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NEW YORK MEDICAL JOURNAL,
INCORPORATING THE
PHILADELPHIA. MEDICAL JOURNAL
AND THE
MEDICAL NEWS.
A WEEKLY REVIEW OF MEDICINE.
EDITED BY
FRANK P. FOSTER, M. D.
ASSOCIATE EDITOR,
John M. Swan, M. D.,
Philadelphia.
Assistant Editors : FREDERICK T. HANEMAN, M. D., CHARLES F. BOLDUAN, M. D., ANDREW F. CURRIER, M. D.,
SAiMUEL M. BRICKNER, M. D., MATTHIAS LANCKTON FOSTER, M. D.,
De SAXTOS SAXE. M. D.
VOLUME LXXXIX,
JANUARY TO JUNE, 1909, INCLUSIVE.
NEW YORK: A. R. ELLIOTT PUBLISHING CO., 1909.
Copyright, 1909, By A. R. ELLIOTT PUBLISHING CO.
LIbT OF CONTRIBUTORS TO VOLUME LXXXIX.
Those whose names are marked with an asterisk have contributed editorial articles.
Abbott, Alexander C, M. D., Philadel- phia.
Adami, J. George, A. M., INl. D., F. R.
S., Montreal, Canada. Allvn, Her.max B.. M. D., Philadelphia. Andeksox, a. AL, M. D. *Ar.mstroxg, Samuel T., M. D. AsHMEAD, Albert S., M. D. Attix, J. C, M. S., D. D. S., Al. D.,
Philadelphia. BAfTisr, H. L.. M. D., Ivy Depot, Va. Barclay, \V. F., AI. D.. Pittsburgh, Pa.
* Barrows, C. Clifford, A1. D. Bartholow, Paul, AI. D. Basch, Sev.mour, AL D. Bassler Axthonv, A1. D. Bauer, F. AL, AL D.
Baum, Joseph, AL D.
Beardslev, E. J. G.. AL D., L. R. C. P.
(Lond.). Philadelphia. Beck, Carl, AL D. Beck, E.mil G., AL D.. Chicago. *Bexedict, a. 'L., AL D.. Buffalo. Bexja.min, a. E., AL D., Alinneapolis. Berxsteix. E. P., AL D. Berry, John AL, AL D., Troy, N. Y.
* Billings, John S., Jr., AL D. Blackwell, H. B.. AL D.
BoGGS, Rusell H., AL D.. Pittsburgh, Pa.
Boldt. H. J., AL D.
BoxNAR, JoHx D., AL D., Buffalo. .
Bopp, Walter F., AI. D.
Br-\t)dock, Charles S., Jr., Ph. G., M. D., Haddonfield, N. J.
Bradley, William N., M. D., Philadel- phia.
Brady, William, AL D., Elmira. N. Y. Branth, Johx Herman, AL D. Braude, AL, AL D., Chicago. Br-M'. A.vron, AL D., Philadelphia. *Brickxer, Samuel AL, A. AL, AI. D. Brixkerhoff, Nelsox AL, AI. D., Phila- delphia.
Browx, Arthur Erwix, Sc. D.. Phila- delphia.
Brow.v. Isaac W., AI. D.. Philadelphia.
Bryaxt. Joseph D., AL D.,
Bryant, W. Sohier, A. AL, AI. D.
Bull, Charles Stedmax, A. AL. AI. D.
*Burtexshaw, James Hawley, AI. D.
Butler, William J., AL D., Chicago.
Calhoun, F. Phinizy", A. B., M. D., At- lanta. Ga.
Carlisle, Robert J., AI. D.
Carr, W. p., AL D., Washington, D. C.
Carrixgtox, p. AL, AI. D.. U. S. Public Health and Alarine Hospital Service.
Carsox, Hamptox L., Esq., Philadel- phia.
Castelli, E., AL D.
Church, C. Herbert. AI. D., Newark, N. J.
Clark, Franklin C, AI. D., Providence, R. I.
Clary, W. A., Jr., AI. D.. Alemphis. Term.
Clay. T. A,. AL D., Paterson, X. J. Cleborxe, Alan Bellingh.\m, AI. D.,
Savannah, Ga. Clothier, Joseph V., AI. D.. Philadel
phia.
Cobb, J. O., AI. D.. Surgeon, United States Public Health and Alarine Hos- pital Service.
Coleman, Warren, AL D.
Cooke. Charles O., A. AL, AI. D.. Prov- idence, R. I.
Cornwall, Edward, E., AL D., Brook lyn.
*Crandall. Floy'd AL, AI. D. Crispin. Antonio AL, AL D. Croftan, Alfred C, AL D., Chicago.
Crothers, Bronson, A. B., Boston. *CuMSTOX, Ch.\rles Greene, AI. D., Boston.
*Currier, Andrew F., AL D., Alount
Yernon, N. Y. Dalaxd, Judsox, AL D., Pliiladelphia. D.\xziGER, Erxst, AL D. Davisox, Robert E., AI. D., Pittsburgh,
Pa.
De.wer, Johx B., AI. D., LL. D., Phila- delphia.
De Bar, George O. B., AL D., Eugene, Ore.
*Delavan, D. Bryson, M. D.
Di Rocco, Joseph, AI. D.
DiTMAX, NORMAX E., AI. D., Ph. D.
Dow, Edmund L., M. D.,
Drennax, Jexnie G., AL D.. C. AL. Kmgston, Canada.
Drum. J. H.. AI. D., Syracuse, N. Y.
DuFFiELD, Warren L.. AI. D.. Brooklyn.
Earp, Samuel E., AL S.. AI. D., Indian- apolis.
Edgar, J. Clifton, AI. D.
Egbert, J. Hobart, A. AL, AI. D., Willi- mantic, Conn.
Einhorn, AIax, AI. D.
EiSENBERG, A. D., AL D., Brooklyn.
Elliott, Arthur R., AI. D., Chicago.
Elliott, Edw.jird Everett, Chicago.
*Elliott, George, AL D., Toronto, Can- ada.
Ellis, Aller G.. AL D., Philadelphia. Erdmaxx, Johx F., AI. D. Fairchild, D. S., AL D., Des Aloines, la. Faught, Fraxcis Ashley, AI. D., Phil- adelphia.
Faulkxer, Richard B., AI. D., Pitts- burgh, Pa.
Files, Charles O.. A. AL, AI. D., Port- land, Ale.
Fischer, Hermann, AI. D.
I-"ischer. L(juis, AI. D.
FiSKE, James Porter, AL D.
Folkes, H. AL, AI. D., Biloxi, Aliss.
Fordyce, John A., AI. D.
*Foster, Fr.\nk p., AL D.
Foster, George B.. Jr., AI. D., Pliiladel- phia.
*Foster, AIatthias Lanckton, AL D.
Foulkes, Sara E., AI. D., Trenton. X. J.
Pricks, L. D., AI. D., U. S. Public Health and Alarine Hospital Service.
*Fridexberg, Percy, AL D.
Fried, G. A.. AI. D.
Gerhard, C. H., AI. D., Philadelphia.
Gilbride, Johx J.. A. B.. AI. D.. Phila- delphia.
GoEPP, R. AIax, AI. D., Philadelphia. GoFFE, J. Riddle, AL D. Gordox. Alfred, AI. D.. Philadelphia. Grace, Ralph, AL D. Graham, George A.. AI. D., Kansas City, AIo.
Graham, St. J. B., AI. D., Ellijay, Ga.
Graxt, Sir James, K. C. AI. G.. F. R. C. P., Lond., Ottawa, Canada.
Greexe, Robert Holmes, A. AL, AI. D.
Gruexixg, Emil, AL D.
Halliday', Charles H., AL D., Beau- tort, S. C.
"Haxemax, Frederick T., AI. D.
Harbridge. D. Forest. AI. D., Philadel- ohia.
Hare. Hobart Amory, AI. D., Phila- delphia.
Harris. William L., AI. D., Providence. R. I.
Harrower, Henry R., M. D., Chicago. Haskell. Charles Nahum, AL D.,
Bridgeport, Conn. Hays, Harold AL, A. AL. AL D. Hays, Walter E., AL D.
Heiser, Victor G., AL D., Alanila, P. I. Hekzig, Arthur J., AL D. HiKST, John Cooke, AI. D., Philadel- phia.
HoFER, Cl.^rexce a., AI. D., Philadel- phia.
H(;gax, Austix, AI. D., Jolinstown, N. Y.
"Howard, Tasker, AI. D., Brooklyn.
Huhner, AIax, AI. D.
Hunt, Charles J., AL D., Philadelphia.
*=HuxT, Reid, AI. D., Ph. D., U. S. Pub- lic Health and Alarine Hospital Ser- vice.
*J.\CKsoN, George Thomas, AI. D. *Jelliffe, Smith Ely', A. AL, AI. D., Ph. D.
Je.nkixs, Xorburxe B., AI. D. Johxston, James C, AI. D.
JUDD, ASPINWALL, AI. D.
Karpas, AloRRis J., AI. D.
*Keenan, Thomas J.
Keller. AIorris J., AL D.
Keller, William L., AI. D., Aledical Corps of the United States Armv.
Kexxedy, J. W., AL D., Philadelphia.
Keowx, JTames a., AL D.. Lynn, Mass.
KiRKPATRicK, A1urr.\y' B., Jr., AL D., Trenton, N. J.
KivLix, C. F., M. D.. Troy, X. Y.
Klotz, J. E., AL D., Lanark, Canada.
K.XbPF, S. Adolphus, AI. D.
KxoTT, Johx, A. AL, AI. D., Ch. B., and D. P. H. (Univ. Dub.) ; AI. R. C. P. I. : AI. R. I. A., etc., Dublin, Ireland.
KxowLES, Fraxk Crozer, AI. D., Phila- delphia.
Kr.^uss, Frederick, AI. D., Philadelphia. L.VMPERT, AI. A., AI. D.. Brooklyn. *L.\xrMAX, A. J., AI. D., London. Landry', Adriax a., AL D., Plaquemine, U.
Laxge, Sidney, AL D., Cincinnati, Ohio.
Lawson, George B., A. AL, AL D., Roan- oke, Va.
Leary, Timothy, AI. D., Boston.
Ledbetter Robert E.. AI. D., Xorfolk, \^a.
Lederer, William J., D. D. S. L"Exgle, Edward AL, AI. D.. Philadel- phia.
Le Roy. Berx.\rd R.. AI. D., Athens, O. Leshure, Johx, AI. D. Lo.M.\x, Eugexe W., AI. D., Bluefield, W. Va.
Longenecker, G. W., AI. D., Elsmore, Kans.
Lydstox. Fraxk, AI. D., Chicago. AIcCormick, William S., AI. D., Phila- delphia.
AIcCoY, George W., AI. D., U. S. Public Health and Alarine Hospital Service.
AIcAIurray, T. E., AL D., Wilkinsburg, Pa.
AIcAluRTRv, Ch.\rles Wood, AL D.
AIcAIurtry. Lewis S., A. AL, AL D., Louisville, Ky.
AIcRae, Floyd W., AL D., Atlanta, Ga.
AIcWiLLiAMS, Clarence A., AI. D.
*AIacKee, George AL, AL D.
AIackixxey', William H., AI. D., Phila- delphia.
AIacWhinnie, a. Morgan, AL D., Seat- tle, Wash.
AIakuen, G. Hudson, AI. D., Philadel- phia.
AIarchisio. Alexander, AI. D. AI.\rkley', p. H., M. D., Camden, X. J. AIay, James V., M. D., Binghamton, N. Y.
*AIayo, Caswell A., Ph. G. AIeeker. Harold Df.nman. AI. D. AIiller. George L, AL D., Brooklyn. AIiLLiCAN, Kenneth W., AL D., Chicago.
IV
INDEX TO VOLUME LXXXIX.
Mitchell, O. W. H., M. D., Columbia, .Mo.
Moore, J. L'i tle, M. U., Toledo, Ohio. Morris, Robert T., M. D. MoKRow, Prince A., A. M., M. D. Morse, John Lovett, A. M., M. D., Bos- ton.
MosKowiTZ, Samuel, D.
Nascher, J. L., M. D.
Newton, Richard Cole, M. D., Mont-
clair, N. J. NicoLL, Alexander, M. D. Noble, Charles P., M. D., Philadelphia. Ogilvy, Charles. M. D. Palier, E., M. D.
Palmer, W. H., M. D.. Providence, R. I. P.vNOFF, Charles Edward, M. D., Brooklyn.
Parrish, Henry, M. D., Philadelphia. Peckham, F. E., M. D., Providence, R. I. Pedersen, James, M. D. Perkins, Charles E., M. D. Peters, W. H., M. D., Providence, R. I. *PiFFARD, Henry G., A. M., M. D., LL. D.
PiTFiELD. Robert L.. M. D., Philadelphia. Polak, John Osborne, M. Sc., M. D., Brooklyn.
PoRCHER, W. Peyre, M. D.. Charlestor^, S. C.
Porter, P. Brynberg, M. D.
Pr.vtt, J. a., M. D., Aurora, 111.
Prince, A. E., M. D., Spring-field, 111.
Proescher, Frederick, M. D., Pitts- burgh, Pa.
Prout, J. S., M. D., Brooklyn.
Rectenwald, J. J., M. D., Pittsurgh, Pa.
♦Richard, Lieutenant Colonel
Charles, Medical Corps, United
States Army. Riesman, David, M. D., Philadelphia. RoBARTS, Heber, M. D., St. Louis, Mo. Robinson, A. R., M. B., L. R. C. P., and
S., Edin. Robinson, Be\-erley, M. D. Robinson, B\t«on, B. S., M. D., Chicago. Robinson, W. F., M. D., Palm Beach,
Fla.
Rose, A., M. D.
RosENBERGER, Randle C, M. D., Phila- delphia. Rosen HECK, Charles, M. D.
RucKER, S. T., AI. D., Memphis, Tenn. Run VON, F. J., M. D., Clarksville, Tenn. Ryan, W. J., M. D., East Mauch Chunk, Pa.
Sajous, Charles E. de AL, M. D., Phil- adelphia.
*Salmon, Thomas W., M. D., U. S. Public Health and Marine Hospital Service.
'Sa.xe, De Santos, ]\I. D.
ScHA.MBERG, J.\Y Frank, M. D., Phila- delphia.
Schurmann, Edward A., AI. D., Phila- delphia.
Schwartz, Hans J., M. D.
*Shaffer, Newton M., M. D.
Sheddan, L.. M. D., Knoxville, Tenn.
*Shively, Henry L., AI. D., LL. D.
Shoemaker, Harlan. A. B., M. D., Phil- adelphia.
Shoe.maker, John V., i\l. D., LL. D., Philadelphia.
Sichler, E. H., M. D., Detroit, Mich.
SiGLER, C. L., M. D., Pinckney, Mich.
Silkworth, W. Duncan, M. D.
Sill, E. Mather, M. D.
Singer, David A., A. B., M. D.
S:vtiTH, E. Franklin, M. D.
Smith, F. H., M. D., Lewisburg, W. Va.
Smith, S. MacCuen. M. D., Philadel- phia.
Smith, Thomas A., M. D.
Soule, Robert E., .-V. B.. M. D.
SouLES, S. G., AI. D., Stanbridge East, Quebec Canada.
Steinhardt, Irving D., M. D.
Stuart, A. F., M. D., Portland. iMe.
Summers, John E., M. D.. Omaha, Neb.
Super, Charles W., Ph. D., LL. D., Athens, Ohio.
Sutton. R. T., M. D.. Kansas Cit)% Mo.
*SwAN, John M., M. D., Philadelphia.
Sweeny, Gilliford B.. M. D.. Pitts- burgh, Pa.
Talmage, John B., M. D.
Talmey, Max, M. D.
Tatchell, W. Arthur, M. R. C. S. CEng.). L. R. C. p. (Lond.), Hankow, Central China.
Tay'lor, Arthur N.
♦Taylor, Henry Ling. M. D.
Teah, Theodore Emil, M. D., Renovo, Pa.
Tho.mpso.v, Francis A., M. D., Milwau- kee. Wis.
Thomson. W. Hanna, M. D., LL. D. Todd, John B., ;M. D., Syracuse, N. Y. Torrance, Gaston, j\I. D., Birmingham, Ala.
TousEY", Sinclair, M. D.
Tri.mble, William B., M. D.
TuRCK, Raymond Custer, M. D., Jack- sonville, Fla.
Twitchell, George B., M. D.. Cincin- nati.
Uhle, Alexander A., M. D., Fniladel- phia.
Vander Veer, Albert, M. D., LL. D.,
Albany, N. Y. Van Sweringen, B., M. D., Fort Wayne,
Ind
Voorhees, Irving \\'ilson, M. S., M. D. W.\inwright, John W., M. D. Wandless, H. W., M. D. Warren, D. E., M. D., Passaic. N. J. Warren, J. N., M. D., Sioux City, Iowa. Watson, J. J., M. D.. Columbia, S. C. Weber, Leonard, M. D. Weil, Henry, M. D. Welch, William M., M. D., Philadel- phia.
Welker. William H.. A. C, Ph. D. *Wheeler. Cl.'\ude L., a. B., M. D., Brooklyn.
White, Francis W., M. D., Philadel- phia.
*Whitehouse, H. H., M. D. Whitford, William. Chicago. Wile, Ira S.. M. S., M. D. Wiley. Harvey W., M. D., Washington, D. C.
*WiLLi.\MS. Tom A., M. B., C. M., Edin.,
Wasnington, D. C. Wilson, Gordon, M. D., Baltimore. Wiseman, Joseph R., M. D., Syracuse,
N. Y.
Wolbarst, a. L., M. D.
Woodruff. Major Charles E.. Medical Corps of the L'nited States Army.
Wright. Barton Lisle, Surgeon, Medi- cal Corps, U. S. Navy.
Wright, Jonathan, !M. D.
Young. A. A., M. D., Newark, X. Y.
Zavatt. Josefa, M. D., Philadelphia.
Zemp, E. R., B. S., M. D., Knoxville. Tenn.
LIST OF ILLUSTRATIONS IN VOLUME LXXXIX.
Page
Acidimeter. One Illustration 24
Adenoids. Three Illustrations 26"
Anthropology. Three Illustrations 1030
Autointoxication. Four Charts 1303
Autoprotective Mechanism of Human Body. Two Illus- trations 433
Bismuth Poisoning. Five Illustrations 18-20
Blood Pressure and Life Insurance. Three Illustrations. 1040
Bull, Dr. William T. Portrait 448
Cardiodilator. One Illustration 1077
Cutaneous Cyst Formations. Twenty - two Illustra- tions 1125-1133
Deficient Oxidation and Nephritis. Three Illustrations.. 1093 Economic Housing of Consumptives. Four Illustrations 727 Electricity in Genitourinary Diseases. Four Illustrations 1038
Flagellation of Leucocytes. One Illustration 1 133
Flat Foot. Six Illustrations 734
Fracture of Neck of Femur. Four Illustrations 22-23
Fracture of Patellae. Two Illustrations 852
French Medical Science During the Middle Ages 978
Gonorrluea in the Male. Six Illustrations 217-218
Hays's Pharyngoscope. One Illustration §23
Hospital of the University of Pennsylvania, New Build- ings of 858
Hypernephroma and Cancer. Three Illustrations I'ss
Hystcrosalpingostf)my. Two Illustrations H93
Ingrowing Toe Nail. Two Illustrations 388
Page
Intraabdominal Injection of O.xygen. Three Ilfustra-
tions 741
Lacerations of the Cervix Uteri. Two Illustrations 153
Marine Hospital Sanatorium for Tuberculosis at Fort
Stanton, N. M. Seven Illustrations 417-424
Mercury in the Treatment of Tuberculosis. Three Illus- trations 1180
Moro Tuberculin Reaction. Three Illustrations 1034
Myocarditis in Children. Two Charts 1295
Nephritis and Deficient Oxidation. Three Illustra- tions 1138-1139
New Frontal Sinus Punch. One Illustration 461
Painful Heels. Four Illustrations 626
Pellagra. Three Illustrations 938-939
Radical Cure of Hernia. Four Illustrations. 528
Serum Diagnosis of Syphilis. Two Illustrations 208
Sound, a New. Three Illustrations 1240
Spirochaeta Lymphatica. Thirteen Illustrations 852
Thoracic Aneurysm. Three Illustrations 4^4
Tonsil Forceps 305
Ureteral Calculi. Three Illustrations.. 1 190
Uretcrorenal Decalogue. Six Illustrations 5.'°
Uterine Dilator. Two Half Tones. 628
\'esicovaginal Fistula. Five Illustrations I57
X Ray Examination of CEsophagus. Five Illustrations. 160-164 X Rav Treatment of Internal Structures. Two Illustra- tion's 622
X Ravs in Thoracic Lesions. Twelve Illustrations 942-947
New York Medical Journal
INCORPORATING THE
Philadelphia Medical Journal The Medical News
A Weekly Review of Medicine, Established 1S4J.
Yo\.. LXXXIX. Xo. I.
XEW YORK. JAXUARY 2. 1909.
A\'iioLE Xo. 1570.
{Briainal Commanitations.
THE RESPONSIBILITY OF THE FAMILY PHYSI- CIAN TOWARD TUBERCULOSIS.*
By S. Adolphus Knopf, M. D., New York.
Professor of Phtbisiotherapy at the New York Postgraduate Medical School and Hos ital; Associate Director of the Clinic for Pulmonary Diseases of the Health Department; Visit- ing Physician to the Riverside Sanatorium for Consumptives of the City of New York, etc.
The treatment of the subject assigned to me in the few minu^es I shall have at my disposal must, of necessity, be incomplete, and I trust that this audience of teachers of medicine, of practising phy- sicians of to-day and of to-morrow, will bear with me if I do not succeed in covering the ground as fully as the importance of the subject demands. To me there is no more vital factor among all those ap- pertaining to the solution of the tuberculosis prob- lem than the responsibility which rests upon the family physician or general practitioner.
