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<div>*** START OF THE PROJECT GUTENBERG EBOOK 59175 ***</div>


<div class='tnotes covernote'>

<p class='c000'><b>Transcriber’s Note:</b></p>

<p class='c000'>The cover image was created by the transcriber and is placed in the public domain.</p>

</div>

<div class='titlepage'>

<div>
  <span class='pageno' id='Page_97'>97</span>
  <h1 class='c001'><span class='xlarge'>NASHVILLE JOURNAL</span><br /> <span class='small'>—OF—</span><br /> MEDICINE AND SURGERY</h1>
</div>

<div class='nf-center-c0'>
<div class='nf-center c002'>
    <div>CHARLES S. BRIGGS, A.M., M.D., Editor.</div>
    <div>W. T. BRIGGS, B.A., M.D., Associate Editor.</div>
  </div>
</div>

<table class='table0' summary=''>
<colgroup>
<col width='33%' />
<col width='33%' />
<col width='33%' />
</colgroup>
  <tr>
 <td class='btt bbt c003'><span class='sc'>Vol. CX.</span></td>
 <td class='btt bbt c004'>MARCH, 1916.</td>
 <td class='btt bbt c005'>No. 3</td>
  </tr>
</table>

</div>

<div class='chapter'>
  <h2 class='c006'>Original Communications</h2>
</div>

<div class="section"></div>
<h3 class='c007'>CASES OF RENAL TUBERCULOSIS ILLUSTRATING MODERN METHODS OF DIAGNOSIS.[A]</h3>

<div class='nf-center-c0'>
<div class='nf-center c008'>
    <div>BY HOWARD S. JECK, PH.B., M.D.,</div>
    <div>New York, N. Y.</div>
  </div>
</div>

<p class='c009'>Renal tuberculosis occupies a pre-eminent place in the list
of those diseases whose initial symptoms are apparently so
insignificant and whose onset is so insidious that the true
state of affairs is either entirely overlooked or else recognized
only after it is too late to accomplish the most good.</p>

<p class='c009'>[Footnote A: To the courtesy and generosity of Dr. Edward L. Keyes, Jr., with
whom I am now associated, I owe the privilege of employing the above
cases, which have been selected from his wonderful storehouse of instructive
case histories.]</p>

<p class='c009'>A large number of the cases that come under our observation,
exhibit symptoms which are referable solely to the
bladder in the guise of a mild cystitis, the patients perhaps
complaining only of a slightly increased frequency of micturition
by day, not even being disturbed once at night to
empty his bladder. Here the temptation on the part of many
physicians at once arises to treat such cases lightly—doubtless
<span class='pageno' id='Page_98'>98</span>to dismiss the patient with assurances that his condition
is one of a mild inflammation of the bladder which, in all
probability, will soon right itself after an irrigation or two,
plus a few tablets of urotropin.</p>

<p class='c009'>On the other hand, the onset may be so stormy or symptoms
so terrifying, that we at once think of all the horrible
conditions to which the genito-urinary tract is heir. But
once our suspicion is aroused as to the possibility of tuberculosis
of the kidney, the question of an exact diagnosis, the
question of which kidney is involved, and the condition of
the other kidney (on which naturally depend the course to
pursue) are matters not always easy to decide.</p>

<p class='c009'>To this end, cystoscopy, ureteral catheterism, renal function
tests and the X-ray, lend themselves as invaluable aids.
But we must remember that even with so much assistance at
hand, the pitfalls are many and it is with the hope of pointing
out a few of the former as well as emphasizing the more
certain means of diagnosis, that I feel justified in this presentation.</p>

<p class='c010'><i>Case I</i>,—E. P. was first seen in September, 1907. He
then complained of an ulcer on the penis and frequent and
painful urination. One brother had died of pulmonary tuberculosis.
The ulcer had appeared a year previously, beginning
with a redness of the meatus, which persisted, with
superficial ulceration. No history of exposure. In April,
1907, the dysuria began, and at the time he first consulted
Dr. Keyes, he was urinating every two hours, day and night.
He had also experienced a chill three weeks before this time.</p>

<p class='c009'>The patient had never noticed any blood in his urine. His
weight had dropped from 170 to 149. Physical examination
showed his kidneys to be insensitive, and his prostate and
seminal vesicles were negative.</p>

<p class='c009'>The urine was acid, showed a fair amount of pus and albumin,
but no casts. No. T. B. bacilli found.</p>

<p class='c009'>A month later the patient was seen again. In the interim
he had suffered an attack of fever (T. 105), and also an intense
pain in the right testicle and right side, lasting four
<span class='pageno' id='Page_99'>99</span>days. The urine suddenly showed a great increase in pus
after which relief followed. All this time the prostate remained
unchanged, but the right kidney was now tender on
palpation.</p>

<p class='c009'>During the next couple of months the patient showed a
quite perceptible general improvement on anti-tubercular
treatment, but had at times passed some blood in his urine.</p>

<p class='c009'>However, in January, 1908, he began to have pain all over
the abdomen. Cystoscopy having been unsuccessfully attempted
two months previously, separate urines from the
right and left kidney were now obtained by means of the
Luys’ urine separator and showed the following: From the
right kidney, 14 cc. of urine, containing 2.4% urea, and a
slight amount of pus; from the left kidney ¾ cc. of urine, a
very little urea and a large amount of pus. A nephrectomy
of the left kidney a few days later revealed a small tubercular
pyonephrotic kidney, with an apparently normal ureter.</p>

<p class='c009'>In April, 1910, this patient was heard from directly for
the last time. By virtue of his social status he was forced
to lead a life which was not in conformity with his personal
welfare, doing hard manual labor most of the time. And
while he has suffered various setbacks, he always managed
to readily recuperate under enforced rest and anything like
proper hygienic conditions. He had even gained considerable
weight when, another setback occurring, due to over-exertion,
he went to the Adirondacks, immediately contracted
pneumonia, and died within a week of its beginning.</p>

<p class='c009'>While the above case does not serve especially well to illustrate
a pre-operative diagnosis of renal tuberculosis, inasmuch
as there was no X-ray and no T. B. bacilli were ever
found in his urine, it does bring out a certain fairly infrequent
symptom which would be extremely—I might almost
say—fatally, misleading in the diagnosis of surgical conditions
of the genito-urinary tract but for other aids in diagnosis.
I refer to the phenomenon of crossed renal pain.
That this was renal involvement of a kind requiring surgical
interference was well evidenced by the blood and pus in his
<span class='pageno' id='Page_100'>100</span>urine, together with his history of pain at various times.
But had we gone strictly by the pain, whose location was
chiefly in his right testicle and right side, the patient would
have been the victim of a nephrotomy, at least of his right
kidney. However, the presence of 2.4% urea with a slight
amount of pus (probably pus from the bladder as the Luys’
separator does not always preclude this possibility) from
the right ureter as against a very slight amount of urea and
a large amount of pus from the left ureter, dispelled all question
of doubt as to which kidney should be explored.</p>

<p class='c010'><i>Case II, E. B.</i>—Male, gave the following history: A father
and two brothers died of pulmonary tuberculosis. Others
in the family had lived to ripe ages.</p>

<p class='c009'>At the age of 31, the patient passed blood in his urine.
Three years later he experienced right renal colics and slight
irritability of the bladder. The colics continued every few
weeks for seven years. Then, because of an attack of intense
bladder symptoms, and profuse hematuria, Dr. Charles
McBurney diagnosed the condition as renal calculus (this
was in 1900—the pre-radiographic days), explored the kidney,
and found nothing.</p>

<p class='c009'>The operation relieved the renal colics. But the bladder
still caused him untold agony, the patient urinating blood
every two or three hours.</p>

<p class='c009'>On January 16, 1908, eighteen years after the first symptoms
of his disease, the patient consulted Dr. Keyes, having
in the interval suffered three vain searches for stone and
two cystoscopies, and having developed double tubercular
epididymitis.</p>

<p class='c009'>Physical examination revealed nothing except ridgy seminal
vesicles. The urine was cloudy and contained a small
amount of albumin, pus, red blood cells, a few hyaline casts
and many T. B. bacilli.</p>

<p class='c009'>The X-ray revealed an irregular shadow in the right kidney
region, which the radiographer reported as “consistent
with a diagnosis of renal tuberculosis.”</p>

<p class='c009'><span class='pageno' id='Page_101'>101</span>Cystoscopy was now tried again, but failed on account of
the extreme pain attending it. Recourse was then had to
the experimental polyuria test, which showed fairly good,
though deficient renal function. The diagnosis of tuberculosis
of the right kidney being now fairly certain, the kidney
was removed in April, 1909. Though the pelvis was uninvolved,
the parenchyma was riddled with abscesses, the latter
confirming the diagnosis.</p>

<p class='c009'>I had the pleasure of seeing this case as recently as February
2d of this year. While the function of his remaining
kidney is evidently quite poor, as shown by an output of only
16% of phenolsulphonephthalein (injected intravenously)
in the first half hour and 10% during the second half hour,
he says he feels fine and has suffered only moderate inconvenience
due to frequency. His weight is now 178 and has
remained so for quite a time. While his urine still contains
pus, a careful search failed to reveal the presence of T. B.
bacilli. Could Dr. McBurney have availed himself of the use
of the X-ray and our present renal functional tests, he doubtless
would not have been satisfied with a mere exploratory
operation. And, finally, eighteen years later, when the X-ray,
together with the patient’s symptoms and urinary findings,
did point out the true diagnosis, and the kidney which
was involved, or most involved, it remained for the polyuria
test to decide the question of operating at all. For, while
the right kidney was tubercular without a doubt, who could
offer any prognosis as to the outcome in the event of a nephrectomy,
without some knowledge of the condition of the
other kidney? That the X-ray showed nothing definite on
that side, told us nothing of the kidney’s functional power.</p>

<p class='c009'>Since cystoscopy, or the passage of any instrument of any
size into the bladder could no longer be endured, reliance had
to be placed on the experimental polyuria test. This showed
fairly good renal function <i>somewhere</i>, and inasmuch as the
X-ray had shown what was probably a considerable involvement
of the right kidney, it was inferred that the “fairly
good renal function” belonged chiefly to the left kidney.
<span class='pageno' id='Page_102'>102</span>The case, also well emphasizes, the fact that renal tuberculosis
may exist for a long time and then respond to proper
treatment.</p>

<p class='c010'><i>Case III, G. S.</i>—In October, 1904, this patient then nineteen
years of age, consulted a physician in Albany N. Y.,
because of moderate frequency of micturition by day and
night, attended by much terminal pain and blood on a few
occasions. T. B. bacilli were found in his urine at that time,
which gave a positive guinea-pig test. Cystoscopy was performed
and as a result the patient had chills, a rise in temperature
to 104, and some pain over his left kidney. A
diagnosis of tuberculosis of the prostate was made and the
patient put on treatment which resulted in an amelioration
of his symptoms for some time.</p>

