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A WEEKLY MEDICAL JOURNAL
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THE MEDICAL NEWS.
A WEEKLY JOURNAL OF MEDICAL SCIENCK
Vol. 82.
New York, Saturday, April 4, 1903.
No. 14.
ORIGINAL ARTICLES.
THE SIGNIFICANCE OF VARIATIONS IN THE IN- TERNAL SECRETIONS.*
BY O. T. OSBORNE, M.A., M.D.,
OF NEW HAVEN, CONN.; PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS AT YALE.
The subject of internal secretions and organic extracts has been so thoroughly discussed during the last year or two that I fear I can offer noth- ing new, but will put into words a few of my as yet chaotic thoughts hoping that some one here may mold them into some tangible form.
Bacteriologists are convincing us that more and more diseases are bacterial in origin, and I find that my clippings of articles and abstracts are going more and more into the files reserved for diseases or disorders of nutrition. These two great divisions of disease, bacterial and nutri- tional, are ever growing larger.
Pathologists are teaching us to class many so- called diseases as simply disturbed conditions, and to me the problem now is are not the glands fur- nishing internal secretions the cause of many of these mal-conditions ?
We then turn to the physiologist to teach us the exact functions of these glands, and to the experimental pharmacologist to tell us what ac- tion to expect from the administration of these glandular extracts. However, our knowledge from both of these sources is as yet insufficient to account for many mal-conditions or to account for many successful therapeutic uses of these glands. Hence we are still in the realm of sur- mise as to the mal-physiology of the ductless glands in disturbed conditions and are perhaps often justified in using these organic extracts empirically. It is my purpose to briefly state what we really know of the most important se- cretions and what we are perhaps justified in sur- mising.
The conditions that have been proved to be caused by disturbances of an internal secretion are acromegaly, cretinism, myxedema, Addison's disease, and about half of the cases of diabetes. The conditions that I would like to see proved as due to some disturbed internal secretion are, hys- teria, neurasthenia, possibly melancholia in its first stages, hemophilia, rickets, atheroma, sclero- sis, gout, leucemia, chlorosis, shock, what we call a neurotic condition, and all cases of diabetes.
During this discussion, to-night, I shall leave out of consideration the various digestive juices and consider only those of the most important ductless glands.
We now pretty well understand the function
• Read at the meeting of the Medical Association of the Greater City of New York, held at the New York Academy of Medicine, December 8, 1902,
of the thyroid, we know considerable of the su- prarenal glands and the pituitary body, we know a little of the thymus, testicle, ovaries, mammary, and parotid glands, and considerable of the pan- creas and spleen.
We may take up the action of the thyroid and suprarenals together, as in many ways they are diametrically opposed. The thyroid is perhaps the main organ of the body to furnish vasodilat- ing material, while the suprarenal glands are without doubt the main organs of the body to furnish vasocontracting stuff. Hypersecretion of the thyroid or the feeding of thyroid substance will always dilate the peripheral blood vessels and reduce arterial tension. On the other hand, the blood-pressure raising power of suprarenal extract is without equal in pharmacology.
Physiologists have never yet proved a center in the brain for the regulation of heat, and many believe that the vasomotor center in the medulla is sufficient to explain this normal regulation of heat production and heat loss. What part these two glands play in this alternating opening and shutting of the blood vessels of course we do not know, but the babe has but an imperfectly developed thyroid, and its adrenals have been ob- served to contain no vasocontracting stuff, and we know that the temperature in the very young varies with the temperature of its surroundings, it having no heat governor or regulator.
The thyroid gland seems to be the one that has the most to do with the health of the skin, keeping it soft and pliable, and causing the nor- mal amount of insensible perspiration. If this gland becomes atrophied or enlarged by connec- tive-tissue elements displacing its normal paren- chyma, the skin becomes harsh and dry, and if the condition is sufficiently aggravated, mucin appears in the tissues and the condition of mu- cous edema or myxedema is present.
Normally the thyroid gland begins to atrophy from forty-five to fifty years of age. The ad- vent of old age allows, sooner or later, the skin to become dry, harsh, rough, and perhaps shrivel or wrinkle. In the condition of the skin just mentioned in old age and where there have been scaly eczemas due to dryness of the skin I have found thyroid to be one of the best treatments.
Diminished secretions of the thyroid allow the blood tension to become higher, hence the old adage that we are always and only as old as our arteries seems to be proved very true. Under- secretion of the thyroid gland tends to allow, I do not say cause, an endarteritis which later may lead to true atheroma. Hence the normal stiffen- ing of the arteries that occurs as age comes on is simply physiological, due to the undersecretion of the thyroid, and if not actually to the oversecre- tion of the suprarenals, at least to the over rela-
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OSBORNE: VARIATIONS IN INTERNAL SECRETIONS.
[Medical News
tive secretion of the vasocontracting stuff. From these two reasons the arteries harden and the blood tension becomes high. That some of these conditions may occur in life is only because any of these glandular secretions may underse- crete or oversecrete at any time, due to various causes, and I believe that the so-called alterative drugs of which we have a large class have such so-called alterative action because they act upon one or more of the ductless glands modifying their secretion.
Perhaps the reason that syphilitics have so much tendency to sclerosis and endarteritis is that mercury long given may interfere with the action of the thyroid gland. I think that probably un- deraction of the thyroid also allows connective- tissue growth in many of the organs of the body. In other words, it allows sclerosis and I believe that the feeding of thyroid in small doses is one of our best treatments to prevent the advance or at least to slow up this connective tissue forma- tion. Also in cases of arteriosclerosis where nitroglycerin in small doses is of value to reduce the disturbances from high tension, such as dizzi- ness, sleeplessness, headache, and possibly asthma, I have found thyroid of marked benefit. The iodides that have been so much used to meet all of these conditions just mentioned have been proved to be stimulant to the thyroid secretion.
To take up the opposite condition from the above, namely that of shock, we have, whether due to pain, severe acute or prolonged subacute, to severe injury or to operations even without loss of blood, from each cause the same pa- thology, viz., very low blood pressure and dilated or even paralyzed vessels. In the meantime, of course, the body is losing the heat, which is so necessary to life from the dilated peripheral ves- sels. Whether severe pain has caused an enor- mous secretion of the thyroid, or what is more probable, temporarily paralyzed the adrenals, or both, we do not know. When such shock fol- lows laparotomy whether from splanchnic plexus injury or from the necessary manipulations dis- turbing the adrenal glands, certain it is that the most prominent indication is for something that will contract the blood vessels, and many times no drug in all our armamentarium is capable of carrying on the fight to a successful termina- tion. I believe that to meet this condition we have in suprarenal, or adrenalin chloride, or supra- renalin solutions the very agents we desire. Su- prarenalin is Armour's selling name for Abel's epinephrin.
The action of this substance in raising the blood pressure is immediate, but unfortunately does not last but a part of a minute. In treating shock it will probably be found best to inject a so- lution drop by drop into a vein timing the rapid- ity by the behavior of the pulse. The solution should be one part to a thousand of suprarenalin, where each drop represents .00005 o^ ^ gram. Adrenalin chloride solution is active and is acid. Any of these preparations" of suprarenal can be
given on the tongue for absorption there, but un- fortunately it has been proved that when taken into the stomach the blood-pressure raising power of suprarenal is absolutely lost.
Suprarenal is also a strong cardiac stimulant as well as a vasomotor contractor. Reichert, of Philadelphia, has recently shown that in pro- found morphine narcosis the adrenal secretion is stopped. This explains some of the symptoms of the last stage of opium poisoning and shows the danger from loss of heat in these cases and sug- gests suprarenal treatment.
Now, turning to the nervous element in thy- roid secretion we find that it is a marked cere- bral stimulant causing wakefulness, acuteness, rapidity of thought, and general brain activity, all of which occur so frequently and so generally in our neurotic patients. If this secretion is greatly exaggerated we have headache, brain irritability, and can even feed it to the point of causing convulsions. What is taking place in the brain in melancholia we do not know, but I have occasionally awakened the mental faculties in morbid conditions by thyroid.
In the vasomotor ataxia (Cohen's term) of neurasthenia it would seem as if the suprarenal glands might not be doing their work, which would give the low blood pressure, the lack of digestive power, the drowsiness due to anemia of the brain when the patient is up and the sleep- lessness when the patient is lying down.
Now, what is the intangible cause of hysteria? We turn again to the thyroid gland, as we know this to normally, in women, hypersecrete with each menstrual epoch. Also, 80 per cent, of all cases of exophthalmic goiter, or, as I prefer to call it, Graves' thyroid disease, occur in women, and I believe this disease to be due to a hyper- secretion of the thyroid, its symptoms being ex- actly those caused by the overfeeding of thyroid, viz., nervousness, restlessness, sleeplessness, pal- pitation, hot flashes, sweating, and increased irri- tability of the reflexes. On the other hand, 80 per cent, of all cases of myxedema also occur in women, and this is well known to be due to un- dersecretion of the thyroid. This hypersecretion of Graves' disease occurs mostly between twenty and forty years of age, in other words during the most active period of thyroid life in women. On the other hand, myxedema occurs almost inva- riably from forty-five to fifty-five years of age when the thyroid normally b^^gins to atrophy. I wish to emphasize the fact that between these op- posite points of profound hypersecretion and practical absence of secretion are all gradations of increased or diminished secretion, and many of the troublesome, unaccountable, intangible symptoms in women are due to this variation in thyroid secretion. The palpitations, the nervous- ness, the restlessness, the increased susceptibility to pain, and even possibly the misinterpretation of pain in conditions of hysteria I think can be due to misbehavior of this gland.
When the menopause takes place, if this gland,
April 4, 1903]
OSBORNE: VARIATIONS IN INTERNAL SECRETIONS.
627
which has normally been hypersecreting once a month, stops its work synchronously with the ovaries, we have the best possible advent of this changed condition. On the other hand, if this gland continues to secrete more than is needed for the organism, we have the hot flashes, the fuU-headedness, the palpitation, and the nervous phenomena so well known to us as the troubles due to the menopause. As a corollary to these last statements I have found that in delayed men- struation, with or without anemia, no drug is as efficient in causing normal menstruation as thy- roid extract, given in three-grain doses three times a day. I have also many times found in feeding thyroid for other purposes that menor- rhagia was caused.
We understand the condition of cretinism, but perhaps do not think that a diminished amount of normal thyroid secretion in the young child may be the cause of the fat, flabby skin, dull fea- tures, chronic eczemas, erosions and fissures, and perhaps enlarged glands of {he neck. I have a number of times seen such cases do better on thy- roid than on any other treatment, and the very aheratives which we sometimes give for this pur- pose and find valuable are those which increase the secretion of the thyroid gland, viz., arsenic, iodide of iron, the iodine of cod-liver oil, and potassium iodide.
The thyroid gland also regulates in some way the elimination of nitrogen in the urine, and we can feed thyroid to patients whether they are obese or not,' and increase the nitrogenous output. On the other hand, at the time when the thyroid begins to normally diminish its secretion is the time when men and women begin to add weight. This is especially true of women after the meno- pause.
Diseased suprarenals give the cause of many of the symptoms in Addison's disease, notably the great diminution of vasomotor tension. Whether this gland has anything to do with the loss of red blood corpuscles in this disease we do not know, but the patient apparently dies of what might be considered an ultimate vasomotor paralysis.
The other functions of the suprarenal glands besides the blood-pressure raising power are still unknown, but it has been lately shown that they have something to do with the production of glycogen (Herter). We certainly do have cases of diabetes mellitus without any pancreatic or nervous disease. I have recently had such a case, and of many treatments tried, the urine being examined weekly, it was found that under the ac- tion of suprarenal substance swallowed we could diminish the output of glucose, cause the diacetic acid to disappear and greatly diminish the acetone and ammonia. In this same case thyroid feeding almost caused toxic acidemia. This boy went along very well on suprarenal feeding for nearly a year. For observation purposes the suprarenal was then stopped for two weeks. Post hoc, ergo propter hoc the patient at the end of that time
developed diabetic coma and died in a few days. It is also interesting to note that hyperthyroid feeding in Graves' thyroid disease can cause glycosuria.
I have long been suspicious of the suprarenals as having something to do with gout. Just what gout is I will let someone else answer, but with gouty joints, with high tension blood vessels, and in gouty asthmatic attacks I have found small doses of the opposite of suprarenal, viz., thyroid not only of considerable immediate benefit, but tending to cause all kinds of gouty attacks to be- come very much less frequent. This may be due partially to the action of thyroid , on nitrogen elimination.
What the pituitary secretion means to the sys- tem is in a measure uncertain. It is probably always hypersecreting in the condition of giant- ism, is certainly always diseased in acromegaly, and probably if every case of giantism lives long enough he will assume the acromegalic type, giantism being nearly homogenous overgrowth of bone, while acromegaly is irregular bone growth. It is possible that always in the begin- ning of acromegaly there is a hypersecretion of the thyroid. If this occurs late in life the enlarge- ment seems to be of the ends of the bones and the extremities, although a few of the long bones grow. Certain it is that in acromegaly there is positive formation of new bone as well as an in- crease of the size of old bone, and this is nor- mal hypertrophy. When this pituitary secretion becomes disturbed we have in these acromegalic cases almost continuous headache, sometimes ex- cruciating in character. I have in several cases found these headaches were made better by feed- ing pituitary.
A corollary of this increased bone growth might be drawn, viz., to feed young dwarfs pituitary substance.
The glands of the body seem to be more or less interchangeable in their functions, if one is un- able to do its work, another seems to take up extra work. This is true of the thyroid gland in acromegaly, and some of the early symptoms of this disease are due to too much action of the thyroid. Later in the disease the thyroid secre- tion is diminished, and I believe in every authen- tic complete autopsy on cases of acromegaly the thyroid has always been found atrophied, at least as to its parenchymatous portion, and a large number of the typical signs of acromegaly are due to this pseudomyxedema. Pituitary substance slightly stimulates the heart and contracts the blood vessels, but is greatly inferior to supra- renal in this respect.
The thymus gland atrophies in childhood and disappears after puberty, and hence probably performs some important function in the develop- ment and growth of the young child. If it per- forms any other function, some other gland or glands evidently assume such work after the age of puberty.
The thymus gland contains the largest amount
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OSBORNE: VARIATIONS IN INTERNAL SECRETIONS.
[Medical News
of nuclein and hence of phosphorus of any gland of the body, and will serve the purpose of any nuclein treatment. An extract of this gland is probably a constructor, and hence reconstructive, and can, as far as I am aware, never cause de- bility and does nothing but good. Inductively it would seem that this gland, which is so active during the period of greatest bone growth of the body, must have something to do with the forma- tion of bone salts. As these earthy salts are all necessary to permanently encapsulate or to heal tuberculous lung lesions, I thought that theoretically thymus should be of value and have found practically that in tuberculous cases it was an aid to whatever hygenic or medicinal treat- ment was instituted. In other words, these pa- tients very generally gain under thymus.
Many cases of exophthalmic goiter improve under the use of this glandular substance, but I have never found any treatment that would posi- tively stop hypersecreting glands except morphine or codeine.
The thymus gland has been found absent in he- mophilia, and it is interesting to note that thymus extract has shown some coagulant action on blood. Hence in hemophilia thymus gland should be tried.
This gland would seem theoretically of value in rickets. Objecfive cases of rickets in this age of good feeding are now so infrequent that in my non-surgical practice I have had no opportunity to give this treatment a proper test.
In the scurvy of children undoubtedly the blood is not getting what it needs, and perhaps it is the thymus gland that cannot get the salts that it requires, and this is the cause of the bleeding and other symptoms of that condition.
We are so much at sea in regard to the phy- siology of the internal secretions of the pancreas, spleen, testicles, ovaries, mammary glands and parotid, that we can draw no safe therapeutic in- dications for their use. Whatever is done in a therapeutic way with these extracts is purely em- pirical and mostly, as yet, experimental. Of course any gland like the testicles that contains nuclein, and hence phosphorus, will give tonic phosphorus to the system.
Turning now for a few minutes to the blood, and it would seem that chlorosis is due to bad chemistry somewhere, probably in the gastro- intestinal canal, but perhaps some gland is not doing its work. At any rate it is often the fact that though these cases will all get well on either organic or inorganic iron, often best the latter, some of them will get well on some saline.
I have lately been much interested in the study of a case of lymphatic leucemia and believe that some interesting physiological facts have been demonstrated. This case is a man sixty-four years of age, who has all of the glands of his body enlarged, internal and external, as far as I can delineate, as well as a large liver and a fairly large spleen. We have had the patient under careful observation for a year and a half, and find
that his white corpuscles remain anywhere from 170,000 to as high as 380,000 per cubic millimeter. Over 98 per cent, of these white cells are lympho- cytes, only a little over one per cent, being poly- morphonuclear leucocytes, while normally about 75 per cent, of whites should be the poly- morphous variety. In the laboratory we settled a mooted point, viz., that these white cells did not break down. If they did, we should have a greatly increased uric acid and phosphorus out- put. This man's uric acid and phosphorus output were perfectly normal on repeated and continued examinations, i.e., normal for a man with 8,000 white cells. The only treatment that markedly increased this uric acid output was an alkali, viz., bicarbonate of soda. Nucleic acid also somewhat increased it. If uric acid is mainly due to nuclear breakdown, this is pretty positive proof that these white cells do not rapidly disintegrate. On the other hand, while this bicarbonate of soda was being fed for one week his white blood count went from 203,900 to 380,000, while at the same time he lost red blood corpuscles.
Another interesting point was that any treat- ment that greatly reduced the size of his glands always made his white blood count greater and his red blood count less. This was true of the bicarbonate of soda, and very true of arsenic. Hence arsenic was in his case, at least, vicious treatment, although the glands grew smaller under it.
Nucleic acid was fed him on the theory that as it always causes leucocytosis, i.e., an increased number of the polymorphonuclear cells, if the lymphocytes were the origin of these cells, we ought to cause a great number of them to be formed. Nucleic acid did not cause any increased number of polymorphonuclear cells. If fed in large amount it did cause a diminished white blood count, but also diminished the red blood count.
One pernicious malarial chill reduced his white blood count from 238,000 to 68,000. The next day they went up to 170,000, and on the next chill, which we were unable to stop with enor- mous doses of quinine, the whites came down to 120,000. From that time on, the chills being stopped, the whites went up to their usual num- ber.
His red blood count ranging between 3,000,000 and 4,000,000 always improved under Armour's red bone marrow and as regularly diminished under any other treatment.
Since the first of last July this man's blood has been counted every week. He has been having red bone marrow almost continually during this period, and his red blood count has averaged about 4,000,000. On October 12 he had been without this bone marrow for five days and his red blood count became 2,510,000, while a week before it was 4,200,000, a loss of 1,600,000 red blood corpuscles in five days without bone mar- row . In six days more on bone marrow he had regained 600,000 of these corpuscles.
April 4, 1903]
OGDEN: SIGNIFICANCE OF OXALURIA.
629
In this case, then, there is undoubtedly disease of the red bone marrow, also it is pretty good physiological proof that the red bone marrow produces red blood corpuscles, and also good proof that the feeding of red bone marrow sup- plies that deficiency.
Physiologists are about equally divided as to whether the lymphocytes are the origin of the polymorphonuclear leucocytes, or whether the polymorphonuclear leucocytes grow from the bone marrow. This case, having practically no corpuscles of this variety and his red bone mar- row showing such evidence of disease, it would seem pretty good physiological proof that these polymorphonuclear leucocytes are formed in the red bone marrow.
I fear you will consider that this rambling talk has had no definite object, but when discussing the organic secretions, one is so flooded with pos- sibilities and probabilities that it may not be amiss to exchange thoughts on the subject.
THE SIGNIFICANCE OF OXALURIA.*
BY J. BERGEN OGDEN, M.D.,
OF NEW YORK;
FORMERLY INSTRUCTOR IN CHEMISTRY, HARVARD MEDICAL SCHOOL; ASSISTANT IN CLINICAL PATHOLOGY, BOSTON
CITY hospital; etc.
Oxalic acid may be regarded as a normal constituent of the urine. It is, however, pres- ent in very small amount, the quantity usually not exceeding 0.02 gram, in 24 hours. This acid exists in the urine in combination with calcium — calcium oxalate — which, under ordinary circum- stances, is held in solution by another normal urinary constituent, i.e., monosodic acid phos- phate. Whenever the production of calcium ox- alate is excessive the monosodic acid phosphate becomes insufficient to hold the oxalate in solu- tion, the crystals separate and are found in the urinary sediment. '
The term oxaluria is used to signify the pres- ence of crystals of calcium oxalate in the urine. As the term is commonly applied, it may mean that the crystals are present temporarily or that their presence is persistent. Properly speak- ing, the term should be employed only to those cases in which the crystals are present for a con- siderable period, for, as we shall see later, oxalate crystals may suddenly appear and as quickly dis- appear from the urine of any healthy individual who is living on the average mixed diet. The number of crystals found in the sediment may be large or small depending upon circumstances. It should, however, be borne in mind that a few large primary crystals may be of far greater im- portance than a large number of the small sec- ondary forms. The continued presence of the crystals always shows an overproduction of cal- cium oxalate which in turn usually indicates some pathological condition that is acting as a cause.
♦Paper read before the New York State Medical Association. New York County, January 19, 1903.
