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The Illinois [ledical Journal. 


The Official Organ ef The Illinois State Medical Society. 





Vol. VIII. No.4. 
25c per copy 


bISEASES OF THE BILE TRACTS.* 


CARL E. BLACK, , JACKSONVILLE. 


Bewildering Situation. — In considering 
seases and disorders of the bile tracts we 
e confronted by a situation which is some- 

\ hat bewildering. 

Rapid Progress.— Progress has been so 
rapid and the advances so irregular that it is 
especially difficult for the general practi- 
tioner who has not kept up with each ad- 

nee to understand the new etiology and 
pathology on which the present surgical treat- 
ment is based. 

Living Pathology.—Surgery has brought 

us a knowledge of conditions as they exist 

n the living subject, and this has led to con- 

clusions at variance with those derived from 

dead-room pathology. 

Post-mortem Pathology.—The great diffi- 
culty at present is that the post-mortem path- 
ology, with its deductions, still possesses the 
minds of the great body of the medical pro- 
fession and the deductions of the operating 
table are only beginning to be understood. 

Double Nomenclature—This gives rise to 

double nomenclature, and in fact, nearly 
every book, no matter how recent, is more or 
less biased by the old conclusions. 

Foundation Principles.—In this study the 
principal thing which one must do is to dis- 
card, for the moment, details and seek found- 
ation principles. 

Questions are Simple.—After reading a 

luminous literature on the subject of “Dis- 
eases of the Bile Tracts,” it appears that after 

the whole question is far simpler than at 

st supposed. In fact, a correct understand- 
ing of any disease or group of diseases always 
leads to simplicity. 

Jaundice Only a Symptom.—At the outset 


*,ead at the 55th Annual 
May 17, 1905. 


Meeting, Rock Island, 


Springfield, Ill., October, 1905. 


SUBSCRIPTION 
$2.00 A YEAR. 


we must dismiss jaundice as only a symptom, 
and in no other way a part cf the classified 
diseases of the bile tracts and not essential to 
them. 

The 
from the practical 
standpoint of treatment, is the correct diag- 


Correct Diagnosis Most Important. 


most important thing, 


nosis. This paper will be larg: ly devoted to 
a consideration of some of the important ele- 
ments in diagnosis. Old Diagnosis Points ar 
Giving Away to New.—Nothing so strongly 
impresses itself in reading the literature as 
the fact that the diagnostic points, which were 
formerly held as all important, must now 
give way to others which until recently were 
either overlooked of 
significance. 


or considered slight 


Correct Diagnosis—The question which 
confronts the surgeon, and prior to him his 
colleague in general practice, is the correct 
diagnosis of the case in hand. The practical 
first, is the disease in the bile 
tracts; second, what part or parts are in- 
volved; and third, what is the character of 
the disorder. 


quest ions are: 


Operation May be Based on Rither Conclu- 
sion.—The anatomical relations of the bile 
ducts and gall-bladder rarely make it possi- 
ble, to apply direct methods of diagnosis. 
Their location the differential 
method. We must often arrive at 


necessitates 
a conclu- 
sion by exclusion and not infrequently resort 
to an and direct examination. It 
will not be difficult usually to determine that 


incision 


the case is one requiring surgical interfer- 
ence and as the practitioner gives these dis- 
eases more careful study it should be almost 
as easy to arrive at a diagnosis of disease of 
the bile passages as of disease of the appendix 
in the female. 

Classification of Diseases.—We find in the 
bile tracts only three classes of disease : 


First, That due to inflammation. 





276 


Second, That due to foreign bodies within 
the bile tracts. 

Third, That due to pressure upon the bile 
tracts from without. 

Injuries and Malformations.—With the 
exception of injuries and malformations, 
there is no disorder of the bile tracts which 
cannot be classed under one of these head- 
ings. 

Inflammatory Disorders. — Inflammatory 
disorders, of course, include all the infec- 
tions, whether acute or chronic, which pro- 
duce catarrhal, suppurative, phlegmonous or 





DISEASES OF THE BILE TRACTS—BLACK. 


ed, which, while they are not very true t 
nature, may assist in following the subject. 


Surgical Treatment.—The surgical trea 
ment of these tracts was, until a comparativ: 
ly recent date, confined to operations for ga 
stones. It would, therefore, seem proper i 
studying the basis of the diagnosis of the: 
diseases that we first consider their relati: 
to gall stones. 

Gall-stones, Their Frequency.—It has be 
estimated that 10% of adults have gall-ston: 
and that 5% of these have symptoms arisi! 
from them or in connection with them. Th 





BILE TRACTS 


AND 


THEIR RELATIONS 


a ¢ pest 








FIGURE. L. 
Bile Tracts and their relations (after Kehr, 1905) showing Gall-Bladder; Bile 
Tracts; Kidneys; Spleen; Pancreas and portions of Liver, Duodenum and Arteries 


and Veins. 


gangrenous inflammations, but these are in 
no way peculiar to the bile tracts, or the gall 
bladder. They occur in the appendix, in the 
tubes and ovaries, and, in fact, are common 
to every mucous surface and mucous cavity. 

Foreign Bodies.—Foreign bodies include, 
first of all, calculi; second, parasites; and, 
third, miscellaneous foreign bodies. 

Pressure from Without.—Those disorders 
which produce disease by pressure from with- 
out include benign and malignant tumors 
and diseases of neighboring parts 


Diagrams.—Several diagrams are present- 


brings up the interesting question, as to what 
causes latent calculi to become active ? 


Gall-stones. Their role in Producing Dis- 
eases of Bladder and Ducts.—The role of ga 
stones in diseases of the gall ducts and gal 
bladder is as yet in much disagreement. It is 
well known that gall stones are frequentl\ 
found post-mortem without having produce: 
symptoms, and in fact cases are on record 
where gall stones have ulcerated through and 
caused intestinal obstruction without suifi- 
cient symptoms from the biliary apparatus t 
attract attention. They are an indirect caus 





DISEASES OF THE BILE TRACTS—BLACK. 


f acute catarrh of the bile passages, and in 
ippurative cholangitis there is frequently a 
story of one or more attacks of gall stone 
lic; and, in fact, some recent authors speak 
' gall stones as one of the most important 
uses of suppurative cholangitis. To say 
e least, suppurative cholangitis is usually 
ssociated with stones in the gall bladder. At- 
icks caused by catarrh of the gall bladder 
ay simulate those due to gall stones so close- 
that it is impossible to differentiate, ex- 
pting that in the catarrhal attacks the 
mptoms are less severe and prolonged. No 
<‘ones are found in the evacuations. Jaun- 
ce is either absent or slight and there is no 
nderness on pressure. 


Gall Stones Active Only in Presence of In- 
ction.—Gall stones rarely become active 
ithout the presence of infection, and they 
never produce symptoms until they interfere 
with drainage. 

Obstruction from Gall Stones—When they 
rovide irritation for infection they produce 
nflammation and when they try to escape 


ey obstruct the flow of bile and produce 
iundice. 


Calculous Formation and Infection.—We 
will not take up the various questions involv- 
d in infection and calculous formation. It 
vill be sufficient to say that there is a wide 

fference of opinion. It is not important to 

ir consideration whether infection always 

precedes, and is the cause of formation of 
ileuli, or whether calculi are formed with- 
it infection and by their irritation invite 
ifection. 

Presence of Gall Stones an Incident.—As 

matter of surgical experience we never find 
ileuli without a certain amount of infection, 
nd the infective disorders are frequently ac- 
mpanied by calculi,which in themselves may 

may not have been symptom producing 
t would appear that the factor of infection 
more important, even in the presence of 
all stones, in the production of symptoms, 
ian the calculi themselves. The presence of 

ill stones is usually an incident of the in- 
ammatory disorders of the bile tracts rather 
1an the cause. However, further studies in 
ie operating room may change or modify 


orn” 
~ae 


this conception. The point is one which is 
still under discussion. The phrase “Gall- 
stone Disease” has given rise to considerable 
misunderstanding as to the real nature of the 
process and should be abandoned as mislead- 
ing. While the formation of calculi is path- 
ological the symptom producing process in 
these cases is usually the inflammation rather 
than the presence of calculi. 


Jaundice.—A peculiarity of these diseases 
is that we have one sign which is absolutely 
reliable in pointing to diseases of the bile 
tracts; namely, jaundice. But while the 
presence of this sign is positive proof of ob- 
struction to the flow of bile, jaundice alone is 
a poor guide as to the location or nature of 
the obstruction, and its absence is no proof 
that disease of the bile passages does not 
exist. 

A Recent Book on Jaundice.—One of the 
most recent and up-to-date books upon this 
subject, published during the present year, 
introduces a chapter upon jaundice, and in 
the second paragraph says, “Like albumin- 
uria, it is a symptom and not a disease ;” that 
it is caused by obstruction to the flow of bile; 
that the cause of the obstruction is the dis- 
ease and jaundice like pain, fever, ete. is only 
a symptom. After making this plain, fair 
and eminently true statement, the author 
proceedes to introduce sixty-four pages upon 
the subject of jaundice, in which he discusses 
its pathology, its varieties, its’ signs, symp- 
toms and diagnosis. He speaks at length of 
its prognosis and its treatment, and later 
takes up the etiology, diagnosis, morbid anat- 
omy and clinical characters of various kinds 
of jaundice. To one who is really desirous of 
getting at the truth of diseases of the bile 
tracts such a mixture of classification savors 
of ancient history. 

The literature of jaundice is voluminous, 
notwithstanding the fact that it is only a 
symptom and not the disease. It is the one 
conspicuous and unmistakable sign of disease 
of the bile passages and, as a consequence, has 
been loaded down with the whole weight of 
diagnostic evidence. It has had so much 
prominence that it is not surprising that ob- 
servers have regarded it as the disease rather 





DISEASES OF THE BILE TRACTS—BLACK. 


than only one important symptom which may 
be absent even in cases of great severity. We 
must return to fundamental principles and 
recognize the fact that jaundice has only one 
cause—namely, obstruction to the discharge 
of bile. This obstruction may be multiple 
from occlusion of the minute bile cappilaries 
as in inflammation of the liver; it may be 
from multiple calculi in the small hepatic 
ducts; from a stone in one of the larger 
hepatic ducts or in the main hepatic ducts: 
from a stone in the cystic duct or in the com- 
mon duct. Instead of stone, the obstruction 


may be from swelling and induration or 








these disorders. Pain is often difficult t 
understand. All are familiar with the pai 
of hepatic colic. 

Pain.—It may vary from slight vagu 
pains in the region of the stomach to the mos’ 
acute localized colic. Pain is most marke: 
in those cases of obstruction in the commo1 
duct, in which dull aching alternates wit! 
acute severe pain, coming on suddenly, usu 
ally in the right hypochondrium and ofter 
shooting up toward the right shoulder, and i1 
severer cases the pain is over the whole ab 
domen. Of course, if we have severe par- 
oxysms of pain accompanied by chill, sweat 








BILE TRACTS «0 THEIR RELATIONS 





FIGURE. Il. 
_. Bile Tracts and their relations, showing Gall-Bladder; Bile Tracts; Liver; Right 
Kidney; Stomach; Duodenum and portion of Pancreas; Spleen and Left Kidney. 


mucous plugs or foreign bodies or from pres- 
sure from without, but, in all these condi- 
tions and locations, the underlying and ulti- 
mate cause of jaundice is always the same— 
obstruction to the flow of bile through the 
ducts and its resorption into the circulation 
where it is carried to all parts of the body 
and discolors by deposit of bile pigment. We 
will not undertake to discuss the effect of re- 
tained bile on the blood and blood vessels al- 
though this is very important when consider- 
ing surgical operation. 

Next to gall stones and jaundice, pain has 
been one of the most important symptoms in 


ing and fever, and deepening jaundice, th: 
diagnosis, as far as the bile tract is concerned 
is plain, but an examination of the histories 
of operated cases shows that neither jaundic: 
nor pain can alone be relied upon, as a basis 
for diagnosis. 


Pain is frequently entirely absent in sup- 
purative cholangitis, while acute catarrh of 
the bile passages is not accompanied by pain. 
In cases accompanied by severe paroxysma! 
pain, occurring at irregular intervals, begin- 
ning in the right hypochondrium and radiat- 
ing over the whole abdomen and through th: 
right scapular region we can feel reasonabl) 





DISEASES OF THE BILE TRACTS—BLACK. 279 


re that we have inflammation of the bile 
ssages and that it may be accompanied by 
ill stones and that the conditions have given 
yse to more or less complete obstruction. 
Flying Pains.—Flying pains in the limbs 
e occasionally present in acute catarrh of 
e bile passages, and in a recent case we have 
served pain in the great toes, simulating 
e pain of gout accompanying a moderately 
vere catarrh of the bile passages. Occasion- 
y we will see cases in which the pain indi- 
tes the presence of gall stones, but the ob- 
ruction is caused not by stone, but by thick- 
ed and hardened mucus. I have recently 
erated on such a case. 
Pains Simulating Other Disorders.—Pain 
iy be in the pre-cordial region and simu- 
te angina-pectoris, or in the epigastric re- 
on, as in gastric ulcer, or it may be low 
wn, as in renal calculus. The pain may 
general; it may be between the scapulae, 
in the extremities. 1 have seen a case in 
vhich both the pain and tumor were in the 
sion of the appendix, and another with 
pain and tumor in the region of the um- 
icus, and diagnosed first an omental carcin- 
a on account of the nodular form of the 
We cannot base a diagnosis upon 
n alone, but must be guided by the pres- 
ce or absence of other symptoms which go 
» make up the differentiation. Pain is an 
portant symptom, but only important in 
nnection with other signs and symptoms. 


mor. 


C'hree Directions for Micro-organisms to 
nter—In considering the symptomotology 
the inflammatory diseases of the bile tracts 
must bear in mind that there are three 
rections through which the organisms of in- 
fection may enter. 

First, and probably most commonly, they 
ay come through the common duct from the 
testinal canal. 

Second, through the liver, which receives 
ud takes care of so much of the waste pro- 
icts of the body. 

Third, directly through the walls of the 
ll bladder. 

The Bile Tracts—We have in the bile 
racts long, narrow tubes connecting with a 
sed mucous cavity. These tubes have their 


origin in the liver and their exit in the in- 
testinal canal, and may become infected from 
either direction. 

Fever.—The fever in acute catarrh of the 
bile passages is usually due to the gastro- 
intestinal catarrh, and disappears with it. 
In the more severe inflammations the fever 
is continuous and frequently associated with 
chilliness and rigors. These are more mark- 
ed after formation of adhesions. While the 
fever is not characteristic, its presence, ac- 





DIAGRAM SHOWING | 
VARIOUS SITUATIONS 
WHICH MAY BE OCCLPIET 
BYCALL STONES | 


ay 


» 
SP 
( / 
— 


~ 


) a 


FIGURE. IIL. 


Showing positions in which calculi may be found 
in the ampullaof V ater; common duct; Cystic Duct; Gall- 
Bladder; Main Hepatic Duct and small Hepatic Ducts. 





l 
P. 








companied by chills and rigors, gives an 
important hint as to the nature of the process. 

Mouth Conditions.—A bitter taste in the 
mouth, the foul breath, and the furred 
tongue are usually present in acute catarrh 
of the bile passages. Loss of Appetite-—In 
all the inflammatory diseases loss of appetite 
is prominent and important and is almost al- 
ways accompanied by nausea, and, sooner or 
later, by vomiting. Vomiting.—Vomiting is 
usually present in acute catarrh, and is often 
a prominent symptom in suppurative cholan- 





280 


gitis. The initial symptoms of cholelithiasis 
are often accompanied by vomiting, which is 
continuous, and may cause death by exhaus- 
tion. It is also a very common symptom of 
stone in the common duct. 

Stomach Symptoms.—Indigestion or dys- 
pepsia, accompanied by loss of appetite, nau- 


sea and vomiting, in which a diagnosis of 


disease of the stomach or of the intestinal 
canal cannot be made and in which a movable 
kidney cannot be demonstrated are almost 
certainly dependent upon some disorder of 
the bile tract. 

In arriving at a diagnosis we should care- 
fully study the diseases and disorders of the 
gastro-intestinal tract ; those from which the 
patient has suffered in the past as well as 
those present. 

Dyspepsia.—Dyspepsia is frequently pres- 
ent in acute catarrh, or comes on as a se- 
quence of such disorders. It often accom- 
panies cholelithiasis, and is usually associated 
with chronic cholangitis, which, in most cases, 
is preceded by gastro-intestinal catarrh. 

Gastro-intestinal Catarrh. — Gastro-intes- 
tinal catarrh, diarrhoea, and dysentery are 
exceedingly important factors in the produc- 
tion of the inflammatory diseases, and a care- 
ful study of them is of the utmost import- 
ance in arriving at a diagnosis. Intestinal 
worms may be a factor in these diseases. 

Enteritis—On the other hand, a mem- 
braneous or croupous enteritis is frequently 
associated with attacks of pain, like gall 
stone colic or inflammation of the gall ducts 
and apparently is caused entirely by obstruc- 
tion to the flow of bile by the inflammation 
in the intestine at the point of exit of the 
common duct without any disease of the bile 
passages. 

Malaise—General malaise is also a prom- 
inent feature of inflammation of the bile 
tracts, suppurative cholecystitis and empyema 
of the gall bladder prior to ulceration and 
there is marked prostration. Loss of Weight. 
—Almost all the diseases of the bile passages 
give rise to loss of weight and they are often 
accompanied by severe constitutional symp- 
toms, especially where suppuration and septic 
absorption are present. Collapse.—Choleli- 


DISEASES OF THE BILE TRACTS—BLACK. 


thiasis may lead to collapse and death in 
severe attack. Occasionally the catarrhal o 
suppurative conditions occur during tl 
course of typhoid fever and are caused b 
the organism of that disease. Such a con 
plication is exceedingly serious. 

Constipation.—Most of these diseases ar 
accompanied by chronic constipation, whi: 
may, from the accumulation of the feces : 
the hepatic flexure, interfere with the regula 
emptying of the gall bladder, or the const 
pation may be the result of the inflammator 
process. Offensive Stools——Fermentation i: 
the intestinal canal is often increased, givin 
rise to gaseous distention and very offensi\ 
stools, while interference with the discharg 
of the bile into the intestine leads to th 
characteristic clay colored _ stools. Cl 
Stools——Clay stools are coincident wit! 
jaundice and arise from the same cause. 

Liver Tenderness. — Liver tenderness 
very important in connection with diseas: 
of the bile ducts. While in acute catarrh t! 
tenderness is either slight or not present, in 
suppurative cholangitis and cholecystitis it 
very marked. In fact, we believe a mor 
careful palpation of cases complaining 0! 
pain in the upper abdomen or indefinite ga-- 
tro-intestinal symptoms will reveal circun 
scribed tenderness much oftener than is get 
erally supposed: This tenderness will not |» 
accompanied by swelling or tumor until ¢! 
ducts are blocked so that the bile is fore 
back into the gall bladder or liver. Empyen 
of Gall Bladder.—Empyema of the gall blad 
der will give rise to marked tumor. 

Other Diseases.—We should always be o: 
the lookout for the history of other diseas: 
and illnesses. Acute inflammations or i! 
fectious fevers, as pneumonia, typhoid fev 
appendicitis, or diathetic diseases as gout an 
syphilis are among those which may be t! 
indirect or occasional cause of acute catar! 
or inflammation, while suppurative append 
citis may be the direct cause of a suppuratiy 
cholangitis. 


Micro-organisms Present.—The charact: 
of the inflammation in the gall bladder an 
ducts is largely determined by the micro-or- 
ganisms present. 





DISEASES OF THE BILE TRACTS—BLACK. 


’osture and Position of Patient—The 
te, dency in the patient to bend toward the 
richt to contract the right rectus and other 
m. scles on the right side, and to draw up the 

it thigh, and especially if accompanied by 
a ‘celing of fullness in the right hypochon- 

im, are exceedingly suggestive. 
mmobility of Abdomen.—Immobility of 

th: abdomen, which is especially marked after 
| peritonitis, has given rise to adhesions, 
ccompanied by tenderness on palpation, 
dulness on percussion are important 

: in arriving at a diagnosis of suppurative 
ecystitis or cholangitis, empyema of the 
bladder, or recurrent catarrh of the bile 

ages with adhesions. 

erforation.—In the catarrhal inflamma- 
s there will be no adhesions if gall stones 
not been present. In the diagnosis of 
icted stones or suppurative inflammations 
usual symptoms of peritonitis are pres- 

t and of great importance. 

\dhesions Found.—In the course of these 
mmations, and especially those accom- 
ed by suppuration, and more particularly 

hose in which gall stones are present, ad- 
hesions to neighboring organs are formed and 
{ten give rise to symptoms similar to those 
if gall stones. Usually where adhesions have 
formed there is an increase of fever, pain, 
tenderness, immobility of the abdomen, tym- 

tes and in fact all the symptoms of a 
ized peritonitis. 

\\here suppuration is followed by perfora- 
of the gall bladder, symptoms of acute 
onitis develop. Gall stones are usually 
nt in such cases. 

Vbliteration Inflammatory Congenital.— 
n the diagnosis and operative treatment of 
lesions of these parts we must not forget 

congenital as well as inflammatory ob- 
literation of the ducts and of the gall bladder 
and may lead to a futile search on 


orc r 


the part of the surgeon who, in his great fear 


of overlooking a gall-bladder, contracted and 


covcred in by adhesions, greatly prolongs his 
search, 


\ 


‘must bear in mind that these disorders 
ery frequently secondary to other dis- 
. occurring even several years before. A 


281 


careful inquiry into the history of such dis- 
eases as well as the condition of neighboring 
organs will give important information and 
be of material assistance in arriving at a 
correct diagnosis. It is impossible in the brief 
time at our disposal to go into the details of 
these inter-relations. 

The one important thing to remember is 
that the diagnosis will most often depend 
upon a careful analysis of the symptom com- 
plex presented by the patient, including the 
history of previous illnesses and allied dis- 
orders as well as the direct symptoms. He 
who depends upon the direct symptoms of 
jaundice, clay stools, and pain for the diag- 
nosis of disease of the bile tracts will over- 
look more than half the cases requiring sur- 
gical treatment and in just so far will fail 
to bring to his patients that relief to which 
recent medical progress entitles them. 

The surgical treatment of these conditions 
has two objects. First, to remove foreign 
usually in the nature of calculi but 
occasionally inspissated mucus, parasites, 
other foreign bodies or new growths. Also 
to remove new growths or adhesions which 
are causing obstruction by pressure from 
without. Second, to secure drainage, which 
is undoubtedly the most important indica- 
tion. 


bodies 


Obstruction to these ducts is principally 
from inflammation and swelling which may 
or may not be associated with calculi or other 
foreign bodies. The obstruction may be in- 
complete, intermittent or complete, but the 
indications are always the same—drainage 
must be secured. This is the object which 
should be sought by rest in bed, and the ad- 
ministration of drugs as well as by surgical 
interference. We must reduce the swelling 
and overcome the obstruction in order that 
these tubes may be restored to a normal con- 
dition. All] other points in treatment are in- 
significant compared with the one point of 
securing drainage, nor is this peculiar to dis- 
eases of the bile tracts. It applies equally 
well to every mucous cavity and mucous 
tracts of the body. Inflammations and ob- 
structions to the antrum, the sinuses, the 
mastoid, the bladder, the intestinal canal and 





282 DISEASES OF THE BILE TRACTS—BLACK. 


the appendix, ete., cannot be treated success- 
fully without drainage. The inflammatory 
products must not be allowed to accumulate. 
The treatment of diseases of the gall tracts, 
as well as all other mucous cavities, and 
mucous tracts, will consist of ways and means 
of establishing and maintaining drainage. 
The application of this principle has opened 
up a field of usefulness for surgery which our 
colleagues of internal medicine must recog- 
nize and apply much earlier than is their 
present habit if we are to give that prompt 
and permanent relief to which modern prog- 
ress entitles our patients. 

In conclusion it is urged that greater care 
in diagnosis and earlier operation will greatly 
shorten the period of suffering, greatly im- 
prove the results, both as to complications 


and mortality and hasten the recovery of our 
patients, and in case of doubt an early explor- 


ation will clear up the diagnosis and enable 
us to apply correct treatment. 
References to Literature. 