<p class='c009'>In January, 1909, Mr. S., first came to Dr. Keyes on
account of frequent urination, incontinence, and a swollen
testicle. There was no family history of tuberculosis, and
his previous history was that given above. A twenty-four
hour specimen of urine gave the following analysis: Amount
2070 cc., sp. gr., 1014, acid, urea 1.2%, a trace of albumin,
no sugar, white blood cells, red blood cells, but <i>no tubercle
bacilli</i>. On physical examination it was found that he had a
lump in the left lobe of his prostate and also in the tail of
his right epididymis. There was in addition, a dense stricture
extending from the peno-scrotal angle to the triangular
ligament.</p>

<p class='c009'>During the next few days, the stricture was dilated sufficiently
to permit a cystoscopy which showed the bladder to
be much ulcerated. The right ureteral orifice was considerably
congested, and the left resembled an irregularly-shaped
volcanic crater. It was impossible to catheterize either
ureter.</p>

<p class='c009'>The X-ray report was pyonephrosis of the left kidney.
After an injection of 2 cc. of phloridzin, no sugar appeared
in the urine until two hours and fifteen minutes had elapsed.
A month later, on account of his stricture having recontracted,
internal and external urethrotomy were done, and
<span class='pageno' id='Page_103'>103</span>it is of interest to note that in place of prostate, there was a
cavity as big as a plum, with hard tubercular walls. Six
days later, another attempt was made to catheterize the
patient’s ureters without success. His bladder picture was
the same as before. Likewise unsuccessful was an attempt
to pass a Luy’s urine separator. At this time, another phloridzin
test gave no sugar at the end of four hours. Two experimental
polyuria tests made a week apart, showed rather
poor functionating power of the kidneys. Although it was
impossible to obtain separate urines from the kidneys, in
view of the functional tests all pointing to an involvement
of one or both of these organs, it was decided to perform an
exploratory nephrotomy especially since the patient was apparently
getting worse in spite of all treatment.</p>

<p class='c009'>The location of the pain in his early history and the X-ray
report certainly indicated the left kidney as the more probable
one to be affected. Therefore, on March 13, 1909, a
nephrotomy of the left kidney was done. The kidney was
low and lay almost transversely. The pelvis and ureter were
entirely uninflamed but much dilated, the ureter being larger
than a lead pencil. An incision into the ureter allowed about
100 cc. of apparently clean urine to escape. A soft rubber
catheter was introduced into the ureter and stitched into
the lumbar wound. Now comes the startling feature of the
whole story. Immediately after the operation, <i>all urine
stopped coming from the urethra and perineal wound</i> and in
its stead came only pus, while apparently normal urine
flowed from the tube in the loin. This continuing to be the
case, forced the conclusion that the right kidney was either
absent or practically destroyed; the latter view was substantiated
by an excellent X-ray, subsequently made, showing a
small atrophied kidney on the right side.</p>

<p class='c009'>The patient made an uninterrupted recovery from his kidney
operation, but his perineal fistula never completely
healed.</p>

<p class='c009'>Three years after his nephrotomy he was re-operated upon
in order to close his perineal fistula and died as a result of
<span class='pageno' id='Page_104'>104</span>shock. In the meantime, however, he had gained much in
weight, had improved generally and returned to his work.
No T. B. bacilli could be found in his urine at the time of
his last operation.</p>

<p class='c009'>Here, then, is an instance in which the X-ray, which had
rendered so valuable a service in the preceding case, deceived
the surgeon and then later redeemed itself, to some
extent, by demonstrating the size of the right kidney. For
the radiograph of the left kidney showed a rather typical
picture of pyonephrosis. Hence, obviously, the lesson to be
learned from this is that under certain conditions, water
may throw a shadow similar to that of pus, so that it is not
always possible to differentiate a pyonephrosis from a hydronephrosis
by such means.</p>

<p class='c009'>The crater-like appearance of the right ureteral orifice,
though quite suggestive, was hardly evidence enough to warrant
a diagnosis of tuberculosis of the right kidney, but had
it been possible to catheterize both ureters or even only one
(either one), the question of the involved kidney, the approximate
amount of involvement, and the condition of the
opposite kidney, could have been readily cleared up.</p>

<p class='c010'><i>Case IV</i>,—J. L., age 30, was admitted to Dr. Keyes’ service
in Bellevue Hospital in May, 1912, with the simple, but
all-important, history of hematuria and frequency of urination
for one year. A physical examination of the lungs
revealed probable tubercular lesions. Cystoscopy with
catheterization of the ureters was performed at once, showing
pus from the right ureter whose orifice was swollen,
with deficient function of the right kidney. A microscopical
examination of the urine from this kidney showed the
presence of Gram negative cocci (which could not be grown,
however,) and later a culture of the bladder urine showed
Gram negative cocci which were positively identified as gonococci.</p>

<p class='c009'>Finally, T. B. Bacilli were found in the bladder urine.
Suspecting the right kidney of being tuberculous, 25% argyrol
was injected into the right renal pelvis, and the right
<span class='pageno' id='Page_105'>105</span>loin X-rayed. An excellent radiograph showed small round
shadows throughout the kidney, and a mouse-eaten appearance
of some of the papillae, a typical tuberculous picture.
This diagnosis was subsequently confirmed by the finding of
T. B. bacilli in the urine from the right kidney. The right
kidney was accordingly removed, and found to be rotten
throughout. It was likewise full of argyrol. When last
heard from (February, 1915), the patient had gained considerable
weight despite his lung condition.</p>

<p class='c009'>The above case was selected mainly to show what was
doubtless a gonococcus infection engrafted on to a tubercular
kidney, as it is only reasonable to suppose that the Gram
negative cocci obtained from the right ureter were the same
as those in the bladder which was subsequently found to be
gonococci.</p>

<p class='c009'>Aside from the readiness with which the diagnosis of
tuberculosis of the right kidney was made (by virtue of the
T. B. bacilli in the urine) the swollen right ureteral orifice,
pus from the same, and deficient function of the right kidney
by the phenolsulphonephthalein test, the case is of further
interest because of the corroboration of this diagnosis
by pyelography after the injection of an organic silver preparation.</p>

<p class='c010'><i>Case V</i>,—P. B., 27. Entered St. Vincent’s Hospital in
February, 1911. Family history of no importance; was a
heavy drinker; denied venereal disease. Pneumonia two
years before admission. On his neck was a scar from a
gland which suppurated at that time. Hematuria was his
chief urinary symptom. Six years before he had had profuse,
spontaneous and painless passage of blood in his urine,
which stopped after a few days. When he was admitted to
the hospital he had been bleeding again, but there were
no other symptoms referable to his urinary tract. He had
lost no weight. Immediately after entering the hospital he
had delirium tremens, which lasted two weeks. At the end
of this time, physical examination showed a very large low
kidney on the right side and a slight pulmonary dulness at
<span class='pageno' id='Page_106'>106</span>the base of his left lung. Cystoscopy revealed a normal
bladder and normal ureteral orifices. The ureters were
readily catheterized, the result of functional tests made being
as follows:</p>

<p class='c009'><i>Right kidney.</i>—5 cc. of urine (in eight minutes) containing
numerous casts, a few w. b. c., but no pus; 1.3% urea.</p>

<p class='c009'><i>Left kidney.</i>—3 cc. of urine (in eight minutes), containing
no casts, no pus; 0.3% urea.</p>

<p class='c009'>One cc. of phenolsulphonephthalein was now injected intravenously.
It appeared in eight minutes from the right
side and in nine minutes from the left. During the next
thirty minutes, the right kidney excreted 3% of the drug,
while only a trace was obtained from the left side; in the
following thirty minutes, the right side excreted 5.6%
while the left showed only 1.7%.</p>

<p class='c009'>The above findings hardly seemed to jibe with the patient’s
symptoms, and physical examination which suggested
tumor of the right side. However, the amounts of
urea and phenolsulphonephthalein excreted from the right
side were so much greater than the amounts from the left
side, that this fact certainly pointed to at least a greater involvement
of some kind of the left kidney, irrespective of
the condition of the right.</p>

<p class='c009'>Accordingly the left kidney was exposed and its upper
third found to be a cheesy mass, obviously an old tubercular
process. The patient was then turned over and an exploratory
incision revealed a low-lying right kidney which was
hypertrophied to twice its size, but otherwise apparently
normal. The patient was now turned back and his left
kidney removed. Both wounds healed by primary union, the
patient making an uneventful recovery.</p>

<p class='c009'>In later reviewing the case Dr. Keyes states that he would
have been warned of tuberculosis on the left side had he but
seen some pus in the urine from that side, for, as he further
says, “casts on one side and deficient function with pus and
without marked enlargement of the kidney upon the other
side, is very suggestive of unilateral tuberculosis.” The
<span class='pageno' id='Page_107'>107</span>case is of further interest on account of the greatly hypertrophied
right kidney. Aside from demonstrating the capability
of one organ to take over the work of its impaired
mate, it should emphasize the necessity of keeping in mind
such possibilities in making a diagnosis.</p>

<div class='chapter'>
  <span class='pageno' id='Page_108'>108</span>
  <h2 class='c006'>Selected Articles</h2>
</div>

<div class="section"></div>
<h3 class='c007'>PUERPERAL INSANITY.</h3>

<div class='nf-center-c0'>
<div class='nf-center c008'>
    <div>ELIOTT BISHOP, M.D.,</div>
    <div>Brooklyn, N. Y.</div>
  </div>
</div>

<p class='c009'>The request from the secretary of this society is a command
when he asks me to read a paper, otherwise I should
be more profuse in my apology for the modest effort I present
to you tonight. For me to present to the gentlemen of
achievement before me any of my rare dashes into the field
of major procedures in gynecology or obstetrics would be
farcical and I was casting about for something of interest
for us all to think about together tonight when two post
partum patients in the Low Maternity one afternoon developed
mental disturbances.</p>

<p class='c009'>As we must all admire the German attitude of continually
interrogating, so we must, when something unusual occurs,
say “Why” and “When?” and then become Yankees again
and say “What are we going to do about it?” Every few
years we must take stock of just such questions and it is perhaps
a reasonable duty for some of the younger and less active
members of this society like myself to make the inventory.</p>

<h4 class='c011'><span class='sc'>Definition.</span></h4>

<p class='c012'>Is it an entity? In Peterson’s “Obstetrics,” Lewis, of Chicago,
tells us that the opinion is gaining ground that it is a
coincidence and without etiological relation to maternity and
that to childbearing can we probably assign only an exciting
etiologic relation in the production of an outbreak of insanity.
The study of so-called puerperal insanity then resolves
itself into the study of the different types of mental disorder
<span class='pageno' id='Page_109'>109</span>as they may occur and reveal themselves in a pregnant, parturient
or puerperal woman. (Pp. 825–830.)</p>

