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Title: Nashville Journal of Medicine and Surgery, Vol. CX. March, 1916. No. 3

Author: Various

Editor: Charles S. Briggs
        W. T. Briggs

Release date: March 31, 2019 [eBook #59175]

Language: English

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                           NASHVILLE JOURNAL
                                  —OF—
                          MEDICINE AND SURGERY


                 CHARLES S. BRIGGS, A.M., M.D., Editor.
              W. T. BRIGGS, B.A., M.D., Associate Editor.

 ───────────────────────────────────────────────────────────────────────
 VOL. CX.                     MARCH, 1916.                         No. 3
 ───────────────────────────────────────────────────────────────────────




                        Original Communications


CASES OF RENAL TUBERCULOSIS ILLUSTRATING MODERN METHODS OF DIAGNOSIS.[A]

                    BY HOWARD S. JECK, PH.B., M.D.,
                            New York, N. Y.

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

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

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

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

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


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

The patient had never noticed any blood in his urine. His weight had
dropped from 170 to 149. Physical examination showed his kidneys to be
insensitive, and his prostate and seminal vesicles were negative.

The urine was acid, showed a fair amount of pus and albumin, but no
casts. No. T. B. bacilli found.

A month later the patient was seen again. In the interim he had suffered
an attack of fever (T. 105), and also an intense pain in the right
testicle and right side, lasting four days. The urine suddenly showed a
great increase in pus after which relief followed. All this time the
prostate remained unchanged, but the right kidney was now tender on
palpation.

During the next couple of months the patient showed a quite perceptible
general improvement on anti-tubercular treatment, but had at times
passed some blood in his urine.

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

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

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


_Case II, E. B._—Male, gave the following history: A father and two
brothers died of pulmonary tuberculosis. Others in the family had lived
to ripe ages.

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

The operation relieved the renal colics. But the bladder still caused
him untold agony, the patient urinating blood every two or three hours.

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

Physical examination revealed nothing except ridgy seminal vesicles. The
urine was cloudy and contained a small amount of albumin, pus, red blood
cells, a few hyaline casts and many T. B. bacilli.

The X-ray revealed an irregular shadow in the right kidney region, which
the radiographer reported as “consistent with a diagnosis of renal
tuberculosis.”

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

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

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


_Case III, G. S._—In October, 1904, this patient then nineteen years of
age, consulted a physician in Albany N. Y., because of moderate
frequency of micturition by day and night, attended by much terminal
pain and blood on a few occasions. T. B. bacilli were found in his urine
at that time, which gave a positive guinea-pig test. Cystoscopy was
performed and as a result the patient had chills, a rise in temperature
to 104, and some pain over his left kidney. A diagnosis of tuberculosis
of the prostate was made and the patient put on treatment which resulted
in an amelioration of his symptoms for some time.

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

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

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

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

The patient made an uninterrupted recovery from his kidney operation,
but his perineal fistula never completely healed.

Three years after his nephrotomy he was re-operated upon in order to
close his perineal fistula and died as a result of shock. In the
meantime, however, he had gained much in weight, had improved generally
and returned to his work. No T. B. bacilli could be found in his urine
at the time of his last operation.

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

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


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

Finally, T. B. Bacilli were found in the bladder urine. Suspecting the
right kidney of being tuberculous, 25% argyrol was injected into the
right renal pelvis, and the right loin X-rayed. An excellent radiograph
showed small round shadows throughout the kidney, and a mouse-eaten
appearance of some of the papillae, a typical tuberculous picture. This
diagnosis was subsequently confirmed by the finding of T. B. bacilli in
the urine from the right kidney. The right kidney was accordingly
removed, and found to be rotten throughout. It was likewise full of
argyrol. When last heard from (February, 1915), the patient had gained
considerable weight despite his lung condition.

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

Aside from the readiness with which the diagnosis of tuberculosis of the
right kidney was made (by virtue of the T. B. bacilli in the urine) the
swollen right ureteral orifice, pus from the same, and deficient
function of the right kidney by the phenolsulphonephthalein test, the
case is of further interest because of the corroboration of this
diagnosis by pyelography after the injection of an organic silver
preparation.


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

_Right kidney._—5 cc. of urine (in eight minutes) containing numerous
casts, a few w. b. c., but no pus; 1.3% urea.

_Left kidney._—3 cc. of urine (in eight minutes), containing no casts,
no pus; 0.3% urea.

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

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

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

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




                           Selected Articles


                          PUERPERAL INSANITY.

                          ELIOTT BISHOP, M.D.,
                            Brooklyn, N. Y.

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

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


                              DEFINITION.

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

Lee, of Manchester, England, in his exhaustive treatise, “Puerperal
Infection,” refers very casually to the maniacal symptoms of the
infection. (P. 290.)

