V V^A _ OF TH E -School of lA^edicine. THE HOSPITAL BULLETIN OF THE UNIVERSITY OF MARYLAND ^/ VOL. VII. MARCH 15, 1911. -4^^<^ No. 1 COINTEINTS ORIGINAL ARTICLES— Some Practical Points Regarding Fractures, with Special Reference to Internal Devices and the X-Ray — A. Aldridge Matthews. ... 1 Tetanus— Alvin Clay McCall .S Fracture of Outer Third of Clavicle— S. E. McDaniel 12 EDITORIALS 13 The Advisory Alumni Council. Needs and Remedies. A New Year. ABSTRACTS H The Treatment of Acute Mania. Brief Summary of Arsenic Treatment of Syphilis Antedating the Modern Elirlich- Hata COG. Laboratory Report of University Hospital. . . IS ITEMS IS DEATHS 2u For V/ ' AMENORRHEA ^ DYSMENORRHEA MENORRHAGIA METRORRHAGIA ETC. ERGOAPIOL (Smith) is supplied only in packages containing twenty capsules. y DOSE : One to two capsules three \ or four times a day. -<■<-< \ SAMPLES and LITERATURE SENT ON REQUEST. c "i.'i ^ 1 The Hospital Bulletin IS THE PROPERTY OF THE Hospital Bulletin Company of the University of Maryland The Bulletin is conducted by a committee of the Hos- pital Staff, and will be devoted to the publication of Hospital material, to the educational interests of the University of Maryland and to the interests of the Alumni of the University, wherever found. Its functions will be educational and social, its promoters having in view the advancement of the educational worl5 of the University from a clinical standpoint and the general welfare of the Alumni of the University by bringing them into more cordial relations and Into closer affiliation. Copies of Thb Bulletin will be sent during the year to every Alumnus whose address can be found. The Hospital Bulletin Company 608 Professional Bldg. Baltimore, Md. A CARD Messrs. Hynson, Westcott & Co. are pleased to announce to the medical profession that they have Extended their Practice of Legilimate and Exclusive Pharmacy by open- ing a branch at Linden and North avenues. This Linden Branch is completely equipped and stocked. It is hoped it will be a helpful convenience to many physicians and tlieir patients. The attention of medical men in the counties is called to the facility with which they and their clientele may receive medicines and supplies, upon mail and telephone orders. TWO LOCATIONS: Charles and Franklin Streets Linden and North Avenues H\ Apparatus for Proctoclysis PEREGRINE WROTH, Jr., M.D., Hagerstown, Md. Previous to February, 1908, when the apparatus described below was devised by the writer, great difficulty had been encountered at the Union Protestant Infirmary, in the continuous administration of Salt Solution by rectum. The difficulties were; 1. Proper control of rate at which the fluid was introduced into the rectum was apparently im- possible when gravity alone was depended upon. 2. Patients almost invariably began to expel large amounts of fluid before the end of 12 hours after administration was begun. This was due either to too rapid or irregular introduction of fluid, or to irritation of Rectal Tube. 3. Any obstruction to flow was not apt to be discovered for an hour or more, because if the Salt Solution is given slow enough to be retained, considerable time must elapse before an appreciable amount runs in. The Apparatus herewith presented consists of: 1. A Metal Frame to hold Flask and Funnel. 2. An Ordinary Glass Infusion Flask, Graduated in CC. 3. A Stopcock with Short Rubber Connecting Piece. 4. A small Glass Funnel. 5. About 8 feet of Rubber Tubing, interrupted about 3 feet from lower end, and by Glass Con- necting Tube 8 inches in length. 6. A tiny Soft Rubber Catheter I4F) connected to Rubber Tubing by Sharp-pointed Nozzle. This Apparatus is hung by Bedside, the catheter inserted from 3 to 6 inches within the Patient's Rectum, the Flask filled with Fluid, and the Stopcock adjusted so that the Fluid drops from the Flask into the Funnel at any rate desired. By the side of the Bed, on a Table or Chair, two water bottles filled with water heated to 212 degrees F. are placed on top of the other, and the tubing at the point where the Glass connecting piece is used, is laid between them. By this means the Fluid which is poured into the Flask cold is brought to body heat by the time it reaches the patient. The Frame holding the Flask and Funnel is now raised until the Fluid flows through the Funnel without back- ing up. The Ghas. Willms Surgical Instrument Co., 300 N. Howard Street, Baltimore, Md. SPECIFIC SKIN AFFECTIONS "I have had remarkable success in the treatment of tertiary syphilitic eruptions and ulcerations with Resinol Ointment," writes a prominent eastern physician. Con- tinuing, he says: "With its aid I healed an extensive ulceration of the skin covering the whole right side of the nose. This case had resisted all of the usual remedies, ' ' RESINOL OINTMENT is not disappointing, but on the other hand, brings results in all eruptions of the skin, whether specific or innocent. It is a most excellent healing dressing for skin ulceration, including syphilitic, varicose, or those resulting from deep burns. RESINOL OINTMENT will relieve the nerve-racking irritation of Pruritus Ani, or an infected Proctitis, quicker than anything else. This ointment contains no mercury, but combines readily with citrine and other of the mercurial ointments. It forms an excellent healing ointment base, in which any of the salts of mercury can be incorporated. RESINOL SOAP should be recommended for bathing all infected parts, or those exposed to infection. This excellent antiseptic also forms the basis of the medication in the Resinol Medicated Shaving Stick, the utility of which is obvious. Send for Samples Resinol Chemical Company BALTIMORE, MD. THE HOSPITAL BULLETIN Published Monthly in tW Interest of the Medical Department o£ the University of Maryland ^<P:)^eE $l.o6 PER. ■YEAR Contributions invited from the Alumni of the University,"' Business Address, 608 Professional Building, Baltimore, Md. Entered at the Baltimore Post-office as Second Class Matter Vol. VII BALTIMORE, MD., MARCH 15, 1911. No. 1 SOME PRACTICAL POINTS REGARDING FRACTURES, WITH SPECI.AL REFER- ENCE TO INTERNAL DEVICES AND THE X-RAY.* Il}- A. Ai.DKiDCE Matthews, J\I.D., Class of lyoo. / 'isitiii:^ Siiri^coii to St. Luke's Hospital. Spokaii..-, Il'asii. There has been considerable written in regard to the open method of treating fractures, but there is a great diversit_\- of opinion still pre- vailing. Dr. Lane claims that the open method should always be followed, when circumstances and con- ditions are favorable for such, but I certainly cannot agree with him in this matter. While there have been great strides made in bone surgery in the past fifteen years, I do not think it has advanced as much as surgery of the abdomen and other parts of the body, and the credit of this advance is much due to the efforts of Scudder, Downey, Hodgen, Simpson, Whit- man, Koche and many others who have con- tributed largely to this class of surgery, such as Krause. whose ambulatory treatment has added much to the coinfort of patients and unquestion- ably saved many lives, especially in the old, who would otherwise die of pneumonia if it were not that the\' could be moved about and move them- selves. Also the introduction of antiseptics, anesthesia and the X-Ray has made bone surgery compara- tively easy to what it was before. The X-Ray has been of great help in detecting obscure frac- tures and has heljied much in the reduction of fractures : at least we can be fairlv certain as to the position of our fragments and can be able to give a reasonably certain prognosis as to the re- * Read before thi? Spokane Medical Society. Spokane. Wash., February 2. 1911. suit. The X-Ray has also been responsible for many mal-practice suits, which, if it were not for this instrument, these suits would not be. And the reason for this is that we may have a per- fectly good and useful result with very little de- formity, but if we take an X-Ray we will see that the reduction was not perfect and our alignments are far from being anatomical, but we have a functionally good extremity The X-Ray cannot be taken as a criterion, for we must remember that the negative is only a shadow which is reflected upon the plate, and a man not accustomed to this special class of work is likely to interpret these shadows wrongly. The positions in which these pictures are taken are very important. A tricky X-Ray man might ex- aggerate a condition very much by knowing how to cast or reflect the shadow, and this introduced into court has great weight with a sympathetic jury, when in reality the deformity may be small and the result fairly good. Another great mistake which is often made with the X-Ray is by taking a negative in only one position ; this is shown by figures y-A and 7-B. If this negative was taken in one position, as 7-A, and no other were taken, it would be con- sidered a fair alignment, but by taking it laterally you see it is far from being in good position. Then again, look at Fig. 3-B. There is a great overriding, and the patient did not know he had this deformity until he had seen the negative, and in this case, while I do not suppose it was intentional on the part of the attending physician, it was fortunate for the patient on account of the great shortening in the other leg. This case I will speak of later. Scudder has said an approxi- mate reduction that is non-anatomic, if followed b\- union and by a functi(jnall)- useful part and no a])i)arent deformity to the jjatient and his non- professional friends, is a good result. Coming back to the subject of operating on fractures, as a whole it should be condemned in my judgment. Of course, in many cases it should THE HOSPITAL BULLETIN be done ; for instance, when we cannot reduce the fracture, when there is interposing tissue be- tween the fragments, in oblique fractures where F'v^. 3-A. — Applioatiim of silvm- plate to fractured femur, taken several mouths after lieiug applied. the muscular contraction causes overriding, or in any condition where a fairly accurate reduction cannot be had and maintained. The most certain Fis. 3-B.— Old fracture of femur, showing strong union with great over-riding. The same patient as 3-A, liut opposite leg. by a radiograph that I was much mistaken. This has happened several times in fractures of the tibia, and in all of these cases I have usually had to resort to the open luethod to accomplish the desired result. The fracture of the patella is a fracture which, as a whole, under favorable conditions, should be treated by the open method. Other types of frac- ture which should come to operation to get good results are fractures of the neck of the femur (not in the old, but in the young) and those of the olecranon. But there are some who even condemn operating upon the patella, even though nearly always the ligament tears off not evenly I'is 3C'.— Bene removed from middle third of femur (3-A> before appl.ving plate. way to determine this is by the X-Ray. Many times I have reduced fractures, at least thought I had, and after putting them up in splints found due to not liaving been properly reduced or onI\ with the bone and usually interposes between the fragments. Another mistake which I think we often make is that of trying to reduce fractures without an anesthetic. \\'e often fail to get a good reduc- tion while our patient is awake, for naturally he resists, even though imintentionally, and espe- cially is this a mistake if we cannot have a radio- graph to be certain after the reduction to see if the position of our fragments is in good align- ment. A verv much abused, if I might sa}', fracture is the Colic's fracture, and we often see bad de- formities following; this fracture, which is usually \' THE HOSPITAL BULLETIN partially so doing, ami here an anesthetic is prac- tically always necessary. I have a man here in town whose wrist I am ashamed of, not that he has not a perfectly useful hand, as practically all of them do get this, but he has a bad deformitx. Tiie only excuse I have to offer is that he was on a debauch w hich lasted some days after the accident, and it was a very hard matter to keep any dressing on his arm. Usually a properly reduced Colle's will remain in position and need but a light dressing. The dressing which I prefer is the plaster splint. The proper time to operate on fractures should vary. If a compound fracture, an immediate ance against microbic invasion. But there is one objection to this waiting, and that is the muscular contraction which so often occurs, which makes it Kig. 4-.\.— Fiactiu'etl til)i,i and fibula, taken tlircnish last. Operation should be performed if such is neces- sary to keep the fragments in position. In such fractures there is already a solution of continuity and it will not add anything to the danger of sepsis or the probability of death if we treat the fracture by the open method. sim]:)ly enlarging the wound already produced. Rut if not com- pound, it is better to wait a week or ten days, as Murphy has suggested, because the tissues are then in a condition of least resistance and after a week or ten days one can do an enormous amount of work without danger of infection, which could not be done on the day of the accident. The lymphatics have been cofferdammed and the new- capillaries are developed to the greatest resist- Kig. 4-B.— Sniiii' :.s 4-\, taken through plastei- cast after reduc- tion and application of silver piate. almost impossible to reduce our fracture, and it becomes sometimes mecessary to resort to my- ot()m\' and tenotomies, whicii is not alwavs an I'ij;. .?.— Hesuits following wiring of femur. Wire removed. advisable operation, although T had to do lo in one case, which Fig. 8 represents. There is such a thing as waiting too long, which, THE HOSPITAL BULLETIN no doubt, all of us who do surgery have seen, and that is bone softening, spoken of by A. F. Jonas as physiological bone softening. This being a Fis. C-A.— Lateral view of fractui-cd tiliia and fibula after re- duction. process of repair which takes place in bone, no- ticeable after two to three weeks, becoming more marked as time passes on, until the calcium salts Ki;r. )i-H. — Same as 6-A. anterior posterior view. begin to predominate and the density increases and the reverse process is carried on until the UDrmal density of the bone is re-established. This is one reason why splints, wires, nails, etc., do not hold and pull out easily when we operate upon old fractures, such as ununited fractures of six to ten weeks standing. This softening is shown very nicely with the X-Ray b\- the lesser density of th6 fractured extremities. In a new fracture any device which will hold the fragments in position is the correct one, whether externally applied splints or the applica- tion of internal devices. If it be the internal one, such as nails, screws, wire, staples, or what not, we must remember that they only hold for a short while and not until the union is complete. We usually have to remove these materials sooner or later, and they are always perfectly loose. I have many cases where these materials ha\e not been Kii;. 7-A.— Old fracture of femur, anterior posterior view. removed and some of several years standing. ( )ne case has had silver wire in the tibia for eight \ears. The loosening- of these devices is due to the lime salt being absorbed around these foreign bodies, therefore we can only expect these ma- terials to act until the main factors cease to oper- ate, and that is muscular contraction, which is overcome in about one week, so by proper internal device and proper external support this can usually be accomplished. The materials that I am most partial to arc the silver plate, wire and nails, but on a number of occasions I have used silkworm gut, chromic gut, screws and celluloid linen. THE HOSPITAL BULLETIN The ivory screws (it Matjinison, spoken of by De Forest Willard, with nietalhc heads are con- siciercd very good, although I have never used tlieni. These screws are screwed into the bone and cut oft' flush w-ith the periosteum, and it is claimed thc\- soon become part of it. I feel a little skeptical about this and cannot see why they would be any more satisfactory than the metallic screws. I am not in a position to speak of the bone clamps for holding fragments in position, or the fracture devices which extend from the bone to the outside, as I have never used them. As a whole, for long bones, I prefer the silver plate held by screws, for it will hold and give, which the steel plates will not flii, and is less liable to After examining him 1 advised a resection and removal of about the middle third of his thigh Vi'^. .-P..— S;inu' !is 7-A. exi/t^jil takiMi hilrrall.v. pull out the screws if strain is put on, as can be seen in Fig. 3-A. See how the plate has bent. I would like to show you a few X-Ray nega- tives which will throw a little light upon what I have been talking about. Figs. 3-A and 3-B represent a man hurt in a wreck in which he had both legs fractured. I did not see him until about ten weeks after his injury, and at that time he had an ununited frac- ture of his right leg, with a great deal of crepitus and a number of sinuses running pus scattered all along his mid thigh. An amputation had been advised and he was sent here for that pur- pose. Fig. S-A.— Bowing of tilii.i mikI fi-ncturoil lower end fibula, anti.'rior posterior view. Fig. S-B.— Same as S-.\, iateral view. bone, for it was very plain to see that the fracture was comminuted and a quantity of dead bone THE HOSPITAL BULLETIN was present. The right leg was united as Fig. 3-B represents. On September 21, irpg, I opened and removed two large spicules and then resected both of the ends of the femur, which you will see in Fig. 3-C. If 3'ou will notice, most of the bone removed is Fig. S-C— Same as S-A, after straightening tibia and resecting end of fibula. Kadiograpli taken tbrougli cast. dead and some of it had a worm-eaten appear- ance, showing absorption is taking place. Then I applied a silver plate with three screws below and two above, which is shown very well in plate Fig. 3-A. After a very protracted stay in the hospital he managed to get a good, useful leg which he can walk about on very well, although it is about six inches shorter than it was before the accident, but he wears a high shoe on this foot and uses a cane. Fortunately, the other leg- is about four inches shorter than it was formerly on account of the over-riding, which is shown in Fig. 3-B. This may be called a fortunate mistake. In Fig. 3-A the slight bending of plate and a little misplacement of ends is possibly due to the position in which it was put up following the operation, for there was naturally great mobility following the operation and the soft parts were puckered up in the middle thigh, which gradually contracted and took care of the slack. He is quite an active man now, and the plate is still in position and gives him no trouble. Figs. 4-A and 4-B represent a young man who had his leg broken by direct violence. I attempted to reduce this fracture, but could not, so put it up in plaster and had an X-Ray taken, which is shown in Fig. 4-A. The next day I opened down upon the fracture and tried to reduce, but on account of the muscular con- traction I could not do so, even though the frac- ture was not more than ten days old, so had to resect and applied a plate, which is shown in Fig. 4-B. This man I kept under observation about three weeks, and he then went down in the coun- try. I have gotten most satisfactory letters from him and his physician. The X-Ray was unfortu- nately taken too high up and does not show the exact result following the application of the splint. It also shows a comminuted fracture of the iibula. I did nothing to this hone, for it only being for muscular attachment, etc., and I felt certain that it would get sufficient union without resorting to any operative treatment. This has been over a year and the plate has not given him any trouble, and his physician recently reported to nie he had an excellent result. Fig. 5. — Male, aged 28, fractured thigh, upper middle third. This man was anesthetized and Kig. 8-D.— Same as S-C, lateral view. fracture reduced and put up with traction, short inside splint and long outside splint, but after about nine weeks found he had no union, so opened down, freshened up the ends of the frag- ments, which were in fair apposition, and put a silver wire suture through the two fragments, but THE HOSPITAL BULLETIN this wire I had to remove about the tenth week after the operation un account of its setting up considerable irritation, and a sinus developed, also a small spicule of bone about the size of a pea came away and then the track immediately healed, and, as you see, he has a very good result, only a little thickening of the shaft. Figs. 6-A and 6-B.- — Male, age 34, shows nothing except a rather vuiusual fracture of the tibia and fibula and a good apposition, the kintl we would like always to get, it being com- minuted. Figs. 7-A and 7-B show strongly the great ad- visability of taking two views of a fracture. If we had only had the one, as Fig. 7-A, we would consider it a fair result, but by taking another view we find it is far from being what we want. This is a posterior deformity and does not incon- venience him, and he told me a few days ago he had just walked nine miles on it, and he was satisfied to leave it as it was. His attending physician at the time of his acci- dent was surprised, for he thought that he had gotten an excellent apposition, but the apposition, as it is plain to be seen, is very poor. The ultimate outcome and usefulness of his leg is good, even though the deformity is much, but being a convex deformity posteriorly it is not apparent to him. One disadvantage most of us have is the inabil- ity of having the femurs X-Rayed on account of not being able to get them to an X-Ray or an X-Ray to them to see the position of our frag- ments, for it is impossible to be absolutely certain that our fractures are always in correct apposi- tion, and I consider this one reason why so often there are ununited fractures of the femur. Fig. 8 shows the radiograph of a little girl, age five, who was referred to me on account of lame- ness. The child gives no history of ever falling or receiving any accident, although you can plainly see by the radiograph that she has a fractured fibula near the lower end. It is also very apparent that this had been done some time before on ac- count of the callus thrown out around the frac- ture. And, too, this child was inclined to walk upon the toe and turn the foot in. The tendo Achillis was very tight. I think possibly what must have happened was that the child had some time an accident, because the fracture could not be produced other than by violence, which frac- tured the fibula and bowed the tibia. I put the child to slee]5, fractured the tibia about between the middle and lower third, correcting the de- formity as much as I could ; also removed a small part of the fibula because it projected out and the skin was tight across it. Figs. 8-.\ and 8-B show leg before the opera- tion ; 8-C and 8-D show the leg a few days after the operation. I found it necessary to cut the tendo Achillis to hold the foot in proper position. I opened down on the tendon, cut it across, but not the sheath, and then put a celluloid linen mattress suture in the tendon, uniting it, or other- wise bridging the space over with the suture, leaving a gap of about one-half to three-fourths of an inch. This child has gotten a very good result, although I cannot say as to the ultimate outcome. It has now been about three months since removing splint, and result is apparently excellent. Dr. William Franklin Twigg, class of 1857, is one of the leading physicians of Allegany county. He was born in Allegany county April 14, 1857, the son of Francis Twigg and Catherine Gelich- man, and is of American-German ancestry. He obtained his early education in the public schools of the county and the normal school at Bedford, Pa. He , then taught school for nine years in Allegany county, and in 1881 matriculated at the University of Maryland, graduating from there in 1883. During his senior year he was a resi- dent student at the University Hospital. He began his professional career at Elk Garden, W. Va., and after practicing there for three years he located permanently at Cumberland, Md., where he has since lived. He married March 23, 1887, Miss Sarah M. Hetzel, of Cumberland, and has three children — Mirian Catherine, Ethlyn Mar- guerite and Nial Franklin Twigg. In politics Dr. Twigg is a strong Republican. He is surgeon to the Baltimore and Ohio Rail- road at Cumberland, and special surgeon for the legal department of the company. He is also a member of the board of pension examiners for Allegany county, and physician at Allegany County Insane Asylum. He is a member of the Medical and Chirurgical Faculty of Maryland, the American Medical Association, the Interna- tional Association of Railway Surgeons and the Allegany County Medical Society. THE HOSPITAL BULLETIN TETANUS.* By Alvin Clay McCall, Class of 19 1 o. Tetanus, or lockjaw, is an acute infectious dis- ease characterized by tonic, muscular spasms, gen- erally extensor in type, occurring at longer or shorter intervals, occasionally aggravated by clonic spasms, these being limited to the jaws or all the muscles of the body. ETIOLOGY. Tetanus is due to bacillus tetani, discovered by Nicolaier in 1884 and grown in pure culture by Kitasato in 1889. The organism is widely dis- tributed ; found in garden soil, manure piles, hay, etc. Occurs in dirty localities, especially among the negroes of the South, but also prevalent in Pennsylvania, Northern New York, New Jersey and Long Island, endemically in New Jersey and Cuba, and is a common sequence to the Fourth of July accidents. Tetanus gains entrance into the body most often through punctured or lacerated wounds, abra- sions, toy-pistol wounds ; in fact, any accident fol- lowing which the wound is contaminated with dirt. Has been seen to follow vaccination where contaminated with organisms and hypodermic in- jections of animal serum. Gains entrance in in- fants through umbilical cord. The wound fre- quently suppurates or sloughs before the symp- toms of tetanus appear. From point of inocula- tion the organism grows anerobically, elaborating toxins, which may spread so rapidly as to cause death in 24 hours (Holt). The toxins enter the motor end nerves, traveling by lymph and axis cylinder to spinal cord, then up the motor tracts to the medulla. The action of the toxins on the motor nerves directly and reflexly cause tonic con- vulsions, and on the sensory nerves cause clonic convulsions. PATHOLOGY. Pathology is very obscure; no organisms found in blood or internal organs. Membranes of the cord and brain are reddened ; small hemorrhages into the brain substance and muscles. Ganglion cells of the cord undergo degenerative changes (lesions which are common to many toxic dis- eases). SYMPTOMS. Incubation average is from 7 to 10 days ; one case reported 12 hours after accident (Kuhn) ; •Read before the LTniver.sity of Maryland Medical So- ciety, November 15, 1910. another four weeks (Groose). First is trismus of the jaw and difficult deglutition, followed by rigidity, jaw being set, and then followed by rigidity of the entire body. Occasionally the arms escape. Rigidity lasts at first from one to two minutes, occurring every 15 to 20 minutes, and then increases in frequency until it is continuous ; then produces the characteristic widespread tonic convulsions aggravated by clonic. Patient is in a hyperextended condition, opisthotonus position; face is drawn, set, eyes fixed, causing a peculiar sardonic smile. Speaks with difficulty, cannot swallow, mouth closed, obstinate constipation and retention of urine. The convulsions grow worse until each clonic spasm, fixing diaphragm and chest muscles, may cause death. Patient is in some unnatural position, face cyanotic, wet with perspiration, eyes bulging, countenance expresses deadly terror and sufifering. Each clonic spasm forces air out through the glottis, causing hissing scream. Spasms are due to peripheral irritations brought on by slightest cause, as drafts, speaking, weight of bed clothes, etc. In cases of recovery above symptoms become less severe and finally cease. If death, increase in severity. Tempera- ture normal, or 101° to 102", Pulse, high ten- sion rate, 80 to 100 per minute. Mind clear; in- somnia obstinate. Chronic tetanus comes on in from 10 days to several weeks ; spasms not so severe ; periods of relaxation permitting sleep. Cephalic Tetanus. — Spasms confined to the face, pharynx and neck. DIAGNOSIS. As it is impossible to isolate the bacillus in many of the cases, the diagnosis is based upon the characteristic tonic and clonic spasms beginning in the jaw and involving the body, the opisthot- onus, sardonic smile, clear mind and very low temperature, but may be confounded with hys- teria, strychnine poisoning, tetany and hydro- phobia. The following points are helpful in differen- tiating: I. Tetanus — History of Wound. — Muscular symptoms commence with pain and stififness in the back of the neck, twitching of the jaw, same being affected first, then rigid and set. Hysteria — History of E.vcitent Nature. — Mus- cular symptoms commence with rigidity of the neck, which creeps all over the body, affecting THE HOSPITAL BULLETIN the extrcniilies last; jaws set before convulsions and remain so between convulsions. Strychnia Poisoning — History of Taking Drug. Muscular symptoms come on rapidly, beginning in the extremities and body simultaneously; jaws last affected, and its muscles relax first after con- vulsions. 2. Tetanus. — Persistent muscular rigidity, generally with a greater or less degree of perma- nent opisthotonus. Hysteria. — Persistent opisthotonus and intense rigidity between convulsions, lasting for a few- minutes. Stryclinia Poisoning. — Muscular relaxation be- tween convulsions : patient exhausted and sweat- ing. 3. Tetanus. — Consciousness preserved until near death. Hvsfcriii. — Consciousness disturbed as second convulsion conies on and thereafter. .^trxehnia Poisoning. — Consciousness preserved unless death is imminent from suffocation. 4. Tetanus. — Eyes open and rigidly fixed dur- ing convulsions. Hysteria. — Eyes closed during convulsions. Strychnia Poisoning. — Eyes stretched wide open. Tetany. — Milder nature of spasms, greater lim- itation of rigidity ; spasms begin in the hands and feet, but not in the jaw or neck. Hydrophobia. — Tonic spasms do not exist. PROGNOSIS. The longer the period of incubation, the less virulent the germ and the better chance of recov- ery. Mortality in young infants practically 100 per cent. Mortality in all cases from 80 to 90 per cent. Average duration of disease, three and one- half days after active convulsions set in. TREAT.MK.XT. Prophyhiclic. — This is most important when we recall the fact that we have no specific treatment, and the mortality is from 80 to 90 per cent. All wounds sliould be treated antiseptically. If made with dirty objects, or if wounds have become con- taminated, they should be incised freely, cleansed and dressed antiseptically. Vaccinations and hy- podermic injections should be made antiseptically. Antitoxins should be given in all doubtful cases which are suspicious in doses of from 1500 to 3000 units. Antitoxins have been proven experi- mentally to retard or prevent infection. As yet no harmful symptoms have been reported from the administration of same. Surgical Treatment. ■ — Always look for a wound. If found, incise, remove all necrotic tis- sue, disinfect, drain and dress antiseptically. General and Medicinal Treatment. — Patient should be kept in a quiet room, catheterized if nec- essary, bowels made to move by purgation or enema, and patient stimulated freely with alcohol. Nourishment given by mouth if possible ; if' not, by rectum. Medicinally, all drugs of cerebral or cord sedatives have been tried, with occasional recovery. Large and frequent doses of chlorals, bromides, morphia, calabar bean and cannibus iu- dica being used mostly. Antitoxin should be given in all cases, numerous cases of recovery fol- lowing its use being reported. The method of administration is unsettled, good results having followed intradural injections either in the cord or brain. Dose, 1500 to 3000 units, repeated daily, and in very severe cases two or three times daily. Ten c. c. of 25 per cent, solution of mag. sulph. injected intraspinally has been followed by re- peated recoveries, acting solely by its anesthetic effect on the cord, putting the patient at rest and saving him from exhaustion. The disadvantages of this, however, are the depressing effect on res- piration and the collection of mucus in the lungs. This can be largely eliminated by elevating the head and giving atropine. Hypodermic injections of emulsion or fresh brain matter has been recommended as the treat- ment to take up the toxins of tetanus, which has a mutual aflinity for nervous tissue. Carbolic acid in a solution of 3 per cent., in- jected deep, is supposed to render toxins inert. Ijut is doubtful. REPORT OF CASES. D. M. — Admitted October 24, 1910; in service of Dr. Hirsh. Age seven ; occupation, school girl. Family history negative. Past history negative to any acute disease : had jaundice when child; vaccinated September 13, 1910. Present llhiess. — Thirty-three days after vacci- nation first signs of illness appeared. In the after- noon, October 18, 1910, on returning home from school, tripped over a stone and fell, cutting her lip. Walked home, but complained of feeling weak and stiff. She continued going to school the rest of the week. Three days later an erup- 10 THE HOSPITAL BULLETIN tion of small pustules appeared over the body. On Sunday morning complained of difficulty in swal- lowing ; later on in day began to have spasms, six to eight during the day. Nature of spasms : Jaws set and patient resting on back of head and heels, lasting a few minutes. Complains of being thirsty, and voids urine involuntarily during spasm. No spasm Sunday night. Was brought into hospital Monday afternoon, October 24, iQio, 39 days after vaccination and the second day of convulsions. Patient was in tonic spasms, aggravated at intervals of 15 to 20 minutes by clonic spasms lasting three to five min- utes, condition having persisted all day. Patient is helpless and in excrutiating pain ; memory per- fectly clear. Pliysical E.vaiidiiation. — Patient is a female, white child, brought into the hospital in an ex- tremely filthy condition. Body covered with dirt and head entirely overrun v^'ith pediculi. Talks with difficulty ; mind is clear ; expression of ag- onizing pain. At intervals cries out for help. Rigid, and position is that of opisthotonus, due to tonic spasms, aggravated by the clonic spasms. Difficult swallowing, and swallowing seems to in- crease severity of spasms, face becoming cyanotic Scalp covered with heavy coating of light brown hair, entirely overrun with pediculi ; large number of small pustules over occipital region. Eyes are set; has peculiar stare. Conjunctivas slightly injected; pupils equal, react sluggishly to light and at times to accommodation. Face muscles rigid, producing peculiar sardonic grin. Contused-looking area site of carbuncle under right jaw. Mouth set; muscles of mastica- tion rigid ; not able to force open more than one- eighth inch. Cannot protrude tongfue. Teeth dirty, but sound. Impossible to examine throat. Neck : Rigid, hyperextended ; no palpable glands ; vessels stand out prominently. Chest : Hyperextended and rigid, covered with small pustules; respiration short, labored, and during clonic spasm is suspended from one-half to a minute. Lungs : Negative. Heart: Negative. Pulse; Increased tension ; rate, 125 per minute. Abdomen : Covered with small pustules, marked rigidity, board-like. Cannot make inden- tations with finger. LTpper extremity : Pcrfectl}- rigid : cannot bend elbows; manipulation of arms increases spasms. Small pustular eruption over arms, and on left one there is a necrotic scab, site of vaccination. On pressure, pus exudes from beneath scab. Lower extremities : Hyperextended ; cannot flex legs; painful to manipulation; knee reflexes absent. Nervous system : Mentally clear ; talks only with difficulty and indistinctly; cutaneous surfaces hyperesthetic. Examination increases severity of spasm. Temperature: Admission, 101.2°; for six days ranged between 99 and 103.4° ; since normal. Pulse: Admission, 122; for six days ranged between 100 and 150; since normal. Respiration : Admission, 28 ; for six days ranged between 20 and 30 ; since normal. TRU.-M'MENT AND COURSE OF DISE.\SE. Patient was given 1500 units of antitetanic serum, immediately after entrance, deep into the right gluteal region ; also given morphia, grain i-i2th. Patient was having tonic and clonic spasms every few minutes, ^\'ould have three or four clonic spasms every hour until midnight, when she was given another one-eighth of a grain of mor- phia, when clonic spasms ceased, but tonic spasms persisted. Restless entire night ; no sleep ; voids urine involuntarily. \\'as given 1^5 grains of calomel and yi ounce of mag. sulph. W. B. C, 16,000. P. N., 85 per cent. Second Day. — Rigid, but no clonic spasms. Drowsy at times ; does not want to be disturbed. Takes water and milk through a tube. Tonic spasms increase after two or three swallows, face Iiecoming cyanotic, lasting about a minute. Mor- phia, one-eighth grain, given in morning and evening ; castor oil, 3 drams : mag. sulph., i ounce ; vaccination scab removed ; cultures taken on agar ; one incubated and the other grown anerobically. Sore cauterized with carlwlic acid. Third Day.— Slept from 1 1 A. M. to 4 P. M., dozing at intervals thereafter. General appear- ance seemed better ; takes nourishment easier ; bowels moved freely after enema. 1500 units serum injected. Eyes washed t. i. d. with boracic acid and mouth with hydrogen pero.xide. Fourth Day. — Slept very little during night; general appearance brighter ; no complaint of pain ; frequently asked to have position changed ; mouth can be opened one-half inch; pulse good; THE HOSPITAL BULLETIN II agar cultures showed staphylococci. W. B. C, 16,000. Fifth Day. — Slept very little ; can be handled without pain ; jaw muscles softer ; can open mouth three-quarters inch and move head from side to side; arms move slightly. Vaccination wound cauterized and dressed. Morphia, i-i2th grain given. Sixth Day. — Slept at intervals ; much brighter ;, can move head freely in all directions ; arms easily Ijent ; mouth open one inch ; eyes normal, except small pupils ; probably due to morphia. Morphia, 5''^th grain given. Seventh and Eighth Days. — Slept at intervals ; opisthotonus disappeared ; no risus sardonicus ; bowels and bladder regular ; no bacilli isolated from anerobic culture. W. B. C, 14,000. H. B., 74 per cent. Ninth, Tenth and Eleventh Days. — Improving; sleeps entire night : legs can be bent to right angle ; arms can be used to help herself ; sluggish knee reflexes ; mouth open to full extent. Twelfth, Thirteenth and Fourteenth Days.' — General appearance excellent. \V. B. C, 9000. Sat up in chair. Fifteenth, Sixteenth and Seventeenth Days. — Allowed to stand; complains of pain in legs; afraid to walk. Eighteenth Day. — Walked one step, but stiff. S. G. — Admitted October 6, 1909; in service of Dr. Hamburger. Age 32 years ; occupation, tailoring ; social con- dition, widow. Family history negative. Past history : Had thyroidectomy performed two years ago. Two weeks ago had taken drugs to bring on menstruation, which lasted for three days. Womb was then curetted, and hemorrhage stopped. Ulcer was found, which was cauterized. Present Illness. — Day before entering the hos- pital, about 12 days after curettement, patient awoke complaining of stiffness in the jaws, diffi- cult swallowing; talking is difficult, and had con- vulsive spells. Body bathed in perspiration, and complaining a great deal of pain. Admitted to hospital on October 7 at i A. M., having typical tetanic convulsions. Pulse weak ; did not respond to cord or cerebral sedatives. Admission temperature, 90° ; temperature ranged between 99 and 104^°. Pulse on admission, 120, ranging from 90 to 160. Respiration on admission, 22, ranging from 20 to 42. Patient ran a very severe course ; continuous spasms ; would not respond to sedatives. Patient was given 15 grains of bromide and 5 grains of chloral. No organisms isolated. Died on second day of convulsions, 27 hours after admission to hospital. M. K. — Admitted March 6, 1910; in service of Dr. Winslow. Age 14 years; occupation, factory hand. Family history negative. Past History. — Ten days prior to present ill- ness ran a rusty nail through the foot, which wound healed readily. Present Illness. — Symptoms began four days ago; that is, 10 days after incurring wound, with stiiTness and rigidity of the jaw, and rapidly de- veloping into general convulsions. Temperature on admission, 100.5°. Foi" three days tempera- ture ranged from 98 to 102°. From the fourth to the sixth day, from lOi^ to 1034^°. Pulse on admission, 102 ; for the first three days ranging from 80 to 130; fourth to the sixth day, from 80 to 135. Respiration on admission, 24; ranging during the six days from 20 to 40. W. B.C., 9600. H. B., 85 per cent. B. P., 120. Had severe course of convulsions, and only after large doses of sedatives were the spasms suppressed. No organism isolated. TREATMENT. First Day. — Wound in foot opened ; spinal puncture done under chloroform for cultures ; 3000 units antitoxin serum injected. Patient was given 30 grains chloral and 60 grains bromide. Second Day. — Was given 6000 units of serum and 10 c. c. of 25 per cent, solution of mag. sulph. intradurally. Third Day. — Was given 6000 units of serum and 10 c. c. of 25 per cent. mag. sulph. Fourth Day. — Was given 6000 units of serum, 40 grains bromide and 20 grains chloral ; spinal puncture done and 6 drams of fluid withdrawn; 10 c. c. of mag. sulph. given. Fifth Day. — Was given 6000 units serum, 10 c. c. of mag. sulph., 15 grains of bromide and 20 grains of chloral. Last or Sixth Day. — 6000 units of serum. Received in all 30,000 units of serum, 70 grains 12 THE HOSPITAL BULLETIN chloral, 115 grains bromide and 30 c. c. of mag- sulph. Nothing seemed to quiet the case, and gradually weakened until death, which occurred on tenth day, after six days in hospital. I'R.VCTURE OF OUTER THIRD OF CLAVICLE. By S. E. -VIcDaniel, Senior Medical Student. The clavicle derives its name from its resem- blance to the old Roman key, "Clavis" Key. It is an S-shaped bone, situated between the head of humerus and scapula on outer side and sternum on inner side. I'rom its position and shape it can withstand a great deal of force. However, it is very liable to fracture, constituting- some 15 per cent, of all fractures of body. I'rom an anatomical standpoint, the clavicle is divided into three distinct parts — an inner, middle and outer third. In pi>int of frequency, the outer third seems the most liable to fracture. Rather just external to middle, where the inner or large curve meets the outer or small curve, at which point the bone is at its smallest diameter. Frac- tures of the outer end are more frequent than fractures of internal end, and much less frequent than fractures of the shaft. Fractures may occur at any age, but perhaps are more common before the age of six. It is said more than half the fractures occur before this age. It is caused b}- direct violence, indirect violence and, very rarely, muscular contraction. The symptoms are : Patient presents himself giving a history of injury to the shoulder. The peculiar way in which he is holding his arm and head would indicate that his collar-bone was injured. Likely he will be holding the elbow of injured side with hand of sound side, and pulling it against the chest. The head is turned down toward the shoulder of damaged side as if trying to listen to something ill joint, thus relaxing the pull of sterno-cleido- mastoid muscle upon inner fragment. He will also have other symptoms of fracture, namely, pain, deformity, abnormal mobility and loss of function. The pain will be increased by motion, pressure and hanging the arm down. The deformed shoulder will be shown by the pulling forward, inward and downward of the shoulder, with a reduction of the distance between the acromion and sternal end of clavicle. Abnormal mobility can be recognized by manipulating the fragments, and is usually accompanied by crepitus. The course of healing is usually uneventful, and union takes place within a month in adults, but some persistent deformity is the rule. Treatment consists in reducing the deformity by drawing or pushing the shoulder upward, back- ward and outward to its normal position, aided when necessary by pressure upon the projecting angle at point of fracture. The subsequent in- dication is to maintain the shoulder in this posi- tion, for the unsupported weight of the shoulder is the main cause of the displacement. This has been done satisfactorily in a great many ways. In children with a transverse, or a complete frac- ture, a simple sling for the forearm is often suffi- cient, but in oblique fracture of adults a per- fect result can rarely be obtained. In girls, when the least amount of deformity is desired, we place them on a smooth bed with a firm, nar- row pillow or cushion between the shoulders and the forearm resting on the chest. Sayre's dressing is in very general use. It requires two strips of adhesive plaster, each three inches wide and long enough to go once and a half around the chest. The end of strip is fixed loosely abiiut the arm of injured side, just below the axilla, and the strip is carried around the back and the op- posite side to chest in front, so as to hold the elbow a little behind the axillarv line ; the second strip is then carried from the top of shoulder on the un- injured side across the back to the opposite elbow up along the flexed forearm to the place of beginning, meanwhile pressing the elbow for- ward, inward and upward. .