<p class='c009'>Lee, of Manchester, England, in his exhaustive treatise,
“Puerperal Infection,” refers very casually to the maniacal
symptoms of the infection. (P. 290.)</p>

<p class='c009'>Williams, in his “Obstetrics,” however, speaks assuredly
of puerperal insanity and gives definite etiological factors,
two of which are the result of childbearing. (Pp. 915, 916.)</p>

<p class='c009'>Hirst, in his “Practice of Obstetrics,” feels that it is an
entity and more distinctly a disease of this period because of
the etiological features he mentions and which will be referred
to later. (P. 248.)</p>

<p class='c009'>Webster, in his “Text Book of Obstetrics,” discussed it as
an entity under a separate heading, but not by any etiological
factor does he separate it from other psychoses. It is
in the frequency of its occurrence that he quotes from Clouston,
of Edinburgh, viz., one in 400 labors, in which Hirst
concurs that we may infer it is a distinct disease. (P. 613.)</p>

<p class='c009'>Berry Hart, of Edinburgh, in his “Guide to Midwifery,”
says “Insanity may come on in women” while childbearing,
and refers to predisposing causes, but gives no well defined
picture of the condition. (P. 574.)</p>

<p class='c009'>Wright, of Toronto, in his “Text Book of Obstetrics,” refers
to insanity of pregnancy: symptomatically ordinary insanity,
but etiologically speaking, the statement that constipation
is frequently marked in the barest allusion. (P. 430.)</p>

<p class='c009'>De Lee, of Chicago, “During the puerperium and lactation,
insanity is a not infrequent disease,” and from his discussion
of it he very apparently holds it as an entity. (P.
373.)</p>

<p class='c009'>Tweedy &amp; Wrench discuss insanity at more length than
any of the other authors and must be convinced that it is a
definite disease. (P. 401.)</p>

<p class='c009'>Edgar refers to the “essential puerperal psychoses” and
discussed their etiology and time of occurrence very definitely.
(P. 800.)</p>

<p class='c009'><span class='pageno' id='Page_110'>110</span>The most comprehensive work on this subject, however, is
that in the <cite>Journal of Obstetrics and Gynecology</cite> of the
British Empire, of Robert Jones, Superintendent of London
County Asylum, Claybury, England, and to quote him is
most convincing. “Of the specially puerperal cases—and it
is in this period that I recognize a special form of insanity—more
suffered from mania than melancholia.”</p>

<p class='c009'>Having covered a fair field of literature in this subject of
definition we must now seriously consider the question—Have
we or have we not a definite disease? Shall we go on
to discuss this subject at greater length or shall we put it
in the category of a broken wrist or an attack of diphtheria,
either of which might occur after the time that any woman
had had a baby? If I should say the latter, I should have
to conclude this paper and take my seat. So let us go a little
farther along and discuss its frequency before the question
is answered.</p>

<h4 class='c011'><span class='sc'>Frequency.</span></h4>

<p class='c012'>In reference to its frequency, we find among the authorities
a great deal of variation and it again shakes our faith
in the value of statistics.</p>

<p class='c009'>In an edition of forty-one years ago of Fordyce Barker’s
“Puerperal Diseases,” he gives the ratio of cases of puerperal
mania to total labors in Bellevue as 1–80. I have purposely
referred to the age of this book because I shall refer
to it again in discussing an attributed etiological factor.
Not long ago after this work appeared, McLeod took the
statistics of births in England and Wales for four years
(1878–82) and found the proportion of women committed
for puerperal insanity was 1,794–3,500,000 labors, or
1–2000. Baker himself was interested in the variation of
statistics and explains part of the difference from the fact
that there were many unmarried women at Bellevue; and
while there were also among the foreign records, in the old
countries, the fact of being a mother and not a wife was felt
far less keenly, if at all than in America! (Pp. 160–191.)</p>

<p class='c009'><span class='pageno' id='Page_111'>111</span>Williams refers to more modern statistics of Berkley and
of Jones, who noted it in 1 in 616 and in 1,100 labors respectively,
but Williams’s own experience has been less frequent.</p>

<p class='c009'>Hirst states “About one in 400 women confined become
insane;” a flat if not grammatical statement, and this proportion
agrees with, if not taken from, the experience of
Clouston of the Edinburgh asylum. Hanson’s figures are
about the same, 1–386.</p>

<p class='c009'>Let us get at this subject of frequency from the opposite
point of view. Among cases of insanity how many are associated
with childbearing? Clouston, of Edinburgh, among
1,500 women, found 10 per cent were classified as suffering
with puerperal psychoses and most of the earlier figures
(and here we have the first real thought) before the antiseptic
era give similar percentages—the New York State
hospitals from 1888 to 1895 give only 5 per cent as puerperal
in origin. Before we draw a too hasty conclusion, let me
quote Lane based on observations in the Boston Insane Hospital
for ten years, “that insanity associated with childbirth
occurs only one-half as frequently as does insanity among
women in general of childbearing age. The vast majority
of women who become insane are between the ages of twenty
and fifty. The task of bearing and nursing children occupies
a considerable portion of the time of the average woman
during these ages. Therefore, we should expect a large
proportion of cases of insanity to begin during such time
even without casual connection.” According to Lane’s view
the childbearing process gives a certain degree of immunity
to insanity instead of predisposition thereto!</p>

<p class='c009'>On the other hand he points out that there are many more
single than married women in asylums—perhaps unmarried
on account of their defects. Hirst says of all cases of insanity
in women about 8 per cent have their origin in the
childbearing process, while Berry Hart gives the lower percentage
of five. De Lee, in his textbook—the most recent at
my command—gives the high percentage of 10–18 of female
inmates affected at this time.</p>

<p class='c009'><span class='pageno' id='Page_112'>112</span>The most reliable figures I have yet obtained came recently
to hand through the courtesy of Dr. Ziegelman, one
of the resident psychiatrists at Kings County Hospital, and
he tells me that of 454 female admissions to the observation
ward there, from October 1, 1914, to March 18, 1915, there
are twenty-six cases of puerperal insanity, practically 5¾
per cent. These are not very different, except suggestively
lower than Jones, of London, who, in 1903, found from 6.4
per cent, private, and 8.1 per cent poor class patients then
in the London Asylum.</p>

<p class='c009'>With so much information, vague and meagre as it is, let
us pause a moment and weigh the evidence. As our ideas of
pathology change with time, so must our viewpoint as to
morbidity and the most recent ideas must settle such questions.</p>

<p class='c009'>Williams, Hirst, Edgar, Webster, De Lee, Jones and
Tweedy &amp; Wrench, refer to it absolutely as a disease. Wright
of Toronto and the Englishmen Berry Hart and Let are more
vague, and only Lewis, of Chicago, calls its occurrence a coincidence.
When we consider its frequency, if only we accept
the very conservative estimate of Williams and the definite
figures from McLeod, of England, of 1–2000 births and
are not so radical as Hirst the obstetrician and Clouston the
Edinburgh alienist, who state 1–400, to say nothing of Fordyce
Barker’s 1–80, we must feel that there is more than a
coincidence, and if we consider the large percentage who are
confined to asylums suffering from it, I feel we have all the
evidence needed.</p>

<p class='c009'>Causes must be studied before we can put pathology on a
sound basis, to say nothing of diagnosis and treatment.
Here again we find many authorities in disagreement and
at times extremely vague.</p>

<p class='c009'>Williams, of the school that, I think we all feel has,
through the laboratory, magnified the science of medicine
perhaps sometimes to the detriment of its art, says:</p>

<p class='c009'>“Puerperal psychoses may be due to one of three causes:
Infection, auto-intoxication, or direct liability of the nervous
<span class='pageno' id='Page_113'>113</span>system. Of these, infection is by far the most important.
This fact has long been recognized, but it is only of late that
the bacteria concerned have been identified, and then only
in a small proportion of cases. In two of the three instances
which have come under my observation, the infection was
due to the streptococcus, and in the third to the streptococcus
and colon bacillus.”</p>

<p class='c009'>Berkeley likewise reports a case due to the organism first
mentioned. Auto-intoxication is also a frequent etiological
factor, and it is probable that the vast majority of mental
disarrangements following eclampsia are due to this condition.
Ordinarily, insanity is regarded as a rare complication
of eclampsia, though Olshauser observed it in 6 per
cent of his 515 cases. According to Hansen and Picque infection
and auto-intoxication are responsible for more than
80 per cent of all cases, while the remainder are to be attributed
to other causes, occurring particularly in women afflicted
with hereditary tendencies, “the exciting cause of the
insanity being shock, extreme mental depression or the rapid
loss of a large quantity of blood.”</p>

<p class='c009'>The general trend of investigation of etiology and pathology
has been of course to ascribe definite tangible factors
as the cause of definite organic changes, and we hear less
and less of idiopathic diseases and functional conditions,
and while the view of Williams may seem to be almost too
definite, please contrast it with the causes ascribed by Hirst,
which he divides into “predisposing—the nervous excitement
of gestation in women predisposed by hereditary influence
to mental breakdown, great reduction in physical
strength and prolonged mental strain or worry * * *;
the exciting causes may be exaggerated anæmia, as from
prolonged lactation, septicæmia; albuminuria; profound
emotion or exaggerated fear of impending danger; remorse
and shame of illegitimate pregnancy; the grief of a deserted
woman; accident or hemorrhage; great physical or mental
exhaustion. In my experience insanity in the childbearing
<span class='pageno' id='Page_114'>114</span>woman has almost always resulted from some profound
emotion.”</p>

<p class='c009'>Webster, of Chicago, says: “Frequently there is a predisposing
cause—e.g., bad heredity and prolonged mental or
physical strain. Anæmia, sepsis, albuminuria, marked emotional
disturbance and the pain and excitement of labor.”</p>

<p class='c009'>Berry Hart only mentions the predisposing causes of a
neurotic constitution, too frequent pregnancies, too prolonged
lactation, and in some cases the shock of a seduction
ending in conception.</p>

<p class='c009'>Wright, of Toronto, as I have stated before, says: “Constipation
is frequently very marked,”—whether he means as
a cause or a symptom is problematic.</p>

<p class='c009'>De Lee, of Chicago, says: “Puerperal infection, mastitis,
eclampsia and allied toxemias, post-partum and other hemorrhages,
especially if grafted on a bad heredity, exhausting
labor and the drain of lactation are the most common
causes. The attack may be developed by a violent psychic
shock, such as the death of husband or child.”</p>

<p class='c009'>Tweedy &amp; Wrench, of Dublin, give us nine subsidiary
causes—drink, toxemia, post eclampsia, acute pain (the perineal
stage), sepsis, severe hemorrhage, prolonged lactation,
no marriage and heredity, laying emphasis on sepsis and
hemorrhage in the puerperium.</p>