Of the vast importance of the early recognition of tuberculosis you have already heard, and you a'! know that it is the family practitioner who has the greatest opportunities for making an earlv diagnosis. To do this he should not wait until the patient coughs, becomes emaciated, has an evening rise of temperature, or a fall below normal in the morning, becomes irritated or tires easily, or has a hsemop- tysis. To my mind it is not only the privilege of the family physician, but it is his sacred duty, to examine the chests of all the members of the familv in which he practises. This should be done not onlv occasionally or sporadically, but periodically : that is to say, every three or four months. If there is a tuberculosis he is thus sure to discover it in time.
\Miat is his duty then? Immediately to inform the patient, if he is an adult, and also the rest of the family, of the condition found. To hide from the intelligent adult the fact that he is tuberculous or that a member of his family is afflicted with the disease, in the light of our modern knowledge, is an absolute wrong, or perhaps it may even be said, a criminal neglect. That the family physician will use the utmost tact in revealing such a condition to the patient or to the friends of the patient is a matter self understood. What we know to-day of the curability of an early tuberculosis makes the task all the more easy. One can inspire the patients
.\ddress delivered at the Museum of Natural Ilistorv before the mass meeting of medical students on the occasion of the Inter- national Tuberculosis Exhibition in New York citv, December S 1908, Professor Edward G. Janeway, M. D., LL. D'., presiding.
Copyright,
and friends with absolute hope for recovery when in the presence of an early tuberculosis.
It has been my practice, in order to overcome the shock whicli the revelation of the presence of the disease at times produces in the patient, to tell him, "be grateful for this early discovery of a curable condition, which, when cured, will leave you a stronger and more vigorous man than you ever were before."
AMiether you should then at once institute the hygienic and dietetic treatment at home, or send the patient away, will depend on the circumstances of the family, upon the patient's character and pos- sible peculiarities. Whether he remains at home for good or only for a few days until accommoda- tions in a sanatorium or health resort can be found, it is your duty at once to institute all the prophv- lactic measures to prevent the infection of others or the reinfection of the patient.
Where compulsory or even only voluntar\- noti- fication is required, notify the health authorities of the existence of the case. You know that they will not interfere when you assume the responsibility for the necessary preventive measures.
Xot all of you will be family physicians right away, and there are a great many families who have no physicians, and you will probably often be called into a family only because the case exists and the early s\mptoms frightened the people sufficiently to make them seek medical aid. In such instances it is your duty to act as if you were the family phvsi- cian. I know it will be a delicate task for you to insist upon the examination of all the members of the faniily, for since you cannot afford to do this in e\-ery instance for nothing, small minds will inter- pret your desire to do your duty as a scheme to niake money. Avoid this suspicion by ir.erelv tell- ing these families that you presume that thev have a tamil\- physician and that you would urge them to call on him for the examination of all the members of the family.
\\'hen you are called into the homes of the well to do to see a patient in the latter stages of the dis- ease, should you advise a change of climate? Yes, if the patient wishes it. Xo. if he does not wish it. In the latter instance make him comfortable, relieve his suffering, prolong his life as best vou can. and let him end his days peacefully amid his famih- and friends.
Should you send a patient with little or no means, in a curable stage of the disease, to a faraway cli- mate, in the hope that in a few v>eeks he may find light employment there, when this patient is in need of rest and care? Xo. .a thousand times no. Unless
1909, by A. R. Elliott Publishing Company.
2
KNOPF: PHYSICIAN'S RESPONSIBILITY IN TUBERCULOSIS.
[New York Medical Journal.
you are absolutely certain that he will be able to work in a few weeks or find work that will permit him to complete his cure, you have no right to send him away. Not unless he is provided with funds sufficient at least to last him for a year, with or without work, and also for treatment during that time, should the patient be sent to any distant cli- mate. By getting rid of a patient without this pro- vision you wrong yourself, you wrong your fellow citizens in Colorado, New Mexico, or elsewhere, by placing an undesired burden upon their community, and, above all, you wrong your patient by depriving him of a reasonably good chance to get well in or near the home where he must live and labor after his restoration to health. Here his chances of staying cured are certainly not so bad, though the time taken to cure him may have been a little longer than anticipated.
Your responsibility is perhaps greatest when you are taking care of a tuberculous parent who has children and must be treated at home. If he is well to do, the task is not so difficult. You can isolate film in a well lighted, well aired, and sunny room. You can make him sleep on the veranda or in a \\indow tent, \ou can assign a nurse to look after him, one to whom you entrust the carrying out of all the preventive and hygienic measures. The children of the patient you will instruct in elementary hygi- ene, you will see that they are properly clad and properly fed. You will develop their chests by ap- propriate respiratory exercises and calisthenics. In other words, you will try to render them imtriune against possible infection and to overcome a possible inherited predisposition" which is nothing more and nothing less than a physiological poverty.
If you fear, nevertheless, that the habitus phthi- sictis, so well described by that great physician of antiquity, Hippocrates, has developed or is de- veloping in any one of these children, you will insist that the future career of this boy or girl will be such a one as to exclude, as far as pos- sible, the development of tuberculosis. You will not send this child to school before the eighth year, and if circumstances permit, you will not send him to the public school at all, but have him taught privately or sent to an open air school. This is easy with the well to do, but how different and how difficult is it in the homes of the poor ! When because of lack of hospital or sanatorium facilities the' poor consumptive must be treated at home, how to isolate him, how to prevent infection, and particularly the drop infection, so dangerous in our crowded .tenements, will tax all your ingenuity. Tlie children of the poor will not be able to receive private instructions at home, and few communities are as yet blessed with public open air schools. The choice of a future career for the boy or girl of a consumptive father or mother has a great bearing on the possibility whether or not he or she shall become a victim of the disease. The son of a con- sumptive printer, stone cutter, weaver, or tailor should not follow in the footsteps of his father, nor should a daughter of a consumptive seamstress be- come likewise a seamstress. To prevent, if possible, that the children of the consumptive poor as well as of the consumptive rich shall choose a career by which they are endangered to fall victim to the dis-
ease with which their parent was afflicted is the duty of every family physician or general practitioner.
I would consider it a violation of my duty as a teacher did I not speak here of the delicate subject of marriage of the tuberculous and the possible pro- creation of a tuberculous race. There, exist in some States laws which prevent the marriage of tuber- culous individuals. With all due respect and admi- ration for those brave legislators who enacted this law, and while I would not wish to underestimate the educational value of such legislation, I can tell them, however, that when tuberculous persons want to be married, they do not care for the law of one State when it is possible for them to be married in another.
I have more than once in my life told consump- tives not to marry. They did it all the same in a good many instances. Should they have children, particularly when the woman is the invalid and when she has passed the incipient stage? Decidedly no! A pregnancy in a tuberculous woman will almost always aggravate the condition, though this aggra- vation may only show itself after childbirth. What can we do? The emptying of the uterus, if done with skilled hands and after due consultation with acknowledged experts, may be justified in some in- stances in order to save the mother's life ; but pre- vention is better, and I am willing to acknowledge that I favor it. I am willing to assume the responsi- bility before the law of man and before my creator for every time I have counselled the tuberculous to cease procreating children. The issue of such pa- rentage means, in the majority of cases, an early death of the mother, or a child with a hereditary predisposition and a constant exposure to postnatal infection, or both.
There is but one more phase of my subject which I must touch in conclusion. It is treatment. This must never be confined to the specialist alone. The general practitioner, the family physician, should know how, must know how to treat ; should treat and must treat tuberculous patients. It is his duty to inform himself of all that is new and good and old and good in the treatment of tuberculosis, and it is his duty to apply it. Without being a culinary artist, he should know how to direct the dietetic treatment. Without being a mechanical genius, he should know how to rig up some sort of device to assure the patient the greatest amount of pure and fresh air. He should know what drugs to give them and what not to give them. Last but not least, he should know how to inspire his patient with confi- dence. He should be firm when firmness is needed, but always kind. He should look upon the patient not as a case but as an individual in need of sympa- thy and help.
We hear much in these days of the Emmanuel movement, of the wonderful cures its promoters have accomplished, not only in nervous and mental diseases, but also in tuberculosis. They report eighty per cent, of cures of pulmonary tuberculosis, comprising all the stages of the disease. It was re- cently my privilege to meet the great leaders of the Emmanuel Church movement, the two doctors of divinity, Worcester and McComb. and the two doc- tors of medicine, Coriat and Pratt. While I have never for a moment doubted the accuracy of their
January 2, 1909. J
CUMSTON: BENJAMIN FRANKLIN.
3
so unusually favorable statistics of cures, I was in- terested to find out why it was possible for these men to obtain and to do what to the best of my knowledge has never been attained or done before. I did not inquire how they cured the habitual drunk- ard, the hysteric, the mentally depressed, or those afflicted with functional disorders, but I did want to learn all I could about their phthisiotherapy. In the true spirit of humanity and of brotherly love, they made no secrets to me of their methods, and I gladly impart them to you. The eighty per cent, of cures which I mentioned relate to twenty-eight cases of pulmonary tuberculosis in various stages of the disease. These patients have been treated for two long years in classes in or near their homes after the most improved hygienic and dietetic treatment with rest in the open air, constant supervision by nurses under the direction of an experienced phthisiotherapeutist.
Thus far for the medical treatment and their patints' physical comfort ; but now listen to the secret. Without imposing their religious conviction, the doctors of divinity went among these patients and, assisted by friendly visitors, inspired them with hope and comfort, talked to thiem of home, children, wives, and husbands. Then the friendly visitors looked after the wives or children, mothers or sis- ters in the home. In all instances when the bread- winner was the invalid, these good women took it upon themselves to see that there was nothing want- ing in that home that was without a breadwinner. In other words,- the invalids and their famiHes were taken care of by the Emmanuel Church people for two years. Perhaps never before in their lives had these individuals so much peace of mind, happiness, and contentment as when lying on their reclining chairs taking the rest cure in the open air and think- ing of their well provided family, their prospective recovery, and having at the same time the assurance given to them that employment would be provided when they were again able to work. And all this without being away from home. The element of homesickness, so distressing to many sanato- rium patients, did not exist. Herein lies the suc- cess of the Emmanual Church movement as far as tuberculosis is concerned. Will it be necessary for us, in order to cure tuberculosis, to imitate the Emmanuel Church movement in all its details, and will we not be able to obtain sitnilar success without calling in the brethren of the church ? You have already heard me say how greatly I respect and admire the work done by the Emmanuel Church, but this will not prevent me from telling you, and here I address myself particularly to you, my young fellow students, be not discouraged. As family practitioners, as citizens, as coworkers in the antituberculosis movements in the homes to which you may return after you will have com- pleted your studies here, you can interest phil- anthropists, noble hearted men and women inside and outside of the church, to help you. If you find a congenial clergyman who, remaining in his sphere of comforting the soul, is wilHng to help you, by all means welcome him and work together. However, I do not think this absolutely necessary, and it is of no great import whether you or he will get the means together to enable you to treat your con-
sumptive poor for two years and to provide for their families for the same space of time. .
If I were to make a suggestion, I would venture to advise those of you who intend to interest them- selves in the treatment of the consumptive poor to follow the example of our brethren in Germany. They presented the cause to the women of Germany, who responded in various sections by organizing themselves for the purpose of giving systematic and practical help to families whose breadwinners are incapacitated by tuberculosis. I refer here parti- cularly to the society known in Germany as Patriot- ischc Frauen von Charlottenburg (Patriotic Women of Charlottenburg). This organization works under the auspices of the German Red Cross Society.
Think what a useful field of labor this would be for our own Red Cross Associations in time of peace.^ They could thus help to combat an enemy far more terrible, far more murderous, far more costly than the mightiest army of the mightiest nation. A work more patriotic and more helpful toward the solution of the tuberculosis problem it would be difficult to conceive. A movement of this kind would by no means exclude the collaboration of the doctors of divinity or sisters of charity. There is a second organization working for the same pur- pose, called German Lay Sisters of Charity. But whoever works with you, be they patriotic women, mothers, wives, sisters, or sweethearts, whether you work with or without the clergy, if you have the means necessary to spare the patient anguish, anx- iety, and sorrow, and give him the best in phthisio- therapy as long as he needs it, I have no doubt that your results will equal those of the Emmanuel Church.
However, to attain these results you must have not only the material means but a complete knowl- edge of phthisotherapy, must have coworkers not only of material wealth but of wealth of heart and mind, and above all you yourself must be a picture of perfect health, and inspiration of hope, an ex- ample of good cheer, of genuine sympathy, and of complete devotion. In short, you must indeed be a physician in the higher sense of the word, a healer of the body or the mind diseased, a friend and counsellor of the soul in need.
16 West Ninety-fifth Street.
BENJAMIN FRANKLIN FROM THE MEDICAL VIEWPOINT.
By Charles Greene Cumston, M. D., Boston,
Member of the Medical Historical Society of France, etc., etc.
Benjamin Franklin is, without doubt, one of the most original and sympathetic figures that is to be found in the history of science. He not only applied his genius to the study of physics and political econ- omy, but he was one of the first to apply electricity to medicine. He also undertook remarkable experi- ments on subjects of physiology. And lastly, we have his little work on smallpox and his dialogue on gout.
In a work entitled: "Some Account of the Penn^
'See New York Medical Journal, November 28, 1908: The Red Cross in the Antituberculosis War.
4
CUMSrON: BEXJAMIN FRANKLIN.
[New York Medical Jolrxal.
syhvnia Hospital; from its first Rise to the begin- ning of the P if til Month, called May IJ34. Phila- delphia: Printed by B. Franklin, and D. Hall. MDCCLH' ." we find Franklin on the list of con- tributors, the sum he gave being twenty-five pounds, while "on the 7th of May, 1752, there was a new- Choice of Directors, and a Treasurer." There were twelve managers elected, among whom we find Franklin. All this goes to show that this versatile man was interested in, and gave much thought to, medicine.
It has consequently appeared to me that it is not without interest to study these various intellectual manifestations in a man that is so greatly a genius, l)ut before entering into the medical side proper, it seems essential to devote a little space to Franklin's life.
Franklin was born in Boston on January 6, 1706. being the last son of a numeroiis family. His pa- rents originated from Northamptonshire, England, and the family had had in possession for at least three hundred }ears a small farm to which was added the products of a forge. For many years back they had embraced the reformed religion, and for this reason at dift'erent times, had undergone much persecution. Franklin had sixteen brothers and sisters, these being the result of .two marriages. His father, Josias Franklin, came to America about 1685. at this time having seven children by his first wife, while ten children resulted from his second mar- riage with Abiah Folger, Benjamin being the last on the list of the pledges of marriage.
While all his brotlters had been placed in dift'er- ent hands in order to learn various trades, Benjamin, at the age of eight, was sent to college as his father destined him for the Church. He, however, re- mained there hardly a year, because on account of the family expenses, his father was unable to con- tinue tlie pay for his education, and he therefore sent him to a school kept by an excellent teacher, in order to learn writing and arithmetic. At the age of ten, his father brought him back so that he might help him in a new trade, that of manufacturing candles and soap, as the business of a dyer which Iil- had followed up to that time was not sufficientl\- lucrative, lienjamin was far from happy in his new surroundings. He had always been attracted by a sailor's life, and at an early age he could swim and steer a boat. His father wished at all cost to deter him from going to sea, so he frequently took him tn watch masons, carpenters, etc., work, thus hoping to discover his son's tastes and keep him on land.
'i"he taste of reading at this time developed in Franklin, and he had soon read all the books in the small library of his father which was composed prin- cipally of works on theology, and he said later in his life that he greatly regretted not to have had access to other bonks at this time. Soon afterwards, however, he obtained a translation of Plutarch that he diligently read and he always considered that he hatl thus employed his time to advantage. The Essay on Projects by Foe had also considerable in- fluence over him.
This disposition at last determined his father to nipke a i)rinter of him, although he had alreadv an- other son in this profession. Franklin's oldest hrotluT had set up business in Boston in 1717, and
owned his press and type. A contract of appren- ticeship was concluded between the two brothers, which bound Benjamin until the age of twenty-one years. At the time the contract was made he was twelve years old. It' was understood that, he would only receive wages as a workman during the last year of his apprenticeship.
I'Vanklin macle rapid progress and soon made him- self useful. Numerous excellent works came to his hands, lent him by apprentices at bookshops with whom he was acquainted. A man of much mind, by name Mathew Adams, who was possessed of a very fine collection of books placed them at his disposal. His reading at last gave him the idea of himself try- ing to write some works. He composed two ballads which were most successful and greatly flattered his vanity, but his father was sensible enough to point out to him the ridiculousness of these productions. According to Franklin himself they were miserable compositions and he w^as grateful to his father for makmg him escape from being a bad poet, the most useless individual of all creation. During the rest of his life he was contented w'ith expressing him- self in prose.
At aliout this time he became intimate with a young man named Collins, and as they were both given to controversy, they had frequent discussions which for them was an agreeable war of words, the fruit of their first readings. How-ever, Franklin soon corrected himself in this respect.
What is of extreme interest is to see how from each happening, whether small or great, in his life. Franklin knew how to deduct some practical teaching, which he was able later on in life to apply. A great controversy on the education of women arose between Collins and himself, but Franklin's father pointed out to the young printer that although he might carry in reason and ortho- graphy, his adversary was superior in the elegance of his language and the choice of expression. Frank- lin saw the justice of these criticisms and resolved to acquire that which he was wanting in.
An odd volume of The Spectator fell to him and he read and reread it and finally decided to adopt the style therein contained. From tiine to time he se- lected pieces from which he made short extracts, then laid them aside and after a few days en- deavored to recomposc them. He thus discovered his faults and was able to correct them.
At the age of sixteen he by chance read a work by Tyron, in which the author recommended a vege- table diet. Franklin wished to try it. but as he was boarding with his brother and the other apprentices with people in the neighborhood, this singular re- gime became rather difficult. He projwsed to his brother to ,give him each week only the half of what he paid for his board and this demand being ac- cepted. Franklin who was always desirous of ac- quiring books was, able to still save one-half of the money given him.
-After a frugal repast, usually composed of bread and fruit, he employed for study the time which re- mained until his brother and employes returned for work. It was at this time that he assimilated Cocke's Treatise on . Irithinetic. a work on naviga- tion by Seller and Stuniy. Locke On the I'nder- slanding. The . Irt of Thinking by the Messieurs of
January 2, 1909.]
CCMSTOX
BENJAMIN FRANKLIN.
5
the Port-Royal, and Xenophon's work entitled "Memorable Things of Socrates." The Greek phil- osopher's way of reasoning and discussing struck him forcibly, and renouncing possible arguments, he tried to limit himself to interrogation.
In his Autobiography Franklin says that, 'from reading Shaftesbury and Collins, made a doubter, as I already was in many jwints of our religious doc- trines, I found this method the safest for myself and very embarrassing to those against whom I used it ; therefore, I took delight in it, practised it con- tinually, and grew very artful and expert in draw- ing people even of superior knowledge into con- cessions, the consequence of which they did not foresee, entangling them in difficulties out of which they could not extricate themselves, and so obtain- ing victories that neither myself nor my cause al- ways deserved."
But these very triumphs showed him the empti- ness of his method, and little by little he abandoned it, only retaining the habit of always expressing himself witli modesty. He having found that the end of all conversation was to instruct or be in- structed, or to please or persuade intelligent men or those having good intentions, weakened the power that they have of doing good by taking a decisive and cutting tone, which rarely fails in displeasing and tends to contradiction.
In 1720 his brother began to publish a paper called The Nezc England Coiirant. It appears that this was the second newspaper published in America, and "curious to see what effect an article from his own pen might produce, he wrote one an- onymously and sent it to the paper. It was great pleasure to him to find that it was approved by cer- tain intelligent men, likewise their curiosity to find the real author, only naming those people who were enjoying a certain reputation of knowledge and wit. Encouraged by other articles that he wrote, these having obtained the same approval, he finally let his brother into the secret, but it appears that the latter was not very content.
Franklin's brother was very violent and frequent- ly beat him, and it is perhaps this hard and tyranni- cal treatment that made him all his life preserve a hatred against arbitrary power. For this reason Franklin was most desirous of abridging his appren- ticeship. The opportunity occurred in a most unex- pected way. A political article of certain violence having appeared in the journal, his brother was ar- rested and sent to jail for a month because he re- fused to expose the author's name. During his stay in jail, inflamed with resentment and having charge of the direction of the journal. Franklin was hardy enough to publish numerous sarcastic items relative to the government.
When his brother was liberated he was prohibited from continuing the printing of the journal under his name, so that it was concluded that the best means to resort to was to publish the paper in the future under the name of Benjamin Franklin. It was decided that the older brother should publicly give over the patent of apprenticeship to the younger, but in a secret clause Benjamin signed a second contract which again bound him to his brother.
A quarrel arose between them and Benjamin, be- ing indignant of the violences he was subjected to,
resolved to profit by the situation. He made good the annulment of his first contract, supposing that his brother would not produce the second, which in reality he did. Quite thrown over by this action, his brother also discredited him to such an extent in Boston that Franklin could find no work there, and then, again, the affair of the paper had rendered hiin suspicious to the government. His indiscreet talk on religion placed him in a very bad way as both an atheist and infidel. Even his own father considered him in the wrong, and so he determined to leave Boston surreptitiously and go to Xew York. His friend Collins helped him in his flight, and in order to make a little money Franklin sold his books and then set sail.
On arriving at Xew York, Franklin, who was at this time seventeen years of age, was without hardh' any money and no introductions. However, an old printer by name Bradford, who had established the first printing house in Pennsylvania, proposed that Franklin should go to Philadelphia, where his son might find employment for him. The trip was fruitful in accidents ; the sea was rough, and, as the yoimg man had gone thirty hours without eating, he was taken w"ith a high fever. He had read that cold water taken in large quantity was a remedy against this affection, and, carrying out this treatment, it was followed by an abimdant perspiration during the greater part of the night, and in the morning he was cured. Franklin continued his trip on foot and then in a boat, which he rowed himself. He arrived at Philadelphia much the worse for wear, almost dy- ing from want of sleep and hunger, and with only a dollar and a shilling in his pocket, which he gave the boatman for his passage.
Sir \\'illiam Keith, who was at this time governor of the province, interested himself in him and of- fered him the superintendency of a printing estab- lishment that he wished to establish on his own ac- count, and proposed to Franklin that he should go to England for the necessary materials. He, however, first returned to Boston, where he was badly received both by his brother and his father, who would give him no help, and he embarked with letters of intro- duction that the Governor had given him.