\ few turns of roller bandage about the arm and chest will give addi- tional support. In this and all other similar cases care must be taken not to allow the bare skin of forearm to rest oji that of the chest, in order to prevent maceration of the epidermis and even ulceration. Cotton wadding, linen or similar ma- terial should always be interposed between the two cutaneous surfaces. Other bandages ma\' be used for the purpose of holding the part in place, such as a figure of eight bandage of plaster of Paris. THE HOSPITAL BULLETIN 13 THE HOSPITAL BULLETIN A Monthly Journal of Medicine and Surgery PUBLISHED BY THE HOSPITAL BULLETIN COMPANY 608 Professional Building Baltimore, Md. Subscription price, . . . $1.00 per annum in advance Reprints furnished at cost. Advertising rates submitted upon request Nathan WiNSLOwr, M.D., Editor Baltimore, Md., March 15, 191 1. THE ADVISORY ALUMNI COUNCIL. On February 28, 191 1, in the office of Mr. Wal- ter I. Dawkins, was born another link in the chain which is working toward the creation of a new and greater University of Alaryland. We refer to the Advisory Alumni Council, which began its formal existence on that date. It was certainly the privilege of a lifetime to attend the organiza- tion meeting of a body which in the future is of necessity bound to wield a powerful influence in shaping the destinies of our dearly beloved Alma Mater. Men from all walks of life were present — doctors, dentists, lawyers, pharmacists, etc. En- thusiasm was rampant in the fact that we had at last realized the fact that we were indeed going to be a factor in the internal direction of the Univer- sity of Maryland ; that we were going to be per- mitted to actually play our part as alumni and have a say regarding the policies of one of the oldest and noblest educational institutions in the United 5tates. We were especially impressed with the fact that we were more or less burning bridges behind us and that the University of Maryland was entering into a new existence. Indeed, it was more or less celebrating a new birthday — a birth- day dedicated to progress. Such were our thoughts, and if we read the signs aright we are not to be disappointed. Although no definite lines of endeavor were laid down to follow at the first meeting, the Ad- visory Alumni Council did not waste time, but got down immediately to hard work. The presi- dent and secretary were chosen and inducted into office — Dr. B. Merrill Hopkinson and Mr. James W. Bowers, respectively. It was also decided to request of the Regents that they empower the va- rious Faculties that the Advisory Alumni Council be given a vote in the selection of professors. The chair was empowered, besides, to select commit- tees to investigate the feasibility and desirability of giving to the dental students a laboratory course in chemistry, another to look into the proper naming of the University buildings, and another still to seek a method to render the libraries more useful. We are only feeling our way, but expect to be able to render signal service to the old University. Anybody who has sugges- tions to make looking toward the betterment of our institution can do so with the assurance that the suggestion will be thoroughly investigated, and if thought wise and helpful will be brought to the attention of the University authorities. We are the connecting link between the Faculties and alumni, and hope that any alumnus who has the welfare of his Alma Mater at heart will avail him- self of this privilege by addressing the suggestion to the president of the Advisory Alumni Council of the University of Maryland, namely. Dr. B. Merrill Hopkinson, Professional Building, Balti- more, Md. NEEDS AND REMEDIES. We are doing business at the same old stand. We are preaching on the same old text. The needs of the medical school are so numerous that it is difficult to specify wherein we are most needy. Certainly the time has arrived for the establish- ment of certain departments upon a full time. paid basis. These are. especially, chemistry, anatomy, physiology and pathology. The profes- sors of these chairs should be scientists, and not practitioners of medicine. In our institution the department of chemistry is under the charge of two accomplished chemists, who are not phy- sicians, but it would be an exaggeration to claim that they were receiving adequate compensation for their services. The departments of anatomy and physiology are under the direction of erudite and enthusiastic teachers, who also receive inad- equate salaries, and who are engaged perforce in the practice of their profession as physicians. It is greatly to be regretted that these gentlemen cannot devote their whole time to the duties of their chairs, and the hope is entertained that cir- cumstances may so arrange themselves that this most desirable change may take place sooner than is now in expectation. At the present time the greatest need of the school is for an endowed 14 THE HOSPITAL BULLETIN department of pathology. The professor of pathology should not practice medicine for a liv- ing. His whole time and abilities should be given to pathological work and teaching, and he should receive a sufficient salary to provide for the necils of himself and his family. We have been solicit- ing contributions rather vaguely for an endow- ment fund ; let us now concentrate our efiforts and our beneficences definitely for the establish- ment of an endowed department of pathology. By a recent legacy the Faculty of Physic will soon come into possession of $5000. This should be devoted specifically to this purpose, and should form the nucleus of an endowment of the patho- logical department. We therefore ask our alumni and friends to help us to raise $100,000 for this special purpose. A NEW YEAR. The editor cannot start into a new year without thanking those who have made the existence of The Bulletin possible for six years — contrib- utors, subscribers and advertisers. It is the edi- tor's earnest desire that The Bulletin measure up to the expectations of its readers, and has endeavored to make it a first-class medical publi- cation. This is only possible by the loyal sup- port of our alumni, and can only be brought about by those interested in the success of the publica- tion occasionally sending us an article, a news item or by subscribing. Considering that we are in existence to give an outlet to the work of our alumni, and solicit papers from no other source, our paper certainly occupies an unique position, as the pages of most journals are open to the pro- fession in general. The Bulletin has steadily improved in tone and quality of articles published, and is performing extremely satisfactorily the object of its creation, namely, the drawing of the alumni into closer bonds of sympathy and the creation of an outlet for the work done in the University Plospital and by our alunuii in gen- eral, no matter where located. ABSTRACTS THE TREATMENT OF ACUTE MANIA. Charles P. Noble, M.D., Sc.D., class of 1884, of Philadelphia, in a paper on the above subject, Medical Record, says he wishes to present to the profession a new treatment of acute mania, based upon a theory of functional insanity, the nature of which he believes he has worked out. This is that functional insanity, so called, is due to the degeneration of the protoplasm of the cortex cells, and of those of the pituitary ganglion, which degeneration he has called molecular de- generation— as it is the degeneration of the units, or the elements, of which the cells are made up, as shown by the difference in the reaction to staining agents in these cells as compared with normal cells. The process whereby the molecular degenera- tion is produced is that of autointoxication, to- gether with hypesecretion of pituitary and of thyroid extracts. The intoxication is the result of the increased metabolism brought abotit by hyperthyroidism. The thought is relatively aber- rant and unvolitional, and the will is relatively exalted and is not under the control of the indi- vidual ; he has, relatively, lost self-control, or, in other words, the power of inhibition. It has been found that the principle and process are the same in both neurasthenia and in acute functional insanity. It is a question of degree, and not of kind. The irritation stage of neuras- thenia may be termed chronic unvolitional irri- tability, or chronic involuntary anger. Mania is the same thing, exaggerated "an hundred fold." Anger is the obverse of righteous indignation ; that is, the one is immoral and the other is moral. It is a disorder of the will, or the spirit, or the soul of man. The irritation stage of neurasthenia consists of unvolitional chronic irritation, or chronic anger. It manifests itself when the indi- vidual is acting, or doing, in outbursts of irrita- bility, or of anger, which is relatively beyond the individual's control — relatively, he has lost the power of self-control, and his thought is aberrant, in that in the irritation stage he is optimistic and in the stage of depression he is pessimistic, al- though he is rational. When the course of living — the environment — which has caused the neurasthenia is persisted in, the degeneration of the cells becomes nro^ressive, and their function becomes more and more mor- bid. The reserve vital force in the cells is more and more exhausted, and the potential energy has about all become actual. If now the individual continues to force him- self to do his work, the overworked, degenerated and exhausted cells react violently, and there is an explosion, called mania. The vicious circle consists of the following: THE HOSPITAL BULLETIN Of too much work, increased metabolism, chronic autointoxication, irritabihty and relative exhaus- tion of the will ; increased secretion of pituitary extract, increased secretion of thyroidin, followed by increased and aberrant thought, and progress- ively increasing autointoxication. The form of treatment which he has to suggest is that when mania first develops, the subject shall be given a hypodermic of morphine sul- phate— about one-third of a grain, repeated if necessary. This will temporarily c^uiet the pa- tient, when he should be anesthetized with nitrous-oxide gas and oxygen. If this is admin- istered properly, the subject can be kept asleep without risk for an indefinite period. The colon should now be filled with, approximately, three quarts of normal salt solution, and at the same time Jiypodermoclysis should be employed — fill- ing the subcutaneous connective tissues with, approximately, two quarts of normal salt solu- tion. If a suitable apparatus is employed, using three Y-tubes, four needles can be inserted at one time, and in this way the salt solution can be administered very promptly. This process can be repeated from time to time, as the condition of the patient indicates. There can be no objection to the refilling of the colon every eight hours, and at first the hypo- dermoclysis may be employed once daily. After two or three days it is probably better to intermit the employment of the hypodermoclysis, lest pres- sure necrosis of the connective tissues ensue. The patient should be kept in a drowsy condi- tion, or else asleep, by means of the administra- tion of hypnotics — sulphonal, trional, the bro- mides, morphine, hyoscine, etc. The object of the treatment is to break the vicious circle — to put the will in abeyance, whereby no nerve force shall be set free in the pituitary gland, and cause the secretion of the extract, and thus in turn, as this extract shall fail to stimulate the thyroid gland, thyrodin will not be produced, and thus in turn it will fail to reach the cells in the cortex of the brain, and thus the aberration of the thought so characteristic of acute mania will not be produced, and hence this thought, this judgment, or this form of nerve force will not set free that form of nerve activity which is called the will; hence the will will no longer be accelerated, but, on the contrary, as the patient should be kept in a drowsy condition, or else actually asleep, he will be will-less. If this treatment shall be kept up for several days the kidneys will be enabled to get rid of the accumulated toxins, and the patient will therefore become rational. The condition of acute mania will have been reduced to the period of convalescence from the irritation stage of neurasthenia. It is not the author's purpose in this communi- cation to supply the data in his possession. It is his desire to present this method of treatment to those who are engaged in treating the insane, in order that they may try it for themselves. He states that the form of treatment, if used with reasonable discretion, is without inherent danger. BRIEF SUMMARY OF ARSENIC TREAT- MENT OF SYPHILIS ANTEDATING THE MODERN EHRLICH-HATA 606. In a paper on the above subject by Professor Dr. med. Edward Ehlers, Copenhagen, and trans- lated by Dr. Ejnar Hansen, class of 1904, of New York {American Medicine) we glean the fol- lowing : Donrinc is the name of a disease in horses. For many years it has been the opinion of veter- inary surgeons that it was a kind of "horse- syphilis," or a disease very closely related to syphilis. Dourine (mal du coit, Beschals krankheit) is a chronic infectious disease attacking horses, don- keys and mules, and only communicated by coi- tus. It is now rarely found in Europe, all ani- mals suffering from it being immediately killed or castrated. It was first recognized in Tripoli, Algeria, Arabia and Persia ; a few cases can also be found in Hungary. In the United States it is sometimes found in Illinois, Nebraska, Wyo- ming and Dakota. Cases have also been found in the East Indies. Rouget first found the parasite in 1894, Doflein (Jena 1901) gave to it the name "trypanosoma equiperdum." The disease has three distinct stages. I. Eleven to twenty days after coitus edema starts around the lower edges of the preputium, it spreads to scrotum, inguinal region and often to the abdominal wall. It is cold and indolent. The temperature is 97 to 97.5°. In a few days this edema will disappear, but the animal is weak and it has difficulty in carrying its rider. II. {Eruption) 40 to 45 days after coitus there will be found on the sides and back infiltrated spots varying in size from a quarter of a dollar i6 THE HOSPITAL BULLETIN to the size of the pahii of the liancl. It feels as though a flat piece of metal was imbedded under- neath the skin. These spots last from I to lo days. The horse becomes thinner, the hind legs lame, the joints soft, and large, swollen glands can be found in the inguinal region. III. (Aiiciiiia and paraplegia). The horse is very lame and has no appetite. Abscesses form which are very difficult to heal. There is con- junctivitis, ulcerative keratitis, distinct crepitus in joints; the bones are easily fractured. At last there is paraplegia and the horse dies. The length of the disease varies from 2 to 10 months. Treatment gives little result, but several authors praise arsenic as being of some benefit. (Trelut, Archawgelsky, Novikoff, Blaise,) Marchal (vet- erinary surgeon Constantine 1903) cured five horses suiTering from dourine by injecting so- dium cacodylate i gram dissolved in 4 cc. of water every day for five days, then omitting five days, and so on until the horses were cured. Dourine can be induced in dogs, rabbits, rats and mice by inoculation. Experiments on these animals showed that atoxyl had a specific effect on the disease. Atoxyl (Ehrlich 1907) was discovered 1863 by a chemist in Montpellier by name Bechamp. Dr. Thomas, an English physician used atoxyl ( 1904) for sleeping sickness. Uhlenhut, assisted by Hybener and Woithe from Kaiserlich gesundheitsamt in the winter of 1906-1907, experimenting on rats, mice and rab- bits inoculated with dourine, showed that atox)l could cure the disease even in its worst form. Schaudinn, who discovered spirocheta pallida, experimented on owls, and in his last work, printed shortly before his death, gave us the theory that trypanosoma and spirocheta are only different steps in the evolution of the same cndo- globular hematozooa. This theory of Schaudinn started Uhlenhut experimenting with atoxyl on a topical spirocheta disease, the so-called chicken spirillosis. His re- sults were surprising. Atoxyl made the parasites disappear from the blood current in 8 to 12 hours, and the sick chicken became lively and well. Injec- tion in other chickens made them immune. These experiments were continued by Hoft'man in his atoxyl treatment of apes. Lesser in Berlin began treating human beings with atoxyl. At the same time similar experi- ments were made elsewhere by Neisser, Salmon, Hallopeau and ]\Ietchnikoff. Hoffmann's and Weidanz's experiments on rab- bits proved that atoxyl had a remarkable effect on S3'philis. Rabbits inoculated with syphilis in the eyes and at the same time treated with atoxyl did not develop keratitis syphiliticus. Other rab- bits with the same disease were entirely cured by the same treatment. Atoxyl did not, at that time, play any important role in the treatment of s\philis in human beings, because so large a dose was necessary that the patients were exposed to the well-known optic neuritis that claimed so many victims as a result of the atoxyl treatment of sleeping sickness. Uhlenhut and Manteuffel then tried a com- bination of arsenic and mercury, but this prepa- ration has as yet not proved very popular. The severe optic atoxyl-neuritis has kept the sxphilol- ogist away from this very interesting combina- tion which, when tried on animals, proved to be of much more value than atoxyl. Rosenthal made some experiments with acidum arsenicosum with satisfactory results. He tried it in 60 cases and used the following solution : .\cidi arseniosi centigram 8. Acoin 12. Aqua destill gram 40. From the above solution he injected one line (Pravaz) every third day, increasing the dose one line until the maximum dose of eight lines. He mentions one very severe case of syphilis of the roof of the mouth and the lower jaw, where the patient could not tolerate mercury. The case was cured with 0.544 gram of above solution injected during five weeks. Ehrlich has been more successful with his new preparation "606." According to the patent it is derived from atoxyl, but differs from it in name and chemical combination. It is a well-known fact that Ehrlich reformed our ideas of the chemical combination of atoxyl. It is he who first recognized it as parainiiio- phenylarsiiiacid, and from this discovery he syn- thetically reached "606." Dio.ry-diaiiiido-arsciio- bciicol-diclilorhydraic. In this combination arsenic is trivalent, and Ehrlich tells us that the pentavalent arsenic com- binations have less value than the trivalent ("606" and arsenophenylglycin. ) It is a ques- tion if Ehrlich is right. The three most inter- esting pentavalent arsanilacids are : Atoxyl. — Paraminophenjl arsinite of Sodium 24% Arsen. THE HOSPITAL BULLETIN Hektin. — Benzo-sulplionparaniimiphcnyl arsin- ite of Sodium 19% Arsen. Arsacetin. — Paracetylaminopheiiyl arsinite of Sodium 22.3% Arsen. The bad effect on the optic nerve has brought distrust to Uhlenhut"s atoxyl and arsacetin. That leaves us hektin. Hektin was discovered by !Moneyrath, professor in cliemistry at the L'ni- versity of L}on. He is known as an associate of Armand Gauthier, who first introduced Ar- rlicnal into the modern therapy. In 1904, wlien he wrote "L'Arscniqiic organiquc," he showed us that the step from Arrhenal ( JNIethylarsin So- dium) to ato.xyl was not a great one. After three years of experiments with these combinations on apes and rabbits inoculated with syphihs, hektin entered the syphiHtic therapeutic field through Balzer and Hallopeau. Moneyrath thinks that the poisonous effect and curative ac- tion of these arsenil compounds is increased by the weight of the aromatic nucleus. The aminoradical NH„ in the arsanilates in- creases the action of the aromatic arsinacid in such a way that the therapeutic dose is smaller tlian the toxic. The amin-group (NH„) can be replaced by hydroxyl with the same result. Two years ago iMoneyrath produced several of these combina- tions and published his methods in Bulletin fraii- cais. 30 juli 1908. He was the first to produce hydroxyaniinophenylarsinacid, which is the com- pound Plhrlich reduced and by which he gained his dioxyamidoarsenobenzol. Ehrlich was the first to use arsenic combinations in therapy, and knowing that acetanilid was less poisonous and better borne than anilin, he introduced the acetyl- ato.xyl-arsacetin. Moneyrath went another way. Pie tried to discoTer how the organism rendered benzol and anilin innocuous when introduced into the blood. Pie found that when a large dose is injected into the veins of a mammal, a part of it is disposed of unchanged, the other part is oxidized in such a way that benzol is converted into phenol (CeH^ to QH-OH), anilin to paraminophenol (QH^- OH/). While phenol is not thus rendered actually harmless and still remains as poisonous as benzol, we have the action of the glycuronic acid (COH [CHOH] 4 COOH) and potassium bisulphate combined with phenolhydroxyl forming the less poisonous potassium, phenol and aminophenyl- sulphates and glycuronates. To counteract the injurious action of the acids (benzoic acid and gallic acid) the organism uses the aminoforming action of the glycocoll and forms amides like hippuric acid. iMoneyrath was chiefly interested in the sul- phones uramides, urinary constituents, and after experiments on animals he decided that hektin and its mercury salt hektargyruni were the best. Hektin plays the same role in the therapy as ben- zoashydrarg, oxycyan mercury and other soluble mercury salts, and for that reason can be used to better advantage than "606," which coagulates albumin. For the same reason it produces hardly any pain, there is no redness, infiltration or indura- tion and it is not necessary for the patient to stay in bed. Hallopeau and Balzer (chief surgeons at St. Louis Hospital in Paris), Milan (Paris), Moniz de Aragua (Brazil), advise fractional doses of hektin, 10 centigram daily or 20 centigram every second day until z-t, gram has been injected. If complications set in, the injection can be stopped at once. Balzer in a large number of cases has only observed three cases of incipient amblyopia, which disappeared as soon as the injections w-ere stopped. The injections can be made intramus- cular, but also locally around the induration, the indolent glands, gummata or tertiary ulcerations. Hallopeau recommends the use of hektin in the manner as above described. ^^'e now know that all attempts to destroy the chancre by cauterizatio\i or excision in order to stop the spread of the infection in the system have been futile, because the spirocheta immedi- ateljr invades the lymph-channels from the place of infection. Hallopeau's method of injecting hektin around the initial lesion seems to open the way to new victories over syphilis. Where the spirocheta can enter, hektin can also enter. Evi- dence gathered by the above-named men, all well known to syphilologists all over the world, show that when hektin is injected early enough around the chancre, and the lymphangitis or indolent adenitis, it will stop the development of the sec- ondary symptoms. Hallopeau has observed a patient cured by hektin who acquired a fresh infection. It must be remembered that all arsenic com- binations are vasodilators, so hektin should not be used when there is arteriosclerosis. Balzer advises against the use of hektin where the patient suffers from disease of the retina or nervous op- ticus. I Jiave been corresponding with Profegsor Ehl- i8 THE HOSPITAL BULLETIN ers in regard to hektin, and he tells me that he has used the remedy in about 56-60 cases, is very well satisfied with it and considers it slow, but also a remedy to be depended upon. It is better adapted to office use than "606," the injections are painless and it can be injected as it is received in ampules, without any extraordinary preparations or mixing. It is made by the Hektin Company in Paris, and no doubt any physician can obtain it, either directly or through some reputable drug house. LABORATORY REPORT OF UNIVERSITY HOSPITAL. February ist to 28th, inclusive. BLOOD EXAMINATIONS. Leucocyte counts 191 Erythrocyte counts 16 Differential Leucocyte counts 7 Hemoglobin determinations 98 Smears for Malarial Parasites 12 Widal Tests 11 Wassennan Tests 20 Blood Cultures 10 Coagulation time 4 369 URIXE EXAMINATIONS. Routine Urinalysis 412 (This included chemical tests for Al- bumin, Bile, Blood, Widal, etc., and in a great many the total estimation for Al- bumin and Urea. In every case a micro- scopical examination was made.) MISCELLANEOUS. Gastric Contents — Chemical-Microscopical Examination ... 11 Feces — Macroscopical, Microscopical, and in some cases Chemical Examination. . . 17 Sputum Examination 26 Bacteriological Cultures and Smears. . . 15 Examination of Spinal Fluid 4 Sections of tissues for Microscopical Examination 30 Autopsies 2 105 Total 886 Dr. J. L. HiRSH, Dr. H. J. Maldies, Dr. R. Diller. ITEMS Dr. Max Kunstler, class of 1907, has purchased the house 2701 Eastern avenue, where he will make his home. In a letter from Dr. Joseph Angelo Devlin, class of 1906, of 168 W. 87th street, New York, we read : "Enclosed please find report of a case occurring in my private practice. Perhaps it will be of sufficient interest to publish in The Bulletin. I hope you can read my writing, but I shan't blame you if you fail, because I can hardly read it myself sometimes. " 'Bill' Hala of 1905 and yours truly are at- tempting to preserve the health and deplete the pocketbooks of the people of the West Side, so you will forgive me if I say good-bye and get back to the fray. "Sincere regards to all who remember me." Dr. W. Cuthbert Lyon, class of 1907, wlio has resigned bis commission in the United States Army J\Iedical Corps, owing to ill-health, has re- turned to Baltimore, and in the near future will open an office in one of the suburbs. At the meeting of the Faculty of Physic, held on March 7, the matter of raising funds for the Department of Pathology was earnestly consid- ered, and the following gentlemen were appointed a committee for this purpose : Profs. Randolph Winslow, John C. Hemmeter, Arthur INl. Shipley. Prof. Randolph Winslow has been appointed by the Provost a member of the Committee on Relations with St. John's ; Drs. Hemmeter, Ashby and Mitchell members of a Committee on Trus- tees. Dr. Joaquin S. Miranda, class of 1908, is Medi- cal Inspector to the City Health Department of Santiago, Cuba. Dr. John G. Hollyday, class of 1868, has been compelled to go to Florida, owing to ill-health. Dr. Houston Boyd Hyatt, class of 1907, of North Carolina, is a patient at the University Hospital. Mr. G. Y. Massenburg, class of 19x1, has been THE HOSPITAL BULLETIN 19 appointed one of the resident physicians at the Church Home and Infirmary. Dr. Massenburg won this distinction by competitive examination. Mr. Richard C. Dodson, class of 191 1, has been appointed assistant resident physician at the He- brew Hospital for the coming year. Dr. Robert Parke Bay, class of 1905, has been selected by Adjutant-General Warfield of the Maryland National Guard as one of the men whose names were submitted to the War Depart- ment to observe the maneuvers of the army now mobilized in Texas. Messrs. Joseph Enloe Thomas, Paul Pressly McCain, Herbert Augustus Codington, William Clinton Marett, and Grafton Dent Townshend, all of the present senior class, have through com- petitive examination been appointed resident phy- sicians at Bayview Hospital. Dr. William D. Cawley, class of 1902, of Elk- ton, Md., is a member of the medical staff of the Union Hospital in Cecil county. His services will be given during the months of March and August, 1911, and January and June, 1912. Among the consultants at the Union Hospital in Cecil county are the following University grad- nates: Drs. Randolph Winslow, class of 1873; St. Clair Spruill, class of 1890; Robert L. Mitchell, class of 1905, and Alexander D. Mc- Conachie, class of 1890, all of Baltimore, and Dr. Granville Hampton Richards, class of 1908, of Port Deposit. Drs. Winslow, Spruill and Rich- ards are consulting surgeons, Dr. Mitchell as- sistant consulting gynecologist, and Dr. McCon- achie consultant on ear, eye and throat diseases. Dr. Robert Parke Bay, class of 1905, has been appointed lecturer on oral surgery in the depart- ment of dentistry of the University of Mar\'land. Dr. Louis Hamilton Seth, class of 1908, was a recent visitor in the University Hospital. Dr. Josiah Sheer Bowen of Mount Washing- ton, class of 1903, read a paper entitled "A Bio- graphical Sketch of Dr. William G. Bodie," at the regular meeting of the Baltimore County Medical Association, held at the Guild House, Towson, March 15, 191 1. Dr. Norman T. Kirk, class of 1910, assistant resident physician in the University Hospital, who recently had his tonsils removed, is suffi- ciently recovered to resume his duties at the hospital. Dr. Summerfield Bond, class of 1883, is a pa- tient at the University Hospital. We are glad to report that Dr. St. Clair Spru- ill, class of 1890, who has been quite ill, has so far improved as to be able to resume his practice. We are glad to report that Mr. William Clinton Marett, class of 191 1, who has been a patient in the University Hospital, has returned to his stud- ies much improved. Dr. Erasmus Helm Kloman, class of 1910, assistant resident gynecologist, is a patient in the University Hospital. Dr. Benjamin Franklin Tefft, Jr., of Anthony, R. I., class of 1905, read a paper on "Sepsis" at the regular monthly meeting of the Kent County (R. I.) Medical Society, held at Arctic, R. I., on February 9. Dr. Tefft is medical examiner for the first district of Kent county. The Red Springs (N. C.) Citizen publishes a portrait of Dr. Roscoe Drake McMillan, and gives an account of the McMillan Sanitarium, which was opened in Red Springs on January iSth of this year by Drs. R. D. McMillan, class of 1909, Benjamin F. McMillan, class of 1882, and John Luther McMillan, class of 1881. The Citi- zen says : "The present sanitarium, which is located in the Grantham building, is provided with ten rooms for patients ; an operating-room and a laboratory for pathological work are features of the institution, the former being equipped with the most modern appliances known to scientific surgery, and the latter having every facility for the examination of the blood for disease germs. Dr. R. D. McMillan, the resident surgeon, re- ceived his diploma in 1909, when he was ap- pointed assistant resident surgeon in charge of the Maternity Hospital connected with the Uni- versity of Maryland, which position afforded a splendid opportunity for the development of both skill and knowledge in the practice of both medi- cine and surgery amidst conditions and under 20 THE HOSPITAL. BULLETIN circumstances that tested ability. Last year, after serving one year in this capacity, he returned to his home and took up the practice of medicine among tiie people of his town. Drs. B. F. and J. L. McMillan are graduates of the same uni- versity and have been practicing here for many years. Mrs. Mattie Smith, the superintendent of the sanitarium, is a graduate nurse of the Mor- gantown State Hospital, at Morgantown, N. C, and has served in the Watts Hospital at Durham and at the A. C. L. Hospital at Rocky Mount, N. C. "It is proposed to erect a three-story building along the railroad tracks for the treatment of white patients and to use a building already erected for colored people, while the building now in use will be devoted to the use of Indian patients. This will give this entire section hos- pital facilities second to none in the State, and operated by a corps of physicians and surgeons who have the confidence and esteem of the entire community, the direct reward of their pronounced skill and knowledge and of the integrity that characterizes all their relations in both a profes- sional and civic capacity." Dr. John C. Hemmeter, class of 1884, delivered the annual oration at the meeting of the Pennsyl- vania Branch of the University of Maryland Alumni Association, held in Harrisburg, Febru- ary 23, 191 1. Dr. Daniel St. Thomas Jenifer, class of 1904, formerly of Atlantic City, N. J., has removed to Towson, where he will engage in practice. Dr. Richard C. Massenburg, of Towson, class of 1884, has entirely recovered from his recent illness. Dr. Josephus A. Wright, class of 1881, assistant superintendent of the Eudowood Sanatorium for Consumptives, has resigned and will practice in Towson. Dr. Samuel Claggett Chew, class of 1858, was re-elected president of the board of trustees of the Peabody Institute at the meeting held Febru- ary 13th. Dr. Howard J. Maldies, class of 1903, has been made lecturer on pathology and bacteriology in the Department of Dentistry of the University. Dr. George W. Dobbin, class of 1894, has been awarded $3,800 damages for injuries received in an automobile collision. Dr. Willard James Riddick, class of 1905, as- sistant surgeon, U. S. N., has been detached from the South Carolina and ordered to the naval sta- tion at Guantanamo, Cuba. DEATHS Dr. George William Mahle, class of 1905, died at his home, 1903 West Baltimore street, Febru- ary 20, 191 1, of tuberculosis. Dr. Mahle was 29 years of age. After his graduation he became resident physician at Bayview, and resigned one year later to become a surgeon in the Robert Garrett Hospital, which position he held until his death. Dr. Mahle was very popular among the University men, and his death is deeply re- gretted. He had been seriously ill about two weeks. lie is survived by his mother, one brother and four sisters. Dr. David Marshall Devilbiss of Woodville,, Frederick county, Md., died at his home Febru- ary 14, 191 1, from nephritis, aged 66 years. Dr. Devilbiss has practiced in Frederick county since his graduation. He was born near Liberty, Md., April 3, 1845, the son of Adam A\'ashington and Rosanna Devilbiss, both natives of Maryland. His ancestors were Huguenots who fled from France during the French Revolution and found refuge in Germany, afterwards coming to An- - ica. Dr. Devilbiss obtained his earlier education at Little Hill Academy and Dickinson College. His preceptor in medicine was Dr. Thomas W. Simpson of Liberty, and he entered the medical department of the University of Maryland in 1870, graduating in 1872. He practiced first at Liberty, then for a year at Adamstown, then returned to Liberty, formed a partnership with his preceptor. Dr. Simpson, and continued in s'jch relationship for seven years. In 1881 he loc. ted at Woodbine, where he has since remained. He has served as health officer of Frederick county and as State Senator from Frederick. He was a member of the Medical and Chirurgical Faculty of Maryland and the Frederick County Me :cal Society. Dr. Devilbiss married Miss L. M. Clary, He is survived by his widow and three children, Marguerite T., Edna C. and Roger M. Devilbiss. THE HOSPITAL BULLETIN Published Monthly in the Interest of the Medical Department of the University of Maryland trice; $x.oo per year Contributions invited from the Alumni of the University, Businiss Address, 608 Professional Building, Baltimore, Md. Entered at the Baltimore Post-office as Second Class Matter Vol. VII BALTIMORE, MD., APRIL IS, 1911. No. 2 A PATHFINDER IN THE ETIOLOGY AND PROPHYLAXIS OF YELLOW FEVER, HENRY R. CARTER, M.D., LL.D. Sl'RCEON LNITED S 1 ATES PCBLiC HEALTH AND MARINE HOSPITAL SERVICE. By JuHX C. Hemmeter, J\I.D., Phil.D., LL.D., Professor of Physiology^ University of Maryland, and Xath.\n Winslow, B.A., AI.D., 1 Associate in Surgery, University of Maryland. Goethe once classified the various kinds of na- ti-,re contemplation in a comprehensive way ". ( i ) The lowest grade is represented by the "Xutacn suclwndcn." the utility-seekers who apply that which nature otters for their utilitarian purposes. (2) The second are the "Wissbegierigen," or those simply eager for knowledge — the '"curious for nature." Cs) The third are the "Auschauen- den. ' who seek to avoid imagination as far as pos'-'ble and reduce everything to intuition (from the i^atin "intueri," to look on or into). (4) The fourji group are die "LTmfassenden" ; these minds operate in the opposite manner from the "intui- lionalist," for they start from preconceived ideas and seek to encompass (umfassen) their problem by a seeking of a realization of their own ideas in nature. This classification is a helpful one in endeavor- ing tp understand great minds like that of H. R. Carti,.r. Tl ; discovery of the transmission of the dis- covery of yellow fever has been credited, and justly so. to the work of Lazear, Reed and Car- roll, the latter a member of the class of 1891 of the ,; Medical Department of the University of iMaryland. These men, it is true, carried out the experiments which ultimately led to the detection of the manner of conveyance by which yellow fever is communicated from one individual to another. No fair-minded man can deny this fact, but one name which is closely linked to this epochal discovery has been singularly overlooked — that of Henry R. Carter, class of 1879. His work was no less important than that of the three above mentioned. Therefore we gladly tender this tribute with the view of placing on penna- iient record the exact part played by Carter in the investigation of yellow fever. Dr. Henry R. Carter is a native of Virginia ; attended the University of Virginia three years ; studied medicine at the University of Maryland, taking the degree of Doctor of Medicine therein in 1870. He entered the United States Marine Hospital Service the same year, in which he has served ever since, mainly in sanitary work, espe- cially in connection with yellow fever. On June 1. 1910, his Ahna Plater bestowed on him the degree of Doctor of Laws. This honorary degree was bestowed for reasons that will be set forth in the following. The work on which he looks back with most satisfaction is : I. The establishment in quarantine practice of the correct relation between the disinfection (fumigation) of vessels and the detention of their personnel for yellow fever. In the Regulations of the L'nited States Gulf Quarantine Station of 1888, formulated by him, the detention of the personnel of the vessel, to cover the period of incubation of yellow fever, was first dated from the completion of the disin- fection (fumigation by sulphur) of the vessel, their last chance of exposure and infection. At that time the ports of the United States which required fumigation of vessels for yellow fever dated the period of detention " days from date of arrival in quarantine," or "from date of departure from last infected port," the number of days varying from "three" to "forty" or "to after frost." But in no case did this period bear any relation to the date of freeing the vessel from infection. It not infrequently happened, then. THE HOSPITAL BULLETIN that a vessel would lie Iter full time — say 20 da}s — in c[uarantinc and be freed from infection ( fumigated) only the day of leaving. Some members of the erew exjiosed to infection just preceding or during this process in the hold or other seldom-visited parts of the ship would con- tract yellow fever and develop it after the vessel had docked and they had gone ashore, the period of incubation — five or six days — from the time the fever was contracted being sufficient to allij\v of this. This principle is entirely obvious and is the pivot of the whole system of combined disinfec- tion and detention, yet it was ignored not only by L'nitcd States ports, but in all the British ports considered infectable by yellow fever — Gibraltar, ;\Ialta, Jamaica, Trinidad, ct a/.^as well as the I'rench and Danish West Indies, and it was not until the L'nited States Quarantine Regulations became mandatory that it became universal in the United States. II. Devising a system of maritime quarantine by which such sanitary measures, prevention of infection or disinfection, are taken for vessels in a foreign infected port as will enable them to sail free from infection for the United States from such ports, these measures being rendered pos- sible by corresponding privileges granted at the port of entry to the vessels which adopt them. This was begun in principle in 1890 and ap- plied extensively in 1893 at the cholera-infected ports of Europe. It is now an integral part of Maritime Quarantine System of the L'nited States, and has been of great value both as a purely sani- tary measure and as removing restrictions to com- merce, especially the last. III. W^'ork on the epidemiology^ of yellow fever, including the determination of its period of incubation in man, and especially the discovery of the "extrinsic incubation" of that disease. Dr. Henry R. Carter showed that while the ex- istence of a case of yellow fever in an infectable environment can render that environment in- iect-cd in a very short time, a few hours, yet a considerable period of time must elapse before that environment becomes infect-;V^ — that is, capable of communicating yellow fever to other men. This Dr. Carter called the "extrinsic incu- bation of yellow fever," and fixed its period at "somewhat over 10 days as a minimum." This is in close analogy with the time as determined by Celli and others that elapses between the date of an anoi)hfles mosquito Incoming infected with the parasite of malaria and becoming capable of con- veying that disease. This fact was used with much advantage in epidemiological work in 1898 and 1899. The genius of Reed, James Carroll and Lazear (it was Lazear who first spoke to Dr. Carter of its implying a living host) used this thesis as a clue to the problem of the convevance of yellow fever. It is this that gives it its especial importance, and it is no small gratification to Dr. Carter to think that his work assisted in the epoch- making discovery of Carroll and Reed. I\'. In addition to the above permanent work of enduring excellence, presumablv we should call attention to Dr. Carter's work in the yellow-fever epidemics of 1893, 1897, 1898 and 1899, the de- tails of which are on record in the United States Public Health and Marine Hospital Service. In these epidemics he represented the L'nited States ; in Louisiana only in 1897; m the entire infected area in 1898 and 1899. This was purely execu- tive work, and was done with practically no au- thority, "in co-operation with State and local health authorities." Yet it was adjudged to have been successful. In his districts commerce was carried on fairly well, panic was quieted, and there was no spread of fever to new sections. In 1898, working with the JNIississippi health authorities, the epidemic of yellow fever at McHenry, a town in Southern jMississippi, was suppressed. This was the first instance of an epidemic of yellow fever in the far South, well under way, in June and July, being suppressed. The method used was the control of the human host. The conve}'ance by the stegomyia was ;wi then known, and, except the unnecessary disinfec- tion of clothing, was not all adapted to that end, even in the modern light of the mosc^uito convey- ance. The same methods here instituted were used successfully by White and Von Ezdorf in an outbreak of yellow fever at Hampton, Va., two years later. We have contrasted this executive work with permanent original or research work. This class of executive work bears the same relation to, say. the determination of the extrinsic incubation of yellow fever that a campaign, the troops using firearms, does to the discovery of gunpowder. The strategist avails himself of what the investi- gator discovers. THE HOSPITAL BULLETIN As an estimate of the value of Dr. Carter's work the following letters are appended : Board of Health Laboratory, Ancon, Canal Zone, October 4, 1900. Dr. ^^■illiam Royal Stokes, City Hall Annex, Baltimore, ]\Id. Dear Dr. Stokes : Before I forget it again I must write to you about a matter that has been on my mind for sev- eral months. Dr. H. R. Carter, who was our first Chief Quarantine Officer, and for four and one- half years Director of Hospitals here, has returned to the States, to be located at Louisville. Ky. Dr. Carter, as you know, by his wonderfully keen observations made during several epidemics of yellow fever, particularly the one in Louisiana, brought out his theory of an "extrinsic period of incubation," \\hich was of the greatest value in helping Reed to a successful issue in his A'ellow- fever experiments. Ronald Ross told iiic in Liverpool three years fl.^o that he had put in Dr. Carter'.; name for the Nobel prize. Dr. Carter has never received (|uite the recognition he deserves for his yellow-fever observations and for his pioneer quarantine work. As you and he are alunmi of the University of ]\Iaryland. I want to suggest that you use your ' influence in getting an honorary degree from the University for him next year. I cannot see why he has been neglected, for his work is recognized abroad and in all literature on the subject, and his name will alwa^'s be linked with Finlay's in con- nection with yellow fever. Reed in letters to Dr. Carter told him how val- uable Dr. Carter's observations had been to him in his }-ellow-fever work. I sent some slides showing malarial zygotes and sporozotes to Dr. Pearce of Winnipeg, and hope thev were of some value to him. \\"ith kindest regards to i\Irs. Stokes and the children, I am. Yours very truly, S. T. Darling. I have also made the suggestion to Dr. Perry, our jiresent quarantine officer, about the honorary degree for Dr. Carter. Board of Health Laboratory, Ancon, Canal Zone, December i, 1909. Dr. ^^'illianl Royal Stokes, City Hall Annex, Baltimore, Md. Dear Dr. Stokes : I have received from the members of Dr. Car- ter's family data relating to his work, investiga- tions and published researches in compliance with your request of October 14. 1st, Tlie determination of the period of incu- bation of ycllozv fever: The determination of the period of incubation of yellow fever in man and the placing of the period of quarantine detention of the personnel for this disease on a rational basis, dating it from their last exposure. The completion of disinfec- tion to cover the period of incubation, while all ports of the United States and Great Britain were dating it from the hour of arrival in quarantine to leaving the infected port, the period of this detention being apparently chosen arbitrarily, as no two ports had the same. The disinfection of vessels on leaving ports infected with yellow fever and dating the time of detention from this disin- fection so that the days en route would count as days in quarantine. This, of course, he applied to all vessels leaving ports wdiere quarantinable dis- eases carried by vessels prevailed. 2d. The discovery that there zvas a period of "E.vtrinsic Incubation" in its environment for yel- low fever and the approximate determination of its minimum duration as somewhat over 10 days: By "extrinsic incubation" was meant that a cer- tain considerable period of time must elapse be- tween the date that a place received infection from a yellow-fever patient before it became infective, i. e., capable of conveying it to other men. These investigations were begun in 1888. The article was written in December, 1899, and January, 1900, and published in May, 1900. He himself, however, had lieen using it as a working basis for several years before — no one else accepting it. 3d. Quarantine ivork at Chandeleur and Ship Island (';ri888 to 1892: ^^'hat was really done at Ship Island and Chan- deleur was the establishment of the United States Maritime Quarantine System and the systematiza- tion of the quarantine methods for yellow fever. Prior to this time the State quarantine stations of the South Atlantic and Gulf ports differed among themselves in regulations, methods of disinfection and period of incubation, and no one station was willing to take the pratique of the other. His effort at Ship Island was to get them all to agree upon one method of handling vessels, doing all that was necessary and nothing that was believed to be unnecessary. . That was successful, and be- fore he left the Southern ports accepted the pra- tique of the United States stations. It was while here that he formulated his ideas of disinfecting vessels at the port of departure so that the days en route should count as days in quarantine. This was proposed at the meeting of the American Public Health Association at Charleston, S. C, in 1890. It was regarded as impracticable by some and dangerous by others, but is now universally accepted by sanitarians and is the key to practically all the methods of the United States quarantine. Its benefits to com- merce can readily be imagined. It was also here, while working upon the problem of the incubation of yellow fever in man, that he discovered the phenomenon of the "extrinsic incubation" of that disease in infected places, which he subsequently THE HOSPITAL BULLETIN 25 worked out in t8o8. Prior to this time, however, he was sufficiently convinced of its truth to use it as a working- basis. Since leaving- Ship Island and Chandeleur he has held every quarantine station of the United States from Ship Island to Delaware Breakwater, and had much to do with founding and equipping- them. He had charge of the train inspection, communication and everything save measures in the city in the P)rnnswick epidemic of yellow fever in 1893. He was in charge of the measures in Louisiana and the train inspection in the epiden-iic of i8<-)7. He was in charge of the South in the epidemics of i8q8 and 1899. In 1898 he was in charge of the epidemic of yellow fever in the little town^of McHenry, Miss., which was, it is believed, the first place in the South in which an epidemic of yellow fever had ever been stamped out in the sunmier time. He organized and had charge of the quarantine of the Island of Cuba in 1899-1900. SOME OF PUS PUBLISHED RESEARCHES. 1st. ".\ Note on the Interval Between In- fecting and Secondary Cases of Yellow Fever from the Records of Yellow Fever at Orwood and Taylor, Miss., 1898." — The New Orleans Medical and Surgical Journal, May, 1900. 