The following is a list, arranged alphabetic- 
ally by authors, of the books and articles to 
which reference has been made in the prepara- 
tion of this paper. A few of the articles have 
not been accessible in the original. 

1. Abbe, Robert—The Surgery of Gall Stone 
Obstruction, Med. Rec. Vol. 43, p. 543, May 6, 
1893. 

2. Addinsell, Augustus W.—Removal of Gall 
Bladder in a Woman, aged 75, British Med Jr.. 
p. 759, No, 2310, Apr. 8, 1905. 

3. Alleban, J. E.—RKeport of Cases in Gall 
Bladder Surgery and Their Sequellae, Ill. Med. 
Jr., Vol. 49, p. 316, Jan. 1900. 

4. Anders, J. M.—Cholecystitis as a Com- 
plication of Lobar Pneumonia: With a Report of 
Three Cases, and Remarks on Icterus in Pneu- 
monia. Am, Med., Vol. [X, p. 431, Mch. 18, 1905. 

5 — Jaundice with Reports of Interest- 
ing lllustrative Cases. A Contribution to the 
Toxic Forms of this Condition. Am. Jr. Med. 
Sci., Vol. (4) 125, p. 596, Apr. 1903. 

6. Bangs, L. Bolten—Illustrative Cases of 
Calculous Diseases, Med. Rec., Vol. 47, p. 513, 
Apr. 2, 1895. 

7. Barbat, J. Henry—Retention Cyst of Gall 
Bladder. Jour. A. M. A., Vol. 32, p. 923, Apr. 
29, 1899. 

8. Beck, Carl—Report of Four Cases of Fat- 
Necrosis in Connection with Gall Stones—From 
a Surgical Standpoint. J. A. M. A., Nov. 2, 1901. 

9. Becker, Wilhelm—Primary Endothelioma 
of the Gall Bladder, Jour. A. M. A., Vol. 40, p. 
897, Apr. 4, 1903. 

10. Berg, Albert Ashton—Surgical Treat- 
ment of Cholelithiasis, Annals of Surgery, Vol. 
38, p. 343, Sept. 1903. 


11. 


A Proposed Method of Retrod 


denal Choledochotomy for the Removal of I: 
pacted Calculi in the Retroduodenal and Pap 
lary Portions of the Common Bile Duct. A 
nals of Surgery, Vol. 38, p. 275, Aug. 1903. 
12. Bevan, A. D.—A New Incision for 
Surgery of the Bile Tracts. Jour A. M. A., \ 


28, p. 1225, 


June 26, 1897. 


13. Biggs, H. M.—The Distoma Sinense 


Rare Form 
Sci., Vol. 10 
14. Billi 


of the Liver Fluke. A. Jr. of M 
0, p. 30, July, 1890. 
ngs, Frank—Gall Stone of the Cys 


Duct, with Situs Viscerum Inversus. Phil. M 


Jr., Vol. 6, 


p. 670, Oct. 6, 1900. 


15. Blake, Edward—Intestinal Catarrhs. 


16. Boor 
rhosis with 


1e, H. B.—Hypertrophic Billiary 
Chronic Jaundice. Jour. Mors 


County Med. So., Vol. 2, p. 14, Sept. 1899. 
17. Brewer, George Emerson—Differen 
Diagnosis in Diseases of the Gall Bladder 


Ducts. Mec 


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t 


\ 





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and 


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LE TRACTS—BLACK. 


. 


9o° 
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Gall Stones 





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286 


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“How to 


SURGERY OF DUODENUM—SUTTON, 


SURGERY OF THE DUODENUM. 
BY EMERSON M. SUTTON, M. D., PEORIA 


Acute duodenal ulcer is rarely found 
dependent of other diseases. Pain, hem 
mesis, melaena, perforation, indicate its 
currence. With a case (1) of strangul 
inguinal hernia, under our care, these s\ 
tomk, less perforation and peritonitis, occu 
on the second day following operation, 
profuse hemorrhages from the bowel 
severe abdominal pain localized to the r 
and on level with the umbilicus, contin 
over four days at intervals. Patient was ) 
of seventy (70), hernia was strangulated 
days, operation necessitated making an 
ficial anus to save time. Recovery promis 
till second day, sudden severe pain in a 
men, hemorrhage from bowel, vomiting b| 
collapse. Embolic ulcer of the duode: 
following laparotomies is mentioned by M 
licz. This diagnosis was made from 
above symptoms and the clot filled intest 
all occurring suddenly. Treatment for he: 
rhage, tightly bandaged limbs, gelatin } 
by mouth, adrenalin and stimulants resi 
in recovery, now three years. Acute he: 
rhage of acute primary ulcer is rarely { 
Fenwick. As the blood pressure is red 
arterial retraction and arrest of blee 
takes place. Patients exhausted from s 
cemia after erysipelas, or severe burns, 
suffer pain in abdomen, with vomiting 
blood and bloody stools. The hemorr! 
due to erosion of: Ist, pancreatica duo 
artery; 2d, gastro-epiploica dextra: 3d, 
creatic and portal veins; 4th, aorta: 
hepatic artery; 6th, superior mesenteric \ 
may be first and only symptom and « 
the result. Possibilities of surgery are nm 
sarily limited here. Perforation rarely o 
and the tendency to healing under the . 
ful handling is worthy of considera 
Should the patient survive the first h« 
rhage and have repeated hemorrhages + 
case of acute ulcer with perforation pr: 
surgical intervention offers a rational | 


*Read at the 55th Annual Meeting, Rock Is 
May 17, 1905. 





SURGERY OF DUO DENUM—SUTTON,. 


for just the same reasons that gastric 

r demands surgery. Uncertainty of diag- 

-is makes for delay and, outside of large 
surgical clinics, and even there uncertainty 
is until the abdomen is opened, and it re- 
nsuncertainty astocause of death—which 

ts in from 50-68% of these cases, Fen- 
Perforation with peritonitis may be 
first symptoms of duodenal ulcer, when 
nosis from other forms of perforation 
be well nigh impossible and surgery to 
fective must be early in the first twelve 


irly diagnosis means early incision, when 

cor of the stomach, cholelithiasis, ulcer of 
r parts of the intestine and appendicitis 

can be excluded at once and uncertainty elim- 
ed. This: applies likewise to injuries of 
luodenum in which the symptoms remain 
bscure and uncertainty exists inregard tothe 
complications following affections in this re- 
gion; peritonitis, hemorrhage, perforation, 
retro-peritoneal abscess, stenosis, peri-duo- 
lenitis of the duodenum, pancreatic compli- 
ns and adhesions. Laboratory methods 
positively scientific in helping to diag- 
nose, but are too far outside the seat of war 
to be effective and the place for the surgeon 
is where action is taking place. Methods 
planned before seeing the actual condition to 
be dealt with are helpful, if time is not lost 
in planning, (they increase the surgeons re- 
In chronic ulcers it is different. 


sources, ) 


Time is not such a great factor and every 
means for making exact diagnosis should be 
sted. 
with 


These cases come late to the sur- 
emaciation added to the other 
of symptoms, perhaps gall stones and 
pendicitis have been eliminated, since the 
ements of those diseases to secure recog- 

n are wanting—that is a comparatively 
operation with relatively low mortality 
ast but notleasthigh fees. The duodenal 
goes on unsought and unhealed, also 
required. The possibilities of sur- 
here, before extreme emaciation exists, 
iturally better than in the class of acute 
with complications and although heal- 

v medical handling is possible, given an 


diagnosis and proper treatment. Sur- 


gical treatment, is necessary by the time the 
patient consults the surgeon. Ulcer of the 
duodenum heals with greater difficulty than 
the ulcer of the stomach, 69% end in perfora- 
tion, (Hemmeter), and the mortality of op- 
erations for perforation stands at 86%, five 
cases, three deaths, Mayo. For these reasons 
surgical handling of duodenal ulcer is ra- 
tional. In arriving at correct diagnosis Gra- 
ham considers careful case taking the greatest 
aid coupled with the power to interpret, clas- 
sify and arrange, and to make correct de- 
ductions. 
Pain, vomiting, emaciation, hemorrhag: 
and we add ever present anaemia, with later 
perforation, constitute the 
which guide us. 60% of 151 
denal ulcers collected by Perry & Shaw, 53% 
of a number of 


clinical 


signs, 
cases of duo- 
cases collected by 
failed to exhibit any symptoms of importance 
prior to fatal perforation. 
This applies to acute ulcers more than to 
chronic, since in chronic cases pain, vomiting, 
hemorrhage indicate the affection in 74% 
of the cases according to Fenwick, whose 
valuable work I am indebted to for the above 
data. 


Cullen 


hemorrhage or 


In this study it must be determined 
whether the ulcer, if ulcer exists, is idiopathic 
or is associated with other pathogenic condi- 
tions, in other words, whether the patients 
condition is the result of ulcer of the duo- 
denum, or the ulcer is the result of a more 
serious Attention is 
paid to the experiments of showing that ulcer 
of the stomach could not be produced in 
dogs, unless the hemoglobin was below nor- 
mal. 


disease anaemia, etc. 


Pain, 70% of the cases most severe when 
ulcer situated in first part of duodenum and 
posterior wall, varies from sense of uneasiness 
to violent prolonged suffering in right hypo- 
chondrium or umbilicus, mostly independent 
of eating, often most severe when stomach is 
empty. Typical pain come 24-4 hours after 
eating solid food, radiates from just below 
right costal arch over upper abdomen and 
back, not localized to one spot. Acidity and 
flatulence may precede and accompany the 
pain or may have no dyspepsia. Vomiting 
20% of the cases, independent of pain. Char- 





288 


acter of the vomit depends on degree of 
stenosis of the bowel due to peri-duodenitis. 
As rule constipation exists, but may be diar- 
rhoea in 8% of the cases. 


Hemorrhage most important sign, 40%. 
Hematamesis and melaena together,20%. 
Hematonesis about 

Melaena alone 


Patients may not suspect blood in stool 
and yet reach verge of death from hemor- 
rhage in the bowel. Blood in stools 40% 
cases is of greatest importance. Methods of 
finding visual, Rutherford. If blood in large 
amounts may be recognized without special 
tests, but great caution should be exercised 
in pronouncing the color of the stool as due 
to blood for many medicines and foods in- 
gested may give the black or red color. If a 
large hemorrhage takes place from a duodenal 
ulcer and the blood passes rapidly through 
the bowels, red blood corpuscles may be 
found on microscopic examination and so 
the presence of blood be certain, but for more 


positive proof Webers modification of the 
Guaiac, turpentine test should be resorted to. 
This consists in shaking out part of the stool 


with 1-3 part of glacial acetic acid, (the 
glacial acetic changing the haemoglobin to 
haemitin), removing the haemitin thus 
formed by gently mixing a small amount of 
ether with above mixture and allowing the 
ether to separate the mixture by standing. 
The ether takes into solution the hemetin and 
this solution in ether should be removed and 
tested by freshly prepared tincture of Guaiac 
and turpentine, when if blood were present in 
the stool, we will get the blue color, indicative 
of blood, as anything acting as a catalytic 
agent will give this reaction, therefore the 
necessity of extracting the blood with ether. 


The spectroscope test is less practical (be- 
cause few of us possess a spectroscope and less 
understand how to use it and what the lines 
mean when we see them.) 


Uleer of the duodenum has the 
etiology, symptoms, pathology and sequela 
as ulcer of the stomach and the treatment is 
on the same line. Medical treatment should 
be resorted to first in both diseases and the 


same 


SURGERY OF DUODENUM—SUTTON. 


result is greater and more satisfactory 
acute ulcers than in chronic. While medi 
treatment, rectal feeding and gradual 
crease of mouth feeding gives happy resi 
in many cases its futility is too often dem 
strated. We, of course, see this very 
quently in chronic ulcers of stomach and 
ulcer of the duodenum is in all things 
ulcer of the stomach it will not be digress 
too far from the subject to briefly relat 
history and show a specimen of ulcer 
stomach which would never be cured by n 
ical treatment. 


Case (I1). Mrs. H., age .., has had s 
stomach, distress amounting to real paii 
epigastrium, vomiting of sour fluid 
heartburn for about eighteen years. Ex: 
ination shows peristaltic waves in stom: 
and tenderness on pressure in region 
pylorus. Rectal feeding resorted to for al 
two weeks without alteration of the sympt: 
and then gastroenterostomy — pylorecto: 
The specimen removed shows two deep u! 
in region of pylorus the largest of whic! 
the fresh specimen was at least 1 inc! 
diameter and 2-3 inch deep with terr 
edges and firm thick walls of such thick 
that healing of the ulcer would be an 
impossibility. 

Perforation 53.5%, peritonitis 50.5%. 
scess .5% accompanied with same sympt 
as perforation of the stomach, vomiting 
ing more frequent. Generally protectiv: 
hesions and infiltrations form about the « 
denum where ulcer is inclined to perfo 
(peri-duodenitis), with formation of | 
often mistaken for cancer of pylorus or 
creas. 

Should perforation take 
these adhesions the fluid may 
toward the pelvis giving rise to diag: 
of appendicitis. 19 out of 51 cases as 
lected by Moynyhan were diagnosed. 
foration with successful protective adh 
gives rise to abscess, which may exten: 
troperitoneally toward the chest or t 
iliac fascia, best reached anterior|\ 
drained posteriorly. 

Case (III). Age twenty-six, married. 
tory good up to present illness, became 


place wit 


gra\ 





SURGERY OF THE STOMACH—BEVAN. 


. vomiting of pregnancy ensued, used 
tifacients pills and liquids, and vomit- 
persisted. Emaciation, pain in abdomen 
ed in umbilical region, smali lump palp- 
to right and above umbilicus. Curettage 
made some two weeks before lump was 
vered. Vomiting blood with absolute 
age of the bowel. All foods and water 
ted soon after taking, blood in stools, 
rapid, temperature normal inclined to 
ormal, abdomen retracted. Under two 
s rectal feeding tumor disappeared, but 
ustion and death resulted without pa- 
gaining ability to digest food taken by 


th. 


\utopsy. Uterus empty, no peritonitis, ad- 
en free from pathological findings, stom- 
deeply congested, no ulceration, wall of 
enum throughout entire length thicken- 
ind mucuous membrane inflamed and 
‘ened multiple ulcers of small size exist- 
oth on anterior and posterior wall. 


ossibilities from gastro-jejunostomy in 
case would have offered success if per- 
ed early, before extreme emaciation. 
er pylorus is diagnosis generally made 

a tumor such as occurred in Case III is 
wered and operation is generally dis- 
iged by physicians whereas incision and 
ction would render a correct diagnosis 
‘le and offer relief. What does it mat- 
= to the exact location of the ulcer, stom- 
r duodenum or part thereof? Operation 
i meets the difficulty, granting fairtrial has 
given to medical handling. Ulcer, a loss 
tissue with no tendency to heal, excision 
overing with healthy tissue would seem 
rational treatment, but we must be con- 
with giving the ulcers physiological rest 
excision of ulcer of the duodenum is 
ht with greater danger, (Mayo). Sight 
not be lost of the possibility of peptic 
resulting from the flow of gastric con- 
into the jejunum as noted by Nothnagle 
aution holds us from too hasty decision, 
nless decidedly proper medical handling 
early in the case, the comparison of 
al and surgical treatment of this affec- 
s out of the question. Difficulties seem- 
unsurmountable render diagnosis un- 


289 


certain just as in more acute troubles in this 
region, yet we remember when appendicitis 
difficult to diagnose and do not de- 
Familiarity 


Was as 
spair. 
various 


with the pathology of 
affections in this region of the ab- 
domen makes it possible to know conditions 
associated with certain symptoms and until 
further surgical treatments are reported ear] 
incision is the safest method. 


THE SURGERY OF THE STOMACH.* 


BY ARTHUR DEAN BEVAN, M. D., CHICAGO. 


In 1903, I published in the Journal of the 
American Medical Association, an article en- 
titled, “Surgery of the Stomach,” in which | 
reviewed briefly the history and status of the 
subject at that time. In the two years which 
have intervened no great advances have been 
made, but an enormous volume of work has 
been done which has enabled us to more ac- 
curately estimate the value of various pro- 
cedures, and more definitely determine the in- 
dications for surgical treatment. The value 
of the surgical treatment of various stomach 
lesions is being more and more generally 
recognized by both the surgeon and the gen- 
eral practitioner, and much is being accom- 
plished by proper surgical procedures in well 
selected cases. With the very rapid develop- 
ment of stomach surgery in the last few 
years have grown up some evils which should 
be recognized and guarded against. Of these 
I shall mention two, which have impressed 
me. First, the doing of surgical operations 
which were unnecessary and uncalled for by 
well-qualified men who were enthusiastic over 
the success of their stomach work, and who 
have extended the range of stomach surger\ 
over a much larger area than even its great 
intrinsic value warrants, some hospital sur- 
geons going so far as to claim all cases ad- 
mitted to the hospital with stomach troubles 
as their own, and denying the right of the 
medical service to any stomach cases what- 
ever. I think that time will show that these 
men have operated on many cases which 


*Read at the 55th Annual Meeting, 


Rock Island, 
May 17, 1905. 





290 SURGERY OF THE STOMACH—BEVAN. 


should have been handled by medical treat- 
ment and not by operation. I have seen cases 
operated on which I am satisfied would have 
been much more benefited by a fishing trip 
or a walking or bicycling tour, or a selected 
diet and the euthanasia of morphine, than 
they were by the surgical operation. 


I think this excess of enthusiasm for stom- 
ach surgery, however, is but a natural se- 
quence of the splendid results that have been 
obtained in cases where operative interference 
was really indicated. This fault must be cor- 
rected by discovering and applying methods 
which will enable us to make more refined 
diagnoses by curbing somewhat our enthu- 
siasm possibly. And, last, and of most value, 
by cooperating with our brother, the internist, 
so that the patient may have the benefit of 
both the medical and the surgical point of 
view. 

The second evil which has impressed me is 
that in the popularizing of stomach surgery 
men who are not in any way qualified to 
undertake this work do undertake it, and 
operate on cases without any very clear idea 
of why the operation should be done, but 
largely because they have seen some promin- 
ent surgeon do a gastroenterostomy with Mc- 
Graw’s ligature, or Murphy’s button, or with 
clamp and suture. I asked one of these men 
once why he had operated on a certain case, 
and without giving any indication, his reply 
was that Prof. Blank, of Philadelphia, had 
done the operation, and he did not see why he 
shouldn’t. There is a bit of danger that in 
the development of stomach surgery we may 
witness, on a very much smaller scale, how- 
ever, what was so common in the develop- 
ment of the surgery of the female genitals, 
and what still remains the curse of gynecol- 
ogy, i. e., unnecessary, uncalled for, and ill- 
advised operations in the hands of the com- 
petent and enthusiastic, and the entering into 
this field of men illy qualified, who are led to 
undertake the work because of the ease of its 
performance and its demonstrated safety, 
with little regard for the indications. 


In spite of the two evils mentioned, stom- 
ach surgery today stands out as the most 
gratifying surgical field in the process of 


rapid development. And this fact, too is por- 
fectly patent that the demonstrated value of 
surgical procedures in treating stomach |e- 
sions warrants a much wider application of 
such methods than are at present practiced. 
My plea is that the cases must be most c:re- 
fully selected ; that we must be sure that an 
operation is strongly indicated. We must 
not operate on cases that could be cured by 
a summer's outing or carefully selected 4 et; 
nor must we operate where operations are 
hopeless. 

I should like to discuss the surgery of the 
stomach under two heads: 

1. Surgical treatment of carcinoma of 
the stomach ; and 

2. The surgical treatment of ulcer and its 
complications and sequelae. 


CARCINOMA. 


Cases of carcinoma of the stomach, except 
those which have progressed to a_ point 
where there is no longer any hope either for 
cure of palliation, are to be regarded as sur- 
gical cases, and are to be treated by surgical 
means. Carcinoma is primarily a local (is- 
ease ; there is a period in the history of every 
carcinoma when the process is so limited that 
a wide removal would effect a permanent cure. 
The truth of this statement is becoming more 
and more apparent from the encouraging re- 
sults we are now obtaining in the early and 
wide removal of carcinoma from more eas!) 
accessible regions, such as the breast and the 
larynx. 

We have no medical means which are of 
service in a curative way in the treatment of 
carcinoma, and newly-discovered agent, ‘hic 
X-ray, which is being experimented with, }as 
proven reliable only in the most superficia!|y 
situated cancers, and of little or no value in 
the deep-seated cases. From our presnt 
knowledge, therefore, there is but one way of 
curing cancer of the stomach, and that is by 
surgical operation. This fact must be 
sisted upon because even among the int: 
gent and well qualified members of our pro- 
fession there are still to be found many w 0 
regard cancer of the stomach as a necessar’ || 
fatal disease, and one in which the duty 
the physician has been fulfilled when he !:0s 





atio: 
cent 
favo 
ance 
of 1 
ston 
pyle 
omy) 
are 
or | 
tim 
muc 
Sper 


rect 


very 
that 
ure. 
nore 
r Te- 
and 


isily 


SURGERY OF THE 


mae a diagnosis and advised the usual means 
of palliation, i. e., special diet, morphine, 


et 


hat can surgery do for cases of carcinoma 

he stomach? It can cure them if the 

; are early diagnosed and operated upon 

time when the entire focus of disease 

be removed. How many of these Cases 

surgery cure today? Probably about 

per cent permanently. This percentage 

d undoubtedly be greatly increased if 

general profession accepted the truism 

cancer of the stomach is a surgical dis- 

as far as treatment is concerned, and 

ged their patients to seek surgical relief, 

as soon as a probable diagnosis of such a con- 

dition is made. And, again, undoubtedly the 

percentage of recoveries will increase in just 

the proportion that more refined means of 

diagnosis are discovered which will enable 

us to discover the existence of cancer of the 
stomach at an earlier period. 


What are the risks of death from the oper- 


ation itself? Probably about 20 to 25 per 
cent. This, although great, compares very 
favorably with the risks due to the continu- 


ance of the disease, i. e., 100 per cent. Out 
of 100 cases operated upon for cancer of the 
stomach in which the diseases is removed by 
pyloreetomy or partial or complete gastrect- 
omy, about 25 die from the operation. Ten 
are permanently cured, and 65 are given more 
or less complete relief for various periods of 
time. Usually this relief is very complete, 
much more complete than the palliation of 
special diet and morphine, and even when 
recurrence takes place the picture is not near- 
ly as distressing as the death from the orig- 
inal condition. I think that I have fairly 
stated the facts, and although by itself the 
picture is gloomy, it is roseate with life and 
hope compared with the picture of utter hope- 
lessness and despair of the 100 cases which 
have not been given the chance of surgical 
treatment. The purely palliative operations 
for cancer of the stomach are not nearly as 
satisfactory as the operations for the radical 
removal of the disease. In fact, the most 
satic factory of these cases are those in which 
the operation cures the patient and proves 


STOMACH—BEVAN. 


that he did not have cancer at all, and these 
cases which are by no means uncommon fur- 
nish really the strongest argument for the 
performance of these palliative operations. 
There is, however, a certain limited field for 
those palliative operations, i. e., cases where 
the pylorus obstruction is marked, where the 
the invasion is so extensive as to make a 
radical operation impossible, and still where 
a considerable amount of stomach tissue is 
free from disease. Here a rapid gastroenter- 
ostomy is warranted. Gastroenterostomy for 
malignant disease carried with it from 10 to 
20 per cent of mortality, and in the cases 
which recover life is prolonged from six 
weeks to a year. Some of these cases are 
greatly benefited, gaining from 20 to 40 
pounds in weight, and obtaining marked, 
sometimes complete, relief from former 
symptoms. The relief obtained is more com- 
plete than can be obtained by any other 
means. The short respite is, however, soon 
followed by either recurrence of symptoms or 
gradual exhaustion and death from general 
carcinosis. 