<p class='c009'>Edgar says that “there is no doubt that the presence of
puerperal sepsis in many of the cases is something more
than a coincidence.” Alienists assure us that since the introduction
of antisepsis into midwifery the frequency of puerperal
insanity has been marvelously diminished. Many cases
of this type of psychoses are said to exhibit more the nature
of delirium—such as is seen, for instance, in typhoid fever—than
of actual insanity. Again, the coincidence of severe
local infection has often been remarked, and gives color to
the toxic theory; while a further coincidence of insanity of
the puerperium with puerperal mastitis, phlebitis, and other
inflammations remote from the genitals helps the assumption
of this point of view. Of other special contributory
<span class='pageno' id='Page_115'>115</span>factors may be mentioned the exhaustion which follows delivery,
extreme prostration being a well known cause of certain
psychoses or of low delirium. In this connection should
be mentioned the influence of post-partum hemorrhage. In
women already disposed to insanity the physiological adjustment
which follows childbirth is doubtless sufficient to set
up mental disorder. Other conditions which excite puerperal
psychoses are the painful emotions.</p>

<p class='c009'>Lewis, of Chicago, who, we must remember, does not call
this a medical entity, says: “The inciting factor of insanity
arising during the puerperal period are due, in from 70–80
per cent of the cases to either toxemia or infection. In
the remainder no exciting cause beyond the general disturbance
due to the bodily state can be assigned, * * *.
The insanity arising in the lactation period is essentially due
to exhaustion and inanition,” occurring in women of the
poorer, harder working, more improperly fed classes. “General
weakness from other causes, such as may follow severe
post-partum hemorrhage or recovery from septic infection,
may be the exciting element.”</p>

<p class='c009'>Before we close the subject of its occurrence and cause,
let us consider the illegitimacy and the number of the pregnancy,
etc. Of 203 strictly puerperal cases collected by
Jones, of London, about 10 per cent were single and 33 per
cent were primiparal. One patient had an attack of insanity
after each of her twelve children and another with each of
nine, both becoming subject to chronic incurable insanity at
the climateric. In lactation cases the insanity did not commonly
follow a first confinement, but appeared to be due to
the strain of frequent pregnancies and the exhaustion of
long continued nursing. Puerperal insanity is most common
between twenty-five and twenty-eight; lactational between
thirty and thirty-four.</p>

<p class='c009'>Jones also gives data pro and con as to the causation of
this condition. One of his investigators found always negative
blood cultures while others have found, as did Williams,
streptococci, staphylococci, and the colon bacilli.  It was
<span class='pageno' id='Page_116'>116</span>rare for any of his cases to have fever and some were admitted
as early as the second day. He also noted in some
cases the signs of endo-toxin development. But he asks, “If
these cases be toxic (and he means either chemical or bacterial),
how is it that insanity occurs most often after the
first confinement?”</p>

<p class='c009'>Before we proceed to the subject of symptoms and pathology,
let me suggest these conclusions: Our disease is decreasing
in frequency, as all evidence shows us. We coincidentally
are increasing our aseptic technique and obstetric
skill and we are continually recognizing the different types
of toxemias both bacterial and chemical, more quickly, with
resultant more rapid institution of treatment. On the other
hand the strong mental shock and emotions that come to
women in connection with, or as a coincidence to, childbirth
are getting no less in this world of ours and I feel that we
must all agree that sepsis and toxemia in the puerperal and
anæmia in the lactational types of insanity are our real
causes:—the emotional factors being secondary or only the
exciting causes in the majority of cases. The other cases
are, however, those of lability of the mental and nervous
systems of probable types and with the same exciting causes.</p>

<p class='c009'>The pathology of many morbid mental states is, I am
sure, poorly defined and not well worked out. Jones, in his
very exhaustive, though hardly recent article in 1903, gives
us, however, very suggestive thoughts on the subject. “Immediately
after confinement the morbid and effete material
which is taken into the maternal circulation during early
uterine involution, must tend to produce in the predisposed
a profound irritation of the nervous system, and especially
so should secretion and excretion be modified by interference,
chemical or bacterial, with the normal functions of the
venous, lymphatic and other excretory organs.” It is in the
early stage of puerperium, the stage of septic infection, and
by that I mean all bacterial disturbances, that the most violent
delirium occurs.</p>

<p class='c009'><span class='pageno' id='Page_117'>117</span>The lactational type shows impoverished blood supply,
uterine sub-involution, and general cachectic condition.</p>

<h4 class='c011'><span class='sc'>Symptoms.</span></h4>

<p class='c012'>Williams has found that the puerperal psychoses are usually
characterized by great excitement during the first few
days, associated with all sorts of hallucinations. Later, the
maniacal symptoms disappear and the patient passes into a
condition of depression with frequently suicidal tendencies.</p>

<p class='c009'>Lewis has found that there are seldom any prodromal,
usually of sight and sound, and great motor and mental excitement,
appear; later motor agitation, subsultus, expressions
of fear and uneasiness. Toxic cases are similar, but
not so severe. Progress toward recovery is gradual—hallucinations
disappear and lucid intervals occur. Lactational
cases come on slowly, hallucinations at first few and later
more constant; not a type of melancholia, but a mild, exalted
mania, with frequently suicidal tendencies.</p>

<p class='c009'>Hirst’s cases have been of mania, melancholia or profound
lethargy, stupidity and mental confusion, and Webster’s experience
has been about the same.</p>

<p class='c009'>Edgar feels that while most of the cases have been classed
as mania, they are in reality hallucinatory insanity.</p>

<p class='c009'>De Lee has found melancholia with suicidal intent most
common, but has also observed mania with infanticidal tendencies,
while Vinay holds that the maniacal forms are the
most frequent.</p>

<p class='c009'>Tweedy &amp; Wrench have found that insanity of the puerperium
is always associated with either severe anæmia from
hemorrhage or with sepsis. The patient is first irritable and
uneasy about unknown dangers. She had a headache, is constipated,
she may refuse food or to see her child or husband,
and sleeps badly, and finally becomes definitely maniacal and
may have suicidal tendencies. During lactation the patient
becomes gloomy, sleeps badly, and is constipated. Definite
melancholia develops with delusions and suicidal tendencies.</p>
<div>
  <span class='pageno' id='Page_118'>118</span>
  <h4 class='c011'><span class='sc'>Prognosis.</span></h4>
</div>

<p class='c012'>All authorities disagree markedly on this most important
aspect. Williams tells that the progress is three to six months
and if longer the prospect is very poor, 20–40 per cent fail
to regain mental equilibrium and 5–10 per cent die, this high
mortality due, he feels, to the underlying infection and not
the mental derangement itself, and with these figures Hirst
is in practical accord.</p>

<p class='c009'>Lewis tells us 25 per cent of the infection cases die, but the
progress of toxic cases is not so bad. Death occurs usually
from sepsis or the exhaustion on account of the motor excitement.
Lactational cases recover in 50 per cent, and they
take eight to nine months.</p>

<p class='c009'>Webster quotes from Clouston of Edinburgh that 75 per
cent of his cases have recovered; one-half of those in three
months and 90 per cent in six months, and occasionally recovery
takes place after years of impaired mentality and,
surprisingly, he states that there is probably a larger number
of recoveries in acute and severe cases than in mild ones.
Dr. Lee states that the prognosis is fair—recovery in the
majority of cases in from six weeks to six months.</p>

<p class='c009'>Edgar tells us that exhaustion is the usual cause of death
but recovery is the rule even from the insanity; if not, it goes
on to a terminal dementia or paranoia. A high pulse-rate is
a bad sign.</p>

<p class='c009'>Berry Hart says the prognosis is good under proper treatment
and the return of menstruation is such a good sign that
emmenagogues should be employed.</p>

<p class='c009'>Tweedy &amp; Wrench say some 60 per cent of all cases recover,
but if, as the patient gets fatter and stronger the mind
does not improve, the prognosis is bad.</p>

<p class='c009'>In the subject of treatment our authorities again differ,
but not in the usual way. Webster briefly dismisses it with
advising an asylum, as does Hirst, except in cases of refusal
of families or friends to commit the patient, when general
symptomatic treatment is necessary. Edgar and De Lee
both are no more explicit. Berry Hart with his regard for
<span class='pageno' id='Page_119'>119</span>the return of menstruation, says when the patient gains
weight to use hot sitz baths, aloes and iron pills and binoxide
of manganese two grains in pills thrice daily should be
administered. In lactational insanity immediate weaning
of the baby is indicated. Williams feels that it is a good
deal of an obstetric problem because of its presumably infective
causes and we must search for the underlying etiologic
factor for the cause. The symptomatic treatment he refers
to only generally and suggests, if immediate improvement is
not seen, to refer to a psychiatrist.</p>

<p class='c009'>Tweedy &amp; Wrench logically prescribe rest, food, excretion,
and exercise as the key notes of prevention and cure. When
the attack is established, use forty grains of bromide and ten
of chloral every two hours. With acute mania, hyoscine is
the best stand-by.</p>

<p class='c009'>Lewis of Chicago gives many practical suggestions.</p>

<p class='c009'>The deduction and conclusions that we may draw from
this summary of the literature and from our own experience
are these:</p>

<p class='c013'>First: We have a definite clinical entity.</p>

<p class='c014'>Second: Its etiology is in a great number of cases toxic,
either bacterial or chemical, except in the lactational type
which is one of general impoverishment of the body from
prolonged nursing.</p>

<p class='c014'>Third: It occurs in about one in 2,000 labors at present
and it causes about 6 per cent of all insanity in the female.</p>

<p class='c014'>Fourth: Its types, which I am poorly equipped to discuss
technically, I will group briefly as manias and melancholias.
At first thought we would expect the former to be the strictly
puerperal type, and the latter the lactational and in general
this classification is correct.</p>

<p class='c014'>Fifth: Symptoms of the former have a more or less
sudden onset frequently preceded by a febrile disturbance
and a pulse that either fails to fall as the temperature does
or even climbs higher. There may or may not have been
foul lochia previously. The onset is characterized by hallucinations,
<span class='pageno' id='Page_120'>120</span>sexual and religious excitement, suicidal and infanticidal
promptings, the latter more common in the lactational
type.</p>

<p class='c014'>Sixth: The prognosis is fairly good and as time goes on
is improving, especially for the class of cases due to infections
or intoxications.</p>

<p class='c014'>Seventh: Treatment will tax all our ingenuity. General
bodily health must be closely watched. The cause of infections
must be met on surgical principles, as in any other infection,
and the emunctories must be carefully looked after
in this class, and, in those of chemical origin, its particular
cause must be run down and met, whether in liver, intestine
or kidney.</p>

