patient’s take anesthesia badly
and the button is the quickest and most perfect method. If we trim
the mucosa down and properly apply the button the union is perfect.
There is another point in regard to gunshot work and that is in regard
to investigation. We have worked out a very careful technic. Every
case that penetrates we assume has perforated and an exploratory
laparotomy is made. We have never had a death from an exploratory
laparotomy, and we have a good record on our gunshot work and
think it is largely due to our system in dealing with cases of this kind.
After opening the abdomen, the stomach, liver and spleen are exam-
ined, the transverse colon is then thrown back, the duodenojejunal
angle is then sought, the jejunum is picked up and the small bowel
given over to the ileo cecal valve, the large bowel is then examined to
the anus. When there is a perforation of the bowel we irrigate these
cases copiously, first to cleanse the abdominal cavity, and second, to
stimulate the patient. In case of shock, immediately you begin the
irrigation the pulse gets better.
As to drainage, we never use gauze in gunshot cases; we have
seen some disastrous results follow the use of gauze. In wounds of
180 The Medical Society of
the liver it is essential; many can be saved by a proper use of the
gauze tampon, and it is the only way many of them can be saved.
As soon as possible after operation these gunshot wound patients are
placed in an exaggerated Fowler position and drained through a glass
tube, which has been placed in the pelvis through a stab wound above
the pelvis, and which is kept in for a varied period of time and when
it is taken out a small gauze or rubber drain is substituted for the glass
tube. Wherever I see the indications I drain, and I generally feel
better when I have a drain.
In all these cases of gunshot wounds we make a median incision.
I believe it is the only incision through which you can make a thor-
ough search. In gunshot wounds the incision is made in the median
line, a little below the ensiform to a little below the navel. By a search
of viscera' such as has been outlined, there is no danger of overlook-
ing a perforation, and we can repair the perforations as we meet them.
This does not require complete evisceration of the patient; only a
small amount of the gut is exposed at a time.
We have in a ward here, a beautiful piece of surgery done by my
assistant, Dr. Doyle, on Saturday. It was a multiple perforation of
the bowel, the resul of a gunshot wound. It was necessary to resect
six feet of the small bowel. Anastomosis was made with the Murphy
button. The patient's bowels have moved and everything points to a
perfect recvery. It is a most interesting case. -
DISCUSSION.
Dr. A. E. MEISENBACH said he had seen Dr. Brown's case when
presented at the St. Louis Medit al Society, and thought it a unique
case in su gery. There had been a tendency to include the colon in
the same category with the appendix, many considering it an unneces-
sary organ and the cause of many ills. This woman was performing
all of her functions in a normal manner in spite of the fact that all of
the colon, except the lower part of the sigmoid and the rectum, had
been removed. It would be a very important and instructive proced.
ure to follow this woman’s history up to a later day. As to Strangu-
lated hernia, there was a time the opionion expressed by Dr. Brown
was opposite to his present opinion, he had considered it a very dan-
City Hospital Alumni. 181
gerous operation. In these cases where it was necessary to make an
anastomosis he always preferred the artificial anus and a secondary
operation. The change of opinion was due to more perfect asepsis
and at that time the Murphy button was unknown, and the button was
entirely responsible for many of the successful cases.
Dr. WILLIAM S. DEUTsch said that the case called for but little
discussion but he wished to congratulate Dr. Brown on the successful
outcome. -
THE PRESIDENT said that he hoped that Dr. Meisenbanch's re-
marks would not be taken seriously. He trusted that no member
present would be misled by that kind of humor to believe that because
the colon had been removed and the patient survived, that therefore,
the colon was unnecessary.
Dr. MEISENBAcH replied that the President had misunderstood
him, that he was not in the least facetious. He was in dead earnest.
Dr. M. G. SEELIG demonstrated the
Combined Ethyl-Chlorid and Ether Anesthesia by Means of
the Bennett Apparatus.
Recent experimental work has shown that the ill effects we fre-
quently attributed to ether, are equally due to chloroform. I refer to
lung and kidney complications. Post operative pneumonia has been
, shown to be due to exposure of the patient during the operation, or
to emboli, as well as to the irritating local effect of the anesthesia.
When everything has been said about chloroform, it still remains that
it is a heart depressant and, again, there are certain patients who have
an idiosyncrasy against chloroform. An ether death rarely occurs
without warning but that chloroform, even the respiration and color may
be good and after four or five breaths the patient is dead and all means
of restoration are of no avail. If I must deal with two deadly drugs
and one is such that it gives me a little warning and the other does
not, I prefer the former. The difficulty with ether is that you require
a very large amount as compared with chloroform and it is naturally
a pulmonary irritant. It is due to the fact that it lessens the quantity
of ether necessary that the Bennett apparatus is so very good. The
anesthesia is started with an evanescent anesthetic, as, for instance,
182 The Medical Society of
nitrous oxid gas or kelene. Since it has been proved that the latter is
so safe an anesthetic I have adopted it, as it avoids the necessity for
carrying a heavy iron cylinder, and it is not a suffocating anesthetic.
Following the kelene we use an ordinary amount of ether. An ad-
vantage in this machine is that there is no smell of ether, although
the ether ready to be used whenever necessary, is not noticed by the
patient. When the patient is once under the effect of the kelene I turn
on the ether gradually. If the ether is too strong and starts up a
laryngal reflex, I reduce it and turn on the kelene, or equal parts of
kelene and ether. A patient going under this anesthestic in three
minutes would require fifteen to twenty minutes with chloroform. I
have anesthetized an hour to an hour and a half with a half ounce.
As a consequence of the small amount of ether administered, the pa-
tient comes out of it very much more quickly than if he had taken a
large amount of the drug. .
DISCUSSION.
Dr. T. C. WITHERSPoon, was very much interested because in the
preceding two weeks the doctor had given this anesthetic for him some
ten times. One case was a vaginal hysterectomy, there were several
abdominal operations, one patient was a little boy and it was necessary
to fracture a badly set arm and reset it, and another was a cranial
case where there was a good deal of chiseling to do. All the patients
had gone under it very quickly and they had struggled very little.
They had slept after it and there was much less vomiting than in chlo-
roform. In two cases there was no vomiting and even in the cranial
case it was but a momentary vomiting and small in amount. In these
cases the doctor had given about one-sixth to one-eighth of a grain of
morphin forty minutes before the operation. Usually the patients slept
for about an hour and when they awakened it was with a very small
amount of nausea. In one case there was rather more vomiting. The
operation was done at 1 o'clock and at 7 o'clock she vomited four
times. He felt safer with it than with chloroform. In one case that
he had operated upon there were not more than five full breaths before
the doctor gave the ether. The patients had not feared the anesthetic
and with the injections of morphin there was a feeling of languor so
that they did not feel nervous. -
City Hospital Alumni. 183
Dr. DEUTsch was sorry this was the only demonstration of Dr.
Seelig's method that he had been able to witness. It seemed to him
that after getting a thorough knowledge of the method it would be
proper to determine in what way it would be of advantage over other
methods. Dr. Seelig had said that he preferred ether to chloroform
whenever he could use it. This was the opinion all over the world
now, and even the men who once advocated the use of chloroform
were beginning to use ether. That simmered the method down
to the advantage of kelene with ether over the use of ether alone.
The first advantage claimed for it was that it reduced the time neces-
sary to anesthetize the patient and that it did away with the vomiting.
Whether that was due to the kelene or to the injection before the
operation the essayist had not made quite clear. After a period of ten
years of giving anesthesia, he believed that ether could be given with-
out the struggling symptoms, without much vomiting afterward, and
that it could usually be given safely. He believed that in the use of
any narcotic sooner, or later some heart disturbance would be noticed.
No patient could well stand a narcotic that so suddenly took away his
vitality. He believed that the blue faces that were sometimes noticed
in anesthesia were due to the fact that the patients had been anesthet-
ized in a hurry, this was a mistake; the surgeon must have plenty of
time for his anesthesia. It was not because a patient wanted to fight
but because the air had been shut off suddenly and he involuntarily
struggled. So it would seem to be the question whether any patient
could be taken and so quickly anesthetized as in the case presented.
If there was any particular advantage to be gained by it, he wanted to
learn of it, and was interested in knowing what the good effects were.
He hoped that the essayist, in closing, would tell them more of his
experience with it, whether he had always had good effects with the
kelene and he wished be shown wherein the kelene in combination
had an advantage over ether alone. -
Dr. GEORGE GELLHoRN said that it afforded him great pleasure
to indorse Dr. Seelig’s statements. He had conducted the narcosis in
* a number of operations done by Dr. Gellhorn, in all of these the ab-
dominal cavity was opened from above or below except in two or three. .
There had been no untoward effects and the vomiting was markedly
184 The Medical Society of
reduced. In about four cases there was some slight vomiting. The
last few cases recovered without any vomiting whatever. The patients
after the operation usually slept from half an hour to an hour and a
half and they did not complain of pain after their return to conscious-
ness. In those cases the anesthesia had done what Dr. Seelig had
promised and had done more than was accomplished in the demonstra-
tion just made. The kelene or nitrous oxid had the great advantage
of reducing the quantity of ether. He felt as Dr. Witherspoon,_an
uneasiness during the anesthesia; but there was no doubt that with the
present method the ether was reduced to a minmum so that the dan-
ger was almost entirely eliminated. The scopolamin-morphin injec-
tions rendered the patients more susceptible to the anesthesia. One
point should be borne in mind. After the injection of the scopolamin-
morphin the patient should be kept entirely quiet and after half an
hour the patient would be more or less somnolent. The method just
presented deserves an extensive trial, though it must be admitted that
a definite judgment can not be passed until reliable statistics covering
thousands of cases can be compiled. One objection that might be
raised was the high price of the instrument and, furthermore, the
necessity of training oneself to this particular apparatus, but he be-
lieved that this objection should not exist in reality. We ought to
adopt the method of England, where anesthesia has become a speci-
alty, where a man does nothing but give anesthetics and where he
keeps himself informed of everything concerning anesthesia.
Dr. JoHN GREEN, JR., wished to know if the doctor had had any
experience with repeated transient ethyl chlorid anesthesia as an anes-
thetic, in tenotomy of the ocular muscles in children, it pressed the
advantage that the child could be allowed to come out from under it,
the effect of the tenotomy noted and if insufficient the anesthesia could
then be resumed. He wished to know it there was any record of a
disastrous effect after repeated use. - -
Dr. ELBRECHT asked the essayist to give his experience with
ethyl chlorid given alone. He wanted to know his experience with re-
gard to its effect as a heart depressant. He added that he did not"
take kindly to any anesthesia apparatus. At the Mayo clinic, Roch-
ester, they gave ether and nothing but ether. No apparatus was used
City Hospital Alumni. - 185
but, instead, about a yard of gauze in four thicknesses, and when they
wished to give more air the gauze could be removed. With the Ben-
nett apparatus, in order to get fresh air the patient would have to draw
it in through the tube. Another thing, he did not like the name
kelene. It sounded proprietary. The only advantage in its use that
he could see was in the way of economy. He referred to one case
where the patient had received forty grams of ethyl chlorid. The pa-
tient went on the table with a pulse of Ioo per minute, full and bound-
ing; respirations 20 per minute, full and deep. During anesthesia the
pulse was about 8o, full and strong, respiration 38, pupils markedly
dilated; the pulse went up to 37 when the patient was put to bed;
There was no vomiting, no nausea. He was much interested in ethyl
chlorid. It was considered a comparatively safe anesthetic by every-
body who had used it. A Boston surgeon had reported 200 cases of
pure ethyl chlorid anesthesia with but one death, and some man in
California had done 4oo operations, some lasting an hour, with good
results in every case. He believed that this anesthetic had its limita-
tions; the only reason he could see for its use was for the sake of
economy. It was very useful as an examing anesthetic, he had put
patients under it and inside of three minutes they were talking to him
feeling no ill effects. Its expense was something against it. He
wished to know if Dr. Seelig had used it in combination with chloro-
form.
He stated that for oculists and aurists it was particularly fine,
ethyl bromid was used in the same way, it could be given in from 2
to 6 grams. Every bit of air must be excluded in order to get the
anesthesia, with all the air excluded the patient would go under it
in thirty seconds and come out of it just that quickly with no bad
effects.
Dr. BRowN hardly felt that he was in position to speak of the
mcrits of this anesthesia inasmuch as his experience was limited to two
cases. The thing that had impressed him most was the rapidity with
which the patients go under it, the small amount of the anesthetic re-
quired, and the rapidity with which they come out from under it. He,
too, thought the open method was the ideal method of giving anes-
thetic. As Dr. Elbrecht had said, he had been much impressed with
186 The Medical Society of
it at the clinic of Dr. Mayo. Another point of interest was in refer-
ence to post-operative vomiting, it had been his experience that with
all patients who are anesthetized, whether by ether, chloroform or by
the method suggested by Dr. Seelig, there was always or nearly al-
ways an evacuation of the contents of the stomach, following opera-
tion but persistent vomiting he had rarely seen at the City Hospital
unless there was some reason for it, as sepsis. Although they had a
variety of cases, they had seldom given a hypodermic of morphin after
the operation, whether the incision was large or small, whether the
enucleation was wide or trivial, from an exploratory incision to a major
operation, the patient would invariably have a stormy time for the first
twenty-four hours, but in all such cases the convalescence was prolonged
by giving opium after the operation. In operation about the stomach
he believed it was always wise to give such hypodermic before the
anesthetic. He had used the method of anesthesia recommended by
the essayist, in two cases, the first anesthesia lasting forty-five minutes.
The other was a pus case with appendectomy and the patient was un-
der the anesthetic for an hour, in each instance the patient had not
seemed to be completely under the anesthetic ; in one, the patient had
been drinking heavily and was on the verge of delirium tremens and
in the other there was quite a good deal of pus in the abdomen and
he had noticed that the abdominal muscles were never completely re-
laxed. Ether given in the method outlined (as used in the clinic at
Rochester) he believed it to be the ideal method, though it apparently
took much more ether, for so much of it was mixed with air. -
Dr. ELBRECHT said that while he and Dr. Brown were at Rochester
they did not see a single patient vomit on the table. The woman had
given 12,000 anesthetics for Dr. Dr. Mayo. They used the regular 1/4
M. can of ether, a large hood with stockinet over it and the piece of
gauze. While the method of Dr. Seelig was very fine it should be re-
membered that not one man in a hundred would get the chance to be-
come familir with it. º
Dr. MEISENBACH said that his first experience in giving ether was
by the good old fashioned method of a towel and a paper cone. Later,
when he came to St. Louis, chloroform was used exclusively and he
had never used anything else except in two classes of cases, namely,
ſº City Hospital Alumni. 187
patients with a heart lesion and those men who take their highballs
long and often ; in those cases the mixed anesthesia was useful. He
had adopted the method of giving opium injections, believing that pa
tients did not need as much chloroform when opium had been previ-
ously injected. The anesthetist must be thoroughly conversant with
the method used and it was harder to get familiar with the giving of
ether then the use of chloroform. It was not quieting to the nerves of
the patient to be drawn out into the operating room with all the para-
phernalia in view and with the operator marching up and down medi-
tating with a serious face upon the outcome of the operation, such
patients, being nervous, would not take the anesthetic kindly. He
never allowed any of his patients to be taken into the operating room
before being anesthetized; a great point was to have the patient in a
calm condition. He had never had a death that he could attribute to
the chloroform, although he had seen but one or two cases that came
near dying owing to the carelessness of the anesthetist. Many times
the anesthetist watches the operator instead of the patient. As to the
bag and other part of the apparatus, Parke, some ten years ago, had
brought a similar bag from Germany for the purpose, and it was neces-
sary to school the individual in the use of the method. He was glad
he had seen the demonstration, it was possible that he might use the
method. One thing he wished to call attention to : Livingstone, of
New York, had made some very dogmatic statements in regard to the
administration of ergot before operating, the first dose being given
twenty-four hours before the operation, in that case there was but little
or no post operative vomiting; possibly there was something in that,
but he was loath to believe that any method was so beneficent as to
do away with all the drawbacks.
Dr. GREEN related a case of an elderly woman with a chronic
purulent bronchitis and cardiac arrhythmia to whom he was compelled
to administer an anesthetic recently. After careful consideration,
chloroform was determined upon. Although' freely stimulated, the
patient took the anesthetic very badly, the pulse dropping and growing
weak. He imagined that the combined ethyl chlorid—ether anesthesia
would be particularly applicable to these cases, as the disagreeable
early bronchial irritation of ether was entirely eliminated.
188 The Medical Society of
Dr. R. E. KANE stated that it was the first time he had seen this
anesthetic given. He agreed thoroughly with what Dr. Deutsch had
said. He could not but believe that an anesthetic that could produce
anesthesia as quickly as this was a very dangerous one—it must se-
verely tax the system, and he thought that the mortality would be
high. If the ethyl chlorid produced anesthesia in the way that ether
and chloroform do, it would certainly be necessary to shut it off at the
right time or disastrous results might follow. He had been so un-
fortunate as to be present when four patients died under the anesthetic.
In two cases he believed it was the fault of the man giving the anes-
thetic; in two cases chloroform had been given; two were minor op-
erations; one had occurred in the City Hospital, in that case the pa-
tient had taken it four times and always did all right, the last time the
patient got about ten drops and was dead; in one other case it was
the same. In another case the patient was an alcoholic and the chlo-
roform was pushed. In chloroform there would be trouble with the
heart before there was any difficulty with the respiration. He had
seen two cases that nearly died under ether, and wished to know just
how the ethyl chlorid produced the anesthesia. He did not believe
the morphin had much to do with the effects produced, but he had
seen it given before chloroform and before ether and yet there had
been much excitement.
Dr. DEUTSCH did not want to be put on record as having made
any objection to this method of anesthesia, and he hoped he would
not be understood as a kicker against a new method. He simply
wished to know what the benefit was, and hoped that what had been
said tonight would help in bringing about specialization in the anes-
thesia line. He had done what he could during the ten years he gave
anesthetics here. In St. Louis the surgeon pays his anesthetist a fee
of $5 or $10 and thinks that amply sufficient; in other cities the bill
goes to the patient and the fee ranges from $25 to $1 oo. It was a
science in itself and if a young man could be induced to take that up
the surgeons of the city should see that such a man got a proper living
out of it.
Dr. LAYTON, referring to the deleterious effects, such as pneu-
monia and bronchitis, said it was a question whether they were due to
City Hospital Alumni. 189
the large quantity of ether, or whether a small quantity would have
the same effect. It was a question how large a part the instrument
played. He thought this instrument just as handy as the Allison in-
haler or any other. If it was desired to give fresh air it was as easy
to remove it as in the ordinary method; the amount of ether was de-
cidedly lessened. He believed that the method of giving the ethyl
chlorid first was very much the liking of the patient. Most patients
dreaded the ether and would take the ethyl chlorid very readily because
there was none of the suffocation that accompanies ether.
Dr. SEELIG, in closing, said that the thing that pleased him most
was that he had aroused a feeling of doubt. When he entered the
hospital in New York they were using the open method. Dr. Bennett
introduced the instrument and a greater hue and cry than was raised
by that house staff he had never heard but in six months they were
absolutely dependent upon the instrument. Dr. Deutsch had asked
whether it was the kelene or the morphin that produced the results.
In reply he could only say that he was not an anesthetist, he was a
surgeon and, as such, was interested in getting good anesthesia for his
patients. As to the expense, even if the instrument did cost $40 that
did not figure for one second. Dr. Kane had thought that so quick a
method must be necessarily dangerous. He could show, from a report
of 50,000 cases, that there was one death from kelene to four from
ether and five from chloroform. Though it might appear that the
patients went under it too quickly, the fact remained that the patients
did not die. Why they did not die he could not say. Kelene, nitrous
oxid and all other evanescent anesthetics depend upon their quickness
for their efficacy. If ether or chloroform was crowded, the anesthetist
killed his patient but that was not true of kelene or nitrous oxid when
a properly made mask was used. Dr. Mayo's name had been quoted
frequently in the discussion. Dr. Mayo was his personal friend and
he admired him as much as any one, but that did not mean that every
method of his, every knot, every suture, simply because it was done by
Dr. Mayo, was one to be adopted. The point that Dr. Elbrecht did
uot bring out but should have brought out, was that the assistant who
gives the aliesthetic for Dr. Mayo has done it for sixteen years, and
any one who had given an anesthetic that long could give it success-
190 The Medical Society of
fully through a gas pipe if necessary and that lady could give it un-
questionably better than he could give it with the Bennett or any
other apparatus. The mistake that Dr. Elbrecht made was that he
wanted every cross-roads doctor to be able to give it. It should be
considered a serious thing to give anesthesia. The appliance was not
made for the general practitioner. As to the open method, the appli
ance could be so regulated that the ether could be closed off entirely,
or given absolutely by the drop method. What advantage has the open
method over this? As to the cost, he did not care what it cost, the
cost of the thing he was going to use did not figure. The Mt. Sinai
Hospital Directors objected because they had to pay $2 for the nitrous
oxid and $40 for the instrument but the druggist kept a tab on the
amount of ether used and found that the instrument soon paid for
itself by lessening the amount of ether required. If he was going to
be operated upon by a cross-roads doctor he would want to take the
anesthetic that that doctor was accustomed to give. He was not de-
fending the instrument. He was thoroughly satisfied with it. He had
seen it used for four years. He had never been so absolutely struck
by anything as by the effectiveness of this instrument. That it had
not entirely stopped the vomiting was due to the fact that the vomiting
was not entirely due to the anesthetic. What he wished to do was
to introduce an anesthetic which, when a patient of his was to be
operated upon, would put him in the best position to stand the
operation.
Meeting of October 6, 1904; Dr. Charles Shattinger,
President, in the Chair. -
The Possible Victory Over the Great
* White Plague.
By S. A. KNOPF, M.D.,
NEw York City.
Mſ R. PRESIDENT AND GENTLEMEN : — Let me
M thank you for the honor you have conferred upon me
by inviting me to address your distinguished Society.
From the title of my subject you know that I am to speak of
City Hospital Alumni. 191
tuberculosis as the “Great White Plague.” I have been in-
formed that my audience here tonight is not exclusively a
medical one; I will therefore try to render my discourse as
popular as possible, and ask the physicians to whom much of
it must sound like the A B C, pardon the occasional discussion
of rudimentary subjects of hygiene.
While the etiology of tuberculosis is well known to the
profession and even to the laity, it might be well to emphasize
once more that the only direct cause of tuberculosis is the tu-
bercle bacillus. Tuberculosis is an infectious, communicable,
preventable, and curable disease. The three methods of in-
fection are by inhaling, ingestion, and inoculation.
Let us treat first the most frequent method of propaga-
tion of tuberculosis, namely, that arising from the indiscrimin-
ate deposit of the tuberculous sputum. A consumptive indi-
vidual, even at a period when he is not confined to his bed,
may expectorate enormous quantities of bacilli. Now, if this
expectoration, or spittle, is carelessly deposited here and there
so that it has an opportunity to dry and become pulverized,
the least draft or motion in the air may cause it to mingle with
the dust, and the individual inhaling this dust-laden atmos-
phere is exposed to the danger of becoming tuberculous if his
system offers a favorable soil for the growth of the bacilli.
By “favorable soil for the growth of the bacilli” must be un-
derstood any condition in which the body is temporarily or
permanently enfeebled. Such a condition may be inherited
from parents, or acquired through alcoholism, or drunkenness,
or other intemperate habits, through privation or disease.
Besides the danger arising from carelessly-deposited spu-
tum, or spittle, the inhalation or ingestion of small particles of
saliva, which may be expelled by the consumptive during his
so-called dry cough, when speaking quickly or loudly, or when
sneezing, must also be considered as dangerous for those who
come in close contact with the invalid. These almost invisible
droplets of saliva may contain tubercle bacilli. Recent ex-
periments in this direction have shown the possibility of infec-
tion by this means.
The next most frequent method of the propagation of
tuberculosis is through the ingestion of the bacilli, that is to
say, when the germ of consumption is taken with the food.
192 The Medical Society of
The third, and much less frequent way of the cause of
tuberculosis, is the inoculation or penetration of the tubercu-
lous substance through the skin.
What should we do to stop the first and most frequent
source of the dissemination of the bacillus P
A patient suffering from pulmonary consumption should
know that, no matter in what stage of the disease he may be,
his expectoration, or spittle, may spread the germ of the dis-
ease if the matter expectorated is not destroyed before it has
a chance to dry and become pulverized. The patient should,
therefore, always spit into some receptacle intended for that
purpose. It is best to have this vessel made of metal so as
not to break. It should be half filled with water or some dis-
infecting fluid, the main thing being to make it impossible for
the expectoration to dry.
In factories, stores, railroad cars, waiting rooms, court
rooms, restaurants, saloons, meeting places, theaters, menag-
eries—in short, wherever many people congregate, there should
be a sufficient number of cuspidors, well kept and regularly
cleaned. They should be made of unbreakable material and
have wide openings. If such measures are carried out there
will be no excuse for anyone to expectorate on the floor and
thus endanger the lives of his fellow men.
When outdoors the patient should use a pocket flask of
metal, strong glass or pasteboard. There are numerous kinds
of flasks in the market, and I show you here a few of them.
A handkerchief should never be used as a receptacle for
sputum. Patients who are too sick to make use of light por-
celain or aluminum cups, should have a number of moist rags
within easy reach. Care should be taken that the rags always
remain moist, and that the used ones are burned before they
have time to dry. The paper spit-cups with their contents
should, of course, also be destroyed by fire.
There will always be some consumptives who can not be
persuaded to use the pocket flask, for the simple reason that
they do not wish to draw attention to their malady. The only
thing for these people to do is to use squares of soft muslin,
cheesecloth, cheap handkerchiefs or Japanese paper handker-
chiefs specially manufactured for that purpose, which can be
City Hospital Alumni. 193
burned after use. They should also place in their pockets a
removable lining of rubber or other impermeable substance
which can be thoroughly cleaned. This additional pocket
could be fastened to the inside of the ordinary pocket by
clamps, and would thus be of no inconvenience to the patient.
A pouch of vulcanized rubber or an ordinary tobacco pouch
may be used in place of the extra pocket of impermeable
material.
The danger of dissemination of the bacilli through the
so-called dry cough is relatively small; we should, neverthe-
less, insist that the patient hold his handkerchief before his
mouth or nose when he coughs or sneezes. The consumptive
should be advised to carry two handkerchiefs with him, one
to hold before his mouth and to wipe it with after having ex-
pectorated; the other to use only to wipe his nose. By being
careful with the use of his handkerchiefs the danger of infect-
ing his nose and bronchial tubes will be materially lessened.
Against the danger from infection through tuberculous
food we will say that whenever one is not reasonably certain
that the meat he eats has been carefully inspected and de-
clared free from disease germs, it should be very thoroughly
cooked. By this means one is certain to kill all the dangerous
micro-organisms. Against the sale of tuberculous milk there
are excellent laws in some states of the Union, which are rig-
orously enforced. In some the laws are less good, and in
some there are no laws at the present time.
As you all know, there is still a disputed point regarding
the direct transmissibility of tuberculosis from the bovine to
man. It was my privilege to be present when Koch announced
his conclusions at the London Congress of Tuberculosis that
the bacillus of bovine tuberculosis was rarely, if ever, trans-
mitted to man. I shall never forget the historical moment
when, at the conclusion of Koch's lecture, the venerable Lord
Lister rose and in a concise, dignified and eloquent way
warned the world not to accept the theory just propounded.
He said there was too much clinical evidence to favor the the-
ory of transmission and he urged repeated experiments before
accepting Professor Koch's conclusion. These experiments
are still going on. What has been published about them up
194 The Medical Society of
to this date is in favor of the acceptance of the transmission
theory, and we physicians should persistently urge that the
people continue to sterilize or boil milk and cook their meat
if there is any doubt as to the absolute freedom from tubercu-
losis of the animals whence these products have been derived.
It might be interesting to cite the other extreme which has
been presented in a work recently published by von Behring.
This distinguished author claims that there is no inhalation
tuberculosis, but that all tuberculous diseases are contracted
during childhood from milk derived from tuberculous cows,
and that when an adult becomes tuberculous, it is, according
to Behring, simply the outbreaking of the latent tuberculosis
contracted during infancy. I venture to say that Behring's
views in this respect are shared by extremely few who have
studied tuberculosis carefully. The other day it was my priv-
ilege to dine with that distinguished Japanese scientist, Pro-
fessor Kitasato, and in the course of our conversation he
touched on the subject of the transmissibility of the bacillus
of tuberculosis from cattle to man. It was a revelation to me
when he told me that in Japan such a thing as feeding a child
with cows' milk was virtually unknown; and yet tuberculosis
was quite frequent among young and adults. This, certainly
would, in my humble opinion, strongly indorse the inhalation
theory. ~ *
Inoculation, or the penetration of the tuberculous sub-
stances through the skin happens, perhaps, most frequently
through injuries received while cleaning nicked or chipped
glass or porcelain cuspidors which have been used by consump-
tives. It is also possible for the bacilli to enter the circulation
if the person cleaning the Spittoons happens to have a wound
or open sore on his hands. Persons entrusted with the care
of the spittoons in a private home or in an institution for con-
sumptives should wear rubber gloves while cleaning these
vessels.
At times the patient may inoculate himself by placing an
accidentally injured finger in his mouth, or by carelessly soil-
ing an open wound with his expectoration.
Physicians, students of medicine or veterinary science,
butchers, etc., are also exposed to the danger of wounding
City Hospital Alumni. 195
themselves with instruments which have come in contact with
tuberculous matter. Extreme care is the only remedy for all
persons thus exposed.
After all that you have heard so far of the contagiousness,
or rather the communicability of tuberculosis, and consump-
tion in particular, I do not wish you to think that a breath in
an atmosphere accidentally laden with bacilli would certainly
render a healthy individual consumptive, or that by a swallow
of tuberculous milk, or a little injury from a broken cuspidor,
one must necessarily become tuberculous. The secretions of
our nasal cavities, doubtless also the blood, and the secretions
of the stomach of the healthy individual, have bactericidal
properties, that is to say, they kill the dangerous germs before
they have a chance to do harm. Therefore, the healthy man
and woman should not have an exaggerated fear of tuberculo-
sis, but they should, nevertheless, not recklessly expºse them-
selves to the danger of infection.
But who are the individuals who must be particularly
careful so as not to be attacked by the almost ever-present tu-
bercle bacillus P
There are four classes: First, those who have a heredi-
tary predisposition to consumption; secondly, those who have
weakened their system and thus predisposed themselves to
consumption by the intemperate use of alcoholic beverages,
by a dissipated life, or by excesses of any kind; thirdly, those
whose constitution has been weakened through disease—for
example, pneumonia, typhoid ſever, smallpox, whooping cough,
measels, syphilis, influenza, etc.; fourthly, those whose occu-
pations, trades, or professions—such as printing, hat making,
tailoring, weaving, and all occupations where the worker is
much exposed to the inhalation of various kinds of dust, have
rendered them particularly liable to consumption.
Before I proceed to give you a few of the essential points
how to overcome such a predisposition to consumption, let me
answer the question which I beliève I read in the minds of
many who honor me by their presence here, namely: What
about those who have hereditary consumption ? Permit me to
say that the popular notion concerning hereditary consumption
is, in my humble opinion, absolutely erroneous. Consumption
196 The Medical Society of
has, perhaps, never been inherited, either from the father or
mother, but the child has usually been infected by its well-
meaning but ignorant consumptive parents after birth.
The most common modes of infection during early child-
hood are, perhaps, the following: The consumptive mother
caresses the child and kisses it on the mouth ; she prepares the
food, tasting it to judge its temperature and flavor through the
same rubber nipple, or with the same spoon the child uses, and
thus unconsciously conveys the germs of the disease from her
own mouth to that of the child. Later on the child will play
on the floor in the room and should there be a consumptive in
the family who from carelessness or ignorance is not prudent
in the disposal of his expectoration, the child is likely indeed
to be infected. The little one, while playing on the floor, may
with great facility inhale the bacilli floating with the dust in
the air and can thus acquire tuberculosis by inhalation, the full
development of which may only take place in later years when
the origin will not be thought of. Again, the little child
touches everything it can take hold of, infecting its fingers
thoroughly, and by putting them in its mouth may cause tu-
berculosis by ingestion which will gradually develop into con-
sumption of the bowel. Lastly, should the child's nails be
neglected, it may scratch itself with the infected fingers and
thus inoculate its system with the disease. Tuberculosis of
the skin, or lupus, may result from such an accident.
Even later on, when the child goes to school, the danger
of contracting tuberculosis is not removed. The child may
become attached to a little consumptive companion and they
may kiss each other when going to or coming from school; or,
again, the infection may result from the not unusual practice
of swapping apple cores, candy, chewing gum, etc.
To prevent these modes of infection during childhood is
certainly possible by taking the following precautions: Not
only should consumptives be religiously careful with their ex-
pectoration but they should associate as little as possible with
young children, and stay away from playrooms and play-
grounds. We repeat that to kiss children on the mouth should
never be allowed, and the little ones should be taught never to
kiss or be kissed by strangers. They should be kissed by
City Hospital Alumni. 197
their own friends and relatives as little as possible, and then .
only on the cheeks. The floor on which the child plays should
be kept scrupulously clean: fixed carpets in such a place are
an abomination; they only serve as dust and dirt collectors,
and not infrequently harbor the germs of contagious diseases.
The hands and nails of little children should be kept as clean
as possible. Expectorating on playgrounds should be consid-
ered a grave offense and should be punished accordingly.
These playgrounds should be kept clean and as free from dust
as possible, being daily strewn with clean sand or gravel.
To protect the child from contracting tuberculosis during
school-life, we must have the co-operation of the teacher and
superintendent of public and private schools, and even kinder-
gartens. If I had my way I would have all the school child-
ren provided with a little leaflet of instructions, which would
read about as follows: -
Do not spit, except in a spittoon or on a piece of cloth, or
a handkerchief used for that purpose alone. On your return
home have the cloth burned by your mother, or the handker-
chief put in water until ready for the wash. -
Never spit on a slate, floor, sidewalk or playground.
Do not put your fingers into your mouth.
Do not pick your nose or wipe it on your hand or sleeve.
Do not wet your finger in your mouth when turning the
leaves of books.
Do not put pencils into your mouth or wet them with
your lips. -
Do not hold money in your mouth.
Do not put pins in your mouth.
Do not put anything into your mouth except food or
drink.
Do not swap apple cores, candy, chewing gum, half-eaten
food, whistles, bean blowers, or anything that is put into the
mouth
Peel or wash your fruit before eating it.
Never cough or sneeze in a person's face. Turn your
face to one side and hold a handkerchief before your mouth.
Keep your face and hands and fingernails clean; wash
your hands with soap and water before each meal.
198 The Medical Society of
When you do not feel well, have cut yourself, or have
been hurt by others, do not be afraid to report to the teacher.
I have said that consumption is not hereditary, and child-
ren born of consumptive but intelligent and conscientious pa-
rents need not necessarily contract the disease. I myself have
seen children of consumptive parents grow up to be strong
men and women; but their parents were not only careful,
clean and conscientious, they were also aware that, while they
did not transmit consumption to their children, they did trans-
mit to them a tendency, or predisposition to this disease. This
hereditary predisposition is, however, a condition which can be
overcome by judicious training, proper food, plenty of out-
door exercises and the avoidance of all excesses. Predisposed
individuals should dress sensibly and according to the season.
They should never wear garments which restrict circulation or
hinder the free physiological function of the chest or abdo-
men. Tightly laced corsets, tight neckwear, tight shoes, are
all pernicious and particularly dangerous to the individual pre-
disposed to tuberculosis.
A predisposition, whether inherited or acquired, may be
explained as a peculiar weakened state of the system which
offers a favorable soil for the growth and multiplication of the
germs of consumption. I have already said what should be
the duty of parents if they are themselves consumptives and
fear to have transmitted to their offspring a predisposition to
the disease. - - -
Concerning alcoholism and other intemperate habits,
which are so often the forerunners of consumption, I desire
to speak plainly. I do not wish to appear to you as a temper-
ance lecturer, condemning all and everything which does not
subscribe to the doctrines of the temperance party. I con-
sider alcohol a medicine, at times indispensable in the treat-
ment of certain diseases; but liquor as a beverage is never.
useful and nearly always harmful. Alcoholism must be con-
sidered the greatest enemy of the wellfare of a nation, the
most frequent destroyer of family happiness, the cause of the
ruin of mind, body and soul, and certainly the most active co-
operator of the deadly tubercle bacillus.
To combat alcoholism (drunkenness or intemperance), ed-
City Hospital Alumni. - 199
ucation above all is required. Extreme prosecution and fanat-
ical laws will do little good. From early childhood the dan-
gers of intemperance and its fearful consequences should be
taught. In schools and at home the drunkard should be pic-
tured as the most unhappy of all mortals. While the very
moderate use of feeble alcoholic drinks, such as light beers,
may be considered as harmless to adults when taken with their
meals, alcohol should never be given to children, even in the
smallest quantities.
The clergy, too, might help in the combat of tuberculosis.
They should have their churches well ventilated, they should
advocate individual communion cups, and in Roman Catholic
churches articles of adoration which are kissed by the devout
should frequently be wiped off with an antiseptic solution. The
kissing of the Bible when taking an oath should be discour-
aged by divines and jurists. Neither clergymen, jurists, states-
men or laymen should indorse patent medicines, the constitu-
ents of which are totally unknown to them.
On the duties of the public press in this fight against the
“great white plague,” the most formidable disease of the
masses, I can not speak earnestly enough. Our daily and
weekly papers have already done much good in disseminating
knowledge regarding the prevention of consumption. By
continuing to spread the literature of the various associations
and committees on the prevention of tuberculosis, they do,
perhaps, more good than any other agent.
Unfortunately, the public press serves also for the adver-
tising of the many “absolutely sure consumptive cures,” which
are from time to time put on the market by unscrupulous
quacks. I am névertheless sanguine enough to hope that in
time the better class of newspapers will, in the interest of the
community at large, no longer extend the hospitality of their
columns to such dangerous advertising matter, especially when
it is protested against by the intelligent reader. How many
poor consumptives have lost their last little reserve fund by
giving everything they had for a dozen bottles of the “sure
and quick cure,” only those who come much in contact with
them know. How unscrupulous some of these charlatans are
in their methods of procuring certificates of cure, which they
200 The Medical Society of
then publish as a bait to the unfortunate help-seeking sufferer,
is something which can hardly be believed. Let me tell you
of one instance: A poor woman in the last stages of con-
sumption came to me seeking advice. When asked for the
name of her former medical attendant, she confessed that she
had been treated for a number of weeks by a quack concern,
and now, her means being exhausted, she was made to under-
stand that they would not continue to treat her unless she
would give them a certified testimonial that she had been
thoroughly cured of her disease, which had been pronounced
an advanced case of consumption by prominent physicians.
This poor sufferer had not derived any benefit whatsoever
from the treatment, and as a result her conscience would not
permit her to become a partner to such a procedure.
Some of these unscrupulous concerns resort to absolute
fraud; to beguile the public they use the name of the great
scientist and benefactor, Prof. Robert Koch, of Berlin, as
though he were associated with them in their business and
treatment. They advertise his picture beside that of an indi-
vidual with a similar name, and head their advertisements with
“Professor Robert Koch's Cure.” While the medical profes-
sion at large was, of course, aware of this evident fraud, the
public did not seem to be, and in order to be able, officially to
deny any such connection, I wrote some time ago to Prof.
Robert Koch, Berlin, Germany. The Professor's answer was
a lengthy one and full of indignation, and I will only give you
the substance of it. He says that the alleged “Lung Cure”
of Dr. Edward Koch, or under whatever name this system of
treatment may be presented to the American public, is a very
base fraud, and that he, Geheimrath Professor Dr. Robert Koch,
has no relations whatsoever, with Dr. Edward Koch, or with
any other individual who may be connected with this concern,
nor with any of its methods of treatment; neither has he ever
had any relations with the same. He hopes that we may be
successful in putting an end to this base and fraudulent con-
cern. This is to be particularly desired in the interest of the
many poor consumptives who have been deceived by the
use of his (Prof. Robert Koch's) name in connection with the
so-called Koch's Consumption and Asthma Cure. -
City Hospital Alumni. 201
There are numerous other concerns which put their secret
consumption remedies on the market and resort to all sorts of
illegimate means to make people believe that their “cures"
are indorsed by the profession.
To break the nefarious trade of the men who deal in
“sure and infallible consumption remedies, to stop the prac-
tice of the men and women who claim to be able to diagnose
and treat consumption by letter, the Christian Scientists, the
Faith Curists, who ridicule preventive measures and the
laws of cleanliness and hygiene—which are the laws of
God—but who, as a token of faith, demand their fees in
advance, we have but one weapon, and that is education;
education by the conscientious press, the clergyman and
the teacher.
All employes, men and women of whatever class, should
be allowed ample regular time for their meals, which should
never be take in the workshops. Lastly, employes should not
be overworked. There should be reasonable hours for all, so
that the laborer may enjoy the bodily and mental rest which
is essential to the preservation of health. The germs of any
disease, but particularly those of tuberculosis, will always find
a more congenial soil for development in an overworked and
enfeebled system. Child-labor, that is to say, the employment
of children under fourteen years of age, in factories, work-
shops, mines, etc., should be prohibited by law. The child is
more susceptible to tuberculosis than the adult, especially when
its delicate growing organism is subject to continued physical
strain. That there are still sections in our country where child
labor is permitted is one of the saddest and most disgraceful
blots upon the good name of our nation.
I have said at the beginning that tuberculosis is a cur-
able disease. Let me emphasize this now by a somewhat
stronger term, in saying that pulmonary consumption is one of
the most curable of all chronic infectious diseases. But how
is it cured P. Not by drugs, nor any specific remedy, not by
quacks, Christian scientists, faith.curists, or other mysterious
powers, but simply and solely by the judicious use of God's
fresh, pure air, sunshine, plenty of good water, inside and out-
side, good food, and all this under the guidance of the physi-
202 The Medical Society of
cian. The latter may prescribe now and then a little medicine
when the just-mentioned means do not suffice to bring about a
cure. Unfortunately, only a few people can have all the ne-
cessary environments, the best of food, the best of air, and the
best of care in their homes; for this reason sanatoria have
been established, that is to say, institutions exclusively conse-
crated to the care of the consumptives.
Modern phthisiotherapy teaches that it is not absolutely
necessary to have these sanatoria in high altitudes, or in cli-
mates reputed to be particularly favorable to consumption.
There are now existing as many, and perhaps more, in the
eastern states, such as Massachusetts, New York, Rhode
Island, etc., than there are in the high mountainous regions,
and the patients in all of these institutions are doing well and
many of them are cured. In my own service on North Brother
Island, where I have as many as sixty to seventy-five consump-
tives all the year around, even there on this island, completely
surrounded by the East River, we accomplish cures. Your
own State, Missouri, and your own city, St. Louis, certainly
offer enough sites to establish sanatoria where you could cure,
and lastingly cure, patients taken there in the earlier stages of
the disease. To have a sanatorium near your city will do
away with nostalgia, (homesickness), which is often such a
depressing factor to the patient sent far away from his home.
Another advantage of a nearby institution is that you can take
care of your advanced cases which you might wish to remove
from their unsanitary homes in order to protect their families
and make the patient himself comfortable and relieve his
sufferings.
A valuable institution to control tuberculosis in a city is a
dispensary. A special dispensary for tuberculosis should,
however, in order to be efficient, not only treat the consump-
tives by medicine and advice, but also provide, in case of ne-
cessity, meals for the absolutety poor, for, as you all know,
food is more important in the treatment of tuberculosis than
medicine. If you don't do this, your tuberculosis dispensary
will only do half its work. Let me, in relation to this, give
you a little anecdote which happened to me in my earlier days
when I had charge of a dispensary class. A young man,
City Hospital Alumni. 203
coming to my class, suffering from a moderately advanced
pulmonary tuberculosis, complained to me of having no appe-
tite. I prescribed for him what I considered a good tonic and
advised him to improve his appetite by moderate outdoor ex-
ercises. A few weeks later I saw him again; the scales re-
vealed an additional loss in weight. I asked him whether his
appetite had not improved P. The reply was in the affirmative.
He saw the puzzled expression in my face and said: “Doctor,
it is not your fault that I did not gain weight; you improved my
appetite, I could eat a whole lot if I only could get the food.
Being out of employment and having but little money left,
I nave lived on milk and crackers ever since you improved my
appetite.” This might sound humerous, but it is really pa-
thetic and shows how much it is necessary for a modern tuber-
culosis dispensary to have something else to dispense besides
advice and medicine. Whether this something else be milk
and eggs or entire meals through the aid of the diet kitchen,
must depend upon the facilities and means placed at the dis-
posal of the dispensary.
To summarize how the victory over the great white plague
may become possible, let me say that we must interest, first
our philanthropists, the majority of whom have been apathic
up to this date toward the sufferings of our consumptive poor
and the tuberculosis problem in general. Instead of more
libraries, more churches, more universities, let us have first
more model tenement houses, more parks and playgrounds,
more sanitarily constructed schools, more public baths, more
healthful places of amusement to counteract the attraction of
the saloon, and more sanitary workshops and factories, so as
to prevent the predisposing causes to tuberculosis.
To cure the tuberculous, let us have seaside or mountain
sanatoria to cure the scrofulous and tuberculous children, pref-
erably with schools attached so that the mental development
of the children shall not suffer while the child's physical con-
dition is being taken care of. To cure the consumptive adult,
let every family physician be especially trained in the early
discovery of pulmonary tuberculosis; let the school boards en-
gage a sufficient number of assistant school inspectors to make
periodic examinations of the chests of all pupils and teachers.
204 The Medical Society of
Let municipalities and philanthropists combine to establish a
sufficient number of well-conducted and well-equipped tuber-
culosis dispensaries for the ambulant consumptive poor, a suſ-
ficient number of special hospitals in or near the cities for the
more advanced cases, and lastly, a sufficient number of sana-
toria at not too great distance from the city, where all the
curable patients may be cured. All three kinds of institutions
have not only for their purpose the cure and care of the tuber-
culous, but also their education in regard to the prevention of
consumption. Thus, whoever has passed through any of
these institutions will, on his return to his former environ-
ment, become a hygienic factor, teaching his fellowmen the
priciples of what to do and what not to do to “catch con-
sumption.” . - * w
* If all these suggestions should be carried out, and in a
land as rich as ours with so many noble, generous-hearted
philanthropists and trained physicians and sanatarians, the
victory over the great white plague should not remain a possi-
bility but soon become a certainty.
DISCUSSION.
Dr. WILLIAM PORTER appreciated the opportunity of adding his
indorsement to what has been said. After listening to Dr. Knopf no
one would wonder that he had become such a leader. Just beneath
us 50,000 men on each side in the struggle between Russia and Japan,
have already yielded up their lives, yet, in the United States every
year 200,ooo die the victims of the great white plague. In St. Louis
alone according to present mortality rates there will be of those now
living, victims to the same extent as in this great Oriental war. Dr.
Knopf has spoken very earnestly of the combat through individual
and municipal work, but he had not told them of his own work. In
New York, through the efforts of Dr. Knopf and his confreres, there
has been a reduction of 40 per cent in the mortality from tuberculosis.
This has been accomplished through improved sanitation, and by the
application of the laws already on the statutes. The same application
can be made here in St. Louis. There has already been an attempt
to do something in St. Louis. Sometime ago, a permanent organ-
ization was effected. That organization work is largely relegated
City Hospital Alumni. 205
to committees. On the publicity committee, headed by a well-known
physician, there is the editor of each daily paper in the city. The
sanitation committee is headed by a sanitary expert and on the finance
committee are some of the best practical business men in the city.
The chairman of these committees form the executive committee.
There is a good deal of ground to be covered and it must be done.
well; their purpose is this: first of all they will have the aid of the
Board of Health in the matter of inspection and of the great charity
institutions in inspection and registration. He believed that registra-
tion could be accomplished in a manner that would not be objection-
able. Physicians will be interested in different parts of the city, each
- giving an hour or so twice a week to patients who may come to them
with a card from these charitable institutions. Then they hope to
have a dispensary. By educational methods, by illustrated lectures,
by talking in the universities, etc., it is hoped that enough interest can
be aroused to bring about a result equal to that accomplished in
Eastern cities. If so much is done it will mean the saving of 40,000
lives; if they can save, say, half of 40,000 lives, it is a great thing to
do. If one will go down through the Ghetto district he will under-
stañd the need of clearing out of what is possibly the greatest foe to
life. The sanitarium can only be a school, an illustration, as it were.
In the consumptive hospital, that is found to be the case; the patients
come to them in such extreme condition that though they can not re-
fuse to take them, their condition can be only ameliorated, but the
patients' friends can be taught how to prevent the disease, how to
guard against infection and how to care for patients in the earlier
stages. The work of the Asssociation has been done quietly until
they were in a position to ask the public to join with them heart and
hand; there can be objection offered to co-operation; no monetary
influence can be against it; there is everything in favor of it, nothing
opposed to it; if the spitting in street cars could be stopped it would
be a long step in advance, it is a duty to have the law enforced. If
physicians will go at this idea rightly it will be possible to limit the dis-
ease; if this work is not carried on as it should be St. Louis will be
an example to other cities of negligence and reproach. When the news
comes to us from Philadelphia and New York that they have done
206 The Medical Society of
so much, it should be a guide and encouragement to the profession of
St. Louis. - - -
Dr. WM. T. CLUTE, Schenectady, New York, said that for the
past nine years he had been interested in public health matters in the
city of Schenectady. The city is rapidly growing, within the last 15
years having increased in population about three times, so that there
are now about 56,ooo people. The people have come to consider tu-
berculosis as they do scarlet ſever or diphtheria and when a patient dies
they go to the Board of Health and ask to be disinfected. Even the
landlords do that, thinking they can rent their houses better. The
speaker considered the points brought out by the lecturer of the great-
est interest to every one connected with the preservation of the public
health. When the people are once educated up to the idea of the
germ theory of tuberculosis there will be no trouble in the control of
it. If the people understood the danger of the tuberculosis germ as
they do the diphtheria germ physicians would have less trouble. As it
is, if the patient uses in public a method of treatment for the preven-
tion of the infection of others, if he uses a sputum cup, for instance,
then the public wants to get away. If some means could be devised
to do away with that it would be a long step in the right direction. . In
Michigan, when a physician reports a case of tuberculosis, letters are
sent out to the family and to the neighbors instructing them how to
take care of themselyes. In the city of New York there is a contagion
hospital where free examinations are made, but Schenectady has not
as yet taken hold of that. •
Dr. ALBERT MERRELL stated that the speaker of the evening did
not need his indorsement. The care of the patient personally and of
his immediate surroundings, together with the education of the patient
and his friends, to protect those with whom he might come in contact, -
are the essentials of the case. In reference to the public press, its in-
fluence is greater far than most people realize in matters medical. To
show that the managers of the St Louis press have a genuine interest,
Dr. Merrell stated he went personally to all the editors of the papers of
St. Louis and without exception they agreed to act on the committees
and to give any reasonable space to matter presented to them on the
prevention of tuberculosis. If the opportunity they have offered is
City Hospital Alumni. 207
utilized great benefit will be derived. Someone has said that the fight
against tuberculosis will have to be made in 98 per cent of all cases in
the homes of the patients. That statement was emphasized by the
statement of Dr. Knopf as to the large degree of poverty among such
patients. Their situation is such that it is almost impossible for them to
seek dispensary help. Many of them would never go near a physician
for fear of a fee. It is that large class that the societies will seek to
ferret out and to assist. It must be done with great delicacy, and at
the same time with whole-heartedness and generosity. It will require
a large amount of money. The patients and his friends must be edu-
cated. Even the sanatorium will have to be, as Dr. Porter said, largely
an educative institution. Education will be the chief work for many
in the sanatorium. - -
Dr. GEORGE HomAN said that when the story was simple the moral
was plain. The facts had been so clearly set forth that there was no -
mistaking their import. It only remained for us to organize in the
most effective manner, and to educate the public in this matter. He
was glad stress had been laid upon the fact that these sanatoriums and
dispensaries are educational in their character. The benefit to the
sufferer, of course, 1s inestimable but their advantage to the public as
teaching institutions can hardly be overestimated, and our efforts, so
far as immediate work is concerned, should be to procure the estab-
lishment of a sanatorium by the State. He believed they were all
pretty well aware of the need and that they could push the work
along and all co-operate in forwarding this movement to a successful
conclusion. -
Dr. L. H. BEHRENS was very glad to have heard Dr. Knopf’s
remarks. He felt that all had been said that could be said upon the
subject but he had a point in mind for which he believed that he and
other physicians deserved censure, and that was the hesitancy they
display in telling their patients that they have consumption. If the
patient has consumption he is told various little hygienic measures he
must carry out, but he will become careless in carrying out the instruc-
tions. He said that for this reason he had recently made it a practice
to break it gently to his patients. The first patient he feared he had
been too harsh with. The patient could not accept the truth and
208 The Medical Society of
the fright was something terrific. He resolved that he would wait
along time before he told another; but the patient carefully followed
instructions and began at once to improve. Talking of duty, he had
been very much surprised two years ago in reference to the spitting
ordinance. When it came up three members of the Civic League were
present and one physician and it was by the hardest kind of work that
it was made a law. He happened to be present that evening because,
as a member of the profession, he was interested. Dr. Behrens was
glad to have a better insight into the league Dr. Porter had formed
and would be glad to work right along those lines and he believed the
press should be kept informed on the subject. The treatment of con-
sumption consisting in prevention rather than cure, the people must be
educated on straight and simple lines.
Dr. PORTER, replying to an intimation made by the speaker, dis-
claimed the honor of being the sole agent or organizer of this league,
and asked that every physician present give his hearty indorsement to
this movement. The work is large enough for all of us, and each is
needed in it.
Dr. C. A. SNODGRAS called attention to the fact that in his exam-
ination of the numerous specimens of sputa he has been endeavoring
to tabulate the information that he can secure in connection with the
specimens. Accompanying each specimen there is a printed slip the
physician is supposed to fill out. In the next annual report there will
be shown all the facts collected from about one thousand cases. Those
facts are based upon the information supplied by the profession.
Though such data is not as valuable as that coming from a hospital,
it was thought wise to show just what the medical profession is doing
along this line. It will contain such information as the answers to the
following questions: What is the earliest possible time the bacilli will
be found in suspected cases? In how many cases is there a family
history of tuberculosis? In how many cases is there no such history !
Dr. Snodgras wished to impress upon the medical profession the aid
they could render in collecting such information. The doctor is a
busy man and it is with difficulty that he can get accurate information.
His object in calling upon the city bacteriologist is to know whether a
given specimen contains tubercle bacilli and often the blanks are not
City Hospital Alumni. 209
filled or only partly. The speaker felt that it was due to science that
such information be collected and that the physicians should attempt
to give the data asked. If the profession would give the data un-
doubtedly much valuable information would be acquired.
The PRESIDENT said regarding Dr. Behrens' dislike telling patients
they have tuberculosis, that he believed all physicians disliked to tell a
patient that he has a dangerous malady, but that he made it a rule to
adhere strictly to the principle that it is a duty to tell patients what
ails them, barring only an occasional exception where the imparting of
such information will prove an injury, and he believed such cases very
rare indeed. Not only in consumption does the profession err in not
telling patients the truth as to the diagnosis; a great deal of the ignor-
ance of the laity, a great deal of the abuse of patent medicines could
be laid at the door of the profession because they do not take pains in
explaining matters fully to patients. He had always held that a pa-
tient coming to him, came to him as an expert in a certain line, and
that he was paid for the truth and unless he gave the patient the truth
he was not giving him an equivalent of his fee. If he hurts a patient
in telling him what ails him he has done no more than when he hurts
him in lancing his finger. In each instance it is done for the patient’s
good. He tells his patient that he is sorry to say he has consumption,
but that he is happy to say that the view regarding consumption has
undergone a change, etc., and in the majority of cases the patient is
converted into an intelligent helpmate of the physician. Dr. Shat-
tinger regarded this crusade against consumption as of a higher sig-
nificance than merely a step in advance in medicine. It showed the
growing assendency of the principle of responsibility—the spirit of the
words, “I am my brother’s keeper” was the foundation of this move-
ment. Only as each individual shoulders his responsibility can the
disease be conquered.
Mr. F. G. EATON, President of the St. Louis Society for the Pre-
vention of Tuberculosis, and Chairman of the Special Committee on
the Prevention of Tuberculosis of the Civic Improvement League, said
that he had enjoyed the popular side of Dr. Knopf’s lecture and
thought he had understood the medical side of it. The Civic Im-
provement League is very much interested in this work of prevention.
2 [O The Medical Society of
It is the aim of both the Society and the Civic League to mitigate the
disease and cut down the number of deaths, and they have the duty
of raising the funds for the work. The question is how to do it. The
public must be solicited and the doctors could be of great assistance.
The physician's work among his patients would mean a great deal in
the advancement of the undertaking, especially if he would say that
the Society stood for a good thing, that it would be a good thing to
belong to the Society and a good thing to subscribe to its and the
League’s special work of prevention. Mr. Eaton asked the physicians
to say to all their patients that if they wanted to spend their money
wisely and in real public charity to subscribe to special funds of the
Society of and of the League for the prevention of tuberculosis. A
special effort must be made to raise money, for without funds little
good can be accomplished, as the education of the public on the
question of preventive measures requires much in the way of publica-
tion, lectures. etc. The key to the door of success in “prevention ”
seems to be public education.
Dr. KNOPF, in closing, said that he thought the audience had had
enough of tuberculosis for one night, and he would be as brief as pos-
sible. Fe regretted that Dr. Snodgras had gone for he had something
to say regarding that gentleman's statements. To Dr. Knopf it seems
important not to wait with the diagnosis of tuberculosis until the dis-
covery of the bacillus in the sputum for then the disease has already
progressed to the stage of disintegration of the tubercles. Again,
even at that stage it is often necessary to have numerous specimens to
find the bacilli In other words, while the presence of the bacillus in
the pulmonary secretion is an absolute proof that we are in the pres-
ence of tuberculosis, the absence of the bacillus does not mean the
contrary when physical examination indicates the presence of the dis-
ease. Even the relative number of bacilli in a given specimen can
not be considered of great prognostic value. A recovering patient
may dislodge, accidentally through a coughing spell, a small particle
of tissue full of bacilli about to incapsulate, and the specimen of spu-
tum examined shows a very large number of bacilli; again, a dying
patient may have a bronchorrhea, and the diluted sputum specimen
may show no bacilli at all.
City Hospital Alumni. 211
Regarding the supervision of the consumptive poor by nurses, the
doctor stated that all patients applying to the Clinic of the Health
Department of New York City were visited by District Nurses who in-
structed them concerning hygiene and a proper mode of living. Pa-
tients who had no private physician were also visited by sanitary in-
spectors. The New York Board of Health was, to the best of his
knowledge, the only authoritive body in the world which had a right to
remove tuberculous patients from their unsanitary environments to a
city or country sanatorium.
He used the word sanatorium and not sanitarium advisedly, for
he preferred the word sanatorium. Brehmer, the founder of the first
institution of that kind, called it “Heilanstalt,” which means a heal-
ing institution; and the word “sanatorium,” from the Latin sanare, to
heal, gives certainly a better equivalent to the German word than the
word “sanitarium.” This latter word is derived from the Latin
sanitas, health, and is usually employed in this country to designate a
place considered as especially healthy, a favorite resort for convales-
cent patients, or an institution for the treatment of mental or nervous
diseases.
In such sanatoria the patients are taught the best means to pre-
vent infecting others and reinfecting themselves, also what to do and
what not to do to accomplish their cure. The result of these precau-
tions is that the well-conducted sanatorium for consumptives is the
best place not to catch pulmonary tuberculosis. Thus, it can be said
that a sanatorium is not a danger to the neighborhood; nay, it is even
a blessing. In the two German villages, Goerbersdorf and Falkenstein,
which surround five of the most flourishing sanatoria, the mortality
among the villagers had been reduced to one-third of what it was be-
fore the establishment of the sanatoria. The explanation of this fact
is to be found in the voluntary, or even involuntary, immitations of
the cleanly habits of the inmates of the sanatoria by the villagers.
The essayist indorsed most highly the eloquent and beautiful re-
marks of the President, that the antituberculosis crusade meant the
coming of a new and better social era for mankind. Since tubercu-
losis attacks rich and poor, the high and the low alike, life in the sana-
torium does away with cast and class. The disease itself seems to
\
212 The Medical Society of
render the hard hearted more gentle, the ungenerous rich more gener-
ous. Dr. Knopf said that he wished to close with an illustration
showing the compassion of the rich consumptive for the poor. The
Sanatorium at Falkenstein is mainly frequented by wealthy patients.
After it had existed for a few years the thought ripened among the pa-
tients that they wished to do something for their fellow sufferers without
means. The result was the creation of a daughter institution at Rup-
pertshain, established by the generosity of the rich consumptives at
Falkenstein.
He closed with an appeal to American philanthropists, who are
so generous in the establishment of institutions for learnings, that they
may now consecrate some of their wealth toward the establishment of
Sanatoria for the consumptive poor. If any epidemic, such as yellow
fever or smallpox, should threaten to invade us, all the necessary
money would be forthcoming, but the rich have become so accus-
tomed to the presence of consumption, that there is a sort of indif-
ference toward this malady which, however, kills many times more of
their fellowmen than any other infectious disease.
Meeting of October 20, 1904; Dr. Charles Shattinger,
President, in the Chair.
Case of Chronic Seminal Vesiculitis; Removal
of the Vesicles; Recovery.
Presentation of Patient.
By BRANSFORD LEWIS, M.D.,
ST. LOUIS.
ATIENT, N. H., aged 38 years, was referred to me by
my friend, Dr. William Winter, November 3, 1902.
He was of German extraction; occupation, street car
conductor in St. Louis. He had been the subject of one gon-
orrheal attack, in 1896, lasting about two or three weeks; after
which he had felt nothing wrong until the beginning of the pres-
City Hospital Alumni. 213
ent trouble, which began March, 1902. Without any apparent
cause, he noted increased frequency of urination, together with
some pain in the left groin and testicle; and there was in-
crease in a painful feeling that had been with him occasionally
since his gonorrhea of 1896, in the sacral region. This pain
had always been increased by cold weather but was better
when it was warm, but he had never been really free from it for
five years.
Following the onset of the acute attack above mentioned,
the patient kept his bed for about five weeks, and was under
the care of an able physician of the city. There was sub-
sidence of the acute inflammatory stage and he went to work
again; but he was unable to attend to his duties with any de-
gree of satisfaction because of two reasons—the frequent ne–
cessity for urinating, and the severe pain in the lower part of
his spinal column.
On consulting me he presented a robust appearance, in
both weight and . complexion. There was no discharge
from the urethra, and the urine was perfectly clear in both
portions. No stricture was present, though the meatus was
smaller than desirable—admitting No. 20 bulb sound. No
tangible evidence of urinary trouble was found until rectal
palpation was made, when marked inflammation of both vesi-
cles was disclosed by the acute tenderness when they were
pressed on, and the fact that several drops of muco-pus were
milked from them. This pus did not contain gonococci nor
tubercle bacilli, but there were cocci and bacteria in moderate
number. After opening the meatus sufficiently, the patient
was placed on the methods of treatment usually adopted by
us for nontubercular vesiculitis. He was given periodical mas-
sages and posturethral irrigations; abdominorectal faradism
and, later, galvanism ; the regular use at his home of my rectal
siphon for hot water, and internal tonics.
While the frequency of urination improved considerably
under these measures, the spinal pain did not, and I began to
suspect that the patient was somewhat of a neurasthenic ; in
fact, would have believed him such had it not been for the di-
rect evidence of continued inflammation obtained by the vesical
milkings. The pus was persistent.
214 The Medical Society of
After ringing in the various changes of treatment usually
efficacious, I acknowledged defeat in that respect and sug-
gested extirpation of the vesicles. This was accepted by the
patient, who said that anything would be preferable to the
continuation of his suffering:
On January 20, 1903, through an inverted L-shaped in-
cision, across the perineum and down to the left of the anus, I
removed the greater part of both vesicles, scraping out the
residue by means of the blunt curette; sewing up most of the
incision afterward with buried catgut sutures and superficial
silkworm sutures—with the exception of a small drain space
at the lower end, in which I left a small rubber tube.
Union was prompt enough throughout excepting at this
point, where there was some delay, but no effort at persistent
fistula. The patient was sitting up within two weeks after the
operation, and the wound was practically healed in three
weeks.
Since the day of the operation the patient has had no re-
turn of the pain that had. persisted for six years previous to
that time. He has again taken up his occupation of street-
car conductor, which necessitates his standing a number of
hours at a time, and, under the stress of World's Fair visitors,
has been quite arduous. He asserts that he is now as well as
he has ever been.
DISCUSSION.
Dr. R. E. KANE asked whether there had been any recurrence of
the shreds in the urine, and whether Dr. Lewis had examined the
scrapings or had the seminal vesicle examined after its removal.
Dr. LEwis replied that the urine had been perfectly clear except
during the one period he had mentioned when the patient had some
trouble, probably due to his hard work. He had not made the exam-
ination referred to by Dr. Kane.
Dr. HENRY JACOBSON said that this condition was very obscure
and only in recent years had been treated successfully. There are
three forms of the forms of the disease—simple, gonorrheal and tuber.
cular. The simple form is supposed to be caused by excesses in sex-
ual congress, masturbation, and unnatural sexual relations, uretheral
applications and instrumentations are exciting factors. Gonorrhea is
City Hospital Alumni. 215
the most frequent cause of seminal vesiculitis. After the patient has
had a gonorrheal inflammation the vesicles are in condition for other
bacteria to invade the reservoir. It has been proven that this reser-
voir contains the colon bacilli, staphylococci and other bacteria, just
as the gall-bladder contains all kinds of bacteria. Tubercular vesicu-
litis occurs frequently in conjunction with the involvement of the blad-
der and prostate. Those cases usually have to be operated upon. In
reference to the reflex symptoms, he mentioned a case that had been
sent to him that had been treated for gall-stones, enteralgia, etc, the
site of the patient’s troubles being the vesicles. By massaging the
vesicles he could elicit pain in the region of the gall-bladder and other
parts of the abdomen. By gentle massage of the seminal vesicles the
pains gradually disappeared showing them to have been reflex. As to
diagnosis in cases of chronic prostatitis and seminal vesiculitis, it is
sometimes difficult to demonstrate where the pus comes from. His
method was to have the patient urinate in three glasses and then fill
the bladder full of clear water. Then, after massaging, if the urine is
cloudy, and the urine in the last of the three glasses was clear, the
seminal vesicles are affected. Otherwise it is difficult to tell whether
the cloudy urine in the last glass comes from the prostate or the semi-
nal vesicles.
Even under the microscope one can not always tell, because the
seminal vesicular sac may have been so inflamed that it does not con-
tain the spermatozoa. He thought he would use the Kraske operation
as for the rectum in removing both vesicles. In the operation
mentioned by Dr. Lewis it would be very difficult to remove both vesi-
cles, while by laying back the sacrum it would be easy to get at both
of them.
Dr. JoHN MORFIT said that Dr. Lewis had followed the surgical
rule. Where there is pus, get at it. His results showed the wisdom
of his action in this case. The speaker could not indorse the radical
operation advised by Dr. Jacobson. Though the normal vesicle sacs
are hard to find, the diseased ones, enlarged and indurated from the
inflammation, are more accessible.
Dr. O. L. SUGGETT laid stress on the difficulty of diagnosis; be-
cause, having a short finger, he had often doubted his ability to feel
216 The Medical Society of
the seminal vesicles. He believed that there should be a difference
in the treatment of the different varieties of seminal vesiculitis. Fuller
called attention to the different varieties as early as 1893, referring to
the atonic variety and the inflammatory variety. The atonic vari.
ety seemed to be adapted to the stripping of the seminal vesicles.
As to the surgical method of treatment adopted by Dr. Lewis, he con-
sidered it a very courageous and heroic one to reach and remove the
seminal vesicles, but it undoubtedly was the proper thing. He had
always been at a loss to account for an epididymitis without a seminal
vesiculitis, although there was no question but that in the majority of
cases there was a seminal vesiculitis. In conclusion Dr. Suggett most
heartily recommended the siphon.
Dr. J. L. BOEHM thought that if the disease was sought for it
would be found more common than is generally supposed, especially
in clinic cases. Many laborers go to the clinic complaining of lumbar
pain and in the seminal vesicles is found the cause. He had seen a
case recently, a man who had been treated by a number physicians
for sciatica. On first examination there was found pure gonorrheal
pus. He was treated, and after three weeks’ treatment he said that
he felt better than he had for three or four years. It might seem a
rather unusual statement to say that locomotor ataxia could be diag-
nosed by a rectal examination, but it had been done in one instance.
A gentleman of intelligence had been elsewhere. One physician had
said that he had vesiculitis. Dr. Boehm examined the vesicles per
rectum and could find no marked indication of vesiculitis. He found
no obstruction and in his own mind he made a diagnosis of incipient
tabes. This gentleman later had occasion to go to Chicago and there
consulted a physician whom he had consulted two years previously.
This doctor, in going over him the last time, told him he had a begin-
ning locomotor ataxia. The patient remained in St. Louis about a
year after that. He would start micturition with a few drops and
then the urine would stop. He has since gone to California and is
being treated there, and it is said, that he is now on the verge of com-
plete paraplegia. When it started it evidently looked like a vesiculitis.
In reference to Dr. Jacobson’s remark relative to the diagnostic value
of finding or not finding spermatozoa, the speaker called attention to
City Hospital Alumni. 217.
the fact that in making a microscopic examination of the milkings in
chronic vesiculitis where pus is found there will sometimes be found
the heads of spermatozoa in the pus corpuscles and that pus is antag-
onistic to the vitality of spermatic fluid.
Dr. KANE said his experience in the surgical treatment of the
affection was limited to the observation of one case and the result had
been anything but satisfactory. The operation which the surgeon did
was a modified Kraske and only, one vesicle removed. The patient
got absolutely no benefit from the operation. Another thing, when
there is a mixed infection and not only the colon bacilli but the tuber-
cle bacilli planted on a gonorrheal infection, absolutely no good can
be done in many cases except by coming around to the surgical treat-
ment.
Dr. HENRY JAcoBson said that in tubercular cases the seminal
vesicles should not be stripped as it would aggravate the case. For
Dr. Suggett’s benefit he wished to call attention to the fact that there
are instruments for prolonging the finger. Dr. Eastman’s instrument
he had used for a long time. He, also, had found the heads of a
spermatozoa mingled with the pus in some cases, but in many other
cases the inflammation of the vesicles had been so extensive there were
no spermatozoa in the reservoir.
Dr. H. J. ScHERck thought that any one who had had much ex-
perience in treating genitourinary diseases would admit that no one
class of troubles puzzles one more and gives less satisfactory results
than seminal vesiculitis; 50 per cent of the pains are pyschical. The
patient becomes a confirmed neurasthenic and it is one of the hardest
things in the world to get the idea out of his head. Regarding the
obscurity of seminal vesiculitis, the pains due to that condition are
sometimes referred to the remotest part of the body. To be able to
diagnose the condition from the subjective symptoms is impossible
and, from the objective symptoms, very difficult. To milk the seminal
vesicles is often impossible. Filling the bladder with sterile water and
having the patient in a squatting position renders it an easier matter
to reach the vesicles. What he had understood by the three glass test
was that the patient was allowed to urinate in one glass, the canal then
being washed, the vesicles milked and the urine then divided between
218 The Medical Society of
two glasses, the first containing the washings of the prostatic urethra.
One of the most common occurrence seen by the practitioner is in
that class of patients who, after having been treated by the ordinary
methods, leave the doctor’s office and treatment with the belief that
they are thoroughly cured and after the slightest excess return to the
doctor with the unpleasant statement that they are not cured. Rein
fection is one of the most common occurrences. The very nature of
the condition precludes cure by any means short of operation. Even
when one can milk the seminal vesicles there is still the thoroughly in-
fected sac. He did not know of a single case of chronic gonorrheal
vesiculitis that could be pronounced cured. Of course, the patient
could be gotten into a comfortable condition in acute cases, but in
chronic cases not much could be expected from treatment other than
a cure effected by time and Nature.
Dr. R. E. KANE wished that Dr. Lewis would describe what he
meant by the three-glass test. The test mentioned by Dr. Jacobson
was a modification of the one usually used. This was, after the first
and second glasses had been used, to milk the seminal vesicles then
have the remainder of the urine voided in the third glass, showing the
relative cloudiness of each.
The PRESIDENT said that he had a keen personal interest in the
patient and congratulated Dr. Lewis on his diagnosis. The patient
was a walking humiliation to him as he had been to his office several
times with the complaints that had been mentioned and he had been
completely misled. He examined the urine and found it always clear,
the reaction normal, and he was led off the track of suspecting urinary
trouble. On one occasion he made a rectal examination and exam-
ined the prostate but did not reach up for the seminal vesicles. His
* diagnosis was one of purely functional disturbance, the treatment,
therefore, was ineffectual. Sacral pain had been mentioned as the
most prominent symptom, yet the speaker did not remember that the
patient had complained of that. It was the stress of frequent urina-
tion that he complained of. He said he could not hold his water long
and on attempting to hold it, it caused him some distress. He com-
plained of some backache. The speaker asked if there were cases
without pain, the condition merely manifesting itself by urethral dis-
City Hospital Alumni. 219
/
charge. Again, how would it be possible to differentiate a chronic
vesiculitis from prostatic disease, when the diagnosis is made by virtue
of an examination of the milkings, supposing that the prostate is not
tender or swollen 2 How could one determine the presence of vesi-
culitis when the urine was all cloudy, supposing there was present an
inflammation of the bladder and it was impossible to get any clear
urine?
Dr. LEwis, in closing, said that the thought had just occurred to
him what a marked difference there was in methods by which the
American medical fraternity arrives at a diagnosis and the French
methods. . He was a pronounced follower of the American method,
which is analytical. Frenchmen will write six to ten pages on the re-
flex symptoms, while the American method is to go right to the spot,
by physical examination. Of course, the patient will want to have a
long heart-to-heart talk and tell all his symptoms for an hour or an
hour and a half, but the physician can tell him more about his condi-
tion after a three-minutes’ examination than by a week’s talk. The
speaker said that he had methods that he applies whether the patient
describes symptoms indicative of stone in the bladder, vesiculitis or
inflammation of the urethra. The history is first gotten. The meatus
is inspected; then the patient is directed to pass most of his water
into two glasses. That tells, in a general way, whether there is any
inflammation and whether it is in the anterior or posterior urethra; if
anterior inflammation, only, the second urine being clear in the blad-
der, and passing over a clean urethra is clean when it gets into the
glass Before any instrument is put into the urethra massage of the
prostate is done. If the patient is put into the correct posture, and
he is not corpulent, the prostate and in most cases, the vesicles, can
be reached. The physician thus learns whether there is hypertrophied
prostate or whether it is acutely tender or not. The meatus is watched
for oozing pus. If one or two drops come down it is evidently from
the prostate and not from the seminal vesicles. Then the seminal
vesicles are milked, the right one, usually, first. If one or two drops
appear and there was no sign of pus while massaging the prostate, the
indication is that it is from the right seminal vesicle. It is then stained
for bacteria, or gonococci, or whatever the indication is. If the pros-
220 • * The Medical Society of
tate has been massaged, and the right and left seminal vesicles, and
no pus has come down, that does not prove that there is no inflamma-
tion there. The next step is for the patient to pass water in the third
glass. In the third glass there is washed down the effect of the mas.
sage and if there is pus then it can be found and stained. If the pus
is mixed with spermatozoa in the third glass of urine, it is positive
evidence that the pus is from the seminal vesicles. Dr. Lewis remem-
bered the point made by Dr. Bryson very well, and it was a very nice
one, but he had never been able to put it to much use, for a chronic
vesiculitis does away with the presence of spermatozoa. So, while it
was a nice point to remember, he did not believe one should wait for
it or place much confidence in its importance. If, after such investi-
gations, there is found no pus, that excludes pus from the diagnosis.
As to the differential diagnosis—whether the pus comes from the blad-
der or from these parts—in inflammation of the bladder the urine is
usually alkaline and cloudy, while if there is suppuration in the vesicles
the urine may be perfectly clear. As to the possibility of seminal
vesiculitis without pain, it is absolutely certain that there are cases
where the patient has never heard of his vesicles. Dr. Lewis had seen
several cases where there was no pain. The reflective pain comes from
inflamed vesicles but it comes in a very odd manner sometimes. In
one case there was marked pain in the cardiac region. He had had
descriptions of pain in the abdomen, on one side or the other, that
was relieved by relief of the vesiculitis. He had not observed pain
farther away than the cardiac region, although he believed some
nasal specialists had observed pain in the fiose. If there was one
thing that he wished to impress upon his hearers it was that these
things were subject to digging out definitely; not by obstruse analysis
and long reasoning, should the physician make his diagnosis, but by a
thorough physical search into the case. He ought not to decide be-
fore he has made the examination. It is for the examination to de-
termine, not hair splitting reasonings. Dr. Lewis said they had had
two cases recently in which there were large stones in the bladder. In
one case there were five, and in the other one, of considerable size.
They were hugged down close under the prostate and could not be
reached by the stone searcher. In the second case the stone was
City Hospital Alumni. 221
large as half an egg and the patient had been examined and told that
he had only a hypertrophied prostate. Two weeks later he examined
him and found that he had a hypertrophied prostate and the stone.
He had failed to find the stone until the cystoscope showed it.
Presentation of Specimens.
Dr. Lewis presented a specimen of prostate that he had removed
subsequent to the removal of a number of stones. The patient was
much run down had been treated for enlarged prostate. After several
weeks he succeeded in seeing a number of stones, five or six—there
was not room enough to count more. They made a perineal cysto-
tomy and got out sixteen or seventeen at the first operation. In all
there were twenty-eight stones in the bladder. The introduction of
the sound in that case immediately met with the stone. It was a case
of multiple calculus. The mass of stones was about the size of a fist
doubled up. At the first operation there were removed all that could
be felt, one or two or three at a time, but because the patient was in
such bad general condition the operation was not prolonged by a
further search. The patient was in a wretched condition and they got
him off the table as soon as possible. He recuperated from the first
operation very satisfactorily and after about ten days Dr. Lewis put in
the retrograde cystoscope and then saw five stones hidden down under
the prostate. As soon as he got into sufficiently good condition he
was put under chloroform and the posterior lobe of the prostate and
the five stones were removed. He recuperated and for the last two or
three weeks has been out on the road attending to his business affairs.
The patient feels perfectly well and strong, better than he has felt for
years. He visits the office every week or two when he gets in from
his trips on the road. He had never met with a case in which there
were as many large stones in the bladder as this one, nor had he ever
read a report of such a case. He had read of cases of one hundred
or more stones of the size of a shot, and he had had a case where
something like fifty came down from the kidney. -
The PRESIDENT asked: Supposing a cystitis to be present, how
could one know whether there was or was not a simultaneous vesicu-
222 The Medical Society of
litis? If one massage the prostate and milk the vesicles and no drop
of pus appear at the urethral orifice and if in the third portion of urine
voided there appears a deposit, how can it be decided whether that be
from the prostate or the vesicles 2
Dr. LEWIS replied that the dense cloudiness of the urine would
indicate an inflammation of the bladder but it could be known whether
there was an inflammation of the vesicles by tactile investigation.
Possibly the condition could not be demonstrated the first time but
after one or two trials there should be no difficulty. Supposing the .
patient passed the two first glasses that were not cloudy or only partly
So, then, after massaging the prostate the third glass would be dis-
tinctly cloudy, or it might be cloudy after massage of the vesicles.
That would be the urine testimony. But in most cases there would
be tenderness and enlargement and these allied points would aid in
the diagnosis.
Meeting of November 3, 1904; Dr. Charles Shattinger,
President, in the Chair.
Left Hemiplegia.
By HORACE W. SOPER, M.D., º
ST. LOUIS, MO.,
HE patient, J. C., aged 27 years; occupation, Superin-
tendent of Street Construction Work. Habits.—Oc-
casionally indulges in alcoholics to excess; uses to-
bacco in moderation. No history of previous serious illness
or injuries; no history of syphilitic manifestations.
The patient entered the hospital on the evening of Sep-
tember 8, 1904. He was unconscious, and examination re-
vealed the presence of a left hemiplegia. The left side of face
was paralyzed, the left arm complete, and rigidly contracted,
the left leg partially paralyzed. The Babinski reflex was well
marked on the left side, absent on the right. The tendon re-
flexes on both sides were exaggerated. No conclusion could
be arrived at in regard to sensory disturbances. The head was
City Hospital Alumni. 223
turned to the side, the eyes diverted toward the left side.
Pupils somewhat dilated and responded feebly to light.
The following day the patient aroused and was able to
take fluid nourishment, but very soon relapsed into coma.
Urine and feces passed involuntarily. During the next ten
days the coma became gradually deeper. Temperature ranged
from IOO to IO2°. The muscles of left arm remaining rigid.
A contusion was found in the scalp just behind the right
parietal eminence, and a history of a fall obtained, occuring
August 28th. He complained of pains in the head after this
fall and the paralysis came on eleven days later. A diagnosis
of subdural hemorrhage was made, based on the following
grounds, viz.:
I. History of head injury with paralysis coming on a
week or so later.
2. The early rigidity of the muscles of the affected side.
3. The youth of the patient and the absence of arterio-
sclerosis.
4. Absence of any history or evidences of syphilis.
The operation was performed by Dr. J. S. Hixson, Sep-
tember 18th, ten days after the paralysis came on. First, the
trephine was introduced near the contusion, no fracture was
discovered. The dura was incised and no clot found. The
second opening was then made over the center of the motor
area with the same result. Although no blood clot was found,
there was marked bulging of the brain after incising the dura,
showing evidence of compression. A drain was left in the in-
cised dura. The day following the patient was much brighter
and continued to improve until the third, when fever reap-
peared and pulse became rapid. This was found to be caused
by an infection of the posterior wound. This soon subsided
and the patient recovered very rapidly, leaving the hospital
ten days after the operation.
Status presens.—Very slight paresis of muscles of the left
side of the face. Arm and leg almost as strong as ever.
Tendon reflexes increased on left side. Posterior wound not
quite closed. General condition good.
224 The Medical Society of
DISCUSSION.
*-
Dr. JESSE S. Hixon had not come prepared to discuss the case.
He had been called upon by Dr. Soper to examine the patient and had
found the paralysis Dr. Soper had already described. The patient was
trephined, the membrane incised and the wound drained. He had an
infection of the posterior wound, which was infected before the opera-
tion. The improvement after the operation was very marked. The
next day he could speak and open his eyes and began to regain
control of the muscles of the bowels. He left the hospital in about
ten days after the operation. There was still a little infection of the
posterior wound. w
Dr. M. A. BLISS said that often when such a case was seen some-
time after the accident it was difficult to be certain as to the exact
conditions. In this case, the fact that they did not find the hemor-
rhage, and the fact that there was still a slight hemiplegia, would indi-
cate that the lesion was deeper He had recently seen a man of 65
years who fell from a street car. He had a fracture extending into the
base at the right side of the occipital bone. After an operation he
was considerably improved, but died five or six weeks after the opera-
tion of edema of the brain. Post-mortem showed the tips of the
frontal and temporal lobes where they dipped most deeply into the
base of the skull, almost pulpified. The upper part of the brain, over
the vault, was uninjured, except at site of fracture. This man had a
hemorrhage following the injury which gave him the capsular form of
hemiplegia. It was still quite evident, but he would doubtless recover
entirely.
The Early Diagnosis of Uterine Cancer.
By GEORGE GELLHORN, M.D.,
ST. LOUIS, MO.
has entered into a new phase. A remarkable move-
ment is developing throughout the civilized world.
In Germany, England and the United States permanent organ-
\ W WITHIN the last few years the question of carcinoma
City Hospital Alumni. 225
izations have been formed in order to centralize a complete
research work on all points bearing upon cancer. The facts
thus far known are appalling. Cancer is on the increase. Ac-
cording to Roger Williams, cancer is four times as common as
it was fifty years ago. Welch and Orth place the uterus first
in the list of organs most frequently affected with primary
cancer, namely, in about one-third of all cases. In England
61,715 women died within a period of fifteen years; of these,
25,000 died of uterine cancer. Of the 25,000,000 of women
in the German Empire, 25,000 die yearly of this disease.
These sad facts are but little influenced by the extirpation
of the carcinomatous uterus. Only about 30 per cent of the
cases of uterine cancer which come under medical observation
are operable at the time of the first examination; and of these
not more than about one-fourth remain free from recurrence,
so that, at the most, only IO per cent of all cases are really
saved from death.
To improve these depressing results, all gynecologists
agree upon the absolute necessity of early operation. Since,
however, an early operation depends upon an early diagnosis,
numerous propositions have been made to bring about a better
understanding of the conditions in question and to diffuse a
wider knowledge of the dangers of the disease and of the
means of overcoming the same. This difficult problem seems
to have been solved by a German gynecologist. Dr. G. Win-
ter, professor of gynecology in the University of Koenigsberg,
in the province of East Prusssia, has opened a systematic war-
fare. He wrote a monograph on the subject of cancer and
sent it to all physicians in his province ; in this monograph he
reviewed the symptoms of uferine cancer and the means of
arriving at the correct diagnosis. Secondly, he issued a pam-
phlet on the same subject to all midwives who, in Germany,
are under governmental control and do a good deal of minor
gynecologic work, especially in rural districts. Finally, he
published popular articles in the daily papers and magazines
addressing himself to the women in general and emphasizing
the dangers of the disease and the necessity of early medical
consultation. Winter's report after one year's experience ap-
peared recently. His results are highly encouraging. Physi-
226 The Medical Society of f
cians, midwives and patients have co-operated to increase the
percentage of operable cases.