Most of our operations for cancer of the 
stomach are begun as exploratory operations, 
and the exact procedure determined upon 
only after an -intimate survey of the parts 
after opening the peritoneal cavity. Then the 
operation either results in an attempt at a 
radical removal, i. e., a partial or complete 
gastrectomy, when such procedures would re- 
move all the microscopic lesion, or in a gas- 
troenterostomy, where such removal is an im- 
possibility, and, as stated above, the pyloric 
obstruction is marked, and there still remains 
most of the stomach uninvolved, or an ex- 
ploratory where radical operation is out of 
the question, and where either the pylorus is 
free or, if obstructed, is accompanied with 
such a small amount of uninvolved stomach 
tissue as to make a gastroenterostomy very 
difficult, or lead one to suppose that the pal- 
liation would be but a matter of weeks and 
not worth the while. I would make a plea 
for a more general recognition of the fact 
that surgical treatment of stomach carcinoma 
is the only treatment to be considered, except 
in the absolutely hopeless cases. Compared 





292 


with all other methods, it is of very great 
value. Our aim must be to improve our 
methods of diagnosis, and endeavor to obtain 
those cases early in the history of the process. 
Our operations should, for the most part, be 
either radical removal or purely exploratory 
in the advanced cases, and not, as now, un- 
fortunately, so largely the palliative opera- 
tion of gastroenterostomy. 

In regard to technique, the operation of 
pylorectomy or partial, even extensive, gas- 
trectomy in suitable cases presents little diffi- 
culty to the surgeon today, thanks to the 
rather simple and satisfactory methods that 
have been developed. A carcinoma involving 
the pyloric end of the stomach is removed in 
the following steps. The omentum extending 
from the duodenum and the great curvature 
of the stomach to the transverse colon is di- 
vided for the extent required, after being 
properly tied off with chain ligature. The 
omentum extending from the duodenum and 
lesser curvature of the stomach to the liver is 
tied off and divided in the same way. 


This frees the portion of the stomach and 
duodenum to be removed, so that large stom- 
ach clamps can be applied, two to the duo- 
denum, close together and well beyond the 
disease, and two also close together on the 
stomach, very widely beyond the cancer. 


A study of the extension of cancer near 
the pyloric end shows a far greater tendency 
to invasion of the stomach than of the duo- 
denum, and, as both Mayo and Moynihan 
have pointed out, this fact demands a much 
wider removal of the apparently normal tis- 
sue on the stomach than on the duodenal 


side. The duodenum is divided between the 
clamps and then the stomach in the same 
way, thus removing widely the disease. The 
duodenum is closed by invaginating its end 
with a purse-string suture of silk, and a sec- 
ond purse-string or catgut. The stomach 
is closed with first a continuous suture of 
silk through all coats, and then a Lembert 
of either silk or catgut. The operation is 
now completed by making an anterior gas- 
troenterostomy between the stomach and a 
loop of jejunum about fifteen inches from 
its beginning. This is essentially the second 


SURGERY OF THE STOMACH—BEVAN. 


Billroth method, and’ is one which is best 
almost all cases. Occasionally a carcin: 

is so limited to the body that a resection of 
but part of the stomach wall is indica‘ 
a strictly partial gastrectomy; and a 
eases will be found where the lesion is so 
tensive that a complete gastrectomy must |y 
madg. In technique there is little differeic 
between an extensive operation by the sec ni 
Billroth method, and a complete gastrecto ,y. 
In doing a gastroenterostomy for carcin: 

an anterior gastroenterostomy with McG 
ligature or an anastomosis either posterior or 
anterior, either with Murphy button-or <ut- 
ure, can be made. Personally, I think t 

is not much choice between these methods. 
I use the suture and prefer it to the meclhian- 
ical appliances. There can be no doubt but 
that splendid results have been obtained by 
the use of -Murphy’s button, and the McGraw 
ligature ; the advocates of these methods must 
remember however, that equally good re- 
sults have been obtained with the suture. 


STOMACH ULCER. 


The well-known statistics of Welch show 
that ulcer of the stomach is an exceedingly 
common disease, occurring in about 5 per 
cent of the population, almost as frequentl) 
as hernia. Post-mortem findings show man) 
more healed than open ulcers. These two 
facts—the great frequency of stomach u!cer 
and the usual spontaneous recovery—demon- 
strate to my mind conclusively the fact that 
ulcer of the stomach is primarily a medical 
disease (if we can employ such a term), i. e., 
a disease which is to be treated by medical 
and not by surgical methods. The clinical 
study of cases also demonstrates this fact. It 
is fair to say that from 75 to 80 per ceni of 
cases are cured by medical treatment. 
treatment is essentially one of rest, 
general and local; rest in bed, and res 
the stomach by limited bland diet or ev-nt- 
ually absolute rest by means of rectal feed ng. 
We can obtain a healing of a stomach » 
by absolute rest just as we obtain a hea 
of a varicose ulcer by absolute rest. Man 
these patients are very anemic, and | 
building up, which is best done by chang: ‘ 
air, scene and occupation—outdoor exer = 





SURGERY OF THE STOMACH—BEVAN. 


as golf, ete. Sonie of the milder cases 
recover under these measures alone, and 

«-e means of improving the general condi- 
of the patient should always, if possible, 
lement and follow the rest cure employed 
1e severer cases. 

\\ hen intelligent medical treatment fails, 
the symptoms return, and persist, and 
patient is invalided, then and not until 
: does the uncomplicated stomach ulcer 
me a surgical problem. The complica- 

1s and sequelae of stomach ulcer which 
and surgical treatment without question 
perforation, obstruction of the pylorus, 

ir-glass contraction of the stomach, and 
sucli secondary conditions as perigastric ad- 
hesions and abscesses, subphrenic abscess, etc. 
One of the sequelae which must be considered 
is that of a carcinoma developing in the ulcer. 
There can be but little doubt that this does 
occur very frequently. Fiitterer has especial- 
ly called attention to this fact, and this pos- 
sible danger is a strong argument in favor of 
surgical treatment to cure the persistent ul- 
cers. It would seem at first glance that the 
rational surgical treatment of uncomplicated 
persistent ulcer would be excision. It has 
been found, however, that excision is not the 
best treatment for several reasons. First, 
stomach ulcer is often multiple, and to excise 
one might not cure the patient, as others 
might be overlooked ; and, again, not infre- 
quently a doudenal ulcer exists in the same 
patient. Clinically, it has been found that a 
gastroenterostomy cures the patient with 
greater certainty than does excision, and it 
is apparently not attended by as great risks. 

Perforation of a stomach ulcer occurs most 

frequently in those situated on the anterior 
wall. The ulcers on the posterior wall and 
greater and lesser curvatures are more apt 
to form adhesions with the contiguous organs, 
as the liver, pancreas, omentum, protecting 
against perforation, even when the ulcer has 
involved the entire thickness of the stomach 
wa!!. The symptoms of perforation are those 
of sudden great pain, shock, collapse, etc., 
whch demand immediate surgical interfer- 
enc». A definite diagnosis is not possible in 
the absence of clear history of the existence 
of on ulcer, but the symptoms demand an 


293 


immediate laparotomy without any hesita- 
tion, because although a definite and absolute 
diagnosis cannot be made between perfora- 
tion of a stomach ulcer and rupture of the 
gall-bladder, of the appendix, of an ulcer of 
the duodenum, or a case of acute pancreati- 
tis, the surgeon is safe in urging an explora- 
tion inasmuch as all of the lesions which are 
capable of producing symptoms such as are 
produced by perforation of a gastric ulcer de- 
mand equally prompt interference. 


The great majority of cases of perforation 
can be saved by early surgical interference. 
Almost all of the cases not operated upon die. 
The whole question is one of immediate ac- 
tion. If a perforation is operated on within 
two hours, the prognosis is excellent. If 
twenty-four hours go by without surgical re- 
lief, but few cases are saved. The technique 
is exceeding simple: A mid-line laparotomy, 
the exposure of the stomach, the finding of 
the perforation, usually on the anterior wall, 
the closure with purse-string suture of silk 
and over this a second purse-string of silk or 
catgut. No attempt should be made to ex- 
cise the ulcer. As a rule, the peritoneal cav- 
ity is found full of stomach contents. This 
is washed out with hot saline solution, and 
the abdomen is closed, if the operation has 
been done early, without drainage, or a small 
cigarette drain. If some hours have inter- 
vened between perforation and operation, 
drainage is indicated. If the perforation is 
in the posterior wall, this is exposed by tear- 
ing the omentum between the stomach and 
colon in an avascular area, turning the pos- 
terior wall into view through this opening, 
finding the perforation, and closing in the 
same way, flushing, and if drainage is indi- 
cated, draining the lesser peritoneal cavity by 
a stab wound in the left lumbar region. Moy- 
nihan, in a recent lecture, published in the 
British Medical, states that of his last 12 . 
cases operated for perforation he has lost 
but two. 


Hemorrhage from stomach ulcer is, as a 
rule, to be treated by rest and expectant 


treatment. There are a few cases, a small 
minority, where it would seem that the pa- 





294 SURGERY OF THE STOMACH—BEVAN. 


tient’s chances of recovery were better than 
without operation. 

Moynihan, who has, operated on 22 cases 
for hemorrhages, divides the cases he has 
seen with bleeding into four groups: 

1. Where the hemorrhage is latent or con- 
cealed, is always trivial and often incon- 
spicuous. 

2. Where the hemorrhage is intermittent, 
but in moderate quantity, occurring spon- 
taneously, and with apparent caprice at in- 
frequent intervals. The life of the patient 
is never in jeopardy from loss of blood though 
anemia is a persisting symptom. 

3. The hemorrhage occurs generally, but 
not always, after a warning exacerbation of 
chronic symptoms. It is rapidly repeated, is 
always abundant, its persistence and excess 
cause grave peril, and will, if unchecked, be 
the determining cause of the patient’s death. 

4. When the hemorrhage is instant, over- 
whelming and lethal. 

Moynihan believes that the conditions 
found in group three require surgical inter- 
ference. If possible, a period in which the 


patient is comparatively free from hemor- 
rhage and symptoms of shock is to be chosen 
for the operation. 

A number of operations have been sug- 
gested—ligation of the bleeding point or 
points, cautery, ligation of the ulcer in mass, 
excision of the ulcer, and, lastly, gastroenter- 


ostomy. The latter has proven to be the 
safest and most successful procedure. 

Of Moynihan’s 22 cases, he excised the 
ulcer alone in one case, this was fatal on the 
eighth day. He excised the ulcer in three 
cases, and did a gastroenterostomy at the 
same time, with one death. 

In 18 cases he simply did a gastroenteros- 
tomy, which checked the hemorrhage, and 
cured the patients in all but a single fatal 
case. It is reasonable to suppose that a 
gastroenterostomy checks the hemorrhage by 
stimulating and permitting a contraction of 
the stomach which checks the hemorrhage 
in much the same way, that contracting of 
the uterus checks hemorrhage from that or- 
gan. 

Pyloric obstruction and dilatation of the 
stomach furnish by all odds the most satis- 


factory groups, as far as the results fr) 
surgical treatment are concerned ; these ca-es 
should practically all be submitted to sur. 
gical operation. I know of no more grati ’y- 
ing surgical experience than that furnis: ed 
by the history of these cases. Taking tl 
poor starved victims of pyloric obstructi 
many of whom have lost a third of tl 
weight, and by a comparatively safe and 
simple operation restore them to health « 
vigor; I have seen a number of these cases 
who have gained from 30 to 75 pounds wit 
six months after operation. The operat 
for benign pyloric obstruction is a properly 
planned gastroenterostomy. Pyloroplasty, th: 
Heineke-Mikulicz operation, and the exag 
gerated pyloroplasty of Finney, and the gas- 
troduodenostomy of Kocher may have a | 
ited field, but are not to be regarded as s 
ous competitors of gastroenterostomy as : 
cure of pyloric obstruction with dilated stom- 
ach. 


As to the technique of gastroenterostoiny, 
much has been written and much careful 
study is being given at present to the sub- 
ject. In my limited time I cannot review 
this entire subject. I desire to say that I : 
impressed with this general proposition the 
the stomach pouch should be drained at its 
lowest point, and that the opening should be 
of good size. . Whether this is done by suture, 
by McGraw ligature, or by Murphy’s bution, 
I think makes little difference, and whet! 
it is anterior or posterior is also not of muc 
moment. 


The ideal operation is the Y-shaped gas 
tro-enterostomy of Roux. The objection 
the Roux and similar operations done } 
Mayo, Crile, and others, is that they take ‘ 
long a time for their performance, and 1! 
carry with them more danger. Taking 
facts into consideration, I think that for ) 


nign obstruction either a posterior gastro: n- 


terostomy with short loop, done as recor 
mended by Moynihan, with clamp and sutvr 
or a very low anterior, anastomosis with a 


to 20 inch loop, done with clamps and =it- 


ure, or with McGraw ligature, offer the 0} 


ation of choice. These simple operations ¢ ve 
extremely satisfactory results, both immed: te 


tion 
gas! 
diag 
ato! 
onl 
cay 
obst 


rh 





SURGERY OF THE STOMACH—BEVAN. 


ani permanent. I think fully as good as the 
more complicated methods. 

\ few cases of vicious circle, and more or 
less persistent vomiting and distress will oc- 
cur, no matter what method is employed. In 
this connection, I want to call attention to 
the value of the castor oil treatment in cases 
of vomiting after gastroenterostomy. I have 
employed it in half ounce to ounce doses, two 
or three times a day, for several weeks, in a 
number of these cases, with marked benefit 
and permanent relief from the symptoms, and 
| would recommend its employment. 

Gastroenterostomy for benign obstruction 
of the pylorus should not carry, with it a 
greater mortality than 5%. A mortality 
which is very smal] when compared with the 
dangers of the continuance of the condition 
itself. 

The safety of the operation in benign dis- 
ease is shown by Moynihan’s remarkable 
serics of 153 gastroenterostomies, done mostly 
with clamp and suture, with but two deaths. 


Hour-glass stomach due to cicatricial con- 
traction, due to ulcer, is a condition not in- 
frequently met with. Where the pylorus is 
free, a plastic agastroplasty uniting the two 
pouches in one, will suffice, if pyloric obstruc- 
tion exists, or in cases of great dilatation a 
gastroenterostomy may also be required. A 
diagnosis can sometimes be made before oper- 
ation, but the cases are usually discovered 
only at the time of opening the abdominal 
cavity in an operation for supposed pylrric 
obstruction. Such complications as perigas- 
tric abscess, subphrenic abscess, and adhesions 
are to be treated along the well-known sur- 
gical lines of well-planned and efficient drain- 
age and separation of adhesions and restora- 
tion of the structures to as near as possible 
the normal conditions. 

The surgery of the stomach has advanced 
toa point where it can claim recognition 
alongside of the surgery of the bile tracts, the 
survery of the kidneys, the surgery of the 
appendix, and the surgery of the female geni- 
tals, for it has been shown that much can be 
done by surgical procedures for lesions of the 
stomach which could not be done by any 
other means. 


295 


In cancer it is our one present hope. In 
ulcer and its complications it can save lives 
and restore health and accomplish an enor- 
mous amount of good. The surgery of the 
stomach is advancing. We must keep pace 
with it, and give to our patients the benefits 
of its demonstrated possibilities. 


Discussion of the Symposium on Surgery of the 
Stomach. 

Dr. Edward H. Ochsner, Chicago: Mr. Chair- 
man—I am sure, we were all impressed with 
the eminent fairness with which the present 
status of the surgery of the stomach was dis- 
cussed this morning. We can all agree with 
what the essayists said about how things stand 
in surgery of the stomach today. There is one 
thing I would call attention to, and that is the 
fact we are still rather behind in stomach sur- 
gery, in spite of the fact that there have been 
tremendous advances made in the last ten years, 
and I have the feeling that we are today in 
stomach surgery where we were ten years ago 
in appendiceal work. Statistics prove that the 
results are not as good as we have a right to 
expect. When we still have a mortality of about 
five per cent from gastroenterostomies;and when 
the best surgeons in the country and in Europe 
still have from ten to twenty per cent of cases 
which must be reoperated; when we still have a 
great number of patients who suffer unpleasant 
symptoms after operation, there is something 
wrong about all of our methods. It is most in- 
teresting, in studying stomach surgery of the 
last two or three years, to note that all of the 
great surgeons had a very good operation two or 
three years ago, an operation attended with lit- 
tle mortality, and with only a few untoward 
symptoms. It is remarkable, however, that hav- 
ing such good operations they have all changed 
their methods of operating within the last year 
or two—every one of them. It means that there 
is something wrong, and personally I feel that 
there is something wrong with all of the opera- 
tions that are employed for gastroenterostomy. 


Some two or three years ago we employed an 
operation that is used by others which we 
thought was excellent. We had some ten or 
fifteen cases that did beautifully, without sec- 
ondary untoward symptoms, without any deaths 
and consequently without the necessity of re- 
operation. The first thing we had two or three 
cases that did badly, that had a vicious circle. 
One of them had a sudden dilatation of the 
stomach due to obstruction, and we found there 
was something wrong with the operation. Other 
surgeons have had the same experience. All 
of those cases go to prove that until we have 
the same results as we have today in appendi- 
citis, there must be some radical change made 
in our gastroenterostomies. The ordinary pa- 
tient is entitled to a cure in at least ninety per 
cent of the cases. He is entitled to the as- 
surance, when he goes on to the operating 
table, that he has not more than three per cent 
risk of dying. He is entitled to know that he 





296 


will not be subject to too great distress after the 
operation; that he does not feel miserable for 
two or three months or possibly until he is re- 
operated, as is the condition under our present 
operations, no matter whether it is an anterior 
or posterior gastroenterostomy, and no matter 
whether we adopt the long or short route, the 
Murphy button, the McGraw ligature, or suture. 


About two years ago Czerny and Peterson re- 
ported very satisfactory results from an opera- 
tion they performed; but in reading over their 
list of operations and in studying the records 
of their cases, it seems to me that the results 
were hot at all satisfactory. They had six or 
seven per cent mortality; they had twenty per 
cent of reoperated cases, which is altogether 
too large. I had a conversation with a promi- 
nent surgeon in Berlin a few months ago which 
illustrates the condition of affairs. I visited his 
clinic; we discussed the matter of stomach sur- 
gery, and I expressed the opinion to him that 
I have just expressed here. He said to me, “I 
have good results; I do not have a high mor- 
tality.” I said to him, “How about the vicious 
circle and other untoward symptoms that other 
surgeons get?” He informed me that he did 
not have them. Within two days I attended his 
clinic again, when the medical chief of the hos- 
pital came in and asked for the chief surgeon. 
He was very much excited. The first assistant 
to this surgeon said that the surgeon was not 
present, and asked what was the matter. “Well,” 
said the medical chief, “Mrs. So-and-So, upon 
whom you did a gastroenterostomy seven days 
ago, has been vomiting constantly; I promised 
her a good result.” I think myself that is just 
about the condition of affairs that most surgeons 
have to confront once in a while, and until we 
get an operation that avoids these untoward 
symptoms and complications, we cannot feel 
that we are exactly on the right road in doing 
gastroenterostomy. 

Dr. James M. Neef, Chicago: Dr. Murphy’s 
experience has corresponded very closely with 
that of Dr. Bevan in regard to performing gas- 
troenterostomy in cases of ulceration and of be- 
nign stricture of the pylorus. His results have 
been exceedingly gratifying and almost ideal 
since he has adopted the short loop Dr. Bevan 
spoke of, doing posterior gastroenterostomy, 
with a loop three or four inches in length. All 
of the cases have gone on to recovery, with the 
exception of two of ulcer of the stomach in 
which a posterior gastroenterostomy was per- 
formed. In these two healing of the ulcer was 
not as rapid as we had hoped, for it was neces- 
sary to keep the patient in bed on a milk and 
Carlsbad diet, with regular medicinal treatment 
two or three weeks after the regular time at 
which they are allowed to be up. Since Dr. 
Murphy has been using the short loop, with 
posterior communication, he has not had trou- 
ble with the vicious circle which he had be- 
fore. He has not had any vicious circle since 
using the short loop. In place of using a round 
button or the Kummel modification, he uses an 
oblong button, which is passed considerably 
earlier, and up to date there has been no case 
of retention of the button either in the stomach 


SURGERY OF THE STOMACH—BEVAN. 


or intestinal tract. The button passes usu: |y 
in from seventeen to twenty-five days after 
operation. The reason for this probably is t) at 
the transverse diameter is so much less th. in 
the diameter of the ordinary round button t at 
it is passed through the opening and into the 
testinal tract and out through the bowel a 
much earlier period. 

Dr. George N. Kreider, Springfield: I « 
gratulate Dr. Bevan on the eminent fairness 
his paper. I think it is valuable to the ordin: ry 
practitioner, as well as to the general surge» 
to have a man of the experience of Dr. Be 
to make such an honest statement of the d 
culties attending the diagnosis, and finally 
operating. Dr. Ochsner’s statement is als: 
valuable one, and it seems to me, in order to 
make progress, it is necessary for us to find »ut 
where we stand, then we will have a foundation 
to work on, as these gentlemen have sugges'«d 
Dr. Harris’ paper was likewise valuable. 

I wish to say a word or two in regard to dis- 
eases of the gall-bladder, as it is in this field in 
which I have had more experience than in the 
others mentioned, and I wish to mention par- 
ticularly cases of bile tract disease in which 
there is or has been tachycardia as a symptom 
I have seen several such cases, one of which 
went on for a long period unrecognized, and 
apparently only by accident was the cause 
found in the bile passages. I wish to refer also 
to a symptom which is not mentioned very often, 
nor not known by the majority of the profes- 
sion, namely, itching and burning of the feet 
of which these patients complain. Dr. Black 
spoke of pain in the toes, but a large number of 
these patients suffering from bile tract disease 
will have itching and burning of the feet. The 
failures which I have had in operating on these 
cases have been in those where the disease has 
existed so long that it is absolutely impossible 
to get coagulation of the blood. Of course, that 
is a well-recognized cause, and I mention it in 
the discussion, so that early diagnosis and early 
operation may be urged in these cases. And, 
finally, I will mention those cases in which there 
appears to be absence of the gallbladder at the 
time of the operation. i 

I saw a case a number of years ago, oper- 
ated by another surgeon, who had failed to find 
the gall-bladder which existed in that case. | 
did not suppose it was possible that the ¢:!!I- 
bladder could not be found; but either the pa- 
tient I operated on last Friday had no ¢:!!- 
bladder, or I was unable to find it, althoug 
searched for over an hour in the region wher 
ought to be. I found a tablespoonful of 
which was confined, with adhesions of 
omentum, in this region, and when I left h: 
the patient was doing very well. 


This case in which the gali-bladder actu 
existed and was not found was interesting, 
cause a year or so after failure to find the g 
bladder the woman was taken with vomiting 
blood, and she vomited fifteen gall-stones by 
mouth. This is one of the cases which I 
because of absolute failure of the blood to 
agulate. We got the woman into the hos] 
two days after vomiting, kept the foot of the 





_ a 


=~ 2 a he 


ften, 
fes- 
feet 
lack 
or of 
ease 
The 
hese 
has 
sible 
that 
it in 
arly 
And, 
here 


SURGERY OF THE STOMACH—BEVAN. 


levated, and waited two days longer before 
peration was performed, at which 150 other 
all-stones were removed from the remains of 
he gall-bladder, which was not difficult to find, 
ut owing to the failure of the blood to coagu- 
ite, the patient died two or three days later. 

I think this is one of the most important 
ubjects that can be considered by the surgical 
-ction of the Illinois State Medical Society, and 
side from the technic of the operation, the 
ictum should go out that all cases having the 
assical symptoms, and even those which are 
ot so certain, should be examined and searched 
wr gall-bladder disease. It is much more fre- 
1ent than we have been led heretofore to be- 
eve. 

Dr. Robert J. Christie, Quincy: I had not 
thought of taking part in this discussion, but 
since Dr. Kreider mentioned failure in finding 
gall-stones and the gall-bladder in one case, I 
will relate briefly my own experience. Being 
only an occasional operator, I have had two 
cases in which the gall-bladder was not found. 
One patient was a young woman in the early 
months of pregnancy supposedly, _ suffering 
severely from gall-stone symptoms, and she was 
recommended or advised to undergo an opera- 
tion. The usual operative procedures were gone 
through, and a careful search made for the gall- 
bladder, but it could not be found. The place 
where it should have been was easily located, 
palpated and inspected. It was found that a 
movable kidney was responsible for her condi- 
tion, the anchorage of which gave entire relief. 