Williams, in his “Obstetrics,” however, speaks assuredly of puerperal
insanity and gives definite etiological factors, two of which are the
result of childbearing. (Pp. 915, 916.)

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

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

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

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

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

Tweedy & Wrench discuss insanity at more length than any of the other
authors and must be convinced that it is a definite disease. (P. 401.)

Edgar refers to the “essential puerperal psychoses” and discussed their
etiology and time of occurrence very definitely. (P. 800.)

The most comprehensive work on this subject, however, is that in the
_Journal of Obstetrics and Gynecology_ of the British Empire, of Robert
Jones, Superintendent of London County Asylum, Claybury, England, and to
quote him is most convincing. “Of the specially puerperal cases—and it
is in this period that I recognize a special form of insanity—more
suffered from mania than melancholia.”

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


                               FREQUENCY.

In reference to its frequency, we find among the authorities a great
deal of variation and it again shakes our faith in the value of
statistics.

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

Williams refers to more modern statistics of Berkley and of Jones, who
noted it in 1 in 616 and in 1,100 labors respectively, but Williams’s
own experience has been less frequent.

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

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

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

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

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

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

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

Williams, of the school that, I think we all feel has, through the
laboratory, magnified the science of medicine perhaps sometimes to the
detriment of its art, says:

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

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

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

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

Berry Hart only mentions the predisposing causes of a neurotic
constitution, too frequent pregnancies, too prolonged lactation, and in
some cases the shock of a seduction ending in conception.

Wright, of Toronto, as I have stated before, says: “Constipation is
frequently very marked,”—whether he means as a cause or a symptom is
problematic.

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

Tweedy & Wrench, of Dublin, give us nine subsidiary causes—drink,
toxemia, post eclampsia, acute pain (the perineal stage), sepsis, severe
hemorrhage, prolonged lactation, no marriage and heredity, laying
emphasis on sepsis and hemorrhage in the puerperium.

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

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

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

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

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

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

The lactational type shows impoverished blood supply, uterine
sub-involution, and general cachectic condition.


                               SYMPTOMS.

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

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

Hirst’s cases have been of mania, melancholia or profound lethargy,
stupidity and mental confusion, and Webster’s experience has been about
the same.

Edgar feels that while most of the cases have been classed as mania,
they are in reality hallucinatory insanity.

De Lee has found melancholia with suicidal intent most common, but has
also observed mania with infanticidal tendencies, while Vinay holds that
the maniacal forms are the most frequent.

Tweedy & Wrench have found that insanity of the puerperium is always
associated with either severe anæmia from hemorrhage or with sepsis. The
patient is first irritable and uneasy about unknown dangers. She had a
headache, is constipated, she may refuse food or to see her child or
husband, and sleeps badly, and finally becomes definitely maniacal and
may have suicidal tendencies. During lactation the patient becomes
gloomy, sleeps badly, and is constipated. Definite melancholia develops
with delusions and suicidal tendencies.


                               PROGNOSIS.

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

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

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

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

Berry Hart says the prognosis is good under proper treatment and the
return of menstruation is such a good sign that emmenagogues should be
employed.

Tweedy & Wrench say some 60 per cent of all cases recover, but if, as
the patient gets fatter and stronger the mind does not improve, the
prognosis is bad.

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

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

Lewis of Chicago gives many practical suggestions.

The deduction and conclusions that we may draw from this summary of the
literature and from our own experience are these:

  First: We have a definite clinical entity.

  Second: Its etiology is in a great number of cases toxic, either
  bacterial or chemical, except in the lactational type which is one
  of general impoverishment of the body from prolonged nursing.

  Third: It occurs in about one in 2,000 labors at present and it
  causes about 6 per cent of all insanity in the female.

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

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

  Sixth: The prognosis is fairly good and as time goes on is
  improving, especially for the class of cases due to infections or
  intoxications.

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

  Rest must be obtained in the proper way. Restraint without
  resistance must be used, a constant attendant rather than a straight
  jacket. Pleasant surroundings make for mental rest as well.

  Food must be nutritious and easily assimilated and its elimination
  must be watched and the kidneys stimulated with all the means at our
  command.

  Exercise to the point of stimulation, but not fatigue, is as
  necessary as in any disease.

  Medication must be studied very thoroughly. Of the hypnotics,
  hyoscine is the best. The suggestion of Berry Hart as to the
  emmenagogues is well worth a trial.

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




                Extracts from Home and Foreign Journals


                                SURGICAL


           INDICATIONS FOR OPERATION IN EXOPHTHALMIC GOITER.

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


                          ACUTE APPENDICITIS.

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


                    EFFECT OF PHLORIDZIN ON TUMORS.

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


      DIAGNOSIS OF EXTENT OF INJURY IN CASES OF ABDOMINAL WOUNDS.

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


                                MEDICAL


                          DIPHTHERIA CARRIERS.