2d. "A Note on the Spread of Yellow Fever in Houses — the 'Extrinsic Incubation.' " — Med- ical Record. June 15, 1901. This was written for the medical convention that met at Havana February, 1901. 3d. "A Correlation of Some Facts in the prop- agation of Yellow Fever, with the Theory of Its Conveyance by the Culex fasciatus." — Philadel- phia Medical Journal, April 6, 1901. This was written while he was sick in hospital in Jjaltimore in November, 1900. 4th. "Are Vessels Infected with Yellow Fever? Some Personal Observations." — Med- ical Record. March 22. 1902. 5th. "Some Characteristics of the Stcgoinyia fasciatus which Afifect Its Conveyance of Yellow Fever." — Medical Record, May 14, 1904. 6th. "The Conveyance of Yellow Fever." — Medical Xezvs, November 5, 1904. Reatl before the Texas State Medical Associa- tion April 27, 1904. 7th. A little memorandum written April 6, 1906 : published in the Medical Record — date not known — aiming to show that yellow fever was habitually contracted in the daytime, at least in Panama, in contravention of the statement of ]\Iarchanx, Simon and Salimbini. Besides this, there have been a number of ar- ticles written for publication by the service, giving in detail the measures necessary in handling yel- low-fever epidemics — i. e., train inspection, com- munications with a town infected with yellow fever, etc. There have been, also, articles on other professional subjects, the first one in 1882, entitled "Syphilis in the Negro." RECENT TAPERS. "Recent Advances in Tropical Medicine." Read before the Pan-.\merican Scientific Congress held at Santiago, Chili, December 25, 1908, to January 5, 1909. "Malarial Fever Work on the Isthmus." Reld before the Canal Zone Medical Association in 1908. In 1905 or 1906 Dr. Carter's name was pre- sented for the Nobel prize in medicine. At that time he prepared a statement of his relations to the study of yellow fever as a sanitarian and an epidemiologist. The substance of Dr. Carter's statement is outlined above. There is no doubt that Dr. Carter's researches induced Durham and Walter Meyer to make the yellow-fever investiga- tion at Para, and that it actually influenced (and as to time determined ) the direction of Reed's investigations as well is borne out by many verbal and written statements by him. Dr. Reed had been much impressed by the valuable observations niade at Orwood and Taylor, Miss., by Dr. Carter on the interval between infecting and secondary cases of yellow fever. Experiments by Dr. Reed confirmed those already mentioned by Dr. Carter in 1898 that at least 12 days must elapse between contamination of the mosquito by the blood of a yellow-fever patient and the communication of the disease. Ronald Ross regarded Dr. Carter's observations on the extrinsic period of incubation of yellow fever as an extremely important one in its relation to the work of the Yellow Fever Com- n-iission in Cuba. Dr. Ross has recently invited Dr. Carter to contribute a chapter on his forth- coming book on tropical hygiene. The above memoranda expresses in bare out- lines Dr. Carter's work in connection with yellow fever, sanitation and quarantine. Ne-vy truly yours, S. T. Darlixg. Baltimore. Md. Dr. John C. Flemmeter : Dear Doctor — A number of the friends of Dr. H. R. Carter have thought for some time that it would be a deserving honor for him if liis .Alma Mater, the LIniversity of Maryland, could confer an honorary degree upon him on account of the early and important work which he carried out and which led directly to the brilliant discoveries of Reed and of his assistants concerning the trans- mission of yellow fever by the mosquito. I am informed by Dr. S. T. Darling, who has charge of the hygienic laboratory of the Canal Zone, that Dr. Carter has left the Isthnius and is about to settle in Louisville. Dr. Darling has very care- fully collected the data which we enclose, and I think that you will agree that this work is deserv- ing of proper recognition. On the other hand, it adds to the glory of our Alma Mater to empha- size such humanitarian work when performed by one of her son.s. We therefore respectfully ex- 26 THE HOSPITAL BULLETIN press the wish and hope that you will attempt to secure an honorary degree for Dr. Carter. The following is the data collected by Dr. Dar- ling concerning the work, investigations and pub- lished researches in compliance with your request of October 14: 1st. The detcriuination of the period of incu- bation of ycllozv fever: The determination of the period of incubation of yellow fever in man and the placing of the period of quarantine detention of the personnel for this disease on a rational basis, dating it from their last exposure. The completion of disinfec- tion to cover the period of incubation, while all ports of the United States and Great Britain were dating it from the hour of arrival in quarantine to leaving the infected port, the period of this de- tention being apparently chosen arbitrarily, as no two ports have the same. The disinfection of vessels on leaving ports infected with yellow fever and dating the time of detention from this disin- fection so that the days en route would count as days in quarantine. This, of course, he applied to all vessels leaving ports where quarantinable diseases carried by vessels prevailed. 2d. The discovery that there zvas a period of "Extrinsic Incnhation" in its environnicnt for yel- low fever and tlie approximate determination of its minimum duration as somezvhat over 10 days: By "extrinsic incubation" was meant that a cer- tain considerable period of time must elapse be- tween the date that a place received infection from a yellow-fever patient before it became infective, i. e., capable of conveying it to other men. These investigations were begun in 1888. The article was written in December, 1899, and January, 1900, and published in May, 1900. He himself, however, has been using it as a working basis for several years before — no one else accepting it. 3d. Quarantine work at Chandeleur and Ship Island t;ri888 to 1892: What was really done at Ship Island and Chan- deleur was the establishment of the United States Maritime Quarantine System and the systematiza- tion of the quarantine methods for yellow fever. Prior to this time the State quarantine stations of the South Atlantic and Gulf ports differed among themselves in regulations, methods of disinfection and period of incubation, and no one station was willing to take the pratique of the other. His ef- fort at Ship Island was to get them all to agree upon one method of handling vessels, doing all that was necessary and nothing that was believed to be unnecessary. That was successful, and be- fore he left the Southern ports accepted the pra- tique of the United States stations. It was while here that he formulated his idea of disinfecting vessels at the port of departure so that the days en route should count as days in quarantine. This was proposed at the meeting of the American Public Health Association at Charleston, S. C, in 1890. It was regarded as impracticable by some and as dangerous by oth- ers, but is now universally accepted by sanitarians and is the key to practically all the methods of the L^nited States Quarantine. Its benefits to com- merce can readily be imagined. It was also here, while working upon the problem of the incubation of yellow fever in man, that he discovered the phenomenon of the "extrinsic incubation" of that disease in infected places, which he subsequently worked out in 1898. Prior to this time, however, he was sufficiently convinced of its truth to use as a working basis. Since leaving Ship Island and Chandeleur he has held every quarantine sta- tion of the United States from Ship Island to Delaware Breakwater, and had much to do with founding and equipping them. He had charge of the train inspection, communication and every- thing save measures in the city in the Brunswick epidemic of yellow fever in 1893. He was in charge of measures in Louisiana and the train in- spection in the epidemic in 1897. He was in charge of the South in the epidemics of 1898 and 1899. In 1898 he was in charge of the epidemic of yellow fever in the little town of McHenry, Miss., which was, it is believed, the first place in the South in which an epidemic of yellow fever had ever been stamped out in the summer time. He organized and had charge of the quarantine of the Island of Cuba in 1899-1900. SOME OF HIS PUBLISHED RESE.\RCHES. 1st. "A Note on the Interval Between Infect- ing and Secondary Cases of Yellow Fever from the Records of Yellow Fever at Orwood and Tay- lor, Miss., 1898." — The New Orleans Medical and Surgical Journal, May, 1900. 2d. "A Note on the Spread of Yellow Fever in Houses — the 'Extrinsic Incubation.' " — Med- ical Record, June 15, 1901. This was written for the ]\Iedical convention that met at Havana February, 1901. 3d. "A Correlation of Some Facts in the Prop- agation of Yellow Fever, with the Theory of Its Conveyance by the Culex fasciatus.'' — Philadel- phia Medical journal, April 6, 1901. This was written while he was sick in hospital in Baltimore November, 1900. 4th. "Are Vessels Infected with Yellow Fever? Some Personal Observations."- — Medical Record, March 22, 1902. 5th. "Some Characteristics of the Stegomyia fasciatus which Effect Its Conveyance of Yellow Fever." — Medical Record, May 14, 1904. 6th. "Conveyance of Yellow Fever." — Med- ical A'ezvs, November 5, 1904. Read before the Te.xas State IMedical Associa- tion April 27, 1904. 7th. A little memorandum written April 6, 1906; published in the Medical Record, date not known, aiming to show that yellow fever was habitually contracted in the daytime, at least in Panama, in contravention of the statement of Marchan.x, Simon and Salimbini. THE HOSPITAL BULLETIN V Besides this, there have been a number of ar- ticles written for publication by the service, giving- in detail the measures necessary in handling yel- low-fever epidemics — i. c, train inspection, com- munications with a town infected with yellow fever, etc. There have been, also, articles on other professional subjects, the first one in 1882, entitled ■'S\'philis in the Negro." RECENT r.\PERS. "Recent .Vdvances in Tropical Medicine." Read before the Pan-American .Scientific Congress, held at Santiago, Chili, December 25, 1908, to January 5, 1909. "Malarial Lever Work on the Isthmus." Read before the Canal Zone Medical Association, 1908. In 1905 or 1906 Dr. Carter's name was pre- sented for the Nobel prize in medicine. At that time he prepared a statement of his relations to the study of yellow fever as a sanitarian and epi- demiologist. The substance of Dr. Carter's state- ment is outlined above. There is no doubt that Dr. Carter's researches induced Durham and Wal- ter Meyer to make the yellow-fever investigation at Para, and that it actually influenced (and as to time determined) the direction of Reed's investi- gations, as will be borne out by many verbal and written statements by him. Dr. Reed had been impressed by the valuable observations made at Orwood and Taylor, Miss., by Dr. Carter on the interval between infecting and secondary cases of yellow fever. Experiments by Dr. Reed con- firmed those already mentioned by Dr. Carter in 1898 that at least 12 da}-s must elapse between the contamination of the mosquito by the blood of the yellow-fever patient and the communication of the disease. Ronald Ross regarded Dr. Carter's observation on the extrinsic period of incubation of yellow fever as an extremely important one in its relation to the work of the Yellow Fever Com- mission in Cuba. Dr. Ross has recently invited Dr. Carter to contribute a chapter on his forth- coming book on tropical h3'giene. The above memoranda expresses in bare out- lines Dr. Carter's work in connection with yellow fever, sanitation and quarantine. Yours very truly, William Royal Stokes. coxclusiox. We have now reached a sufficient degree 01 familiarity with Carter's work and the method of his research and thinking to recognize that he belongs to Goethe's "Auschaiicnden." He is clearly an objective worker who seeks to avoid imagination as far as possible, and humbly sub- mits to the hard facts of observation and experi- ment. The day will come when some great thinker — a medical Bancroft — will write the history of American medicine, and then such pioneers and heroes as James Carroll and Henry R. Carter will stand out on the roll of honor in the American }kledical "IValhalla" as brilliant as the names of any scientists, artists, statesmen, naval or military heroes our nation has ever produced. And this is to let the world know that they are sons of the University of Maryland. A CASE OF PERSISTENT VOMITING FOL- LOWING GASTRO - ENTEROSTOMY, PERFORMED FIVE YEARS AGO — SECOND ABDOMINAL SECTION, DE- CEMBER, 1910— CHEMIC AND PHYS- IOLOGIC STUDY OF DISTURBED CO- ORDINATION BETWEEN THE STOAI- ACH AND DUODENUM. Reported and shozvn by Albert II. Carroll, M.D. ; E. E. tKicnOLS, Senior Medical Student, and W. C. Marett, Senior Medieal Stndent in Prof. John C. Hemme- ter's Clinic on Diseases of Digestion and Mctalbolisni, University of Maryland. This interesting case which we have to present today is one of those obstinate cases of vomiting, with quantities of bile in the vomita, with emacia- tion, anemia and with marked nervous symptoms. An atrophic pancreatic condition was at first sus- pected and carefully looked for. The findings were negative. We are now convinced that this is a case of what is commonly called "vicious circle," following a gastro-entorostoniA-. This operation was done five >ears ago. It appears to us that relief will only be had by undoing the work then done, and this has been recommended. Entrance note. History. Name, C. E. : age, 30 years ; occupation, fireman on steamship of Hamburg-American line ; social condition, single. The patient entered this hospital December 5, 1910, complaining of stomach trouble. He first had trouble with his stomach eight years ago, when lie had severe fullness and "hardness" after eat- ing, with frequent vomiting. He was treated for two years; his stomach was washed out every night. Six years ago — two years after his trouble began — he was operated on in Hamburg, Ger- many, by Professor Urban. At that time a gastro- enterostomy was done. Fourteen days ago he no- ticed a sensation of burning and heaviness in the 28 THE HOSPITAL BULLETIN epigastric region, coming on about one hour after taking food. This was reheved either by vomiting (which was frequent) or disappeared in about two hours. For the first six or seven days he kept on working, but since then he has been confined to bed. The vomitus is "lime-green" in color. Before this operation was performed the patient "vomited blood" twice. His appetite is poor; the bowels are regular. The first six days' stools were black and tar-like. Xo history of jaundice. Examination for occult blood was not made till later, and was not found then. Hub'/s. — Patient worked five years in a brewery in Germany, during which time he drank beer in large quantities. A history of other dietary indis- cretions or of trauma at any time was not ob- tained. We must remember that he is a stoker. Faiiiilv History. — Father died in 1880 in Aus- tralia. JMother living and well ; one sister and one brother living and well. Negative to cancer, tu- berculosis, gout, epilepsy, etc. Past History.- — Negative to diphtheria, tubercu- losis, measles, scarlet fever, rheumatism, pneu- monia and pleurisy. Had typhoid lasting six weeks while in Argentina, S. A., two years ago. He had an attack of gonorrhea at the age of 20 years which lasted nine months, and again at 28 years of age. which lasted five weeks. Past his- tory otherwise negati'V'e, except such troubles as above described. Present Illness. — ^^'hile at work about two weeks ago he was taken with pains of a dragging, dull character in his epigastrium, followed by sour eructations of a burning character and by vomiting. He says that the vomitus was largely composed of mucus of a whitish-gray color. Since then he has had numerous cramps — like attacks which were followed by the vomiting of a green- isli substance. Owing to poor digestion and as- similation, he is weak and has lost weight. He is very downcast and discouraged. Plivsical E.vaniination. — The patient is a fairly well-developed white man. with muscles of fair tone. The head is round, and is covered with a good crop of light hair. Forehead receding: no scars. Ears, no tophi, mastoid tenderness or dis- charge. Nose, no discharge or tenderness over accessorv sinuses. Eyes, pupils equal and react to light and accommodation, conjunctiva somewhat injected, .sclera clear, ocular movement good. Mouth, teeth in bad state of preservation, pyor- rhea marked. Tongue protrudes in the median line, slight tremor. Dorsum fairly clear, breath foul. No tonsillar enlargement. Neck well de- veloped, post-cervical glands palpable. No ab- normal pulsations or tracheal tug. Thyroid gland not palpable. Chest. — Fairly well developed, palpation and percussion normal and equal. Auscultation, voice sounds are decreased on the left side. Heart. — P. M. I. neither visible nor palpable. Sounds at apex beat heard at fifth interspace, to the inner side of M. C. L., of good tone and qual- ity. No murmurs were heard ; absolute cardiac dullness is not increased. Abdomen. — Liver dullness begins at seventh rib, and ])alpab!e two fingers' breadth below cos- tal margin. A median post-operative scar is noted above the umbilicus ; it is about three inches in length. Stomach. — Extends to the umbilicus, and gur- gling sounds were heard on direct percussion, otherwise negative. Inguinal glands palpable. Genitalia. — Large, bilateral varicocele. No scar. Extremities. — Poorly developed. His reflexes are normal. The axillary and epitrochlear glands are palpable. Pulse regular, tension and volume fair, and rhythm good. This case was referred from the medical to the surgical side, and an exploratory laparotomy ad- vised. The abdomen was opened by Dr. J. Holmes Smith, and it was found that a gastro-enterostomy had been performed. The stomach was opened, and both the pyloric and the artificial openmg found patent. No evidence of a past or present ulcer was present, or at least not observed. A large intestinal loop had been used. No obstruc- tion was found, and the openings in the stomach and in the abdomen were closed in the usual way. The patient's condition at first led us to suspect an atrophic pancreatis. (Later findings negate this diagnosis.) It has been noted that gastro-enterostomies are frequently followed by an atrophy of the pan- creas. (The normal stimulation of the pancreas is due in part to ihe action of the acid gastric con- tents on the papilla of Vater. This is supposed to send a reflex stimulation to the pancreas and excite it to action.) There are but few physical symptoms or signs by which a positive diagnosis of atrophy of the pancreas can be made. The pancreas is not nor- mally a palpable organ. Small cubes of boiled Till': HOSPITAL BULLETIN 29 meat enclosed in gauze were fed to this patient. The niicleii were not found in the muscle fibers when the gauze bags were examined after they had passed through the alimentary tract. Pan- creatis is associated with a great deal of weakness, emaciation and epigastric pain. Stools did not contain fat in excess after a- diet of olive oil and milk. Uriiw. — Color, amber ; odor, aromatic. Reac- tion acid. spgr. 1020. Albumen and sugar, ab- sent; sediment.' few epithelial cells and some granular. Stoiiiacli Contents. — On December 7 the patient vomited, and vomitus showed bile present in large amount. Free HCl 8. Total acidity 20. Xo blood. On December 8, after a test meal, the stomach contents were drawn, and consisted of aljout one pint of greenish fluid, with a fine brown- ish sediment. Free HCl absent Total acidity 36. -Again no blood was found. Lactic acid test was negative. Microscopical examination — yeast cells, muscle fibers, cellulose and fat present, bile present. Blood, leucocytes 12,600, reds 3,500,000. Medicinal Treatment. — Had a pancreatitis really complicated this case of "vicious circle," we might have given artificial preparations of the pancreas, pancreatin or papain to replace the pancreatic fer- ments. However, we doubt the presence of an atrophic pancreatis, basing our diagnosis on the microscopical examination of the feces after a fat plus a meat diet. His measurements are as follows : M. X., 8 inches. M. U., 16 inches. -M. S., 8K' inches. X. R. S., 9 inches. X. L. S., 9 inches. S. S., 9 inches. C. at X., 34 inches. A. at X., 90°. Height, 5X> feet. X angle, 90°. Weight, 125 pounds. Age, 30 years. Present clinical findijigs: Hemoglobin, 70°. Urine, negative to albumen and sugar. Feces, no starch or an excess of fat. Stomach contents, no free HCl; total acidity, 30; no blood. Sputum negative to T. B. No gastrojjtosis, and onh- a slight dilation of the stomach. No floating tenth ribs. No occult blood found. Trcotnwnt. — This is surgical. The gastro-en- terostomy should be undone and the opening between stomach and duodenum should be closed. The food will then pass through the pylorus into the duodenum, and thereby restore che norma! stimulus to the pancreas. -Although there was a deficiency of HCl, an undiscovered ulcer is to be thought of, and the return flow of alkaline in- testinal secretions may ha\'e neutralized any hyperacidity. The prognosis is not favorable. The patient has returned to German)'. CARCINOMA OF SCALP.* By .A. -Aldridge Matthews, ]\I.D., Spokane^ Wash. Case VIII. — A. K., schoolboy; age 14. Re- ferred to me October 24, 1910. Past and family history negative. In February of this year he was struck on the head with a dress-suit case, the corner of which lacerated his head in the post-parietal region on the left side. He went to a physician, who cleaned the wound and sewed it up. The wound healed by first inten- tion and seemed to be practically well, but about two months later he noticed a small swelling about the size of a bean, which he thought was a wart starting on his head. He went back to his phy- sician, who excised a little growth, and told him that it would give him no more trouble. -A little later, after the wound had healed, he noticed that the growth was coming back, and he let it grow until it reached the size of half a hen's egg, as he e-xpressed it. At this time he went to another physician, who removed this growth again and sutured the wound together, which healed pri- marily, this being only six weeks ago. Since this time the growth has increased very rapidlv in size and is now the size you see it. about three inches in diameter and one inch in thickness. It occupies the post-parietal and occipital region on the left side. It is very hard and firm to the touch, and painless. The glands down the neck are palpable, the largest being about the size of the end of your •Repoi'ted af Spokane County llcilioal Socii't.v. 30 THE HOSPITAL BULLETIN finger. I removed one of tliese glands and had it examined, and found it to be a carcinoma. This, I must say, I felt skeptical about. From the clin- ical history I made my diagnosis a sarcoma, but the involving of these glands made it puzzling. A day or two after my examination I operated upon this boy, removing a large area of scalp around the growth, also removing the periosteum, and had contemplated removing the bone, but upon removing the periosteum I found that there was no apparent direct connection between the C.\SE .\. K. .\liovp picture represents about thrce-quiirtors of the orisin.il size of growth and a Tcrtieal scar from a previous operation and stitch-holc scars on the sides. gi'owth and the bone, except that it was a little more adherent in the area where I think he re- ceived the original blow, and from that area I removed a piece of bone about the size of a half dollar, although there is a question in my mind whether it was involved. I also made a dissection of the glands of the neck. In closing the incision I had to slip flaps fiom three directions, covering over the area of the bone from which T had removed the periosteum. These flaps were composed of the scalp, but did not disturb the periosteum under them, simply using the flaps alone to cover the bone. The wound healed up primarily, and on the eighth day following the operation I grafted skin on the peri- osteum, from which I had removed my sliding flaps. I would have done this at the time of the operation, but there was so much capillary oozing that I was certain the grafts would not take. The grafts I got from his thigh. The young man up to the present time has been perfectly well and no indication of any recur- rence. This specimen is the growth which I re- moved, but is very much shrunken from the pre- servative solution it has been kept in. Sections made from the growth proved the diagnosis to be carcinoma. REPORT OF A CASE OF S.VRCOMA OF TIBIA.* By A. Aldridge M.vttiiews, M.D., Spokane. JJ'asIi. Case XII. — N. M. L., schoolgirl; age 15. I was called in consultation to see above patient with Dr. J. F. Hall of Spokane. Family history negative. Past history negative. Present trouble dates back about nine months, and at this tiine she claims that her little sister kicked her on the upper third and anterior surface of right tibia. She thought nothing of it at the time, but it remained sore all the time upon pressure, and also com- plained that after using her leg she felt a little soreness in that region. About three months ago a small swelling appeared over this area which had been tender for so long, which was quite hard to the feel and gave her pain upon pressure. ^\bout six months after receiving the injury she went to see a physician, who told her that he thought there was possibly some pus in this area and suggested opening it, but she declined, and after letting it go for some time went to see another physician, this being about six weeks ago, who advised opening down upon this small swell- ing, as he thought there was some pus present. This was done with local anesthesia, but after so doing he advised her that he could do nothing without putting her to sleep and scraping it out. At pixscnt the growth presents a large red swelling of the iiuier upper third of the tibia; *I!eported at Spoliane Counl.v Jleiiical Society. THE HOSPITAL BULLETIN 31 hard, quite sensitive to pressure, and now causes her considerable trouble when she walks. This discomfort in walking is gradually getting worse. The incision, which was done six weeks ago, had perfectly healed, but the growth had increased considerable in size in that time. I agreed with Dr. Hall in his diagnosis as this being an osteosarcoma, and advised immediate amputation. On the next day, the 28th of No- vember, I operated. Before amputating I opened down upon the growth, and felt convinced with- ^^ [S ^^^V'''^ ^M^H ^^^■^7^1 SpIh^h ^^V'^^^'fi^ r^^^^l ' - -^SH^^^^^^^^^H ^^^pK^paBH»n 9 ^^^^^^Kv A sR 1 ^B'ffl '^M^^^^^^^^^^^M ^^^^^^^^^^H T^^^^^^^^^^^l CASE 12. il. jr. L. Osteo-sarcoma of upper third of tibia. out a reasonable doubt that it was an osteosar- coma ; the variety I could not say positively, as I had no means at that time for making sections. I then amputated a short way above the condyles of the femur, this giving me ample flaps to cover the stump. The patient did perfectly well, but the flaps underwent a dry gangrene for no reason as far as I can see. The blood supply seemed to have been ample, although she bled very little at the time of amputation. There was no infection at any time in the wound, not even 10 days after the work was done, and about this time I placed the patient under an anesthetic, trimmed otT the dried back flaps, re- sected about two inches of the femur, "and drew my new flaps over, which healed primarily. This is my second experience in having flaps slough after amputating for sarcoma. I cannot give any reason why this should be, although I have had other men tell me that they have had the same experience. I placed this patient on Coley serum and gave her increased doses for six weeks following the amputation. The patient is well and in excellent condition at present date. TREATMENT OF PUERPERAL ECLAMPSIA.- By RoscoE D. McMillan, M.D., '10, Red Springs, N. C. In presenting this paper I ful-.y realize that I have chosen a subject whose very depths stand as }et unsounded, as we all know eclampsia is one of the most formidable accidents to which the pregnant woman is liable. This subject, like many other questions of medical interest, the older they are the more they are subjected to discussion and to criticism, the more interesting they become, especiallv in these late years when they can be approached and studied, and in some instances solved by scientific methods of investigation, yet this disease is still classed as "The Disease of The- ories." In order to treat any disease successfully, it is very necessary that the doctor have a thor- ough understanding of the cause or causes of the disease he is about to treat, but as yet we are abso- lutelv ignorant concerning the cause of this dread- ed maladv, but we know that there is a toxic sub- stance circulating in the blood which should have been, but has not been, eliminated by the various excretory organs. The treatment may be divided into two heads, namelv, prohpylactic and curative. First, Prophylaxis. — This, if instituted at the proper time, will prevent many cases of eclampsia, and is certainly productive of untold good, but is not always successful or applicable. It is a very unfortunate thing that the doctor rarely sees the •Read hefore FiftU District Medical Society of Xortli Caro- lina October 11. 1910, at Fayetteville, N. C. THE HOSPITAL BULLETIN case until he is called, and the woman is found in labor or in active convulsions. In every case where the doctor has the oppor- tunity he should forcibly impress his patient, as well as her husband, the paramount importance of the proper care of the pregnant woman ; a speci- men of urine should be sent to his office regularly twice a month for the first seven months, and once a week during the last two months of preg- nancy, and he should be promptly advised if any of the characteristic symptoms arise as disturbance of vision, continued headache, edema of face and limbs and scanty urine, ^^'here there is any reason at all to suspect trouble the physician should sec the patient himself and institute at once proper treatment. Restrict the diet principally to milk. with the addition of dry toast, fruits, chicken broths and the use of plenty of good drinking water. Avoid all stimulants, tea, coffee and meats. Keep the skin, liver and kidneys in active condi- tion. Watch }our patient closely for a few da\ s. and if she does not improve under this expectant treatment don't delay, but empty the uterus in the most conservative manner by the induction of premature labor. By the use of these precaution- ary measures the frequency of eclampsia will be greatly diminished, and many valuable lives saved. Curative. — When in the presence of actual con- vulsions, each and even,' case should be treated rationally, the treatment being determined upon and directed against the cause or causes as they present themselves in the individual case, but I strongly advise against the use of chloroform in the hope of cutting the convulsive seizures short. In this case morphia is the sheet anchor. Give a hypodermic of morphia grs. J4, combined with atrophia grs. 1-150 every 30 minutes until four or five doses are given. It is remarkable the immu- nity these patients seem to enjoy against the c\il effects of this drug. A folded towel should be placed between the patient's teeth to prevent bit- ing her tongue. Stimulate diuresis and bowel movements, and for this I know of nothing better than the old and time-honored drug powdered calomel given in large doses, 15 to 20 grains, on back of tongue. If the convulsions come on dur- ing pregnancy or labor, deliver your patient as soon as possible. As Williams says, "delivery should be effected as soon as is consistent with the safety of the patient," and I heartily agree with him. If the head is low down, deliver with for- ceps : if high, it is well to resort to internal podalic version. Of course, eidier should be done under profound anesthesia and rigid asepsis, and ether is the anesthetic of choice. Where the cervical canal is obliterated, or nearly so, the dilation can be completed by the Harris method of finger dila- tation, or with the aid of instrumental dilatation, using instruments with caution. If the canal has not been obliterated, and is very resistant, don't hesitate, but cut the cervix with blunt scissors and empty the uterus. After delivery of the child the eliminative or- gans should be encouraged as much as possible. If the bowels have not moved, give two drops of croton oil in one dram of olive oil on back of tongue. Surround patient with hot packs, blan- kets wrung in hot water, and surround with hot- water bottles. Diuresis and diaphoresis should be encouraged, and I strongly advise against the use of salt solu- tion and the hypodermic injection of pilocarpine. If there is excessive nervousness, give 30 grains of ciiloral and 30 grains of potassium bromide in a pint of hot water passed high into the rectum. In the class of cases with high arterial tension, the withdrawal of several ounces of blood from the arm or a lumbar puncture is sometimes at- tended with happy results. My experience with Veratrum "V'iridi in this class of cases is sufficient to condemn its use, espe- cially in private practice. A very important fact to remember is that in a great majority of cases the heart muscle is weak, and the treatment all along has been of a depress- ant nature ; the fact must not be lost sight of that stinnilation may be necessary. No treatment should ever be pushed to the point of endangering the patient's life from heart failure. In conclusion, will say the entire line of treat- ment can be summed up in one word, namely, elimination, and in every case where delivery has not been accomplished, it is well to hasten delivery by all practical means, as the condition of preg- nancv is the cause of causes. Dr. Rigdon Osmond Dees, class of 1906, is pursuing special work at the University. Dr. Dees and his brother, Ralph Erastus Dees, also of the class of 1906, are located at Greensboro, N. C., and enjoy extensive practices. THE HOSPITAL BULLETIN 3J ■TLIC HO^PITAI Rlll I FTI N ^^^^^ have gone from our threshold each )-ear are also solicited to make contributions as classes, A Monthly Journal of Medicine and Surgery , , , • ,1 u r i i and, where it is possible, a member of each class PUBLISHED BY r ., ^ t ^ -ll 1 • . 1 . for the past forty years will be appointed to com- THE HOSPITAL BULLETIN COMPANY . / .,,,., , ,,•■..,■ „ municate with his classmates and solicit their co- 608 Professional Building .... 01,, operation in this purpose, bome headway has Baltimore, Md. , , , , • , • ■ , 1 already been made in this campaign, and several _ . . . . ^ . , alumni have promised substantial contributions. subscription price, . . . $1.00 per annum in advance „,%„,..,, „.,.,, A ', • • I he r acuity of Physic will devote the bequest of Reprints furnished at cost. Advertising rates . _ , . , . ,. , submitted upon request the late Miss Robinson to this fund. Robinson bequest $5000 Nathan Winslow, M.D., Editor Class of 1873— Dr. T. A. Ashby. Dr. R. - Winslow 200 B.\LTiMORE, Ma, April 15, 191 1. Class of 1882— Dr. J. M. Hundley 250 Class of 1901 — Dr. Nathan Winslow 50 Class of 1902 — Dr. A. M. Shiplev 2=50 ^ THE RANDOLPH WINSLOW SCHOLAR- ' L SHIP. S5750 Another scholarship has been founded for the ABSTRACTS benetit of needy and worthy students of the Medi- -— cal Department of the University of Marvland. t^cttxt T^, • , r , , , . ■, ; , • DEFECTIVE CHILDREN, inis makes four scholarships now avanable m our school for this purpose: The Samuel Leon r)r. Watson Smith Rankin, class of 1901, in an Frank scholarships, endowed by the widow of the address before the North Carolina Teachers' As- lato Dr. Samuel Leon Frank; the two Flitchcock sembly, Asheville, N. C, June 17, 1910, has the scholarship, created through a bequest of the late following to say concerning adenoids in an article Dr. Charles M. Hitchcock of California, and the entitled "The Importance of the Recognition of Randolph Winslow scholarship, endowed by Prof. Physically Defective Children by the Teacher" Randolph Winslow. This bequest has been com- {BnUctin of the North Carolina Board of Health, pleted and becomes available next October. It is October, 1910) : not intended to assist idle and incompetent stu- "Adenoids.— Thty are composed of what we dents, but only those who are both needy and call lymphoid tissue, the principal function of worthy. It is open to students of the senior, which is to act as a filter or sieve to catch invading junior or sophomore classes who are of good germ- Its structure is admirably adapted to its character and who are in need of assistance to I""ction ; it consists of only two parts ; small, very continue their studies and who have maintained ^"^^" threads or fibers of tissue running in all di- an average grade of 85 per cent, in all their nre- sections and interlacing so as to form a structure - vious work. The scholarship is to be awarded bv '''^'^ nothing so much as a spider's web. In the the Trustees of the Endowment Fund upon the "^^^^'^^^ °^ this web is the second part, namely, mil- C nomination of the Facultv of Physic. ^'°"s of very small, round cells. Into this mesh- '_ work of fibers and cells a fluid which is known as THE ENDOWMENT OF THE DEPART- ^"""'P^' '' P^"'^"^' ^"'^ ^'"' '"'"'P'' '' ^''^ ^"''^ ^''^' , |._,^^ ^ „^.^ has exuded from the blood vessels into the tissues which it has nourished and is being returned to Elsewhere will be found an appeal from the the veins. However, in nourishing the tissues the committee on endowment to the alumni and others lymph takes up the waste products of the tissue for aid in raising $100,000 to place our patho- cells and any germs that happen to be in the tis- logical department upon a full time paid basis, sues. It is, therefore, important that before this This is the most urgent need of the medical fluid, the lymph, be poured into the veins, thence school at this time. The committee is working into the heart, and then sent to all parts of the upon this problem. The public will be asked to body, that it be filtered ; and so it is passed through help us in this matter, but the individual classes this lymphoid filter, where any germs it may carry 34 THE HOSPITAL BULLETIN are immeshed in tlie fibers and destroyed bv tlie little round cells. "Nature has wisely placed this filter tissue in those situations where filtration of the lymph is most needed ; that is, in those places where germs are most abundant and most likely to gain entrance into the tissues or flesh. Hence we find large accu- mulations of lymphoid masses, lymph glands, in the armpits, where they guard the body against the entrance of germs that get into the flesh of the upper extremity ; we find many of these lymph glands in the groins, guarding the body against infection from the lower extremity ; the intestine is fidl of germs, and the intestinal tube has an abundance of this filter tissue in its walls, and so, in proportion to the exposure of any localitv of the body to infection, do we find lymphoid tissue in varying amounts. Again, as the child has had less training in fighting germs than the adult, and is more prone to disease than the adult, less able to protect itself, so it needs relatively more of this lymphoid tissue than the adult, and it is a fact that lymphoid tissue is relatively more abundant under 12 than after that age, when, not needed so much, it undergoes considerable shrinkage. "Now, of all places exposed to infection or germs, the tube through which we consume our gaseous food, the tube through which we breathe, is most exposed. Lailike the tube through which we take our liquid and solid food, it is in constant use. In breathing air of average purity we inhale about 25,000 germs per minute; most of those germs are, fortunately, harmless. Through this portal enter the germs causing tuberculosis, pneu- monia, scarlet fever, measles, whooping-cough and other diseases. Tuberculosis and pneumonia, the two greatest causes of death, kill 300,000 people a year, one-fifth of the entire death rate of the L'nited States. The most exposed portion of this most exposed tube is an angle in the tube just back of the nose, where the horizontal or nasal part of the tube joins the vertical or pharyngeal part of the tube. Now, dust and germs tend, by the laws of gravity, to lodge in this angle of the breathing tube. And Nature, following the rule of provid- ing most of this lymphoid or filter tissue where ex- posure is greatest, has abundantly supplied the roof of the throat which is at the back of the nose ; that is, the angle of the breathing tube, with this tissue, "\\'ith these two factors, a large amount of soft, spongy tissue and constant and comparatively se- vere exposure to irritation, we may be on our guard for trouble in the pharyngeal vault. As long as the lymphoid tissue can take care of the germs gaining entrance there is no trouble. But in about 10 per cent, of children this becomes im- possible, and these lymphoid masses swell. If the trouble is soon removed, the swelling subsides and no permanent damage results. On the other hand, should the irritation be unusual in amount or of long duration, a permanent enlargement, var\ing in size from a hazelnut to a hen's egg, re- sults ; and this is what we call adenoids. These enlarged masses of tissue are lobulated, soft, and feel to a finger pushed into the throat like a mass of earth worms, bleed very easily, and are covered over with a la}er of thick mucus which is often mixed with pus or matter. "The first efifect of this nasal obstruction, nat- urally, is to interfere with the breathing. The cliild is obliged to have air, and, being unable to get it through the nose, becomes a 'mouth breather.' If the postnasal obstruction is not too great, the child during waking hours will, by extra muscular effort and by keeping the nose and throat clear of mucus, be able to get in enough air through the nose ; but at night, when these volun- tary processes are in abeyance, the child uses both nose and mouth, and this means snoring. It means, as a rule, disturbed sleep, too. The small amount of oxygen gives to the subconscious mind an uneasv feeling, producing bad dreams which awaken the child with 'night terrors.' As the masses of adenoid tissue grow or become inflamed, mouth breathing becomes more and more a vital necessity, until the child breathes day and night through the open mouth. Now, with the nose par- tially or completely discarded as a respiratory tube, and the mouth having taken up this work, it be- comes necessary that the mouth cavity be enlarged. This enlargement takes place by the roof of the mouth bulging upward into the now useless nasal cavity. This bend having once started, the con- stant inward pressure of the strong muscles of mastication accentuates it, causing the high- vaulted jialate, the narrow dental arch with its forward protrusion and crowded teeth. These factors combined give us the characteristic adenoid expression ; the narrow face, the undeveloped, small nostrils, the short upper lip, the absence of normal lines about the mouth, the narrow nose, the drooping inner angle of the eyes, and the high- arched e\ebrows. THE HOSPITAL BULLETIN 35 "Tlie voice loses that quality given it by an open pharyngeal vault — resonance. The speech is stutty; F is substituted for T H, so that 'teeth' is pronounced 'teef ;' G is substituted for N G, so that 'song' is pronounced 'sogg;' B is substituted tor JNI, and D for N, so that 'common' is pro- nounced 'cobbed,' and 'nose' is pronounced 'dose.' ■'Breathing is greatly interfered with, quantita- tively and qualitatively. The quantity of air ad- mitted is diminished in proportion to the amount of obstruction. If much diminished, there is a par- tial collapse of the spongy lung tissue. This leaves a vacuum in the chest and tlie chest walls ; the softer part of them along each side of the breast- lione become depressed, giving us the chest with the prominent breastbone or pigeon-breast. The quality of the inspired air is altered. Normally, the extensive, convoluted and turbinated nasal walls, giving a very extensive warm, moist sur- face, serve to warm the inspired air and to filter out on their sticky surfaces many of the germs. Xot so when nasal respiration is partially or com- pletely abolished. The air entering the lungs is colder, and, carrying more germs, it makes the adenoid victim very susceptible to cold, grip, pneu- monia, tuberculosis and other air-borne diseases. "Smell is to varying extents destroyed. The in- flamed and mucus and pus-covered adenoid tissue at the back of the nose grows forward into the un- used nasal cavity. The nasal mucous membrane liecomes chronically inflamed and covered with nnicus and pus. This means that smell, located in this membrane and dependent upon its healthy condition, is to varying degrees destroyed. You probably recall in this connection your own loss of this sense when you suffered from the ordinary nasal cold. Now, the sense of smell and taste are closely related ; the sense of taste is two-thirds de- pendent upon smell. In the brain the centers of smell and taste are next-door neighbors. Recall again the loss of taste in colds. Moreover, taste is an important adjunct to digestion. Appetite, the desire for food, is very dependent upon taste. Science has also demonstrated that the secretion of digestive juices in the stomach is due in part to reflex nervous influences originating in taste. Now, when taste is interfered with the appetite is poor, less food is taken, and on account of the de- crease in amount of digestive juice, what is taken is less well digested. Thus, adenoids interfere with the ingestion of a!! foods, gases to the lungs, liquids and solids to the stomach, and with the digestion of the solids and liquids. The result is a stunted growth and a decrease in the capacity for all kinds of work. '■' * * The number and distinctiveness of the symptoms vary with the duration and severity of the disease. "The mild cases sleep poorly, snore, and many of them have 'night terrors.' They are very sus- ceptible to colds and coughs ; many are physically and mentally stunted. "The medium cases have all the symptoms of mild cases accentuated, and mouth breathing is usually present during the day. The character- istic expression, already described, is now easily recognized. "The severe cases show all the symptoms de- scribed in connection with the disease in a pro- nounced and easilv recognizable form." ITEMS The following report was submitted to the Alumni Advisory Council at their last meeting, March 2^, 191 1, by Dr. E. F. Cordell, chairman Committee on Nomenclature : Having been requested to suggest a nomencla- ture for the buildings of the University, I present the following: St. John's being adequately pro- vided for in the designations — McDowell Hall, Humphreys Hall, Pinckney Hall, Woodward Hall, Senior or Mess Hall, Gymnasium, etc. — does not require consideration here. ■ I shall confine myself therefore to the professional schools of the Uni- versitv located in Baltimore. Although the custom of applying the names of eminent presidents, professors, alumni and bene- factors to different departments of universities has been adopted elsewhere and is growing in favor and practice, it has only recently been applied in this institution. I may say, however, without offense I hope, that the results have not been so far very satisfactorv. Perhaps the matter was not considered suflrciently. It seems exceedingly desirable that a systematic nomenclature should be adopted by the Regents. There are practical as well as sentimental reasons for its considera- tion and application that must appear convincing to anyone who gives the matter due thought. Wc are not called on as yet to honor in this way any great benefactor, so that our action must be dic- tated by sentiment. I. The Department of Medicine. There is one name that especially appeals to us in this depart- 36 THE HOSPITAL BULLETIN nieiit for recog'nition, and that is Jolin B. Davidge, the founder of the Medical School and the Uni- versity. To adequately honor him we should as- sociate his name with the main medical building- and call it "Davidge Hall." Professor Potter, also a founder and incumbent of the chair of prac- tice for 36 vears, certainly comes second, and the building- now known as "Davidge Hall" might receive his name. Practice Hall, to which the misnomer Gray Laboratories has been applied, might bear that of De Butts, the eloquent chemist (1809 to 1S31), since it contains the chemical laboratory, a department over which he presided with so much reputation and success. The pro- posed students' dormitory, on the northwest cor- ner of Greene and Lombard streets, might be called "Smith Hall," after the great surgeon, Nathan R. Smith. I would suggest that the name's "anatomical theater" and "chemical theater" be retained, since thev are so appropriate and have been sanctioned by such long usage. The labora- tories do not need any change, and may still be called "The Chemical Laboratory," "The Patho- logical Laboratory," "The Physiological Labora- tory," "The Cliuical Laboratory," and the same in the case with "The Dean's Office," "The Stu- dents' Room," "The Dissecting Room," "The Library" and "The Christian Association Room." In the Department of Law there are five names that especially appeal to us, viz., those of Chief Justice Tane}', John P. Kennedy and S. Teacklc Wallis, who were provosts and men of great emi- nence ; David Hoffman, the first professor of law and founder of the Law School, and John P. Poe, who was so long connected with the reorganized school as professor and dean. It seems eminently appropriate that we should select the greatest of these names to designate the law building, which would thus in future be known as "Taney Hall." There are but two lecture-rooms at this time, so that we are compelled to make a choice of tw(i of the others for these, and I would suggest that they be known henceforth as Wallis and Poe Rooms, respectively. I hope the day is not dis- tant when the other two names shall be commem- orated in some way, perhaps by professorships, scholarships, prizes or medals. In the Department of Dentistry the name of the Father of American Dentistry, Dr. Horace H. Hayden, who delivered in this University in 1837 what was, so far as we know, the first scientific course of lectures given in .