A more perplexing case was one in which I 
was called to do an operation in a country home, 
with two assistants, neighboring physicians. 
The patient was an elderly woman, and the 
difficulties attending the finding of the gall- 
bladder were very great. In fact, no gall-bladder 
could be found. It was entirely absorbed. The 
perplexities in such cases are great, and it is 
very annoying to the surgeon to have a circum- 
stance of that kind. 


Dr. S. C. Plummer, Chicago: I would like to 
comment on one remark made by Dr. Black, 
and that is, the stone may lie latent, not caus- 
ing any symptoms until it tries to escape, and 
then jaundice comes on, with other symptom: 
There is one location to which an exception 
should be made, and that is, the stone may, 
under the neck of the gall-bladder or cystic 
duct, try to escape, and still not cause any 
jaundice, but may produce other symptoms. 


Dr. J. H. Stealy, Freeport: In regard to 
jaundice, I will say that a few years ago I 

‘ked up the statistics of the number of cases 

had operated on, and my recollection is that 

only about thirty-three per cent of the cases 
of gall-stones was jaundice present. I think 
many times we have cases of gall-stones, with 
the gall-stones in the gall-bladder, and we do 
hot properly interpret the symptoms. I under- 
stood the reader of the paper to say that there 
Wes quite a percentage of cases of gall-stones 
that gave no symptoms. I can hardly agree 
wih that statement; but I believe many times 
w do not properly interpret these symptoms, 


The symptoms are not always as classical as 
we may think. Many times we may have pain 
in the region of the kidney which simulates 
very much a nephritic colic, or we may have 
pain at the umbilicus, to the left of it, or even 
in the left epigastrium, all due to gall-stones 
Another thing I have found a few times, and 
that is, I have made an exploration with the 
view of finding gall-stones, and I found them, 
but I believe frequently we may have ulceration 
of the duodenum and we diagnosis the case or 
cases as gall-stones. Of course, in the diagnosis 
of duodenal ulcer one of the prominent symp- 
toms is melena; but in some cases I have not 
always found this symptom. Of course, the 
stools are tarry. 


In regard to malignant growths of the stom- 
ach, which were dealt with by Dr. Bevan in his 
paper, it would seem that his results of recover- 
ies are very flattering. From what little experi- 
ence I have had in this line, if we have a malig- 
nant growth of the stomach, unless it is discov- 
ered in the incipient stage, it is a question in 
my mind whether gastroenterostomy or pylor- 
ectomy is really justifiable. I question very 
much whether a patient would not live just as 
long if he were let alone. 

Dr. M. L. Harris, Chicago: In every paper. 
such as that presented by the first essayist, the 
lamentable statement must inevitably be made 
that the majority of patients affected with car- 
cinoma of the stomach are received into the 
hands of the surgeon too late to be subject 
to a radical operation. This is a very lament- 
able fact. Every surgeon connected with a 
large hospital is frequently receiving into his 
service patients whom he knows, the very min- 
ute he places his hand on the abdomen and feels 
a hard nodular mass in the epigastric region. 
are beyond his help. It emphasizes the state- 
ment made by Dr. Bevan that we must have an 
early diagnosis made. When these cases come 
to us with a palpable tumor in the abdomen, 
they are almost invariably beyond radical help 
The conclusion to be drawn from this is that 
these patients should be brought to the sur- 
geon before a mass can be felt; that means 
that they must be brought to him when the 
diagnosis is still only probable or presumptive, 
If we expect to cure carcinoma of the stomach 
it must be in the very early stages. It is much 
better that we should perform a dozen or twenty 
exploratory laparotomies, in order to perfect 
diagnosis without finding carcinoma, than ta 
allow one case of early carcinoma to go beyond 
the period when radical operation or cure is 
possible. 

The stomach is perhaps the most tolerant or- 
gan in the body. It has always been subject to 
rough treatment, to the introduction of foreign 
bodies, and it never rebels unless there is some- 
thing radically wrong. In every patient, who 
has reached or passed the middle period of life, 
who presents symptoms of gastric disturbance, 
that are not relieved by a reasonable course of 
medical treatment, he or she should be presumed 
to have malignant trouble, and should be turned 
over to the surgeon to perfect that diagnosis by 
exploratory laparotomy, if necessary, and until 





ULCER OF STOMACH—BECK. 


that time is reached our record of operations for 
carcinoma of the stomach will be a sad history 
in the annals of surgery. 

Dr. P. L. Markley, Rockford: I would like to 
ask Dr. Bevan to say a few words regarding the 
diagnosis of carcinoma of the stomach, and tell 
us when he thinks operation is indicated in those 
cases in which he is able to effect 10 per cent 
of cures. I would like to ask him also how long 
he would wait in cases of gastric ulcer before 
he would perform gastroenterostomy? It seems 
to me, it is hard to tell where to draw the line. 
If we wait a little too long, the patient may not 
be able to stand the operation, and at the same 
time we want to give medical treatment a fair 
trial. I would like to have him say something 
in that regard. 

Dr. Bevan (closing the discussion on his 
part): In regard to the diagnosis in conection 
with lesions of the liver and bile tract, there is 
one point which has impressed me greatly re- 
cently, and that is the difficulty in making a 
differential diagnosis between gall-stones and 
syphilis of the liver and bile tracts, and car- 
cinoma of the liver and bile tracts, and cholecy- 
stitis and cholangitis independently of gall- 
stones: While I have not become exactly timic 
about making a definite diagnosis, I must say 
that I am very much more anxious about mak- 
ing a definite diagnosis of gall-stones now than 
I used to be, because I have so frequently, upon 
the basis of the classical picture of gall-stones, 
made a definite diagnosis, then operated, and 
found no gall-stones, but carcinoma, or I have 
found gall-stones and carcinoma, or carcinoma 
without gall-stones, syphilis of the liver and of 
the bile tract, or without gall-stones, the gall- 
bladder a little bit thickened, filled with tarry, 
thick, viscid bile, without any gall-stones, and 
without any very gross microscopic evidence of 
disease, but a cholecystitis which was cured by 
drainage. 

Syphilis of the liver and of the bile tract is 
one of the most interesting studies in differential 
diagnosis. I haye seen several cases recently. 
where the picture presented was diagnosed by 
competent men as one of gall-stone disease, yet 
where an exploratory operation showed gumma 
of the liver, where the classical symptoms have 
been similar in some cases to chills and fever, 
with .a picture of stone in the common duct 
and in other cases independently of chills and 
fever, but almost typical of stones in the gall- 
bladder, yet syphilis found at the time of the 
operation. 

I want to say a word or two in reference to 
Dr. Harris’ paper, particularly with regard to 
the operation of splenectomy in cases of rup- 
tured spleen and for other conditions. I have 
employed the S-shaped incision, which I in- 
troduced for common duct lesions and in ex 
tensive surgery on tke gall-bladder for splen- 
ectomy in a few cases, and I have found that 
it worked admirably. (Demonstration of S 
shaped incision on the blackboard.) One of the 
difficulties attending splenectomy is that of 
separating the spleen from the diaphragm, and 
this incision gives admirable access to the up 
per portion of the spleen, so that this separation 


298 


can be made and give very ample room when 
the spleen is of large size. In one case of larg: 
spleen I extended the incision below the um 
bilicus, making a rather sweeping muscle-split 
ting incision in the flank, because the spleen ex- 
tended down to ‘the anterior superior spine. 

One word in regard to operations for spleni 
anemia. I desire to call attention to the fac: 
that there is great difficulty before an explora- 
tory operation in determining whether the hem 
orrhage is going to be excessive or not. I op- 
erated recently on a case of splenic anemia ir 
which the spleen was very greatly enlarged, an: 
lost the patient from hemorrhage on the tabl 
It was a case in which there were enormous ad 
hesions, it was difficult to separate the spleen 
and I thought I should have desisted from th 
operation, and yet it was one of those éase 
where we get so far into the opération that i: 
is necessary to complete it in order to save th: 
patient’s life. 

Dr. Black (closing the discussion): There i 
only one point I wish to refer to in conclusio: 
and it is this, that the term gall-stone disease i 
misleading; that gall-stones are very largely a: 
incident of disease of these tracts, and not th: 
particular feature; that in the majority of cases 
gall-stones are latent, give rise to no symptoms 
but when they do give rise to symptoms it is o: 
account of the introduction of the element of in 
fection, and we should keep that plainly i: 
mind, that the element of infection has com 
into the case usually when gall-stones give ris: 
to symptoms. 





THE SURGICAL TREATMENT OF THE 
BLEEDING ULCER OF THE 
STOMACH.* 


BY CARL BECK, M. D., CHICAGO. 


Among the pathological conditions, which 
have been drawn into the domain of surge 
within the last few years, is the ulcer of tli 
stomach. The term ulcer is by no means 
a pathologic entity, just as little as the 


term goitre or fungus. It means general|) 
a loss of substance of a surface, either of the 
epidermis or mucous membrane in an at- 
tempt of repair by granulation. But t! 
causes, the extent, and the pathologic siz 
nificance of an ulceration may be mat 
fold. This also applies to the stomach. 
defect of the mucous membrane by any caus. 
traumatism, chemical destruction of ce! 
so-called peptic ulcer, tubercular, syphilit 
or cancerous ulcer are all included in t! 
term. But for the practical therapeut 


*Read before the Chicago Medical Society June 14, 190° 





ULCER OF STO MACH—BECK. 


purposes, a clear differential diagnosis must 
made. Clinically the symptoms of many 
uleers may be the same, in fact there is a 
ypical picture of the case of the ulcer of 
he stomach, which is so classical that if 
the complex of the symptoms be present, 
the diagnosis of the ulcer is looked upon as 
established. Pain and hemorrhage are the 
wo cardinal signs of the ulcer, which if 
resent, simultaneously, almost conclusively 
establish the diagnosis. For the purpose of 
treatment, however, differentiation by addi- 
tional symptoms, which are furnished by the 
exact chemical test and microscopical ex- 
amination of the stomach contents, palpation 
and percussion, to find out the true nature of 
the uleer is absolutely necessary. 


The object of this paper is not to enter 
into the discussion of the treatment of the 
uleer of the stomach, because such a treat- 
ment needs more individualization than 
most kindred pathologic conditions, but 


simply to enter into the discussion of the 
treatment of one symptom, which may re- 


quire an emergency action, namely, the 
hemorrhage. In general I would put the 
question: What shall we do in case of 
hemorrhage from the stomach, arising from 
an ulcer, and in particular, what can we 
do surgically? TI shall discuss only the lat- 
ter exigency. 


Hemorrhage is one of the pathologic con- 
ditions which may cause death, by the 
amount of blood lost at one time or by suc- 
cessive losses and their effects upon the 
organism. Statistics of different authors 
show clearly that a good percentage of the 
cases succumb to hemorrhage, though a still 
larger percentage die from complications 
or sequelae of the ulcer, like perforation and 
carcinoma. These latter conditions form a 
number of indications for surgical interfer- 
ence, and the necessity for operating for 
chronic, gastric ulcer, is a recognized fact. 
Mayo has in a classical paper in the Medi- 
cal News, April 1904, designated clearly the 
indications for operations and methods of 
operation in chronic gastric ulcer, much in 
the same manner as Prof. Leube of Wurz- 
burg, and Mikulicz of Breslau did in the 


299 


Society of German Surgeons in 1897 and 
Tuffier in 1902. 

Mayo calls the indication gastric drainage 
and recognizes four main methods of pro- 
cedure, which have in a large number of 
cases, given to him excellent results, namely, 

(1.) Heineke-Mickulicz operation. 

(2.) Finneys Gastro-duodenostomy. 

(3.) Rodmans excision with Gastro je- 
junostomy. 

(4.) Gastrojejunostomy alone. 

But most of his cases and most of the 
cases of the surgeons in general are operated 


- upon, principally, for the pain and the com- 


plications of ulcer, perforations and gastric 
insufficiency. 

For active hemorrhage of the stomach, 
either abundant or foudroyant as the French- 
men call it, or slow, but continuous, not 
many operations are done as yet. It seems 
that the old fear, or rather the feelings of 
helplessness of the doctor in cases of internal 
hemorrhages still prevails among many and 
that some lives are lost, which could other- 
wise be saved. Some experiences in this 
regard, prompt me to report a few cases 
observed within a short period which illus- 
trate this fact clearly. An internal hemor- 
rhage is dreadful only when the source of 
the bleeding vessel is unknown, especially 
within the large intestinal tract and when 
the vessel is of so large a caliber that the 
hemorrhage exsanguinates the individual 
before the surgeon can stop it. But for- 
tunately, in the stomach, neither of these 
circumstances is the rule, inasmuch as the 
hemorrhage of this part of the digestive 
tract usually gives clear local symptoms 
and the vessels which are bleeding are of 
such a size that it takes at least, some hours 
to exsanguinate the individual. The symp- 
toms are clear, the pallor, the rapid pulse, 
the expression of shock, the stomachal dis- 
tress, vomiting of pure or dark blood, etc., 
are well known, so that the diagnosis is 
made even by the tyro in medicine as a rule 
of the acute foudroyant bleeding. 

Something else, of course, is the slow con- 
stant flow of blood, the severe anemia, with 
the intermittent recovery from smaller losses 





300 


of blood. Here it requires good clinical ex- 
perience and some knowledge to make a diag- 
nosis. But if the diagnosis is made, then the 
main question arises: What shall be done? 
Heretofore most of the cases are treated 
medically. It is true, a large number of 
patients recovers from a single hemorrhage 
and often from a foudroyant hemorrhage. 
Every practitioner of some experience has 
seen a number of instances of recovery from 
hemorrhage and perhaps all cases in his ex- 
perience recovered, but there still remains 
quite a number of cases in which there is no 
recovery but death. Personally I have seen 
a number of instances of absolute recovery 
and no recurrence after one single profuse 
hemorrhage of the stomach, also a great 
number of recoveries of slow bleeding, but 
I have seen some deaths following ulcer from 
bleeding and one within the last three 
months. In a short time I have seen three 
cases of this class, two of which have been 
operated upon with success, and in the third 
one operation was refused and exitus fol- 
lowed, within a few hours, but we were per- 
mitted to make a post mortem, and I am 
going to demonstrate the specimen as an 
illustration of the facts I state in my paper. 

Case 1. Mr. T., a tailor came to see 
me first about 144 years ago with symptoms 
of an ulcer of the stomach, pain being the 
only indicative one without hemorrhage. 
Leube’s treatment of dietetic nature was 
instituted at the hospital with prompt re- 
covery and after about four weeks hospital 
care the patient had gained in weight, was 
absolutely free from symptoms. He kept 
on improving and feeling well for about six 
months, then a relapse of the same complex 
of symptoms brought him back. Again he 
was placed into the hospital and Leube’s 
treatment instituted, this time he promptly 
improved again and left the hospital in good 
condition, free from pain again, normal 
weight. Just about three months ago sud- 
denly the symptoms appeared again, this 
time, however, hemorrhage in the form of 
vomiting of a chocolate colored fluid com- 
plicating the case. 

The hemorrhage kept up as was clearly 
seen by the increasing pallor, the dark stools, 


ULCER OF STOMACH—BECK. 


the steadily weakening pulse for two days. 
The patient was at this time at the hospital, 
watched and prepared for the emergency 
operation of ulcer of the stomach. On the 
first day of the hemorrhage toward evening 
he was seen by Dr. Dodson, who concurred 
in the diagnosis of bleeding ulcer of th« 
stomach, and advised also operation in cas 
of continued bleeding. The pulse of th: 
patient at this time was rapid and weak 
easily compressible. In the morning of th: 
third day it was evident that the bleeding 
was continuous and from the condition 0! 
the pulse it was manifest that the patient 
could not survive much longer if the hemor- 
rhage was not stopped. We decided, there- 
fore, to do the operation. The stomach wa: 
exposed and brought fully forward and out- 
ward, and an external examination of th 
wall by inspection and palpation was made. 
It revealed at once that the region under- 
neath the smaller curvature in the front 
wall about one inch from the pylorus was 
thicker and somewhat discolored, the resi 
of the stomach wall being normal. After 
careful and rapid inspection and palpation 
of the posterior wall and without finding 
any indication of an ulcer, I clamped the 
stomach near both orifices to stop all bleed- 
ing, incised the stomach by a transverse cut 
of about two.inches underneath the infil- 
trated area. The stomach was filled wit! 
fresh liquid blood, which seemed to have 
come from a longitudinal, somewhat irregu- 
lar, deep ulcer within the folds of the pre- 
pyloric region. No bleeding vessel was 
visible. The ulcer was therefore, excised 
parallel to the incision. Temporarily one 
of the clamps was loosened and immed'- 
ately a profuse bleeding started from the 
ulceration. After excision of the ulcer, t!:° 
mucous membrane, muscular coats and per - 
toneum were sutured in vertical directio:, 
thus enlarging the pyloric end instead 
diminishing it by suture. I made ro 
gastroenterostomy for this same reason a: | 
also for the reason of preventing seconda'y 
peptic ulcer as it has been described 
Koerte, Steinthal and others in such cas«:. 
The recovery was uneventful and prom’, 
and I exhibit this case here. He has sin? 





ULCER OF STOMACH—BECK. 


ained much in weight and is in perfect 
ealth. 

Case 2. It so happened that Dr. B. who 

itnessed the operation, told me that he 
ad a case of a man in whom he suspected 

n uleer though the case had never been 
leeding, but who presented otherwise quite 
haracteristic symptoms of the disease. Just 
vo days afterward this patient came to the 

sspital and inasmuch, as he looked very 

ile, had a rapid pulse and suffered from 
istralia, Dr. B. kept him there. Wher 
saw the man with him the next morning, 
is condition had changed. Dr. B. told me 
that the man had vomited black material, 
was pale, restless, his stomach was 
enormously dilated and tender, he had all 
the signs of a foudroyant bleeding of his 
stomach. His pulse was good though rapid 
this time, changeable in volume. I 
advised immediate operation, but inasmuch 
: experience had shown to Dr. B. that many 
ulcers stop Dleeding, he was. inclined to 
postpone the operation until the patient re- 
covered from the shock of the hemorrhage. 
We finally agreed to consult with another 
surgeon, who also thought that the hemor- 
rhage might subside. I was thoroughly 
satisfied that an operation was inevitable. 
This consultation was at }0 A. M., at about 
? P. M. the man died. By courtesy of Dr. 
B. I show you the specimen which is a very 
characteristic one. A deep ulcer through 
the entire wall of the stomach, had pro- 
duced adhesions to the pancreas and the 
artery is open looking, with its large lumen 
into the stomach cavity. Nothing short of 
a resection of the stomach wall, ligation of 
this artery and eventually a stomach plastic 
as Jedlicka advises in his paper on ulcer 
o! the stomach in the stornik-ceskych-lekaru 
would have saved this patient. 

Case 3. Two weeks ago I saw with my 
brother, Dr. Emil Beck and Dr. Wester- 
chulte, a case of a man of about 45 years, 
lowing distinct signs of hemorrhage from 

stomach. Vomiting of chocolate colored 
flid, continuous increasing weakness, pallor, 
ripid compressible pulse, dark stools, every- 
thing indicated an ulcer, hut his age, his 
e:,aciation suggested the possibility of car- 


301 


cinoma. Palpation, however, revealed no 
tumor. Two days he was at the hospital 
and the observation pointed clearly to a con- 
tinuous, though not a foudroyant bleeding. 
There was no possibility of stopping the 
hemorrhage except surgically, every other 
means being exhausted. Consequently an 
operation was advised and carried out by 
my brother and Dr. Westerschulte. The 
technique began in the same manner as case 
I, but on examination it was found that 
the induration and a number of enlarged 
glands extended all along the small curva- 
ture, consequently after clamping 
stomach a resection of the middle portion 
of the same was made with quite a difficulty, 
the glands extending clear up near the 
cardia, and a gastrojejunostomy retrocolica 
was made by suture. The specimen showed 
clearly a typical round infiltrated ulcer with 
the small artery, a branch of the artery of 
the small curvature in the center. The man 
is making a fine recovery, gaining in strength 
daily. 

These were cases in which an operation 
was undertaken for hemostasis. I did not 
mention any case of ulcer operated upon 
for other reasons, pain sequelae etc., inas- 
much as this class of cases forms a special 
group with special indications. From obser- 
vation and from studying the views of othe 
surgeons I would formulate the indications 
for a surgical procedure in hemorrhage as 
follows : 

(1) A first hemorrhage of a previously 
healthy individual, while in most cases heal- 
ing by medical treatment, requires careful 
watching, if prolonged and if the pulse in- 
dicates an arterial hemorrhage, must be oper- 
ated. 

(2) A first hemorrhage of a previously 
suffering patient if profuse or prolonged 
ought to be operated upon at once or shortly 
after the patient recuperates, as it will keep 
on bleeding and certainly will invite compli- 
cations. 

(3) A continuous slight bleeding with 
marked influence upon the patient as anemia, 
weakness, etc., is a clear indication for sur- 
gical interference. A great deal of tact and 
individual discrimination will be necessary 





the - 


302 


on the part of the surgeon to determine the 
indication, but judging from the results on 
one side being most unfavorable and from 
the result on the other being very favorable, 
I should say that we may operate rather too 
often just as in the case of appendicitis. With 
all this, however, the number of cases of this 
kind will be limited, but taking in considera- 
tion the broad indications for the operative 
procedure in cases of chronic gastric ulcer, 
stipulated even by a conservative medical 
man like Leube, many forms of chronic and 
the bleeding ulcer will gradually pass into 
the domain of the surgeon. 

The technique is a very important phase of 
the question. It will greatly decide the suc- 
cess and I believe that by applying the princi- 
ple of temporary clamping of all circulation 
and opening freely the stomach we may 
thoroughly examine the inside of the stom- 
ach and make all resections and sutures like 
in a limb by using Essmarchs compression. 
An ulcer will be easily visible if not palpable 
and cases like some of the literature where 
the surgeon had to resort to gastroenterost- 
omy without finding the ulcer, will be rarer. 
The operation par excellence will remain, the 
excision of the ulcer without gastroenterost- 
omy, if possible, as is also pointed out by 
Jedlicka in his report of some 70 cases from 
Maydls clinic. Of course, in a case of resec- 
tion so large, like in our third case, it is im- 
possible to make a plastic of the stomach, but 
for many cases a flap operation similar to flap 
operations on the skin, will be possible for 
simple ulcer of the stomach. Besides the pro- 
longation of the operation the gastroenter- 
ostomy in cases of ulcerations while primar- 
ily giving good drainage has given cause or 
we may say without prejudice has been asso- 
ciated with secondary peptic ulcers in the 
neighborhood of the anastomosis as cases of 
Koerte, Steinthal and others have shown 
post-mortem. 

The operation of choice therefore ought to 
be the excision with or without gastroplasty. 
Discussion on the paper of Dr. Carl Beck. 

Dr. William Fuller: I think from the paper 
Dr. Beck has read us tonight we can draw two 
valuable lessons. The first is, that gastric ulcer 
treated medically is a very dangerous thing. 


The second lesson is that gastric ulcer is amen- 
able to and curable by surgical intervention. 


ULCER OF STOMACH—BECK. 


Personally, the more I see of gastric ulcer, and 
the more I learn about it, the more I am con- 
vinced that it is totally without a medical side 

It must be remembered that the rather high 
mortality ascribed to operations in gastric ulcer 
are taken from a class of cases which have 
been treated medically for months and years, 
and which have reached a serious complication 
of some kind, necessitating frequently immed- 
iate surgical effort. It is manifestly unfair to 
assign a mortality thus obtained to surgery, be- 
cause an operation in competent hands under 
circumstances such as exists in all cases prior 
to complications, would greatly reduce the 
death rate. I see no justification for the as- 
sumption on the part of the physician that a 
case is in reality improving under medicinal! 
measures, merely because the symptoms which 
characterize this condition, are in abeyance; 
this is the condition in which the so-called 
latent ulcer exists, and which often, without 
warning, perforates or gives rise to serious hem- 
atemesis, which may, and frequently does, end 
the patient's life. 

You will recall the case of the tailor men- 
tioned by Dr. Beck, in which medical treatment 
was instituted on two or three occasions, and 
which each time was followed by apparent im- 
provement, but it became suddenly necessary 
to use means of a radical nature which saved 
his patient’s life. All of these cases should b« 
operated just as Dr. Beck did this case, as soon 
as the diagnosis is made. 