<p class='c014'>Rest must be obtained in the proper way. Restraint without
resistance must be used, a constant attendant rather
than a straight jacket. Pleasant surroundings make for
mental rest as well.</p>

<p class='c014'>Food must be nutritious and easily assimilated and its
elimination must be watched and the kidneys stimulated
with all the means at our command.</p>

<p class='c014'>Exercise to the point of stimulation, but not fatigue, is as
necessary as in any disease.</p>

<p class='c014'>Medication must be studied very thoroughly. Of the hypnotics,
hyoscine is the best. The suggestion of Berry Hart
as to the emmenagogues is well worth a trial.</p>

<p class='c014'>In the lactational type, we have profound exhaustion to
deal with, and rest, more than exercise, will be indicated, but
the most important indication is immediate weaning for the
mother’s sake; while in the early puerperal type, weaning is
indicated to remove from the mother all thoughts of the
labor and also to avoid infanticide. If early improvement
is not observed, a psychiatrist should be consulted and personally,
I feel that a joint conduct of the case, particularly
the early ones, of obstetrician and psychiatrist will give the
most happy results to these unfortunates.—<cite>Long Island Medical
Journal.</cite></p>

<div class='chapter'>
  <span class='pageno' id='Page_121'>121</span>
  <h2 class='c006'>Extracts from Home and Foreign Journals</h2>
</div>

<div class="section"></div>
<h3 class='c007'>SURGICAL</h3>
<h4 class='c011'><span class='sc'>Indications for Operation in Exophthalmic Goiter.</span></h4>

<p class='c012'>Prof. H. Starck states that among 450 cases of Basedow’s
disease observed in the last few years sixty-nine were operated
on by prominent surgeons, nearly all of which had
been seen by him before the operation. From his observations
he concludes: 1. Operation effected a cure (<i><span lang="la" xml:lang="la">i. e.</span></i>, complete
physical and mental restoration) in approximately 30
per cent, improvement in 35 to 40 per cent, while in the other
cases it proved ineffective or was followed by a change for
the worse. 2. The operative mortality was 9 per cent (6
deaths in sixty-nine cases). Kocher had a mortality of only
3.1 per cent; according to others, however, it is 12 per cent.
3. If the surgeon accepts the view that a persistent thymus
is responsible for a fatal outcome, although no positive evidence
is at hand, he must determine whether this gland be
present before resorting to resection of the struma; if it is,
ligation of the vessels or resection of the thymus is to be
considered. 4. The choice of the anesthetic is of great importance
as to the outcome of the operation. The Basedow’s
type with predominating nervous, myasthenic and psychic
symptoms is best operated on under general anesthesia, the
other cases under local anesthesia. 5. Operation is contraindicated
in status lymphaticus; if it can not be avoided, a
local anesthetic should be employed. 6. In many cases the
operation only lays the foundation for successful internal
treatment. 7. The most unfavorable time for operation is
that of increasing intensity of the disease; the most favorable,
the stage of latency, or arrest. 8. The most suitable
cases for operation are those in which there is a “goiter
heart;” also some cases with classical Basedow’s symptoms.
<span class='pageno' id='Page_122'>122</span>Only slight success is to be expected in the presence of a
nervous-myasthenic-psychic symptom complex with but
moderate cardiovascular symptoms. 9. The size of the goiter
as determined by palpation is no criterion as regards the
question of operation. Small, soft goiters are often of
greater significance than large, firm ones. 10. The blood
picture also is of no importance in considering the operative
treatment, since it is not materially influenced by operation.—<cite>The
International Journal of Surgery.</cite></p>

<h4 class='c011'><span class='sc'>Acute Appendicitis.</span></h4>

<p class='c012'>John B. Deaver says the important points that have to be
learned about this disease are that it is the most common
intra-abdominal inflammation; that indigestion is often a
forerunner, preparing the soil for the infection; that being
an infectious disease and the most common infectious disease
of the abdominal cavity, the appendix constitutes the
avenue by way of which infection most commonly invades
the upper abdomen. He considers acute appendicitis from
the anatomical, etiological, bacteriological, and pathological
standpoints: the points of the latter touched upon chiefly
are in connection with peritonitis and abscess. The portions
of the peritoneum most susceptible to infection are the
diaphragmatic and enteronic. The differential points between
a diffuse and a localized peritonitis are that in the
former the pain is greater, the abdominal breathing more
restricted and the rigidity and tenderness embrace a greater
area of the overlying abdominal wall; upon auscultation the
peristaltic waves are heard over a greater area and the abdominal
breathing is less marked in the diffuse than in the
localizing variety. In the early stages the tenderness and
rigidity are best elicited by slight pressure. If the symptoms
and signs, namely, pain, vomiting, fever, tenderness,
and rigidity are interrupted, the diagnosis of acute appendicitis
may be considered doubtful. Leucocytosis is of value
as a confirmatory symptom when the patient reacts well to
<span class='pageno' id='Page_123'>123</span>the infection. The most important point in the differential
diagnosis is the distinction between acute cholecystitis and
acute appendicitis. Acute pancreatitis, perforated ulcer, or
perforated gall bladder, present symptoms so much more intense
than those of acute appendicitis that they should not
give rise to confusion. As to the treatment, the writer states
most emphatically that in all cases of acute abdominal pain
nothing in the shape of a purgative or aperient medicine
should be given until the cause of the pain is understood.
In his experience purgatives play the greatest amount of
havoc in acute abdominal conditions; 90 per cent of cases
of perforating peritonitis have been purged. In the presence
of peritonitis and in the absence of operation the patient
should be set up in bed, given nothing by mouth, not
even cracked ice; he should be given enteroclysis by the
Murphy method and have an icebag over the site of rigidity
and tenderness; the icebag is useful to prevent the doctor
from making too many examinations and for its local anesthetic
affect. The idea that it has any effect in controlling
inflammation is fallacious. In diffuse peritonitis, in the absence
of peristalsis and of a definite point of localization, it
is the writer’s practice to defer operation until the peritonitis
becomes a localized or localizing one. The principles of
anatomical and physiological rest, assisting the functions of
the peritoneum, absorption and exudation, are defeated by
any treatment other than the foregoing.—<cite>Medical Record.</cite></p>

<h4 class='c011'><span class='sc'>Effect of Phloridzin on Tumors.</span></h4>

<p class='c012'>In the experiments cited by Wood and McLean the animals
were injected with phloridzin in suspension in olive oil.
Treatment was begun, as a rule, seventeen days after inoculation.
All treated animals were kept rigidly on a diet of
meat and lard, while the control animals were given the regular
laboratory diet of dry bread and vegetable. From time
to time, at the end of the second or third day period following
injections of the phloridzin, the collected urines were
<span class='pageno' id='Page_124'>124</span>examined for sugar with Fehling’s solution and were found
to give a positive reaction in the case of the treated animals
on the carbohydrate-free diet, while the urine of the untreated
animals as well as a phloridzin solution gave a negative
reaction. The animals under treatment rapidly became
emaciated, the fur roughened, and they appeared to be
very ill; a great many died soon after beginning of the treatment.
For the experiments with the Buffalo rat sarcoma,
324 animals were inoculated, with 90.4 per cent of “takes.”
For the experiments with mouse sarcoma No. 396 mice were
inoculated, with 97.7 per cent positive. Among the mice
bearing spontaneous tumors and Crocker Fund mouse sarcoma
No. 180, there were no cases of absorption of the tumor
under treatment. The Buffalo rat sarcoma showed a
much smaller percentage of absorption among the treated
animals than among the controls, 37 per cent as compared
with 58.4 per cent. In the majority of the experiments the
growth among the treated animals was much more vigorous
than that among the controls. Considering the very great
variability of growth of the Buffalo rat sarcoma, as well as
the high percentage of cases of spontaneous absorption occurring
constantly, but with a great irregularity in different
series of animals, the futility of using this tumor for
therapeutic experiments or of basing conclusions on such
investigations, is at once evident. Any “cures” obtained in
work with the Buffalo rat sarcoma must be ascribed to spontaneous
absorption rather than to the effect of the therapeutic
agent.—<cite>The Journal of the Amer. Med. Asso.</cite></p>

<h4 class='c011'><span class='sc'>Diagnosis of Extent of Injury in Cases of Abdominal Wounds.</span></h4>

<p class='c012'>Kausch has found that it is impossible to determine
whether or not the intestines or other viscera have been injured,
by the discovery of free air in the abdominal cavity.
This is an almost certain sign of perforation, according to
his experience, which has been wide and varied. The army
<span class='pageno' id='Page_125'>125</span>corps to which he is consulting surgeon has served in turn
in Belgium and France, Alsac, Galicia, Russian Poland and
Serbia. A very small incision will reveal whether there is
free air in the abdominal cavity. He makes the exploratory
buttonhole for the purpose in the epigastrium under local
or general anesthesia. The thicker the abdominal wall, the
longer the incision, from 1 to 3 cm. The peritoneum need
be only punctured; a pinhead hole is enough. If air streams
out, he proceeds at once to a regular laparotomy. If not,
the patient is spared a major operation for the time being at
least. He has had cases in which a bullet passed through
the abdomen, front and rear, without perforating the gastro-intestinal
tract. When there was perforation, death was
inevitable without operative relief, and he is convinced that
his prompt operating saved a certain proportion of such
cases. No one was ever harmed by the operation after an
abdominal wound. Kausch was kept informed by telephone
where fighting was under way, so that he was on the spot,
ready to operate, before the wounded began to come in.—<cite>The
Journal of the Amer. Med. Asso.</cite></p>

<div class="section"></div>
<h3 class='c007'>MEDICAL</h3>

<h4 class='c011'><span class='sc'>Diphtheria Carriers.</span></h4>

<p class='c012'>A recent investigation of diphtheria carriers in Detroit is
reported by Goldberger, Williams and Hachtel, in Bulletin
No. 101, of the Hygienic Laboratories, of the United States
Public Health Service. The problem of diphtheria carriers
has become one of considerable importance and has been
given special prominence of recent years by the studies of
von Scholly, Moss, and Nuttall and Graham Smith. The
writers of the report mentioned above studied 4,093 people
in the city of Detroit, and found that 0.928 per cent harbored
bacilli identical morphologically with the Klebs-Loeffler bacillus.
This figure is rather lower than those of some other
<span class='pageno' id='Page_126'>126</span>investigators, but would indicate, as stated by the writers,
that there were from 5,000 to 6,000 diphtheria carriers in
the city of Detroit.</p>