\nierica, suggests it- self, and it would be eminently appropriate that the dental building should receive the name "Hay- den Hall." The laboratories and infirmary need no change, but I suggest that the dental museum receive the name of "Gorgas Museum." in honor of the distinguished dean, to whose labors it is due. There should be some commemoration also of the late Prof. James H. Harris, who was asso- ciated with Professor Gorgas in the founding of the school and was famed as a skilful dentist, but the future must provide for this want. The Department of Pharmacy is not at present in need of a nomenclature, but when it gets a building, as it must soon do, to provide for its growing classes, the name of David Stewart, one of its founders and who enjoyed the distinction of being the first independent professor of phar- macy in America, could well be used to designate its "Hall." I have thus endeavored to fulfil the responsible duty which you imposed upon me at the last meet- ing. It will be seen that I have adopted the name "Hall" for the various buildings, and "Room" for the apartments of the same, following in this respect what I believe is the common usage. The laboratories suggest their own designations. All of which is respectfully submitted. Eugene F. Cordell, ;M.D.. Committee. March 21, 191 1. Dr. Reed A. Shankwiler, class of 1909, who was for some time a resident physician at Eudo- wood Sanitarium, Towson, Md., has been ap- pointed superintendent of the Detroit Tuberculo- sis Sanitarium, which has been recently erected in Detroit. Dr. Shankwiler is at present the guest of his mother at 3809 Park Heights avenue, Baltimore. He was until very recently connected with the Hazelwood .Sanitarium of Louisville. Kv. The imdersigned committee direct the follow- ing appeal to our alumni : Dear Sir — The Faculty of Physics, being firmly convinced that the scientific chairs of a medical school should be filled by scientists who give their whole time to the duties of their chairs, and not by practitioners of medicine, have appointed the subscribers a committee to devise means to bring about this important change in the School of Medicine of the University of Maryland. Wc therefore ask the aid of our alumni and THE HOSPITAL BULLETIN 3? friends in raising the sum of $100,000 for the endowment of the Department of Pathology. Anv amount tliat you may feel able to con- tribute to this object will be gratefully received, as will also any suggestions or other assistance that may expedite our purpose. This fund will be administered by "The Trus- tees of the Endowment Fund of the University of IMarvland," an entirely independent corporation, not connected with the teaching faculties of the University. Subscriptions may be sent to any of the under- signed, and will be gratefully acknowledged in The Hospital Bulletin and in Old Maryland. A'ery truly yours, Randolph Winslow, John C. Hemmeter, Arthur M. Shipley. Dr. Robert H. Hargrove, class of 1877, is lo- cated at Kinston, N. C. Dr. T. A. Ashby, class of 1873, of Baltimore, has sold to Mr. Arthur L. Warthen, president of the Front Royal (Va.) National Bank, the place- known as Belmont, situated about a mile south of Front Royal. The purchase price was $40,000. The tract contains 825 acres, and has long been acknowledged one of the finest fruit farms in \'ir- ginia. The vineyards and wine cellars of Belmont had a national reputation when Marcus B. Buck owned and operated them, and it is said that Mr. Buck spent $200,000 in improving the property, which Mr. Warthen will restore to its former beauty. From the elevation of Belmont a view of the Shenandoah Valley for 20 miles may be had. It is understood to be Mr. Warthen's pur- pose to turn the present house into a handsome colonial residence. Dr. Arthur B. Clarke, class of 1906, is prac- ticing at Plantersville, S. C. Miss Lucy B. Squires, class of 1909, University Hospital Training School for Nurses, is located at 226 East Duval street, Jacksonville, Fla. The editors of The Bulletin are very anxious to secure copies of The Bulletin for July, 1905 : January, 1907, and March, 1908. If any of our readers have copies to spare, they will help u-^ greatly by sending them to complete our files. Miss Henrietta Gourley, class of 1908, Univer- sity Hospital Training School for Nurses, who went to Fayetteville, N. C, to accept a position as superintendent of nurses at St. Luke's Hospital, has been compelled to resign owing to ill-health, and she is now with her brother-in-law, Dr. Guy W. Latimer, class of 1901, of Hyattsvillc, Md. Drs. R. B. Hayes, class of 1906, and T. Marshall West, class of 1908, own the hospital, and are, as Dr. West puts it, "pegging away" very hard toward the success we wish for them. It is likely that Miss Gourley will be succeeded by Miss Kim- mel, class of 1910. The annual commencement of the LTniversity will be held June i, 1911. We regret to report that our beloved Prof. Samuel C. Chew, class of 1858, is very ill with grippe. Among the recent visitors to the University Hospital was Dr. Louis Hamilton Seth, class of 1907. Dr. .Aloysis \\\ Valentine, class of 1904, of 606 N. Carolina avenue S. E., Washington, writes: "It seems that tlie Faculty should impress upon each graduate the importance and the value of pushing the school along after they leave it. The i\dvisory Council is a step in the right direction, but what is wanted is enthusiasm among the men turned out each year. C)ur hope lies in the recent graduates who are more receptive in catching the L'niversity idea. It seems as if the Alumni Asso- ciation is not active enough in securing new grad- uates. Cannot something be done to catch them before thev leave the shop, so to speak ? "Give my best wishes to the bunch, and save some for Dr. Randolph Winslow." The members of the class of 1885 are located as follows : R. L. Allen, Waynesville, N. C. C. W. Barker, 11 16 West Fayette street, Bal- timore. E. M. Beach, West Long Branch, N. J. Joseph Blum, 18 16 Madison avenue, Baltimore. G. F. Boucsein, Ellinwood, Kans. Leigh Buckner, iioi Franklin road, Roanoke, \'a. 38 THE HOSPITAL BULLETIN B. F. Bussey, Texas, Md. D. G. Caldwell, Concord, N. C. P. G. Dill, 1433 West Lombard street, Balti- more. John H. Dorsey, Glencoe, Minn. R. B. Epting, Greenwood, S. C. George Y. Everhart, Dickeyville, Md. Ira L. Fetterhoff, Carrollton and Lafayette ave- nues, Baltimore. Geo. M. Fickes, Seven Valleys, Pa. Alva G. Floyd, Fair Bluff, N. C. H. E. Gale, 260 West Hoffman street, Balti- more. Wm. F. Hall, Crisfield, ,Md. E. T. W. Flail, Freemansburg, W. A'a. J. T. Hering, 1728 St. Paul street, Baltimore. X. M. Hendricks, 1601 East 5th street, Dayton, Ohio. B. M. R. Hopkinson, Professional Building, Baltimore. J. X. Humrichhouse, Council Bluff's, Iowa. J. T. B. Hyslop, Bellehaven, Va. R. E.L.Johnston, 721 E street, I^Iemphis, Tenn. H. M. Julian, 7732 A-^irginia avenue, St. Louis, IMo. Louis C. Carrico, Bryantown, Md. H. L. Clark, Washington, Pa. Edw. C. Coleman, Kosciusko, Miss. John C. Cort, Clairton, Pa. A. C. Coble, Dauphin, Pa. H. C. Conley, Boone, Iowa. I. PI. Davis, Charles and Pleasant streets, Bal- timore. C. K. Jump, 1415 Madison avenue, Baltimore. Geo. C. Kinard, Lincoln, Pa. J. C. Lemmer, Oil City, Pa. J. C. Lockbridge, Driscoll, W. Ya. Lewis W. Morris, Salisbury, Md. V. L. Xorwood, 939 ^^'est Fayette street, Bal- timore. J. C. Perry, U. S. P. H. and :\I. H. S., Canal Zone. S. L. Phillips, 232 Bull street. Savannah, Ga. W. A. Flecker, Hampton, Va. John H. Reed, Logansport, Ind. Howard C. Reamer, Danville, Cal. A\'. J. Rivers, Eastover, S. C. C. W. Sawyer, Elizabeth City, N. C. Samuel Schwalbe, 6618 Michigan avenue, St. Louis, AIo. Wm. A. Shoemaker, 1006 Carleton Building, St. Louis, Mo. M. B. Shupe, Connellsville, Pa. J. Campbell Smith, 3750 Westminster boule- vard, St. Louis, Mo. G. \\'. Todd, Salisbury, Md. H. ^I. Thomas, 1228 Madison avenue, Balti- more. E. P. Turner, Ferguson's Wharf, Va. A. K. A\'arner, 1056 Belmont avenue. Chi- cago, 111. A. S. Warder, Grafton, \\^ Va. John A. IMurray, Patton, Pa. John P. Smallwood, Falls Church, A'a. J. Fletcher Somers, Crisfield, Md. Of the class three members — Frank Camm, G. Linton Shipp and F. I\I. Latham — have died, and we are unable to locate the following members : J. B. Carr, J. M. Emmitt, B. B. Halsey, E. K. Hardin, C. H. Janney, H. C. Jamison, D. T. E. Casteel, P. B. Carter, S. B. Dew. A. F. Keen, W. P. Kennedy, E. T. ^lay, C. E. Rogers and \\'. T. Spruill. If any of our readers know the present location of any of the above, will they kindly notify us immediately? The Bulletin wishes to correctly list each alumnus of the Universitv. Dr. Herbert Seth Anderton, class of 1910. is the guest of his brother in California. A campaign for funds will be launched in the near future to endow the department of pathology in the University of Maryland. Dr. J. Lewis Hanes, class of 1902, is located at ^^'inston-Salem, X'. C. According to the fifty-eighth annual report of the Xortheastern Dispensary, 1224-1226 East ^lonument street, Baltimore, our alumni hold the following positions: Secretary board of di- rectors, Alexander D. AlcConachie, class of 1890: general medicine. Percy E. Lilly, class of 190 1 : eye and ear. Alexander D. McConachie, class of 1890, and Josiah Sheer Bowen, class of 1903: gynecology, AVilliam S. Smith, class of 1883, and chief of outdoor clinic, Percy E. Lilly, class of 1901. Dr. A. Aldridge ^Matthews, class of 1900, of Spokane, AVashington, who was for several years superintendent of the University Hospital, has succeeding in building up a very extensive sur- THE HOSPITAL BULLETIN 39 !;-ical practice in his adopted city. Dr. Alatthcws is a Marylander by birth. His brother, Dr. Jame^ G. Matthews, class of 1905, is associated with him in practice. We are glad to report that Mr. William L. D_\- erly, a member of the medical class of 191 1, who was operated upon recently for appendicitis, has sufficiently recovered to resume his studies. The General Alumni Association will tender a smoker and buffet luncheon May 30, 191 1, at the Medical and Chirurgical Faculty Building, 121 1 Cathedral street, at 8.15 P. M., to the graduating classes of the several departments. This feature was inaugurated last year and will become an annual institution. Amongst our alumni located in North Carolina are : Albemarle. Jasper M. Anderson, class of 1895. William Isaac Hill, class of 1897. Virgil A. Whiteley, class of 1884. ASHBORO. Houston Boyd Hiatt, class of 1907. ASHEVILLE. Charles Collins Orr, class of 1904. Charles L. Scott, class of 1897. Bailey. S. B. Drew, class of 1885. Be.JiUFORT. Charles L. Duncan, class of 1902. Bethel. Guy F. Thigpen, class of 1903. Bryson City. Daniel R. Bryson, class of 1900. BURGAW. Peter Prentiss Causey, class of 1897. Burlington. Charles Manly Walters, class of 1908. Buxton. Judson J. Davis, class of 1891. Carthage. Gilbert McLeod, class of 1882. Casar. Thomas A. Mathews, class of 1890. Charlotte. James Ramsey Alexander, class of 1894. Ephraim M. Brevard, class of 1894. Andrew Johnson Crowell, class of 1893. Samuel McKee Crowell, class of 1895. John E. S. Davidson, class of 1894. John McC. De Armon, class of 1886. John Robinson Irwin, class of 1877. William R. McCain, class of 1897. Calvin S. McLaughlin, class of 1906. J. Pleasant Matheson, class of 1905. Charles H. C. Mills, class of 1897. Edgar Reid Russell, class of 1895. Charles Moore Strong, class of 1889. Charles E. Walker, class of 1891. China Grove. Banks Withers, class of 1896. Clinton. Frank Huske liolmes, class of 1895. COLERAIN. Luther A. Nowell, class of 1894. Columbia. Joseph L. Spruill, class of 1895. Concord. Daniel Greenlee Caldwell, class of 1885. James S. Lafferty, class of 1881. William David Pemberton, class of 1887. Francis Owenton Rogers, class of 1901. COOLEEMEE. John R. Lowry, class of 1904. BIRTHS Dr. Louis Cottin Skinner, class of 190 1, and Mrs. Skinner, of Greenville, N. C, are being con- gratulated upon the birth of a daughter, April 4, 191 1, who has been named Elizabeth Minor. DEATHS Dr. Adolph Gustav Hoen, class of 1873, died at his home in Waverly, Md., March 29, 191 1. Dr. Hoen was born November 28, 1853, of German descent. His father was August Hoen, founder of the lithographic firm of A. Hoen & Co. of Bal- timore, and was born at Frankfurt-on-the-Main, Germany. His mother was Caroline V. Muth, and lived to a very advanced age. Dr. Hoen was 40 THE HOSPITAL BULLETIN educated in a private German school and Loyola College. He afterwards entered the University of Maryland, graduating in 1873. He started to practice in Baltimore, but because of ill-health removed to Burlington, Wis., where he remained for four years, returning to Baltimore in 1878. In 1894 he became identified with the anatomical department of the Johns Hopkins Medical School, having direction of the photo-micrographic labor- atory of this department, and continued as a part of the teaching force of the institution until the end of 1897. He then became director of tho clinical laboratory of the Suffern Sanitarium of New York State, a branch institution of the Pas- teur Institute of New York city, then under the direction of the late Paul Gibier, M.D. In 1900 he became director of the Pasteur Institute of Virginia, located at Richmond, which position he filled until his death. In 1903 he also assumed the directorship of the histological laboratories of the L'niversity College of Medicine of Richmond. He was a member of the Medical and Chirurgical Faculty of Maryland, the Virginia State Medical Society and the Academy of Medicine of Rich- mond. Dr. Hoen married Miss Helen M. Nix- dorff, who survives him. He also leaves four children, Messrs. August, Stanley and Ralph Hoen, and one daughter, Ethel — Mrs. Benjamin Hanson, Jr. BOOK REVIEW Interxatioxal Clinics. A Quarterly of Illus- trated Clinical Lectures and Original Articles. \'ol. I, Scries 21, 1911. Philadelphia. iQii. S2.00. \\'ithout hesitation we pronounce this probably the most interesting volume of International Clinics yet issued. Its articles are on live subjects of the clay — Pellagra in the United States ; Treat- ment of Syphilis by "606;" Poliomyelitis Investi- gations : Open Treatment of Fractures ; Ulcera- tion of the Male Bladder; The Cellular Basis of the Determination of Sex ; Mosquito \A'i irk in the Canal Zone. The inclusion of Maryland on the colored map (frontispiece) among Southern States where pel- lagra is "prevalent" is probably unfair unless her 10 cases came from her own borders ; and even then 10 cases of any disease in one year do not justify the label "prevalent." At the same time the attraction of professional attention to this curious disease (now said to be carried not by spoiled corn, but by the sand-flea), which blooms out in the surface tissues of a chronic patient in summer to vanish in winter so completely that among a hundred summer cases scarcely one win- ter diagnosis can be made (page 2) even by false numerical statements, is pardonable. Though Baltimore cannot get a suflicient num- ber of cases for one medical demonstration at so- ciety meetings, yet there may occur in the practice of any physician obscure cases which baffle de- tection. LABORATORY REPORT OF THE UNI- VERSITY HOSPITAL. Month of M.-^rch. Blood Examinations. Leucocyte Counts 158 Erythrocyte Counts 12 Differential Leucocyte Counts 6 Hemoglobin Determinations 102 Smears for Malarial Parasites 10 Blood Cultures 2 Wasserman Tests 25 315 Urine Examinations. Routine Urinalysis (chemical and micro- scopic ) 464 Total estimation for Urea 23 Total estimation for Albumen 10 497 Miscc'llancons. Gastric Contents ( chemical and micro- scopic) 15 Feces (macroscopical, microscopical and some cases chemical examin.ation) ... 9 Sputum Examination 25 Bacteriological Cultures and Smears (from operative cases) 37 Bacteriological Cultures (throat) 120 Examination of Spinal Fluid i Section of Tissue for Microscopical Ex- amination 7,^1 Autopsies 3 243 Total 1055 Dr. J. L. IIiRsii, Dr. H. J. Maldeis, Dr. R. biLr.F.R. THE HOSPITAL BULLETIN Published Monthly in the Interest o£ the Medical Department o£ the University of Maryland PRICE $X.OO fER YEAR Contributions invited from the Alumni of the University, Business Address, 608 Professional Building, Baltimore, Md. Entered at the Baltimore Post-office as Second Class Matter Vol. VII BALTIMORE, MD., MAY IS, 1911. No. 3 THE WASSERMAxNX REACTION. B_\' Herbert Schoenrich, AI.D., Baltimore, Md. ^^'ith the rapid advancement made in ilie treat- ment of syphilis, hcginning with the more intelli- gent administration of mercnry, potassium iodide and arsenic, followed with the newer compounds of arsenic as arsacetin, atoxyl, arsenophen^dglycin, etc.. and finally with Prof. Ehrlich's famous rem- edy, dioxydiamido-arsenobenzol, and taking intii consideration the remarkable results obtained, the rapidity in the disappearance of lesions, we are confronted more and more with the serious ques- tions, "Is the patient cured? Has he syphilis; if so, to what extent? What are the possibilities of a recovery, of dangerous sequels, etc. ? The pro- fession will agree that there is no answer more reliable, more trustworthy, than the result of a A\'assermann reaction. Most all hospitals are carrying it out weekly in the laboratories ; special- ists are employing it in their office, and, in fact, parts of Europe the test has been accepted as a criterion in medico-legal court proceedings. It is not within the scope of this paper to go deeply into all the details of the test, nor to de- .scribe the many and varied modifications, but more to .give a comprehensive review covering the theory of the Wassermann-Xeisser-Bruck re- action and the technic employed. In order to un- derstand this test it is necessary to be informed in regard to the phenomenon of hemolysis, and to know what is meant by the Bordet-Gengue phenomenon. It has been a long-established fact, discovered by Belfanti and Carbone, that an ani- n'.al of one species acquires a specific htic power when injected with tlie washed red corpuscles ob- tained from an animal of anotlier species. If, for example, you take the washed red corpuscles of a sheep and mix them with the serum of a rab'iit in a test tube, there will be no change, and the corpuscles will gravitate to the bottom of the test tube, leaving the clear serum above. If, on the other hand, you immunize the rabbit with sheep's corpuscles, there will be formed in the serum of that rabbit a new body termed ainbocc[ttor, which, in the presence of coinplcincnt ( a constituent of all fresh, normal sera), has the power of bring- ing into solution erythrocytes. Thus, collect the serum from the immunized rabbit and treat it with sheep's corpuscles, and there will result a com- plete solution of the latter, and the rabbit is said ti^ be immunized against sheep's blood. This phenomenon is known as hemolysis, which means to lake, to render transparent an opaque suspen- sion of blood corpuscles ; and substances which cause hemolysis are said to be hemolytic for the blood corpuscles which they dissolve. The laking of blood is due to the immune body (amboceptor) combining with its specific red blood corpuscles in the presence of fresh complement. Substances, when injected into an animal capable of producing amboceptors, are known as antigens. Bordet and Gengue showed that in the same manner as spe- cific, immune bodies ( hemolytic amboceptor) are produced in animals injected with the blood of another species; by the injection of bacteria or nlbumanoid substances, immune bodies (ambo- ceptors) are produced in the injected animal \\hich will combine with the specific bacteria or albumanoid substance, respectively, in the pres- ence of complement. In using erythrocytes as an antigen the corresponding amboceptor is known as a hemolytic amboceptor. In the case of bac- teria it would be a bacteriolytic amboceptor, and when employing unorganized protein, as agg albumen or alien blood serum, the product formed 42 THE HOSPITAL BULLETIN in the animal is called precipitin. By heating amboceptor for a half honr at 56 degrees centi- grade, it will lose its power to dissolve blood cor- puscles, and is said to have been rendered '"in- activated." Inactivatecl serum, however, does not correspond to normal serum, for if vou add to the former a quantity of normal serum, it will again become activated, repossessing the property of hemolysis. This is explained by the fact that complement is destroyed when heated for a half hour at tlie tem]ierature of 56 degrees centigrade. Thus, when adding normal scrum to inactivated amboceptor, you are adding complement and re- activating tlie amboceptor. Amboceptor itself is more or less stable, and not easily destroyed by heat, and is said to be thcrmostabilc. Comple- ment is destroyed by heat or thermolabilc. In order, then, to bring about hemolysis, three agents are necessary, namely, antigen, amboceptor and complement, which together constitute a hemolytic system. An antibody can show its presence in serum by its power of fixing or taking up com- plement in a hemolytic system. This phenomenon of disappearance of complement in a mixture of antigen and antibod}' is known as "fi.xation ( an- choring or binding) of complement," or the l^>or- det-Gengue phenomenon. The W'assermann reaction depends upon there being something ])resent ( sxphilitic antibody) in tb.e serum of the sy])liilitic patient, which, in the l^resence of certain lipoid or fattv substance ( antigen ) , has the ]:)ropcrty of taking up comple- ment, so that upon the addition of hemolytic am- boceptor and er\throcytes no hemolysis takes place. This binding of complement is made evi- dent by the fact that when you take syphilitic pa- tients' inactivated serum, and. adding antigen and fresh complement and incubate for an hour at 2>7y:i degrees centigrade ( allowing them to unite), that, in spite of of the complement content, there will be no hemolysis by the addition of blood cor- puscles and amboceptor. On the other hand, assuming that the patient's serum were normal, 1. e.. not containing the syphilitic antibody, there would be no com])lement fixation, and con.se- i|uently upon the further addition of amboceptor and blood corjniscles, the com])lemcnt. not having lieen fixed, would be free to act with the cor- puscles, and hemolysis would occur. (See I'lgure I.) Inasmuch as in syphilis it has been impossible t I obtain a pure culture of the specific organism, it was necessary to use as antigen an extract of syphilitic tissue known to contain the organism in large cjuantities. For this purpose e.xtracts were prepared from the livers of syphilitic fetuses, from the fact that livers were very rich in the fatty or lipoid element. Later it was shown, how- ever, that an extract made from normal fetal livers also contained an antigen similar to the one from a sypliilitic liver: in fact, it developed further that a variety of normal organs contained an available "antigen." namely, an extract froiu healthy guinea pigs' heart muscle, from guinea pig livers. Porges and Meier used lecithin as an antigen very success- fully. Other lipoid substances which have been experimented with are sodium glycocholate and taurocholate ( Levaditi) ; sodium oleate (Sachs and Altman) ; oleic acid (Sachs and Rodoni) ; FIGURE I. Aat. > > ^- "• ^- < < J)> \ Amb. <^ Ant. y> \ H. P. S. <^ > > ^^- < <c ,\nr.— .Vnti;^i'U. S. 1', .s.— .Syphilitic patient's senini. C— Cnmplement. E. — I'Jrytbrocytes. Adi1». — Amboceptor. N. P. S. — Normal patient's uerum. cholesterin and vaseline (Fleishman) : sodium cholate (Noguchi). The reagents necessary to perform the test are five in number, namely, antigen, amitoceptor, blood corpuscles, complement and patient's serum. Antigen. — As has been intimated, one of a variety of antigens may be emplo\ed satisfac- torily. Xoguchi devotes a very interesting chap- ter to the preparation of antigens in his recent work on "The Serum Diagnosis of Syphilis." I have i^repared a satisfactory antigen from normal heart ( human) muscle. A quantity of heart muscle is passed through a hashing machine; of this lOO grams are weighed off and placed in a suitable glass jar. Add 500 c. c. of absolute alcohol, close jar tightly, and place it into an incubator for sev- eral days, or keep it at a temperature of 60 degrees centigrade for 24 hours. The solution is then THE HOSPITAL BULLETIN 43 liltereil and preserved in a well-stoppered bottle in a dark place. .\ntii^en is fairly stable, and when jireserved {jroperly will keep for a year or JDiiijer- With antigen pre])ared as described, a dilution of i in lo will usually suffice; it must be tested, bowever, from time to time, so as to ascer- tain that llie antigen tlilution does not cause com- plement fixation witb normal serum. Tbis is de- termined by makinjj a series of dilutions of antigen and combinino; them on the one band witb known s\i)bilitic serum, and on the other hand witb nor- mal serum. Note the dilution in wbicli the anti- <;en does not fix complement with normal serum, l.ut does fix witb syphilitic serum, and use that ii; vour test. In other words, the strongest solu- Uon of antigen is employed that will fix comple- ment with sypliilitic sera, but does not fi.x with normal sera. Aiiilwccptor. — A healthy medium-sized rabbit is inoculated witb the washed corpuscles of a sheep or chicken. The blood must be obtained directly from the blood vessel and collected in a sterile fiask containing sterile beads or broken glass, in order to facilitate the breaking up of the clot. After gentlv shaking the flask for a few minutes the blood is transferred into sterile cen- trifugal tubes and centrifugalized until the cor- jniscles are thrown down, leaving the clear serum above, which is replaced witb .85 per cent, sterile physiological saline solution. Tbis process of washing of corpuscles in order to rid them from their complement is repeated three or four times. Finallv sterile saline solution is added sufficient to make up the original volume of blood employed. The rabbit to be injected is tied down on an animal-bolder or held by an assistant. The usual aseptic surgical precautions should be observed, such as scrubbing up the abdomen witb soap and water, to be followed witb alcohol and a solution of bichloride. Shaving is not always necessary. The blood to be injected is drawn into a sterile syringe provided witb a needle of large caliber, which is inserted through the abdominal wall. The needle should be inserted through the muscles of the abdomen very gently and obliquely, and the peritoneum is entered by giving a slight jerk to the syringe perpendicularly. As the point enters the peritoneal cavity the resistance ceases sud- denly, and the tip of the needle becomes freely movable among the intestines. The greatest dan- ger to be avoided is the puncturing of the intes- tines. After a little practice, however, and by lowering the head of the am'mal, this danger is overcome. The fluid should always be warmed just previous to the injection by i^lacing the I.ieaker containing it in a vessel of hot water at about 45 degrees centigrade ; if not, the animal may die of shock. The injections are repeated at intervals of from five to seven days. The animal should be watched carefully, and if it does not feel well, if it is losing in weight, or if there is any tumor formatinn. the injections should he dis- continued for several days. Three to five injec- tions usually suffice, using the corpuscles from 30 c. c. of blood, from 25 c. c, from 20 c. c-, re- spectively. .\ week following the last injection a few c. c. of blood are drawn from the rabbit's ear and the titre ascertained; if found unsatisfac- tory, another injection is given. Sheep's blood will give a higher titre than that of chicken. With three injections, using the quantities mentioned aljove, I have obtained a titre of 1-3000, using chicken blood. Care must be taken to avoid giv- ing superfluous injections, as the titre would thereby be reduced. One case known to me is where a titre of 1-300 was obtained with seven injections. Having obtained a satisfactory titre, the rabbit is again tied down on a board and anesthetized. After cleaning the parts thoroughly, the animal is bled either from the ear or from the femoral vessels, the blood being collected in sterile con- tainers, then defibrinated and transferred to sterile centrifugal tubes with sterile caps- After cen- trifugalization, the serum is carefully pipetted into test tubes, or preferably preserved in hermeti- cally-sealed beads of about i c. c. capacit\- and stored in a refrigerator. A properly-kept ambo- ceptor will last one year or longer, gradually losing its hemolytic power. It is imperative to standardize the amboceptor ])revious to each test, in order to determine the smallest amotmt which will cause hemolysis of a 5 per cent, suspension of erythrocytes. This standardizing is also known as the titration of th-y omboccptor. Into a series of test tubes are placed dilutions varying from 1-500, 1-800, i-iooo, etc., of inactivated amboceptor with equal units of a 5 per cent, suspension of erythrocytes and i c. c. fresh complement. Incubate at 37J/2 degrees cen- tigrade for an hour, shaking tubes at intervals, and note the highest dilution where there is com- plete hemolysis. Two units of this dilution are used in the test. I mav add that all dilutions in 44 THE HOSPITAL BULLETIN this work are made with .85 per cent, physio- logical saline solution. Blood Corpuscles. — The method of obtaining and washing the corpuscles is explained under the head of "Amboceptor." A 5 per cent, suspension in saline solution is used in the test. Another method is to use one drop of the original corpuscle mush for each tube, thus doing awa)' with the stispension. Corpuscles will keep a few days when kept on ice, after which they assume a dark color, being then unfit for the test. Coiiiplciiicuf. — This is represented in the scrum of the guinea pig; in fact this animal seems to furnish one of the best available complements. The methods commonly employed to obtain the blood are to anesthetize the guinea pig and either cutting the carotid or jugular, allowing the blood to flow directly into a sterile Petri dish, or by carefully drawing a few c. c. from the heart with a syringe. The latter method has the advantage that the guinea pig may live for a varying length of time, thus doing away with the expense of a different guinea pig for every test. The blood is placed in an icebox for several hours, or over night, after which the clear serum is pipetted off. A dilution of i in 10 is used in the test. The question may arise. "Why not use the comple- ment normally ])resent in the patient's serum?" The answer is that the patient's blood contains an indefinite amount of complement, and, as it is imperative to deal with known quantities, the complement of the patient's serum is destroyed by heating it at 56 degrees centigrade for a half hour- Patient's Blood. — The patient may be bled from the basilic vein, or by puncturing either the ear lobule or finger. The blood is collected in suit- able glass tubes and set aside in a cool place to clot. The scrum which has separated, and which should be absolutely free from corpuscles, is pipetted oft' and inactivated on a water bath. Care should be taken not to heat the serum above 56 degrees centigrade, nor longer than a half hour, since the syphilitic antibody, which is more or less sensitive to heat, may be partly destroyed. The serum is diluted i in 5. The outfit necessary to carry out the reaction consists of a water bath, thermostat, refrigerator, a suitable cage for the rabbit and guinea pig, glass tumblers, beakers, a quantity of small test tubes, glass tuliing, pipctts of i, 2 and 10 c. c. capacity graduated in i-ioo, 1-50 and i-ioo, re- spectively, Petri dishes, centrifuge, Florence flask and a sterilizer. The test consists of the experimental tube on the one hand and a series of control tubes on the other. (See diagram.) • The reagents having all been satisfactorily standardized and properly diluted, we add to one set of tubes one unit each of patient's serum, com- plement and antigen ; to the other set the same is added, excepting the antigen, wFiich is replaced by saline solution. Allow to incubate at 37.5 de- grees centigrade for one hour, after which each tube receives two units of amboceptor and one unit of erythrocytes suspension. Again incubate, shaking tubes gently at intervals of .15 minutes, and remove all the tubes as soon as those not con- taining antigen show complete hemolysis- This varies from one to two hours. The tubes are now either centrifugalized or placed in a refrigerator for several hours. The degree of hemolysis may vary, depending upon the amount of syphilitic antibody present in the patient. Thus, -, +, ±, +, + + , + + + , + + ++, signifying negative, doubtful, suggestive, weakly positive, positive, strongly positive, very strongly positive, respectively. Owing to its extreme sensitiveness and com- plicacy, the test should not be entrusted to un- skilled hands, since some of the more experienced observers frequently meet with trouble, the causes of which may be manifold and require careful and untiring laboratory scrutiny. ni.\GR.\M. Experimental tube. (i) _, ^ Inknown scrum -j- antigen. complement, amboceptor and rpuscles. Control tubes. (2) I'nknown serum + complc- inent, anibocei)tor and corpus- cles. ( To prove that the scrum itself docs not fix complement. ) (3) Known syphilitic scrum -f- an- tigen, complement, amboceptor and corpuscles. (To ]3rove that the antigen will fix complement with syphilitic serum-) Q con ^— ' con tubes. o o 1 THE HOSPITAL BULLETIN 45 (4) (5) (6) (7) o o o o Known syphilitic scrum -|- coniplement, amboceptor auvl corpuscles. (To prove that tin; positive serum will in itself not fix complement.) Known hcallhy serum -|- an- tigen, complement, amlioceptor and corpuscles. (To prove that antigen will not fix complement in negative serum.) Known healthy serum -f- com- plement, amboceptor and cor- puscles. (To prove that the negative serum will not fix com- plement.) Antigen -|- complement, am- boceptor and corpuscles. (To prove that the antigen will not fix hemolytic system.) Tube 3 should show absence of heiuolysis. Tubes 2, 4, 5. 6 and 7 should show complete hemolysis. Tube i, of course, depends upon the nature of the serum. Since ^\'assernlann first reported this reaction, in I90.'>. numerous modifications have been ad- vanced, a majority depending, however, on the tlieorv of complement fixation. Some of the more comnidn modifications may be mentioned, viz. : Tschernogubow, Bcrliih Klin. Wochcnschr., 1908, \o. 47, and Deutsche Med. ]]-'ochenschr., 1909, Xo. 15. Weidanz, Deutsche j\led. U'oclieiischr., 1908, No. 48. Xoguchi. Jounial of Amerie. Med. Associat.. 1908, Xo. 22. and Munch. Med. U'oeh., 1909, No. 10. Hecht. J Tien. Klin. U'ocliensehr.. 1908, No. 50. and 1909, Xo. 10. Fleming, Lancet. 1909, 4474. Stern, Zeitschr. f. Inununitatsforscliung, 1909, Vol. I. Bauer, Deutsche Med. JJ'oehenscIir., 1909. No. 10. Detre and \'. Brezovsky. IJ'ien. Klin, ll'och- cnschr., 1908. The statistics regarding the diagnostic value of the W'asserniann reaction are most gratifying. Although this subject may be discussed at length. I will limit myself by briefly saying that in primary lues a positive reaction is present from 60 to 70 per cent. ; in secondaries with symp- toms, from 9S to 100 per cent.; in secondaries withnut symptoms the percentage ranges some- what lower. Late syphilis, including tertiary cases, give about 90 per cent- positive reaction. (Matson. in the Aincrican Journal of Derma- toloi^iy of August, 1910, devotes an interesting article on the Wassermann, based on 2667 cases.) A positive reaction may be obtained in lupus ery- thematoses, framboesia, trypanosomiasis, leprosy, scarletina, tuberculosis, and occasionally in ma- laria. Also in chronic diseases accompanied by marked emaciation near death, this is especially true with tuberculosis, but under such circum- stances there is usually no question of a ditteren- tial diagnosis of syphilis. A positive case may- give negative reaction, because, firstly, the virus has disappeared or is dormant, and there is no specific antibody in the serum ; secondly, the pa- tient is taking mercurial treatment, or thirdly, may form that small percentage who. in any case, may give a negative reaction. In conclusion I may say that in all doubtful cases of syphilis a Wassermann test is by all means indicated. Patients under treatment for a year or more should have their blood tested from time to time. It is surprising to note the change from a stronger to a weaker reaction in some patients who have been under heavy treatment but a few weeks. Practitioners should become more familiar and conversant with its possibilities, and realize that in the ^^'assermann test they have a valuable diagnostic agent at their command. REFERENCES. "Die ^lethoden der Immunodiagnostik imd Im- munotherapie," Dr. Julius Citron. Porges and ^leier, Berliner Klin. Jf'ochen.schr., 1907, p. 1055- ^^'assermann, Neisser, Bruck. Deutsche Jlfed. U'ocliensehr., 1906, p. 745. Fox, iV. Y. Medical Record. 1909, pp. 421-42S. Sachs. Journal A. .U. A.. 1909, 929-936. Xoguchi, "Serum Diagnosis of .Syphilis," Jour- nal E.v. Med-, 1909, pp. 392-401. Matson, American Journal of Dermatology, 1910, pp. 361-371. TT34 Linden Avenue. 46 THE HOSPITAL BULLETIN SHOULD ALL .MEDICAL STUDENTS SEEK HOSPITAL APPOINTMENTS? By Charles Baglev, Jr., ^I.D. A student matriculating in a medical college is passing another milestone of his career; his am- bition is to complete the course creditably and receive a diploma. As he approaches graduation and the anticipation of the diploma is to become a realization, he is astounded with the fact that this is not all he desires and his course in the school has only been a means to an end ; namely, the practice of medicine. !Men who enter a medi- cal school calmly, almost thoughtlessly, tremble as the time approaches for leaving it : for no one knows better than they how inadequate is the instruction which has been imparted if it be re- garded as a final preparation for practice. This instruction is not a completed edifice ; it is a mere assemblage of building materials, valuable if ultimately cemented together by clinical experi- ence, but little more than useless rubbish if not supplemented by the binding power of knowledge gained at the bedside. In considering the question, almost any con- scientious student will conclude that hospital ex- perience is advantageous, and often a necessity, in accomplishing his real purpose, so I will not dwell upon the question of the necessity of hospital work, but will ask you to concede me this truth in order that I may utilize the time in attempting to point out to those seeking positions how they n:ay procure and retain them to the good of the patients, the profession and themselves. Again, I do not want to appeal to those who can readily find and acceptably occupy positions, but I wish to speak particularly to those who are not so for- tunately situated, and to whom the filling of a hospital position is a great undertaking. In attempting to bring this class of students and the hospital position into a happy relation we must first lay down what may be considered the iileal course to pursue. This course will at first sight seem impossible, but in the words of Robert Herrick, "We must attempt the end. and never stand to doubt ; nothing is so hard but search will find it out" The ideal course may be briefly outlined as follows : 1. Bedside work during the senior year. 2. Laboratory work during first year after graduation. 3. Two years in the medical service of a good hospital. He must now look over the work of the years since his graduation with a critical eye, not spar- ing.a strict judgment of himself, and upon the conclusions reached formulate a plan for his life- work. One of three courses will be open to him : 1 . To enter general practice. 2. Seek special medical training. 3. To launch into surgery. If he decides to enter general practice, he should spend the following year in the surgical service. If special medical training is desired, he must continue in the medical service three years- If surgery is decided upon, he should seek an appointment in the general surgical service and learn by close application for four years the gen- eral principles. If he desires to enter a special surgical field, such as eye and ear, nose and throat, or genito- tirinary surgery, an appointment in the special service should be sought, after having spent one year in general surgery. Thus, six or seven years must be given to this, the most important period of the physician's career. To many this would seem appalling, and cause great discouragement, but we must remember that this very plan is be- ing followed by many physicians throughout the country at the present time, and it is safe to say that from this class men will be .sought to fill the higher positions of the profession. The course we know would not be difficult to the student with unlimited means and exceptional ability, but I wish to show that the student, though lacking these valuable assets, may accomplish the end by realiz- ing that his future is not in anxiety for what lies dimly in the distance, but to do well what lies immediately at hand. One of the most frequent replies obtained from a medical student is that he would be very glad tc accept a hospital appointment, but it is neces- sary for him to establish himself in practice and pay off the debt which he has incurred by his several years of study, believing that his first duty, after receiving his diploma, is to return the money to those who have so graciously supplied him with THE HOSPITAL BULLETIN 47 tlie necessary funds diirini^ his course, often for- getting that the greatest debt he owes to those who have sent him to college is to enhance the education which has been given him. An addi- tional debt must be incurred to establish an office, and may mean the placing of another mortgage ; whereas, if he accepts the hospital position with all living expenses, but a small amount of money will be required, and the relief to his friends will be much greater. If a student finds himself with absolutely no means, and perhaps a debt upon which he must begin payments, he should seek a lower position on a hospital staft" which may carry with it a small salary. He may accept this position with the assurance that success in hospital work depends upon the man rather than upon the posi- tion which he may be given. Indeed, I have seen instances where physicians appointed to act as substitutes during the vacation period of the regu- larly-appointed residents have proven themselves so valuable that extra positions have been created for them, in order that their services might not be lost to the institution. It is astonishing and very gratifying to observe that financial difficulties often become insignificant as the professional ability of the resident is demonstrated and the in- stitution realizes that he is not only the happy possessor of a diploma, but the master of knowl- edge by which he is soon to become useful to the profession. Another difficulty frequently encountered is that the student has not made the best use of his opportunities during his course, and is imable to prove to the hospital trustees that he is able to fill their good positions. To these men I would advise intense earnestness and a determination to enter the field, to await an opportunity for a few months, as positions are unfortunately vacated occasionally, either by sickness or otherwise, and a very attractive opening may be found. A careful examination of the hospitals of this city at the present time would reveal the fact that many have been forced to fill vacancies with men not worthy of good positions, the desirable candi- dates having become impatient and established tliemselves perhaps in a rather half-hearted man- ner in general practice. Do not remain idle during the summer months- Seek a position in a dispen- sary, a summer camp, in a physician's office or as substitute in some hospital, always looking with a determination to the much-coveted goal. Having claimed your first hospital position, be- gin at once to qualify for a higher position by work, study, conscientiousness, sobriety and pa- tience. Newly-appointed residents too often view themselves with satisfaction, forgetting that these positions have existed for years, and have often been filled more acceptably than they are going to be able to fill them. It is the duty of a resident to e.xact much of himself. He should be unsatisfied, to be able to fill them. He should be unsatisfied, as this is but the portal, the initial step, of the large temple which he is to explore. He must not be dissatisfied, however, as the difficulties he will encounter, while new to him, have been en- countered and overcome by those who have trav- eled before him. I have mentioned work as a qualification, but will only attempt to touch upon the importance of this work in this connection, as the student may find an entire lecture given to its consideration in the "Master Word in Medicine,"' by Dr. Osier. By work the stupid man among you is made bright, the bright man brilliant and the brilliant student steady. Let us consider for a minute what would be the proper amount of work for the physician holding a position of this character. To begin with, I think the standard should be placed at the point of physical tolerance, daring to go to this point only, for with the proper amount of work success is assured, unless energy fails. By carefully arranging your mode of living you will be capable of a greater amount of work with less risk of becoming a physical wreck. We know- that many are dead ere their prime, sacrificed tc> carelessness of habits in living and neglect of ordi- nary sanitary laws. During the early part of your struggle you will be able to spare but a very small portion of your time, energy and money for social pleasures. Rest and diversion are necessary, but the stu- dent too frequently arranges these at the expense of his training- Do not forget the words of Cow- per. who said "that absence of occupation is not rest ; a mind quite vacant is a mind distressed." A yearly appointment soon passes, and you must endeavor to grasp every opportunity afforded by the position. When you are discouraged and un- able to see the results of your labor, do not sit idly down and bemoan your fate, but remember the master word and continue to work, never forget- ting that a young man in years may be old in hours if he hath lost no time. In idleness alone there is perpetual despair. 