Causes of Oxaluria. — One important cause of an oxaluria is excessive fermentation in the gas- tro-intestinal tract. Dr. Helen Baldwin* pro- duced experimentally in dogs a pronounced oxa- luria by feeding the animals on meat and large quantities of cane sugar or glucose. These sub- stances were given until a marked degree of gas- tric and intestinal fermentation was produced; indeed, in some instances a distinct gastritis was induced. We know that meat contains only an infinitesimal amount of oxalic acid and that cane sugar and glucose contain none, therefore the ox- aluria that was produced by the ingestion of these articles of food must have been brought about by other conditions. Dr. Baldwin noticed that the crystals of calcium oxalate were most abundant in the urine when there were distinct indications of an acute or subacute gastritis.
These experiments have proved highly instruc- tive and important. Up to the time that Dr. Baldwin published the results of her research we were without a satisfactory explanation of the cause of oxaluria in many cases and the treatment of such cases was consequently attended with un- satisfactory results. Although Dr. Baldwin has clearly demonstrated that a marked oxaluria may result from the excessive fermentation pro- duced by the ingestion of meat and large amounts of carbohydrates, we have yet to learn whether or not the proteid element is essential for the production of gastro-intestinal fermenta- tion, and if so to what degree; also whether these fermentative changes and the consequent ox- aluria can be brought about by the ingestion of carbohydrates alone. We still have no knowl- edge of the fungus or organism, if there be one, that appears to cause the undue formation of ox- alic acid during fermentation. There is practi- cally no doubt that a permanent diminution or an absence of hydrochloric acid in the contents of the stomach favors and is perhaps necessary for the development of this fermentative ox- aluria.
There is still another cause of oxaluria whi«h must be constantly borne in mind, i.e., articles of food containing oxalic acid. Some of these sub- stances are sorrel, rhubarb, tomatoes, asparagus, spinach, onions, cabbage, and some of the varie- ties of grapes and apples. Barouxf claims that when fresh fruits containing citric acid are tak- en with some of the above mentioned vegetables, oxalic acid is set free. He has reported nine cases, in one of whom, a young man, pain and an acute gastro-enteritis followed a meal which consisted partly of spinach and cherries. In two children the same symptoms resulted from the ingestion of spinach and oranges. We find no accurate record of the urinary findings in his cases. While the claim of Dr. Baroux concern- ing the chemical processes taking place in the stomach under such circumstances is largely conjecture, we know that oxalic acid is in many
*"An Experimental Study of Oxaluria with special reference to Its Fermentative Origin."— The Journal of Experimental Medicine October, i<;oo.
t Journal des Sciences de Lille.
630
OGDEN : SIGNIFICANCE OF OXALURIA.
[Medical News
instances set free, but how and in what manner, we have yet to learn.
Rhubarb and asparagus probably constitute the chief causes of oxaluria from the food. Since oxalic acid is the principal acid of rhubarb we can readily appreciate the amount of harm that may result from the custom of taking stewed rhubarb and rhubarb pie. Sorrel is for- tunately little used, while the tomato, the apple, the grape and the onion contain only minute amounts of the acid. If food rich in oxalic acid is taken only rarely and in small amounts, the resulting temporary oxaluria will probably very quickly disappear and be productive of little or no harm. But the dietetic element is no less im- portant, especially in those individuals who are already afflicted with an overproduction of oxalic acid.
It is highly probable that many of the in- stances of oxalates in the urine are due both to the oxalic acid preformed in the food and to their formation by intestinal putrefaction or fer- mentation. If, after removing all oxalic acid containing substances from the food, the oxaluria persists, we can be fairly certain that the cause lies in the digestive tract.
Indoxylpotassium Sulphate and Oxaluria. — Indoxyl, also sometimes called "Indican," is a normal urinary constituent, and exists in the urine as an ethereal or conjugate sulphate — in- doxylpotassium sulphate. It appears to be formed by the oxidation and absorption of indol which in turn is a normal constituent of the in- testine and a product of the natural (or normal) intestinal putrefaction. If this putrefaction or fermentation is abnormally great, the indol is produced in unusually large quantity and the out- put of the indoxyl sulphate is correspondingly large. The tests for indoxyl in the urine are, therefore, an index of the amount of fermenta- tion taking place in the intestine. An important fact is that a well-marked oxaluria is almost al- ways accompanied by an increased amount of itjdoxyl, showing that there is a more or less in- timate relation between them and that they prob- ably have a common cause.
Character of the Crystals of Calcium Oxalate. — Calcium oxalate crystallizes from the urine in two typical forms — the octahedral and the dumb- bell crystals. There are, however, various modi- fications of these two forms, according to the positions of the crystals. You are all perfect- ly familiar with the octahedral or so-called "en- velope" crystal, which is made up of two four- sided pyramids placed base to base, and when viewed from the side their characteristic appear- ance is that of a square crossed obliquely by two bright lines presenting the resemblance to a sealed square envelope. Frequently these octahedra coalesce in such a way as to have the appearance of an open umbrella, constituting the so-called "umbrella" crystal. Sometimes each half of the octahedron is connected by a short quadrilateral prism and such have been termed "prismatic" crystals of calcium oxalate.
The dumb-bell and oval crystals are more rare- ly found in the urinary sediment than the octa- hedral forms. The dumb-bell crystals are always associated with the oval or circular forms which have bright centers showing their biconcavity. Frequently two dumb-bells are found crossed at their centers forming a double dumb-bell crystal.
Since calcium oxalate crystals may be found in either an acid or an alkaline urine, the colorless dumb-bell crystals should in all instances be distinguished from the yellowish-red or brown dumb-bells of uric acid and of acid ammonium urate, and the octahedral forms' should not be mistaken for the ammoniomagnesium or triple phosphate crystals found in the sediment of an alkaline urine. These various forms of crystals are usually readily distinguished by their micro- scopic appearance and the accompanying ele- ments, or by chemical tests.
Primary and Secondary Crystals. — From a clinical point of view it is important that a dis- tinction be made between those crystals that are likely to produce mechanical disturbances in the urinary tract and those that are harmless. Two classes of crystals are, therefore, generally ca- pable of recognition, i.e., the primary and the secondary. Primary crystals are those that have separated from the urine inside the body ; they usually consist of the large octahedral and most of the oval and dumb-bell forms. Secondary crystals are those that have separated after the urine has left the body; they arie usually the very small octahedral forms and perhaps a few of the very small oval, circular and dumb-bell crystals. These secondary crystals are most com- monly found in a urine that has been allowed to stand for some time. They generally separate from a urine that is highly charged with calcium oxalate.
Mechanical Action of the Crystals. — The pri- mary crystals of calcium oxalate often produce a more or less marked irritation of the urinary tract, especially if they separate from the urine in the kidney itself or in the renal pelvis; the mechanical action is usually much less severe if the crystals separate in the bladder. Blood glob- ules are the chief accompaniment of the oxalate crystals in the sediment, and there may even be abundant hemorrhage. If the kidney is the seat of an acute irritation, renal casts with adherent blood globules, and sometimes with calcium ox- alate crystals imbedded will be found; if the re- nal pelvis is involved, the small caudate cells which are more or less characteristic of the su- perficial layer of the pelvis of the kidney will be found accompanying the blood and the crystals ; and if the bladder is the seat of the mechanical disturbance, the large squamous cells and the round dense cells from the neck of the bladder will usually serve to locate the source of the blood. Such severe mechanical irritation is us- ually accompanied by pain, often frequent and painful micturition and by a more or less con- centrated urine. If the separation of these pri- mary crystals continues for some time, the ten-
April 4, 1903]
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dency to a calculus formation in the pelvis of the kidney or the bladder is, of course, very great and especially in those cases in which there is or has been considerable hemorrhage.
Oxaluria and Diabetes Mcllitus. — There ap- pears to be a rather close relation between diabetes mellitus and an oxaluria. This is usually seen in two classes of cases : ( i ) those in which the diabetic patient is allowed to take such articles of food as he likes, and who, on account of his craving for sugars and starches, subsists large- ly on carbohydrates; and (2) those in which the diet is restricted almost entirely to a meat diet. It seems to the writer that the explanation of the oxaluria in such cases is probably the gastro- intestinal fermentation which results from either the excessive carbohydrate diet or the abundant ingestion of meat — a nitrogenous diet.
Not infrequently a marked oxaluria is an ac- companiment of nervous disorders, especially those attended with mental depression, a sub- acute or chronic prostatitis, and diseases of the heart and lungs. I am unable to give you any plausible explanation of what appears to be an excessive formation of oxalic acid in these cases. In some instances both the food and the intes- tinal digestion may be at fault, but there often appear to be other unknown causal factors. It has been claimed by some that under pathological conditions oxalic acid circulates as such in the blood, and on account of its poisonous action, causes a certain train of symptoms of which ner- vous phenomena are especially prominent. This theory appears, however, to be untenable. We have no satisfactory proof that oxalic acid ever circulates as such in the blood, or that the ner- vous symptoms are the result of the direct or in- direct action of the acid or of calcium oxalate. In diseases of the heart and lungs the accom- panying oxaluria has been ascribed to deficient oxidation. This theory is based on the belief that oxalic acid may exist in the body as an interme- diate product between uric acid and urea, and that it is formed as the result of incomplete oxi- dation. This explanation may be, to some ex- tent true, but further investigation is necessary to prove that an oxaluria actually has such a cause.
262 Fifth Avenue.
THE PROGNOSTIC VALUE OF THE DIAZO-REAC- TION IN PULMONARY TUBERCULOSIS.
BY FRANCIS CARTER WOOD, M.D.,
OF NEW YORK ; INSTRUCTOR IN CLINICAL PATHOLOGY: COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY; PATHOLOGIST TO ST. LUKe's HOSPITAL.
In one of his early papers on the diazo-reac- tion, published in 1883. Ehrlich speaks of the prognostic value of the reaction both in typhoid and in phthisis. He considered that a marked reac- tion in either disease was an indication of a se- vere infection and that in pulmonary tuberculosis especially, a continuous and strong reaction was a sign of vfery grave prognostic import. A num-
ber of theses and papers by other observers were published about this time, showing that in a large proportion of cases the reaction became more strongly marked as the disease advanced and fre- quently afforded useful prognostic data; but that there were fatal cases which did not show the diazo-reaction before death and that there were mild cases in which, though a strong reaction was present at some time during the course of the disease, yet the patient progressively improved.
Since 1884 but little has been published on this subject; but with the present revival of chemical and microscopical diagnosis in internal medicine, the diazo-reaction has again come into promi- nence especially through the writings of Michaelis, Schraeder and Naegelsbach, Becker, Clemens, and others. The more recent writers, on the whole, agree with the original views pub- lished by Ehrlich, but some have been unable to confirm his results. The subject is one of such general interest that it seemed proper to pursue it further and especially on a large series of cases under similar conditions. This opportunity oc- curred in the wards of St. Luke's Hospital, where a large number of cases of progressive phthisis were under observation. A considerable number of these cases came to autopsy and the anatomical findings were of value in controlling the results of the physicial examinations. Owing to the un- favorable conditions under which tuberculous cases are placed when treated in hospitals within city limits, it is the rule at St. Luke's to retain in the hospital for any length of time only such pa- tients as seem beyond the hope of cure by climatic treatment, and to urge all others for whom there is a reasonable hope of recovery to leave the wards and to attempt to find either homes in the country or care in one of the sanatoria for tuber- culosis. In this way the cases are immediately divided into two sharply distinguished groups. In the first are all early, non-progressive cases, which, as a rule leave the hospital in a few weeks, often sooner. In the other group are those cases in which an active and progressive process is un- der way. Many of these cases die in the first few months of hospital treatment ; others live for a year or more; but very few leave with any im- provement in the pulmonary condition. Oppor- tunity is thus offered to study a series of severe cases of tuberculosis and to observe the variations in the urinary reactions.
The total number of cases examined was 363. In all those patients who remained in the hospital for more than a few days the diagnosis was veri- fied by the finding of tubercle bacilli in the spu- tum. Only in a very few, exceptionally mild cases, were the^ bacilli not found during the short stay of these patients in the wards. Of these 363 cases, 117 died. The results of the examination of the urine of the fatal cases showed that in 81 cases, or 69 per cent, of those who died, the diazo-reaction had been continuously positive be- fore death. In 22 cases, or 18 per cent., there had been a positive reaction during a large portion of the time during which the patient had been
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treated, but this disappeared shortly before death. In other words, about 90 per cent, of the fatal cases show a positive reaction during the last few months of life. Of the 14 remaining cases which at no time showed a reaction, ten had the symp- toms of a chronic diffuse nephritis ; and two of the cases undoubtedly died from the kidney le- sion. The kidney lesion seems to interfere with the excretion of the substance producing the diazo-reaction, a point to which Clemens has called attention. Two other cases not giving a reaction died of hemorrhage from the rupture of a large vessel in the lung, though the tuberculous process was not active at the time.
The cases which were discharged numbered 246. A certain number of them left the hospital for reasons of discipline or because they did not like the treatment which they received. These numbered 22. Twelve were severe cases and had a continuous positive reaction. Three were posi- tive at some time ; seven were negative. Of the remaining 224 cases which left the hospital in good condition, 16 were observed for so short a time that their results should not be included here ; some of these cases gave faint positives or a positive on the day after admission and a nega- tive a few days later. Of the 208 cases left after substracting the above ; that is, cases which could be fairly considered as mild non-progressive forms; 188, or 90 per cent, of those examined for over four weeks showed no reaction. The 20 other cases gave alternating reactions; that is, positive one week or month, and negative the next ; so that no conclusion could be drawn from their examinations. If we take, then, the cases which may be considered as unfit for hospital treatment and capable of cure, we find that some 10 per cent, give occasional diazo-reactions, so that it does not seem possible in this country to apply the rule which is suggested for the German sanatoria by Michaelis and Clemens, to exclude all cases with a positive diazo as unfit for climatic treatment, especially as a good many persons with a very slight lesion give a diazo-reaction on ad- mission, and then, as they improve under the altred hygiene, the good food, and the rest in bed which they obtain in a hospital, never give a reaction during the further period of examina- .tion.
If we collect all the cases which were admitted to the hospital and examine them to see how many gave a positive reaction at some time dur- ing their residence, we find the number to be 154, or 42 per cent, of the whole. The number would be considerably reduced if we were to exclude those cases which gave a single positive reaction on admission and then a continuows negative. If now we compute the number of fatal cases in the 154 which gave a single positive reaction the number will be found to be 103; that is, 66 per cent, of those who apply for hospital treatment and are found to give a positive reaction will die, and the Ir.rgest number within six months.
These results correspond very well with those reported by others. For example, Clemens found
that 87 per cent, of the fatal cases show a posi- tive reaction. Rutimtyer found that 85 per cent, of the fatal cases in his series gave a positive re- action; while Michaelis noted that 72 per cent. of the cases giving a positive reaction die within six months.
Of the exact chemical nature of the substance or substances which cause the diazo-reaction, we are as much in the dark as when Ehrlich first published the method nearly twenty years ago.
We know only that it is produced by the ac- tions of bacterial toxins and during the course of abdominal metabolism such as goes on in a pa- tient sufifering from a gastric carcinoma or from a chronic heart lesion. It may be produced in animals by the injection of the toxins of the tubercle bacilli as they exist in Koch's tuberculin T. R. It is easily destroyed by the alkaline fer- mentation of the urine and disappears from that fluid on long standing or on prolonged boiling, which will distinguish it from the drug reactions especially from that produced by naphthalin or /? — naphthol. In general the drug reactions can be recognized by any one familiar with the color of the diazo-reaction, so that there is but little danger of confusion. The foam is never salmon pink, but yellowish or purple. The reaction is not dependent upon temperature, for some of the cases in my series showed a constant and strong positive with a normal or subnormal temperature.
The appearance of the diazo-reaction in the urine is not a constant phenomenon. In looking over a series of tests carried out for a long period of weeks or months, it will be noticed that the re- action may be continuous and strong for a month or so and then suddenly disappear for a week or so only to reappear later on in its original inten- sity. During this time the condition of the patient may grow progressively worse so that it would be expected that the reaction would remain quite constant. The conditions underlying this varia- tion are not completely understood. It was noticed by my assistant, Dr. N. E. Ditman, that the reaction seemed to vary somewhat with the atmospheric conditions; that is, on excessively hot, damp days the reaction in a group of pa- tients was usually more intense than on cool, dry days. This variation is no doubt due to the fact that the condition of the patient was influenced unfavorably by the excessive heat. Perhaps also the question of food and the body metabolism may be concerned. The variation, however, was never very great and any case showing a strong positive reaction, or a negative, continued to give a positive or a negative, the action of the tem- perature not being sufficient to completely sup- press the reaction or to bring it on. An im- portant factor in suppressing the reaction in the urine is due to drugs. As Burghart has shown, some of the tannic compounds, such as tannalbin, tannigen, or even a decoction of uva ursi which contains tannin, are capable of causing a disap- pearance of the reaction from the urine. Creo- sote and creosotal also cause a great diminution in the intensity of the reaction or may even sup-
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HASTINGS: HYPERACIDITY OF URINE.
633
press it, Clemens has also shown that the pres- ence of bile, urobilin, or hydrochinon in the urine, may interfere with the reaction. In such cases he recommends the removal of the pigment by the addition of a few drops of lead acetate solution or a little animal charcoal and then filtering. It is often possible to obtain a reaction by shaking out the acidified urine with ether or ainyl alcohol, neither of which extracts the diazo-substance. The intense yellow reaction which we often meet with in the urine of phthisical patients has been shown by Burghart to be due to phenol which is often present in excess in the urine of the severe cases ana as a rule completely obscures the reaction. The excess of phenol in such urines can be easily demonstrated by adding to a test tube of the urine some strong nitric acid and boiling. After the mixture has cooled some bromine water is added and if a marked turbidity of the urine is produced an excess of phenol compounds may be assumed. This excessive production and excre- tion of phenol compounds is often observed in severe cases of phthisis and often accounts for the frequent absence of the reaction at that time. Cases, however, of excessive phenol excretion have been observed in. which the diazo-reaction could still be easily obtained so that other causes must play some part. One possibility is that the excretion of the diazo substance in the urine takes place irregularly as has been noted in the normal excretion curve of other substances, no- tably urea. As is well known the urea of the body is not excreted constantly, but there may be a slight retention for a day or so and then the surplus will suddenly be got rid of through the kidneys. This may also be true of the diazo substances. As an evidence of this we may note that in the fourteen cases of phthisis which died without a positive reaction having been present, ten had an active chronic nephritis with casts and albumin. The urinary excretion in nephritics is known to be exceedingly ir- regular and retention of metabolic products is often seen extending over considerable periods of time and it is not improbable that the diazo bodies are subject to the same conditions.
The reagents used were those recommended by Ehrlich in the Chante-Annalen in 1886. Two solutions were employed which were mixed at the time of using:
/ Sulfanilic Acid i
Strong Hydrochloric Acid 50
Aq. ad 1000
// Sodium Nitrite -5
Aq 100
Two c.c. of II are added to one hundred c.c. of /. The mixture will keep in good condition for about two days in a cool place. Equal parts of urine and the reagent are mixed in a test tube, and one-seventh or one-eighth part of ammonium hydrate is added. The salmon pink color of the foam obtained after shaking is the essential point in a positive reaction.
If we sum up in concise form the results of this study they will be as follows :
I. If the urine of a case of pulmonary tuber- culosis shows no diazo-reaction and a kidney le- sion can be excluded the prognosis is favorable. Only ten per cent, of the moderately severe cases here recorded gave a reaction and in a number of these the reaction disappeared on treatment. Early cases not ill enough to apply for hospital treatment do not give the diazo-reaction,
II. If the urine of a case of pulmonary tuber- culosis shows an ocasional diazo-reaction the prognosis is not necessarily grave as only some 66 per cent, of the patients showing an occa- sional positive reaction die.
III. If the urine of a case of pulmonary tu- berculosis shows a continuous strong diazo-reac- tion the prognosis is very grave since a large pro- portion of such cases die within six months.
IV. The presence of a diazo-reaction on the first examination of a patient should not debar the case from a thorough trial of climatic treat- ment in a proper sanatorium.
I wish to express my obligation to Dr. Norman E. Ditman, late pathological interne at St. Luke's Hospital, for his valuable assistance in carrying out the reactions and in the preparation of this paper; also to Dr. J. D. Condit and Dr. F. G. Hodgson, who carried out a portion of the tests during their service as pathological internes at St. Luke's Hospital.
BIBLIOGRAPHY.
1. Asada — Inaug. Diss., Erlangen, 1901.
2. Beck — Prognostic Bedeutung d. Diazo bei Phthisikern, Charite Annalen. Bd. 19, 1884.
3. Becker — Miinch. med. Woch., 1900.
4. Burghart — BerL kiin. Woch., 1899; Berl. klin. Woch., 1901, p. 276; Deut. med. Woch., Vereins-Beilage, 1901, p. i9S-
5. Clemens — Deut. Arch. f. klin. Med., 1899, p. 74.
6. Damen — Nederl. Tijdschrift voor Geneeskunde, 1900, p. 1185; Abst. in Cent. f. innere. Med., 1901, p. 181.
7. Ehrlich— Zeit. f. klin. Med., 1882, p. 285; Charite An- nalen, 188^.
8. Konig — Klin, therap. Woch., 1900.
9. Krokiewicz — Wiener klin. Woch., 1898, p. 703.
10. Michaelis — Berl. klin. Woch., 1900.
11. Rutimeyer — Corresp. f. Schweitzer, Aerzte, 1890.
12. Schraeder and Naegelsbach — Munch, med. Woch., 1899, p. 1339-
HYPERACIDITY OF THE URINE.