Franklin arrived at London on December 24. 1724, and he then learned that Keith did not merit the con- fidence that he had inspired. Isolated and without any friends and little money. Franklin began to work at a printing shop, where he worked on the setting up of a treatise by W'oUaston on Natural Religion, and still imbued with ideas of scepticism, which he was soon to relinquish, he gave vent to them in disserta- tion on liberty and necessity, pleasure, and hardship.
After a sojourn of eighteen months in London, a merchant who was about to leave for America pro- posed to take him as clerk, and Franklin accepted this with great joy. Upon h.is return, however, he met with a great disappointment, because, before leaving America, he had almost become engaged to a Miss Read, whom he tenderly loved. Upon his return he found her married and unhappy.
At this time he established himself in business in Philadelphia with a friend by the name of Meredith, who furnished the necessary funds, and, encouraged by the feeling of ownership, he adopted a wiser and more laborious life. A certain number of learned
6
CUMSTON: BENJAMIN FRANKLIN.
[New York Medical Journal.
persons assembled at his house once a week to dis- cuss morals, politics, and physics.
He soon became the exclusive proprietor of his press, and fortune finally smiled upon him. In 1730 he married his old love. Miss Read, who had become free, having been abandoned by her husband, and she proved for him a tender and faithful companion.
His public life dates from this time, and, realizing how useful books had been to him, he established a library, and in 1732 commenced the publication of his Poor Richard's Ahuanac, in which the wisest advice is given with an originality of expression which renders it easy to understand and quite im- possible to forget. He created a fire insurance com- pany, invented the Pennsylvania fireplace, and taught the people to pave the streets and light them at night.
Of his famous experiments with electricity, his various important political missions in England, be- ing so well known, I need not refer to them here. I would merely point out that during his stay in Eng- land, on several occasions, he came in contact with most eminent men and entered into relationship with the most distinguished scientists. In the summer of 1759 he visited Scotland and there entered into rela- tionship with David Hume, Robertson, Fergusson, and several other well known men. He was also made a member of the Royal Society. Franklin shows a great predilection for the people of letters of Edinburgh, and it would appear that Scotland was, to a certain extent, his intellectual country.
I shall now devote a little space to Franklin's stay in France, which was from 1776 to 1785, because it was here that he contracted many friends among the emi- nent scientists of the day. On account of his personal celebrity he was chosen ambassador to France after the war, while by reason of his discoveries he had, in 1772, been elected a foreign associate of the Academy of Science of France, which brought him in relationship with the most distinguished members of this noted company. One of them, the Due de la Rochefoucauld, whom he had known in London in 1769, had kept up a very continued and intimate correspondence with him. Consequently, upon his arrival at Paris, Franklin was at once introduced to those holding the highest social rank in Parisian so- ciety. His reserve and patient firmness were great- ly admired, likewise his solid judgment and delicate, ingenious mind. His noble features, rendered still more venerable by his long white hair, made him loved by all:
As soon as he arrived he conformed in his ways to the then existing fortune of his own country. AH the art of his politics consisted in forming for him a great personal consideration which he could make reflect on his country, and instead of the embassy upholding the ambassador, it was Franklin who up- held the embassy. The success that he had hoped for soon came, and soon public enthusiasm was at its height, while the departure of M. de la Fayette, which was the result, rendered it more startling and general. Finally, the court, irresistibly forced by public opinion, concluded the treaty of alliance in 1778 with the United States, which was then recog- nized as an independent power. Sweden and Prus- sia followed this example and signed treaties of friendship and commerce througli the hands of
Franklin. This end having been attained, and thus having assured the supreme work of the independ- ence of this country, Franklin remained in France as minister plenipotentiary. He then resided at Passy, in an agreeable retreat, where he could en- joy a commerce with science and the pleasures of friendship. He preferably sought the company of scientists and philosophers, and as he was endowed with a very searching mind, particularly the things of nature, and endowed with scientific truth, he be- came very intimate with a number of eminent physi- cians of his time.
The Royal Society of Medicine had been founded in 1776, and from its commencement had among its members most illustrious men, such as A. L. de Jussieu, Daubenton, Vicq d'Azyr, and as foreign as- sociates, Heberden and Priestley, only to mention a few of the principal ones.
Franklin, who was at that time president of the Philadelphia Society, member of the Royal Society of England, and the Royal Academy of Science of Paris, was the first foreign associate nominated by this company.
In the transactions of the Royal Society of Medi- cine of Paris will be found evidence of his collabo- ration. In 1776 he presented before it a work by Dr. Perkins, of Boston, entitled On the Nature and Origin of Epidemic Catarrhal Fevers. Among the members of this society was Dr. Barbeu du Bourg, with whom Franklin was very intimate, and on ac- count of this intimacy the latter made, in 1783, a French translation of Franklin's works. A physi- cian little known at this time, Marat by name, pre- sented Franklin with a work on physics which he had written, and the contact of these two personali- ties, so different from each other, is singularly sug- gestive.
The therapeutic methods of Mesmer were at this time in great vogue. His partisans and adversaries gave themselves up to heated discussions, and finally a commission was nominated to examine into his doctrine and experiments. The Academy of Science nominated Franklin as one of the commissioners, and other members belonging to this same body who were appointed were Bailly, Lavoisier, Leroy, and de Bary. Five other commissioners were appointed by the Faculty of Medicine, namely, Poissonnier, Caille, Mauduyt, Audry, and Laurent de Jussieu.
The report of this commission, which was ap- pointed on [March 12, 1784, appeared on the nth of August of the same year. The commissioners asked the following questions of Deslon, who was Mes- mer's principal student and representative: (i) To demonstrate the existence of animal magnetism ; (2) to communicate his knowledge on this discovery ; (3) to demonstrate its utility in the cure of diseases. The commission, after having observed what took place at Deslon's, were not at all convinced of the exist- ence of the fluid and decided to experiment them- selves. The members magnetized themselves on several occasions without any result. They then took seven patients who were magnetized at Franklin's home at Passy. Only three of them appeared to be influenced. An entire series of experiments were organized, resulting negatively. The following is the conclusion of the report submitted by the com-
January 2, 1909.]
CUMSTON: BENJAMIN FRANKLIN.
7
mission, and should be consulted at the present time by those who are interested in this subject of hypno- tism and diseases of the nervous system :
Les Comniissaires, ayant reconnu que le fluide mag- netique animal ne peut etre perqu par aucun de nos sens, qu i! n'a eu aucune influence, ni sur eux-memes, ni sur les malades qu'ils lui ont soumis, s etant assure que les pressions et les attouchements occasionnent des change - ments rarement favorables dans I'economie animale, et des ebranlements toujours facheux dans I'imagination ; ayant enfin demontre, par des experiences deceisives, que I'imag- ination, sans magnetisme, produit des convulsions, et que le magnetisme sans I'imagination ne produit rien, ils ont conclu, d'une voix unanime, que rien ne prouve I'existence du fluide magnetique animal, que ce fluide, sans existence est par consequent sans utilite ; que les violents effets qu'on observe au traitement public appartiennent a I'attouchement, a rimagination mise en action, et a cette imitation machin- ale qui nous porte malgre nous a repeter ce qui frappe nos sens. Et en meme temps, ils se croient obliges d'aj outer, comme une observation importante, que les attouchements, Taction repetee de I'imagination, pour nroduire des crises, peuvent etre nuisibles, a cause de cette imitation dont la nature semble nous avoir fait une loi ; et que par conse- quent, tout traitement public ou les moyens du magnetisme sont employes, ne peut avoir a la longue que de effets funestes.
There existed at this time at Auteuil a ntimber of distinguished men, who had formed a club, which has remained celebrated, under the name of the So- ciete d'Auteuil, of which Madame Helvetius was the central figure. The family of Helvetius established itself in France during the reign of Louis XIV, when Jean Adrien Helvetius, a physician of Holland, came there. He is particularly well known in medicine for his studies on the use of ipecac in dysentery. His son, Jean Claude Helvetius, had cured Louis XV when a child of a very serious malady, and for this reason he had been admitted into the medical corps of the young king by the Regent, and later on he was appointed counsellor of state, general inspector of the military hospitals of Flanders, and first physi- cian to Queen- jNIarie Leczinska. The son of Jean Claude, who had become fermier general at the age of twenty-three years, spent the 300,000 francs which represented his salary in all kinds of enter- tainment for men of letters, and very magnificently treated the most renowned among them. He re- signed his position in 1750 in order to give himself up entirely to study. The most celebrated of his works is entitled De I'Esprit, which was published in 1758, was condemned by the Sorbonne and Par- liament, burnt by the executioner, and the author, after having publicly retracted this writing, with- drew himself to the court of Frederick and later re- tired to the court of England.
His wife survived him for thirty years, and her house was the rendezvous of men such as Condillac, d'Holbach. Turgot, Jefferson, Champfort. Abbe, ]\Iorellet, Cabanis, Destutt de Tracy, F. Didot, and Gallois. It is not at all doubtful that Franklin, in his intimacy with these personages at Passy, influ- enced many eminent men, who later on took part in the great revolutionary movement, and that he con- tributed in inspiring them with conscience and bold- ness. It is also quite certain that he had a most happy influence over physicians of merit, and only to mention one, namely, his friend Cabanis. who has left us the following appreciation of Franklin's char- acter :
Ce qui distingue particulierement son esprit, c'est la rec- titude, la siiiiplicite, la sagacite. II s'etait fait de bonne
heure I'habitude de voir les objects sous leurs vrais rap- ports; il ocartait toujours soigneusement tout ce qui pou- vait ou les denaturer ou les obscurcir ; ce n'etait pas a des choses extraordinaires ou brillantes qu'il aimait a s'attacher. II ne faisait pas que de celles qui sont d'une application directe; il cherchait a les ramener aux terms les plus sim- ples et les plus usuels ; et s'il presentait habituellement sa pensee d'une maniere ingenieuse et piquante, il semblait que ce iut seulement pour la rendre plus facile a saisir, et la mettre a la portee des esprits les plus communs. Aucun homme. du reste, n'a jamais vu plus promptement et plus surement tout le parti qu'il y avait a tirer d'une idee qu'on lui presentait, d'un fait qui s'ofFrait a lui. Dans ce que vous lui disiez au hasard, il voyait I'explication ou le lieu d'une foule d'observations isolees ; dans la plus petite experience, il voyait les lois generales de la physique, et ce qui nous passe chaque jour sous les yeux, sans attirer le moins du monde notre attention, lui fournissait souvent I'idee des inventions les plus utiles.
II avait lu beaucoup, mais il n'etait pas ce qu'on appele erudit, et dans la physique meme, il avait plus invente qu'appris, Sa memoire ne retenait de chaque livre que ce dont il esperait faire usage ; mais c'etait pour toujours.
II n'avait rien oublie de ce qu'il avait recueilli d'interes- sant, pendant le cours d'une longue vie, dans le commerce des hommes. Les observations ou les anecdotes qui s'y rap- portaient, toujours presentes a sa memoire, formaient pour lui une espece de science et de morale pratique, dont il trouvait sans cesse a faire I'application dans sa conduite journaliere, ou qui, repandue a chaque instant dans sa con- versation, la rendait egalement altachante et profitante.
II ne faut pas croire au reste que la justesse de son es- prit rendit sa philosophie triste et serieuse. Jamais per- sonne ne fut plus enjoue. n'aime plus a jouir de la vie. II meprisait egalement cette pedantesque ou niinutieuse rec- titude que certains esprits veulent porter dans les choses et dans les idees usuelles, et cette morale grandeuse qui jette un voile funeste sur I'existence. II m'ettait la mau- vaise humeur au rang des vices.
Sir Humphrey Davy was also one of his intimate friends, and he has expressed himself most enthusi- astically of Franklin, pointing out his most singular method of induction, which guided him in all his re- searches, and how, by small means, he established great truths.
The return of Franklin to the LTnited States was a great triumph for him. He again took his place at the Assembly and was elected president twice, but in 1788 he gave up everything on account of his age and his infirmities. In the public assemblies he had a manner of com'porting himself which was quite personal ; he did not discourse, but reasoned, and he endeavored not by great oratory, but by a sudden and well placed word, to strike home, and this com- prised his entire rhetoric. Appointed to request the English minister to cease sending European crimi- nals to the Colonies, the minister pointed out to him the necessity of purging England of them, to which Franklin replied, "What would you say, if, for the same reason, we sent rattlesnakes to you?"
When once he had given up his active work he still had sufficient strength to found some very useful in- stitutions, among which we may mention the Society for the Abolition of Commerce of Slaves. His last years were passed among his family and friends, but he was continually occupied in the accomplishment of viseful things. He did not fear death, and often spoke of it, considering it somewhat like sleep, quite as natural and necessary to the human constitution as ordinary sleep. He was fearfully tormented by gout, and the last few months of his life he was obliged to keep his bed, and resort to large doses of opium to calm the pain. Through all this suffering he, however, retained his quiet gaiety, and died April 17. 1790, at the ripe age of eighty-five years.
8
CCMSTON: BENJAMIN FRANKLIN.
[New York Medical Joukxal.
On June nth of the same year, A'lirabeau an- nounced to the Assemblee Constituante, the death of Franklin, which up to that time had not been made known in France :
Franklin csl mort ! II est retourne au sein de la Divinite. Le genie qui afranchit I'Amerique, et versa sur I'Europe des torrents de lumiercs, le sage que les deux Mondes re- clament, I'homme que se disputent I'historie des sciences et I'historie des empires tenait sans doute un rang eleve dans I'espece humaine. Assez longtemps les cabinets politiques ont notilie la mort de ceux qui ne furent grands que dans leur eloge funebre : assez longtemps I'etiquette des cours a proclame des deuils hypocrites ; les nations ne doivent porter que le deuil de leurs bienfaiteurs : les representants lies nations ne doivent recommander a leur hommage que les heros de I'humanite.
Le Congres a ordonne, dans les quartorze Etats de la Confederation, un deuil de deux mois pour la mort de Franklin, et I'Amerique acquitte en ce moment ce tribut de \-eneration pour I'un des peres de sa constitution.
Ne serait-il pas digne de nous, Messieurs, de nous unir a cet acte religieux, de participer a cet hommage rendu a la face de I'univers, et aux droits de I'homme et au philosophc qui a le plus contribue a en propager la conquete sur la terre ?
L'Antiquite eut eleve des autels a ce puissant genie qui au profit des mortels, embrassant dans sa pensee le ciel et la terre, sut dompter la foudre et les tyrans. L'Europe eclairee et libre doit du moins un temoignage de souvenirs et de regrets a I'un des plus grands hommes qui aient jamais servi la philosophic et la liberte. Je propose qu' il soit decrete que I'Assemblee Nationale portera, pendant trois jours, le deuil Benjamin Franklin.
This proposition was unanimously adopted.
In his will Franklin left to George Washington his walking stick, made of wild apple, which he al- ways took with him in his walks, while the follow- ing is the epitaph written by him in 1728:
THE BODY OF
BENJAMIN FRANKLIN PRINTER
(Like the cover of an old book, its contents torn out and stript of its lettering and gilding) Lies here, food for worms, For it will (as he believed) appear once more In a new and more elegant edition Revised and corrected by
The Author.
We will now take up the scientific correspondence of Franklin, and although many more letters could l>e given, I shall only reproduce a few among many, that arc of interest medically, as they will serve my purpo.se of proving his knowledge of medicine.
Franklin had, apparently, from the following let- ter written to Sir John Pringle, employed electricity in cases of paralysis.
December 21, 1757.
Sir — In compliance with your request, I send you the following account of what I can at present recollect relat- ing to the effects of electricity in paralytic cases which have fallen under my observation.
Some years since, when the newspapers made mention of great cures performed in Italy and Germany by means of electricity, a number of paralytics were brought to me from different parts of Pennsylvania, and the neighboring pro- vinces, to be electrized, which I did for them at their re- quest. My method was to place the patient first in a chair, on an electric stool, and draw a number of large, strong sparks from all parts of the affected limb or side. Then I fully charged two six gallon glass jars, each of which had about three square feet of surface coated: and I sent the united shock of these through the affected limb or limbs, repeating the stroke commonly three times each day. The first thing observed was an immediate greater sensible
warmth in the lame limbs that had received the stroke than in the others : and the next morning the patients usually related that they had in the night felt a pricking sensation in the flesh of the paralytic limbs ; and would sometimes show a number of small red spots which they supposetl were occasioned by those prickings. The limbs, too, were found more capable of voluntary motion, and seemed to re- ceive strength. A man, for instance, who could not the first day lift the lame hand from off his knee, would the next day raise it four or five inches; the third day, higher; and on the fifth day was able, but with a feeble, languid motion to take off his h»t. These appearances gave great spirit to the patients, and made them hope ?. perfect cure ; but I do not remember that I ever saw any amendment after the fifth day ; which the patients perceiving, and finding the shocks pretty severe, they became discouraged, went home, and in a short time relapsed ; so that I never knew any ad- vantage from electricity in palsies, that was permanent, and how far the apparent, temporary advantage might arise from the exercise in the patient's journey, and coming daily to my house, or from the spirits given by the hope of suc- cess, enabling ihem to exert more strength in moving their limbs, I will not pretend to say.
Perhaps some permanent advantage might have been ob- tained if the electric shocks had been accompanied with proper medicine and regimen, under the direction of a skill- ful physician. It may be, too, that a few great shocks, as given in ir.y method, may not be so proper as many sma'l ones ; since by the account from Scotland of a case in which two hundred shocks from a phial were given daily, it seems that a perfect cure has been made. As to any uncommon strength supposed to be in the machine used in that case, 1 imagine it could have no share in the effect produced ; since the strength of the shock from the charged glass is in pro- portion to the quantity of surface of the glass coated ; so that my shocks from those large jars must have been much greater than any that could be received from a phial held in the hand.
I am, with great respect. Sir,
Your most obedient servant,
B. Franklin.
The following letter is in reply to Dr. Perkins, of Boston, who had asked Franklin for the number of patients that had died from inoculation in Philadel- phia, at the instance of Dr. Douglass, who intended to write something on smallpox.
Philadelphia, 13 August. 1752.
Sir — I received your favor of the 3d instant. Some time last winter I procured from one of our physicians an ac- count of the number of persons inoculated during the five visitations of the smallpox we have had in twenty-two years ; which account I sent to Mr. W. V., of your town, and have no copy. If I remember rightly, the number e.K- ceeded eight hundred, and the deaths were hut four. 1 suppose Mr. V. will show you the account, if he ever re- ceived it. These four were all that our doctors allow to have died of the smallpox by inoculation, though I think there were two more of the inoculated who died of the dis- temper; but the eruptions appearing soon after the opera- tion, it is supposed they had taken the infection before in the common way.
I shall be glad to see what Dr. Douglass may \yritc on the subject. I have a French piece printed at Paris, 1724, entitled. Observations sur la Saigncc du pird.et sur Ja Pur- gation, au commencement dc la Petit Verole. et Raisons de double contre I'lnocuJation. A letter of the Doctor's is mentioned in it. If he or you have it not, and desire to see it. T will send it. Please to favor me with the particulars of your purging method, to prevent the secondary fever, &c., &c. Sir, yours, &c.,
B. Fr.\nki.in.
As will be seen T have merely given that part of the above letter which pertains to smallpox. The French work referred to was written by the famous Dr. Hecquet. one of the medical celebrities of Paris at this time.
The following letter written to Iiis parents shows that Franklin was well versed in at least one uro- logical subject, namely that of calculus.
January 2, 1909.]
CUMSTON: BENJAMIN FRANKLIN.
9
Philadelphia, 6 September, 1/44.
Honored Father and Mother — I apprehend I am too bu!)\- in prescribing and meddling in tiie doctor's sphere, when any of you complain of ails in your letters. But as 1 always employ a physician myself when any disorder arises in my family, and submit implicitly to his orders in every- thing, so 1 hope you consider my advice, when I give any, only as a mark of good will, and put no more of it in prac- tice than happens to agree with what your doctor directs.
Your notion of the use of strong lye I suppose may have a good deal in it. The salt of tartar, or salt of wormwood, frequently prescribed for cuttmg, opening, and cleansing, is nothing more than the salt of lye procured by evaporation. jNIrs. Stevens's medicine for the stone and gravel, the secret of which was lately purchased at a great price by the Par- liament, has for its principal ingredient salt, which Boer- haave calls the most universal remedy. The same salt in- timately mixed with oil of turpentine, which you also men- tioned, makes the sapo philosophorum, wonderfully ex- tolled by some chemists for like purposes. It is highly probable, as your doctor says, that medicines are much altered in passing between the stomach and bladder ; but such salts seem well fitted in their nature to pass with the least alteration of almost anything we know ; and, if they will not dissolve gravel and stone, yet I am half persuaded that a moderate use of them may go a great ways towards preventing these disorders, as they assist a weaker diges- tion in the stomach and powerfully dissolve crudities, such as those which I have frequently experienced. As to honey and molasses, I did not mention them merely as openers and looseners, but also from conjecture that, as they are heavier in themselves than our common drink, they might when dissolved in our bodies increase the gravity of our fluids, the urine in particular, and by that means keep separate and suspended therein those particles which, when unused, form gravel, etc.
I will inquire after the herb you mention. We have a botanist here, an intimate friend of mine, who knows all the plants in the -country. He would be glad of the cor- respondence of some gentlemen of the same taste with you, and has twice, through my hands, sent specimens of the famous Chinese ginseng found here to persons who desired it in Boston, neither of whom has had the civility to write him a word in answer, or even to acknowledge the receipt of it, of which please to give a hint to brother John.
We have had a very healthy summer and a fine harvest , the country is filled with bread ; but as trade declines since the war began, I know not what our farmers will do for a market. I am your affectionate and dutiful son,
B. Franklin.
The several letters written to Cadwallader Golden, in which Franklin relates his experiments on the cir- culation and respiration, I shall merely mention here as being of considerable interest medically, but space forbids their reproduction, and I will now re- produce a paper by Franklin entitled: A Conjecture as to the Cause of the Heat of the Blood in Health, and of the Cold and Hot Fits of some Fevers. This piece was found in Franklin's handwriting- among the papers of Cadwallader Colden by Sparks, who remarks that its date is uncertain, but was probably written before the year 1750.