48 THE HOSPITAL BULLETIN Your work should begin between 7 and 8 A. M. and continue without interruption, except for limch, until 6 P. j\I. The evening should be spent in study, not only of textbooks, but of current medical literature and recourse to the Index Medicus. Lay hold upon the valued function of attend- ing carefully to the details of your work. Let this become a second nature, an attention com- pelling characteristic. Avoid the danger of ward rounds becoming a mere passing through the hos- pital twice daily, as required by the hospital rules. Acquire the habit of having all details arranged for the rounds of the visiting physicians. Make a careful study of methods of physical examina- tion, the action of drugs, the effects of food, the draining and dressing of wounds, noting care- fully the progress of the disease upon the chart, never forgetting the comfort of the mind and body of the patient- Wake an exhaustive study of diseases as they occur in the wards ; that is, the study of typhoid fever during the summer months rather than wait until winter, w hen this disease will be replaced by pneumonia. The best method of studying a disease is to collect all cases occurring- in- the service and report them to the clinical society. In the operating-room you must first learn to be prompt and quiet, and spare no efforts in learning well the fundamental prin- ciples of operating. A good operator must first be a good assistant, and an assistant of high rank must learn well the lesson of forethought, con- centration and anticipation, and closely apply the same during each operation. When you have demonstrated your ability to assist the operator, you will find opportunities to operate ; perhaps not frequently at first, but the frequency of these op- portunities will depend upon the use you make of the first few. In working remember that the man who is making satisfactory progress is going to be called u]ion to perform duties in themselves very unattractive, but if you are too big for the small duties you will continually find that the large ones are too great for you. Enter upon your duties with a determination to be patient, rememliering that you are fighting for a high jiosition in the profession — for a posi- tion to which there is no royal road. Do not ex- pect recognition of each individual noble act you perform, or praise for your personal qualifications. Able residents have lieen known to believe that they are more capable of conducting the treatment of patients than their visiting physicians, and I can recall a few sad instances where these able men have rendered themselves almost useless in the ward by attempting to discharge the duties of the visiting physician, whereby the details of his own work have been neglected, that of the visiting physician interferred with, a complete failure resulting, the patient often paying the price. The coveted prize is worth a high price, and you must repeatedly render valuable aid with apparently no recognition before realizing a profit- able return. The seeds of genius must be scat- tered to the winds, and though some may perish among the stony places of the world, and some may be choked by the thorns and brambles of early adversity, yet others will now and then strike root even in the clefts of the rock, struggle bravely u]) into sunshine and spread over their sterile birthplace all the beauties of vegetation. Study carefully an address, and be able to ap- proach the patient and his family in a manner that will gain their confidence for the institution and yourself. Conscientiousness is an absolutely necessary requirement, for by this means only can a phy- j sician be honest to his patients, his companions and himself. You will have responsibilities rang- ing from the care of hospital property to that of a human life; your opportunities to deceive your superiors will be many, and you must continually guard against this evil. Hospital internes have but a slight idea of their real importance in the work of a hospital which aims to attain or main- tain high standing. If their superiors find their orders are carried out in a perfunctory, half- hearted or careless manner, after a few attempts to correct these faults in the internes, and finding their efforts vain, they give up in disgust their attempts to better their service, the patients' suf- fering, and the standing of the hosjjital falls. A few years devoted to a proper preparation for a high future may seem appalling at first, but when they have been wasted in endeavor to battle with the crowd for a paltry position, they seem little, indeed. Physicians so frequently allow themselves to be decoyed from hospital positions by offers to labor in other fields with attractions apparently greater. This attraction is almost uni- versally money, and one is frequently asked by residents if he would not be standing in his light by not giving up his hospital work to accept a position paying a few dollars more a month. To I THE HOSPITAL BULLETIN 49 the man who is loiiging for an opportunity of this rank, and wlio lacks the full a]i])reciation of the principles of a hospital position, it is often ini- possihle to impress upon him that he is making a mistake. I believe that an offer of this kind should simply make him feel that his value has at last increased to the point of this otfer, and then see if this salary can be considered the height of his ambitiiin. If not, he should continue in the hospital work until some offer is presented which measures more nearly with his ideal. It is true that the ideas of success are different, but it should be your duty to place your idea as high as possible, remembering that you are far more likely to come below that mark than you are to go above it. Do not give up your hospital positions in order to better yourself during the first few months of service, but remember that it is not only your dut^' to serve the institution during the time for which you have been appointed, but it is also your duty to yourself to enhance your edu- cation by this means as far as possible. You are to embark upon your lifework, and this must be with a definite purpose, and with the proper knowledge of the work you are to perform. Avoid becoming a member of that class of physicians who ruthlessly trample over the bodies of poor and helpless victims, and thus at last enlightened escape from the mazes of their ignorance and attain real proficiency, or to the class beginning with deeply-rooted misconceptions, doomed to perpetual blunders which will cost the public dear, or to the group affrighted at the dangers that beset them, quickly abandon medicine for some less difficult field. In conclusion I wish to anwser the question by which this paper is titled by reading an extract of a letter I received from a former student who resigned his hospital position after serving but a few months to enter general practice. He writes as follows : "One has to do a little of everything when he is oft' in a town like this- I am called upon to pull teeth, do a little surgery, and last month I was ordered to make a post-mortem examination. It is a good experience to round a fellow out and let him put by a little money. Later he can go to a large city and specialize. This is my intention." Is it not evident that this man, desirous of reaching a special field, has allowed the golden opportunity to pass ? In order for him to satisfy his ambition, it will cost his patients dear, and much time must be contributed by him. There can be no doubt that hospital work and hard work oft'er the quickest and best means of raising the ambitious physician to the loftier levels of supe- riority, which I earnestly hope it will be the good fortune of all rif \'ou to reach. SYJVIELUS. By L. E. Xe.xle, AI.D., Professor of Obstetrics, Unk'ersit\ of Maryland, and J. M. Elderdice, M.D. Dr. John M. Elderdice (Class 1905) of Mar- della Springs, Md., recently sent to Professor Neale the accompanying photographs of a human monster that apparently belongs to the variety known as Symelus. In the magnificentlv illustrated work of Hirst 50 THE HOSPITAL BULLETIN and Piersol on Human Monstrosities (Ed. 1891), in Professor Neale's library, it is found that tliis product of conception belongs to the order of "autositic single monsters, capable of an independ- ent existence." ( Part I, page 83.) "The characteristics of this order are mainly- arrest of development, fusion and displacement of important parts of the Ixidy." In the Symelus variety of this order "there is more or less fusion of the lower limbs, but two feet are to be distinguished," and such seems to be MEDICINE AND SURGERY IN SAN DOMINGO. indicated in one of the photographs of Dr. Elder- dice's specimen. The doctor states that the child was born alive of a colored woman H) years old, in her first preg- liancy. It presented by the breech and lived 30 minutes after birth. There was no evidence of vexual organs in the specimen. We hope that Dr. lUderdice will present this specimen to the college iuuseum. By M.VNUEL E. M.\LLEN of San Domingo, W. I. Senior Medical Student. Mr. \\'illiam Bycrly and ^Ir. Lee of the senior class are acting as assistant obstetricians in the maternity department of the I'niversity Hospital. Thousands of people in the United States are so busy every day unraveling the many perplexing- problems of medicine and surgery that they prob- ably give but little thought to what is being done by some of their close neighbors. San Domingo, the oldest of civilized places in the ^Vest Indies, has almost a million inhabitants, covering a large area. There are seven well developed and modern cities, which have from 15,000 to 35,000 inhabi- tants ; of these Santo Domingo City is the capital, with a population of 20,000 people. The country abounds in plantations of variable proportions in which is grown cof¥ee, tobacco and cane, which comprise the principle exports of the island, and which ofi'er a means of livelihood for many thou- sands of people. There is much American money invested in sugar refinery plants. With this very brief introduction to the island, I will discuss what the profession of medicine is, and what it is doing. There are about 500 graduates of medi- cine practicing on the island, allowing one doctor to every 2000 persons. Most of these men are graduates of medical schools in France and some from the Department of Medicine of the "Insti- tuto Profesional de Santo Domingo," an institu- tion embracing three departments — law, phar- macy and medicine. Alopathic medicine is ex- clusively practiced, the fanaticism of Christian Science and other allied new doctrines which hold the "secrets" of cure for so many American people have not even gained an entry among the people. The laws concerning the practitioners of medicine are not as well developed probably as here ; we have no examining State board, merely a registration board, which is composed of prac- ticing physicians appointed by the Government, and the candidate for practice presents his di- ploma with a certain sum of money, and if he has graduated from a recognized medical school he is given ]iermission to practice in the provinces. Our country is one in which the specialist is un- known : cverylDody is a general practitioner and has to take care of evervthing that falls into his THE HOSPITAL BULLETIN 51 hands. There are niaii)' hospitals throughout the island. Some are owned by the Government, some by Catholic churches and some are private institutions. ]\lost of these hospitals are well equipped with modern facilities for operating on and caring for the sick. Most large plantations make contracts with physicians to attend to their sick laborers. There are no medical societies, and naturally not a great deal of misunderstanding exists among the profession. As far as a financial success goes, medicine offers about as lucrative a means of livelihood as any of the learned professions ; the charges for services have about the same range as in this country. All physicians advertise in the news- jiapers, but have no signs on their doors. l)h- stetrics is the one branch of medicine practiced in a ver}" crude way, midwives being almost ex- clusivelv employed. Of course, medicine is crude as compared with its development in the United States, but in the past few years there have been great strides made towards perfection, and prob- ably in a few years to come the situation wil! present a more favorable picture. There is a school for teaching medicine, supported by the Government, and open to all natives who have sufficient preliminary education. There is no charge for tuition and the faculty is not paid, and there are generally iabout 40 students en- rolled. The course covers a period of three years. After graduating most men go to France to take a post-graduate cour.se. The lectures are deliv- ered in Spanish, but text-books of French authors are chiefl}' used. Most diseases of the tropics are seen here, although some with great rarity. Hook- worm disease is very prevalent and many forms of intestinal parasitic diseases. Malaria is ex- ceedingly common, but is gradually decreasing in frequency, as the people are appreciating the mosquito as the principal causative factor, and crusades for its e.xterminatiort have been started. marshes being sprayed daily with crude oil. Malaria tends to occur in Santo Domingo in the most pernicious forms and has caused many deaths, so the fact that our people are awakening to preventive medicine to this extent may mean that further strides will be made in the near future. Xo steps have been made yet towards combating the hookworm. Among tropical dis- eases which are seldom seen in this country we mav mention ecchinococcus cvst and amebic abscess of the liver. There seems to be a general predisposition towards simple ulcers of the skin, so much so as to be called "endemic ulcers of the skin in the tropics" in text-books. Sugar manu- facturing plants suppl\- the hospitals with accident cases. Cholera, bubonic plague, yellow fever and leprosy are still to be seen. Opium and cocaine habitues are verv rarely to be seen down there, although alcoholics are as prevalent there as in any other part of the world. Beri-beri, tubercu- losis, diabetes, elephantiasis and erisipelas occur with a marked degree of frequency. As far as venereal diseases are concerned, syphilis and gonorrhea occur with disgusting frequency. Chancroids are rare. Abdominal surgery in .Santo Domingo is not much practiced, due to lack of material, though appendicitis, gastric carcinoma, hepatic affections and renal calculi are to be found. COMPLICATIONS OF GASTRO - ENTER- OSTOMY. By Charles L. Schmidt, Senior Medical Student. The complications following this operation are numerous, and I therefore deem it advisable to mention them in the order of their gravity from a clinical standpoint. They are as follows : 1. Regurgitant vomiting. 2. Subsequent contraction of the anastomotic opening. 3. Peptic ulcer of the jejunum. 4. Chest complications. 5. Perforation, owing to want of union at point of anastomosis. 6. Adhesions subsequent to this operation. 7. Internal hernia. 8. Death from asthenia. 9. Hemorrhage. I. REGURGIT.IlXT VOillTIXG. Formerly this complication was very common, and when severe was often fatal. Todav it is THE HOSPITAL BULLETIN rarely seen unless the technique is faulty. It is due to obstruction to the onward passage of the duodenal contents either from paresis of the in- testine, by adhesions, by pressure beyond the jejunal opening, by formation of a spur at the opening point of anastomosis, by acute angulation or kinking of the jejunuiu beyond the anasto- luotic opening, or by compression of the colon by the jujunal loop. This complication, which is a serious one, has been proven clinically to be trace- able to faulty technique. II. COXTR.\CTION OF THE NEW ORIFICE. There is always a certain degree of narrowing of the new orifice, but this can be avoided by mak- ing the opening not less than two inches and ap- proximating the mucous membrane properly. III. PEPTIC ULCER OF THE JEJUNUM. Peptic ulcers are very common in the stomach and very likely more common in the duodenum than is supposed, but are rare in the jejunum. The cause of jejunal peptic ulcer is the same as the gastric or duodenal variety. The peptic ulcer of jejunum complicating gastro-enterostomy is seen to follow the anterior more frequently than the posterior variety. This complication may occin^ from seven days to six or seven years after the operation, and may or may not perforate the in- testine. IV. CHEST CO.MPLIC.VTIOXS. Pneumonia and pleurisy following this opera- tion are not more frequent than following other abdominal operations. Some claim general anes- thesia as a potent factor in its causation. This, however, is an erroneous idea, for they (chest complications) tend to occur even under local anesthesia. JNIayo states that the latest theory is that some of the blood returning from the stom- ach does not go to the liver, and that infected emboli are deposited in the lungs. v. PERFOR.^TION. This is a serious complication and very often fatal. It rarely happens when union is procured by sutures. The use of the Murphy button seems to be an important etiological factor in its occur- rence. VI. .VDHESIONS. If the operation be a thoroughly aseptic one, and hemostasis perfect, this complication would indeed be uncommon. VII. I\TERX.\L HERNIA. This may occur by the passage of the small in- testine through the loop formed above the junc- ture of the jejunum and stomach by a small piece of intestine passing through the slit in the meso- colon, and lastly, in the posterior operation, the whole small intestine passing over the efferent loop and becoming strangulated. \ni. DE.\TH FROM ASTHENI.\. This complication formerly was rather com- mon, but is very rare today. Ten to twenty years ago, after the operation, the patients were not fed until they were well on to the road of recov- ery ; and, again, they were not operated on until they were extremely weak. These two factors were the chief drawbacks to a successful issue. Today patients are given one ounce of hot water in i6 to 20 hours following operation, which is increased as tolerated, and in 36 hours liquid food is permitted. IX. HEMORRHAGE. Hemorrhage is not likely to cause death, be- cause of the fact that the sutures used go through the whole thickness of the anastomotic opening, and therefore act as a compress to the vessels. However, it may occur^y erosion of a vessel wall by an ulcer or a cancer, as it may have done though gastro-enterostomy had not been per- formed. COXCLUSIOXS. The Murphy button is always connected with uncertain results. If the new orifice is made too small, a relapse may follow. Any method which does not aim at the proper continuity of mucous membrane is apt to be followed by too complete closure of the opening. The risk of peptic ulcer in the jejunum is under 2 per cent., and if the opening is made large enough, and the posterior operation performed, the percentage is less than I per cent. The friends of Dr. Norman F. Hill, class of 1882, will regret to learn that he is seriously ill at the Mercy Hospital. Dr. Robert Lewis Mitchell, class of 1905. is ill at the Sydemham Hospital with scarlet fever. THE HOSPITAL BULLETIN 53 THE HOSPITAL BULLETIN A Monthly Journal of Medicine and Surgery PUBLISHED BY THE HOSPITAL BULLETIN COMPANY 608 Professional Building Baltimore, Md. Subscription price, $1.00 per annum in advance Reprints furnished at cost. Advertising rates submitted upon request Nathan VVinslow, M.D., Editor Baltimore, May 15, 1911. THE ENDOWMENT FUND OF THE DE- PARTMENT OF PATHOLOGY. \\'e are actively at work trying to raise this fund of $100,000. Tlie fruition of our hopes is not yet in sight, but we are making progress. We wish to put an appeal in the hands of every living ahinnuis, and shall come very near doing so. We hope those who have benefite(^by the opportunities afforded them at the L'niversity of I\Iaryland, and who have prospered in their work, may in their turn aid their Alma Mater in accomplishing this task. Our need is a very urgent one, and we are taking the only means available to us to meet the issue. Of course, we shall appeal also to the citizens of Baltimore, but we ought to be able to show these citizens that our own alumni are doing all they can to aid us in our effort. The handwriting is on the wall ; the inien- dowed medical school cannot much longer exist. Brothers, help us to put our Alma Mater on such a sure foundation that when the rain de- scends, and the floods come, and the winds blow and beat upon our house, it may not fall. CLOTHE APPEAL FOR THE PATHOLOGICAL DEPARTMENT. The Facultv of Physic, being firmly convinced that the scientific chairs of a medical school should be filled b}- scientists who give their whole lime to the duties of their chairs, and not by practitioners of medicine, have appointed Drs. Randolph Winslow, John C. Hemmeter and Arthur M. Shipley a committee to devise means to bring about this important change in the School of Medicine of the University of Maryland. The aid of our alumni and friends is therefore asked in raising the sum of $100,000 for the en- dowment of the Department of Pathology. Any amount that you may feel able to con- tribute to this object will be gratefully received, as will also any suggestions or other assistance that may expedite our purpose. This fund will be administered by "The Trus- C tees of the Endowment Fund of the University of Maryland,"' an entirely independent corporation, not connected with the teaching faculties of the University. ^ — Subscriptions may be sent to any of the above- mentioned, and will be gratefully acknowledged in The Hospital Bulletin and in Old Mary- land. THE FUND IS GROWING. The following contributions have been made to the endowment fund for the department of pathology to May i : Robinson bequest, in memory of Dr. Aloreau Forrest, class of 1826 $5000 00 Dr. Gideon Timberlake 25 00 Class of 1848, Dr. John J. R. Krozer. ... 50 00 " 1873, Dr. Thomas A. Ashby. ... 100 00 " 1873, Dr. David W. Bulluck.. . . 100 00 1873, Dr. Robert Gerstell 5 00 " 1873, Dr. Randolph Winslow.. . 100 00 1882, Dr. J. Mason Hundley. . . 250 00 1885, Dr. B.Merrill Hopkinson. 2500 " 1900, Dr. Salvatore Demarco. . . 50 00 " 1901, Dr. Nathan Winslow 50 00 " 1902, Dr. Arthur M. Shipley. . . 250 00 " 1903, Dr. Hugh W. Brent 25 00 " 1905, Dr. Robert P. Bay 100 00 $6130 00 LIVING ALUMNI OF THE OLDER CLASSES. We would be pleased to learn the names and addresses of any other alunmi belonging to the following classes : John W. C. O'Neill, Gettysburg, Pa., 1844. John J. R. Krozer, Baltimore, :Md., 1848. R. Pinkney Blackistone, River Springs, Md., 1849. 54 THE HOSPITAL BULLETIN H. R. Roland, Annapolis, Md., 1850. Henry M. Wilson, Baltimore, Md., 1850. Philip S. Field, Baltimore, Md., 1852. Jas. H. Jarrett, Towson, Md., 1852. Thos. B. Owings, Ellicott City, 1852. \Vm. G. Wilson, Shelbyville, 111., 1852. Wm. E. Magruder, Sandy Spring, Md., 1854. E. Tracy Bishop, Sniithsburg, Md., 1855. Joshua W. Hering, Westminster, Md., 1855. John D. Cronmiller, Laurel, Md., 1856. James H. Butler, Baltimore, Md., 1857. Benj. F. Price, Mt. Carmel, Md., 1857. J. Ford Thompson, Washington, D. C, 1857. Samuel C. Chew, Roland Park, Md., 1858. Nathaniel G. Keirle, Baltimore, Md., 1858. Edward F. :\Iilholland, Baltimore, Md., 1858. Somerset R. Waters, Watersville, Md., 1858. Theodore Cooke, Sr., Baltimore, Md., 1859. Robert A. Dodson, St. Michaels, Md., 1850. Ephraini Hopkins, Darlington, !Md., 1859. Jas. G. Linthicum, Baltimore, Md., 1859. Samuel Quinn, Pocomoke, Md., 1859. Benj. L. Smith, Madison. Md., 1859. Thomas P. Robinson, Flintstone, jMd.. 1859. James K. Waters, Thurmont, Md., 1859. Henrv L. Naylor, Pikesville, Md., i860. ABSTRACTS REMARKS ON MEDICAL ETHICS. Dr. Samuel T. Earle, class of 1870, has the fol- lowing remarks in the Bulletin of the Medical and Cliirurgical Faculty of Maryland on the above- mentioned subject : "It is with considerable hesitation that I ven- ture to open the discussion tonight on the subject of 'The Ethical Relations Which Should Exist Between the General Practitioner, the Surgeon and the Specialist' on account of the delicate na- ture of the subject and the difficulties attending their solution, yet the freriuent murmurings and general discontent that we hear whispered from so many sources compel us to open the subject for general discussion among the members of the pro- fession lest a disregard of such warnings should lead us to such an unhealthy condition of affairs in our profession as might bring to us the ])lush of shame. "Among such unwelcome conditions may be mentioned a division of fees and the attempt on the part of the general practitioner to do work for which he is unqualified and unequipped. Self- preservation is but a part of our nature, and it is only reasonable to suppose that a man who has honestly given the required time and application to acquire his license to practice medicine should expect to obtain a competent livelihood by this means, provided his eftorts are energetic and honest. "On the other hand, it is perfectly proper that the large field of medicine should be subdivided among general and special workers, because it is generally recognized that certain classes of this work can be better done by delegating it to spe- cial workers. These two propositions are readily conceded by all. "The problem which now demands a solution from us is the proper recognition and remunera- tion that each should receive for his portion of the work. With the rapid strides made by gen- eral surgery and its special branches, together with the readiness with which its brilliant results can be recognized by the laity, this branch of our profession has received much more recognition from the public and a willingness on their part to render much larger remuneration for such serv- ices than that of other departments which ma}' J have required more thought and study, but which ' have not been so readily appreciated by the public. "It is for the members of the profession who can appreciate the character and quality of the work of each one to determine what recognition and remuneration is due each. The man who does 1 the preliminary work, and in many cases makes ' the diagnosis, but recognizes that a general sur- geon or a specialist can accomplish the cure far better than himself, is certainly entitled to more consideration in many cases than he has thus far received. When he is honest enough to make such a statement to his patient, and sends him to the surgeon or specialist for the relief of this special complaint, the surgeon or specialist should be equally honest and liberal in returning this pa- tient to his regular physician as soon as these special results are accomplished, with instruc- tions to report any further trouble of whatever nature to his regular physician, who is to deter- mine whether or not he shall again be sent to the specialist. Slioukl the case be one that does not come within the jurisdiction of the specialist to whom he was first referred, the latter should either refer him back to his regular physician or confer with his regular physician as to whom else THE HOSPITAL BULLETIN 55 he shall be referred whenever this is practicaljle. The surgeon or speciaHst should also see that hi, brother receives proper compensation for the work he has done, even at the risk of his not getting his regular fee for such special work, but his should all be done openly, with a statement to the patient of his regular charges for such special work, and that they shall only be exacted in full in case the patient is able to pay both the general and special charges. "It is best that we should discuss this subject freely among ourselves, but it can be settled satis- factorilv only by complying strictly with gentle- manly conduct and honesty. "I can probably make my position in this matter more clearly understood by quoting from Dr. H. C. \\'urdemann, Seattle, Wash., Nortlizcest Medi- cine. September, 1910. I fully agree with his views : " 'Professional fees are regulated by several factors, kind of services rendered, amount of time consumed, financial standing of the patient and the responsibility. There are no fixed fees for service, the only professional and legal require- ments being that they be reasonable and in ac- cord with the class of society to which the patient belongs. ■■ 'The giving or acceptance of commissions to physicians (or other people) for sending patients is an unethical and dishonest act, wdiich has not been tolerated by true physicians from the days of antiquity. It is dishonest because the patient is deceived, and the collusion is more dishonorable than that of the condemned commission business between the doctor and the druggist, long frowned upon by both the profession and laity. It is a cowardly proceeding if either of the doc- tors is afraid to let the patient know for what he is paying that which he has an ethical and legal right to know. The medical profession is not a trade, and division of fees without knowledge of the patient would be degrading the whole profes- sion to the trade level. " 'You may have spent time in caring for or in accompanying a patient to the consultant's office and feel delicate about submitting a bill for it. \\'hy? That is pure cowardice; the laborer is worthy ni his hire. " 'On account of his financial condition the pa- tient may not be able to pay the usual fee of the consultant or surgeon, yet you feel that you are entitled to some payment for your services. The matter is easily arranged ; the patient has but to explain his circumstances, and the consultant should be willing to reduce his fees so that the family physician may get some payment ; but this all must be done with the full knowledge and con- sent of the patient. The consultant shotild be willing, when necessary, on account of the finan- cial condition of the patient, to reduce the bill enough, even to giving his services gratuitously, to allow him to pay the family doctor, but the specialist should not pay over part of his fee because tlie other is afraid to demand it of the patient. " 'The consultant should be willing to do any special work for what is a customary fee among specialists of proper standings for patients able to pay the same ; for others who can pay but little, for the proportion of the usual fee they may be able to give after paying for the general practi- tioner's services, and in cases unable to pay any- thing to cheerfully do the work without monetary recompense upon the physician's recommenda- tion : but he should not hire any medical 'barkers' to drum up trade. The strongest reason, aside from the ethics of the case, is that the specialist should value the esteem of the general profession more than business, which he could not retain if he abandoned ethics and customs followed since the days of Galen — yea, even from those of Escu- lapius.' " ITEMS Amongst our alumni located in North Carolin.T. are the following : Croft. Simril N. Henderson, class of 1894. D.\BNEV. Charles D. \\'yche, class of 1888. Davidson. John ^^'ilson INIacConnell, class of 1907. Deep Creek. John E. Hart, class of 1897. Duke. Augustus C. Boyles, class of 1897. Dunn. C. Hector Sexton, class of 1890. Durham. Archibald Cheatham, class of 1888. Robert T. Phelps, class of 1898. Calvin S. Hickes. class of 1904. 56 THE HOSPITAL BULLETIN Thomas A. Alann, class of 1903. Robert Alfred Moore, class of 1891. William Wade Olive, class of 1906. Rufus J. Teague, class of 1890. Edenton. Harry M. S. Cason, class of 1899. Elizabeth City. J. B. Grisgs, class of 1892. William James Lnmsden, class of 1869. Charles W. Sawyer, class of 1885. Herbert T. Walker, class of 1902. Elii City. Benjamin Franklin Barnes, class of 1902. Edwin G. JMoore, class of 1883. Elp.\so. Erastus G. Goodman, class of 1891. EVALIN. J. V. Williams, class of 1889. EVEEETTS. John Watkins Williams, class of 1906. Fair Bluff. Alva G. Floyd, class of 1885. Fairmont. J. P. Brown, class of 1883. Falkland. Jcnness Morrill, class of 1888. Fayetteville. Robinette B. Hayes, class of 1906. James Vance JMcGougan, class of 1893. T. Marshall West, class of 1908. Franklinton. Richard B. Henderson, class of 1884. Fuquay Springs. James A. Sexton, class of 1873. Gaston I A. Charles Edward Adams, class of 1878. Lucius Newton Glenn, class of 1897. Frank G. Wilson, class of 1896. Gibson. John Shaw Gibson, class of 1905. Goldsborough. Thomas ^Malcolm Bizzell, class of 1908. Richard E. Lee, class of 1896. Greensboro. Charles W. Banner, class of 1899. Louis N. Biirleyson, class of 1891. R. E. Dees, class of 1906. R. O. Dees, class of 1906. Julius J. Hilton, class of 1886 Arthur E. Ledbetter, class of 1888. Arthur Ogburn Spoon, class of 1908. J. Pinkney Turner, class of 1896. Buxton B. Williams, class of 1883. Greenville. Louis C. Skinner, class of 1901. Grifton. Walter W. Dawson, class of 1897. William Cobb Whitfield, class of 1884. Gri-meslaxd. Claude i\L Jones, class of 1892. Grissom. Ginnada T. Sikes, class of 1883. Hamilton. Benjamin L. Long, class of 1881. Harrisburg. James C. Black, class of 1886. Haw River. L. W. McPherson, class of 1903. Henderson. Edwin F. Fenner, class of 1905. Hendersonville. James L. Egerton, class of 1877. Columbus Few, class of 1875. Hertford. Robert Walker Smith, class of 1892. Hickory. \^'illiam H. Nicholson, class of 1889. Benjamin Franklin Whitside, class of 1877. HiGHPOINT. William M. Jones, Jr., class of 1903. HUNTERSVILLE. William W. Craven, class of 1903. \\"illiam St. Clair Davidson, class of 1887. Jacksonville. E. L. Cox, class of 1889. Jamestown. John Edward Foscue, class of 190T. Keenansville. Albert Franklin Williams, class of 1901. Kernersville. Romulus L. Carlton, class of 1906. Kerr. Charles S. Kerr, class of 1868. Kinston. William F. Hargrove, class of 1901. Richard H. Temple, class of 1884. THE HOSPITAL BULLETIN 57 Ladonia. K. Thompson, class of i86S. Jolin \\'. B. Smithwich, class of 1895. Lakk Landixg. James Emory Mann, class of 1907. Laukinburg. Peter John, class of 1897. W. D. Jones, class of 190S. Lenoir. Wm. P. Ivey, class of 18S3. Lewiston. Wavland L. Mitchell, class of 1895. Lexington. E. J. Buchanan, class of 1892. LlLESVILI.E. J. Edwin Kerr, class of 1897. LiNCOLNTON. Robert William Petrie, class of 1903. Lin WOOD. James Edwin Cathell, class of 1899. Littleton. Willis Allston, Jr., class of 1903. B. Ray Browning, class of 1891. LOUISBURG. Emmitt H. Bohbitts, class of 1877. Lowell. George R. Patrick, class of 1879. LUMBERTON. John Knox, Jr., class of 1907. Allen ^IcLean, class of 1908. Richard Gregory Rozier, class of 1899. Maiden. Jerry C. Whitside, class of 1877. I\Lanteo. Woodson P.. Fearing, class of 1881. The recent newspapers have published the ])i.>r- trait of Dr. John J. R. Krozer, class of 1848, whu is said to be the oldest living graduate in Balti- more of the University of Maryland Medical De- partment. Dr. Krozer has been practicing for O3 years, and is 84 years of age. Of himself he has the following to say: "I was born in Elizabeth City, N. €.. and raised everywhere. When I was five years old my father died of the Asiatic cholera in its firs: invasion of this cOuntrv. and mv niolher moved with me to Virginia. When 15 years old I en- tered the United States Marine Hospital, and was there for four years before I entered the Llniver- sity. In those days we doctors started early and worked hard to get our degrees. Two years' studv under a physician was then required of a student before he was allowed to enter the Uni- versity, but its diploma, together with that of the University of Pennsylvania, was even then recognized in France, where medicine was at its highest. Those two universities were the only chartered schools in the LTnited States the degree.? of which were recognized abroad." Dr. Krozer was born August 30, 1827, and was the son of Dr. John Krozer. He was educated at the Military Academy of Portsmouth, Ya., en- tering at the age of 15 the L'nited States Marine Hospital, above mentioned, and later the Univer- sit}' of Maryland, from which he graduated in 1848. He resides at 662 West Lexington street, Baltimore. Dr. Krozer has in his office an excellent engrav- ing of the United States Marine Hospital at Ports- mouth, in which he began the study of medicine 69 years ago. He has owned it since 1855, when it was engraved b}' Caspar Bohn of Washington. On it is depicted the old sidewheeler Herald of the Bay Line, which was the twin ship of the Geor- gia, both of which have long since gone to the junk pile. He was also on board the LTnited States frigate .St. Lawrence when she was launched in 1845 from the navy-yard at Ports- mouth. She was built of wood, and was a three- masted sailing vessel. The next commencement of the university, which he will attend, is the sixty-fourth which he has seen since he entered on (.)ctober 15, 1846. A portrait of Dr. James H. Jarrett has been placed in the hall of the Medical and Chirurgical Faculty of Maryland, 121 1 Cathedral street, Bal- timore, by the Baltimore County Medical Asso- ciation. The Sun published the portrait of Dr. Jarrett, and gave the following account of his life: Dr. Jarrett was born February 24, 1832, in Harford county, and is of English descent. The doctor's grandfather, Jesse Jarrett. was born in Harford county, where he became a lead- ing farmer. He had a son, Asbury, who was a soldier in the \\'ar of 181 2, and later became a l)iominent merchant of lialtimore. .\nother son. 58 THE HOSPITAL BULLETIN Jesse, was a farmer in Harford county. The only son of Jesse Jarrett by his second marriage was Luther M. Jarrett, who was Dr. Jarrett's father. He was born in Harford county in 1804, and was a successful farmer and merchant. About 1837 he platted the village of Jarrettsville, which was named in his honor. Lie was one of the leading Democratic politicians in Harford county, and rep- resented his district two terms in the Legislature, and held several positions of trust and honor. In 1848 Dr. James H. Jarrett entered Dickinson College, where he completed his education, and entered the medical department of the University of ^Maryland. He graduated in 1852, and prac- ticed for nine years at Jarrettsville. At the break- ing out of the Civil War every member of the Jarrett family was an advocate of the Confederacy except the doctor, and when he announced that he was in favor of the L'uion and intended to enter the Union Anny his course was bitterly opposed by his family. Undaunted by opposition. Dr. Jarrett at once entered the Purnell Legion, organized by Col. William H. Purnell, as an assistant surgeon, and after serving a year was promoted to surgeon of the Seventh Maryland Infantry, organized and commanded by Col. E. H. Webster of Llarford county, and attached to the Army of the Potomac. His service was on the Eastern Shore of Virginia, and he was within hearing distance of the guns at the battle between the Monitor and the .Merri- niac. He was at the headquarters of Captain Duvall, at Cherrystone, when a messenger came up and announced that he wished to send word to Washington of the battle. Captain Duvall fur- nished an orderly and horse to take the mes- senger to Eastville to telegraph to Washington. Finally his ardous duties and overexertion caused his health to break down, and in 1864 he resigned on account of disability. While in the army he became acquainted with many of the lead- ing residents of Towson and vicinity, and so strongly was he attached to them that in 1865 he decided to make his home at Towson, and pur- chasetl property there. When he started at Tow- son the leading physician was the late Dr. Jack- son Pii)er. In 1855 and 1856, as a Whig, Dr. Jarrett served in the State Legislature from Harford county. He was a member of the State convention which nominated Thomas Holliday Hicks for Governor. There was a three-cornered contest between James Jj. Recaud, William H. Purnell and Hicks. Dr. Jarrett favored Purnell, but on the last ballot changed to Hicks, and thereby made him Gov- ernor. While his family w'ere well known as Demo- crats, Dr. Jarrett cast his lot with the Republican party in i860, and has voted the ticket ever since. At the close of the Civil War he became the public storekeeper at the custom-house, and held the position for four years. Lender President Arthur he was made a member of the United States Pen- sion Examining Board, a position held at present by his son. Dr. Harry S. Jarrett. Governor Lowndes made Dr. Jarrett one of a commission of three to compile and publish a record of the Union soldiers of Maryland during the Civil War. Dr. Jarrett was in Baltimore April 19, 1861, during the riot. In 1852 Dr. Jarrett married Miss Julia A. Spottswood, daughter of William Spottswood of Carlisle, Pa., who died some years ago. He has a son. Dr. Harry S. Jarrett, who is a graduate of the College of Physicians and Surgeons, Balti- more, and two daughters, Mrs. William A. Lee and Miss Julia Jarrett of Towson. Mr. William B. Jarrett of the Internal Revenue Service is a brother. Dr. Randolph Winslow, class of 1873, has re- ceived the following letter from Dr. Charles Ed- ward Scholl of Camden, Ind., a classmate. The ]\Iichael referred to is Dr. J. Edwin Michael of the same class, now deceased. The other members of this class referred to are Drs. Thomas A. Ashby of Baltimore ; John H. Rehberger, also of Baltimore : Truman E. Fairall of Tecumseh, Xeb. ; James A. Sexton of Fuquay Springs. X. C, and David William Bullock of Wilmington. X. C. The letter reads : Camden, Ind., April 13, 191 T. Randolph Winslow, M.D., Baltimore, Md. : Dear Doctor — I received your letter of the 13th inst. yesterday, and to say that I was surprised and delighted but half expresses my true feeling. My wife and I early last fall planned to spend the winter in Baltimore, and had even gone so far in carrying out our -plans as to engage rooms on West Fayette street, but, unfortunately for us, my presence here was required, and we were compelled THE HOSPITAL BULLETIN sy to give up the visit altoL;etIier. I wanted to look up old friends in your city, and to renew old acquaintances. I had often wondered what had become of the old boys of the class of "".v You were the only member of our class that I could locate, as you were the last one — you and Michael — that I had met, and one of the professors of the School of Medicine of the University of In- diana told me that he had met you at Chicago or Washington, I have forgotten which. Your kind letter gave me just the information I wanted. Some of them very familiar ; some I recalled with an effort, as I have been so long out of touch with everyone and everything connected with the old University. I came here nearly 36 years ago, and have had a very busy life, with all the hard- ships and pleasures incident to a country practice, imd now that I am growing old can say, with all others in this life, my reward has been all that I deserved. One of the greatest pleasures your let- ter afforded me was to run over the list of sur- vivors of our class, to recall their peculiarities or characteristics as I remember them. Why, Doctor, it was almost like meeting each one again ! Ashby, Rehberger, Fairall. Sexton, Bullock, and Michael, cut down in his prime ; they were a fine lot of fel- lows ! You ask why I made myself so scarce, and the reply comes naturally enough. New scenes, new associates, new duties mean a new place in life. I have visited ^Maryland man}' times, and several times passed through Baltimore, but each time was impressed with the fact that I had lost my old place there by my removal, and my place was here. If I live I am coming back for h good long visit — perhaps next winter — and then I will give myself time enough to hunt up and meet all the old friends. Remember me kindly to all the class in Baltimore, and accept my thanks for your kind letter, and best wishes for you and yours. I am, Very truly yours, C. E. SCHOLL. The follow'ing members of the class of 191 1 have secured appointments as follows on the staffs of Baltimore hospitals for the ensuing j-ear : At Bayview — Joseph Enloe Thomas of South Caro- lina. Paul Pressly McCain of South Carolina, William Clinton Marett of South Carolina, Her- bert Augustus Codington of Georgia and Grafton Dent Townshend of Maryland as assistant resi- dent jihysicians ; Raymond Garrison Husse_\ of North Carolina as chief physician of the tubercu- losis department; Burt Jacob Asper of Pennsyl- vania as chief physician of the department of men- tal diseases. At the Hebrew Hospital — Charles Lewis Schmidt of ^laryland and Isaac M. Slacks, also of ^laryland, assistant resident physicians, and Isadore Hirschman of Maryland as resident pathologist. At the Church Home and Infirmary — George Y. Massenburg, resident physician. Miss T^Iary Constance Wiggin of New York, University Hospital Training School for Nurses, class of 1910, has received an appointment in the United States Naval Nursing Corps. BIRTHS Dr. Allen Kerr Bond, class of 1882, and Mrs. Bond are rejoicing over the birth of a daughter, Christiana Birckhead Bond, on March 17. 