<p class='c009'>Of nineteen cultures isolated from nineteen of the carriers,
only two were virulent, which would indicate that only
0.097 per cent of the people examined carried organisms capable
of producing disease. An interesting further point is
that the bacillus Hoffmanii was present in at least 41.9 per
cent of over 2,000 individuals examined, and that the forty-nine
cultures morphologically identified as bacillus Hoffmanii
were avirulent. This would confirm the impression
gained, we believe, by most experienced laboratory workers,
that a true Hoffmanii can be distinguished with considerable
certainty from a Klebs-Loeffler bacillus by morphological
examination alone, and that its significance is probably that
of a frequently present saprophyte of the throat and pharynx.
The studies of Goldberger, Williams and Hatchtel
also indicate that in examining for diphtheria carriers, it is
best not to confine oneself either to the nose or throat, but
that cultures should be taken from both places in every case.—<cite>The
Journal of Laboratory and Clinical Medicine.</cite></p>

<h4 class='c011'><span class='sc'>Injuries from Hot Water Bottle.</span></h4>

<p class='c012'>In an action against a sanatorium and its superintendent
it appeared that the plaintiff had employed the superintendent
to perform an operation for hernia. After the operation
was performed the doctor carried the plaintiff to the room
assigned to him and placed him in bed while still under the
influence of an anesthetic. A rubber bottle, filled with very
hot water, had been placed in the bed, and the unconscious
man was laid upon it, and was burned on his back severely.
The witnesses described the wound as being 15 to 18 inches
in diameter. He also received a smaller burn on his side;
the attendants, believing that his struggles on becoming conscious
were due to delirium, having held him down on the
bed for a time and then turned him on his side. He was
<span class='pageno' id='Page_127'>127</span>under treatment from the burns for a number of months
and suffered excruciating pain. The jury found the doctor,
but not the sanatorium, guilty, and rendered a verdict for
$5,000, which the trial court reduced to $2,500. On appeal,
the court said that it did not mean to condemn the doctor,
nor even to say that he was in fact negligent; but, taking
the situation as it found it, and as the jury observed it, there
was evidence to justify them in finding that the doctor had
not exercised proper care; and, having so found, the court
had no right to dispute the verdict. It also held that the
damages awarded were not excessive.—Grosshart v. Shaffer,
Oklahoma Supreme Court, 152 Pac. 441.—<cite>Medical Record.</cite></p>

<h4 class='c011'><span class='sc'>Heart Inhibition During Vomiting.</span></h4>

<p class='c012'>Gam says that while experimenting on intrathoracic and
intra-abdominal pressures, the blood pressure was observed
to fall during vomiting. A series of experiments were performed
to determine the cause of this fall. In all experiments
the blood pressure, the intrathoracic pressure and the
movements of the abdominal wall were recorded. Vomiting
was induced in some cases by means of apomorphin; in others
by filling the stomach with hot salt solution, hot soap
suds, copper sulphate solution, etc. In every case a high
negative pressure was observed in the thorax during the act.
The pressure would fluctuate rapidly from zero to twenty-five
or thirty centimeters (water) of negative pressure. The
blood pressure, however, always fell, sometimes to less than
half its former level. The fall in blood pressure was found
to be due to a vagus inhibition of the heart, for on cutting
the vagi while the vomiting was taking place, and while the
blood pressure was at its lowest, there was an immediate increase
in heart rate and rise to above the normal in blood
pressure. Furthermore, when the vomiting was induced
after the vagi had been cut, there was a rise instead of a
fall in blood pressure.—<cite>The Journal of the Amer. Med. Asso.</cite></p>

<div>
  <span class='pageno' id='Page_128'>128</span>
  <h4 class='c011'><span class='sc'>Home Treatment of Sciatica.</span></h4>
</div>

<p class='c012'>Pœppelmann suggests the following method for the home
treatment of sciatica. A pail of boiling water is placed in
a tub large enough to permit an old chair to be set in it. A
tablespoonful of ol. pini sylvestris is poured into the boiling
water, the patient seated on the chair with his feet outside
the tub, and two sheets pinned around his neck, so that they
reach the floor on all sides, covering him completely but leaving
the head free. In this steam bath the patient is allowed
to remain for twenty minutes. He is then rubbed briskly
with a cold wet cloth, dried and put to bed for an hour. If
necessary, especially with elderly people, cold applications
may be made to the head during the process of steaming.
Internally, iodides are given, preferably iodine-vasogen, 7–8
drops three times daily. The bowels must be kept freely
open. The baths are given every other day, and five to fifteen
sittings are required for a cure. In the author’s hands
a successful outcome has been practically uniform.—<cite>Critic
and Guide.</cite></p>

<h4 class='c011'><span class='sc'>Use of Caffeine in Digitalis Arrhythmias.</span></h4>

<p class='c012'>In the <cite>American Journal of the Medical Sciences</cite> for September,
1915, Barton asserts that all the irregularities of
the heart-beat which are brought about by digitalis tend to
be removed by caffeine. Although in many cases digitalis
arrhythmia will spontaneously disappear when the drug is
stopped, instances arise, unfortunately too common, in which
after prolonged digitalis administration the conductive system
is so depressed that serious results may arise. Under
these circumstances the administration of caffeine will be
of service and is therefore strongly indicated. The action
appears to be due to the increase in irritability of the conduction
system produced by the caffeine, which antagonizes
and finally overcomes the depressing effects which digitalis
<span class='pageno' id='Page_129'>129</span>exerts upon the auriculo-ventricular bundle.—<cite>The Therapeutic
Gazette.</cite></p>

<h4 class='c011'><span class='sc'>The Effect of Caffeine Upon the Blood-Flow in Normal Human Subjects.</span></h4>

<p class='c012'>The <cite>Journal of Pharmacology and Experimental Therapeutics</cite>,
for November, 1915, contains a report of a research
by Means and Newburgh in which they report experiments
upon the blood-flow of two normal subjects during rest, and
of one subject during muscular work.</p>

<p class='c009'>The action of caffeine on the blood-flow was studied in
both subjects while at rest, and in one during work.</p>

<p class='c009'>The average blood-flow of the two subjects at rest was
4.5 and 4.0 liters per minute; the systolic outputs were 61
and 57 cc.; the coefficients of utilization of the oxygen-carrying
capacity of the blood were 31 per cent and 41 per cent.</p>

<p class='c009'>With increasing work a steady rise in blood-flow, oxygen
absorption, and pulmonary ventilation was found. The increase
in blood-flow was produced first by an increase in
systolic output until a maximum of 118 cc. was reached, beyond
that by an increase in pulse-rate. This suggested that
the supply of venous blood in this subject becomes “adequate”
at about 640 kg. meters of work per minute. The
coefficient of utilization showed a slight rise during work,
indicating a slightly greater economy of the circulation.</p>

<p class='c009'>After giving caffeine during rest, or when the supply of
venous blood is “inadequate,” evidence of drug action was
found with both subjects. This action consisted in an increase
in total blood-flow without a corresponding increase
in oxygen absorption, and hence a decreased coefficient of
utilization of the oxygen-carrying capacity of the blood. The
pulse-rate was unchanged. Consequently the systolic output
was increased.</p>

<p class='c009'>During work probably no other action was obtained from
caffeine than possibly an increase in pulse-rate, and consequently
slight diminution in systolic output.</p>

<p class='c009'><span class='pageno' id='Page_130'>130</span>It is suggested that during rest when the supply of blood
to the right heart is “inadequate”, caffeine increases the
blood-flow by increasing the venous supply through an action
upon some mechanism outside the heart. When the
supply becomes “adequate” or approaches adequacy, no
such action is obtained.—<cite>The Therapeutic Gazette.</cite></p>

<div class="section"></div>
<h3 class='c007'>OBSTETRICAL</h3>

<h4 class='c011'><span class='sc'>Diuresis and Milk Flow.</span></h4>

<p class='c012'>There are observations on record which indicate that the
secretion of milk may be influenced by a contemporaneous
diuresis. Precisely what changes in the composition of the
milk may be initiated in this way had not been determined
until recently, when the question of the influence of specific
diuretics on milk flow was investigated by Steenbock at the
University of Wisconsin. He remarks that in view of the
importance which heretofore unknown constituents of diets
and rations have lately assumed, it is of the greatest interest
to dissect the various factors normally operative in the body
under ordinary conditions of diet. Steenbock found that
urea, for example, administered in a diuretic dose, is able
to decrease temporarily the flow of milk. On repeated administration,
however, the increased intake of water which
follows the impoverishment of the tissues with respect to
water content balances the draft for water imposed by the
diuretic, and the milk secretion comes back to normal. Other
diuretic salts, like sodium chloride, may be entirely unable
to depress the milk secretion under normal circumstances,
because they call forth a compensating thirst which simultaneously
increases the water intake. In cases in which diuresis
does lead to temporarily decreased flow of milk, the
percentage of solids in the secretion is ordinarily increased,
the fat being the principal variable. In ordinary experience,
however, the composition of the milk may be regarded as
<span class='pageno' id='Page_131'>131</span>essentially unaltered by slight variations in renal activity.—<cite>The
Journal of the American Med. Asso.</cite></p>

<h4 class='c011'><span class='sc'>Indications and Contraindications For Abdominal Section.</span></h4>

<p class='c012'>Dr. Ross McPherson (<cite>Provid. Med. Jour.</cite>) summarizes
his views in the following conclusions: First. Cesarean section
is a very useful operation for removing the child from
a pregnant woman at or near term in cases: (a) where there
is a relative disproportion between the birth canal and the
fetus, sufficiently large to make the birth difficult or impossible;
(b) in cases of serious obstruction due to tumors, or
deformities congential or acquired; (c) a certain number of
cases of placenta previa, convulsive toxemia, or occasionally
organic disease. Second. The operation should not be decided
upon except by a person whose training and experience
in pelvic and abdominal examination is sufficiently large to
warrant the acceptance of his judgment. Third. The operation
should not be performed by anyone unless he be a skillful
abdominal surgeon, preferably one who has given particular
thought and attention to this subject. Fourth. A
long labor, much handling and manipulation, especially in
the presence of ruptured membranes, predispose the patient
to infection of the peritoneal cavity, and fifth, therefore, intraperitoneal
abdominal Cesarean section should not be undertaken
under those conditions, with one exception, namely
when the religious prejudices of the family demand the saving
of the child at the expense of the mother, and then only
in the presence of and with the advice of a consultant and a
clergyman, after carefully explaining the situation to the
family and obtaining their written consent to the procedure.
Sixth. If the above demands and conditions are fulfilled the
maternal mortality should be practically nothing, the morbidity
negligible, the end result perfect, and with the exception
of those cases undertaken solely in the interest of the
mother, every child should be born alive.—<cite>Medical Progress.</cite></p>

<div>
  <span class='pageno' id='Page_132'>132</span>
  <h4 class='c011'><span class='sc'>Treatment of Ophthalmia Neonatorum.</span></h4>
</div>