Let me say a word or two with reference to 
the manner of dealing directly with gastric 
ulcer. I would emphasize all that Dr. Beck has 
said relative to excision of the ulcer. I believe 
the ulcer should be excised when feasible for 
two reasons: 


First, because it rids that patient of a dan- 
gerous lesion. The next is that, as Moynahan 
has shown, as high as sixty per cent of carcin 
omas of the stomach are preceded by gastric 
ulcer. What I have tried to say is exemplified 
by the case shown by Dr. Beck and by the last 
ease of gastric ulcer which it was my privileg: 
to operate. The patient was a woman 30 years 
old; she had suffered some time, and had had 
several gastric hemorrhages. Several physi 
cians saw her in consultation, and as the in 
ternists predominated in number their advic 
was carried out; under the medical treatmen' 
she greatly improved in every way; the pair 
ceased, the vomiting of blood was not agai 
seen, and the patient gained several pounds i: 
weight. This apparent improvement went o 
for a whole year, and at the end of this tim 
and without the least warning, she was sud 
denly seized with furious bleeding from the 
stomach, which was vomited in large clots, a 
well as fresh blood, which did not show an 
signs of ceasing. 


On the second day after her first attack « 
hematemsis I operated this patient,, which 
now about one year ago. When the stomac’ 
was exposed there was nothing either by palpa 
tion or inspection that seemed to indicate tha 
there was an ulter in the stomach. A lor 
transverse incision laid the stomach well ope’ 





ULCER OF STOMACH—BECK. 


o that an excellent view could be had of the in- 
erior of the organ; on the posterior wall and 
lose to the pylorus was an ulcer about the size 
f a 5-cent piece which appeared to have al- 
nost healed; this ulcer was excised, and the 
pening was closed with two rows of Lembert 
utures. About an inch from this was another 
ulcer looking somewhat like the one just men- 
ioned, and it was treated in exactly the same 
manner. A third ulcer was found much higher 
n the posterior wall than the last, and looked 
1uch more like the one from which the hemor- 
hage had originated. This ulcer was picked 
p with forceps and a ligature was thrown 
‘round its base, and on the out side of the 
tomach just at the point of the ligature a mat- 
tress suture was placed. On the anterior wall 
f the stomach two or three erosions appeared 
which would bieed when even touched with the 
sponge. 

The convalescence was short in this case, no 
more pain was complained of and there was no 
more vomiting of blood; the appetite quickly re- 
turned and the patient took on flesh from the 
start. She has till now, which is just one year, 
remained perfectly well. 


Dr. Victor J. Baccus: I wish to testify to the 
value of immediate surgical interference in one 
case of gastric ulcer which I was called upon to 
treat a year ago. The case was one of acute 
perforation in a patient who had suffered from 
ulcer, but who did not have the classical symp- 
toms. I was called about four o'clock in the 
afternoon to see a man apparently in good 
health; he weighed 160 pounds; his height was 
five feet, eight inches. The history given was 
this: 

He was taken suddenly one morning with an 
acute pain which extended over the abdomen, 
followed by vomiting. As the man was suffering 
extreme pain, it was impossible to obtain any- 
thing in regard to his previous history, with the 
exception that he had suffered a year or two 
previous to this from acute appendicitis. The 
general symptoms, aside from vomiting, were a 
pulse of 120, temperature of 101 degrees, rigid- 
ity of the abdominal wall, with greatest tender- 
ness over the region of the appendix. Recog- 
nizing the seriousness of his condition, I had him 
at once removed to the Policlinic Hospital. Pre- 
vious to operation the differential diagnoses 
were taken in consideration as follows: Acute 
pancreatitis; acute gangrenous appendicitis; in- 
testinal perforation, and possibly gastric ulcer. 
The abdomen was opened over the region of the 
appendix, and as I opened the peritoneum there 
was an escape of fluid which resembled some- 

at a mixture of milk and stomach contents. 

At about the same time, carrying my fingers 

ver the region of the appendix, a healthy ap- 
endix appeared. This was left alone. The exu- 
te was removed. Before proceeding any fur- 

r toward exploration, it occurred to me that 

might use a forceps armed with a sponge and 
irry it in various directions into the abdominal 
ity, with the object of locating the origin of 
this strange exudate, and when it was carried 
toward the gall-bladder region, it became sat- 
urated with bile. I covered the appendiceal re- 
gion with sponges, made an incision in the mid- 


303 


cle of the right rectus, explored the region of the 
gall-bladder, which was negative, also the re- 
gion of the duodenum, which was also negative. 
On devoting my attention to an examination of 
the stomach, an opening was found, situated 
about half an inch from the lesser curvature, 
and an inch and a half from the pylorus through 
which escaped the stomach contents with each 
inspiration. This ulcer was excised and the 
wound closed with a double row of Lembert 
sutures, drainage instituted, followed by a per- 
fect recovery. The after-treatment consisted 
simply of rectal feeding for three weeks. 


PARENCHYMATOUS K ERATITIS, 
IRIDO-CHOROIDAL FORMS WITH 
LOSS OF BOTH EYES * 


BY CHAS. H. BROBST, M. D., 


PEORIA. 


My reason for presentin; a paper on the 
subject of Parenchymatous Keratitis is, that 
it is a disease which occurs quite frequently, 
and interests the physician who is engaged 
in general practice quite as much as the 
ophthalmologist, from the fact that many 
of these cases are first seen by the former. 

Clinicians and writers on the subject of 
interstitial keratitis almost unanimously 
agree that this eye affliction almost invari- 
ably results in a cure with the possible ex- 
ception of a few small opaque spots remain- 
ing on the cornea, but unfortunately we 
can’t all boast of such glowing results as I 
may demonstrate later on. 

Parenchymatous Keratitis—is also known 
as interstitial keratitis and deep diffused 
keratitis. It is a rather frequent disease, 
having as its prototype deep non-suppurative 
keratitis. I shall confine my remarks 
principally to one particular type of this 
disease which is the Irido-Choroidal form 
which has proved to be a great deal more 
dangerous to the impairment of sight and 
even destructive to the eye itself than one 
is led to believe through reading current 
literature on the subject. 

Whatever the etiological factors in this 
disease may be, it is true that the greater 
majority of cases start out in a mild form, 
a grayish discoloration appears in the peri- 
phery or in some other part of the cornea. 

This change of color soon spreads over the 
entire corneal membrane which is infiltrated 


*Read at the 655th Annual Meeting. Rock IslanJ, 
May 17, 1905. 





304 PARENCHYMATOUS KERATITIS—BROBST. 


and its surface dulled throughout. At first 
the infiltration is translucent, like that seen 
in oedema of the cornea; it then thickens 
and becomes of a grayish tint, which deepens 
until the iris is almost or quite obscured from 
view. Vision is greatly diminished and may 
be reduced to mere perception of light. 
There is typical ciliary injection usually 
without congestion of the conjunctiva, ex- 
treme congestion of the iris is always present 
and finally developes into an iritis and 
iridocyclitis. 

Some of these cases before they come into 
the services of the ophthalmologist, have 
passed through these various stages of de- 
velopment until we have the Irido-Choroidal 
form which usually results in greatly dimin- 
ished vision or the loss of sight entirely, the 
result of exudative deposit on the posterior 
of the cornea. 

Very often when the affection is of long 
standing, evident phenomena of cyclitis and 
choroiditis are observed. Chief among 
these may be mentioned the slaty shade of 
the sclerotic around the cornea, which is so 
characteristic of chronic cyclitis. 

Sometimes the sclerotic is infiltrated quite 
as much as it is in scleritis. Subsequently 
ciliary or intercalary staphylomata may 
supervene when, in consequence of posterior 
synechia, the eye has become glaucomatous. 

The corneal: inflammation may be so 
hidden that the condition is spoken of as one 
of irido-choriditis. Fortunately it is com- 
paratively rare that this extreme type of 
interstitial keratitis comes under our obser- 
vation and when it does it is usually in cases 
which were somewhat neglected in the earlier 
stages of the diseases. That is, if the disease 
has progressed for sometime without the 
proper use of mydriatics and other thera- 
peutic interventions fitting the case; how- 
ever these errors are usually brought about 
in failing to recognize the real type of the 
disease. 

Michel, in this connection, distinguishes 
two forms of parenchymatous keratitis; -in 
the one, the disease commences with the 
corneal affection; in ‘the other, the corneal 
affection is absolutely secondary and conse- 
quent upon the uveal tract. 


This latter type of the disease I have 
observed in six different cases; five of these 
cases proved to be very obstinate and pro- 
tracted through the entire course of treat- 
ment, which averaged one year and a hal! 
year for each case until all traces of inflam- 
mation had subsided and with an averag: 
vision of 60%. A slight amount of cornea 
infiltration was noticeable in three cases fou: 
years after the inception of the disease. 

The etiological factor which played such 
a role in these five cases of the Irido-Chorio 
dal forms of parenchymatous keratitis was 
hereditary syphilis; this I have found to b 
the case in about 70% of all the cases ot 
interstitial keratitis that have come unde: 
my observation or rather that I have kepi 
record of in the last fifteen years. 

Then next in frequency is scrofula or a 
strumous condition and this may be in ; 
great many instances a hereditary taint fron 
tubercular parents or a specific conditio: 
handed down for possibly two or thre 
generations. 

I shall take up the history and progres: 
of one of the six cases of Irido-Choroida 
form of interstitial keratitis from the fac‘ 
that its interest lies in the loss of both eyes 
of a young woman twenty years of age wl 
came into my service September 12, 1903. 
I was informed by the patient that three 
years previous, her left eye had been remove! 
after suffering with it for almost four years 
from a disease that had commenced exact!) 
as her right eye was beginning now. There 
was some injection of the conjunctiva aroun! 
the corneal margin, a slight dilation of the 
pupil, tension normal, some photophobia am 
a perfectly clear cornea. The patient also 
stated that the enucleated eye through t! 
course of its disease was always very mu 
influenced for the worse during the me»- 
strual period. 

The patient was sent to the hospital a’ 
in four days time I noticed the first signs «' 


an interstitial keratitis, being exactly tv» 


weeks, after the period of inception of t 
disease. The cornea’ gradually 
clouded as the irido-choroiditis develoyx 
which was very slow in its progress but su 
in its destructiveness. The history of th : 





becam” 





ads 
I f 
wit 
lis. 

A 
slov 
onh 


min 








PARENCHYMATOUS KERATITIS—BROBST. 305 


ase never shed any light on any etiological 
ictors that might play a role whereby one 

iight be guided in his treatment, and with 
he disastrous results obtained in the left 
ye at the hands of a most competent ophthal- 
ologist, the eventual results could be easily 
pprehended. 

1 concluded that the etiology resolved 
tself into three primary factors namely, 
(uberculosis, Rheumatism and Hereditary 
syphilis. 

The pulse rate averaged between 60 and 
5 per minute and temperature 98 degrees. 
n giving the patient the tuberculin test she 
as placed in bed and the temperature taken 
n the rectum every three hours, at seven 
o'clock A. M. it was 97.4 degrees and at 
seven o’clock P. M. 98.2. 

Two tests were given forty-eight hours 
apart, after the first test the temperature 
arose to 98.6 and after the second test the 
temperature was 98.8 degrees and with the 
absence of all other tubercular symptoms 
| formed the conclusion that I had to deal 
with either rheumatism or hereditary syphi- 
lis. 

As we may notice the pulse rate was very 
slow, 65 per minute it being more frequent 
only on one occasion when it was 72 per 
minute right subsequent to the first injection 
of tuberculine and in fifteen hours it fell 
again to 65 beats. 

After giving Salicylate of Soda a thorough 
trial in increased doses for six weeks until 
the patient was taking four grms. every 
four hours and with hypodermic injections 
of pylocarpine and hot packs to produce 
diaphoreses, I however noticed no improve- 
ment in the eye. Potassium Iodide was then 
given in increased doses until the patient was 
king six grms. three times a day without 
vrodueing any beneficial effect on the disease 

manifesting any evidence at all of taking 
e drug. 

The loca] treatment throughout this time 
consisted of application of leeches on the 
temple, hot and cold applications, instilla- 
tim of atropine, subconjunctival injections 
0 salt solution and solution of cyanide of 
Mereury one to one-thousandth with cocain 
a ‘ded, but due to the congested and inflamed 


~onm -F 


state of the conjunctiva these injections were 
always very painful. 

Cocain seemed to have very little effect as 
a local anaesthetic under these conditions. 
The cornea was now quite opaque, the pupil 
about one-half dilated and some adhesions of 
the iris to the lens capsule and there was 
beginning of exudative deposit in the anterior 
chamber. 

The patient was under constant treatment 
and observation ten weeks without the eye 
being in the least benefited. It was also 
evident that no benefit whatever had been 
derived from any therepeutic agent which 
had been administered per os. 

The hypodermic method of administration 
was now adopted by injecting 0.006-1-10 gr. 
of cyanide of mercury in to the gluteal re- 
gions every twenty-four hours until ptyalism 
was established which manifested itself after 
the fifth injection. This method of medica- 
tion must have wrought metabolic changes 
in the economy which other remedies were 
incapable of, where the alimentary canal 
was called upon to perform its function in 
assimilating the drug. The result of this 
treatment was a steady improvement in the 
eye, pain diminished, congestion and in- 
flammation subsided, the cornea cleared up 
to the extent that the patient was able to 
find her way about the streets. 

The injections of cyanide of mercury 
were kept up at longer or shorter intervals 
for over six months with reasonably good 
prospects of having stayed the progress of 
the disease and during the period of eight 
months the approach of the menstrual period 
provoked:no untoward symptoms in the eye 
as had been the case before she received the 
mercury treatment. 

The pulse rate now was about 80 per 
minute and the temperature 98.6, appetite 
good and bowels regular. 

In October 1904, the patient waked up 
early in the morning with a pain, some con- 
gestion and about plus I tension in the eye- 
ball and steadily increased in tension with a 
corresponding augumentation of pain. 

This secondary glaucoma was the sequence 
of a disease of the uveal tract which had 
manifested itself in an interstitial keratitis 





306 COLORADO CLIMATE—WHEATON. 


in the earlier stages of the disease, and was 
rather of an insidious type in the latter 
stages of its duration which was over one 
year until glaucoma manifested itself. 

I am also confident that it is a mistake 
to wait for surgical interference until it is 
indicated in this class of cases by manifesta- 
tion of secondary glaucoma following iridic 
adhesions and exudative deposits. 

If iridectomy is to accomplish anything 
it must be performed early in the disease 
before iridie adhesions have taken place or 
before an advanced irido-choroiditis had a 
chance to develope. 

On several occasions I have performed 
iridectomy in the very beginning of the irido- 
choroidal form of parenchymatous-keratitis 
with excellent results. 

In summing up this case we find several 
interesting features relating to it, which are, 
subnormal temperature from 1 to 1.5 degrees 
and very slow rate of pulse. 

The therapeutic agents which were ad- 
ministered per mouth such as salicylates, 
mercury and potassium iodide bore no in- 
fluence on the disease whatever. Subcon- 
junctival injections of mercury and salt 
solutions had no beneficial affect on the eye 
until after the constitutional results of 
Mercury had been attained by deep hypoder- 
mic injections. 

A sudden development of a secondary 
glaucoma after the eye had been doing well 
for six months, The destruction of both 
eyes four years apart in a similar way. And 
while the history and all other symptoms 
were, negative, this was undoubtedly a case 
of hereditary syphilis. 


THE CLIMATIC TREATMENT OF TU- 
BERCULOSIS WITH SPECIAL 
REFERENCE TO COLORADO.* 


BY CLARENCE L. WHEATON, M. D., CHICAGO. 


Examining Surgeon for U. S. Army Recruiting 
Station, Chicago; Formerly Member of the 
Clinical Staff Denver and Gross Col- 
lege of Medicine; Member of 
the American Medical 

Association,etc., 


It was never designed that in premature 
decay the existence of man should be con- 


*Read at the 65th Annual Meeting, Rock Island, 
May 17, 1906. 


sumed, and that from the stage of life h 
should pass away at a time when everythin; 
about him, his aspirations and his hope 
pointed to the future and to the activity o: 
being. This, it would seem, is too ofte: 
the destiny of the unfortunate afflicted wit! 
tuberculosis. These individuals have ii 
most instances reached maturity; they ar 
frequently people of brilliant intellect, an: 
decidedly valuable citizens to the communit 
in which they reside, and their death is quit 
often a public calamity. In the last Censu 
year 109,750 persons died of pulmonar 
tuberculosis; of these 71,040 were betwee: 
the ages of fifteen and fifty years; betwee: 
the ages of twenty and thirty years ther 
were 31,042 deaths. We may well avail our- 
selves of all remedial agents capable o 
arresting this disease, whether climatic o 
medicinal, and we have reason to insist that 
laws relating to hygienic and sanitar) 
measures be enacted and enforced by th 
municipality and state, and that the poor 
afflicted with tuberculosis be properly care: 
for in state sanatoria situated in a climati: 
zone from which the greatest possible benefit 
may be derived, that they may be cured o 
their disease and returned to the common- 
wealth from whence they came physical!) 
capacitated for labor. 

It is generally conceded that pure air 
stands at the head of all remedial agents 
capable of arresting the disease. Medica 
climatology has, therefore, come to play an 
important role in the affairs of those me: 
who treat tuberculosis. The pendulum 0! 
professional opinion relative to the value ©! 
the arid regions as a place of residence for 
the tubercular seems to have swung with: 
recent years in a far opposite direction. Men 
of recognized ability and wide experien:: 
tell us that life in the open air at home wi 
arrest the disease. Flick has stated th 
“tuberculosis can be successfully treat 
anywhere; climate has practically nothi: 
to do with the matter. Formerly climate w:- 
looked upon as the most important fact: © 
in. the production of tubereulosis, cons: - 
quently it was looked upon as the most ir - 
portant factor in the treatment; for ma! 
men it is difficult even at the present tir 





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COLORADO CLIMATE—WHEATON. 


) give up these ideas.” We recognize the 
t that in Illinois it has been demonstrated 

\ practical tests, notably at the Ottawa tent 
) ony, that life in the open air and sunshine, 


ryper food, well regulated diet, carefully 


i ciplined conduct, has resulted in the 
st of the disease in many cases, and I 
lerstand that these cures accomplished in 

home climate in which the patients 
iain are more lasting and more assured 

n when cures have been attained by 
“porary residence elsewhere. The climate 

' the arid regions contrast to such an extent 
h that of our own state that the necessity 
advancing arguments relative to their 

spective merits is not apparent. 

four years residence in Colorado, the 
great Mecca for the tuberculous in this 
country, and a careful study of conditions 
as they are presented to the health seeker 
in Arizona and New Mexico, have more than 
ever convinced me of the fact that we must 
by determined effort and honest endeavor on 
our part solve the tuberculosis problems at 
home. The mass of the afflicted element 
are not well enough equipped financially to 
take long journeys to distant states endeavor- 
ing to seek a more favorable climate. 
Financially embarrassed, weak and en- 
feebled by disease, they soon become a charge 
upon the county until death, their only 
friend, claims them. In prescribing climate 
to those afflicted with tuberculosis the 
greatest care and discretion must be exer- 
cised. As the able surgeon knows well his 
anatomy, so the medical adviser should be 
acquainted with meteorological facts and 
climatie data relative to a given health resort. 

ideal climate for the tubercular would 
ear to be one possessing the greatest possi- 

» amount of sunshine, a mild climate, a 

dry atmosphere, light winds, and porous 
with elevation sufficient to increase the 
s)iratory act in depth and vigor. 

Colorado partially fulfills those require- 
mets, constituting an ideal climate. 

The Signal Service has contributed from 
time to time its reports of this region, and 
they are all of scientific exactness and 
worthy of study by those residents of less 
favored regions. The winter temperature, 


307 


about 30° F., approximates Topeka, Kansas, 
Kansas City, Boston, Springfield, and New 
York City, the mean winter temperature of 
St. Louis, Cincinnati, Washington, and 
Baltimore is 5° higher; yet Colorado is 
noticeably mild, as compared to these cities. 
The hourly wind velocity, covering ten years’ 
observations, is reported less than seven miles 
per hour. 


We attribute this mildness to dryness and 
diathermancy; sunshine and diathermancy 
are very noticeable to the early resident of 
Colorado. 


All students of climatology recognize the 
germ-destroying power of sun light, its power 
to destroy tubercle bacilli, and the utilization 
of the violet rays of light, notably by Kime 
of this country, is an argument as to the 
value of sun light in the arrest of tuberculo- 
sis. Furthermore, the mental effect of sun- 
shine can not be overlooked, such as promot- 
ing a cheerfulness of disposition and repose 
of mind in those compelled to live an out-of- 
door life. 


Atmospheric clearness and transparency, 
the so-called diathermancy, is a test of 


purity. Dennison in his Colorado observa- 
tions of 1876 proved that it steadily increases 
with elevation by consecutive thermometric 
observations of the sun’s influence at differ- 
ent heights and near sea-level, and under 
conditions calculated to exclude radiation. 
He found that for each rise of about 235 
feet, there is one degree F. greater difference 
in temperature between sun and shade at 2 
P. M., as shown by metallic thermometers. 
This increasing purity of the air, the absence 
of dust and smoke, or of moisture, with its 
attendant infusoria, is a decided feature of 
elevation. Tyndal is quoted as having shown 
that each higher successive stratum contains 
less and less of infusoria. Meguel, of Paris, 
found the same until with rise in elevation 
the number of bacteria in ten cubic meters 
of space was reduced from 55,000 in the 
Rue de Rivoli, Paris, and 7,600 in the park 
of Montsouris, near by, to 600, 85 and 8, 
respectively ; in a hotel at Thums, 560 meters 
elevation in its environs, while at 2,000-4,000 
meters high there were none. 





308 


Dennison’s conclusions are that purity 
goes with dryness, coldness, and rarefaction 
of the air incident to elevation. There are 
on the average three hundred days of sun- 
shine during the year in Colorado; on the 
eastern slope of the rockies, there is a tract 
of land 280 miles long, extending from 
Wyoming on the north to New Mexico on the 
south, in which are located the cities of 
Denver, Colorado Springs, Manitou, Pueblo, 
Trinidad, Boulder, Golden, Fort Collins, 
Greely, Canon City, and other smaller towns 
of the State. The sun shines for about 
seventy out of every one hundred hours that 
it is above the horizon. At Denver, which 
may be recognized in many respects as typi- 
cal of the entire eastern slope of the rockies, 
the average annual precipitation of rain and 
snow is fourteen inches; the _ relative 


humidity is for the winter, 57; spring, 56; 
summer, 51; autumn, 50. 

The city of Denver lies within twenty-five 
miles of the rockies, at an elevation of 
approximately a mile above the sea; its 
present population is 175,000; the city is 


modern in every respect, and its many 
palatial homes and public buildings, its well 
paved streets, and their freedom from filth, 
are features that soon become noticeable to 
the most careless observer. 

The large hospitals, such as St. Joseph’s, 
St. Anthony’s, St. Luke’s and Mercy hospital, 
compare favorably with similar institutions 
in New York and Chicago. These 
institutions, however, do not receive tubercu- 
lar patients. The following are equipped 
for the care of the pulmonary invalid: 
National Jewish hospital for consumptives, 
90 beds; Y. M. C. A. Health Farm, 45 beds, 
Agnes Memorial Sanatorium, 150 beds; Rest 
Haven Home for Consumptives, 50 beds; 
Mrs. Lares Tent Colony, tents are here 
erected as patients are received; Glocknor 
Sanatorium, at Colorado Springs, 80 beds; 
Emma Booth Tucker Memorial Sanatorium, 
at Amity, Colorado, conducted by the Salva- 
tion Army, 100 beds; Colorado Sanatorium 
at Boulder; Fox Hall, at Denver, a private 
sanatorium conducted by Dr. Beggs; Rocky 
Mountain Industrial Sanatorium at Welling- 
ton Lake; Ballard Sanatorium at Pueblo; 


COLORADO CLIMATE—WHEATON. 


Tented City, near Denver, conducted | 
the Jewish Consumptive Relief Societ.. 
“The Home” for Consumptives at Denver ‘s 
doubtless one of the most thorough') 
equipped institutions of its kind in this 
country. Here every comfort is provide., 
for the pulmonary invalid cases of early i 
fection do not mingle with those cases mo 
advanced, and every effort seems to ha 
been made to improve the surrcundings and 
make cheerful the daily life of a small army 
of sufferers who reside at this institution. 
This sanatorium, until quite recently, offered 
the only comfortable home for the invalid 
who journeyed to Denver, and it should ever 
remain a monument to its founder, the Rev. 
Frederick Oakes. 