Based upon the work of Winter, it was suggested, at the
recent meeting of the Gynecologic Section of the International
Congress of Arts and Science, by Dr. F. J. Taussig, of this
city, that the American Medical Association should undertake
a similar system of warfare against uterine cancer. The mat-
ter was left in the hands of a committee to report at the meet-
ing next June. l
We should, however, not remain idle pending the action
of the National Organization, but every one of us in his little
circle should consider it his duty to emphasize again and again
the points bearing upon cancer and to dwell incessantly upon
the means with which to arrive at an early recognition of this
disease.
It is from this standpoint that I take the liberty of pre-
senting to you today a few specimens of uterine cancer—speci-
mens, which though they are of every day occurrence, are
nevertheless of eminently practical importance to the general
practitioner who in the majority of cases is first called upon to
decide the presence of cancer. To speak with Cullen, Winter
and many other authorities, the responsibility for the timely
diagnosis of cancer rests with the family physician. It is he
upon whom “we must rely to recognize the early symptoms
and to indicate to the patient the appropriate treatment. With-
out his assistance the gynecologist will almost invariably see
the case only when the disease is too far advanced to permit
of a complete removal of the morbid growth.”
The first case is that of a lady, aged 50 years, who came
to me with the diagnosis of submucous myoma. Her sole com-
plaint was copious hemorrhages at the menstrual period. Al-
though very stout, she had grown even more corpulent of late.
There was no vaginal discharge. Upon examination, a round
tumor with smooth surface was seen within the outer os, dila-
ting the latter to the size of a 50-cents piece. It was only after
an attempt to enucleate this tumor and after I had examined
miscroscopically the pieces removed that I realized my mis-
take and made the diagnosis of cancer. The disease, how-
ever, had already spread out considerably, and as you see in the
City Hospital Alumni. 227
specimen, had involved the entire mucous membrane of the
uterus and left tube. I have reported this case in another
connection in the Interstate Medical Journal, November,
1901, and will only add here that I saw the patient for the
last time September 26, 1904, i.e., almost four and one-half
years after the operation and found her perfectly free from
fe Curren Ce.
The second case was referred to me a year ago. The pa-
, tient, aged 64 years, had been in the menopause for the last
fourteen years. A slight bloody, and at times, offensive dis-
charge, which occurred at irregular intervals for the last four
months, had awakened the suspicion of her physician. There
was nothing in the objective findings of the examination that
pointed toward carcinoma. I made an exploratory curette-
ment. Dr. Fisch had the kindness to make the microscopic
examination during my absence from the city and found a
typical adenoma. November 17, 1903, I extirpated the uterus
by the vaginal route. The organ, as you see here, is very
small ; yet, upon opening the uterine cavity, I found that the mu-
cous membrane had been fully regenerated though at the very
thorough currettement, less than four weeks previous thereto,
the uterine cavity had been vigorously cauterized with a 25
per cent solution of chlorid of zinc., Moreover, in the uterine
wall itself there was a round place distinguished from the
surrounding normal tissue both in color and consistency
which appeared macroscopically as an extension of the patho-
logic process. This macroscopic appearance is verified by the
microscope. You will see in the section under the microscope
that the morbid growth extends into the deeper layers of the
uterus and presents the characteristics of a true carcinoma
much more pronounced than in the section through the scrap-
ings under the other microscope. I saw the patient last Sep-
tember 27, 1904, i.e., ten months after the operation and found
as yet no recurrence.
The third case, a lady, aged 38 years, came to me with
the diagnosis of carcinoma of the uterus. From her history
only a few points require mentioning. Her mother and two of
her aunts died of carcinoma of the stomach and breast re-
spectively. Her menstruation was regular, but was very scant,
228 The Medical Society of
lasting five days; it occurred last just four weeks previously.
She had had one confinement sixteen years ago. Lacerations
of perineurm and cervix resulting from this parturition were
not sewed up until three years ago. For the last year she has
had local treatment for “ulceration of the uterus ” with tem-
porary relief. Nine days prior to my examination she hap-
pened to consult a physician at a watering place in Texas on
account of a very slight offensive discharge. This physician
made the diagnosis of cancer which was afterward confirmed
by her family physician, who made a microscopic examination
of a small excised portion. There were no other symptoms
nor was there any appreciable loss of weight, but the patient
looked decidedly cachectic. The examination revealed a small
erosion and two hard nodules in the scar of the old trachelor-
rhaphy. I extirpated the uterus by the vaginal route Septem-
ber 7, 1904. You will observe in this specimen that in spite
of the insignificant symptoms and the short duration of the
disease, the cancer has already deeply invaded into the tissue
of the cervix. The patient has made an uninterrupted recovery
but, of course, it is too early to say whether the operation was
done in time.
You have noticed that in these three cases the cancer was
rather far advanced and, yet, it was only through the micro-
scope that the correct diagnosis was obtained with exactness.
How much more is the microscope of paramount importance
in determining the earlier and earliest stages of the disease.
Now and then, but fortunately growing less frequent, the view
is expressed that the microscope can not be relied upon, that
microscopic examination has, in certain cases, failed to reveal
the presence of a carcinomatous process, and that the only
certain signs are those of clinical observation. It is easy to
show the incorrectness of such statements. It has to be proved
first that the microscopist who has failed to find cancer in the
section, though the disease was in existence, is a reliable and
skilled examiner. If he be such, mistakes may be said, for
all practical purposes, not to exist.
This statement is well illustrated by a sad experience in
my own practice: A woman, aged 53 years, already in her
menopause, had been treated during the last four months for
City Hospital Alumni. 229
“ulceration of the womb.” Her physician dissatisfied with
the progress of the case, sent her to me, April 2, 1904, to ob-
tain my opinion as to the possibility of cancer. There were
no suspicious symptoms whatsoever. Upon examination, the
condition of the genital organs was so nearly normal and the
erosion was so well healed that I sent the patient back to her
physician, but instructed her to consult him again in case ir-
regular hemorrhages should occur. Such a complication arose
only two and one-half months later when I was asked the
second time by her physician to take charge of the case. I
found the patient greatly weakened by an abundant hemor-
rhage which had existed for almost a week. I immediately
transferred the patient to a hospital and made a thorough cu-
rettement. The vaginal portion was extremely friable and
from the posterior wall of the uterine cavity, particularly on
the left half, numerous pieces of tissue, some of which
were as large as a pigeon's egg, were removed with the
curette. You may picture my surprise when the microscopic
examination of these pieces which macroscopically resembled
carcinoma most closely, revealed nothing but a hypertrophic
endometritis. Thinking that the carcinomatous degeneration
might by chance have been absent in the one piece examined,
numerous sections were made from all the removed pieces.
Yet, no malignancy could be detected.
The situation was most perplexing. Here was a woman of
advanced age seized with a persistent and abundant hemor-
rhage half a year after cessation of menses. A large soft mass
was localized in the uterine cavity, and the pieces removed
strongly resembled carcinomatous tissue. This, then, seemed
to be a case in which the insufficiency of the microscope was
apparent. The clinical observations concurred in the estab-
lishment of a diagnosis which the microscope was unable to
verify. Moreover, there seemed to be no other affection to
which the macroscopic findings could be attributed. Conse-
quently, after a long and careful consideration of the case, I
determined to ignore the negative outcome of the microscopic
examination and performed a vaginal hysterectomy seventeen
days after curettement. In addition to the supposed cancer,
the patient suffered from a mitral insufficiency and a chronic
230 The Medical Society of
*.
nephritis which, unfortunately, resulted in her death four days
after operation. Any other cause, such as sepsis, intestinal.
obstruction, etc., could be excluded with certainty.
If you will look at this specimen you will see the uterus
considerably enlarged and thickened, but there is macroscopic-
ally no sign of cancer anywhere; nor did the microscopic ex-
amination of several excised pieces show any cancerons de-
generation. This experience serves as a good illustration of
the fact that clinical symptoms, however clear and convincing,
are not unimpeachable until verified by the microscope.
While it should be borne in mind that in the early stages
of uterine cancer which form the sole subject of this paper,
the microscope furnishes us with the only positive means of
arriving at an exact diagnosis, yet there are a number of other
factors which we must not neglect. These may conveniently
be divided into, first, general diagnostic considerations, and,
second, the diagnostic signs of special forms of carcinoma.
The general diagnosis begins with the family history.
Though heredity in cancer is not established, the frequency of
this disease in members of the same family is too important a
fact to be left out of consideration.
In the personal history of the case, the age of the patient
has to be noted. Carcinoma is most frequent in women over
35 years; yet, as a matter of fact, no period of life is exempt.
The earliest recorded case was one of 8 years of age, and
in the Gynecologic Section of the recent International
Congress of Arts and Science, there were reported two
authentical cases of cervical cancer in young women of 23
years of age. *
Child-bearing and injuries sustained during parturition are
generally conceded to have important relation to the develop-
ment of cancer. Chronic inflammatory affections of the
uterus, viz., endometritis and erosion are noteworthy etiologic
factors.
While in the early phases of uterine cancer the classical
symptoms, viz., abundant hemorrhages, offensive discharge,
pain and cachexia, are, as a rule, lacking, there may appear
certain symptoms which should at once awaken the suspicion
of the physician and should induce the latter to insist upon a
City Hospital Alumni. 231
thorough examination and careful search for carcinoma. These
symptoms are slight hemorrhages occurring after coition,
straining at stool or lifting of burdens. Post-climacteric hem-
orrhages are highly suspicious. Nor should any departures
from the normal menstral type or irregular hemorrhages occur-
ring between menstruations escape the attention of the physi-
cian. The older the individual the greater is the probability
of cancer. In connection with slight hemorrhages or in
the absence of the latter, a more or less copious watery
discharge is eminently suggestive of early stages of uterine
carcinoma. -
Symptoms arising from adjacent organs and structures do
not occur until the cancer has extended beyond the limits of
the uterus. The only exception is a urinary disturbance due
to a bullous edema of the bladder which is claimed by several
authors to precede in some cases all other manifestations of
the disease. Therefore, bladder trouble of obscure origin
in older patients should call for an examination for uterine
cancer.
The special diagnosis depends upon the location of the
new growth. Carcinoma may arise : -
I. From the vaginal portion.
2. From the cervix. -
3. From the body of the uterus.
The diagnosis of carcinoma of the vaginal portion is com-
paratively easy because of the greater accessibility to sight
and touch. A cauliflower-growth will readily be recognized.
The infiltrating form with an overlying covering of intact mu-
cous membrane is more difficult to distinguish. Yet, broaden-
ing of the cervix, the irregular nodular surface, the circum-
scribed cartilaginous consistency and the bluish discoloration
which is intermingled with yellowish dots is very suspicious;
if an ulceration commences, no doubt is left as to the carcino-
matous nature. In these ulcerations which are surrounded by
hard, irregularly elevated borders, the friability of the tissue
is very pronounced. A fingernail or sound can easily be forced
into the tissue and will produce copious bleeding. The curette
will, without difficulty, remove smaller or larger pieces of
tissue. -
232 The Medical Society of
We, then, have, in order to establish the diagnosis in these
cases, at our disposal, first, palpation; second, - inspection
through a speculum; third, the use of the sound and of the
curette. There will, however, remain a large number of cases
in which the diagnosis can only be made by a microscopic ex-
amination of an excised piece of the suspected portion. The
less experienced physician should make free use of this
method, inasmuch as the exploratory excision is but a slight
and easy procedure. The technic of excising a piece is as
follows: Under the ordinary antiseptic precautions grasp the
cervix with tenaculum and pull it downward as far as the en-
trance of the vagina. With knife or scissors remove a wedge
including part of the suspected portion and part of the ap-
parently healthy tissue. Close the wound with catgut sutures
and pack the vagina with iodoform gauze. An anesthetic is,
as a rule, not necessary. The excised piece should not be
handled but placed at once in absolute alcohol or Io per cent
formalin solution. * -
The differential diagnosis in early stages of carcinoma of
the vaginal portion is of paramount importance. Cauliflower
growths may sometimes be simulated by submucous fibroids
with ulcerated surface. Examination with the sound will prove
that the tumor in question springs from the inside of the cer-
vix or uterine body and is surrounded by the external os. In
addition, the consistency of these fibroids is much harder than
that of carcinoma. Circumscribed inflammatory thickening
of the vaginal portion might be mistaken for carcinoma, espec-
ially if there are distended follicles, so-called Nabothian cysts,
which cause an irregularly nodular contour of the portio. In-
spection will reveal the smooth mucous membrane and the
small transparent retention cysts. In doubtful cases, micro-
scopic examination is indispensable. .
The physician is often confronted by the question whether
he has to deal with a cancerous ulcer or an ordinary erosion.
An erosion is but seldom elevated above the surface of the vagi-
nal portion, the papillary erosion alone forming an exception.
As a rule, the erosion surrounds the entire os of the uterus; it
shows no well-defined and hard border as does the carcinoma
and presents a gradual and irregular transition into the normal
City Hospital Alumni. 233
pale bluish epithelial covering cf the portion. Its color is bright
red. It feels slightly granular and is not firm nor does it
usually show any tendency to bleeding. Not infrequently
small patches of whitish epithelium are seen dispersed over the
surface of the erosion.
An erosion is never a disease sui generis; it is only a
symptom, just as headache or jaundice are not diseases but
symptoms of some other affection. Generally speaking, it is
caused by the irritating and macerating discharge from the
uterus. The latter may be produced by inflammatory changes
in the mucosa of the cervix or body of the uterus or may be
but an expression of some constitutional dyscrasia, e.g., anemia
and chlorosis. Although it seems but logical that the cure of
an erosion depends upon the cure of the underlying cause,
exclusive treatment of the erosion itself has been, in the past,
the play-ground of minor gynecology. Saenger, Duehrssen,
Thornton, Cullen, Winter and, quite recently, Sinclair, have
pointed out that there is no indication for local applications to
the eroded surface alone, and yet, daily experience proves
that many physicians treat these erosions weeks after weeks
with an stringent, antiseptic or caustic medicines. The pro-
tracted course of such treatment leads unavoidably to delay
in diagnosis, and if the erosion be of a carcinomatous nature,
this delay may prove fatal. The only possible course to pur-
sue, then, is self-evident; in any case of erosion treat the un-
derlying cause or, if there exists the least doubt as to malig-
nancy, excise a piece for microscopic examination,
True ulcers which might be mistaken for beginning carci-
nomă are: 2”
I. Decubitus ulcers found in prolapsus of the uterus or
as a result of ill-fitting pessaries; these heal rapidly after the
cause is removed.
2. Tuberculous ulcers which usually are associated with a
general or a genital tuberculosis; microscopic examination is
required. -
3. Soft chancres recognized by their multiplicity upon
the vaginal portion and other parts of the vagina as well as
upon the external genitals.
4. Syphilitic ulcers, the correct diagnosis of which is
234 The Medical Society of
greatly aided by the history of the case. In doubtful in-
stances, microscopic examination will, at once, decide the
question.
The early diagnosis of carcinoma of the cervix is greatly
impeded by the fact that the growth is not accessible to the
sense of touch or sight hidden as it is above the external os.
Upon examination there might be nothing but a thickening
and hardening of the cervix, and inspection through a speculum
reveals a smooth normal mucous membrane covering the
vaginal portion. In these cases the slightest suspicion aroused
by one of the carcinomatous symptoms enumerated above
should justify the dilatation and curettement of the cervical
canal. Friability and profuse bleeding point toward carci-
noma. When the destructive process reaches the outer os
thus producing an ulceration or, later on, a crater, the diag-
nosis is easy. Unfortunately, in such cases the disease is, as a
rule, far advanced and the chances for timely interference are
greatly diminished.
The only conditions that might be mistaken for cervical
cancer are chronic metritic processes and cervical fibroids. In
none of these affections, however, is the infiltration of the
tissue of the cervix uniform and diffuse nor is the tissue itself
friable. To confirm the diagnosis, the microscope will have
to be resorted to. º
The diagnosis of cancer of the body of the uterus presents
the greatest possible difficulties. The clinical symptoms are
not pathognomonic and may as well be interpreted as symp-
toms of endometritis. Nor can the bimanual examination of
the size and consistence of the uterus be relied upon. The
exploration of the uterine cavity is indispensable wherever
there is the slightest suspicion of cancer. No case with a
watery discharge or irregular menstrual or climacteric hemor-
rhages should be left unexamined. The exploration of the
uterine cavity is accomplished by the examining finger after
dilatation of the uterine canal, by the sound or by the curette.
The last is, by far, the best means of making a diagnosis.
The curettement should be made in a systematic manner and
should remove the entire uterine mucosa. The microscopic
examination should not be limited to one or two pieces but
should include the entire scrapings.
City Hospital Alumni. 235
I am well aware that I have not brought forward anything
new nor original. But the subject of cancer does not suffer by
repetition—it is a subject concerning which we should never
tire of speaking; it is a field the established facts of which
must become perfectly familiar to every one of us. To recog-
nize this deadly disease in its earlier stages when proper treat-
ment offers its best chances is as much to the patient and to
the good of mankind as the treatment itself.
BIBLIOGRAPHY.
Clado.—Diagnostic Gynecologique, 1902.
Cullen, T. S.–Cancer of the Uterus, 1900.
Duehrssen.—Deutsche Med. Woch., p. 60, 1899.
Findley, P.-Gynecological Diagnosis, 1903.
Winter, G.-Gynaekologische Diagnostik, 1896.
Winter, G.-Die Bekaempfung des Gebaermutterkrebses, 1904.
The Etiology and Management of Brow
Presentations.
By F. J. TAUSSIG, M.D.,
ST. LOUIS, MO.
“B” presentations have been but little studied be-
cause they occur so rarely (I in 2000 labors) and yet
just because they are so infrequent they ought to be
considered with greater thoroughness, theoretically, for when
they do occur they may put the uninitiated in an embarrassing
position and easily lead to rmisfortune for both mother and
child.”
The above-quoted words of Schatz' represent in part my
reason for reporting the following case of brow presentation;
in part, however, it is because the etiology of my case is of
unusual interest and because circumstances suggested a new
method of treatment that may be of use in selected cases.
The patient under consideration was a newly married wo-
man, aged 30 years, who had never before been pregnant. The
last menstruation took place about the middle of December,
1903. August 29, 1904, at IO a.m., that is three weeks before
236 The Medical Society of
her expected time of confinement, the membranes ruptured
and within a short time a large quantity of amniotic fluid es-
caped. Labor pains did not start until twenty-four hours later.
They were of good strength and at frequent intervals, but
nevertheless it was not until 9:30 a.m. on the following day
that the cervix was completely dilated. For four hours the
pains continued but the head made little progress. At the
end of that time the fetal heart-sound, which had heretofore
been strong and regular, began to grow fainter.
It was at this stage that I was called in consultation by
the physician in charge. On my arrival half an hour later I
found the following conditions of affairs : Maternal pulse
strong and regular, 90 to the minute. Pains at frequent inter-
vals but rather short in duration. A contraction ring could be
distinctly felt at a point one finger's breadth below the umbil-
icus. The head was engaged in the pelvis and the back of the
child lay to the left. The fetal heart-sounds, which had been
heard but a short time previously, had now become inaudible;
consequently, all things were prepared for immediate delivery.
On vaginal examination the cervix was found completely
dilated and the membranes ruptured. The examining finger
came upon a highly-developed caput succedaneum, to the left
of which could be felt the large fontanelle. As the finger
passed to the right and forward it came upon a ridge which
could be distinguished as the orbital, and a prominence which
was recognized as the base of the nose. The head was fixed
in the pelvis with a large segment already engaged. The di-
agnosis was, therefore, brow presentation, mento-dextro-
anterior.
The lower blade of the forceps was introduced along the
left side of the pelvis so as to catch around the occiput. This
blade was steadied with the right hand, while the fingers of
the left hand were placed against the brow. Pressure upward
was now exerted by these fingers while simultaneously gentle
traction efforts with the forceps blade were made in the hope
of thus correcting the malposition of the head. In view of
the necessity for immediate delivery this method could only
be tried a minute. Unfortunately, no assistant was at hand to
aid abdominally in this manipulation. It did not succeed in
City Hospital Alumni. 237
correcting the deflection of the head. The forceps were then
applied in the right oblique diameter. When the head reached
the perineum the traction efforts were directed upward so as,
if possible, to save the perineum. Owing to the extremely
critical condition of the child it was impossible to wait for
complete dilatation and in consequence the perineal body was
torn to the second degree.
The head developed in the usual way. The nasal bridge
was pressed against the symphysis, the occiput delivered over
the perineum and then the rest of the face expelled. The
cord was twisted twice around the neck of the child and so
tightly that only one convolution could be freed before the
child was completely delivered. There was no pulsation in
the cord or fetal heart-beat.
The placenta was expelled forty minutes later in its en-
tirety. Labor, therefore, lasted altogether about thirty hours.
The perineovaginal tear was rather ragged, and for the
first five days, post-partum, there was an evening rise of tem-
perature to IOO.5°, due to localized sloughing of the vaginal
wall. The temperature then dropped to normal. The pelvic
measurements of the mother, who was only 4 feet, I 1 inches
in height, were rather small, but showed no deformities. The
sacral promontory could not be reached by the vaginal fingers.
The child was somewhat below the average development,
weighing approximately 6 pounds. There was, therefore, no
disproportion between pelvis and child beyond that due to the
presentation of the head by a large diameter.
Definition.—There has been considerable discussion as to
the proper definition of brow presentation and the difference
of opinion as to the frequency of its occurrence can be largely
attributed to this inaccuracy. Some authors include therein
the cases in which the anterior fontanelle lies lower than the
posterior and the brow can be felt but is not truly the present-
ing part. The Germans call this “Vorderscheitellage.” Muel-
ler” justly claims that in true brow presentation we should be
able to feel the brow as the lowest point, to one side of it dis-
tinguish the large fontanelle, and to the other make out the
orbital ridge and the root of the nose. We must also exclude
from our classification those cases in which the head is not yet
238 The Medical Society of
engaged in the pelvis. Here, even if brow and orbital ridge
can be felt, correction takes place before the head enters the
pelvis. e
Frequency.—If we take this definition of brow presenta-
tion we find most authors giving the frequency of its occur-
rence as about I in 15OO or 2000. Webster” states that at
Guy's Hospital there were 14 cases in 24,582 labors (1 in 1756).
Palotai" reports. I2 cases in 17, Io9 births (I in 1430). In cer-
tain districts in Switzerland, however, brow presentations as
well as face presentations seem to be far more frequent.
Moosmann,” of Berne, reports 44 brow cases in 19,725 births,
or about I in 448.
Etiology.—The explanation of this difference leads di.
rectly to a discussion of the etiology. Moosmann makes the
prevalence of congenital struma accountable for the frequency
of deflected vertex positions in these regions. It is readily
comprehensible how such a growth would interfere with the
proper flexion of the child's head and bring about a presenta-
tion of either brow or face. Only a small percentage of the
total number of cases can, however, be explained on such a
basis. At times it is difficult, if not wholly impossible to ar-
rive at a satisfactory explanation of the cause. That it oc-
curs more frequently in twins may, as Ahlfeld” points out, be
due to the anterior surfaces of the two fetuses coming in con-
tact and thus mutually disturbing the normal flexed attitude,
so that extension is facilitated.
By all authors the children in brow cases are given as be-
low the average in development. Hecker" gives the mean
weight as 2872 grams. The majority also find a certain amount
of contraction in the pelvis and frequent prolapse of an arm.
The main cause, however, according to Stumpf” lies not in the
relation of the bony parts but in conditions of the lower uter-
ine segment interfering with the proper flexion of the head.
Webster” gives the causes of brow presentations as similar to
those of face presentation. He mentions nine possible factors:
I. New growths of the neck or chest.
2. Displacement of arms under the chin.
3. Coiling of the cord several times around the neck.
4. Smallness or mobility of the fetus.
City Hospital Alumni. 239
Hydramnios.
. Sudden escape of the amniotic fluid.
Displacement of the long axis of the uterus.
Contractions of the pelvic brim.
9. Certain occipito-posterior cases in which there is much
resistance to the descent of the occiput.
Doubtless, in most cases it is rather a combination of cir-
cumstances than any one factor that is responsible for the mal-
position. A clearer insight into the significance of these vari-
ous factors is obtained if we classify them under the following
heads:
A. Factors interfering with proper flexion of the head,
such as–I, struma; 2, twins; 3, arms under the chin; 4, cord
several times around the neck. The last named would be par-
ticularly true where the shortened cord passed over the back
and thus in addition exerted a backward pull.
B. Factors allowing greater freedom of motion to the fetus,
thus increasing the opportunity for an abnormal vertex pre-
sentation, such as–I, smallness of the fetus; 2, hydramnios ;
3, contracted pelvis. Such a pelvis would interfere with the
early fixation of the head. Hence the presenting part would
float above the brim.
C. Factors that tend to fix the head in the deflected
position in which it lies at the onset of labor, such as—I, early
and complete rupture of the membranes; 2, abnormal rigidity
of the lower uterine segment; 3, spastic contractions of the
lower uterine segment and the internal os.
With the exception of congenital struma, we must in
every case have one of the factors, in Group C, present in or-
der that as the head enters the pelvis the brow remains fixed
as the presenting part. In my case the etiology seems fairly
clear.
While the smallness of the child, together with the hy-
dramnios, may have assisted in deflection, probably the most
important factor was the double coil of cord around the child's
neck. With the sudden complete escape of the amniotic fluid
the head was firmly grasped in this deflected position by the
lower uterine segment and a later correction of the malpre-
sentation thus prevented. Although no special test was
:
240
The Medical Society of
N.
made, there must have been considerable rigidity of the cer-
vix and uterine segment, since the patient was a primipara of
over 30 years of age. .*
I
FIG. I.-Author’s Manipulation for the Correction of Brow
Presentation.
The arrows in the illustration serve to indicate roughly the point of
application and direction of the forces applied to the child's head
and body. At the time at which this procedure should be at-
tempted, the deformity of the child's head is not yet as exagger-
ated as in the illustration, so that the difficulties to be overcome
in the manipulation are not as great as they would seem.


City Hospital Alumni. 241
Mechanism.—Even after the brow has begun to enter the
pelvis there may be a spontaneous correction of the malposi-
tion. This, according to most authors, is more frequently in
the direction of a face presentation than in that of a vertex.
Where no correction occurs the head may lie in the pelvis
transversely and even in a few cases, where the children are
small, be born in that position. Occasionally the chin will
rotate posteriorly, the occiput anteriorly. The more usual
form, however, is the opposite. The bridge of the nose lies
against the symphysis, and the occiput is delivered first, then
the face. The form of the fetal head in these cases is a very
characteristic one, as seen in the accompanying illustration. It
becomes more marked in premature rupture of the membranes,
owing to the enormous caput succedaneum and, hence, very
typical in our case. The caput lies over the forehead, extend-
ing from the orbital ridges to the large fontanelle. The fore-
head is very prominent and square, the mento-occipital diam-
eter being lessened, the fronto-occipital increased.
The duration of birth is usually considerably increased in
these cases. Von Steinbüchel” gives the average in primiparae
as thirty-four hours, in multiparae as thirty-one hours.
Prognosis.-The prognosis in these cases is certainly seri-
ous, particularly for the child. For the mother the greatest
danger lies in rupture of the uterus. The maternal mortality
is given by Long" as IO per cent, by von Hecker" as 5 per
cent. Stumpf reports one death from ruptured uterus in Io
cases. Injuries to the soft parts are of very frequent oncur-
rence. Von Steinbüchel gives the proportion of perineal tears
as 25 per cent of all cases. Necrosis with resulting fistulae are
occasionally encountered. Infections are more frequent.
The morbidity of mothers is given by Knaiske" as 36.6
per cent.
The prognosis for the child is certainly very grave. The
prolonged labor accompanied by direct compression of the
child's head together with the frequency of operative interfer-
ence (50 to 75 per cent) is productive of an increased fetal
mortality, Stumpf reports 6 deaths in Io cases; Olshausen,”
2 I deaths in 41 cases; Palotai, 41.6 per cent mortality;
Knaiske, 36 per cent.
242 The Medical Society of
Treatment—The treatment in brow cases consists, where
possible, in a correction of the malpresentation, changing it
into one of the more favorable forms, face or occipital. This
can be attempted in two ways: I, by posture; 2, by manual
procedures. The former method is cited by Kolischer” as oc-
casionally effective. The patient lies upon the side toward
which the chin points. This increases the flexion of the head,
producing a face presentation. By this procedure there is,
however, danger of producing a transverse position.
Of the methods of manual correction the best known is
that of Thorn” (“Thorn’scher Handgriff”). This author with
the internal hand tries to bring down the occiput, while the
external one pushes backward the chest of the child and an
assistant pushes forward the breech. In this way the child
may occasionally be brought to assume a correct attitude.
Benjamin” recommends placing the patient under an an-
esthetic and then forcibly pushing back the nead from its im-
pacted position in the pelvis. When thus freed, the presenta-
tion can be corrected.
Where manual correction fails and delivery has not taken
place spontaneously, it will usually soon become necessary for
the sake of either mother or child to aid the progress of labor.
If the head is still movable and the condition of the uterus
permit it, most obstetricians, among them Williams” and
Runge" recommend version.
When version is contraindicated, we must resort to forceps
but they must be applied with the greatest care to avoid in-
juries to the child and the maternal soft parts. It ranks
among the most difficult of such operations. Owing to the
unfavorable diameter presented the blades are particularly
liable to slip. When the head has reached the perineum,
traction should be made upward in order, if possible, to avoid
a tear.
Lauro” was the first one to suggest symphysiotomy for
these cases. This would, of course, be permissible only if the
child were still alive and manual correction or version impos-
sible. Wallich” reported 7 cases of symphysiotomy for this
indication with 2 fetal and no maternal deaths. If the child
be dead and there be difficulty in delivery, the operation is,
of course, craniotomy. &
City Hospital Alumni. 243
One word, in conclusion, as to the method tried in my
case to correct the position of the child by means of a forceps-
blade and the fingers of one hand. During this manipulation
I had the impression that considerable flexing power could
thereby be obtained but did not not feel justified in persisting in
the efforts owing to the extremely critical condition of the
child. It might, in selected cases, meet with better success.
Where the hand can be introduced far enough to reach around
the occiput, doubtless Thorn's procedure possesses the ad-
vantage of greater leverage. But where the head is already
impacted in the pelvis and any attemp to push it out of the
pelvis would be attended by the risk of a rupture of the uterus,
my procedure might be given a trial. As already noted the
blade corresponding to the side of the pelvis toward which the
occiput lies, is slipped around the occiput and held in place.
Then two or three fingers of the other hand are introduced
into the vagina for the purpose of exerting pressure upward
on the brow, while with the forceps-blade traction is made
downward. In order that the latter do not slip off, a certain
amount of counter pressure must exerted laterally by both
fingers and forceps-blade. An assistant should simultaneously
exert pressure abdominally to push the chest of the child back-
ward and breech forward. In this way force can be applied at
four points to correct the abnormal attitude.
Even if the indications were such that a forceps applica-
tion must be made immediately afterward, if the presentation
had thus been previously corrected, the instrumental delivery
would be attended by far less risk to mother and child, owing
to the lessened diameter thus obtained for the passage of the
child's head through the pelvis.
I, at one time, thought of testing the method on a man-
ikin but came to the conclusion that this would be valueless.
In brow cases the fault usually lies in abnormalties of the soft
parts and these relations as well as the altered shape of the
fetal head could never be imitated on the manikin.
REFERENCES.
1Schatz.-Saenger-Herff, Ency. des Geb. u. Gyn., p. 295.
*Müller.—Centralblatt f. Gyn., p. 313, 1901.
*Webster—Text-book of Obstet, 1903.
244 The Medical Society of
*Palotas.-Orvosi Hetilap, No. 19, 1902 (ref. in Centrl. f. Gyn.)
*Moosmann.— Centrl. f. Gyn., p. 812, 1904.
*Ahlfeld,—Die Ents. d. Stirn. u. Ges., Leipzig, 1873.
"Hecker.—Archiv f. Gyn., Bd. 20.
*Stumpf–von Winckel’s Handbuch der Geb., vol. 1, part 2, p. Io92, 1904.
*Von Steinbuechel.—Uber Ges. u. Stirn., Wien, 1894.
*Long.—Am. Jour. Obstet., Vol. 18, No. 9.
*Knaiske.—Ueber Ges. u. Stirn., Breslau, 1901.
*Olshausen.—Leh. der Geb., 1894.
*Kolischer.—Deflected Presentation in Labor, J.A.M.A., p. 551, 1902.
*Thorn.—Die Stell. der Man. Um. in der Ther. der Ges. und Stirn., Volk-
mann's Samb., No. 339.
*Benjamin —Phil. Med. Jour., Jan. 12, 1901.
*Williams.-Text-book of Obstet., 1903.
"Runge.—Geb., 6te Auf.
*Lauro.—Arch. di Ostet. e. Gin., No. 9, 1896.
*Wallich-De la Symphy. dans les Present. Persist. du Front. Comf Rendus
de la Soc. d’Obst., etc., p. 18, 1902.
DISCUSSION.
(The speakers discussing both papers taking them in their order).
Dr. H. SchwARZ indorsed every word that Dr. Gellhorn had said
and hoped that his paper would find a wide circulation. For years he
had made it habit not only to have every suspicious case examined but
to have the slides on record, so that in case the patient should go into
other hands or leave the city and some other physician would want a
record of her previous condition, it would be possible to supply it.
Physicians owed that in part to their patients and in part to themselves.
For example, if a woman of fifty had had a flooding spell and had
been curetted and the microscope failed to show evidence of carci-
noma and if the flooding recurred later and there was a suspicion
of carcinoma, it would be to the advantage of the physician to
be able to refer to his slides to prove the condition at the former
examination. &
As to Dr. Taussig’s paper, such cases were exceedingly rare. He
had seen only one such case where the shape of the head illustrated
in the drawing was attained. Brow presentations were perhaps more
dreaded than they deserved to be. Many students and young men
thought brow presentations were more frequent than was really the
case, and that they called for more activity. In cases where the physi-
cian had charge of the patient long before delivery, face and brow pre-
*
City Hospital Alumni. 245
sentations could be avoided. Most of those cases originated at the
very beginning of labor and were due to the position of the child
which was such that when labor set in the occiput escaped into the
right or left iliac fossa. In such cases, if they were examined a month
or two before delivery it would be possible to correct that. In most of
the cases seen where the head was not engaged and the condition was
allowed to go on until the membranes ruptured, the head was then
brought down into a faulty position and was fixed there by the severe
contractions of the womb, and a face presentation resulted. In
regions where there was a good deal of pelvic contraction, face, and
conseqently, brow presentations were more frequent; here they were
less common. As to the treatment of such cases, he had always
thought that face presentations should be let alone. Very few cases
came under observation where the head was still movable. He should
prefer to perform version if the head was perfectly movable, but
in most cases he preferred to leave the case to nature and wait until
either the brow or face had come down and rotation forward had taken
place in a degree and the forceps could catch the head from side to
side. The danger to the perineum was always great in such cases.
So far as the application of the lever or one blade of the forceps was
concerned, in a proper case it might be successful but in those cases
that had been left alone so that the head had become impacted tightly
in the pelvis, no lever could change the conditions.
Dr. CARL Fisch had been much interested in Dr. Gellhorn’s paper,
and in the intelligent and clear way in which he presented his views.
There were one or two points that he wished to take up, and the first
was the introduction to Dr. Gellhorn’s paper, in which he seemed to
take the position that the lately established methods for the investiga-
tion of cancer had brought the cancer problem to a new stage of de-
velopment. In this he did not agree with Dr. Gellhorn. There were
cancer laboratories and societies using yearly hundreds of thousands
of dollars. They had been in existence six to eight years. What had
been the result 3 No one was a step farther in his knowledge of can-
cer than he was before. The statistics had been made more complete,
but as to the essential nature the investigators of today knew no
more than their forefathers knew. A member of the English Cancer
246 The Medical Society of
Commission had expressed that view, saying that so far no means ex-
isted to get at the bottom of the cancer problem, that new means of
research must be found, perhaps accidentally discovered, to enable us
to learn more of the condition. The second remark concerned the
early microscopic diagnosis of the disease. Dr. Gellhorn had explained
that clearly, and he only wished to mention some of the difficulties
connected with the investigation. In the first place, it had been, and
still was, customary in examining uterine curettings to use one or two
little fragments. It was necessary, in order to be sure, to have ex-
amined every little fragment of the material. Objections had been
raised to that on the ground that it required a great deal of time but
he had never found it tedious. That, of course, the microscopical
examination did not always give the proof was easily explained for
reasons that were familiar to all. But what was carcinoma 2 How
could carcinoma be microscopically diagnosed ? In going over the
text books it was all very nicely explained, and one was told that this
was carcinoma, and this other was not. But in practice that would be
found not always so easy to apply. There were a number of cases where
pathologists hesitate to express the suspicion of malignancy. In such
cases he thought it would be better to operate on the base of a suspi-
cion than to allow a case to go on to a complete development of the
disease. He mentioned a case in which he had been furnished a small
piece of portio-tissue for examination. He found a peculiar epithelial
proliferation. Of course, such epithelial proliferations occurred which
suggested malignancy, yet, were due to nothing more than the effects
of inflammatory processes. In this case, had he gone by the text-
books he would have pronounced it an abnormal hypertrophy, but he
reported his suspicion that the condition was malignant. The suspi-
cion was not regarded. The case was allowed to go on, and two
months later he received another piece from the cervix showing a typi-
cal epithelioma. It had then involved the whole cervix; hysterectomy
followed, but the woman was now dying of metastasis. He most
earnestly and seriously advised the examination of all uterine curet-
tings; the way, which in Germany, lately has been taken in this direc-
tion, ought to be followed with us, too. The frequently-made objec-
City Hospital Alumni. 247
tions against the value of microscopic diagnosis are based on a lack
of knowledge on the principles involved.
Dr. HUGO EHRENFEST said that there could not be any doubt but
that Winter's dictum has proved true, that not more extensive opera-
tions but earlier diagnosis would guarantee better Iesults. The micro
scope is the best aid in securing the early diagnosis. We can, how-
ever, not entirely rely upon it. It is of positive value only if the find-
ings are conclusive, negative results of the microscopical examination
of scrapings do not exclude the presence of a cancer. In certain
locations the carcinomatous tissue if limited to a small area may evade
the curette. The scrapings may show a histologic picture that is sug-
gestive but not conclusive for malignancy. In the speaker's opinion
the possibility of such deficiencies in the microscopical diagnosis
should be duly mentioned in all those papers that are written for the
purpose of emphasizing the value of the microscope in the early diag-
nosis. Such a practice would deprive those who antagonize the micro-
scope (probably because they do not know how to use it), of their
good opportunity to quote those comparatively rare instances in which
the microscope has failed to establish the diagnosis.
When of late the advocates of the abdominal route published
their better results with the more radical operations, they have, in the
speaker’s opinion, neglected to consider the fact that they have un-
doubtedly operated upon a comparatively larger number of cases in
an early stage of the disease. Much good has been achieved in the
last few years in this respect by a systematic propagation of a better
knowledge of the earlier symptoms of uterine carcinoma.
He was much interested in the etiology of Dr. Taussig’s case.
He, himself, saw a case in which also the winding of the umbilical cord
around the neck was responsible for a face presentation. One point
which Dr. Taussig probably intentionally omitted in discussing the * ...e.
therapy is the perforation of the living child. There can not be any
doubt that under certain conditions brow presentation may necesitate
this operation.
Dr. WILLIAM S. DEUTSCH believed, as Dr. Fisch had stated, that
it would be a very good thing to have the uterine scrapings in every
case examined even when there was no suspicion of carcinoma. If
that could be done many cases might be saved.
248 The Medical Society of
posture.
Dr. NORVELLE WALLACE SHARPE expressed his personal apprecia-
tion of the papers, but he thought that if the force of the finger tips
was presented in the direction of the arrow in the drawing that the
head would not be changed. In other words, the head was correct
but the position of the arrow quite wrong.
Dr. FRANCIS REDER said that while we were always looking for
the earlier symptoms of carcinoma, yet, when a positive diagnosis was
made the question was how much good could we do the woman. If
we could give her relief for from three to five years, we could congrat-
ulate ourselves. He could not agree with Dr. Gellhorn on having
operated regardless of the revelations of the microscope. He believed
that when everything had been done with no relief to the patient that
ablation should be performed even when there was no evidence of
malignancy at the time, simply because one could never know a con-
dition of malignancy manifest itself.
He thanked Dr. Taussig for presenting a paper of such value to
the Society, for such papers were very rare in this Society. In his experi-
ence he had had but one similiar case, and it was classed a face pre-
sentation. In that case the right eye was closed by a large swelling.
Dr. Ehrenfest had mentioned a very important point, that of deep
anesthesia. However, he would not apply deep anesthesia with the
expectation of being able to push back the head, but with deep anes-
thesia he hoped to gain complete relaxation. The danger to the peri-
neum had been mentioned. He believed that in such a case one
should proceed with delivery and occomplish it as rapidly as possible
regardless of the perineum. In deep anesthesia the genupectoral
position would be given some preference, for if any advantage could
be gained by change of position it would be with the patient in that
Dr. FRANK HINCHEy, discussing Dr. Gellhorn’s paper, called at-
tention to the fact that so many members of the profession treated
many of these cases of early cancer as they would a menorrhagia.
He had recently refused to treat three patients in this manner. He
had insisted on the necessity for a curettement. They had the symp-
toms of cancer. Two of those patients he subsequently had occasion
to hear of indirectly. They were being treated by physicians who
City Hospital Alumni. 249
i
were not quacks, yet, they were “treating” simply for menorrhagia—
none of them had been curetted. He told each of them that there
was no way of deciding the possibility of cancer without curetting, and
he had pictured all the horrors of the danger that threatened them.
He understood that one of those patients was said to be “too weak”
to stand the chloroform. It simply showed that there were men who
were either ignorant or unprincipled. There was great need of
education of the profession. At least two of these men were not
ignorant men, by any means, and he believed they were simply
unscrupulous.
Dr. Taussig’s case of brow presentation was very interesting.
Last summer he had had a patient who had complained all through
her pregnancy of a great deal of pain in the lower quadrant so that
she had spent much of her time in bed. The movement of the child
seemed to be tumultuous and increased the pain. The child, from its
very active movements, could easily have gotten into malposition at
the onset of labor. When he saw her the os was well dilated and he
could get the fingers pretty well down on the superior maxillary. See-
ing that she would have to have anesthesia he 'phoned Dr. Gettys that
he might be with him to give her the chloroform. The membranes
had ruptured and the pains were coming rather slowly She was placed
in the Trendelenburg position thinking it would be favorable for
version as the uterine pains were not very strong and he thought he
might prevent the leakage of the amniotic fluid. He saw the futility
of attempting to drag down the occiput but wanted to prevent
the sweeping back of the chin to the hollow of the sacrum and
thought that if he could get in the hand that he could save the turning
of the head. The case continued that way with the patient in the
same position and he was enabled to push the brow up as he supposed
thus aiding nature to convert into a face presentation with chin under
the symphysis; although he could not say whether he had made any
change in the position or not. The woman struggled so that he really
could not tell whether he was pushing the child or her, she having re-
fused anesthesia. He thought he might have rendered some little
service. However, the case terminated as a face delivery. Whether the
Trendelenburg position helped or not he did not know. It would at
250 The Medical Society of
least favor the retention of amniotic fluid in such a case, as the pa-
tient was not having strong pains.
Dr. J. C. FALK said that his own experience emphasized the im-
possibility of rotating the head after it had become as firmly impacted ºr
as the drawing indicated. If one could satisfy himself that there was
enough amniotic fluid there he might be justified in attempting to push
the head back, otherwise there did not seem to be anything to do but
to leave it to nature or put the forceps on. g *
Dr. M. J. LIPPE said that he had been requested by Dr. Fisch to
report a case in which the uterus had been removed some eight months
before, and asked Dr. Gellhorn to present the specimen. The case
itself was a sermon on the early diagnosis of carcinoma of the uterus.
The patient was passed 60 years of age, and a well-preserved woman.
For some time before consulting Dr. Lippe there had been a slight
bloody discharge and some pain. He found a very small uterus that
had undergone senile atrophy. After observing the patient for several
weeks he advised that she be curetted, which was done and the speci-
men was sent to Dr. Fisch for examination. The cervix was apparently
normal and the uterus small. An experienced gynecologist saw the
woman with Dr. Lippe and said that he would let the woman alone,
but Dr. Fisch reported that the curettings indicated an adenocarcinoma
and patient was operated upon, and made a perfect recovery and was
still in excellent health. Within the fundus of the uterus there was a
point the size of the thumb nail that was a carcinoma. It was an
adenocarcinoma that had not spread. He wished that Dr. Taussig
would say whether he used traction or whether he used the blade of
the forceps as a lever.
, Dr. GELLHORN, in closing, said that he had no criticism to offer
for he had had no experience with the condition in question but the
* paper of Dr. Taussig had been very instructive to him.
He thought the suggestion of Dr. Schwarz to keep the slides was
a very important one and in addition to the practical advantage of the
protection of the patient and pnysician, the slides would be of great
scientific interest. If all negative slides were kept it would be possible
to state, in a great many cases, the exact date of the beginning of the
carcinoma. He did not quite share the pessimism of Dr. Fisch in re-
City Hospital Alumni. 251
gard to the investigations being made in this and Continental countries.
While it was true that nothing of great practical value had been
achieved, there was every reason to hope that that might be accom-
plished in the near future, and in the meantime any light on the sub-
ject was welcome. Dr Fisch, in speaking of the examination of the
scrapings, had remarked that in some instances the typical changes of
carcinoma might not be present but that there might be changes that
would give a hint of the possible later development of carcinoma, and
he emphasized that every particle of the scrapings should be examined.
But if he understood Dr. Fisch rightly, he had not said that the entirely
negative outcome of the examination should not prevent the examiner
from passing judgment. That was a point Dr. Ehrenfest brought up
and on which he disagreed with Dr. Ehrenfest. Dr. Ehrenfest had said
that if one did not find gonococci in a specimen that did not indicate
that there was no gonorrhea. The logical consequence in any given
case would be, that the physician would never be able to give a def-
inite judgment as to the presence or absence of the disease. It is
true, if no evidence of cancer is in a first examination, then judgment
must be suspended until a second examination, but if, after two ex-
aminations, there is still no evidence, then one has no right to insist
that there is a carcinoma, and he has no right to extirpate such a
uterus. Dr. Reder had referred to the case in which Dr. Gellhorn had
operated in spite of the negative outcome of the microscopic examina-
tion and had favorably commented on the action taken by Dr. Gell-
horn. He, Dr. Gellhorn, however, would never again extirpate a
uterus only on account of clinical symptoms if repeated microscopic
examintions did not reveal cancer. Such a practice would be too
dangerous to the patient to be justifiable. Operations, and particu-
larly major operations, such as hysterectomies, should not be done un-
, less strictly indicated.
He would be very glad to respond to Dr. Lippe’s request to pre-
sent the specimen referred to, (Demonstration) Under the microscope
it is plainly visible that in one small area of the inner uterine surface
the glandular formations suddenly dip down deeply into the uterine
muscle thus exhibiting two signs of malignancy: Proliferation and ex-
tension into foreign tissue.
Dr. TAUSSIG, in closing, said that one of the specimens under the
252 The Medical Society of
microscopic was from a case of unusually early carcinoma of the cer-
vix. The patient was 49 years of age and had come to the Gyneco-
logical Polyclinic for treatment without any of the symptoms of carci-
noma. She had some dragging sensation and some vaginal prolapse.
At her second visit he noticed an eroded area about 1 cm. in diameter,
near the external os, he applied some 4 per cent silver nitrate and
that it bled. On her third visit he snipped off a small piece
for examination and found what he considered to be one of the
earliest cases of carcinoma. It extended only about 2 mm. into the
CerVIX.
As to the diagram, he wished to offer some apologies. It repre-
sented the altered shape of the head in brow presentation but that
altered shape was acquired after the head had passed through the birth
canal. The head did not show such alteration before it had passed
through the canal, and the manipulation described is hence not as dif-
ficult as the diagram would make it appear. As to the arrow, that was
to show that the pressure should be made toward and against the
force of the forceps blade on the other side. The blade was to be
drawn downward and somewhat inward and to be used as a lever and
for traction. As to the suggestion for using deep anesthesia for such
cases, he had read the paper of Dr. Benjamin’s but thought it could
seldom be applied because of the danger of rupture of the uterus.
In his case the contraction ring was within one finger's breadth of the
umbilicus and any pressure of that kind would have been fraught with
danger to the mother.
Meeting of November 17, 1904, Dr. Charles Shattinger,
President, in the Chair.
Dr. J. G. MooRE, of the Emergency Hospital, World's Fair, pre-
sented a specimen of a large
Salivary Calculus.
There were absolutely no symptoms until a few days before he
saw the patient. The gentleman had come from Alaska and when
he reached Seattle his mouth was sore and by the time he reached St.
Louis he could not talk. Dr. Moore removed the calculus from the
right sublingual gland.
City Hospital Alumni. 253
Fallacies, Aims and Methods of Hydrotherapy
in Fevers.
By SIMON BARUCH, M.D.,
NEW YORK CITY.
HE axiom of Hippocrates, “Cold water warms; warm
water cools,” was Dr. Baruch's text. For years the
medical profession, with the exception of Winternitz,
Brand and a few others, believed the reverse and even today
the average physician applies cold baths for reducing temper-
ature, and when it fails, if he has the courage of his convic-
tions, he makes the bath colder. To this error may be at-
tributed all the failures in the hydrotherapy of fevers. Hydro-
therapy in ſevers gradually spread throughout Germany into
a systematic method, the clinical results of which far excelled
the expectant plan previously in vogue. The dominating idea
was that the chief merit of cold baths lay in their power to
reduce temperature. At that date hyperpyrexia was regarded
as the chief lethal agent in fevers and it was the logical de-
duction that the cold bath, which was at that time regarded as
the only real antipyretic in existence, diminished the fatality
of fevers by the reduction of excessive temperature. Brand
labored earnestly to prove that antipyresis was not the chief
aim of the cold bath. Not until the true antithermics were
discovered in the coal tar preparations did it dawn upon the
medical mind that high temperature was not the chief lethal
factor in fevers.
The true function of the cold bath in fevers was not un-
derstood until Winternitz and Brand had insisted upon it again
and again and brought down upon themselves criticism and
contumely. In England, where the most influential works on
the subject were written, this treatment has not become popu-
larized, and the Brand bath has never been adopted by Eng-
lish physicians. In this country the bath was almost unknown
until Dr. Baruch made a plea for its application in typhoid
fever, before the New York State Medical Society, in Feb-
254 The Medical Society of l
ruary, 1888. The Medical Record, February 16th of that year,
stated editorially that “it would be difficult to persuade the
profession to adopt the heroic method of cold bathing.” The
same journal, May 7, 1898, stated: “It is generally conceded
that excellent results are obtained by judicious cold water
treatments, and the closer the Brand method has been fol-
lowed the better the reports seem to be.”
In the hospitals of Berlin, Dresden, Halle, Jena and Leip-
zig, the Brand method has gone out of vogue. The essential
principle of the Brand bath, which is not at all temperature
reduction, has been misunderstood. Brand's whole propa-
ganda was in opposition to the antithermic idea of the cold
bath. Sir Lauder Brunton says, in “Action of Medicines: ”
“Another way of applying cold is to put the patient into a cold
bath and leave him there for a certain time. In St. Bartholo-
mew's Hospital the cold bath is stated to be water at 65°F. or
reduced by the gradual addition of ice water to 40°F. or be-
low,” a temperature from which the most enthusiastic hydro-
therapist would shrink with horror. Perhaps the chief reason
why hydrotherapy has not become more general in practice
lies in the absence of correct teaching of the subject in our
schools. Little progress can be made until such terms as cold
water, warm water, hot water, are abolished, and exact temper-
atures stated in their stead. It were better to designate water
as cold or warm when its temperature is below or above that
of the skin, which in a normal subject is about 98°F., and in
fever subjects higher. The reason for adopting this rule lies
in the hydrotherapeutic law that the so-called shock from cold
water and the reaction, which is its object, are in proportion to
the difference between the temperature of the skin and that of
the water used. When water is applied having a temperature
of the skin the effect is neutral because the thermic irritation
is absent. A lower temperature produces the irritation of the
sensory nerve terminals and contraction of the cutaneous
arterioles; the lower the temperature, the greater the sensory
excitation.
Another mode of dosage of water applied externally is
by changing the duration of the treatment. If water Io’ or
more below the temperature of the skin is applied briefly, re-
gº
City Hospital Alumni. 255
action follows quickly—as noted in sprinkling the face of a
fainting person. If the same temperature of water is applied
to the same person for a longer duration and upon a larger
surface, as in a bath tub, reaction is slower and depression may
ensue if continued too long. It is a well-known fact that cold
is a thermic irritant and, like all irritants, it stimulates when
mild, depresses when severe and destroys vitality when very
intense. vº
What, then, is the aim of applying water below the tem-
perature of the skin in fevers. The chief aim is to produce a
reaction which may lead to the invigorating and refreshing of
the organs and thus enhance its capacity to resist the lethal
toxins circulating in the blood. The intensity, duration and
efficacy of the reaction is in proportion to the so-called shock
produced by the cold procedure. That all peripheral excita-
tions are conveyed upon sensory tracts to the central nervous
system and, returned upon motor tracts to the various parts of
the organism is a trite physiological fact, but that the effects
of cold procedures are simply due to thermic excitations which
are conveyed and reflected in a similar manner from the cuta-
neous to the various parts of the organism is, unhappily, not
as familiar to the average physician as it should be. The con-
tracting effect of cold upon the cutaneous arterioles is also a
trite physiological fact, but the potent influence upon the en-
tire circulation due to a sudden narrowing of this enormous
vascular area and the subsequent tonic widening of the arte-
rioles during reaction are not so familiarly known as they
should be by him who would master the best method of hydro-
therapy in fevers. Reaction after cold procedures is, therefore,
divided into two varieties, namely: The nerve or reflex reac-
tion and the vascular or vasomotor reaction. The first is ob-
served when a still-born infant is sprinkled with cold water.
The local excitation of the sensory cutaneous terminals is con-
veyed to the central nervous system and through the vagus
and other nerves to the inspiratory muscles, there is the
familiar gasp, heaving of the chest, and breathing is estab-
lished.
The second or vascular reaction is exemplified in its pure
form in the application of cold water to a frost-bitten part.
256 The Medical Society of
The congested and paretic vessels are contracted, followed a
tonic dilatation, more vigorous circulation and a restoration of
normal condition.
In the application of cold water in fevers a combination
of the vascular and reflex reactions is obtained. This is most
Surely secured by the cold friction bath devised by Brand,
which is administered as follows: A tub containing water at
70°F. is placed alongside the bed. The patient is given half
an ounce of brandy or a small cup of black coffee. His face
is bathed with ice water. He is placed upon a small hammock
from which the sticks have been removed. He is then lifted
easily by two persons, who twist the upper and lower ends
of the hammock into a cord, and placed into the tub. The
edges of the hammock are hung over the sides of the tub
or dropped into it; two or more nurses practice constant
friction over successive parts of the body, avoiding the right
iliac region. Twice during the bath the patient is raised suf-
ficiently to receive an affusion from a basin of water at 50°F.
over the head and shoulders. During the bath the bed should
be prepared for his return by placing upon the sheets a blanket
covered by a linen sheet. Upon this he is lifted by means of
the hammock from which the surplus water is allowed to drain
while he is held a moment over the tub. Removing the ham-
mock the patient is now quickly wrapped in the linen sheet
and blanket. If shivering continues, he is dried at once and
placed in bed, otherwise he is allowed to remain in the pack
for half an hour or longer if he is asleep. After drying, the
sheet and blanket which constituted the pack, are removed
and he is placed between his own sheets, dressed in his gown.
This technic, with the exception of the hammock, which Dr.
Baruch added for convenience in lifting, was obtained directly
from Dr. Enrst Brand 12 years ago. Any deviation from this
technic must not be termed a Brand bath. Friction is the
most important element of the Brand bath, as it should be of
every cold procedure. Friction enhances the thermic excita-
tion, causing the arterioles contracted by the cold to dilate so
that the skin of a patient issuing from a properly-administered
bath is ruddy, though cold.
What is the object of the friction bath in infectious
City Hospital Alumni. 257
fevers ? The chief lethal factor in infectious diseases is heart
failure. Stimulating the vainly laboring heart is llke spurring
a jaded horse. How much more rational it would be to study
the rationale of this so-called heart failure and avert it by
measures based upon such a study. This has happily been
done by Romberg and Paessler of the Leipzig Clinic, and by
others who have found that heart failure is not due to a degen-
eration or failure of the heart muscle but a failure of the
peripheral circulation. The toxins circulating in the blood in-
duce a paretic condition of the peripheral arterioles. Their
normal function of resistance for the maintenance of tone of
the vasomotor system is impaired. Their tone is lost and as
a result the heart is forced to exhaust itself by redoubling its
efforts to compensate for the sluggish flow at the periphery.
Plying stimulants to the heart under such conditions is like,
shoveling coal into the boiler of a locomotive which is vainly
revolving its wheels over a slippery track. The engineer does
not attempt to increase the power, he sands the track. Here
a similar result is obtained from a properly-administered cold
bath, or milder procedures, ablutions, affusions, etc. The
stimulation of these arterioles by friction restores the lost vaso-
motor tone at the periphery, the heart feels the tonic resistance
and, reinforced by impulses sent from the refreshed central
nervous system, it sends the blood in joyous currents to the
outlying area in the glandular vessels, enhancing the patient's
resistance to the toxemia which menaces him with sure and
resistless force until the life period of the Eberth bacillus is
terminated. This is the rationale of the cold friction bath;
the whole machinery of the organism receives a refreshing im-
petus every three or four hours.
Based upon these principles Dr. Baruch has adopted the
following method of managing typhoid fever. When a pa-
tient manifests a temperature of IOI* or over, rapid ablutions
with gauze or linen cloths, dipped in water at 85°, are given
every two hours with gentle friction over the trunk only. The
temperature of each ablution is reduced two degrees until 60°
are reached. After the patient is dried by patting, not rubbing,
with a thin linen towel, a wet compress is placed over the en-
tire abdomen. This compress is prepared by wringing three
.*
258 The Medical Society of
folds of linen out of water at 60°. This is snugly held by a
flannel bandage an inch wider than the compress around the
entire body secured by safety pins. If there be a persistent
temperature of IO3° or over, without local manifestations, the
friction bath of 90° for twelve minutes may be administered
in the bath room. If the temperature rises to Io9% again
within four hours, the bath is repeated at 85°, four hours later
at 80°, again at 75°, always insisting upon active friction. If
one of these baths reduces the rectal temperature more than
2°, the case is pronounced not one of typhoid. Based upon
the fact that baths are not an efficient antithermic agent in
infectious fevers, this diagnostic bath has been evolved. It is
as reliable in the first week of the fever as are the lenticular
spots in the second week. The smaller the reduction of rectal
temperature from one of these baths the more positive is the
diagnosis of typhoid fever, and, pari passu, the larger the re-
duction, the less positive is it. As soon as a diagnosis of typhoid
is made the friction bath is no longer administered in the bath
room because the latter is inconvenient and does not permit of
nurses standing on both sides of the tub. A tin tub, six feet
in length, is placed on the stools alongside the bed. The pa-
tient having been inured to cold water by previous ablutions
and cold compresses, and the friends having observed their re-
freshing effect, objection is rarely made to a bath of 75°, which
may be reduced one degree at each subsequent four-hourly
bath until a temperature of 70° is reached. Chilling must be
prevented by continuous friction; the patient should not be
removed even if he entreats for escape, unless the teeth chat-
ter and the lips are cyanosed. A thready pulse often frightens
the inexperienced into abandoning the friction bath. Careful
examination of the pulse will reveal that it is slower and less
compressible; smallness being due to contraction of its mus-
cular walls by the cold water. Patients usually dislike the
Brand bath and it requires all the persuasive power of the
nurse, doctor and friends to retain them, but reliable statistics
have demonstrated the value of the Brand bath.
Summing up his observations of the past ten years, how-
ever, Dr. Baruch is disposed to modify the strict Brand bath
in all cases seen after the first week of typhoid, but to approxi-
City Hospital Alumni. 259
mate it as nearly as the reactive capacity displayed by the
patient warrants. In American hospitals cases are rarely seen
before the first week expires. He had never seen a case result
fatally if the treatment was begun before the seventh day. A
good substitute for the Brand bath is the sheet bath, the pa-
tient being rubbed vigorously while wrapped in a wet sheet.
This repeated every three or four hours when the rectal tem-
perature rises to 102.5°. Reaction must always be insured
else the sustaining value of the bath is lost. In cases of feeble
reaction, with compressible pulse and other signs of a dynamia,
affusion of one or more basins of water at 60 to 50° over the
head and shoulders of the patient held in a tub containing six
inches water at 95 to IOO’ is of advantage. These may be
applied every two or three hours until reaction is established
when resort can again be had to a plunge bath at 70 to 80°,
applied either as a dip repeated two or more times successively
or as a full bath with friction for five or more minutes. No
remedial agent is so flexible in dosage as water. Regard
must be had to the fact that that brief applications stimulate
and are applicable in most desperate conditions as a measure
to tide over emergencies, just as alcoholic stimulants are ap-
plied. The Brand bath illustrates what the maximum dose is
capable of accomplishing in infectious fevers. The treatment is
begun with milder procedures, as ablutions, compresses, short
tubbings, affusions, towel and sheet baths, the physician always
bearing in mind that the longer the bath and colder the water
within the limits indicated by the Brand bath, to which the
patient has the capacity to respond, the more efficient and endur-
ing will be the effect. It is faulty practice to increase the
temperature of a bath or other cold procedure when the pa-
tient feels uncomfortable or reaction is imperfect. Instead of
increasing the water temperature, the duration of the procedure
should be diminished, and more friction applied. Friction
during a cold bath prevents the demand for friction, hot water
bags and stimulants after the bath.
During the past few years Dr. Baruch has, in advanced
cases, adopted a method which has enabled him to apply
hydrotherapy in conditions that would otherwise forbid it. To
illustrate the method he reported the following case:
260 The Medical Society of
Mrs. R., to whom I was called by Dr. Fraenkel, of New
York, on the tenth day of a severe case of typhoid, had been
seen on the third day by Dr. Abraham Jacobi, on the sixth
day by Dr. Francis Delafield and, her condition growing worse,
on the ninth day by Dr. E. G. Janeway. Dr. Fraenkel was
anxious to apply cold tubbing and had procured a portable
tub. But Dr. Delafield, an earnest teacher and advocate of
the Brand, counselled against any cold procedure in this des-
perate case, because the temperature was only Io2°, the heart
was feeble, the pulse 160, there was coma vigil and delirium
and involuntary movements had existed for several days. I
did not favor a cold water procedure until the reactive capacity
had been tested without harming the patient. The central
nervous system was so overwhelmed that it could not respond
to thermic stimuli, as was proved by the absence of the in-
spiratory gasp when a basin of water at 50° was dashed over
her head and shoulders. How was this cerebral obtuseness
to be removed? I suggested the addition of a chemical irri-
tant, harmless and transitory in its effect, for the purpose of
arousing the feeble cutaneous arterioles to do their work. By
adding the Nauheim salts to a tub bath of 80° and placing
the patient into this latter while the carbonic acid gas was
bubbling, the cutaneous arterioles were aroused from their
lethargy. After five minutes bath the pulse was 150 and five
minutes later, friction being constantly applied by three per-
sons, it registered 140 and had become more resilient. The
bath was prolonged to fifteen minutes. She was then lifted up
and two basins of water at 50° poured over her, despite which
she continued her stolid gaze as if nothing had been done. She
was wrapped in a previously prepared sheet and blanket, dried
and fell asleep, and continued for four hours in a calm slumber.
When she awoke the bath was repeated, with the result of
again improving the pulse, inducing sleep and diminishing de-
lirium. Not until a fourth bath had been administered did the
patient's brain feel the stimulus of an improved blood supply,
consciousness return and delirium ceased. A slight intestinal
hemorrhage precluded bathing for thirty-six hours. An ab-
dominal compress at 60° was applied every hour to maintain
the thermic excitation without disturbing the patient. When
City Hospital Alumni. 261
washing the rectum brought no traces of blood– the bath was
resumed with the result of complete recovery.
In conclusion Dr. Baruch said that this interesting case
illustrated the flexibility of hydriatic methods and their favor-
able application in most desperate conditions. He hoped that
as a result of his remarks this remedial agent would be more
frequently employed in the daily combat with disease and
death.
IDISCUSSION.
Dr. BARKER said that shortly after leaving the hospital service it
had fallen to his lot to treat quite a number of typhoid cases, more,
perhaps, than usually comes in one’s first year of general practice
and, interested at that time in some articles by Dr. Baruch and others
on hydrotherapy he had attempted to follow out the plan of bathing
known as the Brand method. During the first twelve or eighteen
months he had had ten or a dozen cases of typical typhoid fever. In
the hospital it had been the custom for the internes to do the thing
thought best for the patient whether the patient thought so or not, and
that custom was of service to him when he began the use of the Brand
bath. To put it very mildly, the results from the start were quite sat-
isfactory. A great deal of his work had been among people of limited
means. Some were not even able to buy the necessary tub. He sur-
mounted that difficulty by having a set of tubs at his office, and many
a night the large tin tub might have been seen moving down the street,
his office man under it. The restored tonicity was something which
had particularly struck him in the Brand treatment. The vasomotor
paralysis was counteracted. The benefits derived from the bath were
certainly manifold. The reduction of temperature by bathing as a
criterion in the recognition of typhoid fever seemed unreliable to him
and he would like to hear more about it before regarding it as of much
value.
Dr. E. S. SMITH understood that the greatest disturbance came
through the disturbance in the peripheral circulation due to the vaso-
motor paresis, and all the nerve symptoms in such cases were due to
that sluggish circulation. Physicians generally believed that the dis-
turbance in the nerve centers in typhoid was due directly to the effect
262 The Medical Society of
of the toxin on the nerve tissue and, therefore, they felt that those
cases in which the nerve symptoms predominated were the ugliest. It
was a comfort to feel that those disturbances in the nerve centers were
due to a temporary nerve disturbance. The tonic effect upon the
heart was certainly interesting and it was a point that had not been
appreciated in the treatment of the disease. It was a comfort to
know that the cardiac failure was in a large proportion of cases conse-
quent upon peripheral disturbance in the circulation. This is contrary
to the common belief that cardiac failure was due partly or largely to
the effect of the toxins on the heart-muscle. If he had understood
correctly it would make him all the more enthusiastic in his advocacy
of the Brand bath.
Dr. H. W. SoPER said that one method of treatment of typhoid
in vogue here might come under the head of hydrotherepy. A normal
salt solution enema was given daily as a routine method. He knew of
several physicians who gave it regardless of hemorrhage or diarrhea,
and he wished that Dr. Baruch would give his opinion of that
method. He also desired his opinion of proper bathing in true heat
stroke.
Dr. A. E. MEISENBACH used antipyretic drugs occasionally with
happy results in the early part of the fever. He was glad Dr. Baruch
did not wholly disapprove of them. A point in regard to temperature
reduction had been brought to his mind forcibly when the doctor had
referred to the case in which the temperature was comparatively low.
Now, the question was, did the patient need a stimulation or elimina-
tion ? He wished the doctor would say more regard to that point, and
in closing his paper express himself in regard to the necessity and in-
dication for the reduction of temperature.
Dr. W. S. DEUTsch wished to know what could be expected from
that treatment in typhoid fever where there was hemorrhage, not only
slight but profuse. It was always a question how far one could go
with the Brand method. The essayist claimed that the results were
due to the tonic effect; if that was so it would open a new field in the
treatment of diseases other than typhoid fever; if they could get the
same tonic effect, thereby helping the enfeebled circulatory system to
throw off those septic matters, they would have a potent remedy at
\.
f
City Hospital Alumni. 263
their command. He did not believe this bath method had been used
very much in cases of sepsis, where it might have a similar salutary
effect.
Dr. J. L. BoEHM said that a good illustration of the statement
that hot water cools and cold water warms was brought about in a-
case of inflammation of the prostate where the patient had violent at-
tacks of priapism. He at first advised a cold water siphon; after the
use of the cold rectal siphon he was a great deal worse. On the con-
trary heat, at 1 Io° (the patient having begun with a temperature of
Ioo") gave relief. He finally used it at a temperature of 115° with
perfect ease and was now using it at 116°. When an attack came on
he got more relief from it than from large doses of bromides, chloral,
etc. Another illustration of the good effects of cold applied extern-
ally was in three cases of adrenalin poisoning. It seemed it had a
peculiar effect upon the peripheral circulation, though his experience
with the drug was confined to urethral work. The three patients be-
came intensely cyanotic, the temporal blood vessels became engorged
and looked like lead pencils thrust under the skin. All that he had
done in these three cases was to apply towels wet in cold water to the
head and when they became warm other cold wet towels were wrapped
about the head; the effect was a very pleasant one.
Dr. V. P. BLAIR called attention to a contrivance that had been
used for baths; it was a frame six feet long and six feet wide, set on
legs eight inches long, and covered with a white rubber sheet; it had
the advantage that a pillow could be placed under the patient's head.
Finally it was used under a very heavy person and a piece of carpet
was placed under the back; with this contrivance friction could be ap-
plied to the back.
Dr. HENRY JAcoBson mentioned the beneficial results from the
use of a curved rectal tube (prostatic pschycophore) he had obtained
in a case of pelvic inflammation between the cul-de sac of Douglas
and the rectum; he had used hot water at Io.2° and inside of a week
there was a marked decrease in size of the inflammatory mass. He
wanted to hear from the President on the use of water in typhoid
fever as he had devoted a great deal of attention to the use of bathing
in typhoid fever.
264 The Medical Society of
Dr. GEORGE HOMAN wished the doctor would state, in closing,
whether he considered the Nauheim salts a valuable addition in
routine practice.
Dr. M. J. LIPPE said that the amount of ignorance in the use of
water was simply astonishing. He had had a patient with typhoid in
one of our largest hospitals and they had no tub; he then tried to in-
struct the nurse how to give a bath with friction and she had told him
that she was quite proficient in the method. The next day the patient
was no better and when he had inquired about the method of giving
the bath the nurse had said she had wrapped the patient in cloths dip-
ped in ice water. Of course, that had not helped the temperature
very much nor was the peripheral circulation much improved. The
value of the bath as a diagnostic measure in fevers had been taken up
by one of the ablest diagnosticians, Dr. Musser. In hydrotherapy in
the diseases of children he had often noticed that a cold bath would
send the temperature up while a warm bath would bring it down,
explainable by the effect of cold or warm water on the peripheral
circulation.
Dr. HUDSON TALBOTT had used the Brand bath but he had not
carried it out as the doctor advised; the results might have been bet-
te. He was surprised to hear the doctor say the temperature was not
reduced at all. His experience had been that the temperature was re-
duced to a certain extent, in most cases, yet, he often found no re-
duction, and, while the bath had been used to reduce the temperature
it was with the idea also of producing a general tonic effect, and aside
from other considerations, the knowledge that his patient would go off
into a sweet sleep even after a short bath was enough reason for his
use of the bath.
Dr. GEORGE GELLHORN said that he was sorry that he could not
take part in discussion of typhoid fever, but since hydrotherapy had a
wide field in gynecology he wanted to ask Dr. Baruch whether the
the tonic effect of the friction bath would not be intensified by the ad
dition of sea salt. He had been using cool sea salt bath with friction
for several years past in the treatment of neurasthenic patients in
whom he wished to stimulate the vitality. There was another point
which he wished information: Ten or twelve years ago Krueche, of
City Hospital Alumni. 265
Germany, had said that cold compresses tightly wound around the
forehead would relieve ovarian pain and explained the phenomenon by
saying that anemia of the ovarian region was produced, which did not
seem a very satisfactory explanation. He would be very glad to learn
from an authority on this subject how such a result could have been
obtained.
Dr. J. C. FALK said that he, like all those present, was a thorough
believer in the value of hydrotherapy in typhoid fever. He had re-
ceived his training at a time when the work of Dr. Baruch was begin-
ning to take effect in this country; had followed it up in the hospital,
and tried to carry it out in private practice afterward. He has adopted
the routine practice of treating typhoid fever with water spongings and
had found them quite satisfactory. The average family was not sup-
plied with the necessary conveniences or with competent nurses, but
if they were given instructions to sponge the patient at a certain tem-
perature they would follow those directions and the patient would thus
get the necessary amount of friction, He instructed the nurse to
Sponge the patient when he was restless and nervous, and when his
general condition seemed to demand it, even though the temperature
might not be very high. After sponging the anterior surface from head
to foot the patient was turned over and the back sponged and this
procedure continued until the patient was cooled down, the sponging
to be repeated as often as necessary. This method had given very
satisfactory results. Hydrotherapy was valuable in many other dis-
eases; he used it in all acute febrile conditions, as for instance, in
pneumonia, diphtheria, scarlet fever and other acute diseases when com-
plicated by high temperature; he added that he had seen less typhoid
fever during the summer than in any summer in recent years and sug-
gested that possibly the improved water supply of St. Louis had some-
thing to do with lessening the disease.
The PRESIDENT said that the cordial welcome given the doctor
was in marked contrast to the reception accorded the speaker when,
enthused by Dr. Baruch's teaching, he had presented the subject before
the St. Louis Medical Society. He had suffered considerable ridicule
on that evening but had been able to silence criticisms, however, for
he had had statistical charts made, and among them was one with a
266 The Medical Society of
line indicating the death rate as shown by the statistics in the local
health office, and above that the results obtained by the true Brand
treatment. Every doctor in St. Louis who had a pet treatment had to
acknowledge that the results of his pet treatment were included in the
statistics from the health office, and the contrast was clear and striking.
In one or two points a little additional experience from another
worker might be of interest. Someone had asked about hemorrhages;
as he understood it, the treatment was to be discontinued or modified
when there are hemorrhages, but he had become so confident in its
application that he had departed from that rule. In one case of severe
hemorrhages, a more rigorous application of the treatment seemed to
subdue the hemorrhages after a lapse of forty-eight hours. The ex-
tremely interesting remark of the doctor as to the diagnostic value of
the bath could receive substantiation from him. Having used the
bath in other fevers, he had been struck with the rapidity with which
those fevers were overcome, although it had never occurred to him to
utilize the bath as a diagnostic measure. In true malarial fever, where
large doses of quinin failed to speedily arrest the disease, the addition
of cold baths succeed; he could not explain this unless it was that the
resistance of the organism was increased so as to enable it to better
cope with disease. It seemed to him that this treatment utilized the
natural curative powers of the organism itself, and in so doing was in
line with modern methods; it was just as modern as antitoxin or the
serum therapy; those did not act by the introduction of any foreign
substance, but were means of whipping up the natural curative forces,
causing the cells to produce antibodies, etc. Hydrotherapy, unques
tionably, acted in a similar way. Speaking of his enthusiasm in the
use of hydrotherapy in fevers, he said that if he, himself, were sick
with typhoid fever, and could get a tub and begin early enough, he felt
that he might get along without a doctor, Patients treated early
enough were able to step in and out of the water. If patients could
be seen early enough and the Brand method applied, there would not
be over 2 per cent mortality. The speaker said that he hoped that
Dr. Baruch would understand that what he had said was only to show
that the seed he had sown had fallen upon fertile ground, and that there
were some in St. Louis who had taken up his work and were carrying
.*
City Hospital Alumni. 267
it on. There was only one trouble in carrying out the treatment of
typhoid by cold baths, and that was the opposition encountered. It
was not difficult to get tubs, and there was no trouble about getting
the water, but people were more afraid of water than of arsenic
or stychnin. All fever patients wanted to be let alone. “Let me
alone, don’t bother me, give me some more phenacetin,” was their
cry, and when the advocate of the cold bath found himself opposed by
the consultant as well as by the patient and the family, then laissez
faire triumphed over energy.
Dr. BARUCH, in closing, said that his lines had fallen in pleasant
places. He had evidently struck a camp of his friends, and he was
glad that his paper had aroused interest and discussion; indeed, a
great deal more than he had elicited elsewhere. The carrying around
of a tub, mentioned by Dr. Barker, reminded him of his own experi-
ence in 1875 or 1880, when he used the Ziemmssen bath. He was a
country practitioner at that time in South Carolina, and he had a tub
that looked like a coffin ; he was surprised that his patients were not
often frightened when it was sent to the house; he would send it to the
house and have the patient treated and then have it carried on to an-
other house.
Dr. Smith had inquired about the nerve disturbance. The toxins
from the bacillus first attack the nervous system and inasmuch as the
nervous system was the power-house for the whole organism, every
organ in the body suffered. It was a vicious circle beginning with
toxemia, localizing in the intestinal glands, affecting the nervous system
and then the heart. When the vasomotor system is so affected the
heart becomes incompetent, then the circulation in the organs fails
and the lethal conditions in typhoid ensue. If this were an evanes-
cent condition, as for instance, the patient were only delirious like a
drunken man, he would not die; but, here, the peripheral circu-
lation in the skin and liver and in all the organs becomes paralyzed,
the resistance to the cardiac impact is diminished and the blood
passes through the arterioles as through a lifeless tube and elimination
is interfered with. He had seen, after the application of four or five
Brand baths, the urine measure rise from 30 ounces to 120 ounces in
twenty-four hours. The improved cardiac impulse drove the blood in
268 The Medical Society of
a more normal condition into the kidneys and better elimination re-
sulted. He insisted upon the Brand method as the most rational
treatment because it was based upon pathology and bacteriology. We
do not need ground cockroaches for we had gotten out of the cock-
roach age; he did want the method taken on faith. New drugs were
being continually put on the market; no rational explanation of their
action was given, but the doctor tried some of these antipyretics and
found they did give relief from the high temperature or something of
the kind, and so continued to use them.
The question asked by Dr. Soper about the normal salt solution.
That was not exactly hydrotherapy but it was an application that he
used a great deal. He had in mind one case that he had recently seen
in consultation with Dr. Woolley, of Long Branch. The patient was
sent to the hospital and was in a desperate condition; the application
of the bath was out of the question; even with the Nauheim salts the
patient did not have the proper reaction ; he was called to see the pa-
tient again; the temperature was Io.4 or Ios”, the pulse 140 or 150
and the patient was so saturated with the poison that there seemed to
be a complete toxemia; he recommended an ice bag over the heart.
As a rule, the ice bag was placed over the heart or head or abdomen
and kept there for a long time; he had known of one case where the
ice bag had been kept over the abdomen for five or six hours, and he
wanted his hearers to think what must happen in such a case. The
entire skin becomes cyanotic, later it assumes a dark hue because the
arterial blood is driven into the deeper tissues, the venous blood re-
mains; hence, there was venous congestion. An ice bag to produce
a stimulating effect upon the heart should be placed over the cardiac
region fifteen or twenty minutes only and then removed for fifteen or
twenty minutes; one should always get the reaction before putting it
on again. In this case the ice bag was applied and then he thought
of the normal salt solution and ordered four quarts, about one quart
at a time, to be introduced high up into the rectum and then allowed
to flow out again, for the purpose of absorption and also for
the purpose of mechanical irrigation; it had the most happy result; he
had never seen so large a quantity absorbed and the patient rallied
and made a good recovery.
City Hospital Alumni. 269
f
\
As to heat stroke, that was a very enticing subject. The treat-
ment that had been commonly used was an illustration of how badly
hydrotherapy had been used by the best men, for the teaching had
been, the colder the water the better the effect. Several years ago
there was an epidemic of heat stroke in New York City and the sub-
ject was freely discussed. One prominent physician placed his patients
in a bath of floating ice. One of Dr. Baruch's colleagues had reported
that he placed his patient in a tub of water at 11 o’ and reduced it to
50°; that was hydrotherapy with a vengeance; he gave the bath until
the temperature was reduced to normal. The trouble was, the tem-
perature was taken in the mouth, which was only a little better than if
it had been taken in the axilla. The only reliable temperature was
that taken per rectum, as the rectum was not directly cooled by the
cold bath. The most successful men according to the statistics gath-
ered by Dr. Baruch at the time, used water at about 75°, and used it
with force. The stimulating effect of cold upon the nervous system
was not produced by an immense reduction of temperature; One did
not stimulate the nerves by blunting them. Water at 75° was poured
over the patient while somebody rubbed him. The next best mortal-
ity was that of the Flower, Homeopathic Hospital; they used plain
water from the hose, the temperature being about 75° and no baths
at all. A heat stroke patient should never be placed in a bath below
60°, and one should be guided by the temperature. He believed a
heat stroke was a toxemia and the cutaneous vessels needed stimula-
tion in order to restore the lost heat diffusion.
Dr. Meisenbach’s inquiry, if elimination or stimulatiou was the
object. Stimulation resulted in elimination, so that one could not get
stimulation without elimination. The enfeebled heart action, and the
high temperature, etc., were merely manifestations of the toxins in the
circulation and the point was to get at the root of the matter—to get
the toxins out of the system. Whether the bath should be tepid, cold
or ice water was often a confusing question; that depended entirely
upon the case. To reduce the temperature a bath of 95° is more ef-
fective than one at 70° or less. The best temperature reducing bath
in one of 95° for three or four hours (so-called continuous bath). Such
baths had been used very successfully in typhoid and he thought that
270 The Medical Society of
some time he would use such a bath in some case where he was afraid
to use the Brand bath. In order to produce stimulation he would
recommend water much below the temperature of the skin.
Dr. Deutsch had asked what was to be expected of the treatment
when there were hemorrhages. He never used the bath during the
continuance of the hemorrhage, for everything that would stimulate,’
or shock or arouse the system would be objectionable, but Vogl had
shown that the number of cases which had hemorrhage were reduced
and the number of hemorrhages were diminished, the number of per-
forations were diminished and in fact the number of complications that
kill the patient were diminished by the strict Brand bath. The Brand
bath improved the circulation so there was less sloughing around Peyer's
patches and less kidney complications, so that the treatment of hem-
orrhage by that bath was to prevent it. As an example of the fallacies
in the use of hydrotherapy in the septic condition, he said that several
years ago in a hospital in New York City they had a good deal of sep-
sis; the pathologist of that hospital told him that in order to combat
the temperatures of IoS, Ioé and Io8°, they used Kibbé's cot, en-
veloped the patient in a sheet and pured ice water upon him until the
temperature became almost normal, and used ice applications on the
abdomen. Of course, the patients died. If they had used the cot
and sprinkled the patients with cold water at 40, 50 or 60° they might
have done some good, but the doctor told him that they died and that
he had seen the muscles of the abdomen absolutely frozen without the
slightest effect upon the inflammation of the peritoneum. That proved
that the application of ice on the outside did not cure an inflammation
on the inside.
Gilman Thompson, twenty years ago, in order to prove that fact,
pushed a thermometer through the rectum of a dog so to bulge the
abdominal wall and then applied ice bags over the bulb covered by
the tissues; the temperature was not affected at all; the tissues were
too thick to prevent any effect upon the temperature. Dr. Baruch
stated that he used ice in appendicitis cases as an anesthetic because
he did not not want to use morphin and added that he was guilty of
having had the first case of perforating appendicitis that was operated
upon successfully. The giving of morphin obscured the symptoms
City Hospital Alumni. 271
and then the surgeon found the diagnosis obscure, so whenever he had
a case of appendicitis and could not get the surgeon at once he put
on ice to soothe the parts.
Replying to Dr. Lippe, he said the illustration of the engine was
not original with him but was an illustration used by Dr. Hobart Hare,
of Philadelphia. Dr. Talbot had said that aside from the reduction
of temperature, the promotion of sleep had satisfied him. No prog-
nostic sign in fevers was so important as sleep or want of sleep When
his patient had to be fed on anodynes and hypnotics his prognosis was
shaky. The reason patient slept after the bath was because he felt
the impetus of new life and his brain felt it, and that was why he slept,
and because he slept he got well. It had been asked if the tonic ef-
fect of friction would be intensified by the use of sea salt. It would,
but the chief effect aimed at in infectious fevers was for refreshment
of the nervous system and response of vascular tonicity aroused by
the friction. The cold aroused a reflex action and the effect of fric-
tion would be intensified by the salt, giving a reddening of the skin
which meant an active peripheral circulation. Formerly mustard was
used for this purpose but that could be used only a short time and
afterward the patient was in great discomfort. By the use of the cold
bath the patient got red from the enhanced normal circulation and all
the good effects upon the heart ensued. As to the compresses for
ovarian neuralgia, he did not wonder that Dr. Gellhorn could not ex-
plain it; that was one of the troubles that the hydrotherapist had to
face; the hydrotherapist was simply a doctor who used water as one
means of treatment; the hydropaths use nothing but water; even
ovarian neuralgia they cured with cold compresses.
As to the procuring of tubs, he was glad they could be secured
here, for the department stores did not keep anything that was not
called for, and the fact that they had them here was good evidence
that the Brand bath was used to some extent. Dr. Shattinger’s ex-
perience had been similar to his own when he had read his first plea
for the Brand bath, before the New York State Medical Society in
1889. Dr. Jacobi and several lesser lights were present and there
were two country doctors there, one of whom said that he had seen two
patients killed by the bath and the other thought he would not care
272 The Medical Society of
to resort it. That had been his experience twenty-four years ago.
That the bath would overcome other fevers more effiicently than ty-
phoid was exactly why he advised it as a diagnostic measure. He or-
ders in all suspicious cases with a rectal temperature of Io 3° or over
a tub bath of 90° with friction for twelve minutes. In four hours if
the temperature is still Ioo’ or over, a bath at 85°, again in four hours
at 80°, then at 75°. If one of these baths reduced the rectal temper-
ature more than 2° during the first week of fever – typhoid may be
excluded. Dr. Baruch was led to this diagnostic bath by his observa-
tion in the Manhattan Hospital in 1891. He gave instruction when-
ever a patient was brought in with a temperature of Ioo° or over to put
him in a tub of 90° and reduce the water gradually to 68° for half an
hour (Ziemmssen Bath). One day he had come in and found a man
with a temperature of a 106° in the tub. He had been found uncon-
scious with his dinner bucket in his hand. He had eaten his dinner
and vomited some green material. He was pumped out by the ambu-
lance surgeon who suspected Paris green poisoning. His temperature
was found to have gone down to IoI*, after the bath and a diagnosis
of typhoid fever was made; next day he was found to have pneumonia,
he had no more baths and got well. The next was a case of osteomy-
elitis. A boy had jumped upon butcher’s wagon; he had a temper-
ature of Ioé°, he was bathed and his temperature went down to Ioo
or IoI°, and the bath were continued with this effect: It seemed an
excellent method of treating typhoid fever; however, osteomyelitis
developed and the patient was taken to Mt. Sinai Hospital, where he
died later.