The parts of fluids are so smooth, and roll among one another with so little friction, that they will not by any ( niechanical) agitation grow warmer. A phial half full of water shook with violence and long continued, the water neither heats itself nor warms the phial. Therefore the blood does not acquire its heat either from the motion and friction of its own parts, or its friction against the sides of its vessels.
But the parts of solids, by reason of their closer adhesion, can not move among themselves without friction, and that produces heat. Thus, bend a plummet to and fro, and, in the place of bending, it shall soon grow hot. Friction on any part of our flesh heats it. Clapping of the hands warms them. Exercise warms the whole body.
The heart is a thick muscle, continually contracting and dilating nearly eighty times in a minute. By this motion there must be a constant interfrication of its constituent solid parts. That friction must produce heat, and that heal
must consequently be continually communicated to the per- fluent blood.
To this may he added, that every propulsion of the blood by the contraction of the heart distends the arteries, which contract again in the intermission ; and this distension and contraction of the arteries may occasion heat in them, which they must likewise communicate to the blood that flows through them.
That these causes of the heat of the blood are sufficient to produce the effect, may appear probable, if we consider that a fluid once warm requires no more heat to be applied to it in any part of time to keep it warm than what it shall lose in an equal part of time. A smaller force will keep a pendulum going, than what lirst set it in motion.
The blood, thus warmed in the heart carries warmth with it to the very extremities of the body, and communi- cates to them ; but, as by this means its heat is gradually diminished, it is returned again to the heart by the veins for a fresh calefection.
The blood communicates its heat, not only to the solids of our body, but to our clothes and to a portion of the circumambient air. Every breath though drawn in cold is expired warm ; and every particle of the materia perspir- abilis carries off with it a portion of heat.
While the blood retains a due fluidity, it passes freely through the minutest vessels, and communicates a proper warmth to the extremities of the body. But when, by any means it becomes so viscid as not to be capable of passing those minute vessels, the extremities, as the blood can bring no more heat to them, grow cold.
The same viscidity in the blood and juices checks or stops the perspiration, by clogging the perspiratory duct, or, perhaps, by not admitting the perspirable parts to sep- arate. Paper wet with size and water will not dry so soon as if wet with water only.
A vessel of hot water, if the vapor can freely pass from it, soon cools. If there be just fire enough under it to add continually the heat it loses it retains the same degree. If the vessel be closed, so that the vapor may be retained, there will from the same fire be a continual accession of heat to the water, till it rises to a great degree. Or, if no fire be under it, it \w\\\ retain the heat it first had for a long time. I have experienced that a bottle of hot water stopped, and put in my bed at night, has retained so much lieat, seven or eight hours, that I could not in the morning bear my foot against it, without some of the bedclothes in- tervening.
During the cold fit, then, perspiration being stopped, great part of the heat of the blood, that used to be dissi- pated is confined and retained in the body ; the heart con- tinues its motion, and creates a constant accession to that heat ; the inw ard parts grow very hot, and, by contact with extremities, communicate that heat to them. The glue of the blood is by this heat dissolved, and the blood after- wards flows freely as before the disorder.
We now come to the dialogue between Franklin and the Gout, which was written by him during one of his stays at Passy, and as it is a little gem of both hygiene and treatment of this afifection, I will repro- duce it in full :
Midnight, October 22. 1780.
Franklin — Eh ! oh ! eh ! What have I done to merit these cruel sufferings ?
Gout — Many things : You have ate and drunk too freely and too much indulged those legs of yours in their indo- lence.
Franklin — Who is it that accuses me? Gout — It IS I, even I, the Gout. * Franklin — What? My enemy in person? Gout — No. not your enemy.
Franklin — I repeat it — my enemy ; for you would not only torment my body to death, but ruin my good name : you reproach me as a glutton and a tippler ; now all the world, that knows me, will allow that I am neither the one nor the other.
Gout — The world may think as it pleases; it is always very complacent to itself and sometimes to its friends; but T very well know that the quantity of meat and drinV proper for a man who takes a reasonable degree of exer- cise would be too much for another who never takes any.
Franklin — I take — eh ! oh ! — as much exercise — eh ! — as I
lO
CUMSTON: BENJAMIN FRANKLIN.
[New York Medical Journal.
can, Madam Gout. You know my sedentary state, and on that account it would seem. Madam Gout, as if you might spare me a little, seeing it is not altogether my fault.
Gout — Not a jot; your rhetoric and your politeness are thrown away ; your apology avails nothing. If your situa- tion in life is a sedentary one, your amusements, your recrea- tions, at least should be active. You ought to walk or ride, or if the weather prevents that, play at billiards. While the mornings are long and you have leisure to go abroad, what do you do? Why, instead of gaining an appetite for breakfast by salutary exercise, you amuse yourself with books, pamphlets, or newspapers which commonly are not worth reading. Yet you eat an inordinate breakfast — four dishes of tea with cream and one or two buttered toasts, with slices of hung beef, which, I fancy, are not things the most easily digested. Immediately afterward you sit down to write at your desk or converse with persons who apply to you on business. Thus the time passes till one without any kind of bodily exercise, but all this I could pardon, in regard, as you say, to your sedentary condition. But what is your practice after dinner? Walking in the beautiful gardens of those friends v/ith whom you have dined would be the choice of a man of sense ; yours is to be fixed down to chess, where you are found engaged for two or three hours. This is your perpetual recreation, which is the least eligible of any for a sedentary man, because, in- stead of accelerating the motion of the fluids the rigid attention it requires helps to retard the circulation and obstruct internal secretions. Wrapt in the specula- tions of this wretched game you destroy your con- stitution. What can be expected from such a course of living but a body replete with stagnant humors, ready to fall a prey to all kinds of dangerous maladies, if I, the Gout, did not occasionally bring you relief by agitating those humors and so purifying or dissipating them? If it was in some nook or alley in Paris, deprived of walks, that you played a while at chess after dinner, this might be ex- cusable ; but the same taste prevails with you in Passy, Auteuil, Montmartre, or Sanoy — places where there are the finest gardens and walks, a pure air, beautiful women, and most agreeable and instructive conversation; all of which you might enjoy by frequenting the walks. But these are rejected for this abominable game of chess. Fie then, Mr. Franklin! But amid my instructions* I had almost forgot my wholesome corrections, so take that twinge — ^and that !
Franklin — Oh ! eh ! oh ! oh-h ! As much instruction as you please, Madam Gout, and as many reproaches ; but pray, madam, a truce with your corrections !
Gout — No, sir, no. I will not abate a particle of what is so much for your good ; therefore
Franklin — Oh ! eh-h-h ! It is not fair to say I take no exercise, when I do very often, going out to dine and re- turning in my carriage.
Gout — That, of all imaginable exercises, is the most slight and insignificant, if you allude to the motion of a carriage sus pended on springs. By observing the degree of heat obtained by different kinds of motion, we may form an estimate of the quantity of exercise given by each. Thus, for example, if you turn out to walk in winter with cold feet, in an hour's time you will be in a glow all over ; ride on horseback, the same effect will scarcely be perceived by four hours' round trotting; but if you loll in a carriage, such as you have mentioned, you may travel all day, and gladly enter the last inn to warm your feet by the fire. Flatter yourself, then, no longer that half an hour's airing in your carriage de- serves the name of exercise. Providence has appointed few to roll in carriages, while he has given to all a pair of legs, which are machines infinitely more commodious and serviceable. Be grateful, then, and make a proper use of yours. Would you know how they forward the circulation of your fluids in the very action of transporting you from place to place, observe, when you walk, that all your weight is alternately thrown from one leg to the other; this oc- casions a great pressure on the vessels of the foot and re- pels their contents ; when relieved, by the weight of being thrown on the other foot, the vessels of the first are al- lowed to replenish, and by a return of this weight this repulsion again succeeds; thus accelerating the circulation of the blood. The heat produced in any given time de- pends on the degree of this acceleration ; the fluids are shaken, the humors alternated, the secretions facilitated, and all goes well ; the checks are ruddy and health is es- tablished. Behold your fair friend at Auteuil, a lady who received from bounteous nature more really useful science
than half a dozen such pretenders to philosophy as you have been able to extract from all your books. When she honors you with a visit it is on foot. She walks all hours of the day and leaves indolence and its concomitant mala- dies to be endured by her horses. In this see at once the preservative of her health and personal charms. But when you go to Auteuil you must have your carriage, though it is no further from Passy to Auteuil than from Auteuil to Passy.
Franklin — Your reasonings grow very tiresome.
Gout — I stand corrected. I will be silent and continue my office ; take that, and that.
Franklin — Oh ! oh ! Talk on, I pray you I
Gout — No, no. I have a good number of twinges for you tonight, and you may be sure of some more tomorrow.
Franklin — What, with such a fever ! I shall go distract- ed. Oh ! eh ! Can no one bear it for me ?
Gout — Ask that of your horses; they have served vou faithfully.
Franklin — How can you so cruelly sport with my tor- ments ?
Gout — Sport! I am very serious. I have here a list of offenses against your own health distinctly written, and can justify every stroke inflicted on you.
Franklin — Read it then.
Gout — It is too long a detail, but I will briefly mention some particulars.
Franklin — Proceed. I am all attention.
Gout — Do you remember how often you have promised yourself the following morning a walk in the Grove of Boulogne, in the Garden of de la Muette, or in your own garden, and have violated your promise, alleging at , one time it was too cold, at another too warm, too windy, too moist, or whatever you please, when in truth it was to nothing but your inseparable love of ease ?
Franklin — That, I confess, may have happened occasion- ally, probably ten times in a year.
Gout — Your confession is very far short of the truth; the gross amount is one hundred and ninety-nine times.
Franklin — Is it possible?
Gout — So possible that it is fact; you may rely on the accuracy of my statement. You know M. Brillon's gardens and what fine walks they contain ; you know the handsome flight of one hundred steps which lead from the terrace above to the lawn below. You have been in the practice of visiting this amiable family twice a week after dinner, and it is a maxim of your own that "a man may take as much e.xercise in walking a mile, up and down stairs, as in ten on level ground." What an opportunity was here for you have had exercise in both those ways ! Did you em- brace it and how often?
Franklin — I cannot immediately answer that question.
Gout — I will do it for you. Not once.
Franklin — Not once?
Gout — Even so. During the summer you went there at si.x o'clock. You found the charming lady, with her lovely children and friends, eager to walk with you and entertain you with their agreeable conversation ; and w hat has been your choice? Why, to sit on the terrace, satisfy yourself with the fine prospect, and passing your eye over the beau- ties of the garden below, without taking one step to de- scend and walk about in them. On the contrary, you call for tea and the chess board; and lo! you are occupied in your seat till nine o'clock, and that besides two hours' play after dinner ; and then, instead of walking home, which would have disturbed you a little, you step into your car- riage. How absurd to suppose that all this carelessness can be reconcilable with health without my interposition !
Franklin — I am convinced now of the justice of Poor Richard's remark that "Our debts and our sins are always greater than we think for."
Gout — So it is. You philosophers are sages in your max- ims and fools in your conduct.
Franklin — But do you charge among my crimes that I return in the carriage from M. Brillon's?
Gout — Certainly ; for having been seated all the while, you cannot object the fatigue of the day, and cannot want, therefore, the relief of a carriage.
Franklin — What, then, would you have me do with my carriage ?
Gout — Burn it if you choose; you would at least get heat out of it once in this way: or, if you dislike that proposal, here's another for you : Observe the poor peasants who work in the vineyards and grounds about the villages of
January 2, 1909.]
CUMSrON: BENJAMIN FRANKLIN.
II
Passy, Auteuil, Chaillot, &c. ; you may find every day among these deserving creatures four or five old men and women, bent and perhaps crippled by weight of years and too long and too great labor. After a most fatiguing day these people have to trudge a mile or two to their smoky huts. Order your coachman to set them down. This is an act that will be good for your soul ; and at the same time after your visit to the Brillons, if you return on foot, that will be good for your body.
Franklin — Ah ! How tiresome you are !
Gout — Well, then, to my office; it should not be forgot- ten that I am your physician. There !
Franklin — Oh-h-h ! What a devil of a physician !
Gout — How ungrateful you are to say so ! Is it not I who, in the character of your physician, have saved you from the palsy, dropsy, and apoplexy, one or other of which would have done for you long ago but for me?
Franklin — I submit and thank you for the past, but en- treat the discontinuance of your visits for the future ; for in my mind one had better die than be cured so dolefully. Permit me just to hint that I have also not been unfriendly to you. I never feed a physician or quack of any kind to enter the list against you ; if, then, you do not leave me to my repose, it may be said you are ungrateful, too.
Gout — I can scarcely acknowledge that as an objection. As to quacks, I despise them ; they may kill you, indeed, but cannot injure me. And as to regular physicians, they are at last convinced that the gout, in such a subject as you are, is no disease, but a remedy; and wherefore cure a remedy? But to our business; there!
Franklin — Oh ! oh ! for heaven's sake leave me, and I promise faithfully nevermore to play at chess, but to take exercise daily and live temperately.
Gout — I know you too well. You promise fair, but after a few months of good health you will return to your old habits ; your fine promises will be forgotten like the forms of the last year's clouds. Let us, then, finish the ac- count, and I will go. But I leave you with an assurance of visiting you again at a proper time and place ; for my object is your good, and you are sensible now that I am your real friend.
In closing, I will refer to Franklin's Plain In- structions for Inoculation, a rare little work, which was written because he felt assured, as he states in the introduction, that the practice of inoculation "would be much more general among the English on the Continent of America, and of course many lives would be saved, if all who are desirous of being in- oculated could easily be furnished with the means of having it done." The Instructions comprise seven and a half large pages and indicate the necessary preparations to be made, the season of the year proper for inoculation, the age and constitution of the patient, the technique of inoculation, and the after treatment of the case. To these pages I would refer the reader desirous of learning more of the method of inoculation employed in those days, but I will here transcribe in toto the introductory letter to this work, because, as will be seen, it is an historical document of considerable importance relative to smallpox. The exact title of the work is as follows : Some account of the Success of Inoculation for the small-Pox ill England and America. Together zinth Plain Instructions, By which any Person may he en- abled to perform the Operation, and conduct the Patient through the Distemper. London: Printed by W. Strahan. M,DCC,LIX.
London, Feb. j6. 1759. Having been desired by my greatly esteemed friend, Dr. William Haberden^ F. R. S., one of the principal Physi- cians of the city, to communicate what account I had of the success of Inoculation in Boston, New England, I some time since wrote and sent to him the following paper, viz. :
About 1753 or 54. the Small-pox made its appearance in Boston, New England. It had not spread in the town for
many years before, so that there were a great number of the inhabitants to have it. At first, endeavours were used \o prevent its spreading, 'oy removing the sick, or guarding the houses in which they were; and with the same view Inoculation was forbidden ; but when it was found that these endeavours were fruitless, the distemper breaking out in different quarters of the town, and increasing. Inocula- tion was permitted.
Upon this, all that inclined to Inoculation for themselves or families hurried into it precipitately, fearing the infec- tion might otherwise be taken in the common way ; the numbers inoculated in every neighborhood spread the in- fection likewise more speedily among those who did not chuse Inoculation ; so that in a few months the distemper went thro' the town, and was extinct ; and the trade of the town suffered only a short interruption, compar'd with what had been usual in former limes, the country people during the seasons of that sickness fearing all intercourse with the town.
As the practice of Inoculation always divided people into two parties, some contending warmly for it, and others as strongly against it; the latter asserting that the advantages pretended were imaginary, and that the Surgeons, from views of interest, conceal'd or diminish'd the number of those who died of the Small-pox in the common way: It was resolved by the Magistrates of the town, to cause a strict and impartial enquiry to be made by the Constables of each ward, who were to give in their returns upon oath ; and that the enquiry might be made more strictly and im- partially, some of the partisans for and against the practice were join'd as assistants to the officers, and accompany'd them in their progress through the wards from house to house. Their several returns being received and summ'd up together, the numbers turn'd out as follows :
Had the sinnll- Received the dis-
pox in the temper by
common way. Of these died. inoculation. Of these died.
Whites. Blacks. Whites. Blacks. Whites. Blacks. Whites. Blacks.
5.059 485 -152 62 1,974 159 23 7
It appeared by this account that the deaths of persons inoculated were more in proportion at this time than had been formerly observed, being something more than one in a hundred. The favourers of Inoculation, however, would not allow that this was owing to any error in the former accounts, but rather to the Inoculating at this time many unfit subjects, partly through the impatience of people who would not wait the necessary preparation, lest they should take it in the common way ; and partly from the impor- tunity of parents prevailing with the Surgeons against their judgment and advice to inoculate weak children, labouring under other disorders; because the "parents could not im- mediately remove them out of the way of the distemper, and thought they would at least stand a better chance by being inoculated, than in taking the infection, as they would probably do, in the common way. The Surgeons and Phy- sicians were also suddenly oppress"d with the great hurry of business, which so hasty and general an Inoculation and spreading of the distemper in the common way must oc- casion, and probably could not so particularly attend to the circumstances of the patients offered for Inoculation.
Inoculation was first practiced in Boston by Dr. Boyle- stone in 1720. It was not used before in any part of Amer- ica and not in Philadelphia till 1730. Some years since, an enquiry was made in Philadelphia of the several Surgeons and Physicians who had practic'd Inoculation, what num- bers had been by each inoculated, and what was the suc- cess. The result of this enquiry was. that upwards of 800 (I forget the exact number"), had been inoculated at differ- ent times, and that only four of them had died. If this ac- count was true, as I believe it was, the reason of greater success there than had been found in Boston, where the general loss by Inoculation used to be estimated at about one in 100, may probably be from this circumstance ; that in Boston they always keep the distemper out as long as they can, so that when it comes it' finds a greater number of adult subjects than in Philadelphia, where since 1730 it has gone through the town once in four or five years, so that the greatest number of subjects for Inoculation must be under that age.
Notwithstanding the now uncontroverted success by In- oculation, it does not seem to make that progress among common people in America which at first was expected. Scruples of conscience weigh with many, concerning the
12 THOMSON: ASIATIC CHOLERA.
LAWFULNESS of the practice : and if one parent or near relative is against it, the other does not chuse to inoculate a child without free consent of all parties, lest in case of a disastrous event, perpetual blame should follow. These SCRUPLES of a SENSIBLE CLERGY may in time remove. The EXPENSE of having the operation performed by a Surgeon weighs with others, for that has been pretty high in some parts of America ; and where a common tradesman or artificer has a number in his family who have the distem- per it amounts to more money than he can well spare. Many of these, rather than own the true motive for de- clining Inoculation, join with the scrupulous in the cry AGAINST IT, and influence others. A small Pamphlet wrote in plain language by some skilful Physician and publish'd, directing what preparations of the body should be used before Inoculation of children, what precautions to avoid giving the infection at the same time in the common way, and how the operation is to be performed, the incisions dress'd, the patient treated, and on the appearance of what symptoms a Physician is to be called, etc., might by en- couraging parents to inoculate their own children be a means of removing that objection of the expence, render the practice much more general, and thereby save the lives of thousand's.
The Doctor, after perusing and considering the above, humanely took the trouble {tho' his .extensive practice af- fords him scarce any time to spare) of writing the follow- ing Plain Instructions,^ and generously at his oivn private expense printed a very large impression of them, which ivas put into my hands to be distributed gratis in America. Not aiming at the praise which, however, is justly due to such disinterested benevolence, he has omitted his name ; but as I thought the adz'ice of a nameless Physician might possibly on that account be less regarded I have zvithout his knowledge here divulg'd it. And I have prefix'd to his fmall but valuable ivork these pages, containing the facts thai give rise to it because Facts generally have, as indeed they ought to have, great zveight in persuading to the prac- tice they favour. To these I may also add an account I have been favoured with by Dr. Archer, physician to the Small-pox Hospital here, vis.:
There have been inoculated at this hospital since its first institution, this day, December 31, 1758, 1,601 Persons. Of which number 6 died.
Patients who had the Small-pox in' the common way in this Hospital, to the same day, 3856. Of which number have died 1,002.
By this account it appears, that in the zvay of Inoculation there has died but one patient in 267, zvhereas in the com- mon ivay there has died more than one in four. The mortality indeed in the latter case appears to have been greater than usual {one in seven, when the distemper is not very favourable , being as reckon d the common loss in towns by the Small-pox, all ages and ranks taken to- gether), but these patients were niostlT; adults, and were received, it is said, into the Hospital, after great irregular- ities had been commiftd. By the Boston account it ap- pears that, Whites and Blacks taken together, but about one in eleven died in the common way, and the distemper then 7fas therefore reckon' d uncommonly favourable. I have also obtained from the Foundling Hospital (where all the children admitted that have not had the Small-pox are inoculated at the age of Ave years) an account to this time of the success of that practice there, which stands thus, viz:
Inoculated, boys 162; girls, 176; in all, 338. Of these died in Inoculation, 2 ; and the death of one of those two cases was occasioned by a worm fever.
On the whole, if the chance were only as two to one in favour of the practice among children, would it not be sufficient to induce a tender parent to lay hold of the ad- vantage? But luhen it is so much greater as it appe^irs to be by these account?, (in some even as thirty to one) surely parent?, ivill no longer refuse to accept and thank- fully use a discovery God in his mercy has been pleased to bless mankind zvith; wliereby some check may noiv be put to the ravages that cruel disease has been accustomed to make, and the human species be again suffered to in- crease as it did before the .Small-pox made its appearance. This increase has indeed been more obstructed by that dis-
'To make the plainer and more generally intelligible, the Doctor purposely avoided as much as possible the medical terms and ex- pressions used by Physicians in their writings.
[New York Medical Journal.
temper than is usually imagin'd: For the loss of one in ten thereby is not nearly the loss of so many persons, but the accmnulated loss of all the children and children's children the deceased might have had, multiplied by successive gen- erations. B. Franklin,
of Philadelphia.
871 Beacon Street.
ASIATIC CHOLERA
And its Lessons hozu Infectious Diseases Should Be Classified.* By W. Hanna Thomson, M. D., LL. D., New York.