<p class='c012'>G. A. Neuffer, in the <cite>Journal of the South Carolina Medical
Association</cite> for February, 1915, states that he has met
with universal success in this condition by means of the
following treatment: A sixty-grain (4 gram) to the ounce
(30 c.c.) solution of silver nitrate is at once applied to the
conjunctiva and immediately precipitated with a solution of
sodium chloride made by dissolving one teaspoonful of the
salt in a glassful of water. This application is repeated
once every twenty-four hours, until one is satisfied that the
disease has been controlled. Only in extreme cases are more
than two applications necessary, and often one proves sufficient.
In addition, an ounce (30 grams) of boric acid is
ordered dissolved in a quart (litre) of hot water and the solution
kept constantly warm. With this the nurse or mother
is instructed to wash out the eyes as often as any pus collects,
even if this is required a hundred times a day. One
drop of a one per cent solution of an organic silver preparation
is dropped into each eye three times a day as long as
there is any pus; after this an astringent lotion is substituted.
The author also has squares of lint kept on a block
of ice and applied constantly, with frequent renewals, for
forty minutes in each hour. The treatment described should
be applied both day and night until the condition has been
mastered.—<cite>New York Medical Journal.</cite></p>

<div class='chapter'>
  <span class='pageno' id='Page_133'>133</span>
  <h2 class='c006'>Editorial</h2>
</div>

<p class='c015'><span class='sc'>Publisher’s Notice</span>—The Journal is published in monthly numbers of 48 pages
at $1.00 a year, to be always paid in advance.</p>

<p class='c014'>All bills for advertisements to be paid quarterly, after the first insertion of the
quarter.</p>

<p class='c014'>Business communications, remittances by mail, either by money order, draft, or
registered letter, should be addressed to the Business manager, C. S. Briggs, M. D.
corner Summer and Union Streets, Nashville, Tenn.</p>

<p class='c014'>All communications for the Journal, books for review, exchanges, etc., should be
addressed to the Editor.</p>

<div class="section"></div>
<h3 class='c007'><span class='sc'>Slow Dissemination of Knowledge.</span></h3>

<p class='c012'>Charles Darwin, in his “Descent of Man,” published in
1871, writes thus of the appendix: “It is occasionally quite
absent, or again is largely developed. The passage is sometimes
completely closed for half or two-thirds of its length,
with the terminal part consisting of a flattened solid expansion.
In the orang this appendage is long and convoluted:
in man it arises from the end of the short cecum, and is
commonly from four to five inches in length, being only
about the third of an inch in diameter. Not only is it useless,
but it is sometimes the cause of death, of which fact I
have lately heard two instances: this is due to small, hard
bodies, such as seeds, entering the passage, and causing inflammation.”</p>

<p class='c009'>But Darwin was not the first to recognize the uselessness
and danger of the appendix, since M. C. Martins, in “<cite><span lang="fr" xml:lang="fr">Revue
des Deux Mondes</span></cite>,” which was published in 1862, mentioned
the fact that this rudiment sometimes caused death. Indeed
it is said the ancient Egyptians knew the appendix became
inflamed and caused death, but for this we can not vouch.</p>

<p class='c009'>In spite of these <i>hints</i> of Martin and Darwin, physicians
called the symptom syndrome of what is now known to be
appendicitis, typhlitis or perityphlitis for years, although
the cecum itself is seldom inflamed without some pathological
change in the appendix. The latter structure, however,
<span class='pageno' id='Page_134'>134</span>is often very badly diseased while the cecum is perfectly
normal.</p>

<p class='c009'>The first methodical operation for appendicitis was performed
in 1886 by Reginald Fitz, and even today it is sometimes
hard to persuade a patient to have this structure removed
simply because recovery often occurs without operation.</p>

<h4 class='c011'>EUGENICS.</h4>

<p class='c012'>The same author, Charles Darwin, in the same book,
writes as follows: “Man scans with scrupulous care the
character and pedigree of his horses, cattle, and dogs before
he matches them; but when he comes to his own marriage
he rarely, or never takes any such care. He is impelled by
nearly the same motives as the lower animals, when they
are left to their own free choice, though he is in so far superior
to them that he highly values mental charms and virtues.
On the other hand he is strongly attracted by mere
wealth or rank. Yet he might, by selection, do something not
only for the bodily constitution and frame of his offspring,
but for their intellectual and moral qualities. Both sexes
ought to refrain from marriage if they are in any marked
degree inferior in body or mind; but such hopes are Utopian
and will never be even partially realized until the laws of
inheritance are thoroughly known. Everyone does good
service who aids toward this end. When the principles of
breeding and inheritance are better understood, we shall
not hear ignorant members of our legislature rejecting with
scorn a plan for ascertaining whether or not consanguineous
marriages are injurious to man.”</p>

<p class='c009'>Though the above was written thirty-five years ago, little
real progress has been made in eugenics. It is true we have
laws against miscegenation and against certain consanguineous
marriages; some States have passed and other States
have attempted to pass, laws making certificates of health
necessary before marriage licenses can be issued; if we mistake
not, in some States the habitual criminal is unsexed,
and in many States this question has been discussed, but
<span class='pageno' id='Page_135'>135</span>ignorance in regard to the laws of heredity is still the rule
and not the exception.</p>

<p class='c009'>Wealth and social position, rather than health and intellectuality,
determine as many marriages today as when Darwin
wrote, and America’s highest legislative body has not yet
repealed the law against the dissemination of knowledge of
means to prevent conception. Yet too many children in poor
families not only means dire poverty and unhappiness instead
of comfort and happiness, but oftentimes desertion,
divorce, forced immorality or crime. It is just as necessary
to be able to limit the number of children so that each will
at least get a good start in life as it is to bring healthy children
into the world, since healthy children can not remain
healthy and develop as well under unfavorable as under
favorable conditions.</p>

<p class='c009'>Did the law affect rich and poor alike it would not be so
pernicious, but such is not the case, since the largest families
in this country are found among the poor and ignorant,
the very ones who can least afford to have many dependents.
Without being so intended, it is class legislation. The
healthy, well nourished and well educated class escapes, the
poor, ill-nourished, and ignorant class bears the burden until
this burden is shifted on society in the form of beggar, defective,
imbecile or criminal.</p>

<p class='c009'>If all the members of Congress made a tour of the tenement
districts of New York or other large cities, saw the
overworked fathers and overbred mothers, the ragged, ill-nourished
and oftentimes diseased children, inquired into
the total earnings of the family and the necessary expenses,
ate of their bread and breathed their air, if our congressmen
did this, then the fate of the law as it now stands would be
sealed. But our congressmen are not going to make any
such tour, they are not even going to inform themselves by
study of the actual conditions, but will do something far
easier by voting an appropriation for the study of hog cholera,
the foot and mouth disease of cattle, the Texas cattle
tick or some other measure of more apparent benefit to the
<span class='pageno' id='Page_136'>136</span>people—and the congressman. To vote on appropriations
like the above can not weaken the legislator, to vote to repeal
the present law might lose him a large following in some
communities. Yet the repeal of the present law in regard
to preventives is the first step in eugenics, and without the
repeal the best efforts of the best men and women will accomplish
but little.—<i>W. T. B.</i></p>

<div class="section"></div>
<h3 class='c007'><span class='sc'>Public Health Service Hospitals Curb Trachoma.</span></h3>

<p class='c012'>The establishing of small trachoma hospitals in localities
where this contagious disease of the eyes is prevalent presents
the best solution of the trachoma problem, according
to the statement contained in the annual report of the Surgeon
General of the United States Public Health Service.
The Service now has five trachoma hospitals in the three
States of Kentucky, Virginia, and West Virginia, and so
great has been the number of applicants for treatment that
a waiting list has been established. In the past fiscal year
12,000 cases of trachoma have been treated, the larger proportion
of which were cured, while those in which a cure was
not effected have been greatly improved and rendered harmless
to their associates. The great majority of these trachoma
patients were people who lived in remote sections far
removed from medical assistance, and who, but for the hospital
care and treatment provided would have remained victims
of the disease practically the remainder of their lives.</p>

<p class='c009'>“When it is considered,” the report of the Service states,
“that thousands of persons suffering with trachoma, a dangerous
contagious disease, would otherwise remain untreated,
it is realized how farreaching results have been obtained
through these trachoma hospitals and the other public
health work done in this connection. It would be impossible
to estimate with any degree of accuracy the number of
people who have been saved from contracting this communicable
disease by thus removing these thousands of foci of
infection.”</p>

<p class='c009'><span class='pageno' id='Page_137'>137</span>In addition to treating persons with the disease the hospitals
have been used for educational work. Doctors and
nurses have visited the homes of the patients and have explained
how to prevent the development and recurrence of
the disease. One thousand three hundred and eight such
visits were made during the year in Kentucky alone. “It
has taken some time,” the report continues, “to educate the
people afflicted with this disease to the importance of cleanliness
and the use of simple hygienic measures in their daily
life.” That results have been obtained is evidenced by the
noticeably better observance of hygienic precautions by
those among whom the work has been done.</p>

<p class='c009'>In addition to the hospital work, surveys were made in
sixteen counties in Kentucky, especially among school children.
Eighteen thousand and sixteen people were examined,
7 per cent being found to have trachoma. Similar inspections
in certain localities of Arizona, Alabama, and Florida
resulted in finding the disease present in from three to
six children out of every hundred. Periodic examination of
school children for the disease and the exclusion of the afflicted
from the public schools, are two of the recommendations
the Public Health Service lays emphasis upon.</p>

<p class='c009'>One of the special features of the trachoma work was the
giving of lectures and clinics before medical societies in various
counties where trachoma hospitals could not be established.
Patients were operated upon in the presence of physicians
and the most modern methods of treatment demonstrated.
Throughout, the purpose has been to stimulate
local interest in taking up the campaign to eradicate
trachoma.</p>

<div class="section"></div>
<h3 class='c007'><span class='sc'>How the Government is Meeting the Malaria Problem.</span></h3>

<p class='c012'>Four per cent of the inhabitants of certain sections of the
South have malaria. This estimate, based on the reporting
of 204,881 cases during 1914, has led the United States Public
<span class='pageno' id='Page_138'>138</span>Health Service to give increased attention to the malaria
problem, according to the annual report of the Surgeon General.
Of 13,526 blood specimens examined by Government
officers during the year, 1,797 showed malarial infection.
The infection rate among white persons was above 8 per
cent, and among colored persons 20 per cent. In two counties
in the Yazoo Valley, forty out of every one hundred inhabitants
presented evidence of the disease.</p>

<p class='c009'>Striking as the above figures are they are not more remarkable
than those relating to the reduction in the incidence
of the disease following surveys of the Public Health
Service at thirty-four places in nearly every State of the
South. In some instances from an incidence of fifteen per
cent, in 1914, a reduction has been accomplished to less than
4 or 5 per cent in 1915.</p>