About a year ago he had found three cases that had been in the
hospital under his predecessor, all very able men, for about a week.
The diagnostic baths were ordered in each case; in one case he
doubted the presence of typhoid, although he had the the Widal re-
action; nevertheless, the temperature became normal after he had had
four baths; another case recovered in about four days, and another
proved to be typhoid, the rectal temperature only falling one degree
after the diagnostic bath. On inquiry, as to who had made the Widal
test he found that the undergraduates in the laboratory had made the
test and pronounced it positive. Thus, was his confidence in the
diagnostic bath established by clinical observation.
City Hospital Alumni. 273
He said, hydrotherapy is a scientific therapeusis; it is based upon
rational theories, but it does not cure all diseases, in fact, it is not a
curative agent at all; it simply restores normal conditions of the cir-
culation more or less permanently according to the temperature and
duration of the hydriatric procedures.
Meeting of December 15, 1904; Dr. Charles Shattinger,
President, in the Chair.
A Review of Methylene Blue Eosin
Blood Stain.
A Report of Some Modifications in Method of Preparation.
By GEORGE C. CRANDALL, B.S., M.D.,
ST. LOUIS, MO.
Professor of Internal Medicine, Medical Department, St. Louis University,
NE of the most important clinical observations we make
O is the condition of the blood which, on account of the
delicate technic required, is often neglected or made
in such a cursory manner as to afford little or no valuable in-
formation. The microscopic examination of fresh blood is of
clinical value in ascertaining the number of red and white
cells; also, in part, the general condition of the red cells, and
it may show the presence of blood parasites as malarial or-
ganisms, filaria, etc.; but, as a rule, the most accurate informa-
tion requires a well-made, well-stained blood film, showing the
histologic and pathologic elements so clearly defined that they
may be readily recognized. This can be accomplished only
by the use of a good differential stain, and that which is at-
tracting most attention for general blood work is some com-
bination of methylene blue and eosin, which has undergone
various methods of preparation during the past decade.
Romanowsky used an alkaline methylene blue solution,
which was allowed to stand until mould formed upon the sur-
274 The Medical Society of
face, oxidizing some of the methylene blue into methylene
azure. Of the methods preceding and suceeding Romanow-
sky's, those using any kind of oxidized alkaline methylene
blue obtained some chromatic staining, the others were defic-
ient in this regard.
A few of the prepared staining solutions which I secured
from different sources gave good staining reaction, but other
samples obtained from the same sources gave quite indifferent
results, and I hawe endeavored to ascertain the reason for such
variations.
After numerous prepararations of the stain during the
past two years, I have found the following method uniformly
satisfactory: e
Prepare the fresh solution of the primary stains.
Methylene blue solution—
Sodium bicarbonate thoroughly dissolved in distilled wa-
ter to make a one half of I per cent solution, to which add suf-
ficient methylene blue to make I per cent of the blue. Steam
in Arnold sterilizer for one hour, then cool.
Eosin solution—
Make one-tenth of I per cent solution of yellowish aqu-
eous eosin in distilled water.
Add the eosine solution to the methylene blue solution,
stiring the mixture constantly, until about five parts of the
eosin have been added to the blue; then begin testing the
staining reaction of the mixture, in a sense titrating the stain
and controlling the end reaction by the actual application of
the stain to freshly-made blood films. This test is quite easily
made by filtering ten drops of the mixture through a small
piece of filter paper, dry the residue on the paper and put it
in a small test tube with about ten drops of pure methyl alco-
hol, agitate thoroughly to dissolve stain on filter, and with this
stain a freshly-made blood film. This will give an index of the
staining reaction, and more of the blue or eosin solution may
be added until the test gives the desired results. A light pink
color of the red cells in the thin areas of the film and a bluish
color of the thick areas is most satisfactory, since with this
color the other blood elements stain clearly; if the red cells
are an intense pink the blue is over neutralized and the white
City Hospital Alumni. 275
cells and organisms do not stain well; if the red cells stain too
blue there is not the contrast necessary to show clear defini-
tion of the other elements. *
When the mixture is finished it should be filtered through
filter paper and thoroughly air-dried, or dried over the flame
at a distance easily borne by the hand. Make a saturated so-
lution of the powder, about three-tenths of 1 per cent, in C.P.
methyl alcohol, filter and add to it one-quarter more of the
alcohol; or make a one-fourth of I per cent solution of the
residue in C.P. methyl alcohol and filter. Preserve in tightly-
corked bottles in the dark. Keep the bottles quiet when using,
avoiding shaking, so as not to distribute through the solution
any precipitate that may form.
In applying the stain filter ten drops directly upon the un-
fixed film or use a pipette freshly rinsed in methyl alcohol,
take ten drops of the stain from the center of the solution, put
on the unfixed film ; leave one minute, then add to the stain
on the film one or two times as much distilled water as stain
and leave two or three minutes more; wash quickly three to
five seconds under a strong stream of distilled water; dry
promptly with blotter; then air-dry thoroughly or hold over
flame at hand distance; mount in pure balsam. The entire pro-
cedure requires less than five minutes. *
The film will vary somewhat in thickness, the color of
the thin areas being light pink and that of the thick areas
bluish.
Sligh variations in the amount of water added to the stain
on the film, the length of time it remains, and the length of
time it is washed may vary the tint somewhat, but with ordin-
ary care uniform results will be obtained. .
If the stain is kept quiet, slides thoroughly cleaned, films
well spread, the stain not allowed to evaporate on any portion
of the film before the water is added and a strong stream used
in washing off stain, there will be little or no difficulty in the
precipitate, which forms while staining, adhering to the film.
I have found Gruebler's brands of stain satisfactory, viz.,
“Med. Methylene Blue,”“Bx,” “Koch” and “Ehrlich,” and “Yel-
lowish Aqueous Eosin B.A.” I have secured good results
276 - The Medical Society of
also with Merck’s “Med. Methylene Blue” and “Yellowish
Aqueous Eosin.”
It is important to know that the methyl alcohol" is pure,
or at least neutral in reaction, since some of the C.P. methyl
alcohol contains a trace of acid which may be sufficient to inter-
fere with the blue. The alcohol should be C.P., and if found to
be faintly acid, as can be determined with litmus paper, it should
be neutralized with sodium bicarbonate solution before dis-
solving the stain, otherwise the eosin will be too intense, and
the blue very pale. If the alcohol used has not been corrected
when necessary, a little of the sodium bicarbonate solution
may be added to the finished stain which will intensify the
blue. g - 4'
It is also essential that pure distilled water be used for
making the stain, likewise for diluting the stain on the film and
in washing the stain off the film.
In conclusion, the chief advantages of such a combined
methylene blue eosin stain are the following:
The rapidity of application; the power to stain cytoplasm,
chromatin and granules; the good differentiation of leucocytes,
the clear staining of pathologic elements, and the durability
of both the stain and the stained preparations.
As a result of numerous tests and observations, I believe
that the reason for the variation in the staining power of the
different samples of the stain made by the various methods is
that the primary solutions have been combined in too definite
quantities; not adapting these solutions, which may vary some-
what, to each other; also that not sufficient attention has been
given to the purity of the methyl alcohol and the distilled
Water.
I have obtained uniform results in making the stain by
some of the other methods when I have tritrated the mixture
and used pure distilled water and pure alcohol. •
I have used many of the blood stains for different patho-
logic conditions, but during the past two years I have relied
upon the oxidized methylene blue eosin exclusively, and can
*Kahlbaum, of Berlin, supplies a methyl alcohol which is said to be free from
acid, and I have found it satisfactory without any correction. I have obtained it
from Eimer & Amend, New York. and the Heil Chemical Co., St. Louis.
City Hospital Alumni. 277
fully corroborate Cabot's opinion as expressed in the new
edition of his work on the blood, viz., that it is the best for all
purposes for which one uses a blood stain at all.
I would especially emphasize the following points con-
cerning it: Use some of the reliable crude stains for making
the primary solutions, test the staining power of the mixture
well before filtering and drying, be sure that the C.P. methyl
alcohol is neutral, and use pure distilled water.
A.B. Streedon del
DESCRIPTION of THE PLATE.
The plate is a reproduction of a water color composite picture of the blood
of a patient suffering from double tertian malaria.
The blood was taken during a paroxysm and all the figures except o, p, r, x, y
and z represent a few of the characteristic organisms and cells found under a 3/4-
inch circle cover glass; the others were from films taken from the same patient at the





278 The Medical Society of
same time, the organisms being abundant in various stages of development. The
blood was stained with the titrated eosin methylene blue stain described, and the
figures were outlined with a camera lucida, Richert microscope. They represent a
magnification of about 14oo X. .
a.—Young organisms free in the blood, the cytoplasm, blue; the chromatin or
nucleus, red. * -
b, c, d and e —Early stages of development in red the blood cells, so-called
ring forms. .." & -
f, g, h and i.-Later stages of development, distinct enlargement of the invaded
cells which stain less intensely, beginning of granular degeneration of the red cells,
also appearance of the pigment of the organisms. tº -
j-Adult organism, pigment abundant and scattered, nucleus beginning to di-
vide. - - -
k—Adult organism, pigment scattered, nucleus divided and distributed through
the organism. .
l—Organism undergoing segmentation, nuclei in the segments, pigment col-
lected in the lower part of the organism.
m.—Rosette appearance of the segmenting organism, pigment collected in the
center. • *
n.—Organism showing segmentation complete, young organisms and pigment
being liberated from the ruptured red cell. -
o.—Crushed red cell containing an organism the granules of the degenerating
red cell scattered. - *-
p.—Adult organism free in the blood.
y.—Intracellular flagellum. - * ſº
z.—Extracellular flagellum.
d.—Young organism with two nuclei.
f—Red cells invaded by two organisms each.
q—Neutrophilic leukocytes, intensely stained nuclei, neutrophilic granulation
of cytoplasm granules small and irregular, a mass of malarial pigment in the cell
to the left of the nucleus. -
r—Mast cell, feebly stained nucleus, basophilic granulation of cytoplasm, gran-
ules large and deeply stained.
s.—Eosinophile, intensely stained nuclei, eosinophilic granulation of cytoplasm,
granules sperical.
t-Crushed neutrophilic leukocyte, scattered chromatin and granules.
u.—Lymphocyte, intensely stained nucleus, light-blue nongranular cytoplasm.
v.—Large mononuclear cell, moderately stained nucleus, neutral, somewhat
granular appearance of cytoplasm. *
w.—Blood p'ate, indefinite trabecul...r structure, various sizes and shapes.
x-Blood plates lying upon a red cell.
aa-Red cells showing blue granulations incident to anemia.
Several normal red cells are shown unlettered. .
[4287 Olve ST.]
: DISCUSSION.
Dr. WALTER BUAMGARTEN said the one thing to be desired in the
preparing of a stain was the obtaining of a uniform stain, one giving
uniform results. Heretofore that had certainly not been the rule in
City Hospital Alumni. 279
stains prepared by the manufacturer or by the individual. He thought
Dr. Crandall had done a very considerable service in devising a defi-
nite method that would give definite results.
Dr. CARL FISCH agreed with Dr. Baumgarten that in using the
eosinate of methylene blue one should have a reliable method, and he
appreciated how much work it had cost Dr. Crandall to lead to these
results. Of course, his method of preparation properly followed must
give absolute results. The trouble with the Romanowsky solution had
been all along that the methods of preparing the solution were uncer
tain and unreliable. Any solution would give the same stain if prop-
erly prepared. But all of these solutions undergo secondary changes,
that interfere with their staining capacity. So, too, will do Dr.
Crandall’s solution. But the attempts to utilize the isolated active
principle of this solution for staining had succeeded and since that had
been done two years ago there was no reason to bother any more with
such mixtures. The disintegration of the methylene blue varied
greatly according to surroundings and can not be controled. Any
slight change in the alkalinity or any slight change in the temperature
would make a difference. Methods to prepare the active chromatin-
staining principle, the methylene azure have been discovered so that
today the azure stain is as exact and certain as other histochemic re-
actions. The material could be easily obtained and could be used
with greater facility than the method just described. A disadvantage
of all the staining solutions was that the stain did not remain con-
stantly in the solution, the solutions after a time lost their staining
efficacy, while the methylene azure stains kept for years and gave al-
ways absolutely the same results. That being true, why bother with the
the solutions? The method was now in use everywhere except in
America.
The PRESIDENT said that blood stains in general and Jenner’s
stain in particular had caused him agonies, and he felt exceedingly
grateful to Dr. Fisch for having put him in the way of using the chemi-
cal principle itself. As Dr. Fisch had said, all that was necessary, was
to prepare the azure and the eosin solutions in proper strength to get
absolutely certain results. It never failed. He fixed the specimens
with C.P. methyl alcohol which he obtained from Henry Heil. He had
280 The Medical Society of
not been aware that it contained any acetone, but it made no difference
for the stain came out just as well. To get a perfect stain, as Dr.
Fisch had instructed him, required an hour's time, while with Jenner's
stain it took but one minute. He had not found it a disadvantage to
let the blood remain in the staining solution an hour because he could
meanwhile attend to other work, then wash it off and it was ready.
One of the great troubles with the Jenner's solutions that he had tried
was the precipitates that formed on the slide. In some of his earlier
* experiments he had been misled by those precipitates, not having
recognized them as such. He felt satisfied that the use of the chemi-
cal principle was in the large majority of cases the preferable pro-
cedure.
Dr. Fisch said that it was possible to get the stain so prepared
that but two or three minutes were required. -- -
Dr. CRANDALL, in closing, said that in regard to the stain of
which Dr. Fisch had spoken, he had used that and had adopted the
one he now used on account of the time. The stain that he used
could be gotten ready for the microscope in five minutes. When one
was examining a number of specimens that was an advantage. With .
this stain he had always obtained good results. He had stains a year
old that gave fairly good results and for six months it stained well and
rapidly. With this no fixing was necessary. Students, after a few
tests, learned to use it quickly and easily. As to obtaining a precipi-
tate on the slide there was but little difficulty. Most of the films were
absolutely free from any precipitate, and it was not difficult to recog-
nize the precipitate, as such. The Jenner stain was not a chromatin
stain. There was no methylene azure or methylene red in that stain.
With that one could not stain the nuclei of malarial organisms. The
reliability and quickness of the stain described were the important ad-
vantages. If the manufacturers would make the mixture in a way to
control staining power, it would have an advantage over any stain that
he had seen. As to the chemistry of the stain, a paper that had been
written by Dr. Baumgarten gave a good review of the stain.
City Hospital Alumni. 281
The Ruediger Blood Test for Typhoid.
By GEORGE C. CRANDALL, B.S., M.D.,
º ST. LOUIS, MO.
Professor of Internal Medicine, Medical Department, St. Louis University.
|URING the past few years the Widal agglutination test
for typhoid fever has proved itself a most valuable aid
in differentiating continued fevers, and recently there
has appeared a modification of this test which must certainly
add greatly to its usefulness.
The new test consists of a macroscopic agglutinative reac-
tion occurring in a bouillon culture of typhoid bacilli and blood
serum. This test obviates the necessity of a living typhoid
culture, and a microscopic examination, making it as easy of
application by any physician as a test for albumin, which in
appearance it resembles very much.
Ficher,’ of Berlin, reports very favorably upon its use and
considers it thoroughly reliable, being applicable to dried as
well as fresh blood.
Radzikowski,” of Vienna, reports seventeen cases in which
he had tested this method, using fresh and dry blood of typi-
cal typhoid cases which gave the Widal reaction and found it
positive in all. He concludes that it is simpler than the Widal,
is as reliable, requires shorter time and enables every physician
to make his own typhoid test. w
Ruediger,” of Chicago, reports thirty-four cases and as his
method of applying the test is one of the simplest, I will give
it somewhat in detail:
Inoculate 500 cc. bouillon with B. typhoid, incubate at
36°C. for twenty-four hours, and add to this I per cent forma-
lin. Make a 1/500 formalin solution. These are the two stock
solutions. Put four drops of blood in 2 cc of the formalin
solution which makes approximately a I/IO per cent solution
of the blood, likewise lakes the blood. Add Io co. of blood
formalin mixture to 4 cc. of the bouillon culture which make
approximately 1/50 dilution.
282 The Medical Society of
In a few minutes to an hour there appears a coagulum
suspended throughout the solution which gradually settles,
resembling very closely the albumin test of urine when small
amounts of albumin are present. This contrasts closely with
the control solution which shows a fine cloudiness charisteris-
tic of the bouillon culture. *
Ruediger has found that the reaction will appear in I/IOOO
or 1/2OOO solutions after three to ten hours. He considers it
fully as reliable as the Widal test, also found it applicable to
dried as well as fresh blood, obtaining a characteristic reaction
with dried blood one year old. His thirty-four cases which
showed the reaction were thirty typical typhoid, one doubtful,
two paratyphoid and one tuberculosis. w -
I have used the test on about fifty cases of typhoid which
gave the Widal reaction, and find it equally accurate.
All observations, so far as I have gathered from the liter-
ature, agree that it is fully as reliable as the Widal test and it
has the great advantage of placing in the hands of every phy-
sician a very simple means of testing the blood of his own
typhoid cases and it must make more accurate the diagnosis of
the great number of continued fevers. -
Further than this, there is the possibility of the applica-
tion of this principle giving similar macroscopic evidences of
other infectious diseases. Investigators are already experi-
menting along this line and we may hope for fruitful results.
REFERENCES.
*Ficker.—Berliner Klin. Woch., No. 45, 1903.
*Radzikowski —Weiner Klin. Woch., No. Io, 1904.
*Ruedigen.—Jour. of Infec. Dis., Vol. 1, page 262, 1904.
DISCUSSION.
Dr. R. B. H. GRADwohl had tried this test and been very suc-
cessful, having gotten a quantity of the tubes from Parke, Davis &
Company. It seemed to work very well and he believed it was a good
thing for those who could not keep a culture going. -
Dr. Fisch said that the idea that the Widal reaction as usually
made was of diagnostic value, was erroneous. If this were true, that
the diagnosis of typhoid could be made by the methods used it would
City Hospital Alumni. 283
be a very valuable addition. Seemingly all records showed that the
Widal reaction had in the great majority of cases coincided with and
confirmed the clinical diagnosis. In America the Widal reaction was
made from a drop of dried blood, the volume of which was not known.
The bacteriölogist in making an agglutination reaction must know ab-
solutely the exact quantity of the substances reacting upon each other
to be able to draw his conclusion. It was well known now that sera
that agglutinated typhoid bacilll agglutinated other bacilli. In normal
persons there was found a reaction in which the agglutination was ob-
tained in a dilution up to 1 in 200. In the Widal reaction when car-
ried out in the ordinary way, he felt certain that the dilution never
reached more than 1 to 50, rarely up to Ioo. And such a positive
Widal reaction could not make nor confirm a diagnosis. The observa-
tion that so many of the Widal reactions conincided with the clinical
diagnosis simply expressed the fact that the serum of a typhoid patient
in a dilution up to 1 to 200 must necessarily give this reaction, since
it gave it always at dilutions up to 1 to 5,000, this reaction, therefore,
& simply coincides with and prove the presence of typhoid, but does not
diagnose it. The Widal reaction was a reliable, but difficult method
if performed properly; it was reliable only when the limit of dilution,
at which agglutination occurs, would be known, and when at the same
time the limit for other bacilli was determined. In Germany they did
not think of making it in any other way. Too much stress could not
be laid upon the practical importance of the results obtained when it
. had been scientifically carried out. It may be that in the future there
would be found a more accurate way for practical application but until
then we could not draw any conclusions alone from the positive re-
sults obtained after the present methods.
Dr. CRANDALL, in closing, said that it was true that the more accu-
rately these tests could be made, the better, but he felt sure the doctor
did not mean to greatly disparage the Widal reaction. In Johns Hopkins,
where they had reported a large series of cases, they obtained the
serum in a small capillary tube for the purpose of graduating the
quantity. The Parke, Davis & Company method was similar to the
Ruediger. The physician drew 15 or 20 drops of blood and pured
the serum into other tubes. He had had several Parke, Davis & Com-
N.
284. The Medical Society of
pany’s tubes and tried them side by side with the Ruediger method
He did not agree with Dr. Fisch in his disparagement of the Widal test
and he thought this particular method would be of advantage to physi-
cians in the country. It would control many diagnoses and it was
possible that it might be found of use even in St. Louis. Replying to
Dr. Sharpe, Dr. Crandall said that he had tried the method on malarial
blood and had never obtained the agglutination.
Dr. HowARD CARTER asked if Dr. Crandall had tried the effect
upon the blood of a patient who had had an attack of typhoid within
a year or two. He understood that within one or two years the blood
continued to give the Widal reaction. & §
Dr. CRANDALL replied that he had never tried it, but it had been
reported that in one case the blood had given a distinct Widal re
action after fifteen years.
Medical Society
—OF—
CITY HOSPITAL ALUMNI
TRANSACTIONS.–1905.
Meeting of January 19, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
The Protozoan=Like Bodies Described
in Scarlet Fever.
By R. L. THOMPSON, M.D.,
ST. LOUIs, MO.
N the Journal of Medical Research for January, 1904, Dr.
Mallory described in the skin of four subjects who had
died from scarlet fever, certain bodies that in their mor-
phology strongly suggested that they might be protozoa, and
I am asked tonight to speak regarding the appearance and
significance of these bodies.
To all progress there is opposition and it is fitting that
it is so. The establishment of any hypothesis is only possible
by long and convincing labor. It was years after the discov-
ery of bacteria that their relationship to disease was suggested
and it was years after this suggestion that such relationship
was established. But even after the discovery of the relation-
ship of certain bacteria to certain diseases, a gap was left in
our etiological knowledge of infectious disease that could not
be filled in by bacteria on the one hand or neurasthenia on the
2 The Medical Society of
other. And it is only recently that certain evidence has been
brought forward to show that the protozoa may form a few
cases at least in this desert of ignorance.
In certain of the protozoan diseases the organism is of a
type that puts discussion beyond question, e.g. trichinosis and
amebic dysentery. In others, e.g., malaria, no one questions
the etiological significance of the parasite and its cycle can be
well understood through the discovery of its development and
transmission by an intermediary host. In yellow fever we sus-
pect a parasite and in kala azar the discussion is not as to
whether the organism found is a protozoan or not, but, how
shall it be classified. In smallpox, bodies have been described
by Wasalewski, Guaneario, Pfeiffer, Councilman, Howard, De
Korte and many others, and more or less of a life cycle of the
organism constructed, while one who has worked with these
bodies can not help but believe in them. Their etiological
significance as a factor in smallpox is still a moot question but
I am sanguine that their significance will be established. The
organism described by Mallory and later by Duval in scarlet
fever were found by Mallory in the protoplasm of the epithe-
lial cells of the epidermis, between these cell and free in the
lymph vessels and spaces of the corium. The majority vary
in size from 2 to 7 microns in diameter. Duval, in addition to
these situations, found them in the fluid of blisters obtained
by the application of aqua ammonia. The bodies found in
the skin are of two kinds, the reticular bodies and the rosettes.
The first are round, oval, elongated or lobulated, and stain
lightly but sharply with the blue, composed of finely granular
reticulum either close-meshed or coarse-meshed. These forms
are found both in and between cells of lower layer of corium
and in lymph spaces of corium close to the epidermis.
The second group of bodies present a radiated structure
(same situation). Sometimes the segments may be free from
the central body. The frequent wheel and star shapes of
these rosettes has led Mallory to propose the name of cylas-
ter scarlatinalis for these organisms.
These bodies were found, as I stated, in but four cases.
These were all early cases; the bodies are not found-in the
desguamative stage and the difficulty of getting material in
early cases of scarlet fever may well be understood.
City Hospital Alumni. 3
These bodies, Mallory suggests, may be interpreted in
three ways—as artefacts, as degenerations or as protozoa.
Against the first is the fact that in three pieces of skin from
one of the cases fixed, preserved and stained exactly in the
same way, the bodies were absent in the first, few in the sec-
ond and numerous in the third.
Against there being degenerations is the fact that they
appear not only in and between the epithelial cells but in the
lymph spaces of the corium and they were found in cells that
were in mitosis, besides their size, morphology and staining
reaction separate them from being degenerated leukocytes,
lymphocytes or epithelial cells.
In favor of their being protozoa is their distinct morphol-
ogy (similar to the asexual cycle of malaria). A change can
be followed from the small bodies to the formation of rosettes
and from segments of rosettes to re-formation of small bodies.
Provided they are protozoa, have they causal relation to
scarlet fever? They have never been found in normal skin.
In the fifty-four cases of scarlet fever studied at Harvard with
same preservation and fixation, bodies like these were never
found.
We can not fulfill Koch’s law with protozoa—they can
not be cultivated save in the tissue. In order to prove a se-
ries of bodies protozoa, we depend on ameboid motion, char-
acteristic morphology and on developmental cycle (and of size,
division, re-formation of bodies from which cycle started). In
hardened tissue ameboid motion is sometimes suggested but a
large of material is necessary to construct a cycle.
If these bodies are protozoa it is impossible to classify
them until more is known of their life cycle. The majority of
the forms suggest the schizogony of the malarial parasite.
Until we can study them in cultivation their significance can
not be clear.
I am not familiar with all the details of Duval's work, but
it is, in the main, similar to Mallory's. His work is soon to
appear in Virchow's Archives. Personally, I believe these
bodies to be protozoa and to have an etiological significance
in scarlet fever. I shall be glad to demonstrate the prepara-
tions I have at any time.
4. The Medical Society of
DISCUSSION.
Dr. R. B. H. GRADwohl was personally very much interested in
this subject and thought that some of the members would remember
that in 1899 he had demonstrated before the Society a bacterium which
had been first described by Dr. Class, of Chicago, and which he
thought the etiological factor in this disease. It was a diplococcus
which he found in the throat, blood, secretions, urine, etc., of scarlet
fever patients. Dr. Gradwohl was attracted by his work and did some
work on his own account while in the City Hospital and demonstrated
the fact that these organisms were present insscarlet fever patients.
Some work was done by Class in inoculating this organism into ani-
mals. He inoculated young pigs and produced the fever and eruption
with desquamation, but not a fatal disease. Sections of the organs of
the animals killed afterward showed the bacterium. The speaker had
thought with Class that this was the cause of scarlet fever. He had
not done much work along that line since, but in view of the researches
of Mallory and others, he was doubtful if the work done by Class, him-
self and others, explained it as well as they had thought it did. Scar-
let fever was a disease in which the symptoms were due to more than
one organism. It was possible that the streptococcus was responsible
for some of the untoward symptoms and some of the inflammatory
conditions found in scarlet fever patients. The question had been
asked him whether this diplococcus was not a form of streptococcus.
He did not believe it was. Baginsky, of Berlin, had found an organ-
ism which, in his opinion, was a streptococcus and he thought he had
found the cause of scarlet fever in that organism. From the descrip-
tion given by him Dr. Gradwohl had always thought it was of the same
class as the one found by Dr. Class and himself. However, but few
others had succeeded in finding the organism that they did and whether
they were in error or whether it had existed only in the cases they
studied, he did not know.
Dr. A. E. TAUSSIG said it should not be forgotten that there
was a good deal of evidence speaking for the streptococcus as the
cause of the scarlet fever. It had been found in the blood of a con-
siderable number of cases. A number of observers had reported the
results of an examination in cases of a scarlatiniform rash due to a
City Hospital Alumni. 5
streptococcic infection and resembling scarlet fever so distinctly
that they might be considered the same disease. Moreover, the re-
sults obtained, especially by Viennese clinicians in the treatment of
scarlatina by means of antistreptococcus serum have been so striking
as to lend much weight to the view that streptococci are the chief
agents in the production of this disease. Even if the structures under
consideration were shown to be purely protozoan their etiological sig-
nificance in scarlet fever could not be shown until their life history had
been worked out and particularly until the sexual as well as the asexual
stage had been demonstrated.
Dr. GEORGE HOMAN supposed that the three specimens men-
tioned by the speaker were taken post motem, but this was not quite
clear, if such was the fact he would like to have it stated.
Dr. CLARENCE LOEB said that if these organisms had not been
found in the desoluamative stage, he would like to ask the esssayist
how he accounted for the infectious nature of the disease, at that
period.
Dr. THOMPSON, in closing, said that these bodies represented only
a certain stage in the development of the life cycle of the organism.
There must be many stages they knew nothing about. They either.
broke up into small bodies that could not be seen with the microscope
or that could not be differentiated from granular matter. It was sup-
posed that these spores were present in the scales and gave rise to the
infection. In reply to Dr. Homan's question Dr. Thompson stated
that the cases of Mallory were all autopsy cases. The specimens were
obtained in the early eruptive stage. He had been glad to hear the
remarks relative to the bacterium and its origin. The streptococci
were of great significance in scarlet fever and smallpox. Practically
all smallpox patients who died, died of streptococcic septicemia. The
lesions at a certain stage always contained pyogenic organisms.
*/
6 The Medical Society of
A Peculiar Cystoma.
By WILLIAM S. DEUTSCH, M.D.,
ST. LOUIS, MO.
Senior Assistant Surgical Clinic, Medical Department, Washington University;
Associate Surgeon to the Jewish Hospital.
HE case of Post Rectal Cystoma, which I report this
evening, I had charge of in the Washington University
Hospital for Professor Tuholske, before and after op-
eration. Mrs. C. was sent to the Clinic by Dr. Wm. L. Mosby,
of Bardwell, Ky. and gave the following history: Father died
of heart disease at the age of 63 years; mother died of phthi-
sis at the age of 44 years. Four brothers and one sister died
in childhood of causes unknown to the patient. One sister
living and healthy. One brother living and healthy, and one
has phthisis. No history of tumor or cancer in the family.
The patient was delicate during her early years, having had
most of the diseases of childhood. She began menstruating
at the age of 16 years and has continued to do so regularly
and without trouble. At the age of 20 years, while walking
on a log she fell astride of same and suffered for a few days
with pain in the perineal region, but which apparently gave
her no further trouble. She was married at the age of 31
years, and eleven months later her physician had to perform
embryotomy to deliver the child on account of the obstructed
canal. She passed through the puerperal state normally, and
with the exception of a very painful and difficult defecation
seemed no worse for her confinement.
Physical Examination.—The patient is a brunette, height,
5 feet 8 inches; weight, I80 pounds, with normal chest and ab-
domen, quite an amount of adipose tissue. Temperature,
pulse and respiration normal. Urine Io 19, negative. Red
blood cells 4,OOO,OOO, white cells 40OO. Hemaglobin 75 per
cent. A vaginal examination, made extremely difficult on ac-
count of the tumor crowding up the posterior wall of the vagi-
na, revealed the uterus and adnexa normal, but the outlet of
the pelvis encroached upon by a semi-solid mass about the
size of a large cocoanut, springing, apparently from the rectal
City Hospital Alumni. 7
region. Rectal examination showed the mass to lie posteriorly
to the rectum, and so pushing on the rectum as to bring it
against the vaginal wall.
Diagnosis.-Post rectal cystic tumor.
Operation was advised and the following method was
carried out : A semicircular incision was made along
the coccyx and sacrum. The coccyx was now removed
and the parts widely retracted so as to see well the
territory to be dealt with, when the dissection toward the tu-
mor was attempted. In dissecting off the wall the cyst rup-
tured and a large quantity of a thick glue-like fluid escaped.
No hair or bone was found. The cyst wall was dissected out
as far as it could be reached, the epithelial lining membrane
curetted out thoroughly, leaving a large open cavity extending
back into the hollow of the sacrum which was packed with
gauze and the skin wound sutured. The rectum was not in-
terfered with in the least as was shown by digital examination
and irrigation, as well as by the normal bowel movements
which the patient had after the operation. The patient had a
long process of wound healing, owing to the continuous drain-
age necessary, for which I found the glass drainage tube, with
the patient in the Syms' position, everything to be desired.
Sections of the cyst wall were given to Professor Tied-
man, pathologist of Washington University, who reported
cystoma, probably of rectal origin, with colloid carcinomatous
degeneration.
Some of these sections are under the microscope, which
I will be glad to have the members examine.
I report this case to you this evening because I consider
this form of post rectal tumor a very rare one, espec-
ially one that grew to a large size in this region, suffic-
iently large to make its bulging anteriorly toward the
vagina a hinderance to the passage of the fetal head.
In this case the history tells us that the size of the tumor made
the crushing of the child's head necessary to allow delivery.
From the embryological standpoint there is every reason to
believe that this class of tumors owes its origin to the post-
anal gut and should not be confounded with that form of rec-
tal tumors which grow from the rectum, usually peduculated,
S The Medical Society of
and occasionally present as a projection from the rectum.
While the patient leads us to think that the fall she had astride
the log caused this growth, literature only too plainly shows
us that this variety of tumors is of congenital origin.
Bland Sutton, in his admirable work, “Tumors, Innocent
and Malignant,” says the following: “In order to appreciate
the nature of cysts arising in the immediate neighborhöod of
the rectum, it will be necessary to consider a few points in con-
nection with the embryology of this portion of the alimentary
canal. In the early embryo, the central canal of the spinal
cord and the alimentary canal are continuous around the cau-
dal extremity of the notocord. This passage, which brings
the developing cord and the gut into such intimate union, is
known as the neurenteric canal. When the proctodem invag-
inates to form a part of the cloacal chamber it meets the gut
at a point some distance anterior to the spot where the neu-
renteric canal opens into it; hence, there is for a time a seg-
ment of intestine extending behind the anus and termed in
consequence the post-anal gut. Afterwards, this post-anal
section of the embryonic intestine disappears, leaving merely
a trace of its existence in the small structure at the top of the
coccyx, known as the coccygeal body. There is good reason
to regard the post-anal gut as the source of that variety of
congenital tumors situated between the rectum and the hollow
of the sacrum—congenital cystic sarcoma.”
Dr. Dewis C. Bosher, of Richmond, Va., reports operating
on seven cases of sacrococcygeal fistulae caused by the rup-
ture of cysts spontaneously in the median line. He cured the
fistulae by dissecting out and destroying the cyst wall.
In looking over the literature of these cases I find no
mention of any malignant tendency in these tumors which
makes the case I have reported one of especial interest, and
I shall watch, with great concern, the future of the patient.
DISCUSSION.
Dr. ERNST JONAS had examined this case several times before the
operation took place. Upon first examination he recognized it as be-
ing a tumor entirely different from all tumors of this region he had
ever seen. The examination proved that the doctor was more or less
City Hospital Alumni. 9
|
right for having adopted the course he did in the confinement. Upon
vaginal examination he came upon this tumor, about one and a half
inches from the introitus of the vagina which crowded the left side of
the vagina to its right ride, leaving only a small cleft. To get through
this cleft he had to press the tumor away and crowd his way further
upward to the uterus. The uterus showed nothing abnormal but the
vaginal wall was closely attached to the tumor. The right side of the
vaginal wall was absolutely undisturbed, and only the mucous mem-
brane of the left side could be moved upon the cystic tumor. The
first and most important question was whether this tumor was intra-
peritoneal crowding the peritoneum downward, or whether it was ex-
traperitoneal crowding the peritoneum upward It was not decided
with absolute certainty, but the diagnosis of extraperitoneal cystic
tumor was responsible for the route of operation.
Perineal incision with removal of the coccyx was selected. He
believed this tumor might have been attacked just as well through the
left side of the vagina, though perhaps, the perineal route was the safer
one. The rectal route is a nasty one and not often seclected now on
account of of the danger of infection. Whether there was any reason
for the embryotomy in the confinement was not a question at issue,
but the tumor being a cystic one might have given the doctor a chance
for puncture. The microscopic examination of the removed tissue
seemed to show it to be malignant, but the clinical picture was against
that. The drainage tube-was left in and the wound healed up per-
fectly. The woman went home apparently cured. Of course, if the
microscopical examination was absolutely right, patient has no chance
of staying well.
Dr. N. W. SHARPE, while he considered the operative attack, as de-
scribed, skillful and beyond reproach, felt it was most unfortunate that
the wall of the cyst had been ruptured. It was also unfortunate that
it had not been possible to get numerous sections of the wall, for as it
was, it was impossible to determine the actual extent of the carcinoma-
tous degeneration. If the condition was absolutely localized and had
been entirely removed, the patient would probably be cured; if how.
ever, the degeneration had penetrated the wall, or if the malignant
process had penetrated the wall, and had begun to invade contiguous
10 The Medical Society of
or neighboring structures, the patient stood a chance of a future spread
of the disease. He was not inclined to believe Dr. Deutsch's fear
would be confirmed, viz., that there would be a breaking down of the
local tissues followed by carcinomatous degeneration, unless a reim-
plantation of carcinomatous tissue had occurred during the operative
attack, assuming that the carcinomatous condition had not penetrated
the outer mural layers, and that all of the growth had been removed.
If there was a return of the condition it might more confidently be
looked for in the local and pelvic and and lumbar glands, with poss-
sibly a secondary involvement of the liver.
Dr. DEUTSCH, in closing, said that he thought Dr. Sharpe's theory
a little far fetched as the growth had nothing whatever to do with the
peritoneal cavity and it could be approached from behind without en-
tering the peritoneum or vagina and if this should return it would not
involve the pelvic glands as they were some distance from the growth.
One who had attempted a dissection in that region, knowing the space
between the cocyx and rectum, would realize that in the case of a
tumor adherent to all the structures it would be almost impossible, to
dissect out all the cyst wall, and the best that could be done was
through curettage. If the curette should leave a great deal of cyst
wall, there might be filling up again and a return of the growth.
Meeting of February 2, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Two Cases of Penetrating Gunshot Wounds of
the Abdomen, and One of Giall=
Stones Disease.
Presentation of Patients and Specimens.
By JOHN YOUNG BROWN, M D.,
ST. LOUIS, MO.,
Superintendent and Surgeon in Charge City Hospital.
HE first patient I wish to present was admitted to the
Institution with the following history: Rocko Salvini,
male, aged 30 years, native of Italy, was admitted to
City Hospital Alumni. 11
the St. Louis City Hospital December 29, 1904, at 9:40 a.m.
Forty minutes before admission, while in a frenzy, he had as-
saulted his brother, cutting him into ribbons with a large
butcher knife. When an officer attempted to arrest him, he at-
tacked the officer and, in self-defense, the officer shot him. On
examination he was found to have a penetration gunshot
wound of the abdomen. The bullet entered just below the
costal margin of the left side and emerged between the ninth
and tenth ribs on the right side. The patient was suffering
greatly from shock and showed symptoms of marked internal
hemorrhage. Hypodermoclysis was practiced and he was im-
mediately prepared for operation.
Operation.—The abdomen was opened through a median
incision extending from a little below the ensiform cartilage to
an inch below the umbilicus. On opening the peritoneum, blood
gushed freely from the incision. The liver was sought. The
bullet was found to have penetrated the right lobe near its
lower border. The hemorrhage from this wound was severe.
The wound in the liver was plugged with gauze, which at once
controlled the hemorrhage. The gall bladder was found per-
forated. Cholecystectomy was quickly done. Two wounds
in the pylorus were found, each was closed with a through-
and-through stitch and then buried with Lembert sutures. A
cigarette drain was placed down to the stump of the cystic duct,
being retained with a fine catgut stitch. This drain, with the
gauze through the liver, was brought out at the upper angle of
the wound. The abdomen was copiously irrigated with nor-
mal salt solution and a stab wound was made above the pubes,
through which a glass drain was placed into the vesicorectal
pouch. The abdominal wound was then closed with a through-
and-through suture of silkworm gut. The operation was com-
pleted in thirty-seven minutes. The patient left the operating
table in fairly good condition, his pulse responding readily to
frequent hypodermoclyses. The glass drain was removed in
forty-eight hours and the gauze drain was taken out on the
tenth day. The patient was discharged from the Hospital on
February 5, 1905, having fully recovered from his injuries.
Recoveries following extensive injuries to the abdominal
viscera are far more frequent than they used to be. The now
12 The Medical Society of
generally accepted teaching, that all penetrating wounds
be immediately explored, is responsible for the gradual de-
crease in the frightful mortality which followed late surgery
and the expectant plan of treatment of such cases. At the
Memphis Meeting of the Mississippi Valley Medical Associa-
tion (American Journal of Obstetrics, Vol. XLVIII, No. 5,
1903) the writer reported a series of twenty-two cases of pen-
etrating wounds of the abdomen with nineteen recoveries and
three deaths. In this paper the importance of early and sys-
tematic work was demonstrated conclusively. In a subsequent
article on the “Technic of Acute Intestinal Surgery,” read
before the same Society at the Cincinnati Meeting, which pa-
per appeared in the Journal of the American Medical Associ-
ation, of March 4, 1905, the technic of this work as now be-
ing carried out by the writer at the St. Louis City Hospital
was fully described and illustrated. The conclusions arrived
at in the two papers may be briefly summed up as follows:
I. In all penetrating wounds of the abdomen, perforation
should be assumed and immediate exploratory section should
be done. The operation should be conducted quickly and
systematically.
2. The incision should be a long one, extending from an
inch below the ensiform cartilage to two inches below the um-
bilicus and should be made in the median line. All sources
of hemorrhage should be immediately controlled by ligature.
Hemorrhage from wounds in the liver and spleen is best con-
trolled by tightly packing with gauze, the gauze being brought
out through a stab wound in the region of the injury. The
hollow viscera should next be gone over in the following man-
ner, beginning at the stomach: If the stomach is perforated,
the wound in the anterior surface is repaired. The omentum
is then thrown through and the posterior wall is examined.
The transverse colon is next examined and repaired if injury
is found. It is then thrown back and the jejunum is readily
picked up at the angle of Treitz, just as in making a gastroen-
terostomy. The small bowel is then examined rapidly, inch
by inch, to the ileocecal valve, a 1 wounds closed with a silk
or linen suture through all the coats of the bowel, and the
line of suture covered with a Lembert stitch.
\
City Hospital Alumni. 13
If multiple perforations of the bowel and mesentery are
found in close proximity, resection should be done, the anasto-
mosis being made either with the Murphy button or by suture.
The large bowel is next examined from the ileocecal valve to
the rectum, all injuries being carefully repaired. The perito-
neal cavity is then copiously irrigated with hot normal salt solu-
tion, and a stab wound is made above the pubes through which
a glass drainage tube is carried down to the vesicorectal
pouch. The wound in the abdomen is then closed, and as soon
as possible thereafter, the patient is placed in an exaggerated
Fowler position. Should no wounds of hollow viscera be
found, irrigation and drainage are unnecessary. An operation
systematically conducted in the manner above outlined pre-
cluded the possibility of overlooking bowel injuries and en-
ables the surgeon to work rapidly, sparing the patient the shock
which always follows the unnecessary handling and exposure
of the peritoneal contents. The value of the glass drain, placed
as above described, and supplemented by the exaggerated
Fowler position, I wish strongly to emphasize.
CASE 2.—This patent was admitted to the City Hospital
November I I, Igo4, suffering from a penetrated gunshot wound
of the abdomen. He was immediately prepared for operation.
On opening the abdomen nine perforations of the small bowel
and six of the mesentery were found. Seven feet two inches
of the small bowel was resected, anastomosis being made with
the button. The technic carried out in this case was practic-
ally the same that was used in the case just presented. This
man, as you see, has made an uninterrupted recovery.
CASE 3.−This patient was operated on ten days ago for
gall-stones. The specimens I present were removed from the
gall-bladder and common duct. The interesting feature of the
case is that the woman presented many symptoms pointing to
malignancy of the stomach. A diagnosis of gall-stones was
made, and at the operation the stones, which I show, were re-
moved. I merely present the case to call attention to the
difficulty sometimes. encountered in diagnosing pathological
conditions in the right upper quadrant of the abdomen.
14 The Medical Society of
DISCUSSION.
Dr. GEORGE HOMAN had been present when Dr. Brown presented
one of these patients at the St. Louis Medical Society together with
three similar cases, and he had been instructed as well as impressed
by his care in making the distinction between abdominal penetration
and visceral perforation. It was of the highest importance that these
distinctions be observed and that it be remembered that penetration
did not necessarily mean perforation. He believed Dr. Brown had
said that the gall-bladder in the second case was penetrated, but he
understood it was perforated.
Dr. F. A. BALDw1N wished to emphasize one of the points Tr.
Brown had brought out, namely, that exploratory operations should be
performed oftener. Taking gall-stone cases as an example, many
cases of acute pancreatitis and necrosis are due almost entirely to the
action of gall-stones, and they can be avoided when taken in time.
Another condition is malignancy of the stomach. It does not take
long for a new focus of growth to start in the lymphatics around the
pylorus, setting up an inflammatory condition, so that the longer the
operation is delayed the more difficult it becomes. This is especially
true of the pylorus because of the anatomic markings in that region.
Multiple Aneurism of the Aorta.
By WARREN N. HORTON, M.D.,
ST. LOUIS, MO.
HE specimen which I wish to present this evening is one
of multiple aneurism of the thoracic aorta from a pa-
tient, R. T. C., who was admitted to the City Hospital
September 17, 1903, and was presented to this Society for
diagnosis during that year.
The case was an interesting one from a diagnostic stand-
point as well as a pathological one. In order that you may
appreciate the specimen in connection with the clinical condi-
tions, I will present a brief history as made at the time of his
City Hospital Alumni. 15
admission and relate some differences found in the physical
examination made two days before the patient's death.
Hoðits.-He drank whisky moderately, smokes and chews
tobacco, eats regularly but rapidly, and slept well before this
last illness; no drug habits; sexual habits excessive. His
work was that of a railway mail clerk, and later as a dry-
goods salesman.
Family History.—Father was killed by accident at the
age of 36 years. Mother died at the age of 65 years of some
hip trouble. Three brothers and six sisters living and healthy.
No history of any hereditary disease.
Previous History.—When 25 years of age he had measles
complicated with pneumonia and was sick two months but
made a good recovery. He had a severe attack of influenza
when 33 years of age and says that he has never felt entirely
well since; hearing and sight were impaired. At the age of
26 years he had sores on the penis, followed by suppurating
inguinal adenitis. At 21 years of age he had gonorrhea which
persisted for eighteen months. When 18 years of age he had
an attack of articular rheumatism. Since the attack of influ-
enza he has been subject to colds on the slightest exposure, and
for the past two years he has been troubled with dyspnea on
slight exertion.
Present Trouble.—One year ago last January he contracted
a severe cold, with this he had a thumping pain on the left
side of the spine below the tenth rib, partially posteriorly, also
palpitation of the heart with pain near the left costal arch.
The thumping pain in the back lasted about three months and
then changed into a dull aching pain. This he says is his
most pronounced annoyance. His heart gave him no trouble
for a time but is worse than ever at present and he has a feel-
ing of oppression as though a weight was above his heart; the
entire chest feels sore and he has difficulty in swallowing solid
foods, some dyspnea and a slight cough, which is dry; voice
is husky, throat feels dry and he has a constant dull pain in the
region of the umbilicus. He has lost 30 pounds since he was
taken sick.
Physical Examination, made September 1903, showed the
patient to be 5 feet 7.5 inches in height, weight I40 pounds, is
16 The Medical Society of
much emaciated, muscular development scanty, no adipose
tissue, skin dry, facial expression languid, attitude passive,
tongue coated.
Palpation of chest, no abnormal fremitus felt. Percussion
note tympanitic, anteriorly, especially on the left side; normal
posteriorly, Auscultation, moist rāles heard over both lungs.
Heart.—The area of dullness extends from the fourth rib
downward to the costal margin and from the median line to the
mammillary line; apex beat is in the seventh interspace one-
half inch to the outer side of the mammillary line. On aus-
cultation, a loud cystolic murmur is heard at the apex; second
pulmonic sound is not accentuated.
Abdomen.—Right kidney can be palpated, pulsation visi-
ble on the left side of median line below the costal arch, some
tenderness on palpation around the navel.
Physical examination made two days before death revealed
conditions differing greatly from those recorded fifteen months
prior. The patient was extremely emaciated, skin yellow and
dry, feet slightly edematous, superficial vessels tortuous, finger
tips clubbed-shape, right pupil dilated.
Examination of chest showed the right side full and round,
the upper left side was flat above and moved sluggishly on in- .
spiration, apex beat diffused in a position below and to the left
of the nipple. Posteriorly, a distinct pulsating tumor could
be seen between the lower angle of the scapula and the spinal
column.
Percussion gave a hyperresonant note over the entire
right side of the chest, extending down in the mammillary
line to the upper border of the sixth rib. Over the left side
of the chest percussion note was not dull but flat throughout.
Auscultation over the right side of the chest revealed nu-
merous large and small moist rāles. Over the left side no
breath sounds could be heard but a loud systolic murmur
everywhere, this could also be heard in the second and third
interspaces on the right side of the sternum and in the brach-
eal artery of the right side. Posteriorly, a distinct bruit could
be heard over the pulsating tumor. k
City Hospital Alumni. 17
What symptoms were present indicating an aneurism of
the arch of the aorta ?
I. Constant pain in the upper portion of the chest (not
radiating down the arms or along the intercostal nerves).
2. Dyspnea which had lasted over a period of two and a
half years, with a dry hacking cough.
3. Dysphasia which had been present for one year, con-
stantly growing worse until the patient spoke only in a
whisper.
4. Dilatation of the left pupil.
5. Difficulty in swallowing solid foods.
6. Distinct tracheal tugging which could not only be felt
but seen.
Physical signs not present that would point to aneurism
of the arch were, first, that no inequality of the radial pulses
could be made out, the pulse was weak and soft but synchro-
nous on both radials, also in the common carotids, with sys-
tole of the heart; second, that no diastolic shock could be
heard, since the loud systolic murmur was continuous, with a
sound which was not unlike the distinct bruit heard posteriorly.
Neither was I able to hear the whiffing, interrupted breath
sounds. The loud murmur also obliterated any creaking
sounds, caused by adhesions to the sternum, when the patient
was made to raise and lower his arm (as pointed out by Perez).
Examination of the left chest gave us another doubt as
to what condition actually existed. The respiratory move-
ment was impaired. In the upper half, anteriorly, there was
no increase in tactile fremitus, no breath or voice sounds could
be heard at any point over this side. Percussion note was dull
over every part, and yet there could be heard everywhere
this loud systolic bruit. What was here P A hydrothorax P
No | This would account for the absense of breath sounds,
but the heart murmurs could be heard. A consolidation of
the lung would do, provided the bronchus was occluded.
Could a pneumothorax produce it? Yes, provided the valve-
like inlet be closed and the intrathoracic air pressure be suffic-
iently high. The most plausible condition, however, was that
it was a large aneurism filling the left chest.
That there was an aneurism posteriorly was certain, since
18 The Medical Society of
there was a distinct bulging between the lower portion of the
scapula and the spinal column, which pulsated, having an ex-
pansive movement synchronous with the heart-beat and over
which could be heard a distinct bruit.
With all this in mind we patiently waited for the man to
die which he was kind enough to do.
On opening the chest we found the manubrium and costal
cartilages strongly adherent to the tissues below. The right
lung extended beyond the median line, the left lung was not
visible owing to dense fibrous adhesions, the apex of the heart
was found at the level of the upper border of the ninth rib, the
thoracic viscerae were removed intact. The right lung was
about one half the normal size, its pleural surface was bound
to the parietal pleura by strong bands of adhesions. On sec-
tion it was found honeycombed from apex to base by small
tubercular cavities containing a mucopurulent material.
The left lung lay curled up in the upper posterior portion
of the thoracic cavity. When removed it measured 7x1.5x4.5
inches, and at no part did it contain air.
The pericardial sac was obliterated completely by fibrous
tissue which bound the heart muscle to the sac; the valve seg-
ments were all found to be intact.
At a point on the right anterior portion of the beginning
of the aorta is a small aneurismal sac, 2 1/4 inches in diame-
ter; on the upper and posterior part of the arch is a saccu-
lated aneurism which was filled with an organized clot.
On the descending aorta was a still larger aneurism, the
posterior wall of which was formed by the posterior thoracic
wall from the lower border of the fifth rib to the upper border
of the eighth rib and from the middle of the bodies of the
corresponding vertebrae to a point 5 inches to the left. The
bodies of the vertebrae were about one-fourth gone and the
sixth rib was almost eroded through.
The remainder of the thoracic and abdominal aorta as
well as the other large vessels showed a marked atheromatous
condition. The abdominal organs showed interstitial changes
with numerous milliary tubercles of the kidneys.
City Hospital Alumni. 19
Dr. F. A. BALDwiN presented specimens of
Thoracic Aneurism.
Thirty-six hours ago Dr. Kirchner asked me to show the Society
some of the aneurisms we had at autopsy. We have had two very
good ones and I brought over two other aortae that are very interest-
ing. All of these aneurisms were found in patients who had some
form of nephritis, chronic interstitial or chronic parenchymatous. In
all were histories of excessive drinking. One of them gave a history
of excessive sexual habits and all of them were in types of men in
whom one might find a certain amount of syphilis, although all denied
it. In one it was found, accidentally, two were diagnosed, and in the
third it was a dilatation, but had the patient lived long enough there
would doubtless have been a marked aneurism. In the first the aorta
is sclerotic, in patches entirely calcified. There was a chronic paren.
chymatous nephritis with mitral insufficiency, and chronic edema.
The second case was one in which the aneurism was found acci-
dentally. There was a chronic interstitial nephritis. There was a
small aneurism just below the arch of the aorta. Lower down I found
another very small aneurism and which I cut, not expecting any aneu-
rism. In other words, there are here two beginning aneurisms. -
The third case had been diagnosed by one man as adrtic stenosis
and by another as aneurism. The autopsy revealed the following con-
dition. The heart measured Io.5x11x2x4 cm. I was unable to get
out all the aneurismal sac. It was firmly attached to the vertebrae and
two of the vertebral bodies had been eroded. It was a dissecting
aneurism of the lower wall of the arch of the aorta.
The fourth was most interesting from a clinical standpoint. The
man had never noticed that he had anything the matter with his heart
or the larger vessels until one night when returning home someone with
him touched him on the back and asked him, what “that bunch"
was: Later, a diagnosis was made. I have here part of the spinal
column. A clot had recently formed in the cavity and that part of the
mass made by this aneurism had eroded the bodies of the fifth, sixth
and seventh vertebrae. The sixth rib was eroded about 4 cm. and the
fifth and seventh rib for about 2 cm. and in this space the aneurism had
20 The Medical Society of
-penetrated the muscular layers of the back so that when I cut the skin
I cut immediately into the aneurismal sac. There was a large amount
of edematous tissue and though it could not be entirely removed I cut
out as much as I could. The four specimens make a very fair set of
the early and late stages.
DISCUSSION.
Dr. AMAND RAvold had formerly held, along with Clifford Albutt
and others of the English school, that aneurism was, as a rule,
caused by excessive strain put upon the circulatory system, independ-
ent of constitutional diseases. But his work in the post-mortem room
for the last few years and especially his association abroad with the
great German pathologist had led him to think that a great majority of
cases have for a primary cause some constitutional disease, and high
above all, ranks syphilis. Although he could not entirely agree with
the dictum, “No Aneurism without Syphilis,” still the evidence pre-
sented by some great workers in pathology is overwhelming in its
strength and abundance. As for its diagnosis, all the faculties of the
mind should be bent on making it early in the disease. It would lead in
too large a field to elaborate upon its differential diagnosis, but he wished
to insist upon one essential point, that pain is the first, the most
notable and the most persistent symptom of the disease and especially
is this so of abdominal aneurisms, a fact always to be kept in mind
when dealing with abdominal pain of obscure causation.
Dr. GEORGE HOMAN was reminded by the case of an almost
identical one that he had seen a number of years ago at St. Luke's
Hospital. The man was a Kansas farmer and the force of the aneu
rism, as in this case, was directed upward and to the left, displacing
the scapula and causing a complete separation of one or more ribs with
exposure of the coverings of the spinal cord. The pain was not con-
siderable. No operative procedure was done except the use of elec-
tricity in the hope of effecting consolidation. He got along quite
comfortably but finally died suddenly from rupture of the sac and the
entire chest cavity was found filled with blood at the autopsy. That
there had been such an amount of osseous destruction with so little
pain was astonishing.
City Hospital Alumni. 21
Dr. HUDSON TALBOTT wanted to know more about these cases.
The cause of death had not been mentioned in any of these cases.
Aneurisms behaved very differently. They were immensely large in
some cases. Dr. Ravold had spoken of pain in the abdomen being
one of the marked symptoms. This reminded him of a specimen that
he had seen recently at post-mortem. The aneurism was of the
ascending aorta and reach to the arch, but it was small, about the size
of a hen’s egg. The cause of death in that case was hemorrhage. The
aneurism had eroded the trachea. There were four pinhead perfora-
tions. He supposed that in the first specimen mentioned the patient
had died of tuberculosis, yet there was a very large aneurism there.
In another, the spine was eroded, even the cord approached. As to
treatment, probably nothing had done them a marked amount of good.
Injections of gelatin were used a few years ago; he had not followed
that up and did not know whether they were still used; they had
caused a good deal of clotting. In these specimens there was no
such clotting. Dr. Loeb had presented a specimen in which that
treatment had been used and the layers could be seen on the wall of
the aneurism.
Dr. HoRTON, in closing, said that although the man denied all
history of syphilis there were found on his legs a few sharply-defined
grayish colored scars, the cause of which he could not satisfactorily
explain. Pain in this case was a constant symptom, beginning early
in the disease and later becoming so severe that sedatives were re
quired to procure rest. As to diagnosis—that there was an aneurismal
condition of the arch of the aorta was almost certain, but the condi-
tion in the left chest at the time of death was still doubtful. The pa-
tient was given the rest cure and died of phthisis pulmonalis, which is
not at all unusual.
Dr. BALDw1N, in closing, said that a marked sclerosis had been
found in the case that died of pericarditis. In the other case the man
died of chronic nephritis. They were both dissecting aneurisms which
had ruptured. The point mentioned several times, namely, that
syphilis was a prominent factor, could not be emphasized too strongly.
Syphilis and alcoholism were the two chief factors, and next might be
mentioned overwork. By far the greater majority of all aneurisms
22 The Medical Society of
might be traced to one or the other of these causes. In reply to a
question by Dr. Ravold, he said that he believed the atheroma had
antedated the aneurism. The sclerosis and nephritis had been sec-
ondary factors.
Huntington’s Chorea.
By G. H. COTTRAL, M.D.,
ST. LOUIS, MO.
Senior Assistant, City Hospital.
HOREA is derived from a Greek word, meaning to dance,
that is rhythmical movements of a voluntary nature, as
salutatory, natatory and salaam. Many others were
further comprised, these forms belonging more or less to
hysterical manifestations. The term was then used for all
rhythmical voluntary movements and then as a matter of fact
was used to express those diseases characterized more or less
by rhythmical involuntary movements of which a few are now
studied enough to have become recognized as morbid entities,
by the names of chronic or Huntington's chorea and common
or Sydenham's chorea.
Cases were first reported by Dr. George Huntington, of
Pomeroy, Ohio, in 1872, although it is credited that Dr. Waters,
a Long Island physician, recognized the disease as early as
1842. Huntington described it in a journal hard to obtain at the
present time, namely, the Philadelphia Medical and Surgical
Report, No. 15. In this article he brought forth one of its
characteristics, its hereditary tendency.
This form of chorea has been described by him and to it
his name has been given to specify that certain form of dis-
ease, yet it remains to be determined whether or not it is a
special disease, as the name indicates, or only a form of the
common chorea. Huntington's chorea takes its place among
the many recently described muscle and nervous diseases, such
as pseudohypertrophy, described first by Duchenne, Fried-
rich's ataxia and Thompson's disease, arising at the same
time as a familiar and singular hereditary affection, which as a
matter of fact act as does Huntington's chorea. The informa-
City Hospital Alumni. 23
tion and reports of the writings of Huntington had little effect
for a long time, until at last several interesting works concern-
ing the disease were written in Germany. The most important
of these works was one of Huber, in Virchow's Archives, which
contains a large number of interesting facts. There is also a
work written by Hoffman, of Zurich, the title of which is
“Chorea Chronica Progressiva,” also very rich in new observa-
tions, which can also be found in Virchow's Archives. Charcot
was the first to present a case of Huntington's chorea in
France, which, according to his writings, had been barely
mentioned in their various publications, and always with ref-
erence to the American or German works. No individual ob-
servations were made either to uphold or question the asser-
tions and observations of the different American and German
authors. Charcot further states, that according to Huntington
and his followers, who are in accord with his ideas, the main
character of the affection as already stated would be the pe-
culiar hereditary tendency. The family tree, I herewith show
you, which was taken from the work of Huber will tell you
more than I can by way of explanation bring home to you, of
its hereditary nature in the most expressive manner.
Heinrichº
Magdaline { Anna
Jacob%
ſ Hans”
Jacobº
Christopher *
Christopher Rinderknecht -
Conrad.* -(
ſ Elizabeth?
Conrad.*
| Jacob.”
*Chorea.
A certain Christopher Rinderknecht, himself healthy, at
least not suffering from chorea, had four children of which the
24 The Medical Society of
fourth by the name of name of Conrad opened the line of
disease. This man suffered from an affection characterized by
all clinical manifestations of Huntington's chorea except the
hereditary trait. The hereditary tendency is therefore the
only sign which he developed in this affection to enable its
differentiation from the infantile chorea of Sydenham, which
later often connects itself with articular rheumatism. The
third child of Christopher Rinderknecht, by name Magdaline,
married a Kuhn, who was not troubled with any nervous mani-
festations. They have one child, which like its uncle Conrad,
develops chronic chorea. Later two other children are born of
which the second child again has chorea. It will be noticed
that descendents of Conrad are rich in cases of chorea, scat-
tered very much as follows: sº
Of five children, as shown in the above diagram, there are
four cases of chronic chorea, namely, Hans, Jacob, Christo-
pher and Conrad. Conrad, the latter, again has five children
of which two, Elizabeth and Jacob have chronic chorea. This
gives a beautiful picture of the hereditary tendency in this dis-
ease showing itself from generation to generation, making it
impossible for us to find a suitable cause for its occurrence.
Without cause it appears some day just about the same period
in life.
Unfortunately not all the cases of Huntington's chorea are
as clear and lacking of questionable phases as is this family of
Rinderknecht. 49
Moróid Anatomy.—Nothing pathognomonic has been
found, though many careful observations have been made. In
many of the cases the dura mater has been found in a condi-
tion of chronic pachymeningitis, with or without hematoma,
while in nearly all there were present evidences of chronic pia
arachnitis, with a varying degree of adhesion of the pia to
the surface of the cerebral vertex. The most common
changes noted in the brain itself are those of primary degen-
eration of the neurons or of a chronic encephalitis. The most
frequent, according to certain observers, consists in dissemi-
nated foci of round cells in the cortex and subcortical white
matter. There were also observed changes in the interstitial
tissue and vascular system. The pathology of the disease is
City Hospital Alumni. 25
*
most obscure but the histological changes met with point to a
parenchymatous degeneration, in which the neurons suffer
primarily and in which any interstitial change is secondary.
Others contend that a vascular and interstitial change is at the
base of the morbid condition. We know nothing of heredi-
tary influences which are of great importance as an element in
its etiology, though that it depends upon prenatal factors
there can be little question. We are, however, more fortu-
nate in our knowledge, of what determines the manifestations
of the disease at that particular time of life when these most
commonly assert themselves. According to Dana, Lannois
and Paviot, the defect is found in teratology, a hereditary mal-
formation; the disease has for its starting point certain embry-
onic cells possessed of hereditary taint, they having less power
of resistance to forms of excitation. Other views are, that
these cells are wanting in power to survive under the same en-
vironment as do the ordinary ganglion cells.
Symptomatology.—A summary of Huntington's article re-
peated by Osler gave as salient features: First, the hereditary
nature of the disease; second, the association of psychic
troubles; third, the late onset, at or about the 30th or 40th
year of life.
The onset of the condition is gradual and insidious with
motor disturbances first to manifest themselves, consisting in
irregular movements. If in the face, resembling those of tic
convulsiva. If in the legs, the ataxic unsteady gait. It is also
asserted that mental symptoms, at times, manifest themselves
before motor symptoms. Spasmodic movements resemble
those of ordinary chorea, in being involuntary, irregular and
without rhythm, differing only in being slower. In the early
stages so slight are the muscular contractions that there may
be little or no evidence of derangement of muscular tone, re-
sembling somewhat the fine tremor seen in cases of exophthal-
mic goiter. After the disease is more advanced the spasmodic
movements occur during rest and during voluntary acts, in-
creased by emotion and lessened by repose, sometimes being
arrested voluntarily in the early stages and at other times the
involuntary movement is arrested by the substitution of a vol-
untary act. It is said that the spasmodic movements can not
26 The Medical Society of
Ä
be arrested voluntarily when the disease is fully manifested.
The parts then are in constant agitation and the movements
are suspended only during sleep.
The ocular muscles have been implicated, the facial
muscles, causing grimaces, contortion of the tongue, causing
difficulty in speech, said to be due to spasms during the act of
deglutition. Speech is thereby affected, the words first slow
and halty, later becoming pronounced very indistinctly, inter-
rupted at times by inspiratory and expiratory grunts, the re-
sult of laryngeal spasms. Alterations in handwriting occur,
making it finally impossible for the patients to write at all.
The attitude of the patient with limbs separated, hands
abducted, eyes carefully directed to the floor, lateral and
anteroposterior swayings of the body gives one the typi-
cal picture of an alcoholic approaching the stage of subcon-
sciousness.
In walking, the swaying movements of the body are ex-
aggerated and there appears that sudden stiffening and pulling
himself up in time to prevent falling. Following this, walking
becomes altogether impossible. As a rule, muscular power is
not diminished until the disease is well advanced. Defects of
general sensibility and special senses take no part in symptom-
atology. The tendon-jerks are usually increased, sphincters
retain their natural tone. The natural course of the disease
is toward progressive mental deterioration.
First, patients are depressed and irritable, memory fails
and the intellectual faculties become blunted. It is said, that
associated with these mental changes, there is a strong tend-
ency to suicide, which in the latter period of the disease ends
in complete dementia.
They have their hallucinations, illusions and delusions of
persecution. The typical course persists until death, an end
which may not occur for twenty or thirty years following the
first manifestations of the disease.
The patient now before you, was admitted to the hospital
in July last, is a native of Illinois, occupation farmer, married,
with a wife and three children, the latter being well and
healthy, oldest child, a boy 21 years old, in whom no evidence
of nervous trouble is so far manifest.
City Hospital Alumni. 27
Statements regarding the patient's remote family history
fail in securing evidence of nervous or mental trouble. As to
the patient's previous history, several years ago, he had con-
gestive chills of severe variety. Other than this was never
sick, no specific or venereal history obtainable. Six years ago
last January while prospecting in Arizona the patient became
lost in a desert and was nine days without food or drink.
During this time he was caught in a snow storm, and his feet
and hands partially frozen or frost bitten. He at no time
allowed himself to rest, continuing through days and nights
searching for some form of habitation. Reaching this, he
was sent to a California hospital, where he received a treat-
ment for five months.
After leaving the hospital, he secured work on a milk
wagon, not at the time suffering any of the symptoms or
characteristics now manifest. He continued to hold this posi-
tion for one and half years, during which time he first began
to stagger and noticed the constantly increasing weakness in
his legs. He says he would feel a sort of heaviness or drag-
ging sensation, would stagger and frequently fall, and further
noticed that his hands and arms were in a weakened condition,
claiming that he often spilled milk owing to his “nervous-
ness.” Up to that time, he says, he experienced none of the
jerky inco ordinate movements of hands and feet as are now
in evidence nor was there at any time any twitching or spas-
modic contractions of the muscles of the face. He complains
at all times of feeling cold even in hot weather, and says if it
were not for that, he would feel as well as he ever did.
Being in the hospital and under observation as to his men-
tal condition it was soon found that he was in no way danger-
ous to himself or to the welfare of those around him. He at
no time has any pain, his tactile sensibilities and sense of taste
are not impaired. There is no trouble with his eyes, Argyll-
Robertson pupil not present, the heart sounds normal, appetite
and digestion good, sphincter action lost in neck of bladder,
has no trouble with bowels. His gait is decidedly ataxic as
are the upper extremities. There is no ankle clonus, Rom-
berg's sign not present. The swaying movements are more
apparent when the eyes are open than when the eyes are
28 The Medical Society of
closed; knee-jerks is slightly exaggerated. There seems to
be a general atrophic condition present in both arms and legs,
with decided weakness. The patient claims that his inco-
ordination is worse at night and that the involuntary move-
ments continue during sleep. This statement is not true, for
in watching him it is noticed that all involuntary movements
cease, but that upon waking there is an exaggeration of these
symptoms seeming as though all energy had been “stored up”
during the period of physiological rest to be exploded im-
mediately upon this return to consciousness.
During the patient’s stay at the hospital there has been
no change in his mental condition noted, although he is ap-
parently more irritable than he should be, but does not mani-
fest his anger to those about him, but has in every instance
and very cleverly seen fit to be the first one reaching proper
authority with the story of his trouble.
During his explanation of these troubles his whole de-
meanor is focalized upon this one thing, he actually posseses
increased strength, a concentration of nervous energy, after
which his condition shows the reaction, and he is weaker than
before.
Stigmata are encountered here, which are regarded as
evidences of congenital and hereditary neuropathic diathesis.
The ears show unusual forms, not the “shell-shaped,” but of
the Darwinian variety, the palpebral fissure to a certain degree
is narrowed, the hard palate is extremely high and long with
the Gothic arch, except these two or three anatomical stigmata
there is little diagnostic significance attached, on account of
there being no striking combination or unusual number. The
paresis or loss of power in the muscles of the upper extremi-
ties, such as biceps and triceps, are easily determined by ask-
ing him to flex or extend his arm, at the same time applying a
certain amount of resistance. He has no tremor of the tongue
or hands. Babinski's sign is not present. An involuntary
grunt is often noted during examination.
Diagnosis may be confused in the early stages with pri-
mary dementia, which has the mental symptoms exaggerated
over the motor symptoms, also the periods of excitability and
of melancholia, alternating as they do, which symptoms are
City Hospital Alumni. 29
lacking in Huntington's chorea. The diagnosis in this case is
apparently easy, there being no sign or symptom determined
objectively to indicate a pathological condition of brain or
cord. The pathological findings, as above spoken of in these
cases, bear out my conclusion. Huntington's chronic adult
chorea, with its persistent progressive course, is not distin-
guished from senile chorea or chorea of the aged, which differs
from it only in the hereditary tendency and which, to my
mind, is not sufficient reason for separating maladies which in
all other respects are identical. Treatment is entirely symp-
tomatic; nothing can be done by way of medicine to shorten
the course or alleviate the condition.
REFERENCES.
J. S. Rissen Russell.
Allbutt's System of Medicine.
Hammond’s Nervous and Mental Diseases.
DISCUSSION.
Dr. RAvold asked if there were any anesthetic areas, Dr. Cottral
replying that there were none.
Dr. Given CAMPBELL felt the Society was to be congratulated in
having a very beautiful illustration and an excellent paper on the sub-
ject. He had made some kinetoscope pictures of the case with suc-
cessful result. He would present these to the Society later, along with
some other pictures. He was glad to notice that Dr. Cottral called it
chronic progressive chorea rather than hereditary chorea. He had
seen seven cases in the last few years and there was a hereditary ele-
ment in but two of the seven. This man had, at the time Dr. Camp-
bell examined him, abolished Achilles-jerks.
Dr. A. M. BLISS said that although this was classed as a neurosis
he thought that there was always something found; but the trouble
was to gather up a sufficient sum total to determine the pathology.
Lesions were not always in the cortex. In the majority of instances,
at least, it was a fact that the members of the family subject to the
condition were attacked about the same time in life. It certainly did
bear a resemblance to certain kinds of tic. He had seen last summer
a case of paramyoclonus multiplex in a boy about 14 years of age,
30 The Medical Society of
who was defective mentally. A group of muscles would begin the
wave and then all the muscles would take up the movements. The
attacks came on every three or four months and lasted probably forty-
eight hours. There were a good many things that had a choreic look.
In one case there was an electric chorea which began in the occipito-
frontalis. The condition had lasted a year and a half and was gradu-
ally disappearing. It was always overcome by a firm voluntary con-
traction of other muscles. The condition was beautifully illustrated
in this case but he had also seen two other cases in the City
Hospital, both of which showed a more rapid movement, and a
flinging out of the arms and feet. This seemed to be a vermicular
! }
affair. }
Dr. HoRACE W. SoPER wondered if this condition attacked ani-
mals. He had seen a dog that seemed to have a distinct case of chorea.
There was a constant jerking of the head and in excitement he seemed
to get worse. A case similar to the one reported had been under ob-
servation during his term in the City Hospital. In that case large
doses of arsenic had seemed to help. The patient was given 3o
minims of Fowler’s solution three times a day and improved so much
that he left the hospital and was lost slight of. He asked if any of
the neurologists had observed any beneficial effect of large doses of
arsenic in such cases.
Dr. M. A. BLISS replied that he did not know anything about the
effect of arsenic from experience but authorities almost uniformly
stated that it had no effect. +
Dr. AMAND RAvold said that this was the first case, to his knowl-
edge, that he had ever seen, and thanked Dr. Cottral for his able pre-
sentation of it. He asked if the lesion was in the brain or cord, Dr.
Campbell replying that it was in the brain. -
Dr. Given CAMPBELL said this man showed one difference from
the movements in Huntington’s chorea. In Sydenham’s chorea the
movements were usually at the extremities, twitching of the fingers,
etc., and in Huntington’s the muscles moving the larger joints affected.
In Sydenham's chorea a definite muscular act was liable to make the
movementS more Severe.
Dr. JoHN GREEN, JR. presented a patient with
City Hospital Alumni. 31
Partial Subluxation of the Lens.
About ten months ago, a piece of kindling wood struck the pa-
tient in the right eye. It bled a few minutes, hemorrhage ceasing
sponstaneously, The patient noticed nothing the matter with the eye
immediately afterward, but a few months ago he observed a shadow
before the right eye. The fight pupil is somewhat dilated, the anterior
chamber deeper than normal, the iris tremulous. The ophthalmoscope
shows a partial dislocation of the lens into the vitreous. As the pa-
tient moves his eye the lens moves in different directions. A portion
of the pupil is occupied by the dislocated lens. This can hardly be
regarded as a one of complete subluxation for the lens is held by
remnants of the suspensory ligament on the inner side.
Meeting of February 16, 1905; Dr. John Green, Jr.,
President, in the Chair.
Presentation of a Specimen of Multiple
Sarcoma of the Spinal Column.
By M. A. BLISS, M.D.,
ST. LOUIS, MO.
ALE, aged 22 years; dentist; single; height about 5
feet 8 inches; weight 145 pounds. Father, mother,
one brother and two sisters living and well. The pa-
tient is the youngest of the family. He had typhoid five years
ago, no sequelae. No other serious illness except diseases of
childhood which were passed through without disaster. He
had been only moderately robust, but health excellent up to
the beginning of his last illness. He had a prominent forehead,
rather dark large eyes, and was of nervous temperament.
April 25, 1904, he consulted Dr. Homer Davis on account
of pain on movement in the cervical and lumbar spine, which
he attributed to a cold. April 28th, the back was better but
the neck was somewhat stiff and sore. May Ioth, there was
much pain in the neck muscles; he used his hands to carry
32 The Medical Society of
his head when changing position; his back giving no trouble.
There was tenderness on deep pressure over the left posterior
neck muscles but none over the cervical spines. A little later
there was a protrusion of the lower jaw so that the inferior in-
cisors articulated in front of the superior. This could always
be corrected with a little effort and pain, and disappeared for
a period in June, and later returned. May 20th his back be-
came lame again and caused him much pain on voluntary
motion or when he was moved but was alway quite comfort-
able when he was lying still. * &
During the time recorded there was no deviations from
normal temperature or pulse, appetite was excellent. Patient
examination failed to discover anything abnormal in any organ
of the body. At times improvement would occur in the neck
so that he could move it freely and at times he could move his .
back muscles without pain. He was always free from pain
when at rest.
June 23d, the patient was taken out of bed and placed in
a Morris chair but was so uncomfortable that he was almost
immediately returned to bed. He screamed with pain on be-
ing moved back, and following this excursion he complained
of pain and coldness of the knees, lost all motor power and
soon reflexes at the knee, and response to all sensory stimuli
was much lowered up to the knees.
Retention of urine occurred, the bowels moving only with
enemas. The anesthesia progressed upward but was higher
on the left than on the right side, and became more nearly
total. There was no deformity of the spine to be made out at
this time, (about July 5th) and an attempt at lumbar puncture
was rewarded with only two or three drops of clear fluid of
doubtful origin. There were no cranial or cervical nerve in-
volvements at this time. Grasp was good, urine entirely clear,
no pain when at rest. w *
The patient sat, propped with pillows, in an almost erect
posture in bed, with the head protruded forward, giving the
neck the appearance of a hypertrophic cervical meningitis.
There was a slight swelling on the left side of the neck pos-
terior to the sternocleiodomastoid, which, though not painful,
suggested an inflammatory origin.
City Hospital Alumni. 33
From the 6th to the 11th of July the swelling in the neck
increased rapidly, fully doubling in size and the forward pro-
trusion of the lower jaw recurred. The anesthesia had crept
up eight inches above the knee on the left leg and four
inches above the knee on the right leg. Dr. Harvey Mudd
made an incision into the growth on the neck on the 12th of
July, and the microscopic examination of a piece removed
showed small round celled sarcoma. A growth pushing down-
ward and forward on the nasopharynx was made and the pa-
tient breathed through mouth. He was able to take some
solid food.
About this time the left pupil contracted and this, with a
slight ptosis (left), was the first sign of involvment of any
cranial or cervical nerve. The tongue was disabled and speech
became very indistinct. Later, anesthesia occurred over the
left side of the neck down to the clavicle. Breathing became
labored. On August 1st, at 3 a.m. the patient was bright
and cleaned his own teeth but at 5 a.m. he lapsed into uncon-
sciousness, dying two hours later.
Post-mortem, I 3 hours after death, was limited by request
to the spinal column. Rigor mortis was well marked. The
tissues of the back were peculiarly hard, due to embalming
fluid, board-like, and the skin was very hard to incise in the
area below the lumbar region. The bodies of the 2d, 3d and
4th cervical and the 1st and 2d lumbar vertebae were digested
by the sarcoma so they could be broken down readily by
pressure of the fingers. The swelling in the neck contained a
digested looking material and the finger could be pushed en-
tirely through it to the anterior side of the cervical vertebrae,
the remains of portions of the vertebrae forming a part of the
contents of the tumor.
On removal of cord and its membranes one of the inter-
vertebral discs in the lumbar region came away adherent to
the dura. Macroscopic examination after splitting the mem-
branes disclosed no involvement of the cord thickening in ad-
vance of the sarcomatous infiltration affecting only the dura.
No sections have been made of the cord Although this fact
places us in a position of partial uncertainty we conclude the
partial paraplegia to have been produced by pressure due to
34 The Medical Society of
collapse of the spinal column at the time the patient was
moved into the Morris chair and to be equal to a fracture-dis-
location. The involvement of the cervical nerves was due to
direct encroachment of the sarcomatous process.
DISCUSSION.
Dr. AMAND RAvold had been greatly interested in the specimen,
as some fifteen years ago he had had a case of multiple sarcoma which
also caused paralysis by invading the spinal column. He was asked
one day at the House of the Good . Shepherd to see a young woman
complaining of a painful growth on her leg. The patient was a large,
well-formed, handsome girl of about 18 years of age, and on the out-
side of her left leg, midway between the knee and ankle he found a
hard, redish, painful tumor, about half an inch in diameter. It was
imbedded in the muscles below and attached to the skin above, but not
to the bone. It looked and felt somewhat like a gumma, but a nega-
tive syphilitic history denied it. Erythema nodosum and induration
were excluded and a tentative diagnosis of malignant growth was made.
He immediately called in Dr. H. H. Mudd, who also made a diagnosis
of malignancy, probably sarcoma, and urged its removal at once. The
patient asked for fime to consult her mother, who lived in a near by
city. The mother came and both she and the patient refused the plead-
ings of both i \r. Mudd and himself for surgical aid, nor would they
permit a piece of the tumor to be excised for microscopic diagnosis.
Then began a most terrible and tragic drama. About ten days after-
ward he was asked to see the patient again and found the growth on
the left leg fully 2 inches in diameter and very painful, also a large nest
of tumors could be felt and seen in the left groin. He again urged
their removal, but unavailingly. In a few days, metastatic growths
appeared in the right elbow-joint, grew rapidly to great size, fixing the
joint at right angles; another grew on the back of the neck, enlarged
rapidly, pushing the head forward and downward and fixing the chin
on the chest; a third growth formed in the lumbar region and also
grew rapidly into a large mass which eventually broke down, making a
great sloughing bed-sore. A short time after this a growth began to
manifest itself in the socket behind her right eye. It grew apace push
ing the eye out before it, downward and inward, until at last it stared,
City Hospital Alumni. 35
wide-open into her suffering mouth. Thus, within a month after the
refusal of surgical aid this once beautiful young woman was trans-
formed, by the malignancy of this disease, into the most awful looking
and terribly tortured creatures he had ever seen. The growth in the
lumbar region involved the vertebra, pressed upon the spinal nerves
and produced a paralysis of the lower extremities. After this she lived
two weeks longer a most miserable wretch, a fetid burden to herself
and all about her. She lived from the time of the first visit until her
death, about two months in all.
The frightful malignancy of this disease is demonstrated by these
cases, showing the necessity of speed and accuracy in making a diag-
nosis and the importance of prompt surgical interference. Sections of
the tumor made post mortem and studied microscopically by Dr.
Rohlfing and himself show the tumors to be sarcoma of the small,
round cell variety.
Dr. C. G. KIRCHNER said that about a year and a half ago a
case had presented itself at the City Hospital, the patient was a man with
a swelling about the sacrum. A diagnosis of tumor was made and
operation advised. The tumor, a sarcoma, was removed, as was also
the surrounding area. The operation resembled that of Kraske, the
greater portion of the sacrum being removed. The patient did well
for a time, but three or four months afterward returned to the hospital
in a much worse condition than before, the growth having involved a
much greater area and he was then almost helpless. He had come
for relief and when told that nothing could be done for him, was re
moved from the hospital. The case showed how difficult it was to
treat such cases by operation. The location of the one presented by
Dr. Bliss was also very interesting, as it involved the spinal column.
Dr. JoHN C. MoRFIT stated that his connection with this case was
limited to two occasions, once during the first part of the illness and then
at the autopsy. On the former occasion the condition was veiled in
obscurity, after a most careful examination, including an unsuccessful
lumbar puncture. He could not see at the time why spinal fluid was
not obtained but later developments proved beyond a doubt that the
exploring needle entered the tumor mass and not the spinal canal,
which was obliterated. At the first visit attention was called to a slight,
36 The Medical Society of
almost imperceptible swelling at the angle of the jaw on the left side. It
was impossible to know whether this was a neoplasm or inflammatory,
mass although the latter view was favored at the time, and tuberculosis
was regarded as most probable. This growth proved the key to the
whole problem, for its immediate and rapid increase led to exploratory
and microscopic investigation. The cause became clear, but the
manner of its action was not exactly known. The conclusion was that
the paraplegia was due to a metastatic growth in the cord itself,
whereas the autopsy revealed that the cord was not intrinsically affected
or diseased, but was pressed upon by the collapse of the spinal column,
due to the digestion and softening of the bodies of several vertebrae—
an injury comparable to fracture dislocation as Dr. Bliss aptly stated.
Dr. L. H. HEMPELMANN said that the lateness of the pressure
symptoms called to mind a case of tuberculosis of the spinal column.
The man considered himself perfectly well and one day in leaving an
office building he slipped and partly fell, catching himself before fall-
ing. He noticed pain in his back and later the limbs began to stiffen
and in two days there was complete paralysis. He sank rapidly and
died within the course of a week. At the post-mortem it was found
that several of the cervical vertebrae had been completely destroyed by
the tubercular process and the shock of the fall had been sufficient to
dislocate them.
Dr. RAvoLD, replying to a question by Dr. Bliss, said that the
pain in the initial lession had been very great, but that in the larger
tumors which developed afterward the pain was not so severe and,
fortunately, was easily controlled with opiates.
Dr. BLISS, in closing, said that he had asked Dr. Ravold about
the pain because Starr, in his work on nervous diseases, mentions pain
as one of the symptoms. The man was perfectly free from pain when
at rest. Starr had also mentioned the fact that these cases resembled
meningitis cervicalis hypertrophica. In this case the neck and inferior
maxilla were protruded and certainly gave the impression of that condi-
tion. But from April until the time of his death he was entirely free
from pain when at rest The difficulties of diagnosis were considerable
when they first saw the case. There was no suggestion that the con-
dition in the neck was a growth involving the spine. There was nothing
City Hospital Alumni. 37
in the arms or hands to indicate that. Yet had the finger been placed
in the pharynx it might have been possible to discover a soft spot
there, for the bodies of the cervical vertebroe were practically all
gone.
A Delicate Test for Albumin in Urine.
Demonstration with Two Specimens.
By AMAND N. RAVOLD, M.D.,
ST. LOUIS, MO.
| wish to present two specimens of urine which have come
to me during the last week and which proved so interest-
ing that I believe they will interest the members of the
Society. I also wish to call the attention of the Society to a
reliable and delicate test for detecting minute quantities of al-
bumin in urine. -
Some years ago Spiegler published a report of his exper-
iments with a solution composed of corrosive sublimate, tar-
taric acid, glycerin and water, for the detection of small quan-
tities of serum-albumin. Later this solution was modified and
very much improved by Jolles, who replaced the tartaric acid
with succinic acid and the glycerin with sodium chlorid. This
very delicate and reliable test seems to be very little known.