191 1. DEATHS Dr. John Richard Thomas Reeves, class of 1858, died at his home in Chaptico, Md., April 14, 1911. Dr. Reeves was born at Charlotte Hall, St. Mary's county, Maryland, October 8, 1832. He was the son of Thomas Courtney Reeves and Mary Elizabeth Edwards. His early education was received at Charlotte Hall Acadeni\-, For some years after graduation he taught in private families, afterwards matriculating at the Univer- sity of Maryland. Dr. Reeves was at one time tutor in the family of Governor Samuel Sprigg. Dr. Reeves was devoted to his profession, and though during the last few years of his life he was not engaged in active practice, he never lost in- terest in the work of his fellow-practitioners. He married on October 16, i860, Miss Eliza- beth Ellen Hayden, who died in 1899. Dr. Reeves is survived by six sons — Thomas Garner. George Richard, John Courtney, Samuel Sprigg. \\'illiam Pinkney and John R. T. Reeves — and one daugh- ter. Miss Bessie C. Reeves. One incident of Dr. Reeves" life which he loved to relate was a trip he made to Gettysburg im- mediately after the great battle there in order to 6o THE HOSPITAL. BULLETIN render medical aid to a mortally-wounded brother- in-law. After some difficulty in getting through the lines he finally succeeded in reaching the ob~ iect of his cjuest. While there a wounded Con- federate soldier, who thought he was about to die, handed his sword to Dr. Reeves, as he did not wish it to fall into the hands of the L'nion sol- diers. Dr. Reeves managed to get the sword home without being detected, and a full 20 years after met again by a round-about method the owner of it, who was able to identify the sword by the blood spots on the handle, still perceptible. Dr. Jacob Dimmitt Xorris, class of 1878, died at iiis home, 1221 West Fayette street, at 12.30 o'clock April 24, 191 1, of heart trouble. He had been in I>oor health for several weeks. Dr. Xorris Vias born in Belair, ]Md.. August i, 1854. He was the son of Lloyd A. Norris and Alary A. Stansbury Norris, and a descendant of Sir John Xorris, an admiral in the British Navy. He received his earlier education at the Springfield Institute, near Fallstiin. ^^■hen Dr. Xorris was 19 years of age the Civil ^\'ar broke out. He entered the Con- federate Army at Nashville, and fought through- out the Civil War.' At the close of the war he went to St. Louis, Mo., and later to Eldorado Bar, N. M., and still later to Helena, Mont., where he engaged in mining. In this, however, he was unsuccessful, and later took a position on a ranch. This, also, was not to his taste. He then went to Walla Walla, Wash., and studied medicine for a year with Dr. J. C. Blacklock. He then started East on horseback, in 1876, coming as far as St. Louis in that manner and by train the rest of the way to Baltiiuore. A year later he entered the L'niversitv of Maryland, graduating in two years' time. He received an appointment as vaccine phvsician by Alayor Latrobe. and was reappointed 1)\- Mavor Hodges, who also appointed him cmi- niissioner of Franklin Square. President tirover Cleveland, during his second term, appointed Dr. Xorris as president of the second Pension Board of I'.altimore. He was one of the first luen to join the Fourth Regiment of the Maryland National Ciuard. and at the time of his death was chief surgeon, ranking as major. Fie accompanied the regiment on several trips, notably the one when they were ordered out to quell the riots in the Frostburg (Md.) mining districts. During the administration of Mayor Thomas Hayes Dr. Norris was elected to the City Council from the Twent}-first \\'ard. He married in 1881 Aliss Mary Eunice \\'ar- field of Frederick county, who survives him. He also leaves two daughters — Misses Hester and Jessie Xorris, and one son, Dr. Lester D. Xorris, class of 1908, surgeon for the Baltimore & Ohio Railroad at Wheeling, W. ^'a. The Masonic order, of which Dr. Norris was a member, had charge of the funeral services. Interment was in Lorraine Cemeterv. LABORATORY REPORT OF THE UXI- \ERSITY HOSPITAL. AIoxTH OF April. Blood E.vaniiiiatioiis. Leucocyte Counts 156 Erythrocyte Counts 103 Diflferential Leucocyte Counts 7 Flemoglobin Determinations 103 Smears for Malarial Parasites 8 Blood Cultures 2 Wasserman Tests 18 Widal Tests 5 402 Urine E.vaniiiiatioiis. Routine Urinalysis { chemical and micro- scopic ) 388 Total estimation for Urea 2 Total estimation for Albumen 4 Total estimation for Sugar 2 396 Miscellaneous. Gastric Contents (chemical and micro- scopic ) II Feces (macroscopical, microscopical and some cases chemical examination) ... 12 Sputum Examination 18 Bacteriological Cultures and Smears (from operative cases) 8 Examination of Spinal Fluid 2 Section of Tissue for Alicroscopical E.x- amination 32 Autopsies 4 87 Total 885 Dr. J. L. HiRsii. Dr. H. J. j\I.\LDEis, Dr. R. Dii.ler. THE HOSPITAL BULLETIN Published Monthly in the Interest of the Medical Department of the University of Maryland PRICE $1.00 PER YEAR Contributions invited from the Alumni of the University, Business Address, 608 Professional Building, Baltimore, Md. Entered at the Baltimore Post-office as Second Class Matter Vol. VII BALTIMORE, MD., JUNE IS, 1911. No. 4 ADDRESS OF DR. HARVEY W. WILEY, DELIVERED AT THE LYRIC THEA- TER JUNE I, 1911, at 4.15 P. M., ON THE OCCASION OF THE GRADUAT- ING EXERCISES OF THE UNIVER- SITY OF ]\IARYLAND. Members of the Faculty of the University of Maryland, Students and Graduates of the University: As a farmer I am struck with this fact today — that there is one crop in this country that never fails, no matter liow dry it may be nor how late the frost may come in the spring, nor how apa- thetic a husbandman may prove himself to be, the crop of bachelors and the crop of doctors never fails us. But it is, I suppose, a mark of the won- derful prosperity of the country that this crop goes on, ever increasing in volume. As I saw this great concourse of gowned young men and one or two young women — for I see you have a sprinkling of a competition which you have got to look out for in the future — I wondered where you are going to find places ; if you are all going to get jobs. And remember, that there are other universities besides that of Maryland in this coun- try. I have been going now for about two weeks almost every day addressing people who are grad- uating, so to speak, so I have seen a great many of them, and I hope that the pleasure which I get upon looking into the faces of young graduates may never be denied me as long as I live and have a voice. I hope that the institutions of this coun- try will continue to ask me to come to their com- mencements, because I can assure you that great as your pleasure is in receiving your diploma, it gives me even greater pleasure to look into the faces of these young people who are to be the arbiters of the destinies of this country. So I am glad to see you to-day; I am glad to see such numbers of you, so many who have completed the courses assigned and who are ready, I suppose, to begin the more active duties of life. Some of you are unfitted for that yet, because I see some are only bachelors of arts or bachelors of science. Now, with what profound pity you must look down upon a bachelor of arts, you who bear the dignity of doctor of medicine or of law ! The one is only a preparation for the degree which you have already received, but let me tell you bach- elors of science and bachelors of arts that there is not so very much difference sometimes, after all, between the amount of learning which a bachelor of science or of arts may have and that which is borne by a doctor of medicine or a bachelor of law. I have been opposed for a great many years — but I do not want you to draw from this any reflection upon you young bachelors or doc- tors of medicine — but I have long been of the opinion that it is not proper to give the degree of "Doctor of Medicine" to a graduate in medicine, because the word "doctor" does not mean a physi- cian any longer. It never did; although in this country when we speak of a man as a doctor we associate the idea with the practice of medicine in some way in one form or another. The word "doctor" does not have anything to do with medi- cine necessarily. The term "doctor" means one who is learned, one who has approved himself as a man of learning. I think the English custom is a great deal better. It is a long while after graduation in medicine before the English physi- cian can assume the title of "doctor." But that has nothing to do with the case today. You are doctors, or soon are to be, and I do not suppose you ought to be deprived of that pleasure, but it is a long while before you can get to be doctors of laws, and some of you never will. I was almost 62 THE HOSPITAL BULLETIN as old as I am now before 1 got to be a doctor of laws. You do not have to be a lawyer to be a doc- tor of laws. But the term doctor, I claim, should be reserved to give to a man after he has proved himself in the active field of service. In the old times, and probably yet, there was a fiction which said : "The king can do no wrong." That is to say, that there is a divinity that doth hedge about the king which prevents him from doing a wrong. That naturally goes with the idea of the divine right to rule. And in those olden days, too, in the feudal times, the lord or baron was supposed to be the protector of his people. They had no other protector except their lord. If he did not look after them they had nobody to look after them. And hence there came to be associated with the lord of the realm, the baron of the realm, an idea of justice or protection and of support among his people, and hence when this title was given to the lord of the realm, as it usually was, he be- came the lord or the aristocrat or noble of the province. If he was the right kind of man — and being a man he generally was the right kind of man, because most men are — he looked out for and protected his people. If you have studied Greek you will know that the term "aristocrat" means the rule of the best, agatlws being the Greek for "good," and aristos being the superla- tive. I mention this because it is about 40 years since I studied Greek, and I want you to under- stand that I have not forgotten it. These aris- tocrats all looked after the people and protecteil their rights in those early days, and there- fore there came into existence this idea which the French have so beautifully expressed by the phrase noblesse oblige. The noble, the high posi- tion imposes an obligation, in other words, upon the men who have achieved it. So I say to-day that the distinction of receiving a diploma from this ancient and honorable University imposes upon each one of you an obligation, an obligation as the minister has so beautifully said in his prayer, to serve humanity. And let me tell you that the only good you will ever get out of your diploma will be in proportion as you real- ize the obligation it imi)oses upon you. To be sure, the old diploma.s — and I suppose the new ones also — used to read in very bad Latin that you were admitted to all the rights and privi- leges of the academy, but in the olden times they added to it and also all the duties thereunto per- taining. This is not a mere admission to a privi- lege, but it is an admission to a privilege on the condition that the duty which is attached to that privilege is performed. So I am going to speak to you today on that idea of noblesse oblige. The obligation which graduation imposes upon each one of you in the particular course of duty which you are to per- form is embodied in this idea of noblesse oblige. Now, in a graduation of this kind, where all the schools are represented, I can hardly select any particular one to whom to address my re- marks, and so I am going to make them as general as possible, so that all may be included. Now. let us begin with this distinction — that the difference between the man who bears a diploma and the one who does not is one of broad- ened intellectual conception. The man with a diploma ought to have a broader view of things than the man who has not a diploma. Sometimes that is not the case. Some quite learned men have never been to college, and some who have been through colleges and universities and who have diplomas are pretty narrow, I have found, in their views, and the principle which I enun- ciate, then, is a general one, and does not al- ways apply. But if you do not have a broader view of things, then your course in this institution has been in vain in so far as you are concerned. If you have not knowledge and a knowledge how to apply knowledge, which the man who does not bear the diploma has not got, then you have not done your duty in this institution or the institu- tion has not done its duty to you — one of the two. Now, having this increased power, having become a nobleman in the true sense of the word, there is imposed upon you that obligation of noblesse oblige. What are some of the things that are imposed upon you ? In the first place, you should become good citizens of this country. That is the first thing you ought to look out for — to see that you have the right view of public affairs. Now, I am not going to give any tirade on politics, only to say this — that we are too apt in this country, all of us, to go blindly in our political creed. We all have been brought up, perhaps — I know most of us have — to some particular religious creed, and we are ver\' apt, when we grow up, to follow that creed. Sometimes we get away from all creeds, which is an unfortunate thing. It is better to follow the one you were brought up in than to have none at all, even if that be faulty. And the same is true with politics. You ought to have J THE HOSPITAL BULLETIN 63 some politics, and if you haven't time to have some of your own, you ought to take those of your father, if you have faith and confidence enough in your father's politics, and I trust you have. If you haven't time to study them for yourself, then follow along in the line in which you have been brought up. But it is very hard, indeed, to break away from those moorings, and yet the duty of ever}' young man and every young woman is to have some politics. I say "young woman" be- cause you are going to vote very soon. I see you back there in the audience ; you are going to have the ballot just as sure as I stand here, and you are going to take part in the civic uplift of this coun- try, and it is the duty of every young man and every young woman to think about political affairs, and not to be blindly led by your leaders, whoever they may be. This is a country of free thought. We have not had any restriction placed upon a man's thoughts and their expressions un- less they tend to disrupt society. As long as your thoughts are right, as long as they are for the benefit of mankind, you have your right to your thoughts and your right to your religion and your right to your politics and your right to your phi- losophy and your right to your medical profession, or whatever you want, and it is your duty to be an independent thinker on matters referring to the welfare of the State, whether it be of the city or State or the nation. So I see a development in this country, and largely among college and university-bred men, toward that spirit of political independence which means so much for the wel- fare of our country, and so much for the perpetua- tion of our free institutions. Now, let me tell you young people that we are entering upon an age of ferments ; the whole civic body is teeming with those organisms which produce the fermentation of the civic spirit, and we are having developed in this country dangerous tendencies as a result, and as a natural result, of the condition of atf'airs which exist in this country today. You cannot expect the people of this country to sit quietly by and see all the wealth of this great nation in a few hands. There must be something wrong when conditions of that kind prevail. Now, how are those conditions to be met? I say by philo- sophical inquiry, b)' a judicial spirit of inquiry, and not by mob and force and violence, as those conditions have been met in other countries, and will be met in this country if they are not met in some other way. Therefore, I say the solution of these great problems of socialism and anarchy and the rights of the common people and the rights of the workmen and the housing of the workmen and all Ihiise things which work for public sanitation and welfare and civic uplift have got to be solved by philosophical inquiry and a judicial disi)Osition of the mind. And it is the educated people of this country who are going to solve those problems ; the graduates of our univer- sities and of our colleges are to be the leaders in this, and you as citizens will have to face these problems in the near future. They are upon us now, and you have to act wisely and well in order that their solution may be a proper one. We do not want to see this country precipitated into the throes of a revolution because the proletariat is deprived of its rights. The man who is born in this country has the right to live and the right to earn his living and the right to work, and the right to receive the wages for his work, and every time that a dollar is improperly diverted to a coffer where it does not belong, just that mo- ment one dollar is taken from what the people of this country should have as a common inheritance. You have read Henry George and his theories of the land. Nobody owns land in this country. We all say we own land, and think we do, but there is not a man in this house, nor in any part of this country, who owns a foot of land. He holds it by the sufferance of the public, and the State can come in and take every foot of land that he owns to-day if it wants to. Why do you have to pay taxes on things you own? Because you do not own them ; if you did,, nobody would have any right in them at all. And we recognize the right of taxation and the right of eminent domain and the right which every State had to take not only the property, but the lives of its citizens for the public service. Just think for a moment, then, that you are not independent ; you are not standing alone, but you owe your property, your service and your lives to your country, and hence as citi- zens this sense of obligation, this noblesse oblige, rests upon you to become good citizen^. Then you want to make good husbands and fathers. And while I believe in the rights of women, that a woman has every right in the world that a man has, she has the right to vote, she has the right to earn her own living and she has the right to enter any profession she chooses to enter; but the woman's sphere is not alone in professional life ; it is as a mother and in the 64 THE HOSPITAL BULLETIN home, and there is only work enough in this coun- try for half of the grown people to do ; even if there were not, I would not want to see the women do the work ; I do not want to live in a country where the men sit in idleness and the women do the work, because, while a woman can adorn an idle chair, a man cannot. At the same time I would not deny any woman of this broad land a single right that I possess. She has a right to her own views in politics, she has a right to own property ; just as much as anybody can own property ; she has a right to rule her husband if she can — and most of them can — and she has a right to vote, and she has a right to be a physi- cian, and also a minister of the gospel and a citi- zen of this great republic, the highest honor of all. But with those rights — and in this it is the same as with the diploma — go the duties of women, and the duty of the woman is at the home, to be the mother. Tliat is her duty. Every right has a duty imposed with it, every single one. No man ought to claim any protection under the laws of his country who does not give some service to that country. The right of protection under the law rests wholly upon the duty which citizens render to the State. So we cannot claim that pro- tection unless we render that service. Then again, you young people have a duty which you have already performed to a large ex- tent, and that is in a preparation for this service which you propose to render. You have already, by passing the examinations and receiving the approval of your faculties, shown that you have prepared yourselves for the several duties which you are ])roposing to undertake. But do not fall into this error of thinking that the period of preparation and study is past. It is only begin- ning. You have only fabricated the implement up to the present time, the plow which you are to use in the cultivation of the field, and I do not care how skilful you are in theories, it does not neces- sarily spell success. I could sit down, if I knew how, and teach a man how to make a watch, and tell him how every single part of that watch was to be made, what size it should be and how it should be put together, but I would not like to trust that man to make a chronometer to run the universe by the first time he attempted it. He would make a sorry spectacle of it. Once I heard a story of an eminent specialist, an oculist, who was compli- mented on his skill in being able to save the sight of the eyes. He saved the sight in cases that were almost hopeless, and when complimented upon his skill he said : "Yes, I am skilful ; I can do these things; I can operate upon an eye with the greatest precision and restore apparently a vision that has vanished and prevent the destruction of that which seems to be going," but, he says, "I destroyed a bushel of eyes before I learned how to save one." Now, it is hard on the people who have the bushel of eyes. I expect it is going to be hard on some of the sick people in this country when they first fall into the hands of these young doctors, and hard on some of the clients who go before the courts represented by some of these }Oung lawyers. I fear they will be mulcted more heavily than they should when these young law- yers take hold of them. And I expect that many a tooth will ache that ought to be in placid retire- ment when these dentists get hold of them, and many a person, I fear, may have qualms in his stomach when the young pharmacist first pre- scribes for him. They tell a story of a man who had a lawyer who was very skilful. His client knew he was guilty and that he was going to be convicted. It was a civil case, so he did not have to be in court at the time. So the lawyer presented his case to the jury, and much to the lawyer's surprise the jury brought in a verdict of not guilty. He tele- graphed his client, "Justice has been done," and he received immediately a repl\- by telegram, say- ing, "Appeal at once." A mother once called in the old-fashioned "root and yarb" doctor for her boy, who was suffering with chills and fever. Now, I was born and brought up in Indiana, and I know what the "ager" is. A man was not a respectable citizen in that State unless he had an "ager-cake" as big as a bread basket. It was his title to nobility. The mother called in this old doctor, as I said, who prescribed for the boy. He took from his stock of herbs one of the roots, and he scraped it very carefully and put it in a glass and poured hot water on it and set it to one side. Then he scraped another piece from the same root and put it in another glass and poured hot water on it and set it to one side. Then he said to the mother: "When the boy has a chill you give him the first preparation, and when he has fever you give him the second one." "But," she said, "you took those botli from the same root, didn't you?" "Ah, yes, I did, but did you notice that I j scraped the first one up? That is high-cocka- ' scraper i THE HOSPITAL BULLETIN liiruin. And I scraped the second one one down — this is lo-cockahighrum." Now, I fear that much of the Ijeginning practice of the young physician will be of the high-cocka- lorum and the lo-cockahighrum stripe, and I say it is hard on those persons who lost the bushel of eyes in order that you may become skilful, but we have to take these chances in this world, and if we are brave enough to employ the young physi- cian or the young dentist or the young lawyer, we at least confer a service on those who come after us. Therefore, I say that the preparation or acquir- ing of the skill which you have largely accom- plished must be supplemented by its actual prac- tice, and that is where the judgment, the intel- ligence and the good sense — what we used to call "horse sense" (I do not know why they called it that, because I have seen some horses that have less sense than any human beings I ever saw), but the good horse sense of the individual, his individuality, his power of discrimination — come into use, and it makes a success of one man, and the lack of it makes a failure of another. Now, you are not all going to succeed. I am not going to specify those of you who are going to fail, so you need not take it personally. But here there are 210 graduates, I may say, and at least 10 of those are going to make failures of life. You can draw lots, all of you, to find out who they are, because I cannot tell you to-day which ones they are, but partly it will be the re- sult of environment in which they are placed, and largely it will be the result of the subject himself. There are some people who would be hungry if you were to turn them loose in a ban- quet hall filled with all the best things to eat in the world, and if you were to tell them to help themselves they would not know how to eat. There are some people who would fail under the most favorable circumstances for success. There are others who will succeed where the environ- ment seems almost hopeless. And I tell you that one of the principles which is the most impor- tant in this respect is wise patience. The man who will calmly wait under difficulties, under stress, under hardships, under privations, feel- ing that he has the stuff in him to make a success, and that he will succeed if he just keeps on, that man is almost certain to succeed, almost certain, I say. Yet, it is one of the hardest things in the world to teach a person the faculty of waiting. The young man wants to bound at once into suc- cess. He has had four or six or eight years' study in preparing for life, and now he expects in one year to make a reputation and a name for himself, and to make an income. Now, that is impossible, except in rare instances, at the present time, so the man who patiently waits, and who works while he waits and never gives up, never gives up his purposes, holds to the one purpose, is bound to succeed. But, young men, you are never going to succeed by trying this thing to-day and that thing tomorrow. You want to try this thing to-day and tomorrow and all the time when you make up your mind to try it. Never give up. I never saw a man yet who got into a habit of going from pillar to post trying this and trying that who ever made anything of himself worth making. You make your way by perseverance and patient waiting. And do not be discouraged because you do not become famous in a day, be- cause you have no clients the first day you put your shingle out, because you have poor success when you do get them. Stand by your guns. Be patient, be hopeful, be reliant. "Did you tackle the trouble that came your way With a resolute heart and cheerful ? Or hide your face from the light of day With a craven soul and fearful ? O, a" trouble's a ton, or a trouble's an ounce. Or trouble is what you make it, .\nd it isn't the fact that you're hurt that counts, But only how did you take it? "You are beaten to earth? Well, well, what's that? Come up with a smiling face ; It's nothing against you to fall down flat. But to lie there — that's disgrace. The harder you're thrown, why, the higher you bounce ; Be proud of your blackened eye ! It isn't the fact that you're licked that counts; It's how did you fight — and why ? "And though you be done to the death, what then ? If you battled the best you could, 1 f you played your part in the world of men. Why, the Critic will call it good. Death comes with a crawl, or comes with a pounce. And whether he's slow or spry. It isn't the fact that you're dead that counts, But only how did you die?" 66 THE HOSPITAL BULLETIN So stick to it : don't give up. And always be- lieve in yourself and in your ability and in your future, and do not get married until you get some- thing for your wife to live on. It is hard enough for one man to starve, but it seems to me to be a great deal worse if there are two to starve. And if you love your wife as well as you ought, you wouldn't eat anything, so that she could have a full meal. So just wait a while. Do not wait too long, however. Do not wait until you get ten thousand dollars a year ; when you get a thousand dollars that is enough. Do not wait too long. Let your faith be always in the future. And then there is a service which you owe to the State. You ought to make a good living, you ought to prepare yourselves to do it, and to work hard to do it, but that is not the object of life; that is not the ambition which is carried in the phrase noblesse oblige. True, every man wants to make a living, and he must make a living, and does make a living, except in extraordinary cases. but the acquisition of wealth should never be the sole ambition of any educated man. Let the un- educated people get rich ; let the educated people ser\'e the State. In that service you must sacrifice to a large extent your own personal views and preferences. I do not believe there is a man living who ever really has a proper feeling of contentment and self-respect who cannot look back every day on some service he has done humanity. The mere selfish acquisition of wealth, it seems to me, is the most unsatisfying feeling that coukl come to a human being. But if you feel that you have done your client a service be- fore the bar, if }ou feel that the sick man's pains have been alleviated and he has been ]iut upon the road to recovery, if you feel that the man who leaves your dental chair has a better set of teeth than he ever had before, and if you feel that the prescription you put up at the corner drug store is of the purest and best drugs, you can feel that you have done a service to humanity in doing that. In other words, a service well done- — I do not care how menial it is — is a service to humanity. They say of the Roman Senators that in derision of Cato, and being angry with hitn, they created the office of Commissioner of Sewers, and to humiliate him they appointed him the commis- sioner of the great Cloaca Maxima, and he so discharged the duties of that despised office, with such benefit to the State, that ever after that to be Commissioner of Sewers was the highest honor to which a Roman Senator could aspire. So never despise a thing because it is menial, but do it well. I read the other day of a man who got a prize of one hundred dollars for plotighing the best furrow in a field out in Illinois. I would have been as proud to get that hundred-dollar prize as if I had won the gold medal at this Uni- versity. Those of you who are going to get those medals to-day know how proud }0u are. But I do not care how menial the service is if you do it^ well, especially a service to humanity, and unless it is done well you are not doing your duty to humanity. Service should be the cry, the ambition of every educated man. Service, service, service! To do something to help the world along. The world will recognize you not in proportion to your claims upon the world, but in proportion as you serve the world. The world has no sentiment. You are going into the great capacious maw of this great world, and you will be eaten up, swallowed whole, and the world will pay no attention what- ever to you until you make yourself felt upon the surface of the earth by your service, and not by your claims, nor by your diplomas nor your science, but by what you do. That is the meas- ure by which the world will gauge you and judge you in the future. Service ! Do something to help the world along. "There are hermit souls that live withdrawn In the place of their self-content ; There are souls like stars, that shine apart In a fellowless fimiament. There are pioneer souls that blaze their paths Where the highways never ran. But let me live by the side of the road, And be a friend to man ! "Let me live in a house by the side of the road. Where the race of men go by — The men that are good, and the men that are bad— As good and as bad as I. Why should I sit in a scorner's seat. Or hurl a cynic's ban ? Let me live in a house by the side of the road,. And he a friend to man ! THE HOSPITAL BULLETIN 67 "I see from my house by the side of the road, By the side of the highway of life, The men that press on with the ardor of hope, And the men that are faint with strife. But I turn not away from their smiles nor their tears — Both parts of an infinite plan ; Let me live in a house by the side of the road. And be a friend to man ! "I know there are brook-gladdened meadows ahead, And mountains of wearisome height, And the road passes on through the long after- noon, And stretches away to the night. But still I rejoice when the travelers rejoice, And weep with the strangers that moan. Nor live in my house by the side of the road, Like a man that dwells alone. "Let me live in a house by the side of the road. Where the race of men go by ; They are good, they are bad, they are weak, they are strong. Wise, foolish, and so am I. Then why should I sit in a scorner's seat. Or hurl a cynic's ban ? Let me live in a house by the side of the road. And be a friend to man !" URTICARIA."* By Norman T. Kirk, M.D., Assistant Resident Phxsician in University Hospital. Synon \uis. — Hives, nettlerash. Classified as angioneurosis. Definition. — Urticaria is an anaphylactic mani- festation produced in a sensitized subject by cer- tain specific toxic proteids or chemicals, character- ized by lesions of the skin or mucous membranes, evanescent, whitish, pinkish or reddish elevations or wheals, variable as to size and shape, attended by itching, stinging and burning sensations. Etiology. — The causes of the various urticarial diseases have been divided into three heads — predisposing, internal, external. Predisposing.- — Sex — JNIore frequent in female. •Read bpforo University of Maryland Medical Society, Feb- ruary 21, 1911. Age — early childhood and middle adult life. Family history frequently shows gouty, rheumatic, neuro-arthritic, asthmatic and neurotic taints. F'unctional and organic diseases, especially of the ovaries, uterus and nervous system are frequently seen. It is often associated with jaundice, gout, rheumatism, purpura, and occasionally co-exists v.ith albuminuria and glycosuria. Among the internal causes, the condition ap- pears after the ingestion of certain foods, espe- cially shellfish, as clams, oysters, lobster, shrimp'; also pork, sausage, almonds, cucumbers, straw- berries, tomatoes, mushrooms, and even at times after milk and butter. Drugs frequently produce the condition, as copaiba, cubeb, chloral, turpen- tine, salicylates, quinine, opium, the iodids and many of the coal-tar products. It is frequently seen after the use of antitoxins, vaccines and the Pasteur treatment for rabies. Emotional or psychic causes, such as anger, fright or sudden grief, seem to excite an outbreak. Among the external causes are irritants such as the sting of the nettle, jellyfish, wasp or caterpil- lars ; and occurs in oyster shuckers and has been known to occur in sensitized persons by applica- tion of egg-white to the skin. All of the above have been seen in clinical observation. Stelwagon says there are many causes, but a peculiar indi- vidual predisposition is necessary, inasmuch as the same cause may not produce the eruption in dififerent individuals. Along this line more recent work and thought has brought out the hypothesis, and some experi- mental work has been done to show that urticaria is an anaphylactic phenomenon, closely allied to asthma, and is caused by certain specific proteids; either animal of vegetable in origin, acting as a toxin to those subjects which have been sentitized to that particular proteid. An urticarial rash is frequently seen accompanying or is one of the symptoms of an anaphylaxis following a second injection of an antitoxin in the so-called serum poisoning. The condition occurred in a fellow- classmate after the course of treatment for rabies. Experimental work showed that serum, taken from a inan who for two years after eating a sau- sage suffered from an immediate eruption of net- tlerash whenever he ate pig meat, injected into a guinea pig excited immediately an extremely clear anaphylaxis with regard to pigs' serum. It would seem, then, that these phenomena of hypersusceptibilit}' to certain definite proteids 68 THE HOSPITAL BULLETIN nia\- be congenital, acquired or inherited; that these proteids may be absorbed from the food in the digestive tract through the circulation, olfac- tory tract or by injections, and is always a spe- cific condition. Persons sensitized to crab are not susceptible to berries, or vice versa. The causes mentioned above and grouped as internal and ex- ternal contain the specific proteids. Pathology. — The condition is an angioneurosis, the lesions which are found on the skin being primarih' at least due to vasomotor disturbances, brought about by the action of the toxic proteids. Barthilemy believes dermatographism to be due to a toxic vasomotor dermatoneurosis. The urticarial lesions are due to dilatation, fol- lowing spasm, of the arterioles, resulting in eflfu- sion with migration of leukocytes. This condi- tion causes pressure on the central portion, bring- ing about paleness, which was preceded by pink- ness and redness, the darker tint on the periphery and size and shape of the lesions being due to the blood, which has been pressed backward, and the depth of the involvement. There seems to be an increase in the secretion of lymph, as well as a paralysis of the vessel walls. In the ordinary forms only the superficial layers are involved, while in urticaria gigans the whole thickness is involved, and in the edematous variety infiltration occurs in the loose meshes of the sub- cutaneous areolar tissues. The pathological anatomy of a wheal shows it to be more or less of a firm elevation of a circumscribed or somewhat diflfuse collection of semifluid material, especially limited to the corium, which has been shown by Dr. T. C. Gilchrist to be the seat of an acute in- flammatory change. The blood vessels, especially around the sweat ducts, are enlarged, contain and are surrounded by a large number of polynuclear leukocytes, while the lymph spaces contain a gran- ular debris. Mast cells are found in the corium. The epidermis is not involved. Symptoms. — The urticarial eruptions are ery- thematous in character, usually come on suddenly, may be preceded by burning or itching and con.sist of scanty or profuse eruption of pea or bean- sized elevations, linear streaks or small or large irregular ])atches, or admixtures of these forms. The distril)ution may be localized or general. The outbreak may he preceded or accompanied by gastrointestinal symptoms, febrile action at times in acute, severe cases, or none of these may oc- cur. The lesions are fungacious in character, dis- appearing and reappearing in the most capricious manner. They are firm to the touch, and vary in color ; pinkish or reddish, with white central por- tions. The subjective symptoms are usually quite marked, consisting of stinging, intense burning or itching sensations. These may last from a few minutes to half a day, disappearing only to re- appear again. The intervening skin is normal. If the lesions persist for several days or a week, condition is known as urticaria persistens. Ill-defined pufifiness of the hands and feet oc- curs at times with above subjective symptoms. During the outbreak it is usually possible by drawing a pencil somewhat firmly over the sur- face to bring out linear wheels. This will re- main from a few minutes to several hours ; condi- tion is known as urticaria factitia or dermato- graphism. The eruption is not always confined to the ex- terna! surfaces, but the mucous membranes of the mouth, throat, larynx, or even intestines, may be involved. Numerous forms of lesions exist, as giant urticaria or acute circumscribed edema, which is a localized edema, occurring in the loose subcu- taneous tissues airound the mouth, eyelids, ears and scrotum, and may be free from subjective symptoms, coming on rapidly, lasting for a day or so, to disappear again. L^rticaria may be acute or chronic, usually the former, lasting from a few hours to several days. Periods between attacks vary, depending upon the e.xposure to the etiological factor. The chronic form — urticaria persistens — has the same features as acute, save the duration is longer, con- dition remaining for days and weeks with marked suffering in general health of the patient, due to worry, etc. .Several other forms exist. Diagnosis. — Is usually easy from the distribu- tion and subjective symptoms, their evanescent nature and dermatographism, which is usually present. Prognosis. — The acute disease is of short dura- tion, disappearing spontaneously or as a result of treatment in a few hours or several days. It has tendency to recur when person is exposed to the etiological cause. The prognosis of the chronic THE HOSPITAL BULLETIN 69 form is to be g'liarded until the causing toxin can be found. Treatment. — The prophylactic treatment con- sists in finding the specific toxin to which the pa- tient is sensitized. Remove this from his diet if it be found in his food and the attack will not recur. To relieve the condition we should aim to first get rid of the toxin by free purgation and elimi- nation, and put the patient on a light diet for a few days. Give antacid remedies internally, as sodium bicarb., salicylates, etc. Ichthyol in as- cending doses is recommended by some; quinine, atropin and coal-tar products often do good. For the local condition give sodium bicarb, bath, soothing ointments or wash, as carbolic ointment, calomine lotion, etc. The chronic form is the most obstinate. Pre- disposing factors, as internal or ovarian trouble, neurotic and gouty disturbances, diabetes and ne- phritis, should be sought for, treated or removed if possible. MORTON'S TOE. By T. Gay Whims, Senior Medical Student, and Nathan Winslow, M.D. The disease takes its name from Dr. Thomas G. Morton of Philadelphia, who first described it, and is characterized by acute cramping pains at the base of the third or fourth toes. It occurs in nervous persons, most frequently in women ; children are very rarely affected. Heredity may play some role in the causation of the disease. The exciting cause comes from the plantar nerves being pinched or pressed upon by the heads of the metatarsal bones, the normal relation between these having been for some cause dis- turbed. This disturbance in the relation of the metatarsal bones is usually brought about by wearing shoes which are too tight. The condi- tion is often associated with flat foot. The pain usually comes on suddenly while the patient is walking, and it may be so severe that she has to sit down at once and remove her shoes. The pain, which is sharp and cramping, is in this way partly relieved. Rubbing also helps to allevi- ate it. After the acute attack a sense of soreness and numbness remains. The pain can be pro- duced by squeezing the foot in the hand. The attacks tend to become more frequent and severe. Plantar flexion of the toes is usually and dorsal flexion sometimes limited. The pain is often ac- companied by a snapping of the metatarsal bones, and this has been known to be the chief symptom in this condition. The arch of the foot may be somewhat lowered, the front of the foot may be flattened with a depression on its dorsum, over the middle metatarsals, or it is possible for the foot to be normal in shape. The characteristic symptoms make the diagnosis easy. Mild cases in which there are no deformities of the foot may be cured by employing massage and by wearing of properly fitting shoes. In cases with deformity it is usually necessary to employ braces or plates of such a shape as to overcome the deformity. The gastrocneinius muscle is sometimes contracted, and should in such a case be stretched. In severe cases removal of the distal end of one of the metatarsals, and even resection of the metatarso-phalangeal articulation, have been resorted to. The cure from these operative measures may not be permanent, however. Some cases are reported to have been cured by excising a portion of the superficial branch of the external plantar nerve. Rel<ort of Case. — Miss E. S. W., aged 24, white, came under observation two years ago for severe pain in fourth metatarso-phalangeal articu- lation. The pain was cramp-like, extremely ex- cruciating in character and came on stiddenly while walking. It was only relieved by removal of shoe and rubbing. With time the pain grad- ually became worse and occurred at more frequent intervals. The joint was sore on pressure and was sore to the touch for some time after the at- tack. The dorsal surface of the foot was slightly swollen and red. A felt pad was placed under the joint to no avail, so operation was advised, which was con- sented to. On the 14th of May, 1910, the patient was anesthetized, the operative area properly cleansed, and a dorsal incision made directly over the joint and carried down to the bones to the side of the extensor tendons. The head of the fourth meta- tarsal and the proximal end of the fourth phalan- geal bone were excised, and a few strands of silk- worm gut were inserted as a drain. These were removed in two days and the wound allowed to close by primary intention. The patient was about in a week, and since then has had no return of the THE HOSPITAL BULLETIN' symptoms. It is yet too early to prognosticate the ultimate result, but after a year and five months of continuous use, with no recurrence of pain, we may reasonably assume she is per- manently cured. DIRECT INGUINAL HERNIA. By Jas. J. Edelen, Senior Medical Student. There are two forms of inguinal hernia, the oblique and the direct. The oblique inguinal hernia is of very frequent occurrence and occurs as both a congenital and an acquired malady. On the other hand, direct inguinal hernia is a com- paratively rare affection, though perhaps it occurs more frequently than is generally thought to be the case. It probably occurs in about to per cent, of all cases of inguinal hernia in the adult. It may possibly be a congenital affection, but, if so, this occurs so very infrequently that it mav be regarded as an acquired disease in practically all cases. Males are much more frequently the sub- jects of this condition than females. Whilst it has been observed in childhood in a few cases, it is so infrequent during that period of life that in upward of 2200 operations in ch.ildren at the New York Hospital for Ruptured and Crippled, reported by Dr. William B. Coley, there was none for direct inguinal hernia. .lnatoin\. — Direct inguinal hernia derives its name from the fact that it does not traverse the inguinal canal, Init protrudes directly through the abdominal wall at the external abdominal ring, and does not descend into the scrotum. The hernia e.scapes from the abdominal cavity at Hes- selbach's triangle, a s]:)ace bounded internally by the outer edge of the rectus muscle, externally by the dee]i epigastric artery, and below by Poupart's ligament. The intestine either pushes the con- joined tendon in front of it, or passes through a slit in this structure or slips to the outer side of the conjoined tendon. The e])igastric artery invarialily lies to the outer side of a direct inguinal hernia, and the relation of the artery to the neck of tlie hernical sac determines whether we have to deal with an (jhlique or direct inguinal rupture. If the sac is on the outer side of the deep epigas- tric vessels it must be an oblique form of hernia ; if it is on the inner side of these vessels it is a direct hernia. The coverings of direct rupture differ somewhat from those of the oblique, being skin and superficial fascia, intercolumnar 'fascia, conjoined tendon, transversalis fascia and peri- toneum. The cord is usually situated in front of the hernia or to its outer side, and not behind it as in the indirect variety. Syniptoius. — There are the usual signs of her- nia, but the lump develops rather slowly and does not descend into the scrotum. The swelling is rather globular in shape and is situated closer to the penis than the oblique variety. The finger can be pushed directly backwards into the ab- dominal cavity and does not traverse the inguinal canal. Too much reliance, however, cannot be placed in the physical characteristics of this hernia, as frequently one is mistaken in the diagnosis, or the diagnosis is onlv made after the incision of the tissues. .Sometimes the bladder also pro- trudes in connection with direct hernia, and one should always bear in mind the possibility of this complication, and in operating for the cure of this form of hernia any abnormal appearance of the sac or surrounding tissues should excite sus- picion and cause especial care not to injure this viscus. When the bladder is incised it must be sewed up and a drain placed in the lower end of the wound. A direct inguinal hernia is liable to become strangulated, but apparently this does not often occur. Treatment. — In some cases it may be proper to wear a truss, but this is usually very unsatisfac- tory. In most instances a radical operation should be performed. The best method is Bassini's, but the results are not so good as in the oblique va- riety. Coley gives 85 per cent, of cures in direct inguinal hernia. The occurrence tliis session of several cases of this form of hernia in the service of Professor Randolph Winslow has prompted the writing of this brief essay. In oblique inguinal hernia Professor Winslow usually employs Fer- guson's method ; that is, the spermatic cord is buried beneath the internal oblique muscle. In the direct inguinal hernia he performs Bassini's operation, and it is better to place the cord be- tween the skin and the aponeurosis of the external oblit|ue muscle, and to suture the external ab- dominal ring tit;htl\'. THE HOSPITAL BULLETIN 71 ADDRESS.