<p class='c009'>One of the important scientific discoveries made during
the year was in regard to the continuance of the disease
from season to season. Over 2,000 Anopheline mosquitoes
in malarious districts were dissected, during the early
spring months, without finding a single infected insect, and
not until May 15, 1915, was the first parasite in the body of
a mosquito discovered. The Public Health Service, therefore,
concludes that mosquitoes in the latitude of the southern
states ordinarily do not carry the infection through the
winter. This discovery indicates that protection from malaria
may be secured by treating human carriers with quinine
previous to the middle of May, thus preventing any infection
from chronic sufferers reaching the mosquitoes and
being transmitted by them to other persons.</p>

<p class='c009'>Although quinine remains the best means of treating malaria,
and is also of marked benefit in preventing infection,
the eradication of the disease as a whole rests upon the destruction
of the breeding places of Anopheline mosquitoes.
The Public Health Service, therefore, is urging a definite
campaign of draining standing water, the filling of low
places, and the regrading and training of streams where malarial
mosquitoes breed. The oiling of breeding places, and
<span class='pageno' id='Page_139'>139</span>the stocking of streams with top-feeding minnows, are further
recommended. The Service also gives advice regarding
screening, and other preventive measures as a part of the
educational campaigns conducted in sections of infected
territory.</p>

<p class='c009'>This study is typical of the scientific investigations which
are being carried out by the Public Health Service, all of
which have a direct bearing on eradicating the disease. The
malaria work now includes the collection of morbidity data,
malaria surveys, demonstration work, scientific field and
laboratory studies, educational campaigns, and special studies
of impounded water and drainage projects.</p>

<div class='chapter'>
  <span class='pageno' id='Page_140'>140</span>
  <h2 class='c006'>Reviews and Book Notices</h2>
</div>

<p class='c016'>“Pellagra.” By George M. Niles, M.D., Gastro-enterologist to the Georgia
Baptist Hospital, Wesley Memorial Hospital and Atlanta Hospital,
Atlanta, Ga. Octavo of 261 pages, illustrated. Philadelphia
and London. W. B. Saunders Co., 1916. Cloth, $3 net. W. B. Saunders
Co., Philadelphia. London.</p>

<p class='c009'>We are in receipt of the second edition of this work upon
a subject that has of late attracted a great deal of attention
from the profession. Pellagra has in recent years sprang
up in an unaccountable manner, especially in the southern
section of the United States, and it behooves every practicing
physician to equip himself with such knowledge as will enable
him to recognize the disease when encountered in his
practice and to handle it in a scientific manner. This work
in its second edition, although following the appearance of
the first edition so closely has undergone many changes and
had numerous additions so that it has been brought fully up
with the present state of knowledge. The chapter on etiology
contains the results of the recent investigations of Dr.
Joseph Goldberger, Special U. S. Agent for the study of the
disease, and Thompson-McFadden Commission on Pellagra.
The work is that of a southern physician and should receive
the warm support of southern physicians everywhere.</p>

<hr class='c017' />

<p class='c018'>“A Practical Treatise on Infant Feeding and Allied Topics.” For Physicians
and Students. By Harry Lowenberg, A.M., M.D., Assistant
Professor of Pediatrics, Medico-Chirurgical College of Philadelphia;
Pediatrist to the Mt. Sinai Hospital; Pediatrist to the Jewish Hospital;
Assistant Pediatrist to the Medico-Chirurgical Hospital and to
the Philadelphia General Hospital; Formerly Instructor of Pediatrics,
Jefferson Medical College. Illustrated with Sixty-four Text
Engravings and Thirty Original Full Page Plates, Eleven of which
are in color. Philadelphia. F. A. Davis Co., Publishers. English
Depot. Stanley Phillips, London. 1916.</p>

<p class='c009'>Our thanks are due the obliging publishers for a copy of
this exceedingly valuable book. The author’s long experience
and intimate acquaintance with the subjects treated
<span class='pageno' id='Page_141'>141</span>of eminently qualify him to present a work that will prove
of most valuable assistance to physician and students.
The work is eminently practical and presents throughout the
subject matter in an easily accessible form. The arrangement
of the text is systematically perfect and only such material is
used as may render the work available for the needs of practitioners
and students. The importance of breast-feeding
is emphasized and artificial alimentation discussed thoroughly
so as to furnish the best schemes for obtaining the best
results. The article upon “Surgical Treatment of Infantile
Pyloric Obstruction” is by the celebrated surgeon, Dr. John
B. Deaver, a chapter that adds much to the value of the
work. A feature of the work is the presentation of a number
of plates showing in colors the appearance of stools in
various conditions of alimentary disturbances. We are
greatly pleased with this work and can conscientiously recommend
it to students and practitioners.</p>

<hr class='c017' />

<p class='c018'>“Annual Report of the Surgeon General of the Public Health Service
of the United States.” For the Fiscal Year 1911. Washington.
Government Printing Office. 1914.</p>

<p class='c009'>This is the forty-third annual report of the operations of
the Public Health Service, in the one hundred and sixteenth
year of its existence, issued by the Surgeon General of the
Public Health Service of the United States. This treats of
the seven divisions of the bureau under the following heads,
viz. (1) Scientific Research and Sanitation; (2) Foreign
and Insular Quarantine and Immigration; (3) Domestic
(Interstate) Quarantine; (4) Sanitary Reports and Statistics;
(5) Marine Hospitals and Relief; (6) Personnel and
Accounts; (7) Miscellaneous. The report contains a great
deal of interest to the general reader, especially to those interested
in sanitary matters, and shows the methodical and
systematic manner in which the affairs of the bureau are
administered.</p>

<div class='chapter'>
  <span class='pageno' id='Page_142'>142</span>
  <h2 class='c006'>Publisher’s Department</h2>
</div>

<div class="section"></div>
<h3 class='c007'>“<span class='sc'>In Particular Cases.</span>”</h3>

<p class='c012'>Therapeutic efficiency in the use of the bromides is often
as dependent on the avoidance of untoward effects as on the
attainments of maximum physiologic activity. For this
reason Peacock’s Bromides offer the most satisfactory bromide
therapy, for not only does this happy combination of
carefully selected bromide salts insure all the benefits of the
most active bromide preparation, but it does so with the
great advantage that gastric disturbance and all tendencies
to bromism are reduced to a minimum. This is why in “particular
cases” so many physicians are in the habit of insisting
on the use of Peacock’s Bromides.</p>

<hr class='c017' />

<p class='c009'>Notwithstanding the large number of Hypophosphites on
the market, it is quite difficult to obtain a uniform and reliable
syrup. “Robinson’s” is a highly elegant preparation,
and possesses an advantage over some others, in that it holds
the various salts, including iron, quinine, and strychnine,
etc., in perfect solution, and is not liable to the formation of
fungus growths. (See advertisement in this issue.)</p>

<hr class='c017' />

<p class='c009'>“Many cases of acute coryza and naso-pharyngeal irritation
are often due primarily to the streptococcus rheumaticus
and respond to the usual rheumatic therapy.”</p>

<p class='c009'>In these cases commonly called “colds,” generally deep-seated,
painful and exhausting, Tongaline mitigates the congestion
and by rapid elimination of the poison or germs,
promptly relieves a condition often very obstinate and if not
corrected within a reasonable time, attended with serious
results and always with a tendency to become chronic.</p>

<p class='c009'>For special stimulation to the kidneys, Tongaline and
<span class='pageno' id='Page_143'>143</span>Lithia Tablets; if malaria is indicated, Tongaline and
Quinine Tablets.</p>

<div class="section"></div>
<h3 class='c007'><span class='sc'>Not a Digestive Substitute.</span></h3>

<p class='c012'>The amount of actual harm done with the best intention,
by continually supplying the digestive organs with digestants,
or ferments, instead of encouraging them to generate
their own, is doubtless greater than we realize. It is not
very often that one need order predigested food for a
patient, although occasions may and do present themselves
when this is advisable. But the indiscriminate use of pepsins
and similar substances from the vegetable kingdom, in
the management of many patients with weakened digestive
powers, is scarcely to be justified. A much more useful
remedy, because of its being a true stimulator to the digestive
functions, gastric and intestinal, is Seng. This well
known preparation contains the active principles of Panax
(Ginseng), and is especially useful because it stimulates the
physiologic activity of the digestive glands and thus “helps
them to help themselves”—obviously the most desirable
therapeutics in all functional cases. It should be remembered,
therefore, that Seng is not a ferment to digest food
which weakened organs can not care for in their natural
manner. Instead, its action is to restore tone and vigor to
the secretory structures so that they are able to evolve and
supply their own ferments. Seng is a very agreeable remedy
to take, and its benefits are manifested in surprisingly short
order. In convalescence from fevers or diseases impairing
the digestive functions it is unquestionably one of the most
efficient remedies being used by medical men today.</p>

<div class="section"></div>
<h3 class='c007'><span class='sc'>Interol.</span></h3>

<p class='c012'>The world is full of fallacies—It is fed upon half truths.
It drinks in sophistry and then wonder is expressed that the
millenium is so long deferred.</p>

<p class='c009'><span class='pageno' id='Page_144'>144</span>Take for instance the unfortunate use of the terms “expensive”
and “high-priced” or of “costly” and “cheap.”</p>

<p class='c009'>Price—be it high or low, is what one pays.</p>

<p class='c009'>It has nothing to do with what is received.</p>

<p class='c009'>Quality on the other hand, is what one gets, or fails to get.
Service ditto.</p>

<p class='c009'>A useless, or inferior article or service, even when bought
for a low price, is expensive and costly!</p>

<p class='c009'>On the other hand, the better or higher the Quality or
the Service that is obtainable, the higher the price—which is
a great natural law. Hence, high-priced should, and usually
does men, high quality or service.</p>

<p class='c009'>In fact, a moment’s reflection will show that the impression
created in the mind of a person of average intelligence,
by the word “cheap” applied to a person or a thing, suggests
inferiority.</p>

<p class='c009'>A cheap person or thing is apt to prove the most expensive.
A high-priced person or thing usually turns out to be
the most economical.</p>

<p class='c009'>And, it is a most important fact that this applies with especial
force to therapeutic agents of any kind intended for
use by the physician, and with fulminant emphasis to drugs
or agents that have to be put into the human body.</p>

<p class='c009'>The physician who hesitates or is influenced by “high
price”, provided he knows the reputation and standing of
the parties marketing the product, is false to his obligation
to himself and to his patient.</p>

<p class='c009'>All of which applies with especial force to mineral oil and
particularly to Interol.</p>

<div class='pbb'>
 <hr class='pb c008' />
</div>
<div class='tnotes'>

<div class='chapter'>
  <h2 class='c006'>TRANSCRIBER’S NOTES</h2>
</div>
 <ol class='ol_1 c002'>
    <li>Silently corrected typographical errors and variations in spelling.

    </li>
    <li>Retained anachronistic, non-standard, and uncertain spellings as printed.
    </li>
  </ol>

</div>








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