It is made up as follows:
Corrosive sublimate. . . . . . . . . . . . . . . . . . . . . . grams IO
Succinic acid. . . . . . . . . . . . . . . . . . . . . . . . . . . . { { 2O
Sodium chlorid. . . . . . . . . . . . . . . . . . . . . . . . . . { { 2O
Water. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . “ 5oo
Dissolve with heat and filter.
The specific gravity of the fluid is IO50. The test is made
by first adding acetic acid to the urine (I co. to 5 cc. of urine),
filtering and then by aid of a pipette floating the urine upon
the reagent in an inclined test tube. If even a minute trace
of serum albumin is present a white ring immediately appears
at the point of contact of the two fluids and it will not disap-
38 The Medical Society of
pear when heated. The reagent, it is claimed, will detect
O.OO2 gram of albumin to the liter. Nitric acid, by the layer
method, will show o.o.2 gram of album in to the liter. It is
thus seen that this reagent is ten times as delicate as nitric
acid. -
Recently, Dr. R. M. King and I while working with an
urine of high specific gravity, which contained a trace of albu-
min, found great difficulty in floating the urine on the reagent.
No matter how dexterous we were we could not prevent the
two fluids mixing intimately. This prompted me to begin a
series of experiments with various neutral substances added to
the Spiegler Jolles reagent, for the purpose of increasing its
specific gravity without interfering with the delicacy of the re-
action. I finally adopted magnesium sulphate. The resulting
solution is of a specific gravity of II 50, and has all the deli-
cacy and reliability of the old solution.
It is prepared as follows:
Corrosive sublimate. . . . . . . . . . . . . . . . . . . . . . . grams 2
Succinic acid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . & 6 4
Sodium chlorid. . . . . . . . . . . . . . . . . . . . . . . . . . . £ 6 4.
Water. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CC 5o
Heat and filter.
This is added to 50 cc. of a filtered saturated solution of
magnesium sulphate. The test is made in the same way as
with the Spiegler-Jolles reagent.
The first specimen of urine which I wish to demostrate is
from a case of arteriosclerosis, sent to me by Dr. A. S. Barnes,
Jr. Quantity of urine in twenty-four hours, 26 ounces; spe-
cific gravity, IO37; acid; color, reddish-brown. I will now
test this urine with heat and acetic acid, nitric acid by the
layer method, and potassium ferrocyanic by the drop method,
and as is seen not the slightest trace of albumin is to be de-
tected by any of these methods, but when I float the urine by
aid of the pipette upon the Spiegler-Jolles reagent, or my
modification of it, a white ring of albumin immediately ap-
pears at the point of contact of the two fluids. That this is
serum albumin is demonstrated by negative results in further
tests for globulin, mucin and the albumoses. x
City Hospital Alumni. 39
The question as to whether this is a pathologic albumin
or not is affirmed by the history of the case, and the fact that
the centrifugalized sediment microscopically examined shows
large numbers of small and large hyaline casts, quite a num-
ber of finely granular casts, and a few epithelia of probable
renal origin.
The second specimen is from an applicant for a large
amount of life insurance. He was examined by two physic-
ians. The first physician found a trace of albumin in his urine
to the heat and nitric acid tests. The second physician, in a
specimen passed the next day, found no album in to the stand-
ard tests. A third specimen examined by both physicians to-
gether showed no album in to heat, nitric acid or potassium fer-
rocyanid. This specimen, when brought to my laboratory,
and floated on my modified Jolles' solution showed a distinct
ring of albumin. -
Each of the standard tests, as I now make them before
you, show not a trace of albumin in this urine, but when I float
it on the Spiegler-Jolles, or the Jolles-Ravold solution, as my
reagent is labeled, you notice that a white ring of albumin im-
mediately appears where the urine comes in contact with the
reagent.
I know nothing of the history of the man who passed this
urine except that the physicians state that he is of medium
size, robust-looking, of florid complexion and that he has
drunk freely of alcoholic beverages for a number of years, nor
do I know anything about the quaniity of urine passed in 24
hours, etc. Microscopic examination of the centrifuged sedi-
ment of this urine, however, shows quite a number of hyaline
casts and a few epithelial cells renal in character.
The serum albumin here is very probably pathologic
and not physiologic, and this fact coupled with the micro-
scopic findings and the meager history will permit us to say,
that very probably this man has a kidney disease. A chronic
interstitial nephritis in its primary stage.
It is in just such cases as this that so much can be done
for the future welfare of a patient if a diagnosis can be made
early enough, and it is here that a reliable and delicate test, as
shown, proves its value.
40 The Medical Society of
I am aware that there is such a thing as physiologic albu-
minuria, and that some observers claim fully as high as 30 per
cent of healthy men show traces of albumin in their urine, but
it is, nevertheless, difficult to believe that serum albumin will
leak through healthy renal epithelium. With this test, so far,
I have not found serum albumin in the urine of healthy indi-
viduals. I can highly recommend the test as delicate, reliable,
cheap, easily prepared and very simple of application.
DISCUSSION.
Dr. Louis BEHRENs said that those who did insurance work also,
would certainly heartily appreciate having this test brought to their at-
tention. He thought that either Dr. Ravold had used a very poor
nitric acid or he had shown them a very delicate test. It was very
simple and should really be of use. The fact was that one often got
a very dilute nitric acid and as a result did not get the reaction.
Dr. M. A. BLISS said that some time ago he had taken part in a
discussion as to the absence of albumin in the presence of casts. It
was the rule in their office to make a microscopic examination of the
sediment in every specimen examined. Dr. Harry Johnson claimed
that he had never found a specimen of urine in which he found
casts that he did not find albumin, and so the first time Dr. Bliss dis-
covered such a specimen he had taken it to Dr. Johnson in triumph.
But Dr. Johnson, after adding the acid, took the test tube out in the
yard and holding it up against the light demonstrated the albumin very
clearly. Wherever Dr. Bliss had found casts, Dr. Johnson had always
been able to show the albumin, which proved that some of the old
tests, where carefully enough applied, would show the albumin if pres-
ent. Many test tubes would not bear inspection They must be
bright and clean and brilliant. The test of Dr. Ravold showed a very
slight trace of albumin in a very striking manner -
Dr RAvold, in closing said that the concentrated nitric acid he
had used was bought ſrom Henry Heil and it was first class. As for
the heat and acetic acid test mentioned by Dr. Bliss, he had tested
both specimens in his office with it and studied in the sunlight aided
by a dark background. That he had not only looked through the
urine in a test tube horizontally but also vertically. No trace of albu-
min could be made out. He knew it to be much more delicate than
the heat test and wish to recommend it highly. s
City Hospital Alumni. 41
Meeting of March 2, 1905; Dr. John Green, Jr.,
President, in the Chair.
The General Subject for the evening was:
The System of Control and Administration of Municipal
Hospitals in St. Louis.
CHARLES NAGEL, Esq., spoke on the question:
WHAT ARE THE INTERESTs AND JUST DEMANDs of TAx PAYERs 2
I am one of those citizens who believe we have just about what
we are entitled to. If our institutions are not in better condition
than they are, it is our own fault. The people mean right; but for our
neglect to bring conditions fairly and squarely before them, condi-
tions would be better than they are. As to the interest of the tax
payer, it might be well to have the revenue distributed on a dif-
ferent basis than it is. A larger proportion should go to our munici-
pal institutions, and a smaller proportion should go into strictly ma-
terial improvements. I have taken that position for years. The over-
whelming influence of the World's Fair served to block that idea.
When we had once assumed that responsibility we had to consider
material interests on all sides, and we were compelled to postpone the
interests we are here to discuss tonight. But I believe our day has
come, and that we have the right to say that the reputation of a great
city with nearly a million inhabitants rests, in part, at least, upon the
condition of the institutions in which the poor and the decrepit find
their protection. We have a further interest in knowing how the rev-
enue, that is, the proportion of revenue set apart for these institutions,
is expended. We are interested in the system and the method by
which this money is expended; there are a number of questions that
come up in this connection. The first one is, what is the province of
a hospital? The tax payer might say that he waits upon you for sug-
gestions. And in general it might be suggested to the tax payer that
the hospital should serve several purposes; it should take the best
possible care of its inmates, it should give an opportunity to science,
and the opportunities afforded physicians and superintendents should
42 The Medical Society of
be such as to attract the best possible talent to these institutions.
How it is to be done you ought to know. You have the experience of
other cities to guide you. But you should find some common ground
where the interests of the sick poor, the interests of science, and the
interests of the best talent in the profession may be harmonized. I
say to you, if your medical schools can not unite to further the cause
of medicine, the cause of the destitute and decrepit, there is something
wrong. Beyond that, we may consider the system, as it is regulated
by our law, an antiquated system in which, as I understand it, intelli-
gent work is practically impossible. We have a system under which
the Mayor appoints a Health Commissioner with general authority over
all the institutions The Mayor also appoints superintendents of these
institutions; and after the superintendents have been installed, the
Commissioner tells them what force they are to work with, and he ab
solutely controls this force. The superintendent is thus deprived of
the power to meet the responsibility he has assumed. The question
of which I am now speaking is purely a political one; and the diffi-
culty is that the whole system of our hospitals and municipal institu
tions, suffers from the fact that the political office seeker has trespassed
upon the sanctity of that domain. I have never recovered from the
charge that I at one time nominated Dr. Homan as Health Commis-
sioner. There was a suspicion that Dr. Homan did not belong to my
party, but I have never had reason to regret my act.
It has been demonstrated in this city that all we have to do is to
show the will to succeed. Take the school board, for an example.
The wretchedness of that board was the cause of a reaction. We
adopted a new law; but that law alone would not prevent the board
from doing just as much damage as before. Public opinion was made
so plain and manifest that the board is glad to obey the public will. The
politician is ready and glad to obey the public will, but he is entitled
to know what that will is. If we want to relieve the poor, the desti-
tute and the helpless, if we want to aid science, all we have to do is
to make it an issue in a political campaign. Nothing is easier than to
get the great public mind interested in this cause. That is my obser-
vation and my experience. You can have the people appreciate that
these are the institutions in which they are interested. I have said to
City Hospital Alumni. 43
the people many times, that they have no money issue, no large prop-
erty interests, but they do have the daily questions of wrong and right,
and they are interested in having the most competent judges that can
be found. Such discussions led to the adoption of some of the courts
which we now have, and just in the same way, if you will send your
speakers out, you will make the people realize that the se institutions
are theirs, that you are their champions and you can carry the issue.
I do not believe that it is as difficult as you may think. It is impor-
tant to have it driven home with the great public that these are their
institutions. Give them real pictures of the Poor House, tell them
what the City Hospital is as a building, and couple with it what praise
you will for the management that has succeeded in making a reputable
place out of a building that should have been long ago condemned
by the authorities. Twenty million people could pass under the walls
of our hospital during the World’s Fair, and fortunately for us, not one
could suspect that it was a hospital. We should not only have one
institution that can be shown, we should have no institution that can
not be shown. Strong as we are, not having suffered financially even
from the strain of the World's Fair we should now be in position to
say that we will give second place to merely material questions. If
the politician must be satisfied on the material side, let him be satisfied
there. When it comes to these institutions, where science should be
at home, let us call a halt; let us say that we will have no one em-
ployed there without a fair examination ; no one who does not come
to pay tribute, to the best of his ability, to the cause of those who
have been cast upon the charity of the community.
Rabbi SAMUEL SALE discussed :
WHAT ARE THE INTERESTS AND RIGHTFUL CLAIMS OF PATIENTS 2
The question of caring for the sick poor is one that must arouse
the warmest sympathy of every man who has a heart in him. From
year to year we have been told that we have had in this city a hospital
that was not only not a credit to us, but that, with the exception of the
good men, both superintendent and internes, was actually a shame and
disgrace to the city. I happen to have visited the City Hospital, and
I was not impressed by any means by what I saw there. I felt that
44 The Medical Society of
the City Hospital was really in keeping with our general municipal
housekeeping.
About two years ago I was unforunately forced to take my wife
into the City Hospital at Frankfort on the Main. At first I objected
to having my wife go into the City Hospital. I asked the Professor in
charge if he had not a private hospital. He asked for my objections
and I said: “Is the treatment as good as it is in a private hospital?”
He replied: “Do you suppose I would be connected with this institu-
tion if it were not as good as any in this country?” He added:
“You come from America. Probably your ideas are different from
ours.” Later I went through the hospital and found it a model. It
was an institution perfect in its equipment in every way. The Physi-
cian-in-Chief was put there, not for any political reasons, but because
he was the biggest man in his city, and because the interests of the
people would be best subserved through him. His staff was composed
of men who had achieved reputations in their several lines of research
and practice, and I was assured that the poorest of the poor got as
good care and attention as the richest could possibly have had in the
best hospitals in Germany.
I take it that it is the object of this movement to bring about such
a condition of affairs in our city, that the poorest man can get as good
care in our city institutions as the richest can get in any private hos
pital. It should be the pride of our city to bring about such a condi-
tion of affairs, so that instead of being ashamed of them, we would be
glad to point out these institutions as a proof of the excellence of our
municipal housekeeping.
I was asked to speak of the interests and rightful claims of patients.
The interests and claims of the poor are identical with the claims of
the rich, and they must always be identical for us. Our interests can
never be separated from those of every other class in the community.
When we believe that we can treat even our criminal class in such a
manner as to deny them every vestige of humanity — when the State
thus permits its criminal classes to be treated as they are treated in
Jefferson City, then the State commits a crime against all classes of
humanity. When the sick or the poor receive treatment that is scant
in any way, then the city is inflicting a wrong on every other class in
City Hospital Alumni. “, 45
in society. A wrong that affects the poor or the cause of science cer-
tainly will wreak its own vengeance. When a scourge of typhoid or
diphtheria is making its rounds of the city, homes of the rich are as
much open to the disease as the homes of the poor I had my atten-
tion called to this in Baltimore very forcibly. A resident of that city,
a man worth millions, had one child. His home was surrounded by a
high stone wall which he had erected, because in his grounds there was
some statuary that the authorities objected to, and which he was un-
willing to remove. This man’s only child, shut off as it was from the
whole city, was carried off in one of these scourges. It brought home
to me the truth that we are all affected by what affects one of us. If
we permit the water at the fountain head to become murky and turbid,
it will certainly affect every household in the city. This is a question
that affects in the last remove our larger humanity. The old Romans
and the old Greeks did not build hospitals. The best of representa-
tives among them believed that the weak and the decrepit should be
exposed to die. They bore the mark of the ill will of the gods and
were not a credit to the State, and therefore, it was to the interest of
the State to rid itself of them. Such sentiments and principles
never built orphan asylums and hospitals. It is the principle that we
should love our fellow man as ourself that has gradually been finding
its realization among us. If we are really in earnest in believing that
every one has an equal part in the community, rich and poor, high and
low, then it must be our most serious endeavor to make of our City
Hospital an institution in which our brother, though he be the poorest,
can find such care and consideration and treatment, when he is stricken
with sickness, as the richest of us can find in the best private institu-
tions. What private individuals can do, the whole city, if it be in
earnest, can certainly do. The reward will come, not only in the bet-
ter treatment of the poor, but in many ways of which we are consci-
ous. Those coming from our city institutions will have received the
best care we can give them and they will return to the civic body, feel-
ing that they were really in a hospice, they were friends and guests of
the city, that they were brothers among brothers. When these people
come back to the civic body with such a feeling, you may be sure that
we are guarding our best interests. When we scant them, when we
46 The Medical Society of
give them little or nothing, when we treat them, as they have perforce
been treated in our city institutions, you can well understand the feel-
ing that possesses them when they go back among their fellows. In
their attempt to make our hospitals a credit to the city, our physicians
are actuated by that deep seated love for their kind which alone makes
the true physician, a man of God, and a lover of mankind. When
they have succeeded, we shall see institutions that equal those of
Europe, and in which the poor will find that their patrimony, the love
of God and man, has given back to them again.
What are the Interests, Duties, Rights and
Privileges of the Medical Profession ?
By FRANK J. LUTZ, M.D.,
ST. LOUIS, MO.
N common with all citizens who are concerned in every-
| thing which makes for the uplifting of our city, the med-
ical profession is interested in the control and adminis-
tration of the municipal eleemosynary institutions. The
especial interest of medical men is founded upon the obliga-
tion which we assume impliedly and ostentatiously by the
peculiar relationship which we hold to those who are thrown
upon the public when in need, sick or infirm with age. The
poor, the sick, the afflicted and the aged have always had and
now have the solicitous care of medical men.
The history of medicine furnishes numerous examples
when medical men alone have been the champions of these
unfortunates. And medical men may point with pardonable
pride to the faithful discharge of the duties which they have
assumed or which may have been assigned to them in the care
of public wards. As in other things, so in the assumption of
and the performance of duty rights are conferred and in the
instances of medical men, special rights flow not only from
the discharge of duty as medical men but rights which we
should demand as citizens and as contributors to the public
treasury. ſ
City Hospital Alumni. 47
The lack of self assertion and the habit of modesty, be-
gotten by constant contact with humanity in its softer moods,
has permitted the impression to go out that if medical men
had any rights to be consulted as medical men even in things
in which they are especially interested, and concerning which
their judgment ought to be first considered, because it is based
upon extensive experience, they have “slept upon their rights,”
as our friends, the legal men, would say.
Our unwillingness to push our own claims for recognition
has given rise to the opinion that medical men are incompe-
tent to assert their rights, or if opportunity were given them,
they would be incompetent to take upon themselves the con-
trol of affairs which from their very nature come especially
within the province of medicine.
On an occasion such as this when the management and
control of municipal hospitals is under consideration, it would
be highly improper to call attention to the privileges which
medical men enjoy on account of their close personal relation-
ship to their patients, and yet we can turn to good account
this intimate association which we hold to those who, with
implicit confidence, entrust to us their comfort, their health
and their lives. Who can come closer to the man in authority
than he in whom is reposed every confidence of this same
man in all his physical relations to life. Or who is in duty
bound more than the medical man to take advantage of the
privileges he enjoys for the purpose of furthering the public
good.
If we are to discharge the duties of medical men to their
fullest extent we must not confine our work, as is too often
done, to individuals. We should resent on all occasions the
charge that our field of usefulness is limited to the individual
and to the family. We should set a firm face against those in
our own ranks who superciliously talk of medical politicians,
for such have a limited conception of their own duties and
privileges and they lack the courage of their own convictions.
The time is past when it is considered sub dignitate for
a medical man to interest himself in the general affairs of life,
and the public is beginning to understand why we should take
the initiative in things in which after all we must be the final
48 The Medical Society of
arbiters, and an enlightened public opinion demands that we
give some of our time and some of our knowledge and the
results of our experience to public matters, not only those be-
longing to medicine but to all public affairs. The public is be-
ginning to realize, perhaps as much as the medical profession,
that the medical faculty is no unimportant factor in the intel-
lectual life of the commonwealth.
It is, therefore, clearly our duty to present our views con-
cerning the proper management of municipal hospitals not
only to those enjoying a little brief authority but also to the
general public. The community should be made to under-
stand through us that the present system of control and of ad-
ministration of public hospitals is not for the best interests of
the patients; that it does not subserve the best interests of
municipality and that one of the objects incidental to public
charity, namely, the advancement of science and the educa-
tion of physicians, is not only not assisted by the methods
now in vogue but is absolutely retarded by them.
From a selfish view point alone it would be to the city's
advantage to place the control of her eleemosynary institu-
tions into the hands of competent physicians; for the results
obtained by this course as judged by the experience of other
cities would be an enormous improvement upon what is now
accomplished, and such an impetus would be given to medical
education as to attract to our city those youths who are cast-
ing about for places where they can obtain the best advant-
ages. The oft-repeated phrase that St. Louis must be made
a medical center can be practically carried out to the advant-
age of the city of St. Louis by a contribution on the part of
the municipality which it now pretends to make but which in
reality is farcical. º
Nor should we be content to act simply in an advisory
capacity. In the past counsel has been offered and most often
respectfully heard. But we must make the confession that no
well-matured plans representing the concerted action of med-
ical men have been brought to the attention of either our mu-
nicipal legislators or the proper executive officers nor to the
general public.
If we expect to exert the influence which we can wield,
City Hospital Alumni. 49
we must present definite, well-rounded and comprehensive
schemes and urge their adoption, through the public, upon
those charged with the performance of public duty.
We are on the eve of selecting our servants, or masters,
if we prefer to have them to act as such. Can we be induced
to systematically determine before election who will be in fa-
vor of a plan intended to remedy existing evils and to cure
defects in our methods of administering our charitable institu-
tions P Are we ready to co operate in order that the funda-
mental law governing the department of health can be so
framed as to include the plan suggested by the medical pro-
fession when the inevitable revision of the charter will be pro-
posed. Why should not medical men be directly represented
upon any commission or body to whom may be assigned the
work of preparing a new charter for a new St. Louis.
When we shall have performed our full duty then only
can we expect those, who may be charged with either initi-
ating or executing our suggestions to assume the full responsi-
bility which failure to give us proper heed would imply.
Let the medical men come together, agree upon what is
needed, then make our wants known through the proper chan-
nels and I prophesy that not only will the municipal institu-
tions be administered in such a way as to place our city
abreast of others but far in advance of them.
{}r. W. E. FischEL spoke on :
WHAT ARE THE PROPER ExPECTATIONS AND PRIVILEGES OF PHYSI-
CIANS IN THESE INSTITUTIONS AS AFFORDING FIELDS OF
INSTRUCTION TO STUDENTS 2
After listening to Mr. Nagel and Dr. Sale and getting from them
the encouraging words that any reforms which the physicians of this
city might desire would be met with not only encouragement but with
the enthusiastic approval of the people of this city, I feel that there is
a chance for that part of the profession of the city who are interested
in ministering in part to the dependent poor in our eleemosynary insti-
tutions and who, in doing so, are at the same time placed in a position
50 The Medical Society of
which will force upon them to give the best possible advantages to
aspiring medical medical men. I feel that we have a chance to accom-
plish something for the medical men and especially for the community
of St. Louis. Some years ago this same question came before our
municipal assembly. At that time I was requested to present my
views before a committee of that assembly, hoping that we might pre-
vail upon them to make such changes as would further the interest of
medical education. I did what I could. I tried very hard to be im-
personal and yet much to my unhappiness I found that I had incurred
the ill will of the gentlemel, at the head of the eleemosynary institu-
tions. Nothing can be further from my mind than to criticise the men
who are at the head of our city institutions, and I know from my per.
sonal connection with one of these men that much is being done to
elevate the character of that institution and that it is the aim of the
superintendent in charge to do everything in his power to have these
things changed, but one man can not do Imuch. No matter how great
his skill or how diversified his ability, one man simply can not do
justice to three or four hundred suffering people. It is beyond him.
The labor should be divided. We should have two men at the head
of such an institution. We should have an Executive Superintendent
and we should have in the true sense of the word a Hospital Superin-
tendent. But we should have also a body of men, chosen in a way
that would have to be determined, by whatever method the profession
may deem most fit, who will more than divide the labors of the man
who is Superintendent of the Hospital.
Most hospitals are looked upon primarily as surgical hospitals.
Our city hospitals are looked upon as surgical hospitals. As far back
as I can remember the gentlemen in charge of our city hospitals have
been primarily surgeons and they have lost track absolutely of the tre-
mendous importance of clinical medicine to surgery. They have not
thought it worth while to devote any part of their energy (and I speak
feelingly and knowingly) or to devote any part of their time to scientific
medical investigations. It is human nature, it is perfectly natural, but
it is the system that is wrong and such condition of affairs could not
be possible if the entire system of our eleemosynary institutions were
different. Every specialty should be well represented. Every individ-
City Hospital Alumni. ' 51
ual put on the staff should be given an opportunity to do original
work. Every member of the staff should have at his command that
which will give him opportunity to do original work We should have
a pathologist, not a city pathologist and a city bacteriologist (and I
would say that we have a most capable man in that position) The
city bacteriologist has his hands full without this work. He already
has a hundred things to do. We should give a man an opportunity to
make a record by his work. We should have a laboratory and we
should have a set of young men in these institutions anxious to learn,
and I will say with all modesty that the set of men we have there now
is just as good as we may hope for, but the opportunity is not good.
The reason is, we have no system. I enjoy the privilege of going to
the City Hospital once a week, and I must say for Dr. Brown that he
always gives me the privilege of choosing the cases that I want, but
by absolutely no fault of the Superintendent of the Hospital it is im-
possible to have these cases worked up before I get there. The facts
that exist in these cases escape the young men, yet there is no one
there upon whom they can fall back simply because the Superintend-
ent has not the time, it is simply a physical impossibility.
I believe, therefore, that every effort of which the medical pro-
fession is capable should be put into force to prevail upon this com-
munity to have laws enacted which will place our eleemosynary institu-
tions on a par with other institutions. In 1885 the City Hospital of
Boston was managed about as the St. Louis City Hospital is today.
The people rose up against that, and what has been accomplished ?
In five years every building of the old City Hospital was torn down
and new ones erected, the entire administration was changed, the
function of the Health Commissioner was done away with and six men
were elected, called a Board of Overseers. $1,300,ooo was raised and
put into the hands of this Board of Overseers, a laboratory was estab-
lished, a pathologist employed and the Board of Overseers appointed
a consulting staff all of whom were teachers in the leading medical
colleges of Boston. They work in perfect accord not only with the
profession but with the municipality of Boston. Within the past ten
years they have added buildings estimated at millions and the
money value has gone always hand in hand with the scientific value.
That is what we should aspire to and it is entirely possible of accom
plishment.
52 The Medical Society of
What Experience Has Shown.
By GEORGE HOMAN, M.D.,
ST. LOUIS, MO.
T may not be known to all of those now engaged in advo-
| cating a change of system in the control and administra-
tion of public hospitals in St. Louis that the form of
management they propose—long tried and approved as it has
been elsewhere—in no novelty here either, the City Hospital
having been operated at one time in accordance therewith for
a full year until a change in the municipal government and the
exigencies of. partizanship caused a reversion to what should
be obsolete practice in hospital conduct.
That such was the fact, however, is within the personal
knowledge of the writer whose hospital experience here
included a trial of both plans, and who, therefore, may pre-
sume to speak with some knowledge and confidence in regard
thereto.
The change in system was brought about by a board of
health of whose membership Dr. E. H. Gregory is the sole
survivor, an official consciousness obtaining even then that the
method in vogue was inadequate and fell far short of what was
rightfully demanded for the good of the public, the patient,
and the medical profession—the three conjoined, participating,
inalienable interests in this form of organized benevolence.
Of the staff of resident internes who served during the
year in question, are Dr. W. A. McCandless, of this City; Dr.
Walter Wyman, of Washington, in charge of the Public
Health and Marine Hospital Service; Dr. T. E. Holland, of
Hot Springs, Ark.; Dr. B. N. Torrey, of Creston, Iowa, and
others in more distant parts of the country; while on the vis-
iting staff of specialists quite a number still remain in active
professional work in this City.
The change was not effected without opposition and fore-
bodings of evil, but nevertheless it was accomplished through
the reasoning and insistence of the medical members of the
Board, Drs. Gregory and A. P. Lankford, the latter being most
active in the work, and the new system, adapted as closely as
City Hospital Alumni. 53
was possible to existing conditions but without express author-
ity of law, went into smooth and successful operation. In
regard thereto, I quote from the report of T. F. Prewitt, Resi-
dent Physician of the City Hospital for the year ending April
30, 1874. (“Seventh Annual Report Board of Health,” page
8.I). His resignation having been accepted, he says:
*
“The various departments have been so thorough-
ly systematized, that the new régime, which it is
proposed to inaugurate, will find, I hope, but little to
amend, or to clog its successful operation.”
The outcome justified the forecast—a new spirit took pos-
session of the internes for the fact of being charged directly
with professional responsibility in the care of the divisions as-
signed to each of them, under the watchful daily observation
of the visiting staff of experts, served to arouse a spirit of
emulation and develop all their zeal and resources with the
result that the patients were advantaged, the public better
served, and the proper expectations and requirements of the
medical profession were reasonably well met and satisfied ;
and altogether it was deemed by those in a position to judge
the most successful year the institution had known.
An objection urged by some against the proposed change
was that the visiting staff would not regularly and faithfully
fulfill their daily appointments. How idle this was I believe
all will testify, but let me speak only from my own expe-
rience: At the outset I was in charge of a division in
the surgical service of the late Dr. John T. Hodgen, then in
the full tide of his honored career, whom no stress of circum-
stance, or tax on energy could avail to cause him to miss his
hospital call, if in the City. Often this visit would be made
at 5 or 6 o'clock in the morning, and repeated later if there
was need, his devotion to this duty being most marked, but not
singular or confined to him.
The editor of a local daily paper, who is now among the
first of his profession in the East, in a tribute paid to the char-
acter of this man at the time of his death a few years later,
among other things, said: “He was our first citizen. In
54 The Medical Society of
mind and heart and soul—in science, intellect, and work—in
the vastness, self-sacrifice and importance of his labors for
mankind there was none to stand before him.”
Those who knew best the lamented subject of this eulogy
can say how fitly spoken were these words, and it may be re-
marked that if such a man could make the dependents on the
bounty of a public hospital the objects of his first daily care,
no lapse from such an example is likely to befall, for out of
the multitude of demands made on physicians for free service
it is rare indeed that a charge of neglect can be truly laid
against them—to so respond being accounted no merit, but
not to do so spelling professional dishonor.
Legal complications arose before the end of this munici-
pal year that required a show of return to former conditions,
but in semblance only. The work went on, being regarded
by those most concerned as the natural, fitting, legitimate or—
der of things, and as bearing on this point I quote from the
report of George Homan, Acting Resident Physician City
Hospital for the year ending April 30, 1875. (“Eighth An-
nual Report Board of Health,” page 56):
“The internal management of the Hospital has
been free from any unpleasantness since the inaugu-
ration of the new plan of conducting it, the relations
of the physicians, as well as other officers, having
been most harmonious and without conflict of au-
thority.” º
So much then for what the test of experience locally ap-
plied has shown to be the right system, even though such
teachings were discredited by relapse into outworn methods
strangely persisting to this day, and calculated to draw the
wondering comment of progressive people to a survival of an-
tique administrative fashion scarcely believable in the case of
a city that so lately besought the world to be her guest and
view here the marvels of a rising civilization—a redeeming
feature of which is the swift adaptation of better methods to
the cure and comfort of ill or injured humanity.
Therefore, having in mind the lesson of this experience
City Hospital Alumni. 55
considered in connection with the almost universal consensus
of professional and business opinion on this subject in this
country and abroad, and while most earnestly disavowing any
wish to cast a doubt on the high professional character and
executive capacity of the Superintendents of the institutions
in question, I believe the judgment of an unprejudiced ob-
server must infallibly be that the present system, good as it
was in proper time and place, has outlived its usefulness, and
must be replaced by what has been tried and proved to be
better; and, accordingly the public-spirited, progressive mem-
bership of this Society should borrow something of the stern
spirit of the elder Cato of whom history speaks as proclaim-
ing at the close of every speech, on any subject, “As for the
rest, Carthage must be destroyed; ” so, too, we, in season and
out of season, should unflinchingly voice our firm conviction
that, nevertheless and notwithstanding, the system must be
changed.
{ºmºsºmsºmºmº
WHEREAS: The present system of administration of public hos
pitals in St. Louis having been duly considered by the Medical Society
of City Hospital Alumni, and it being the sense of this Society that the
said system is discredited and practically obsolete elsewhere, and ap-
pearing totally inadequate to present-day needs and requirements for
the following reasons, to-wit :
FIRST, that the tax-paying public does not now get full value in
return for moneys expended thereon :
SECOND, that the patients can not receive the full professional
care and benefit to which they are reasonably and humanely entitled:
THIRD, that the medical profession is hindered in its undeniable
right and duty to bestow on these patients all the advantages afforded
by the best special skill in treatment ; and, moreover, is practically
excluded from these institutions as fields for medical teaching; there-
fore,
A'esolved, That the Medical Society of City Hospital Alumni
earnestly address itself to the work of effecting a change in the system
of public hospital control and administration in St. Louis, and to this
end would invite the co-operation of other medical bodies and public
spirited citizens generally in the framing of measures and influencing
their enactment into laws such as will serve to bring these institutions
56 The Medical Society of
*
fully abreast of the times in all scientific relations and humanitarian
requirements; and further
A'esolved. That in pursuing this course of action this Society,
would expressly disclaim any purpose to reflect in any manner on
the efficiency or integrity of the heads of these several institutions,
recognizing that the existing defects are inherent in the system itself
and due to no fault of the administrative personnel.
Dr. JoHN YOUNG BROWN, Superintendent, spoke on :
THE CITY HospitaL AS Now ORGANIZED AND MANAGED.
I do not think it would be in keeping with the spirit of this meet-
ing to go into a detailed discussion of the management of the City
Hospital. As I am in perfect harmony with the purpose of this meet-
ing I believe it would be well to limit my remarks to a brief review of
the laws governing the institution. No one can doubt that the laws
governing our health department are fearfully and wonderfully made.
The Superintendent of the Hospital has no authority to employ or to
discharge anyone under him. He has not even the power to name the
assistants working with him at the operating table. The Health Com-
missioner has the authority to discharge, without cause at any time any
one; from the Superintendent down to the stretcher carriers. That it
is an injustice not only to the Superintendent but to the profession at
arge I am willing to admit. I am in hearty accord with a good deal
that Dr. Lutz has said. The greatest objection to the system is the
political objection. The city and female hospitals and the poor house
should be removed absolutely from politics and the question comes up
how this is to be done. I do not believe that it would better matters
in any way to take the power out of the hands of the Health Commis-
sioner and vest in the Mayor. Granted that when we have an excel
lent mayor it works satisfactorily, yet the time will come when we will
have a mayor who will appoint as the heads of these institutions men
who are incompetent. The same is true if we give the authority to
the health commissioner. As Mr Nagel has said, we can point with
pride to our school system and it seems to me that if the medical pro.
fession of this great City of St. Louis would get together on the matter
City Hospital Alumni. 57
of changing the charter or the making of a new charter so that there
could be elected a board after the order of the school board and that on
that board there should be representatives of the profession, that our
system of control of the eleemosynary institutions of St. Louis might
be as good as our school system. On that board there might be three
high class laymen and the medical societies could come together and
name three of the medical profession to go on that board, the mayor
to act as ex-offiicio chairman of the board. That such a change is
feasible I do not think there is any question if the profession will take
it up. It is a matter that should be discussed at length The per-
sonal equation should be eliminated in the discussion. This matter
should not be taken up lightly. A number of propositions will have
to be considered, not only as to the appointing power but there are
issues such as the school issue to be taken up requiring careful, pains-
taking discussion. I feel that I can speak for the other members who
are the heads of public institutions in this city and I want you to feel
that you have our hearty co operation but we do feel that this thing
should be carefully gone over. I realize fully the handicaps under
which I have worked and the profession will bear me out that I have
worked to the utmost of my ability to conduct the City Hospital along
lines thoroughly clinical and to keep all scientific matters out of the
public press. I have taught my internes not to comment on conditions
and in every way possible myself and my assistants, Dr Doyle and
Dr. Kirchner have done everything we could to better conditions. How
far we have succeeded it is for the profession to judge, but at all times
we have been handicapped not only by the building in which we are
located but by the laws under which we have to work.
Outline History of Hospital Commission
(1895––1899).
- By ALBERT MERRELL, M.D.,
ST. LOUIS.
N the early summer of 1895 certain members of the City
Council convinced that the then existing conditions in
our eleemosynary institutions were not up to needed re-
5S The Medical Society of
quirements for carrying on the work, and that more spacious
and better equipped quarters were badly needed in the inter-
est of inmates and for the credit of the City which had un-
dertaken their care. Prior to this, the method of control and
management had been under discussion by several well-known
physicians with a view to finding a way to improve the same.
It was considered advisable to remove the medical, surgical
and nursing service as far as possible from partisan political
control, believing that thereby, the needs of the patients, the
uses of the medical profession and the obligations of the mu-
nicipality would be best subserved.
Prof. Halsey C. Ives, who had a short time before become
a member of the City Council, introduced a bill in the Coun-
cil providing for a Hospital Advisory Commission. On July
I2th, this bill passed the Council, and after some vicissitudes
arising from differences of opinion as to details, between that
body and the House of Delegates, became a law March 16,
I896, nine months after its introduction by Mr. Ives. With a
view of providing funds to make possible the early beginning
of work that might be recommended by the Commission and
approved by the Assembly, Mr. Charles Nagel prepared a bill
providing for a “Hospital Construction Fund,” which provided
for setting aside for the purpose I per cent of the annual mu-
nicipal revenues. This bill was also introduced into the Coun-
cil by Prof. Ives and became a law April 5, 1896, having been
approved by Mayor Walbridge on that date, about two
months after its introduction on February 4, 1896. This bill
is still in force and was known as Council Bill 186.
The ordinance creating the Hospital Commission is num-
bered 18374. It provided for a membership composed of the
Mayor, the Health Commissioner and two physicians appoint.
ed by the Mayor, a member of the Board of Charity Com-
missioners appointed by the Mayor, a member of the Council
and one from the House of Delegates to be appointed by
their respective presiding officers—seven members in all.
The great cyclone which destroyed the old City Hospital
occurred May 27, 1896, and on May 29th, Mr. Ives was ap-
pointed to the Commission as a member for the Council. On
August 27th, or two months later, Mayor Walbridge appointed
\
| City Hospital Alumni. 59
Mr. Singer of the Charity Commissioners, Dr. C. H. Hughes
and Dr. Albert Merrell; the Speaker of the House of Dele-
gates appointed Mr. Edward E. Mepham, thus, with Health
Commissioner, Dr. M. C. Starkloff, completing the member-.
ship of the Hospital Commission, five months from the ap-
proval of the ordinance creating it.
Early in the autum of 1896 the Commission was called
together for organization and elected Prof. H. C. Ives, Chair-
man; Dr. Merrell, Corresponding Secretary, and Mr. E. E.
Mepham, Recording Secretary. A sub Committee, consisting
of Prof. Ives, Drs. Starkloff and Merrell, was selected and as-
signed the duty of making preliminary studies for an Emer-
gency Hospital structure for acute medical and surgical cases,
and submitting to the Commission a scheme for the location
of future buildings to be erected, when authorized, as rapidly
as the fund accumulated under Council Bill 186, would admit.
This work of the sub-Committee was pushed to completion
as rapidly as the difficulties of the problem would permit. No
money was provided the Commission by the ordinance
creating it, whereby the needed expense of its work might be
met. The expense of the preliminary studies, sketch plans
and surveys of the old hospital site were met by the sum of
one hundred dollars from Mayor Walbridge's contingent fund,
which sum was paid the draftsman employed in making sketch
plans, and the expense for service of an expert engineer, $128,
was assumed by the Department of the President of the
Board of Public Improvements. These two items cover the
total expenditure of public funds for the work of the Commis-
sion. On January 29, 1897, the sub-Committee presented
their report and sketch plans to the Commission who, after
mature deliberation, unanimously adopted the same and di-
rected that they be formally transmitted to the Mayor with
the request that he have the needed ordinances formulated
and introduced into the Municipal Assembly with his recom-
mendation that they be passed. At the meeting, the same sub-
Committee was directed to take up and report on the remain-
ing duties of the Commission, to-wit: To formulate a scheme
for the administration of hospital affairs and make such other
recommendations as would improve the condition and man.
60 The Medical Society of
agement in City institutions having relationship to its hospi--
tals. The separation of the chronic insane and the other in-
mates of the Poor House was early decided to be essential to
a satisfactory arrangement for the care of insane patients.
With this idea a piece of property owned by the City and
which lies south of Robert avenue near the River des Peres
was carefully examined, with a view to its ultimate use as a
location for a new structure for the care of the poor, thus re-
lieving the present Poor House, which, with needed repairs
and changes, it was believed would serve the City's needs for
the care of the chronic insane and afford relief to the crowd-
ing at the Insane Asylum. After a careful study of the situa-
tion, Sketch plans were drawn in accordance with approved
ideas of alms house construction.
In March, 1897, the Commission was called together by
its Chairman who announced that as yet no legislation had
been begun looking to putting into force its recommendations.
Inquiry showed that the Commission's report had not been
transmitted to the Mayor as directed by vote two months be-
fore. The report was found later and transmitted to Mayor
Ziegenhein, who, by a construction put upon the ordinance
creating the Commission, succeeded Mr. Walbridge to mem-
bership thereon. Mayor Ziegenhein assured the Chairman of
the Commission that the report would receive his prompt
attention. r f
The sub-Committee proceeded with its remaining work
of formulating a scheme for hospital administration until the
Spring of 1899, when, it appeared that it was impossible to
unanimously agree on a report to be submitted to the Com-
mission as a whole. It was then determined to put the sug-
gestions of the different members of the sub-Committee into
the hands of the City Counselor, with the request that he
formulate an ordinance based thereon for hospital administra-
tion, to be submitted as a report from the sub-Committee to
the Commission. *
As the Mayor had taken no action on the Commission's
first report and recommendations placed in his hands two
years before, and as the Hospital construction fund, created as
before explained, had now grown to something over $2OO,OOO,
City Hospital Alumni. 61
it was thought best to submit to the Commission the form of
an ordinance, also drawn by the City Counselor, authorizing
the beginning of construction work on the Hospital for acute
and emergency cases on the old city hospital site It was es-
timated that the sum named, $2OO,OOO, was sufficient to begin
and complete the heating and ventilating plant and two pavil-
ions, according to the plans proposed by the Commission. As
each pavilion constituted in itself a complete working hospi-
tal and as the fund could be relied on for about $50,000 per
year, it was believed that beginning with two pavilions the
first year, the entire plant could be finished (each pavilion
used as soon as built) and all paid for by the present year. Of
course, this relates only to the care of acute medical and sur-
gical cases, as proposed by the plan of the Commission.
The two bills formulated by City Counselor Schnur-
macher, in co-operation with the sub Committee, were sub-
mitted to the Commission June 27th—all members being pres-
ent. The result of this meeting was, through various changes
and amendments insisted on by those interested, such a
change in the original as to make it almost unrecognizable to
those who formulated it. A report was adopted transmitting
the bills to the Mayor but without the unanimous recommend-
ation of the Commission. The Mayor sent both bills at once
to the Assembly and they received their first reading June
3Oth. The bills as reported were imperfect and contradictory
in form. The Hospital Construction Bill, aſter an ineffectual
attempt to amend it by the substitution of the Commission's
original scheme, was not reported to the Council for its action,
so far as the writer has ever heard The bill relating to Hos-
pital Administration met a similar fate after the form of a
public hearing, when it, was made clear that the Committee
had already reached the conclusion to report the bill adversly,
on representation made to them by those who felt that the
proposed changes would conflict with their official power and
personal professional preferment. The bill was killed by a
vote of the Council on recommendation of its committee. The
Hospital Commission after transmitting the last report and
the bills referred to, had completed the work it was created to
perform and expired by legal limitation with its meeting of
June 27, 1899.
62 The Medical Society of
A bill creating the office of City Bacteriologist and Path-
ologist to the City Hospital was also prepared and recom-
mended by the Commission. This bill failed with the others
presented. Subsequently, the same bill was introduced into
the Assembly and became a law during the present adminis-
tration. It has recently been amended by providing certain
needed assistants and under its able and industrious head is
doing much scientific and practical work of great importance
to the City's interests.
The foregoing is a mere outline of the history of the
Hospital Commission. It gives no adequate idea of the detail
work performed in the hope that the purpose of the Commis-
sion might be realized. It does indicate the vexatious delays
incident to such efforts and suggests the sources of opposi-
tion and of the final defeat of plans which the originators and
advocates of the Bill creating the Commission believed and
still believe would vastly improve our system of caring for
City's charges and its eleemosynary institutions.
The purpose of the Bill was to correct what were believed
to be deficiencies in the existing system, both as to buildings
and administration. It was an honest protest against the con-
tinuance of plans adopted fifty years ago for a city now
grown to over half a million in population.
It was met by opposition from officials who were unable
to subordinate their private and temporary personal interests
to the public good, not seeing or being willing to be shown
that a broad-minded respect for public interests always has
merited recognition and promotes, but does not hinder, pri-
vate reputation and reward.
Dr. MERRELL also read copy of Ordinance proposed by him, as
follows:
COUNCIL BILL, No. 39.
An Ordinance Providing for the Management of the City Hospitals by
Creating “A Visiting Hospital Staff,” A Board of Hospital Ad-
ministration, Defining the Powers and Prescribing the Duties of
the Members of said Staff and said Board; Providing for the Ap-
pointment of a “Resident Staff of Internes; ” and Defining the
Powers of the Superintendents of Hospitals.
City Hospital Alumni. 63
Be it Ordained by the Municipal Assembly of the City of St.
Louis, as follows:
Section 1.—There is hereby established and created a Visiting
Hospital Staff, to be composed and to consist of such a number of
members as may be determined from time by the Health Commis-
sioner, with the approval of the Board of Health. All members of
said Visiting Hospital Staff shall be appointed by the Health Commis.
sioner, subject to the approval of the Board of Health, and they shall
serve upon said staff for one year and until their successors shall have
been duly appointed and qualified, unless removed by the Health
Commissioner, with the approval of the majority of the members of
the Board of Health.
Section 2. — Members of said Visiting Hospital Staff shall be re-
putable practiciug physicians, and shall be selected from the various
schools of medicine having medical colleges in the City of St. Louis
in the ratio or proportion that the number of medical students of all
the colleges of each such school of medicine shall bear to the total
number of students attending at all of the medical colleges in the
city. Such ratio shall be fixed and determined annually by the Health
Commissioner, and the first appointments in the absence of a ratio
shall be made by the Health Commissioner as nearly as practicable in
accordance with the foregoing plan. Within five days after the appoint-
ments to said staff shall have been made, the members shall meet and
subdivide the staff into sections so that at least one section shall visit
each of the hospitals of the city daily during a definite part of the
year. Such subdivisions of the staff shall be submitted to and ap-
proved by the Health Commissioner.
Section 3.-Said Visiting Hospital Staff shall, with the co opera-
tion of a Resident Staff of Internes, have the entire responsibility for
the medical and surgical treatment of all patients at the city hospitals.
Patients shall be assigned to the care and treatment of the members
of the hospital staff of each school of medicine in the proportion or
ratio that the number of members of said School of medicine on the
staff bears to the aggregate number of members composing the staff;
providing, however, that where patients shall express a preference for
any particular school of medicine they shall be assigned to the care
of members representing such school, by the physician on duty at the
tlme.
Section 4.—The members of each section of such staff, shall, by
majority vote, elect a secretary from among their number, and said
secretary shall keep such records of the doings of his section, and
make such reports from time to time to the Health Commissioner, as
64 The Medical Society of \
shall be required by the rules of said Commissioner, which rules the
said Commissioner is hereby authorized to make.
Section 5.—The Visiting Hospital Staff, shall, within ten days
after the appointment of its members, meet on call of said Health
Commissioner at his office, and shall proceed to organize as a Board
of Hospital Administration. The Health Commissioner shall be ex-
officio president of said Board of Hospital Administration. The
Health Commissioner, with the approval of the Board of Health, shall
appoint a person who shall act as secretary of the Board of Hospital
Administration. Said secretary shall keep such records and make such
reports to the Fealth Commissioner as may be required of him by the
rules or orders made by said Health Commissioner, and for his services
the said secretary shall receive an annual salary of twelve hundred
dollars, payable in equal monthly installments at the end of each
month. He shall be the official secretary of the Board of Hospital Ad-
ministration, and shall certify to all documents signed by the president
or acting president of said Board of Hospital Administration.
Section 6.- Each member of the Visiting Hospital Staff may sub-
mit to the Health Commissioner for appointment, subject to the ap
proval of the Board of Health, the name of an alternate, who may, if
so appointed and approved, take the place and perform the duties of
the member upon said staff in case of sickness or disability of said
member. Alternates shall possess all of the qualifications and re-
sponsibilities of the members by whom they are designated.
Section 7.-No member of said board, and no alternate, shall re-
ceive any compensation whatever for his services. -
Section 8.-The Board of Hospital Administration shall formu
late rules governing its members and prescribing their duties, and the
duties of internes, nurses and other employes, and providing generally
for the internal management of the hospital. The board shall sub-
mit such rules so formulated to the Health Commissioner, and should
such rules meet with his approval, said Commissionershall, thereupon,
promulgate and announce the same with the advice and consent of the
Board of Health, and said rules shall thereupon go into effect; pro-
vided, however, that such rules may be amended or added to at any
time by the Health Commissioner, with the approval of the Board of
Health.
Section 9. – Said Board of Hospital Administration shall provide
for and conduct clinical instructions at the city hospitals for the bene-
fit of students of medicine at the various St Louis colleges, apportion-
ing such work, as to instructors and hours, among the various members
of the board, with regard to the schools of medicine they represent, in
City Hospital Alumni. 65
the same ratio as govern the appointments of Visiting Hospital Staff.
All rules and regulations governing said clinical instructions shall be
prepared by the Health Commissioner with the approval of the Board
of Health.
Section Io.—Said board shall, through its secretary, keep a record
of all its meeting, and of all its doings in matters pertaining to hos-
pital work, clinical instructions, hospital statistics, and of all other mat-
ters pertaining to hospital management, for the use of the Health
Department.
Section II.—The Health Commissioner, with the approval of the
Board of Health, shall appoint a resident staff of internes for duty at
each hospital, to consist of such number as he may from time to time
deem necessary; said staff to consist of graduates from the various
medical colleges in St. Louis, selected from the various schools of
medicine or practice, in the same ratio or proportion as the members
of the Visiting Hospital Staff are required to be seclected. Said ap-
pointments of internes shall be for one year, unless sooner removed by
the Health Commissioner, and shall be made on the order of merit as
ascertained by competitive examinations to be held under the super-
vision of the medical members of the Board of Health, therapeutics,
however, to be omitted from such examinations. Said internes so ap-
pointed shall perform such duties as the Health Commissioner shall
prescribe, by and with the approval of the Board of Health. They
shall be paid no compensation but shall receive free board and wash-
ing at the hospital to which they are appointed, except three of their
members, to be selected and designated as assistant physicians, who
shall receive the salary now provided by Section 542. A residence of
of two years in the city shall not be necessary as a qualification to ap-
pointment under this section.
Section 12.—The internes shall have immediate charge of all
hospital patients, subject to the general direction and supervision of
the Visiting Hospital Staff and the rules of the hospital. They
shall also co-operate with said Visiting Hospital Staff in clinical
instructions.
Section 13.—Clinical instructions at the hospital shall be open to
all licensed physicians and students of reputable medical colleges, on
presentation of a hospital ticket issued by said Board of Health. Such
ticket may be issued by said board for one year, on payment of five
dollars therefor, no ticket, however, to be transferable, or to be used
by any other person other than the one to whom it shall have been is-
sued. All moneys derived from the issuance of such tickets shall be
paid over quarterly to the City Treasurer and shall constitute and be
66 The Medical Society of
kept as a special fund to be expended under the directions of the
Health Commissioner for maintaining and improving the facilities for
clinical instructions at the hospital.
Section 14.—The superintendents of the various hospitals shall
be the executive heads of their respective institutions, shall enforce the
rules promulgated by the Health Commissioner, and shall themselves
be bound by such rules.
Section 15.-The Health Commissioner, by and with the ap-
proval of the Board of Health, shall make all rules relating to the ad-
mission, discharge and transfer of patients at the hospital.
Section 16.-Nothing in this Ordinance shall be so construed as
to give to the Visiting Hospital Staff, or to any of its members, any
power or authority to create any indebtedness, either for supplies or
for repairs of any kind for any of the hospitals of the city, or to
allow in any way, for the compensation of any employes; but all such
matters are to be under the control and management of the Health
Commissioner as now provided for by ordinance.
The System Under Which Charity Hospitals'
Operate in Other Cities. .
By L. S. LUTON, M.D.,
ST. LOUIS, MO.
LL the large cities in this country care for their charity
A sick in one of three ways: First, in their own institu-
tions, as here in St. Louis; second, by sending them
to various hospitals controlled by universities, medical col-
leges, or religious organizations and paying for their care and
treatment at stipulated rates, as in. Baltimore ; third, by a
combination of both methods, as in Buffalo.
In trying to secure a common standard for comparison in
the various cities, I have for obvious reasons confined my in-
vestigations to those nstitutions owned and controlled by the
city, or by the city and ts county The facts here presented
in a very condensed orm have been gleaned from authorita-
tive letters, annual reports, rules and regulations, etc.
There are in the United States (census 1900) eleven cities
having a population of over 300,000, and rom all of these ex-
City Hospital Alumni. * 67
cepting San Francisco, I have been able to obtain the infor-
mation desired.
The city hospital idea reaches its greatest development
in New York, where they maintain about one dozen hospitals. ,
The same system prevails in all of these, viz., an executive
head, a professional visiting staff and resident internes. Belle-
vue and three small allied hospitals treat in one year between
30,000 and 40,000 patients, the visiting staff numbering 82
and the resident internes about the same number. In Phila-
delphia the City Hospital admits annually between I2,OOO and
14,000 patients, or approximately as many as are admitted in
our own City, Emergency and Female Hospitals. The vis-
iting staff, 68 in number, is, judging from the list, made up of
medical and surgical skill of a high order. The internes
about equal in number those of the visiting staff.
In the Cleveland City Hospital they have in one year,
perhaps, 2,000 cases, a resident staff of 8 or IO and a visiting
staff of 50. The general management of city hospitals in
other cities of over 300,000 to which I have not referred spe-
cifically is, excepting in St. Louis, practically the same. I
can speak more intimately of the conditions present in the
Cook County Hospital at Chicago, where I served as an in-
terne for eighteen months.
This institution is the charity hospital for the city of Chi-
cago and Cook County. Here they admit annually about
2O,OOO patients who are under the professional care of a visit-
ing staff of 85 physicians and a house staff of resident in-
ternes numbering 40. In a short sketch of this kind I can do
little more than reflect the spirit of the institution and I
would do this from the standpoint of the patient, the interne,
the visiting physician, the educational interests and the public
at large. g
Any citizen, regardless of his social station, may at any
time be brought to the City Hospital. In the Cook County
Hospital this patient at once becomes the professional charge
of one of the members of the visiting staff, in this way secur-
ing for the city's sick the services of physicians and specialists
representative of the best in the community. The interne
who has secured his service on merit alone through a compet-
68 The Medical Society of
itive examination is very quick to appreciate the advantage to
himself in having in every case an instructor who has been
appointed on the staff because of his ability in one of the
specialties in medicine.
It is a significant fact that many internes come back to
the hospital a few years after their graduation, as members of
the visiting staff.
The members of the visiting staff with facilities at hand
in the hospital for a complete history, exhaustive examination,
and the trained execution of their orders, do the best work of
which they are capable. In the clinics they are demonstrating
their cases to a critical audience and under these circumstan-
ces the diagnosis and treatment is apt to be thorough.
The reputation of Chicago as a medical center for under-
graduate and post-graduate students has been materially aided
by the large number and variety of cases in the clinical am-
phitheater at the hospital, where for the major portion of the
year at almost any hour of the daily clinics are in progress.
All the medical colleges, on the West side particularly, in
their announcements emphasize the value of the County Hos-
pital clinics to their prospective students. In the summer
months many physicians from the South and West during
their stay in the city for post-graduate work, avail themselves
of these clinics.
The citizens of Chicago know that at the County Hos-
pital the unfortunate sick are cared for by some of the best
practitioners of the city. The training given a large number
of medical students every year in the clinics, and especially
the experience gained by the internes (generally admitted to
equal the first fifteen years' experience in private practice),
many of whom locate in the city, raises the standard of the
local profession and thus lowers the risk to the citizen to med-
ical incompetence.
To sum up : All cities of over 3OO,OOO population, with
the exception of St. Louis, that maintain their own institu-
tions for the treatment of the charity sick, secure for these
patients the services of a representative visiting staff who as-
sume the professional responsibility and, working with the
staff of resident internes, direct the treatment of the cases.
City Hospital Alumni. 69
DISCUSSION.
Dr. B. M. HyPEs had had some experience both in the City Hos-
pital and others. For years the medical profession of St. Louis had rec-
ognized the weakness of the laws, the injustice of the management of
the eleemosynary institutions and the decided need for a change in the
system of management. The various speeches that had been made
coincided with the expressions that had been predominant in the pro-
fession. He thought they should at once go to work to make this
change; though they would meet with many difficulties those difficul
ties might be overcome. In order to get this matter in shape, Dr. Hypes
moved that a committee of six be appointed to take in hand the gen-
eral subject of the city’s eleemosynary institutions, their needs and
demands, and that they give the Society and the profession at large
their recommendations as to what they considered necessary to be
done. There should be no attempt to go on working under a system
that had outlived its usefulness.
Dr. O. H. ELBRECHT thought the spirit of the meeting seemed to
be one of indignation. He thought the chief function left was to plan
a mode of attack, for it would be necesary to get legislative enact-
ments to change the situation, and the Society would need the assist-
ance of counselors in the legal profession. A law should be passed to
require that men be put up and voted for as the members of the school
board are. The Mayor should be made ex-officio chairman of the
board and it should be eliminated as far as possible from politics. The
autocratic power should be disposed of and to do that it would be
necessary to change all of the laws dealing with the subject in hand.
They were now simply a web of puzzling and ridiculous laws, most of
them framed by one individual centralizing the power in one man’s
hands. The main question before the Society was how to get at this.
It was very gratifying to know that this movement had been started,
and the heads of the institutions would certainly stand by the Society
in everything they could. It was too late to do anything at the com-
ing election, it would be necessary to wait for another. In order to
get the matter in shape it would be necessary to get the bill through
the house and council and it would take at least six months to get the
70 The Medical Society of
power to allow the people to vote on the issue. He believed the other
Societies of St. Louis would fall in line.
Dr. H. S. ATKINs thought that what had been said was more
critical than suggestive. St. Louis was the only city in the Union that
was taking care of its insane poor. Many of these laws needed chang-
ing, but if the plans on which the institutions in other cities are con-
ducted were considered, it would be found that there was a great dif-
ference in them. The laws should be changed but it should not be
done hurriedly.
Dr. W. B. DoRSETT said that he knew the necessity for some of
the laws, as they were enacted from time to time, and he rather thought
it was unjust to accuse one man and hold him responsible for these
laws. They should rather accuse themselves. The laws were enacted .
to cover emergencies, to meet necessities. As a former superintend-
ent he was in full accord with the expressions of Dr. Elbrecht and Dr.
Brown that the superintendent was handicapped from the time he went
into the office until he left it. He was the target of politicians and
when a politician wanted to get a nurse in or to have someone else
employed he went to the Health Commisioner with the demand.
There had been times when if the Health Commissioner wanted an
appropriation for someone of these institutions he had to be very
liberal with the appointments suggested by the members of the house
of delegates in order to get these large appropriations. The Health
Commissioner many times had to humiliate himself and go to these
men for money. The true cause of it all was that the members of the
profession had not asserted themselves before. They should blame
no one else for having gotten up these laws when they had done noth-
ing themselves. He was heartily in accord with the remarks of Mr.
Nagel and others, and he hoped to see the day when conditions would
be changed.
Mr. NAGEL said that it was not necessary for another year to
elapse before taking effective steps. If the committee would work
promptly it might be able to formulate a general idea in such a way as
to get it impressed upon the platforms about to be made. The whole
thing could in that way be raised for discussion in the present cam-
paign and the prairie would be burning before they knew it.
City Hospital Alumni. 71
Meeting of March 16, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
The Duty of the Medical Expert to the
Individual and to the State.
By R. B. H. GRADWOHL, M.D.,
ST. LOUIS, MO.
Instructor of Pathological Anatomy in the Medical Department of St. Louis
University; Physician to the Coroner of St. Louis.
HE main flaw in our present system of medical expert
testimony is its extremely partizan character. There
are other flaws in the system. Some of these flaws
and abuses were developed in a remarkable degree in a case
in which I was recently retained as an expert. I propose to
recite the medical facts of this case and such other points con-
nected with it as are necessary to appreciate fully the argu-
ment. I refer to what has been called the “Watson case,”
recently tried in New London, Missouri, before the Circuit
Court of Ralls County. The facts follow :
Dr. Taylor J. Watson, a married man, aged 40 years, a
native of Ralls County, settled in Pueblo, Colorado, several
years ago and engaged in the practice of osteopathy. From
all accounts he lived on terms of perfect happiness with his
wife. Last July he came back to New London, accompanied
by his wife, to visit relatives, intending later to visit the Uni-
versal Exposition at St. Louis. One afternoon, while driving
with his wife in his brother's buggy, Watson journeyed down
the Organ Ferry road to the iron bridge which crossed Salt
River, about one mile from New London. The bridge is 35
feet high and rests upon piers set in the river near either bank.
There is a wooden rail on the bridge, about 4 feet in height
near the approaches to the bridge, increasing in height toward
the center The evening in question was July 5, 1904; it was
raining. About 8 p.m. the horse and buggy, with no occu-
pants, was found near the south end of the bridge (Watson
72 The Medical Society of
drove on the bridge from the northern approach). The dash-
board and shafts of the buggy were broken. Investigation
revealed the unconscious form of Watson on the bridge. Help
was summoned; Dr. W. T. Watson made a thorough examin-
ation and made a diagnosis of concussion of the brain; the
patient was taken to town; search was made and the body of
Mrs. Watson was later found in the river, under the bridge,
floating on the surface of the water. She was prepared for
burial; no visible marks of violence on the body were made
out. She was embalmed and buried. Her husband recovered
consciousness in thirty hours. He explained the accident by
stating that the horse became frightened at a piece of paper
lying on the bridge and began lunging; memory of all events
thereafter was completely lost. His version was accepted and
nothing more was thought of the case, except the unfortunate.
manner in which Mrs. Watson lost her life.
When the accident insurance companies who had insured
the life of Mrs. Watson to the extent of $18,000 in favor of
her husband were apprised of the case, they began an invest-
igation to satisfy themselves that this was truly an accident.
Apparently they thought there were suspicious circumstances
connected with the case. They conducted a system of es-
poinage on the movements of Watson, who subsequently came
to the Exposition at St. Louis. Fortified by the results of
their “shadowing” of Watson, emboldened by the convictions
of their adjuster-detective representatives that foul play had
been committed; working the science of deduction “overtime,”
to use a slang expression, the insurance companies employed
two medical men of St. Louis to perform an autopsy on the
body of Mrs. Watson. The body was exhumed and the au.
topsy was performed in the Court House at New London by
the St. Louis physicians, in the presence of a number of local
physicians. Their findings, as reported at the Coroner's in-
quest were, briefly, that they saw no signs of violence on the
body, except a small abrasion over the nose; they found the
pupils equal and contracted to the size of the “head of a pin.”
The brain and its membrains were normal. They testified
that they opened the larynx, trachea, bronchi and lungs and
found no foreign material present, no water, no sand. They
City Hospital Alumni. 73
testified that the lungs were “full and crepitant.” They found
clotted blood in the heart; liver, kidney and spleen were nor-
mal; the stomach was half filled with fluid. They stated that
there were no signs of violence or of drowning, or of disease,
and, consequently, thought the subject had been poisoned.
The particular poison used, in their opinion, was morphin. For
chemical proof they tied off the stomach, cut off pieces of the
liver and kidneys, took the heart and brain in toto, dumped
all the viscera into an ordinary tin bucket and poured over
them some alcohol purchased from the village drug store. A
piece of paper was used as a cover for the bucket. They
testified that the bucket and its contents were safely taken to
St. Louis, locked up in a laboratory and afterwards delivered
to a physician in East St. Louis for chemical analysis. He
was directed to look for morphin. This physician stated at
the Coroner's inquest that he obtained three distinct color re-
actions of morphin. The verdict of the Coroner's Jury was
to the effect that Watson killed his wife with morphin and af-
ter she was dead put her body in the river. Watson was held
on an information issued by the Prosecuting Attorney of Ralls
County for murder in the first degree.
Watson, now defendant charged with murder, employed
Messrs. J. O. Allison, R. F. Roy, C. T. Hays and G. W. White-
cotton as counsel. These gentlemen mapped out his defense
along clean-cut, intelligent and honest lines. Their straight-
forward and manly methods in the conduct of the case stood
out prominently against the pettyfogging and “grand-stand
play” on the part of the State's attorneys and confrères. Struck
by the demeanor of the State's experts while testifying before
the Coroner's inquest, knowing the facts of their partisan em-
ployment by the insurance companies, and not by the Coroner
of Ralls County; satisfied from the comments of other phy-
sicians who had been present at the autopsy that it had been
incompletely performed; appalled by the fact that the viscera
for a most exacting and delicate series of chemical manipula-
tions had been ruthlessly and ignorantly deposited in a com-
mon, unclean tin bucket for transportation to the laboratory,
subject to contaminations of all kinds while in this repository;
feeling sure that their client was innocent, that his wife had
74 The Medical Society of
been accidentally drowned and not poisoned, these able men
drew up their case.
A second autopsy was performed in a most painstaking
and careful manner, observing everything, omitting nothing,
concealing nothing, belittling nothing, magnifying nothing and
manufacturing nothing. Most remarkable facts were adduced
at this second autopsy. The lungs were found “full and crep-
itant,” as described by the State's experts. The testimony of
the State's experts that they had freely incised the lungs, tra-
chea, bronchi and larynx, seeking signs of drowning, met
startling refutation at the second autopsy which disclosed the
fact that the only incision made into the entire respiratory
tract was a small incision which had cut off a piece of pul-
monary tissue about three or four inches long from the lower
part of the right lung, also the margins. The lungs had not
been separated from their attachments; the bronchi had not
been opened; the trachea had not been exposed; the larynx
was untouched; in short, the second autopsy showed that the
gentlemen testifying for the State had not spoken truthfully
in regard to their autopsy findings. The evidences, the plain,
honest evidences of sand and other foreign material, nay, even
of water, in the trachea, bronchi and lungs, could not have
been sought for, by virtue of this inadequate examination on,
the part of the first autopsy physicians.
I later examined the débris found in the respiratory tract,
in larynx, trachea and bronchi, and found sand and plant cells
in abundance. The second autopsy showed that the esopha-
gus had not been opened at the first autopsy. It also con-
tained sand and plant cells. The second autopsy showed that
one kidney was intact and that a very small piece of the other
had been cut off; a very small piece of the liver was missing.
Further examination was made to determine the cause of
death. The middle ear cavity on one side showed eight drops
of clear fluid present. This fluid was neutral in reaction, con-
tained no albumin and no cellular constituents, and was, con-
sequently, not an inflammatory product.
These several findings convinced the physicians at the
second autopsy that ample signs of drowning were present.
Nevertheless, a chemical examination was deemed expedient.
§
City Hospital Alumni. 75
Accordingly, the viscera, liver, kidney, small intestine and
lungs were placed in separate clean glass jars, sealed, and
taken in the custody of the sheriff of Ralls County to the lab-
oratory of Dr. Victor C. Vaughan, of Ann Arbor, Michigan,
where they were delivered to him in person. A sample of the
embalming fluid was taken for chemical analysis. No analy-
sis of the embalming fluid had been made by the State's
chemist. In due time Dr. Vaughan reported that no signs of
morphin were present in these viscera.
. The testimony of the State's experts at the trial was very
similar to what they said at the Coroner's inquest, excepting
that cross-examination brought out some very “interesting”
statements. The physician who made the first autopsy on the
part of the insurance companies, gave his opinion that the
cause of death was morphin poisoning; this was based on the
minutely contracted pupils, and the “absence of any other
signs pointing to any other cause of death.” He denied the
presence of any signs of drowning; he denied that “full and
crepitant lungs” indicate drowning, although this is diametric-
ally opposed to authoritative teaching. He claimed that blood
clots in the heart indicate morphin poisoning. While admit-
ting that water in the middle ear is a good sign of drowning,
he acknowledged that he had not looked for it, because, he
said, “what is the use of it when the temperature is so hot you
can almost faint, that you go in and saw out the ear, when you
have all the other signs but that?” Later on, in rebutting
the defense testimony that water was found in the middle ear
at the second autopsy he maintained a most novel and strictly
preposterous proposition, i.e., that there is normally 60 drops
of clear lymph in the middle ear cavity and this is what was
found at the second autopsy This is an anatomical piece of
information that is peculiarly his own, as the usual conception
of the middle ear cavity is that it is an air space, under norm-
al conditions ! This same State's expert maintained that in
every case of drowning, water in determinable quantity is to
be found in the lungs. Confronted with Ogston's statistics,
that water in the lungs is found in but 48 per cent of observed
cases (and Ogston has handled thousands), this expert stated
that “if he tells you he has handled thousands of cases, he
76 The Medical Society of
must have been so busy it made him mentally off, and he
would not be competent to write about it.” This needs no
comment. In general, he testified under cross-examination,
that he considered medical literature of small moment com-
pared to the results of his own experience.
The testimony of the physician who made the chemical
analysis for the State can be dismissed with a few words. He
stated that he had obtained “three color reactions for morphin
at a preliminary test” of the stomach contents. Later, 'com-
plete' examinations gave none of these reactions of morphin
with the viscera. He presumed that the presence of the em-
balming fluid (which he discovered contained formaldehyd by
its odor when extracting the tissues) probably prevented the
appearance of the color reactions of morphin Not a word in
his direct examination as to whether he found the crystals of
morphin ; in his cross-examination, he admitted that the find-
ing of the crystals is an essential point to absolutely swear to
morphin poisoning, yet acknowledged that he had not sought,
and consequently had not found these essential crystals. His
evidence indicated that he was not sure in his own mind at the
time while testifying that he had found morphin, although he
had been sure at the Coroner's inquest. -
Dr. Victor C. Vaughan, of Ann Arbor, testified that he
found no reactions for morphin in the tissues of Mrs. Watson.
Testifying along expert lines, he stated that the color reactions
are deceptive and unreliable; that many ptomains give color
reaction resembling those of morphin ; that in short, the color
reactions of morphin when present, do not necessarily mean
that morphin is present; when absent, it means that morphin
is not present. Dr. Vaughan stated that the only positive
means of identifying morphin in these toxicological investiga-
tions was to find the crystals of morphin. Without finding
the crystals we can not swear that morphin is present. Asked
as to the presence of the formaldehyd embalming fluid, and
its influence on the prevention of the appearance of the color
reactions in animal tissue containing morphin, Dr. Vaughan
stated that among experienced workers, there is no possibility
of this interference, because it can be easily avoided by slowly
evaporated off all the formaldehyd.
City Hospital Alumni. 77
The testimony of Dr. J. T. White, who performed the
second autopsy, developed the signs of drowning. My testi-
mony corroborated Dr. White's.
Dr. W. T. Watson testified concerning Watson's condi-
tion. Dr. T. J. Downing testified likewise. They maintained
that Watson had concussion of the brain. The State claimed
he was shamming. There were additional experts on the
question of concussions, Drs. Paul Y. Tupper and C. G. Chad-
dock, who answered hypothetical questions in regard to Wat-
son's condition. They believed that he had concussion.
The jury promptly returned a verdict of acquittal and
Watson is now a free man, after having languished six months
in a prison cell awaiting trial. The case was an illustration of
how a private interest, in this case the insurance companies,
can use the machinery of the criminal law, not only to prose-
cute, but even to persecute. In this case the dead woman's
father was supposed to be the prosecuting witness, yet he was
merely a blind, behind which stood the detective-agents of the
insurance companies, pulling the wires which moved the
State's attorney and the State's experts. The character of
the State's expert testimony represented the acme of partisan
testimony; they not only magnified the medical points favor-
able for the State and “forgot” the points favorable for the
defense, but they actually hesitated not to drive home their
statements with deliberate untruths. Medical expert testimo-
my has suffered many a blow before the tribunal of justice, but
I venture to say that no more disgraceful episode has ever oc-
curred in court than the one I have here recounted.
This brings me to the question of the proper duty of the
medical expert. We all realize that the partisan character of
his employment militates against him. He unconsciously be-
gins to feel that he must develop only those points favorable
to his client. He becomes the medical advocate and loses
his character as a witness. There was once a time when med-
ical expert testimony in the courts of our country possessed
almost judicial weight. Alas, that time no longer exists. As
Wharton in his work on “Evidence,” truly says, “when expert
testimony was first introduced, it was regarded with great re-
spect. An expert was viewed as a representative of a science
T 8 The Medical Society of
of which he was a professor, giving impartially its conclu-
sions.” Two conditions have combined to produce a material
change in this relation. In the first place, it has been discov-
ered that no expert; no matter how learned and incorruptible,
speaks for his science as a whole. Few specialties are so
small as not to be torn by factions, and often the smaller the
specialty, the bitterer and more inflaming and distorting are
the animosities by which these factions are possessed—Nihil
tam absurdo, which being literally translated means that there
is nothing so absurd that the philosophers won't say it. In
the second place, the retaining of experts by a fee proportion-
ed to the importance of their testimony is now as customary
as is the retaining of lawyers. No court would take as testi-
mony the sworn statement of the law given by counsel re-
tained on a particular side, for the reason that the most high-
minded men are so swayed by an employment of his kind as
to lose the power of impartial judgment; and so intense is
this conviction that in every civilized community the retention
by a judge of presents from suitors visits him not only with
disqualification, but with disgrace. Hence, it is, apart from
the partisan part of their opinions, their utterances have lost
all judicial authority, and are entitled only to the weight which
sound and consistent criticism will award to the testimony it-
self. In making this criticism a large allowance must be made
for the bias necessarily belonging to men retained to advocate
a cause, who speak not as to fact, but as to opinion and who
are selected, on all moot questions, either from their prior ad-
vocacy of them, or from their readiness to adopt the opinion
to be proved. In this sense we may adopt the strong language
of Lord Kenyon, that “skilled experts come with such a bias
on their minds to support the cause in which they are em-
barked that hardly any weight should be given to their evi-
dence.” This opinion of expert testimony is held by most
judicial authorities in this country.
We should ask in first order, why should this state of af-
fairs have arisen, this disrepute of the medical witness in court,
and demand why should it be allowed to continue P Witthaus
says that the main reason for the bad repute of the medical
expert is the “employment of blatant, ignorant persons, or
City Hospital Alumni. 79
even persons who do not hesitate to commit plain perjury.”
Certainly, the honest, competent medical man will give fair
testimony to a certain extent, yet human nature is such that
no matter how honest one's instincts are, there is often felt the
intangible, indefinite, yet positive influence, of employment.
One expert on a certain side knows nothing of the facts of his
adversary and consequently can not scientifically sift out the
good from the bad. This might be remedied by a conferance
of the experts before the case goes to trial. In some parts
of England, experts refuse to testify unless there has been
such a conferance. &
Another reason for the present disrepute of expert testi-
mony is the fact that very often men are allowed to qualify in
court as experts along certain special lines in which they do
not really possess expert qualifications. They may be hon-
est in their primary instincts, but they are ignorant. They
are, perhaps, pitted against men who are really experts; in
their zeal and ignorance they make misstatements and disa-
gree with the other side. Their titles may appear much more
high-sounding and elaborate than those of the opposite ex-
perts of merit. And it is a matter of common knowledge
that “fools rush in where angels fear to tread,” the ignorant
and misguided expert can always be counted on to make ab-
solute and sweeping statements, while his better-posted and
more conservative adversary will qualify his answers; thus, it
frequently happens that the real expert is apparently over-
shadowed by another expert who is mentally his inferior.
Responding again to the original proposition by offering
a remedy why should this state of affairs have arisen, we
might add that in general a higher standard of medical educa-
tion be required. The incompetent men, products of the di-
ploma mills, are in abundance. They exist because the diplo-
ma mill and “wild-cat medical college” is allowed to exist. The
irregular schools each year are feeling the noose tightening
more securely around their necks. When asphyxiation of
these pests will finally have be accomplished, then will we
have a natural death of their offspring—the incompetent phy-
sician and the incompetent witness. And I wish to emphasize
here the point that legal medicine is not taught in our average
80 The Medical Society of
American medical schools. With but few exceptions, the
course is limited to a few lectures by some prominent member
of the bar on “Medical Jurisprudence.” Legal medicine is not
medical jurisprudence. Legal medicine is a specialty of med-
icine. In some schools legal medicine is taught by each spec-
ialist devoting a few hours to medical facts coming within his
particular field, i.e., the obstetrician teaches his students the
signs of abortion, the chemist teaches the rudiments of toxi-
cology, the pathologist teaches autopsies, etc. Yet, as Prof.
Draper, of Harvard, says in his admirable “Text-Book on Le-
gal Medicine,” “such a scheme, while plausible, is impractica-
ble. In the nature of the case, it is unfruitful. An instructor
gives instruction first and with the most zeal in matters which
specially interest him. He does not readily turn aside to dis-
cuss topics which, however important they may be, are more
or less remote from his immediate themes. Moreover, it is
evident that there are some things, the knowledge of which is
essential to a full comprehension of medical jurisprudence,
but which are outside-any of the ordinary departments of in-
struction, and should, therefore, have independent treatment.
Such topics, for example, as medical evidence in court and the
legal relations of physicians to their patients and the commu-
nity deserve special treatment.” Another class believe that if
one is well trained in medicine, if he knows his anatomy, his
chemistry, his surgery and midwifery, if he is honest and tells
the truth, he need not fear to meet any crisis in court.
Forensic medicine, it is declared, is not an independent
part of medical science, but a pretender without valid right to
recognition. It is asserted that it offers nothing new in medi-
cal knowledge of every educated and properly-equipped prac-
titioner. That this is an unreasonable position, it requires but
a moment's reflection to show. The knowledge is the same
in general and forensic medicine, but in the latter it has novel
relations and applications out of the common course.
“Medical questions,” says a high authority, “assume a
very different aspect and reflect very novel hues when viewed
in the glare of the court of justice from what they do in the
midlight of the sickroom or the hospital ward.” Germany
has the best corps of medical experts in the world. I can
City Hospital Alumni. 81
quote from the Verzeichniss of the University of Berlin, in
the winter semester of 1900–1901, when I was studying there,
showing twelve different courses on legal medicine. Austria
and France vie with Germany in the teaching of legal medi-
cine. And we should have it taught in our schools without
delay.
I have pointed out the flaws in our system. What is the
remedy? The answer is difficult, yet the query can be an-
swered. Mr. Henry Wollman, of the Kansas City bar, in a
paper read before the Medico-Legal Society of New York
(Medico-Legal Journal, March, 1900) suggests the appointment
of a committee of experts by the representative medical soci-
ety of each district, this committee to serve, say, for six
months of a year. When expert testimony is required in such
a district, let the attorneys go to this committee for their ex-
perts. Let no member of the society consent to appear in
court as an expert witness unless his fellow practitioners have
appointed him a member of that committee. This plan ap-
pears practicable. Another plan is the appointment by the
court or by the Governor of each State of a commission of ,
experts. Let these experts be nominated by their representa-
tive societies. Let them decide matters of expert testimony.
Let their fees be paid by the court and the costs afterward as-
sessed against the side which loses the suit. Let the whole
proposition of the partisan employment of experts be abol-
ished. It is that partisan spirit which militates against the
giving of impartial testimony. It seems contrary to the spirit
of the Anglo-Saxon law to hope for a system of expert testi-
mony in vogue now in France, Austria and Germany, where
the expert is selected by the government on account of spec-
ial training and qualification.
He examines into the medical features of a given case
and submits his findings, which are absolutely judicial and ad-
mit of no argument. The Cruppi law in France regulated the
appointment of experts for the defense in criminal causes.
These experts, of course, are well qualified. The French law
introduced by Brouardel in 1884 and adopted in 1900, de-
mands a special course of nine months at the Paris University
to become a medico-legal expert.
82 The Medical Society of
The legal physician of Germany must go through a spec-
ial course and pass the special “Physikats-Examen” before he
is qualified to be appointed. Could we have in this country a
special diploma in legal medicine as proposed by Wyatt John-
stone, of Montreal, we could soon have a special class of men
who would be eligible for positions like medical examiners or
coroners' physicians. There is a demand for such men. The
fact of them possessing a special diploma in legal medicine
would well qualify them as experts. They would soon be rec-
ognized in court, and their statements be quasi-judicial, even
though other testimony could be introduced; in short, while
not possessing officially the absolute dictum-like character of
the German or French government experts, they would prac-
tically decide the technical medical aspect of a murder charge,
relieving the jury of that most arduous, unpleasant and, oft-
times, impossible task of obtaining an appreciation of the
medical points of a case, and yet withal, Article VI of the
Amendments to the Constitution of the United States would
be held sacred, which demands thas “in all criminal prosecu-
tions, the accused shall enjoy the right to a speedy and public
trial, by an impartial jury of the State and district wherein
the crime shall have been committed, which district shall have
been previously ascertained by law, and to be informed of the
nature and cause of the accusation ; to be confronted with wit-
nesses against him; to have compulsory process for obtaining
witnesses in his favor, and to have the assistance of counsel for
his defense.”
f
DISCUSSION.
Mr. S. SCHWARTZ felt that it was a privilege to have listened to
the paper by Dr. Gradwohl. The subject was one that was interesting
to the members of the medical profession and he doubted if there was
one that was of more interest to the legal profession. The subject
was one that both professions should take up conjointly. The evil had
been growing in proportion to the contingent fees in law, and it was
probable that the services of medical men could be obtained in the
same ways in law. That was the greatest danger, that it did seem
possible to obtain the services of medical men not on the basis of a
City Hospital Alumni. 83
fixed remuneration, but that the fee of the medical man was made
contingent just as the fee of the lawyer.
The word expert recalled the story of a Kentucky trial of a crimi-
nal case. An expert was pitted against a country doctor and the
counsel for the State told the jury that maybe they didn’t know what
an expert was, that he was not a man who looked at their tongue and
felt their pulse, etc., that that was unnecessary; that he would simply
extract a drop of blood and put it in a crooked neck bottle with some
strips of pink paper and then he could tell them in a minute who their
mother and father was. The difficulty was, the expert was biased.
Before being put on the stand if asked a certain question he might
reply, yes, possibly such conditions would follow; but when he was put
on the stand knowing that a positive yes, or no, was expected of
him, the opposite counsel would find it difficult to shake him. The
better members of the legal profession, when they had a case in which
medical experts would be required, simply got medical experts of their
own, prepared their hypothetical questions and left the jury where it
was. The jury was usually instructed that if they chose, they might
disregard entirely the expert testimony and decide the case on its mer-
its as they understood the facts, or that, if they chose, they might follow
the testimony. The suggestion that the experts on one side confer
with the experts on the other side was something that Mr. Schwartz
did not expect to see during his life. That would necessarily carry
with it the statement “where counsel on both sides agree to submit
their case,” etc., but about one case in twenty thousand was ever sub-
mitted on an agreed statement of facts. He admired very much the
doctor who took the stand and answered frankly every question, stat-
ing the reason for his opinion with necessary qualifications, but he had
had two or three experiences that really in justice to his client, made
him hesitate to put an expert on the stand. One experience, of some
four years ago, was an example. He had an expert, a charming man,
an educated man, a man in whom, if he had needed any one to look
after his mental state; he would have had every confidence. He had
used this man in a case that involved a question of sanity and he was
so clear and so qualified in every statement that it had been unneces-
sary for his adversary to put an expert on the stand. A jury of intel-
84 The Medical Society of
ligent men would have given that man's statement weight, but this jury
was not that kind, He had had a second experience, in a will case,
in which he had conferred for two months with experts in Cincinnati
, and he had concluded not to put either of them on the stand for the
same reason A plan should be worked out along some such line as
Dr. Gradwohl had suggested. Of course, in a case where a person
had been injured, that person would be entitled to present the physi-
cian who had treated him. Some such system as are obtained in
France or Germany might very well apply here. If the medical pro-
fession did attempt to put through any such measure they should see
to it that they kept the matter in their own hands, they should not give
the power into the hands of any holder of a political office. The
power to appoint men to sit over the rights of others should not be in
the hands of the politician.
Dr. GEORGE HOMAN felt that this was a subject to tax the
best thought of the medical and legal professions, to find a workable
plan, but the need was apparent and some practicable outcome could
certainly be found. A witness was sworn to tell the truth, the whole
truth and nothing but the truth. He was put on the stand and the
aim of opposing counsel then was apparent, to bring out not the truth
but rather half-truths and quarter-facts. Again, there should be some
distinction drawn between those qualified as experts to testify on ques-
tions of sanity, and those summoned to testify as chemists. The laws
of chemistry are as far reaching and exact as the law of gravitation
and this should be borne in mind. One expert dealt with questions
and interpretations of fact, the other with matters of opinion. So that
such a state of affairs as the one mentioned by Dr. Gradwohl, where
there different findings by chemical workers should be avoided. The
reactions of carbon and magnesium, for example, would be the same
on the sun or the dog star, as on the earth, if the conditions were the
same. So it was certainly possible to avoid such a scandal as this. In
cases where sanity was in doubt there was a field for honest differences
of opinion. Dr. Homan wished to know if the gentlemen whom Dr.
Gradwohl had confronted on the stand were members of this Society,
to which Dr. Gradwohl replied that they were not. If they were, the
question might properly come up what should be done with them in
City Hospital Alumni. 85
the way of discipline. If they held membership in and bodies affiili-
ated with this Society it would be the duty of those bodies to investi-
gate to what extent such practice could be permitted. In regard to
the general subject, it should be followed up and a plan formed by
which the evil pointed out could be avoided, or at least minimized.
This matter should be gone on with and further deliberations and con-
ferences held respecting the attitude of the two professions in the ef-
fort to see whether some practical plan can not be hit upon to avoid
such possible or actual miscarriages of justice.