BY T. W. HASTINGS, M.D.,
OF NEW YORK ; ASSISTANT INSTRUCTOR IN CLINICAL PATHOLOGY, CORNELL UNI- VERSITY MEDICAL COLLEGE.
The recognition of symptoms of disturbance of the genito-urinary tract arising from the acid character of the urine is found in medical books of 20 to 30 years ago^; and recently Brown^ has reported nine cases presenting symptoms of cystitis in which the symptoms could be directly referred to excessive acidity of the urine, this hyperacidity being regarded as probably of neuropathic origin, since all these cases "ex- hibited neurasthenical, neurotic or hysterical manifestations" and the bladder symptoms be- came much worse "under severe mental or ner- vous strain ; and by the result of treatment."
In the writings of 20 years ago, e.g., Gross* Surgery, Vol. II, 1882, p. 704, the acid character
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of the urine is given as one of the causes of incontinence in children, and to-day in some cases afflicted with enuresis, it will be found that excessively acid urine is being" voided, the condi- tion improving or disappearing entirely under treatment directed to correction of the hyper- acidity.
Some books on nervous diseases describe a "lithemic neurasthenia'*; a condition improved by treatment with acid or alkali, the alkali being more often beneficial, in addition to measures to improve the general condition. The acid or alkali was given empirically, no means being known for determining beforehand which would be the better.
Brown's cases correspond to the cases improved by taking alkalies. The determination of the ex- cessive acidity of the freshly voided urine fur- nishes a reason for the administration of alkalies rather than acids in such cases.
Text-books^ on genito-urinary diseases give "over-acid urine" as one of the causes of "neph- ralgia," a term applied loosely to a dull deep ache extending from the back or lumbar region down- ward and forward to the bladder and urethra, and the urine of such cases is described as follows : high specific gravity, deep color, the "alkaline tide" after meals usually absent, a heavy precipita- tion of amorphous urates after cooling and of uric acid a few hours after voiding, and more or less pus present in proportion to the amount of ir- ritation and the duration of the complaint. The precipitation of urates and uric acid should have been considered of little significance, but the ab- sence of the "alkaline tide" and the presence of pus cells, or rather polynuclear leucocytes in varying amount are suggestive of an over-acid urine.
The Normal Acid Reaction of the Urine. — Normally the urine shows a decrease in acidity or a faintly alkaline reaction to litmus a few hours (i to 3), after eating, the decrease varying in in- verse ratio to the amount of acid secreted in the gastric juice and with the nature of the food. Sahli* states that this relation to the gastric juice is such that with a pathological hyperacidity of the gastric juice the urine may show a deposit of or readiness to precipitate phosphate? which is er- roneously looked upon as a "phosphaturia" due to some anomaly of metabolism, while in fact this reduction in acidity and the deposit of phos- phates is a basis with likelihood for the diagnosis of a gastric afifection.
An excess of meat in the diet, in that it fur- nishes much proteid, and the increased destruc- tion of body-proteid in fevers favor a marked acid reaction to the urine, but in the cases of hy- peracidity with symptoms referred to, the diet is rarely found at fault and the patients are afebrile. It is probable that the over-acid reaction depends more often upon the relation of the primary and secondary phosphates in the urine than upon an excess of phosphoric acid derived from the food or from excessive destruction of body-proteid.
The urine does not contain free acid under any
conditions (Neubauer and Vogel, Analyse des Harns, 1898, p. 2).
The normal acid reaction is due to acid salts, principally if not entirely to the primary salt of phosphoric acid (MH2PO4).
Hammarsten^ states that from neutral sub- stances (proteids, etc.) arise within the body acids such as sulphuric and phosphoric and organic acids as hippuric, uric, oxalic, and aro- matic oxy-acids, from which it follows that the acid reaction cannot be dependent upon one acid alone, but the general opinion is that the acidity of the urine of man is due to the primary salt of phosphoric acid.
The degree of acidity does not, however, de- pend alone upon the amount of primary salt present, but also upon the relation between the primary and secondary salts (MHjPO^ and M.HPOJ.
In normal urine the primary salt may vary from 34.9 per cent, to 74.2 per cent, of the total phosphates, and when 34.9 per cent, or under the reaction is amphoteric to litmus in all other cases acid.® Of the total phosphoric acid in 24 hours about 0.6 is in the form of the primary salt and 0.4 in the form of the secondary salt.'^ Amphoteric reaction to litmus is obtained when the solution contains 0.3 to 0.5 of the primary salt and 0.7 to 0.5 of the secondary salt.^ The primary salt is acid and the secondary salt alkaline against lit- mus, and both may be present in solution in the proportions last mentioned without the one interfering with the reaction of the other to lit- mus, thus explaining the amphoteric reaction.
Estimation of Acidity. — The old idea, still prevalent, that excessive acidity is indicated by the precipitation of uric acid and oxalic acid is without good foundation. In certain febrile con- ditions and in concentrated normal urine, the urates and uric acid are often quickly precipi- tated causing at first a diffuse cloudiness and later, after standing a few hours, a sediment. The acidity of such a urine may or may not be increased ; and, further, the precipitation of these substances does not necessarily mean an increase in the excretion of these substances, for their precipitation probably depends upon the relations between and interaction among the urates and phosphates, rather than upon the amount of uric acid present.^
Although many over-acid urines contain crys- tals of oxalate of lime this is no indication of de- gree of acidity nor is it an index of the amount of oxalic acid present, for such crystals "are found with every degree of acidity from highly acid to alkaline; with every degree of specific gravity and with every color" (Baldwin^**).
The precise method for estimation of the acid- ity is that for the estimation of the primary salt of phosphoric acid (Hammarsten^^). Of the simpler methods, the reaction to litmus paper gives no idea of the degree of acidity and in the titration of phosphates litmus gives no sharp color change.
Neumeister's^^ modification of Maly's method
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HASTINGS : HYPERACIDITY OF URINE.
635
is unreliable, according to Nageli". Blumenthal" recommends it. The best method to employ is that recommended by Nageli^°, similar to the method used to determine the total acidity of the gastric contents, using phenolphthalein as an in- dicator and titrating with a decinormal solution of sodium hydroxide (j^^ NaOH).
This method gives roughly the excess of acid- equivalents over the base-equivalents, but is no in- dex of the basic-capacity of the urine, for only as much alkali-equivalent is added as is already contained in the phosphates corresponding to the primary salt (MH2PO4) which enters into the re- action.
Those acids which are excreted in the form of neutral salts (as NaCl) or in the form of salts re- acting alkaline to phenolphthalein (as secondary phosphates, M2HPO4) are not included in the acidity (Sahli^^).
Haig^" found the average acidity of the 24 hours' urine in health equivalent to 5.5 gm. of oxalic acid or 3.5 gm. of sodium hydroxide. Ham- marsten^* gives the acidity equivalents for 24 hours as 2 to 4 gm. of oxalic acid or 1.3 to 2.39 of hydrochloric acid. Haig's equivalent of 3.5 gm. of sodium hydroxide in terms of hydrochloric acid is 2.44 gm., so that both of Haig's equiva- lents are higher than those of Hammarsten.
Brown found that normal urine immediately after withdrawal from the bladder was neutral- ized by 2.5 c.c. of decinormal sodium hydroxide solution for 10 c.c. of urine, or 25 c.c. for 100 c.c.
Provided these patients were passing the aver- age 1,500 c.c. of urine in 24 hours the equivalents in terms of oxalic acid and hydrochloric acid are considerably below Haig's, but within the lower limits of Hammersten.
Among dispensary patients of various sorts with normal urines we have found the average degree of acidity to be 3.1 c.c. of deci- noimal sodium hydroxide solution in 10 c.c. of urine, equivalent to 2.4 gm. of sodium hydroxide in 24 hours, or a little over a fourth less than Haig's figure. In the normal urines of healthy persons the variation has been from 1.5 to 4.5 c.c. of decinormal hydroxide solution.
In estimating the hyperacidity, urine not over a few hours old should be used, if albumin is present it should be removed, and, if dark in color the same should be diluted to prevent interfer- ence with the sharpness of the change in color of the phenolphthalein. To 10 c.c. of urine add a few drops of an alcoholic solution of phenol- phthalein (o.i per cent, in 50 per cent, alcohol), and titrate with decinormal sodium hydroxide so- lution to a well-marked red color. The precise tint depends of course upon the tint for which the decinormal solution has been standardized. The period of the day iii which the urine is taken matters but little, since a urine which is suffi- ciently acid to produce symptoms does not show the marked reduction in acidity or alkalinity seen in a normal urine after meals.
A hyperacid urine shows a marked acidity throughout the 24 hours. After standing a few
hours the normal decrease in acidity may inter- fere with the estimation in a urine slightly above normal, but an overacid urine which is the cause of symptoms will often give an acidity 3 to 5 times above normal 10 to 24 hours after voiding.
The so-called "acid fermentation" will not in- terfere with the estimation, for the urine prob- ably never undergoes such a fermentation in that the change in color and the deposit of crystals of uric acid and oxalate of lime are unaccom- panied by an increase in acidity, as noted by Roech^» in 1874.
Roech stated that the acidity of the urine gradually decreased from the moment of voiding and that a deposit of urates and uric acid did not mean an increase in acidity but was due to con- centration, in over 20 urines followed from day to day.
Urine which shows a faintly alkaline reaction to litmus will sometimes show a slight degree of acidity with phenolphthalein. Such a urine will usually be found to be amphoteric to litmus.
Note. — Solutions of ammonium carbonate (e.g., in the urine) react alkaline to litmus and produce no change (to a red color) with phenol- phthalein, thus accounting for a urine alkaline to litmus and at the same time showing a certain degree of acidity when titrated with ^^ NaOH solution with phenolphthalein as an indicator.
Cases of Hyperacidity with Symptoms. — Brown^" designated the normal acidity 10 (= 2.5 c.c. yV NaOH for 10 c.c. urine) for convenience, and his cases showed degrees of acidity varying from at least twice above normal, to nearly five times normal. A degree of acidity equivalent to
4 c.c. is often found without symptoms, but as <n Brown's cases urine above 5 or 6 c.c. often pro- duces symptoms in the genito-urinary tract, such as burning on micturition, frequent micturition, enuresis, and symptoms of cystitis in neurotic individuals particularly.
Among 100 cases, 40 presenting symptoms of disturbance of micturition in the course of some affection were tested in regard to acidity of the urine and 30 of this number were normal. These 30 cases included acute articular rheu- matism 2, acute muscular rheumatism i, chronic interstitial nephritis 18, chronic cystitis and ure- thritis 2, alcoholic hepatic cirrhosis i, carcinoma of rectum with marked secondary anemia i, me- dian palsy I, hemiplegia 3, and facial neuralgia i.
Ten cases including acute articular rheumatism 3, chronic interstitial nephritis 6, and chronic valvular cardiac disease i , gave an acidity varying from 6 to 14 c.c, and the disturbance of micturi- tion was no greater than in the 30 negative cases.
In 19 cases of urethral and cystic disturbances with symptoms suggesting inflammation of these parts no other causes than a neurotic individual and an increased degree of urinary acidity (from
5 c.c. to 15 c.c. of decinormal alkali solution) were found to account for these symptoms, which disappeared under attention to the general condi- tion and the taking of alkalies (sodium bicar-
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LAMBERT: ALBUMIN IN THE URINE.
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bonate or potassium citrate) without local treat- ment.
Three of these cases had apparently recovered from recent attacks of urethritis.
As stated by older writers, hyperacidity of the urine is found to be the cause of some cases of enuresis and the condition is improved or cured by the administration of alkalies or of strychnine. In 10 of these cases the degree of acidity varied from 5 c.c. to 1 1 c.c. of decinormal alkali solution and in 10 similar cases the acidity of the urine was normal.
The simple treatment with alkalies causing dis- appearance of the symptoms in these over-acid cases upholds the view that hyperacidity alone is at times the cause of the condition, but the cause of the hyperacidity is not so readily determined, in .that the dietary in these cases seems to have been normal, the average amount of exercise taken, and the general health excellent. No in- quiries were made in regard to the use of "pre- served foods" which might contain boric or ben- zoic acids or borax.
From the experiments of Tunnicliflfe and Rosenheim^^ we learn that the taking of boric acid does not increase the acidity of the urine, though we find statements to the contrary, while borax may increase it but slightly.
The third set of cases includes 21 diagnosed as neurasthenia after thorough clinical and labo- ratory examinations, these patients referring to some disturbance of micturition, among the nu- merous complaints in regard to disturbances in various parts of the body.
The only abnormal change in the urines of 14 of these cases was an increase in acidity, from 5.5 c.c. to 12 c.c. of decinormal alkali solution, corrected by a more persistent giving of alkalies than required by the cases of enuresis and of genito-urinary disturbance without the marked stigmata of neurasthenia.
The seven remaining cases showed normal degrees of acidity, suggesting that hyperacidity in such cases may be of neuropathic origin, as suggested by Brown, thus accounting in part for the necessity of persistent administration of alka- lies in addition to treatment of the general con- dition.
Some of the urines from the above cases quickly deposited urates, uric acid and oxalate of lime, these deposits being in no way related to the degree of acidity. Of the 47 negative cases with an acidity below 5 c.c. of decinormal alkali solution II (23.4 per cent.) with an acidity from I c.c. to 4.5 c.c. deposited urates, uric acid, or oxalate of lime soon after voiding. Of the 53 positive cases with degrees of acidity from 5 c.c. to 15 c.c. of decinormal alkali solution 15 (28.3 per cent.) deposited urates, uric acid, or oxalate of lime, and 38 cases, one with an acidity as high as 15 c.c, showed no deposit after standing twenty-four hours.
In three urines (acidity 8 c.c.) the primarv (MH2PO4) and secondary (MgHPOJ phos- phates were respectively 0.7 and 0.3 of the total,
while the total phosphates were low, 1.5 gm. to 181 gm. in 24 hours.
The number of cases referred to is insufficient to give a definite idea of the frequency of occur- rence of such cases, but some of them serve to add to the value of Brown's reported nine cases, and to suggest a simple and reasonable method of treatment for some cases of frequent micturi- tion and nocturnal incontinence.
BIBLIOGRAPHY.
1. Hoffman and Ultzmann — Untersuchung des Harnes, 1878, p. 26.
2. Brown — Johns Hopkins Hospital Reports. Vol. X, 1901, PP- 38,^39-
3. Keyes — Genito-urinary Diseases, 1888, p. 322.
4. Sahli — Untersuchungsmethoden, 1902, p. 471.
5. Hammarsten — Physiologische Chemie, 1899, p. 417.
6. Neubauer u. Vogel — Analyse des Harnes, 1898, p Ref. 7.
7. Neubauer u. Vogel — Analyse des Harnes, i Ref. 4.
8. Neubauer u. Vogel — Analyse des Harnes, 1898
9. Neubauer u. Vogel — Analyse des Harnes, i8( 624.
10. Baldwin — Journal Experimental Medicine, Vol. V, No. i, P- 33-
11. Hammarsten — Physiologischen Chemie, 1899, pp.418 ;479.
12. Neumeister — Lehrbuch der physiologischen Chemie, 1895, II, pp. 225-226.
13. Sahli — Untersuchungsmethoden, 1902, p. 550.
14. Blumenthal — Pathologic des Harnes, 1903, p. 6.
15. Sahli — Untersuchungsmethoden, 1902, p. 547.
16. Sahli — Untersuchungsmethoden, 1902, pp. 548-549.
17. Sahli — Untersuchungsmethoden, 1902, p. 550.
18. Hammarsten — Physiologischen Chemie, 1899, p. 419.
19. Reoch — Lancet, 1874, vol. ii, p. 549.
20. Brown — Loc. cit.
21. Tunnicliffe and Rosenheim — Journal of Hygiene. Vol. I, No. I, p. 168.
23.
P- 23,
p. 29. !, pp. 623-
THE PROGNOSTIC SIGNIFICANCE OF ALBUMIN IN THE URINE.
BY EDWARD W. LAMBERT, M.D.,
OF NEW YORK.
Is IT possible to make a dififerential prognosis when albumin is found in persons apparently healthy ?
Injudicious living is the cause of most of the bodily ills from which we suffer, and is also that which induces unduly early degeneration in the majority of cases met with by medical men. In- judicious living I mean to be taken in the broad- est sense. It includes the excessive wear and tear of an active business life, the nervous strain and worry necessary in the mad rush to become rich; the incessant drain upon one's vitality by the daily excesses in eating, the abuse of alcohol and tobacco, and the excesses common to those who have never learned the art of self-control. In such cases, sooner or later, largely dependent upon the inborn vitality of the individual, occur changes in the minute tissues of the bodily organs. The organ which ordinarily gives the first hint of this commencing degeneration is the kidney. It would be a waste of time to describe either its minute anatomy or functions. We all know it is the most important excretory organ, and that perfect peace reigns when its functions are normal. One of the first symptoms the kid- ney gives that something has gone wrong in the complex mechanism and functions of the body is the passing of albumin with the urine, more or less abundantly. In my judgment no healthy individual has this substance in the urine,
April 4, 1903]
LAMBERT: ALBUMIN IN THE URINE.
(^37
and its presence is a sure indication that some- thing is out of gear somewhere in the functions of the body. On finding this albumin must we infer that the individual is doomed to an unduly early death or that he necessarily has an or- ganic disease? By no manner of means, as the kidney is so sensitive to temporary disorders, so sure to carry off every abnormal product found in the blood, that it often suffers from temporary disability, quickly rallying when the offending substance has been eliminated. Again, when sudden excessive heat or cold prevails, and the nerve centers are temporarily depressed, the kidney feels the lack of its proper nerve supply, allows albumin to pass through, coming back to its normal function without pennanent damage as soon as the excessive temperature ceases. It is not necessary to consider the many causes of al- buminuria, known and suspected, because their name is legion, and you know well enough that most causes are temporary in character, doing no apparent injury unless the cause is continued long enough or is frequent enough to start tissue changes in the structure of the kidney and pro- ducing in time a fatal termination.
With this introduction this paper has been written from the point of view of a life insurance examiner, to see if any information can be given by which one can judge in any given case whether the albuminuria is due to temporary con- ditions or is the beginning of a degeneration of the kidney tissues, necessarily fatal. In other words, is it possible to differentiate in regard to prognosis in apparently healthy persons between temporary albuminuria and that which means such tissue changes as must necessarily seriously interfere with the expected longevity of the in- dividual ? Please remember that an applicant for life insurance is not knocking at our door for treatment. He presents himself as a presumably healthy person. He is surprised, annoyed, often angered, sometimes frightened, when informed that anything is wrong. The medical man is abused, called a crank, narrow-minded and a fool, with strong adjectives prefixed to the fool. If a rejected man happens to live ten years the case is quoted, brought up as illustrating the absurd rul- ings of the doctor, the accuser forgetting the many apparently similar cases which have proved fatal in the meantime. Our learned Professor Osier wrote a very interesting article in 1901, showing how some men having been rejected by prominent life insurance companies were still liv- ing and in good health after many years, and em- phasizing the importance of basing a judgment less on the urine than on the general condition of the applicant. Then he goes on to show very clearly that men living a most injudicious life are rejected, but being disturbed by the rejection con- sult their family physician, receive most excellent advice and live many years in excellent health. This is a good criticism, but the Professor must remember that the men did not change their in- judicious living until the life insurance doctor had refused them, and their wise decision fol-
lowed the rejection. The medical examiner can- not assume that any man having lived a reckless life for thirty or forty years is going to suddenly change to a sober, temperate one. Unfortunate- ly, my personal experience has been that men of forty, fifty or sixty years, who have never exer- cised self-control in regard to their animal de- sires, do not change suddenly and become models of virtue. They may be frightened for a short time, try reformation, but the tendency is to re- turn to their former habits. The Professor ends his article with this true statement : "That a trace of albumin and a few tube casts are danger sig- nals, the red lights of danger, which may mean an open drawbridge or a wrecked road-bed ahead, and may be simple warnings for the engineer to go slow."
I can best illustrate my opinion on this subject by giving a few leaves from my experience dur- ing the past forty years.
From 1868, when I began regularly to test for albumin, until 1888, during which time I was daily engaged in making personal examinations, persons declined for albuminuria died within twelve months after their rejection, saving in losses to the company each year sufficient to pay the entire expenses of the medical department in New York City.
Let us look at the different varieties of albu- minuria. First the so-called physiological albu- minuria. Two partners came in for examina- tion, both hearty, fine-looking specimens of physi- cal vigor. Albumin was the only blemish in either case. Number one had such a faint trace that after repeated tests Dr. Edward Curtis and I thought it must be a case of the much-talked-of physiological albuminuria. The man died in eighteen months of Bright's disease. Case num- ber two had excessive albuminuria, was rejected, but lived many years until I lost track of him. Our faith in this kind of albuminuria was badly shaken.
Secondly, let us consider the so-called cyclic or intermittent albuminuria. That such a condition is quite common is beyond dispute. A gentle- man whom I had accepted a few years before came into the office one afternoon to take the largest policy the company then issued. He was a personal friend and a fine specimen of a healthy man. To my disgust and his very great annoy- ance I found distinct traces of albumin. He went uptown to see his family physician and was told to bring a morning specimen for examina- tion. Nothing was found and on his way to his office he came to see me about 11 o'clock, and I could find nothing abnormal. At my request he called again about 3 P.M., with the result of albumin being distinctly present. I watched him for weeks and could always find albumin after 12 noon, but never before that hour. The man was taken by other companies and I was severely criticized. I received a long scientific explanation from an uptown expert that there was no kidney disease. The man died five years later of serous apoplexy due to disease of the
638
MATTISON : NARCOTIC ABUSE.