* Bv Gi-:oR<;i-: R. Gaitiier. It is a difficult task in addressing the alumni of this old L'niversity of Maryland to suggest any new or interesting train of thought for your con- sideration. In the splendid training which the college graduates now enjoy, and in the present infinitely varied means for diffusing intelligence and ideas throughout the land, it is practically impossible for any speaker in an evening's ad- dress to portray the modern tendencies of the in ■ tellectual thought of the day or the varied achieve- ments of our complex civilization in the few min- utes which I shall trespass upon your attention. It is my purpose, if possible, to call }-our atten- tion not to these positive requirements, but to some of the factors in man's development which in mv mind are most important, and yet whicii are being largely neglected in the mad rush of modern development and the complex conditions of modern civilization. The old division of the powers of mankind into three great agencies seems as vital to me today as in every age of man's life upon this earth. The intellect, the will and the emotional or spiritual part of man are the forces through which his development and prog- ress have been created. In the wondrous de- velopment of all channels and institutions for in- vestigation, education and original research of the present age there is but little danger that the intellect of man will not receive all of the power, energy and training which has been so essential to the splendid development of the intellectual powers, and the "rule of reason" would seena destined to perpetual existence. Likewise, in the great domain of action the will of man finds ex- pression in the infinitely varied products of man's genius and eifort which surround us on every side and excite our wonder and admiration. The age which has produced such material results can never want for the stimulus which directs and moulds man's actions. The danger is rather that the creator will he lost in* the creation ; that the trium])hal car of invention and combination for the benefit of the great mass of humanity will operate like some human juggernaut in crushing •Dolivfred bpforo tlio Annu.1l Smoker of the Oradu.'jting Classes and the General Alumni Assoeiation of the University of Maryland. .Tune 1. 1911, at the Hall of the Medical and Chlrurgiral Kaculty of Maryland. out the inner life of the individual. The eternal lestless tide of modern civilization seems to sweep all forces before it in its resistless might. On the other hand, what has been the effect of these great agencies in the development of those qualities which make the charm of each individual life, and whose existence in the ages which have passed has brightened and glorified the pages of history? Is there any force in the universe com- parable to man's spirit, and to the many manifes- tations of its infinite power, which have broadened the horizon of humanity and lifted it beyond its carthh' environment? Is not the age of machin- ery and reason calculated to stifle rather than to develop these momentous forces which exist in each individual, and whose united strength has made the progress of the vi^orld ? Is there no place for the development of the finer qualities of man- kind in a civilization such as ours? Who of us has not thrilled at the enthusiasm and self-sacri- fice which swept over Europe at the time of the Crusades ? Who has not longed for the qualities which made the chivalry and romance of the I\Iiddle Ages ? Who has not gloried in the cease- less zeal, heroic endeavor and unselfish devotion of the army of martyrs and patriots of all the ages who have struggled and fought for the supremacy of human rights and the emancipation of suffer- ing races from tryanny and oppression ? Are not the qualities of patriotism, self-sacrifice, heroism, gentleness, courage and faithfulness as necessary for the welfare of mankind in this modern age as the material and intellectual development which we have acquired ? Nay, are they not more so if we are truly to enjoy the blessings of civilization? May the day speedily come in our national life when the qualities which make the man will be of more solicitude to our people than the protec- tion of our material possessions or the distribu- tion of our great productions. Already there are bright signs of a new era and a new epoch in our national life. In the future I trust and believe that we shall establish new standards of life and living : that health will be deemed of greater value than wealth ; that happiness will be paramount to mere physical comfort, and that mankind will once more realize that his world is a ''stepping- stone to higher things," and not a mere arena of senseless struggle or a stage setting for an empty play. And with the true development of the spirit of man, supplementing his matchless intellect, will come the revelation of the mysteries of an ■J2 THE HOSPITAL BULLETIN unseen world of spirit — one whicli surrounds us now on every side. "But while tliis muddy vesture of decay Dotii grossly close us in, we cannot see it." A REPORT OF THE PROGRESS OF THE NEW MATERNITY. By L. E. Neale, j\I.D., LL.D., Professor of Ob- stetrics ; E. H. Kloman, Ph.G., M.D.. Asso- ciate in Obstetrics; W. L. Byerly, M. D., L. H. Douglas, M.D., S. E. Lee, M.D., Resident Phvsicians. The old Maternity, situated at 622 West Lom- bard street, has long served the purpose as a free lying-in hospital, but until recently we have not been able to accommodate private obstetrical cases in the maternity department. On the first day of April, 1910, the new quarters were com- pleted in the general hospital, occupying the wing which had previously been the nurses' home and had been remodeled into a modern maternity. The chief fault with the old building was one of the marked features of improvement in the new one — !• c. the accommodations for private patients. The new Maternity has a private waiting ward, as well as a private puerperal ward. Each con- tains six to seven beds. These wards are modern in all respects and are situated in a part of the hospital where the patients are out of contact with those in the general hospital. Across the hall from the wards are the private rooms that are suited for those desiring better accommodations. These rooms are supplied with ideal furniture for the lying-in room. On the same floor is a private operating and delivery room, nursery, bath, diet kitchen and modern sterilizing-room. This whole floor is devoted to private patients. On the first floor above are two large wards for the free pa- tients, one for colored and one for white patients. These wards are also subdivided into waiting and puerperal wards. This floor has also its own op- erating and delivery room. The nursery is one of the great improvements. Instead of using the large beds to place infants upon, we now have separate beds. Each infant has its own separate j white enamel crib, and this makes isolation prac- ' tically a constant feature. The nursery also pos- sesses a modern incubator, where many of the premature infants are raised which otherwise would seem impossible but for this modern asset. The resident staff has recently been increased to three instead of two, and we have now one senior and two junior residents. A\'e also have a graduate nurse to superintend and train those nurses tak- \ ing their obstetrical training. As a result of all this modern equipment it gives us great pleasure to make a very favorable report after one year's trial. The number of cases treated for the year end- ing June, 191 1, has just doubled those treated the previous year, the greatest part of this increase being with the private patients. There were four times as many private cases this year as the year previous. This department now treats all abor- tions and miscarriages, which has heretofore been out of the question, due to lack of room and ac- commodations. The free out-patient department likewise in- 1 creased, as you will see below. How has this in- | crease in the out-patient department helped our free clinic ? It has been our desire to have the abnormal and operative cases under our direct care. We aim to accomplish this by having our I residents go into the field and select such cases that require hospital treatment and bring them into the clinic before labor begins. This has given the student a better chance to see operative work, has given the residents better opportunity to do operative work, and has fitted the clinic with excellent material for post-gradu- ate work. The out-patient department has grown markedly. This is in part due to the care which the students are required to use in their work with free cases and frequent visits by the resident phy- ■ sicians. The students are required to make pre- \ liminary examinations, to keep in touch with and to report any abnormal case. j This gives them excellent training in palpation, and they are taught to make a diagnosis by exter- nal palpation, hence lessening the risks for in- fections. In the present graduating class each man will average 40 cases which he has seen and been as- sociated with, and of these he will average 15 which he has personally attended in the out-pa- I tient department. i THE HOSPITAL BULLETIN 73 THE HOSPITAL BULLETIN A Monthly Journal of Medicine and Surgery PUBLISHED BY THE HOSPITAL BULLETIN COMPANY 608 Professional Building Baltimore, Md. Subscription price, . . . $1.00 per annum in advance Reprints furnished at cost. Advertising rates submitted upon request Nathan Winslow, M.D., Editor Baltimore, June 15, 191 1. SOWING AND REAPING. "Behold, a sower went forth to sow ; and when he sowed, some seeds fell by the wayside, and some fell upon stony places, but others fell into good ground, and brought forth fruit." We have been sowing seed, good hard No. i wheat. The work has been somewhat interrupted by the examinations and other duties incident to the closing weeks of the session, but the seed has still been scattered. Doubtless much that has been sown has fallen by the wayside or upon stony hearts, but some has brought forth fruit. It is the unexpected that usually happens. This is true in almost all the avocations and contingencies of life. It has proven true in the short effort we have been making to excite interest and raise money for the endowment of the pathological department. Those best able to help us, and those whose loyalty should be strongest, have not responded to our cry as yet, while from far-off California, from the Red River of the North, from South Carolina, from the sturdy old North State, and from the mighty city on Manhattan, as well as from the progressive State of West Virginia, responses to our appeals have been received. We thank these friends, as well as those nearer at hand, who have encouraged us with their approval and helped us with their means. We shall continue our efforts, but we beg our alumni not to leave this matter entirely in the hands of a few of us, but let each one constitute himself a committee to push along the work. The writer would like to see an alumni chair of pathology, endowed by the alumni and to a large extent controlled by them. Let us con- tinue to sow the seed, for we believe "that in due season we shall reap, if we faint not." MAKE YOUR WILLS. Only two things are said to be certain in th.is world — death and taxation. If one has been for- tunate enough to acquire property, the taxgatherer will certainly find him out; hence it is not neces- sary to be too eager to hunt him up. He will come soon enough. Another unsought visitor frequently seeks us and takes all that we have. Next to lay- ing up treasure for our own eternal use, "where neither moth nor rust doth corrupt, and where thieves do not break through nor steal," is the duty of so disposing of our property that it may be de- voted to the best use possible. If one has a family, it is his duty and privilege to so arrange his affairs that those who are dependent on him shall be ade- quately provided for. He should, therefore, make his will, in order that his wishes may be carried out. Particularly is it important for the man of small means to make his will, leaving all his prop- erty to his wife, as in this manner the estate is kept intact and the wife is better able to provide for the family, if there are children. Another matter should also be kept in mind by the alumni of the University of Maryland, and that is the privilege of leaving a bequest, large or small, to the medical school for such purpose as may seem desirable to the donor. If our alumni would remember their alma mater in their wills they would rest with the assurance that some of their labor will not have been in vain. \\^\TCH THE FUND. The following contributions have been made to the endowment fund of the department of Pathology to June i : Robinson bequest $5,ooo 00 Dr. Hugh Hampton Young, J. H. L^ . . . 100 00 Dr. Gideon Timberlake 25 00 Mr. H. P. Ohm 10 00 Dr. Samuel W. Moore, D.D.S 25 00 Dr. John J. R. Krozer, 1848 50 00 Dr. Joseph T. Smith, 1872 10 00 Dr. W. J. Young, 1872 25 00 Dr. Thomas A. Ashby, 1873 100 00 Dr. David W. Bulluck, 1873 100 00 Dr. Robert Gerstell, 1873 5 00 Dr. Randolph Winslow, 1873 100 00 Dr. H. T. Harrison, 1874 5 00 Dr. J. :\I. Hundley. 1882 250 00 Dr. Henry Chandlee, 1882 10 00 Dr. B. Merrill Hopkinson, 1885 25 00 74 THE HOSPITAL BULLETIN Dr. H. C. Reamer, 1885 Dr. C. W. McElfresh, 1889 Dr. Harry Adler. 1895 Dr. Joseph L. Hirsh, 1895 Dr. R. W. Sturgis, 1896 Dr. Louis W. Armstrong, 1900 Dr. Salvatore Demarco, 1900 Dr. M. S. Pearre. 1900 Dr. Nathan Winslow, 1901 Dr. A. j\I. Shipley, 1902 Dr. Hugh W. Brent, 1903 Dr. Robert P. Bay, 1905 Dr. S. L Meltzer, LL.D., New York 10 on 100 nn 100 00 50 7 no nn ID 50 5 50 250 25 100 DO GO 00 GO no no 00 10 00 $6,602 GO CHANGES IX THE MEDICAL FACULTY. At a recent meeting- of the Medical Faculty Dr. Harry Adler, Clinical Professor of Medicine and Director of the Clinical Laboratory, was elected Professor of Therapeutics and Clinical Medicine; Dr. Gordon Wilson, now Associate Professor of Practice of Medicine, was made Professor of Clinical Medicine, and Dr. Joseph Gichner was made Clinical Professor of Medi- cine and Associate Professor of Physical Thera- ])eutics. We cannot commend these promotions too highly, and believe they will meet with the approval of ever\'one concerned in the welfare of the University. Dr. Adler is a B.A. of the Johns Hopkins L'niversity and an M.D. of the L^nivcrsity of Maryland, class of 1895. Since graduating he has been continuously associated with its teach- ing fofce. He is a tireless worker and a teacher of proven ability. Dr. Gordon AVilson is an i\I.D. of the LTniver- sity of Virginia and an ex-assistant resident physician of Johns Llopkins Hospital. He has been associated with the Department of Medicine of the University since 1903, and has given gen- eral satisfaction as a teacher alike to faculty and students. Dr. Joseph E. Gichner, class of 1890, has had added to the duties pertaining to the Chair of Clinical IMedicine those of Physical Therapeutics. The latter is a much-needed course, as physical remedies are gaining in importance daily. Dr. Gichncr's knowledge of the physical agents is such as to warrant the expectation of a very in- teresting as well as beneficial series of lectures. DISPENSARY REPORT. DISPENS.A.RY C.\SES, .\rEIL I, I9IO, TO APRIL I, I9II. Department. New. Old. Total. Surgical ( i ) 1,052 5,247 6,899 Medical (2) 1,225 2,896 4,121 Genitourinary (3)... 681 3.182 3.863 Nervous (4) 269 1,658 1,927 Stomach (4) 520 1,407 1,927 Eye and Ear (5) 6S7 1,147 i,834 Women (6) 68g 1,131 1,811 Throat (8) 652 924 1,576 Lung (7) 805 928 1,733 Children (9) 583 733 1,316 Skin (10) 351 523 874 Orthopedic (11) 47 236 283 Rectal ( 12) 36 44 80 8,188 20,056 28,241 Total new cases 8,188 Old cases 20,056 Grand total 28,244 Grand total, 1909- 1910 25,881 John Houff, M.D., Dispensary Physician. THE ONE HUNDRED AND FOURTH ANNUAL COMMENCEMENT. The annual commencement of the University of Maryland was held at the Lyric Thursday afternoon, June i, 191 1, at 4 o'clock. The order of exercises was as follows : Overture — "Fest" Leutner Selection — "Pink Lady" Caryl Waltz — "Spring Maid" Caryl Music — March, "Aida" Verdi Prayer by Rev. Oliver Huckel, D.D. Music — "Meditation from "Thais" Massenet Address to the Graduates, Harvey W. Wiley, Ph.D., LL.D., Chief of the Bureau of Chemistry, Depart- ment of Agriculture, Washington, D. C. Music — March, "Patriotic" Rosslyn Conferring of Degrees by Bernard Carter, LL.D., Provost of the University. Candidates for the Degrees "Bachelor of Arts" and Bachelor of Sciences" presented by the Dean of the Facuhy of .'Krts and Sciences. Candidates for the Degree "Doctor of Medicine" pre- sented by the Dean of the Faculty of Physic. Candidates for the Degree "Bachelor of Laws" presented 1iy the Dean of the Faculty of Law. Candidates for the Degree "Doctor of Dental Surgery" presented ]iy the Dean of the Faculty of Dentistry. THE HOSPITAL BULLETIN /o Candidates for the. Degree "Doctor of Pharmacy" pre- sented by the Dean of the Faculty of Pharmacy. Conferring of Honorary Degrees. Presentation of a Bust of the late Prof. James H. Harris, M.D., D.D.S. Music — "Pas de Echarpes" Cliaminade Award of Prizes. Music — March, "Stars and Stripes" Sousa The address of Dr. Harvey W. Wiley appears on page 6i of this issue of The Bulletin. There were 203 graduates. They were presented by the deans of their respective departments, and were classified as follows : Bachelor of Arts 16 Bachelor of Science 2 Doctor of Medicine 70 Bachelor of Laws 50 Doctor of Dental Surgery 43 Doctor of Pharmacy 22 Students who received degrees are : B.\cHELOR OF Arts. Rowland K. Adams. L. Claude Bailey. Clark Ferguson Brown. E. Foster Davis. S. Carl Drake. Henry Lee Johnson. Wilbur L. Koontz. J. Eccleston Marsh. John L. Morris. Robert Graham Moss. Eugene M. Owen. Thomas Parran, Jr. Emerson B. Roberts. George E. Rullman. William Stanley. Herbert Douglas Taylor. B.VCHELOR OF SCIENCE. John Frederick Koenig. William Roland Vansant. Doctor of Medicine. Edward Garrett Altvater, Maryland. Burt Jacob Asper, Pennsylvania. Henry Benedict Athey, Maryland. Walter Compton Bacon, Maryland. Mordccai Lee Barefoot, North Carolina. Frederick Lewis Blair, Rhode Island. Buchlcr Shoup Boyer, Maryland. Archie Eugene Brown, South Carolina. Ernest S. Bullock, North Carolina. William Luther Bycrly, Maryland. Samuel Hopkins Cassidy, Tennessee. Belton Drafts Caughman, South Carolina. Henry Dickinson Causey, Delaware. Herbert Augustus Codington, Georgia. James Erwin Diehl, Pennsylvania. Richard C. Dodson, Maryland. Louis Harriman Douglass, Maryland. Charles L. Dries, Pennsylvania. William Joseph Durkin, New York. James Joseph Edelen, Maryland. Joseph Benjamin Edwards, South Carolina. Otto Fisher. Virginia. Jacob Jesse Greengrass, New Jersej'. Isidore Isaac Hirschman, Maryland. Abraham Lewis Hornstein, Maryland. Grover Latham Howard, Virginia. John Thomas Howell, North Carolina. Raymond Garrison Hussey, North Carolina. Jose E. Igartua de Jesus, Porto Rico. Kenneth B. Jones, Maryland. Charles Hutchison Keesor, West Virginia. Charles Edward Kernodle, North Carolina. Charles R. Law, Jr., Maryland. Samuel Engle Lee, Maryland. Frank Levinson, Maryland. Willis Linn, New York. Paul Pressly McCain, South Carolina. Lawrence E. McDaniel, South Carolina. Isaac Michel Macks, Maryland. Manuel Eulalio Mallen, Santo Domingo. William Clinton Marett, South Carolina. George Yellott Massenburg, Maryland. John Guirley Missildine, Pennsylvania. Allen T. Moulton, Massachusetts. Adolph Mulstein, New York. Walter Saulsbury Niblett, Delaware. Elijah Emera Nicliols, Delaware. Vernon Llewellyn Oler, Maryland. John Ostro, Delaware. James Earle Quigley. Pennsylvania. Themistocles Julian Ramirez, Porto Rico. Stanley H. Rynkiewicz, Pennsylvania. Harry Bagenstose Schaefifer, Pennsylvania. Charles Louis Schmidt, Maryland. Dallas C. Speas, North Carolina. Louis Stinson, Mississippi. Joseph Stomel, Pennsylvania. Eniniett O'Brien Taylor, South Carolina. Ralph Leland Taylor, Georgia. Joseph Enloe Thomas, South Carolina. Grafton Dent Townshend, Maryland. Ralph J. Vreeland, New Jersey. Louis Kyle Walker, North Carolina. Charles Stuart Wallace, Oklahoma. Sydney Wallenstein, New York. Charles Alexander Waters, Maryland. Albert G. Webster, Maryland. Thomas Gay Whims, West Virginia. Java Cleveland Wilkins, North Carolina. Richard Lloyd Williams, Pennsylvania. Prizem.\n. University prize, gold medal, Burt Jacob Asper. Certificates of Honor. Charles Louis Schmidt, Thomas Gay Whims, Joseph Benjamin Edwards, Isaac Michel Macks, Themistocles Julian Ramirez, Charles Hutchison Keesor. Jose E. Igartua. 76 THE HOSPITAL BULLETIN Bachelor of Laws. Chester Alan Arthur Albrecht, Joseph Anthony Ambrose, James Conner Lee Anderson, Oswald Athanase Beaulieu, Charles Brown Bosley, Charles Henry Buck, William Winfield Scott Causey, John Leslie Cornell, James McGrath Crockett, Arthur Wilson Dowell, George Eckhardt, Thomas Joseph Fraley, Harry Freedman, Lee Ey-ster Gilbert, John Stewart Glen, Moses Henry Goldstone, Cyril Hansell, Edwin Hanson Webster Harlan, Louis Joseph Jira, Walter Eugene Keene, Dave Benjamin Kirsner, Anthony Walter Kraus, Philip Edward Lamb, Stephen Wells Leitch, Jacob Levine, Edgar Henry McBride, Cyprian William McSherry, Titus Lyde Mason, Jr., Charles McCurdy Mathias, James S. Clarke Murphy, Clapham Murray, Jr., Joseph Nathanson, Elbert Ray Nuttle, George Brauer Oehm, Peter Peck, Saul Praeger, Hannibal Hamlin Reid, George Albert Rossing, Herbert Alger Schloss, Harry Lamar Smith, Warren Adams Stewart, Philip Louis Skyes, Arthur Le Mar Vickers, Raphael Walter, Daniel Lloyd Wilkinson, John Wirt Wilmer, Harvey Hill Wilson, Eli Gardner Ziegler, Marshall Frederick Lahm Zeigler, Henry Zoller, Jr. Doctor of Dental Surgery. Lloyd Mehring Basehoar, Pennsylvania. Lawrence Welling Bonnoitt, Virginia. Daniel Bratton, Maryland. Rhodes Burrows, Connecticut. Lucas Angel Cambo-Ruiz, Cuba. Thomas John Claggett, Maryland. William Francis Courtney, Connecticut. William Lee Davidson, South Carolina. John Gleason Donnelly, Jr., New Jersey. Solomon M. Feldstein, New York. Howard Morton Finch, Connecticut. Leo Freiburger, Austria. Henry Andrew Folsom, Vermont. Risden Bennett Gaddy, North Carolina. Samuel Hawthorne Gluckman, New Jersey. Howard Crosby Greene, Connecticut. Sherman Jenkins Hamilton, New York. Seaborn James Hargrove, Jr., Georgia. A. Douglas S. narrower, Virginia. Daniel Edward Healey, New York. William Stuart Hart Heermans, Jr., New York. Lowell Philip Henneberger, Pennsylvania. Benjamin Frederick Herman, Connecticut. Daniel Pinkney High, Jr., North Carolina. Adolph John Hoffmann, New Jersey. Samuel Boss Johnston, Virginia. M. Lafayette Justice, North Carolina. Alfredo E. Justiz-Maspons, Cuba. Gabriel K. Jureidini, Egypt. Carter Inskeep Long, West Virginia. Arthur Franklin Lynch, Rhode Island. Henry Martin, Connecticut. Anibal F. L. Montcro y Diaz, Cuba. Taylor Phifer Nisbet, South CaroUna. Alexander Horn Paterson, Pennsylvania. Samuel Roth, Maryland. Robah Harrison Shore, North Carolina. Robert Thomas Skelton, New York. Allen G. Thurman Twigg, Maryland. Randolph M. Urmson, Pennsylvania. David Clark White, Louisiana. Charles E. Wingo, Jr., Maryland. Olin Harold Youngs, Connecticut. Prizeman. University prize, gold medal, Alexander Horn Pateison. Honorable Mention. Henry Andrew Folsom. Doctor of Pharmacy. Filiberto Artigiani, Italy. Noel Sifly Avinger, South Carolina. Flora Blattstein, Roumania. Carvilla Brian Boyd, Pennsylvania. Leon Dettelbach, Maryland. Paul Francis Flynn, Connecticut. Frederic Garrison, New York. Aloyuise Hergenrother, Maryland. Otis Leroy Johnson, South Carolina. Lawrence Regis Laroque, Maryland. Harry Clarendon Lewis, Maryland. Nicholas Thomas Lombard, Italy. Clifford Otto Miller, Ohio. Carl Wilhelm Oertel, Maryland. R. Gorman Piielps, Maryland. Thomas Ellsworth Ragland, Jilaryland. James Edwin Stokes, South Carolina. Joseph Samuel Sandler, Maryland. Powell Parker Towers, Maryland. George Harry Waltz, Maryland. William John Wannamaker, South Carolina. John C. Woodland, Maryland. Prizeman. Gold medal for general excellence, Clifford Otto Miller. Certificates of Honor in Order of Merit. Filiberto Artigiani, Paul Francis Flynn. Special Prizes. Simon medal for superior work in chemistry, Clifford Otto Miller. Gold medal for superior work in pharmacy, Thomas Ellsworth Ragland. Alumni medal for superior work in vegetable his- tology, Clifford Otto Miller. Distinctions in the Junior Class. Gold medal for general excellence, Herman Dietel, Jr. Honorable Mention in Order of Merit. Sidney J. Brown, Lee Hodges, Henry F. Hein, T. Stanley Smith, Ethan O. Fricrson. THE HOSPITAL BULLETIN 71 ITEMS By special request we give our record of the class of 1897 as follows : G. W. Banks, Shepherdstown, \\''. Va. Harry Lewis Baptist, Ivy, Va. Bernard Barrow, Barrows' Store, Va. Henry Thomas Batts, died July 10, 1902. A. E. Bell, Mooresville, N. C. William Newbold Bispham, Major, U. S. A. Peter P. Causey, Suffolk, Va. Harry C. Chappelier, Ilughville, j\ld. Calvin E. Clay, Martinsburg, W. \'a. . Charles Franklin Cooper, Pitts, Ga. Walter VV. Dodson, Laurens, S. C. Isaac C. Dickson, 3053 West North avenue, Baltimore. Frederick Dobyns, tio North Eutaw street, Baltimore, Md. J. J. Durrett, Fairmont, W. Va. Osceola Dyer, Franklin, W. Va. Arey C. Everett, Pegues, N. C. William E. Fahrney, Timberville, A'a. Percy Roland Fisher, Denton, Md. Henry M. Fitziiugh, Jr., Westminster, Md. Charles R. Foutz, Westminster, Md. Page A. Gibbons, Morgantown, W. Va. Lucius N. Glenn, Gastonia, N. C. Samuel Butler Grimes, Roland Park, Md. Samuel N. Harrell, Tarboro, N. C. Lurty Noel Harris, Mill Creek, W. \'a. John Ellis Hart, Deep Creek, N. C. Arthur C. Hearn, 156 Milton avenue, Balti- more. Timothy O. Heatwole, 2003 North Charles street, I'altimore. William Isaac Hill, .\lbemarle, N. C. James Lee Hopkins, Havre de Grace, Md. John .S. Howkins, 16 East Liberty street. Sa- vannah, Ga. Peter John, Laurinburg, N. C. James E. Kerr, Lilesville, N. C. Jennings M. King, Buckhannon, W. Va. Samuel Peachy Latane, died May i, 1910. George W. Lautenbach, 625 Mosher street, Bal- timore. James D. Love, Jacksonville, Fla. Carville V. Mace, Rossville, Md. Cliarles D. Marchant, Harmony Milage, \'a. William R. McCain, Charlotte, N. C. R. H. McGinnis, Jacksonville, Fla. L. Wardlavv Miles, Princeton University (not practicing). J. C. Monmonier, Jr., Hillsdale, Md. F. Alan G. Murray, Mt. Savage, Md. T. McL. Northrop, St. Pauls, N. C. R. Walter Patterson, Clarksburg, W. Va. Oliver Parker Penning, 171 1 St. Paul street, Baltimore. Walter Stith Philips, Rapidan, \'a. Richard F. Richards, Hampstead, Md. Compton Reily, 2025 North Charles street, Bal- timore (orthopedic specialist). Robert Conrad Rind, 121 East Madison ave- nue, Springfield, Ohio, Oscar Leslie Rogers, Sandersville, Ga. Sidney G. Sarratt, Union, S. C. Reverdy Sasscer, Upper Marlboro, Md Rupert Leroy Savage, Rocky Mount, ;^,'. C. Thomas Littleton Savin, 1349 York road, Bal- timore. Henry Franklin Schamel, Brunswick, Md. Charles L. Scott, Asheville, N. C. Gilbert Tyson Smith, Jr., U. S. G. and C. Sur- vey, stationed in Alaska. Guy Steele, Cambridge, Md. Charles R. .Stevenson, De Lancey, Pa. William H. Clendenin Teal, died January 28, 1910. J. Brown Wallace, 322 Hyde Park avenue, Tampa, Fla. Charles A. Wiest, Stover, Mo. F. Delaphaine Willis, Newport News, Va. We are unable to locate the following members of this class : William S. Huggins, Garrett John Landers, W. H. Lippitt, X'V'illiam Matthews, Ed- win R. Ramsey. John J. Sullivan and Julius Wein- berger. We will thank any of our readers for any information as to their present location or other knowledge concerning them. Dr. Albert H. Carroll, class of 1907, is at Woods Hole, Mass., and will spend the summer there, working in the physiological and biological lab- oratories. Dr. Norman T. Kirk, class of 1910, has been appointed surgeon to the Atlantic Coast Line Railroad, to be located in their hospital at Rocky Mount, N. C. The University of Maryland Training School for Nurses held its commencement exercises on THE HOSPITAL BULLETIN Thursday evening, May ii, 191 1, at Lehmann's Hall. Rev. A. B. Kinsolving of Old St. Paul's P. E. Church, opened with prayer. The diplomas were conferred by R. Dorsey Coale, Ph.D., dean of the JNIedical Faculty, and the address to the graduates was made by Dr. Arthur M. Shipley, class of 1902, Professor of Materia Medica and Surgical Pathology. The graduates were ^lary Louise Gephart, ^Maryland; Anne Schooley Grubb, Florida ; George Allen Hutton, Maryland ; Frances Woodbridge Sprecher, INIaryland ; Eliza- beth Cromwell Patterson, Pennsylvania; Barbara Ellen Stouffer, Maryland; Mary Gertrude Brady, ^Maryland ; Nellie Elizabeth Curtiss, Maryland : Alarvel E. Scarff, Maryland; Elizabeth Evelyn Robinson, Maryland ; Stella L'dore Ricketts, Pennsylvania ; Naomi Helland, Maryland : Ivy Irene Kinney, West Virginia ; Alva Mae ^^'il- liams, Maryland; Ruth Elizabeth Berlin, Penn- sylvania; Mary Ellen Sullivan, Massachusetts, and Jennie Rockhold Garner, Maryland. Dr. John C. Hemmeter left June 12 for Woods Hole, Mass., where he has taken a cottage for the season. He will move into his new home on Charles-street boulevard December i. wrist. There was not another doctor in town at the time, but Drs. Gibson and Timmerman came from Batesburg and set the fracture. The patient is doing well. "No braver thing than Dr. Riser's action has ever been seen in Leesville. There were about 10 children, all small, on the grass in the park, and the horse was running directly for them. Dr. Riser was in no danger where he was, but he saw that some of the children would be crushed unless he saved them, and he did his best, absolutely re- gardless of danger to himself. Needless to say, the people whose children were saved by liis action will not soon forget him." Dr. Edgar G. Ballenger, class of 1901, of At- lanta, Ga., has just had published a book entitled "Genito-L'rinary Diseases and Syphilis." We wish Dr. Ballenger much success, both with his magazine — the Journal-Record of Medicine — and with his book. Dr. Randolph Winslow, class of 1871, will leave on June 17 for the annual meeting of the Ameri- can Medical Association at Los Angeles, Cal. The State, a daily paper of Columbia, S. C, publishes the following special from Leesville, S. C, concerning Dr. Luther Allen Riser, class of 1908, in its issue of May 25, 191 1 : "Yesterday afternoon, about 6 o'clock, a horse belonging to two fruit-tree agents from Tennes- see ran away here. The horse started running on the eastern edge of the town, and came through Main street, hitched to a buggy. At H. F. Hen- drix's store the horse turned west, and made di- rectly for a crowd of children who were playing in the street, all unconscious of their danger. Dr. L. A. Riser was sitting in his buggy in front of the Hendrix Hotel, out of danger, but seeing the danger of the children, he jumped in front of the mad animal, in an attempt to turn it out of its course. He did this, but as the animal turned the buggy went over and knocked the young man down. He caught under the buggy and was dragged several yards. Finally the horse broke loose from the buggy, and Dr. Riser was able to get out, with one knee skinned, his head bruised and his left arm broken just above the Mrs. Ethel Palmer Clarke, University Hospital Training School for Nurses, class of 1906, has been appointed superintendent of nurses at the L^niversity Hospital, succeeding Miss Bell, re- signed. Mrs. Clarke is a native of Richmond, and has just resigned as superintendent of the De Soto Hospital, Jacksonville, Fla. Miss Nettie Flanagan, class of 1902, has re- signed as superintendent of St. Luke's Hospital, Spokane, Wash. Misses E. A. Strohm and P. V. P'leasants, class of 19 10, have taken charge of the De Soto Hos- pital, Jacksonville, Fla. Misses Vera Wright and AL \'. Saulsbury, class of 1909, have taken positions at tlie Presbyterian Hospital of New Orleans, La. THE HOSPITAL BULLETIN 79 Miss Mary C. Wiggin, class of 1910, and Miss Nellie F. Ferrel, class of 1905, have joined the nursing corps, \J. S. N. Dr. Walter Van Swearingen (otherwise Sevy), class of 1904, is located at 1703 25th street N. \V., Washington, D. C. In a recent letter to Professor Randolph Wins- low, Dr. William Osier, Regius Professor of Medicine, Oxford University, England, says : "I am so glad to see the old school is booming. After all, you fellows have done splendidly for it, and it is a great credit to your brains and pockets." MARRIAGES Dr. Kivy I. Pearlstine, class of 1906, of Charles- ton, S. C, was married on Monday, June 5, 19:1, to Miss Rita Henriette Pinkussohn, daughter of ]\Ir. and Mrs. I. S. Pinkussohn, also of Charleston. S. C. The couple will be at home after June 20 at 126 Calhoun street, Charleston. Miss Anne E. Chapman, University Training School for Nurses, class of 1906, was married on May 24, 191 1, at Mount Calvary Protestant Epis- copal Church, Baltimore, to Mr. Joseph E. Wright of Easton. The couple will reside in Easton. DEATHS Dr. Richard Sappington, class of 185 1, died at his home in Waverly, Baltimore, Md., May 14, 191 1, aged 84 years. Dr. Sappington was born in Darlington, Harford county, Maryland. March 14, 1827, the son of the late Dr. John Sappington and Lavinia Bagley Sappington. His grand- father, Dr. Richard Sappington, for whom he was named, was a surgeon in the Continental Army in the Revolution. Of himself he says in a sketch, which is a treasured relic in his family : "Until 1846 I attended school in Harford county at Darlington Academy. There I read Caesar, Virgil and Cicero and acquired some knowledge of Greek. These languages were of great assistance to me later in the study of medi- cine. In 1846 I decided to leave Harford county for Baltimore city. I wrote to a friend in the city, Thomas Piggott, who had formerly lived opposite our home in Darlington, and asked him to find me a situation, 'even if it should be in a drug store.' fn 1846 I came to Baltimore and at once began to learn the apothecary business. "In 1848, on St. \'alentine's day, I bought the stock and fixtures of a drug store on Pennsylvania avenue and moved the outfit to Gay and Asquith streets. While conducting the business I attended the Maryland University, where I was graduated in March, 185 1. "Soon after I was graduated in medicine I ap- plied for admission to the Medical and Chirurgi- cal Society of Maryland. This society would not accept me because I was a druggist. I understood that the Maryland College of Pharmacy would not admit me because I was a physician. Later the College of Pharmacy changed in that respect, and I joined it." For 35 years Dr. Sappington kept a drug store on Gay street, between High and Front streets, and 14 years ago moved the business to the south- west corner of Gay and Lexington streets. He had lived 42 years in the house in which he died. Dr. Sappington was an honorary member of Concordia Lodge of Masons and a member of Monumental Lodge of Odd Fellows. For 25 years he had been a vestryman of St. John's Church. A widow, Mrs. Aralanta Robbins Smith Sap- pington; three daughters, Mrs. James H. Giese, Mrs. William G. Hall and Miss Gertrude E. Sap- pington ; two sons. Dr. Purnell F. Sappington of Belair and Mr. Reginald P. Sappington ; ten grandchildren and four great-grandchildren sur- vive him. Dr. Joseph T. Pindell, class of 1865, a medical cadet in 1864, and then for two years surgeon in the Army, at one time a member of the Council and Mayor of Wellsville, Kans., died at his home in that city May 22. 191 1, from nephritis, aged 81. ^Vhile temporarily deranged from overstudy Dr. George W. Hafele, class of 1908. committed suicide of shooting himself with a .32 calibre revolver May 3, 191 1. at the residence of his sister, Mrs. C. Catherine Burke, 1833 Pennsyl- vania avenue, Baltimore. Dr. Hafele was a na- tive of Philadelphia, and came to Baltimore about nine years ago, entering the College of Physicians and Surgeons, and then finishing his course at the University of Maryland. After a short period 8o THE HOSPITAL, BULLETIN of practicing in Baltimore he accepted a position as resident physician in the Adarian Hospital, Punxsutawney, Pa., resigning sisc months ago to engage in the practice of his profession. Dr. Frederick- B. Baker, class of 1888, died at his home in East Norwalk, Tenn., April 14, 191 1, aged 79 years, of cerebral hemorrhage. Dr. Reuben A. Wall, class of 1904, died at his home in Catonsville, Md., May 4, 191 1, aged 34 years. Dr. Wall was the son of Alexander M. and Ida M. Wall. Dr. Wall was generally be- loved, and his classmates and associates \\ill sorely miss his presence. He is survived by his wife. Dr. Norman F. Hill, class of 1881, of The Walbert, Baltimore, died at the Mercy Hospital, Baltimore, May 12, 191 1, after an operation for gall-stones. Following the operation his condition im- proved, and at the end of two weeks he was able to leave his bed and be wheeled about the halls. Later, however, he suffered a relapse, and sank rapidly. Dr. Hill was born at Thorpland, Prince George county, ^Maryland, in 1847. He was the youngest son of the late Charles and Anne Eliza- beth Snowden Hill. After graduating from Georgetown L^niversity in 1866 he came to this city and studied medicine at the University of Maryland INIedical School, receiving the degree of doctor of medicine in 1881. Dr. Hill was a member of one of the most prominent families of the State. He traced his descent from the Hills of Somersetshire, Eng- land, one of whom came to the province of Mary- land in 1662 in company with Charles Calvert, the third Lord Baltimore. He is .survived by his widow, Mrs. Carolyn Hill ; one daughter, Mrs. Lylden Brice of Chester- town, Kent county. Maryland : six sons — Messrs. Norman F. Hill, Jr.. and Carroll E. Hill of St. Louis; Ernest M. Hill of Buffalo; Richard S. Hill of Atlanta, Ga., and Joseph K. and Nevitt S. Hill of this city — and two brothers. Mr. Eu- gene Hill of Kansas City, !M"., and ^Major N. S. Hill of this citv. Dr. Robert Atkinson, class of 1854, died at his home in Baltimore May 22, 191 1, aged 79 years. Dr. Cameron Tiggott, class of i88j, died at his home in Sewanee, Tenn., .April 30, 191 1, aged 55 years. Dr. Piggott was Professor of Chemistry at the Universitv of the South. LABORATORY REPORT OF THE UNI- VERSITY HOSPITAL. Month of May. Blood Examinations. Leucocyte counts 169 Erythrocyte counts 13 Differential leucocyte counts 8 Hemoglobin determinations 84 Smears for malarial parasites 5 Blood cultures 8 Wasserman tests 18 Widal tests 26 33 r Umic Examinations. Routine urinalysis (chemical and micro- scopic ) 380 Total estimation for urea 5 Total estimation for albumen 4 Total estimation for sugar 2 391 Misccllancons. Gastric contents (chemical and micro- scopic) 13 Feces (microscopic, etc.) 13 Sputum examination 18 Bacteriological cultures and smears ( from operative cases) 7 Vaginal and ureteral smears 10 Examination of spinal fluid 2 Examination of pleural exudate 2 Sections of tissue for microscopical ex- amination 15 Autopsies 2 82 Total 804 Dr. J. L. HiR-SH, Dr. H. J. AL\LDEis, Dr. R. Diller, Dr. R. C. Dodson. THE HOSPITAL BULLETIN Published Monthly in the Interest of the Medical Department of the University of Maryland FRICE $1.00 PER YEAR. Contributions invited from the Alumni of the University, Business Address, 608 Professional Building, Baltimore, Md. Entered at the Baltimore Post-office as Second Class Matter Vol. VII BALTIMORE, MD., JULY IS, 1911. No. 5 REPORT OF TWO CASES OF FATAL GASTRIC HEMORRHAGE.* By A. Aldridge Matthews^ M.D., Class of 1900. Before reporting these cases I would like to run over briefly some of the causes of hemorrhages from the stomach due other than to cancer and ulcer, and I cannot do better than to quote from Dr. I. Boas. Besides ulcer and carcinoma, portal vein stasis, gastric varicosities, trauma, scurvy, hemophilia, leukemia, Hodgkin's disease, acute yellow atrophy of the liver, ruptures of blood vessels, acute in- fectious fevers, such as typhoid ; yellow fever, cholera, plague, malaria (Hemmeter), acute and chronic gastritis (ulcerosa) and pyloric stenosis, miliary aneurisms, corrosion through caustic poisons, syphilitic and arteriosclerotic conditions, hysteria, cholelithiasis, etc. The hemorrhages of gastric carcinoma are usually easily differentiated from those of ulcer- The former are, as a rule, small in quantity ; they do not bring about bloody stools, or at least very rarely ; the blood is decom- posed and of a coffee or chocolate brown color. Cases of carcinomatous ulcers and carcinoma of the cardia, in which severe hemorrhages occur- ring toward the end may terminate fatally, are exceptions. In rare cases of hysteria and crises gastriques hematemesis has been reported. These instances are very rare, and the picture is essen- tially different. In such cases, however, organic or functional nervous diseases may be coincident with ulcer, as Debove rightly emphasizes. Hemorrhages resulting from stasis in cases of liver affections, especially cirrhosis, may easily be mistaken for hemorrhages from gastric or ♦Read at Mospnw. Idaho, April 10, 1911. "North Idabo Dis. trlct Medical Society." duodenal ulcers. Leichtenstern pointed out that there is a form of cirrhosis of the liver which may give almost the precise picture of the course of an ulcer. Repeated, usually very copious, gastric hemorrhages, which return in intervals of weeks and months, take place. The patients are very anemic, not at all jaundiced, ascites and enlarge- ment of the spleen are absent, probably on account; of considerable hemorrhages, through which the portal circulation is relieved. Leichtenstern found a latent cirrhosis of the liver in several cases of this kind which terminated fatally within a few days from repeated gastric hemorrhages. We should always, therefore, think of the possi- bility of a developing cirrhosis of the liver in all cases of sudden gastric hemorrhages of persons who had been healthy up to this time, and the more so if symptoms of a gastric ulcer have not preceded or followed a hematemesis (Oppolzer). Gastric hemorrhage or melena occurs in cases of chole- lithiasis with or without icterus, and may suggest gastric ulcer, particularly as other subjective or objective symptoms may be entirely absent at this stage, or may be masked. Differential diagnosis may be often difficult in cases where hemorrhages occur suddenly, and previous history does not give any hints. De- crease of liver dullness and enlargement of spleen may be decisive, though their absence does not ex- clude cirrhosis of the liver, as just mentioned. WHiere previous history is known, we have on the one side to pay attention to the presence of epi- gastric painfulness, which is either missing en- tirely or, if present, is only slight, and on the other side, syphilis or abuse of alcohol- Besides the above-named sources, there are cer- tain parenchymatous hemorrhages, for which Harttung suggested the name of "plica-hemor- rhage," as they Usually originate in the folds of the gastric and intestinal mucosa. In these cases 82 THE HOSPITAL BULLETIN the gastric mucosa may be perfectly intact, witli the exception of small erosions, visible sometime.; only by the magnifying glass. Dieulafoy recently described these occasionally fatal ecchymoses, which affect only the most superficial strata of the gastric mucosa, as "exulceratio simplex, " and sees in them the first stage of the true Cruveil- hier's ulcer. Case No. I. — White ; male ; single ; age 27 ; a carpenter by trade. Physical examination nega- tive, except liver dullness decreased, spleen palp- able. His past and family histories were negative, with the exception of having had several hemor- rhages from the stomach within the last two or three years. None of these hemorrhages were very severe, except the present one. He gave no history of being a bleeder, nor did he give any history of any gastric disturbance whatsoever, except a little dyspepsia, and he had drunk con- siderably at intervals. I saw him a short while after a hemorrhage, and suggested to him an oper- ation, thinking at this time that he had a gastric ulcer, although the symptoms pointing to an ulcer were rather negative. I had never seen a hemor- rhage from the stomach other than from ulcer or cancer at this time, and my diagnosis was made more from the hemorrhage than from any other symptom. He submitted to an operation, and, after thoroughly examining his stomach, I elicited no induration or thickening anywhere that would suggest an ulcer. Not being satisfied, I examined the stomach as carefully as I possibly could the second time, thinking I might have overlooked something, but was not any more successful than before. I did a gastro-jejunostomy, for I still thought there must surely be an ulcer which I could not find- This patient made an uneventful recovery, so far as the operation went, up until the eighteenth day, at which time he was up and about, but on that day he had a violent hemor- rhage from his stomach, vomiting blood ; also pass- ing blood in his stools, and died within 12 hours from the time hemorrhage started from shock. On this case I had a post-mortem, and found a hemorrhagic condition of the mucous membrane of the whole cardiac end of the stomach, extend- ing well up into the esophagus. There was no evidence whatsoever of ulcer anywhere to be found. I appreciate now that my gastro-jejunos- tomy was of no avail, and could not possibly have done him any good. The other pathological con- dition that I found was a large spleen and a much contracted liver, the cut surface showing a gray- ish-white appearance surrounding greenish-yellow island-like areas. The liver substance being much firmer than normal and cut with considerable resistance, I should have made my diagnosis of cirrhosis of the liver when I operated, but this was five years ago, and time, with experience, is our best teacher. My mind was centered on the trouble being in the stomach, and I did not consider these other con- ditions as I should and would do today. Osier claims that the most extreme grade of atrophic cirrhosis may exist without symptoms; so long as the compensatory circulation is main- tained the patient may suffer little or no incon- venience. The remarkable efficiency of this col- lateral circulation is well seen in those rare in- stances of permanent obliteration of the portal vein. Case No. II. — L. E. A.; age 33: white; male ; married ; occupation laborer ; family history negative; physical history negative; rarely took a drink ; no history or evi- dence of syphilis; physical examination negative. Past history negative, with the exception that about 14 months ago he was referred to me with a great deal of pain radiating over the upper part of his right abdomen and vomiting. This pain had persisted three or four days before I saw him. He gave no gastric symptoms, and claimed never to have suffered with indigestion or any gastric disturbance, although he gave history of having had several gastric hemorrhages, the first one oc- curring about seven years ago. He thought he vomited possibly three or four ounces of blood, and from that time up to the present he has had four hemorrhages of considerable size, each time vomiting anywhere from an ounce to four ounces of blood, and having tarry-black stools. About two years ago he had quite a severe hemorrhage, which incapacitated him from work for a few days, but at no time did he have the least distress or discomfort before or after eating, or during his attacks or hemorrhages. He has had no hemor- rhages for the past year. Upon palpating his ab- domen (14 months ago) I could detect a large hard mass extending down from imder the costal border to the right, which gave him considerable pain upon pressure, and moved up and down in deep breathing, which I diagnosed as a distended gall-bladder. I opened the abdomen, making the usual in- THE HOSPITAL BULLETIN 83 cision, and found a very nuicli distended gall- bladder, iiaving a whitish appearance and quite tense, which I drained, but found no stones — only viscid mucus. Neither could I detect any obstruc- tion or trouble in his cystic duct, although there was no bile present in the gall-bladder at that time- I inserted a tube, which I left in for about eight days. There was very little drainage, and that whicii did come away was only slightly stained with bile. I was very much concerned as to whether there was some obstruction in the cystic cliict which I had overlooked, but upon removing the drainage tube the tract healed at once, and he had no further trouble and no return of his old condition. I saw him several times between the operation and his present illness ; at no time did he have any further trouble or discomfort with his gall-bladder, and did laboring worlc from that time until present illness. 