Dr. BRANSFORD LEwis considered this an extremely valuable
contribution and a very timely one. He had heard considerable criti-
cism of the medical profession in its relation to expert testimony. The
expert was often shown up to be very little posted in the profession he
claimed to be expert in, or else showed his dishonesty. When that
did occur it affected all the profession who got the obloquy attached
to it, notwithstanding the fact that but a very small proportion of the
profession would be guilty. He had been at a trial where he had
been called to give his testimony, and he had heard one these gentle-
men testify and his testimony was just as preposterous and far from
the truth as in this case. The testimony of the “expert” was abso-
lutely farcical and he knew he was giving it not for the purpose of
evolving the truth of the matter at hand but simply to bolster up his
side of the case. Each time that occurred it would redound to the
discredit of the profession and it was time for the Society to take it
up. He could hardly see how the situation could be controlled by
having the medical witnesses get together before the trial. It would
be a better plan to have only certain members of the profession eligi-
ble to stand as experts. Let the societies determine who would be
honest and intelligent in that line, leaving out those who would act in
a biased way. It was a very hard thing for one not to be biased, but
that was a very different thing from actual intent to deceive. Certain
practical results could be brought out of a conference on this subject
and these one sided doctors could be eliminated.
Dr. M. J. LIPPE felt that they should be proud of Dr. Gradwohl.
The so-called expert testimony was not expert testimony at all. When
a man did not even open the esophagus or air-tract, and then swore
86 The Medical Society of
that there was no sign of water in the lungs, he was not an expert, he
was a criminal, and when a man testified to having opened the esopha-
gus or the trachea, in a case where a man’s life or liberty was in the
balance, when in reality he had not done so, he ought to be prose-
cuted. Those things were facts that were established. The propor-
tion of fluid in the middle ear, for instance; any tyro in medicine
knew it was impossible to have 60 minims of fluid in the middle ear
normally and in such a case text books should be brought forward to
prove the falsity of such statements. That was not a question of ex-
pert testimony. Any physician who made such a statement was a
lunatic or a criminal. There were questions in chemistry, physiology
and neurology that had not been decided and never would be, at least
not during our life time, but when a man stated that he had opened
the esophagus and examined the trachea and lungs, when he had not
done so, that was a different proposition and that man ought to be
dealt with by the criminal law.
Dr. G. C. CRANDALL had had considerable experience in this line
of work and nearly every time he had undertaken it he had resolved
that he would never take any more. This work as conducted is very
unsatisfactory for the physician and often equally so for the attorney,
and frequently unsatisfactory for the jury. It was to be regretted that
such a discrepancy of facts as had been reported should have occur-
red. It was true there were men in the profession who would do such
things and it was a question whether such men should be disciplined.
When men went upon the stand and made statements absolutely false,
the reflection upon the profession should be resented in some manner.
The fact that medicine was not an exact science made it possible for dis-
crepancies to occur. The expert knew the hypothetical question which
would be put by the attorney on his side but he did not know what
would be asked by the attorney of the other side. As a rule, the
expert witness was called when his testimony was needed and was only
present long enough to give his testimony. He heard but one side of
the case and was not in a position to draw accurate conclusions, natu-
rally being biased by the presentation of the case which he hears.
How those difficulties could be overcome had been seriously consid-
ered for a long time. In New York there had once been an effort to
City Hospital Alumni. 87
have the experts appointed by the judge but there was a criticism that
this arrangement would take the trial to a certain extent out of the
hands of the jury and place it in the hands of the commission. The
suggestion that there be men trained and vouched for would certainly
be an improvement, but it was a most difficult question to handle.
Dr. Crandall had been connected several years ago with a murder
case one point in which showed the absolute futility of expert evi
dence. The case had been taken to the country on a change of venue,
and the trial was about to close when the prosecution thought of a
very shrewd scheme, and called in a local physician, who knew noth-
ing of the individual whose life was at stake. That physician went on
the stand and testified against the defendant. The man was con-
victed. This physician was the family physician or acquainted with
several of the jurors and though he knew absolutely nothing of neu-
rology, they gave his testimony greater weight than that of the neurol-
ogists who had studied the case. He was convicted mainly on that
one man’s testimony. The better education of men acting as experts
would accomplish a certain amount of good and the appointment of
men by local and State associations would probably be better than the
present plan.
Dr. WILLIAM E. SAUER, replying to a question by the Chair, said
that it was well known that the normal ear could not contain 60 min-
ims of fluid, but the question whether the ear was normal at the time
should be taken into consideration.
Mr. SCHWARTZ, referring to Dr. Homan's statement that the mem-
bers of the legal profession sometimes attempted to elicit only half-
truths, said that that was their business. The difficulty they had to
confront was practically the same that the competent physician had to
confront when called as an expert. A conscientious lawyer was very
frequently surprised by the strength of his opponent's case, because
his client has slighted certain facts or because he did not deal frankly
and honestly with his own counsel, so that the lawyer had been able
to put to the physician only his side of the story, as he, in turn, had
had it from his client. Hence the physician went on the stand know-
ing only his side of the case. After the physician was once placed on
the stand the difficulty so frequently was that of pride in one’s own
Q f
88 The Medical Society of
opinion, of partisanship engendered by having heard but one side of
the story, and of that pernicious element, the thought of remunera-
tion. Of course, it would never be possible to deprive a man of the
right to call as a witness whomsoever he might choose to testify in his
behalf. The medical and legal profession could not formulate any
plan by which a man would be compelled to draw his witnesses from
a certain body of men, but they could manage some scheme by which
they might make it possible for competent men to be appointed who
might be called upon for expert testimony. For instance, suppose it
were a well-established fact in the City of St. Louis for the medical
bodies to select from their number certain committees, the members
of which were experts on certain specific questions. Then it would be
a tremendous lever on their side if it could be shown that the person
called was one selected by his own profession. When public
opinion had been educated up to that it was about all that could be
accomplished.
Dr. GRADwohl. in closing, expressed his appreciation of the dis-
cussion of his paper. Partisan employment of experts must be abol-
ished if the standard of the expert was to be raised. Every man was
a partisan and must remain so, the only question was to put the mat-
ter on broad lines. He had simply mentioned this case as a glaring
instance of what expert evidence might amount to. Of course, he did
not consider this a fair example of what might be expected of the
medical expert. Probably there was not another case on record where
such glaring inconsistencies and such deliberate lies were told by medi.
cal men under oath. This thing should be stopped. He did not lay
claim to be any more moral or honest than the average man, but it had
been a pleasure to him as coroner’s physician to make autopsies, to
discover the cause of death and to report what he knew about a case
as he found it, having no axe to grind and no employment on the case,
It certainly ought to be possible for expert evidence in general to be
given in the same way and for absolute impartiality to be secured.
State Control of Human Tuberculosis.
Dr. GEORGE HomAN presented a summary showing the official
action of several States in providing sanatoriums for consumptives,
City Hospital Alumni. tº 89
this information having been collected through correspondence while
promoting legislation for this purpose at Jefferson City, early in the
present year (1905).
DISCUSSION.
Dr. J. C. ORR expressed his gratitude to Dr. Homan for bringing
to their knowledge this complete information of what the states gener-
ally were doing and the great benefits that were being derived from
the care and treatment of patients suffering from this terrible disease
in institutions of this character. The point he had brought out so
well, the great value of these institutions in assisting earnest and in-
telligent physicians to interest the laity in learning how to protect .
themselves and how to prevent others from contracting the disease,
was of the greatest importance and would be received with the great-
est enthusiasm. In Missouri there had recently been an act passed
creating such an institution and the citizens of Missouri were certainly
fortunate in having a good climate and a favorable location in certain
parts of the State. The question came home to all physicians, especi-
ally those who came in contact with these patients a great deal, as to
how to advise them, knowing them to be victims of the disease, as to
what was best to do. Aside from their physical condition their finances
often prevented their seeking remote climatic benefits. These institu-
tions when established and receiving financial aid would make the
work of advising these patients and enabling them to receive the best
of care, very much easier. The aim should be to educate the laity in
the proper care of these patients and as to the best means of prevent-
ing the spread of the disease.
The PRESIDENT said that he had recently noticed among other
placards in the street car one placed there by the Civic Improvement
League, to the effect that any individual might be a menace to the
community through infection by tuberculosis, such infection being con-
veyed to others by spitting. It was plainly worded and the distribution
was very general. The President asked Dr. Homan whether these
sanitaria contemplated the care of cases of tuberculosis other than
pulmonary cases, to which Dr. Homan replied that they would under-
take treatment of cases of tuberculosis of the air passages only.
90 The Medical Society of
Dr. HomAN, in closing, said that the question had arisen at Jeffer-
son City, in the early part of the session, why those in the advanced
stage of the disease should not be admitted into this proposed institu-
tion. The answer was that all the world was before those unfortunate
people who had but to die, while few places, indeed, were open to
those others less advanced in which they could learn not only how not
to die but how to get well and stay well. It was with no disposition
to be inhumane but the idea was to send those only who could still be
saved and who would go out and become missionaries, reaching classes
of workers who could not be taught in any other way, employes in
mills, factories, mines, etc., where such instruction was most needed.
Even the physician had difficulty in reaching these classes. Every one
who has had experience in public health affairs knows there is often a
great deal of skepticism, even when medical men try to teach on this
subject, but when such advice and teaching come from the people of
their own class, who show in their own persons the benefits of this
way of living, it would have a better effect. Aside from the question
of common humanity, there is involved a vast economic benefit. Dr.
Homan added that he had been very much shaken in his former be.
lief that the strongholds of consumption were in the so-called slums.
The guilt lay higher up. His personal experience in clubs, hotels and
office buildings with acres of carpeting almost convinced him that the
most active sowing of the seeds of consumption took place right there.
The chambermaids and the people who did the sweeping and dusting
were probably the principal but not the only victims. They caught it
there and then took the disease home. To illustrate what the dangers
are, in one of the largest clubs in the city, appealing especially to the
younger element as a means of health and development of muscle,
after a year’s experience as a member he had been actually driven out
of it through the dangerous methods of housekeeping pursued in spite
of protest. On entering the dining room to order a meal frequently
the sweeping and dusting of carpets and furniture had gone on along
side of him. Remonstrance, protest, denunciation, and finally, with-
drawal on his part had been the result, failing any betterment of con-
ditions. He had observed the same thing in the largest hotels, so
that he had come to the conclusion that the chief strongholds of tuber-
City Hospital Alumni. 91
culosis was to be found, not low down but high up in the social and
economic scale. &
Meeting of April 6, 1905; Dr. John Green, Jr.,
President, in the Chair.
*
Rabies: With Report of a Case.
By L. H. HEMPELMANN, M.D.,
ST: LOUIS, MO.
Instructor in Clinical Medicine, Washington University.
ABIES, or hydrophobia, is a rare disease, the very ex-
istence of which has been questioned. From time to
time cases appear, however, so that it is well to have
at least a passing acquaintance with its symptomatology and
prophylaxis. Before speaking of rabies in general, I would
like to report a case that I happened to attend about one year
ago :
A boy, aged 13 years, was bitten on the right wrist No-
vember 26, 1903, by a stray dog. The wound was a small, su-
perficial one and the boy, , who was an inmate of an orphan
asylum, applied to the nurse immediately to have the wound
dressed. She applied a 5 per cent carbolic compress and in
less than half an hour after the time he was bitten swabbed
the wound with 95 per cent carbolic acid and then dressed it
with a 1 per cent carbolic dressing. It healed kindly and the
boy was in perfect health for a month.
December 25th he complained of pain in the dorsal part
of the back and did not partake of the Christmas dainties as
an orphan home inmate is wont to do. He said he had had a
fight with another boy on the previous day and had been
struck over the back with a stick, the marks being still visible,
so that the soreness was attributed to this. However, that
panacea for all children's diseases, calomel in I/IO-grain doses
was given him and later an enema, which emptied the bowels
thoroughly.
92 The Medical Society of
The next day he still complained of backache and did
not care to eat. His temperature was normal. That evening
(26th) the attendant noticed that he was quite nervous and ex-
cited but was still without fever at Io p.m. He was restless,
however, and slept only at intervals, and at midnight his tem-
perature began to go up. At 3 a.m. (December 27th) it was
IO3° and he complained of difficulty in deglutition. He ex-
pectorated a great deal and vomited several times at intervals
until 7 a.m., when I saw him for the first time. I found him
quite nervous and excited and talking almost incessantly—it
was not a delirium but a constant flow of words, jumping from
one subject to another, reminding one somewhat of the ideen
flucht of an acute mania. The house was quite warm but he
complained of the draft the minute the door was opened and
also complained of the cold when I threw the cover back to
examine him. This hyperesthesia to cold and draft has been
noticed in many cases of rabies and was really one of the most
pronounced features in this case. The pupils were dilated but
reacted slightly to light and to accomodation. He was con-
stantly making gestures with his hands; sitting up and often
attempting to get out of bed. I asked for a glass of water
but immediately he sat up in bed and cried out that he could
not swallow. I then pursuaded him to try a little milk but as
Soon as he attempted to swallow it he was seized with a spasm
of the throat which ended in a retching until finally he brought
up a little mucus. The scar on his wrist was not sensative to
pressure or reddened and he did not seem to be particularly
alarmed about his condition. Temperature IO2°, pulse I2O,
respiration 20, heart and lungs normal.
A hypodermatic of morphin was given and a chloral-
bromid mixture ordered per rectum. He quieted down for
about half an hour and then his nervousness returned, The
nurse left the room for a few minutes and on her return found
that he had gotten out of bed, upset the chairs, thrown the
bedclothes on the floor and was attempting to break the furn-
iture. At about I I a.m. he became so violent that she had to
call a man to help restrain him.
I saw him again at 5 p.m. The nurse stated that he had
had several convulsions since my morning visit but that he had
City Hospital Alumni. 93
been much quieter for the past hour, that is, he had not at-
tempted to get out of bed. I found him lying in bed, an anx-
ious look on his face, talking and spitting incessantly. Occa-
sionally he had a retching spell but it did not seem to incon-
venience him. He complained of no pains; on sharp question-
ing he would answer in monosyllables, then go off on another
subject. The pupils were dilated but still reacted slightly to
light, the eye movements were coordinate ; the knee-jerk and
Kernig's sign were absent and there was no hyperesthesia of
the muscles; there was no lockjaw by any manner of means,
but he seemed unable to move his legs.
Another morphin hypodermatic was given. He died that
evening at 8 o'clock. Autopsy was refused.
To recapitulate: We have a 13-year old boy who, one
month after having been bitten by a stray dog, after two days
of backache and malaise, is attacked by a rapidly-fatal illness
which is accompanied by great excitement and restlessness,
hyperesthesia toward cold and draft, dilated pupils and
delirium. * \
In the diagnosis we must differentiate between hysteria
(pseudo-rabies) tetanus, belladonna poisoning, infection of the
central nervous system with diphtheria and rabies.
Hysteria is usually not accompanied by fever and does
not end in death.
In tetanus we have the lockjaw, episthotonos, rigidity
of the limbs and often no fever. The course of the disease,
too, is not so rapidly fatal.
The fact that there was no belladonna in the Home at the
time that the boy was attacked, that there was no rash or dry-
ness of the throat, all speak against belladonna poisoning.
Drs. George Douglas Head and Louis Wilson' have re-
ported a case of infection of the central nervous system with
diphtheria, which developed two months after the bite of a
dog in the cheek. The disease closely resembled rabies but
cultures showed the presence of diphtheria bacilli, and diph-
theria antitoxin protected inoculated animals. Death resulted
fourteen days after the onset of the trouble. In our case the
rapid course of the disease speaks against such an infection.
The bite of a stray dog, the stage of incubation and of
94 The Medical Society of
excitement, the hyperesthesia to cold and draft, the convuls-
ions and the rapidly fatal course of the trouble, all make the
diagnosis, rabies, in our case quite positive, in my opinion,
even without a post-mortem.
Hydrophobia is an infectious disease which is usually
propagated through the bite of some of the carnivora, most
often the dog. *
These animals when attacked by the furious form of the
disease, and, by the way, the so-called dumb rabies is only an-
other form of the same disease, have a tendency to roam away
from home and bite anything that crosses their path. It is this
“wanderlust” that makes the bite of a strange dog more danger-
ous than that of others and which spreads the disease. In the
dumb rabies there is an early paralysis of the lower jaw which
prevents the animal from biting, but people have often thought
the animal had a bone in his throat and have gotten infected
by trying to remove the fancied obstruction.
The stage of incubation in human beings is usually from
fourteen days to two months, although Dr Viala” reports a
case which developed twenty-one months after the bite. The
patient had been treated by the Pasteur method and this may
have delayed the onset of the trouble; another of seven
months is reported.” Only IO to 20 per cent of the persons
bitten by rabid animals develop hydrophobia. It is stated
that 30 per cent of those bitten on the head and face; IO to
15 per cent of those bitten on the arms and hands, and 5 per
cent of those bitten on the body or legs, develop rabies. Mul-
tiple, lacerated or punctured wounds are more dangerous than
superficial ones.
After two or three days of malaise, during which there is
usually severe itching in the scar, the stage of excitement
commences; fever sets in and soon difficulty in deglutition
and convulsions appear until death releases the sufferer in
from one to three days. Rabies never lasts longer than one
week; any similar illness lasting longer than seven days is not
rabies.
The urine is usually normal and a blood examination has
shown the presence of a polymorphonuclear leukocytosis in
SOIſle CalSCS. *.
City Hospital Alumni. 95
The autopsy usually shows edematous meninges and punc-
tiform hemorrhages in the cerebrum and the medulla. In dogs
one usually finds foreign indigestible substances in the stom-
ach. The microscope shows a proliferation of the capsule cells
in the medulla and especially in the plexiform ganglia on the
pneumogastric and an infiltration of round cells around the
nerve cells: These latter changes are generally called the
“Rabid Tubercles of Babes.”
Cases of Rabies Reported in England with and without the Muzzling of Dogs.
Cases in Dogs. Cases in Human Beings.
1889 { 312 3O
Muzzling Ordinance Enforced,
1890 I29 8
1891 79 *
1892 38 6
Humanitarian Objections to Muzzling,
1893 R 93 4.
1894 248 * I3
1895 672 2O
1896 438 8
Muzzling ordinance Strictly Enforced,
1897 I5I * 6
1898 17 2
A
1899 . 9 O
I90o 6 * O
}
The specific germ remains unknown but the virus has been
passed through a coarse Berkfeld filter, showing that the
germs, whatever they may be, are too small to be visible with
our microscopes of today; perhaps the Zeiss Ultramicroscope
may reveal them.
• The central nervous system, the cicatrix, the sciatic nerves
and the salivary glands and saliva have all been found capable
96 The Medical Society of
of transmitting the disease. Dr. Adrien Lair" has also demon-
strated that in rabbits, at least, the virus is capable of passing
from mother to fetus. Dr. Pamponki,” the director of the Pas-
teur Institute in Greece, reports a case where a lady developed
hydrophobia sixty-nine days after being bitten by a dog which
showed the first symptoms of rabies eight days after having
bitten the lady in question, thus showing that the saliva is ca-
pable of transmitting hydrophobia even before the disease has
manifested itself in the animal.
The prognosis of the developed disease has already been
given, it is invariably fatal within a week. As a prophylactic
measure it would be wise to enforce the muzzling of all dogs
and the destruction of homeless ones. The accompanying
table, taken from an article by Dr. D. E. Simon,” will show
the utility of this method.
If one has been bitten by a dog or other carnivorous an-
imal, it is advisable not to kill the animal but to keep it under
observation for a couple of weeks to see whether rabies de-
velops. If, as is so often the case in cities, some polieceman
has already acted as executioner, we should have the medulla,
brain and plexiform ganglia examined by a competent pathol-
ogist. It is not advisable to wait for the results of inoculations
into rabbits or guineapigs, as the earlier the Pasteur treatment
is commenced the better is the result. The wound itself had
best be cauterized, either with the actual cautery, or with fum-
ing nitric acid. .*
Dr. Cabot,” of the New York Board of Health, states
that fuming nitric acid will prevent the development of hydro-
phobia in 90 per cent of inoculated guineapigs even if ap-
plied twenty-four hours after the inoculation. Still, I do not
think it safe to rely on its action alone. Perhaps the action of
the carbolic acid, which was used in our case, was too
superficial. * f • .
The Pasteur treatment consists, as you know, of the hy-
podermatic use of a virus attenuated by drying. It is the
only treatment which holds out hope of preventing the dis-
ease after a person has been bitten by a rabid animal and even
it does not save the cases which have a short period of incu-
bation.
City Hospital Alumni. 97
The first injection into a human being was made in 1885,
and it is all the more remarkable that Pasteur, with the limited
knowledge of bacteriology of that time, and no knowledge
whatever of antitoxins and sera, should discover a method of
immunizing a person during the stage of incubation by the
production of an antitoxin. This antitoxin is produced by
the tells of the body and results from the frequent injection
of increasing-doses of the virus which has been somewhat
modified by passing through a series of rabbits. The attenu-
ation by drying is probably dependent on the death of a cer-
tain number of the specific germs, whatever they may be. It
is quite similar to the immunizing of horses to diphtheria.”
The treatment as used at present consists of daily subcu-
taneous injections for eighteen days, beginning with a cord
dried ten to fourteen days and using a fresher one every day.
It is very probable that the duration of treatment will be re-
duced to ten days in the near future, as it has been found that
the virus fire is not as virulent for human beings as Pasteur
supposed it to be.
In the preparation of this attenuated virus a rabbit is in-
oculated under the dura with the virus fire, it is then killed af-
ter the disease has developed, the head is cut off and the
spine divided in the lumbar region and the whole cord is then
pushed out of the cephal end of the spinal canal into a ster-
ile test-tube by means of a sterile rod applied to the lumbar
extremity of the same. The cord is then hung in a sterile
flask at room temperature and after four days a section of the
*As there was some discussion on this particular paragraph, I desire to call at-
tention to the following, taken verbatim from McFarland’s “Text-Book on Patho-
genic Bacteria,” Fourth Edition (1903), page 406:
“It is remarkable that that this theory, based upon limited accurate biologic
knowledge and upon experience with very few bacteria, should find absolute con-
firmation as our knowledge of immunity, toxins and antitoxin progress. What
Pasteur did to produce immunity against rabies is what we now do in produing the
antiserums—that is, gradually accustom the animal to the poison until its body
cells are able to neutralize it. As in the case of rabies, the specific poison can not
be cultivated outside of the body because the bacilli, micrococci, or whatever they
may be, have not yet been discovered Pasteur introduced the unknown poison-
producers, attenuated by drying and capable of generating only a little poison, ac-
customed the animal first to them and then to stronger and stronger ones until im-
munity was established. It was upon the same principle that Behring subsequently
began his work upon diphtheria investigation.”
98 The Medical Society of
cord is cut off every day and preserved in glycerin. This ob-
viates the necesity of inoculating a fresh rabbit every day.
The virus remains unchanged in glycerin for thirty days. I
owe these details of the preparation to the kindness of Dr. C.
Fisch, of this city.
The accompanying table is compiled from reports of Dr.
Viala in the Annals d’Institute Pasteur.
Compiled Table from Dr. Viala's Report.
Bitten on Bitten on | Bitten Else- | Total,
Head, Cases, Hands, Cases, where, Cases,;
% Deaths. Ž, Deaths | ?, Deaths. Ž Deaths.
Diagnosis confirmed by
inoculation of animal,
I900 2O O Io9 2.75 5o 2 I79 2.23
I90I 2O O 93 O 58 o 171 o
I902 2O O 87 2.3 43 O I5O I.33
Diagnosis made by post-
mortem of dog,
1890 78 o 555 O 233 O 866 o
1891 8o o 521 O.77 184 o 785 O.51
1892 5I O 405 O 169 o 625 O
Suspected rabies, no post-
mortem of dog,
I900 28 o I88 O I59 O 375 O
1901 23 4-34 I86 O I 53 O 362 o
I902 2I O 190 o I IQ o 330 O
1900.-Nine cases excluded—devoloped rabies during treatment or less than 15
days after completion of same. \
1901.-Three cases excluded for the same reason.
1902.-One case excluded for the same reason.
Up to 1897, 20,166 case were treated with a mortality—head wounds, 1.1%;
hands and arms, O.47%; other parts of the body, o.30%.
Dr. Carl Fisch, who administers the Pasteur treatment in
St. Louis, tells me he has treated 152 cases, in 122 of which
the diagnosis was confirmed by post-mortem examination of
City Hospital Alumni. 99
the dog. Two of the patients died while under treatment,
none of the others developed hydrophobia. The mortality in
untreated cases is IO to 20 per cent.
After the disease has developed we can only try to relieve
the patient by means of morphin, chloroform, etc., until death
supervenes. *
BIBLIOGRAPHY,
*Journal of Experimental Medicine, 1899.
*Annals d’Institute Pasteur, 1902, 1903 and 1904.
*Berliner Klin. Woch., Sep. 28, 1902.
*Med. Rec., Nov. 23, 1901.
*Quoted by Dr. Fielding L. Taylor, Medical News, 1903.
DISCUSSION.
Dr. CARL Fisch said that there was not much to add to ſ r.
Hempelmann’s report. Since Pasteur’s investigations very little had
developed, in fact, as yet very little was known about rabies. Dr.
Hempelmann’s case was in all respects identical with the many obser-
vations that he had made in such cases. Of course, everyone was in-
terested in the diagnosis of rabies in animals as well as in human be-
ings. In his paper Dr. Hempelmann had mentioned several methods.
That of von Gehuchten, Dr. Fisch considered was so far the most
reliable, referring to changes in the spinal and cerebral ganglia it was
almost specific for rabies; in any case where such changes were found
it was at least suggestive of rabies. The inoculation of rabbits had
so far been held as the only conclusive method, but it had been super-
seded recently by another one which originated from the theory that
hydrophobia was a protozoic disease. The formations found by
Negri, an Italian, were very peculiar and they had the peculiarity that
they were always found only in animals and human beings who had
died from rabies. They were peculiar little bodies inclosed in ganglion
cells, in a number of places in the nervous system, the cerebellum, the
medulla, the cerebral ganglia, but never found in the cord, Their
presence in any case means the diagnosis of rabies. They were cer-
tainly the product of a protoplasmic degeneration of these cells and
were only found in those cases of rabies where the period of incuba-
tion was at least twelve days, nothing present in an animal that had
developed the disease in ten days. The period of incubation is
100 The Medical Society of
usually longer than twelve days. They were very easily demonstrated
and it was a very convenient method of arriving at a diagnosis. In
dogs there might occur a form of the disease that did not resemble
the classical forms of rabies. In one case a dog became sick and a
diagnosis of rabies was made, he was referred to a dog hospital, where
he was cared for until all the symptoms disappeared He lived in ap.
parently perfect health for ten days, was pronounced perfectly well and
taken home. That night the dog died. This aroused suspicion and
a portion of the brain was sent to Dr. Fisch for examination. He
found in the hippocampus these bodies described by Negri. This
case illustrated the difficulties of clinical diagnosis that occasionally
obtain for dogs. Regarding the Pasteur treatment, Dr. Hempelmann
was not correct in calling it an antitoxin treatment. It was a vaccina-
tion, absolutely similar to the vaccination for smallpox. The differ-
ence in the virus used for treatment and that in animals naturally af.
fected was simply that this virus was obtained by successive inocula-
tions of rabbits, increasing the virulence of the virus for them. Its
virulence went parallel with its decrease in virulence for other animals.
Experiment had shown that this virus fixe was not nearly so virulent
for dogs and for human beings as the street virus. So that this virus
was in reality a vaccine which under extraordinary circumstances could
cause the disease. The reason for failures of the Pasteur treatment
might lie in Pasteur’s apprehension that the immediate injection of a
virulent virus would be dangerous for the patient, so that his method of
inoculating in the beginning a virulent and feebly virulent material
took eighteen to twenty one days, entirely preventing any help for
those patients in whom the incubation period would be less than that
time. It had been learned now that the injections of attenuated virus
was a waste of time. By beginning with a strong virus in the com-
mencement of the treatment it would in the future be possible to save
those cases that would otherwise not be benefited by the treatment.
Dr. FISCH said that in inoculating the virus they were simply in-
oculating a living virus, so that they certainly vaccinated with an ambo-
ceptor-producing principle and certainly not with a passive antitoxin.
No doubt one injection of virus fixe would protect the patient, but the
difficulty was that they could not experiment on human beings. It
City Hospital Alumni. 101
f
had been tried frequently on dogs with complete success. In other
words, the Pasteur treatment as followed now was, he believed, some-
times a dangerous waste of time. Still he had no right to put his
theory into practice and experiment with his patients.
Dr. AMAND RAvold agreed with Dr. Fisch that the Pasteur treat-
ment for rabies is a vaccination, and is so spoken of by members of
the Institute in Paris. He was aware, that in a restricted sense, vac-
cination meant inoculation with lymph derived from cows, cowpox, but
the word is also used in a general to mean, inoculation with the modi-
fied virus of any specific disease, either to produce the disease in a
modified form or to prevent its attack. The question is one of at-
tenuation and the manner in which it is accomplished In the Pasteur
treatment, the spinal cord of animal dead of the disease is used and
the virus which 1t contains is attenuated by time, while in bovine vac.
cination the virus of smallpox is attenuated by first passing it through
an animal less susceptible to the disease than man. He was very
much impressed with the English statistics presented by the essayist
upon the rapid disappearance of rabies following the muzzling of dogs
since 1896.
In 1896 while attending the Pasteur institute, in Paris, he had met
several Englishmen at the Institute receiving treatment for bites from
rabid dogs. He asked one of them why he had come to Paris for
treatment. The Englishman replied: “Because, the life and comfort of
a dog is looked upon as more important than that of a man in my coun-
try. Rather than a dog should go muzzled, or a Pasteur Institute be
established in England, a flock of dog lovers and antivivisectionists
believe and act upon the belief that the bitten man should die.”
These statistics demonstrate that common sense at least reigns in
that country.
Here in St. Louis that there is a plentiful lack of common sense
on that subject, is shown by the fact that two papers reporting two
cases of hydrophobia are presented tonight. Unmuzzled dogs are
permitted to run about, with licensed liberty to bite, whenever and
whomever they please, and, “What are you going to do about it?”
Never a day passes but two or more cases of dog bite are reported in
the daily press, while the veterinarians are busy killing rabid animals.
102 The Medical Society of
One veterinarian had informed him, that in one week, he alone, had
killed, on request, five dogs suffering with rabies. He believes that
the Society should take cognizance of the conditions and take steps
leading to legislation for the mitigation of the evil.
Dr. CLARENCE LOEB asked if it would not be possible to inocu-
late dogs in such a way as to prevent their going mad, as is done in
the case of vaccination of people against smallpox.
Dr. FISCH replied that dogs could be protected in the same way as
human beings. The immunity would last for about one year.
Dr. H. S. CROSSEN asked Dr. Fisch if any untoward results had
ever followed this treatment.
Dr. FISCH replied that nothing more had come of it than the re-
ports of a few cases in which there were observed certain nervous dis-
turbances during treatment, but the influences of the nervous excita-
tion over such an accident could explain that.
Dr. WALTER BAUMGARTEN asked why it was, if the injections were
comparable to vaccin, that the cases that developed earlier than the
fourteenth day were not protected.
Dr. AMAND RAvold asked where Dr. Fisch looked for these cells.
Negri had said that they were to be found in the pyramidal cells of the
cortex, the hippocampus major and in several other places. Now,
where should one look first for these cells in a human being 2
Dr. GEORGE HomAN asked, if there was a bite on the hand, body
or face, how was the constitution infected through the branch or lymph
channels or did the virus travel along the nerve branches to the cen-
tral nervous system.
Dr. FISCH, replying to Dr. Baumgarten’s question, said that it was
in consequence of the course in which the treatment was given. Dur-
ing the first ten days days the virus injected contained so little of the
virulent material that the patient reacted only slightly. By the present
method sufficient immunization was not obtained within less than
thirty days. As to the first place to look for the Negri bodies, he said
that it was in the hippocampus. Replying to Dr. Homan’s question,
he said that the virus of hydrophobia was never found in any organ of
the body except the salivary glands, it was never found in the blood
or the lymphatic system but always in the nerves. The distribution
City Hospital Alumni. r 103
of the virus led to the conclusion that it was not absorbed by the cir-
culation. The primary infection starts at the point of the injury,
and travels slowly along the nerve paths to the centers.
Dr. SHUTT, asked what effect it would have to remove all the tis-
sue in the neighborhood of the wound. Would it have any effect in
preventing the disease ?
Dr. Fisch replied that if applied immediately in all cases it would
in many instances prevent the occurrence of the disease. But it was
not generally reliable. Very extensive experiments had been made in
Germany about the effect of bichlorid, nitric acid, etc. A series of
rabbits were infected by causing a superficial abrasion of the skin and
rubbing the virus into the injury. After one, two, etc. minutes the
wounds were cauterized and the animals observed Those cauterized
ten minutes after inoculation developed the disease at the usual time.
In those treated in a shorter period, the period of development was
delayed, while in cases of those cauterized one to two minutes after-
ward, some remained alive for two years, others developing the disease
after 200 or 3oo days. As to preventing the disease, it could be done
easily by resecting the corresponding nerves, at a certain distance
from the point of injury. Replying to a question by Dr Ravold as to
the present status of the Negri bodies, Dr. Fisch said that they were
pathognomonic of the disease.
Dr. HEMPELMANN, in closing, said that in vaccination a certain
number of germs were introduced at one time, and if this was simply
vaccination he did not see the utility of repeating the process. One
injection ought to do the work. In other respects he accepted the
corrections made by Dr. Fisch.
\
104 The Medical Society of
Hydrophobia Developing Eight Months After
Primary Injury.
By C. H. SCHUTT, M.D.,
ST. LOUIS, MO.
! - *
HE patient, Henry P., a school-boy, aged 9 years, and a
resident of this city, was admitted to the City Hospital
at 8:30 p.m., March 17, 1905. He was accompanied
by his father, was able to walk and seemingly had strength
and good use of his muscles, but appeared very much excited,
would not remain seated in one place only a few moments and
talked only when spoken to; his answers were intelligent and
showed an exceeding keenness of perception and increased
mental activity. His sense of hearing was acute—he answer-
ing questions from such a distance that ordinarily they would
not be heard. *
His father stated that the boy was bitten near the base of
his right thumb by a stray cat last July. The cat escaped. A
definite account of the accident was not obtainable. The bite
healed nicely, leaving a scar one inch long, Further trouble
was not experienced until about a week previous to his enter-
ing the hospital. At that time, while at school, he noticed a
headache, vertigo and felt weak, and was allowed to go home.
This condition gradually grew worse, swallowing became dif-
ficult and he retched and vomited during a period of one day
before he entered the hospital.
The patient was a white boy, weighing about 85 pounds,
fairly well nourished; skin pale, moist, slightly flushed over
the cheeks and apparently healthy; muscles firm ; eyes large,
slightly exophthalmic and pupils widely dilated; teeth good ;
tongue clean and the mucous membranes had a very deep-
pink color; chest fairly well formed, respiration arrythmical,
breathes freely and normally three or four times then suddenly
gasps and breathes rapidly and deeply several times, then res-
piration ceases for a short time. At other times he had at-
tacks of dyspnea. He had no appetite and could eat but lit-
City Hospital Alumni. 105
tle—he ate only a quarter of an orange while in the hospital.
He could not swallow any liquid and the sight of it caused an
intense feeling of disgust, and at times spasms of the throat
muscles; complained of soreness in the throat but no areas
of inflammation could be found. The cardiac area was slightly
increased, the apex beat was forceful, the sounds were not eas-
ily made out, no murmurs were heard; pulse rapid, irregular,
weak and easily compressed.
He said that his bowels had not moved for ten days and
a laxative enema was ineffective. His urine was passed norm-
ally. All his special senses appeared to be intensified. His
temperature was 99.6°. He complained of slight drafts
through the ward, saying that they made him uncomfortable.
He was put to bed and remained there voluntarily. At-
tacks of dyspnea were frequent; he frothed at the mouth and
became very restless about half an hour before his death at
3:45 a.m., March 18th.
The post-mortem was held by the Coroner, and Dr. Carl
Fisch, who was present, reported that the usual signs of rabies
were present in the brain. There was no meningitis.
Meeting of April 20, 1905; Dr. John Green, Jr.,
President, in the Chair.
Eclampsia.
Report of Three Cases, With Two Recoveries, and the
Autopsy-Findings of the Third.
By PERCY H. SWAHLEN, M.I).
ST. LOUIS, MO.
N defining our modern idea of eclampsia, Edgar quotes the
words of Charpentier, that it is an acute morbid condi-
tion, making its event during pregnancy, labor or puer-
peral state, which is characterized by a series of tonic and
106 The Medical Society of
clonic convulsions, affecting first the voluntary and then the
involuntary muscles, accompanied by complete loss of consci-
ousness and ending in coma or sleep. v
In diagnosing eclampsia we must keep in mind hysteria,
epilepsy, meningitis, and some mention apoplexy, but if we are
able to obtain a comparatively accurate history and can estab-
lish the fact that the patient be pregnant, note carefully the
nature of the convulsions and examine the urine, at least from
a qualitative standpoint, we may reasonably designate the af-
fection as “The Disease of Theories.”
Regarding Case I, I am under obligations to Drs. Taake,
Evans and Eastmann, the first for data concerning her while
an inmate of the Salvation Army Maternity Hospital and to
the latter for their co-operation while she was under our care
at the St. Louis City Hospital.
CASE I.—Anna W., single, aged 21 years; German par-
entage; nativity, Illinois.
Aſabits.-Regular hours for sleep and meals. A mod-
erately hearty eater of plain food. Occasionally drank a small
amount of beer. No drug habit. Bowels always moved well
daily till she became pregnant. Sexual habits good.
Family History.—Father died at age of 58 years, cause of
death unknown, but he was always considered a healthy man.
Mother living and always healthy, had ten children and always
arose from bed four or five days after confinement. Six broth-
ers and sisters died in infancy and a brother and sister at the
ages of 24 and 25 years respectively, causes of death unknown.
One sister confined at about the age of 20 years without any
abnormality, but when confined again at about the age of
25 years had several very severe convulsions. At each con-
finement, sister was delivered of an average-sized, living child,
she died shortly after second delivery. No family history of
insanity, tuberculosis or malignant growth.
Past History.—Always lived in the country and remem-
bered having no disease save a mild attack of rubeola in the
spring of 1904. Began menstruating at the age of I2 years,
was regular each month, flow lasted three or four days and was
of moderate quantity, and the patient seldom experienced
pain. No miscarriages or former pregnancies.
City Hospital Alumni. 107
Present Affection.—Last menstruation about June 26, 1904.
The following three months she vomited considerably. When
she became aware that she was pregnant she worried con-
stantly and came to the Salvation Army Maternity Hospital
hoping to avoid the fatal affection of her sister. At this time
she was suffering considerably from constipation and had felt
“quickening” for about two months.
Physical Examination.—On January 30, 1905, no abnorm-
ality of the patient was found save a slight edema of both ex-
tremities but this condition gradually became more marked
until March 21st, when there was a slight improvement. On
this latter date, according to Dr. Ehrenfest's notes, the uterus
was found to be very large and had a “high protuberance”
around the umbilicus. Uterine walls were so tense that
palpation was almost negative and lower portion of abdominal
walls was edematous. Striae edematous and protruding.
The small fetal parts were felt in left uterine cornu. A
center of distinct heart sounds (23 or 24 in ten seconds) was
heard just above the umbilicus and two or three inches to the
right, while another was heard just above symphysis and to
the left.
Vaginal examination at this time showed the cervical
canal to be about 1/4 inch long, open for one finger and mem-
branes tense. Fetal head felt above brim, deviated to left.
Bones of skull markedly soft. Diagnosis—either twins, the
first in head, the second in breech presentation or (less prob-
able) hydrocephalus. Urine showed no abnormality.
About 1:30 a.m., March 23, 1905, the patient was suddenly
seized with a convulsion. By 2:30 a.m. she had had six con-
vulsions and these were followed by more at the rate of two
each hour till delivery at 8:OO a.m. At 1:30 a.m. the patient
rceived morphin sulphate grain 1/4, hypodermatically. At
2:30 a.m. chloral hydrate grains 50, per rectum and at 3:OO
morphin sulphate grain I/4, hypodermatically.
The patient entered the St. Louis City Hospital at 4:2O
a.m., March 23, 1905, and was soon seen in a convulsion. At
first the fingers showed slight twitchings, then slight move-
ments of muscles of face and oscillations of the eye balls,
followed quickly by marked flexion of the fingers, rigidity of
108 The Medical Society of
muscles of limbs and trunk, sterterous breathing, frothing at
mouth and slight opisthotonos. These phenomena gradually
diminished in the order of their occurrence and had entirely
disappeared at about the end of two minutes, when coma en-
sued. *
Between attacks the patient's temperature was 99° axil-
lary, respirations 28 per minute costal and regular; pulse
96 per minute, regular and tense. Ten ounces of urine were
drawn. No qualitative abnormality of the urine was found, and
the enema was retained. One minim of oleum tiglii was given
on the tongue. At 7:00 a.m. ten minims of Norwood's tinc-
ture of veratrum viride were given hypodermatically. Heart
sounds indicative of endocarditis and large moist rāles were
heard at the bases of both lungs posteriorly. Reflexes in-
creased but no organic affection of the nervous system was
elicited. Pelvic measurements—conjugate 2 I cm., intercrestal
28 cm., interspinal 26 cm. and intertrochanteric 31 cm. One
fetal heart sound was heard faintly about two inches to the
left and about three inches below the umbilicus. Another, still
fainter was heard about one and one-half inches to the right
and about three inches above the umbilicus. The os was di-
lated to admit three fingers, and a L. O. A. position was
diagnosed.
Delivery.—The patient was given chloroform, the os slowly
dilated (in about 15 minutes) manually, membranes torn by
the finger and high applications of the forceps made. Living
male child weighing about 6 I/2 pounds was delivered at 7:45
a.m. Another child felt at fundus of uterus. Podalic version
was performed, and a living female child weighing 5 1/2 pounds
was delivered at 7:55 a.m. Placentae came away readily about
20 minutes after the delivery of the second child. Both chil-
dren were very blue and died about one hour after birth. A
bilateral laceration of the second degree repaired by taking
three silk-worm gut sutures on each side within the vagina and
two deep ones through the perineum.
At 9: I 5 a.m. a hypodermoclysis of 300 cc. of normal saline
solution was given and one pint of blood drawn from the me-
dian basilic vein. At 11:00 a.m. the patient apparently rested
more easily, but at 12:OO m. the axillary temperature registered
City Hospital Alumni. 109
IO2.4°, the pulse was regular but tense and 130 per minute.
Respirations costal, regular and 24 per minute. The patient
restless. Uterus nicely contracted. At 3:45 p.m. the patient
had a slight convulsion similar in nature to those before deliv-
ery. Urine voided involuntarily. At 6:00 p.m the axillary
temperature registered IO4° Pulse I40 per minute, regular
and tense. Convulsion at 6:45 p.m. Veratrum viride (Nor-
wood's tincture), ten minims, were given hypodermatically.
7: IO p.m. A slight convulsion.
7:35 p.m. High alum enema was given.
7:45 p.m. Bowels moved weil.
9:OO p.m. Bromid and chloral mixture, five ounces, were
given per rectum. Temperature, axillary IO3.8, respirations
36, pulse I28.
9:05 p.m. Urine passed involuntary. Veratrum viride
ten minims, were given hypodermatically.
I2:OO m. Temperature, axillary IO4°, respirations 32,
pulse IO4°.
Veratrum viride, ten minims, were given hypodermatically
throughout the night of the first day and all of the second
day, every three hours, when the pulse had reached its lowest
rate—80 per minute—was regular and of fair tension. Res-
pirations 36 per minute, regular and costal. Temperature
IO4°.axillary.
Third Day.—9:OO a.m. Urine negative, bladder and
bowels moved involuntarily but the patient was quiet and con-
scious all day. Blood spread showed possibly a slight increase
of eosinophiles, vaginal smear showed streptococci. Tempera-
ture 98.8°, mouth, respiration 24, pulse 90.
Fourth Day.—9:OO a.m. Culture from sterile urine (?)
negative. No albumin, sugar or casts. Leukocyte count
3,945. Temperature IOI.8°, mouth, respirations 28, pulse 108,
regular and good tension.
From the fourth day on the patient gradually became
stronger, but for three weeks the morning temperature was
about 100°, respirations about 34 but normal otherwise, and
pulse about I 15 to I2O. The evening temperature was about
I° higher and other symptoms in like ratio, Widal reaction
negative.
110 The Medical Society of
The patient’s only complaint during this period was a
slight cough, but condition of heart and lungs gradually im-
proved under the administration of adrenalin hydrochlorate,
ten minims of I/IOOO solution, every three hours, and symp-
tomatic treatment. Hot vaginal douches of 1/3000 bichlorid
of mercury were given for a period of 20 minutes daily.
Stitches removed on tenth day, and parts well approximated.
A bilateral laceration of about half of the cervix was found.
The patient was allowed to sit up on the 21st day and im-
proved steadily till the 25th day when she was considered no
longer in need of medical treatment.
In connection with this case I wish to state that in spite ,
of the strictest asepsis a small abscess developed at each site
of the hypodermic injection of the veratrum viride.
CASE 2.-Lillie C., aged 24 years; fair education; house-
maid by occupation.
Habits.—Usually regular hours for meals and sleep.
Small eater of plain food. Never used tobacco or any drug.
Occasionally drank beer in small quantities. Bowels usually
moved well daily. Sexual habits good.
Family History.—Father living and healthy. Mother
dead, age and cause of death unknown. One living brother.
No knowlege of tuberculosis or insanity in family.
Past History.—Had ordinary diseases of childhood from
which she readily recovered. No history of veneral affection.
Began menstruating about the age of I4 years, and had been
fairly regular. Duration and amount of discharge about
normal and accompanied by but little pain. No miscarriages
or former pregnancies.
Present Affection.—Thinks her last menstruation was about
the 24th of December, 1904. Vomited considerably during
the month of January, 1905, and later brooded considerably
over the fact that she was pregnant. Had a severe cold for
about two weeks before entrance to the hospital—coughed
considerably but bowels moved well daily and noticed no ab-
normality of micturition.
At no time did she notice any swelling of limbs, face or
abdomen but was often dizzy after “ironing day.” Never ex-
perienced any abdominal or thoracic pain. Had severe frontal
City Hospital Alumni. 111
headaches during the day for three days prior to March 26,
1905, but these always disappeared at night. With the excep-
tion of this headache she felt very well during the day of
March 25, 1905, and took a warm tub bath before retiring.
Remembered nothing afteward. She was brought to the St.
Louis City Hospital in an ambulance, at I: I 5 p.m., March 26,
I905.
Physical Examination.—Well nourished colored woman.
Weight about 120 pounds. Inspection revealed no marks or
scars; respirations 26 per minute, costal ; lower portion of
abdomen bulging. Thoracic organs apparently normal save
the breath sounds were of a bronchical nature and heart sounds
slightly roughened. No organic lesion of nervous system
was found but the patient was unconscious and reflexes rather
lively. Pulse regular, 88 per minute, and strong. Tumor of
abdomen proved to be uterus, which extended half way to the
umbilicus. External as soft but admittted only end of index
finger. Urine showed almost 1/2 per cent albumin and numer-
ous hyaline and granular casts. The patient had three slight
convulsions similar in nature to those described under Case I,
but of less severity, between I: I5 and 2:30 p.m., March 26,
1905. At 4:30 p.m. the patient had a severe convulsion and
this was follow by numerous slight convulsions until 8:OO p.m.
when the entire contents of the uterus were expelled, while
being prepared for premature labor. Fetus about 5 months.
At this time the rectal temperature registered IO2, respirations
30 per minute, costal and regular, and the pulse IO8, regular
and tense. At Io:OO p.m. the patient had a slight convulsion
and another of similar nature IO: IO p.m. At Io: I 5 p.m. Nor-
wood's tincture of veratrum viride, ten minims were given
hypodermatically. At II: I 5 p.m. pulse was 88, respirations
28, and rectal temperature IO2, when a like dose of veratrum
was given.
At 7:00 a.m. the patient was semiconscious but very rest-
less. Pulse I24, respirations 30 per minute, and rectal tem-
perature 99.6. Veratrum viride was given hypodermatically
until at I:30 p.m. pulse was 78, respirations 30 per minute.
Rectal temperature 99.4°. After this the patient rested
quietly, and pulse remained about 80 with normal temperature
112 The Medical Society of
*
for forty-eight hours. The respirations, however, were more
rapid from time to time with intervals when they were normal.
The urine showed but a trace of album in the day following
delivery and but few casts, and no abnormality was found on
the third day. *
The patient was markedly irrational at times for ten days
after delivery when she had apparently become normal in all
respects and was discharged as cured one week later.
In this case as in the preceeding an abscess was formed
at the site of the injection of Norwood's fluid extract of vera-
trum viride.
CASE 3.-Ella W, married, aged 20 years; waitress by
occupation, white.
The patient was admitted to the hospital in a semicon-
scious condition which soon became of a comatose nature so
a complete history was not to be obtained.
On entrance pulse was IO4, regular and tense; respira-
tions 28, costal and regular; rectal temperature IO2.2°. Urine
showed small amount of albumin and a few hyaline and gran-
ular casts. Between II:30 a.m., March I 3, 1905, and I: I5 a.m.,
March 14, 1905, the patient had eight severe convulsions of
the nature described under Case 1. Despite hot packs, ene-
mata and hypodermoclyses and opium tincture the patient
gradually became worse and was delivered manually of about
a 7-months' dead fetus at 8:15 p.m., March 1, 1905. Chloro-
form was used during convulsions and bromids and chloral
were given per rectum but the patient never recovered consci-
ousness and had a temperature of IO2 4°, axillary, respirations
44 per minute, and pulse 16O per minute an hour before death
at I: I 5 a.m., March 14, 1995. §
The interesting part of this case is the pathological work
which Dr. Baldwin has kindly consented to discuss.
Dr. F. A. BALDWIN said that this case had come to autopsy one
day when he was very busy, so that he had had Dr. Horton perform
the autopsy.
Microscopical examination of the kidneys showed cloudy swelling
and localized fatty degeneration; the liver showed marked fatty de-
generation; the lungs marked congestion and edema. He found some
City Hospital Alumni. 113
multinucleated masses in the pulmonary capillaries which were not
surrounded by protoplasm, except in a few, where a small amount of
homogeneous, hyalin protoplasm surrounded them. In the liver he
found cells in the hepatic capillaries which had dark staining, slightly
lobulated nuclei, surrounded by a small amount of clear hyalin proto-
plasm. The sections of the hemorrhages present in the meninges did
not reveal these cells.
DISCUSSION.
Dr. HUGO EHRENFEST had seen the first patient for several
months. Probably two months before the expected confinement the
atient developed marked edema of the lower extremities reaching up
to the abdomen. Albumin had never been found. The abdomen
was much larger than he would have expected to find it, which led him
to suspect twins. He tried to palpate them but never succeeded. A
few days before the time of her expected confinement he had been
able to reach the head and at that time made a diagnosis of twins be-
cause the segment of head to be felt was too small and too soft for a
fetus so large as it must necessarily be if there were not twins. This
was the largest abdomen that he had ever seen and he presented two
pictures taken, six to eight hours before the convulsions started. The
patient had been very despondent; she said that her sister had died
in convulsions and that she would too. Her mother had gone to see
Dr. Ehrenfest and had said that her daughter was convinced that she
was going to have convulsions. Without any warning she had her first
convulsion. The patient was sent to the City Hospital where she had
arrived about 3 o'clock, but she was not delivered before 8 o’clock.
In the second case reported the physicians at the City Hospital had
waited seven or eight hours and in the third case some time had
elapsed before an attempt at delivery was made. He wished that
that point would be taken up in the discussion: Whether there was
any excuse for that delay in delivering a patient in such a condition?
Prophylaxis and Treatment of Eclampsia.
Dr. HENRY SCHWARZ said, in speaking of this subject, one could
hardly do so without taking into consideration the causation. He dit-
114 The Medical Society of
fered in a good many points from Dr. Ehrenfest but thought they had
both come to the one conclusion, that after all they did not exactly
know. In a great many cases seized with eclamptic convulsions the
urine gave no indication but there were a great many other cases
where such was not the case. Nevertheless, the urine in a great
many instances was the only guide the physicians had in watching the
pregnant woman. The toxic condition of the pregnant woman’s blood
was in a measure responsible and it was believed that she was less
likely to become toxic if all the organs of elimination were kept keyed
up to the highest degree of efficiency. It would therefore seem natu-
ral that every pregnant woman should be placed under observation
and her urine examined. During the first half of pregnancy the uriº
should be examined once a month, then once a week. The presence
of albumin and even the presence of casts was not always followed by
eclampsia, but when the physician took such cases in hand and as-
sisted the kidneys, he felt that he had assisted in preventing the catas-
trophe. In cases in which there was only a moderate degree of albu-
minuria a modified diet might be sufficient, but in every case showing
pronounced albuminuria, especially in the presence of casts, a strict
milk diet should be resorted to. Where that treatment was used the
general condition almost invariably became better and the albuminuria
much lessened if it did not no disappear altogether. Of course, there
were cases where the condition might take a turn for the worse. When
the albumin continued to increase and casts were present the patient
should be surrounded with all necessary precaution in case an eclamp-
tic convulsion should occur. Of course, when there were no changes
in the urine, the physician was absolutely without a guide and could
do nothing to prevent the outbreak of convulsions. After convulsions
took place, the treatment should be such as could be resorted to by
any practitioner under any surroundings. The object was to reduce
the mortality, but the fact was that the mortality had never yet been
reduced. The best clinics in Europe show a mortality of 20 per cent.
It was not the fault of those clinics that the mortality was so high for
the cases were brought there when they were in a more or less hope-
less condition and when seized by the attack they were not in proper
surroundings so that much valuable time was not lost. It also ap-
/ -
City Hospital Alumni. 115
peared that the new modes of treatment never would and never could
have a tendency to reduce the mortality, for lumbar puncture,
Cesarean section, decapsulation of the kidney, etc., could only be
resorted to in first-class hospitals and the great majority of cases did
not occur in hospitals but in the homes all over the land. It was
necessary, therefore, that a treatment be selected that everybody could
follow. A great majority of the cases would not occur if the patients
were properly watched. When convulsions occurred during pregnancy,
it should be remembered that sometimes one or two attacks might take
place and the patient outlive the attacks. If the child was not viable
those patients should be given a chance if there was no change in the
urine. In such a case the first thing to do would be to administer
chloroform, a hypodermic of morphin or chloral per rectum. When
those three agents were named they included all the methods known
for effectively treating eclampsia short of immediate delivery. The
physician should not temporize, he should give half a grain of morphin
and watch the effect, note whether the patient regained consciousness
and watch the pulse. When the arterial pressure was high more con-
vulsions might be expected unless that tension was relieved. Vene-
section was the most satisfactory mode of reducing arterial pressure,
as it not only relieved this pressure but carried off a certain amount
of the toxins circulating in the blood. Venesection of a pint or more
was a very valuable resource if there was no change in the urine.
The speaker did not believe in veratrum for convulsions except after
delivery, but he knew there were those who had had larger experience
than he with veratrum and had found it serviceable in all cases. He
did know, however, that it was possible to give it hypodermically with-
out forming abscesses, for he had given it over and over again without
causing abscesses. The pulse could be reduced to 60 but it was
necessary to give 20 minims to start with and that was always a dan-
gerous means and there were those who felt afraid of it. The post-
partum cases, in view of the amount of blood lost in post-partum
hemorrhage, were the most suitable cases for veratrum. In the ma-
jority of cases recovery usually followed delivery, if delivery was ef.
fected quickly enough, and it was well known that the danger was in-
creased with each convulsion. After a woman had been carried about
116 The Medical Society of
the city and had remained seven or eight hours in the hospital before
delivery she had not the chance for recovery that she would have had
if delivery had been effected quickly. The only question was, in what
way should the patient be delivered, when she was not parturient and
there was no inclination on the part of the uterus to contract or the
cervix to dilate. Any woman could now be quickly and safely deliv-
ered, no matter in what stage, if she was in good surroundings. In
dilating the cervix uteri there was one instrument the physician would
always have at his immediate service and that was the hand. [t was
useless to tell a man on a lonely farm to get a Bossi dilator for ac-
couchement forcé, but he could use the hand. When the cervix was
softening and yielding and one could dilate with the finger, he should
do it, if not, then a little steel dilator could be used. Or one could
use Duehrsen’s vaginal Cesarean section. Duehrsen’s method of
splitting up the cervix should not be called by so formidable a name.
It was a good method and when the physician found that he had not a
Bossi dilator or anything that would answer the purpose he could
adopt this. All that it was necessary to do was to pull down the cer-
vix and make a little transverse incision, through the vaginal mucous
membrane, push the bladder up out of the way and take the scissors
and cut through the cervix, from the external os to well above the in-
ternal os, then repeat the operation posteriorly. But it was surprising
in how few cases this was necessary. Cases that had had a few con-
vulsions would be found more ready to yield than was generally admit-
ted. When the Bossi dilator first appeared all were enthused over it,
then all turned their backs upon it and said that the Duehrsen method
was the thing. The truth was, as usual, about in the middle. The
cases in which it was unsuccessfully used were probably unsuitable
cases. By its use in primiparae the speaker had found that he could
get the cervix open in ten minutes ad maximum, the woman was de-
livered and he could find no tears. At a subsequent pregnancy he
could see that no harm had been done, so that he believed such instru-
ments were serviceable. But he would not base the treatment of
eclampsia upon such an instrument because he did not believe they
could be made universal, so that they could be found in every obstet-
rical satchel. When convulsions occurred during parturition the wo-
City Hospital Alumni. 117
man should be delivered as quickly as possible. When the patient
was in labor there was no difficulty in delivering quickly. If hasty de-
livery seemed to endanger the life of the child, it was sometimes pos-
sible to await the end of the first stage of labor, but if the woman re-
mained in a comatose condition following the convulsion, she should
be delivered at once. The third class of cases, those in which the con-
vulsions occurred after delivery, were not quite so easy to meet. The
remedies were morphin, chloroform and chloral hydrate and, if the ar-
terial tension was high, those were very good cases in which to try
Norwood's tincture. Luckily most of those cases of post-partum
convulsions got well but occasionally one found cases that did not get
well and they were cases exceedingly hard to explain on any of
the theories Dr. Ehrenfest had named. After all, just about as little
was known about the etiology as twenty-five years ago. It was to be
admitted that twenty five years ago, when the speaker had first begun
to teach, they had taught many theories they really did not believe in
themselves, there were some things they could not fathom, and so it
was today. While it is now believed that the mortality could be re
duced by careful watching and treatment, yet no matter how early
they were seen or how prompt the attention, a certain number of cases
would baffle treatmel,t and one should be very charitable with his
brother practitioners who failed to cure cases as one thought they
should. Many cases were lost because the physician had not outlined
a decided Course of action. Every man should have a radical
course of procedure, no matter what that course might be, and it
should be promptly followed out. Nothing could be more fatal than
activity not well directed. *
Dr. B. M. HYPEs felt that the subject of puerperal eclampsia had
been most thoroughly treated by the speakers, yet it was a subject of
which they could not hear too much and which they could not study
too thoughtfully. Both in regard to its etiology and its treatment all
were in doubt, and, as the speakers had indicated, each man generally
had a special line of treatment which he considered the best. He
had nothing but commendation for the speakers of the evening and he
had nothing more to add except to report, as he had already done
to the City and State Medical Societies, his own experience and ob-
118 The Medical Society of
servation in managing these cases. As Dr. Schwarz had very prop-
erly stated, any man who expected to treat these cases should have a
very definite outline in his mind so that when he did meet such a case
he would know how to manage it properly. Time was of the utmost
importance. A few hours, where the temperature rose rapidly and the
convulsions occurred frequently, were sufficient to thwart all treatment.
His own experience had been principally with the use of veratrum
viride. He had treated and tabulated 11 cases, treated principally—
and all of them partially—by the use of veratrum, and the result had
been that, out of the II cases, ten had recovered and I died. The
fatal one he had seen only an hour before her death ; the woman was
then in a moribund condition, she had had convulsions many hours,
was undelivered and in a comatose condition. He at once gave, hy-
podermically, 20 drops of Squibb’s fluid extract of veratrum, and then
delivered the child; but the patient died within an hour. This case
ought not be recorded as for or against any line of treatment, for there
was no opportunity for the successful use of any remedy after he had
seen the patient. In the management of eclampsia heroic measures
should be used ; especially was it, true that small doses of veratrum,
morphin and chloral were of little value. The successful treatment
was by heroic doses. If one used morphin he must use a large dose.
The speaker had not used it for a number of years for, as he believed,
it was contraindicated and an account of his results in the employ
ment of veratrum. Followinig the veratrum to keep up a quiet con-
dition of the nervous system, chloral hydrate might be used, for there
was no doubt that the exhausted condition of the patient’s nerves
from the strain that had been put upon her mind and body had placed
her in a condition to render her liable to eclampsia. It must be remem-
bered that it was only in pregnancy that tetany, chorea and certain
other nervous conditions were observed in the adult woman. So that
the condition of the patient’s nerves should evidently be attended to
and chloral hydrate met that condition. During his years of practice
he had held venesection in the treatment of eclampsia in very high re-
gard. Professor Boisliniere had taught them that it was the remedy
and Professor Lusk had taught that venesection was the first means to
adopt in puerperal eclampsia. He had combined this with the use of
City Hospital Alumni. 119
veratrum in 5 of the cases referred to. In connection with venesec-
tion the use of salt solution should not be forgotten. It was beneficial
in all depressed conditions but was especially indicated in puerperal
eclampsia. Since 1889 it had been very popular with the profession.
At that time a number of cases were reported from the Rotundo Hos-
pital in which the mortality was reduced from 47 per cent to 17 per
cent, proving its use to be a very import factor in the treatment of
eclampsia. It was especially valuable when a certain amount of the
toxic material had been removed by venesection. With him, venesec-
tion had been nearer a quart than a pint and that blood was replaced
by normal salt solution. In that way the poison was diminished about
one-fourth or one-fifth. Many authors laid stress upon one point:
That the indication for venesection, veratrum viride, etc., was a bound-
ing, strong pulse, but the speaker said most emphatically that he had
never seen a bounding, strong pulse in one of these cases. The pulse
was always weak and rapid. The only contraindication for venesec-
tion was an anemic condition. If the patient had sufficient blood,
extract it and if the pulse was rapid veratrum should be used. There
was but little danger in the use of veratrum. If the patient was kept
in a reclining position and stimulants given, if necessary, the dangers
might be overcome. In all the use of veratrum for fifty years, given
from a teaspoonful to a tablespoonful of Norwood's tincture at a dose,
not a single fatal case had ever been reported. It did tend to produce
syncope but as above mentioned, a reclining position and stimulants
would overcome that. .*
Dr. EHRENFEST replying to Dr. Elbrecht's question, as to how
long before delivery albumin appeared in the urine, said that there had
been no albumin present two or three days before and as long as she
was in the City Hospital no albumin was found according to the state-
ment of Dr. Swahlen.
Dr. ELBRECHT, said that the kidney was the only organ that would
give the physician an index of the trouble that was coming. It was
impossible to observe the other organs mentioned by the essayist
but the kidney should give the indication by its products. As to vera-
trum, he had seen half a dram given and he had given 30 minims
but had stopped the use of it entirely, treating all cases as a
120 The Medical Society of
toxemia. The first thing to do was to get rid of the cause, and that
was done in delivering the woman, and then get rid of the toxins.
The most efficient means that he had found was the use of croton oil.
The moment a patient was seized with a convulsion two drops of the
croton oil with a dram of any bland oil, were placed on the patient’s
tongue. If there was no action. within two hours, the dose should be
repeated. He had given as high as eight drops but he had always
gotten action from it Then pilocarpin should be given and the pa-
tient surrounded with hot water bottles. One patient whose urine
contained 1 1/2 per cent albumin showed prodromal signs of eclamp-
sia and was also partially insane. In this case he had produced pre-
mature birth with the Bossi dilator. There resulted a bad cervical
tear and a typical eclampsia, but the patient had only one convulsion
after delivery. The chloral and morphin treatment was in his opinion
symptomatic treatment pure and simple. The first thing to do in such
cases was to deliver the woman in order to get rid of the cause and
to get elimination ; as one could not get it through the kidney, one of
the quickest and most copious ways was through the alimentary tract.
This treatment was suggested by Dr. Williams. He had given up the
veratrum because he believed it was possible to reduce the pulse and
dilute the toxins by the use of saline solution following venesection
more quickly than in any other way. It was in these cases as in any
toxemia, the first thing to do was to remove the poison and then to re-
vive the structures. He had tried to get a new cathartic. There were
plenty of cathartics but when one wanted them to act quickly and
positively they often failed. In croton oil one had the most concen.
trated dose of any cathartic. If there were some hypodermic cathar-
tic, something analogous to apomorphin in its quick and certain action,
it would be the ideal method. If something could be found that would
act upon the center in the brain thus producing catharsis it would be
quicker than croton oil. Eserin sulphate given hypodermically in
horses produced catharsis and he hoped that he could some day report
favorably on some hypodermic cathartic. As to the pulse, it had been
his experience that it was always high and sometimes weak. When
the toxic blood was supplanted with saline solution it brought the
strength of the pulse up quickly. While the pathology of this disease
City Hospital Alumni. 121
was a very beautiful study it was well not to get so much of the numer-
ous theories in one's head as to lead him to forget the practical treat-
ment. Dr. Elbrecht added that if any of the members of the Society
were familiar with a hypodermic cathartic, he would like very much to
know of it.
Dr. Louis TRECHSLER said there was one point which he had
observed in a case of eclampsia on which he had performed an autopsy
at the City Hospital, and that was the small size of the kidneys; this
point he had never heard mentioned
A case of eclampsia came under his observation recently. The
message stated that the patient had given birth to a full-term baby
and was now in convulsoins; he carried with him pilocarpin, digitalis
and strophanthus and necessaries to make a urinalysis. Found the
patient in fourth convulsion of epileptiform character and unconscious
for five hours, edema was highly marked, the uterus was larger than
at this stage—three weeks after delivery, showing that subinvolution
had not taken place. He gave a hypodermic of digitalin. In at-
tempting to give hypodermic of pilocarpin the syringe clogged, so he
gave the pilocarpin with tincture of digitalis and strophanthus in weak
salt solution, per bowel. Urine coagulated on adding nitric acid in
the test-tube. He wrapped the patient in hot, wet blankets covered
with oil table cloth, exposing only her head. This operation was repeated
twice, covering in all five hours. The convulsions immediately ceased,
edema strickingly reduced and she became conscious. Treatment
later consisted in mild laxatives, vaginal hot douches, pilocarpin for
two days, digitalis for two weeks and senna for two months. All traces
of albumin disappeared in six weeks.
He did not believe in giving morphin in these cases, as we have
an insufficient renal circulation and our first aim should be to start
elimination, he believed morphin retards it. This same patient con-
sulted him four years previously, showing all signs of anemia and com-
plaining of long lasting headaches, while the urine did not show any
albumin. He advised her to get careful attention should she become
pregnant. In her first pregnancy she was attended by a midwife
without any complication. Her second pregnancy resulted as above
stated.
122 The Medical Society of
Dr. AMAND RAVOLD wanted to know why the gentlemen had con-
fined themselves to the finding of albumin and casts in the urine as
indicative of the functionating power the kidney.
Dr. JULES M. BRADY said that the pathological findings in this
case were of interest. Often at the post mortem table there was no
history; the discovery of multiple hemorrhages of the liver would at
once point to eclampsia as the possible cause of death. These hem-
orrhages are thought to be due to thrombi originating in the small
branches of the portal viens; that they may also be due to the pla-
cental giant cells which are taken up in the blood current and carried
to the liver acting as emboli similarly as they are frequently found in
the pulmonary capillaries seems to be beyond doubt.
Kaufman mentions two cases of hemorrhages into the substance
of the brain being the direct cause of death in eclampsia ; in each
instance the hemorrhage depended upon the rupture of a varix but in
extent and effect resembled very much arterial hemorrhage.
Dr. FELIX GARCIA had had a case some two years ago of chorei-
form convulsions occurring twelve hours after delivery, and for two or
three days he had used all the remedies but croton oil (and he did not
know whether he was sorry or not that he had never heard of the value
of that in such cases), but the patient grew no better and finally she
was removed to the insane asylum and it was found to a case of in-
sanity due to lues.
Dr. SCHWARz, in closing, said that he differed from Dr. Ehrenfest
in that he did not believe that toxemia was present to a greater or
less degree in every pregnant woman, nor did he believe that the
minor ailments of pregnancy were due to toxemia, nor that the desire
for strange articles of food were due to a toxemia. These strange
articles were usually chalk, or beans or rice grains, nothing likely to
produce toxemia or to result from it. He differed from him, too, in
the belief that the one or two cases of hydatiform mole in which
eclampsia had occurred proved that the toxemia causing the convul-
sions arises in the syncytium. It simply proved that it did not arise
in the fetus but it did not prove Veit’s theory that the syncytium was
the cause. While all admitted that it was the disturbed metabolism
of the maternal system which created the toxemia, yet it seemed prob-
City Hospital Alumni. 123
able that it was not the uric acid and urea, but some lower form, such
as xanthin or hypoxanthin and other forms resulting from the faulty
metabolism which produced the conditions. The syncytium in the
blood was still a disputed question, and it was a question whether
there really was such a thing as a fetal syncytium. It was possible
that the chorionic covering was all maternal in origin, and these cells
were not found in such quantities as was generally supposed. The
only cases in which Schmorl found them in the system were those in
which the placenta had been forcibly detached. In the other cases
they were simply giant cells in great numbers, showing no inclination
to be dissolved by syncytiolysin or anything else and they were found
in all cases of early misearriages, being always found at the very
period when eclamptic convulsions were least frequent.
Dr. Swahlen, in closing, said that, in regard to the urine in Case
I, the patient was catheterized when brought into the Hospital and the
urine was examined every day for five or six days and not by one test
only, but four different tests; sediments were obtained from fresh urine
by the centrifuge, and also from urine allowed to settle for twenty-four
hours. In no single instance were casts or albumin found. In Case
2, the reason they had not brought on premature labor was that the
patient was about five months’ pregnant and they had some hope of
saving the fetus. In Case 3, the reason for delay was that the fetus
was thought to be about seven months and the albumin and casts were
small in amount.
Dr. BALDWIN stated that in many cases in which these giant cells
are found it is practically impossible to tell their origin. Usually
these cells are represented by a large mass of chromatin jammed into
the pulmonary capillaries in such a manner that little of the cell struc-
tures can be made out; rarely is there any protoplasm surrounding them.
The capillaries of the lung contain the largest number of these chro-
matin masses although occasionally they will be found in the liver.
These cells are either syncytial or bone marrow giant cells. The only
means of identification, is the presence of chorionic villi due to the
division of trophoblasts. In the case described above, no such villi
were present.
In cases of eclampsia the cells found in the pulmonary capillaries
124 The Medical Society of
are no more abundant than in other cases not showing eclampsia, or
in some infections in either male or female. In many infections the
bone marrow giant cells are prone to wander into the circulation so
that cases similar to the ones above where no definite chorionic villi
are present, it is impossible to tell whether the cells are bone marrow
giant cells or trophoblasts. He had seen cases reported by Schmorl
in which definite chorionic villi were seen in the lung capillaries.
In every placenta trophoblasts are being constantly desoluamated
and we have no evidence that there is a greater desoluamation in cases
of eclampsia than in cases of normal pregnancy, consequently it seems
rather far-reaching to assume that the ordinary trophoblasts is the
cause of eclampsia. Others claim that eclampsia is due to syncyti-
alysins or other lysins. If this is true the lymph glands ought to show
Some changes produced by the hemolysis. In the case mentioned
above no such changes were found.
1)r. EHRENFEST said that Drexler had the advantage of him – the
speaker certainly could not diagnosticate a case of eclampsia four
years before its occurrence. He thought a case could hardly be called
a puerperal eclampsia when the convulsions occurred three weeks after
the birth of the child. This reminded him of an instance of puerperal
eclampsia recently reported in an American medical journal as occur-
ring in a child two years of age. Dr. Elbrecht had implied that the
speaker paid no attention to the kidney. He had simply said that it
was not the only organ to be considered. The liver was equally as
important though its condition was not so easily studied. Of course,
careful observation of the kidney function was very important. He
realized perfectly that the simple examination for albumin and a few
casts did not amount to much. As to his theory of toxemia of preg-
nancy, Dr. Ehrenfest did not want to enter here into a discussion of
the subject. The syncytium was certainly carried into the whole sys-
tem and the villi that I r. Baldwin had seen were really villi that had
been carried off and not villi that had been formed in the lungs. The
deportation of chorionic tissue seemed to be quite common. Dr.
Elbrecht had carried out. Dr. Ehrenfest’s theory in his adoption of ac-
couchement forcé and then the use of stimulants. He wished to re-
mind those gentlemen who did not believe that hyperemesis, etc., were
City Hospital Alumni. 125
due to toxemia, that the treatment of all these disorders of pregnancy
was practically the same, to-wit, the bringing about of elimination. Dr.
Elbrecht had denied the value of narcotics, but narcotics were neces-
sary to reduce the reflex irritability of the nervous system and in this
way they were a necessary symptomatic treatment.
The Etiology of Eclampsia.
By HUGO EHRENFEST, M.D.,
ST. LOUIS, MO.
Assistant Professor of Obstetrics, Medical Department, St. Louis University.
Pº only a few of you, gentlemen, are acquainted
with the immense literature which, within the last few
years, has appeared on the question of the etiology
of eclampsia.
The question obviously suggests itself whether all the ob-
servations and investigations embodied in this literature yielded
any tangible results. I would answer this question as follows:
The problem of the etiology of eclampsia has not yet been
solved. There has been considerable light thrown on some
points, which I shall have occasion to mention later, but the
one great thing which in my opinion has been accomplished
within the last few years is a clearer conception of the nature
of this dreaded complication of pregnancy and labor.
If you open textbooks at random you find in one eclampsia
considered in a chapter, dealing with the complication of preg-
nancy with diseases of the nervous system, in another in a chap
ter, which is devoted to a consideration of the complications
of pregnancy with diseases of the urinary system. You can
thus, at a glance, see what position the author takes in the
question of the etiology of eclampsia. But I think that in
in accordance with most advanced thought eclampsia belongs
to the one chapter which is devoted to the toxemia of
pregnancy.
You probably know that the oldest literature, that we pos-
sess on eclampsia, explained this condition on the basis of an
126 The Medical Society of
intoxication, as the result of an accumulation of some kind of
toxic material in the maternal blood. The most advanced
theories stand exactly on the same ground, with the one es-
sential difference, that as the result of very ingeniously con-
ceived and carefully carried-out investigations, we have reached
a better understanding of the nature of the responsible tox-
emia, of its etiology, symptomatology and to a certain extent
of its treatment.
We seem at the present time justified in assuming that all
the disorders and disturbances caused by pregnancy, from the
very slightest to the gravest, are probably due to but one
cause, namely, toxemia, which is a most common occur-
rence in the course of gestation. In my opinion, eclampsia is
but one special type of a toxemic condition, and if you ask
me to give you here to night a brief outline of the etiology of .
eclampsia, I can comply with your request only by speaking
on the etiology of toxemia in general.
We understand by toxemia or autointoxication a condi-
tion which is produced by a pathologic accumulation of toxic
substances in the blood. §
From the classic investigations of Bouchard we know, that
toxic material is being constantly resorbed into the blood and
eliminated from it. These toxins consist of toxic material in-
gested directly with the food, and of the end products of di-
gestion, of metabolism, in fact of all cell activity in the body.
The living organism rids itself of this toxic material partly by
elimination, partly by chemical destruction. The most im-
portant eliminating organs are the kidneys, the bowels and the
skin, and to a certain extent the lungs. Toxins are destroyed
through the action of the liver, the thyroidea and probably
some of the glands with an internal secretion.
You will now easily understand that a condition of tox-
emia will result, if either the introduction of toxic material
into the blood is excessive, or its elimination or chemic de-
struction are insufficient.
I shall endeavor in the following to demonstrate that both
these possible causes of the development of a toxemic condi-
tion are commonly present during pregnancy, and that, there-
City Hospital Alumni. 127
fore, a certain degree of toxemia seems almost typical or
physiologic for the pregnant state.
Let us first consider the introduction of toxic material. If
you think of the peculiar longings of most pregnant women,
which most often are directed toward very indigestable food,
we may be justified in assuming that in pregnancy more harm-
ful material is introduced with the food than in the non-preg-
nant state. The end products of fetal metabolism are to the
greatest extent resorbed into the maternal blood, which thus
accepts toxic material from both the mother and the fetus.
This source of toxic material was known for some time and
has always played an important role in the etiology of eclamp-
sia. That this source of toxins really is of great importance
is easily proved by the fact that grave autointoxications are so
much more common in twin-pregnancy, and by the not uncom-
mon observation, that even grave symptoms may disappear
quite suddenly if the fetus dies in the uterus, even before it
is expelled.
But besides the resorption of the end products of
the fetal metabolism we have during pregnancy one more
important source of toxic material. It is probably the most
important one, and has been recognized only within the last
few years.
It was known for some time that during pregnancy
fetal tissue especially syncytium is carried into the maternal
system. Very painstaking biologic investigations have shown
that fetal tissue acts toward maternal blood almost like the
tissue of another species. You all are acquainted with
Ehrlich's theory of immunization. According to this theory
the introduction of any foreign substance into the blood which
proves toxic to the blood, is followed by a counter action of
the blood which more or less sucessfully combats the harmful
effect of the introduced substances. Veit first applied this
theory of Ehrlich to the phenomenon of deportation of fetal
tissue into the maternal system. I can, of course, not attempt to
explain to you here the exact nature of the theory of Veit, or
of similar theories that at the present day are widely discussed
in obstetrical literature.
The main features of these theories are about the follow-
128 The Medical Society of
ing: The fetal tissue, always originating from the chorionic
epithelial cover of the placenta, which is carried into the ma-
ternal system, is in the maternal blood partly dissolved at the
same time causing the destruction of red blood cells of the
maternal blood. In this way syncytiolysins and syncytio-
toxins are formed which on the other hand cause the reactive
formation of the corresponding antitoxic substances. If we
study the papers of Weichardt, Ascoli, Liepman and a few
other workers in this field. we see that there is still some dis-
sensus of opinion, whether the syncytiolysins, or an abundance
of the anti-syncytiolysins give rise to the toxic symptoms.
Of late it has been shown that it is probably not necessary at
all for this fetal tissue to be carried off into the maternal system,
because it seems probable that this mutual reaction of fetal and
maternal tissue upon each other may occur ºn loco, that is while
the syncytium still is in connection with the villus. But the differ-
ences in these theories are of minor importance in connection
with my remarks here. We have to admit the fact that the chori-
onic cover of the placenta has undeniably been recognized as a most
important source of toxic material. If there was in anybody's
mind any doubt. about the validity of these theories, it must
have, of necessity, been removed by two observations recorded
last year. Eclampsia has been observed in cases of hydati-
form mole. In these cases there was no fetus present, no fetal
metabolism existed and the toxins of necessity must have
originated from the periphery of the ovum. These two observa-
tions have furnished ideal proof for the correctness of the Veit
theory and the others related to it. These two observations
at the same time explain why we may expect to see symptoms
of toxemia very early in pregnancy. As long as we had to
regard fetal metabolism as the only source for toxic material,
it seemed impossible to explain nausea, morning-sickness or
other symptoms of the earliest stages of pregnancy on the
ground of a toxemia. To day we can do so, because we know
that just in the earliest stages of pregnancy chorionic tissue in
form of the trophoblast shows a very marked tendency to
penetrate into maternal tissue.
After this consideration of the introduction of toxic ma-
terial into the maternal system, we have to admit that during
City Hospital Alumni. 129
pregnancy a much larger amount of toxins reaches the blood
than in the non-pregnant state.
And now, let us speak of the elimination of these toxins.
It is obvious that during pregnancy increased demands
are made upon the organs of elimination or, as they are
very appropriately called by some writers, these “organs of
defense.”
If these organs at the time of impregnation are in a
normal and healthy condition, they are as a rule capable of
complying with the demands for an increased activity. But
quite different is the result if these organs at the onset of
pregnancy are not fully developed or in an abnormal condi-
tion. The harmful effect of underdevelopment is probably
most distinct in the thyroidea. It has been shown that in
many cases of eclampsia the thyroidea is found to be strikingly
small. You know that in the course of pregnancy this gland
usually is found to increase in size, probably hypertrophies in
order to respond to the greater demands. I will just remind
you in this connection of the very good results that have been
obtained in the treatment of eclampsia with the administration
of thyroid extract.
An abnormal condition of these organs of defense may be
due to a congenital anomaly or to disease. Of paramountim-
portance in the etiology of toxemia of pregnancy is a diseased
condition of the eliminating organs. This pathologic condi-
tion may have been existing at the time of impregnation or
may have appeared in the course of pregnancy, in the latter
case it may be but an accidental complication, or pregnancy
itself may be responsible for its existence, and just this latter
possibility is of the greastest importance for the proper under-
standing of toxemia of pregnancy.
Some of these organs are, especially in later stages of
pregnancy, harmed by the pressure exerted by the large uterus
either directly against them, for instance kidneys, liver, bowels,
or by partial compression of arteries and veins regulating their
blood supply.
But of still greater weight is the harmful effect of the
higher toxicity of the blood combined with the necessity of
an increased function of these organs. These two causes
130 The Medical Society of
result, during pregnancy, in certain histologic alterations of
these organs, alterations, which under normal conditions would
have to be called pathologic, which, however, during preg-
nancy, on account of their almost typical occurrence, must be
considered still within the physiologic limits. I will remind
you of the so-called kidney of pregnancy. There we have
a fatty degeneration of the renal parenchyma. We find similar
degenerative processes, as a rule, in the liver. If such altera-
tions transgress a certain limit, as seems to be quite common
in later stages of pregnancy, then the function of the organs
is interfered with. The elimination of the toxins becomes
insufficient. Toxins are retained, the toxicity of the blood in-
creases further and with it its harmful effect upon the eliminating
organs. A most dangerous vicious circle is established, which
finally becomes responsible for the gravest forms of toxemia.
If one of the important eliminating organs is diseased at
the time of impregnation, then obviously a pathologic degree
of toxemia will result from the very beginning, which will
prove most harmful to the diseased organs and lead to a
rapid decrease in their function and a further aggravation of
the toxemic condition.
As soon as the equilibrium between importation and elim-
ination of toxins is disturbed, the symptoms of autointoxica-
tion appear. They first become manifest in form of disturb-
ances in the digestive and nervous system. Nausea and vom-
iting, probably the first symptoms of a pregnancy toxemia, are,
as you know, characteristic symptoms of almost every form of
intoxication. If the toxemic condition becomes aggravated,
if the patient is possibly especially susceptible, the vomiting
may become very obstinate, it may develop into a hypereme-
sis, into uncontrollable vomiting. We find as one of the symp-
toms appearing in the domaine of the nervous system an in-
creased reflex irritability. This symptom is quite common for
certain intoxications in the non-pregnant patient. An aggra-
vation of the toxemic condition with a simultaneous increase
in the reflex irritability, also due to the toxemia, may cause
slight contractions of single muscles, in graver forms those
convulsions which are comprised as a special disease under the
name eclampsia. Since it is my duty to speak to you only
City Hospital Alumni. 131
about the etiology of eclampsia I can not enumerate here
all the various symptoms of toxemia of pregnancy, but I have
just mentioned these few in order to furnish some proof for
my contention that nausea, morning-sickness, hyperemesis, or
headache, albuminuria, increased patellar reflexes and eclamp-
tic convulsions are not different diseases, but only differ-
ent symptoms of various degrees or forms of pregnancy
toxemia. If you ask me why one patient in case of real grave
intoxication develops hyperemesis, the other an eclampsia,
then I shall refer you to the fact, that, as I have endeavored to
show you, the toxins retained in the maternal system are of a
very different nature, and that the prevalence of the one or the
other, whether end product of metabolism or syncytiolysin or
something else, may decide the special form of toxemia.
If we at some future day should know more about the
chemical constitution of these toxins, and should have detected
the one substance responsible for the convulsions, then we will
be able to speak about the etiology of eclampsia; to-day we
have a clear conception only concerning the etiology of tox-
emia in general. &
In concluding my remarks I wish to point out briefly a
few of the mistakes that are commonly made in the considera-
tion of the causation of eclampsia. There seems to exist a
great deal of confusion between cause and effect. Many of
the pathologic changes described in kidneys and liver are not
so much the cause as the result of toxemia, and only second-
arily, by way of the vicious circle which I have endeavored to
explain to you, help to exaggerate the existing toxemia. An-
other mistake which is very prevalent, is, that altogether too
much stress is laid upon the importance of the kidneys. I
have demonstrated that the kidneys certainly are not the only
organs which by elimination prevent a pathologic accumulation
of toxins. The function of liver or thyroidea are just as important
in this respect. Of course, the urine offers an easy means of
ascertaining the conditions of the kidneys, and therefore, it is
so much easier to recognize an alteration in their function.
But I think it is absolutely useless to fight about the question
which particular renal lesion is chiefly responsible for eclamp-
sia. All is dependent upon the total work of all the eliminating
132 The Medical Society of
organs, and if in some cases of eclampsia, no renal lesion can
be detected, and no albumin is found in the urine, then prob-
ably in these cases the eliminative action of liver or thyroidea
or another important organ is absolutely inefficient, or possi-
bly, by some process still unknown to us, a very large amount
of toxic material was suddenly thrown into the maternal cir-
culation, too large to be taken care of by the “organs of
defense.” *
Meeting of May 4, 1905, Dr. John Green, Jr.,
President, in the Chair.
Premature Infants.
The Necessity for and the Difficulty of Formulating a
General Plan for Their Care.