[Medical News
kidney, the death certificate being signed by my learned uptown expert, who stated in his death certificate that the disease had lasted to his knowledge five years. On the other hand, many have come before me presenting albumin in the urine so evidently due to temporary causes that a favorable judgment was given, the parties liv- ing many years in the best of health. Tests made at our office upon members of the medical staff show that few men pass six months without occa- sionally having albumin and tube casts in their urine. Cases can be given in abundance illus- trating the dangers of albuminuria, but enough has been said to demonstrate the difficulties pre- sented to the medical examiner when called upon to make a differential prognosis in albuminuria. The amount of albumin found gives no necessary evidence of possible future danger.
Thirdly, let us take up the albumin of adoles- cence occurring in young persons between the ages of seventeen and thirty. These cases cause less worry to the medical men, as most are tem- porary and the prognosis is good. The physical condition and the mode of daily life are more important factors in young subjects than the al- buminuria.
In the past few years we have brought the microscope to aid us in forming a prognosis, with the result that it is confusion worse confounded. Hyaline casts abound, granular casts are not in- frequent in urine free from albumin. The older the individual the more frequently do we find the various kinds of tube casts. In young subjects of both sexes having albuminous urine, the mi- croscope often shows hyaloid bodies, usually club shaped at one end and tapering at the other, striated, somewhat larger than a tube cast, which have attached to their larger extremity a cluster of highly refractive, mononuclear, epithelial cells, about twice the size of a leucocyte. These cells, as a rule, show no granulation of the protoplasm. They are usually joined together at their smaller extremities, thus radiating from a common cen- ter. The albumin in these cases is usually transient, often disappearing in twenty-four hours. Ninety per cent, of these cases are thirty years and under, and it is extremely rare to find them in persons over forty.
What is the practical result to be drawn from this condition of the kidneys, and what is the prognosis in each case? The amount of the albumin gives no indication of the future result.
The presence of tube casts of any variety, does not necessarily mean permanently diseased kid- neys, as the casts are found too often in persons otherwise healthy. The most important factor, and one too often neglected, is the daily manner of the life of any individual. The worry neces- sary to the carrying out of large financial schemes, the habit of having too many financial operations going on at the same time, the excessive use of food highly seasoned, of great variety and con- taining too much nitrogen; the abuse of alcohol and tobacco, the excessive yielding to the other animal appetites, give as a natural sequence the
loss of nature's best restorer, sleep. From my ex- perience and point of view it would seem that the prognosis depends more upon the daily mode of life than upon the findings in the urine.
NARCOTIC ABUSE AND THE PUBLIC WEAL,*
BY J. B. MATTISON^ M.D.^
OF BROOKLYN; MEDICAL DIRECTOR, BROOKLYN HOME FOR NARCOTIC INEBRIATES.
Twenty-six years ago, in a paper, "The Im- pending Danger," Medical Record, 1876, atten- tion was called to a situation that seemed to me ominous — weighted with peril to the public weal — in that the use of morphine had become so gen- eral that it involved the risk of this nation be- coming largely one of opium inebriates, A dec- ade later, an added risk obtained in the coming of cocaine — a drug wonderfully rich in its power for good, in some conditions, when rightly used; but with a destructive energy all its own — one unique and appalling, that may well be called dia- bolic, and with which no other agent for ill, save one, can compare.
During the twenty years following the publi- cation of that paper, the high-water mark of this narcotic abuse, so fraught with danger, was reached — in my opinion — and since then there has been a steady decrease in the use of these drugs among medical men, so that a present sur- vey makes me largely optimistic, and hopeful that in the near future, we shall note still larger decline. Why this faith within me need not detain us now. Despite adverse thinking o( some, reasons good and sufficient make me think narcotic inebriety in America on the wane, and that we have come out of a condition that was critical as to the public good, because it threatened an untold number with more of sorrow — ^mind and body — than the world would ever know.
But while felicitating ourselves on escape from that peril, there is still cause for concern in that we are menaced by a danger, less open — but none the less real — because its fell work is done by those with whom private gain is above public good, and among those who, quite unaware of the risk lurking in these so-called, but often specious, h;elps to good health, find them- selves, early or late, in the grip of a poisonous power they are helpless to resist.
The drift of my paper you, at once, appreciate. It is solely toward the danger involved in the law- less sale — lawless because not safe-guarded by law — of the many nostrums in which morphine and cocaine play the largest part for harm. As a nation largely neurotic — both ancestral and acquired — we offer an inviting field to venders of such wares, who ply their trade with a vigor worthy a better cause, and with result of which we must make note if we would conserve the best interest of many whose well-being is given to our care. It goes without saying that the larger,
• Read before the American Association for the'Cure of Inebriety, Boston, Dec. i8, 1902.
April 4, 1903]
PARK AND PAYNE: FORMALIN INJECTIONS.
639
by far, number of the many nostrums — nervines, anti-neuralgic pills, powders, tablets and liq- uids— so much heralded and lauded for relief of pain and nervous unrest, have morphine as their active part. And this "part," in some is not small. In one, largely advertised, there is one-eighth gr. in each teaspoonful. The risk of morphinism, in certain persons, from that amount, is large ; in fact, a smaller, in a highly nervous patient, on whom it acts kindly, will create the disease. A ten years' case of morphinism, under my care, seven years ago, had its rise in a one-sixteenth gr. daily dose.
Even larger risk of inebriety obtains in using the various nostrums containing cocaine, so much lauded for the relief of coryza and other nasal ills In the form of catarrh snuffs and solutions, its power for harm is far greater than when taken by mouth; in fact it ranks almost — or quite — with its subdermic effect, by virtue of the highly ab- sorptive nasal mucous membrane, and its nearness to the brain, making its seductive power and ill effect on mental health specially prompt and per- nicious. One of these nostrums contains 1% per cent, cocaine — two per cent, is the strength often used for anesthesia — and any "cure" having that amount is dangerous. Insanity is certain, if its use be continued.
Case after case of cocainism, the genesis of which was its use by a rhinologist, has been un- der my care. One of the most notable — and quite unique — was during the last summer; a New England physician, who, three years ago, used it for acute coryza. It snared him, and he continued it, changing from nose to mouth, never swallowing, but holding till he felt its ef- fect, and taking it, hourly, to extent of 24 grs. daily, till demented. The wrecks sequeling this and the more common subdermic using — the lat- ter, mainly, among our own confreres, but now, happily, on the wane — make a sad chapter in the gruesome story of narcotic abuse during the last 15 years.
Such the situation. What the need ? This :
An act, making it illegal to sell morphine or co- caine except per prescription, and the prescrip- tion not to be refilled, save by order of attending physician.
A law compelling the maker of every nostrum to print the formula on wrapper, and those con- taining morphine or cocaine, the amount of the drug in each dose. America is behind the times as to what could and should be done to avert this ill. The American Association for the Cure of Inebriety can, and, it is to be hoped, will, make earnest effort along this line, and so, effectively safeguard one phase of the public weal.
Canadian Doctors Cannot Practise in South Africa. — Three Canadian doctors, two from Ontario and one from McGill, who went to South Africa with the Canadian army mddical corps, tried at the conclusion of the war to practise in the Transvaal colony. As only English diplomas were allowed there, they were prohibited from continuing, and even on appeal to Lord Milner, without success.
THE RESULTS OF INTRAVENOUS INJECTIONS OF
DILUTE FORMALIN SOLUTION IN
SEPTICEMIC RABBITS.*
BY WM. H. PARK, M.D., AND WM. A. PAYNE, M.D.,
OF NEW YORK.
This work was undertaken at the Research Laboratory, Department of Health, after the re- port by Dr. Barrows of a case of streptococcus septicemia in which recovery had followed the in- jection of formalin solution. In all of our experi- ments, first the culture, then afterward the forma- lin solution were injected intravenously. Healthy unused rabbits were employed; and controls were always made. In order to roughly determine the effect of intravenous injections of formalin in rabbits, we injected a number of rab- bits with varying dilutions and amounts. We found one c.c. of pure formalin to be immediately fatal ; five c.c. of a one-tenth solution to produce alarming convulsions, later anemia, paralysis and death ; ten c.c. of a one one-hundredth dilution to produce slight temporary disturbances with fol- lowing anemia. Ten c.c, twenty c.c, thirty c.c, and fifty c.c. of a one five-thousandth solution produced no apparent immediate disturbance, but one hundred c.c. caused abortion in a pregnant rabbit a few hours afterward. This may have been due, not to the formaldehyde, but to the large amount of fluid injected. One rabbit died during the inoculation of fifty c.c. of this same dilution. As far as immediate danger is con- cerned, ten c.c. of a one one-hundredth dilution seems to be within the bounds of safety for a full-grown rabbit. Ten c.c. of a one two-hun- dredth dilution given a young rabbit was followed by a pronounced edema of both ears. Rabbits re- ceiving large amounts of formalin showed after two to three weeks emaciation and pronounced anemia.
The quantity of formalin which could safely be given having been determined we injected a number of rabbits intrayenously with from one to ten c.c. of an ascitic broth culture of two strains of slightly virulent streptococci recently obtained from human blood, an amount sufficient to kill probably in from one to four days. Of each set of rabbits a certain proportion after inoculation received intravenous injection of formalin solu- tin. About half of the rabbits injected are pre- sented on the following table. The results in the others were similar. One rabbit which received one hundred c.c. of a one five-thousandth solu- tion of formalin, twenty-four hours before the streptococcus, lived considerably longer than the controls.
The slight virulence of the streptococci in the above series of experiments hampered us in de- ducting conclusions as to the amount of protec- tion which would be afforded in case fewer but more virulent streptococci had been employed; but these experiments certainly demonstrate that after even large doses of formalin the strep- tococci can still increase in the blood and
* Read before the New York Pathological Society, Feb. ii, 1903.
640
HOWARD : EXPERT EVIDENCE.
[Medical News
cause death through' septicemia. All the rab- bits receiving formalin after the streptococcus died before those receiving the streptococcus alone. In the other table we show another series of rabbits which were injected with a virulent culture of pneumococcus sent to us by Dr. Wads- worth. Here, as before, with the streptococci, the formalin failed to give the least protection. Table II gives the results in eight rabbits, four of which received the formalin dilutions after the pneumococci.
Table I. — Showing results of intravenous in- jection of dilute formalin solution in rabbits, one to two hours after infection with streptococci from cultures A and B.
RABBIT EXPERI- MENT NUMBER
AMOUNT OF CULTURE I^JECTED
10 C. C. A 10 C. C. A
10 c. c. A 10 c. c. B 10 c. c. B 10 c. c. B
AMOUNT OF FORMALIN INJECTED
DURA- TION
SO c. c. 1-5,000 sol. iShours Control ; no formalin 22 hours Control; no formalin 24 hours
10 c. c, 1-200 sol.
6 days
10 c. c. normal salt 15 days solution I
Control
10 days
SMEARS AND CULTURES AT
DEATH
SHOWED IN
BLOOD
Abundant streptococci
Abundant streptococci
Abundant streptococci
Abundant streptococci
Abundant streptococci
Abundant streptococci
Table II. — Showing results of intravenous in- jections of formalin solution in rabbits within one hour after the injection of a surely fatal dose of a virulent pneumococcus. A got pneumococci alone; B got pneumococci and later formalin solution.
RABBIT EXPERIMENT
AND AMOUNT OF CULTURE USED
I c. c. I c. c. S c. c. S c. c. S c. c. 5 c. c. I c. c. I c. c.
AMOUNT AND
DILUTION OF
FORMALIN
USED
None S c. c, i-ioo
None* S c. c, i-ioo
None IS c. c, i-ioo
None 10 c. c, i-iooo
TIME OF FORM. INJ.
I hour after
Immediate
I hour after
30 mins.
after .
|
DURA- |
|
TION |
|
OF |
|
LIFE |
|
I day |
|
I day |
|
3 days |
|
2 days |
|
4 days |
|
2 days |
|
3 days |
|
2 days |
OS g
/ ^':
* Received s c. c. of normal salt solution.
From the tables it is seen that the injections of formalin were given in some cases equal to and in others far beyond the comparable dose advised by Barrows in man, and yet these rabbits died uniformly before the controls. Although these experiments are limited in number, yet they are so uniform in their outcome, that it seems fair to assume that non-lethal formalin injections can-
not stop a septicemia already started in healthy animals. The results of Fortesque and Bricks- dale, published just as we were finishing these tests, agree in every point with ours. They used anthrax bacilli and streptococci. (Lancet, Janu- ary 10, 1903).
During these experiments streptococci have been obtained, either by Dr. Wilson or Dr. Poor, from the blood of four cases of streptococcus sep- ticemia in man. Each of these cases received two or more intravenous injections of from 500 to 750 c.c. of a one five-thousandth solution of formalin. Streptococci were found in the blood of two of the cases the day after the formalin injection. In the other two cases no cultures were made. All four died. Their deaths took place in from five days to three weeks after the injection of formalin so- lution. In the blood of these cases the strepto- cocci were present to the extent of 4 to 25 per c.c. and were thereafter probably more abundant than in the Barrows case where, according to the report from the Cornell Laboratory, a growth of streptococci occurred in only one of the three lots of broth inoculated with the patient's blood.
The experiments reported here and elsewhere, and the fatal outcome of septicemia in man after diluted formalin injections should cause us to be guarded in using formalin, and make it necessary to weigh each case injected not only to determine when improvement ensues whether recovery has been promoted, but also when death occurs as to whether harm has been done. An intravenous injection of water plus sodium chloride may prove better than water plus formalin.
EXPERT EVIDENCE: A REPLY TO HON. JOHN WOODWARD.*
BY WILLIAM LEE HOWARD, M.D.,
OF BALTIMORE, MD.
Justice Woodward's criticism of expert testi- mony,* his statement: "So notorious is it (the abuse of expert testimony) becoming that, if it is not checked, it seems to me a reaction must in- evitably come that will abolish such testimony altogether," contains so much truth from the legal side, and so few facts from the medical side, that it calls for a reply from the physician.
The low estimate in which the medical expert is held, the disrepute into which he has fallen, and the seemingly commercial basis on which he is placed, is partly due to the members of the Bar. My profession is by no means guiltless of assistance in bringing about this deplorable state, but has, by its indifference, or through its lack of a national educational standard, allowed individ- uals to pose in courts as representatives of prog- ressive medicine, when in reality, many have been those who seek the notoriety and emoluments ac- companying such temporary false standing. But as I shall show further on, the legal profession can do much to rectify the present status of the
* Expert Evidence, by Hon. John Woodward, Justice of the Ap pellate Division of the Supreme Court of New York.— North Ameri- can Review, October, 1902.
April 4, 1903]
HOWARD: EXPERT EVIDENCE.
641
medical expert, and look to it that honorable men are treated honorably. When this occurs ex- perts can be found who will be respected and be- lieved, justice aided, and forensic medicine again takes its place as one of the highest offices for the protection of honor and life. Let the lawyer once understand that medical men do not always recognize the maxim : "Justitia non novit pair em, nee matrcm, solum veritatem speetat justitia," and that the reputable physician cannot at all times and under all circumstances subscribe to the legal principle : ''Lex non fovet votis delica- toriim," and he will gain an insight to the reason for the difference between the working of the medical and legal mind.
There is a feeling among medical men that the legal mind is not always in sympathy with the fine and delicate problems presented to the physi- cian in the sick chamber and on -the witness stand. The lawyer often demands facts which the medi- cal man considers sacred secrets, and it is fre- quently the bullyragging — which unfortunately in some cases the Bench allows — that the medical witness is subjected to, that makes him an un- satisfactory and unwilling witness. He is often accused of witholding evidence and clogging the wheels of justice, when in fact, he is endeavor- ing to be faithful to his trusts — his patients. In ethical matters the physician and lawyer speak two languages.
In some respects the legal opinions governing the practice of medicine in the United States do not differ from those of the time of Henry VIII, for up to that period the common law of Eng- land did not recognize the inability of the pub- lic to discriminate between the qualified and un- qualified practitioner of medicine. Practically this is true of the United States so far as allowing a jury composed of men of varied education and diverse environmental conditions to pass upon the statements of opinion of the medical expert. That is, these twelve men of dubious scientific knowledge are to judge between the value of the opinions of a man whose alma mater is a public school and whose diploma as a doctor of medicine was granted after a two years' course of seven months each, and that of a man who has spent a life of study and preparation in school, at col- lege, and the university. Legally — thanks to the bewildering statutory laws — both have an equal standing in court and each may hold the impres- sive title of professor. A recognized national standard of medical education and a Minister of Medicine in the Presidential cabinet are absolute- ly necessary in order to clear up this chaotic con- dition. "In the United States the legislation of each state has authority to prescribe qualifications which must be possessed by those practising medi- cine and surgery within its borders and it may be said without exception that the legislation of each state has exercised this right to a more or less degree." — Taylor. •
There is at present great effort being made by n^edical men to force a standard for medical edu- cation, and considerable progress^fes been made
along this line, although there still exists a tend- ency among a certain class of medical colleges to evade this standard by resort to technical methods and tricks known to the unscrupulous. It is un- necessary here to bore the reader with the worn out platitudes of the honesty of both professions, but we must face facts which are well recognized by physicians, although seldom given publicity through fear of offending the innocent.
Prof. R. A. Witthaus justly declares that one of the reasons expert witnesses are in bad repute, is : "The employment of blatant, ignorant per- sons, or even persons who do not hesitate at plain perjury." Such will always be the case until the unscrupulous and uneducated men are driven out of the profession. This can only be accomplished by having a national standard of education. This standard must be high. The candidate for the medical college must be one who has mentally and morally been tested by years of preparatory study — not a two years' course, and then receive a baccalaureate degree. This is the only remedy on the medical side for the disgraceful status of the medical witness to-day, a condition which indirectly is a stigma on the profession of medi- cine.
The American INIedical Association is constant- ly endeavoring to bring about a satisfactory standard of medical education, forcing those medical schools which have no excuse for exist- ence save a commercial one, to adopt a standard of education for entrance, and to make compul- sory a four years' course. Progress has been made along this line, and the last five years have shown a marked improvement in the education and personnel of the medical student. It is often forgotten by the average juror that the moral make-up of the expert has as much to do with the value of his testimony as his technical knowl- edge, and it is this mental attitude of the juror that has thrown a pall of distrust around all medical experts, and which has made it difficult • to get men of honor and self respect to go on the witness stand ; many of the large hospitals and real universities having an unwritten law to the effect that physicians connected with the same shall not be employed by lawyers seeking medical testimony in damage cases. This state of affairs is caused by the number of unscrupu- lous lawyers — ambulance chasing solicitors — that swarm around the courts of every city like struggling gnats. It is the purely commercial spirit that governs these shysters which makes them a menace to justice, a drag on the legitimate business of the courts, and is certain to cast a ray of suspicion upon the physicians they employ as experts. If the cDurts do not take cognizance of these persons, the physician will. Already too many have suffered innocently from these legal parasites.
In many States the candidate for the practice of medicine must exhibit a diploma from a recog- nized college having a three years' or four years' course before he can be licensed by a State board of examiners. In some States he is not required
642
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to have a diploma from a medical college, but only to pass an examination by a State board. "In some States it is provided that he shall never have been convicted of a felony," — Taylor. It has been decided — People vs. Rice — that an un- licensed physician may testify as a medical ex- pert, yet the law^s of the State of New York make it a misdemeanor to practice without a license. The New York Court of Appeals in passing upon the question of the non-licensed expert, used the following language, Chief Judge Alton B. Parker writing the opinions : "After a careful consideration of the subject we have reached the conclusion, that if a man be in reality an expert upon any given subject belonging to the domain of medicine, his opinion may be re- ceived by the Court, although he has not a license to practise medicine." Justice Woodward in his article has this to say : "An expert is a specialist, the value of whose evidence given in the form of opinion, is proportioned to his character, to his reputation for honesty in the community, and to his standing in his specialty or profession." — Page 488.
According to the legal citations above, an os- teopath with a large following could give satis- factory evidence of having all the qualifications demanded by Judge Alton B. Parker, while a "natural bone setter" without legal authority to practice medicine, possesses all the knowledge necessary to contradict the opinions of an honor- able professor of anatomy in one of our large universities, and furthermore, there can be found members of the Bar who will gleefully assert this fact in court. Again, thousands of men and women can be found who will claim that Mrs. Eddy's knowledge of diseases places her as an expert far above any regular physician, and that she more than fulfils Justice Woodward's de- mands in her "reputation for honesty in the com- munity" and to her "standing in" her "specialty or profession."