There is no disease which illustrates more than does Asiatic cholera the wonderful progress made in our generation by the medical profession in the knowledge of the infections . But it also must be admitted that nothing so illustrates the short- comings of the profession in acquainting the pub- lic, by a proper terminology, as the distinction be- tween the three great classes of infectious diseases. Instead of that, we find both individual members of the profession and official bodies confounding in a highly injurious degree the terms used to dis- tinguish one class of infectious diseases from an- other. Due to this confusion, an uncertainty pre- vails widely in the minds of the public on this subject, with the result that panics, most costly to the community and disgraceful to our civiliza- tion, have repeatedly occurred even within recent years. The history of the epidemics of Asiatic cholera strikingly illustrates this truth. In the year 1855, the officials of the Massachusetts State Board of Health issued a statement intended to reassure the public, about the nature of Asiatic cholera, which then threatened to become epidemic. In this state- ment they strongly insisted that Asiatic cholera was not at all a contagious disease, but was due to a miasm pervading the atmosphere. Both these state- ments were mischievous errors, because it was then understood that in denying that Asiatic cholera was contagious it was also intended to deny that it was communicable from person to person. Whereas the truth is that this disease, without being properly contagious, and hence no one need run away from a cholera patient, nevertheless is a highly communi- cable disease, in that no case of cholera occurs with- out having contracted it from a previous case of cholera. We now know that the second statement was equally erroneous. There is no miasm ; for even the disease called by its ancient name, malaria or "bad air," we now know is an infection caused solely through a hypodermic injection by a mosquito. The whole conc<?ption of a deadly miasm arising from swamps and unhealthy localities, which has for ages weighed upon the medical mind, is a mistake, and therefore there arc no unhealthy localities or un- healthy climates as such, but only regions infected by a certain variety of mosquito, and which medical science therefore knows now how to disinfect and render as healthy as any other climates.
Had the Massachusetts State Board of Health only perused the reports published by the government of
*Paper read at the meeting of the Medical Association of the Greater City of New York, November 16, 1908.
January 2, 1909. J
THOMSON: ASIATIC CHOLERA.
13
Denmark on the epidemic of cholera in that king- dom ni tne }ear 1653, they would at once havt known, as the profession ever since has known, that cholera does spread from person to person, and spreads in no other way, and is never disseminated through the atmosphere, 'i his was proved by the Danisn government issuing directions to all physi- cians practising in country districts in Denmark, to report the first case of cholera occurring in their rural neighborhood, then the second, and third, and fourth, up to the fifth case. When these reports were collected it was shown that the case of each second, third, and fourth patient could in some way be traced as having had some communication with the first patient, although in one instance, a laun- dress who had washed the clothes of a cholera pa- tient was taken sick, who never saw the patient, and lived ten miles from him.
'1 his leads me to say that this fact affords a valuable illustration how country practitioners may greatlv assist their profession by systematic observa- tions on the epidemic prevalence of certain infec- tions, when occurring in isolated rural communities. When I was president of the Academy of Medicine I was asked to see in consultation a case of polio- myelitis in a schoolboy on a farm in Dutchess. County. I then learned that a schoolmate of his who sat next him in the schoolroom was taken with the disease a week before he was, and died in five days. I was also told that a young lady living three miles away from his country house was dying from some cerebral trouble. I was driven to her house and found her comatose, with a history of cerebro- spinal meningitis. On further questioning I learned that she was a cousin of this first patient mentioned ; that that boy had passed the night on a visit to her house three nights before she was taken sick. My two medical friends whom I met in consultation then told me that an epidemic of meningitis and myelitis had been prevailing some ten weeks in their neighborhood. I tried strongly to recommend that their local medical society should at once take up the investigation of this epidemic, after the fashion of the Danish physicians mentioned about cholera, to note whether any kind of communication had oc- curred between the different cases before they devel- oped. I told them that only men in their position could give satisfactory observations on such infec- tions, compared to us who practised in large cities. In Xew York everybody,, sooner or later, comes in very close contact with his fellow citizens, and dur- ing the rush hours at the Brooklyn Bridge, or on our trolley cars, all one can do sometimes is to pre- vent being telescoped by somebody either before or behind him. How infectious diseases are therefore spread in cities is impossible to determine, whereas only a little trouble would be sufificient to give valu- able information on such a subject in a country dis- trict, where everv one knows every one else. I ofYered to have the report published by the New York Acadmy of Medicine, but no such report was forthcoming. Year before last we had just such an epidemic prevail in this city, but it was impossible then to settle just how its victims were infected.
But to return to the subiect of a popular classifi- cation, with the corresponding terms to be used for the guidance of the public, I should recommend a short statement adopted by some authoritative med-
ical society, defining the three classes of infeciious diseases, as follows :
The term "'infectious" should include every dis- ease caused by the entrance into and subsequent multiplication in the body of its own specific micro- organism. This term, therefore, ought to cover them all, from smallpox to tuberculosis and malariaL infectious diseases are divisible into three classes. First class, that in which the disease is communi- cated from the sick to the healthy directly, and in which mere proximity to the sick with them is enough to endanger those. who are susceptible to the disease. To this class only should the term "con- tagious" be applied. The chief members of this class are smallpox, scarlet fever, measles, diphtheria, influenza, whooping" cough, mumps, and typhus fever. Though the term contagious implies their spread by personal contact, it is doubtful if this actu- ally occurs except in syphilis and gonorrhoea, but the term "'simple proximity" fully sufifices to designate their nature.
As all the infectious diseases are accidental, and the body by no process of its own, normal or ab- normal, can give rise to them, any more than a field spontaneously generates what grows in it, therefore all these diseases should be prevented like any other accidents. The only method for prophylaxis of a contagious disease is by quarantine or the segrega- tion of those sick with them.
To the second class belong those diseases which are communicated from the sick to the healthy, not directly, but indirectly through some intermediate carrier. Prophylaxis or prevention of them, there- fore, is secured by discovering what the intermediate carrier is, and then destroying the infecting agent on or in them. These diseases not being contgious. can be attended by their friends, nurses, and physi- cians without any danger of their contracting the infection. The chief members of this class are Asi- atic cholera, typhoid fever, and tuberculosis.
The third class comprises those diseases that are communicated only by inoculation, through some puncture, or wound, or equivalent lesion of the skin or mucous membrane, and therefore they are not dangerous to bystanders, as the contagious diseases are. It is in this third class that the greatest triumphs of preventive medicine have been secured. They con- stitute the entire class of malarial infections by the bite of the mosquito, also yellow fever by the same means, also other very fatal maladies, as the sleep- ing sickness of Africa, caused by the bite of the tsetze fly, and the no less fatal kala azar of the East Indies, which is produced by the bites of bedbugs, and finally the bubonic plague, which is propagated to human beings by the bites of fleas which have bitten rats infected by the plague bacillus. Much the most important members of this class are those pyrogenic organisms which become inoculated into the blood during surgical operations, or by the uterus after delivery. Tetanus and hydrophobia also belong to this class.
Now, I do not assert that this classification covers every means by which infection can occur. Any in- fection mieht be communicated by intravenous injec- tion ; smallpox and scarlet fever can be carried bv letter: but these are not the usual methods by which they spread, and hence it is not necessarv to confuse the public with such details. On the other hand, it
14
THOMSON: ASIATIC CHOLERA.
[New York Medical Journal.
is especially of the second class or those which are propagated by intermediate carriers, that the public need to be fully informed as to their nature. We cannot expect the cooperation of the community in our efforts to get rid of tuberculosis, or to diminish the prevalence of typhoid fever without the public becoming so well informed on these very points that they will then see the reasonableness of supporting the preventive measures recommended by the med- ical profession. This is well illustrated by the history of the last visit of Asiatic cholera to the port of New York, when it came to us by steamers from the highly infected port of Hamburg, in the summer of .1892. Its approach was heralded in the newspapers all over the country, and accordingly, very soon upon the first news of an infected ship entering New York harbor, a widespread business panic took place which very seriously affected the commerce of the city of New York. As more vessels arrived, the authorities attempted to have the passengers of the infected ships landed at places on the southern shore of Long Island. Armed mobs were quickly collected among the inhabitants of those localities to prevent by force any persons sick with cholera being landed, and no one was allowed to leave the ships. Mean- time, it had not occurred to any one to account for the fact that it was the steerage passengers on those ships which were seriously affected, while not a single case occurred among the saloon passengers, although they paced the deck right over them. At the same time, it w"as reported to the Academy of Medicine that some Italian laborers who had diar- rhoea had escaped from these ships, and who were employed by a contractor on the Harlem railroad, where, in the town of Bedford, they were huddled in cabins with the water closets draining into a brook which discharged into the Croton river. The Academy of Medicine at once conferred with the board of health, how to prevent the contamination of the Croton water by this means, and they were met with a statement that the city officials proposed to buy a strip of 300 yards in width on both banks of the Croton river and disinfect these strips, so that the Croton should not be contaminated. This real estate speculation did not commend itself to the academy, and a committee was appointed, of which I was chairman, to go to Albany and to demonstrate to the Senate Committee on Cities that this plan would not $ufifice at all to shield the city against the infection.
As I began, in my remarks to the senate com- mittee, to refer to the extensive experience with this disease in English cities, the chairman of the senate committee roared out : "We do not want anything English here ! God Almighty Himself contaminates the Croton when he sends his rain !" As it was plain to our committee that we might as well ad- dress a bench of Mohammedan muftis as this body of senators, we withdrew. In the next morning's papers, the Academy published to the panic stricken city a statement showing what a danger to public health politicians can be in such emergencies.
We cited, at the time, what I was not allowed to show to our senators, the official reports that had been sent to me hy the Hamburg authorities. The latter, when they found that one side of a street had many cases of cholera, if it was supplied by water from the Elbe, while the opposite side of the same
street, which had a different water supply, did not have a case, at once ordered scientific engineers to construct great sand filters to purify the Elbe water. On the completion of these filtering plants cholera ceased, but not until ships infected with it had al- ready started for New York. The authorities, alarmed by the newspapers, asked for another con- ference with our committee, promising to adopt any bill that the Academy would draft. But when the Academy proposed that a faltering plant for the Croton should be constructed by experts chosen from the American Institute of Engineers, instead of by the City Board of Public Works, the city officials were much incensed. As the cholera scare meantime had died out. New York city to this day continues to drink unfiltered Croton water, with the result that thousands die here from typhoid fever, which, like cholera, is a water borne disease, and which every year becomes more rife as the Croton runs low. Philadelphia also has its yearly epidemics of typhoid, which the medical profession there has protested might be obviated by filtering the Schuylkill waters. So it might, but for the poli- ticians making a job of the construction of the filter works, so that they get the money out of it but leave the typhoid germs in. The drainage of Connecticut towns also infects the oyster beds of Long Island Sound, and I have been called in consultation to patients at our most fashionable hotels, ill with typhoid from their habit of eating raw oysters for their first course at dinner.
A striking illustration of how a knowledge of the methods of propagation of a member of the third, or intermediately carried infections, may be used to arrest its prevalence, is furnished in the case of Asiatic cholera. The present generation hardly knows how the dread spectre of this epidemic once made all the western nations tremble when the news came that it had started afresh on its travels from its native India. The British government had dis- covered there that its chief outbursts coincided with the great Hindu pilgrimage, which occurred once in twelve years, to Hardwar, on the Ganges. How cholera might abound on such an occasion is well shown bv the description of Dr. Simpson, the able health officer of Calcutta.
At this pilgrimage, which is also held as a fair, from Soo.ooo to 1,000.000 Hindus collect to drink the holy waters of their sacred Ganges, and to bathe in the great tank con- structed at the riverside. From April 8 to April 12, 1891. it presented the spectacle of a seething mass of humanity in constant motion through the pool at the rate of 400 to 500 per minute. Now, it can easily be imagined that a few cases of cholera introduced into such a multi- tude would easily induce not only an outbreak of cholera there and then, but by the returning pilgrims would be car- ried far and wide. Thus a sanitary commissioner says of previous Hardwar gatherings that very little remains on record, but that little is a record of disease and death. So grave was the outlook that the question of prohibiting the pilgrimage in 1891 was seriously discussed, and many offi- cials of great experience reported that the most complete sanitary arrangements would be powerless to prevent the spread of cholera if the fair were held.
As this prohibition might entail the dancer of a general insurrection, the British government decided to hand the management over to the Indian Medical Staff. The latter, now knowing just how cholera infects, and that, without being taken in food or drink, it cannot travel six inches. • allowed the fair to be held. They promptly removed to appointed tents every case of the disease in this Asiatic crowd as soon as reported. All discharges from the pa- tients were quickly disinfected, with the result that the
January 2, 1909.]
RIESMAX: ADDRESS TO NURSES.
15
cholera was stamped out as effectually as a fire can be extinguished if taken just at its beginning.
What a gain it is to humanity that the civihzed world now knows that tuberculosis is not -conta- gious! Not many years ago the New York City Board of Health announced that tuberculosis, being an infectious disease, was therefore contagious. The board was promptly called to account for this out- rageous statement. Every one knows what a con- tagious disease is smallpox. Because of its being contagious, the patient's nearest and dearest friends should keep away from him. Hence, after this offi- cial pronouncement, many a poor consumptive was needlessly discharged by his employer as a danger to all his fellow workmen, whereas thousands of consumptives never infect the members of their .own families. A few simple precautions, w^hich would be utterly useless against a really contagious disease, would effectively remove the danger from him. Now that it is widely known that tuberculosis al- ways has to be carried by something outside of the patient, attention is directed, not to the patient so much as to the carrier of the infection, and the pub- lic, learning this fact, is willing intelligently to join as never before in the crusade against it, until we may hope that ere long tuberculosis will become as uncommon as leprosy.
23 West Forty-sevexth Street.
ADDRESS TO NURSES, Delivered at the Graduation of Nurses, Polyclinic Hospital Training School, November 11. igo8.
By David Riesmax, M. D., Philadelphia.
The history of nursing is the history of all revo- lutionary movements. The pioneers idealized, or rather overidealized, the cause they were engaged in. Those who took up the work in the middle of the last century felt a sentimental elevation of spirit quite akin to that which possessed the knights and ladies in the age of chivalry, the newness of the call- ing, and the fact that many of those who entered it did not have to work for a living, having encom- passed it with a halo of sentiment that could not long endure. The reaction came, and with it a purely com- mercial view of the profession of the nurse, from which we are now happily beginning to emerge. There is unquestionably a drift toward a riper and nobler conception, in wWch the ideal of work, not wages, is dominant; the feeling that each woman must work out her salvation for herself, with her own hands, with her own brains, in the field best suited to her talents, whether it be in the home or in the world at large. This feeling has energized woman's latent powers, and in the case of your pro- fession has given it a tremendous force.
Daily the nurse's calling is increasing in impor- tance and in scope. Training schools are multiply- ing in the larger cities : and in smaller tow' ns, the building of hospitals, a thing virtually impossible were it not for the nurses filling the important posi- tions, is going on apace. In many of these smaller new institutions, the appointments of which are often of the best, training schools are also being established.
There is now, too, a greater use of nurses by pri-
vate families. Even within my recollection there was a period when it was difficult to persuade a family in moderate circumstances to have a trained nurse. A few days ago I had such an experience — a middle aged woman had been taken ill, not seriously, yet I thought it would be best to have a nurse to watch her. The members of the family were opposed to it. "We don't believe in trained nurses ; they make so much bother, and are but lit- tle help." I waited for a few days, then I insisted again, and carried my point. The nurse came, with the result that on two occasions when the patient wanted to discharge her, thinking she could get along without a nurse, the family begged me to persuade the patient to keep her. This is not an un- common occurrence.
In the sociological field the scope of nursing has widened enormously — slum nursing, district nurs- ing, nursing in public schools — what a magnificent field ! In the home the nurse has, however, not fully reached the measure of her possibilities ; she is not yet all that she should be. She is still in many in- stances merely a nurse, a machine, instead of, in the Emersonian sense, woman nursing. To achieve that ideal she must expand, not only along technical lines — and here I want to take issue with those who advocate a shortening of the curriculum — but also along general cultural lines. With regard to tech- nical education, I want to urge you not to stop study with graduation ; do not stand still ; read your text- books and your notes frequently ; from time to time, as new editions of textbooks come out, try to get them ; and then, to keep more fully abreast of the advances in your profession and in touch with your sister nurses, read systematically a nursing journal. Nurses after their graduation live too much indi- vidual lives, and often care but little for the gen- eral good of their calling or whether the position of their profession is bettered or not, just so long as they have steady employment. This is a narrow spirit that does harm to the nurse herself and de- tracts from the strength and influence of the cause she represents.
I believe in organization — less perhaps for offense and defense than for the purpose of intellectual ad- vancement and the furthering of an esprit dc corps. I should like to see nurses'" societies established" somewhat on the lines of our scientific medical socie- ties, composed of the graduates of all reputable training schools, at which papers would be read per- taining to nursing, or to medical subjects in so far as they are of interest to the nursing profession. In a general way, such meetings should further both tech- nical and cultural advancement. The nurse, with her varied experiences in the home and in the wards of the hospital, has so much of interest and of value to tell that the opportunity should be given her to do so. How much the younger nurses would profit by listening to those who have been in practice for many years and are living lives of intense activity! This is rather a pet idea of mine, and I hope you will think it over. Medicine, the most progressive of all sciences, discovers something new every day. I am afraid, however, that for the majority of nurses all the new things coming after graduation remain un- known. That is not right ; that is not as it should be; it is a sad anticlimax to a three years' course
I
i6
BECK: BISMUTH POISONING.
[New York Meuical Journal.
of ardent study. The nurses" society is the place for learning about these new things. From time to time a doctor might be invited to read a paper ; but for the most part the nurses' contributions should make up the programme of the meetings. The society should possess a library, or, if that is im- possible for pecuniary reasons, arrangements should be made with the trustees of public libraries for the establishment of a special nurses' library with text- books and nursing journals.
I stated a little while ago that the nurse had not fully realized the importance of her mission in the home. I want you to be not only nurses, not only ministers of health for the sick, but apostles of hy- giene to the well, for in this capacity you can be of the greatest help to the physician in the spreading of the principles of preventive medicine. There are many, many lines of the best kind of missionary work for you. Take vaccination, for example — - you will be astonished when you go out to find how strong is the prejudice against it; and yet there has never been a discovery that has done more good to mankind. Vaccination is a sure preventive of smallpox, and nothing in the whole range of medicine compares with it. I have not time, nor is this the place, to s'o into the objections raised against it ; but taken all together they have no weight.
Another idea I desire you to combat in your mis- sionary vv-ork is the idea that all children must have children's diseases, measles, chickenpox, whooping cough, scarlet fever, and that if one child in the household is afflicted, the best thing to do is to ex- pose them all, so that all the trouble may come about the same time and the doctor's bill be lessened by reason of wholesale service. It is not necessary for children to have all the diseases of childhood, and bv sheltering them in a sensible manner they n:ay escape some of them ; one can never tell, even the mildest is at times fatal or leaves after effects that cause lifelong suffering and regret.
Another idea, the spreading of which among the ])eople would be of benefit, is the love of fresh air. You must support us in our crusade in this field to the best of your ability ; the people must be told that .fresh air, whether itjjc night air or day air, is not harmful ; that the sleeping room windows should i;e wide open at all seasons : and that stuffy houses do more harm than winter snows or autumn rains. Gradually the knowledge is growing among the lait\- that colds are contagious and that ordinary sore throat may be communicated : but acquaintance with this indul)itablc fact is not as widespread as it should be. Mere, too, you can do a little preach- ing ; but be careful not to impress upon the laity such a fear of contagion, such a dread of germs, as to make life miserable.
And then the great subject of diet, how little it is understood ! I am afraid the blame falls some- what upon us physicians ; yet you have learned a few things about this in your three years' course, and can liclp in diffusing your knowledge among the f)eople. Under the iicad of diet I would include the drinking of water. Make it known to all that watiM- is f)ne of the best things of the earth taken at tlie right time and in the right quantities; that it promotes health and lessens the need for drugs.
These things that I have been telling you are im- portant, and you must ever keep them before you. There .is only one thing more that I have to say and that goes deejDer, goes nearer to the root of things — it is that the one really great thing in life is zvork. That is the ideal with which you must start out. Carlyle says : "It is the grandest cure for all the maladies and miseries that ever beset mankind- honest work, which you intend getting done. The most unhappy of all men is the man who cannot tell what he is going to do, who has got no work cut out for him in the world. Work is life, and to have one's work cut out for him and to do it is to live." Just think, then, how fortunate you are in having a purpose and the capability to carry it out. I want you' to go from here glorifying work. I care but little whether in beginning to practice your pro- fession you think it is the grandest in the world ; it does not matter ; indeed you need not think about it at all if only you have the impetus within you to work. The real truth, after all, is not that you are working in nursing because it is the grandest pro- fession, but that because of work in it it becomes the grandest profession. Moreover, you must re- member you help to cure, not only because you are nurses, but because you are women. Renan. whose love for his sister gave him a profound lui- derstanding of the female sex, eloquently says : "Who wovild dare to assert that in many cases, certain injuries always excepted, the touch of a gentle and beautiful woman is not worth all the resources of pharmacy? Cure is eft'ected by the mere pleasure of seeing her. She gives what she can, a smile, a hope, and it is not in vain."
TOXIC EFFECTS FROM BISMUTH SUBXITRATE, With Reports of Cases to Date. By Emil G. Beck, 'M. D., Chicago,
Surgeon to the North Chicago Hospital.
Toxic effects from the use of bismuth subnitrate in medicine and surgery are so rare that, until re- cently, physicians have regarded its administration as perfectly harmless. Schuler ( i ) and von Bar- deleben (2) have pronounced its action as nontoxic, the latter having treated one hundred cases of ex- tensive burns by dusting with bismuth subnitrate, and observed no unpleasant symptoms therefrom. Professor Muhlig (3) administered 20 grammes daily for a prolonged period without producing any poisonous effect.
It was, therefore, not surprising when radiogra- phers began to use bismuth subnitrate for the ])ur- pose of obtaining radiographs of the stoniach and intestines, that they had no hesitancy in administer- ing large doses, and boasted of the safety with which as much as forty grammes in one dose could be administered. The subject of bismuth poisoning came into comparative revival only within the past two years, when radiographers began to employ the drug more extensively.