By VILRAY P. BLAIR, M.D.,
ST. LOUIS.
| | E who has cared for even a small number of premature
infants will, until he has formulated or adopted some
scheme, feel the special need of an efficient general
plan of treatment. As in many other instances, marked suc-
cess is credited and denied to each of the several different
plans of treatment, so that one seeking help in the literature
is apt not to be satisfied. In the following it is proposed to
consider briefly, first, the reasons for this general plan and
next, the reasons for the discrepancies in results and give a
few reasons for one part of the plan I have adopted.
The discrepancies and variations have been given special
prominence in Dr. Zahorsky's recent papers. While in con-
tradiction to the premise of this paper we all state that we do
and try under all circumstances to regulate the particular con-
ditions of heat, stimulations, feeding, etc., to the special needs
of the individual, still we must acknowledge that there is no
class of cases that must be treated so much on general princi-
City Hospital Alumni. *. 133
ples as these babies during their period of artificial gestation.
The reason of this is that evil symptoms develop so unexpect-
edly and when developed may be so difficult of correction and
so rapidly fatal that, to be successfully combated, they should be
treated before they arise, hence the reason for a general plan,
that will correspond to the hygiene of the more mature. Of
course, the question of a general plan has a bearing in all cases
but here, on account of the instability of the organism consid-
ered, it is of much greater importance, while the limited
amount of material renders very difficult the formulation of
such a plan.
The next point of consideration is the radical difference
in the plans proposed. This seems to depend somewhat upon
the fact that besides lack of material we have to deal with a
peculiar difficulty.
The term infant is capable of breathing air at 70° or low-
er, not only without harm but with positive good from the
stimulation of the cold. This infant can also take crude nour-
ishment, prepare and assimilate it for itself, being benefited
by the very effort required in the exercise of the function, and
its nutrition is sufficient to maintain its body heat. You see
the point P Shall we try to imitate Nature's care of a child of
this development, which to do perfectly is impossible P shall
we treat them as term infants, which most often results fatally,
or shall we place them in a special class between the born and
the unborn ? This is the logical plan, but in drawing his con-
clusion each observer has to decide first, to what extent shall
these infants be treated like their more mature brothers living
in the same world and exercising the same functions and, next,
what concessions shall be made to their premature state.
It depends upon both the temperament of the observer and
the general circumstances of his observations to which side he
shall incline and the plan formulated will vary accordingly.
We now turn to the consideration of the lack of uniform-
ity between the results of originator and inventor, which for
want of time, may be dismissed on general grounds of lack of
appreciation of the basic principles, technic, or ill-advised at-
tempts at eclecticism. Other things being in the same pro-
portion a man should follow the plan with which he is most
134 The Medical Society of
familiar. When bad symptoms do arise there is a grave ques-
tion to decide. On the one hand, they call for more or less
of a departure from the plan of treatment on general princi-
ples, and on the other he may not be sure that this departure,
while it combats the peculiar symptoms, does not interfere
with the general principle to the extent of doing more harm
than good. *
In the foregoing I have not attempted to deal with imme-
diately practical questions. I think I have indicated that as
much is to be gained from the discussion of men who have
made extensive observations on term inſants as from those of
less experience with the premature. The minute they become
air-breathing and are obliged to ingest food it is from the
standpoint of the normal infant that we must reach out to
treat them, and any concessions made to their prematurity
can be but feeble imitations of the uterine condition, necessa-
rily temporary and more or less at variance with the normal
demands of mundane life.
It seems to be a late observation that sick people, adults
or infants, thrive best with a moderately warm temperature
that might be at times somewhat cooler than the feelings of
the person would suggest, usually about 70 to 72°. When a
patient apparently demands a higher one, it is probably the
patient and not the temperature that is at fault and other
measures than change of temperature will be found advanta-
geous. Reasoning from this it is natural to ask, is it always
well to keep premature infants at as high a temperature as at
first thought it apparently demands. Should not other meas-
ures to adapt it to a relatively “moderate” temperature be at-
tempted rather than to pamper to the limit its demands for
artificial heat? This is reasonable and is correct. The only
question is, as stated before, how quickly and how far will the
infant respond to the stimulus of cold and how much of a con-
cession must be made to its poor heat-producing process. Bu-
din's answer is that they need little artificial heat. Working
out this idea, under certain environment, certain climatic influ-
ences, and with a certain race of people has obtained excel-
lent results, and he has described his whole procedure appar-
ently to his own and other peoples' satisfaction. This being
City Hospital Alumni. 135
so, why all this discussion, for the whole, then, should be plain
sailing. All this may sound queer from one who has been
cited as using the highest temperature incubator on record,
but follow me a minute longer. The reason for the discussion
is that none of his attempted immitators have been able to ob-
tain like results. No one seems to have discovered what pre-
vents them from having the same or even average results by
apparently the same treatment. Lacking such results each
has been forced to resort to some plan of his own that seems
to best suit the condition that confronts him. For this reason
in spite of the previous deductions I have used high tempera-
tures in some, though not all, cases. I have used them in so
many cases that I have an average higher temperature than
anyone publishing his results. Yet every time I keep an in-
fant in an incubator at a temperature of 90°, I do it as a com-
promise to some threatening condition the importance of
which seems at the time paramount. I used to start with an
incubator temperature of about IOoº as one method cf Com-
\bating the high mortality that occurs within the first hours,
though I now believe 90° is better. In the article referred to
by Dr. Zahorsky are given my ideas of the indications that
permit of lowering it. While I stated that these infants will
stand for hours a body temperature considerably above normal,
this should not be taken to mean that I ever intentionally
maintained such. I but called attention to the fact that such
an accident is not apparently harmful. The temperature of
the fetus in utero is above that of the mother. It is my belief
that, as a rule, when there is no sweating, premature infants
thrive better at a body temperature of 99 than 97°. The
morbidity of premature infants is extremely high and when
sick they will require more artificial heat, though possibly the
increased heat may contribute to the tendency to disor-
ders. This is a pertinent question and it is possible that bet-
ter average results will follow the use of low incubator temper-
atures in all cases, letting those succumb that will not adapt
themselves. This, however, is a solution at which I have not,
as yet, arrived.
These infants when sick seem to be in a state of cold,
with cold extremities and excreting quantities of mucus. When
136 The Medical Society of
thus affected they thrive best with a body temperature of 98.5
or 99°. In this condition their heat-producing power is the
poorest.
I lately saw an infant of apparently 8 months' gestation,
weighing 2.8 pounds, one week old when placed in the incu-
bator. At the time it was extremely listless and had a rectal
temperature of approximately 90°. An incubator tempera-
ture of 93° gave a rectal temperature of 98° and relieved the
bad symptoms. Upon a persistent effort to reduce the incu-
bator temperature to 85° the above symptoms and body tem-
perature recurred and the child died. I do not include this
case in the percentage of results given below. ſº
Since last writing on this subject I have cared for an infant
for Dr. Gellhorn, which was also seen by Dr. Tuttle in consul-
tation, in which case, for the above-mentioned reasons, the in-
cubator temperature for a few days was as close as possible to
98°, which was an unfortunate necessity, and this infant has
developed into a vigorous, healthy child. In this particular
case I do not beleive this happy result would have been ob-
tained without some such accompanying stimulant as the bath,
which is given on the same theory as the Brand bath.
This treatment has netted me an average of 83.3 per cent
successes in all infants, infected or healthy, that survived the
first twenty four hours after being placed in the incubator. I
have never had to contend with hospitalism but have had a
high rate of morbidity.
I must concur with Dr. Zahorsky's views of complicated
heat regulators, both because they are delicate and inefficient,
and because it is a relative and not an absolute temperature
that is needed. It is this that led me to construct an incuba-
tor without any mechanical heat regulator, depending only on
a large water jacket and the even flame of an oil lamp.
DISCUSSION.
Dr. JoHN ZAHORSKY had always been interested in premature
babies, but in the last few months had been especially so and had em-
bodied his experiences in a series of papers (St. Louis Courier of
MEDICINE) which were a discussion of what was best in the care of
City Hospital Alumni. 137
these children. In that series of papers he had pointed out that Dr.
Blair's incubator temperature was higher than most authorities gave,
but Dr. Blair's results had been so good that there was no question-
ing it. When anyone could have a mortality of only 17 per cent then
his method was correct. But many rules are laid down as to how
these infants should be nursed and the question was, which rules should
be adopted. There were cases in which it was absolutely necessary to
have the incubation temperature high. A rectal temperature of 98 to
99.6° was probably the best temperature—99° might be considered
the best rectal temperature for most babies. If the incubator tempera-
ture was put at Ioo? when the baby’s temperature was subnormal, it
was done to warm the infant, but the baby could be warmed much
better by a hot bath than by hot air. It was impossible to maintain
the temperature of the incubator at 98° and keep the baby’s tempera-
ture at 99° if the baby had any power of oxidation. One must always
allow a certain difference between the baby’s rectal temperature and
the surrounding medium even in the case of the smallest infant. There
should be a difference of at least 4°. He had been especially im-
pressed with that fact that high temperature in the incubator might not
be satisfactory, for many of the babies at the Pike had fever as a result
of this. Another thing, such babies got cyanosis very readily. It
had been said that the cause of cyanosis was subnormal tempera-
ture, but these babies could get a temperature down to 95° without
cyanosis while a rise in the temperature would produce it. After a
child was several days old it could better withstand a high temperature.
The chief disadvantage was that the child did not digest its food well.
If an incubator temperature of 92 or 93° did not maintain the heat at
98 or 99°, then baths should be given One could use a very warm
incubator and give the bath to cool the baby or a cool incubator and
a bath to warm the baby. Budin, Professor of Obstetrics of the Fac-
ulty of Medicine, Paris, the highest authority on the rearing of prema-
ture infants, recommended a temperature of 80°, but almost all
of his babies were over three and a half pounds. He did not discuss
babies weighing under 1200 grams. So his rule could not be taken as
the universal rule when an attempt was made to save smaller babies,
and there were many such babies to be considered. It was true that
138 The Medical Society of
only occasionally such babies lived. When under seven months gesta-
tion and weighing less than 12oo grams, not many of them would live
under any method of treatment. It must be remembered that even
with an incubator one could not supply internal energy. For the child
to live, certain process must take place, it must breathe, and the incu-
bator could not supply the energy. He held that the feeding was the
most important thing. If the baby could assimilate a certain amount
of food it could thrive on a lower incubator temperature. When a baby
is starving from indigestion it was necessary to keep the temperature
higher. Budin’s death rate in the past few years had been 7 per cent,
which was remarkable. The speaker did not believe that babies weigh-
ing over 1800 or 190o grams should be placed in an incubator. Those
weighing from 1200 to 185o grams were especially fit for the incubator,
but for those over that weight a warm room, 75 to 80° was sufficient.
Dr. Zahorsky passed around a weight chart of a baby, a seven months’
gestation, weighing four pounds, which had been kept in a room tem
perature of 75 to 80°, well-wrapped, and fed at the breast and thrived.
One objection to the hot incubatór was that very warm air caused
rapid evaporation resulting in a loss of weight for it was exceedingly
difficult to keep up a proper moisture, so, if a baby weighed more
than 18oo grams, unless it showed great feebleness, he believed it
should not be put in an incubator. But it was exceedingly difficult to
formulate definite rules. Each physician would use what he had found
best. But the main thing was the feeding. One must commence
feeding the baby a few hours after it was born. It had no fat stored
up and unless one got some food into it, the respiration would stop.
It was astonishing what feeble efforts would cause sufficient oxygena-
tion of the blood, provided these efforts were made. The muscles of
respiration soon tired out because they did not get sufficient food. He
had a list showing a series of all kinds of temperatures, ranging from
IoI to 96° rectal temperature and still the babies had had attack after
attack of cyanosis until they died. It was a debatable point whether
the mucous in the stools meant a cold. Mucous was usually indicative
of the presence of some irritant in the canal. At whatever tempera-
ture the baby might be kept, when it had indigestion mucous would
be found in the stools. He had tried to settle what rectal temperature
City Hospital Alumni. 139
would the least dispose to indigestion, but failed. He believed that
they digested their food better when they were not quite so warm, but
as Dr. Blair had said, it was necessary, in certain cases, to keep the
temperature pretty high.
Dr. W. L. JoHNSON felt that his experience did not justify a talk
on this subject. He had not expected the essayist to confine himself
almost solely to the heat of an incubator. He had thought he would
present some plan whereby an incubator could be gotten quickly and
someone to take care of it properly. Dr. Zahorsky had touched the
important point, that was, the feeding. He did not believe a high
temperature was necessary except, as had been indicated, in some
emergency. Usually they got along well at a much lower temperature,
often down to 85°. He had seen three or four babies kept in impro-
vised boxes near a radiator and they got along as well as in the incu-
bator. Physicians should pay more attention to the babies and be able
to recognize those which were premature. In a recent case where the
baby was unquestionably premature it was not recognized as such,
was treated as a normal child, and lost weight and strength so that it
never did recover. If they were always recognized as such, some
would be saved that otherwise would be lost. He knew of two cases,
one where the baby was only 1o inches long and weighed 1 1/2 pounds
and one 9 inches long and weighing 1 1/2 pounds, where both babies
were saved. When one considered that infants of that weight, or rather
lack of weight, could be saved, it should encourage them to formulate
some plan, however difficult that plan might be. There should be
some way by which incubators could be furnished. He had had one
child, a six months' gestation, weighing a little more than three pounds,
that might have been saved could he have gotten an incubator early.
He had 'phoned to Dr. Blair for an incubator, but before the father had
started off for the incubator, the child was dead. It was along this
line, some plan whereby incubators might be gotten expeditiously and
someone to handle them that he hoped the discussion would be. As
to the scientific care of these babies and the degree of heat that they
needed, he was not in a position to speak. The main thing was the
feeding, giving them either breast milk diluted or peptonized milk.
Dr. GEORGE M. TUTTLE had come with the same idea that this
140 The Medical Society of
was to be a discussion on incubators rather than on the temperature.
When Dr. Blair had asked him some little time ago if he would take
part in the discussion he had been tempted to say no, for his experi-
ence had been so unfortunate as to keep him from being much of an
advocate of them. His experience with incubators had been exclus-
ively in institutions, and he had never used them in private practice,
and anyone who knew the effects of hospitalism would understand his
reason for being biased against the incubator. As to the temperature,
a human being should have a normal temperature. A well developed
adult did not perform his functions well in a high temperature or one
much below normal. This was more than true of premature infants.
It must be remembered, too, that its heat regulating apparatus was
just as premature as its whole organism, consequently any change in
its temperature, was likely to interfere with the performance of the
functions, as digestion, for instance. If there was any function that
the incubator performed it was to keep the temperature regular, and
right here was where it seemed to break down. Authorities differed
as to the proper temperature, ranging from 98.5° blood temperature,
down to 78 or 80°, the temperature that many full grown Americans
lived in all the time. The real test was this, to try to keep the infant’s
temperature somewhere within a degree above to a degree below 98.5°,
but no incubator seemed to be able to do this. The warm bath to
raise temperature and the removal of the infant from the incubator to
lower temperature are part of the armamentarium of all incubator
users. In other words the incubator broke down in the very point it
should attend to. Another thing, a premature baby needed a certain
amount of exercise, and this exercise was given by changing its posi-
tion and by massage, and it was recommended by incubator experts
to remove the baby for this purpose, and to feed it and cleanse it and
for occasional bath, so that the incubator users themselves rather
recommended that the babies should not be kept in a uniform tem-
perature. So in analyzing this subject he could not help being driven
to the conclusion that they were not up against the problem of main-
taining a uniform temperature, but that the question was first, to feed
the baby properly (and that meant invariably mother's milk), and,
second, the temperature problem. The public had this idea reversed.
City Hospital Alumni. 141
It was very difficult to get mother's milk at first. The mother did not
have it and ordinarily it was hard to get.
Dr. F. J. TAUSSIG said that Dr. DeLee, of Chicago, had spoken
of transporting these babies from their homes to incubator stations.
He would like Dr. Blair's opinion of some such plan, and of Dr.
DeLee's incubator.
Dr. A. S. BLEVER reported a case that illustrated the vital point
of feeding. He had seen the child two weeks after birth. It was a
26-weeks' baby and weighed within I Ioo grams. It was kept in a
clothes basket surrounded with hot water bottles, it was frequently
taken out of the basket, fed on Borden's milk and lived ten weeks.
The weight increased to 1200. grams but fell again to 1 Ioo grams.
The digestion seemed to take care of itself very well. The environ-
ments were not good, or the baby might have survived.
Dr. N. W. SHARPE said that as he was neither an obstetrician nor
a pediatrist he hesitated to enter upon a discussion of the theme of
the evening, but as he was somewhat interested in medico legal mat-
ers, he had telephoned to an ex judge who had said that if these
modern methods actually permitted premature children, that would
otherwise die, to live, that this would change the entire legal view of
the viability of infants, and that the work that was now being done
would so alter the period of legal viability that the law itself would be
changed. He therefore asked: Was it actually true that by these
modern methods any appreciable difference had been made so that
under ordinary circumstances a younger child might be expected to
live? It is not infrequent that the surgeon is tendered large sums of
money to save life, and, though many of these people are but the
wrecks of humanity, yet enormous labor is undergone in the effort to
save them. He desired to emphasize the fact that all this labor and
expense was not to be put in comparison with the work of the men
who were engaged in the modern methods of caring for children; the
men who, from very unpromising material were yet able to sustain life
which without their aid would be absolutely lost. Far greater was it
to develop from a premature infant a healthful, growing child, than
to save the life of a diseased adult, often but a fragment of human
wreckage.
142 The Medical Society of
Dr. TAUSSIG brought up the question whether the weight alone
determined whether the child was premature. Mature children varied
greatly in weight. Should they, in the treatment of these cases, be
governed at all by the history of the case, whether from the date of
the last menstruation they should be led to determine whether the child
was premature or not.
The PRESIDENT, referring to certain statistics quoted, in which
Dr. Zahorsky had said that infants under 12oo grams were disregarded,
asked Dr. Zahorsky why this was 2
Dr. ZAHORSKY replied that Dr. Budin did not state. He simply
said that infants weighing less than 12oo grams at birth with very few
exceptions did not live. Budin did not place so much weight on the
gestation. Budin thought the weight the best guide and at the hos-
pital he either did not receive them or divided them into several
classes. One series being babies under 1200 grams, I case; an-
other, I2Oo to 15oo grams, 5 cases; I 5oo to 18oo grams, 75 cases.
That was why his results were so remarkable. Almost anyone with
reasonable care could get good results with babies of such weight. And
the older the baby, even if it weighed little, the better the chances
for it.
Dr. TUTTLE thought St. Louis would shortly be considered the
center of the United States on the incubator question and he thought
they should feel very proud of these gentlemen and especially of the
work that was appearing in the Couri.ER OF MEDICINE.
Dr. BLAIR called attention to the fact that he had said that when
he brought up the temperature it was always to govern some special
symptom.
Dr. ZAHORSKY wanted to know if Dr. Blair, in his cases, had
kept any record of the actual weight and also of the length of the
baby and the length of the gestation. It did not matter what rules
were given unless one also gave the weight of the baby and the length
of gestation, otherwise they were worthless.
Dr. BLAIR replied that he had not kept accurate statistics. He had
not attempted to have any very set rules. He had been guided by the
apparent demands of the children and had as yet not been able to
formulate a rule. The child he had mentioned as demanding a very
City Hospital Alumni. 143
high temperature for several days had weighed something like 5 pounds
and was very close to a nine months' gestation. The youngest child
he had attended was a six months and four days gestation. The light-
est he had ever got that appeared as if it would live (though it had
died due to being kept too cold) weighed 2 3/4 younds Smaller than
that they had all died.
As to temperature vs. exercise and feeding, it was absolutely
necessary that the child breathe, ingest food and develop vital energy
by voluntary motion. No incubator would make up for that. But
where these functions were exercised to their physiologic limit but not
sufficiently to keep up the temperature, then a little help given by the
incubator might bring about success while without the incubator there
might be failure. The baths with friction would to a certain extent
make up for this lack of voluntary motion on the same plan as
massage took the place of exercise in the adult. The warm bath
stimulated the vital energy and assisted in the elimination of the pois-
ons. It made up for the exercise of function. He did not believe
that a low temperature was essentially responsible for the state of ex-
cessive secretion of mucous, but, granted that the child was in that
state and had colic, the raising of the temperature or giving a warm
bath would keep off the acute exacerbations, and lowering the tem-
perature he was certain did increase the secretion of mucous. He had
often noted in this condition that when the incubator temperature had
fallen, a few hours afterward there would be mucous ejected dfrom the
bowel or the child would begin to sneeze.
When a child was too hot it became cyanotic, and when too cold, it
became listless. As to the temperature at which the incubator should
be kept, when the child was sick (had a cold or indigestion) it did
much better with an even temperature and a little high. For that
reason he bathed them right in the incubator. A temperature of Ioo
to 95° was a cold bath, Io 3 to Iosº a warm bath. A term infant could
stand an immense alteration of temperature. They could be taken
out doors when the temperature was 50° below their body temperature
and they would thrive on it. Young puppies and chickens could also
stand this same great change in temperature. For that reason he be-
lieved a child did better on a low temperature. But a sick child could
144 The Medical Society of
not stand it. Anyone interested in the physiology of premature in-
fants should read Ballantine, (Brit. Med. Jour., Vol. 1, 1902). This
author had also later, brought up the point that in this age of small
families the life of the infant was of greater value than in days when
larger families were the rule. In the treatment of such children the
great consideration was not to continue the life of the child but to
produce a healthy child. It was better from an economic standpoint
that a child should die than to live as a sickly child and adult. But the
incubator would produce much healthier children than those who, though
they continued to exist, did so for several weeks with a body tempera-
ture of 95 or 96°. Those that had survived in an incubator were more
apt to be good, healthy children. There was no question but that
feeding was a most important point and was correlated to temperature.
Babies were sometimes kept at a high temperature for a day or two to
carry them along on the least possible food to give the digestive func-
tions a chance to recover. The proper treatment for digestive dis-
turbances in term infants is to withhold the food for twenty four hours,
but a premature baby could not live that long without any food, so if
one could get the temperature up and get the bowels to act and per
haps give some peptone and use the baths there was a possibility of
bringing the baby through. High temperatures were necessarily dan-
gerous and a distinction should have been made with regard to this
point, between very young and older children. This was a distinction
that he had not made. It would probably be safer in the case of a
child weighing 15oo grams to put it in at a low temperature and see
how that temperature was borne, but the very young ones he believed
should be put in at a temperature of Ioo°. As to the use of an incu-
bator, almost any one could regulate the temperature. The point was
to have the temperature chamber the same. By hanging two wet -
handkerchiefs in the improvised box and keeping them wet a degree of
moisture could be maintained. Any one who wanted to use an incu-
bator was always welcome to one of his, as he had several and they
were idle much of the time. He had never seen the incubator used
by Dr. DeLee. If one had not an incubator at hand, a basket lined
with hot water bottles would serve very well till one was obtained.
Dr. SHARPE again asked if there was any change in the age at
City Hospital Alumni. 145
which an infant could be reasonably expected to live, when subjected
to modern methods and precautions.
Dr. Zahorsky replied that he did not think there was any
change. They saved more babies, but they did not save them any
younger.
Dr. BLAIR believed that by the careful use of higher temperatures
they could save more younger babies, say, for instance, seven months’
babies.
Dr. ZAHORSKy stated that obstetricians for years had determined
upon a date, say about twenty-four or twenty-six weeks, or six months,
at which babies might be considered viable and he was sure incubators
had not affected that in the least
Dr. F. J. TAUSSIG asked if any statistics had been collected to
determine the exact time of gestation, and whether there were any
statistics on the time that had elapsed since the first fetal movements,
so as to determine the exact time at which a child might be expected
to live.
Dr. J. C. FALK thought that if these gentlemen were willing to
admit that because of the modern use of the incubator a greater
number of premature infants were saved, that answered the question,
since the age of viability was lowered. If, heretofore, one hundred
premature infants of six and a half months' gestation, 99 per cent had
died, and with incubators but 90 per cent died, did not that lower the
period of viability ?
Dr. BLAIR thought that Dr. Falk was correct in his belief that
the age limit at which a child might be considered viable, in the sense
that the child could live, had been lowered.
Dr. SHARPE said that because it was assumed that under the new
regime 90 per cent of children under a certain age could be saved, it
proved nothing more than that the percentage of mortality under said
age had been lowered. They all knew that medical men frequently
acted unwisely when on the witness stand, hence he had thought this
point, the viability of the child under modern methods, whether it has
been altered or not, should be made perfectly clear so soon as possi-
ble; that in the future statements should not be made on the witness
stand to the discredit of the profession, of a purely speculative charac-
ter, and not in accord with facts.
146 The Medical Society of
Meeting of May 18, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Cancer of the Uterus.
Presentation of Specimen.
By GEORGE GELLHORN, M. ().,
ST. LOUIS, MO.
HIS patient presented the usual history of uterine cancer.
Being 44 years of age, she had had irregular men-
struations during the last six months. These men-
struations were copious and extended over a period of two to
three weeks, usually leaving her with only about a week be-
tween the hemorrhages. There was a copious, and, at times,
offensive discharge. The patient became markedly emaciated.
Upon examination a tumor was found in the vagina, which al-
most completely filled the lumen of the vagina, and it could
not be determined whether this growth originated from the
anterior or the posterior lip of the uterus. The left parametrium
was of normal length, and yet at the same time doughy. The
right was shorter than the left, and I got the impression that
the disease had invaded the parametria. However, the whole
mass was freely movable, and the operation was thus clearly
indicated.
The question arose as to what sort of operation would be
best in this case. We know, from extensive statistics, that
cancer of the cervix extends very early to the parametrium,
and furthermore that 3/4 of all the recurrences after operation
are found in the parametrium; the conclusion being, therefore,
that we can only hope for a cure if we extirpate the parame-
tria, which are the site of the recurrences. If you see a uterus
after an ordinary extirpation, you will notice that the uterus is
cut out close to attachments. There is no part of the para-
metrium adherent to the uterus. It is the consensus of opinion
that we must, in the future, resort to operations which enable
us to extirpate the parametrium. We can accomplish this either
City Hospital Alumni. 147
by an abdominal method or a vaginal method. Personally, I
prefer, in most instances the vaginal method.
But for the reasons just given, the old vaginal hysterec-
tomy, as ordinarily employed, is no longer justified. In order
to reach the parametria we have at our disposal the paravaginal
method, devised by Schuchardt in 1893. This method is dis-
tinguished by a very deep and extensive incision through the
wall of the vagina into the paravaginal tissue and through the
perineum into the pararectal tissue. This incision completely
does away with the vagina as a long tube and changes the lat-
ter into a shallow excavation at the bottom of which both
uterus and parametria are within easy reach so that the extir-
pation of the uterus together with the parametria can be ac-
complished under the constant guidance of the eye. I have
employed this method a number of times, and this specimen
will demonstrate to you that we are thus enabled to remove
the pelvic connective tissue to such an extent that we diminish
the chances of leaving carcinomatous tissue behind.
Furthermore, it is of the utmost importance that steps be
taken to guard against the implantation of carcinomatous cells
during the operation, and such methods should be adopted as
have been devised to this end. The best, and only means, in
fact, is the one which is carried out by means of the thermo-
cautery. Instead of using the knife to open the lymph chan-
nels and vessels, we use the thermocautery. This prevents the
Ca.11CCI" particles from being forced, as it were, into the tissues,
and at the same time, the heat which is required will de-
stroy the cancer particles which may be present at the line of
incision.
The case from which this specimen was taken, the thermo-
cautery was employed in this way: the clamp was first ap-
plied to the parametrium and the tissues were burned through
with the cautery but afterward a suture was inserted behind
the clamp as a protection against hemorrhage. In the place
of the cervix, you see a crater. In this case, the tumor was
so large that it was excochleated and cauterized prior to the
extirpation of the uterus so as to give more room. Both
tubes are normal. The two ovaries we found to form serous
cysts, the right one about the size of a fist, and the left a little
148 The Medical Society of
smaller. Both were bound down by many adhesions. How-
ever, the removal was very easy.
The salient point to which I desire to call your attention,
is the fact that in this specimen both parametria in their entire
extent are in continuity with the uterus. If, in future, you
should see a uterus extirpated for cervical cancer without the
parametria, you may safely assume that the operation had not
been a radical one.
Convalescence, in my case, was undisturbed, and the
patient left the hospital in best condition three weeks after
operation.
DISCUSSION.
Dr. TAUsSIG said that there was only a point or two that he wished
to mention in connection with this operation. One was in regard to
the ureters. In this operation, as in a number of other Schuchardt
operations which he had witnessed, it was impossible, in the course of
the operation to see the ureters. They might be pushed up out of the
way, but could not be distinctly seen as such. That had always im-
pressed him as one of the objections to the vaginal method as distin.
guished from the abdominal method. In this latter method, the entire
operation is done with a clear knowledge of where the ureter lies, and
so far as this phase of the subject is concerned, the Doctor thought
the abdominal method distinctly superior to the vaginal method.
Whether more parametrium can be removed vaginally than abominally
is still an open question, but it had always impressed him that the mat-
ter depended somewhat upon the site of the cancer. If it were along the
vaginal walls so that the paravaginal tissues were probably involved, it
would seem that the paravaginal method would have some advan-
tages; but where there is a cancer of the cervical canal, it would seem
that more of the involved tissue can be removed by the abdominal
method.
As to the use of the cautery, he believed that it certainly had its
advantages, but he did not know whether that advantage extended to
the prevention of implantation and metastasis. The cancerous cervix
could not be properly protected. Most of the cancerous tissue is cov-
ered, but we cannot prevent some of that cancerous secretion escaping
City Hospital Alumni. 149
and comig out upon the incision. On the other hand, he did believe
that the use of the cautery along the broad ligament, to a certain
extent, adds to the prevention of the return of the cancer.
Dr. N. W. SHARPE said that he had seen this operation, and that
it had been very successfully performed. He wished to emphasize in
connection with this incision the point that there is actual change of
the vagina, that is, a remarkably increased caliber and decreased
depth.
In his opinion, there were considerations involved, which limit the
scope of this operation to those cases which may be put into a hospital,
where skilled assistants can be had. He doubted very much whether
this operation could be done by country practitioners, while there were
certain other operations which they could perform quite satisfactorily
and attain very good results. It must borne in mind that the majority
of cases can not be brought to the towns and placed in hospitals. The
operation furthermore requires somewhat extended time, which would
necessarily increase the shock. It can not, therefore, be indorsed with-
out limitation.
The point brought out in regard to the use of the ligature behind
the clamp is excellent, especially in view of the fact that the mass which
is cut by the cautery is sometimes so thick that a heat is required
which is so intense as to favor hemorrhage, and, it is a prudent pro-
cedure to thus guard against complicating oozing.
He preferred the protection of catheter in each ureter, because
the ureter has no definite site. Furthermore, it was easy to see how a
cancer extending further than one could readily see, and involving
tissues enclosing the ureters, that the operator would be working at a
great disadvantage, when deprived of the intraureterine catheter.
A special technic is required to carry through this operation, which
he feared the majority of men today do not possess. He believed
that without this special technic better work could be done with less
risk to the patient by the abdominal method, particularly in cases that
are relatively spare; if, however, they have thick abdominal walls,
this procedure might be most serviceable, *
Dr. GELLHORN stated that he did not share the fear of Dr. Sharpe
that the risk to the patient is greater in this paravaginal operation than
150 The Medical Society of
it is in the abdominal operation. This is shown by the extensive
statistics on this point, which have shown that the mortality from the
paravaginal operation is 12 per cent and a fraction, while that of the
abdominal operation is 21 per cent and a fraction. The mortality
from the abdominal operation is almost 1o per cent higher than that
from the vaginal operation. It is generally accepted, also, that the
vaginal operation is accompanied by less shock than the abdominal
operation. This patient in particular, although she was very cachectic,
and had been subjected to to an operation of two hours, showed prac-
tically no shock whatever.
Dr. SHARPE wanted to known whether it was not a fact that the
statististics referred to Ly Dr. Gellhorn were in the majority of cases
in hospitals and in the hands of skilled assistants.
Dr. GELLHORN said that he did not think any major operation
should be performed in any other place than in a hospital. If in a
private house, untoward results may not be due to the operation, but to
the fact that the operator has not availed himself of the best facilities
for the work. It is expected that every man who expects to operate
will learn the technic. The mortality should not be laid altogether at
the door of the operation, but at the door of the operator, if he should
fail to prepare himself for his responsible work or if he should leave
anything undone that might improve the chances of his patient for
recovery.
Scopolamin = Morphin as an Adjuvant in the
Administration of General Anesthesia.
By M. G. SEELIG, M.D.,
ST. LOUIS, MO.
Associate-Surgeon to the Jewish Hospital; Assistant in Anatomy at the
Medical Department of St. Louis University.
HE purpose, of this paper is to present a series of 65
general anesthesia administrations, showing that the
method used is one that merits recommendation and
trial. This series included the following range of cases: Ab-
City Hospital Alumni. 151
dominal hysterectomy, 8; vaginal hysterectomy, 6; hernia, 5;
plastic operations, 8; operations on the tubes and ovaries, I I ;
uterine fixations, 6; curettements, 6; hemorrhoids, 3; fistula
in ano, 2 ; thyroidectomy, craniectomy, orchidectomy, appen-
dicectomy, costectomy, nephropexy, tumor of breast, cyst of
neck, pelvic abscess, exploratory laparotomy, one each. In
every instance the patient received a hypodermic injection of
scopolamin hydrobromid, grain I/IOO, and morphin, grain I/6,
one-half hour before the administration of the general anes-
thesia. The general anesthesia was induced by means of the
ethyl chlorid-ether sequence administered through the Ben-
nett inhaler.
The Bennett inhaler was used because an experience of five
years with it has assured me of its practicability, and because
I find disadvantages in all other inhalers. In the recently de-
scribed inhaler of Iglauer," for example, the anesthetist is un-
able to administer ether or gas at will, after once having started
the administration of ether. Ethyl chlorid is substituted for
nitrous oxid gas, because it is practically as safe, induces
quicker anesthesia, causes no cyanosis or asphyctic symptoms;
and obviates the necessity of transporting bulky steel cylinders
of the compressed nitrous oxid gas. Herrenknecht,” in a most
extensive monograph, confirms the above statements. Gaudi-
ana” reaches the same conclusions, and shows that not one of
the few instances of death laid at the door of ethyl chlorid .
was due solely to the drug itself. Danill,” the instructor in
anesthetics at the Royal Infirmary, Edinburgh, says of the
ethyl chlorid-ether sequence, “the method certainly has some
advantages over the gas-ether sequence, and is a most excel-
lent one. I have never had reason to complain of it, either
from the point of view of safety or for any other reason.
The advantages of the ethyl chlorid-ether sequence are practi-
cal ones.”
In order to make the Bennett inhaler suitable for the ad-
ministration of ethyl chlorid, a slight modificatration was
necessary. A piece of small-caliber brass tubing (length 3
centimeters, lumen I.5 millimeters) was inserted about a half
an inch distally to the air-valve. This brass tubing is placed ,
obliquely, so as to throw the ethyl chlorid spray toward the
152 The Medical Society of
rubber bag of the inhaler, thus insuring against any of the
fluid reaching the patient's face. By means of a three or four
inch piece of rubber tubing, a connection is made between the
ethyl chlorid container and the inhaler, through the brass tube.
As the ethyl chlorid container hangs suspended from the brass
tube, the rubber tube kinks and effectively shuts off the escape
of any ethyl chlorid gas. By one movement the flask of ethyl
chlorid is turned spout end down, and the rubber tube straight-
ened out, so that a measured quantity of the fluid runs into
the rubber bag. There is no frosting or freezing, and conse-
quently no more chance for the much-talked of “refrigeration
of the lung’’ than there is with any other anesthetic. The
method really simplifies the Bennett inhaler, in that it does
away with the large and cumbersome gas-bag. In this very
simplicity the modification seems to possess a decided ad-
vantage over the more complicated one recommended by
Pedersen”.
At this day there is certainly no occasion for a statement
of facts justifying the use of ether as a routine general anes-
thetic. It has been shown repeatedly during the last few
years that the formerly much dreaded “post operative pneu-
monia’’ is by no means solely referable to ether. Aspiration
of mucus and vomitus, exposure, and pulmonary embolism,
have been pretty clearly demonstrated to be the predisposing
factors of post operative pneumonias; and no particular anes-
thetic, not even local anesthesia, does away with the danger of
exposure, of embolism, or vomiting. Moreover, experimental
proof is gradually accumulating to show that ether is not the
only anesthetic that has an injurious effect on the kidneys.
Kemp" showed, as early as 1899, that “renal complications
may follow any anesthetic, * * * for there is no known
anesthetic administered in any effective quantity, whatever the
method of administration, which does not affect the renal Cir-
culation.” Moreover, M. Jaquet' in a comprehensive investiga-
tion of the comparative merits of chloroform and ether, shows
that chloroform causes a parenchymatous degeneration of all
the organs, whereas, ether produces no histological lesions;
and this fact has been confirmed in a lately published r * * arch
of Offergeld.” The latter author even shows that tº paren-
City Hospital Alumni. 153
chymatous degeneration induced by chloroform may be the
cause of death some time after the administration of the
anesthetic. §
Unfortunately, the physiology of artificially induced anes-
thesia is not positively known. The important conclusions
worked out by Overton” are generally credited as being cor-
rect, and are already finding their place in standard works on
physiology. For the clinician, the important aspect of Over-
ton's work is not so much the establishment of the doctrine
that anesthetics act by going into solution in the lipoids (fat,
cholesterin, and lecithin) of cells, as the other fact, that the
injury wrought in these cells is directly proportional to the
quantity of anesthetic used. It is probably fair to assume that
not one operator in a hundred concerns himself with the
quantity of anesthetic administered to his patient. Yet we
read in one of the latest published works on physiology" that
“ cell death is caused by a prolonged anesthesia.” One of the
ends to be aimed at in the administration of all the anesthetics
is to reduce the amount administered to a minimum. The
ethyl chlorid ether sequence most positively aid's us in the at-
tainment of this end. -
We are further aided, however, by the administration of
scopolamin-morphin hypodermatically. Scopolamin is an
alkaloid of hyoscyamus niger of the order solanaceae. Its
sister alkaloids are hyoscin, daturin, duboisin, atropin, and
hyoscyamin. Although much has been written concerning
scopolamin (chiefly as a result of the investigations of psychi-
atrists and chemists), it still remains to be settled in just what
particulars it differs from other alkaloids of the belladonna
group. It is most closely related to hyoscin. Kunzel,” Stein-
buechel,” Kochman,” and others state that it is identical with
hyoscin, whereas, Ladenburg" claims to have shown that hyo-
scin and scopolamin are by no means identical: The résumé
of the physiological action of scopolamin is given by Stein-
buechel.” He states: - -
I. Small doses raise blood pressure by stimulating the
vasomotor center. Large doses lower it by influencing the
cardiac excitomotor mechanism.
2. The pulse is usually slowed a trifle, but is ordinarily
154 The Medical Society of
not influenced by small doses. Large doses cause a vagus
pulse.
3. The cerebral cortex is rendered less excitable when
stimulated by the faradic current. Sleep is induced, but not
analgesia.
4. Respiration is not influenced by small doses. Large
doses slow respiration. -
5. Sweat, mucus, and saliva secretion are markedly
diminished. - -
6. Mydriasis is induced. - … -
7. The motor end-apparatus supplying the intestine is
paralyzed, and the tone of the splanchnic increased.
8. The drug is excreted by the kidney.
Kochman” states that there has never been a death attrib-
utable to scopolamin. Dogs react to the drug exactly as do
human beings, yet a dose of thirty grains, injected intraven-
ously into a fifteen pound dog, does not kill.
In 1900, Schneiderlin” published the first paper advo-
cating the use of scopolamin as a substitute for general anes-
thesia by inhalation. Scopolamin itself does not induce an-
algesia, but combined with morphin it induces a state of gen-
eral anesthesia sufficiently profound to permit the performance
of any operation. The method of administration and dosage
was more carefully worked out by Korff" and Blos”; as a re-
sult of Korff's work, in particular, the following dosage was
adopted: Scopolamin, O.OOI2, and morphin, O.O25. This was
divided into three doses, and hypodermically, three, one, and
one half hours before the operation. Schneiderlin, Korff,”
and Blos all reported excellent results.
Rational objections were gradually advanced against a
method of inducing anesthesia by means of fixed dosage, one
author even going so far as to pronounce the method useless
and dangerous.” In addition, three unfortunate deaths occur-
red during the following operations on patients to whom scop-
olamin and morphin had been administered. These deaths,
although not wholly referable to the anesthesia, nevertheless
served to place scopolamin-morphin narcosis in discredit.
There it remained, until Carl Hartog” suggested that both the
scopolamin and morphin be administered in much smaller
City Hospital Alumni. 155
doses than was recommended by previous authors, and that
ether be relied upon to complete the anesthesia. Hartog re-
ported 75 cases, and spoke of his results in most glowing
terms. It was my good fortune to observe most of the cases
he reported, and to be able to confirm all his statements.
Through the kindness of Drs. Gellhorn, Ehrenfest, With-
erspoon, Bartlett, and Mudd, I am able to report a series of
65 cases in which scopolamin hydrobromid, grain I/IOO, and
morphin, grain I/6, were administered half an hour before in-
ducing general anesthesia with ethyl chlorid-ether. In more
than half the cases the anesthetic was administered by Dr. W.
E. Leighton. As a result of my experience with the method,
I feel that I may say without reserve that I have never seen
results even approximating those that were obtained by this
method. Unstinted praise always carries with it the suspicion
of a somewhat biased critic. Yet, so exceptionally smooth
were these narcoses that they warrant one in carrying the
burden of this suspicion until it is proved unfounded. Of
these 65 cases only one patient vomited or retched while on
the operating table. 77 per cent of the patients did not vomit
at all. One-third of the patients that did vomit, vomited only
once, and then only from two drams to one ounce of clear
mucus. Nausea was never pronounced, except in two cases,
and vomiting never occurred earlier than two hours after opera-
tion. This last fact is of supreme importance, for in all cases
where vomiting did occur, laryngeal sensibility was intact, and
as a complete safeguard against tracheal aspiration, and the
consequent danger of an aspiration pneumonia. There is no
occasion for dilating upon either the discomforts or the dangers
attendant upon post-anesthetic vomiting. They are well-
known. I can find no record of a series of general anesthesia
administrations followed even by approximately so small a
percentage of vomiting, and if the preliminary administration
of scopolamin-morphin did nothing else than lessen the liabil-
ity to vomit, its use should be highly recommended
But it does more. First of all, it markedly lessens the
quantity of anesthetic necessary. About 4 ounces of ether
per hour of operation are used when the drug is administered
skillfully and carefully. In a personal communication to me,
*
156 The Medical Society of
Dr. T. L. Bennett, of New York, tells me that he uses about
4 ounces of ether per sixty minutes of anesthesia, and that for
a 2-hour operation he requires about 6-ounces. This averages
3 I/3 ounces per hour. We used barely a fraction over 2 ounces
an hour. It has already been pointed out how great a desid-
eratum it is to administer a minimal quantity of ether.
After the administration of scopolamin-morphin the pa-
tients are in a peaceful state of mind, and go under the influ-
ence of the general anesthetic without passing through the
usual state of excitement. Salivation is almost invaribly ab-
sent, thus adding another safeguard against aspiration pneu-
monia. After their return to bed the patients lie absolutely
quiet and awaken without the slightest excitation. After re-
maining awake for a short period they usually doze off again,
or at least remain quiet and peaceful. The first twenty-four
hours following the operation is attended by much less pain
and discomfort than in cases where the scopolamin is not ad-
ministered. These advantages: lessened amount of anesthetic
necessary, absence of salivation, avoidance of the stage of ex-
citement, marked reduction in the liability to vomit, and quiet
and freedom from pain after operation, have been confirmed
by Tuffier,” of Paris, Israel” and Dirk,” of Berlin, and by
Robertson,” of our own country (Robertson used hyoscin in-
stead of Scopolamin).
There is no reasonable objection to the use of scopolamin
hydrobromid and morphin in the doses recommended of I/IOO
and 1/6 of a grain respectively. The recent experimental
work of Crile” shows that morphin lessens the intensity of
many of the afferent nerve impulses reaching the vasomotor
centers, as the result of stimulation of the peripheral nerves,
and thereby lessens the susceptibility to shock. Scopolamin
exerts a distinct influence in raising blood-pressure, and
thereby also aids in preventing shock. So, from the point of
view of prophylaxis, the combination of the two drugs strongly
recommends itself. Only he who has witnessed a series of
ether administrations preceded by scopolamin-morphin injec-
tions can appreciate what a boon these drugs afford both to
the patient and to the operator.”
City Hospital Alumni. 157
BIBLIOGRAPHY,
*Iglauer.—The Nitrous Oxid-Ether Sequence by Means of a New Inhaler.
Cincinnati Lancet-Clinic, March 18, 1905.
*Herrenknecht.—Ueber Aethyl Chlorid und Aethyl Chlorid Narkose, Leipzig,
I904. .
*Gaudiana.-Ethyl Chlorid Narcosis. Riforma Med., January 29, 1904.
*Danill.—Mixed Anesthetics. Edingburg Med. Jour., February, I905.
*Pedersen. —An Attachment to Bennett's Inhaler. New York Med. Jour., De-
cember 24, 1904.
*Kemp —Further Experimental Researches on the Effects of Different Anes-
thetics on the Kidneys. New York Med. Jour., November 18 and 25, December 7,
I904. -
"Jaquet.—Semaine Med., December 7, 1904. -
*Offergeld.—Experimenteller Beitrag zur toxischen Wirkung des chloroform auf
die Nieren. Archiv f. klin. Chir., B. 75, H. 3.
*Overton.—Studien ueber die Narkose. Jena, 1904.
19Frey.—Vorlesungen ueber Physiologie, p. 26. Berlin, 1904.
*Kunzel.—Handbuch der Toxicologie. p. 714. Jena, 1899.
1°Steinbuechel.-Schmerzverminderung und Narkose mit specieller Beruecks-
ichtigung der kombinirten Skopolamin-Mo phium Anesthesia. Leipzig, 1903. F
Deuticke. -
18Kochmann.—Ueber die therapeutschen Indicationen des Skopolamin hydro-
bromicum. Ther. der Gegen., May, 1903.
1*Ladenberg.—Bemerkungen zur Skopolamin Narkose. Monatsch. f. Geburts.
u. Gynak, B. 18, p. 627.
*Schneiderlin.—Aerztliche Mittheilungen aus und f. Baden, No. Io, I900.
16Korff–Munch. med. Woch., No. 29, 1901, p. 1170, and No. 27, 1962.
"Bloss.-Beitrage zur klin. Chir, B. 30, 1902.
18Corff.—Berl. klin. Woch., No 33, 1904.
*Flatau.-Munch. med. Woch., No. 33, 1904.
*Hartog.—Die Aethernarkose, in Verbindung mit Morphium-Skopolamininjec-
tionen. Munch. med. Woch., No. 46, 1903.
*Tuffier –Gaz. Med de Paris, No. 8, 1905.
*Israel.—Deutsche med. Woch., No. 10, 1905.
28 Dirk.-Ibid.
*Robertson.—Med. Rec., January 9, 1905.
*Crile —Blood-Pressure in Surgery.
*It must be added that the consensus of opinion is, that many of the irregular-
ities in the action of scopolamin are referable to impure preparations of the drug.
All the authors quoted are in accord that Merck's scopolamin is the most reliable
preparation. Moreover, scopolamin hydromid does not keep well in solution; and,
in order to avoid the constant preparation of fresh solutions, I have had Parke, Da-
vis & Co. make up tablet tritura es of Merck's scopolamin hydrobromin in tablets
of 1/100-grain each. One of these tablets should be dissolved with 1/6-grain tablet
of morphin and injected hypodermatically 30 minutes before the administration of
the general anesthetic. Scopolamin may be used with advantage as an adjuvant to
chloroform as well as to ether.
158 The Medical Society of
DISCUSSION,
Dr. REAM, in opening the discussion, said that he esteemed it a
very great privilege to have been permitted to hear this paper read.
He was greatly interested in the subject of anesthesia, but had had no
experience with the preparations which the Doctor had mentioned in
the paper. Heretofore nitrous oxid was regarded as transient in its
effects, so that it was only used in momentary operations. Since,
however, there is an apparatus on the market for the administration of
the gas, prolonged anesthesia can be procured. There are cylinders
that contain one hundred gallons of nitrous oxid gas, and forty gallons
of oxygen, which are light enough so that they can be easily trans-
ported. Some of the eastern operators are using nitrous oxid. He
remembered a recent report of a case in Cleveland, Ohio, where anes-
thesia lasted one hour and thirty minutes, the patient experiencing no
sickness or other unusual symptoms.
It is common for him to obtain prolonged anesthesia with nitrous
oxid and oxygen, lasting from fifteen minutes to one hour without the
slightest inconvenience to the patient.
Dr. GELLHoRN said that he certainly felt indebted to the Doctor
for having brought up this question of anesthesia which is by no means
a settled question. He personally felt very much indebted to the es-
sayist for having induced him to try this scopolamin-morphin anesthe-
sia in his operations. He read of it when it came out in the journals,
but hesitated to try it in his own practic. Since giving it a trial, how-
ever, he had received such uniformly good results that he was glad to
indorse Dr. Seelig's statements.
In the paper, mention was made of the fact that a smaller amount
of ether was required after the injection of scopolamin-morphin, and
it was claimed by some authors that the injection of morphin-atropin
would give the same result. When a student, the speaker had given a
number of narcoses with preliminary injection of morphin-atropin and
he remembered very vividly the large quantities of chloroform, which
were required to keep the patient under anesthesia. Moreover, he ex-
perienced a number of asphyxias. During the last year, since the in-
troduction of scopolamin-morphin in his narcoses, he had had none
of these disturbances.
City Hospital Alumni. 159
Another point of importance brought out was the rare occurrence
of vomiting. This the speaker said he could also confirm. He never
saw excessive vomiting, but in the beginning he observed several times
that the patients vomited twice or three times after the operation. In
the beginning, he injected scopolamin 1/15o and morphin 1/6 of a
grain. Later, however, he had given this dose twice, the first dose
two hours and the second dose a half hour before the operation, and
had since noticed no vomiting. He believed that the time when scopo-
lamin morphin is injected has something to do with this. Whenever
it was given only a half before, vomiting was apt to occur, while in
those cases that received it two hours before the operation, vomiting
did not occur. For illustration, this cancer patient, the uterus of
of whom I demonstrated tonight, received two injections, and did not
vomit at all. On the other hand, this morning a patient was anesthet-
ized for operation, there was one.injection a half hour before the nar-
cosis, which did not last more than ten minutes, and yet the patient
vomited twice.
The pain after operation is minimized. The patients, as a rule,
sleep two or three hours after they have been brought back to bed,
and the pain during the rest of the day is slight, in fact, so small that
in very rare instances did he give morphin. In most cases he was able
to give in the evening after the operation 7.5 grains of veronal, thus
producing sleep without the undesirable effects of morphin.
The excessive dryness of the mouth and throat, caused by scopo-
lamin is, at times, distressing after the patients awake. Recently, the
use of eserin has been recommended after operations, by Craig, of
Boston. Eserin has two effects; first, it produces peristalsis; second,
it produces moisture in the throat, which is no longer to be avoided.
The Doctor expected in his next case to try this eserin after an opera-
tion with scopolamin morphin.
In connection with this scopolamin-morphin, he had made the
observation that the amount of urine excreted during the first twenty-
four hours after operation is very small, and it had occurred to him that
this reduction in the amount of urine may be due partly to the scopo-
lamin. He had not noticed, however, that this reduced amount of
urine had any bad effect on the patient. He had had made tests of
160 h The Medical Society of
the urine and had found that the kidneys were not affected except
where they had been affected before operation.
Dr. Seelig had spoken of the exclusive use of scopolamin-mor-
phin to produce narcosis, without general anesthetic. This, Dr. Gell-
horn had tried in three cases. Although the results had been insuffic- .
ient to finish the operations, he did not intend to make more than the
most restricted use of this form of anesthesia.
Dr. EHRENFEST said that he could heartily confirm what Dr.
Seelig and Dr. Gellhorn had said, as this anesthesia had been given
in several of his own cases. The patients take it very nicely, and be
have much better immediately after the operation. Dr. Ehrenfest did
not believe there could be any doubt but that the use of this system
was almost ideal.
If we speak of the use of scopolamin with morphin, it should be
borne in mind that scopolamin is a very near relative of hyoscin.
Some authorities, in fact, do not believe that there is any difference.
The latter is a very near relative of atropin, and thus it seems reason-
able to assume that a simple atropin-morphin tablet would give about
the result. There is some disadvantage in the use of morphin. He
found it a little harder to get the first action of the bowel after this
anesthesia, and this is probably due to the morphin. In his last two
cases the Doctor had tried to overcome this by giving calomel im-
mediately before the beginning of the anesthesia.
Dr. Seelig excludes from his statistics the cases which begin to
vomit after the first twenty four hours. This seems just. We have
every reason to be satisfied if the patient does not vomit within the
first twenty-four hours. Sometimes, however, there is quite persistent
vomiting the second and third days. He thought that this might pos-
sibly be due to this special form of anesthesia. The patient feels so
well during the first twenty-fours that we do not resist the desire to
have something to drink. Sometimes they are given water, or some-
thing more substantial, and then the vomiting begins the second and
third days. &
Dr. GELLHORN said that in his cases, after the injection of scop.
olamin-morphin, the ether drop method had been used. The only
difference he had been able to see was that it took the patient longer
City Hospital Alumni. 161
to get under the influence of the ether. After that it differs in no way
from the other narcoses.
Dr. M. J. LIPPE felt indebted to the Doctor for bringing this
subject to the attention of the Society. He saw a broader field for it,
if it would produce a freedom from pain that we get from 15oth dose
of atropin and 1/6 grain of morphin.
In regard to the atropin morphin combination, we know that it is
frequently followed by vomiting, and in many cases we look for vomit-
ing. Now, if scopolamin-morphin does not produce this vomiting, it
would seem that although it belongs to the same group, that it is cer-
tainly a different article. r
Dr. TAusSIG wanted to call attention to one of the particular
benefits of this anesthesia, namely, the quietness of the patient after
the operation, and the absence of vomiting. It was a case “A stitch
in time saves nine.” The amount of morphin given the patient before
the operation is very small in comparison with the amount which would
have to be given afterward to quiet the patient. In iliustration of this
he cited the case of a patient who, being awakened at six o'clock in
the evening, thought that she had just been removed to her bed
from the operating room, although that had occurred six hours
previously. She was dozing and sleeping and free from pain during
all that time.
Although not under the head of this paper, there is another
method that may be used, and that should not be forgotten, and that is
the spinal injection of cocain-adrenalin. Recent experiments have
shown that this is not a closed chapter. The results show that it is
not as dangerous a method, if used with reasonable care, as it was
originally thought to be.
Dr. GELLHORN in answering a question in regard to the use of
eserin stated that Dr. Craig used it after opening the abdomen and
ascertaining whether or not the peristaslis would be harmful to the
patient. He, then, gives it during the operation, about five minutes
after the abdomen is opened. The peristalsis begins from eight to
twenty-four hours after the operation. If, however, the conditions
within the abdominal cavity should be found to be such that rest
162 The Medical Society of
would be good for the patient. e.g. in the case of suppurating appen-
dicitis, or operations upon the intestines, the eserin is not injected.
Dr. GREEN wanted to know whether the Wohlgemuth apparatus
for the administration of combined chloroform-oxygen had been used
recently. He recalled that a paper by Wohlgemuth had appeared in
the Interstate Medical Journal several years ago, and that {\r. Ehren-
fest had procured the apparatus and had used it with success.
Dr. Ehrenfest stated that one of the reasons for his discontinuing
the use of the method was the impossibility cf obtaining oxygen in
receptacles of convenient size. .
Dr. REAM stated that oxygen can now be obtained in 40 gallon
iron tubes, weighing about fifteen pounds, and he uses it constantly
in his office. -
Dr. SEELIG said, in closing, that he felt very much indebted to the
gentlemen for the interesting manner in which they had disscussed his
paper. He could most heartily confirm Dr. Ream's statements regard-
ing the nitrous oxid-oxygen mixture being the safest anesthesia.
However, it could not be used in abdominal operations. To ad-
minister it properly requires a great deal of attention and a great
deal of skill; but it is preferable to plain nitrous oxid because it
avoids cyanosis.
In regard to the question of vomiting, he had searched rather
diligently to find some definite cause for vomiting after anesthesia. It
had occurred to him that it might be due to the swallowing of saliva,
which might have become impregnated with ether. The scopolamin
unquestionably does away with salivation and thus diminishes the
tendency to vomit; however, it will not do away with all the vomiting;
and no one should attempt to use it with the idea that it will.
Scopolamin is not a drug to be tampered with. It seems that the
physiology and pharmacology of the drug is so uncertain that the lead-
ing authorities themselves have reached no definite conclusions. He
had written to Merck, himself, and they seemed to know about as little
about it as he did. They wrote a letter from which he could not make
out whether they themselves know whether or not it is identical with
atropin. At present, all that can be said is that we must be careful in
*~
selecting Merck’s preparation of the drug. He would not like to go
City Hospital Alumni. 163
on record as creating in the minds of the members present that it was
a nontoxic drug. The patients do seem to be more constipated after
the use of the drug. This, the Doctor had noted, as well as some of
his friends. It seems to have an inhibitory effect on the peristalsis;
but the bowels move after a little rest.
As to the administration of morphin and atropin. He, himself,
had used it for over six months. Its effects had been demonstrated
over and over and over again. It does not in any way approach the
effect of scopolamin morphin.
Meeting of June 1, 1905; Dr. John Green, Jr.,
President, in the Chair.
A Case of Albuminuric Iridocyclitis.
By N. M. SEMPLE, A.M., M.D.,
ST. LOUIS, MO.
INCE the first classical report of Leber' in 1885 of what
S he considered as an iritis albuminuria, there has ap-
peared in the literature very little definite upon this
subject. Yet, from the few cases reported, and from analogy
of iritis in other forms of constitutional disease, e.g., diabetes
mellitus, it seems justifiable to consider a possible etiological
relation between iritis and albuminuria. And the report of
any case that might throw possible light upon the subject is
worthy of consideration. This is my excuse for the following
report, in which, unfortunately, there exists a lack of many
points of scientific accuracy especially that of pathological
findings. *
The following is the clinical history:
º J. H. D., male, single, aged 28 years, conductor on street
railway.
Family History.—Good as far as obtainable.
Past History.—When 9 years old patient had chickenpox
—has suffered from three or four attacks of malarial fever.
Eight years ago had gonorrhea followed by involvement of
164 The Medical Society of
joints. Six years ago had what attending physician pro-
nounced syphilis, antisyphilitic treatment being immediately
begun, as to the nature and extent of which definite report
could not be obtained. During the past three years the patient
has noticed intermittent periods of increased frequency of
urination, which he attributed to the more or less constant
standing and jolting necessitated by his work—that of a con-
ductor. During the past few months he has had to pass urine
in good quantities two to three times during the sleeping
period of eight to nine hours, otherwise he has suffered no in-
convenience whatever.
Patient first reported to me August 1 1, 1904, with the
history of having gotten the day before glass into left eye from
a broken window pane. On examination no glass could be
found, a slight cut of the scleral conjunctiva could be made
out near the outer limbus. There was present considerable
conjunctivitis with slight edema of the lower lid. The follow-
ing day the edema of the lid had markedly increased, the con-
junctiva Sclerae became edematous, and in a short time symp-
toms of a severe iritis developed—ciliary injection, swollen,
muddy iris, decided pain and intense photophobia. Later
the aqueous became cloudy, and extensive deposits appeared
on the posterior surface of the cornea, indicating involvement
of the ciliary body.
On account of the suggestive history of syphilis of six
years previous, the patient was put upon antisyphilic treat-
ment, the iodid of potassium being rapidly pushed to the ex-
treme of tolerance. The iris responded very sluggishly to
the energetric use of atropia. The globe became very sensi-
tive, and the edema of lids and conjunctiva sclerae became
very marked, the patient suffering intensely. On September
26th (three weeks after the onset of the disease) there appeared
hemorrhages from the iris. This first attack lasted until
October 17th, when the patient returned to work, still report-
ing for observation. At that time the ophthalmoscope showed
the fundus normal. V. =*/is, no injection of the eyeball.
On November 8th occurred a relapse of even greater
severity than the first attack.
On account of the indefinite history of syphilis, and the
\
City Hospital Alumni. 165
lack of response to the specific treatment which had been
kept up vigorously, and on account of the possible irritant ef-
fect of the prolonged use of the iodid, the patient was taken
from the antiluetic treatment, for which was substituted
aspirin, which seemed best to control the pain. The second
attack continued with more or less severity, and a hemorrhagic
tendency, for about six weeks, the patient returning to work
on December 24th, the eye apparently normal.
About a month later, February Ist, patient again returned
with signs of a beginning relapse.
On making a more thorough general examination of the
patient than was made during the first attacks, at which time
a syphilitic etiology was assumed, a careful examination of
the urine was made. Here I should like to emphasize the im-
portance of such a routine examination, especially for the
phyician doing special work, who is very apt to neglect the
importance of the general examination of the patient.
The first analysis of the urine (made at the beginning of
third attack) gave the following result: N
Color, muddy yellow, excess of sediment of urates, re-
action slightly acid, specific gravity IO33, quantity in twenty-
four hours, 82 ounces.
Albumin I/IO per cent, no sugar. Microscopical examin-
ation showed fairly large number of hyaline-granular casts
with an occasional epithelial cast. There were no symptoms
of general systemic involvement, except the complaint of the
patient of occasional shortness of breath on exertion. Un-
fortunately the report of the heart examination made at the
time is not at hand.
The patient was immediately put upon a vigorous diet,
consisting chiefly of milk and vegetables, and at first the
free use of saline purgatives, later replaced by the mild
aperient waters.
There was an immediate improvement in both the iritis,
and the condition of the urine. The latter at the end of a
month had regained it normal clear straw color, specific grav-
ity 1020, only occasional trace of albumin, and hyaline or
granular casts could be demonstrated with difficulty. At this
time patient could sleep eight to nine hours without the neces-
166 The Medical Society of
sity of voiding his urine. The iris responded especially
promptly, the iritis never approaching the severity of the two
former attacks. There was no edema of the lids or scleral
conjunctiva. The pupil was fully dilated by the atropia, and
the patient suffered practically no pain. The eye was kept
under the influence of atropia for about a month on account of
a slight but persistent injection. Since this attack the patient
has been under constant observation for about four months,
during which time there has been no tendency to relapse, the
eye remaining normal, V.-"/is.
In reviewing the history of the above case, there are a
number of points that would seem to justify the conclusion
that there existed an etiological relation between the iritis and
the albuminuria. There can hardly be a doubt but that the
patient was suffering from an albuminuria, that there were
organic changes in the kidney—albeit of slight character. The
fact, that, when first examined, the urine showed a slight in-
crease of quantity, a rather high specific gravity, albumin, and
hyaline granular casts in fairly large numbers, and the fact
that the condition was at least temporarily greatly improved
by proper attention to diet, etc., would lead us to think that we
had to do with a chronic nephiritis, whether interstitial or dif-
fuse, it would be difficult to say, but which had not advanced
so far but that it was at least temporarily amenable to treat-
ment. That the iritis was of the same etiology seems strongly
to be inferred by the nature of the attacks, and their response,
or lack of response, to treatment. The first attacks showed
absolutely no response to the specific treatment of syphilis,
while the third attack responded immediately, when the treat-
ment was directed toward the albuminuria. Nor has there so
far been a tendency to relapse.
The lack of symptoms indicating the invasion of other
organs by the albuminuria would hardly lead one to doubt its
existence, nor would the rapid and marked improvement of
the urine on strict attention to diet, etc., necessarily mean that
we had to do merely with a transient accidental albuminuria.
The improvement in cases of marked general involvement is
often decided, and of long duration. In the case cited in this
report the iritis was apparently the first sign of trouble, with
City Hospital Alumni. 167
the exception of the increased frequency of urination, which
had not inconvenienced the patient sufficiently to cause him to
consult a physician. * -
But why can not the iris as well as the retina be the seat
of first signs of the general disease? That the involve-
ment of the retina is often the first symptom of albuminuria
is a long established fact. Why could not the same indi-
vidual susceptibility—albeit very rare—be present in the
iris, where the circulatory system is also of the finest, and
most delicate P
In all the cases that I have been able to find in the litera-
ture, the diagnosis of nephiritis had been made previous to
the patient's coming under the observation of the ophthal-
mologist. Neither in the case of Leber, nor in the one re-
ported by Schapringer” was there a post-mortem examination.
In the former there was an extensive involvement of the
choroid, less so, of the retina. In the case reported by
Schapringer the retina seemed also to have been involved.
In the very peculiar case reported by Pollak,” in which the
miscroscopical findings were made by Alt, there seems to
have been a septic uveitis, simultaneous with a nephritis
caused by staphylococcus pyogenes aureus. The case cited
in this report showed no involvement of other membranes of
the eye, except that of the iris and ciliary body.
BIBLIOGRAPHY.
*Von Graefe's f. Ophth., Vol. xxxi, No. 4, page Ioy.
*Iritis as a Symptom of Brights Disease. Amer. Jour. of Ophth., July, 1893.
*Ophthalmia Albuminurica. Ibid., May, 1893. *
*Croupous Iridochorioiditis. Ibid.
/ DISCUSSION.
Dr. AMAND RAvold said that to draw conclusions as to the
character of the kidney trouble from the urinary findings was an ex-
tremely difficult thing to do. Even experts will miss it in more than
50 per cent of the cases. But that this patient had kidney trouble
seemed undoubted, and that kidney trouble may have been due to
syphilis. The antisyphilitic treatment may have but lighted up that
kidney trouble. w
168 The Medical Society of
Dr. J. C. FALK wished to know if Dr. Semple had obtained a
history from the patient as to how long he had been under antisyphi-
litic treatment.
Dr. SEMPLE replied, he did not know.
Dr. FALK thought it was a question of importance how much
antisyphilitic treatment the patient had received; whether he had had
enough treatment to make it appear reasonably certain that the disease
had been subdued. He agreed that this patient probably had a
chronic parenchymatous nephritis and that this was aggravated by the
iodid of potassium and the mercury. He had recently seen a case of
a woman who had an attack of uremia resulting from a chronic inter-
stitial nephritis. She also was known to be a syphilitic and received
very active antisyphilitic treatment subsequent to the attack of uremia.
It was not long until she had another attack of uremia which was
fatal. The fact that Dr. Semple's patient did so well under the dietary
treatment and the lapse in the treatment with the iodids probably gave
the kidneys an opportunity to improve in condition. The syphilis
may have been a predisposing cause and the nephritis an exciting
cause of the iritis, the nephritis being aggravated by the treatment
with iodid of potassium.
Dr. FELIX GARCIA had had a case some years ago, a man with
secondary syphilis. He never missed his treatment and at the end of
three years he had come under the observation of Dr. Bryson, in con-
sultation. After the three years he was taken off the antisyphilitic
treatment, but was kept under observation two years and was later
married with the approval of [\r. Bryson. He had a baby girl about
two years afterward and she showed no symptoms of syphilis. About
three or four years after his marriage he was attacked by paresis. Dr.
Fry had seen the patient with the speaker and confirmed his diagnosis.
The man had since died. The doctor felt very much disheartened
and did not think the treatment totally dislodged the condition. He
wished Dr. Luedeking would give his ideas of the futile treatment in
some cases of syphilis. In relation to the present case Dr Garcia
meant these remarks to illustrate that in some cases the disease
marches on in spite of the most careful treatment.
Dr. LUEDEKING thought that the standpoint of the present day
City Hospital Alumni. 169
\
was not at all to the exclusion of other underlying causes of paresis.
It was not limited to syphilitic etiology by any means. At any rate he
would not for a minute entertain the thought that the syphilis in this
case had anything to do with paresis. Paresis and tabes developed in
cases where he thought it very dubious that these changes should be
attributed to any syphilitic condition through which the patient might
have passed twenty or thirty years previously. There seemed not the
remotest connection traceable.
The PRESIDENT inquired as to the patient’s vision and whether
the iritis was of the plastic type.
Dr. SEMPLE, replying to the President, said that the condition was
more on the order of a serous iritis. There was no gumma. The
vision was very much impaired. A practical test was not possible, the
photophobia was too great.
The PRESIDENT said that Dr Semple had referred to a paper by
von Michel in which he reported the result of his investigations in 84
cases of primary iritis with reference to the etiological factor. Von
Michel had concluded that of these 84, 7 could be ascribed to tuber.
culosis (apart from tuberculosis of the lungs or glands), 14 seemed
dependent upon or associated with tuberculosis of the lungs and
glands, 29 cases were associated with chronic nephritis, and circulatory
disturbances were causative in 13 cases. Of the series of 84, only 5
cases were ascribed to syphilis. The speaker did not understand
how, in a series of 84 cases syphilis could be the etiological factor in
only 5. Iritis dependent on nephritis was said to be more frequent
in females. It was apt to be unilateral and was a disease of middle
life.
A thing of considerable importance in this connection was the
fact that specialists were inclined to omit a general examination of the
patient. This was an unfortunate omission, especially in cases of in-
flammatory ocular trouble. The specialist laid himself open to criti-
cism unless he viewed such cases in their larger apects. A general
classification of the etiology of iritis would unquestionably place syph-
ilis first, then rheumatism, gonorrhea, tuberculosis, diabetes and other
disorders.
Dr. WALTER BAUMGARTEN asked whether an ophthalmoscopic
170 The Medical Society of
examination was made at any time. He also wanted to know whether
the antisyphilitic treatment would be likely to aggravate kidney inflam.
mation if the latter condition was due to syphilis
Dr. SEMPLE said that at first the photophobia was too great to
make a satisfactory ophthalmoscopic examination. Later it was made
and no change was found in the choroid or retina.
Dr. GEORGE HOMAN asked if the age of the patient, 28 years,
would not exclude a chronic parenchymatous condition. He would be
inclined to take the view whether or no this specific condition had been
present, that the treatment mentioned had brought about the kidney
irritation. The prompt recovery was rather against the theory of
chronic parenchymatous nephritis.
Dr. RAVOLD said that the discussion brought up the perennial,
but nevertheless important question of how best to administer potassium
iodid so as not to produce iodism. Many physicians have been taught
and still give a saturated solution believing that each drop of the solu-
tion contains I grain of the drug. The absurdity of the belief needs
no discussion. Most of the great syphiologists, especially the French,
make use of a 50 per cent solution so that every 2 drops of it con-
tains I grain of the iodid. This permits accuracy in measuring the
amount of drug administered. They begin with an initial dose of
from Io to 3o grains and increase it by adding a grain to each succeed-
ing dose until 50 to 60 grains at a dose are given three times a day.
To prevent gastric irritation, it was invariably prescribed to be taken
in milk after meals. To do away with the iodid eruption, patients are
instructed to keep the skin clean by bathing not less than twice a day
as the eruption seems to be due to free iodin excreted by the skin.
The results obtained are highly satisfactory as far as the skin is con-
cerned, but some patients have the eruption in the nose and external
auditory canal, in spite of all precautions.
Dr. FALK thought the iodin was an irritant to the kidneys no
matter how it was given, whether in a “ Ioo per cent” solution, a 50
per cent solution or in large quantities of milk, the latter method
simply had in view a lessening of the irritating effects on the stomach.
Milk was a very good vehicle for the administration of large doses of
the iodids. Whether given by the mouth or skin lodin was always an
City Hospital Alumni. 171
irritant to the kidneys. After applying the ointment to the abdomen
he had within twenty minutes detected iodin in the urine. When iodid
of potassium is given in a case of nephritis it was at the risk of the
kidney structure, whether syphilitic or non syphilitic, it made no dif-
ference. -
Dr. BAUMGARTEN said that as this iritis existed before the anti-
syphilitic treatment was given, and as two attacks occurred in close
succession, the last attack occurring after the dietetic treatment was
given, it would be interesting to know how the condition of the urine
now compared with the urine during the last acute attack.
The PRESIDENT said that he had used a 50 per cent solution,
twice diluted, and he could not recall a case of iodid erruption.
Dr. RAvold called attention to the fact that the syphilis existed
in this case before the iritis.
Dr. SEMPLE, in closing, replied first to the question Dr. Ravold
had brought as to the causation of the kidney trouble by the use of
iodids. The iodids were not used until the acute attack. It was true
that the accuracy of the history of syphilis was in doubt. The patient
gave a history of syphilis some 6 years before the speaker had seen him,
having been put on antisyphilitic treatment before the secondary con-
dition. Dr. Wilson said that the scar at the sulcus was indicative of
a hard chancer. When the patient was put on aspirin the pain seemed
to yield somewhat. He doubted the propriety of pushing the anti-
syphilitic treatment when the case did not seem to respond to it.
Between the first and during the second attack the antisyphilitic treat-
ment had been continued. Unfortunately there was no history of
kidney trouble and the urine examination was not made until the be-
ginning of the third attack. The history Dr. Semple had gotten from the
patient later indicated that he had had intermittent attacks of frequent
urination during the last year. He had had no edema or anasarca.
At the time of his first attack he gave a history of increased annoyance
during that time and also during the second attack. The examination
of the urine made on February 14th indicated that there was some
kidney trouble. Whether it was parenchymatous or interstitial nephri-
tis was a question, but that the condition responded to treatment and
the fact that there was an increased amount of urine with an increased
172 The Medical Society of
specific gravity and the presence of granular, hyalin and epithe-
lial casts, would seem to indicate that the condition was of a paren-
chymatous nature. Since the treatment he had been unable to dem-
onstrate any hyalin or granular casts but he had found a small amount
of albumin occasionally. The interesting point to him had been the
fact that there was present a very severe form of iritis, not the charac.
teristic plastic iritis of lues, but more of a serous nature, and there
was a certain amount of hemorrhage, an immense amount of edema º
of the lids and very marked photophobia. Most forms of iritis with-
out the formation of a gumma were found in the secondary and not in
the tertiary cases. Here there was no sign of gumma and the history
of syphilis was of six years’ standing.
Meeting of June 13, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Stab Wound of the Heart.
By R. H. CAMPBELL, M.D.,
ST. LOUIS, MO.
Sº 7, 1903, near midnight, Wm. Wilkerson and
Laurence Davenport, who were married to sisters and
living in the same house, returned home from a Satur-
day celebration, somewhat under the influence of liquor.
They engaged in a quarrel, during which Davenport stabbed
Wilkerson in the chest with a long-bladed pocket knife.
Within thirty minutes from the time he was stabbed Wilkerson
fell unconscious on the back steps of their common home. A
physician was called, who dressed Wilkerson's wound and
placed him in bed. He regained consciousness, and remained
in bed until the night of September 13th, when he died. His
attending physician's diagnosis was traumatic pneumonia.
September 14th, the morning following Wilkerson's death,
I was requested by the Coroner to make a post-mortem ex-
amination of the body. I found at the lower border of the
5th rib in the line of the nipple a lacerated wound an inch
City Hospital Alumni. 17 3
long, penetrating the thoracic cavity and plugged with a strip
of gauze. On opening the thorax, the left lung was com-
pressed upward, the left, pleural cavity was filled with a san-
guineous fluids and the pleura was covered with a fibrosan-
guineous coating. An incised wound about 3/4 of an inch
long was found in the pericardium. This wound and the peri-
cardial cavity were filled with a dense clot and some sanguin-
eous fluds.
Opposite the incised wound in the pericardium a similar
wound was found on the surface of the left ventricle of the
heart about I inch from the apex.
On opening the heart this wound in its surface was found
to penetrate the left ventricle, making an opening fully I/2
inch long, and severing several of the chordae tendinae at their
base. The incision in the heart wall was plugged with a
dense clot. Af
The man had lived six days with this penetrating wound
of the heart without surgical interference and apparently died
of sepsis which might have been avoided had the true con-
ditions been known. *
DISCUSSION.
Dr. GRADWHOL had seen 2 cases of stab wound in the heart in his
service-in the coroner’s office, one of which was a wound of the same
kind in which about half of the rib was cut through by a knife some-
what similar to this one, The patient lived a few hours. In another
case death was intantaneous. It seemed to him that what the Doctor
said was very true, that if this area had been drained recovery might
have taken place, though he believed that in some cases stab wounds of
the heart got well because treatment was not instituted. The forma-
tion of the clot stopped the bleeding and he believed there were a
number of cases where the bleeding in the pericardial sac had been
stopped by the necessary clotting. He asked if the Doctor had
made a complete autopsy in this case and whether he had found an
embolus.
Dr. CAMPBELL replied that he had not made a complete autopsy.
He believed the cause of death in this case was not the wound in the
heart. Had the pericardial and pleural cavities been drained and a
174 The Medical Society of
chance given for ordinary respiration and the result of the infection
removed by free drainage, the man would probably have recovered.
This had simply brought up the question to his mind whether there
was so much value to be given to the suture of the heart as to the
treatment that goes with it.
Dr. GRADwohl asked what was the fate of the individual who
stabbed this man.
Dr. CAMPBELL replied that both the sisters swore that the man
who received this wound was the aggressor and that the brother-in-law
who killed him had to do so in self-defense.
The PRESIDENT asked whether, from a medico-legal standpoint,
the finding of the Coroner would have any bearing on a possible suit
for malpractice, death occurring as a result of the failure to detect
the wound.
Dr. GRADwon L replied that this was probably a matter of expert
surgery. If the expert's opinion would be that he used ordinary skill
he would be protected, otherwise he would not.
Anatomical and Pathological Observations on
the Formation of Hernia at
Hesselbach’s Triangle.
By WILLIAM T. COUGHLIN, M.D.,
ST. LOUIS, MO.
DO NOT wish to offer this as a prepared “paper” on
| this subject, I wish only to make mention of something I
have observed frequently in the dissecting-room and I
think that to remark it in connection with 1)r. Kirchner's pre-
sentation will be singularly apropos. I have not looked up
the literature on the subject, aside from the ordinary English
and American text-books on anatomy and I think you will
agree with me when I say that in these text-books the condi-
tion I will describe is not given the notice it deserves.
Looking at the posterior surface of the anterior abdominal
wall one observes in the average abdomen five ridges in the
City Hospital Alumni. 175
peritoneum a median and four lateral (two on each side) radi-
ating downward from the umbilicus toward the pelvis. The
median ridge is the elevation of the peritoneum caused by the
uraehus. This ridge I have not seen more than half an inch
high in its most prominent part. Its most prominent portion
is usually an inch or an inch and a half above the level of the
pubic crest. On either side of this part of the ridge is a de-
pression—the internal inguinal fossa. !
Of the lateral ridges the most external is caused by the
deep epigastric artery. It extends from a point midway be-
tween the anterior superior spine of the ilium and the sym-
physis pubis toward a point in the linea alba a short distance
below the umbilicus. This ridge also is more evident in its
lowest part but can usually be plainly demonstrated through-
out it entire length, very plainly until the artery has entered
the sheath of the rectus. |
It is to the more internal of the lateral ridges that I wish
to direct your attention. This ridge is caused by the obliter-
ated hypogastric artery, which you remember formerly con-
veyed the blood from the internal iliac artery of the fetus to the
placenta. That part of the artery reaching from the internal
iliac to the side of the bladder still is patulous, as the superior
vesical artery, but the remainder reaching from the side of the
bladder to the umbilicus is now only a fibrous cord.
In a little more than 22 per cent of the bodies examined
this ridge formed by the obliterated hypogastric artery has
been an inch or more in height in its highest part, its highest
part being just at or slightly above the level of the pubic spine.
The ridge when so high has not stood straight backward from
the abdominal wall but has been seen with its free edge or
summit pointing outward or outward and backward. It would
seem as if in the growth of the individual the stretching or
growth of the obliterated artery had not kept pace with the
lengthening of the anterior belly wall and so the artery now
stands away from the wall (as the string stands away from a
bow) and carries a double layer of the peritoneum with it.
One might almost liken this double layer to a mesentery or
rather to a peritoneal ligament.
176 The Medical Society of
In Fig. I, the ridge is hardly evident and the fossa D is
correspondingly shallow.
In Fig. 2, both ridge and fossa are more pronounced and
this I think is the most usual codition.
In Fig. 3, note the manner in which the peritoneum is
carried away from the wall by the artery: outward or outward
and backward from the median line. Note also how the fossa
D is consequently deepened. In several cases it was even
more pronounced than the diagram makes it appear.
C
A –4–
F. g .

C
<
A —Neº-
B


A D B
Fig 3
AB is the cut edge of the peritoneum, looking down upon it, section
just at level of pubic spine. A is at the median line. C is the
cut end of the obliterated hypogastric artery. D is the middle
inguinal fossa.
When the condition is present it is usually bilateral but
in most of those examined it was more pronounced on the
right side.
One can not fail to see that a fossa such as that in Fig. 3
would predispose to hernia.
The pro-peritoneal fat at A is more loosely attached to
the peritoneum here than elsewhere to permit the bladder to
rise in distention. It is also more abundant in this region
than laterally. These conditions might favor a pro-peritoneal
hernia in this region.
City Hospital Alumni. 177
It is possible that in Dr. Kirchner's specimen the gut or
omentum entered the pouch D, fig. 3, and pushed toward the
median line A. The constricting ring may have been the
obliterated hypogastric artery for the Doctor observes that
there was no hemorrhage when the constricting ring was cut.
DISCUSSION.
Dr. A. H. MEISENBACH said that the subject of hernia was al-
ways of great interest to the surgeon. Although it was assumed that
a great deal was known about it, there were many things yet to be
learned. In his anatomical studies, although he had not paid special
attention to this subject, he had never observed this condition. It
might have been and escaped him because he did not look for it. But
the condition was certainly unique, and the explanation of how the
development took place was interesting. It was well to remember this
for from the standpoint of differential diagnosis it would play an im
portant role. He remembered operating on a woman for femoral
hernia a number of years ago on whom an operation for shortening the
round ligaments had been done. A hernia had formed in cutting
down, in making the incision, all at once there was a gush of fluid.
He had said to his assistant that this seemed to be the bladder and he
had found that the inner wall of the sac was formed by the bladder.
Possibly there was some such arrangement as this just described, in
this woman’s case, the bladder being saculated and practically forming
the internal wall of the hernial sac. Fortunately he had been enabled
to do a typical operation for inguinal hernia and the patient made a
good recovery, but it was always well to keep these anatomical points
in mind. The diagnosis was very important and might be more or
less obscure. One could well see how such a properitoneal hernia,
strangulated and incarcerated, might lead a man at first blush to be-
lieve he was dealing with an appendicitis. It was well known that the
appendix makes diverse excursions, the focus of pain being away from
the classical McBurney’s point. In a case of this kind initially it
would be a fine point to determine the pathological condition to be
dealt with. Even when fecal vomiting had set in it was sometimes
very difficult to locate the point of obstruction. Of course there must
178 The Medical Society of
be some laxity of the structures to allow the invagination to take place
and the ultimate formation of the sac, intra-abdominal pressure tended
to make the sac larger and larger, ultimately resulting in strangulation.
In the differential diagnosis the external abdominal ring would have
to be taken as the criterion.
Dr. Meisenbach added that there was no medical society in St.
Louis that had the opportunity of doing such original work and placing
itself upon a high pedestal as the Medical Society of City Hospital
Alumni. It was right here that research work could best be done.
Captain LLEweLLYN WILLIAMS had been much interested in the
presentations of specimens. The question of hernia interested them all
because they all met it sooner or later. The army surgeon and the
country doctor did not have a surgeon at hand and were thrown upon
their own resources. It was necessary, therefore, for them to make a
special study of the anatomical points involved and for this reason he
had been particularly interested in Dr. Coughlin's remarks on the anat-
omy of the region
Formation of Hernial Sac by the Obliterated
Hypogastric Artery.
Report of a Case.
By w. C. G. KIRCHNER, M.D.,
ST. LOUIS, MO.
Y interest in the formation of the hernial sac was
aroused a few days ago when I had an opportunity
to discuss the subject with Dr. Coughlin, who, while
engaged in the dissecting room, had made certain original ob-
servations in regard to position and relation of the obliterated
hypogastric arteries. These observations lead to the belief
that the obliterated hypogastric artery may at times contribute
to the formation of the hernial sac, and for the purpose of
illustration I shall present specimens and report a case of pro-
peritoneal hernia in which interesting, but rather unusual con-
City Hospital Alumni. 179
ditions were encountered. The hernia which had taken place
in this case was of the interparietal type, and is rather rare.
A brief history of the case and a description of the condition
is as follows:
The patient, a colored man, aged 40 years, was admitted
to the Hospital May 9, 1905, with a diagnosis of appendicitis.
He took sick five days before entering the Hospital, with pain
in the right inguinal region. On the second day, the symp-
toms persisting, the patient began to vomit, the vomitus be-
coming fecal in character. When entering the Hospital his
abdomen was distended and tympanitic and his features bore
a pinched and anxious expression indicating serious abdominal
trouble. His temperature was IOO’, respirations 24, pulse IO4,
and he was vomiting fecal matter. There was no swelling in
either inguinal region, no pulse on coughing, and the external
inguinal ring was about of normal size on either side. The
patient stated that for many years he had felt a fullness in the
right inguinal region, but there was no external evidence of
hernia. A diagnosis of bowel obstruction was made and the
patient immediately prepared for operation. Median incision
below the umbilicus was made and a considerable quantity of
sero-sanguinous fluid evacuated. The bowel, of brownish red
color, was distended with gas and contained liquid fecal mat-
ter. In the region to the right of the bladder a mass about
the size of a fist was found, and it was learned that this mass
was a sac containing strangulated bowel. The ring of the sac
was severed in the direction toward the median line. There
was no hemorrhage, and the contents of the sac, consisting of
eighteen inches of gangrenous bowel was brought forward.