It would be surplusage to parallel further, but it is on account of this uncertainty of the com- pany the regular physician will be pitted against, that frequently causes him to avoid giving his valuable opinion in court. Nor is it entirely due to the admittance of the irregular practitioner in court, but frequently to the opposing side who have hired a "professor" whose reputation cannot be openly assailed, yet whose unsavory odor has penetrated the sensitive ethical rules of the medi- cal society. This man is a professor in a medical college, has a legal right to be called an expert, will have a large following, and by the public will be placed on the same educational standard as the reputable man. But there is a great gulf between them, they can seldom meet on the same scien- tific ground. The man who has gone from school to college, from college to university and from university to the hospital, is, thanks to our lenient, and often farcical statutory laws, discourteous- ly contradicted on the witness stand by a man who has jumped from the soda water counter to a two years' course in an easy-going medical
school. vSuch are a few of the conditions which have driven honest physicians from the court- room. There are others — the fault of the Bench and Bar — the impertinent questions, discourtesy, and ithe misleading and senseless hypothetical questions emanating from a certain class of law- yers.
It is the long and tangled hypothetical ques- tion put to the expert witness that displays the misunderstanding of the lawyers and apparently makes a fool of the doctor. Questions are asked to make the unexplainable explainable, while the jury is not told that the physician deals with conditions that are continually furnishing excep- tions to general rules. If the doctor on the stand tries to explain this fact he is told to stop, and confine his statements to his opinions based on the hypothetical question. Says the Hon, Wm, B, Hornblower : "Expert testimony based upon' one-sided hypothetical questions is almost of ne- cessity favorable to the questioner, and the seem- ing inconsistency of expert witnesses of equal ability is largely due to this mode of questioning." The jury and the press do not consider that physi- cians of equal intelligence and education may as honestly differ upon one or more series of ques- tions put to them by a layman, as may the op- posing attorneys in an interpretation of a propo- sition in law. The medical man now realizes his anomalous position as a witness, the false attitude he is placed in, and the impossibility of being allowed to tell the truth as he understands it. Opinion witnesses receive unfair treatment from lawyers who take cases not for the truth that is in them but for the lies that can be put into them. The physician knows it would be possible to establish a reasonable degree of truth were not everything done to prevent it. The expert realizes that he is permitted to know only one side of the question as it afTects the interest of the parties who call him. Let him have without reserve the facts from both sides. Give him an opportunity to consult with the expert for the other side, then even if they disagree in opinion they will most surely agree on facts. But to this mutual consultation Istwyers will not agree. They will not, especially in damage cases, place in the possession of op- posing counsel any information which they may wish to use for their own side. This may be ethical from the legal viewpoint, but to the doctor it looks like injustice. Physicians are not in the habit of looking on one side only in their investi- gations and studies, hence this attitude of the law- yers has driven conscientious men away from the courts. It is essential that an expert witness should be made as familiar with all the facts ap- pertaining to a case in which he is to testify, as that the attorneys should know the whole of their case before trial. "The element of judgment and opinion must be based upon the same facts as those of the lawyer, and upon these our inter- pretations must rest," — W. P. Giddings, M.D.
McKelwav tritely says : "It is the lawyers who have brought expert testimony into disrepute,
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and who to a degree have brought their own profession into disrepute by the arts which they have practised for the concealment or destruc- tion of truth rather than for its disclosures and denotement." — Albany Med. Annals, Oct., 1898.
When the physician has clearly in his mind the case as he views it, has formulated his opinions as based upon facts, and would give them to the jury regardless of the consequences to the side employing him, he is partially gagged by the surprised lawyer who only wants such opinions as will win his case — not the truth. The only logical method for the medical witness is to state in sequence his conclusions, the reasons for them and the conditions which might change or modify them, but he is not allowed to so pro- ceed ; and, humiliated, with the feeling of loss of self-respect, and conscious of having been placed in a false light, he leaves the stand swearing never to be used again as an expert. He seldom is, for when the lawyer trumps up another damage case he looks around for a more pliable tool whose opinion will coincide with his own. And this is the way he will proceed : He goes from physician to physician, giving his side of the case, insinuat- ing in manner, and elastic with facts. He pays the fee for consultation — sometimes, and as each physician retains the secret of the consulting room the lawyer consults many with impunity until he finds one whose opinion can be readily molded into the attorney's shape. Now we see the medical expert made to order. These are facts well known to men of both professions. Mather wrote : "The expert witness is not called to tell what he knows, but what he thinks." In truth he is not wanted to-day for what he thinks, but to tell what he thinks his employer thinks.
A litttle attention on the part of the legal pro- fession would disbar this unscrupulous lawyer who makes flattering offers, insinuating pleas and indirect bribes to his medical fellow in perjury. Let the legal profession get rid of the Bar bullies and shysters and the medical profession will have fewer scamps. The Supreme Bench has here work to do. Are maintenance, barratry and champerty no longer punishable?
In quoting Jones,* Justice Woodward tells a tale only too well known to the public: "The notorious fact that experts of equal credibility and skill are found, in almost every cause, testi- fying to directly opposite conclusions, illustrates both the fallibility of such testimony and the fact that a conviction for perjury based upon such evidence would be very diflficult." It is the train- ing the legal mind receives along the line of precedents, of relying upon facts established in passed decades, of reference to aged decisions and immovable tradition, and of reference to ancient rules of procedure, that causes the lawyer to denounce as unreliable one or all of the experts who diflFer radically in their opinions, and who seem, to the lay observer, to give each other the lie direct. Because two medical men of rigidly honest intentions contradict each other in the
* " The Law of Evidence in Civil Cases." by Burr W. Jones.
answers to some hypothetical question put to them on examination, does not convey any idea of perjury or dishonesty to the scientist.
In no branch of the sciences has there been such rapid progress as in that of medicine the last ten years. Hourly, daily, new theories are re- placing the old, and what was thought the truth yesterday, is to-day sworn to be a fallacy. Statements are made daily in medical societies which have their confident supporters and like- wise their bold deniers. The new ideas are dis- cussed pro and con with honest intentions and faithful adherence, yet there is no display of ac- rimony, never an idea that your opponent is a liar. When a member of the Bar wishes to con- sult some legal authority he refers to an ancient tome that his father, or perhaps his grandfather, was accustomed to quote. Let a medical man refer to a work that has been five years on his shelf, or let him rely on his text-books of student days, and he will without doubt be flatly contra- dicted by a wiser man when the two meet in court. Both will be equally honest and sincere in their statements, but the wiser man can give facts regarding recent discoveries which will cast doubt in the minds of the jury upon the state- ments of his confrere. This is one of the reasons why medical men do not believe experts have any place in trial by jury. Again, regarding a medi- cal question, two men may give greatly diverg- ent opinions, and both be giving their honest opinions. There is at present so much uncertain- ty in certain branches of medicine, especially in psychological physiology, that it is a bold man who undertakes to nail down his fact so it can- not be displaced. In referring to a statement of a physician that it would be an easy matter to get half a dozen competent medical men who, in answer to a hypothetical question put by the District Attorney, would give quite exactly op- posite answers. Justice Woodward remarks : "Is not the remedy for these frequent, and after all infrequent, instances of professional dishonor in the hands of the medical profession itself?" No; it is in the hands of the legal profession, some of whose members keep a morally weak physician on a retaining fee, or, more often share with him the small sums they can obtain by ver- dicts in damage cases ; or by unscrupulous "bluff- ing" where there is no case. It is the lawyer in these cases who is the suborner, the physician the flaccid tool and perjurer. Is a suborner any less guilty than the perjurer? Justice Woodward would have the latter expelled from the medical society, — a very difficult matter, as is well known by those familiar with medical cliques and the humiliating jealousy therein existing — but would it not behoove the Bench and Bar to pluck out its own beam? In all large cities the number of lawyers who throw tempting bait to the strug- gling young physician is steadily increasing, and it is safe to say that once in the hands of these legal pirates the physician is lost to all sense of self-assertion. So notorious have these legal parasites become that the Baltimore Evening
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News has been editorially stimulated to make the following remarks :
"Ambulance-chasing" lawyers and their side partners, the "runners," are becoming more num- erous every day in Baltimore. Frequently now dim hints at their methods are made in court. Vexatious damage suits are being promoted in Baltimore to an extent never known before. It is a growing abuse of great proportions, in which the taxpayers are interested directly.
"All of Baltimore law-courts are behind with their work. This is largely due to the perni- cious activity of the damage-suit lawyers. At least one-half of the suits that go to the trial dockets of the law-courts are damage suits for alleged injuries to persons or property. It is probable that an investigation would show that four-fifths of the docketed suits which ultimately call for trial are of this sort. The majority of such suits are worked up by "ambulance-chasing" lawyers and "runners," and have very slight foundation. Yet this pressure of frivolous litigation will very soon make necessary an additional judge, with bailiffs, clerks, deputy sheriffs, jurors and all the paraphernalia of a court. It costs about $60 a day to conduct a court with a jury, and the public will have the pleasure of paying that ad- ditional amount to aid "ambulance-chasing" law- yers in "plugging" corporations and individuals. That is about what it amounts to. In the mean- time, legitimate litigation will have to wait."
I have briefly outlined some of the salient points or difference between the medical and legal methods of thinking, and the difficulties which present themselves whenever an attempt is made to settle the much-discussed "Medical Expert Testimony" question. From the medical viewpoint there seems to be no reason why the experts of both sides could not have a conference before the trial in order that they might come to some mutual understanding, or formulate a joint opinion. Such a procedure would further the ends of justice and save expense to the State. Another plan which seems feasible would be to have the expert an officer of the court, similiar to a court surveyor as exists in some States. Maine has a court surveyor to give evidence in cases of disputed land boundaries. When no agree- ment as to facts has been reached, the Court, upon request, selects a court surveyor, who when asked, goes over the disputed boundaries, and identifies marks and bounds, and makes his offi- cial report. Whichever side asks for his appoint- ment pays the expense. But to any such pro- cedure of saving time and expense ; of any method which will hasten the ends of justice and put a stop to disgraceful bickerings and disputes, the legal cry of "unconstitutional," "jeopardizes the rights of the defendant," "impossible under our rules of procedure" and other stereotyped expressions arise which makes th^ medical man wonder at the immovability of the law's pro- gressiveness. Until the legal profession allows us certain concessions, until it modifies the rules of the admissibility of evidence in criminal proce-
dure, so that the expert witness may have the protection which rightly belongs to him, there will always be difficulty in getting medical men of probity and honor to dignify the witness stand with their presence at criminal trials.
MEDICAL PROGRESS.
MEDICINE. Human and Bovine Tuberculosis. — This knotty problem is attacked once more by Nathan Raw (Brit. Med. Jour., Jan. 31, 1903), in a preliminary communi- cation which recounts his experiments and presents the following conclusions: (i) That there are two dis- tinct varieties of tuberculosis affecting the human body, one produced by human tubercle, the other by bovine;
(2) that these two forms are separate and distinct;
(3) that bovine tuberculosis may set up Tabes mesen- terica in children ; (4) that bovine tuberculosis is proba- bly the cause of enlarged lymph glands, tuberculous joints and lupus; (5) that pulmonary tuberculosis is not due to bovine infection but to human.
The Etiology of Acute Rheumatism. — Many hy- potheses have been advanced to explain this and other closely allied joint conditions, but the present state of our knowledge is summed up by the conclusion that a small micrococcus, absolutely distinct from that of ordinary septicemia, is the cause of this well-known train of symptoms. R. M. Beaton and E. W. A. Walker (Brit. Med. Jour., Jan. 31, 1903) believe that the coccus which they have isolated from rheumatic cases, is identical with that obtained by Triboulet, Was- sermann, Paine, Poynton, and others. The slight variations in the descriptions given by these observers are probably due to variations in technic. The or- ganism is a tiny micrococcus arranged in pairs and short chains. It is not decolorized by Gram's method. It stains well with all the ordinary dyes. It is not capsulated. It does not agglutinate. When this diplo- coccus is injected into an animal, characteristic and positive results are to be expected. There is fever, wasting, mono-arthritis, polyarthritis, paresis of limbs, pericarditis, endocarditis, septicemia and death. Some rabbits have two or three attacks of acute arthritis following successive inoculation and in one case, now doing well, the disorder was successfully induced four times. If an excessive dose be given, death occurs within 48 hours, the post mortem usually revealing a large pericardial effusion, often pleural effusion and cardiac engorgement with vegetations upon the mitral and tricuspid segments. The joints are very hyperemic and may contain a clear effusion. The organism is found in pure culture in the blood in all the exudations and in the urine. In moderately large doses death may occur in from three to seven days or as late as three weeks. The autopsy shows the effusions to have become turbid or purulent. Small doses produce conditions in animals which are closely identical with what is usually known as acute rheumatism in man. The heart lesions, however, can rarely be made per- manent, as occasionally happens in us. Nor have the observers seen a true chorea result even in the case of young animals. Their conclusions seem positively to indicate that the bacterial specificity of acute rheuma- tism has been positively established.
Persistent Jaundice. — A most remarkable case in which a general icterus has been present for fifty years. is^ reported by W. T. Cocking (Quart. Med. Jour.. Yorkshire, Teb., 1903). The patient stated that she had been afflicted until the present since three weeks old
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and at various times has had attacks of "biliary colic" when the jaundice would get worse. The cause of the condition was not obvious, but the symptoms and physi- cal signs pointed to partial obstruction of the common duct possibly congenital. The latter, however, is usual- ly fatal in a few weeks. Operation for exploration was refused.
Complications Attending Use of Antitoxin. — That peculiar idiosyncrasy toward diphtheria antitoxin may be manifested by certain patients is shown by the re- port of a case by A. Reckles (Quart. Med. Jour., Yorkshire, Feb., 1903). He gave 4,000 units of anti- toxin to a woman suffering from diphtheria of the throat. A few days later convalescence was established but a severe urticaria set in. A sudden attack of dysp- nea, with lividity and pain around the heart then came on and suggested angina pectoris. This, however, could be ruled out and it seemed that the serum was at fault. In the next few days, nine successive attacks occurred and then recovery was jneventful. It was later found out that two years previously she had been given antitoxin for diphtheria and similar symp- toms of dyspnea and lividity were noted.
Hepatoptosist — The errors in diagnosing obscure abdominal tumors will never be fully known, remarks Irving Miller (Amer. Jour, of Obstet., Feb., 1903), inasmuch as the surgeon always falls back on the ex- ploratory incision to supplement his deficiency in diag- nostic technic, and seldom looks the least bit perturbed, however far from the true condition he may have been. The following case will show how easily the diagnosis may escape one. Examination showed a tumor in the right flank easily moved to the median line, and down in the iliac fossa on the right side. The edge of the hand is easily insinuated between the tumor and the ribs neither does the mass rise with inspiration. The tumor is convex and was thought to possess a decided kidney shape, though large. There was no sharp border to be felt. Later the kidney was made out. A later examination showed the mass to be globular and not so mobile as at the first examination. Tumor of the gall-bladder was now. thought of and an exploratory incision was decided upon. Examination of the mass after the abdomen was opened showed it to be the liver and that, not at all enlarged. Diagnosis, floating liver.
Malarial Vertigo. — Although this symptom may be markedly accentuated, it has, according to T. J. Mays (Jour. Am. Med. Assoc, Feb. 7, 1903), been noticed by few recent writers. From a study of his own cases the author has often found that in apparent good health intermittent daily attacks appear, marked by dizziness and unsteady gait. Persistent headaches and backaches are present, together with depression of spirits and exhaustion. In all cases there was a well- defined history of intermittent fever, which may have been latent for some time. Best treatment is quinine in doses, sufficient to produce ringing in the ears. May be combined with strychnine, blue mass and capsicum.
Mortality in Pertussis. — The commonly accepted opinion as to the fatality of whooping-cough is errone- ous, but the dangerous character of the disease, especial- ly among infants, is becoming* better recognized. M. H. Hull (Phil. Med. Jour., Feb. 7, 1903) reports five fatal cases in an epidemic at an orphanage in At- lanta, Ga., and collected 55 cases in a period of two years which ended "fatally. In the author's cases, the complications which only existed in some, were not the primary cause of death. The danger signal, par- ticularly in young infants, was either a developing stupor or an attack of prostration from which they re- covered temporarily, to go into a state of increasing stupor and exhaustion until death. In studying the
larger series of fatal cases it was found that a catar- rhal affection of the mucous membrane is the most probable complication and liable to prove the most fatal by lowering the resistance of the body to the toxic effects of the infection. Average age of the fatal cases was less than one year and duration three weeks. Most of the deaths occurred between April and Sep- tember. As to the etiology, the author thinks that the characteristic lesion is a bronchial catarrh, caused by the specific micro-organism, the toxin of which acts principally on the nerve centers. The treatment com- prises (i) support of the patient by tonics and stimu- lants, by plenty of fresh air and good food; (2) the es- tablishment of an equilibrium in the nerve centers, also by tonics, iron and quinine, and by nerve sedatives ; (3) prevention of the further absorption of toxins by de- stroying the micro-organism producing them — probably best done by antiseptic sprays.
Pos.timpetiginous Nephritis in Infants. — Five cases of nephritis occurring in children, in which the kidney lesion seemed to be directly traceable to the skin af- fection, are reported by A. Filia (Policlin., Feb. 14, 1903). In the author's belief, the eczematous lesion opened the way for the transmission of infection through the lymphatics, thence into the general circulation and to the kidneys. That this was so seemed probable from the fact that the same organisms (staphylococci and streptococci) found in the diseased skin, were also present in the urine; and these persisted some time after albumin and casts were no longer present. It was shown, through injections into animals of cultures of staphylococci found in such urine, that the organisms had acquired a high degree of virulence compared to staphylococcic cultures from other sources. This is in accord with the experimental experience that the ad- dition of urine to ordinary culture media increases the pathogenic power of organisms so cultivated. Ex- amination of the blood of the animals which had re- ceived the injections, showed staphylococcic septicemia in twenty-four cases out of thirty-three.
Prognosis in Tuberculosis. — The prognostic value of tubercle bacilli in septum as manifested in quantita- tive changes is commented on by L. Brown (Jour. Am. Med. Assoc, Feb. 21, 1903). He has examined a large number of cases at the Adirondack Sanitarium. In 169 cases with tubercle bacilli, 42 per cent, had lost their bacilli on discharge, — of the incipient cases 75 per cent, were apparently cured and of the advanced, only 19 per cent. This shows the better prognosis for the early cases. Other observations also prove that one specimen proves little or nothing in regard to prognosis. If the number of bacilli steadily decrease in a series of examinations at intervals sufficiently long, the patient may be improving, but the constitutional symptoms and local signs give much more accurate information. If on repeated examinations large quantities of tubercle bacilli are found, the disease has probably advanced to cavitation. Repeated observations seem to show that the morphology of the tubercle bacilli affords little or no ground for prognosis, but the short bacilli are suggestive of a more active process. The arrangement in clumps is more apt to be found in the severer cases, but may occur in all.
Blood Investigations in S3rphilis. — As a continua- tion of their researches on the iron contents of the blood in the early stages of syphilis, G. Lowenbach and M. Oppenheim (Deut. Arch. f. klin. Med., Vol. 75, Nos. I and 2) have lately published the results of their investigations of the same character in the later forms of the disease. Included are gummata and specific ulceration more particularly of the skin, bones and mucous membranes. They found a marked reduction
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from the normal in the quantities of both iron and hemoglobin, neither condition being influenced by thera- peutic measures. The number of red and white cells varies within normal bounds. The authors were un- able to verify the differential diagnosis of syphilis by the variations in hemoglobin after the administration of mercury as proposed by Justus.
Blood Changes Due to Syphilis and Mercury. — An extensive series of observations with especial ref- erence to their diagnostic value has been made on the hemoglobin contents of the blood of syphilitics by J. Justus (Deut. Arch. f. klin. Med., Vol. 75, No. i) Over 500 cases of all varieties are included, treated and untreated. He finds that untreated cases of syphilis show a diminution of hemoglobin which lasts a longer or shorter time, depending on the severity of the dis- ease. A gradual increase then takes place as the signs of syphilis subside. If a therapeutic dose of mercury is introduced into the affected organism by injection or inunction, a relatively sudden decrease of the hemo- globin content is observed. (10° to 20° in the Gower's or Fleischl's hemoglobinometer.) This sinking may again be compensated for in the course of a few days, depending on the severity of the symptoms and the general condition of the patient. If the treatment is continued the hemoglobin may reach a higher point than before the former was inaugurated, and the point when no further decrease takes place marks the period when healing of the specific lesions begins. It is further claimed that the changes in hemoglobin values just noted are only to be found in the blood of florid syphi- litic patients and have not been observed in health or in any other disease. The reaction can be also found when invasion of distant lymph glands takes place and in all varieties of the disease. It disappears when the syphilitic lesions disappear, but can again be demon- strated if any recurrence takes place. In using the test for diagnostic purposes, care must be taken to employ the proper dose of mercury, at least 3 grams of the offi- cinal blue ointment for adults, by inunction. Adminis- tration by mouth is not effective, because of the gradual absorption. Observations should be made the morning after the inunction. Subcutaneous injection of mer- cury bichloride (0.05 gm.) should be followed by observation eight to nine hours later. The author pre- fers the Gower hemoglobinometer modified by Sahli. A diminution of five degrees or more in the latter in- strument indicates the presence of a florid syphilis. In secondary and tertiary syphilis the same result obtains provided the specific lesions have not undergone in- volution. A negative result is not therefore diagnostic of the absence of the disease (at some previous time). The author finds, from a study of all cases where the test was properly applied, a positive result in from 70 to 80 per cent, of all doubtful cases.
