V
V^A _
OF TH E
-School of lA^edicine.
THE HOSPITAL BULLETIN
OF THE
UNIVERSITY OF MARYLAND
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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
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For V/ '
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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
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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
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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
\'
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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,
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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.
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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
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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
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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
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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-
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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;
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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
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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
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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
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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:
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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
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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
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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
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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.
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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-
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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.
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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
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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