There are many scattered tent colonies and 
smaller institutions throughout the State, 
many of them in the hands of responsille 
persons, others designed to fleece the invalid. 
The facilities throughout the State are on 
the whole good for caring for the invalid. 

I believe that an unwarrantable fear exists 
in the minds of many medical men as to the 
effect of altitude upon those individuals who 
have long been accustomed to a residence at 
a lower elevation than 5,000 feet. Patients 
sent to Colorado usually experience an in- 
crease in the rapidity and energy of the 
heart’s action; this is usually accompanied 
by a lowering of the blood pressure. The 
respiratory act is increased in depth and 
vigor ; thus more lung tissue becomes aerated, 
and the expansion of the chest increases, a 
process of compensation occurs, and the 
pulse and respiration return to normal. 

Dr. Kahn, of Leadville, in 1902, reported 
his observations on the pulse and respirations 
at an altitude of 10,200 feet, as follows: 
One hundred cases examined, 83 men, |? 
women, average pulse 76.5; average respira- 
tions, 20.48. Average age, 83 men, 32.'!7 
years, average pulse 76.36; average respira- 
tion 20.28. Average age, 17 women, 26 '9 
years ; average pulse, 77.17; average resp 
tion, 21.41. The youngest woman was |§ 
years of age, the eldest was 45, The young +t 
man was 19; the eldest man was 64. 
lowest pulse was 60, in a man of 29; «1¢ 
lowest respiration was 15, in a man of ° 





COLORADO CLIMATE—WHEATON. 


highest pulse was 92, in a man of 21, 
and in a man of 45, the highest respiration 
os 26; in a man of 64, the lowest combina- 
ion proportionately of pulse and respiration 
ras 72 to 15 in a man of 25; the highest 
combination proportionately of pulse and 

piration was 92 to 23 in a man of 21. 


he pulse and respirations are not acceler- 

ed to the extent naturally supposed. It 
will be observed that even at an elevation of 
10,000 feet the pulse and respirations com- 
pare favorably to the normal at sea-level. 

so much in brief for the consideration of 
a region that has effected as many cures of 
tuberculosis as any known. 

lhe cases to be sent here must be carefully 
selected ; they should have a permanent in- 
come of, at least, $50.00 per month; they 
should be accompanied by intimate “friends 
or relatives in their journey away from 
home. The tubercular invalid is prone to 
develop nostalgia, which is always a factor 
for evil in these cases and destroys many 
lives that might otherwise have been saved. 


As mentioned in my contribution to the 
New York Medical Journal, August 27, 1904, 
the disease should be recognized, if possible, 
before ocular demonstration of the germ. 
If, at this time, the patient is sent away, 
recovery is assured with great certainty. 

Compensated valvular disease of the heart 
is not a contraindication to an altitude of 
5,000 feet in every case. Cases in the 
second stage, without laryngeal involvement, 
will improve in this region. If the throat 
is involved, I believe the Salt River Valley 
of Arizona to be more beneficial. Patients 
with tuberculosis of the bones and joints, of 
the cervical, lymphatics, and of the testicle, 
especially those cases with open wounds, will 
fini the sunshine of this region a potent 
facior contributing to their cure. 

it would seem more charitable for us to 
persuade the invalid in the third stage of 
tuberculosis to remain at home; the most 
favorable climate can offer him but little, 
an contribute vastly less to his comfort as 
compared to the home _ environment. 
Pa‘ ients should not be sent to a health resort, 
with the expectation of engaging in labor, 


309 


thereby supporting themselves during their 
stay in a favorable climate. They will find 
competition keen, and only those physically 
capacitated for labor are successful in obtain- 
ing employment. The services of those weak 
and enfeebled by disease are no more in 
demand here than elsewhere. Without excep- 


- tion, every invalid sent to a health resort 


should be referred to some reputable physi- 
cian. All the well known health resorts 
support an army of quacks and nostrum- 
mongers. These frauds are in most instances 
totally devoid of any professional ideals, 
and their methods usually represent the 
lowest types of commercialism in medicine. 
They find in the ever hopeful consumptive 
a ready victim. 

In conclusion, I will say that in properly 
selected cases of tuberculosis, climate is not 
a will o’ the wisp, whether it be the climate 
of sand-shrouded Arizona, or that of the 
pine-clad wilderness on Unilaska’s shore, 
“the end of the bow of promise to these 
patient, hopeful sufferers does not rest on 
the mystic shores of the spirit-land.” 

92 State Street. 





INSANITY FOLLOWING SKULL IN- 
JURIES.* 


BY E. MAMMEN, M. D., BLOOMINGTON. 


It is proposed to limit this brief discussion 
to those traumatisms of the skull which have 
been sufficiently severe to produce more or 
less pronounced changes in the cerebral cor- 
tex and of such character as to produce in- 
sanity. 

Injuries to the skull, whether of the base, 
frontal region, parietal, or occipital region, 
are liable to result in insanity. 

Epilepsy produced by trauma, has for 
many years received its share of atten- 
tion from the surgical standpoint, and opera- 
tions for its relief are common, and some- 
times successful. 


As results of injuries; other symptoms oc- 
casionally appear—such as aphasia, amnesia, 


*Read at the 65th Annual Meeting, Rock Island, 
May 17, 1905. 





310 


agraphia, the impairment of the musical or 
arithmetical faculty. These and others, but 
especially the occurrence of decided mental 
impairment, present resultants of skull in- 
juries, which have not received that consid- 
eration which their importance demands. 
Many of these patients apparently recover in 


a short time, but later, sometimes years after, © 


develop symptoms, which if properly traced, 
are to be ascribed to injuries of the skull. 
These may have been forgotten and are over- 
looked at the time the examination for in- 
sanity is made. Acute cases, such as develop 
within a few weeks or months after injury, 
are of course sufficiently striking to arrest at- 
tention. 

That head injuries should affect psychic 
processes, when they occur in such a way as 
to involve psychic centers, is quite as evident 
as that injuries affecting motor areas should 
produce epileptiform movements or paraly- 
sis of some function or group of muscles. 

However, if an insane man is brought into 
court, put on the defensive, because he is in- 
sane (because he has a diseased or injured 
brain) The form of verdict in this State 
concludes with “and that he (or she) was in 
person actually present with full liberty to be 
heard in defense” and such a man presents 
history of injury to the cranial vault or base, 
of depression or fracture of bone, which has 
been neglected or overlooked, it will not al- 
ways be possible to convince either court, 
jury; friends, or physicians, that such injury 
may be, or is the prime factor in the causa- 
tion of this insanity—provided of course, 
other causes can be conclusively eliminated. 

In this connection, it is of interest to note 
our inability to localize the performance of 
mental processes in the brain. Many physi- 
ologists have placed them in the frontal lobes. 
Phelps, of New York, states that injuries to 
the left frontal lobe are always followed by 
mental changes. Others have collected facts 
that demonstrated the inoccuity (harmless- 
ness) to the mental faculties of injuries to 
this part of the brain. The majority of phy- 
siologists locate the centers forthe intellectual 
faculties in the anterior parts of the frontal 
lobes. Haliburton and others again locate 
the intellectual faculties in the occipital lobes 


SKULL INJURIES CAUSING INSANITY—MAMMEN. 


stating that experimental physiology lends : » 
support to the view that the frontal brain ; 
the seat of the intellect. This view is su .- 
ported by Clapham and others. Agai: 
Schaefer, and a number of physiologists, | - 
lieve that the intellectual faculties are bow 
up in the brain as a whole. Practical obs: r- 
vation shows that trauma, whether of ‘ \e 
base, occipital, frontal, or lateral regions of 
the skull, has been followed by insanity, with 
a predominance in frequency when the n- 
jury occurred to the frontal lobes. 

Insanity may follow skull injuries, thouzh 
such injuries do not constitute fractures, or 
fractures of the internal table may have oc- 
curred, without a corresponding fracture of 
the external table, or there may be more or 
less extensive fractures of all degrees of se- 
verity, which are followed by recovery, with 
the ultimate sequel of insanity. This is more 
especially true of those subjects, in whom 
there is a family predisposition, but occurs 
every now and then where no trace of neuro- 
tic tendencies can be discovered. Injuries 
producing only brief temporary loss of con- 
sciousness, are frequently classed as concus- 
sions. These are more accurately cases of 
cerebral contusion, of minute structural 
lacerations, producing extravasation of blood, 
disconnection of nerve cells, disassociating 
neurons, while in the cerebral coverings, there 
is histological laceration of pia, arachnoid, 
dura, and even of bone tissue, as well as of 
the periosteum and scalp. In recovery such 
conditions may lead to degenerative changes 
in the cortex, in nerve cells or their fibres, or 
to sclerotic and adhesive changes in the men- 
inges or bony covering, sufficient to produce 
marked sequelae. These may not appear for 
weeks or months, but appearing finally in- 
crease in severity and terminate in permanent 
irritation and injury to the subjacent ncu- 
rons. Such changes in the gray matter, my 
not be appreciable, but become appar 
through derangement of function. In more 
severe cases, spiculae of bone, adhesions » 
the meninges, partially organized clots, cy 's 
of the arachnoid of hemorrhagic origin, 
hyperaemic bone, have constituted the 
fending causes, whose removal has been { '- 


_ lowed by most brilliant results. 





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SKULL INJURIES CAUSING INSANITY—MAMMEN. 311 


Without operation, the prognosis in all of 
hese cases is exceedingly bad. With opera- 
‘ion, the patient’s prospects may be improved 
hat is a cure may be established in some of 
hem. It is not always certain that the in- 

iry to the brain tissue is subjacent, or even 
\djacent to the skull injury. There may be 
contra-coup, there may be histological con- 
‘usion in other localities, or the character of 
the nerve cell destruction be such as to render 
restoration of them impossible. But these 
cases are hopeless from the standpoint of 
medical treatment—hence, whatever will give 
relief, or a reasonable hope of relief, is in- 
dicated. Crisp English shows that relief has 
come to many of these cases, even though 
operation was performed late. [In all, to 
give best prognosis, operation should be per- 
formed early—before constant irritation and 
pressure has added to the severity of the case, 
and produced permanent change of nerve 
cells. The type of insanity is not constant, 
nor is it constant for injuries in a given local- 
ity, such as the left frontal lobe. Some ob- 
servers have, however, found two types: 
ist. Insanity due directly to the actual in- 
jury and entirely distinct from hereditary or 
predisposing causes. 2d. Indirect insanity, 
occurring as the result of lowered resistance 
of the brain consequent upon injury in those 
in whom there exists some predisposition, 
hereditary or-otherwise. In the latter case, 
the prognosis is nearly always or perhaps al- 
ways hopeless. The following three cases 
from my own practice belong to the former 
class, and may serve to further illustrate this 
subject : 7 

Case I. J. S. H., aged 47, master brick 
mason, of excellent health and physique. No 
trace of insanity or disease of the nervous 
system in the family, nor any evidence of 
svphilis, hereditary or acquired, was hit on 
he top of the head by a tile, falling from the 
oof of a five story building, producing a de- 
ression furrow about an inch long and half 
an inch deep. This was located a little to 
ie right of the sagittal suture, and near its 

iddle, and a little to the right of the su- 

rior longitudinal sinus. The blow was not 
eceeded by unconsciousness, and the wound 
aled, leaving the depression, but he went 


about his business as usual, feeling apparent- 
ly as well as ever. In a few months he had a 
severe attack of herpes zoster, involving the 
sixth and seventh intercostal nerves, but he 
recovered. Gradually his character began to 
change. From possessing a mild tempera- 
ment he became irritable ; little things would 
annoy him. He became nervous, fretful, was 
unable to get along with his men, lost flesh, 
lost appetite. Then began to fancy that his 
home people were his enemies, conspiring to 
annoy him. He became incapable of pro- 
longed exertion, then complained of‘ head- 
aches, had hallucinations, wandered about 
away from home, hence, had to be watched, 
and his friends brought him into court, 
where he was seen by me and examined. The 
attention of judge, jury and friends was 
drawn to the injury as the cause of his in- 
sanity, and the advice given that the bone 
pressure be relieved. No attention was paid 
to the advice and the patient was removed to 
Kankakee hospital about a year after having 
received the injury. He remained there from 
July 4, 1892, to November of the same year, 
when he was discharged improved. He came 
home in a submissive mood, quite apprcia- 
tive of his friends and home, but gradually 
lost all interest in affairs—complete demen- 
tia ensued, and after a short period of coma, 
died, Jan. 11, 1904, there having been no 
rise of temperature at any time. 

It is not diffieult to infer what would have 
been the result in this ease, had early eleva- 
tion of bone been the method of treatment. 

Case II. W. S., farmer, aged 25, of ro- 
bust health and strength, with a clean fam- 
ily history, was thrown by a running horse, so 
that the force of the fall was delivered upon 
the anterior parietal portion of the right side 
of the skull. He was unconscious for a num- 
ber of hours. There was no cut of the sealp 
or evidence of fracture. He remained quiet 
a few days, then feeling quite well, resumed 
his duties about the farm. For a time noth- 
ing out of the ordinary happened. Then his 
friends noticed periods of depression, ques- 
tions would be answered in unusual ways. 
He became restless, would not content him- 
self at home. Finally would wander away. 
Had to be brought back several times, and 





312 


with difficulty. Brought into court the his- 
tory of the injury was recited, and I advised 
operation, but the advice was not heeded. 
Patient was adjudged insane and sent to 
Jacksonville hospital where he remained three 
months and was then allowed to return home 
improved. A short time later, he, however, 
manifested the same symptoms. About this. 
time, Dr. C. M. Noble, of this city, advised 
that a skiagram be made and that elevation 
of the bone be performed, should thickening 
or depression be shown. This time the ad- 
vice was heeded. A skiagram, made by 
Fuchs, showed heavy shadow at region of in- 
jury. I made the operation by means of a 
large omega shaped incision, and found dura 
adherent. This adhesion was loosened, then 
a portion of the inner table split off and the 
flap replaced. Recovery from the operation 
was prompt—recovery from insanity perman- 
ent. Four years have elapsed, and he con- 
tinues in good health. It should be added 


that for several months after operation, care 
was taken to insure quiet and mental rest 
for the patient. 


Case III. A. L., carpenter, aged 38, father 
of six children. On July 11, 1900, he fell 
from.a scaffolding, producing a fracture in 
the skull, over the left parietal region. It 
was a large stellate fracture with depressed 
bone in the center. Profound unconscious- 
ness supervened. The bone was elevated by a 
colleague of mine, but patient continued in 
a stupor for several days, after which he 
slowly improved, and was able to leave the 
hospital after about four weeks, and resumed 
work in October following. After the lapse 
of about two years, it was noticed that he was 
more than usually irritable, and morose, and 
had delusions about people. entering his 
house by stealth, and their illegitimate rela- 
tions with his wife. He was sent to Jack- 
sonville hospital, and discharged after some 
months, improved. On returning home, he 
resumed his usual occupation, but in a short 
time again became morose, irritable, sus- 
picious, and fretful. He quit work, saying 
that he had a competency, did not need to 
work any more. He again had delusions 
about parties having illegitimate relations 
with his wife, and finally seized her, choked 


SKULL INJURIES CAUSING INSANITY—\MAMMEN, 


her, and threatened to kill her. He was again 
brought into court, his insanity reestablished 
and with the consent of the court, his wife 
and friends, the advice of three physicians 
that operative interference was necessary 
was taken. By means of rongeur forceps, : 
large omega shaped incision was mad 
through the skull, so as to surround the sea 
of the injury, where a large depression re 
mained. The bone flap was laid over, so tha 
the subjacent structure could be freely ex 
amined. Unfortunately, the longitudina 
sinus ‘suffered laceration from the too fa 
downward projection of the rongeur, and ex 
cessive hemorrhage prevented as free an 
careful examination, as was desired. The ad 
herent dura was liberated, no spiculae o/ 
bone were found. No pressure of bone coul 
be demonstrated but such as may have ex- 
isted was relieved, and the adherent dura 
loosened. 

Three months after operation, patient 
stated that he was glad of the operation, that 
his mind had been off, but was then all right. 
His wife found him improved. In a short 
time, however, the mental symptoms re- 
curred. He remained at home with his fam- 
ily. Jealousy of his wife, and inordinate 
sexual passion, are again his leading symp- 
toms, and although physically able, he refuses 
to work. 

Should question still rise, as-to whether or 
not head injuries are direct causal factors in 
producing insanity of themselves, these thr: 
cases—devoid of hereditary and other causes 
would certainly aid in demonstrating an af 
firmative answer. In persons with hereditar 
tendencies, injuries have frequently acted : 
exciting causes. This is clearly shown by 
many observers. Crisp English (L. Lance‘ 
February 20, 1904) follows up three hu 
dred cases of head injuries, and finds tha 
ten per cent suffered from traumatic insa! 
ity, besides a number who had ment: 
changes. Welt collected fifty-nine cases, 0° 
whom twelve had mental changes, and Phe)) 
a list of twenty-eight cases, showing ment: 
disturbance after injury to the left front: 
lobe. English shows conclusively that man 
eases of skull injuries are followed by ment: 
changes, that are not pronounced insanit) 





MALIGNANCY IN UTERINE MYOMATA—LEWIS. 


ile a large per cent of those injured in 
ny part of the skull, developed traumatic 
anity. 

[he results of operation in the above case 

recovery is encouraging. While the case 

' A. L. was not benefited, it is certain that 

condition is no worse than before. The 
ilts of operation in other hands, shows 

1\t only a small portion of those operated on 

yr insanity were cured, 

‘onclusions : 
Injuries to the skull whether contu- 
ions or actual fractures, cause insanity in 
ie cases. 
Insanity may occur independently of 
he locality in which the injury is located. 
Operations for insanity from skull in- 
juries are sometimes successful, especially 
when their seat is accessible, and the damage 
to the nerve structures, correspond to the 
external wound. 

|. Operations for relief of insanity, 
should be performed as early as possible, and 
be followed by a prolonged period of mental 
and physical rest. 

5. Operations upon the cranial vault, un- 
der aseptic precautions, are as safe, as upon 
other cavities of the body—therefore, opera- 
tion treatment of these cases, should always 
be advised. 





MALIGNANCY IN UTERINE MYO- 
MATA.* 


BY HENRY F. LEWIS, M. D., CHICAGO. 


stant Professor of Obstetrics and Gynecology in Rush 
Medical College. 


terine myomiata, more strictly called 
myomata, typically are benign and inno- 
growths which only cause trouble by 
ason of their mechanical presence, result- 
g in pressure symptoms; by reason of their 
luence upon the uterine musculature and 
lometrium, resulting in hemorrhage, and 
by ‘eason of their degeneration, resulting in 
zrene, infection or malignancy. Many a 
roman carries a myomatous tumor in her 
us unknown to herself. Sometimes its 


| before the Surgical Section of the Illinois State 
lical Society at the Rock Island Meeting, May 17, 


313 


presence is only revealed when it obstructs or 
complicates labor, sometimes when genital 
bleeding calls attention to it, sometimes when 
its increasing size interferes with bladder, 
rectum or other pelvic organ or causes it to 
rise into the patient’s ken in the abdomen, 
sometimes when the secondary results of its 
degeneration or infection cause more or less 
alarming symptoms. The neurotic element 
also must not be belittled. The knowledge 
of the presence of a growing tumor, even if 
she is assured that it is entirely benign, is a 
source of much anxiety to the average woman 
as it would be indeed to the average man. It 
is my purpose to consider only the question 
of malignancy in myomatous tumors of the 
uterus; how often it occurs, what are its 
varieties, what are the clinical and patho 
logical appearances and how far should the 
chances of the supervention of malignancy 
go in determining our decision for or against 
operation. 


Some authors, notably Uleska-Stroganova, 
describe a peculiar form of malignant degen- 
eration in myomata which appears to be not 
true sarcoma but in which the characteristics 
ot malignancy are pronounced. It is con- 
sidered that there is a special form of ma- 
lignant disease arising in myomata whose 
starting point is the muscle cells. This is 
called leiomyoma malignum. Clinically the 
tumor shows its malignancy by its rapid 
growth, its tendency to recur and the fre- 
quent occurrence of metastases. Microscopic- 
ally the matrix of the developmient of the 
malignant myoma is the muscle cell. There 
is an extraordinary difference in the cell 
forms. Polynuclear cells are abundant. 
There are also numerous and diverse cleavage 
figures. The elongated cells are seen in vari- 
ous stages of change, from the ordinary un- 
striped fibre of the myoma and the uterine 
wall to spindle-shaped bodies differing little 
from true sarcomatous elements. There is in 
the tumor a preponderance of young muscle 
cells. These authors would believe that there 
is a special malignant myoma distinguish- 
able from sarcoma of the uterus; even from 
sarcoma arising in fibromyoma. It is more 
frequent than generally supposed, being usu- 
ally classed with ordinary sarcoma. True 





314 


sarcomatous degeneration of a uterine myo- 
ma is considered by Stroganowa as very rare. 
Tumors which show young muscle tissue and 
which certain authors describe as sarcoma, 
others as ordinary myomata, must be care- 
fully observed for quick changes and a tend- 
ency to undergo malignancy. 


It seems to me unprofitable to try to dis- 
tinguish malignant disease of the mesoblastic 
type in the uterus as malignant myoma and 
as sarcoma. The definition of sarcoma is a 
malignant neoplasm composed of mesoblastic 
elements. Its origin may be in muscle, in 
connective tissue elements between muscle 
fibres or in the connective tissue of the endo- 
metrium. Unless we contend that all sarco- 
mata of the uterus arise from the endome- 
triumy or from the connective tissue of the 
uterine wall and not from the muscle ele- 
ments we are not justified in classing as a 
tumor of a separate variety those malignant 
neoplasms which take their origin from the 
muscular cells of the myoma itself. The di- 
viding line between these latter growths and 
tumors which would by everybody be classed 
as sarcomata is vague. Some malignant 
growths of the uterus there are which are 
largely composed of cells apparently recently 
developed from young muscle cells. These in- 
deed are usually soft and of rapid growth. 
There are other malignant mesoblastic 
tumors conyposed chiefly of spindle-shaped 
connective tissue cells. These are usually 
harder and perhaps do not exhibit quite so 
rapid a malignity. Between these are many 
varieties of tumors, composed of young mus- 
cle cells, spindle cells, large round cells, 
small cells and polynuclear cells in varying 
proportions. The same tumor in parts not 
very widely distant may show different stages 
of all the above characters. These tumors 
are all more or less malignant, in that they 
tend to recur, to grow rapidly, to become ne- 
crotic and to form metastases. They are con- 
sequently all sarcomata. There are tumors 
arising in the endometrium of the body or 
the cervix, entirely independent of myomata, 
which exhibit characteristics grossly and 
minutely different from the sarcomata which 
we are considering. They are rather more apt 
to be composed largely of round cells and 


MALIGNANCY IN UTERINE MYOMATA—LEWIS. 


their spindle cells have no appearance 
muscle fibres. Microscopically they are us 1- 
ally more or less pedunculated or grape like 
in appearance and project into the uterine > 
cervical cavity, resembling adenomatcus 
growths. 


The change from muscle cell to spindle « 
has been observed and demonstrated |) 
drawings and specimens by several authors. 
Von Kahlden in 1893 -was the first to tric 
this change of the muscle cell of a myoma 
the spindle cell of a myosarcoma. Whitri: 
Williams the following year also demonstrat- 
ed a case. Pick and Chrobak have since cvn- 
firmed these observations by reports of cases 
studied by them. On the other hand, Ricker 
thinks that Williams and Pick mistake for a 
metamorphosis of the muscle cells spindle 
cells of the sarcoma growing in between the 
muscle cells. Other authors consider that 


the sarcomatous cells arise from the adventi- 
tia of the blood vessels of the fibromyoma 


A fibromyoma of the uterus is composed, 
in varying proportions, of the smooth muscle 
fibre, little different from that of the uterine 
wall, and of connective tissue bundles, differ- 
ing only in their arrangement from the same 
elements in the uterus. There is never a 
true myoma of the uterus except at the very 
earliest stages of growth. There is almost 
never a true fibroma of the uterus. lt is 
probably true that the softer tumors, com- 
posed mostly of muscle tissue are more prone 
to malignant degeneration than the older and 
harder ones composed mostly of connective 
tissue. 