SURGERY. Resection of the Common Bile Duct. — This opera- tion, combined with hepaticoduodenostomy, is claimed by H. Kehr (Miinch. med. Woch., Jan. 20, 1903) to be the first one recorded. The patient, a man of fifty-three years, presented an annular carcinoma of the common duct, which necessitated resection of al- most its entire length. The gall-bladder had also to be removed and the hepatic duct was sutured to the duodenum a short distance from the stump of the common duct, which was simply tied off. A small bit of omentum was then sutured to the point of entrance of the anastomosis, the wound sewed up except for exit of small tampon. There was a slight discharge of bile for a time, but the patient made a good recovery. He discusses the clinical differences between carcinoma
and stone of the common duct and believes that car- cinoma is more frequent in men than in women, there is seldom colic and usually icterus begins very gradu- ally, but becomes intense and regular. The stools are usually clay colored. The duration of the disease is usually about six months for cancer, whereas with stone it may extend over a long period, even up to twelve years. Chills and fever are rare in carcinoma, cachexia is marked, the gall-bladder is large and palpable (80 per cent.). Ascites is ordinarily present. The good results obtained lead the author to extend surgical interven- tion to include cancers of the common duct and to recommend operation in cases of chronic icterus which suggests an obstacle in the common duct or pancreas in hope that it may be a case of chronic pancreatitis.
Treatment of Fracture, — The following details of treatment of fracture are offered by Dr. Borchard (Z'blatt f. Chin, Jan. 31, 1903). Massage is begun on the day of injury. Then application of splints and immobilization of the broken ends in exact position after the disappearance of the swelling and from the beginning of callus formation up to the time of con- solidation, which prevents the displacement of the bone fragments, excepting with great force. This lasts per- haps twenty-six days, and is followed by massage and gentle movement of the joints, until union is formed. Finally, voluntary movement is allowed. The aims are to prevent stiffness of the joints, atrophy of the muscles, and a late edema as soon as normal position is resumed.
Needle Holders. — The shops of instrument makers exhibit great numbers of needle holders, many of which are complicated and fall short ot their purpose. Latter- ly several have been devised upon the principle of two V-shaped notches grasping the needle from opposite sides. Their form permits any size of needle within the ordinary range of surgical needles to be grasped, necessarily at one point of the holder. The following modification of Hegar's has just been brought out by G. BuRCKHART (Z'blatt f. Gyn., Feb. 7, 1903). It consists of a long and a short jaw. The long jaw makes up the tip of the instrument and is so cut that two surfaces at right angles to each other mark its inner aspect. One of these surfaces runs along the whole jaw, up to the base of the tip, where it is joined by a very short surface. Against this shorter sur- face the needle is held by the tip of the short jaw, which is ground off at an angle, thereby repeating the principle alluded to above, namely, of giving a V- shaped, variable notch, in which the needle is held,- and permitting any size of needle within the ordinary range to be held within the same point of the instrument. So simple an arrangement will commend itself to most operators.
Appendicitis in its Acutest Forms.- — The treat- ment of this disease is probably more important than the diagnosis, which has come to be so much a matter of general familiarity as no longer to be overlooked as ordinarily as formerly. J. A. Macdougall (Lancet, Feb. 21, 1903) says, as to treatment, that he holds opium to be undesirable, because it masks the guiding symptoms. When unavpidable, a suppository or lauda- num by rectal injection is better than morphine sub- cUtaneously. When evacuation of the bowels is neces- sary, and it often is, enemata are preferable to cathar- tics by mouth. The method of operation in these cases done early, that is, within the first forty-eight hours, is, as a rule, straightforward and simple. Simplicity and safety, he thinks, are gained by making the in- cision more close to the anterior superior spine of the ilium than is usually advised. It is possible to display a removed diseased appendix without any protrusion
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of the small intestine. He has, as a rule, greater trust in sponges and swabs than in irrigation, and in drain- age tubes of large size, with gauze wicks than in gauze packing. The later treatment of bad cases is better managed with normal salt solution, used subcutaneous- ly, both as a cardiac stimulant and as a means of over- coming the poisonous material within the system, by increasing its elimination through the skin and kid- neys.
Improvement of General Anesthesia. — The im- provement on the basis of Schleich's principles with special reference to anesthol is discussed in a most interesting paper by Willy Meyer (Jour. Am. Med. Assoc, Feb. 28, 1903). The effort heretofore has been directed not only to the discovery of a new and less dangerous narcotic but also to improve the chemical conditions of the known anesthetics by making them absolutely pure. Schleich's investigations were con- ducted on an entirely different plan and he started to find an anesthetic of which the boiling point would correspond to the body temperature, substituting a physical for the chemical basis, so that the amount eliminated during expiration would almost equal that absorbed during the previous inspiration. He finally devised an apparently suitable mixture of ether, chloro- form and petrolic ether (benzine). Meyer made a series of trials with this mixture, and although fairly good results were had, substituted finally for the pe- trolic ether, ethyl chloride and called the product anes- thol. It contains ethyl chloride 17 per cent., chloro- form 35.89 per cent, and of ether 47.10 per cent., repre- senting a proportion of about i :2 13. Its boiling point is 104° F. Meyer has used it in many cases for four years past and is very well satisfied with it. It should be given by the drop method with an Esmarch mask. The patients do not struggle, the pulse does not vary much, but respiration at times becomes shallow. The anesthesia caused is not very deep and some of thf^ reflexes may not be lost. In abdominal cases, therefore, morphine, gr. V12 to %, may be given by hypo about half an hour before operation with excellent results. Salivation and cyanosis are absent and the awakening is quick. Vomiting varies, but is never persistent. Other sequelae are rarely met with. Two deaths are reported, both severe kidne}' operations and with marked shock, not especially due to the anesthetic.
Actinomycosjis in Man. — The following are of- fered by R. Von B.\racz (Arch. f. klin. Chir., B. 68, H. 4) : (i) Ray-fungus should be regarded as a spe^ cial and peculiar fungus, and not as a collective name for a variety of bacteria which might be classed as ray- form. (2) The ray-fungus passes into the human or- ganism, not through the teeth, but through the mucous membrane of the digestive tract or of the respiratory apparatus. Occasionally its entrance is gained through the skin. (3) The vehicles of this fungus are, for the most part, foreign vegetable matter in a dried condi- tion, chiefly various grains, fragments of grains, and the like, which have become infected with the spores of the fungus, and then find their way into the cavity of the digestive canal or are breathed into the lungs in their ordinary function. It is only exceptionally that these force their way through the skin into the organ- ism. (4) Fungoid growths do not belong primarily to the actinoid processes of the ray-fungus. They belong, probably, to the degenerative forms of the same, and represent, as a rule, the later stages of the disease only, and occasionally the first stages of the disease when the conditions of growth are unusually favorable. Occasionally in actinomycotic gland there are found with the typical thin threads, very thick, thorn-like threads, which must be regarded as a development of
the fungus itself or as a development of the same, and must not be looked upon as a specially foreign form of bacteria, for the reason that they have an alygous con- struction with the typical actinomycosis, and because they are closely related to these in a later development stage of the fungoid growth, and because the whole course of the sickness concurs with this theory. (5) The contagiousness of actinomycosis between man and man or man and animals, or the reverse, must be re- garded as rather unlikely, especially as ray-fungi, which are obtained from man, seem to possess very little virility. (6) As a means of prophylaxis, contact must be avoided with the various dried and dust particles of vegetable matter, for example, fragments of straw, corn and the like, such as are found in the threshing of grain. (7) Actinomycosis in the regions of the face and neck may rarely cure itself. (8) Operative treat- ment of actinomycosis is limited to free incision and enucleation and antiseptic packing of the superficial, easily approachable masses. The most severe opera- tions should, as a rule, be avoided. In the smaller foci of this disease, injection of tincture of iodine or similar antiseptics might be tried. (9) In actinomycosis of the lungs or of the internal organs, operations are exceed- ingly difficult, and should be limited to an intravenous injection or argentum colloidale Crede, combined with the use of Crede's ointment rubbed into the skin.
OBSTETRICS AND GYNECOLOGY.
Extra-uterine Pregnancy. — During the last ten or fifteen years there has been so much discussion upon this subject that in about fifty per cent, of cases of extra-uterine pregnancy the true nature of the trouble is now recognized by the family physicians. H. J. BoLDT (Med. Rec, Jan. 10, 1903) reiterates the typical symptoms of this important and dangerous affliction. The non-appearance of menstruation at the expected time with the signs of pregnancy when a patient has previously been regular, followed in a few days to five weeks or more by the symptoms of partial or complete rupture. Usually only a week or less elapses after the expected menstrual flow before symptoms begin to man- ifest themselves. Pain in the lower abdomen most marked on the affected side is perhaps the first indica- tion of trouble. It is usually severe and cramp-like in character, lasting an hour or so, and then subsiding for a few days or more. Following the attack of pain there is usually a flow of blood which is thought to be the menstrual flow, but is darker and more tarry than nor- mal. The severity of symptoms depends upon the ex- tent of the process, whether it is a tubal abortion or a partial or complete tubal rupture. In the latter case the pain is very intense, and the patient usually col- lapses as a result of the pain, and the large intraperi- toneal hemorrhage. Bimanual examination will show the uterus somewhat enlarged, and its consistency re- laxed. To either side of the organ, and sometimes be- hind it a mass will generally be felt, unless the rupture has been complete, and the blood is still free in the general peritoneal cavity, and even then there is usually a fulness in the cul-de-sac. The consistency of the blood-mass depends upon its age, the longer it exists, the more firm it will become. The passing of a decidua is not common. The pain may be no greater than some- times is seen in dysmenorrhea, and as the bleeding may come at or about the same time as the normal men- struation,' and even be normal in appearance, the diag- nosis is frequently very difficult. In any doubtful case an examiiiation should be insisted upon. In regard to treatment there are but two methods worth considera- tion, the conservative and the surgical. If a patient is seen who has a tubal abortion in progress, and from
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the examination it is evident that the blood is well formed into a clot, determined by its consistency, it may be permissible to watch and wait, provided she is amid surroundings which will permit of immediate sur- gical interference. She should then be carefully watched, on a fluid diet, with ice coil on abdomen and absolutely at rest, even if morphine is necessitated. In favorable cases the tumor will then become gradually smaller and more firm. Again, if the history and symp- toms show that the patient has had a complete tubal abortion, objectively determined by the absence of an enlarged Fallopian tube, such as we would find if the embryo still remained in the tube, and if she has re- covered from the shock thereof, a similar course is permissible. A hematocele will then form in the course of a few days to such an extent that it is readily recog- nized by the examining finger, and its further progress can be carefully watched. It is probably best to operate at once on all cases who have a progressive condition or who have not a well-defined hematocele. Abdominal section is rapidly made, the tube is found and caught by a clamp as soon as possible and the abdominal cavity cleared of the blood and clots. It is not necessary to remove all the fluid blood. Hot saline solution is freely added and the abdominal cavity filled with it before suturing. Infusion is frequently necessary.
Conservative Surgery on the Adnexa. — Realizing the many disadvantages that most women labor under after having undergone the recognized mutilating opera- tions upon the genital organs, J. Kiriac (Gaz. de Gyn., Jan. 15, 1903) proposes a conservative operation that is believed to be entirely original. The operation not only frees the diseased organs from the unhealthy parts, but preserves either the ovary or tube in its totality. The ovary is freed from its adhesions, and brought out of the wound. It is then divided from end to end, as in treating a kidney. The two cut surfaces are then carefully examined. All cysts and diseased portions are removed. This operation is called by the author "scapsie," from the Greek "scapto," to sculpture or to hollow out. If the ovary alone is operated upon, it is "ooforoscapsie i" if the tube is in question, it is called "salpingoscapsie," and when both tube and ovary are operated upon, "salpingo-ooforo-scapsie," or more briefly, parartimato-scapsie. After having removed the diseased parts with a curved bistoury or a pair of scissors, the two fragments are brought together, that is to say, the organ is reconstructed. If there has been much tissue removed, two sets of sutures are necessary to hold the parts together ; deep, retention layer, and a superficial layer. If in the case of an enormous de- struction of either organ by abscess or cystic formation, the best procedure is to remove the whole organ, as there is nothing remaining to be preserved. This method of operating has given excellent success in six cases.
Rupture of the Uterus with Recovery. — This is so relatively rare a termination of a dread complication that it is worthy of record. Claude B. Pasley (Brit. Med. Jour., Jan. 17, 1903) records a case of a primi- para, aged twenty-eight years, suffering from advanced aortic valvular disease. The presentation, as usual, was transverse and the pelvis slightly contracted. The condition was corrected to a vertex presentation, a binder applied and the patient left to continue her labor. Six hours later, it was found that the transverse posi- tion had recurred. The vaginal temperature was 103° F., and the waters had come away. The child was delivered by forceps two hours later, the patient's temperature having risen to 10414° F., pulse 140. The placenta was delivered ten minutes later, and the woman was so near death that no chloroform could be
used during any part of the procedure. Strangely enough, without operative intervention, although the case was diagnosed as one of rupture, the patient pro- ceeded to rally, and although there was a large ab- dominal blood clot, this absorbed, and she made an uninterrupted recovery.
Uretero-Ureteral Anastomosis. — The unintentional division of the ureter in operations in the abdominal and pelvic cavities is not of frequent occurrence. Nevertheless, remarks George Ben Johnson (Am. Gyn., Jan. 19, 1903), this accident is apt to occur in cases in which numerous adhesions exist, and the anatomical relation are much disturbed. The ureter may be so displaced from its normal position, and be so com- pletely embedded in a mass of adhesions, as to make its identification practically an impossibility. In the event of such an accident, a decision as to the best procedure to follow is of paramount importance. Sev- eral methods of dealing with the condition are at hand : (i) The kidney on the injured side may be removed; (2) the ureter may be passed into the intestine, colon or rectum, into the vagina or through the abdominal wall; (3) the kidney may be brought down, and the extremity of the ureter sutured into the wall of the bladder; (4) an anastomosis may be made between the extremities of the divided ureter. This classification, while not exhaustive, covers the most important pro- cedures so far devised. Of these methods the last two are the most worthy of consideration. Uretero-ureteral anastomosis would seem to be the operation of choice. Uretero-ureteral anastomosis, or uretero-ureterostomy, as the operation is designated by Kelly, may be per- formed in various ways. Henry Morris gives the fol- lowing classifications : , (a) End to end anastomosis by suturing the ends together in a transverse line; (b) end to end anastomosis; (c) lateral implantation; (d) end to end anastomosis by suturing the ends together in an oblique line. The transverse end to end method was used by Schopf (1886) in the first recorded cases of uretero-ureteral anastomosis. The objections to the operation were so serious that the operation has been almost discarded to-day. Poggi originated the end to end anastomosis. Lateral implantation was devised and described by Van Hook in 1893. Kelly was the first to apply this method to the human subject. The oblique end to end anastomosis was first used by Bovee. The author reports two successful cases in which the Van Hook method was employed.
Ventrofixation. — The following adverse criticism of the various forms of this operation are given by R. Gradenwitz (Z'blatt f. Gyn., Jan. 31, 1903) : (i) The procedure of employing stumps of ligatures after the adnexa have been removed is not advisable. If retro- version or retroflexion has been present, ventrofixation is unnecessary, if the stumps may be sewn together or partially sewn together; (2) ventrofixation carried out on stumps of ligaments, that is, without an operation upon them, is to be condemned for the reason that they lead to the making of a pocket. Better results are ob- tained by the Alexander-Adams operation; (3) the method of bringing the front surface of the fundus up to the abdominal wall promises the best cure for retro- version, but should be condemned because of its danger of metritis, hernia through the abdominal wall, and dis- turbance of pregnancy and childbirth; (4) if one liga- ment has been removed, this operation leads to the danger of ileus. The Alexander-Adams operation is a. good substitute, especially for posterior colpotomy; (5) after the climacteric, vaginal fixation is perhaps the best operation for these cases.
Management of Difficult Breech Presentations. — Difficult but not impossible breech presentations are
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most often seen in primipara, where the child is dis- proportionally large, because the mother's pelvis is slightly contracted; it may occur in any case in which the cervix, vagina and perineum are unyielding, and in multiparae, when the child is extraordinarily large. It includes original breech presentations, and those which were vertex and have changed to breech by ver- sion. The following method of delivery, H. J. Stacey (Am. Jour. Obstet., Feb., 1903), believes to be original. Allow labor to progress naturally, until the breech is down nearly to the perineum; if the cervix is not dis- posed to dilate sufficiently to permit this, dilate with the fingers. Dilating instruments are not of use in this operation. Now gently push the child upward and bring down bbth feet. With the child's thighs in the cervix, reintroduce the hand — the palm of which, in the semiprone position, corresponds to the child's ab- domen— and dilate the cervix and lower uterine seg- ment thoroughly, until they are practically paralyzed. See that the cord is out of the way. Grasp the feet and draw the child slowly downward until the um- bilicus is nearly at the mother's vulva, while an as- sistant, or the operator's hand, if necessary, keeps the head flexed so as to avoid extension, and consequent catching at the brim. The arms and shoulders are then quickly delivered, delivering the posterior arm first, and then rotating and delivering the opposite arm. The assistant then takes the child, while the operator quickly but carefully delivers the head with forceps. The advantages of this method of delivering breech presentations are (i) the time of labor is shortened; (2) there is little or no laceration of the mother; (3) the child is neither strangled or mutilated.
Sarcoma of the Uterine Parenchyma. — Sarcoma arising in and developing from the myometrium as a multinodular new growth of the uterus is a very rare and, from a clinical and pathological standpoint, one of the most interesting diseases of the female genital tract. Henry D. Beyea (Am. Jour, of Obstet., Feb., 1903) was unable to find more than seventy or eighty such cases in the literature. It would seem that no accurate clinical study of this class of uterine sar- comata had been made. Their hystogenesis is unde- termined and is a question which has led to much dis- cussion. Some investigators believe that they arise through a metaplasia of the muscle cells of a preexisting myoma of the uterus and are myosarcoma ; others, that they arise in the connective tissue cell of such a tumor; still others, that they are primary sarcomata of the myometrium. It would seem probable that the first theory^ was the correct one; possibly some arise from the connective tissue and others from the myometrium. The author reports a case in which the hystogenesis was most doubtful and impossible to determine.
Frequency and Etiology of Extra-uterine Preg- nancy.— The various statistical studies of this sub- ject show widely differing points of view as regards cause and frequency. An additional series of cases is presented by W. Hahn (Miinch. med. Woch., Feb. 10, 1903) who has collected all the cases in the Vienna hospitals and analyzed them. From 1892 to 1899, 241 laparotomies and 45 vaginal sections were done for extra-uterine pregnancies, with 21 deaths in the former and seven in the latter. These numbers are probably far below the actual figure, as private records were inaccessible. The author also found that the most common cause was gonorrhea, which accounts for the greater number of cases in the large cities. The in- crease in this condition, \vhich has been noticed during the past few years, must be attributed to the greater prevalence of gonorrhea and also to the fact that a more precise knowledge of the history and symptoms
has aided the diagnosis and has demonstrated that the disease is more frequent than heretofore considered. The final results of treatment, both operative and con- servative, are quite good, the danger has been lessened and the prognosis in most cases can be considered favorable. The best prophylactic measure, it seems, is to guard against gonorrheal infection.
Toxemia of Pregnancy. — The eclamptic seizures are at the present day considered to be due to a general toxic condition of the blood rather than to a disease of the kidneys. W. H. Wells (Phil. Med. Jour., Feb. 21, 1903) has also observed the effects on pregnant women of gastric and intestinal catarrhs following in- fluenza, and considers that they are often the predis- posing cause of what appears to be a very resistant form of toxemia. Plethoric rather than anemic women are affected, and the main symptoms are headache, ocu- lar pain and soreness, photophobia, frequent micturi- tion, urine less normal, a slight pyrosis, nausea and edema. One set of cases are marked by lesions pointing to the kidney disease. The second set presents symp- toms of chronic gastro-intestinal catarrh, but with a urine characteristic of toxemia. Urea excretion should always be the principal guide in diagnosis and the latter should never be made from the presence or absence of albumin alone. The symptoms may resemble those of hysteria, and attention is called to the fact that hysteria may be caused by toxemia. Other conditions which must be eliminated are threatened miscarriage and acute indigestion. The author's recommendations for treat- ment are to increase elimination by bowels, kidneys, liver, and skin. He advises calomel, but in fair-sized doses, 5-10 grs., and combines it with sodium phosphate, I dram in four to five powders q. i h. High rectal ir- rigations are of greatest value on the verge of eclampsia.
Fibroids of the Uterus. — Impaction of a fibroid in the pelvic cavity is not a very uncommon complica- tion, and is always fraught with considerable difficulty for the practitioner and danger for the patient. A. H. G. Doran (Lancet, Feb. 21, 1903) says that pushing up the impacted fibroid is never a safe procedure, and is especially dangerous during pregnancy. Pregnancy may be overlooked in a young woman where menor- rhagia is present and simulates menstruation. The fibroid is usually firmer than the gravid part of the uterus, and not rarely very much harder; the danger of pushing a hard mass against a soft mass is evident. A hard mass in the pelvis, associated with a pregnant uterus is usually supposed to be a fibroid, and when impaction is threatened many practitioners try to push the mass out of the pelvis. Experience teaches, how- ever, that a small, thick-walled, dense ovarian cyst, pressed down into the pelvis may feel very hard when the hand contrasts it with the soft, pregnant uterus. The fact must be remembered, as rupture of an ovarian cyst in pregnancy is serious. Finally, about the whole matter of pushing up pelvic tumors in pregnancy, he insists upon the difficulty of diagnosis in these cases, where the tumor can seldom be exposed by manipula- tion. A swelling resembling a cystic fibroid might prove to be a hydatid cyst. Even when pregnancy is not present, a fibroid should not, in every case, be pushed out of the pelvis, because the fact of impaction is only certain when the operator knows on very reliable evi- dence that the mass thus fixed in the pelvis was re- cently free and movable. Tearing a broad ligament fibroid might entail serious consequences.