Cases of poisoning resulting from the administra-^ tion of bismuth subnitrate have been reported as earlv as tjc)^, but these were, thought to be due to the ini]nirities in the drug, such as arsenic, etc. The
January' ji, 1909. J
BECK: BISMUTH POISONING.
17
first authentic report of bismuth poisoning was made by Theodor Kocher (4) in 1882, who ob- served that the insoluble bismuth preparation, when applied to large wound surfaces, is capable of yield- ing so much bismuth to absorption as to produce poisonous ef¥ects, characterized by acute stomatitis, black discoloration of the mucous membrane, usual- ly beginning at the border of the teeth, but later spreading over the whole mouth, followed by intes- tinal catarrh, pain, and diarrhoea, and in severe cases, desquamative nephritis.
Similar cases were reported by Professor Peter- son (5). Thereafter the literature on the subject remained silent until 1901, when Professor Muhlig (3) reported the following two cases:
Case I.- — A man, twenty-six years of age, received a burn on both arms, hand, and neck, the same were dressed with oil for three days and the pure bismuth subnitrate applied. Two weeks later a black border around the teeth appeared, and within five more days the whole mouth and uvula were greyish blue and slightly ulcerated. Urine remained nor- mal, digestion normal. Recovery took place after wounds were curetted and freed from bismuth.
Case II. — A man, thirty-four years old, was burned on both legs, Treatment same as in Case I. Twelve days after first bismuth dressing symptoms identical with those in Case I appeared. Urine and stool remained normal. The curet- tage of the wounds resulted in prompt remission of the symptoms. The bismuth used in these cases was free from impurities.
A similar case was reported by Dressman (6).
Case III. — A man, thirty years old, received a burn of third degree. Five days later a ten per cent, bismuth salve was applied. Three weeks later a black sediment was discov- ered in the ruine. A severe stomatitis with deglutition pains followed. A bluish green border around his teeth was noticed, and the mouth resembled the condition which exists after eating huckleberries. After the bismuth dress- ings were stopped the symptoms abated, but even six months later there were blue marks around the teeth.
Wordan, Sailer, Pancoast, and Davis (7) reported two cases, in which sixty and 120 grammes were administered in one dose. In both cases the char- acteristic symptoms of bismuth poisoning developed and both patients recovered.
The first fatal case, directly traceable to the ad- ministration of bismuth subnitrate for diagnostic purposes, is reported by Bennecke and Hoff- man (8).
Case IV. — A three weeks' old_child, suffering from en- teritis, weak and emaciated. A mixture of three grammes of bismuth subnitrate in 100 c.c. of buttermilk was admin- istered by stomach, in order to diagnosticate a pyloric sten- osis by rontgenograph. Twelve hours later cyanosis devel- oped, collapse followed, and the child died three hours later. Post mortem examination revealed bismuth in the bowel, and small quantities in the liver and blood. Methremoglo- bircem.ia was present.
From the same clinic another similar case was re- ported by Bohme (9).
Ca.se V. — A child, one and a half years old, markedly rachitic, artificially fed and marasmic, received a few grammes of bismuth subnitrate by stomach for radio- graphic purpose. Stomach was washed and no symptoms of poisoning appeared. Two days later a few grammes of bismuth subnitrate were injected by the rectum for the same purpose, and again the bismuth was washed out. Three hours later the child was suddenly seized with pain, cried, became cyanotic, pale, skin cool, pulse small, and died in twenty to thirty minutes.
Section : Distinct mcthsemoglobinsemia, all mucous mem- branes were brownish discolored, marked rachitis, dilation of the stomach, with stenosis of pylorus. Colon contained large quantities of black and white bismuth.
Professor Hefter suggested that death might; have been caused by nitrate poisoning. The blood and pericardial fluids were tested, and in both nitrites were found. Bismuth could not be detected in the liver or blood. These chemical findings threw new light on both cases and prompted Dr. Bohme to determine the true cause of bismuth sub- nitrate poisoning. The results of his experiments were as follows:
A number of pure cultures of the Bacterium coli were found to liberate nitrites in every case, when added to bouillon to whicli some bismuth subnitrate was added. The controls of bouillon, treated the same way but without the addition of bismuth, remained free from nitrites. This ex- periment was repeated by using a solution of children's stool instead of pure cultures, and in every instance the for- mation of nitrites was marked, while the same experiments with stools from grown persons showed nitrites absent in forty per cent., slight in thirty-five per cent., and marked in only twenty-five per cent, of the cases. The ingestion of food seemed to have no influence in regard to nitrite for- mation, as some of the adults received a milk diet.
The next question Bohme determined was whether the formation of nitrites would occur in feeding lower animals with bismuth subnitrate. Cats and rabbits were used for experiments, and after finding their stools and urine free from nitric acid, they were given from three to five grammes of bismuth subnitrate in milk. Nitrates appeared in the urine after a few hours and did not cease to be eliminated from the kidney for twenty-four hours. Reaction to nitrites was absent in the rab- bit and only faintly marked in the cats.
To prove that children's fasces mixed with bismuth subnitrate would liberate nitrites in the bowel of the rabbit, Bohme injected a inixture of five grammes of each into a part of the bowel, by first ligating the loop. Nitrates and nitrites were found in the urine, but ,not in the blood taken from the hearts of the animals. In the faeces of the ligated part of the bowel a large quantity of nitrates and nitrites was found. In trying larger quantities by the same method, and testing the urine hourly, the quantity of nitrates and nitrites increased, but not enough was absorbed to cause metha;moglobinaemia.
By these experiments Bohme proved by test tube and animal experiments that the fasces of children when in contact with bismuth subnitrate will liber- ate nitrites, which are quickly absorbed from the intestine and found in the urine. While methsemo- globinsemia was not caused by the absorption, it must be assumed that the absorption of larger quantities would produce methaemoglobinaemia. Ex- periinents proved this to be a fact.
CoUishon (10) reports two cases of accidental nitrite poisoning in which sodium nitrite instead of the sodium nitrate was given. The symptoms were cyanosis, extreme weakness, and a greyish blue discoloration of the mucous membrane and the tongue. The symtoms were so severe as to produce collapse, but cleared up after the drug was discon- tinued. Binz (11) injected dogs with small doses of sodium nitrite, causing their death in a few hours, with symptoms of gastroenteritis and methaemoglo- binaemia.
Harnack (12) killed a cat by administering five grammes of sodium nitrite within five minutes. Methaemoglobin?cmia was present.
BECK: BISMUTH POISONING.
[New York ilEDiCAL Journal.
Fig. I. — Lung abscess. Case CLXVII. Child six years old. Bismuth paste injected at point A, cavity B.
Routenberg (13) reported a case in which a methaemoglobinaemia with the usual symptoms of nitrite poisoning folfowed the rectal injection of fifty grammes of bismuth subnitrate in 400 c.c. of oil of sesame, and while the author ascribes the poi- soning to the contamination of the oil, the analogy with other similar cases leads one to suspect that it was a case of nitrite poisoning.
A recent report of a fatal nitrite poisoning due to bismuth subnitrate is published by Novak and Gutig (14).
Case VI. — A man, forty-four years of age, who, a year after a retrocolic gastroenterostomy, sufYered from symptoms of obstruction, received in July, 1908, a rectal injection of four tablespoonfuls of bismuth subnitrate suspended in two litres of water, to test the function of the anastomosis. Soon after the X ray examination, the bowels were washed out. After a restless night the nurse noticed a discoloration of the pa- tient's skin. This condition was not discovered until nine and a half hours after injection, and it was assumed that it could have been detected much sooner by daylight. Gradually the patient became greyish green, mucous membranes cyanotic, temperature 40° C, pulse 96. Patient did not respond to treatment and had stertorous breathing. Flush- ing of bowels and administration of oxygen had no effect. Venesection revealed the blood to be of chocolate color, due to methremoglobinsmia. Patient died eighteen hours after rectal injection of bismuth subnitrate. Spectroscopic examination of blood of a few hours after death showed that blood became normal, brown color having changed to red. Two days later the post mortem examination revealed that the methxmoglobinfEmia, which was positive before death, had now disappeared and blood resumed a normal color.
This case also gave further impetus to investiga- tion. "The administration of 100 grammes of bis- muth subnitrate by mouth, then by rectum, and through a fistula into the small and large bowels of dogs and rabbits, failed to produce any symptoms of poisoning, while in cats much smaller quantities (twenty grammes) would cause death in ten hours.
.Seven hours after ingestion of this quantity the cat vomited, her mucous membranes became bluish grey, blood assumed a chocolate color, and spectro- scope revealed the methsemoglobin stripe in the red."
This proves that certain animals are susceptible to nitrite poisoning, while others are not. It is not yet fully determined to which class the human be- longs.
It has been proved that nitrites, when formed in the bowel, may be neutralized. By adding iodine nitrate to the faeces containing nitrites, the latter will disappear in two to three days. Maasen proved that certain bacteria in the bowel convert the nitrites into ammonia or into nitrogen. It is likely that the bis- muth subnitrate ingested always causes a liberation of small quantities of nitrites, which are either ab- sorbed, and owing to the small amount cause no toxic symptoms, or are changed in the intestine into ammonia or nitrogen.
When, however, large quantities of bismuth sub- nitrate are given, and the liberation of nitrites is abundant and cannot be neutralized quickly, so that large quantities of nitrites are absorbed, typical sypmtoms of nitrite poisoning will appear. Alco- hols and glycerin accelerate the formation of nitrites in the intestines. This suggests to us a practical point, namely : When we encounter a case of nitrite poisoning, to withhold alcoholics and glycerin from ingestion and administer some form of iodine.
From these experiments and reports of fatal cases we must conclude that the poisonous effects of the bismuth subnitrate were not due to the absorption of the metallic bismuth, but to the absorption of nitrites, which caused the methsemoglobin to pre- cipitate in the blood. The methaemoglobinsemia ap- pears to be the factor producing most of the clin-
Fic. 2. — Lung abscess. Case CLXVIL Radiograpli two months later showing absorption of paste.
January 2, 1909.]
BECK: BISMUTH POISONING.
19
ical symptoms, the cyanosis, dyspnoea, diarrhoea, and cramps. They indicate that the sudden change in the blood impairs the internal or tissue respiration, and the patients succumb with symptoms of suf¥oca- tion.
It appears that the intestine, and especially the sigmoid and the rectum, are the laboratories for the liberation of nitrites. The bacteria in this part of the intestinal tract evidently are the nitrite splitting factors, whereas, those in the stomach and small in- testine allow the bismuth subnitrate to pass into the large intestine without liberation of any quantities of nitrites.
This probably accounts for the fact that in Novak's and Gutig's experiments the small intestine was usually found empty, while in the large in- testine was found bismuth subnitrate. The animals appeared perfectly well for several hours, but as soon as the symptoms of poisoning appeared, the in- tensity progressed rapidly, causing death very quickly.
The fatal cases thus far reported were all suf- fering from intestinal diseases, especially diarrhoea or constipation, which suggests that the intestinal putrefaction accelerated the nitrite formation and rapid poisoning.
During the past two years the author (15) has employed bismuth subnitrate quite extensively in the treatment of empyema, sinus and abscess cavities, l)y injecting a mixture containing thirty-three per cent, bismutli subnitrate incorporated in petrolatum into the cavities. The question as to what became of the bismuth paste after the injection arose. A study of the subject revealed the facts that if the paste did not discharge from the sinus soon after injection, but was retained, it became encapsulated and absorbed. In nonresilient cavities, such as bone â– cavities, the mass was generally penetrated from all sides by fibroblasts, and gradually replaced by con- nective tissue, while in collapsable cavities, such as the pleura, the expanding lung gradually replaced the slowly absorbing bismuth paste. This could be confirmed by taking radiographs of the regions so injected at certain intervals (Figs, i and 2).
This, then, proves that the bismuth paste is ab- sorbed, and the question arises : How is the bismuth -excreted, and is its absorption harmful ? These two problems are now being investigated, but as the in- vestigation is not completed, I shall, in this paper, bring forth only practical and conclusive facts, and defer the publication of the theoretical aspect until the data obtained will warrant definite conclusions.
Harnack (16) states that bismuth subnitrate is slowly absorbed and slowly eliminated. OrfiUa found bismuth subnitrate in the liver. M. M. Ber- geret (17) states that bismuth subnitrate is found in the urine, in the serous exudates, a few hours after administration, and in rabbits the administra- tion of a few grains could be detected in the spleen, muscles, and blood. Professor E. S. Wood (18) has detected bismuth in the urine four weeks after administration, proving its slow absorption. We may, therefore, conclude that the bismuth is slow- ly absorbed and slowly eliminated.
Before attempting to answer the second ques- tion. Is the absorption harmful? we must decide Avhether the harmful effects noted in the cases re-
Fic. 3. — Empyema pleurse. Case XXIX. 720 grammes of paste injected, but not allowed to be absorbed.
ported are due to the absorption of the liberated nitrites or of the bismuth itself. By comparing the symptoms of the two cases reported by Collishon, which were caused by a sodium nitrite overdose, with those of other authors, caused by the administration of bismuth subnitrate, one can hardly doubt that the source of poisoning is identical, and that the nitrites are the factors which are responsible for the sudden and violent attacks of poisoning. This fact is sup- ported by the experiments of Bohme, and Novak and Gutig.
In my experience with the injection of bismuth petrolatum into sinus and abscess cavities, I have not encountered any case in which the train of symp- toms would correspond to that of an acute nitrite poisoning, so graphically described by the various authors who have met with these cases. In many patients I have noticed a slight lividity of the mu- cous membranes and skin, a bluish border at the margin of the teeth, otherwise the conditions were perfectly normal. In one patient I noted a distinct ulceration in the mouth, which was characteristic of the bismuth absorption as Kocher describes it. It disappeared in a few days. In another patient with an empyema pleurae, in whom I injected into the pleural cavity 720 grammes of thirty-three per- cent, bismuth paste, which was retained there for six weeks, when a desquamative nephritis devel- oped, there appeared albuminuria, rapid loss of pre- viously gained weight, and the blue border around the teeth (Fig. 3). As soon as the bismuth paste was withdrawn by means of injecting olive oil and then applying a specially devised suction pump, all the symptoms disappeared, and the patient regained his weight in a few weeks.
I further desire to put on record a case referred
20
BECK: BISMUTH POISONING.
[New Vokk Medical Journal.
FtG. 4. — Photomicrograph, section about 4 micra thick. Some liver cells loaded with bismuth. Magnification 1,000 diam.
to me by Dr. Roberts, in which the bismuth injec- tions had caused severe bismuth intoxication, and after same abated the patient died.
Case VII. — Mr. R., a lawyer, fifty-seven years old, for many years an invalid, had a tuberculosis of his hip since 1896, and after extensive operations retained several sinuses which discharged large quantities of foul pus. In March liis sinuses had been injected by the house physician twenty times in a period of sixty days with a thirty-three per cent, bismuth petrolatum paste, the total amount representing about 400 grammes of pure bismuth subnitrate. While his general condition improved at first, and his sinuses healed, all signs of typical bismuth intoxication gradually developed, as described by Kocher. The mucous mem- brane of the mouth and gums became bluish black, with ulcerations, teeth became loose and lips oedematous. He experienced great thirst, diarrhoea, and had desquamative nephritis. The symptoms gradually abated, and he became well enough to resume his work as an attorney, and for two months was active in his vocation. A radiograph taken of his pelvis demonstrates that there .were only small quantities of bismuth within the tissues, but they appeared to be disseminated through the entire pelvis.
August I, 1908, he fell, injured his wrist, and a large abscess formed, which was op- erated on by Dr. V. Verity. A large area of necrosis followed. From this time his temperature varied from 99° to 101.5° C. He lost in strength, his urine was loaded with casts and albumin; his heart became weaker, and irregular, and he died August 16, 1908.
Post mortem examination, made by Dr. A. Gelirmann and myself, showed findings a? reported in the following:
Subject is an old man, rather poorly nourished Right leg shows some shorten- ing. (Finding in region of right hip by Dr. Beck.)
.\bdominal cavity : A small amount of fluid present. No adhesions or evidences of tumors or inflammatory exudates.
Liver: About normal in size, dark brown- ish in color. Section fails to show any no- ticeable changes.
Spleen : Normal in size, but unusually dark, quite soft.
Pancreas: Negative.
Intestines : Somewhat distended with gas but otherwise negative.
Vermiform appendix: Negative.
Mucous membrane of intestines shows dark color, very marked.
Kidneys : About normal in size. External surface of Doth shows some evidence of beginning contraction aS the capsule is irregularly depressed. Sections show both kid- neys to be of dark color with the cortical markings not as distinct as in a normal organ.
Pelvis and Ureters : Free. On the right side in the pelvis the retroperitoneal tissue appears gelatinous, but more con- sistent of a whitish glistening appearance, as though filled with a foreign substance.
Chest : Pericardium negative. Heart about the size of subject's fist. Heart muscle rather softer than normal. Valves negative and coronary arteries negative.
Lungs : Few adhesions about apices on both sides. Some hypostasis on both sides. Otherwise negative.
Inspection of bones of thorax and spine as far as possible fails to show fractures, tumors, or inflammatory changes.
Head not posted.
The microscopical examination of the tissues from the liver, spleen, kidney, heart muscle, and intestine, and the chemical analysis of tissues were made by Dr. Maximilian Herzog, and his report is as follows :
Liver: The liver parenchyma cells in general do not show r.ny marked pathological changes. Some cloudy swelling is noticeable here and there, but the process is not at all extensive, but on the contrary, quite limited. There is very little fatty infiltration and fatty degeneration seen. Quite a number of parenchyma cells show bile granules in their paraplasm. Whether the latter also contain here and there bismuth is a question which cannot be definitely de- cided, since we do not know of any microchemical reaction for bismuth. However, it appears that we find frequently in liver cells granules darker than the bile granules, and that they are bismuth granules. The latter can first be seen distinctly and beyond doubt in the intralobular capil- laries. Here we see the dark granules in the lumen of the small vessels and crowded in fusiform cells, probably the star cells of Kuppfer. In the interlobular veins (the ter- minal branches of the portal vein) bismuth is present to a large extent ; it is found in the vascular endothelium and
KiG. 5. — Photomicrogra|ih, section of liver about 4 micra thick. In the centre an interlobular vein, to the right and above a suhlobular vein. The intima of both lined with bismuth. Magnification, 210 diam.
January 2, 1909. J
BECK: BISMUTH POISONING.
21
deposited in the torm of fine granules on the free surface of the mcima. Occasionally one sees in the interlobular con- nective tissue a vessel, apparently a sublobular vein (the terminal branch of the hepatic vein), which likewise con- tains bismuth. But this point is not clear beyond doubt, as is the presence of bismuth in the portal system. Bile capillaries containing bismuth can be distinguished here and there between the liver cells ; bismuth is also occasion- ally found in the small interlobular bile ducts, but the biliary ducts and capillaries are generally collapsed and empty (Figs. 2, 4, 5).
Kidneys : The renal tissue shows chronic interstitial changes with hyaline degeneration of a considerable num- ber of glomeruli. A few of the degenerated hyaline spheres contain lime salts. Some tubules contain hyaline casts, besides here and there the tubular epithelia show marked cloudy swelling. There is no bismuth present in the renal sections.
Spleen : There is some thickening of the capsule and of the trabecule noticeable. The pulp spaces are not very dis- tmct, well crowded with erythrocytes and leucocytes. The Malpighian bodies are not well defined. Some bismuth is present in the shape of amorphous granules and denser masses in the pulp spaces.
Myocardium : Striation is not very distinct, there is here and there a fine vacuolation, also occasionally some cells which show the pigmentation of brown atrophy. But these pathological changes are very moderate in degree. On the whole, the myocardium is fairly normal. A few subperi- cardial round cells foci are present.
Intestinal Tissue : Nothing except a very few thick, ir- regular sections were accessible for examination. These show an extensive infiltration of the mucosa with bis- muth. The lymphoid tissue likewise shows bismuth, and much of the latter is found in the veins of the submucosa.
Chemical Examination — i. Heart muscle: A faint trace of bismuth.
2. Spleen (very small piece) : Distinct reaction for bis- muth.
3. Liver : Contained 0.13 per cent, of bismuth oxide (bis- muth 2, oxide 3). The tissue was pressed fairly dry be- tween filter paper. Weight = 2.292 grammes; total ash weight = 0.030 grammes, in which bismuth 2, oxide 3 = 0.003 grammes.
From the above incomplete microscopical examination it might appear that the bismuth was first absorbed into the lymphatics, that it was transported to and excreted into the intestines. However, much was reabsorbed by the portal circulation and transported to the liver, to be there excreted into the bile passages. There is no evidence that any of the bismuth was excreted by the kidneys.
The above case does not present the typical symp- toms of an acute nitrite poisoning, such as collapse, cyanosis, etc., and while the absorption of the metal bismuth is proved by microscopical examination and chemical analysis, the question still remains as to whether the absorption and presence of metallic bismuth in the tissues was a cause of death. The pathological changes in his liver, spleen, and heart muscle, do not indicate that a severe destructive process, which would interfere with function was going on. The interstitial nephritis was probably not due to the bismuth absorption, since the renal tissue was free from deposits of the metal and such pathological conditions could be expected in an old man who has for years suflfered from a chronic sup- purative disease. Dr. Verity reports to me that the patient was treated by him ten years ago for chronic nephritis.
The discussion to-night should decide whether this case should go into literature, classed as a fatal case from bismuth intoxication, or a case recovering from the effects of bismuth absorption, death being only accidental and due to other causes.
Conclusions : i — Bismuth subnitrate administered by stomach, in small doses, is harmless.
2 — In the presence of certain bacteria in the faeces
of children bismuth subnitrate will liberate nitrites, which will be absorbed by the intestines and elim- inated by the kidneys, and if the production is faster than the elimination, methsemoglobinsemia will re- sult.
3 — In large doses by mouth it is liable to pro- duce an acute nitrite poisoning, characterized by cyanosis, collapse, methasmoglobinsemia, and may terminate fatally.
4 — Rectal injection of small doses of bismuth sub- nitrate may cause nitrite poisoning much quicker and more severe than when administered by mouth.