Resection was necessary and two and a half feet of bowel re-
moved, anastomosis being made with Murphy button. While
the resection was in progress, the proximal portion of the in-
testines was drained of its contents by means of a rubber tube,
which had been fastened in the gut. The sac was examined
and no communication could be found between that and the
external or internal abdominal ring. The sac was brought for-
ward a rubber drainage tube having been placed in the de-
pendent portion, the opening was sutured. The abdominal
cavity was copiously irrigated with saline solution. The pa-
180 The Medical Society of
tient died suddenly four days later apparently from heart fail-
ure, following general septic condition. An autopsy was per-
formed, and the specimen showing the hernial sac I will show
later. I shall also present a specimen showing the internal
markings and fossae of the abdominal wall, and in which the
pouches formed by the obliterated hypogastric arteries can
easily be seen.
The hernia, which was encountered in this case belongs
to the class known as interparietal and is of the properitoneal
type. An interparietal hernia is one in which the hernial sac
forces its way between the layers of the abdominal wall and
there enlarges. This interesting subject has been reviewed by
Goebell (George Sultan, Atlas und Grundriss der Unterleiðs-
bruche, 1901, p. I44), who has revised the classification and has
simplified the nomenclature.
The properitoneal hernia is situated between the perito-
neum and transversalis fascia and may be directed either to-
ward the bladder or toward the iliac fossa. According to
Goebell, hernias belonging to this type have been observed 69
times, having occurred 67 times in men and twice in women.
They were incarcerated in all but seven cases and the majority
were bilocular.
In the interstitial type, the hernial sac may lie between
any of the contiguous layers of the muscles or fascia of the
abdominal wall, or it may lie within the muscle itself by sepa-
ration of its fibers. This type of hernia is more frequently
met with and Goebell has collected 199 cases, of which 162
were found in men and 37 in women.
In the superficial type the hernial sac lies between the
skin and aponeurosis of the external oblique muscle. As a
distinct and separate type it was reported but I4 times, though,
no doubt, this condition has been oftener encountered. *
The properitoneal hernia has merited our special atten-
tion and is also of interest because at times there is great
difficulty of diagnosis. There may be swelling, impulse on
coughing, and the usual signs of hernia, but the external ab-
dominal ring will be found to have retained its normal size.
At times the diagnosis is impossible, and the symptoms may
be those of strangulated hernia with reduction en masse, and
City Hospital Alumni. 181
in these uncertain cases exploratory laparotomy furnishes the
only means of arriving at a correct diagnosis. In the present
case the constricting ring, which was also the entrance to the
sac, was located to the inner side of the epigastric artery.
Why hernias should occur in this region furnish an interesting
topic for discussion, and are prepared to hear what Dr. Cough-
lin has to say on this subject. º
Hernia is something I am greatly interested in. On the
right side in this specimen you will notice a fibrous cord, all
that remains of the obliterated hypogastric artery. It is this
fibrous cord that is carried away from the abdominal wall
with a fold of peritoneum. It does not stand straight away
from the abdominal wall but is deflected to one side forming
with the anterior parietal peritoneum a pouch, and this pouch
opens away from the median line. The deeper this pouch the
greater the predisposition to hernia.
Dr. KIRCHNER said that reasoning along the lines Dr Coughlin
had laid down, a suitable explanation for the formation of the hernial
sac in the case he had reported, was furnished. One could readily
see how such a hernia might easily take place. It seems as if the hernial
sac had started in the depression just behind the external ring and
had intended to become a direct hernia but was deflected from its
course and became a subperitoneal or properitoneal hernia instead.
Dr. Cough LIN, in connection with the insertion of the conjoined
tendon, stated that it was inserted into the anterior border of the crest
of the pubes and backward and outward along the ilio-pectineal line;
thus lying in front of and passing around the outer edge of the rectus
muscle. For that reason he had often wondered why it was said that
in the operation for hernia the edge of the rectus was to be brought
down and sewn to Poupart’s ligament. If that can be done without
injuring the conjoined tendon then his idea of the anatomy of the
region was wrong. He believed that the conjoined tendon might have
something to do with the direction of hernia in Dr. Kirchner’s case if
the pouch just described was deep enough so that its bottom lay in-
ternal to the outer edge of the conjoined tendon. It would then pass
behind the conjoined tendon and behind the transversalis and lie be-
182 The Medical Society of
tween the peritoneum behind and the conjoined tendon and trans-
versalis in front. If the bottom of that pouch were external to the
outer margin of the conjoined tendon then it would not be a properi-
toneal hernia but a direct one.
Dr. W. C. G. KIRCHNER presented two interesting and unique
cases of
Injury About the Knee.
{
In one case there was rupture of the patellar tendon while the man
was trying to step into a car. In the second there was a rupture of
the quadriceps muscle due to muscular violence. The patient was
standing by a table and someone suddenly flexed the knee resulting
in the rupture.
Tillman quotes Maydl reporting 61 cases of rupture of the quad-
riceps. He also gives 57 cases of rupture of ligamentum patellae. Of
the published accounts there were Io9 cases of rupture of the muscles
of the upper extremities.
In this case of ruptured quadriceps an incision was made along
the course of the muscles, holes were bored through the patella, and
the muscle sutured to the patella; chromicized catgut suture was also
placed around the patella and through the tendon. It has been about
six weeks since the injury occurred. In the other case a semi-
circular incision was made below the knee, the joint exposed, and
the tendon was then sutured together. Both cases made an unevent-
ful recovery.
City Hospital Alumni. 183
Meeting of September 7, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Juvenile Glaucoma Simplex Associated With
Myasthenia Gastrica et Intestinalis.
Report of a Case.
By JOHN GREEN, JR., M.D.,
ST. LOUIS.
Pº glaucoma is observed in three principle forms
—acute, chronic congestive and chronic simple. Each
is sufficiently distinct in character to render diagnosis
in typical cases a matter of no particular difficulty. Mixed
forms in which the clinical picture is less clearly defined are
also encountered.
You are, doubtless, familiar with the appearances observed
in an attack of acute glaucoma. After ominous premonitory
signs the storm bursts in all its fury. The agonizing pain,
rapid loss of central and peripheral vision, congested globe,
steamy cornea, shallow anterior chamber, hazy media, increased
tension and cupping of the disc constitute an unmistakable
series of symptoms. The second type—chronic congestive
glaucoma—occupies a position intermediate between the acute
and chronic simple forms. This type, as the name indicates,
is essentially chronic in character. It bears the usual ear-
marks of glaucoma, namely, diminished vision, contraction of
the visual field, slight shallowness of the anterior chamber,
semi-dilated pupil, increased tension, cupping of the disc, etc.
From time to time exacerbations occur in which the disease
partakes more of the character of acute glaucoma.
Chronic simple glaucoma, the least clearly defined of the
three types, comes insidiously upon its victim like a thief in the
night. One eye is usually attacked before the other and the dis-
ease may have made great progress before the patient is aware
of any trouble. Indeed, an unobservant patient may become to-
184 The Medical Society of
tally blind in one eye, realizing his condition for the first time
when the fellow eye begins to fail. To outward appearance the
eyes may seem entirely normal, though occasionally there is
Some congestion incident to a dilation of the anterior perforat
ing vessels. The cornea is transparent, the media are un-
clouded. The anterior chamber is normal in depth, or only
slightly shallow. The pupils are round and mobile to light
and accommodation. Frequent tests at different times in the
day are usually necessary to determine the state of the intra-
Ocular tension, which in this type is not constantly above the
normal. The ophthalmoscope discloses a glaucomatous exca-
vation of the nerve head. Central vision is often well preserved.
The visual fields are almost invariably contracted either con-
centrically or from the nasal side.
It is not my purpose to enter into a discussion of the
etiology of glaucoma. This is a very large subject about
which there are theories galore, no one of which satisfactorily
accounts for all varieties of the disease. The sine qua non of
glaucoma is increased intraocular tension. Upon the latter
depends all the other signs of the disease. It is sufficient for
our present purpose to understand this fact without delving
into the mystery of its origin.
The case which I wish to review with you this evening is
one which has been of great interest to me because of an ap-
parent connection between the ocular disease and a constitu-
tional trouble. I fear that specialists, especially workers in so
sharply limited a field as ophthalmology find some difficulty
in extending their medical horizon beyond the limits of their
own domain. As this case illustrates the advantage of a
more extended view, I trust you will find it of interest from the
standpoint of general medicine.
Miss A. A., aged 30 years, a tall, sallow woman came under ob-
servation July 7, 1904. The following ocular history was elicited :-
When 15 years of age the patient accidently discovered that she could
not tell the time on the school room clock with the left eye. The
sight grew progressively worse and 6 years ago the eye became totally
blind. From the age 15 to 18 years she attempted to study music but
was finally compelled to relinquish this pursuit as well as to cease using
City Hospital Alumni. 185
the eyes for any purpose whatever on account of ocular aching. On
two different occasions during the past 8 years she has obtained glasses
which failed to relieve the symptoms. The eyes have never been in-
flamed or severely painful.
At present she is entirely unable to use her eyes, the print waver-
ing and blurring almost as soon as she directs the gaze upon the pa-
per. The eyeballs feel tense and ache. There is a sense of pressure in
the orbits. Latterly she has had much occipital pain.
Ocular examination: The left eye diverges about 15°. The
globes are free from congestion, except that the anterior perforating
veins in the left eye are somewhat enlarged. The right pupil is 3.5
mm. in diameter, circular, and reacts well to light and convergence.
Left pupil is slightly larger and fixed. The anterior chambers are
of normal depth. Left cornea is anesthetic. Right eye T. -- ? Left
T.--I. º
R.E.V. 16/19. L.E.V. faint p. 1.
Ophthalmometer, R E. As. I. Mc. 15°. L. E. As. 3. Mc. 165°.
Ophthalmoscope, R.E. Media clear, optic disc of a whitish-gray
and the seat of a steep glaucomatous cup measuring 8 D (nearly 3
mm.) The nerve head is surrounded by a well-marked scleral ring.
Arterial pulsation at the disc can readily be elicited by gentle Inassage
of the globe.
L.E. presents quite similar appearances except that the disc is
excavated to a depth of 12 D. (4 mm.) The visual field for white
determines a slight inferonasal contraction. A diligent search failed
to reveal partial scotomata or sector defects within the limits of the
field. Color vision normal. No central scotomata either for form or
color. Diagnosis: Glaucoma simplex, both.
A single small drop of eserin sulphate 1/3 of 1 per cent pro-
duced marked but not excessive miosis. The patient was instructed
to use a drop of an aqueous solution of pilocarpine muriate 1/2 of I
per cent, three times a day. It was noted that the miosis resulting
from each instillation lasted about two and a half hours.
The effect of this treatment was to lessen the ocular discomfort
and to relieve partly the occipital pain. There was no effect on the
field of vision. Before leaving for home the patient was provided
with spectacles for constant wear—R.E.--.75 cyl, ax. 15°. L.E.—o.
One month later the patient returned and stated that she had been
practically free from ocular discomfort but was entirely unable to use the
eyes on account of the immediate appearance of a blur over the print.
R.E.V. 16/24. Alteration in the strength and axis of the cylinder did
not improve vision. Visual field unchanged. Pilocarpin solution was
186 The Medical Society of
supplemented by a 1/5 of 1 per cent solution of the alkaloid of eserin
in castor oil, which was used once a day. As the latter drug in this
strength produced ocular pain lasting several hours, I substituted a
weaker oily solution (1/10 of 1 per cent) which proved equally effec-
tive as a miotic and did not evoke any ocular discomfort.
In October, 1904, the conditions were practically unchanged ex-
cept that the field on the temporal side had shrunk a little.
In December, 1904, the field was the same as in October but
central vision had gone off to 16/30 On attempting to read a maga-
zine the words “danced and wavered ” and the eyes pained.
Up to this point the course of the disease certainly did not augur
well for the future. There had been a slow but steady loss of central
vision and a gradual drawing in of the temporal field. I suggested
to the patient the possible necessity of an iridectomy, explaining the
immediate and remote hazards of such a procedure.
With a view to obtaining as much collateral information as pos-
sible, careful inquiry into the patient’s general medical history was
made. Although she had never been strong she had never suffered
any prolonged illness. She admitted, however, being habitually con-
stipated, a condition which had persisted since early childhood. Num-
erous drugs had been tried with only temporary relief. The patient
was referred to Dr. Jesse Myer, who elicited the following additional
points: The father died of some stomach trouble, presumably cancer,
and the mother of “locked bowels.” For the past 9 years the patient
has had stomach trouble characterized by pain in the epigastrium and
belching. She has never vomited or passed blood.
The chief complaint is of constipation. Appetite is good and
there has been no loss of weight. The patient can eat practically
everything she cares to without suffering distress. Physical examina-
tion determined a floating tenth rib, intermittent and weak heart
sounds (dropping every sixth beat); pain on pressure in the left hypo-
chondrium and posteriorly over the eleventh dorsal vertebra; stomach
displaced downward. Urine showed a trace of albumin (no casts).
Diagnosis: Myasthenia gastrica et intestinalis, probably congenital.
The patient underwent a course of dietary and electrical treatment with
abdominal massage for two weeks, early in January, 1905. Improve-
ment in the abdominal symptoms was immediate. On January 17th
the patient volunteered the statement that “the treatment for consti-
pation had helped the eyes a great deal.” It appeared that she had
been whiling away the tedious hours at the hotel by reading novels
and was gratified to find that each succeeding day gave her additional
ability to use the eyes. She was now able to read continuously for ninety
City Hospital Alumni. - 187
minutes without any sense of strain or blurring of the letters. This
statement was confirmed by a reading test in my office extending over
a period of two hours. R E.V. had risen to 16/19. The recognition
of the letters was quick and unhesitating. No enlargement of the
field. She was permitted to return to her home with instructions as to
the continuance of the constitutional treatment. The pilocarpin and
eserin drops were continued.
June 6, 1905, the improvement in the general condition has been
maintained, the patient having a daily movement from the bowels.
R E.V. 16/15. The field has again widened on the temporal side.
Treatment continued.
August 16th, still able to use the eyes freely. R.E.V. 16/12.
(Quick recognition). Field as on June 6th. Patient was cautioned
against excessive use of the eyes.
To summarize: A young woman free from hereditary
ocular taint and afflicted with a chronic constipation beginning
in earliest childhood, is attacked shortly after puberty with
glaucoma simplex. In one eye the failure of vision is pro-
gressive and results in blindness. Near work is found to be
impossible on account of ocular pain and blurring. Finally,
the vision of the fellow eye beginning to fail, she seeks relief.
Treatment with miotics over a period of several months
fails to check the progress of the disease. General treatment
directed against the constipation is instituted. Improvement
in the general condition is accompanied by a like amelioration
in vision, in the ability to use the eyes, and later by a widen-
ing of the field.
Inferences drawn from the study of a single case are ad-
mittedly of little value. We must be content with noting the
facts which to my mind are at least highly suggestive of an
immediate etiological relationship between the constitutional
and ocular condition. Constipation is, indeed, accorded a
place among the “possible contributing constitutional causes
of glaucoma,” (Treacher Collins); but in this case the as-
sumption of a more intimate relationship seems not unjusti-
fiable. -
One word with reference to treatment. Ophthalmic sur-
188 The Medical Society of
geons are pretty well agreed that in the acute and chronic
congestive types operation is imperatively indicated.
Despite the transitory popularity of such procedures as
sclerotomy, paracentesis of the anterior chamber and sympa-
thectomy, the classical iridectomy still remains the operation
of choice. No operation in surgery gives greateſ satisfaction
to the surgeon and patient alike than a successful iridectomy
in acute glaucoma. The immediate relief of agonizing pain,
rapid subsidence of the symptoms, with restoration of vision
to an eye almost blind may confidently be expected in the
majority of these cases.
But with iridectomy in glaucoma simplex the showing is
far less favorable. While the immediate result may be excel-
lent, the operation has seemed, not infrequently, to hasten the
downward march of the disease. Certainly a pessimistic view
would seem the only justifiable one in the light of recent
statistics published by Wygodsky (Klin. Monatsäl. f. Augenh.,
September, 1903). In a study of the immediate and remote
effects of iridectomy in 458 cases of all kinds of glaucoma,
he found that the immediate effect was favorable in all cases
of acute glaucoma, in 49 per cent of chronic irritative glau-
coma and in 90 per cent of glaucoma simplex. A re-examina-
tion two or more years later determined certain very striking
differences which may be tabulated as follows:
No. and type Improved Unchanged Deteriorated Blind.
37 Acute cases 76% 5% II 7% 8%
I47 Chronic cong. Io ſò 40% 30% 20%
I 29 Simple I Ca,SC 16% 48% 35%
Such statistics explain the reluctance of many surgeons
to pin their faith to an operation which promises results in
cases of simple glaucoma less satisfactory than those attained
by persistent and intelligent non-operative management.
In conclusion I would again call attention to the lesson which
this case enforces, namely, that certain of the problems which
confront the specialist can be satisfactorily solved only by
collaboration between the specialist and his brother in gen-
eral medicine.
City Hospital Alumni. 189
DISCUSSION.
Dr. JESSE S. MYER said that the patient referred to by Dr. Green
was one of a type very frequently met with by the internist: It was
one of those cases of myasthenia gastrica et intestinalis of congenital
origin, at least it had been impossible to find any definite cause for
the condition. There was a marked degree of gastroptosis and the
colon was also in a state of ptosis, there was a movable right kidney,
displaced about one half its length downward and fixed in this position,
a floating tenth rib, a very marked degree of emaciation and a very
long thin thorax. Myasthenia intestinalis is very frequently found in
married women after labor but in this case it could be explained, so
far as known, through an inherited tendency, the patient being an un-
married woman. The patient had tried everything in the way of drugs
for constipation. Systematic treatment was instituted consisting of a
proper diet, massage of the bowels and simultaneous application of
the Faradic current. He also used a prescription consisting of resor-
cin grains 3, extract of nux vomica grain 1/4, belladonna grain 1/10
and cascara Sagrada, which he had found exceedingly good in cases of
atony of the intestines. She took these pills for a long period of time.
All he had hoped to accomplish in her case was a correction of the
constipation. She had responded to the treatment much better than
he had expected and the gastric symptoms as well as the constipation
were relieved. The last time he had seen her she was complaining
only of vertigo, which he judged to have been due to the glaucoma
rather than the general condition. The improvement in the glaucoma
following the improvement in the general condition was new to him.
He hoped it was true and not merely that relief of symptoms that
sometimes occurred in these cases from time to time. In cases of
myasthenia gastrica et intestinalis, especially the former, the treatment
usually laid down in the text-books did not yield good results. Some
authorities on the subject suggested that these patients be put on a
dry diet. Dr. Myer's plan had been to give the patient frequent
meals and frequent small amounts of fluid. Fluids are especially
necessary where constipation is present, and its withdrawal does harm
as a rule.
190 The Medical Society of
Dr. N. M. SEMPLE considered the case reported by Dr. Green
interesting, especially in that it was a case of glaucoma simplex in a
young person. Most of these cases were associated with senility and
it was just in these cases of glaucoma simplex that there was the most
doubt as to the etiology and the real existence of glaucoma. In the
classical study of glaucoma made by von Graefe, in 1857, the latter
claimed that these cases should be separated from real glaucoma in-
asmuch as the typical signs of glaucoma (e.g. of increased intraocular
tension) were absent. It was sometimes difficult to know whether in-
creased intraocular tension was present at all. Yet, such cases since
1861 (after Donders) had all been called glaucoma and had been
treated as such, but recently there had been a tendency to go back
to von Graefe's idea. There were many cases that presented the
symptoms noted in Dr. Green’s case, in which there were no inflam-
matory signs, where the increase in tension was somewhat in doubt,
cases that ran a chronic course and were only included in the glau-
coma class because of the excavation of the disc and the contraction
of the field of vision. There had been an attempt to explain the
former on the ground that it was possible that in certain cases the
normal tension of the eye might produce an excavation of the disc
because of a weakened condition of the lamina cribrosa, resulting in a
certain amout of atrophy of the nerve fibers, which would be shown
by the contraction of the peripheral field. Most frequently the cases
of so called glaucoma in young people were of this type, which might
be another reason for taking these cases out of the real field of glau-
coma. From the fact that glaucoma in its typical form is found
almost entirely in old people and just such cases as the above are
found chiefly among young people, might not the latter be due to
some change in the optic nerve or its supporting tissue where it entered
the eye rather than to whatever might be considered the real cause
of glaucoma. It seemed to him, also, that just from this standpoint
the general condition of the patient might be of importance. For
instance, if these cases were real optic atrophy, then the general con-
dition of the patient might have a good deal to do with producing
just such conditions about the cribriform plate as to bring about this
state of affairs. These patients rarely complained of rainbow lights
City Hospital Alumni. 191
or mists before the eyes or anything to indicate an inflammatory con-
dition, the anterior chamber was normal and the pupil itself was
normal in shape He had had recently at the university clinic, a pa-
tient 32 years of age, with practically an identical history with that of
Dr. Green's patient. The excavation was marked. He believed that
it was often very marked in young people. In this case it was 7 to 8
diopters. Attention to the general condition produced some improve-
ment in the ocular condition. In reviewing this case and others re-
ported lately, he felt that the old view of von Graefe, that these cases
should be really taken from the class of glaucoma and given a name
to themselves was correct. The oculist would not be limited to the
idea of merely reducing the intraocular tension, for in the majority of
cases it was entirely absent as far as could be made out. The old
idea of calling these cases amblyopia with optic excavation was very
pertinent.
Dr. CLARENCE LOEB, in looking up the literature at his disposal,
could find only that glaucoma had been associated with both diarrhea
and constipation. There was no a priori reason why the condition
should affect the eye. He had noticed in the discussion that Dr.
Green had said that the use of the stronger solution of pilocarpin
gave considerable pain and he had had to use a weaker one, and Dr.
Myer had stated that he had given the patient extract of belladonna
three times a day. These statements called to mind a paper which
appeared two or three years ago in which the author advised the use
of atropin in glaucoma as opposed to myotics. This paper had not
impressed Dr. Loeb very much at the time but in listening to the dis-
cussion it had occurred to him that there might be something in the
use of the belladonna. He did not like to be quoted as advocating
the use of belladonna or its alkaloid, atropin, but it seemed to him
that all the light that could be thrown upon the subject was of value,
and he merely offered the suggestion that the belladonna given
internally might have acted upon the condition through the general
circulation, and brought about the improvement in that way.
Dr. CHARLES SHATTINGER suggested as a possible factor in the
improvement of this case, the very marked effect abdominal massage
has upon the blood pressure. He understood from Dr. Myer that
192 The Medical Society of
massage was given for a period of about three weeks, each time a
half hour. Certainly massage of that kind would affect the general
blood pressure, not only temporarily, but also permanently. He
knew altogether too little about the etiology of glaucoma –and ac-
cording to Dr. Green hardly anyone else knew anything definite—but
it seemed to him that no matter what the exact causation of the in-
creased ocular tension, an improvement in blood pressure, in the di-
rection of a suction on the venous vessels of the upper part of the
body, for instance, would necessarily affect the eye. Even if it did
not affect its tension directly it would affect its nutrition. Constipa-
tion often interfered with the venous circulation in the abdominal or-
gans, and the removal of that condition would have more or less in-
fluence upon the blood pressure of the body. He had noted repeatedly
that in abdominal massage, the earliest improvement was noticed in
the complexion and in the eyes, even before any improvement was
noticed by the patient. In a pamphlet by Schmidt-Rimper explaining
expression by the eye, he attributes the luster of eye to the circulation
of fluids in the ocular tissue. When this is interferred with, the eye
becomes lusterless. Whenever he noticed the eyes of a patient gain-
ing in luster, Dr. Shattinger always felt that a change in health would
follow.
Dr. LOUIS DRECHSLER had received a report from a patient hav-
ing an ocular trouble in which constipation was a very troublesome
condition, the oculist had sent the patient back to him for general
treatment. The constipation having been relieved the ocular trouble
had improved so that the patient went to work. He asked if there
might not be cases of ocular disease other than glaucoma, constipa-
tion also being present, when the ocular disease showed improvement
after relief of the constipation.
Dr. FELIX GARCIA hesitated to discuss a specialist’s paper. It
seemed that this woman had endured this condition a number of years,
the loss of one eye and almost the loss of the other, before seeking
treatment, showing that the general practitioner was responsible for
detecting these cases. Many of the patients were dismissed with an
eye-wash. He hoped that Dr. Green would continue his papers so
that they might hear more on this subject of ocular disease.
City Hospital Alumni. 193
Dr. GREEN, in closing, said that, in regard to the vertigo Dr.
Myer had mentioned, when he saw the patient in August (Dr. Myer
having seen her last in June) the vertigo had disappeared entirely.
At the time of her visit in June Dr. Myer had stopped the regular use
of the nux vomica, belladonna and resorcin pills. Dr. Green could
not feel assured that the present improvement was going to be perma-
nent, but he hoped that the general treatment and the use of myotics
would hold the ocular disease in check indefinitely. A point, perhaps,
not sufficiently emphasized, was the youth of the patient. Glaucoma
was a disease of the fifth and sixth decades, most cases occurring be-
tween the fiftieth and seventieth years. It was an extremely rare dis-
ease below twenty, He could not say as to the frequency of the
acute as compared with the chronic type of glaucoma in early years.
His impression was that, in young people, it was apt to be of the acute
type leading promptly to blindness. The point of particular interest
was the occurrence of juvenile glaucoma associated with myasthenia
gastrica et intestinalis. In regard to the dissociation of glaucoma
simplex from other types, he was inclined to agree with Dr. Semple,
who mentioned that the excavation of the nerve head was apt to be
greater in young people. He believed this was true, also. Dr. Loeb
had referred to the use of an oily solution of pilocarpin. It was an
oily solution of eserin that he had used. A very weak solution would
produce excellent myosis and such a solution could be entrusted
to the patient to use as it did not produce conjunctival irrita-
tion. He recalled the paper Dr. Loeb had mentioned and it had
struck him as a most ludicrous affair, one not to be considered at all.
The suggestion of Dr. Loeb that the use of the belladonna internally
might have resulted in an ocular improvement, was interestin g but he
would not like to subscribe to it off hand. As to the improvement in
other diseases of the eye following treatment for constipation, he had
had no experience. Dr. Garcia had called attention to the fact that
many general practitioners did not recognize disease of the eye early
enough. But in glaucoma simplex there was no obvious external sign to
indicate the condition. It was only on testing the vision that there was
found deterioration of one or the other eye. Usually these patients made
little complaint except of occasional occipital pain or aching in the
194 The Medical Society of
eyes. The general practitioner was certainly not to be held responsi-
ble for not recognizing this type of ocular disease. Of course in in-
flammatory conditions, such as iritis, conjunctivitis, etc., it is imperative
that the general practitioner should be able to make an early and cor-
rect diagnosis. *
Dr. GEORGE HOMAN asked if it was not possible that a prolonged
general malnutrition might result in glaucoma.
Dr. GREEN, replying to Dr. Homan, thought it might be possible
but he would not like to hazard a guess.
Dr. GARCIA asked if nephritis was an etiological factor.
Dr. GREEN replied that he did not know that it was, but there
were many glaucomatous people who had nephritis.
Dr. HoMAN thought that the expression used in the paper “con-
stitutional treatment” was, perhaps, not quite accurate, as it possibly
implied more than Dr. Green had meant to convey. Perhaps, general
treatment would be a preferable term.
\
Meeting of September 21, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Dr. GEORGE GELLHORN presented a patient operated upon for
Atresia Vaginae.
DISCUSSION.
Dr. TAUSSIG had witnessed the operation and followed the case
in the after-treatment. The Doctor was to be distinctly congratulated
on the result. There were several points to be learned from this case.
Regarding the etiology of atresia, he believed the text-books spoke too
much of the congenital forms. The majority of atresias were prob-
ably due to such traumatism as had occurred in this case, necrosis re-
sulting from the injuries produced during prolonged labor, and another
class of cases in which the atresia was due to gonorrhea in early child-
hood. Very often these cases were overlooked until at puberty, when
menstruation commenced, the collection of fluid bulging out showed
the complete obliteration of the vagina. In these plastic operations
stress should be laid not upon speed but upon carefulness. Re-
City Hospital Alumni. 195
sults show that only careful work gives satisfaction. Three points in
particular must be carried out: There must be a complete elimina-
tion of all scar tissue; secondly, a careful stopping of bleeding; and,
finally, there must be a careful, painstaking approximation of one
surface to the other so as to leave no raw area for granulation and new
scar tissue formation.
Dr. McConnell said that at the University of Pennsylvania he
had seen a case which he had been reminded of when Dr. Taussig had
referred to gonorrhea as a factor in the causation of this condition.
The patient was a colored woman, pregnant about five months. No
vagina could be found but an opening that would admit only a small
bougie. But she had been impregnated and was later delivered. In
this case there was a history of gonorhea in early childhood.
Dr. JACOBSON had recently seen a case of almost complete atre-
sia. This woman gave no history of any of the causes named but
stated that she had worn a pessary for a long time, which sometimes
caused atresia vaginae. He had seen several cases of atresia from the
use of pessaries. In one case the pessary had been in the vagina for
six months and a difficult operation was required to remove it. In-
crustations had formed around it. Another cause of atresia not men-
tioned is syphilis. Also injuries in infancy and early childhood.
Dr. CARSON, in regard to the etiology, said that his experience
was that most of these cases were due to traumatism. A case had re-
cently presented itself and he had not cared to undertake it. There
was almost complete, if not complete, absence of the upper wall of
the vagina. He had recently suggested to Dr. Gellhorn an operation
that had occurred to him in a study of two cases of complete absence
of vagina and uterus. In one of these cases he had operated and re-
stored the vagina by using the labia minora. ' After dissecting the
bladder from the rectum he then carried the nymphae, which had been
dissected and spread out, up into the space this making a vagina
several inches in length. The case was a rather peculiar one. This
young woman had come to him as a young girl. She wished to be
married and he advised her to let it alone. She saw Dr. Mudd, who
urged the same thing, and several other physicians did the same. They
all advised against an operation, but she was insistant and so was the
196 The Medical Society of
young man she was to marry, and an operation was done and, so far
as Dr. Carson had been able to learn, with success. As to how best
to close the large openings, where there was almost complete loss of
bladder wall, he suggested dissecting above the pubes into the vagina,
taking a flap of skin from the abdominal wall, turning it into the
vagina and filling up the defect. Where there was atresia, the vagina
should be previously enlarged. It seemed to him that this might be
possible. He thought he would try it on a cadaver some time. He
wished to hear whether Dr. Gellhorn or others thought this operation
feasible.
Dr. GELLHoRN, in closing, stated that he considered Dr. Carson’s
idea to be an absolutely new and ingenious one. Whether it could be
carried out in the living could only be determined by experimenting
on the cadaver. But he thought this might be a good way to furnish
the surgeon with material, which frequently was so difficult to obtain,
in order to line the entire length of the vaginal tube with suitable
tissue.
Treatment of Empyema.
Report of Cases.
By ROLAND HILL, M.D., C.M.,
ST. LOUIS, MO.
FEW of the cases of empyema that have come under
my observation have presented conditions so out of the
ordinary that I thought a report of them might be of
interest to the members of this Society. As a preliminary
to this report, a few general remarks on the treatment of em-
pyema may be appropriate.
In cases of acute empyema we are all agreed as to the
necessity for the evacuation of the pus as early as possible.
On the other hand, in chronic cases, where the patient is
emaciated, the heart weakened, the chest deformed, and a
septic condition existing, it is sometimes a matter of most
careful judgment to decide as to how far operative measures
City Hospital Alumni. 197
should be carried. Before operating on these cases, we should
consider a number of important facts :
I. The general condition of the patient.
2. The duration of the disease, and degree of deformity
of the chest.
3. The presence or absence of sinuses.
4. Complications, as, for example, tuberculosis.
I. The general condition of the patient is most important,
and must be carefully considered. If he has been having
repeated attacks of septic troubles, followed by discharge of
pus from one or more sinuses an operation should be done when
he has recovered a fair degree of strength. Occasionally, we
get cases, as cme here reported, where patients have lived for
years with sinuses continually open and discharging. It is not
uncommon in these cases to find more than one sinus open at
the same time, and scars where others have existed.
While the patient is suffering from this constant menace
in the thoracic cavity, there is always danger of amyloid or
lardaceous degeneration, as well as any other complication
that might attack any enfeebled organism. The sinuses that
enable nature to throw off the pus may open in any situation.
Very often they open just above and posterior to the nipple.
Many of these are long and tortuous, and filled with low
grade granulations that bleed very readily when the finger or
probe is inserted into them.
The degree of contraction of the chest varies within wide
limits, and is of extreme importance. The heart is often
bound over to the right with strong adhesions. In exploring
a cavity, it is well to leave these adhesions alone, as manipula-
tion may be followed by collapse. The presence of adhesions
binding the heart in a new position greatly reduces cardiac
power, and often leads to swelling of the lower extremities.
It also tends to cause a passive hyperemia of the liver, and a
hydremic condition of the vascular system.
2. It is necessary that the duration of the disease be given
careful attention. If the lung has been bound down for
months, it is not likely ever to expand sufficiently to fill the
cavity. In children there will be much more expansion
than in the adult, because the lungs, not having attained their
198 The Medical Society of
full growth, make every effort to fill the cavity as the child de-
velops. In a child the chest is not so rigid, and the lung more
elastic, hence, the probability of perfect recovery is much
greater in a child than in an adult.
3. In those cases where discharging sinuses exist, the
condition of the patient is poor, and it may be necessary to
do a temporary operation to secure drainage before attempting
to secure closure of the cavity by the method of Estlander.
This may consist in simply dilating the sinus, and inserting a
tube, or if this can not be done, a rib may be resected in en-
deavoring to secure free drainage, and improving the patient's
condition prior to radical operative measures.
4. Other complications naturally affect our prognosis very
materially. Thus, we know that in a certain percentage of
cases the purulent collection is caused by an invasion of the
tubercle bacilli. In nineteen cases investigated by Erlich, tu-
bercle bacilli were found to be present in seven cases. This,
of all complications, should lead to a guarded prognosis.
The operative measures for empyema may be considered
under the following heads: A, Aspiration; B, Incision; C.
Resection of ribs, including Estlander's ; D, Schede's thoro-
plastic operation.
A. Aspiration should always be done to determine the
presence of pus, unless the existence of sinuses should render
it unnecessary. In doing an aspiration for empyema, an ordi-
nary trochar may be employed, but it is preferably done by
means of an aspirator, to which you can apply considerable
suction force.
For aspirating an empyema it is essential that a needle or
trochar be of sufficient size to allow of thickened pus and
fibrinous flakes passing through. One may aspirate a chest
half full of pus with a hypodermic needle, and still be unable
to determine its presence, owing to the impossibility of getting
very thick pus through a small needle. Aspiration will never
cure a case of chronic empyema, although it may possibly
cure an acute case in a very young child. Still, it is a very
useful procedure for diagnostic purposes, and also for tempo-
rary relief in cases where a radical operation would be danger-
ous. It is very useful as a preliminary measure a day or two
City Hospital Alumni. 199
before doing a radical operation, as it gets structures long
pressed upon by purulent collections used to less pressure, and
hence, lessens the risks that always follows the sudden with-
drawal of a large amount of pus from a pleural cavity. Aspi-
ration is done in almost any situation, but preferably near
angle of scapula, or in mid axillary line in fifth or sixth inter-
costal space. In aspirating a pus cavity, every antiseptic pre-
caution should be taken in order to prevent a secondary infec-
tion of the pus, and decomposition with its attendant septic
troubles. An aspirating needle is inserted just above a rib
forming the lower boundary of the intercostal space.
Aspiration, properly performed, is a harmless procedure,
and gives invaluable information to the surgeon, and great
temporary relief in many cases to the patient Even aspira-
tion, however, requires to be 'done with care, for the lung may
be punctured, and a man, if very careless, might even injure
the pericardium. If, during aspiration, the patient becomes
weak and depressed, it should at once be discontinued for
twenty-four to forty-eight hours.
B. Incision. The treatment of acute empyema in young
children by simple incision will sometimes result in perfect
recovery. In chronic cases it is difficult to see how a simple
incision could, by any means, effect a permanent cure. The
incision in these neglected cases should only be done where
an abscess is pointing, and pus threatens to escape. Here, we
can incise, draw off the pus, and the radical operative proced-
ures can be resorted to later.
C. The radical measures referred to comprise the resec-
tion of enough of the bony structures of the thorax to allow
of thorough drainage, and also, if possible, of sufficient con-
traction to close the cavity that exists. In cases of empyema
where the ribs are too close together for the insertion of a
tube between them, or where discharging sinuses remain after
incision, resection of ribs is necessary. This will be found
invariably the case in all cases of chronic empyema. If
the discharge comes from a small sinus where a tube has
been retained too long, this should be dilated, curetted and
probably a piece of rib removed, and the cavity packed al-
lowed to heal from the bottom. The vast majority of these
200 The Medical Society of
cases, however, do not present conditions so easily dealt with.
In most of them a cavity of considerable size exists, the
lung has been considerably impaired, possibly completely
carnified and bound down by adhesions, the chest retracted.
This is the class of cases that gives the greatest amount
of trouble, and in which it is most difficult to secure a de-
sirable result.
In resecting ribs in these cases, the point of resection is
opposite the portion of lung that can expand no more, and
the pieces of ribs removed should correspond as closely as
possible to the anterior limits of the cavity it is desired to
close. Thus, in adults, it may be necessary to remove sec-
tions of several ribs varying in length from one-half to several
inches.
The exposure of ribs to be resected, may be done either
by several incisions each being in the intercostal space, be-
tween the corresponding two ribs to be resected, or by one
long incision, exposing all the ribs necessary at once. The
latter is recommended by Goodlee, who holds that it is the
best and most expeditious procedure. Jacobson, in his opera-
tive surgery opposes this, and thinks that the shock will be
greater, and more blood will be lost than where several incis-
ions are made. It would seem, however, that the greater
rapidity with which one flap could be raised, and the lessening
of time under the anesthetic would more than counterbalance
any objections to the procedure.
Whatever operation is done should have for its object
the removal of sufficient of the bony structures to allow of
complete closing of the cavity. With regard to the time at
which this operation should be done, as a rule, it may be stated
that it is necessary when the patient has recovered from the
primary operation, and the powers of obliteration at a stand-
still.
D. Schede's thoroplastic operation is sometimes resorted
to where the preceding one of Estlander fails. This is only
adapted to cases where heroic measures are necessary. It
consists in resecting not only the bony structures covering
the cavity, but the muscle and pleura as well, leaving only a
skin flap, which is then brought in contact with the inner side
City Hospital Alumni. 201
of the cavity. The operation, from its very severe character,
is adapted to a very limited number of cases.
The first case I have to report is that of Annie B., white,
German-American, aged 21, living on a farm with her parents
in Warren County.
I first saw this patient on October 27, 1898. She was
very thin and emaciated, and had been practically bed-ridden
as a result of an attack of empyema that had occurred ten
years before. The patient had suffered from repeated and
very serious septic attacks, but Nature had come to the rescue
each time, and a new sinus had formed and pus had been
freely discharged, leading to an improvement in her condition.
At the time I saw her she was very much emaciated, and very
anemic. The left side of her thorax was very much shrunken
and deformed, and the heart was markedly displaced to the
right so that the left border was approximately at the end of
the sternal base. There were two open sinuses, one above,
and the other above and to the inner side of the left breast.
A further examination showed several scars where other si-
nuses had existed, and healed. *
I considered the case very serious, and refused to do any-
thing until her friends were informed of the dangers of opera-
tive measures. The patient, herself, decided to take the risk,
and I deemed it my duty to do what I could to relieve her de-
plorable state. I first made an incision into the upper sinus,
so as to introduce my finger into the cavity, in order to get an
idea of its size and contour. Then a vertical incision was
made, and a flap turned back so as to expose the ribs covering
the cavity. These were so drawn that some were superim-
posed directly above others, two deep. However, after resect-
ing four ribs a good, free opening was made into the cavity.
and a large quantity of pus evacuated.
The patient suffered from pronounced shock; a tube was
quickly inserted in the upper sinus, and out through the cavity
and new opening. The wound was then dressed, and the patient
put to bed. It was necessary to give stimulants very freely
for some hours, as it seemed as though she would not survive.
However, she soon began to improve, and the wound closed
in rapidly. As I left shortly after the operation, I was kept
202 The Medical Society of
informed of her condition by Dr. James Stewart, of Holstein,
who had charge of the case. She improved slowly, but grad-
ually, and it was a long time before she gained much strength.
She wore the tube in the side for five years, a new one being
put in at intervals. It is only a couple of years since I advised
Dr. Stewart to dispense with it entirely. Now, however, she
is well, and does the work of an ordinary country girl.
The next case is that of E. M. S., aged 41 years, white,
Austrian by birth, an insurance agent by occupation.
Mr. S. has always been a man of exceptionally good con-
stitution, but two years before his present illness he had been
drinking very heavily. In the early part of February, 1903,
he became ill with classical symptoms of pneumonia; sudden
chill, pain in the side, bloody expectoration, etc., and sent for
me to see him February 2, 1903. His condition was so grave
that I expected an early and fatal termination. However,
after remaining in a most critical state until early in the second
week, the symptoms abated somewhat, and it looked as
though recovery would take place by lysis. The bloody ex-
pectoration gave way to that of a purulent character, and im-
provement did not continue. The patient's temperature ran
from 99 I/2 to IO2°, the pulse was weak and rapid, and the
cough very severe. The matter expectorated had a most of
fensive character. g
February 19th, fearing that we were dealing with an em-
pyema, I inserted an aspirating needle in the pleural cavity,
and drew off a quantity of exceedingly offensive pus that had
the same odor as the expectoration. On the 22nd of Febru-
ary, I resected a portion of the sixth rib, in the mid axillary
line, inserted a tube, and brought one end out between the
eighth and ninth ribs. A quantity of the most , offensive pus
escaped, and free drainage was established. The patient's
condition remained critical for two weeks, and then he began
to improve. The temperature became normal, appetite im-
proved, and the patient began to gain in weight.
I dressed the wound every day, and because of the of
fensive discharge used irrigation to get the cavity as clean as
possible. Each time we irrigated, the patient would cough
very severely, and claim that he could taste the irrigating
City Hospital Alumni. 203
fluid. To prove definitely whether there was a communica-
tion with a bronchus, in the early part of April I injected into
the drainage tube two ounces of a solution of methylene blue.
Immediately a lot of this fluid came out of the patient's mouth
and nose, dyed his moustache, and ran on the floor. This
condition was evidently, the result of an absces of the lung
that had broken into the pleural cavity, so that there was a
direct communication with a bronchus.
On dressing the wound April 30th, I discovered that a
very unpleasant little complication had occurred. The pin
holding the tube was in the dressing, but the tube was absent.
There was only one place that it could be, and that was in the
cavity. I tried to reach this tube by means of different
kinds of forceps, but did not succeed, and was forced to
put the patient under chloroform, and resect a portion of the
seventh rib, and found that the tube was nicely curled up
behind it.
The further history of this case is uninteresting, as the
patient rapidly improved. Early in June the last tube was
dispensed with, and he went to Texas for a trip, and was gone
several weeks, during which time he did considerable busi-
ness. Since his return, he has been feeling well, working hard,
and looks better than he has for years.
The third case that I have thought worth reporting is
that of Mrs. John A., aged 38 years, white, American.
, Mrs. A. is the mother of four children, and has always
been a strong, healthy woman. On February 25, 1904, she
was taken seriously ill with a well-defined pneumonia, affecting
the lower lobe of the right lung. The case ran a severe
course, but without any unusual symptoms until end of the
ninth day, when temperature subsided, respirations became
slower, and the patient seemed to improve. The temperature,
however, did not reach normal, but continued to range from
99 I/2 to IO2°.
Dullness continued very marked over right mammary
region, extending from the upper border of fourth to sixth
rib, and out as far as the mid axillary line. On March 13th,
an exploring heedle was introduced between fifth and sixth
ribs in mid axillary line, to see if presence of pus could be
204 The Medical Society of
determined, but none was found. The patient's condition re-
mained about the same, and on February 27th, we aspirated
between fourth and fifth ribs, to the inside of the mammary
line, but without result, but on inserting the needle again, we
found pus at the anterior axillary line.
The patient was removed to Mullanphy Hospital, and on
March 30th I removed a section of the fifth rib, I 1/2 inches
long, just below the mammary glad, and a large amount of
pus evacuated. Rubber drains were inserted, and the dis-
charge was very free for some time. At the second dressing,
a piece of lung tissue was discharged, tending to support my
belief that the abscess originated primarily in the lung, and then
became superficial with pleural adhesions.
The patient improved rapidly, and as the cavity healed
the drains were gradually shortened. In June we were able
to dispense with all drainage, and discharge the patient as
well. This case illustrates an interesting condition, and one
of practical importance. I have known two cases to die from
want of repeated aspirations. In one of these cases, particu-
larly, several aspirations were made, but pus not reached,
and the post-mortem showed an abscess about an inch from
one the punctures.
Therefore, where we suspect pus, it may even be neces-
sary to put the patient under chloroform, and make a num-
ber of aspirations in a systematic way to assure ourselves that
pus is not present.
DISCUSSION.
Dr. McConnell discussed the subject from its bateriological
side. The bacteriology in these cases of empyema seemed not to
differ so frequently in adults as in children. Probably the streptococcus
was the most common, taken all together, but among children the
pneumococcus was most frequently found. It seemed to be a much
more rapid and benign affection in children than the streptococcic
which is slower but more severe. In adults the tubercular form was
quite common and in that the method of infection was different. It
may have gained entrance through the rupture of a tubercular ab-
scess. In other forms, the pneumococcus particularly, the infection
City Hospital Alumni. 205 .
seemed to extend through the lymphatics while the tubercular form
did so through rupture of the pleura. When there was found a pri
mary involvement of the pleura in these cases there would also be
found some implication of the lung.
Dr. SHARPE said that this paper of Dr. Hill's brought to mind the
difficult cases the surgeon sometimes encountered. He used the term
“difficult” advisedly because in the advanced cases conditions were
encountered that were sufficient to tax the ability of the best men.
He regretted that owing to the scope of the paper Dr. Hill had been
obliged to omit a presentation of differential diagnosis; for it was
sometimes very difficult to determine whether an empyema really ex-
isted or not. Aspiration was of definite service from a diagnostic
point of view and of curative value in children; but it should be rele-
gated to the past as a curative measure with this exception. When,
in old cases of empyema, the pleura had become densely fibroid, it
was practically impossible with an ordinary needle, used in the ordin-
ary fashion, to make a successful aspiration. One might realize in
time the probability of encountering such a condition and use a special
needle, but even then the operation will usually prove a failure. In
dissecting off the pleura as is done in the radical attack one some-
times develops a flap that is simply surprising in density and thickness.
In these severely critical cases the patient's vitality must be conserved
to the utmost. For that reason he would be opposed to giving a gen-
eral anesthetic for diagnostic aspirations and incisions. Much could
be accomplished by the use of infiltration anesthesia; and he advised
a consideration of scopalamin-morphin anesthesia in preference to ether
or chloroform, in the critical and asthenic form,
Dr. PFEIFFENBERGER called attention to the fact that the Doctor
had not said anything about irrigation. In his time of service in the
City Hospital, the practice had been on about the second or third day
after they had been allowed to drain, irrigation with permanganate
solution was resorted to. He had seen five or six cases in which irri-
gation was done and it seemed to hasten recovery rather than result
in collapse.
Dr. DEUTSCH had found the Gigli saw of great advantage in these
cases. It could be used around, one or several ribs without pulling
the ribs. The rib cutting shear, while a useful instrument, gave the
ribs a tremendous jerk and often lacerated the vessels running under
the rib. He wished to specially recommend the Gigli saw in these
cases, and hoped the Doctor would try it in his next case.
Dr. TooKER, referring to Dr. Pfeiffenberger's statement regarding
the efficacy of irrigation, said that since leaving the City Hospital he
S 206 The Medical Society of
had seen two cases that had been irrigated there for several weeks.
One patient had an empyema a year and a half ago, and had
small pieces of two ribs removed; the cavity had been washed out for
almost two months. The patient was operated upon at Mullanphy
Hospital about five months ago, evacuating a quart of pus, and an
extensive thoracic resection performed. Wound was kept open for
two months with gauze drains. At the present time the patient has
evidences of some pus in his chest. Some of these cases seem to be
very obstinate and discouraging.
Dr. HILL, in closing, said that in regard to Dr. Deutsch's recom
mendation of the Gigli saw, he considered it a most excellent idea.
He could readily see how a certain amount of shock might be saved,
though he had never used it in such a condition. Dr. Sharpe's re-
mark about anesthetics was a very good one. In an ordinary aspira-
tion Dr. Hill very rarely used a general anesthetic. In removing the
ribs, however, he did use general anesthesia. Dr. Sharpe had called
attention to another very important matter, namely, the thickness of
the pleura in these old empyemas. Sometimes one got the needle into
tissue like sole-leather. One of the cases just reported had occurred
up in the country. In this case the ribs were drawn one above the
other and beneath them the pleura was at least three quarters of an
inch thick and it was very difficult to secure drainage. Another point
of importance was that the heart should be left alone. This patient
had done very well until he had gotten his finger against the heart,
when she collapsed and nearly died In regard to irrigation, he had
not done much in that line. When the tubes were kept and good
drainage secured, enough had been done.
Meeting of October 5, 1905; Dr. John Green, Jr.,
President, in the Chair.
Posterior Basic Meningitis.
By LOUIS M. WARFIELD, M.D.,
\ ST. LOUIS, MO.
that occurred in an infant about IO months old. The
family history was negative. The child had been ill
D* LOUIS M. WARFIELD reported briefly this case
City Hospital Alumni. 207
for two months before admission with wasting and constant
vomiting and retraction of the head. The parents also said
that the infant did not take notice as it had done, and seemed
to have become blind. The condition was characterized by
rigidity of the extremities with exaggerated reflexes, marked
and progressive emaciation, constant vomiting, increase in
size of the head, with retraction of the neck varying in severity
from time to time, and progressive blindness. The eyes were
glassy, wide open, and staring. No nystagmus was observed,
no-irregularities of the pupils or strabismus. The infant died
about one month after admission making the duration of the
illness from time of onset about twelve weeks. Permission to
open the skull was given. The brain was soft, the ventricles
were markedly distended with clear, limpid fluid. At the base
was organized fibrin, showing evidences of a chronic inflam-
mation. The convexity of the brain revealed no pus, only
considerable general congestion. Dr. Warfield discussed the
differential diagnosis, called attention to the recent work of
Koplik which showed that these cases were not cases of a
separate disease, but were due to the diplococcus of Weichsel-
baum. He expressed the opinion that, while further work
was necessary to prove conclusively this view, yet enough had
been done to prove that this condition was not a separate
distinct form of meningitis.
DISCUSSION.
Dr. ZAHORSKY had seen probably three cases in infants in which
that diagnosis was made. None of the cases were thoroughly studied.
One occurred in the Bethesda Foundling Home. It was an infant
about six months old. Gradually the typical symptoms developed.
The child died but no autopsy was performed. Another case in which
Dr. Zahorsky had made such a diagnosis, but which recovered, had
occurred in his private practice about a year ago. It was an infant
five months old, cried a great deal, was bottle-fed, was somnolent. It
had one convulsion, would not sleep, there was some chronic diges-
tive disturbance but most noticeable was the enlargement of the head.
There was no fever. One physician here who has a large practice
among children pronounced it a case of congenital hydrocephalus.
208 \
The Medical Society of
In certain rachitic cases some enlargement of the head occurs together
with an increase in the cerebrospinal fluid. In this case the enlarge
ment was marked. There was rigidity of the muscles, increased patel-
lar reflexes and quite a little retraction of the head. Fortunately, after
two or three months the child gradually improved and got well. An-
other case was the child of a physician of this city. After having con-
siderable trouble with its nutrition for a month or six weeks it suddenly
within a few days developed an acute hydrocephalus. The child grew
worse very rapidly and died. The speaker could not say positively
that this was a case of acute posterior basic meningitis. A culture
taken from the fluid was negative. There was no fever. No autopsy
was made. But the question was, might this not have been a very
rapid, serous meningitis? It was sometimes very difficult to differen-
tiate tubercular meningitis from congenital hydrocephalus, and then,
again, from serous meningitis. As far as the literature was concerned,
and Still’s work in particular, Dr. Zahorsky had not yet been con-
vinced that the infection was a modified form of the diplococcus
intracellularis in all cases. He regarded the evidence as yet incon-
clusive.
Dr. HogE did not quite understand, from the description of this
case and what could be seen of the specimen, why it should be called
distinctively a posterior basic meningitis. Possibly in the fresh state
the enlargement in the basic vessels might have been more marked,
but in examining the specimen he could not distinguish any special
thickening about the membranes of the base. The symptoms were
no doubt largely due to hydrocephalus. The cranial nerves were ap-
parently not compressed by an exudate. It was unfortunate that an
examination could not have been made of the spinal meninges. Prob-
ably the process would have been found to extend to the spinal men-
inges, showing a cerebrospinal meningitis.
Dr. TUTTLE thought there was too much of a tendency in medi
cine to try to get up new diseases and this posterior basic meningitis
was a British invention, so to speak. It seemed to have been de
scribed there and most of the cases were reported there. Every one
knew what a wonderful difference there was between certain cases of
epidemic cerebrospinal meningitis. The fulminant cases sometimes
City Hospital Alumni. 209
died within two days, others resulted in a chronic hydrocephalus last-
ing possibly two years. So far, the bacteriology of neither disease had
been so positively settled as to enable one to say that this was merely
a phase of cerebrospinal meningitis, yet, the evidence seemed to point
that way. Last winter there had been in the East one of the worst
epidemics of cerebrospinal meningistis ever known, and though there
had been no such epidemic here, yet, sporadic cases were more likely
to occur in other districts during one of the epidemics. In a discus-
sion of the subject before the British Medical Association last year
Dr. Osler had said he was convinced that this was only a phase of
cerebrospinal meningitis.
The PRESIDENT asked if there had been an examination of the eye
grounds or whether the only evidence of the failure of vision was that
the child did not blink when the hand was brought suddenly up to the
eyes?
Dr. WARFIELD, replying to Dr. Green’s question, said there had
been no examination of the eye. It was interesting to note that
Thursfield in the Zancet, 1901, took the view that Still does. He said,
also, that there was an optic neuritis. Lees in a report of 94 or 95
cases said there was no optic neuritis. So far as he could learn, Dr.
Warfield thought this was merely a form of cerebrospinal meningitis
that took on this unusual symptom complex in children under one
year old. What bacteriological work had been done by the Americans
went to show that it was due to the diplococcus which was the cause
of cerebrospinal meningitis, that in acute cases one might find this
organism while in chronic cases the picture was simply one of chronic
meningitis. There was not a great amount of evidence to show that
the diseases were the same though the probabilities were that the
accumulation of evidence would tend to show that they were.
210 The Medical Society of
Meeting of October 19, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Is Syphilis or TMercury Responsible in the
, Etiology of Dementia Paralytica and
Locomotor Ataxia P
By O. L. WOLTER, M.D.,
ST. LOUIS, MO.
BECAME interested in the subject of the etiology of pa-
I resis and tabes while at the City Hospital. I saw many
cases of tabes, but the most severe cases I saw were
those in which secondary syphilis was mild and tertiary syph-
ilis entirely absent.
A number of tabetics of vague secondary and absent ter-
tiary syphilis had taken thorough mercurial treatment covering
a period of years. Why should tabes follow victims of lues,
if the destructive processes are mild or absent, constituted an
interesting proposition. Why should victims of intense syph-
ilis proportionately escape locomotor ataxia and its congener
paresis, and why are these diseases rare in the negro, were
equally interesting questions. The most severe case of tabes
I ever saw was a City Hospital patient. He is a white man,
in the middle period of life. About eight years ago he had a
sore on the penis, and a physician whom he consulted pro-
nounced it a specific chancer. This patient always had a
morbid fear of lues and, as a result, he readily submitted to
heroic mercurial treatment covering several years.
Careful examination and questioning brought out the fact
that he never had characteristic secondary syphilis.
The history of the chancer was not pathognomonic and
tertiary syphilis was not demonstrable. The patient had lost
the greater part of his teeth while submitting to the specific
treatment.
It occurred to me that the diagnosis of syphilis in tabet-
City Hospital Alumni. 211
ics and paretics was often wrong and that the mercurial treat-
ment following a mistaken diagnosis in these so-called mild -
cases of syphilis is largely responsible in the causation of pa-
resis and tabes. The absence of sclerosis of the brain and
cord in the negro could only be explained on a similar line of
reasoning.
I believe the subject worth discussing, and that is the ob-
ject of this paper.
Syphilis is a protean disease and for that reason it is not
made to serve as a scapegoat in many instances. In order to
evade too direct an accusation writers call the pathological
findings of paresis and tabes a parasyphilitic or a metasyphi-
litic condition. They quote about the similarity and entity of
the clinical picture of these two diseases, and they declare
syphilis will simulate any known disease, yet no matter in what
form it appears, it has recognizable earmarks, and by its ear-
marks we recognize syphilis in progressive dementia and tabes
dorsalis.
The opinion of writers on the subject is well illustrated
by Arthur Conklin Brush. It is shown as follows:
“No syphilis, no tabes.”—Ferrier.
“Tabes is a syphilitic process.”—Wiegert.
“It can not be said that tabes never originates without
syphilis.”—Bailey.
“That syphilis is not the only cause.”—Gowers.
“It is not a syphilitic process nor a sequelae of syphilis.”—
Peterson and Burr. W
“That syphilis is the most important cause, but distinctly
not the only cause.”—Bramwell.
“Less importance is now given to syphilis and more im-
portance to other poisons.”—Fulton.
The above quotations illustrate the opinions of well-
known writers on the subject.
A disease as protean as syphilis can easily shoulder the
trouble, but is it really to blame P There are important rea-
sons to believe that syphilis plays a minor rôle in the etiology
of sclerosis of the brain and cord. For instance, although
about 90 per cent of negroes in our great cosmopolitan city
have syphilis, can any one remember ever seeing a case of
2 12 The Medical Society of
paresis and posterior spinal sclerosis in an Ethiopian P. The
rarity of these diseases in this race, though for the most part
syphilitic and debauched, is most singular. Who will explain
the absence of tabes and paresis in the colored man P
It can not be argued that they are more thoroughly treated
for syphilis and it can not be said that they are endowed with
ancestral immunity. The average negro most frequently re-
ceives no treatment for lues, and the most severe secondary
and tertiary lesions are found in the colored man. Writers
claim lack of proper treatment tends to develop the disease,
but in this instance does it appear to do so P
The theory that paralytic dementia and tabes in 90 per
cent of all cases is a metasyphilitic condition is, to my mind,
not so sound as the theory that the diseases are usually a me-
tacurial condition.
The points to be considered in the discussion of the latter
theory may be grouped as follows:
I. The disease is rare in the negro.
2. Why is the brainy individual the usual victim P. 4×
3. The pathology of paresis and tabes does not compare
with the pathology of primary, scondary or tertiary syphilis.
4. Why does it take paresis and tabes a long time to
develop P
5. How mercury may produce the pathological changes
as found in paresis and tabes.
6. The fact that antisyphilitic treatment does no good—
but actually does harm.
7. Why is it natural that syphilis should shoulder the
trouble.
I. Why is the disease rare in the negro P I have never
seen a typical case of paresis or tabes in an Ethiopian. In
order to question my experience more thoroughly, I made in-
quiries. Dr. Atkins, Superintendent of the City Hospital for
the Insane, and a man of considerable experience as a neurol-
ogist, declared: “I do not remember ever having seen a typ-
ical case of dementia paralytica or locomotor ataxia in the
negro.”
Dr. Max E. Witte, Superintendent of the State Hospital
City Hospital Alumni. 213
for the Insane, Clarinda, Iowa, a most careful, observing and
competent neurologist, says; “I have seen several cases of
organic dementia due to syphilis in the negro, but I can not
remember ever having seen a well-marked case of true paresis
or locomotor ataxia. * : * * My explanation is that paresis
occurs in the highly developed brain only.”
Substantially the same reply was received from other
SOUII CCS.
The rarety of these diseases in the negro can not be at-
tributed to proper surroundings and regular mode of life, be-
cause here we have a people addicted to every known excess.
They live in unhygienic surroundings, they observe irregular
hours, as regards eating and sleeping ; they expose themselves
to bodily violence, and they are addicted to alcohol and sex-
ual excesses long before adolescense. As a result of venery,
the negro in our large cities is both a syphilitic and a gonor-
rheric, and those affected with syphilis are, in 80 per cent of
cases, alcoholics and to a great extent addicted to cocain and
morphin. Bodily violence, alcohol and venery are supposed
to lower the vitality and in that way come in for their share as
a predisposing or direct factor in the causation of these dis-
eases in the white man, but then why do they form an excep-
tion in the negro P
Having become a syphilitic the colored man allows it to
run, a pretty typical course without interference. Within the
course of a number of years he presents himself with syphi-
litic gummata, syphilitic osteitis, syphilitic hemiplegia and foul
ulcers. The course it runs is typical, and a negro once a
syphilitic is always one. Some receive some sort of treat-
ment—others receive no treatment. If they do take mercury,
it is with no system; it is taken irregularly and for no pro-
longed period of time. Syphilis is given free rein and it ex-
hibits itself by running a typical, uninterrupted, course. Pri-
mary, secondary and tertiary syphilis succeed each other in
their natural evolution. But then why do they not become
victims of paresis and tabes?
2. And why is the brainy individual the usual victim P To
say the negro lacks a highly-developed brain, which some
writers declare is essential in the production of paresis, does
214 The Medical Society of
not stand the test of criticism and, therefore, such reasoning
is not well taken and, hence, illogical. Is there such a thing
as more highly-developed brain P A fully-developed nervous
system means a normal nervous system. If it is not fully de-
veloped, it is faulty, and an ill-developed nervous system is
quickly recognized by its manifestations, as seen in imbecility,
idiocy and epilepsy. The average negro's nervous system is
as fully developed as ours. It may lack training, but it is just
as susceptible to impressions, stimuli and disease as our nerv-
ous system. That paresis and tabes loom up prominently in
wealthy, brainy and professional men can not be denied. But
the reason follows, brains are usually associated with wealth, and
brains and wealth are the requisites in obtaining thorough anti-
syphilitic treatment. If an individual has no money he can not
afford to pay for a treatment of lues covering months or years.
Then, again, if he has not the intelligence he can not under-
stand why he should continue treatment for a disease after all
the apparent symptoms have disappeared. It follows that the
requisites of thorough antisyphilitic treatment are brains and
money—and, since these are the essentials in obtaining the
treatment, it gives us the reason why paretics and fabetics are
usually individuals of prominece. Why individuals of inferior
caste are greatly immune, and we find reason on comparison
to trace the etiology of progressive dementia to mercuraliza-
tion and not to syphilitic virus.
The man of brains tries to escape the baneful energy of
this loathsome disease but does he escape anything P
The same facts as regards the negro hold true of the
lowly white man. Like the negro, he is saturated with active
untreated syphilis, usually the victim of dissipation and every
other known syphilitic condition, but proportionately he es-
capes paresis and tabes. Are bodily violence, alcoholism, a
neuropathic diathesis and every known mode of dissipation
potent predisposing factors P
3. The morbid physiology of paresis and tabes does not
compare with the pathology of primary, secondary or tertiary
syphilis. The so-called infectious granulomata characteristic
of the secondary or tertiary lesions are totally absent. The
pathology of tabes is a sclerotic process, pure and simple. A
#
City Hospital Alumni. 215
hyperplasia of the connective results from decay of function-
ating tissue. Whether this substitution is the result of primary
decay of the parenchymatous tissue or whether initial hyper-
plasia of the interstitial tissue causes the sclerosis is of little
concern. The fact remains that there is no analogy in the
pathology of paresis and tabes comparable with the pathology
of syphilis. Since the morbid anatomy does not correspond
with the pathology of any stage of lues, it alone creates suf-
fisient reason to seriously question the specific pathogenesis
of paresis and tabes.
4. Why does it take paresis and tabes a long time to de-
velop P Tabes and paresis do not become apparent soon after
one has been infected with syphilis. It takes time. It usually
takes Io, 20 or even 30 years. Why does it take that long P The
period of time required, shows that the process of destruction
taking place in the cord and brain is not malignant. It demon-
strates itself to be a gradual, insidious process—a destructien
that apparently does not exist, but after a number of years it
amounts to a dreadful reality. The mode of destruction may
be compared to the wearing out of a rock caused by the con-
stant dripping of the drops. The rock appears to be unim-
pressionable and impervious to the dripping of the drop, but
still it wears out. After a number of years of continuous
dripping it becomes evident that its destruction will soon be
complete. The infinitum becomes a magnitum. As unim-
pressionable and impervious as the rock seems to the dripping
of the drops, allow the wear to continue and multiply the in-
jury by a number of years, then it becomes evident that it
will soon be destroyed.
Similar to the process of destruction caused by the drop,
is the process of destruction of functionating nerve tissue of
the brain and cord in paresis and locomotor ataxia. Analys-
ing the slow, gradual and insidious decay of the brain and
cord in these two diseases, we find it just what we could ex-
pect of nerve tissue permeated and infiltrated with a foreign
substance like mercury. Constantly present and constantly
replenished by years of mercurialization—the vitality of this
vital tissue is lowered, and death of the most specialized and
vital tracts and the substitution therefor of fibrous tissue is
216 The Medical Society of
the ultimate result. The decay, necrosis, with hyperplasia of
interstitial tissue can not be accomplished at once. It takes
time. It takes years. The pathogenesis of these two dis-
eases must be the same, hence the analogy of morbid anatomy
and morbid physiology.
5. It remains to be explained how does mercury produce
the pathological changes of paresis and tabes. In order to do
this, it becomes necessary to define inflammation:
The most acceptable definition of inflammation is a modi-
fication of Sutton's as quoted by Park. “Inflammation is an
expression of the effort made by a given organism to rid itself
of or to render inert noxious irritants arising from within or
introduced from without. The causes of inflammation are
classified as bacteriological, thermal, mechanical and chemic.
Of all causes bacteria play the most important part.
Inflammation caused by chemic bodies is typically seen
in nephritis due to Spanish flies, or in neuritis due to plumb-
ism or as seen in chronic arsenic poisoning.
Mercury is a chemic body, and all therapeutists agree
that it is a most diffusible element. As an infiltrant it permeates
all the tissues. One treated for syphilis for two years or more
must expect the entire body to be infiltrated by this metal and
it is safe to assume that the intensity of the infiltration is pro-
portionate to the amount supplied and the length of time it is
taken. As an adventitious body to the tissues, it must neces-
sarily be followed by tissue reaction, and this reaction is the
result of the effort made by a given organism to render inert
noxious irritants introduced from without. It is a reaction of
invaded healthy tissue against injury. Mercury, a heavy
metal, with an atomic weight of 200 and endowed with the
property of diffusibility finds lodgement in the vital tissue of
the cord and brain. Here it must act as a foreign body, and
reaction of the tissue follows. Having become permanently
lodged this chemic substance exerts its energy, which may be
considered twofold: First, its energy exerted as a foreign
body, and, second, by virtue of its chemical and therapeutic
properties. Diffused in the tissue of the cord and brain as a
foreign substance, irritation around the site of lodgement
takes place. Being a permanent adventitious body a continu-
|
City Hospital Alumni. 217
ous irritation results. Irritation, whether chemical, bacterial,
thermal, or mechanical, means inflammation. The intensity
of the inflammation depends on the nature of the irritation.
The nature of the inflammation corresponds to the nature of the
irritation, but no matter what the degree of inflammation may
be changes in the surrounding cell structure result with conse-
quent perversion of cell function.
The changes that occur are degeneration and destruction
of cell with subsequent cell regeneration—or by cell repair
only.
Cell repair is all that can be expected following decay of
highly organized tissue. Degeneration and necrosis of the
nervous system is followed by repair only.
The repair that follows is substitution of complex func-
tionating tissue by simple non-functionating tissue. Simple
non-functionating tissue is fibrous tissue, and fibrous tissue is
interstitial tissue.
Decay of parenchymatous tissue with interstitial tissue
substitution is the dominant feature.
The process of destruction is insidious, covers a long
period of time—just as can be expected of tissue, highly
organized, permeated and infiltrated with mercury.
The pathology of paresis and tabes does not compare
with the pathology of any stage of lues, and since there is
nothing to prove that the cicatricial process in these two dis-
eases is due to lues—except a history of previous syphilis, the
question reasonably follows: Is mercury responsible in the
etiology of dementia paralytica and locomotor ataxia P
The virtue of the chemical properties of mercury on the
tssues is not well understood. It is claimed by writers to be
an alterative. It is supposed to alter in some way not fully
understood tissue metabolism. It might be assumed on such
authority that as an alterative it may also be responsible in
interference of cell structure as well as of cell function.
6. In the treatment of paresis and tabes we find that anti-
syphilitic treatment does harm. If a certain cause provokes
an injury, would not an aggravation of the cause result in
more injury P Such a conclusion is warranted, therefore, if
the administration of mercury in these two diseases does
218 The Medical Society of
harm, it may reasonably be questioned, is it the etiological
factor P But writers declare, sometimes it does good, and the
patient shows marked improvement. In a few cases he does,
but probably his improved condition was mostly due to the
antagonistic action of mercury on a field of active syphilis that
in a certain number of clouded cases was responsible for his
condition. Then, again, the data must be taken from the
greatest number, and all writers are united that in well-marked
cases of paresis specific treatment does harm.
The fact that the administration of mercury does harm in
these two diseases gives sufficient reason alone to the question:
Is mercury responsible in the etiology of progressive dementia
and tabes dorsalis?
7. As quoted in the beginng of this paper, writers are
unanimous that syphilis plays the great rôle in the production
of paresis and tabes. Syphilis they claim is responsible. But
from the above discussion, does not the syphilitic etiology of
these diseases appear questionable.
It can not be denied that these patients usually have had
syphilis, but neither can it be denied that mercury was not
their treatment. It is just as easy to blame syphilis instead of
the treatment as to blame specific urethritis for the production
of the coccus of Neisser when really the gonococcus is the
specific cause of gonorrhea. -
That paretics and tabetics are syphilitic is not denied, but
that they have been mercurialized is equally true.
It is this question, is mercury or is syphilis responsible in
the etiology of dementia paralytica and locomotor ataxia, I
hope to have discussed.
[1403 O’Fallon Street.]
DISCUSSION.
I)r. JACOBSON thought Dr. Wolter argued from the wrong premi-
ses. Hebra and others had made extensive experiments in a large
number of cases. They gave large inunctions of mercurial ointment
to healthy people, the patients were watched for several years and no
injurious results followed. Von Zissel who had a large clinic in Wi-
enna, in his expectant treatment gave neither mercury or iodids, sim-
City Hospital Alumni. 219
ply treating the local conditions and looking after the hygienic condi-
tions of the patient. A proportion of these patients developed nerv-
ous diseases but not a larger proportion than those taking the iodids
and mercury. Those facts alone were enough to prove that Dr. Wolter
was wrong. Fournier had stated that chronic nervous conditions de-
veloped in those patients who had received no antisyphilitic treatment
at all. He also stated that those having severe relapses improved
rapidly under mercurial treatment. Erb and others believed that
syphilis was one of the important factors though he also took into
consideration other factors, such as exposure to cold, malarial fever,
etc. He had made the surprising statement that women never had
locomotor ataxia. Dr. Jacobson did not understand why Dr. Wolter
had picked out posterior spinal sclerosis as being caused by mercury,
why not include myelitis and other nervous affections following syphi-
lis ? He could not agree that syphilis was not the cause of these con-
ditions. Negroes, he believed, did not have dementia paralytica be-
cause they do not worry and do not use their brains very much and
with rare exceptions, their cerebral nerve centers were not ex-
hausted by over-use. Actors, who burned the candle at both ends
frequently suffered with paresis. These people studied much and
slept little, and over indulged in all ways. Negroes are peculiar in
many ways. They rarely have stone in the bladder or a renal calculus.
Gowers had reported a case of congenital syphilis in an eight year old
boy in which there were brain and cord lesions. Gummata were found
at the base of the brain and there was an endarteritis of the cerebral
vessels and this patient had had no mercurial treatment at all.
Dr. DRECHSLER thought that one of the reasons the negro race
was not afflicted with locomotor axtaxia was that he did not live long
enough to get it. At the hospital whenever a negro was to be operated
upon they had always looked for signs of syphilis and had invariably
found it. The negro men who were always fighting and in all sorts of
trouble, when they had an attack of lues, did not live long enough to
get locomotor ataxia, usually dying of some tubercular abscess or some
kidney affection. Down South there were old darkies 90 years old
but the present generation would not live that long. The speaker had
under his observation at this time a case of locomotor ataxia in which
220 The Medical Society of
there was no history of syphilis, though the patient was a reasonable
man and would be willing to give such information.
Dr. Bliss said that in regard to the occurrence of locomotor
ataxia and paresis in women, he had been trying to recall how many
cases he had seen in women and he thought he had a record of at least
five cases of locomotor ataxia. He has at this time two cases. He
had never seen a case of paresis in a woman. He was not under the
impression that syphilitic women took less vigorous treatment than
men. Dana and other neurologists had advocated the use of hypo-
dermic injections of benzoate of mercury in very early cases of tabes.
Two years ago the speaker had had a case of tabes in a very early
stage. The patient had a stammering bladder, pupils rigid to light, re
duced knee-jerks and anesthesia. His station was moderately good and
walk fairly good, weight 175 pounds,height six feet,five inches. He abso-
lutely denied having had syphilis but acknowledged a gonorrhea which
had lasted a year. He objected seriously to antisyphilitic treatment
but Dr. Bliss had used vigorous inunctions of mercury and after five
or six months the result was a cure except that there was no change in
the pupil. The patient had remained well. Other instances in which
this method was employed were similar. It was firmly held by some
observers that there were cases of early paresis and tabes that could
be stopped by the use of mercury. Dr. Bliss believed there were a
considerable number of cases of tabes and paresis which had never
had a considerable amount of mercurial treatment, and he believed
there were cases of locomotor ataxia which had not had syphilis and
consequently had had no mercurial treatment. While it was not now
lcaimed that syphilis was the sole cause of locomotor ataxia and pa-
resis, it was certainly found in an immense proportion of cases. It
was equally true, also, that a large number of patients who had been
treated vigorously for syphilis had never developed locomotor ataxia
or paresis.
Dr. LIPPE said that in discussing anything theoretically much
could always be said pro and con, but in this instance it did seem to
him possible that that there was something in Dr. Wolter's argument.
The mere fact that a man was so unfortunate as to have tabes or
paralysis did not warrant the presumption that the individual was a
City Hospital Alumni. 221
liar and had had syphilis. That the drug of an atomic weight of 200
absorbed and carried to the ganglionic cells might destroy them, thus
producing sclerosis, seemed reasonable. The argument put forth by
the Doctor was certainly very logical.
Dr. BoEHM had seen within the last three years a number of
cases of tabes and had been in correspondence with one of the most
scientific men at Hot Springs, Arkansas, who had given this subject
much study. This gentlemen went into the matter thoroughly. He
made it a rule in all cases to make a hemoglobin estimation at once,
also a blood count, before administering mercury. About a year and
a half ago the speaker had been told that this gentlemen felt that a
good many cases of tabes that came to him were probably overtreated
by their physicians at home with specific treatment. On the other
hand there were many who had not received syphilitic treatment. In
regard to the early recognition of syphilis, patients sometimes pre-
sented themselves at clinics who were unaware of a previous urethral
chancre. Urethral chancre was very common if looked for. Physic-
ians did not use their microscopes often enough. In a case of urethri-
tis the physician should at least make a smear preparation and if he
failed to find the gonococcus he should at least try to find what was
the cause of that urethritis. Even when the urethroscope failed to
reveal a nodule there would often be found a placque. The same kind
of mucous patches occurred in the urethra as in the mouth. There
were cases on record of locomotor ataxia giving no syphilitic history
that, if they had been treated by an observing physician when they
had the primary lesion, this also would have been found. The lesion
might be in the intestinal or gastric mucous membrane. All genito-
urinary clinics in this country were very large and the tendency was to
rush the cases through. In the clinic with which the speaker had been
connected they had preferred to treat a few cases thoroughly. Their
records for the last six years would show some very interesting de.
velopments.
, Often when a patient denied any knowledge of specific infection
it was due, not so much to his intent to deceive as to the
carelessness of the medical examiner who had looked him over. This
point of administering mercury was something he was working over,
222 The Medical Society of
trying to determine how far the mercury should be pushed, examin-
ing the blood periodically during the administration of the mercury.
Syphilis was something that required to be treated scientifically. In
some' of the larger cities there were men who devoted their entire time
to it. It would become more the practice as more was learned about
mercury to make blood examinations during its administration. Many
tabetic patients presented themselves with a primary bladder trouble.
From the description one would think there was a constriction of the
neck of the bladder. Whether syphilis or mercury was the cause of
tabes, would only be explained by years of close study. After a num-
ber of years’ experience every observing physician could recall cases
in which he had been able to satisfy himself that the individual was
syphilitic though the patient was unable to say that he had ever had a
primary lesion. The fact that there was no such history did not prove
that the patient was not syphilitic. Again, the fact that tabes often
did not react favorably to syphilitic treatment did not prove that it
was not due to a syphilitic lesion. It was agreed that in sclerosis the
cicatricial tissue was the result of an inflammatory condition. If this
was due to syphilis, in the early stages some benefit might be expected
from syphilitic treatment, but if the case had progressed until the tis-
sue was destroyed, what result could be expected from syphilitic treat-
ment? Because antisyphilitic treatment did not relieve tabes did not
prove that the primary cause was not syphilis.
The PRESIDENT asked Dr. Bliss if his experience accorded with
Dr. Wolter’s in that the negro race was relatively immune from tabes
and paretic dementia.
Dr. BLISS could not recall ever having seen a case of paretic de-
mentia or locomotor ataxia in a negro. He had an impression that he
had done so, but could not recall the instance. Some five years ago
Osler had stated that he had never seen a case of diabetes mellitus in
the negro. When this statement came to Dr. Bliss's attention he
happened to observe a case in a negro woman and he had written
Dr. Osler about it. Dr. Osler replied that since the writing his
article he had observed several such cases. The question of locomo
tor ataxia and paretic dementia in the negro had not been much dis-
cussed and he was hardly in a position to make any statement on the
City Hospital Alumni. - 223
subject, for not a half dozen negro patients visited his clinic in a year.
A negro physician here who treated a large number of colored people
` might be able to throw some light on the subject.
Dr. HoRwitz said that during his service at the Insane Asylum
he had not seen a single case of locomotor ataxia or paretic dementia
in the negro.
Dr. LIPPE asked if that case of diabetes mellitus gave a syphilitic
history, Dr. Bliss replying in the negative. The speaker added that
in a recent number of the Wew York Medical Record there was a
report of some twenty cases of diabetes mellitus in which a cure had
been effected by the administration of mercury and the iodids in con-
junction with some electrical treatment of the writer’s own.
This shows how far syphilis is blamed for many diseases whose
etiology is not understood.
The PRESIDENT said that it was an interesting fact the ocular tis-
sues of the negro were not susceptible to certain disease processes.
This was exemplified by the immunity of the negro to granular lids.
Again, the negro race was practically free from lachrymal obstruction,
this being due to anatomical conditions, the duct being much wider
than in the white.
Dr. Wolters, in closing, said: Dr. Jacobson quotes experi-
ments of Hebra and others. He reports complete vindication for
mercury. He says large quantities of mercury were administered by
inunction to healthy people. No injurious affects followed. Probably
all those healthy people inuncted by Hebra and others had mercurial
idiosyncrasy, but the declaration of Dr. Jacobson needs no refutation.
What physician has not observed the pernicious action of mercury on
the human being—especially if it be a healthy person. It has long
been known that the serious symptoms of secondary and tertiary
syphilis can be produced by mercury as well as by syphilis. Dr.
Jacobson does not understand why the subject of this paper does not
include myelitis and other nerve lesions. No explanation is needed.
They are not allied in any particular to either tabes or paresis. Why
not include astronomy also 3 The reason that the posterior
columns of the cord, the great sensory tracts, are principally involved
is probably because they are most vital—more highly specialized.
224 The Medical Society of
The most vital and delicate tissue must suffer especially. Supposing ,
syphilis is the etiological factor, why should it affect the posterior
columns mostly 3 ---
In hydrargyrism, why are the lower incisor teeth the first and
almost the only ones to fall out 3
Arguments trying to explain the absence of sclerosis of the brain
and cord in the negro as racial immunity does not prove anything and
likewise does not explain the comparative absence of these diseases
in the lowly white man. He had especially in mind that white individ-
ual who has untreated syphilis and who is the victim of every known
€XCeSS. f :
In the treatment of syphilis by mercury he would advise its ad-
ministration with extreme care. Too much harm is done by over
treatment. He favored the intermittent form of treatment, administer-
ing the drug with caution, when syphilis seems to become active and
during the quiescent period administering the medicine in minute doses,
or not at all. - -
To give mercury for years of continuous treatment, stopping it
just short of ptyalism and at times even salivating the patient is giving
a drug not understood and a good thing over done, and it is in
just that class of patients so treated that he had seen tabes in its worst
form.
City Hospital Alumni. 225
Meeting of Wovember 2, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Darier’s Disease.
By H. W. MOOK, M.D.,
ST. LOUIS, MO.
BROUGHT this patient here to show the effect of the x-
I ray treatment on the disease. In all, some thirty-five or
forty cases have been reported. No treatment has ever
influenced the course of the disease in the least. About three
months ago I got this patient from the City Hospital and took
him to the Skin and Cancer Hospital and put him under x-ray
'treatment. Improvement being so marked, I brought him
down to show him to you. It is a very rare affection and a
histological examination shows that the lesion lies entirely in
the epidermic layer of the skin. His face three months ago
was covered with these cornifications. Dr. Grindon reported
this case about two or three years ago. The immediate effect
of the x-ray was to dry up the secretions from the fungoid
growths in the genitocrural region. In a few weeks the
growths were markedly reduced in size and have continued to
reduce until now they are about one fifth as large as when the
treatment was begun. Formerly curretting was necessary for
their reduction with a rapid recurrence. The x-ray treatment
has entirely relieved the pain and burning sensation which are
constant features at this stage, if the x-ray treatment is not
given regularly.
Splenectomy for Rupture of the Spleen.
*-* By DR. FREUND,
ST. LOUIS, MO.
HIS patient walked into the City Hospital on the 12th of
last month; a laborer, single, aged 23 years. There
was a diagnosis of internal injuries. There were symp-
226 The Medical Society of
toms of shock, but the patient's mind was clear and the tongue
clean. Examination of lungs negative, temperature IOO’,
pulse 96, respirations 24. Flatness in the lower half of the ab-
domen, no vomiting, mucous membranes pale. Internal hem-
orrhage was suspected; he was sent to the operating room and
given ether. The abdomen was found to contain a large amount
of dark colored blood. Incision was made across the rectus.
Rupture of the spleen was found. The organ was removed and the
abdomen closed as soon as possible, with a glass drain in posi-
tion. A hypodermoclysis was given, tube drained every three
hours. At no time was the temperature above IOI* except on
the second day when it went to 104°, respirations rising as high -
as 40. He continued to improve. He had trouble with a
cough and dullness in the apex of the left lung, but no tuber-
cle bacilli were found. Blood examination showed that the
leukocytes averaged 18,000. When he entered the Hospital
the leukocyte count was 9,000. The patient has lost about 32
pounds in weight. Today there was found about 42 per cent
of hemoglobin, though up to this time he has averaged 35 to
38 per cent.
Presentation of the Spleen.
By W. C. G. KIRCHNER, M.D.,
ST. LOUIS, MO.
I saw Dr. Doyle remove this spleen. The patient came
in with a history of injury to the left side. There was pro-
nounced shock and the condition was such that operation
seemed advisable, not that he was pronouncedly collapsed, but
experience has taught us that in all of these cases the safest
procedure is exploration, not only when there is contusion of
the abdomen but where hemorrhage is suspected. Dr. Doyle
made a median incision. There was a good deal of hemor-
rhage. The spleen was at once sought. It was large and
soft so that we thought the patient was suffering from some
disease. This is one of a series of these cases that we have
had. The chief lesson to be drawn from these cases is that
exploratory laparotomy is always indicated. In one case of
City Hospital Alumni. 227
gunshot wound of the spleen there was extreme hemorrhage.
The spleen was removed but there was a fatal result, hemor-
rhage and shock were too great. Another case on which I
operated the patient had been struck on the left side with a
wagon tongue. There was great shock and it was thought
operation would result fatally. He was put to bed and care-
fully watched. Dullness was made out on the left side. We
thought it a rupture of the spleen. He continued to improve
for several days, then one morning was found in collapse. He
was placed on the operating table at once and the abdomen
found filled with blood. The spleen had a thickened capsule into
which the hand could be placed. Hemorrhage was so terrific
that the patient died a few hours after operation. Dr. Doyle
had another case which did favorably until about ten days
after the operation, when he died of an infarction of the lung.
Dr. Brown has since operated on two cases in which the spleen
was removed, and in one there was complete recovery. The
other came to us rather late and the result was fatal. Of some
five or six cases we have had three or four recoveries. If we
want any results in these cases they should come to operation
early. Our attention was led to the spleen in this case of Dr.
Doyle's because there was pain in that locality, shock and
hemorrhage. The patient was injured by falling between two
freight cars. He fell from the door and hurt the left side.
º
DISCUSSION.
Dr. ELBRECHT thought the City Hospital had been particularly .
fortunate in getting this line of work. A few years ago these opera-
tions were undertaken with a good deal of timidity but the fact that
they were undertaken had taught surgeons a great deal about the sub-
ject. The fact that the hemoglobin was so low was particularly inter-
esting. The blood was the most valuable thing to study in this case
from now on, since the surgery was complete, and was a most beauti-
ful piece of work. Dr. Carstens, of Detroit, had reported three
cases of splenectomy with recovery. The blood in this case should
be studied further to see what physiological changes were brought
about.