Ectopic Gestation. — The following conclusions on this subject are offered by Kromer (Arch. f. Gyn., V. (^, H. i). The imbedding of the ovum in the tube is completed in accordance with physiological principles exactly as in the uterus, in the fact that the tissues
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of the mother take up and completely surround it. The difference between the later development of the ovum in the tube and those which occur in uterine implanta- tion are probably explained by the structure of the tube wall, which is not adapted to the purpose of nourishing the fruit. The possibility of transference of the im- plantation of the ovum from the tube is at the present unknown. This is a fact which is probably explained by the deep intramuscular embedding of the ovum and the occurrence of pregnancy in a tube otherwise normal.
NEUROLOGY AND PSYCHIATRY. Transverse Myelitis in a Newborn Infant. — A
most interesting and unusual case of spinal cord lesion in an infant is reported by A. H. Davisson and D. J. McCarthy (Phil. Med. Jour., Feb. 21, 1903). When first seen by the authors the child was two months old. The family history was negative. This, the fourth preg- nancy, was a breech case and no details of the labor are given except that primary respirations were long delayed. The failure to move the lower limbs was noticed when four weeks old. At eight weeks the child seemed fairly well nourished, but presented a flaccid condition of the abdomen and lower limbs with ab- solutely no voluntary movements. There were no res- piratory movements of thorax or abdomen, but at regu- lar intervals there was a sinking in of the sides of the chest wall. Reflexes and sensation were absent up to the level of the xiphoid cartilage, above this the con- ditions were normal. No atrophy of the lower limbs was present, and the feet were warm. The diagnosis lay between a transverse lesion at the second or third dorsal segments and a stretching of the spinal roots. The latter, however, could be almost excluded by the anesthesia up to the cervical segments. The age at time of death is not mentioned, but the autopsy showed the cord collapsed from the second to the eleventh dorsal segments. The cervical and lumbar portions seemed normal. The pia of the collapsed area was thickened and the vessels tortuous. Microscopical ex- amination was unsatisfactory, but the authors think the cord filled the pial tube, but as the result of a hemor- rhagic process, softening of the cord and resorption of the degenerated cord substance took place. This may have been the result of injury at birth or it may have developed in the last months of pregnancy.
Reflex Convulsions in Growing Boys and Girls. — Convulsive attacks occur in rickety and highly neurotic infants during teething and other reflex irritations. It is not so well known, according to E. Smith (Lancet, Jan. 24, 1903), that they also occur in pure reflexes during worry in children about 11 or 12 years old, members of families of distinct neurotic tendencies. There is one symptom in common deserving attention, namely, habitually cold feet in these individuals. It usually provokes little attention, but, if disregarded, may thwart the best efforts of the physician in treat- ment. With these cold feet, the child's sensibility to chills is increased. He can offer no effectual resistance to the sudden changes of temperature. Digestive de- rangement follows, malnutrition, and weakness and in- juripus tendencies are irritated. The nervous system is then readily thrown off its balance. If such nervous conditions may be controlled in the infant, they cer- tainly may be in the older child. Such nervous seizures are as harmless in the older child as in the younger child, and apparently leave the patient in no worse con- dition, but there are cases where the condition becomes so chronic and recurrent that hardly any appreciable excitable cause may exist to bring them about. It is therefore advisable that the children should have their health built up, and such sickness and general depres-
sion as coldness of the feet should always have attention.
Pathogenesis of Delirium in Infectious Diseases.
— Stimulated by the success of Betti in the treatment of delirium through application of leeches to the mas- toid process, A. Amantini (Gazz. Osped., Feb. 8, 1903) has made use of the same measure in six cases ; with the result that in all, delirium ceased within a few minutes to an hour after application. Judging from this experience, the author believes with Betti that de- lirium is largely induced by circulatory disturbances ; and that the withdrawal of blood through the mastoid vein, and through that from the endocranial circula- tion, has a salutary effect upon cerebral congestion. To the objection that the circulatory disturbances of car- diac cases do not give rise to delirium, he makes reply that there is a distinction between cerebral congestion in general, and that occurring when the blood is charged with specific toxines ; yet the small amount of toxine withdrawn from the system by leeching, in such con- ditions, would not alone account for its favorable ef- fect. Moreover, many patients who give evidence of intense infection do not become delirious. The coin- cidence of delirium with hyperpyrexia, Amantini be- lieves, is not due solely to the high temperature, but rather to congestion ; as shown in the patient's face and at autopsy ; viscosity of the cerebral tissue accom- panied by arterial and venous hyperemia being seen. A further argument in favor of the congestive origin of delirium is found in a case reported by the author, in which delirium ceased upon the occurrence of epistaxis. Predisposition to delirium through alcoholism or hered- itary neuropathy was definitely excluded in all the au- thor's cases.
On the Permanent Care of the Feeble-minded. — In dealing with various plans for the care of feeble- minded persons who naturally fall within the numerous well-defined classes of this condition, E. F. Pincent (Lancet, Feb. 21, 1903) mentions the following as the last kind of work recently undertaken by the Birming- ham After-care Committee. It had been known for some time that there were a large number of idiots, imbeciles, epileptics and feeble-minded persons who had not passed through the regular classes of the insti- tutions, and were not on the ordinary after-care lists of the committee. With the aelp of the School Board officials and others, a list of these cases was collected. After a sufficient number had been found, it seemed advisable to appoint a committee, consisting almost en- tirely of medical men, who undertook to examine and report on these cases. In this way the committee hopes to inform the city council of Birmingham the pVecise extent to which the evils exist. At any rate, it is in- tended to classify these cases under various heads, which should of themselves make it possible to do something for these dangerous and unfortunate mem- bers of society. The classes under which it is pro- posed to bring these cases are the following, consisting chiefly of two main divisions, namely, patients of the school age and those over the school age. Class A, those of the school age, i.e., those under sixteen years of age, are divided into (i) those suitable for special classes for the feeble-minded. These, of course, have already been dealt with by the School Board appro- priately, although the medical committee is finding some few cases which hitherto had escaped notice. (2) Cases which, for various reasons, could be better dealt with in boarding schools for the feeble-minded. Such cases have already been recognized, by the London School Board, for example, and classified under the following heads : (0) Mentally defective children who, but for their defect would be committed to industrial
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or truant schools; (&) mentally defective children liv- ing in very bad homes; (c) mentally defective children whose regular attendance it is not possible to secure at any school; (d) mentally defective children so far from any day school that it would be impossible for them to attend; (e) defective children known as "mor- ally defective." (3) Epileptics. (4) Epileptics who are also feeble-lminided. (5) Feeble-minded children who are also crippled, blind or deaf mutes. (6) Im- beciles and idiots. The class which includes those over the school age embraces the following subdivisions: (a) Mentally deficient, but capable of industrial work under supervision, i.e., cases suitable for a permanent industrial colony; (b) mentally deficient, incapable of work, i.e., suitable for a permanent colony; (c) epi- leptics who are capable of work in a colony; (d) feeble-minded epileptics ; (e) feeble-minded persons who are also crippled, blind or deaf-mutes, and (/) imbeciles and idiots.
PHYSIOLOGY.
Role of the Duodenal Mucosa in Digestion. — Re- cent studies have shown that the duodenal mucosa plays an important part in digestive processes, says L. Hal- lion, (Jour, de Med. de Paris, Feb. i, 1903), through its elaboration of secretine and enterokinase ; the func- tion of the former being to excite the secretion of the pancreatic juice, and of the latter to intensify its di- gestive power. The author quotes the experiments of Bayliss and Starling, which showed that when shreds of the duodeno-jejunal mucosa were treated with hydro- chloric acid, a substance was obtained which, when in- jected into the blood, provoked an abundant secretion of pancreatic juice. To this substance the name of secretine was given. It is believed that the gastric juice with its hydrochloric contents fills a like role. Passing to the intestine, it there gives rise to chemical reaction resulting in the production of secretine. So also, the author states, will the administration of hydro- chloric acid or kephir (a substance similar to kumyss and rich in lactic acid) in cases of deficient gastric se- cretion, excite production of secretine in the intestine and this in turn passing through the blood to the pancreas, stimulates the flow of the pancreatic juice; thus enabling the intestine to supplement, if not re- place, the crippled gastric function. The author empha- sizes the necessity in gastro-intestinal anastomoses for pyloric affections of making the anastomosis as high as possible, that the gastric juice may come in contact with an extended surface of the duodeno-jejunal mucosa; where alone secretine is elaborated. With a dry ex- tract of the duodenal mucosa to which the name of enkinase is given, Hallion has demonstrated, in vitro, that neither that substance nor the pancreatic juice alone accomplish albuminous digestion ; but when combined, such digestion is complete. In collaboration with Car- rion, Hallion has made therapeutical application of these findings, in the preparation of an extract of the duo- denal mucosa described as enkinase, which permits the utilization of the secreted pancreatic juice, and also in a combination of three parts of pancreatine with one part of enkinase under the name of kinopancreatine, the digestive power of which is said to be very great. These substances are given in specially prepared gluten capsules, so that they may not be affected by the gas- tric juice.
Urobilin. — An interesting paper read before the Anatamo-Clinical Society of Lille has for its author M. D'Hallvin (Nord. Med.,- Feb. i, 1903). He states that urobilinuria may be encountered under varied con- ditions as in febrile diseases, exaggerated destruction of red cells, hepatic affections, etc. It is well known that
the hemoglobin derived from the destruction of the red cells, is transformed by the liver into bilirubin; and as such finds its way into the intestine through the bile. Under the influence of the intestinal fer- ments, the bilirubin is changed to urobilin. As to its ultimate fate, considerable diversity of opinion obtains; some holding that it is entirely eliminated in the feces; according to others it undergoes partial resorption by the liver, but never passes into the general circulation. D'Hallvin, however, holds that urobilinemia does occur either when resorption by the liver fails to take place or when that organ elaborates urobilin instead of bili- rubin. According to the author a transitory urobili- nemia occurs in infectious diseases ; but it is permanent in the cirrhoses, in which the hepatic cells are more or less changed. When urobilinemia is present, the kid- neys carry off the urobilin from the blood, and uro- bilinuria results. Aside from this secondary urobili- nuria, it may occur when there is no trace of urobilin in the blood, but when bile is present in that fluid. In this condition of cholemia, the kidney has the power, by reduction and hydration, to change the bilirubin of the blood to urobilin. As to the prognosis, urobilinuria secondary to urobilinemia indicates disturbance of the resoiptive and secretory functions of the liver. Uro- bilinuria secondary to cholemia. also points to hepatic trouble, but not of so serious an order. Moreover, ab- sence of urobilinuria in the presence of urobilinemia indicates disturbance of the filtrating power of the kid- ney; and when cholemia exists, the non-appearance of urobilin in the urine suggests insufficiency of the kid- ney's reducing and hydrating function.
Cigar-smoke and Hydrocyanic Acid. — The discov- ery of prussic acid in various species of plants has awakened considerable interest in the inquiry, whether this highly toxic substance is present in tobacco-smoke or not. J. Habermann (Hoppe-Seyler's Zeitsch. f. Physiol. Chemie, Vol. 37, No. i), finding only contra- dictory results in the literature concerning this theme, pursued a new investigation with the following results : In all cases the findings were negative as regards the fumes of cigars, not even the faintest trace of hydro- cyanic acid could be detected.
PEDIATRICS.
Arthritis Deformans in Children. — While the num- ber of reported cases of this disease is not great, writes I. A. Abt (Wise. Med. Jour., Jan., 1903), yet two dis- tinct types have been distinguished. One type does not differ essentially from the disease in adults, but the other is different in its morbid anatomy and clinical symptoms. This latter variety shows a chronic, pro- gressive enlargement of the joints with enlargement of lymph-nodes and spleen. The joint lesion consists of a thickening around the joints, rather than of changes in the bone or cartilage, and does not usually show the bony irregularity, or grating or effusion of the other variety. The onset is usually insidious, though occa- sionally there are rigors and high fever. Bad feeding and privations seem important causative factors, and the disease usually begins before the second dentition. A constant symptom is the lymphatic enlargement and the palpable spleen. Endocarditis has never been re- ported, though there have been cases with a low grade of pleurisy and pericarditis. In time the process seems to remain stationary, but the patient is helpless, owing to the joint involvement. The variety resembling that of adults usually begins after the second dentition, but Heberden's nodes are rare. Most of the cases follow exposure to cold and wet. Pain is a marked symptom, whereas it is almost absent from the other variety. The synovial membranes and the joint cartilages dis-
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appear, the bones becoming of ivory hardness and developing osteophytic growths at their margins. Atro- phy of the muscles follows close upon the joint in- volvement. The two most important theories of causa- tion are that it is a nervous disease, also An infectious disease. The enlarged spleen, involvement of the glands, and a daily temperature in the first described variety would favor the infectious theory, while the symmetry of the lesions, the atrophy of the muscles, and the glossy skin seem to point to a nervous origin. The treatment consists in the use of iodide, proper hygiene and a warm climate.
Tuberculous Peritonitis. — From a study of 41 cases at the Paddington Green Children's Hospital, G. A. Sutherland (Arch, of Ped., Feb., 1903) reports that 27 were treated medically with 22 recoveries (81 per cent.), and 14 surgically with 7 recoveries (50 per cent.). Of the 29 that recovered 10 were under ob- servation for less than a year, and 19 for from one to six years. The author's conclusions are that in un- complicated tuberculous peritonitis the prognosis is good, is still favorable in the presence of tuberculous pleurisy and is less favorable if the patient shows a strong family history of tuberculosis, an infancy passed under bad hygienic or dietetic conditions, a feeble con- stitution, or a severe infective illness in early life. The symptoms which affect the prognosis unfavorably are continuous pyrexia, persistent diarrhea, rapid pulse, rapid wasting or recurrent acute exacerbations. The complications of unfavorable import are intestinal tuber- culosis, extensive caseation of the mesenteric lymph- nodes or of tuberculous masses, localized suppuration from infection through lymph-nodes or the intestine, and obstructive symptoms from bands or matting of the intestine. A bad prognosis results from the rupture of a suppurating lymph-node, or the perforation of an in- testinal ulcer into the peritoneal cavity, pulmonary tu- berculosis, tuberculous meningitis or general miliary tu- berculosis. The prognosis is not appreciably affected by simple laparotomy.
Eczema in Nursing Infants. — Aside from lack of cleanliness and the application of irritants to the skin, authorities recognize four great causes for this condition, viz. : parasites, dentition, neuro-arthritic heredity, and disturbances of digestion. F. Quillier (Le Prog. Med., Feb. 28, 1903) believes that dentition may play an indirect role in causation by inducing improper nursing. It is noteworthy also, that the parts of the face supplied by the trigeminal nerve, which also supplies the dental region are most susceptible to eczema especially at the time of dentition. Heredity cannot be more than a pre- disposing factor. But, of all causes, the most common is improper or excessive feeding. It is the breast-fed infant and not the artificially fed that usually develop eczema, for, in the artificially fed, the mother's attention is directed to the care of her child, the quantity and quality of the food is definite and constant, the feeding more regular and cleanliness more likely to be observed. On the other hand the mother's milk is quickly affected by abuse of coffee, beer, etc., the return of menstrua- tion, mental emotions, diet, etc. Not infrequently the milk becomes altogether too rich for the baby's simple digestive organs, as a result of indulgence by the mother in rich foods, especially meat. Often, also, a breast-fed infant is a regular glutton, taking 100 to 150 gms. of milk in three or four minutes. For treatment, first remove all scales and dessicated exudate by wet appli- cations of potato- starch poultices, then apply an oint- ment as
R Vaselin
Lanolin, aa gm. 15
Zinc oxid 4
Precip. sulphur i
Or a powder of talc or bismuth subnitrate. Internally keep the alimentary tract sweet by calomel, sodium bi- carbonate of benzonapthol used in great moderation. At the same time regulate carefully the mother's habits and the times or nursing, if necessary, putting the child for a short time on mixed or wholly artificial feeding.
HYGIENE. Transmission of Yellow Fever. — Although the exact specific cause of yellow feVer has not yet been found, authorities are generally agreed that it is a parasite similar in its life cycle to the malarial Plasmo- dium. That it can be introduced into the human being by the bite of a mosquito has been proven beyond a doubt and that this is the only method of communica- tion seems most plausible both from its analogy to other diseases and as a result of the most careful scientific experiments. J. W. Ross (Med. Rec, Jan. 24, 1903) describes the experiments which were conducted in Havana to infect human beings by means of fomites and also the wonderful results which followed the attempts to prevent the mosquito from biting yellow fever pa- tients and then subsequently biting well persons. The marked improvements in the sanitary conditions of Havana which followed the American control during 1899 and 1900 had an immediate beneficial effect in the spread of all infectious diseases except yellow fever. Early in 1901 special attention was paid to the exter- mination of the mosquito and the thorough isolation of all yellow-fever patients from the mosquito. As a re- sult there was at once a gradual decrease in the num- ber of these cases and since September, 1901, not one case has arisen in Havana. As no attention was paid to any other means of communication of the disease it seems just and reasonable to conclude that the mos- quito is the only intermediate host between man and man for the specific cause of yellow fever.
GENITO'URINARY AND SKIN DISEASES.
Open-air Treatment of Syphilis. — The importance of a general constitutional treatment in cases of syphilis does not seem to be fully appreciated and insisted upon. E. H. DouTY (Med. Rec, Jan. 31, 1903) believes that the ravages from this disease depend more upon the soil upon which the poison falls than upon the virulence of the poison itself. In a large practice in a university town he had been greatly impressed with the fact that whereas a poor, underfed scholar, if infected, was hit painfully hard, the well-to-do athletic undergraduate generally suffered lightly, in spite of the fact that the latter was often very casual about taking his mercury. On account of this complete reliance which is placed upon mercury and potassium iodide, the general health is frequently much neglected and the disease is never entirely eradicated even if greatly improved. That such constitutions are in a favorable condition to acquire tuberculosis is proven by the fact that from 30 to 50 per cent, of the phthisis patients seeking relief in the mount- ains of Switzerland are syphilitics. If the inportance of careful attention to the general health and, if possi- ble, a life in the open-air, which is recommended for the early cases of tuberculosis, could be urged upon the unfortunate victims of syphilis, the distressing tertiary lesions might be greatly reduced.
Radiotherapy in Cancer. — Of 47 cancers treated with X-rays by C. W. Allen (Jour, of Cut. Dis., Feb.. 1903), 10 were mammary, i each, rectal, uterine and of the lymphatics of the neck ; 3 sarcoma, and i sup- posed to be sarcoma, leaving 30, more or less, skin cancers alone, of which 2 involved the skin, 9 the nose or the nose and the cheek, 3 were multiple, 5 were upon the cheek near the eye, 4 were on the lip, and 2 on the arm. The results were : deaths, 5 ; cures and
April 4, 1903]
MEDICAL PROGRESS: EYE, EAR AND NOSE.
653
discharged, 25; improved and ceased treatment, 3; un- improved, 5 ; improved and still under treatment, 9. The conclusions which this author offers and bases upon this record are as follows: The X-ray possesses decided therapeutic power; but occasionally produces injury. His results show that it is not a passing fad. likely to be dropped after a brief experiment. The effect of the method sometimes produces severe symptoms in the heart, lungs and other viscera, pointing to absorption of disintegration products, which are thrown into the circulation more rapidly than they are eliminated. Metastases occur in grave forms at times more rapidly than in patients not so treated. Cancer itself may be produced by the injurious effect of the rays in a per- son not known to be predisposed. An example is fur- nished by a case which he reports of an X-ray tube- maker whose arm was amputated for cancer developing in an X-ray scar. X-ray dermatitis and many of the good effects as yet depend upon the proximity of the tube, the completeness of the vacuum and the degree of heat of the anode tubes may at times reach a "burn- ing state"' which must be learned by experience and observation. There is nothing to indicate when this condition is present, aside from the effect produced. This method of treating cancer is not to be relied upon solely in all forms of cancer. In the nodular, warty and dry growths, other means of removal, preferably by arsenic paste, should be employed, and then the rays may be app'ied. Indiscriminate application of X-rays to all forms of disease, as claimed to be practised by advertising institutions and by charlatans, and the de- ceit practised by calling other rays by this name are apt to bring much undeserved reproach upon a method which is really useful and whose effect is at times al- most magical, but quite frequently disappointing.
EYE, EAR, NOSE, AND THROAT.
Chronic Sphenoiditis and Middle-ear Disease. —
This subject is introduced by Emerson (Laryngoscope, Jan., 1903), who examined 268 cases of chronic catarrh ofn the middle ear. Caries of the sphenoid was found 25 times. These 25 and 10 seen later gave 32 unilateral, and 3 bilateral cases. Twenty-one cases were of chronic catarrhal otitis, 4 chronic suppurative, 7 chronic catar- rhal on one side and chronic suppurative on the other. Headaches were the rule ; 9 had vertigo. The head-pain was often only one-sided, where the sinus trouble was on the same side. Tinnitus often disappeared when the middle turbinate of the side affected was removed and the sinus curetted. "There is a relation between the pus formation incident to sinusitis and atrophic changes in the nasopharynx."