5 — Children are more susceptible to nitrite poi- soning due to administration of bismuth subnitrate.
6 — Persons suffering with intestinal putrefaction are very susceptible to nitrite poisoning when bis- muth subnitrate is injected into the bowels.
7 — The bismuth injected into these sinuses, and encapsulated, will be gradually absorbed, and may be found in the liver, spleen, muscles, and intestines.
8 — Characteristic symptoms of black borders of gums, ulcerations of mucous membranes, diarrhoea, desquamative nephritis may appear several weeks following the injection of the paste.
9 — After the injection of large quantities of the bismuth paste into suppurating sinuses, mild symp- toms of nitrite intoxication may appear.
10 — ^The acute nitrite poisoning is to be regarded as a distinctly separate affection from the more chronic bismuth absorption.
11 — Radiographers should employ some other preparation of bismuth than the nitrate, and refrain from injections of subnitrate into the bowels, espe- cially if intestinal putrefaction is present.
Since writing the above article a report has ap- peared in the Centralblatt fur Chirurgie, October 31, 1908, No. 44, by Dr. H. Eggenberger from the Clinic of Professor Wilms, of Basel, of a fatal case of bismuth intoxication subsequent to the injection of a sinus following a psoas abscess in a child, seven years old. Thirty grammes of the paste were in- jected and retained for six weeks. A stomatitis developed, resembling mercurial intoxication, pulse rose to 130, and a picture of toxic cortex, such as is often observed in uraemia, developed. The ab- scess cavity was evacuated, but the child died a few days later.
Autopsy revealed only hyperaemia condition of the central nervous system, no apparent anatomical changes. Small haemorrhagic spots were observed in the mucous membranes of the stomach. The in- testinal follicles were red and swollen, and on the valvula Bauhini, a greenish brown ulceration, 2 to 3 cm. in circumference was found.
References.
1. Schuler. Zeitschrift fiir Chirurgie, 1885.
2. Von Bardeleben. Deutsche medicinische Wochen- schrift, 1901, No. 23, p. 544.
3. Muhlig. Munchener medizinische Wochenschrift, 1901, No. 15, p. 592.
4. Theodor Kocher. Volkmann's Klinische Vortr'dge, 1882, p. 224.
5. Peterson. Deutsche medizinische Wochenschrifi, June 20, 1883.
6. Dressman. Munchener medizinische Wochenschrift, T901, No. 6, p. 238.
7. Davis. University of Pennsylvania Medical Bulletin, 1906.
SOULE: FRACTURE OF NECK OF FEMUR.
LAew Vork Medical Journal.
8. Bennecke and Hoffman. Miinchener medizinische Wochcnschrift, 1906, No. 19.
9. Bohme. Archiv fur experimentelle Pathologic und Pharmakologie, p. 441, 1907.
10. Collishon. Deutsche medizinische Wochenschrifi, No. 41, 1889.
11. Binz. Archiv fiir experimentelle Pathologic una Pharmakologie, xiii.
12. Harnack. Ibid, 1908, p. 246.
13. Routenberg. Berliner kUnische Wochcnschrift, 1906, No. 43, p. 1397.
14. Novak and Giitig. Berliner klinische Wochcnschrift, 1908, No. .39, p. 1764.
15. Beck. Illinois Medical Journal, April and July, 1908.
16. Harnack. Arzneilchre, 1883, p. 383.
17. Bergeret. Journal de I'anatomic , 1873, p. 242.
18. Wood. Transactions of the American Neurological Association, 1883, p. 23.
173 L.^KE View Avenue.
METHOD OF TREATMENT OF FRACTURE OF THE NECK OF THE FEMUR.
By Robert E. Soule, A. B., M. D., New York,
Attending Surgeon to the New York Orthopaedic Dispensary and Hospital; Surgeon in Chief to the New Jersey Orthopaedic Hospital and Dispensary, Orange, N. J.
Consideration of the procedures adopted in meth- ods of treatment of fracture of the femoral neck, particularly of the difificulties to be overcome in con- trolling the accurate apposition of the fragments when replaced (viz.. the necessary skilfulness of assistants during the replacement and application of the plaster of Paris dressing, the inability to ob- serve the position at all times during treatment, to- gether with the hot, clumsy, and unsanitary dress- ing of the plaster of Paris), has led me to adopt the following method, which has in the single instance used by me given a most satisfactory result, as shown by radiographs, function and actual meas- urements.
The case in question was a boy, J. K., five years old, who was brought to me July 31, 1907, with the diagnosis of tuberculous disease of the right hip joint.
From the history I learned the child had a fall four days previously, since which time he had been unable to walk, owing to extreme pain and deformity. This was evident at the time of my examination. Inspection showed the right thigh abducted, externally rotated, and flexed 35° ; at- tempted manipulation elicited pain, acute spasm of thigh groups of muscles, and crepitation.
To make a more thorougii examination the patient was anaesthetized, when the muscle spasm relaxed and defor- mity lessened. Manipulation developed false arc of motion and distinct crepitation, and traction produced equality in length of limbs.
With the patient still under the anaesthetic a set of swansdown adhesive traction straps was applied to limb, as shown in Fi?;ure i, in such a manner that the force of the pull was e(|ually distributed about the thigh, thus re- lieving the strain upon the structure of the knee joint, a very important consideration. This dressing was protected from loosening by applying a spiral muslin bandage over it, beginning at the ankle.
The limb being dressed and the deformity overcome, the limb was held in position by an assistant making traction in 15° to 20° abduction and slight flexion, while the Taylor extension hip splint was applied, as seen in accompanying Figure 2.
The illustration of the brace used is more de-
scriptive than words, as is also the photograph showing the patient with brace applied, without the spiral muslin bandage and secondary application of adhesive support. The chief advantage lies in the accuracy of the extension by means of the key when turned in the lock, causing the grooved rod to slide downward in the sheath, procuring accu- rate position of the limb.
W ith the traction adhesive straps buckled to the straps attached to the foot piece of the brace and counter pressure obtained by soft padded perineal straps attached by buckles to the hip band of the brace anteriorly and posteriorly, so that their pres-
FiG. I. — Showing patient with apparatus applied without the encir- cling adhesive strapping of thigh.
.sure on the perinseum is just external to the tuber ischii. the detail of the application of the brace is complete.
To overcome any tendency to external rotation of thigh and dropping backward of the lower fragment, adhesive straps were applied, encircling the leg and including the shaft of the brace as high up as the perinaeum would permit.
The child was then placed on a hard mattressed bed with board between spring and mattress to maintain a level sur- face. There was no weight and pulley, and raising of the foot of the bed to prevent patient from slipping down lov/ard the footboard as is the case with the Buck's exten- '^ion. and no other restraint to prevent the patient from being turned and handled freely in his apparatus for the purpose of bathing, etc., no heavy, hot. and unsanitary
January 2, ig-^g.J
SOULE: FRACTURE OF NECK OF FEMUR.
23
plaster of Paris dressing, but a simple, comparatively com- fortable, sanitary, and accurately fixing appliance.
In the fifth week the patient was allowed up in a semi-
reclining position. At the end of the fifth week the brace was removed and the patient was examined. Union seemed firm and motion free, the splint was reapplied, and the child
Fig. 3. — X ray showing limb restoied. Arrow denoting point of fracture.
was allowed to stand and walk about. The seventh week the brace was removed and the child allowed to walk. Limbs were equal in length, there was no deformity, and arcs of motion were nearly equal to those of left thigh. Patient was discharged and not seen again until March 17, 1908, when X ray photographs were taken with all apparatus re- moved and limb restored. (Fig. 3 and Fig. 4.)
From this result the method as described would seem to me to be a feasible one to adopt and one by which the most satisfactory result can be obtained.
The thigh and pelvis thus held and maintained throughout repair constantly accessible to observa- tion, examination, and measurements, would seem to me to present the least chance for malposition,
Fig. 4. — Photograph of patient after apparatus was removed'.
and did in my case restore the limb to an equal' length, normal arc of motion, with no limp, no de- formity save a slight thickening of the neck due to- callous formation as shown in the radiograph, from which it also appears there is a good angle of neck to shaft of femur.
The extension hip splint with coaptation splint has already been successfully used in fracture in the continuity of the shaft of' the femur, but I have not found any instance where this method was adopted in fracture of the neck.
601 Lexington Avenue.
24
NARROWER: ACI DIMETER.— BRAV : DISCOLORATIOM OF CONJUNCTIVA. LNew Vork
' IMedical Jouknau
A NEW INSTRUMENT FOR THE ESTIMATION OF THE URINARY ACIDITY.
By Henry R. Harrower, M. D., Chicago.
In an attempt to simplify the technique of the various laboratory estimations, which should be rnuch more frequently made by every general prac- tician, I have for some time been working with a very simple little instrument which I have found useful in the estimation of the urinary acidity.
It is not intended to supplant the very necessary graduated buret employed by workers in the larger clinical laboratories, but to provide the wherewithal for the busy man to perform this important test in daily routine. The idea was gained from a very handy little tube invented by Gunzberg for the estimation of the acid- ity of the gastric juice.
The acidimeter which I 'have designed consists of a glass tube so graduated that lo c.c. is the first measuring point. From this upward the tube is graduated in fifths of a degree to ioo°, each degree representing the amount of decinorma! sodium hydroxide solution required to neutralize lOO c.c. of urine.
The method of using the acidimeter is
70°-f 60°-f 50°-f
30°^ 10°^
'10
CjR-
as follows : The tube is filled with the specimen of urine to be tested, until the lower edge of the meniscus is just on the 10 c.c. mark. Two drops of phenolph- thalein indicator solution are added, and then with an ordinary medicine dropper decinormal sodium hydroxide solution is slowly added, inverting the tube after each addition, until the color of the fluid has been changed from a yellow to a light rose pink. The acidity in degrees is now read of? on the tube at the level of the fluid. The normal urinary acidity of a mixed twenty-four hour specimen should be between 30 and 40 degrees.
If the urine is alkaline in reaction and it is desired to estimate the degree of al- kalinity, decinormal hydrochloric or ox- alic acid solution must be used in place of the sodium hydroxide, the pink color present being just discharged by the acid. The advantages of this instrument are : I. Facility of handling, it can be car- ried in the pocket or bag and is not easily broken as is the burette. No stand is re- quired.
2. Accuracy of results, the graduations being just the same as in the standard delivery buret.
3. Price, the first cost is considerably less than that of a buret, and as the acidimeter is far less liable to breakage the eventual cost is very much less.
easily broken as is the burette. No stand is re- tendant, or his wife may be quickly taught its rapid and accurate use.
I believe that this instrument will simplify the present laboratory facilities of the medical man, thus increasing his diagnostic capabilities and hiy professional success.
2806 North Paulina Street.
Acidimeter.
A CASE OF BLUEISH DISCOLORATION OF THE CONJUNCTIVA FROM AN INDELIBLE PENCIL.
By Aaeon Brav, M. D., Philadelphia.
Miss A. H., age nineteen, bookkeeper, consulted me Octo- ber 30th, 10 a. m., and gave the following history : "While sharpening my indelible lead pencil a piece of the lead struck my eye, which began to smart somewhat. I tried to rub my eye in the endeavor to remove the foreign sub- stance when I noticed a discoloration on my finger. I hur- ried to the looking glass and found my eye a purple blue. I have no actual pain, but a stinging sensation."
On examination I found the right eye perfectly normal. Left eye cornea and pupil normal, no foreign bodv notice- able, a small laceration of the conjunctiva of the lower lid, and both the conjunctiva of the lower lid as well as the bulbar conjunctiva up to the lower corneoscleral margin was a dark purple, blue mass. The patient was very anx- ious for information. She wanted to know the prognosis as to its ultimate disappearance, and how long it would take for the disappearance of the discoloration. I confess I was at a loss to prognosticate the exact amount of time necessary for the absorption of the stain. I felt, however,, sure that the vascularity of the conjunctiva would eventu- ally restore the eye to its normal color. And at the same time, considerino- the fact that I had a laceration of the conjunctiva and the possible reaction of the then to me unknown substance of the indelible pencil with the albumin- ates of the tissues, it was not surprising that I felt it a duty on my part to my patient, whose anxiety can easily be imagined, to consult a reliable chemist on the subject. 1 consequentlj' called the chief chemist of the Mulford Chem- ical Company to the telephone and inquired of him as tO' the chemistry of the indelible pencil and its possible reac- tion with the albuminates of the tissues to form an insol- uble salt. After half an hour research in the laboratory, the answer was that the indelible pencil contained the ani line dyes, that it had no special reaction on the tissues, and that no insoluble salt would form with the albuminates of the tissues. As to the time of its complete absorption, this would depend upon the vascularity of the part and the quantity of the dye. Needless to say that I was very grate- ful to him for the information, and my thanks are due to the house for the readiness to serve the profession. After this information I was able to give full assurance to my patient, who, being an intelligent girl, highly appreciated my investigation in her behalf. I prescribed an alkaline wash, ten grains of sodium biborate to the ounce of water, to bathe the eye several times, and asked my patient to see me to-morrow.
During the afternoon I had a chance to see many of the physicians and ophthalmologists, neither of whom had had the opportunity to observe such a case; in fact, one was of the opinion that it would take a long time for the ab- sorption.
Next morning my patient came back and not a trace of any stain could be noticed ; the eye was slightly irritated, and the conjunctiva somewhat lacerated. She told me that she watched the eye very closely, and that by six p. m. the discoloration entirely disappeared. To use her language, absorption was so rapid that she could see the process going on. It required eight hours for the complete disap- pearance of the stain.
This case may not be of great importance to the profession, yet the physician who will happen to be in the same embarrassing position that I have been after reading this will find the value of this report and appreciate my effort in placing this case on record. Indelible pencils are used very exten- sively, and the occurrence may puzzle any of my professional colleagues, so that this report is intend- ed tc ;av: them the embarrassment.
917 Spruce Street.
janiiary 2, 1909. J
JUDD: ENLARGED THYREOID.
25
FURTHER REPORTS OF TREATMENT OF EN- LARGED THYREOID. By Means of the X Ray and High Frequency Currents.
Bv ASPINWALL JUDD, M. D.,
New York,
Adjunct Professor of Surgery and Radiologist, New York Post- graduate Medical School and Hospital.
In 1905 to 1906 I made a preliminary report in the Medical Record of eight cases of enlarged thy- reoid treated in our clinic at the Postgraduate Hos- pital and in my own private work. These patients had been under treatment for a sufficient length of .time to make it seem probable that the results ob- tained were not merely transient or the result simply of a remission of symptoms, which so often occurs in this class of cases. A review of these cases up to the present writing, together with a report of six additional cases, may prove somewhat instructive.
Such a mass of data from other observers has ac- cumulated since my last reports as to make it a mat- ter now, of surety, that, with the exception of opera- tive interference and perhaps of the Roger serum, the X ray and high frequency currents of¥er the best means of alleviation or cure in this ver^ distressing disease. The percentage of cure or very decided improvement, four patients cured and two improved in our first series,, and of three cured and one im- proved in our second list, makes the statistics on this treatment, so far as we have been able to ascertain, better than that of any other means at our com- mand.
In observing the reactions caused by our treat- ment we have come to roughly divide our cases into three classes : First, those in which a true hyper- plasia of the gland existed, either with or without exophthalmus, and these cases have been the ones that have reacted most kindly to treatment ; second- ly, those in which the struma or fibrous elements of the gland were greatly in excess. On these the treatment has had little effect beyond producing an increase in the fibrous elements. The third class of cases were those with large colloid deposit. These cases have been little or not at all affected.
The physiological action of the x ray upon gland- ular tissue is to produce at first a stimulation, in- creased activity, and proliferation; secondly, by overstimulation, a fatty necrosis and death of the cell elements, together with an obliterating endarte- ritis by destruction of the intima of the smaller bloodvessels, and consequently a deprivation in great measure of nourishment to the gland. Upon connective tissue, however, its effect is to produce an exaggeration of the adult type of connective tis- sue, with a disappearance of the cell elements and an increase in the number and size of the fibres. The second effect of obliterating endarteritis also occurs in this type of tissue to a more limited extent.
To return to our first series of cases. Of the cured patients, three have remained in perfect health to the present time. Two of our patients have re- lapsed, but further treatment has once more proved effectual.
Of our second series of cases, two patients dis- continued treatment after three months, unim- proved. One patient, a case of extreme severity,
with dilated heart, very rapid pulse, and greatly en- larged thyreoid, is still under treatment at the end of six months, somewhat improved as to pulse, gen- eral nervous symptoms, and size of gland. How much of this improvement is due to rest in bed and medication it is impossible to determine. One pa- tient, after eight months' treatment, is so far im- proved as to tempt me to include the case as a cure, were it not that I have frequently seen a recurrence of symptoms after cessation of treatment after a considerable interval of time. In this case, which was accompanied by exopthalmus, no change has occurred in the eyes. The pulse, which ranged from 120 to 150 at the beginning of treatment, now aver- ages between 80 and 90. The neck measurement has diminished nearly two inches in circumference. The nervous symptoms have entirely disappeared. The patient considers herself well, and complains somewhat of our insistence upon her continued treatment.
C.'\SE V. — This was a case of beginning enlargement in a young girl of fourteen, and was coincident with the beginning of menstrual history. There was no exoph- thalmus in this case. The gland was of the true hyperplas- tic type, the pulse no, the heart apparently otherwise nor- mal, and there were no nervous symptoms. Two treat- ments a week, for fifteen minutes, for five months, were suflicient to produce a disappearance of symptoms. It is in this class of cases that the x ray and high frequency cur- rents have proved particularly valuable.
Case VI. — This was a boy, fifteen years of age, with a tremendously, symmetrically enlarged gland, both right and left lobes and isthmus participating in the swelling. The gland was firm and hard in parts, and elastic, almost fluc- tuatmg, in others. There was no exophthalmus, no history of nervous symptoms, no rapidity of pulse ; but, on the other hand, the boy was dull, apathetic, with heavy features, and, in short, with beginning symptoms of myxoedema. His history was that of a normal child up to about fifteen months previous to his appearance in our clinic. . My diag- nosis was that of a fibrous gland, with possibly cysts filled with colloid material. At the suggestion of the physician of the medical clinic, who referred him to me, however, and where medical treatment had been tried, I subjected him to X ray treatment for nearly three months. The gland continued to increase in size, the symptoms of myxoedema increased also, and I finally operated upon him, removing practically the entire thyreoid gland. Upon exposing the same, I found my diagnosis was correct. After the opera- tion, the boy was fed upon thyreoid extract, with a con- siderable amelioration of the symptoms, but finally suc- cumbed at the end of six weeks.
Our method of treatment has differed somewhat from that used by most x ray workers. I have found that a very high tube, that is, one rich in pen- etrating X rays, placed at a distance of nine inches from the patient, the tube focused upon the gland and the other parts well protected with lead foil, has given the best results. The treatment is usually maintained for fifteen minutes twice a week, and up to the present time without even symptoms of erythema. A slight browning of the skin usually results, however. In cases where the tachycardia is extreme, it has been our custom, in addition to the x ray, to use the high frequency, Tesla current, applied by means of a glass electrode over the cer- vical sympathetic on both sides of the neck. The effect of this current, as noted by other observers, as well as by myself, is distinctly sedative, both as to the heart action and the general nervous system, the pulse rate falling from 10 to 20 possibly before the cessation of the treatment, which is continued.
26
OUR READERS' DISCUSSIONS.
[New York Medical Journal.
as a rule, for five minutes on each side. This diminution in the pulse rate persists for from a few hours to forty-eight hours, gradually increasing in length as the treatment goes on. Whether the ef- fect of this current is simply that of a general seda- tive in which the heart partakes, or whether it is due to a specific action upon the cervical sympa- thetic, I am, as yet, unable to determine. When ap- plied to other parts of the body its gentle sedative action is quite as marked. Indeed, it is not tmcom- mon to find our patients, when treated for whatever cause, drowsv to the point of somnolence, and, in- deed, even sleeping quietly, if in a reclining posi- tion, at the end of the treatment; but I have not found such marked eflFect in lowering the pulse rate as when applied over the cervical sympathetic.
It has been my fortune during the past three years to operate in four cases of enlarged thyreoid treated by myself or other men by the x ray. One I have mentioned before. Two other cases were treated by the ray with the result of rather increas- ing the size of the gland. Pathological examina- tion of the specimens in these two cases showed a great increase in the fibrous element and a des- quamation and partial obliteration of the acini. The fourth patient, in whom improvement had been very considerable from the treatment, but in whom a re- lapse had occurred, showed a gland, hyperplastic in character, with the cells in many of the acini ob- literated and with small necrotic areas and a cer- tain amount of obliterating endarteritis. I am still convinced that our choice of procedure in enlarged thyreoid is an operatiorf for the removal of a por- tion, at least, of the gland, and in these days of bloodless operation, with its consequent immunity from thyreoid poisoning, and keeping in view Kocher's admonition to operate before dilatation of the heart has taken place, operation offers us the best means at our command for the relief of this disease.
Where we have an enlarged gland due to increase of fibrous or colloid elements, accompanied by pressure symptoms or deformity, of course, an op- eration is indicated, the x ray having either no ef- fect, or of merely increasing the fibrous elements, and, consequently, the size of the tumor. In that class of cases, however, in which dilatation of the heart has already supervened or in which we are unable to obtain the patient's consent to an opera- tion, the X ray offers us in a sufficient number of cases, either relief or cure, to be given, at least, a trial.
137 West Sixty-ninth Street.
^
Death Rate From Tuberculosis.— R. W. Philip gives the following table in the Boston Medical and Surgical Journal of the death rate from pulmonary tuberculosis per 10,000 of population in the principal towns of Scotland :
1897. 1901. 1906.
Glasgow 20.3 18.5 15.6
Dundee 22.3 17.2 16.9
Aberdeen 16.7 13.9 12.2
Leith 21.2 19.2 12.7
Paisley 17.8 16.6 12.8
Greenock 20.7 14.8 13.2
Perth 22.1 16.1 17.9
(0ur ^tnhxs' §\msnm.
A SERIES OF PRIZE ESSAYS.