1 examined the stomach for ulcers, especially on account of his history of previous gastric hemorrhages, but apparently the stomach was normal at this time. He was again referred to me on December 19. 1910, after having had several hemorrhages, and at the time I saw him he was practically bloodless, facial expression very much pinched, and the ordinary symptoms that go along with severe hemorrhage. I had him transferred to the hospi- tal, and transfused him as soon as I could get a suitable subject who would volunteer to give up his blood. At this time I opened a vein in his arm and used the radial artery of the donor, who was a young laborer (white). Would have preferred some blood relation for this, but he had none in this section of the country. The transfusion was a great success, the patient's condition improved immediately and his general appearance and con- dition was wonderfully changed for the better and his outlook bright, but the following night he had another hemorrhage, in which he vomited at least six or eight ounces of bright red blood, and his condition was the same as it was the day before. On this occasion I transfused him again, this time getting a brother-workman, using his radial artery and the vein in the opposite arm of the recipient, and the improvement was equally as much as it was the day before, but the follow- ing night he had another hemorrhage, and almost died from shock before relief could be had. And then again, the third donor, a large plethoric man, lawyer by profession, was used, and this time I used the radial of the donor and a superficial vein of the leg of the recipient. At this time his improvement was greater than at either of the preceding ones. The pinched expression left his face entirely, his ears became pink and, as I said before, I considered his condition better than it had been following the other transfusions. About 15 hours later he had another hemorrhage, and died as a consequence. I might say, also, that I fed him gelatine the whole time that he was under my observation. Two of the donors were paid, or, in other words, hired to give up their blood. Of course, the question arose as to where he was bleeding from, whether from an ulcer or ero- sion, or just a hemorrhagic condition of the stomach due to cirrhosis of the liver. The condi- tion that was most forward in my mind was that of ulcer, although it made me feel doubtful, be- cause at no time had he ever complained of dis- tress or indigestion, and I could not elicit any such history from him, although I inquired into this especially. That made me a little skeptical, but upon a post-mortem I found nothing except a hemorrhagic condition of the mucous membrane at the cardiac end of the stomach. The rest of the mucous membrane and his stomach appeared to be normal. There was one place at least two inches in diameter that showed evidences of hav- ing bled near the esophegal opening. The gall- bladder was functionating, although very much thickened, and there was no evidence that it had given him any further trouble. There was no stones in any of his ducts. I had sections made of his liver, and found little or no cirrhotic con- dition existing, but there was a passive congestion. The size of the liver seemed about normal, but I had no means of weighing it at that time. In the April issue of The Bulletin we stated that we were unable to locate several members of the class of 1885. We have since learned that Dr. J. B. Carr died November 20, 1907; Dr. William P. Kennedy died November 9, 1902, and Dr. W. T. Spruill died July 28, 1895. We would be very glad if our readers would assist us in locating Drs. J. M. Emmitt, B. B. Halsey, E. K. Hardin, C. H. Janney, H. C. Jamison, D. T. E. Casteel, P. B. Carter, S. B. Dew, A. F. Keen, E. T. May and C. E. Rogers, all of the class of 1885. Dr. Harry W. Stoner, class of 1907, is recover- ing from an infected hand. 84 THE HOSPITAL BULLETIN SKIN-GRAFTING— WITH A REPORT OF TWO VERY SUCCESSFUL CASES RE- CENTLY PERFORMED IN THE UNI- VERSITY HOSPITAL BY DR. RAN- DOLPH WINSLOW, PROFESSOR OF SURGERY, UNR'ERSITY OF MARY- LAND. By Burt J. Asper, 'ii, Senior Medical Student. Skin-grafting is a part of that special branch of operative surgery to which the term plastic or reparative has been applied, and which has for its object the reconstruction of the contour of the body for cosmetic reasons, the readjust- ment of anomalous relations of parts for utilita- rian purposes, as well as the substitution of one organ or tissue for another to give physiological efficiency. The inception of this branch of surgery prob- ably dates back many centuries ; certain it is that in India the surgical restoration of the external nose, which is often cut off in that country for supposed marital infidelity, has been practiced for many years before the first published records of methods and results were put into the hands of the surgical profession. This was first done in the latter part of the six- teenth century, when Togliacozzi of Bologna pub- lished an illustrated volume in which he dicussed the possibilities of plastic surgery with reference especially to nasal reconstructions, but for nearly two centuries this important surgical contribution 'made but little impression upon the surgical world. It was in the middle of the eighteenth century that the revival of plastic surgery was begun — when Rosenstein and Dubois discussed the possibility of replacing lost structures by re- parative operations and proved that reconstructive surgery was possible by securing historic evidence of noses and lips having been made from the tissues of forehead, thigh and buttock by Indian and Italian surgeons of previous centuries. Fol- lowing this the experimental work of John Hun- ter on the grafting of tissues was done. From this time on the interest in reparative surgery became very great, but the greatest strides were not taken tmtil after the investigations of Lister, which made the aseptic healing of wounds possible. From this time on the field of reparative surgery widened rapidly, and there were estab- lished as legitimate operative procedures success- ively, epidermis grafting, tendon transplantation, nerve grafting, arteriorrhaphy and arterial trans- plantation, oseoplastic resection and reconstruc- tion, thyroid grafting, etc., until at present the transplantation of internal organs, blocks of va- ried tissues and even of whole limbs seems a possibility of human surgery. The specific purpose of skin-grafting is to sup- ply a cutaneous covering to any part of the ex- ternal surface of the body, the superficial struc- ture of which has been lost from any cause what- ever; wounds, burns or ulceration, thereby either accelerating a healing which would have occurred very much more slowly, or rendering possible the production of continuity in tissue which nature unaided would never have effected, and at the same time avoiding the deformities and impair- ment of function which so constantly result when such raw surfaces are permitted to heal by the natural process of cicatrization. The physiological basis for the operation of skin-grafting is the process of growth and repair of living tissues, supplemented by the ability of groups of animal cells to retain their vitality for a short time, even when separated from all direct connection with the heart and central nervous system. Successful operations demand aseptic wounds, sound tissues and good general health of the patient. .-\s syphilis and lupus are frequently the catise of the lesions demanding skin-grafting, it is absolutely essential in the first disease that some months shall have elapsed since any mani- festations of syphilis were detectable, and that the patient shall have been treated for a prolonged period with antisyphilitic remedies, while in a patient who has suffered from lupus, it is impera- tive that all the diseased tissue should have for some time been destroyed. It is absolutely essen- tial to success that complete asepsis be secured and maintained, because all antiseptics endanger the vitality of the graft, and when in any part of the operation antiseptics are required to secure asepsis, they should be thoroughly removed by the prolonged use of sterile normal salt solution. The deprivation of the protoplasm of the cells of their living power by bacterial and chemical irri- tants constitute the chief cause of faihire in this operative procedure. Skin-grafting is performed in three ways — the Reverdin method, the Thiersch method and the THE HOSPITAL BULLETIN 8S Wolfe or Krause method. In the first, very small particles of the epidermis with the underlying upper layer of the cerium are transplanted. In the second, long strips of the same material are used, while in the third, pieces of the entire thick- ness of the skin several square inches in size are transplanted upon the raw bed. The first two might with propriety be called epidermatoplasty ; the last dermatoplasty. The grafts are usually obtained from some other portion of the patient's own body, the skin of the front and inner side of the thigh and arm being preferable, since it is elastic and not apt to be excessively hairy, while the resulting cicatrization is on a part of the body covered by clothing ; or, the graft may be obtained from the body of another individual. It is best that the donor be young, and all possibility of specific trouble must be excluded, as syphilis may prevent the graft from taking. The skin of any of the lower animals may be employed, especially that covering the abdomen of the frog. Since it is not definitely known whether graft from the skin of a negro transferred to a white patient will re- main pigmented, it is best always to graft blacks from blacks and whites from whites. Thiersch's Method. — Thiersch states that heal- ing of a granulating surface results, first, from a conversion of the soft vascular granulation papillre by contraction of the young connective tissue cells into "dry cicatricial papillae" actually approximat- ing the surrounding tissues, thus diminishing the area to be covered by epidermis, and secondly, by the covering of these papillae by epidermic cells. Contraction having gone on as far as the laxity of the tissues will admit, and the capacity for de- veloping new epidermic cells by the margins of the wound being limited, the granulations of the imliniited central portion remain stationary, i. c.. vascular and soft ; few, if any, of these component cells having undergone development into con- nective tissue, the maximum of contraction has not yet been attained, but will be promptly reached if they are covered by epidermis. Furthermore, microscopically, two layers of granulation tissue are discoverable, the more superficial possessing vertically disposed capillaries, the deeper con- taining a horizontal network of vessels from which the former spring, coursing through a structure more or less dense, according to the age. A free removal of this upper soft layer of granu- lations, yet capable of full contraction, must be effected to prevent cicatricial contraction and the risk of separation of the epidermis, this danger being avoided by laying the graft directly upon the layer of granulations with horizontally dis- posed capillaries, to which layer the transplanted portions will become firmly adherent, and will remain so, undisturbed by cicatricial contraction. Method of Operating. — Complete asepsis hav- ing been secured as before indicated, and all anti- septics washed away with salt solution, the soft granulations are scraped away with a sharp spoon, including a small portion of the newly-healed margins if they do not appear healthy, and the bleeding surface irrigated. All bleeding is stopped by compression with an antiseptic pad of gauze. The operator then reverts to that portion of the body from which the grafts are to be ob- tained, usually that of the thigh or arm, the part having been previously shaved, sterilized and bathed with sterile salt solution. The skin is put upon the stretch by one hand, while with the other a wide, sharp razor is applied flatwise, best pre- viously wet with sterile salt solution, and the upper layerof the skin removed byato-and-fro movement of the knife, the skin also being wet with the salt solution. Each graft should be as broad and as long as possible, should include only the most superficial portion of the true skin with the corre- sponding epidermis, and should be immediately laid upon the prepared surface, upon which it is floated from the knife by salt solution. A probe may be used to facilitate this movement, draw- ing the edge of the graft on to the edge of the wound surface while slipping the blade away; subsequent correction of position may also be effected by the probe. Each graft must be gently pressed into place, and must be in contact with its neighbor, or, better, slightly overlapping its fel- low and the margins of the wound ; otherwise, separation of the grafts is apt to occur. Having placed as many grafts as desired, the grafted area is covered by rubber tissue, pre- viously perforated in many places, so as to allow the free escape of any fluid, serous or purulent, which may accumulate ; over this a dry gauze dressing so firmly applied as to press the graft against the raw surface. It is left undisturbed, usually, for five or six days. Some operators prefer an aseptic moist dressing, kept continu- ally wet. It is usually advisable to anesthetize the patient from whom the grafts are taken, although local infiltration anesthesia has been employed. The appearance of blood beneath the graft as 86 THE HOSPITAL BULLETIN indicated by a bluish color, while endangering their vitality, does not necessarily cause their loss. A pink tint at the end of several days usually in- dicates success, while if the grafts be at this time of a dead white color, they will probably exfoliate, although only the outer layers may disappear, while the deeper active ones remain ; sometimes the grafts are perforated by the granulations, and disappear for a time, to reappear as epidermic islets later on. The surfaces from which the grafts were obtained are dressed with dry sterile gauze, or first dusted with iodoform and then sterile dressings applied. The Thiersch method is very valuable ; by its use very large ulcers and wounds can be made to heal quickly. It is especially valuable in causing rapid cicatrization of large ulcers following burns, the grafts in such cases being applied as soon as the sloughs have separated and the surface can be made sterile, since delay allows cicatricial con- traction to become increasingly great. The im- mediate union between grafts and vivified granu- lation surface tends to obviate much of the dis- figurement likely to occur from vicious cicatricial contraction. This method does not make a deep wound where the grafts are cut, so that quite large surfaces will heal rapidly. Keetly states that a valuable use of this method is to line deep aseptic bone cavities, which frequently begin to fill up by tissue developing under the grafts. He also believes that epitheliomatous and tuberculous ulcerations which have been excised show less tendency than usual to recurrence if Thiersch's grafts are employed to fill up the gap in the soft tissues. Reverdin Method. — Having rendered the ulcer and the neighboring skin and the part from which the grafts are to be taken sterile, the point of an ordinary aseptic sewing needle should be thrust under the epidermis, the skin elevated and the grafts shaved ot¥ by a sharp scalpel, or cut with a pair of small curved scissors. To be sure of obtaining the deeper active epithelial layer, a small portion of the derm should always be removed. The grafts must then be gently deposited, with the cut downward, upon the granulations by means of the needle, avoiding pressure such as will induce bleeding. Perforated rubber tissue is then placed over the graft, sterile dressing applied and left undisturbed for four or five days. In many instances these small grafts shed their cuticle and become invisible, the operation ap- parently having failed from a loss of the entire graft ; but at the next dressing commencing growths of epidermis will often be shown by bluish-white spots not only where the grafts were supposed to have taken, but also where they were thought to have been shed. As the grafts extend eccentrically, each capable only of producing an area of about one-half inch of cicatri.x, they should be placed about half an inch from each other and the margin of the wound. The islands grow in extent, and apparently stimulate the edges of the wound or ulcer to similar activity, until after a time the islands of cutification coalesce and join with the margin, and the former raw surface be- comes completely covered with skin. As is also true in the case of the Thiersch method, if one grafting will not suffice, the operation should be repeated. Unfortunately, but little diminution of the cica- tricial contraction is effected by the Reverdin method, and, while healing is more rapidly se- cured, too often an almost equally rapid breaking down occurs of the new-formed cicatri.x, either from no recognizable cause or from causes which would be inadequate to produce such a result in a scar formed by the ordinary process of healing. Wolfe or Kraxise grafts consist of the entire thickness of the skin, and must be free from sub- cutaneous fatty tissue. The circumference of the free flap to be cut is marked by an incision through the skin. An end is then seized with forceps and raised, so that the operator is able to dissect it free from the superficial fascia. The knife used should be sharpened ; its edge should be turned to- ward the skin, in order to avoid raising some of the subcutaneous fatty tissue with the skin. The raw surface should not be touched with the finger, and the operation should be dry. The graft may be obtained by dissecting up skin and subcuta- neous fat from the deep fascia and then clipping all the fat away from the under surface with scis- sors. This method leaves a wound easily clo.sed after undercutting its margins. The graft is carefully laid in the bed that has been aseptically prepared, and is pressed into place, so as to drive out any air beneath it. Sutures may or may not be used. Dry dressings are to be firmly applied, and are not removed for about four days. Then there may be blebs on the surface, and it may look as if necrosis of the flap was about to occur. The blebs should be punctured and drained, and dry antiseptic dressings applied. They usually live THE HOSPITAL BULLETIN 87 if proper technique lias ]5een carried out, even if they are several square inches in area. Motion of the part to which the grafts are applied should be prevented by means of splints whenever neces- sary. C.\.SE I. SKIN-GRAFTING OF H.\ND, BOTH PALMAR AND DORSAL ASPECTS, AS FAR AS THE WRIST JOINT, FOLLOWING CRUSHING OF THE FINGERS AND DENUDATION OF THE HAND BY CORN-HUSKING MACHINE. Patient, E. R. ; white; male; age 16. Admitted to LTniversity Hospital to the service of Prof. Winslovv on the evening of January 4, 191 1. History. — On the afternoon of the above-men- tioned day, while feeding a corn-husking machine, patient introduced his right hand into the machin- ery to free an ear of corn which had become lodged ; in so doing the hand became caught, and dragged between the rollers. Patient threw ma- chine out of gear at once, but could not free his hand until machinery was taken apart by his fel- low-workers, the whole process requiring about 15 minutes. The physician who was called dressed the wound and hurried the boy to the Uni- versity Hospital. Examination revealed that all four fingers and thumb of right hand were badly lacerated, and the skin of the remainder of the hand was entirely stripped off as far back as the wrist, very much after the fashion of the removal of a kid glove. Treatment. — Patient was prepared for opera- tion at once upon admission ; was given an anes- thetic and the hand thoroughly scrubbed up and treated with antiseptics, following which the skin was replaced over the denuded surface and su- tured in position, openings being made at several places through this skin for the insertion of drain- age. Temperature on admission was 99 5-10° F. The next day temperature reached 103 and pulse 120, in the meantime patient suffering very severe pain. He was treated by ice to the head and anodynes, and 1500 c. c. of antitenanic serum was administered. The infection proved too virulent, and, despite the fact that the hand was kept im- mersed in a continuous hot bichloride bath, the replaced skin, and also the fingers, began to slough, the process continuing until the thumb and all the fingers were separated at the meta- carpophalangeal articulation. With careful attention the infection was over- come, and the general condition of the patient be- came very good, and the operation of skin-graft- ing was deemed advisable in order to shorten con- valescence, and also to prevent the deformity and loss of function, which would have resulted from cicatricial contraction had the raw surfaces been permitted to heal by the process of granulation. Operation.- — The grafting was done in two operations, the Thiersch method being employed in each. At the time of the first operation, on February 11, the dorsal surface was covered, the skin being taken from the left thigh. On March 8 the palmar surface was grafted, the grafts this time being secured from the right thigh. At the time of this second operation there was present in the middle of. the area an island of cicatricial tis- sue about the size of a quarter. This was per- mitted to remain and the grafts made to sur- round it. Results. — The grafts took beautifully ; there was no sign of sloughing. The stump, which at the time of grafting was large and ruddy, and had scarcely any semblance to a hand, decreased in size progressively, until at the time of discharge it had assumed practically normal proportions. Patient was discharged on April 8, the hand being" completely covered by skin, with the exception of two small spots, dime-sized, one upon the radial and the other upon the ulnar side of the dorsal aspect of the hand, which were quite healthy in appearance. There was no cicatricial contraction whatever, motion at the wrist and be- tween the carpometacarpal articulations, including that of the thumb, being perfect. CASE 11. ANNULAR ULCER OF RIGHT LEG, LARGE ULCER OF LEFT LEG. Patient, Mrs. M. W. ; white ; age, 43 ; occupa- tion, housewife. Admitted to University Hos- pital on February 9 to the service of Prof. Ran- dolph Winslovv. History and E.vantination.— The duration of the ulceration on the left leg was given as four years, while that of the right leg was of six months' duration. No history of syphilis could be ob- tained. The left leg was encircled at a point about two inches above the internal maleolus by an infected sloughing ulceration about four inches 88 THE HOSPITAL BULLETIN in width. On the right leg, also about two inches above the internal maleolus on the internal aspect of the leg, was a second ulcer, which measured about as follows : Two and one-half inches in length, two inches in breadth at base and one inch at apex. Its surface was also sloughing and in- fected. Both legs were greatly thickened and in- durated, both above and below the ulcerated areas. The patient was put to bed ; the ulcer of the left leg was cleaned antiseptically and hot com- presses applied over the ulcerated area every two hours, this treatment being continued for 24 hours. At the expiration of this time soap poul- tices were applied twice daily until February 12, the day of operation. The evening of the pre- vious day the right thigh of the patient was shaved, prepared aseptically and soap poultices were applied until the time of operation. The ulcer of the right leg had been cleansed at the time of admission, and sterile dry dressings were then applied. It was not intended that both legs should be grafted during the same operation, but at the time of this operation it was decided that both legs should be grafted, which was done accord- ingly, grafts being applied not only to the left leg, which had been prepared according to usual routine, but also to the right leg, which has re- ceived no preparation other than the cleansing at the time of operation. The Thiersch method was employed, both ulcerated surfaces being covered with grafts obtained from the right thigh. They were then covered with perforated gutta percha, and sterile dry dressings employed. The dressings were removed in four days. Some suppuration had taken place, the surfaces being quite moist, and the issue was at this time rather doubtful, but at the time of the succeeding dressing, five days later, it was found that the grafts on both right and left leg had taken kindly ; there was no more suppuration, and the areas had a healthy pink color. After this dressing the gutta percha covering was discontinued, and the legs washed daily with sterile normal salt solu- tion and alcohol and dressed with smooth sterile dressings. Healing went forward uninterruptedly until, on March 20, the patient, whose general condition had become excellent, was discharged "cured," all raw surfaces being completely covered over by new skin. A FURTHER ANTHROPOMETRIC STUDY OF ENTEROPTOSIS — REPORTED FROM THE CLINIC ON DISEASES OF DIGESTIVE ORGANS — PROF. JOHN C. HEMAIETER, WITH THE HISTORY OF A CASE OF ENTEROP- TOSIS, ACCOMPANIED BY AN ANTACID GASTRITIS AND MARKED ATONY. By Albert Hynson Carroll, M.D., AND Waltf.r C. Bacon (Senior Medical Student). The conditions of displaced abdominal viscera had been the "Pons Asinorum" of clinicians until the brilliant French clinician Glenard began to publish his life work on these abdominal states. Glenard pulilished his first scholarly researches in a journal known as LyoH Mcdicalc in March, 1885. ("Enteroptose et Neurasthenic.") He has Figs. 1 and 2.— T.vpical enteroptic fifi:iii*e. poorly nourished, muscular insufficiency. Note small size of thorax as com- pared with pelvis, and the \veak abdominal walls. Stomach two inches below the umbilicus. Transverse colon prolapsed. Nervous symptoms marktd. since then published many interesting studies on the nervous, physical and chemic abnormalities of displaced abdominal viscera. It was he who first coined the word "enterop- tosis." In the year 1853 \'irchow reported autopsy findings which led him to argue that in the ma- jority of cases they were the result of local peri- tonitic processes. It is doubtful if \"irchow ever THE HOSPITAL BULLETIN 89 reported a case of genuine enteroptosis as Glenard conceived it, for these typical cases are congenital, and are not accompanied by any evidence of peri- tonitis. Many prominent European and American ob- servers became interested in enteroptosis after Glenard's epoch-making publication. The litera- ture is too extensive to even cite the more impor- tant articles.* This literature consists mostly of speculations concerning the causes of this intensely interesting pathologic state. The best contribution was made by Stiller — "Die Asthenische Konstitutions krank heiten" — in which the first clinical logic is given that prove.s this condition to be not simply an abdominal dis- placement of the digestive organs, but a distinct constitutional anomaly that is inherited, and is almost always accompanied by an infirm nervous system and a poorly-developed musculature. The next most instructive contribution was by Hemmeter.t For the first time it was here clearly shown that enteroptosis could be recognized by the dis- proportions of their bony dimensions, and sec- ondly, that their hearts, were as a rule, displaced also. liemmeter regards enteroptosis as a patho- logic product, a sign of a hybrid race, and makes interesting biological suggestions concern- ing its origin. I C.\SE 24,146, UNIVERSITY HOSPITAL DISPENS.\RY. Name, J. W. ; age, 22 years ; race, white ; sex, male ; social condition, unmarried ; occupation, "surveyor's helper." Diagnosis. — Antacid gastritis, with gastroptosis and marked gastric atony. Family History. — This shows us nothing. His parents were not blood relatives, as far as he knew. There was no history of tuberculosis, can- cer, syphilis, gout, rheumatic tendencies or ner- vous diseases. Both patients are alive and well. Past History. — The patient has had the usual diseases of childhood, but has not had typhoid fever, appendicitis, any veneral diseases or marked gastric disturbances in the past. He states, how- *See Hemmeter's tpxtbook on "Diseases of the Stomach." and also his two-volume work on "Diseases ot the Intestines. " "'Anthropometric Studies of the Osseous Proportions, with a View to Obtainlns a Mathematic Expression for Enterop- tosis." See R. Smith. "Enteroptosis, With Special Reference to Its Etiology and Development," Journal A. it. A., Vol. Iv, Xo. 22. tSonderabdnck aus : Internationale Beitrage z. Pathologie u. Therapie der ErniihrungsstBrungen. Bd. 2. Heft 3. ever, that he has had slight attacks of heartburn, and has been somewhat constipated at times dur- ing the last few years, but that for the last 10 years he has not been really sick up to the time that his present trouble began. He denies any venereal diseases. Present Illness. — About two months ago, while working in the hot sun {he is a surveyor's helper), he was suddenly taken sick with severe "cramp-like" pains in the epigastric region. He did not faint or fall. These pains were accompanied with nausea, but he did not vomit. He was very miserable for several days. Since then, although he has been very careful what he eats, the pains have been almost constant, although not so severe, regard- less of the kind, the amount or the time food is ingested. He has not vomited food or blood. There has been diarrhea and constipation at va- rious times since he was taken sick. The epigastric pains are often accompanied vv-ith burning pains in the back. (Ulcer was thought of, but later findings — absence of free HCl., etc. — ruled this out.) He eructates fre- quently ; at times some food particles come up, and he complains of a lump rising up into his throat after eating, of being hungry, but afraid to eat on account of the increased distress : of great thirst all the time, but he drinks but little water, as it "drags like lead" in the region of the umbilicus. Habits. — He has led a fairly regular life ; denies the use of any alcoholic beverages, but has smoked inveterately for several years "to quiet his nerves." The head, mouth and throat show nothing of importance. His lungs are negative. The heart extends toward the middle line. (Note Hem- meter's observations on this point.) There were no valvular lesions noted. The pulse was regular and of good tone. His chest is long and narrow, with two floating tenth ribs. The subcostal angle also attracts attention ; it is only 69°. The liver, kidneys and spleen were not palpable. The stomach, on dilating with air, reached to about two inches below the umbilicus. The trans- verse colon was prolapsed also. All of the reflexes are normal. There is no apparent anemia. The blood was not examined.. 9fJ THE HOSPITAL BULLETIN The orthopometric measurements, secondary to Hemmeter's original method, are as follows: Case No. Height .Weight Age-. X Angle Pr. Weight Patient's measurements are the following: Manubrium to xyphoid, 8 inches. Manubrium to umbilicus, 15 J4 inches. Manubrium to symphisis, 22 inches. Xyphoid to right anterior spine, iiJ/> inches. Xyphoid to left anterior spine, 11 J/, inches. Spine to spine, 10 inches. Circumference at xyphoid, 29 inches. Angle (sub-costal), 62°. (Some other observers, in attempting to arrive at similar results, have taken measurements which embraeed the fatty portions of the body, i. e., the circumference at the level of the pelvic spines, at the umbilicus, etc. Hemmeter depends on "fixed points of the bony framework" to measure from, in much the same way as the obstetrician does when he is measuring the female pelvis. A large number of athletes at the Baltimore Athletic Club and elsewhere, including Cits Schoenline (Ameri- cus), the wrestler, and Roy Nelson, the champion swimmer, lead one to believe that Hemmeter's method is the only correct one. I am of the opinion, hozvever, that the patient's height plays but a small part. A short man often has a sub- costal angle equal to that of a six-footer- In two well-developed men the angle, the distance from "spine to spine" and the circumference at the xyphoid are often the same, regardless of their height. Dr. Hemmeter finds that the height of the patient is necessary to secure a correct inde.v. The small angle, the presence of movable or de- tached tenth ribs and the general shape of the thoracic cavity, particularly when the distance be- tween the tti>o anterior sup. spines is great, should call immediate attention to a probable ptosis of the abdominal viscera). The urine was less than normal in amount (probably due to the dilation of the stomach), and was negative to albumin and sugar. Sp. gr. 1020. Test lileal. — After withdrawing the usual double test meal, free HCl. was found absent. Cabbage and beans, eaten 48 hours previously, as well as evidences of both test meals, were ob- served. The odor was foul. There was not a great amount of mucus, and no occult blood. Lactic acid tests negative. The "bromine water" test failed to give the "tryptophon reaction,'' which might have indicated malignancy. Bile was absent. Feces. — Negative to intestinal parasites or ova. Starch granules, bile-stained cellular particles and hairs present. Small amount of fat. Sputum. — Negative to T. B. Treatment. — 1. Dietary. 2. Medicinal. 3. Daily lavage before breakfast. 4. Electrical (not instituted). 5. Surgical (not advisable). 1. Dietary Treatment : The patient was put on a "bland diet" ; he was told to avoid all fatty or fried foods, and that his food should be taken four or five times a day, and that thorough masti- cation was most important. Boiled rice, poached eggs, boiled fish, spinach, creamed mashed pota- toes, milk toast, thin soup, citrous fruits, etc., were recommended. 2. Medical Treatment : Strychnine sulph. gr. 1/40 t.i.d. before and HCl. dilute gtts. 30 in water after meals were given. The bowels were ordered kept open with cascara sagrada in case of consti- pation. THE HOSPITAL BULLETIN 91 3. The patient was given a daily lavage with .1 warm solution of Na. CI. and sodium bicarb, oz. I to a quart of water before breakfast for 10 days, when a marked improvement was noted. Free HCl. 10. Motility was apparently also improved. The lavage was continued for five weeks. 4. Electrical Treatment : This could not be instituted, although a Faradic current adminis- tered with an intragastric electrode was indi- cated to diminish the degree of dilation and as a stimulant to secretion and motility. 5. Surgical interference was thought of, but not indicated. A support of abdominal bandage would not have helped in this case. Patient's Present Condition. — Later, after he had been under about two months' treatment, he returned to the dispensary for discharge. There was a gain in weight. The epigastric pains had entirel}' disappeared. K final test meal showed free HCl. 10 and no evidence of the first (8.30 A. l\r.) test breakfast. This case illustrates what can be done with patience and an obedient patient. It is much to be regretted that some means (compulsory meas- ures, if you wish) cannot be devised and put into execution by which a dispensary patient will be required to report at stated periods, and finally return for a "discharge." A letter from the patient's pastor, or from some other reliable source, might be used as an excuse, except in emergency cases, but otherwise no way presents itself to me just now except to require a deposit, say, with the "dispensary physician," this to be refunded at the proper time. It is most discouraging to have a patient return a month or so after receiving temporary relief after three or four treatments and to have to start all over again. Suggestions would be appreciated. "Evergreen," Hampden, Baltimore. A CASE OF GASTRIC ULCER WITH GASTRO - ENTEROSTOMY PERFORMED. In our list of the class of 1897, published in the June Bulletin, we were unable to locate Dr. W. H. Lippett. We are indebted to Dr. A. C. Everett, same class, of Rockingham, N. C, for the infor- mation that Dr. Lippett died at Pittsborough, N. C, about 1900 or 1901. Presented by Albert H. Carroll, M.D., and Vernon L. Oler and Ralph L. Taylor, Class of 191 1, before Dr. John C. Hemmeter's Clinic, University of Maryland. Operation by J. Holmes Smith, M.D. Dr. Lay Gordon Burroughs, class of 1906, of 319 South Aurora street, Collinsville, 111., was a recent visitor to the University Hospital. Nothing unusual presents itself in this case, except, perhaps, the prompt relief afforded by a gastro-enterostomy and the patient's rapid con- valescence, the operation having been decided upon after a brief trial of medicinal treatment, under which the patient's condition gradually grew worse. His pains became continuous. The patient first came under Dr. A. H. Car- roll's treatment in the dispensary. Owing to his inability to carry out the prescribed treatment at his home, he showed no improvement, and he was then advised to come into the hospital. He did so. patient's history. Name, C. H. ; American ; white ; male ; age 42 years ; single ; occupation "packer." Dispensary No- 1728. Complaint. — "Pains in the stomach, vomiting and loss of appetite." Family History. — Father dead ; cause unknov, n. Mother dead (tuberculosis, 16 years ago ; he lived with her). He denies any history of malignancy, nervous, mental, kidney or cardiac diseases in his family. Past History. — He says that he had measles when a child, but that he has never had scarlet fever, typhoid fever, pneumonia, malaria or any veneral disease. There is no history of trauma. Present Illness. — On November 25, 1910, while at work the patient experienced severe cramp-like pains in his left epigastric region, which radiated downward below the umbilicus. He was com- pelled to stop work and go home. After a while these pains subsided, and he ate a little supper. The meal was followed by severe pains, which lasted during the entire night- On the following day the pains subsided, and his condition improved. Two days later he re- turned to work, but after two weeks, during which time he often experienced these cramp-like pains, suffering greatly, vomiting black vomitus, but no red blood, he then came to the dispensary for 92 THE HOSPITAL BULLETIN treatment. The patient was ordered to eat a test meal and return the next day at 12 o'clock. The contents, after being secured and examined, showed free HCl. 40, total acidity 65 ; no blood ; some mucus. Pulmonary and cardiac examinations show nothing pathological. Nervous System. — Negative as to diseased con- ditions, but the patient is somewhat nervous, al- though he is apparently of a cheerful disposition. He complained of his inability to sleep, owing to the excruciating pains at night. This was the main reason for sending him early to operation. Genito-urinary Tract. — Negative ; no scars. Habits. — It has been impossible to discover any vicious habits- He does not drink whiskey and but a small amount of beer. He smokes very irioderately, and denies using drugs of any de- scription. Treatment. — The patient was told to go home and to go to bed ; to eat nothing, and to drink only small quantities of milk at frequent intervals. He was given bismuth and alkalies. He returned two days later complaining that the pains were almost constant, and that he could not retain his medi- cine, and that even water made him vomit. He says that he had not slept for two nights. His pulse at this time was rapid, his skin cold and damp and his conjunctiva pale. On December 24 Dr. J. Holmes Smith, Sr., ex- amined him, and told him that to enter the hospital would be advisable. He did so the next day (De- cember 25). He was closely observed and given medical treatment, under which his pain contin- ued, but his vomiting ceased. He was a sick man- LABORATORY FINDINGS (aFTER ENTRANCE). Stomach Contents. — Free HCl., 50; combined acidity, 70; much mucus present, but visible or occult blood was absent. Urine. — Amount, 1800 c. c. ; amber color; re- action acid ; Sp.Gr., 1020 ; albumin negative ; sugar negative ; an occasional granular cast. Blood. — R. B. C. 4,500,000 W. B. C. 7,000 Hbg 80 Feces. — Negative to occult blood. 5'/>m/«»;;.— Negative to T. B. A gastro-enterostomy was done January 5 by Prof. J. Holmes Smith at this hospital. Ol'ERATION. The abdomen was opened by an incision four inches long and about one inch to the left of the median line, above the umbilicus. The stomach and intestines were exposed. The bowel was caught in an intestinal clamp just beyond the duodenal jejunal flexure. An incision was made through the meso-colon, and the posterior wall of the stomach was made to project through it. The stomach was then caught in a clamp, which was placed close to the lower border. The clamped stomach and intestines were placed side by side, the intestines having been turned so as to make the peristalic movement of the stomach and intestine in the same direction. The serous surfaces were united by continued sutures for about 2^^ inches, and the two visceral surfaces were then incised above the suture. The mucous layers thus ex- posed were then sutured with chromic catgut. The upper layers were united in a like manner, the mucous surfaces being united with chromic catgut sutures and the visceral layers by continued silk sutures, and the site of anastomosis was rein- forced by a strip of omentum sutured around it- The patient was returned to his bed. Procto- cylysis of half-strength normal saline solution was given by Murphy's method, the head of the bed being elevated, with the patient in a half-sitting posture. Twelve hours after the operation an ounce of hot water was ordered to be given by the mouth every hour. Forty-eight hours after the opera- tion the patient enjoyed reading the morning paper, experiencing no pain whatsoever, although eructations had been persistent previous to the operation. He "did not belch" after the opera- tion. Flis pulse, temperature and respiration were normal. His recovery was uneventful, and he was discharged from the hospital on January 18, 1911. PROGNOSIS. As to the cure of the gastric ulcer, the prognosis is fair, although complications may arise. Per- sistent vomiting or "vicious circle" may follow. According to some of the latest writers on this subject, there is a liability to pancreatic atrophy, with its concomitant digestive disturbances, and perhaps also the development of neurasthenia. Some advise a second operation after the healing of the gastric ulcer is complete, doing away with the gastro-enterostomy, and thus restoring the passage of food through the pyloric orifice into the duodenum again. •A very similar case, in which surgical Interference was postponed, had a severe hemorrhaj-'e in ward "A" last night, and died this morning. We must Imow when to operate. THE HOSPITAL BULLETIN 93 THE HOSPITAL BULLETIN A Monthly Journal of Medicine and Surgery PUBLISHED BY THE HOSPITAL BULLETIN COMPANY 608 Professional Building Baltimore, Md. Subscription price, $1.00 per annum in advance Reprints furnished at cost. Advertising rates submitted upon request Nathan Winslow, M.D., Editor Baltimore, July 15, 191 1. CHARGE AND COLLECT. There is, perhaps, no class of the community that does as much unselfish and unrequited work as the physicians. They spend their days, and often their nights as well, in performing laborious, irksome, it may be, and frequently unremunerated, services. They usually continue to pursue their beneficent calling while they are able to work, and are generally stricken down with their armor on and their blade drawn for the battle. As a rule, the physician does not accumulate a large estate, and frequently he dies poor and leaves his family destitute. This should not be so, and to a large extent it is due to the neglect of the doctor in observing the most elemental principles of busi- ness. While the poor are ever with us, and it is proper to render gratuitous services to such as are in distress and poverty, nevertheless one should not get into the habit of working without com- pensation. The first principle of medical business should be the regular, frequent rendering of bills to those who are able to pay, remembering that it is easier to pay a small fee than a large one, and not waiting until the aggregate is large and per- haps burdensome. The professional charge should not be too small. There is a vast difference between the average fees of the lawyer and those of the physician. The lawyer expects a fee com- mensurate with the work done, and he usually gets it. On the other hand, the doctor usually charges ridiculously low rates for his services, and he does not collect what he charges. The people respect the successful lawyer, and pay him; they love the old family doctor, and let it go at that, if they can. The second rule of medical business, then, should be, collect vour bills from those who are able to pay, or let them go elsewhere when they fall sick. This will, of course, be somewhat difficult, but when your clientele thoroughly under- stand that you are in earnest in demanding just and regular compensation, they will comply. The physician is a mark for all kinds of sharpers, and he is solicited to invest his money in all kinds of wild-cat enterprises. It is a good thing for the doctor when he begins to make more than his ex- penses to buy a home and furnish it, or, if living, in the country, to purchase a farm. Whether living in the country or in the city, it is best for him to invest in some solid security, real estate, mort- gages, ground rents or attested bonds, rather than in speculative undertakings. The royal road to competence and to wealth is to spend less than you make. It is not what one makes that tells, but what one spends. The writer had no idea of in- flicting this homily upon anyone when he began this article, neither is he a brilliant exponent of the efficacy of the principles enunciated above ; however, he makes no charge for the advice given, and the turning loose of another class of gradu- ates affords an opportunity for reflections and suggestions. LOUIS McLANE TIFFANY. Those of us who have had the pleasure of lis- tening to the charming and instructive lectures of Prof. Louis McLane Tiffany will be glad to learn that our friend and former teacher has suf- ficiently recovered from his recent illness to leave for his daughter's home on the coast of Massa- chusetts. Dr. Tiffany was an ornament to the School, and his serv'ices were invaluable. Those who kno^ him would deeply regret to learn that any misfortune had befallen him. His former colleagues, friends and students unite in wishing him a speedy return to his former good health. WATCH IT GROW. The following contributions have been made to the endowment fund of the department of path- ology to July I : Robinson bequest $5,000 00 Dr. Hugh Hampton Young, J. H. U. . . 100 00 Dr. S. J. Meltzer,