Electrolysis in the Eustachian Tube. — In the Jan. 1903, number of the Laryngoscope two articles of value on this subject are given. The first by Norval H. Pierce gives the result of a study of this treatment in 20 cases after other treatment had been tried. Ten were cases of "oto-sclerosis, or rarefaction of the laby- rinthine capsule." Eight were catarrhal, one nervomus- cular, one syphilitic. The oto-sclerosis cases were all treated once a week for two months together with cathe- terization every other day. Audition was not improved in any one of them ; nor were the entotic sounds di- minished. Tuning fork tests for upper and lower limit were unchanged. In none of the eight catarrhal cases was there any improvement beyond that by other methods. "In a certain few cases where there is proba- bly a soft exudate near the isthmus, ths treatment may be of some value." In thfr second article by J. O. Tansley a minute account is given of the finding of a broken end of an electrolytic bougie in the pharyn- geal opening of the tube, whose removal permitted of beneficial treatment by the ordinary methods. The
analysis of 33 cases given by Harris, is referred to as showing its results, which are disappointing and the treatment not without danger and certainly not better than other methods.
Follicular Conjunctivitis and Trachoma. — The larger number om cases of trachoma, which have been reported among school children of this city, has led to the suspicion that a mistake in diagnosis has been frequently made. Considering how difficult it is even for an expert to differentiate between follicular conjunc- tivitis and trachoma it is perhaps not to be wondered at that the superficial exam.inations made by inex- perienced men should result in numerous errors. E. M. Alger (Med. Rec, Jan. 24, 1903) points out that trachoma is a comparatively rare condition in children while follicular conjunctivitis is very common. They are both characterized by granulations which cannot be differentiated either macroscopically or microscopically. These granulations are simply collections of adenoid tissue. In trachoma the essential feature is the hyper- trophy of the conjunctiva. Without this there can be no future development of scar tissue and the disease is a trivial one. The subjective symptoms of trachoma are noticeable. The patient complains of gluing of his lids, photophobia, sand in his eyes, the upper lid is partly dropped and there is more or less purulent dis- charge. In a portion of the cases injury to the cornea follows, either ulceration or pannus. When the thick- ening of the conjunctiva has reached a certain height a process of cicatrization begins and continues till the hypertrophic tissue has been replaced by a thin white scar and it is from the contraction of these scars that the most troublesome sequelae come. Follicular conjunc- tivitis is simply the reaction through the lymphatics of the conjunctiva to local irritation which may be chemical, mechanical of bacterial. On the lids there are small wound granules, not larger than pin heads because they are limited by the close adhesion of the membrane to the lid, but in the loose tissue of the for- nix they are much larger, resembling frog spawn. The symptoms are usually very slight and the trouble will disappear if the cause of the irritation is removed. Since a fair percentage of the children who were re- cently condemned to trachoma, received their first inti- mation of any eye trouble when they were told by the examining physician it is reasonable to believe that the jiatural mistake of confusing the two conditions was frequently made. In treatment there has been an equal confusion. In trachoma it is considered an ideal result to get finally a thin white scar not capable of contracting unduly or of causing irritation to the corneal surface, and many have been led in the pur- suit of this ideal to treat with bluestone and silver nitrate follicular conjunctivitis which would not de- velop scars even if left entirely without treatment. The latter cases are generally benefited by cod-liver oil and iodide of iron. Locally, good results maybe obtained by applying with a swab, at least three times a week, a solution consisting of:
I^ Ichthyol 1T|, XV
Tr. lodi 3 j
Glycerini 5 j
As the conjunctiva improves the solution is rubbed in more vigorously. On the alternate days an instillation of the following is made at home :
H Zinci Sulph gr. j
Vin opii TT\, viij
Aquae 5 ss
M. et Sig. : One drop in each eye t. i. d.
Expression is perhaps helpful if the child can be closely watched but it is unnecessary and a majority of the cases must be treated without it. The treatment of real trachoma demands a more thorough and care-
654
MEDICAL PROGRESS : THERAPEUTICS.
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ful management under the close observation of a com- petent medical man, to avoid the serious results of scarring.
Ozena in Nurslings. — One-tenth of the cases of ozena treated by A. Riviere (Jour, de Med. de Paris, Feb. 15, 1903) occurred in infants under one year; therefore he holds that the affection is of more frequent occurrence in early life than is generally supposed ; and that in many cases diagnosed as chronic coryza and infectious purulent or impetigenous rhinitis, care- ful examination would show^ the characteristic atrophy of the turbinates and nasal mucosa, wide nasal fossae, crusts and malodor of ozena. Under appropriate treat- ment he has not only seen the local trouble subside but complicating gastro-intestinal disturbances disappear ; marked improvement in the general health ensuing. Riviere treats such cases by daily irrigation of the nasal cavities with halt or boracic acid solution; using in preference a soft urethral catheter connected with the delivery-tube of a vessel suspended not more than 0.15 to 0.20 above the child's head.
THERAPEUTIC HINTS.
Large Doses of Salicylates in Uveitis. — By mis- take a patient of H. McI. Morton had taken four or five 6o-grain doses of salicylate of soda every three hours with marked improvement next day of the uveitis. In subsequent use of large doses he had noticed similar response in this disease. He cites Marageliano in sup- port of the view that it is not a depressant of the heart, for the arterial pressure is elevated in moderate dosage. In severe cases Morton (Oph. Record, Jan., 1903) gives 40 grains of the salicylate every two or three hours till relief is obtained.
Calomel in Pneumonia. — The beneficent influence of calomel in pneumonia is emphasized by C. Bertalozzi (Gazz. Osped., Jan. 18, 1903) who, in one case, not only gave the drug with excellent results in the onset of the disease, but apparently brought about a sudden and re- markable improvement when the disease was at its worst and the patient profoundly exhausted from its effects, through repetition of the initial treatment, i.e., calomel 0.65, scammony 0.25. Prior to its administra- tion the temperature was 39.5 C, pulse no, respiration 43. The day following, the temperature dropped to 36.6 C, pulse 70 and respiration 38. This seemed to mark the turning point in the disease; abundant pers- piration ensuing after the one large stool produced by the remedy, and evidences of the breaking up of con- solidation soon being apparent on percussion and aus- cultation. The author concludes that the influence of calomel in pneumonia is to be attributed to the cuta- neous vasoparalysis and subsequent perspiration it in- duces in common with antipyretics in general, and to its intestinal derivative effect by means of which a good part of the blood is drawn from the lung and the toxic principles with which the organism is embarrassed, car- ried off in the abundant stools.
Pilocarpine in Scarlet Fever. — The physiological effects of this drug are exerted chiefly upon the secre- tions in the following order of potency : salivary, muci- parous, mammary, sudoriferous, lacrymal and renal. Vomiting is frequent, the pulse slower and softer, the respiration superficial and retarded. Amblyopia oc- casionally supervenes, and the growth of hair may be stimulated. Increased leucocytosis is invariable. There are many contraindications to the use of the drug, as in cardiac or respiratory difficulties, asthenia, the very young, the aged, and where the system cannot stand depression. E. W. Saunders (Arch, of Ped., Feb., 1903), finding that, according to the researches of the Pasteur Institute, the saliva possesses the greatest toxi- lytic power of all the secretions and is poured out
in the locality where the scarlatina toxins are formed, regards pilocarpine as the most valuable single agent against scarlatina and its associated affections. It should not be given in immediate conjunction with the coal-tar antipyretics, and each dose is better preceded by bathing. Chloral is nearly always indicated in small, frequently repeated, doses. In case of disagreeable effects from pilocarpine, a hypodermic of atropine, the "physiological antidote" will protect the patient. Toleration is rapidly established. A great gain is in the prevention of parched mouth and lips.
Gelatinized Serum in Typhoid Hemorrhage. — On the eighteertth day, in a case reported by Vidal (Le Progres Med., Feb. 14, 1903), the patient having sus- tained a large hemorrhage, was given an injection of 250 gm. of saline. The bleeding continued, however, in spite of two subsequent saline infusions. So 20 c.c. of gelatinized serum were injected hypodermatically and 250 gm. given by rectum. The next morning the pa- tient was better, having been through the night stimu- lated with caffeine, strychnine and camphorated oil. Apparently the bleeding had ceased. Ten c.c. more of gelatin serum were administered and saline every twelve hours, and there was no further hemorrhage. To make gelatin serum it is necessary to take a very pure gelatin, that prepared for bacteriological purposes, dis- solve it in an isotonic liquid, such as. normal saline, filter it hot into flasks, and subject these to a tempera- ture of 115° C. for fifteen minutes. If it is heated longer the serum may solidify very hard on cooling. This is a fine culture medium for bacteria, therefore should be fresh made and much care taken in its preparation. The serum slowly solidifies, so before use it must be brought to a perfect liquid at 50° C. (122° F.). Should it be kept, contamination is at once evident by the ap- pearance on its surface of bacterial cultures. Falling of the Hair. —
^ Pilocarpinae nitrat... 0.50 (gr. viij)
Tinct. cantharidis 10. (3iiss)
Glycerini 25. (3vj)
Aq. Cologniensis ad. 240. (5viij)
— Bulletin Gen. de Therapeutique, Jan. 30, 1903. Headache from Eye-strain. — Of local applications, the simplest, most effective and least harmful, accord- ing to C. A. Wood and T. A. Woodruff (Med. Stand., March, 1903), are very hot or very cold fomentations. Fold a towel to twelve inches by four, dip into water at 40° C. or at 160° to 180° F., and press gently against eyes, forehead and temples. Repeat every fifteen sec- onds for five minutes. A soothing collyrium may re- lieve by its action on the congested conjunctiva, as: li Sod. borat.
Ac. borici aa. gm. 2. (5ij)
Aq. camphorae 15. (3ss)
Suprarenal 0.7 (Sss)
Aquae q. s. ad 60. (gr. x)
Shake well, allow to stand an hour or two, and use the supernatant liquid to drop into the eye. Another effective eyewater is :
IJ Chloreton .' o.i (gr. jss)
Sod. borat 0.5 (gr. viij )
Aquae ....... ^ 30. (3j)
A local application to forehead and temples is :
IJ Spt. Camphorae 30. (5j)
Spt. Lavand 90. (Siij)
Alcohol 90. (5iij)
Or the following liniment :
B Chloroformi 30. (5j )
Camphorae 8. (3ij )
Tinct. aconiti 8. (3ij)
01. menth. pip 0.7 (tT\,x)
Alcohol 60. (5ij)
Temporary relief may usually be obtained from a weak galvanic current.
April 4, 1903]
EDITORIAL.
655
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SATURDAY, APRIL 4, 1903.
THE SIMPLICITY OF MODERN SURGERY.
It is gratifying to be able to feel that a very simple cosmos is shortly coming out of the dread- ful chaos in which surgery has been for the last thirty years. It was a prodigious effort for the great surgeons who are now all but passed away, to assimilate, to practise, and to teach the over- whelming changes which have come within that time. They occupied an unenviable position in that they were obliged to graft upon the teachings more ancient than ^sculapius the wonderful rev- elations of an undreamed of science. Very nat- urally none or almost none of them were able to disentangle themselves from the old, from the useless, from the dross that had been handed down to them from the past centuries. Even modern text-books of surgery, which are writ- ten by the students of this great generation of men, are still encumbered by much that is old, ill timed, and useless.
Starting with the assumption that asepsis has made all things possible in surgery, it is exceed- ingly interesting to note what sweeping changes have been made in time-honored operations by the perfection of some sijnple technic or the intro- duction of an insignificant instrument. When Reverdin and Thiersch taught that the trans- plantation of skin grafts was a simple matter, they
little dreamed how destructive the application of their experiments would be on many operations that had been considered impregnable in their perfection. Take for example the modifications wrought by this innovation in the technic of am- putation of the breast. It has done away here as in many other cases with plastic surgery.
Not as important as this from the standpoint of saving life, but of great value in giving to the living longer, and therefore more useful, extrem ities after amputation, is the application of skin grafting to the stump following the removal of fingers and of toes. In many cases, even rela- tively proximal amputations are finished by skin grafting instead of by the use of the classical flaps. This efifects a saving of perhaps ten per cent, in the length of the part.
Finney has taught how unnecessary are the complicated operations for that minor but griev- ous disorder, ingrowing toe-nail, all requisite be- ing a shaving away of the nail and soft tissues followed by skin grafting. So grafting is seen to modify surgery as well as other arts.
An immense amount of space is devoted to such classic works as Pancoast's Operative Surgery, to the methods of ligating arteries in their continu- ity. Page after page deals with the problem of arresting hemorrhage. How rarely do we see an artery tied to-day proximal to the seat of trouble and how easy it is to control the flow of blood with our hemostatic forceps.
It is, perhaps, in the most recent treatment of peripheral aneurisms, that we can recognize, bet- ter than elsewhere, the simplicity of the modem trend. The Greek, Phillagrius extirpated the sac in toto. Antyllus left it in situ, Ijgating above and below. Hunter, Anel, Brasdor, Wardrop, and others selected special points at which to tie. Tufnell, of Irish fame, recognizing the futility of all existing treatments, proposed that all aneur- isms be treated by the formula : "Rest, starve, purge and K. I." It never occurred to anybody that the simplest treatment was to open the sac, ligate the lumina which lead to the vessel and ob- literate the cavity by a few simple stitches, thus curing the disease without interrupting the po- tency of the artery. This has very recently been successfully practised by Matas of New Orleans. For thirty years asepsis had made such a technic possible but the yoke of the old treatments clings so tightly that progress is painfully slow.
We are arriving, however, and the students of ten years hence will not have to unlearn so much surgical dross as it has been our lot to do.
656
EDITORIAL.
[Medical News
PNEUMONIA'S INCREASING VICTIMS.
The fatal months of the year, that is, the months in which the most deaths occur, are March and April. This is of course for adults, for, as is well known, for children under five years of age, July and August are the special death months. Practically all the statistics show March to be the most fatal month of the year, but, curiously enough, April is a very close sec- ond. When we consider how presumably un- healthy are the colder blustery winter months, from December to February, it may be some- what of a surprise to find April with so bad a reputation. The month deserves it, however, mainly because of the large number of deaths from pneumonia which occur during this change- ful period.
Pneumonia is coming to occupy an ever more and more prominent place in the mortality list of our large cities. Even in the last three years there has been a distinct deterioration of condi- tions, so that a still higher death-rate from pneu- monia is found to exist than even in 1900. The Chicago Board of Health made a public state- ment not long ago that since the census year, 1900, pneumonia has claimed more than one- eighth of all the victims of the Grim Reaper in Chicago, one-third more than consumption and 46 per cent, more than all the other contagious and infectious diseases combined, including diph- theria, erysipelas, influenza, measles, puerperal fever, scarlet fever, smallpox, typhoid fever and whooping cough." The total number of deaths from all these diseases, during 1901 and 1902 was only 4,489, as compared with a total of 6,562 deaths from pneumonia.
Since pneumdnia has thus become "the cap- tain of the men of death," to use Professor Osier's expressive phrase, replacing consumption, which had occupied that bad eminence for so long be- fore, it is important that prophylactic measures should now be directed mainly to the reduction of pneumonia mortality. The task is not an easy one and looks by no means promising, but twenty-five years ago to have announced that the reduction of the morta:lity from consumption must be at- tempted would have seemed quite as hopeless a task. At the present time, however, the consump- tion mortality has diminished about one-third on the average in the large cities of this country and the outlook for further favorable progress in this matter is most promising. Doubtless the same thing will be true of pneumonia, if persistent and concerted effort is made, with the proper realiza-
tion of what the elements of danger with regard to the disease really consist in.
Pneumonia is most fatal at the extremes of life, among the very young and the very old. These classes of individuals then must be guarded as carefully as possible from infection and contagion and must never needlessly be allowed to associate with those who are suffering from pneumonia, or be brought in contact with any of the discharges from the lungs of such patients. This may seem a needlessly refined precaution, or rather it may seem pushing precautions entirely too far. Twen- ty-five years ago the same objection would have been made to the taking of similar precautions with regard to tuberculous sputum. Now regu- lations insisting on the utmost care with regard to expectorated material are accepted as the only rational course to pursue. It is well known that pneumonia, no matter what its cause, in a hospital ward containing a number of young patients, is likely to affect several of them in succession and while not virulently contagious, there is surely a contagious element present.
The deaths from pneumonia among adults usually occur under special conditions. Fatal cases occur typically in individuals who contract pneumonia while suffering from kidney or heart trouble. It is well understood that among the middle-aged, according to the familiar expression, it is not the pneumonia itself that is dangerous, so much as what the patient takes into the pneu- monia with him. Patients suffering from heart disease or nephritis, should be warned to avoid, especially in the springtime, what are now gener- ally conceded to be the occasions of pneumonia. They should, during unsettled weather and par- ticularly while pneumonia is prevalent, avoid, as far as possible, getting into crowds in cars or depots and the like, and should not frequent crowded theaters and other overheated public places. These precautions are especially neces- sary for those who have once suffered from pneumonia, as it is well understood that the dis- ease, far from conferring immunity, rather pro- duces a predisposition to recurrence.
Another important factor in the mortality of pneumonia is the delay so often foolishly pre- sumed upon by young and otherwise healthy adults, in giving up their ordinary avocations and recognizing that they are ill. A patient who walks about until the third or fourth day of a pneu- monia, no matter how robust his previous health, will surely succumb to the disease. Family physi- cians should make it a rule to warn members of
April 4, 1903]
ECHOES AND NEWS: NEW YORK.
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families under their care that the occurrence of a chill after a few days' uncomfortable feeling-s, followed by some febrile temperature, should be the signal for remaining in bed until the physi- cian's permission has been obtained to go out again. This simple rule, if faithfully followed would save many a life. The exhaustion conse- quent upon even slight muscular effort during the initial stage of a pneumonia is enough in itself to make an otherwise mild case likely to be fatal.
There is and remains a curious coincidence, at least between the curve of frequency of pneu- monia and the occurrence of windy days, during which dust is blown about. It seems not un- likely that this points to the necessity for our municipal health authorities taking care to lay the dust and by efficient street cleaning prevent- ing the accumulation of material that may prove pathogenic when inspired. A dustless city is no Utopian dream, and will some time surely come. Meantime it is to be hoped that the enforcement of the regulations against expectoration in public places, which has been begun in very serious spirit of late years, will be continued. Pneumonia is no accidental occurrence. The germ may be present and virulent, but there seems no doubt that every opportunity given for its distribution is an invitation for the spread of the most fatal disease with which we have to deal at the present time.
MEDICAL JOURNALISM.
Those of us who are still wrestling with the problem of how to supply a sufficient quantity of literary pabulum to our medical brethren feel a touch of envy at the slippered ease of our whilom contemporary, Dr. James C. Johnson who, until recently edited and managed the Journal of Cu- taneous and Genito-Urinary Diseases.
He indulges in a little retrospect of medical journalism in the columns of the Philadelphia Medical Journal and cleverly sets forth an editor's "struggles with printers, photo-engravers, lithog- raphers, paper-makers, post-office authorities and non-paying debtors."
It is a heart-to-heart talk that reveals the edi- tor to the contributor, and both to their readers. He admits the fact that we do not write all our own editorials and book-reviews and abstracts, and that we are publishing about twenty-five times as many journals as our readers really need.
He voices our own opinions when he says "Cir- cumnavigation of the circumambient is a favorite
pastime of medical authors." "A meaner man than the one who married on Christmas day a girl whose birthday was the twenty-fifth of De- cember is he who sends his article to all the journals he knows of at once, and prays for an immediate hearing."
He touches the author's heart when he says, "The best reviewer is one who not only knows the subject, but has written on it, if possible, a book. His justice is then tempered with mercy. De- structive criticism is almost the easiest of literary pyrotechnics and, while it may be a choice spec- tacle, there is nothing left but aerial smoke."
As he tritely remarks, "Journalism is, like ec- zema, a blood disease, and can rarely be cured in a lifetime;" so those of us who are undergoing the throes of editorship are only hoping that Dr. Johnson will have another attack.
ECHOES AND NEWS.
NEW YORK.
Eastern Medical Society. — The Eastern Medical Society held its Annual Reunion at the Hotel Marl- borough, Saturday evening, March 28, 1903.
City Consumption Camp. — Commissioner Lederle of the Health Department sent to Mayor Low Mon- day a letter urging the establishment of a sanitarium for the treatment of tuberculosis on the tent and ducker plan, on a tract of twenty acres in Orange county, which has been offered to the city for two years, without rent. Dr. Lederle says that 8,883 persons in this city died from lung diseases in 1902, and 8,135 in 1901. The time has come, he says, when the city should increase its facilities for treating tuberculosis. He has been much impressed by the opinions of leading physicians with regard to the efficiency of the open-air treatment, but the plan of the Charity Organization Society's committee for a tuberculosis sanitarium and camp is too elaborate and costly. With the appropriation of $35,000 he could operate a camp for sixty patients on the Orange county tract from May i to Dec. 31 next. The occupation of this ground will cost the city nothing, and if the outdoor treatment suggested should prove successful he predicts there will follow a development on a large scale of this method of dealing with tuberculosis.
The Late Dr. T. Gaillard Thomas.— At a meeting of a committee appointed by the Medical Board of the New York Infant Asylum held March 30, 1903, the following resolutions were adopted:
Whereas, The late Dr.