Sarcoma arising from fibromyomata of the 
uterus or existing coincidently therewit! 
by no means common. MeDonald obser\ 
only three in 280 fibromyomata operated 
on by him or seen at autopsy. Noble, am: n; 
278 cases operated upon, found only 
cases of sarcoma. A. Martin out of 205 c:-es 
of fibroid tumor, saw only six where sarco’ \a- 
tous degeneration of the tumor had occu! 
Baker and Graves observed three sarcon 
among 33 cases of fibroid. Frederick rep rts 
a series of 125 cases of fibromyoma in 
of which sarcoma was present. Kiistner > 
lieves that 3% of fibroids become malign.\nt. 





indle 
n the 
that 
renti- 
na 
yosed, 
yuscle 
berine 
liffer- 
same 
ver a 
> very 
lmost 
It is 
com- 
prone 
r and 
ective 


of the 
‘it! 


MALIGNANCY IN UTERINE MYOMATA 


sually by the appearance of sarcoma. East- 
ian states his opinion that 5% of uterine 
‘bromata undergo sarcomatous degeneration 


ut supports it by no statistics. Hunner, in | 


00 consecutive cases of fibroid of the uterus, 
observed sarcoma twice. In Klein’s series of 
38 cases of fibromyoma, 3 were sarcomatous. 
scharlieb, analyzing 100 consecutive and un- 
selected cases, states that she observed sarco- 
ma six times. Cullen thinks that from 1% 
to 2% of fibromyomatous tumors beecome 
sarcomatous. Haultain considers sarcoma- 
tous or other malignant degeneration of a 
fibroid tumor of the uterus very rare, even 
if an authentic case has really ever been 
proven. He considers the existence of the 
two together as merely coincident. In 400 
cases of fibromyoma he saw only one sarcoma. 
The figures of Cullingworth are similar. He 
saw one case of myxosarcoma in 300 cases of 
myoma. In 300 of Simpson’s cases of fibroid 
none was found to have undergone malignant 
degeneration. On the other hand von 
Franqué estimates the frequency of sarco- 
matous change in myoma of the uterus to be 
between 3 and 4%. 

Whitridge Williams divides sarcoma of the 
uterus into two classes. The first he calls 
myoma sarcomatodes. This is a sarcoma 
springing from the muscle cells of a fibro- 
myomatous tumor. The second he calls myo- 
sarcoma. This is merely a mixture of myo- 
matous and sarcomatous cells due, as a rule, 
to sarcomatous change in the connective tis- 
sue elements of the tumor. To these Weir 
would add a third class, namely, a malignant 
neoplasm resulting from sarcomatous changes 
in the connective tissue of the uterine wall 
without the previous existence of any myo- 
matous tumor. A fourth class ought to be 
added, namely, the sarcoma arising in the 
connective tissue of the endometrium of 

dy and cervix. The majority of uterine 
sarcomata are of this fourth variety. They 

rm circumscribed polypoid growths or dif- 

e infiltrations, both varieties subsequently 

viltrating the wall. The sarcoma of the 

vix, less common than of the body of the 

rus, assumes a peculiar grape-like form 

‘ often a polypoid or nodular type. 

\bel says that the sarcoma which begins 


LEWIS. 315 


in the wall of the uterus is usually sarcoma- 
tous degeneration of myoma. Gebhard con- 
siders sarcoma of the uterus relatively fre- 
quent. The myosarcoma loses the bundle 
form in the arrangement of its elements and 
becomes more homogeneous in appearance. 
Considerable necrosis is common and also 
many areas of hemorrhage throughout the 
growth. The sarcoma often extends beyond 
the original bounds of the myoma. Beyea 
looks upon sarcoma of the uterus as a meta- 
plasia of myoma into sarcoma. Early begins 
a softening and necrosis in the center of the 
affected tumor, often with great blood extra- 
vasation. The sarcoma cells are large and 
often polynuclear, containing much chroma- 
tin. The spindle cells retain their form for a 
long time, showing origin from the muscle 
cell. Sanger believes that all myomata con- 
taining giant cells are sarcomatous. 

Sarcomatous change in a fibromyoma of 
the uterus shows itself by signs and symp- 
toms of rather significant character. A myo- 
matous uterus has perhaps lain dormant for 
several or many years, perhaps causing few 
symptoms, perhaps only noticed because of 
its size, perhaps not even suspected. Within 
a few weeks or months a rapid growth of the 
tumbr within the abdomen has taken place. 
When the tumor thus increasing in size is a 
submucous one it often happens that portions 
of it are cast out of the genital tract piece- 
meal. These pieces are usually more or less 
necrotic and are usually accompanied by a 
discharge which smells offensively. Micro- 
scopic examination of such discarded por- 
tions will show sarcoma. If subserous or in- 
terstitial the tumor may be locally softened. 
Cachexia is not long in making an appear- 
ance. The commonest time for the superven- 
tion of such symptoms is a little while after 
the menopause, sometimes several years later. 
Infection of the softened regions or of the 
endometrium over an intra-mural fibroid of 
this character may often occur, accompanied 
by hectic symptoms. The most marked signs 
however are the sudden rapid growth and 
the softening. 

Such tumors removed by myomectomy, by 
subtotal hysterectomy or by spontaneous ex- 
trusion per vaginam show myomatous 





316 MALIGNANCY IN .UTERINE MYOMATA—LEWIS. 


nodules in the substance of which are areas 
of softer and more homogeneous tissue, often 
of a paler hue than the rest, sometimes con- 
taining numerous hemorrhagic extravasa- 
tions. 

The sarcomatous disease usually develops 
in the substance of one of several myomata 
and may exist in the subserous, interstitial or 
submucous varieties indefinitely. The firm 
cross-grained fibromyomatous tissue is re- 
placed by a homogeneous yellowish white 
growth devoid of fibroid arrangement and 
closely resembling raw pork. Various fur- 
ther degenerations in the sarcoma tissue are 
frequent. The microscope reveals spindle 
cells replacing the muscle cells. In some 
places spindle cells are situated between the 
smooth muscle fibres, in other places the 
latter are entirely replaced by the former. 
Polynuclear cells are frequent. In many 
tumors of this class large and small round 
cells are numerous but in most or all of the 
sarcomatous degenerated myomata the spin- 
dle cells are the chief neoplastic elements. 


Carcinoma, contrary to the opinion ex- 


pressed by many authors, is a more frequent 
accompaniment of fibromyoma of the uterus 


than is sarcoma. A direct etiological se- 
quence can be more frequently traced in 
fibromyoma and sarcoma than in fibromyoma 
and carcinoma. However, the two exist in 
the same uterus in the latter instance more 
often than in the former, because carcinoma 
is a commoner primary neoplasm of the 
uterus than is sarcoma. 


Carcinoma may arise from several sources 
in a myoma of the uterus. It may extend 
from the mucous surface of a polypoid car- 
cinoma of the body or from the glandular 
structure of an adenoma malignum. Such a 
tumor Gebhard calls myocarcinoma. A few 
authors believe that the muscle cells of a 
myoma themselves may change and become 
of the epithelial character of carcinoma, just 
as they may become changed into the spin- 
dle cells of sarcoma. The occurrence of such 
a metaplasia has not been proven. It seems 
to me unnecessary to bring in this theory to 
explain phenomena which can be more plau- 
sibly explained otherwise. Remains of the 
Wolffian ducts may be included within a my- 


oma and may undergo carcinomatous growth 
The socalled adenomyoma is a cystic fibroi 
tumor, usually of the posterior uterine wall 
in which these Wolffian remains have great! 


- hypertrophied but have not become malig 


nant. 


Roger Williams states that carcinoma c 
exists with fibroids in nine per cent of th 
cases of the latter, but that carcinomatous d 
generation of the fibrom'yoma is of rare o 
currence. Dorland reports a case of carci! 
oma of the body of the uterus where th 
diagnosis was made by examination of th 
curetted scrapings. On removal the uterus 
was found infiltrated with small nodular 
fibromyomatous growths of some which ha 
become involved in the cancerous process. 
One, near the mucous membrane just aboy: 
the cervix, showed adenocarcinoma, which 
was also seen on the mucous membrane cov- 
ering the fibroid. A second tumor was a 
small polyp of a glandular character but not 
malignant. A third was a small fibroid 
polyp with carcinomatous degeneration on ils 
surface. 

It seems well established that carcinoma 
of the uterus accompanying myoma is more 
common than sarcoma complicating the same 
tumor. Among McDonald’s 280 cases of 
fibromyoma were 6 cases of adenomyoma, as- 
sociated with adenocarcinoma of the body 2 
of carcinoma of the cervix and one of chorio- 
epithelioma malignum. Noble, among 275 
cases of myoma, had 6 of adenocarcinoma of 
the corpus, 4 of epithelioma of the cervi 
one of chorioepithelioma malignum and one 
case of carcinomatous infiltration of the 
fibromyoma arising from adenocarcinoma 
the body of the uterus by metaplasia. Mar- 
tin’s 205 cases of myoma were accompan} 
by adenocarcinoma of the corpus in 7 an! 
carcinoma of the cervix in 2. Frederic’, 
among 125 cases of fibroid of the uterus ha! 
6 cases of carcinoma of the body and 2 
epithelioma of the cervix. Scharlieb’s seri 
of 100 cases had carcinoma complicating t 
fibroid in 2 and one case of carcinoma inva 
ing the fibroid tumor itself. Hunner’s 1'\) 
cases had accompanying carcinoma of | 
body in 3, adenomyoma in 2, carcinoma 
the cervix in 2. ‘ 


omé 
mal 
pret 
the 
the | 





MALIGNANCY IN UTERINE MYOMATA—LEWIS. 


That there is an etiological relation be- 
tween adenocarcinoma of the corpus uteri 
nd fibromyoma seems probable, although the 
exact relationship cannot be stated. Richelot 
says that every fibroma of the uterus is ac- 
companied by hypertrophy of the mucous 
membrane of the uterus. He also expresses 
the opinion that fibroids really predispose a 
uterus to malignancy. Wyder and von Combe 
tend to show by their studies that fibroma 
induces hypertrophy of the mucous mem- 
brane. It has long been the opinion of gny- 
ecologists that the hemprrhages in cases of 
uterine fibroids were caused by hypertrophic 
endometritis accompanying the tumor and 
caused thereby. On the other hand Theilha- 
ber and Hollinger, in a study of 19 cases of 
' myomatous uteri, found that the bleeding 
fibroids were accompanied with little or no 
hyperplasia of the endomentrium while in 
those which did not bleed the mucous mem- 
brane averaged a little thicker. The muscu- 
lar layer is always much thicker in myoma- 
tous uteri and also in carcinoma of the body. 

It is unlikely that the casual connection 
between fibroids and carcinoma of the body 
is on the side of the carcinoma influencing 
the fibroid because the growth of the carcin- 
oma is usually rapid while that of the non- 
malignant fibroid is slow. When a fibroid is 
present in the wall of the uterus the rest of 
the wall is much thicker than normal and 
the blood supply to the whole organ is greater. 
The tendency is to a supernutrition of the 
endometrium and a hypertrophy of the 
glandular portion, which frequently may go 
on to malignancy. The fact remains, how- 
ever one explains it, that adenocarcinoma of 
the body is relatively more frequent in myo- 
matous uteri than in others. 

Babcock gives a careful pathological report 
of three cases operated upon by Noble. They 
were three hysterectomies for medium-sized 

ultiple myomata complicated with carcino- 

Two were affected with adenocarcinoma 
the body and one with extensive epithelio- 

a of the cervix. All three were in women 

siderably past the menopause. The symp- 

ms began with irregular hemorrhages and 
tor a serous and offensive discharge. Nu- 
erous authors write of the relative fre- 


317 


quency of adenocarcinoma of the body of the 
uterus accompanying fibroid tumors. These 
tumors are usually interstitial.or submucous, 
just the sort which cause most circulatory 
disturbance and irritation to the endome- 
trium and musculature of the uterus. Roger 
Williams describes 7 cases of cancer of the 
uterine body, two of which were accompanied 
by fibroids and a third of which had been op- 
erated upon five years before for the removal 
of a submucous fibroid. In one of the cases 
thé epithelial growth had penetrated the 
myoma itself. Stone gives 4 cases of malig- 
nant adenoma of the corpus uteri in which 
the uterus was inspected and in one subperi- 
toneal and interstitial fibroids were present. 
Kelley reviews one hundred cases of uterine 
cancer and finds that fibromyoma was also 
present in 8.6 of which 8 were adenocarcino- 
ma of the body, 1 adenocarcinoma of the cer- 
vix and 1 epithelioma of the cervix. Schroe- 
der estimates that only 3.4% of uterine car- 
cinoma originate in the body. If therefore 
adenocarcinoma of the body and fibromyoma 
were merely coincident, we would not expect 
that the two would be found together so 
much more often when the cancer was in the 
body than when it was in the cervix. If 
merely coincident, we would expect the pro- 
portion of coincidences in the cervix to be as 
great as the proportion of preponderance of 
cervical over corporal cancer. 


Croisier reports one interesting case which 
illustrates one phase of the question. A 
woman of 39 years began to experience a 
prolongation of duration of the menses, a 
slightly increasing frequency and an increas- 
ing loss of blood. The severity of these 
symptoms progressed until in a few months 
the hemorrhages were almost constant. 
Through the speculum a polyp could be seen 
protruding through the os. This seemed to 
account for the hemorrhages and tampon was 
employed to dilate the os preparatory to 
snaring off the polyp. When dilatation was 
accomplished it was found that the pedicle 
was too large for snaring. Some pieces of 
the tissue of the polyp removed in the 
efforts to snare were subjected to microscopic 
examination and adenocarcinoma was found. 
A supravaginal amputation of the uterus was 





318 MALIGNANCY IN UTERINE MYOMATA—LEWIS. 


performed. A spherical tumor of whitish 
yellow color and the size of a pigeon’s egg 
was attached by a pedicle at the fundus, the 
tumor filling the uterine cavity. Several 
nodules as large as peas were at the base of 
this tumor. The structure of the tumor was 
of young connective tissue elements and mus- 
cle fibres with a preponderance of connective 
tissue. At the level of the pedicle the 
mucosa of the uterus was of a papular form, 
thickened and ulcerated. There was no line 
of demarcation between the mucosa and mus- 
culature. Numerous epithelial tubes pene- 
trated the muscularis; in short there was a 
typical adenocarcinoma around and at the 
base of the fibrous polyp. The rest of the 
endometrium showed signs of endometritis. 
In the discussion Richelot stated that it was 
not necessary to establish a causal relation 
between fibroid and adenocarcinoma that the 
former be large. Of 4 uteri removed recently 
by him for carcinoma of the body all 
possessed fibromyomata in addition. He 
deduces the conclusion from his experience 
that a fibromyomatous uterus is a soil on 
which carcinoma may readily develop. 


Malignant disease of the cervical stump 
recurring after sub-total hysterectomy is 
considered by this author to be sufficiently 
common to warrant panhysterectomy in all 
cases. In his experience this occurred in 
3 cases out of 13. Bland Sutton reports a 
case where carcinoma was present unsuspected 
in a case of total hysterectomy for fibroids 
and reappeared in the vaginal cicatrix. 


Malignant disease, as has already been 
stated, is a rarer form of complication of 
fibroids in the cervix than in the body. 
Haultain, in his long experience, saw it only 
once with a large fibroid and 3 times with 
small fibromyomatous nodules. Grube 
records a curious case of delivery per vias 
naturales of a fibroid polyp as large as a 
hen’s egg in a woman suffering also from an 
inoperable carcinoma of the cervix involving 
the bladder. There ‘was no carcinoma of the 
body. 


As we have seen the presence of adenocar- 
cinoma of the body in connection and in the 
same uterus with fibromyomatous tumors is 


not very rare, indeed common enough t 
make it a serious factor in our estimation 
of the disease. The actual invasion of th 
myoma by carcinoma cells is not ofte 
recorded, indeed it is a very rare occurrenc« 
Such a case is recorded by Scharlieb. Th: 
patient was a single woman aged 61. Inter 
mittent hemorrhages and foul discharge fron 
the uterus led to examination and discover 
of an enlarged uterus and carcinoma of th 
cervix. 

The bulk of the organ was caused by 
fibromyoma one portion of which was at 
tacked by carcinoma of the same histologica 
structure as that of the cervix. No dire 
extension of the cervical growth could | 
traced upwards into the corpus. 

Under the microscope I show a specime 
of fibromyoma taken from the fundus in th: 
small nodules of which are numerous nests 
of epithelial cells resembling those found in 
carcinoma of the cervix of the same uterus. 
The growth is seen mostly within the 
fibromyomata and much less abundant in the 
other musculature of the uterine body. 


Noble reports a case of invasion of th. 
fibromyoma by adenocarcinoma of the body. 
A virgin, aged 63 years, who had passed 
the menopause at 45, began to have profus: 
and foul smelling leucorrhea with frequent 
slight hemorrhages. There was also irrita- 
bility of the bladder with occasional incontin- 
ence. A clinical diagnosis was made of 
degenerating fibroid from these symptoms 
and the discovery that the uterus was mucl 
enlarged and nodular. Curettage ani 
microscopical examination revealed no car- 
cinomatous scrapings. Supravaginal ampu- 
tation was performed. The uterus was : 
large as a fourth month pregnancy and con- 
tained in its cavity a pedunculated fibroi: 
The endometrium appeared normal macro- 
scopically but microscopically showed aden: 
carcinoma at the apex of the fibroid an 
on the opposite wall. Within the fibroid we 
numerous areas of carcinoma in considerab: 
part resembling squamous celled cancer b 
also showing something of the adenomato 
type. The cervix is reported to have look: 
normal at the operation and was not r 
moved. 


Wi 
m 


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To 

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tum 
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MALIGNANCY IN UTERINE MYOMATA—LEWIS. 


\ few other cases of extension of carcinoma 
m other part of the uterus and cervix into 
tissues of the myoma are reported and 
case of metastasis into the fibroid from 
er in the lung. 


low far does our present knowledge of 
probabilities of the supervention of 
elignancy in a fibromyoma justify us in 
ing rules for operation upon such 
mors? What fibromyomata should be 
rated upon and what may safely be left 
thout operative interference? It is not 
y purpose to consider those indications for 
operation like complications with ovarian or 
tubal disease, necrosis of the tumor, twisted 
pedicle of a pedunculated fibroid, pressure 
on neighboring structures causing symptoms, 
complication with pregnancy and the like. 
To all of these factors as indications for 
operation may be added the possibility of 
malignancy. If operation is decided upon, 
is myomectomy the proper procedure or 
should im all cases the uterus be totally or 
partly removed ? 


Most modern authorities advise operation 
if symptoms are present which threaten life 
or which cause suffering or even great dis- 
comfort. Hirst would operate in only 20% 
of his cases of fibromyoma. It is generally 
conceded at this time that no other treat- 
ment except operation is worth trying or 
indeed safe to try. That is, in other words, 
if we do not operate we ought to let the 
tumor alone. If the tumor demands any 
treatment except that of a placebo, it de- 
mands operative treatment. 


R. Williams attempts to prove that fibro- 
myoma of the uterus is not a very fatal 
Others have stated that the mor- 
of operations undertaken for fibroids 
is greater than the average mortality if the 


disease. 
talit 


tumors are left without treatment. In the 
report of the Registrar-General of England 
for \901 it appears that, out of a population 
of 1> million females, only 339 are recorded 
to have died of uterine myoma. The 20th 
U. ». Census shows a record of 657 deaths 
fron. myoma in a population of 37 million 
females. From this the inference is, unless 
we - udy further, that uterine myoma is not 


319 


a disease that causes death in any consider- 
able proportion of instances. The discre- 
pancy however between the figures for 
population and for deaths from myoma will 
diminish when we consider the ages and 
social states of the women who have 
myomata. The prevailing age when the 
diagnosis is made is from thirty-five to fifty- 
five. Many more single women are affected 
than married women. Many more sterile or 
nearly sterile women are affected than pro- 
lifie women. Williams hazards the belief 
that 20% of all women over thirty-five years 
old have fibroids. From that assumption he 
jumps to the conclusion that one million 
patients in England are affected with fibroid. 
This is equivalent to saying that 10 females 
in every 36 are over thirty-five years old, a 
preposterous assumption. On what justifica- 
tion stands the original statement that 20% 
of all women have fibroids after thirty-five 
no one has shown us. On the other hand 
also the figures 339 deaths from myomata do 
not represent all the damage done by such 
tumors. Death certificates are notoriously 
inaccurate upon which to base conclusions as 
to frequency of diseases. Those cases only 
are recorded where the myoma was the sole 
or the prominent cause of death. In an 
immense number it is probably a more or 
less remote accessory cause. Peritonitis and 
sepsis from infection on account of the 
fibroid will be entered under other headings. 
In cases of carcinoma of the uterus ac- 
companying fibroid of that organ the death 
will almost always be entered as due to the 
malignant disease. We also leave out of 
account those cases of heart disorder ac- 
companying or bearing a causal relation to 
fibromyoma which must in many instances 
be more or less close accessory causes of death. 


It may be doubted whether 20% of all 
women over thirty-five have fibroids but it 
is certain that a very large number have 
them without symptoms. Autopsies after 
death from other causes frequently find large 
or small fibromyomata and operations upon 
the uterus or pelvic organs often reveal small 
fibroids which had been causing no appreci- 
able symptoms. Such, however are not the 
fibroids which are diagnosed as fibroids. 





320 


When a pelvic examination reveals a fibroid 
it almost always happens that the woman 
came for such examination because of symp- 
toms and these symptoms usually have been 
caused by the presence of the fibroid. 


From the statistics of McDonald, Noble, 
A. Martin, Frederick, Hunner, Scharlieb 
and Haultain I gather that, out of 1518 
cases of fibromyoma of the uterus observed, 
72 were accompanied by malignant disease 
of the same uterus. Therefore from these 
figures we judge that about 434% of fibro- 
myomata of the uterus are associated with 
malignancy.* This per centage then is the 
contribution which the chance of malignancy 
alone makes to the indications for operation 
in fibroids. 


Klein advised extirpation of the uterus 
when the fibromyoma continued to grow after. 
the climacterium. He would dare wait only 
where the tumors were of small size and 
then only when they were under constant 
or frequent observation. Most of the best 
modern authorities are becoming less and 
less conservative in regard to operation in 
case of fibroids. 


*Author. 


Adeno-carc of 
Choria-epith. 


: @eam~aa2m body. 


Frederick 
Hunner 
Scharlieb 
Haultain 


Kt & bo bo & bo co Sarcoma. 
> po bo to m te Carc-Cervix. 


Per centages 


Many cases like that of Croisier, already 
quoted, will appear perfectly benign but after 
operation the microscope will prove the 
existence of the germs of malignancy. The 
indications for operation.on fibroids grow 
with the improvement of the technique. The 
smaller the tumor the easier, other things 
being.,equal, is the operation. The longer 
we: let a fibroid grow the harder will it be to 
remove when we finally decide to operate. 
‘The average hysterectomy for fibroids done 


MALIGNANCY IN UTERINE MYOMATA—LEWIS. 


by the best operators has a mortality at les t 
no greater than four per cent. The morta! 
for the operation in cases of small tum: ’: 
operated upon when the patient is in g 
condition, not weakened by repeated losses 
blood, not poisoned by long continued sep 
absorption and not mentally depressed by 1: 
knowledge for a long time that she \ 
carrying a tumor in her abdomen, must 
even much better. For the favorable ca 
we would expect the mortality of the op: 
tion to be little more than for the averi se 
laparotomy. 
The signs and symptoms showing 

actual presence of malignant disease wit! 

a fibromyomatous uterus are not quickly dis- 
tinctive. By the time they have indicat 
the diagnosis it is often too late to hope fo 
anything from operation. I would make 


a working rule that every fibroid of the uter: 
should be operated upon as soon as the 
diagnosis is made except small ones whose 
only symptoms are the slight discomforts 
due to their mechanical presence in the 
pelvis. These should only be excepted when 


the patient can be under proper surveillance 
and is willing to undergo examination at 
intervals of a few months and to report at 
once upon the occurrence of noticeable symp- 
toms of any kind. 