Questions for discussion in this department are an- nounced at frequent intervals. So far as they have been decided upon, the further questions are as follows:
LXXXI. — How do you treat chronic eczema? (^Closed December 15, IQ08.)
LXXXIl. — How do you treat chronic lead poisoningt {Answers due not later than January 15, igog.)
LXXXIII. — How do you treat acute dysentery? (An- swers due not later than February 15, igog.)
Whoever answers one of these questions in the manner most satisfactory to the editor and his advisers will re- ceive a prize of $25. No importance whatever will be at- tached to literary style, but the award will be based solely on the value of the substance of the answer. It is requested (but not required) that the answers be short; if practica- ble, no one answer to contain more than six hundred words.
All persons will be entitled to compete for the prise, zvhether subscribers or not. This prize zvill not be awarded to any one person more than once within one year. Every answer must be accompanied by the writer's full name and address, both of which we must be at liberty to publish. All papers contributed become the property of the Journal. Our readers are' asked to suggest topics for discussion.
The prize of $25 for the best essay submitted in ansiver to question LXXX has been awarded to Dr. Paul F. Ela, of East Douglass, Mass., whose article appeared on page- 1225 of the previous volume.
PRIZE QUESTION LXXX. THE TREATMENT OF ASPHYXIA NEONATORUM.
{Continued from Lxxxviii, p. 1228.)
Dr. Theodore Emil Teah, of Renovo, Penn., says:
By asphyxia neonatorum is meant that condition' of the new born where there is a deficiency of res- piration. Any condition that exists which will act as an obstacle to the blood supply of the new born,, thereby cutting off its supply of oxygen, will brings about this condition.
Asphyxia neonatorum is usually divided into two- classes: 1st, Asphyxia livida, that condition in which; there is an accumulation of carbon dioxide in the blood, yet circulation and reflexes persist. 2d, As- phyxia pallida, an advanced stage of the former characterized by a weakness of the heart, a slow- ness of pulsation, and an abolition of reflexes. In this last condition the prognosis is very unfavorable. The prognosis of asphyxia neonatorum in general depends upon the heart action, for as long as the heart continues to act there may be some hope for resuscitation. This will suffice for the aetiology^ symptomatology, and prognosis of the subject.
For the prophylaxis of asphyxia neonatorum it will be well to avoid any malposition of the uterus before labor and to correct the same if possible, the correction of any position which threatens impac- tion, speedy relief of spastic rigidity of the cervix, acceleration by manual compression, preservation of the bag of waters, and lastly to avoid any abuse or the over indulgence in the use of chloroform.
The curative treatment consists of the following steps : In case the diagnosis of intra partum as- phyxia is made immediate delivery should be our course, the choice of which in most cases will be by the use of forceps. If after the expulsion of the child marked cyanosis is present the cord should be divided at once and allowed to bleed until about an ounce of blood has escaped. In case the child should
January 2, 1909. J
OUR READERS' DISCUSSIUNi,.
27
present a condition of asphyxia pallida it would be best to cover the infant with hot flannels and wait for the cessation of pulsation of the cord.
Where delivery has taken place and asphyxia neonatorum is present it is our duty first to remove any foreign substances or particles from the respira- tory passages, and this is usually accomplished by inverting the infant in the following manner: With the left hand grasp the feet of the child and invert, the little finger of the right hand is wrapped with gauze and the mouth and throat swabbed out, there- by removing any foreign substance. However, the cleansing of the mouth and nasal passages should be performed upon immediate delivery of the head. In cases of obstruction of the larynx as the result of tumefaction of the muscles of the neck or the result of mechanical interference to the passage of air, catheterization of the larynx and inflation of the lungs are advisable. The best method of applying this form of artificial respiration is with a No. 6 soft rubber catheter cut at the end and a pipette inserted in the catheter so that the bulbous portion catches the aspirated fluids. The catheter is then gently passed and inflation practised. The application of the fol- lowing reflex stimuli applied after the cleansing of the respiratory tract usually suffices : Blowing in the face of the infant, slapping the buttocks, sprinkling or the immersion in hot or cold water, being used alternately, the dropping of alcohol, ether, cold or warm water on an exposed chest from some height. Dilatation of the anus with the finger or traction upon the tongue may now be tried when the others fail.
If the application of external stimuli fails to have the desired result the several methods of artificial respiration may be used : Mouth to mouth insuffla- tion; a soft pillow should be placed under the in- fant's neck, the head having been well extended, a piece of gauze or soft towel placed over its mouth, the physician then takes a deep breath and blows the first part of the expired air into the infant's mouth, the head is then flexed and the chest compressed. This is practised many times until this seems of no avail, when the Schultze method should be tried : The infant is wrapped in a towel to protect it from being chilled, and turned upon its back ; it is grasped by the shoulders, the open hand having been slipped beneath the head, the last three fingers remain ex- tended in contact with the back while each index finger is inserted into an axilla. The child so held is allowed to swing feet down, and so suspended it is now swung over the operator's shoulder. This swinging motion is practised fifteen or twenty times. The infant then immersed in warm water for a few seconds to raise its temperature and the movements tried again.
Sylvester's method of artificial respiration is im- practicable as a result of weakness to the muscles of the chest, but Marshall Hall's method of suspending the infant in a towel, then rolling it from side to side so suspended, may prove useful at times. After all the methods have failed I always consider the case hopeless.
The after treatment of asphyxia neonatorum should also be taken into consideration. After re- viving an infant deeply asphyxiated it will more than likely die within forty-eight hours after birth ; however, it should be carefully watched in order to
detect the most feeble heart action and any evidence of feeble respiration or intracranial disturbance. Routinially I give to such infants five drops of spiritus frumenti and one drop of tincture of digi- talis in a little hot water every four hours, keeping the infant surrounded in cotton wool and the appli- cation of hot water bags or bottles as the case requires.
Dr. Saro E. Foiilks, of Trenton, N. J., observes:
The normal child should make efforts at respira- tion shortly after it emerges from the vulva. If this does not occur the mouth should be cleansed with sterile gauze, the child grasped by the feet and with body hanging down slapped vigorously with the palm of the hand. If success' does not follow, cut the cord and immerse the body in a hot bath, about io8°, alternating with a cold one. Care should be exercised to keep the head above water and well supported, and circulation encouraged by rubbing the skin of the limbs and trunk briskly all the while.
Counter irritation plays an important part in re- suscitation and may be easily practised while the child is in the bath. Compresses wrung out of hot water alternating with cold ones, placed over the sternum or direct rubbing of the abdomen and chest with a lump of ice, or a few drops of alcohol or ether allowed to fall upon the chest from a height has often proved useful in its quick results. A few drops of aromatic spirit of ammonia upon a piece of absorbent cotton may irritate the nasal mucous membrane to such an extent that respiration not only begins, but movements of the whole body are re- flexly instituted. In some cases the asphyxia persists and other measures are necessary. If there is any suspicion that the bronchial tubes contain foreign matter a small elastic No. 9 French catheter should be introduced and the material removed by suction.
One of the most efficient means of resuscitation and one which if practised early often results favor- ably is the forcible expansion of the lungs with air by means of the mouth to mouth method. The air should be propelled by no greater force than can be exerted by the cheeks of the operator, thus avoiding rupture of the alveoli with resulting emphysema. To be sure, much of the air enters the stomach, but enough traverses the tubes to expand to some extent the lungs and a gasping breath followed by weak but certain respirations often results when all other methods have failed. The efficiency of this method may be increased by first introducing a catheter into the larynx and forcing the air through this. Too much stress cannot be laid upon the early and per- sistent use of this procedure.
If still the child seems lifeless, wrap it carefully in blankets, surround the body with heat in some form and apply Laborde's method of resuscitation. This consists briefly of the following : Lay the child upon a table or chair, allowing the head to overhang the edge. Grasp the tip of the tongue with a piece of gauze and draw it as far forward as possible, then allow it to recede. Do this ten to twenty times per minute at regular intervals. If no results follow after a few tractions the case may practically be con- sidered hopeless.
One very efficient means of forcing air into the lungs is that of Schultze, which in a few words is as follows : The operator grasps the shoulders of the
28
CORRESPONDENCE.
INew VoRr. Medical Journal.
child, applies his index fingers under the axilla and his thumbs over the thorax, at the same time press- ing the palms of the other fingers to the back while the head is held firmly by the balls of the thumbs. He first allows the child to hang down, then carries it slowly over his head, allowing the body to flex upon itself and the legs fall toward the face, then gradually brings it back to its original position. Re- peat this eight to ten times per minute. After swinging a few times try again the hot and cold tubbing. Though so efficient that air may be heard to enter the lungs of a dead child, this method has many opponents, as fracture of bones of the thorax or rupture of internal viscera has been known to occur. This procedure would of course never be used in the pallid variety of asphyxia.
Byrd's modification has gained of late considerable favor. The swinging is done away with ; simply rest the back of the child upon the palms of the opera- tor's hands, with thumbs pointing upward. Ap- proximate the hands and bring the child's head and feet closely together. This compression of the thorax causes expiration and the reverse inspiration.
In obstinate cases beneficial results sometimes fol- low hypodermic injections of a few drops of whiskey or ether or a minute fraction of strychnine. If pos- sible a faradic battery may be used. This has found favor in the sight of many. One pole should be placed above the clavicle, the other at the edge of the ribs at the right side.
In the livid variety blood letting has been recom- mended, but as a rule this is unnecessary, as warm bathing and brisk rubbing relieves the internal or- gans by attraction to the skin.
When asphyxia is due to depressed fracture of the skull, elevation of the fragments should be under- taken only by a competent operator and when the heart beats strongly though slowly.
With all the methods use perseverance. Efforts should be persevered in as long as the heart con- tinues to beat and even if it does not one after another method should be tried in hopes of some re- sult, as success is not unusual after trials lasting an hour or more.
After deep asphyxia watch the child carefully for several days and keep well covered and in an even temperature, supplying artificial heat in some form to its body whenever needful. If too weak to take the breast a little colostrum or milk should be coaxed out and the baby fed by means of a dropper. Avoid handling as much as possible and keep perfectly quiet on a pillow.
(To be continued.) <$>
LETTER FROM LONDON. The King's Hospital Fund. — The Barnato Bequest. — An Alleged New Cure for Cancer. — The Revision of the Pharmacopeia. — The Medical Curriculum.
I^NDON, December 15. igo8. The King's Hospital Fund held its annual meet- ing yesterday at Marlborough House for the pur- pose of awarding grants to the hospitals and other institutions for the present year. The Prince of Wales, who is the president, took the chair, and there was a very large and influential gathering
present. The Prince directed attention in particular to the valuable work which is being done in improv- ing the administration of the various hospitals and convalescent homes and coordinating them by amal- gamation or otherwise, so as to equip the metropolis with agencies for the relief of the sick poor in ac- cordance with a carefully considered scheme. Hith- erto the provision has been to some extent hap- hazard. Some districts have been well provided, while in others there has been inadequate accom- modation or equipment or both. The fund is acting in the interest of all who subscribe to the main- tenance of hospitals and convalescent homes, so as to obtain the best value for the money available. It is the fairy godmother of these institutions, advising as occasion requires, insisting on efficient and eco- nomical administration, and checking overlapping. This year the amount available for distribution reaches the handsome total of £140,000, an amount larger by £19,000 than that available in 1907. In their donations the Council of the Fund are giving greater attention to convalescent homes and to coun- try sanatoria for the care of tuberculous patients. Among the largest grants are £12,000 to the London Hospital and £8,000 to Kings College Hospital, in- cluding £5,000 toward the removal fund. The build- ing of this hospital at its new site in Denmark Hill has now been begun. Guy's Hospital gets £7,500, and most of the other large hospitals get sums vary- ing from £2,000 to £5,000. Among the smaller hos- pitals, the West London gets £4,500 and the Ealing Cottage Hospital £2,000, a remarkably large dona- tion for a cottage hospital. The London Hospital will also obtain a large sum of money as the result of its quinquennial appeal. Up to the present time the sum of £70,000 has been obtained, which, though large, is less than was expected.
Another windfall to hospital charities is the be- quest of the late Henry Isaacs Barnato, who left a quarter of a million sterling to found a hospital or other charitable institution in memory of his brother, Barney Barnato, and his nephew, Woolf Joel. The trustees have absolute discretion as to the apphca- tion of the fund and the fullest powers as to the equipment, endowment, and management of the institution. It is suggested that an institution be established for some specific purpose, such as for the treatment of tuberculous disease in childhood, for which there is at present very inadequate provi- sion. It is thought, however, that the money will be u.sed in establishing a large Jewish hospital, which will make special provision for the treatment of poor Jewish patients. For such an institution there appears to be a decided want, notwithstanding the existence of the London Hospital, in the crowd- ed Jewish neighborhood of the East End.
The Daily Telegraph has given publicity to an alleged new cure for cancer introduced by Professor Octave Laurent, of Belgium. The treatment con- sists in the injection of a concentrated solution of formol directly into the diseased part. The "cure" is, however, not new at all. At the Cancer Hospital. Brompton, this remedy has been thoroughly tried, with negative results, and not only formol. but numerous other compounds and derivatives, none of which have proved to be in any true sense a "cure" for cancer. The action of formol is simply that of
January 2, 1909 ]
THERAPEUTICAL NOTES.
29
a powerful caustic, and it may be able to destroy a small cancer in its beginning, but it is obvious that this can be done with much more certainty and pre- cision by the surgeon's knife, and there will be less likelihood of recurrence after operative treatment in the early stages.
The news thus given widespread publicity will only raise false hopes in the minds of the poor suf- ferers, and the feeling is that such publications in the lay press cannot be too strongly condemned.
There is no doubt that modern therapeutics is largely indebted to commercial enterprise, and the Therapeutic Committee of the British Medical Asso- ciation tacitly acknowledges this in its recommenda- tions for the revision of the British Pharmacopma. The addition of about fifteen new remedies is sug- gested. Among them are chloralamide, veronal, guaiacol, a solution of formaldehyde, antidiphthe- ritic serum, and a "preparation possessing the prop- erties of the suprarenal gland." There are also sev- eral recommendations for deletions, and they include applications which in former times were very famil- iar, such as emplastrum, calefaciens, an old fash- ioned, mild counterirritant. Cerium oxalate is stated not to possess the specific action attributed to it, and caffeine citrate is objected to because it is unstable and is decomposed when dissolved in more than three parts of water. The omission of spiritus vini gallici is suggested on the ground that it is very rarely prescribed as such and requires no official description. For the rest, however, a large propor- tion of the deletions relate to what were regarded at one time as pharmaceutical elegancies, such as cherry laurel water, carraway water, elder flower water, fennel water, and the like.
The Education Committee of the General Medical Council have been considering the question of the retardation of medical students in passing their ex- aminations. It was brought out that the average time taken in obtaining a diploma was seven years in England, six years in Ireland, and five years and a half in Scotland. Only a small minority of stu- dents are able to obtain a registrable qualification in the minimum period of five years. It has been shown that the delay is due to the failure of the student to pass his examinations at the proper time, and a further point brought out was that, in many instances the greater part of the delay occurred in the early period of study, that is, in the period de- voted to chemistry, physics, and biology, and then in anatomy and physiology. There was a brief dis- cussion by the council as to the practical conclusions to be drawn from these data, and the remedies sug- gested for this state of afiFairs. It was suggested that the preliminary subjects, chemistry, physics, and biology, should be completed before the student be- gan his medical curriculum, and this suggestion met with some support. Another point discussed was the question of devoting the fifth year entirely to clinical work, as it was suggested that this was en- croached upon by the student doing work at this period which ought to have been completed earlier. No steps, however, have yet been taken by the council in the matter, and the probability is that there will not be any alterations in the medical curriculum for the present at any rate.
1 ^erapfutital Jotfs.
Liniment for Sciatica. — -The following is rubbed into the painful parts night and morning (Yzeta, Journal de medecine de Paris, November 21, 1908) :
I* Olive oil 5y.iii;
Oil of turpentine, Biiss;
Ammonia water, 3x;
Tincture of cantharides, 3iv.
M.
Haemoptysis Treated by Adrenalin. — Adrenalin
in combination with calcium chloride and adminis- tered internally is employed by Dr. Pronchinski (Gazeta lekarska, July 25, 1908) in the treatment of haemoptysis. The mixture is said to be more effective than either ergotine, gelatin, or opiates. It
is prescribed as follows :
R Calcium chloride 3v;
Solution of adrenalin (one per cent) TH, xlv ;
Distilled water 5vii.
M. et Sig. : One tablespoonful every two hours.
For Gastrodynia. — A correspondent of The Pre- scriber says the following prescription has been given successfully in cases of gastrodynia in tipplers and
in similar gastric troubles :
R Heavy magnesium oxide, Jss;
Bismuth subnitrate, .3ii ;
Gallic acid, 3iss;.
Aromatic powder, Sj.i
Peppermint oil, gtt. xii.
M. et. Sig. : A teaspoonful in a little water every morn- ing.
Iodine as an Antidote to Carbolic Acid Poison- ing.— A diluted tincture of iodine has been used with good results as an application to the skin to counteract the corrosive action of carbolic acid. It has also been recommended for internal use as an antidote against poisoning by the acid (J. Alaberly: Repertoire de phannacie; through L'Union pharma- ceutique, November, 1908). Tincture of iodine neu- tralizes the corrosive action of the acid on the mu- cous membranes of the mouth and oesophagus, over- comes the poisonous symptoms, and is said to pre- vent lesions of the stomach and intestines by the probable formation of a nontoxic phenol iodide. The author regards the action of tincture of iodine in cases of carbolic acid poisoning as superior to that of the alkali sulphates.
Sodium Nucleinate in Acute Infections. — Laine
publishes {The Therapeutic Gazette, November, 1908) reports of ten cases of infectious disease in which injections of sodium nucleinate were used with good results. Among the cases reported were several of purulent i>eritonitis following appendic- ular inflammation, pyosalpinx, epiploitis following an operation for hernia, and phlebitis. The best re- sults were obtained by one or two massive doses (five grains) once or twice a day. The injections must be given deep in the muscles, as the one ob- jection to their use is that they are somewhat pain- ful. The beneficial results seem to be caused by the production of an artificial hyperleucocytosis. It is noted by the author that the sodium nucleinate is a combination of nucleinic acid, derived from fish or the flesh of animals (not yeast), with soda.
30
EDITORIAL ARTICLES.
[New York Medical Journal.
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NEW YORK, SATURDAY, JANUARY 2, 1909.
RESUSCITATION AFTER APPARENT DEATH.
Death upon the operating table is not a common occurrence, but when it does happen it is of grievous importance. The patient submits to an operation in the hope that some pathological process will be over- come ; his family spend the time in anxious waiting for the result, which they hope will prolong the life of one of their number ; the surgeon undertakes the manipulation, not, as many people profess to believe, because he is anxious for an opportunity to try his operative skill, but because he hopes to be the means of the realization of these hopes on the part of his patient and his patient's family. It is demoralizing, then, for the surgeon to have to announce to the family that the patient has died on the table. It is demoralizing to all connected with the operation. It was in the line of pure philanthropy, therefore, that, in his Miitter Lecture on Surgical Pathology, deliv- ered at the College of Physicians of Philadelphia on Friday evening, December nth. Dr. George W. Crile, professor of clinical surgery in the Western Reserve University, described his method of resus- citating individuals apparently dead.
The patient is placed in the prone posture and rapid rhythmical pressure is made on the lower por- tion of the chest, which produces artificial respira- tion and, to a certain extent, artificial circulation. A cannula is rapidly inserted into any artery and di- rected toward the heart. To this a rubber tube and funnel arc attached and sterile normal salt solution
or Locke's solution or Ringer's solution is poured into the vessel. Other fluids may be used, even to tap water, but the solutions mentioned are prefera- ble. When about a quart of fluid has passed into the bloodvessels, fifteen to thirty minims of a one to one thousand adrenalin solution are injected into the ves- sel by inserting the needle of the hypodermic syringe through the rubber tubing close to the cannula. Synchronously with this injection the rhythmical pressure on the chest is brought to its maximum, so that the adrenalin solution shall reach the heart promptly. When the pressure within the coronary arteries reaches thirty to forty millimetres of mer- cury the heart will begin to beat. The cannula is then withdrawn. The saline solution is used for the purpose of filling the arteries so that the adrena- lin solution will reach the heart promptly. If, how- ever, there has been much haemorrhage, the saline solution fills the depleted vessels, giving them a fluid to circulate. Such a technique must be applied promptly in order to be of service ; the operating room staff must be so trained that the materials and instruments may be produced within two minutes after the cessation of respiration or of the heart beat.
Dr, Crile has applied his method to a number of patients who have apparently died after accidents such as drowning, shock by live wires, etc., and he finds that the human heart responds to the treatment more readily than the hearts of experimental ani- mals. One patient so treated recovered permanent- ly. The method does not destroy the chance of per- manent recovery of the patient. It does prevent operative death on the table, and allows the fatal termination to come after the return of the patient to his bed, a much less distressing circumstance. It is, in Dr. Crile's opinion, the best method of re- suscitation, excepting the direct transfusion of blood, and including the administration of stimulants, oxy- gen, electricity, and cardiac massage. Direct trans- fusion of blood is considered to be a specific remedy in haemorrhage and shock.
SURGICAL AN/EMI A AND RESUSCITATION.
The method described by Dr. Crile in his Miitter Lecture is based on careful experimental work. We see in the results of the experiments performed by Dr. Crile a benefit to the human family, as we have indicated in the preceding article. Dr. Crile says that death is relative or definitive. In relative death some of the functions of the body are sus- pended, but others are still present and active. Relative death admits of resuscitation for varying periods after the occurrence of complete anaemia. Resuscitation of dead tissues may be accomplished
January 2, 1909.]
EDITORIAL ARTICLES.
31
locally or for the entire economy. As an example of the former, the prevention of local death of tis- sue following the relief of pressure on the aflfected parts may be mentioned.
The death of the entire organism is usually due to anaemia of the brain. In thirty-three per cent, of cases of neck operations cerebral embolism follows ligation of the common or internal carotid artery from the loosening of the clot in the ligated vessel. As operations on the neck are usually performed for the relief of carcinoma, studies were under- taken to determine whether this condition could not be prevented. It was found that if the carcinoma had not invaded the wall of the artery, ligature