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

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


                    INJURIES FROM HOT WATER BOTTLE.

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


                   HEART INHIBITION DURING VOMITING.

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


                      HOME TREATMENT OF SCIATICA.

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


               USE OF CAFFEINE IN DIGITALIS ARRHYTHMIAS.

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


  THE EFFECT OF CAFFEINE UPON THE BLOOD-FLOW IN NORMAL HUMAN SUBJECTS.

The _Journal of Pharmacology and Experimental Therapeutics_, for
November, 1915, contains a report of a research by Means and Newburgh in
which they report experiments upon the blood-flow of two normal subjects
during rest, and of one subject during muscular work.

The action of caffeine on the blood-flow was studied in both subjects
while at rest, and in one during work.

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

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

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

During work probably no other action was obtained from caffeine than
possibly an increase in pulse-rate, and consequently slight diminution
in systolic output.

It is suggested that during rest when the supply of blood to the right
heart is “inadequate”, caffeine increases the blood-flow by increasing
the venous supply through an action upon some mechanism outside the
heart. When the supply becomes “adequate” or approaches adequacy, no
such action is obtained.—_The Therapeutic Gazette._


                              OBSTETRICAL


                        DIURESIS AND MILK FLOW.

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


        INDICATIONS AND CONTRAINDICATIONS FOR ABDOMINAL SECTION.

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


                  TREATMENT OF OPHTHALMIA NEONATORUM.

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




                               Editorial


  PUBLISHER’S NOTICE—The Journal is published in monthly numbers of 48
  pages at $1.00 a year, to be always paid in advance.

  All bills for advertisements to be paid quarterly, after the first
  insertion of the quarter.

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

  All communications for the Journal, books for review, exchanges,
  etc., should be addressed to the Editor.


                    SLOW DISSEMINATION OF KNOWLEDGE.

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

But Darwin was not the first to recognize the uselessness and danger of
the appendix, since M. C. Martins, in “_Revue des Deux Mondes_,” which
was published in 1862, mentioned the fact that this rudiment sometimes
caused death. Indeed it is said the ancient Egyptians knew the appendix
became inflamed and caused death, but for this we can not vouch.

In spite of these _hints_ of Martin and Darwin, physicians called the
symptom syndrome of what is now known to be appendicitis, typhlitis or
perityphlitis for years, although the cecum itself is seldom inflamed
without some pathological change in the appendix. The latter structure,
however, is often very badly diseased while the cecum is perfectly
normal.

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


                               EUGENICS.

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

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

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

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

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


             PUBLIC HEALTH SERVICE HOSPITALS CURB TRACHOMA.

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

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

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

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

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


           HOW THE GOVERNMENT IS MEETING THE MALARIA PROBLEM.

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

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

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

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

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




                        Reviews and Book Notices


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

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

                  *       *       *       *       *

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

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

                  *       *       *       *       *

  “Annual Report of the Surgeon General of the Public Health Service of
    the United States.” For the Fiscal Year 1911. Washington. Government
    Printing Office. 1914.

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




                         Publisher’s Department


                         “IN PARTICULAR CASES.”

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

                  *       *       *       *       *

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

                  *       *       *       *       *

“Many cases of acute coryza and naso-pharyngeal irritation are often due
primarily to the streptococcus rheumaticus and respond to the usual
rheumatic therapy.”

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

For special stimulation to the kidneys, Tongaline and Lithia Tablets; if
malaria is indicated, Tongaline and Quinine Tablets.


                      NOT A DIGESTIVE SUBSTITUTE.

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


                                INTEROL.

The world is full of fallacies—It is fed upon half truths. It drinks in
sophistry and then wonder is expressed that the millenium is so long
deferred.

Take for instance the unfortunate use of the terms “expensive” and
“high-priced” or of “costly” and “cheap.”

Price—be it high or low, is what one pays.

It has nothing to do with what is received.

Quality on the other hand, is what one gets, or fails to get. Service
ditto.

A useless, or inferior article or service, even when bought for a low
price, is expensive and costly!

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

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

A cheap person or thing is apt to prove the most expensive. A
high-priced person or thing usually turns out to be the most economical.

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

The physician who hesitates or is influenced by “high price”, provided
he knows the reputation and standing of the parties marketing the
product, is false to his obligation to himself and to his patient.

All of which applies with especial force to mineral oil and particularly
to Interol.

------------------------------------------------------------------------




                          TRANSCRIBER’S NOTES


 1. Silently corrected typographical errors and variations in spelling.
 2. Retained anachronistic, non-standard, and uncertain spellings as
      printed.
 3. Enclosed italics font in _underscores_.







*** END OF THE PROJECT GUTENBERG EBOOK NASHVILLE JOURNAL OF MEDICINE AND SURGERY, VOL. CX. MARCH, 1916. NO. 3 ***


    

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