The PRESIDENT asked if any one could enlighten them as to the
2 :8 The Medical Society of
ultimate condition of these spleenless individuals. , Did they get along
well indefinitely 2
Dr. BAUMGARTEN, replying to the question by the President, said
that no reports had been made of cases that had been followed suffici-
ently to determine any definite change in the blood picture; after a
prolonged period there had been changes, but they were not uniform.
Dr. GARCIA suggested that the case be kept under observation
and reports sent in later, say one six months from date and another at
the end of a year.
Dr. ELBRECHT suggested that the patient be asked to return to the
Hospital to report from time to time. In the three cases operated
upon by Carstens no ill effects had been noticed.
Dr. FREUND, replying to a question by Dr. Baumgarten, said that
the number of red cells were less than normal.
Dr. KIRCHNER said that in the case operated upon by Dr. Brown
which recovered there were no untoward symptoms.
Dr. HoMAN asked what the physiologists looked for in these
cases. He also wanted to know how the work which the spleen per-
forms was carried on when that organ is removed ?
Dr. BAUMGARTEN, replying to Dr Homan’s first question, said
that the pictures in these cases had not been uniform. Some of the
patients had presented a normal blood picture except for enemia. In
others the leukocytes had been very variable. As to how the work of
the spleen was carried on, the answer to that depended on the idea of
what the work of the spleen was. Very little was known about it.
Tumor of the Face.
By H. W. MOOK, M.D.,
ST. LOUIS, MO.
ſº
HE patient, aged 70 years, was admitted to the City
Hospital on the 23d of last month. Had used alco-
hol moderately and formerly smoked. No history
of tuberculosis, carcinoma or anything of the kind. Had reg-
ular habits of sleep, father and mother healthy. He has suf-
*s
City Hospital Alumni. 229
fered with asthma for three years. No venereal disease.
Four years ago the patient first noticed a small grayish spot
on the tip of his nose. It increased to the size of an orange.
The pedicle of the growth is small. Every night he has severe
attacks of asthma. Appetite is poor, digestion fair, bowels
costive, breath offensive. No tumor or mass palpated in ab-
domen. Respiration not increased, fremitus on both sides the
same. Pulse regular, small and weak. Heart sounds can
hardly be made out. No cardiac murmurs heard. Urinalysis;
specific gravity IOO3, acid, cloudy, albumin negative, sugar
negative, no casts. *
I saw this case about a week ago. Besides this large
tumor there were a number of smaller ones. Usually in these
molluscum fibromata the lesions occur all over the body.
They are according to Recklinghausen supposed to grow from
the nerve sheath. They are occasionally very painful and
sometimes resection of the nerve is necessary to give relief.
Rhinophyma is an increase in the size of the sebaceous
glands and is an advanced stage of acne rosacea, and that is .
what I thought this was at first, on account of its soft lobulated
appearance and location. When these tumors upon the body
become very large they hang down like a large sac. These
tumors frequently recur. Cases have been reported with two
or three thousand tumors on the body. They sometimes
weigh ten or fifteen pounds. The patient has had this
condition for five years and says that before that time the
nose was red.
According to Crocker, Neumann and others, the mollus-
cum fibromata tumors consist of a hyperplasia of the connect-
ive tissue of unknown origin.
DISCUSSION.
Dr. CANNON had seen four cases of fibroma molluscum. In one
case the tumors varied in size from a pinhead up to a hazelnut. The
patient had very few on his face. Another patient, a man forty years
of age, had them over his entire body, on the hands and on the dor-
sum of the foot. Only one of these tumors was as large as a small
orange. The third patient was the mother of this latter patient; there
230 The Medical Society of
were one or two on the face and others on the body. The fourth was
a man forty-five years old; he had very few of the tumors, mostly on
the back, none on the face or scalp. None of these patients had any
pain.
Dr. ELBRECHT said that Dr. Grindon had a case which he demon-
strated before his classes each year. The patient had several hun-
dreds of these tumors ranging in size from a pea to a peach kernel.
Dr. Grindon had removed several of theim and they had always
returned.
Dr. SINGER said that in one case at the Female Hospital, a post-
operative case, the patient had a number of these tumors ; they were
rather flat, none larger than a dollar. The patient died of erysipelas.
She stated that her mother had had a similar condition.
Dr. Mook said that according to Recklinghause these tumors were
sometimes supposed to grow from the connective tissue of the nerve
sheath and some of the cases gave a history of neuralgic pain.
He had seen a twelve pound tumor of this character removed from
below the scapula, but it returned This condition had no effect on
the general health, except, perhaps, mechanical when the growth was
in such a position as to cause obstruction.
Dr. KIRCHNER stated that this tumor had hung down in such a
way that it obstructed the air passages and it was a very difficult mat-
ter, also, for the patient to eat and sleep. It was taken off principally
for these reasons.
Stab Wound of the Abdomen.
By DR. FREUND,
ST. LOUIS, MO.
HIS patient entered the City Hospital with a stab three
inches long above the symphysis. Practically all
the small intestines were hanging out of the abdo-
men. He is a man aged 20 years, works eight hours a day.
He entered the Hospital conscious. Pulse was small and
rapid, temperature subnormal 98.6°, extremities cold. He
arrived at 1:20 a.m.; had been stabbed a little after 12 o'clock.
City Hospital Alumni. 231
He was anesthetized. No perforation of the gut was found,
and after exploring the intestines, which were covered with
lymph, they were returned and the abdomen flushed and
drained. Respirations 38, pulse increased to 130. Next day
the pulse was 140, temperature IOS.4°. The following day
the temperature was IO2.4°, pulse 150. He was given I ounce
of salts. The bowels did not respond either to the salts or a
laxative enema. An alum enema was given and resulted in
a small stool. Three days after the operation he vomited a
greenish fluid which later became brown, pulse rose to 160,
the abdomen was tympanitic and the symptoms alarming. On
the 9th of October he was given 3 grains or calomel followed
by an alum enema. Passed much flatus, pulse rose to 163, but
from that time the pulse continued to drop. On the sixth
day he was given a hypodermoclysis, 3OO or 400 cc., contain-
ing 1 ounce of whisky. I present this case because there was
so much of the gut out and all the symptoms of an infection
of the peritoneum. We could notice the fibrin on the intes-
tines when he was first examined. The abdominal drainage
was red, containing some clots.
DISCUSSION.
Dr. CANNoN said that this case was interesting because there was
so much of the gut outside of the cavity. Usually when the intestines
got outside the clothes it set up such a severe peritonitis that the pa-
tient succumbed. He had seen a similar case with his father. The
patient, a man, was stabbed in the abdomen, which was laid almost
wide open with the knife. He carried his intestines in his hands and
ran across the street to a livery stable, where he fell. The intestines
were scattered over his clothes and on the floor of the stable. The
intestines were washed and put back perfectly clean and the man
recovered. This case showed what might be done by careful technic.
Dr. KIRCHNER had hoped to present a case that had come in
shortly after this one. It was a very similar case, a prolapse of the
intestines, but not so much. There was an incised wound of the in-
testine which was treated in the usual manner and the patient had left
the Hospital. These cases were of great interest to the surgeon. To
treat them successfully a certain technic must be instituted. The
232 The Medical Society of
sooner the surgeon got at these patients the better. It was rather un-
usual to have these cases where the bowel or omentum was infected,
recover. The line of technic was well laid down. The incision in case
of stab wound depended upon the location of the wound. In gunshot
wounds the median incision was to be preferred. Careful search should
be made for hemorrhage and that controlled, if possible. The pre-
senting loop of intestine should be searched for perforations and, if
found, those should be sutured. When the intestine did not seem to
be injured it was well in all these cases to make a systematic search
for a possible injury, otherwise injuries to the viscera might be over-
looked. In the case just referred to, while the protruding loop showed
a perforation, there was a second perforation that might easily have
been overlooked but for such a search. It was a good rule to begin
at the ileocecal valve or at the ligament and examine the whole
intestine. It had been the custom in the City Hospital to flush these
cases when the injury was recent. In the case of an old injury with
a pronounced peritonitis no good ever came of flushing. When the
vitality of the peritoneum was intact great good might result from a
thorough irrigation. All these cases should be drained and upon the
thorough drainage depended the ultimate success of these cases. The
drainage that had been used at the City Hospital with good results
was the glass tube. This should be used regardless of the location of
the wound. Even if the wound were in the stomach, for instance, the
tube should be placed in the lower portion of the abdomen through a
stab wound. There was sometimes considerable hemorrhage with-
out the symptoms of it. The patient being placed in the Fowler posi-
tion by means of gravity the cavity was thus drained, through the de-
pendent portion. It was always well to make the lapal otomy wound
through a supplementary incision. The second case that he had de-
sired to present illustrated this point. Incision was made through a
supplementary wound apd closed in layers. The original wound was
drained. A few days afterward the patient developed a temperature
and an abscess developed at the site of the stab wound but the lapa-
rotomy wound remained perfectly clean, and the patient made a good
recovery. Peritonitis was to be looked for on many of these case and
there is then little or no peristalsis. Even when the patients were
& City Hospital Alumni. 233
restless it was, therefore, unwise to give them opium. A better plan
was to give the patients laxatives, and salts seemed to serve the pur-
pose best. This patient's pulse and temperature had been exceedingly
($ high, but he was able to retain the salts and as soon as evacuation
took place he began to improve. When there was much vomiting it
was better to wash the patient's stomach. It gave great relief. As a
rule these patients need but litle stimulation. The stimulation from
drugs, aside from those used in shock, was of little avail. Physio-
logic salt solution under the skin gave the best results. Strychnin
seemed to make the patients more restless and no good results seemed
to a CCrue.
Meeting of November 16, 1905 ; Dr. John Green, /r.,
President, in the Chair.
Typhoid Perforation.
Report of Cases and Remarks Upon Diagnosis.
By HORACE. W. SOPER, M.D.,
Chief of the Medical Clinic, St. John’s Hospital,
ST. LOUIS, MO.
T is not my purpose to present to you the literature of ty-
| phoid perforation. This has been done recently by Keen,
Harte and Ashurst, J. Alison Scott, and others. For a
complete review of the entire subject I would refer you to the
excellent monograph by E. A. Babler. I wish in this paper
to report cases illustrating the difficulties I have encountered
in attempting the diagnosis of this condition. As a reminder
of the importance of this subject I may be pardoned for quot-
ing a paragraph from the paper read before this Society about
a year ago by the eminent surgeon, Dr. W. W. Keen :
“Taylor states, that based upon the Census and the Ma-
rine Hospital Reports on the frequency of typhoid in the
United States, we have about 500,000 cases a year with a mor-
tality of about 50,000. Osler attributes about 30 per cent of
234 The Medical Society of
the mortality to perforation. If this is so, there are annually
about I 5,OOO deaths in this country due to perforation. On an
average we can now save 30 per cent of these cases of perfor-
ation, which would mean 4,500 lives saved annually. In their
recent paper, Harte and Ashhurt collected from January, I898,
to December 31, 1903 (the six years following my monograph),
only 201 cases operated upon the world over. Yet, it would
seem that in these six years in the United States alone 90,000
patients died from typhoid perforation, nearly all of whom
should have been operated upon and about 27,000 lives saved.
Have I not reason then to select the topic of the evening when
it is so evident—so painfully evident, that the profession at
large have not even begun to appreciate the need for opera-
tion in typhoid perforation ? It is especially the family phy-
sician, the one who attends typhoid fever, rather than the sur-
geon, who needs to be taught that perforation means opera-
tion, as a rule, just as he has painfully learned that, as a rule,
appendicitis means operation. Iteration and reiteration are
needful, here a little and there a great deal, and in time the
profession will be convinced, but only, I fear, after the loss of
many valuable lives.”
Please note that these case records are not intended to be
complete, but are purposely condensed to describe the signs
and symptoms especially involved in the diagnosis of perfor-
ation.
CASE I.—Male, aged 30 years, occupation bookkeeper,
entered the Protestant Hospital in July, 1904, about the sixth
day of the typhoid infection. The case was a mild one, the
temperature ranging from IOO to IO3°. No complications ap-
peared and the case was progressing favorably in every re-
spect, when suddenly, at the end of the third week, without
known cause, the patient had a severe chill, followed by a drop
in the temperature from Io 3 to 99°. I saw him a few minutes
after the chill and he complained of feeling cold, the face had
an anxious expression and he was perspiring freely, extremi-
ties were cold, pulse I2O, small volume and low tension. No
pain in the abdomen, no tenderness to pressure, no tympanites,
no rigidity. One hour later severe pains began in the right
iliac region, the muscles became rigid and distension could be
City Hospital Alumni. 235
made out. The pain persisted throughout the night and the
tenderness, rigidity and distension rapidly increased. The
temperature rose to Io9', the pulse became full and the ten-
sion high, and by 7 o'clock the following morning, twelve
hours after the initial chill, all the symptoms of a general per-
itonitis were present. Operation was advised early and de-
clined by the patient. Death occurred forty-eight hours after
the first chill. No autopsy could be secured. This case is
interesting chiefly because the symptoms closely approach
what might be termed a typical case.
CASE 2.-A robust young man, aged 24 years, laborer by
occupation, entered the ward at St. Jonh's Hospital in June,
I905. The fever was of moderate severity and presented no
difficulties in diagnosis, it lasted four weeks, during which time
no complications arose, the temperature ranging from IOI to
IO4°. In the latter part of the fourth week, when the morn-
ing temperatue was normal with I* of evening rise, he was
seized at 4 a.m. with a sudden, sharp colicky pain in the abdo-
men, located about the umbilical region. A chill soon follow-
ed and he vomited a thin greenish fluid. The temperature
rose from 99 to IO3°, the pulse from 80 to IOO. No dietetic
error could be elicited as a probable cause. The pain, dis-
tension and fever persisted until 4 p.m. There was some gen-
eral tenderness to pressure of the entire abdomen but no lo-
calization. No pain on micturition. The face wore an ex-
pression of pain and not one of collapse. The pulse was
steady and of good volume and did not rise above Ioo.
The tympanites was of high degree. Several high enemata
were given and the symptoms gradually subsided, so that by
the following morning he was as well as before the attack.
Convalescence was uninterrupted and he made a good recovery.
This case illustrates how a gastrointestinal disturbance may
simulate a perforation. In deciding against this I relied chiefly
upon the absence of rigidity of the abdominal muscles, the
absence of localized tenderness and the character of the pulse
and respiration ; but the tympanites, pain, nausea and vomit-
ing persisting for twelve hours were very disturbing factors,
especially when I recalled the cases reported by Keen, where
the patient's general condition remained good for twenty-four
hours after perforation had occurred.
236 The Medical Society of
CASE 3.—Female, aged 24 years, entered St. John's Hos-
pital, September 30, 1905, after an illness of one week's dura-
tion. She was an extremely neurotic woman, and the case
was an exceedingly difficult one to manage. The first three
weeks were characterized by the following symptoms :
Insomnia, cephalgia, anorexia, nausea and occasional
vomiting. Abdominal pain was frequently complained of, lo-
cated chiefly in the upper segment along the rib margins; this
I attributed to a dry, harsh, tearing cough which was very in-
tractable to treatment. During this period the sensorium was
clear. Tympanites moderate, temperature ranged from IOI to
IO4°, pulse from 120 to 140. At the beinning of the fourth
week the clinical picture underwent a change, the toxemia
deepened, delirium appeared, tympanites increased, stupor re-
placed the nervousness, the temperature remained near IO4
and IoS*. On October 20th, two days before death, the tem-
perature reached 106.4° and pulse (48. The following day
the temperature declined gradually, reaching 100.5° at 4 p.m.
Accompanying this fall in temperature was a decided improve-
ment in the subjective symptoms. The sensorium became
clear and the patient slept quietly. Also the distension was
less marked and no rigidity could be detected. During the
night she was extremely restless but did not complain of pain.
At 8 a. m. the following morning she had a severe chill and the
temperature jumped from IO2 to IOG”, the pulse reaching 150.
I could not detect any change in the condition of the abdomen
until II o'clock, three hours later, when the distension gradu-
ally increased, a general tenderness over the entire abdomen
could be elicited and rigidity of the abdominal muscles pal-
pated. The pulse became more rapid and weak and the ex-
tremities cool, vomiting now began at frequent intervals. Fin-
ally at 4 p.m. I secured consent to operate. This was done at
5 p.m. by Dr. Willard Bartlett. The perforation was found in
the cecum about two inches from the ileocecal valve. It was
pin-head in size and a small stream of fecal matter could be
seen spurting from it. A general peritonitis was evident. The
intestine was sutured to the abdominal wall and a drainage
tube placed in an incision above the pubes. Ether dropped
on an Esmarch inhaler was the anesthetic used and very little
City Hospital Alumni. 237
sufficed. The patient was placed in Fowler's position and
stimulation continued. The time consumed in operation was
ten minutes and seemed to add no shock to the patient's con-
dition, on the , contrary, the ether seemed to stimulate the
heart and respiration. The patient became progressively
weaker and died at 12:10, a.m., seven hours after operation.
In this case the profound toxemia so masked the symp-
toms that the diagnosis of perforation was not made until the
onset of a general peritonitis. In all probability the perfora-
tion occurred on the day before death when the temperature
dropped to IOO.5°, but the amelioration of the symptoms at this
time was certainly very misleading.
CASE 4.—Male, aged 25 years, mechanic, entered St.
John's Hospital, October 25, 1905, after two weeks' illness,
during which time he was attended by Dr. B. Bribach, who
made a provisional diagnosis of typhoid fever. We confirmed
the diagnosis on the clinical picture presented, although the
Widal reaction was reported negative. Slight tympanites was
present, roseola well marked; his temperature ran a course
ranging from 99 to IOI’ and everything looked favorable until
October 30th, five days after entering the Hospital. He now
began to complain of pains in the left lumbar region radiating
down to the left testicle, they were paroxysmal in character and
quite severe. Renal calculus was suspected and the urine was
closely watched. There was voluntary contraction of the
abdominal muscles but no tenderness could be found, and no
genuine rigidity was present. The pain became so great that
morphia was administered hypodermatically. The pain sub-
sided until 4 a.m. the following morning when it returned with
increased intensity and the temperature dropped to 98.5°; at
8 a.m. the pain was still severe, the patient had a violent chill,
and the temperature rose to IO3°; the pulse which had been be-
low IOO rose to I36, respiration 44. At 12 o'clock the temper-
ature had reached IO5°, pulse 160, respiration 56. Patient cya-
nosed, extremities cool, no distension of abdomen, no rigidity,
but the patient persistently referred to the abdomen as the site
of pain. After prolonged and careful search I was now enabled
to locate a small area of consolidation in the left lung
near the heart, this rapidly spread until by evening the entire
238 The Medical Society of
left lobe was involved. The pneumonia proceeded as usual
until the 7th instant when the rectal temperature dropped to
99.8° On the evening of the same day pains appeared on the
right side and a lobar pneumonia rapidly developed, the tem-
perature rising to IO4°. Expectoration which had been scanty,
now became profuse. Examination of the sputum showed
the presenced of tubercle bacilli, also Friedlander's bacillus.
In this case there had been no symptoms to call special
attention to the chest, not even the ordinary bronchitis of ty-
phoid. The patient is alive but is losing ground daily, and I
will probably make a more complete report later on. I have
mentioned it here, because before the pneumonia was discov-
ered there were good reasons for suspecting a perforation,
especially when I recalled the warning of Osler: “That perfo-
ration and peritonitis may occur when the abdomen is flat or
even scaphoid.” Also, I remembered one of a series of cases
recently reported by Dr. Geo. L. Hays in which no distension,
tenderness, or change in temperature and pulse were present.
He made the diagnosis solely on the symptoms of chill, pain,
and slight rigidity; the operation disclosed the perforation and
recovery ensued.
Dr. FRANCIS REDER presented a specimen of
Intestinal Perforation Due to Trauma,
and said: The paper of the essayist recalled to me this specimen.
This man was carried a block beyond his destination one evening in
returning home, and in trying to gain time in hurrying back he ran into
a post used as a support to a telegraph pole. He reached home about
7:30, p.m. suffering great pain. I saw him about 9 p.m. In making
the examination I found an old inguinal hernia on the right side and a
new one on the left, also inguinal, about the size of an orange. He
complained of much pain about two inches below the umbilicus, radi-
ating over to the left inguinal region. Pulse and temperature were
normal, facies indicated shock, yet, the more pronounced symptoms of
shock were masked in some way. The patient was perfectly conscious.
I reduced the hernia on the left with some little difficulty. The right
I did not succeed in reducing. The patient informed me that that
City Hospital Alumni. 239
rupture was always out. I was not satisfied with his condition and
suggested that he allow me to take him to a hospital and open his ab-
domen as I suspicioned some damage to the bowel. Consent was not
given. I remained with the patient about two hours. Gave no opi-
ates. There was extreme tenderness and marked rigidity of the abdo-
men, no vomiting. I suggested that another physician be called in to
aid me, but consent was not given. In the morning I found the pulse
running up to 120, temperature subnormal, and an ashy color to the
countenance. Consent to operation was then readily given. I oper
ated and found this perforation (showing specimen . The man died
on the fifth day from septic peritonitis. What I censure myself for is
that I was not imperative in demanding an operation at the hour, or
the second hour, after I saw him. If the operation had been done
then, the man would have had an excellent chance for recovery. He
was 63 years old and in the best of health. The perforation was
about 60 inches from the ileocecal junction, on the left side. There
was no external evidence of any injury but in cutting through the skin
and exposing the underlying tissues the extravasation of blood over a
circumscribed area (about the size of a quarter) was very marked.
DISCUSSION.
Dr. TAUSSIG said that there were unquestionably very few matters
coming up in internal medicine more difficult to judge than typhoid
perforation. It was generally recognized that none of the cardinal
symptoms of perforation but might be missing and for that reason the
diagnosis was sometimes extremely difficult. It was rendered more
difficult, too, by the fact that it was possible to have a perforation im-
peratively demanding operation, in the absence of any symptoms that
would enable one to conclusively diagnose perforation, and again there
might be an apparently typical symptom complex and no perforation.
Dr. Taussig had seen a case similar to the one reported by Dr. Soper.
The patient was a young woman, toward the end of the third week,
with high pulse and a good deal of meteorism. She was attacked one
evening by excruciating abdominal pain, the temperature dropped, the
pulse was fast and thready, the abdomen rigid and there was much
meteorism; leukocyte count, 9,000. It seemed that here was a case
*:2
240 The Medical Society of
of perforation. Against my better judgment, apparently, I allowed
myself to be persuaded against operation. The next morning the pain
had ceased entirely, the abdomen was less rigid, the pulse as it had
been before the attack, and there was nothing to lead to the belief that
perforation was present. Had an operation been done, doubtless no
perforation would have been found. During convalescence this pa-
tient was attacked by a post typhoid dementia, so that possibly the
symptoms might have had a neurotic basis. Whenever a sudden
change for the worse occurred, it should be remembered that there
was a possibility of perforation, but on the other hand there might be
sufficient symptoms to apparently justify operation without there being
a perforation.
Dr. BARTLETT agreed that the matter of diagnosis in the perfora
tions occurring in the course of a typhoid fever were of the utmost
difficulty. So distinguished an authority as Dr. Osler stated in one of
his last monographs that the only sure evidence was finding the hole.
The men at Johns Hopkins who did most of the advance work in this
line operated on three of their cases on a false diagnosis. All three
of these cases, Dr. Bartlett thought, were operated on by Cushing.
They were not typhoid perforation, but in neither of the cases was the
result of the operation fatal. In the case referred by Dr. Soper, in
which Dr. Bartlett had operated, after the operation he had compli-
mented Dr. Soper on his diagnosis, for he had not felt very sure of a
perforation when cutting into that abdomen. Within the the last year
or two he had operated on three of these cases. One he had already
reported. There was the sudden, typical pain, a drop in the tempera-
ture from a 104 to 96.5°, increase in the pulse from Io4 to 130 and
evidence of intense shock. The patient commenced to vomit and it
was a typical case. The abdomen was opened twenty hours after the
onset of abdominal symptoms and the perforation found in the ileum
a few inches from the ileocecal valve. This man was now perfectly
well. There was an extensive low peritonitis. The second case had
occurred about a year and half ago. A woman in the fourth week of
typhoid suddenly began to present pronounced abdominal symptoms.
Dr. Bartlett did not see her till three days later. She had commenced
to vomit, there was the characteristic abdominal pain, the abdomen
A
City Hospital Alumni. 241
tympanitic. When he saw her the condition had reached such a
stage that he was unable to make out anything of the abdominal con-
dition. The patient was simply gurgling out one mouthful after an:
other, without any apparent effort, the usual characteristic of
dynamic ileus. For want of a better diagnosis in the face of such
conditions the abdomen was opened and no perforation was found, but
a peritonitis as far as one could see, with lots of fibrin. There was
an immensely distended small bowel due to volvulus of the ileum.
The patent improved immediately as soon as the gut was untwisted,
but died later of another complication. The third case was the one
just reported by Dr. Soper. It was certainly to the advantage of this
subject in St. Louis that Dr. Soper's case had been reported, in con-
sideration of the little symptoms there had been on which to make the
diagnosis and on the strength of which Dr. Soper had advised opera-
tion, perforation being found at the operation. The cases could not
be cured without operation. One point on technic; if the patient was
bad, without resistance to stand a serious operation, the intestine
should not be resected, nor should there be even an attempt to sew up
the wound in the intestine, it should be merely brought to the surface
and anchored there. Such patients would not stand more than ten or
twelve minutes surgical work. In Dr. Keen's second monograph he
said that he had considerable praise for the man who did these opera-
tions in thirty minutes, and that of 157 cases he had not known of one
that survived an operation of over an hour. These patients must be
given the chance of a very short operation, eleven minutes or less
was Dr. Bartlett’s urgen, advice.
Dr. SMITH, felt that the subject of diagnosis in these cases was
of paramount importance. This would be appreciated when one con-
sidered how early death ensured after this accident, and, therefore,
how soon surgical interference must be had in order to have the pa-
tient in a state of some resistance. Of a series of tabulated cases,
33.3 per cent died on the first day, 29 per cent on the second and 83 3
during the first week. Hence, if anything was to be accomplished by
this operation, not only must the diagnosis be made as early as possible
but the interference must be prompt. In the diagnosis, a number of
conditions would have to be excluded. Early in this work, and while
24.3 The Medical Society of
Dr. Smith was in the City Hospital, he had been greatly impressed by
one case that he had seen there. In those days the internes were
afraid to admit that they had so much as a pain in the stomach for
fear of an abdominal operation. A patient came in suffering with
severe abdominal pain and was sent to the surgical ward, and ordered
prepared for operation. Dr. Smith had the task of cleaning him up
and while doing so the patient began to cough. Upon listening at the
chest there was found a very distinct crepitation. The surgeon was
notified and after considerable discussion it was decided to wait awhile.
The patient developed a typical pneumonia and they saw no more of
the abdominal symptoms. Other conditions might produce symptoms
simulating typhoid perforation, for instance, thrombosis of the iliac
veins. Again, one must be on guard against appendicitis, which
might occur in typhoid. Recently a case at the Mullanphy Hospital
had illustrated this point very well. A patient in the third week of ty-
phoid developed abdominal symptoms. It was taken at that time to be a
disturbance about the the appendix. The patient later developed
marked abdominal symptoms which pointed to perforation. During this
second exacerbation of the trouble while he had marked and ex-
quisite tenderness and rigidity of the abdomen, he did not have the
classical drop in temperature and rise in the pulse. There was no
change in either. But after the abdomen was opened up several per-
forations were found and a focus was found in the ileum, near the
ileocecal junction, in which there were old adhesions, and which prob-
ably accounted for the first attack. This focus was walled off. As
Dr. Taussig had said, the development of a leukocytosis might aid,
somewhat in the diagnosis. Some recent observation had been made
by Briggs in two cases in connection with the blood pressure. In one
case where the patient had a rise in the blood pressure, four hours later
there developed violent symptoms of perforation and five hours later
the perforation was found. The inflammatory process was eight to
ten hours old. In the second case case, there were abdominal symp-
toms and the blood pressure was negative. At operation no perfora-
tion or peritonitis was found found. This might possibly prove to be
another aid to the diagnosis. The subject was a most important one
City Hospital Alumni. 243
and the Society was certainly under obligations to Dr. Soper for calling
the matter to their attention.
Dr. Bliss had seen a case similar to that of Dr. Taussig. This
patient was his brother-in law 23 years of age. In the fourth week of
the typhoid he was seized with a sudden pain and a chill. The tem-
perature dropped to 97.5°, and pulse rose at the same time He had
a great deal of pain and the facies indicated abdominal trouble. Dr.
Bliss had had no doubt at all that perforation had taken place and
neither had Dr. Nifong. The patient was kept perfectly quiet, the
symptoms subsided within the forty-eight hours, the patient recovered
and remained well, though he had all the classical symptoms of a per-
foration.
Dr. SHARPE hoped that Dr. Reder would state, in closing, what
he thought was the age of that perforation. In the specimen it cer-
tainly looked older than a few hours. Possibly it might have existed a
day or two before the operation.
Dr. Soper’s paper was most interesting. It was true that all the
classical sympsoms of perforation might be absent, yet, the perforation
be present, or on the other hand with all classical symptoms present
the perforation might not exist. This being admitted, it was not well
to severely blame the general practitioner for his failure to diagnose
the condition promptly. But when the physician did believe that a
perforation was present and failed to promptly call a surgeon in con-
sultation, he was a dangerous man in the community ; and the surgeon
who, when brought into contact with a perforative case, failed to
operate because he was afraid to, was an even more dangerous man.
If a man had not the courage of his convictions and a reasonable con-
fidence in his ability to do surgical work, he should abandon surgery.
It is now generally recognized that these perforative cases have,
without operation, an almost invariably fatal termination. It must also
be recognized that all operations to be effective must be made early in
the condition, and be of the most rapid character.
Dr. WILSON had seen a case some two weeks previously at the
Female Hospital. Patient gave a family history of phthisis, father
having died of lung trouble. Patient lived in poor hygienic surround-
ings and worked in a steam laundry. On entrance to the Hospital,
244 The Medical Society of
her temperature was 96.4° and pulse roo. She gave symptoms only
of general weakness and rheumatism in right knee; evidently there
was some inflammation, the knee being tender and 3/4 inch greater in
circumference than that of left. Patient was put on tonic treatment
and allowed to be up until the morning of the 5th day, when she began
to complain of pains over her lower abdomen. She was kept in bed
and on examination that evening, found abdomen tense and tender to
pressure; no vomiting or nausea but temperature IoI*. The only
signs of peritonitis being rigidity of abdominal wall, temperature and
tenderness. Consultation was held with Dr. Elbrecht and corps; peri-
tonitis being diagnosed, it was decided to operate early the following
morning. Patient was then prepared for operation and given the
usual 2-ounce magnesium sulphate, but she died about 4 a.m. that
morning. The question arose whether this was an ambulatory typhoid
or a tubercular perforation.
At autopsy the peritoneum and intestines were congested and
covered with plastic membrane. There were many ulcers along intes-
tines and several perforations in ileum. Microscopical examination of
the ulcers showed tubercle bacilli. The magnesium sulphate may have
increased peristalsis so as to empty the intestinal contents into perito-
neal cavity and thus hastened death.
Dr. DEUTSCH wished to voice the sentiment of Dr. Bartlett in re-
gard to the necessity for rapid work in these cases, and he added that
these operations should not be attempted under general anesthesia
when possible to avoid it. Local anesthesia was preferable. Nine
out of ten deaths in this class of cases were due to the anesthesia.
Neither should these operations be used as technical displays. There
should be enough work done to accomplish the purpose of saving life.
The internist was responsible for the death of these patients when he
failed to recommend operation in the presence of symptoms of perfo-
ration. The prognosis without operation was very poor, it was the in-
ternist’s duty, therefore, to advise operation in such cases.
Dr. RAvold had never seen a typhoid perforation, but it was a
most interesting question. Suppose the internist had come to the con-
clusion that a patient had a perforation, what should he do, have the
surgeon operate, or wait 2 The literature and statistics replied that
City Hospital Alumni. 245
the operation be done quickly. But suppose that the perforation was
not found, what harm had been done to that patient? Were there any
statistics on this point. Another thing, what were the cardinal symp-
toms of this perforation ?
The PRESIDENT thought Dr. Bartlett had answered one of Dr.
Ravold's questions. The three cases operated upon at the Johns
Hopkins Hospital had recovered, though no perforation had been
found.
Dr. REDER said that in view of the prevalence of typhoid and
the frequency with which perforation occurred (one in every four cases),
it was the duty of the physician to follow up these cases until the pa-
tients were well. One of his own patients had had a perforation when
he was practically well, (in the sixth week). He had seen the man
about half an hour after the perforation had occurred. Operation was
not permitted and the man died forty hours later. The autopsy showed
perforation about five inches from the ileocecal junction. In another
case, presumbly perforation, Dr. Reder failed to find the perforation.
Conditions did not permit of more than the exploring with the finger
of the iliac fossae. The adhesions that had formed to the abdominal
parietes were so extensive that it would have been dangerous to make
further search. The abdominal cavity was dry, the intestines were all
agglutinated together and distended, they appeared transparent. In
this case the operative intervention had no effect upon the patient’s
condition, i.e., it did not hasten death ; the condition was about the
same after the operation as it was before. In another case, that of a
girl, aged 14 years, he had found the perforation after much difficulty.
After brushing away a large piece of lymph he found three cribriform
perforations. He simply attached the perforated intestine to the abdo-
minal wall and allowed a fistula to form. This was five months ago. The
girl is well but still had the fistula. It was sometimes impossible to
make a differential diagnosis between typhoid fever and appendicitis.
As to the surgical intervention in these cases of typhoid perforation it
should be borne in mind that a patient with a perforation still has to
fight the battle against the fever for some weeks to come. The least
amount of surgery in the shortest time possible will give such a pa-
tient the best chance for recovery.
246 The Medical Society of
In closing, Dr. Reder, replying to Dr. Sharpe stated that the age
of the perforation could not be in doubt. It had occurred about 7:30
o'clock, he had seen the man about 9 o'clock and had operated
the next day at 8 o'clock. The operation disclosed a septic peritonitis,
the abdominal cavity was full of a floculent, yellow matter with a fecal
odor. The patient had been a strong wine drinker and the stimula-
tion caused by this had probably been sufficient to mask the symp-
toms of shock.
Dr. SOPER, in closing, said that it had been clearly established by
writers on this subject that the cardinal symptoms were sudden pain,
localized tenderness and rigidity of the muscles, Keen and Richard
Hart, of Philadelphia, had emphasized particularly that the rigidity
must be involuntary. Hart stated that with this set of symptoms—
onset of sudden pain and localized tenderness and rigidity of the ab-
dominal muscles—in a typhoid patient, operation was indicated. Dr.
Soper believed this was the position taken by most of the surgeons
who had done this kind of work. In looking over a large number of
case reports the speaker had been impressed by the frequency with
which chill occurred. It was certainly a danger signal and should lead
the physician to watch for something to develop. Replying to a ques-
tion by Dr. Ravold, Dr. Soper stated the experiments by br. Briggs
were very recent and he believed that as yet that method had not been
carried out by others.
The Cause and Prevention of Post-
Operative Cystitis.
By F. J. TAUSSIG, M.D.,
ST. LOUIS, MO.
N THE prevention of the various diseases that on every
side beset humanity and the cure of these manifold afflic-
tions when they have already attacked their victims have
heretofore occupied so much of our time and study, how much
more reason is there to give more attention to those condi-
tions directly resulting from our surgical procedures—condi-
tions for which we ourselves, therefore, are in part responsible,
City Hospital Alumni. 247
that at times prove so trublesome to our patients and may
even result in their death. Among the most frequent of these
conditions is post-operative cystitis. Every gynecologic sur-
geon has had instances where his best results have been marred
by this complication and his patients at times left in worse
condition than before the operation. It was while working
in the Kaiserin Elizabeth Hospital, in Vienna, in 1902, at a
time when Wertheim was just beginning to obtain better re-
sults with his radical operation for uterine cancer, that the fre-
quency with which post-operative cystitis followed this opera-
tion in particular, induced me to give the subject more study.
To my amazement I found that the literature on the subject
was practically a blank. The etiology of cystitis in general
had been thoroughly investigated by such men as Melchior,
Rovsing, Guyon and others, but that form appearing after op-
eration, its cause, prevention and treatment was only mentioned
casually in connection with other matters.
Investigations carried out at this Hospital with the kind
permission of Professor Wertheim showed that out of 282
gynecological operations, cases in which the bladder was more
or less denuded, 60, or 21 per cent had urine retention, and
hence had to be catheterized longer than three days, and 43,
or 15 per cent had to be catheterized longer than six days.
Of these 43, all but one or two developed cystitis of greater or
less severity.
Frequency.—If I stated that in 43 of the 282 cases on my
list a cystitis developed, it must be remembered that in 35 out
of these 43 patients there had been done a radical panhyster-
ectomy for cancer with extirpation of as much of the broad
ligament as was possible. In two-thirds of the patients sub-
jected to this procedure catheterization had to be resorted to
for over a week. It would not be fair, therefore, to take 15
per cent as an average of the frequency with which post-oper-
ative cystitis occurs after gynecological operations. Yet, I
find that Frankenstein who included only vaginal operations
in his list records a post-operative cystitis in 9.3 per cent of
his cases. The frequency of these bladder complications
seemed to be directly dependent on the extent of the bladder
denudation. Thus I ſound it to be only 2 per cent in vaginal
248 The Medical Society of
hysterectomy, I4 per cent in the extensive operations for pro-
lapsed uterus and 64 per cent in the Wertheim panhysterec-
tomy for cancer. Frankenstein in similar wise recorded o per
cent for simple Alexander's operation, 5.9 per cent for Alex-
ander's operation combined with vaginal plastic and 9.5 per
cent in more extensive vaginal operations.
In the past few years I have made inquiries to see wheth-
er the frequency of bladder trouble complicating the radical
cancer operations was found in equal proportion by other men.
From Professor Kroenig I received a letter stating that he had
had 6 cases of cystitis out of 28 such operations. From Doe-
derlein's clinic Baisch reports a majority of the patients oper-
ated upon for Čancer suffering from urine retention but a con-
siderable diminution in the percentage of cystitis owing to
prophylactic bladder irrigation. Sampson, then working un-
der Kelly, of Baltimore, performed even more extensive oper-
ations and his results prove how important a part the urinary
tract plays in this operation. A cytitis occurring in I2 out of
his I6 cases and twice an ascending renal infection resulted in
the death of the patient. Finally, Brettauer, of New York,
was kind enough to send me a complete urinary report of 3
Werthein operations for cancer performed by him; in 2 of the
3 patients urine retention and cystitis resulted.
Causes.—Coming now to a consideration of the general
causes that produce post-operative cystitis in women we have
in the other forms of this trouble two main factors—trauma-
tism and infection ; the one is incapable of producing a cysti-
tis without the other. A third factor, urine retention, is, as we
have seen in the clinical statistics, of the greatest etiologic im-
portance, but its influence is almost wholly an indirect one, i.e.,
increasing the danger of infection through the necessity of
frequent catheterization. Kolischer has apparently misunder-
stood my point of view in this regard. Urine retention is not
the 1mmediate cause of cystitis, unless the bladder be allowed
to dilate to such an extent as to cause trauma. No one would,
of course, allow such a condition to arise. But the greatest
danger of catheter infection resulting from such urine reten-
tion can not be gainsaid.
We must, therefore, in a consideration of the etiology of
City Hospital Alumni. 249
post-operative cystitis include those circumstances that tend
to produce an inability to empty the bladder spontaneously.
Other factors being equal, an abdominal operation will more
often be attended with inability to void urine than a vaginal
one for the reason that the former, to a certain extent, inter-
feres with the proper action of the abdominal muscles. These
muscles are of almost as great assistance in micturition as in
defecation. In my series the frequency of urine retention af-
ter simple abdominal hysterectomy was 3.4 per cent, whereas
after vaginal hysterectomy it was 2 per cent.
Furthermore, it is claimed that if the anatomic relations
of the bladder to the other organs of the pelvis be greatly al-
tered, we may more frequently expect a disturbance of its
functions. It is not a rare thing that after Alexander's oper-
ation, when the bladder itself is not touched, urine retention
occurs. Gutbrod seeks to explain this as due to the antevert-
ed and elevated position of the uterus in this operation. The
uterus thus not merely presses against the bladder but through
its elevated position the urethra is bent anteriorly and the
normal expulsion of urine interfered with. I can not say that
this explanation is wholly justified by the actual anatomic
condition. Just what the true cause of urine retention in
these cases may be, still seems an open question.
Injury to and interference with the blood vessels and
nerve supply of the bladder is doubtless more often to blame
for inability to urinate spontaneously after operation than any
other cause. It is but rational to suppose that if a greater
area of the bladder be denuded and the afferent vessels to
this region be ligated, the muscular action of the detrusor ves-
icae in this region would be almost annihilated. If the vessels
ligated supply a large portion of the organ or if the surface
denuded with its attendant multiple injury to the smaller su-
perficial branches be extensive, the portion remaining will of-
ten be unable to expel the bladder contents. Thus can be ex-
plained the occurrence of urine retention after operations for
vaginal and uterine prolapse If we consider the excellent
anastomosis of bladder vessels and the great rarity of blad-
der necrosis after even extensive denudation we must seek
some other factor to explain the extraordinary frequency of
250 The Medical Society of
urine retention after the radical abdominal operations for can-
cer. Both Sampson and Baisch concur with me in laying the
emphasis here on the extirpation of the ganglionic system ly-
ing in the broad ligaments. By shutting off a great part of
the nerve supply of the bladder, as we do in this operation, it
is not surprising that we should find a long-enduring paralysis
of the detrusor vesicae with consequent inability to void urine.
Traumatism.—From what has been said about the blood
supply it is evident that in many operations, particularly if the
bladder be handled roughly, the organ will be subjected to
much contusion. Ecchymotic areas are found with compara-
tive frequency and a superficial desºluamation of epithelium
is not at all rare. Stoeckel in his excellent book, “Cystosko-
pie des Gynaekologen” devotes a chapter to the cystoscopic
appearance of the bladder after operation. After hysterecto-
my he finds quite frequently submucous hemorrhage in the
bladder fundus. These are doubtless associated with hemor-
rhages in the bladder wall and may be due either to trauma in
separating the bladder from surrounding structures or to ven-
ous stasis resulting from the ligation of the bladder vessels.
That the catheter is not to be blamed for the hemorrhages he
shows conclusively. One case in which the trauma during op-
eration was practically nil and urine was passed spontaneously,
showed cystoscopically extensive ecchymosis. These Stoec-
kel ascribes to venous stasis resulting from interference with
blood supply. No cystitis developed in this case.
Naturally the danger of cystitis is even greater where the
bladder has been either accidentally or purposely incised in
the operation. Ureteral implantation into the bladder is nec-
essarily attended with the exposure of more or less surface in
the bladder.
Infection.—Even the most extensive injuries, however, are
insufficient to produce a cystitis, if we can exclude the en-
trance into the bladder of pus-producing micro-organisms. In
illustration of this I should like to cite a series of animal ex-
periments recently made by me on the bladders of rabbits.
In 9 cases the superior vesical and the vesical branch of the
uterine were ligated and cut on each side and wherever
the rabbit had attained puberty the tubes, uterus and upper
City Hospital Alumni. 251
vagina were extirpated as in the cancer operations. As the
work was done without assistance the asepsis occasionally suf-
fered, and in 2 cases a stitch abscess developod. All the rab-
bits survived the operation and were killed at varying times,
varying from five to twenty days.
In the rabbit the superior vesical artery can be distinctly
seen coursing upward to the vertex of the bladder and its
ligation is a comparatively simple matter. I found that after
tying it could be cut without danger of bleeding from the dis-
tal end by anastomotic vessels.
Following is an abstract of the cases:
CASE I.—Female, adult. Operation November 20, 1903. Mor-
phin o.o.3 gram, followed in three quarters of an hour by chloral o.3
gram. Vesical arteries tied, uterus and tubes extirpated. Rabbit
roused from anesthesia before conclusion of operation. Infection
probable.
November 25th, rabbit recovered from operation. Killed by cer-
vical fracture (Nackenschlag). Post-mortem, abdomen showed local-
ized suppurative peritonitis in pelvis, a sac containing yellowish pus
near the left ureter. Intestines adherent to fundus of bladder. Blad-
der one-third the size previous to operation. On opening the bladder
a suppurctive-cystitis localized to the vertex was discovered.
CASE 2.-Female, adult. Operation November 3, 1903. Tied
both superior vesical arteries, removed uterus and tubes. November
21st, rabbit killed. Bladder rather high ; adhesion of large gut to left
side of bladder. Slight injection of vessels of trigone. Mo cystitis.
CASE 3.—Female, young. Operation November 8, 1903. Tied
off and cut all vesical arteries and veins. Accidentally perforated the
bladder fundus with needle point; some urine escaped through this
opening. November 13th, rabbit killed. Bladder adherent to intes-
tines. Vertex of bladder contained several dark red thrombotic areas.
Bladder contained 2 cc. of clear urine. Mo cystitis.
CASE 4.—Female, young. Operation Nevember Io, 1903. Li-
gated and cut superior vesical and uterovesical arteries. November
21st, rabbit killed. Slight adhesion to abdominal wall; stitch abscess
near left vesical artery. Urine cloudy; fundus shows profuse purulent
cystitis. Base of bladder free; bladder greatly contracted.
CASE 5.— Female, adult. Operation Novermber 8, 1903. Tied
vesical arteries as heretofore and removed uterus and tubes together
with 3 1/2 cm. of vagina. November 13th, rabbit killed. Fundus
252 * The Medical Society of
adherent to abdominal incision; bladder contained only 2/3 cc. clear
urine, Fundus shows thrombosis; base normal. No cystitis.
CASE 6.—Female, adult. Operation November 1, 1903. Tied
all four vesical blood vessels. November 14th, rabbit killed. Intes-
tines adherent to fundus, vessels going from mesentery to fundus, no
thrombi visible. Bladder contracted and empty. No cystitis.
CASE 7-Female, adult. Operation October 3, 1903. Tied
the uterovesical and superior vesical arteries on both sides. Novem-
ber 1st the abdomen was opened, bladder found to be apparently
normal. Compensatory circulation apparently established through the
peritoneal fold. Tubes, uterus and two-thirds of the vagina removed,
all blood vessels tied near their point of origin. November 14th, rab-
bit killed. Bladder very small, no adhesions. Fundus showed regen-
erated thrombotic area. No cystitis.
CASE 8.— Female, adult. Operation October 17, 1903. Two su-
perior vesical and one uterovesical branch tied off. October 27th,
rabbit killed. Adhesion of fundus to abdominal incision, urine clear,
no signs of thrombosis. Mo cystitis.
CASE 9.–Male, adult. Operation November 20, 1903. Superior
and middle vesical arteries tied. November 25th, rabbit killed. Ad- .
hesive peritonitis, no pus to be seen, bladder walled in by intestinal
adhesions and contained large hematoma in left wall. Considerable
edema. Mo cystitis.
Microscopic sections were made of various portions of the
bladder 1n all 9 cases. In the 2 that developed a cystitis a
well-marked pyogenic membrane was found upon the hemato-
matous area. The infection was, however, localized to this
area. The remainder of the bladder mucosa was intact and
showed no leukocytic infiltration. The cases that developed
no cystitis and where the animal was killed within five days
after ligating the vessel, were uniformly characterized by the
presence of larger or smaller hemorrhages into the muscular
and mucous coat. Over such areas the epithelium was at
times absent, at times it was partly cast off or edematous.
Here, too, the affected portion was sharply differentiated from
that in which no disturbance of circulation had occurred. In
those rabbits that were killed, two to three weeks after opera-
tion the regeneration was practically complete, only here and
there a small sanguino-fibrinous patch marked the site of a
former hematoma. The epithelium was intact. As far as
City Hospital Alumni. 253
they go, therefore, the experiments show the close correlation-
ship of trauma and infection in the etiology of cystitis. In
spite of the severest trauma, no germs being present, a cystitis
failed to develop, and vice versa, where germs did gain an en-
trance, the cystitis was localized to that area in which the
trauma occurred. *
The manner in which bacteria may gain entrance into the
bladder is various. To begin with, it must be remembered—
Kolischer lays great emphasis on this point, that many patients
have a cystitis before operation. It may have given rise to a
few if any symptoms and so been overlooked. So uncertain,
in fact, is the symptomatology of this trouble that Sampson
insists that a cystoscopic examination should be made and
bacteria found in the urine before the diagnosis can be determ-
ined. A previous cystitis may in part account for the com-
parative frequency of bladder trouble after prolapse opera-
tions. However, out of the sum total of post-operative cys-
titis, this factor of previous infection is of secondary impor-
tance.
Next we come to the cases of spontaneous entrance of
germs from the urethra, the rectum and the vaginal wound
either directly or along the lymph channels. No direct proof
of such an occurence has as yet been given though much ev-
idence points to some form of spontaneous infection. We
know of cases of free cystitis who, after operation and with-
out catheterization, developed a cystitis. I can not here go
into a consideration of the animal experiments on this subject
more than to say that apparently, if there be trauma to the
bladder and also some break in the continuity of the rectal
mucosa colon bacilli may wander through the intervening cel-
lular tissue and cause an infection. Baisch claims that these
cases of spontaneous infection are due rather to an ascent of
bacteria from the urethra. The careful bacteriological exam-
inations of the female urethra carried on by Pilz under his di-
rection certainly showed in a large percentage of cases the
presence of pus-producing micro-organisms. A certain anal-
ogy would appear between this mode of infection of the blad-
der and that of spontaneous ascent of germs from the vulva
into the uterus post-partnm. Kolischer argues that the germs
254 . * The Medical Society of
found in the urethra a non-virulent type and hence, would riot
produce infection. Natvig has, however, shown that while the
virulence of germs on the vulva may be very mild, yet those
same germs introduced into the uterus may become extremely
dangerous and give rise to the most severe infection. Viru-
lence seems to depend primarily on the point of implantation.
Thus, germs that are innocuous in the urethra may start up an
intense cystitis if either by catheterization or spontaneously
they gaine entrance to a susceptible bladder. Kolischer and
Stoeckel both believe that in many cases the bacteria that
give rise to the cystitis pass through the bladder wall from the
wound cavities. Certainly, as Sampson points out, where the
ureter has been implanted into the bladder, germs may read-
ily find a point of entry from the vaginal wound along the
ureteral sheath. If this, however, were the usual mode of in-
fection we should expect it to occur more frequently wherever
there was trauma.
We find, however, that in the vaginal panhysterectomies
performed by Wertheim, numbering IO2 cases, a large per-
centage of which were associated with suppurative conditions
requiring drainage, only 2 or 3 per cent developed a cystitis.
While such spontaneous infection may, therefore, be of more
frequent occurrence than has been heretofore admitted, I think
reports thus far justify the belief that in the vast majority of
cases the catheter is to be held responsible for the bladder
infection. e
Kolischer speaks of uncleanliness in catheterization as if
this were the usual way in which catheter infection was
brought about. The modern glass catheter can be so easily
sterilized and the female urethra so readily exposed that with
moderate care the danger of infection from germs in the cath-
eter or bacteria lodged about the vestibule is very slight.
It is different, however, with germs residing in the ure-
thra. Hoping in some way to reduce the frequency of blad-
der infection in his cancer cases, Wertheim for a time had
every catheterization done by the house surgeon under asep-
tic precautions after repeatedly mopping the meatus urinarius
with a I/IOOO bichlorid solution. His results remained the
same as heretofore.
City Hospital Alumni. 255
Baisch examined the urethral secretions of 30 women en-
tering his clinic. In every case staphylococci were found, and
in 20 of the cases the colon bacillus likewise. Since the colon
bacillus is found with such great frequency in post-operative
cystitis, he decided to supplement his examinations by exam-
ining bacteriologically the urethral secretions of 45 women
free of cystitis who were confined to bed for some operative
condition. In these 45 cases he invariably found the colon
bacillus, appearing after the third or fourth day. Similar tests
with similar results were made on women who were not oper-
ated on but simply confined to bed. Furthermore, Baisch
showed that urination itself cleanses the urethra of many
germs. Patients who were told to empty their bladder only
twice a day showed pathogenic germs in their urethra that
heretofore had not been present.
The question arises, can the urethra be made sterile by
irrigation previous to catheterization? While bacteriologic
tests are, to my knowledge, lacking on this point, clinical ex-
perience at Wertheim's Hospital showed that irrigation of the
urethra with one pint of boric acid, before each use of the
catheter did not suffice to prevent infection. Considering the
anatomy of this canal, it would certainly seem impossible to
free it of becteria. In this connection I quote Piltz's conclu-
sions:
“Since a disinfection of the urethra is impossible, numer-
ous pathogenic micro-organisms are carried from the urethra
at each catheterization, and here, under certain circumstances,
(urine retention and trauma of the bladder wall), they may
give rise to a cystitis. We must, therefore, ascribe to patho-
genic germs vegetating in the female urethra an important, if
not the main, influence in the etiology of catheter-cystitis.”
Finally, one point not sufficiently emphasized in the etiol-
ogy is the influence of the frequency of catheterization upon
infection. Why is it that one or even half a dozen catheteri-
zations usually are harmless, whereas if the number reach fif-
teen or twenty, infection is the rule 2 It is this fact more than
any other apparently that leads Kolischer to the belief that
the catheter is not usually the infecting agency. I grant that
we are here touching upon matters that are still much in the
256 The Medical Society of
dark, but apparently there seems to be a point beyond which
the human organism can no longer resist the invasion of path-
ogenic germs. It is a well-known fact that the peritone-
um, for instance, can take care of a considerable number of .
pathogenic bacteria. The same capacity resides with the
bladder, but with each attack the viscus is left in a condition
less resistent to infection. Apparently it is “the straw that
breaks the camel's back.” Between the fifth and seventh day,
as a rule, the limit of endurance is passed and we have a sud-
den and tremendous increase in the number of bacteria, al-
most invariably confined to one sort, and associated with ob-
jective and subjective signs of bladder inflammation.
To repeat briefly the main points in the etiology of this
condition :
I. Post-operative cystitis is met with not at all infrequent-
ly after gynecological operations, particularly after the radical
abdominal operations for cancer.—60 per cent.
2. The frequency and severity of the affection is directly
proportionate to the amount of bladder denudation.
3. The two main factors in the etiology are trauma and
infection, to these a third, urine retention, may possibly be
added.
4. Urine retention is only to a slight degree a direct fac-
tor in the etiology by giving a chance for bacteria to multiply
in the stagnating urine. For its relief, however, it requires the
introduction of a catheter and this is undoubtedly the most
frequent cause of post-operative cystitis, so that indirectly it
is of the utmost importance in a consideration of the etiology.
5. The urine retention may be due to a bend in the ure-
thra caused by malposition (after Alexander's operation) or to
paralysis of the detrusor vesicae due to interference of its
blood supply or to excision of a portion of its nerve supply.
6. Trauma in these cases is usually due to ligation or
bruising of the bladder vessels. To these is occasionally as-
sociated an incision into the bladder either accidentally or, as
in carcinoma or ureteral implantation, intentionaly.
7. The bacteria producing the infection may be originally
in the bladder (previous chronic cystitis). They may have
migrated from the rectum, the vaginal wound, along an im-
City Hospital Alumni. 257
planted ureter, or by ascention from the urethra. Such modes
of entry are doubtless the exception. The rule is that a post-
operative cystitis is primarily a catheter cystitis.
8. Investigations show that every urethra in women con-
fined to bed contains not merely staphylococci but colon ba-
cilli as well. The disinfection of the urethra is an impossibil-
ity. Hence, with each catheterization, germs are carried into
the bladder.
9. A few catheterizations rarely produce a cystitis. When,
however, the number is increased as in retention prolonged to
five or six days the organ seems no longer able to resist the
invasion and a rapid multiplication of bacteria with beginning
inflammation results.
Prevention.—The prevention of post-operative cystitis is
in a great measure dependent on a proper appreciation of its
causes. Considering the latter in the same sequence as be-
fore, our first consideration will be : What can be done to
avoid post operative urine retention ?
Urine Retention.—Numerous have been the suggestions
offered thus far but all have their drawbacks. No measure is
uniformly successful. Werth, of Kiel, after his laparotomies
fills the bladder with sterile salt solution at body temperature
before closing the peritoneal cavity. As the capacity of the
bladder varies greatly it is necessary to keep it under direct
surveillance while filling it. Frankenstein recently published
the results of Werth's suggestion in the hospitals of Kiel.
After this procedure in only 85 out of 875 laparotomies was
there post-operative ischuria (9.7 per cent), whereas without
this procedure it occurred 57 time in 91 cases (55 per cent).
The post-operative cystitis was reduced from II to 2.9 per
cent. For vaginal operations the method did not seem so ap-
plicable, the reduction of urine retention was only from 55.5
to 38.6 per cent. Personally, I have no experience with this
method but believe that it would hardly influence the class of
cases in which urine retention persists a long time.
From Baisch comes the recommendation to inject 20 cc.
of a 2 per cent boroglycerin solution into the full bladder on
the evening of the operation. He claims that this procedure
has been almost invariably successful in producing spontane-
258 The Medical Society of
ous urination in all cases except the radical operations for
cencer. In the latter it failed to have any effect. Only rarely
does the injection have to be repeated. Occasionally consid-
erable discomfort is experienced by the glycerin injections.
In my experience they proved a greater stimulant to the de-
trusor than any of the methods previously recommended, such
as faradization, massage, hot applications, or strychnin injec-
tions. Several times, however, the effect seemed only to be
temporary, and after one or two spontaneous urinations, reten-
tion would again set in. At times, also, we noticed that in
spite of spontaneous urination there would still be consider-
able urine left in the bladder. Cystitis occurred in two of our
cases, and the suspicion can not be avoided that this, in part,
may have been due to the hyperemia produced by the glyerin.
Frankenstein reported failures by this method in 50 per cent
of his cases. Baisch's success, however, certainly warrants
giving this plan a fair trial before abandoning it. It should be
added, that in every case the instructions of Baisch to cathe-
terize if urine was not avoided in thirty minutes was carried
Out.
Apparently, Ries has had unusual success in avoiding
post-operative urine retention by permitting his patients to get
up to void urine a few days after operation. I doubt if he
would find many to agree with him in permitting a patient on
whom had been done an extensive vaginal plastic or a radical
operation for cancer, to get out of bed as early as the third day.
On the other hand, I have had patients propped up in semire-
cumbent posture to void urine as early as this, with good
results and believe where urine retention exists, we should get
patients out of bed as soon as it is reasonably safe. Doubt-
less our ideas of the dangers of such a procedure have been
exaggerated but the safety of Ries' suggestion needs further
proof before it can be generally recommended.
Failing in my efforts to find some means of stimulating
the detrusor, I attempted in a few cases at Wertheim's clinic a
dilatation of the urethra sufficient to produce a paralysis of
the sphincter or at least a decrease of its tonicity. The suc-
cess was only partial and on the strength of a case at Johns
Hopkins Hospital in which Dr. Sampson was kind enough to
City Hospital Alumni. 2: 9
give this method a trial, I must hesitate to recommend it.
Here dilatation up to number 14 Hegar after operation resulted
in urinary incontinence. In spite of this there was a large
quantity of residual urine. It was only the overflow that
passed out of the bladder involuntarily. A severe cystitis de-
veloped.
The introduction of a retention catheter has been recently
recommended by Gutbrod. Theoretically it would seem that
by so doing we would avoid the danger from infection result-
ing from repeated catheterization. Gutbrod used this method
exclusively after colporrhaphies or Alexander's operation.
The catheter was left in the bladder for five days. He gave
urotropin O.5 gram three times a day during this time and re-
ported in 50 cases no cystitis. Like several other suggestions
already considered, this procedure while applicable to the
simpler operations, is ineffective, even dangerous, in the more
extensive ones. Sampson in 4 of his radical operations for
cancer used a retention catheter. In all 4 a cystitis developed,
resulting twice in ascending renal infection and death. In a
3rd case a patchy membraneous cystitis developed, the patches
corresponding to those portions of the bladder that came in
contact with the catheter. Sampson declares that such a
catheter can not be kept sufficiently clean.
No work has done so much to throw light upon the prob-
lems of bladder and ureteral injury after the radical cancer
operations as has that of Sampson. One of the most interest-
ing facts connected with his experiences is that out of 4 cases
in which no cystitis developed, there was 3 times a vesicovagi-
nal fistula, or to put it a little differently, three such fistulae
developed in his I6 operative cases and in all three instances
the bladder remained free from inflammation. How are we to
explain this interesting fact P That bacteria had gained en-
trance was proven bacteriologically, trauma was certainly pres-
ent, and yet there was no cystitis. Sampson believes that the
reason no infection developed was that the bladder was in a
state of rest with opportunity for perfect drainage. Sampson
is unwilling to recommend making a vesicovaginal fistula arti-
ficially for the relief of urine retention after cancer operations.
He says, however, that if in spite of bladder irrigations fol-
96() 'lhe Medical Society of
lowing c \theterization a cystitis developed and this does not
yield promptly to treatment, a vesicovaginal fistula should be
made for the relief of the cystitis.
It seems to me these cases of vesicovaginal fistula are ad-
ditional evidence to the theory of cumulative infection in this
form of cystitis as already outlined. The introduction of a
few germs at repeated intervals will for a time be successfully
resisted by the organism but each time it becomes less resist-
ant to infection than before. If there be no opportunity for
the bladder mucosa to return to its normal state an infection
will invariably result. But if on the other hand through a
vesicovaginal fistula the bladder be allowed to remain in a
state of rest and the bacteria that enter be given no chance
to multiply in a stagnating urine, it can successfully resist the
invasion of the germs present until the traumata of the opera-
tion have healed. By this time the fistula itself will be almost
closed, but the germs in the bladder have now to deal with a
bladder cured of its traumatic areas and able to expel urine
spontaneously. Hence no cystitis results.
Trauma.--It need hardly be said that for the prevention
of cystitis we should always guard against handling the blad-
der roughly. Many operators are careless in the use of he-
mostats to check vesical bleeding. Where uterus or vagina
are separated from the bladder in the right layer there should
be very little occasion to use any hemostats. Furthermore, in
operations where extensive denudation occurs, as in those for
uterine cancer, the area as Kroenig suggests should again be
covered as far as possible with peritoneum. Glockner re-
ported that after following Kroenig's suggestion his percent-
age of post-operative cystitis in cancer cases fell from 77 to 44
per cent.
Infection.—The proper disinfection of catheter and ex-
ternal meatus does not here require special mention. As al-
ready stated the greatest danger lies in the germs normally
found in every urethra. Irrigation of the urethra prophylacti-
cally was found to be of no avail. We have finally the double
catheter of Rosenstein. This consists of an outer shield re-
sembling a short urethroscope, through which is passed the
catheter proper. In this way Rosenstein wishes to avoid the
City Hospital Alumni. 261
introduction of germs into the bladder. The objection to his
instruments I have stated in a previous communication and will
not here repeat. More recently Rosenstein published a report
of 34 cases in which he had used his catheter with only one
infection. Striking in this report, however, is that in only one
half of these 34 cases was the bladder touched in the operation
and in but 7 cases was the catheterization repeated over fifteen
times or estimated at three times a day, over five days. We
can not say that Rosenstein's double catheter guards against
infection until there exists more clinical proof and until bac-
teriologic examinations show that in fact no bacteria are intro-
duced into the bladder by its use. Still, while emphasizing
the necessity for further proof, I believe some such modication
of our method of catheterization ought to lessen the chance
for infection very much.
Granting that germs have been introduced into the blad-
der, our prophylaxis finally extends itself to the means at our
disposal of rendering them harmless. Medicinally urotropin
and its related compounds helmitol, cystogen, etc., un-
doubtedly give to the urine certain antiseptic properties.
Wannier, Sachs, Schumburg, and Grosglic have all treated this
question experimentally. Their results correspond with our
clinical experience at Wertheim's hospital. Mild cases of in-
fection were soon exterminated, but the severer ones not ap-
preciably affected. Its prophylactic use was attended with no
positive success.
Irrigation of the bladder with protargol solution was tried
by Wertheim extensively, commencing the day after operation
but did not yield the expected results. On the other hand
Baisch found that by irrigating the bladder after each cathe-
terization with one pint or more of 3 per cent boric acid, post-
operative cystitis only rarely developed, even after the exten-
sive cancer operations. He has recently given a detailed re-
port of his results. Out of 31 patients on whom a radical ab-
dominal operation for cancerous uterus had been performed
only I was able to urinate spontaneously on the evening of the
operation; 5 died; the remaining 25 were subjected to blad-
bladder irrigation following operation, sometimes for as long
as eighteen days. Only three of them developed a cystitis
262 The Medical Society of
and in but one case was it a severe infection. Sampson failed
to get results even with this method, for in four out of 5 cases
in which he tried it, cystitis arose. I believe Baisch does well
to emphasize the importance of carrying on such irrigation
until there is no longer any residual urine. For, in many
cases a spontaneous urination may occur without the bladder
being completely emptied. I recently had a good illustration
of this point. A patient on whom I had done the extensive
Wertheim plastic for complete prolapse was unable to void
urine after operation. She was catheterized and irrigated after
each catherization. On the fourth day after operation there
were four spontaneous urinations but the total amount was
not great. Suspecting a retention I catheterized and found
in the bladder 20 ounces of urine. In spite of continued
spontaneous urinations she was catheterized twice daily and
irrigated with 1/2 pints of boric solution until the tenth day
when there was no longer any residual urine. No cystitis
developed.
For prophylactic measures boric acid irrigations are prob-
ably to be preferred to silver solutions since the latter would,
if used frequently, give rise to irritation. While requiring
much care and time for their use, they are probably the most
effective means of avoiding bladder infection after operation.
The chief points in the prophylactic would, therefore, be:
I. Try to avoid urine retention by the use of one or sev-
eral of the following methods, filling the bladder with sterile
water at the conclusion of the operation, injecting borogly-
cerine solution into the full bladder, having the patients sit up
out of bed as early as the nature of the operation will allow.
2. In the operation handle the bladder carefully and
cover its denuded surface as well as possible before the close.
3. Prevent the introduction of germs from the urethra as
far as possible by using a double catheter such as devised by
Rosenstein.
4. Internally you may give urotropin, helmitol, etc.
5. Above all, wherever catheterization has been continued
for some time, irrigate the bladder each time with I-2 pints of
boric acid solution and continue such irrigations with each
catheterization not merely until the first spontaneous urina-
tion but until there is no longer any residual urine.
City Hospital Alumni. 263
BIBLIOGRAPHY.
Baisch.-Bacteriolgie u. experi. Untersuchungen ueber Cystitis nach gy-
naek. Operationen. Hegar’s Beitraege, vol. 8, p. 297.
Baisch.—Aetiologie und Prophylaxe bei post-operativen Cystitis. Vortrag
gynaek. Congress, Wurzburg, 1903.
Baisch.—Erfolge in der prophylactischen Bekaempfung der post-operati-
ven Cystitis. Central. f. Gyn., p. 380, 1904.
Faltin.—Experi. Untersuchung ueber die Infection der Harnblase vom
Darm aus. Central. f. d. Krank. der Harn. u. Sexual organe, heft 8,
I90I.
Frankenstein.—Ueber die Erfolge der kuenstlichen Blasenfuellung bei gyn.
Operationen als Mittel zur Verhuetung nachfolgender Harnverhaltung.
Gyn. Con., Kiel, rev. in Monat. f. G. u. G., vol. 22, p. 179.
Frankenthal.--Discussion, Chicago Gyp. Soc., May 5, 1903. Am. Jour. of
Obstet, vol 48, p 378.
Glockner.—Verhandlugen des gyn. Congress, Wurzburg, vol. Io, p. 603.
Grosglik.-Ueber Urotopin. Central. f. Harn. u. Sexual organe, p. 225,
I90O.
Gutbrod.—Die Vermeidung von Blasenstoerungen nach gyn. Operatio-
nen. Central. f. Gyn., No. 10, 1905.
Guyon.—Pathogenie des accident infectieuses chez les urinire. Annales
gen.-urin., 1892.
Kolischer.—Post-operative Cystitis in Women. Am. Jour. of Obstet, vol.
48, p. 349.
Kroenig —Zur Technik der abdominellen total extirpation des carcinoma-
toesen Uterus. Monat. f. Gyn. u. Geb., vol. 15, p. 879.
Kroe nig.—Personal communication, Dec. 31, 1903.
Melchicr.—Cystitis und Urininfection. Berlin, 2907.
Natvig.—Bacteriologische Verhaeltnisse im weiblichen Genitalsecretes.
Arch. f. Gyn, vol. 76, p. 860.
Piltz.-Ueber den Keimgehalt der Vulva u. Urethra. Arch. f. Gyn., vol.
72, p. 537.
Ries.—Discussion, Chicago Gyn. Soc. Am. Jour. of Obstet, vol. 48, p.
380.
Roesenstein.-Ein Doppelkatheter zur Verhuetung der Cystitis. Central.
f. Gyn., p. 569, 1904.
Rovsing.—Die Blasenentzuendungen und ihre Aetiologie. Berlin, 1900.
Sachs.-Experimentelle Untersuchungen ueber Harnantiseptika. Wiener
Klin. Woch., No. 17, 1902.
Sampson.—The Relation between Carcinoma Cervicis Uteri and the Blad-
der, and its Significance in the More Radical Operations for that Disease.
Johns Hopkins Hospital Bull., vol. I5, p. 156, 1904.
Sampson.—The Invasion of Carcinoma Cervicis Uteri into the Surrounding
Tissues. Jour. Am. Med. Ass'n, Oct. 29, 1904.
Schumburg–Zur Desinfection der Harnes Bei Typhusbakteriurie durch
Urotropin. Deutscher Med. Woch., No. 9, 1901.
Stoeckel.—Cystoskopie des Gynaekologen. Leipzig, 1904.
Taussig.—Ueber die postoperative Harnverhaltung und deren Folgen.
Munch. Med. Woch., No. 40, 1902.
Wannier.—Experim. Unters. ueber d. baktericice Wirkung einiger Harn
264 The Medical Society of
derinfizientien. Central. f. Harn u. Sexual organe, vol. 12, p. 593.
Watkins.—Discussion, Chicago Gyn. Soc. Am. Jour. of Obstet, vol. 48,
p. 379.
Werth.-Bemerkungen zur Laparotomie. Vrhdl. d. Ges. dtsch. Naturfor-
scher u. Aertzte in Muenchen, Leipzig, 1900.
Wertheim.—Ein neuer Beitrag zur Frage der Radical operation bei Uter-
uskrebs. Arch. f. Gyn., vol. 65, p. 37.
DISCUSSION.
Dr. EHRENFEST said that it was well-known that Dr. Taussig
had published on this subject several papers recognized extensively
in German and American literature. One point undoubtedly interest-
ing was his belief that it was not so much the retention as the injury
which was responsible for the cystitis. The speaker, for obvious rea-
sons, is especially interested in retention of urine after childbirth.
Possibly in the majority of these cases the retention in his opinion was
due to the interference with the innervation, the fetal head pressing
the nerves against the bones of the pelvis. Dr. Ehrenfest had had
two cases of this kind within the past year, both patients being the
wives of physicians. One patient was catheterized for seventeen days,
the other for thirteen days, about four times each day. In neither
case did the slightest trace of a cystitis develop. In these cases there
was no injury and good care was taken in the catheterization and pos-
sibly but few bacteria were carried into the bladder. He had tried the
glycerine injections several times in cases of retention with satisfac-
tory results. I\r. Taussig had brought out the point that cystitis could
be almost positively avoided if the bladder was washed out at each
catheterization. In this connection Dr. Ehrenfest demonstrated a
simple device of his own that he is using for washing out the blad-
der. It consists of a medicine bottle into which fits a rubber stopper
with two holes. Through the one air is pumped by means of a rubber
balloon into the bottle, through the other a rubber tube is pushed,
through which the fluid is conveyed,into the bladder. By the interpo-
lation of 3-way stop-cock, the fluid can be directed either from bottle
to bladder, or from bladder to waste jar or from bottle to waste jar.
This apparatus enables one to wash out the bladder in a simple manner
without the help of an assistant under reliably aseptic conditions.
City Hospital Alumni. 265
This apparatus has the advantage over both the typical bladder syringe
and the fountain syringe, that it is cheap, can not get out of order, can
be boiled and permits one to accurately measure the amount of fluid
injected into the bladder. It certainly is an ideal apparatus to com-
bine catheterization with washing of the bladder as a routine pro-
cedure.
Dr. RAvold thought there were two points here of especial value,
this condition might arise: I, When there was injury to the blood
supply of the bladder, 2, when there was injury to the mucous lining
of the bladder, thus permitting bacteria to develop in the urine. Dr.
Taussig had emphasized that the bacteria came in from below but
bacteria, especially the colon bacillus, might come in from the kidney,
as in typhoid fever, so also in these cases where the bowels had been
constipated the organism might pass down through the ureters and in-
fect the urine.
Dr. JACOBSON urged that the nurses be watched after operation,
otherwise they might use vaseline on the catheter, etc.; of course,
vaseline should be discarded. It had been found by experiment that
the proteus vulgaris which developed when there was retention of urine,
would produce a cystitis. There was a difference of opinion as to the
cause of cystitis, but the consensus of opinion was that retention was
a most decided factor, causing changes is the urine. He thought
Dr. Ehrenfest was mistaken in his belief that the pressure of the child’s
head upon the nerves was in any way responsible for cystitis. It was
probably partly due to the shock transmitted to the urinary nerve cen-
ters, and possibly the chilling of the surface might have something to
do with the tendency to retention of the urine. One investigator had
made a cystoscopic examination of the bladder in 663 cases of so-
called irritable bladder. There were but two of these in which there
was not a hyperemia of the trigone and a beginning cystitis. As to
the means of entrance of the bacteria, the colon bacillus might pass
directly from the rectum to the bladder through the bloodvessels and
lymphatics. The proteus vulgaris has frequently been found in the
• vagina and urethra and then may travel to the bladder or be conveyed
there by the catheter.
Dr. TAUSSIG had had the privilege of working up bacteriologically
266 The Medical Society of
a case of cystitis for Dr. F. J. Taussig, a case which illustrated the fact
that the bacteria might pass directly from the rectum to the bladder.
The patient was a negro woman upon whom a severe operation had
been performed and the urine contained not only pus but gas. Every
time the urine was catheterized the bacillus lactis aerogenes was
demonstrated, a bacillus probably more or less related to the colon
bacillus, and usually found in the stools of people fed chiefly upon
milk. In culture with the colon bacillus this organism produced car-
bon dioxid. In this case the patient was catheterized in the Hospital,
by the nurses, and there was no reason to suppose it was carried in by
the catheter.
Dr. CROSSEN considered post-operative cystitis a most interesting
condition, not only those cases following severe operations but those
occurring where the operation did not touch the bladder at all. There
were so many points to be considered that he could touch upon only
some of the more important ones. In the preparation of a patient for
abdominal section it was a good idea to saturate the patient with water.
In his own work this was a routine measure The patient should be
directed to drink as much as possible every twenty or thirty minutes,
and it was surprising how much they could drink and it was also sur-
prising how much it increased urinary secretion. He believed that it
helped the kidney action after the strain of severe operations. In
operations where it was expected to denude the surface of the bladder,
it was wise to give some urinary antiseptic some days before the opera
tion. This would to a certain extent tend to prevent the cystitis. After
operation it was impossible to emphasize too strongly the danger of in-
fection of the bladder. The nurse should be instructed not to catheterize
the bladder if possible to avoid it without too much distention of the
bladder. Some patients could go a much longer time without cathet-
erization than others. In the case of patients who had taken a great
deal of water, the bladder filled up quickly, and it seemed to him that
this rapid filling of the bladder with comparatively normal urine aided
spontaneous urination. Propping the patient up considerably to aid
urination was less dangerous than invading the bladder with the cath-
eter, even with the most rigid asepsis. Another point that could not
be emphasized too much was the irrigation of the bladder after each
City Hospital Alnmni. 267
catheterization, for it prevented the rapid accumulation of bacteria.
It was difficult to establish that the urinary antiseptics in use helped
to bring on spontaneous urination, yet, he believed that they did and
when he at all suspected that such trouble might occur, he employed
such medication. It was certainly unwise to say that such medication
did not have this effect until there was more evidence to prove the as-
sertion. There were cases where there had been little injury and which
did not yield to minor measures, such as propping the patient up in
bed, and external irrigations with warm solution, and there seemed to
be no reason why there was not spontaneous urination. There might
be no appreciable cystitis. In such cases certain irritating injections
were sometimes of avail, such as boroglycerin, and injections of silver
nitrate. He had used the boroglycerin in two cases close together, in
one with good results, in the other with apparently no effect. In an-
other case, lasting twelve or thirteen days the injection of slver nitrate
solution brought on spontaneous urination. The handling of such
cases was still in the experimental stage, and as far as the speaker
knew, no entirely successful method of caring for them had yet been
devised.
Dr. JAcOBSON referred to a case that had a bearing on Dr. Cros-
sen's remarks. The patient after a hysterectomy in which there was no
injury to the bladder, developed cystitis. For about three weeks
catheterization was necessary. After she had recovered perfectly from
the hysterectomy; every time she became ill from any trouble, for ex-
ample, shock from news of her sister's death, result of accident, she
had a retention of urine for two weeks, and in every examination of
this retained urine Dr. Jacobson had found the colon bacillus. There
was a neurotic element in nearly all these cases of cystitis following
operation of any kind in the abdominal region. General tonics had a
very good effect.
Dr. TAUSSIG, in closing, said that he thought Dr. Ehrenfest had
given them another demonstration of his mechanical ingenuity and as
his device seemed both simple and practical, the speaker intended to
try it. As to the possibility of infection from above, he had simply
omitted from lack of time, to refer to any of these cases; they are
very rare. The result of animal experimentation had been varied.
268 The Medical Society of
Some experimenters had gotten the renal infection by causing a stag-
nation of the urine and feces. From animal experimentations no defi-
nite or satisfactory conclusions could yet be drawn, for there had been
practically very little evidence. In patients confined to bed for some
time the colon bacillus is found in the urethra. This was not due to
any negligence on the part of the nurse but the multiplication of bac-
teria in this region, consequently if the bacillus lactis aerogenes
happened to be in the stools it was not surprising to find them in the
urine. In regard to negligence in catheterization, Dr. Taussig believed
that it was necessary to be very careful, yet, that factor should not be
overestimated. A glass catheter could be very easily sterilized and a
nurse must be very dirty indeed if she could not insert that catheter
without carrying in with it a quantity of bacteria. The surgeon should
not be too prone to blame his nurse with the post operative cystitis.
Meeting of December 7, 1905 ; Dr. John Green, Jr.,
President, in the Chair.
Cerebellar Tumor of Syphilitc Origin.
By J. J. SINGER, M.D.,
ST. LOUIS, MO.
HE case to be presented tonight is one in which a diag-
nosis of gumma of the cerebellum, was made in
June, I904.
The patient, F. L., female, aged 22 years, married at the
age of 16 years; first child at 15 years of age; three children
after marriage; three children died in infancy. The patient
thinks three of them died of lues. Husband was a phyisician,
so patient claims. She had no miscarriages.
She claims never to have had venereal trouble until Feb-
ruary of 1904; at that time thinks she had chancroids. Gives
no symptoms of chancre or secondaries.
Occupation.—Waitress.
Płabits.—Inclined to be sexually loose; does not drink or
smoke. There is a family predisposition to phthisis.
City Hospital Alumni: , 269
In March of 1904, the patient fell backward from a chair
striking the back of her head against a radiator; became un-
conscious and remained so for half an hour or so. Since that
time, complains of severe headache and dizzy sensations.
A short time after, while riding in a street car, she knelt
down, unconsciously to pray; she was removed from there by
the police and sent to the City Hospital for observation. Her
case was diagnosed as hysteria, and in a few days she was
transferred to the Female Hospital. *
While here she complained of such severe headache as to
keep her awake all night; she also kept everbody else awake
by her wild shrieks, and was therefore, transferred to the ob-
servation ward, where she could not disturb anyone.
On June 6, 1904, she showed the following symptoms:
1. Headache.—Of the occipital type, well-marked, for she
continually kept her hand over that part. Now and then she
would scream with pain, especially at night.
2. Vomiting.—Vomited very frequently, and often it was
of the projectile type. There was seldom any retching or
Iºla U1S6 a.
3. Vertigo—In this the case resembled a cerebellar ataxia;
on the slightest motion the dizzy sensation was manifest. The
patient could scarcely stand; she would reel as if drunk if she
attempted to walk; consequently, she remained in bed all the
time and while in bed there was no vertigo.
4. Mental State.—Memory was practically blank; was
childish, crying or laughing for no apparent cause. Imagined
she heard people in the room speaking ill of her; at times she
would curse and use foul language.
5. Speech.—A sort of aphasic condition was present. She
often wished to say things; knew what to say but could not
articulate them; at other times when she could speak it was
of a scanning nature.
6. Vision.—Unfortunately on intraocular examination no
trace of optic neuritis was seen. However, the pupils were
both widely dilated; she could not read or write then, but
could before this attack and does now after the attack.
7. Appetite.—Was poor; the patient became quite emaci-
ated.
270 The Medical Society of
8. No fever or night sweats.
All these clinical symptoms warranted a diagnosis of
tumor of the cerebellum, probably gumma. As to its being a
gumma, the the therapeutic test proved it to be correct; she
was therefore, put on antiluetic treatment of the third stage.
Treatment.—Iodid of potassium was given her together
with tincture of nux vomica; she was given 20 grains per dose
six times in the twenty four hours, increased 5 grains per day.
Tincture nux vomica, Io minims.
After one week of treatment, the patient began to show
beneficial effects of the iodid. In three weeks, headache was
very slight, speech was somewhat but still slightly scanning in
nature; vomiting had ceased; vertigo still present but not
marked. The patient could walk about her room reeling
slightly. About this time she began to be able to read and
write; her pupils were not so dilated ; disposition was entirely
changed; was pleasant and very thankful and polite; her
memory had returned.
She was now getting IOS grains of potassium iodid four
times in the twenty-four hours; no iodid eruption throughout.
The dose was then reduced to 50 grains three times per day
and increased IO grains per day. *
July 15, 1904, the patient was well enough to be used as
a detail on the division.
July 18th, a small, hard mass, about the size of a walnut,
was felt over the right linea aspera ; about the middle portion,
there was slight pain but no inflammation. The potassium
iodid was then increased, also I/8 grain of the protoiodid of
mercury was given. The tumor disappeared in a week.
July 30th. The patient was discharged; had picked up
in weight and showed no more symptoms of tumor of the
brain. She was cautioned, however, to place herself under
constant medical care.
She visited the Hospital every few weeks but after two
months returned as a patient. She showed the following
symptoms: Slight headache, vertigo, loss of appetite, some-
what emaciated, drowsy feeling. Potassium was again given
with good results. About this time, we had no potassium
iodid in the institution and did not have any for two or three
City Hospital Alumni. 271
weeks. During this time, the patient's headache and vertigo
returned, and on given potassium iodid again these symptoms
disappeared.
Present Time.—Knee jerk is slightly spastic; ankle clonus
not marked; Babinski sign present; all these showing evi-
dence of previous brain lesions.
Although the patient feels quite well now on the sus-
pension of potassium iodid, the headache, which is now frontal,
returns.
REFERENCES.
Anders says, “In regard to tumors of the cerebellum, middle lobe, there is
headache, vomiting, vertigo, ataxia, reeling gait, staggering, falling, optic neuritis,
and possible deafness.”
Tyson says, in regard to mental symptoms, “There are peculiarities of temper,
sullen, indifferent, absentminded, loss of memory, mania, and often convulsions.”
Osler says that patients with cerebellar tumor often give symptoms resembling
dementia paralytica.
Butler says that there is somnolence, mental slowness, weakened memory, loss
of power of attention, childishness, and speech disturbances. In regard to cerebel-
lar ataxia he says, “Patients walks in a reeling manner and while in bed they show
no ataxia.”
Church and Peterson say, in regard to treatment, that patients who have had
attacks of cerebrospinal ataxia are never safe and must be under antiluetic treat-
ment all their lives
DISCUSSION.
Dr. CAMPBELL had seen this patient before and could testify to the
benefit following the administration of the iodid. This patient was
certainly very much better than when he had seen her some four weeks
before. The case practically illustrated the good the iodid did in condi-
tions of this kind. It was probable that there was a cerebellar disturb-
ance but it was also probable that she had cerebral syphilis and, prob-
ably, some meningitis along with it. It was difficult to ascribe all the
lesions to one point, for syphilis of the brain was so apt to affect many
parts at the same time. The disease had to be treated continually or
repeatedly and the symptoms would often yield whenever the treatment
was instituted.
Dr. BRADY said that the only remedy which would prevent the
formation of connective tissue was mercury and he would use that
first, last and all the time.
Dr. GRAVES felt it would be difficult to say at the present time just
272 The Medical Society of
what the conditions had been one and a half years ago. At present
the patient did not present symptoms of cerebellar disturbance. It
was always difficult to localize the process in syphilis of the nervous
system. From the fact that there had been no return of the symptoms,
it seemed probable that the condition had been diffuse. What was
striking was the fact that there had been absolutely an absence of all
cranial nerve symptoms. The left pupil was characteristic of the
syphilitic process. The absence of its light reflex was the only evi-
dence of the involvement of the nervous system. The Argyle-Robert-
son or even sluggish reactions were at times the only symptoms of
lues cerebri. If the patient had the Babinski sign it would imply the
involvement of the pyramidal tracts. The symptoms which the pa-
tient had presented, he believed, were due more to a diffuse cortical or
rather arterial involvement than to a localization of the process at the
base of the brain.
Dr. SINGER, in closing, said that the case was reported more to
show the effects of the iodid on the disease than with reference to the
diagnosis. In regard to the mercury, the patient had seemed to do
so well that it did not seem advisable to give the mercury until the
small mass was found on the tibia.