What operation shall be recommended’? 
Shall myomectomy suffice, shall we urge 
supravaginal amputation or total hysterec- 
tomy? If the tumor is small, no larver 
than a hen’s egg, if there are only a few of 
them, especially if they are near the peri- 
toneal surface, myomectomy will be sufficient, 
provided that at the same time careful «x- 
amination of the curetted scrapings uncer 
the microscope does not reveal any sign of 
malignant growth of the endometrium. 
the tumors or the affected uterus is lar 
than one three months pregnant, if hen 
rhages have been a prominent symptom 
the tumors or tumor are near the mu 
surface, supravaginal amputation should 
done. Under other conditions total hys' '- 
ectomy should be the operation of choice. 0 
any event, the tumor after a myomect: 
or the body of the uterus after an amp 
tion should be opened at the time of 





MALIGNANCY IN UTERINE MYOMATA—LEWIS. 


peration and inspected for signs of malig- 
nancy. If possible the freezing microtome 
should be brought into play by a competent 
ssistant while the pelvic toilet is being 
ade. On any suspicion the rest of the 
iterus or the cervix should also be removed. 

wultain says that a fibroid in the pelvis is 
orth two in the museum. I am inclined 


) think that a uterus under suspicion of 
alignancy is in its best situation when 
laced im a jar. 


References. 
Abel—Gynecological Pathology, p. 104. 
Babcock—Coexistence of Carcinoma and 

fibroma, Am. Gyn. and Obs. J., 1898, XITI., p. 401. 
Babes—Wiener Allg. med. Zeitung, 1882, No. 


Baker & Graves—Am. Jour. Obs., 1903, Sep. 
Beyea—Am. Textbook Pathology, p. 1040. 
Bishop—Uterine Fibromata, London, 1901, p. 
324. 
Buhl—(Extension 
uterus), Mitt. 
1878, p. 291. 
Busse—Ueber sarkomatose Entartung der 
Myome, Deutsche med. W. 1904, XXX p. 371. 
Chrobak—Myosarkom, Monats. f. Geb. u. 
Gyn., 1896, III. 
Croisire—Gynecologie, Paris, 1904, No. IX, p. 


to fibroid of cancer of 
a. d. path. Inst. zu Munchen, 


9. 
Cullen—Cancer of Uterus, p. 410. 
Cullen—Jour. Am. Med. Assoc., 1903, p. 367. 
Cullingworth—100 Cases Uterine Fibromata, 
Jour. Obs. and Gyn. Brit. Emp. '02. 
Danville—Cancer du corps develloppe sur un 
fibrome, Bull. et mem. soc. anat. Paris, 1903, 
LXXVIII, p. 915. 
Delage—Coexistence fibrome et cancer du 
col, ditto, 1901, p. 341. 
Dirner—Fibrom und Karzinom in demselben 
Uterus, Zentralb. f. Gyn., 1904, p. 782. 
Dorland—Coexistence of Carcinoma 
Fibroid Phila. Med. Jour., 1901, p. 618. 
Eastman—Shall We Remove All Fibroids of 
the Uterus on Diagnosis, Am. Jour. of Obs., 1904, 
p. 678. 
Ehrendorfer—Karzinom und Myom, Centralb. 
f. Gyn., 1892, p. 513. 
Flaishlen—Myom und Corpus 
Zeitsch. f. Geb. u. Gyn., 1901, p. 179. 
Ford—Fifteen Years Experience with Uterine 
Fibroids, Amer. Med., 1904, VII, p. 543. 
Frederick—125 cases Uterine Fibromata, Am. 
Gyn., 1902, p. 255. 
Garrigues—Diseases of Women, p. 454. 
t‘ebhard—Path. Anat. der weib. Sexualor- 
» p. 114. 
‘lockner—Myom mit Corpus Carcinom, Zen- 
alb. f. Gyn. 1904, p. 551. 
tottschalk—(Carcinom u. Myom), Monats. f. 
u. Gyn., XIX, p. 147. 
Grube—Zentralb. f. Gyn., 1903, p. 703. 
Hauber—Sarkom und. Myom, In. 
unchen, 1903. 


and 


Carcinom, 


Diss., 


321 


Haultain—Malignant Uterine Complications 
of Fibromyomata, Jour. Obs. and Gyn. Brit. 
Emp., 1904, p. 120. 

Hirst—Textbook of Gynecology. 

Hitschmann—aArch. f. Gyn., B. 69, H. 3. 

Hoffmeyer—(Cardiac Diseases and Fibroids), 
Pozzi’s Gynecology, p. 203. 

Hunner—100 Consecutive Cases of Myomata 
Uteri, Ala. Med. Jour., 1902-3, XV, p. 411. 

Jacobi—Case of Myosarcoma, Am. Jour. Obs., 
1902, p. 218. 

Jesset—Cancer of Uterus, p. 73. 

Von Kahlden—Ziegler’s Beitrage, XIV, 1893. 

Kelly—Operative Gynecology, vol. II. 

Liebmann—(Cancer of Myoma from Wolf- 
fian Remains), Virchow’s Arch., 1889, CX VIII, p. 
$2. 

Martin, A.—Centralb. f. Gyn., 1888, p. 389. 

Martin, .F. H.—North Am. Practitioner, Mar. 
1896. 

McDonald—Complications and Degenerations 
of Uterine Fibromata, Jour. Am. Med. Assoc., 
1904. 

Noble—Complications and Degenerations of 
Uterine Myomata, Brit. Med. Jour., 1901, p. 170. 

Noble—Amer. Gynecology, 1903, p. 297. 

Noble—Report of a Case of Invasion of a 
Fibroma by Adenocarcinoma, Am. Jour. Obs, 
1904, XLIX, p. 306. 

Phillips—A Case of Fibromyoma of the 
Uterus with Cancer of the Cervix, Lancet, 1904, 
Il, p. 1209. 

Pick—Myosarkom, Arch. f. Gyn., XLVIII. 

Richelot—Traitement du Cancer du Uterus, 
Ann. de Gyn. et d’Ost., Paris, 1900, LIV, p. 214. 

Ricker—Virchow's Arch., CXLII, 1895. 

Rohrig—Zeits. f. Geb. u. Gyn., 1880, V. p. 265. 

Rolly—(Cancer of Myoma from Wolffian 
Remains), Virchow’s Arch., 1897, CL, p. 555. 

Ruge und Veit—Zeits. f. Geb. u. Gyn., 1881, 
VI, p. 261. 

Schaper—(Carcinoma in Fibroids by Metas- 
tasis from Lung), Virchow’s Arch. CXXIX, p. 
61, 1892. 

Scharlieb—Analysis of 100 Cases Fibro- 
myoma, Jour. Obs. and Gyn. Brit. Emp., 1902, 
Il, p. 323. 

Spanton—Sarcoma and Myoma of Uterus, 
Brit. Med. Jour., 1904, I, p. 19. 

Stockel—Myosarcoma Corporis, 
Gyn., 1904, p. 1086. 

Stone—N. Y. Med. Jour., July 27, 1895. 

Szasz—Combination Fibrom mit Karzinom, 
Zentralb. f. Gyn., 1903, p. 177. 

Theilhaber und Hollinger—Arch. f. Gyn., B. 
71, H. 2, p. 298. & do B. 73, HI, p. 1. 

Ulesko-Straganova—Ueber das maligne 
Myom, Monats. f. Geb. u. Gyn., XVIIL H. 3 
& 4. ‘ 

VanHoosen—Sarcomatous Degeneration of 
Uterine Fibroid, Am. Jour. Obs., 1903, LVII, p. 
233. 

Weir—Muscle Cell Sarcoma of Uterus, Am. 
Jour. Obs., 1901, p. 618. 

Williams, R.—Is Fibromyoma of the Uterus 
Often a Fatal Disease? Brit. Med. Jour., 1964, 
I, p. 461. 


Williams, R.—Uterine Tumors, London, 1901. 


Zentralb. f. 





322 


Williams, W.—Myosarcoma, Am. Jour. Obs., 
XXIX, 1894, do 1904. 

Wilson—Heart Disease with Uterine Fibroids, 
Jour. Obs. and Gyn. Brit. Emp., 1904, August. 

Wyder und von Compe—aArch. f. Gyn., B. 
XXIX. 





THE COURSE AND SO-CALLED COM- 
PLICATIONS OF CHOLECYSTITIS. 


BY BAYARD HOLMES, M. D., CHICAGO. 


The object of this paper is to call attention 
to the serious consequences of cholecystitis, 
and thus to secure an early recognition of the 
disease and an adequate surgical treatment. 
There are difficulties of diagnosis to be over- 
come which will only be considered when the 
dangers of cholecystitis are sufficiently ap- 
preciated. 

Cholecystitis is the initiatory disease of 
trifling significance and often unobserved 
manifestations which is followed by a series 
of most terrible and explosive disasters in the 
upper peritoneal cavity. While appendicitis 
is a disease of the young and of all subse- 


quent decades, cholecystitis is more generally 
recognized as a disease of middle life; and 
while appendicitis is a disease more frequent- 
ly observed in males, cholecystitis and its 
complications are particularly frequent in 


females. There is hardly any disease of the 
stomach, liver, duodenum, small intestine 
and the blood vessels which may not be de- 
pendent directly or indirectly upon cholecy- 
stitis. The course of cholecystitis is onward, 
progressive and destructive, though slow and 
uncertain. It may terminate disastrously at 
any time, and it must termfnate sooner or 
later in one of the sequelae peculiar to itself 
or in the passage of the stone into the com- 
mon duct and the manifestations of this 
dread disease. If we were to catalogue the 
ills which follow cholecystitis, we ought to 
refer to those which are clinically most com- 
mon, and a series somewhat like the follow- 
ing would be formed; indigestion, gastric 
hypersecretion, gastric insufficiency, atonic 
gastritis, dilatation of the stomach, general 
toxemia, recurring sickheadaches, biliary 
colic, gangrene of the gall-bladder, rupture 
of the gallbladder, pericystic abscess, abscess 
of the liver, not to mention the complications 


CHOLECYSTITIS—HOLMES. 


that follow the passage of the stone into t! 
common duct. 

Since cholecystitis terminates naturally i 
the passage of the stone or stones into t! 
common duct, it is more rational, logical a: 
systematic to consider those complications « 
sequelae of cholecystitis which occur in t! 
natural progress of the disease before tlw 
stone reaches the common duct, and consider 
those which follow or attend the passage 
the stone through the common duct in an 
article by themselves. The reason that such 
a division is desirable rests upon the fa 
that the surgical treatment of these two 
groups is quite different. The treatme: 
of a cholecystitis and its immediate comp)|i- 
cations is under the best circumstances ; 
cholecystectomy, a relatively simple, dire: 
and effective procedure. The treatment 
cholelithiasis after the stone has reached thie 
common duct is much more difficult, dan- 
gerous and less effective, and the number of 
operative procedures necessary is consider- 
able, and their technical difficulties numer- 
ous and great. The multiplicity and the re- 
lations of these complications are like the 
streets of a city going out from the port or 
market place They are graphically but in- 
completely shown in the following scheme : 

COMPLICATIONS OF CHOLECY- 

STITIS. 


A.—Those that occur before the passage of 
the calculus from the cystic duct 
into the common duct. The first 
act of the disease. 

(1) Obstruction of the cystic duct, 
or without calculus. 

(a) Without infection within the 
bladder (?) -Hydrops of 
bladder. 

With infection within the ¢g 
bladder, with or without stone. 
Empyema, (b) Gangrene of 
gallbladder. 
(1) Rupture of gallbladder into fre 
peritoneal cavity. 
(1) Local peritonitis. 
(a) Uninfected. 
traumatism. 


(b) 
(a) 


(a) Fre 





CHOLECYSTITIS—HOLMES. 323 


(2) General peritonitis. 
(b) Infected. (b) 
gic. 
(2) Rupture of gallbladder into attached 
viscera or tissues. 
1. Into duodenum. 2. 
3. Into colon. 4. 
stance. 

Into the abdominal wall. 

Into the round ligament of the 
liver. 

Into the perirenal connective 
tissue spaces. 

Into the pelvis of the kidney or 
ureter. 

Into the diaphragm, thorax, 
pleural cavity, pericardium 
or lung. 

10. Into a small intestine. 
11. Into a hernial sac. 
12. Into the portal vein. 
(3) Pressure and partial or complete ob- 
struction by the distended gallbladder or 
eystie duct. 


Patholo- 


Stomach. 
Liver sub- 


1. Upon the duodenum, ectasia of 
the stomach. 

2. Upon the hepatic or upon the 
common duct, jaundice and 
cholemia. 

Upon the portal vein, ascites or 
gangrene of the ileum. 

Upon the hepatic artery, anemia 
of the liver, aneurysm of the 
hepatic artery. 

Upon the mesenteric artery ( ?) 

Upon the pancreatic duct (?) 

Upon the transverse colon. 

Upon the receptaculum chyli ( ?) 

9. Upon the vena cava. 

(4) Attachment of gall bladder or cystic 
duct to adjacent viscera or tissues by old ad- 
hesions. 

1. To abdominal wall. 

2. To duodenum. 3. To stomach. 

4. To colon. 

(5) Displacement of the gallbladder. 

1. Hypertrophy of the mucosa, 
papilloma of gallbladder. 

2. Atrophy of gallbladder. 

3. Hemorrhage from gallbladder. 


4. Suppurative lymphadenitis in 
glands to which gallbladder is 
tributary. 

5. Carcinoma of gallbladder. 

B.—T hose that occur at or after the passage 
of the stone into the common duct. 
The second act of the disease. 
Obstruction of the common duct. 
(a) Cholemia. (b) Hepatitis. 
(c) Pancreatitis. (d) Cholangi- 
tis. 


(1) 


(2) Rupture of the common duct. 
Same as (1) and (2). 

(3) Suppurative lymphadenitis in glands 
to which the common duct is tributary. 

(4) Pressure, extension of inflammation, 
partial or complete obstruction, by distended 
common duct. 

(a) 
(b) 
(c) 
(d) 

(5) Attachment of the common duct by 
old adhesions to adjacent viscera. 

Hydrops of the gallbladder is a condition 
which is occasionally observed—though a case 
has never come into my clinical experience— 
in which the cystic duct is obstructed and the 
gallbladder is filled with its own uninfected 
secretions. It is a condition of little clinical 
significance except for the fact that this 
aseptic condition is not likely long to pre- 
vail. Sooner or later it passes into a condi- 
tion of infection, if it has not held during 
the whole time somp microorganism of 
diminished vitality or virulency, and if the 
system has not been protected by an intact 
mucosa. 

Empyema of the gallbladder occurs both 
with and without stone, and it appears in 
patients who have suffered many years un- 
consciously of the disease, as we find at oper- 
ation when the gallbladder is half to three- 
quarters of an inch thick, and the cystic duct 
for the first time completely obstructed by 
a calculus three-quarters of an inch in diam- 
eter. The suddenness with which the em- 
pyema is precipitated is one of the peculiari- 
ties of the disease. Through some unusual 
attitude of the body or activity of the ab- 


Upon the duodenum. 
Upon the portal vein. 
Upon the hepatic artery. © 
Upon the pancreatic duct. 





324 


dominal viscera, or trifling injury, the stone 
becomes fixed in the cystic duct. The in- 
fection which has silently and quietly drain- 
ed through the common duct is suddenly ar- 
rested; the mucosa is rendered anemic; it 
undergoes necrosis; the infection gains ac- 
cess to the lymiph channels, and the patient 
suffers the sudden toxemia of abscess forma- 
tion. The temperature rises high, with a 
rapid pulse and a hyperleucocytosis, with all 
the symptoms of sepsis. If this is an event 
early in the progress of a chronic cholecysti- 
tis, the muscularis and serosa may be rend- 
ered edematous with the infected lymph, and 
a pericholecystitis, with pericholecystic peri- 
tonitis of greater or less éxtent, may be added 
to the picture of an abscess of the gallblad- 
der. Such a case was that of Miss C., and in 
her case the rapidly increasing tumor happily 
gave rise to that ominous symptom, black 
vomit, which secured prompt attention. The 
enlarged gallbladder obstructed the duo- 
denum analward of the entrance of the com- 
mon duct, the bile was regurgitated into the 
stomach, and it was vomited. In the case 
of ‘Dr. W.’s patient the primary, chronic dis- 
ease had been present for years, and the 
complete obstruction of the cystic duct and 
abscess of the gallbladder came on during 
the removal of the morphine in the morphine 
cure, and the symptoms were overlooked until 
the gallbladder was almost perforated by 
anemic necrosis. 


Gangrene of the gallbladder is incident to 
the peculiar blood supply of this viscus. It 
will be noticed that the gallbladder is sup- 
plied with blood by an artery leading off 
from the hepatic, which divides itself into 
two main branches. They pass close together 
on to the gallbladder in a connective tissue 
framework which carries the cystic duct. 
Most of the stones which produce complete 
obstruction of the cystic duct find them- 
selves in the haustra of this irregular and 
tortuous strait, and the obstruction of the 
cystic duct with a stone is liable therefore 
with the distention of the gallbladder to 
thrust the stone violently and constantly 
against the cystic artery, compressing it 
against the thickened and almost cartilagin- 


CHOLECYSTITIS—HOLMES. 


ous connective tissue and lymph glands at the 
neck of the gallbladder. In this manner, 
and in the process of inflammation, and on 
account of the arteriosclerosis which affect: 
all the blood vessels of the gallbladder in th 

course of a chronic cholecystitis, the bloo 

supply of the whole viscus is cut off at onc 

and the anemic gallbladder quickly unde: 

goes necrosis. The tissues about the ston 

are invaded with every microorganism whic): 
has gained access to the gallbladder, and we: 

it not for the slight collateral circulation be- 
tween the gallbladder and the adjacent liver 
this would be more complete than it usu- 
ally is. 

When the gallbladder has become a mass 
of thickened connective tissue, with scarce] 
a trace of muscular fibers in it, with a great!) 
atrophied mucosa and imperfect arterial, 
venous and lymph circulation, the obstruc- 
tion of the cystic duct is a much more seri- 
ous affair. The patient has probably suffered 
for twenty years of recurring attacks of ob- 
struction of the cystic duct and infection of 
the gallbladder, and has come to look upon 
gallstone colic as a terrible punishment of a 
week or so of agony, to be followed by months 
of relative relief and comfort. He and his 
physicians have overlooked the fact that each 
attack has changed the character of the gall- 
bladder wall; each attack has found a less 
elastic, less vascular, and more sclerotic gal!- 
bladder; until, at last, with the hypertrophy 
of the lymph element, the atrophy of the 
muscular and mucous element, and the con- 
traction of innumerable scars, the site of 
hemorrhages, ecchymoses, infarcts in thie 
mucosa, and pressure atrophy ulcers, th 
parchment-like gallbladder is unable to wit!- 
stand further insult, and gives way at tl. 
fundus or at some beginning diverticulum, 
with a whole mass of necrosis and gangrene 
of a large segment of the viscus. 

Rupture of the gallbladder into the free 
peritoneal cavity is an event which may | 
looked upon as the one indication for sur- 
gical treatment upon which physicians, sur- 
geons and laymen alike agree. It occurs nt 
only in the process of empyema and gangre ie 
of the gallbladder, but it also appears as 4 





CHOLECYSTI TIS—HOLMES. 


local, pressure atrophy necrosis immediately 
over a stone in a haustra of the cystic duct. 
Perforation must then be looked for in the 
callbladder in the course of over-distention, 
phlegmonous inflammation, and massive gan- 
grene, and also in the cystic duct or in a 
diverticulum of the gallbladder into which 
a caleulus has become irremovably entangled. 
The result of rupture of the gallbladder is 
dependent upon the infected or uninfected 
condition of the escaping content. If it is 
pure bile, then the reaction of the surround- 
ing peritoneum is a toxic peritonitis, which 
is repairative in its tendencies and limited in 
its character. It matters not how extensively 
it invades the peritoneal cavity; as soon as 
the rupture is repaired and the escape of bile 
is arrested, the peritoneum takes up the effu- 
sion, and nothing is left to show what has 
occurred except a few crystals of cholesterin 
resembling bisected gallstones attached to 
the peritoneum which made up the bed of 
the receding lake of bile. This condition is 
illustrated by a gallbladder and the sur- 
rounding lake of stagnant bile which was 
operated upon by Dr. Weller Van Hook, and 
the gallbladder and a piece of the omentum 
preserved in the laboratory at the North- 
western University Medical School. The ex- 
tensive lake was bounded by abdominal wall, 
omentum, and portions of other viscera, 
which were encrusted with innumerable con- 
cretions resembling gallstones and feeling 
like the back of a reptile. One of my pa- 
tients had an effusion which filled the whole 
upper peritoneal cavity and the pelvis and 
was mistaken for a periappendiceal abscess. 
The two lakes were connected by a narrow 
straight along the outer or lateral side of the 
ascending colon. This patient recovered af- 
ter the drainage of the cephalic and pelvic 
lakes. The gallbladder was untouched, and 
the perforation closed and has remained so 
for several years. 


When the rupture occurs in an infected 
gallbladder or cystic duct, the resulting peri- 
tonitis is dependent upon two conditions; 
the first is the extent of the peritoneum in- 
volved, and the second is the character or 
viruleney of the infecting microbe. When the 


325 


perforation takes place into the general peri- 
toneal cavity, a general peritonitis results. 
When it occurs into a peritoneal pouch which 
has been walled off from the general peri- 
toneal cavity by protective, adhesive periton- 
itis, a local abscess or infection results. When 
a gallbladder infected with the typhoid bacil- 
lus alone, or with the pneumococcus, breaks 
into the peritoneal cavity, the resulting peri- 
tonitis is less virulent, septic and toxic than 
that which follows the discharge of strepto- 
coccus or colon bacillus pus from an empye- 
ma or gangrene of the gallbladder. The ap- 
pearance of a perforation can never be fore- 
told, suspected or prevented. Sometimes it 
occurs with the very first sym¥ptom of biliary 
colic. Again, a patient may suffer innumer- 
able attacks of a most threatening aspect, 
and the gallbladder remain intact. It is not 
a wonder that physicians of extensive prac- 
tice trust to the uncertain eventualities of 
biliary colic after seeing the threatening 
symptoms of these attacks pass off willy nilly 
into the sunshine of health. Nothing can so 
impress the uncertainty of perforation of the 
gallbladder as the record of a case which 
occurred in a young man of apparently per- 
fect health who had never suffered of any 
symptoms of biliary disease until the attack 
which ended his life. 


Mr. W., age 26, a thoroughly well-built 
young man, weighing 170 pounds, and stand- 
ing five feet ten inches in height, was a 
train dispatcher on the Big Four at Kan- 
kakee. He had never been sick in his life 
and had never needed the attention of a phy- 
sician. His appetite and digestion had been 
perfect. There was no history of typhoid 
or any other protracted disease, and he had 
never been troubled with colic, vomiting, or 
other abdominal disturbance. He had been 
married eight months. Three weeks ago he 
had an attack of pain in the abdomen, which 
came on just as he was leaving his work at 
seven in the morning, which he attributed to 
eating some peanut candy. His occupation 
required him to be at work from ten in the 
evening until seven in the morning. He 
vomited several times on his way home, and 
felt so uncomfortable during the next day or 





326 CHOLECY STITIS—HOLMES. 


two that he remained in bed. He frequently 
had severe abdominal pain, which could 
hardly be termed a colic. He took a mer- 
curial laxative, and after three or four days 
of rest he went to work again feeling perfect- 
ly well. Two weeks later, on Tuesday morn- 
ing, April 22, 1901, he vomited several times 
on his way home and had such great abdom- 
inal distress that Dr. John A. Brown was 
called that evening. Wednesday morning his 
temiperature was 100 and his pulse 120. A 
large boggy tumor was felt in the upper left 
hand side of the abdomen, which was thought 
to be a fecal impaction. A large enema was 
given, the bowels moved several times, and 
the tumor seemed to disappear. His suffer- 
ing and pain, however, greatly increased, his 
pulse became more rapid, his temperature 
went down. He was frequently in a profuse 
sweat. Thursday morning he was in worse 
condition. The abdominal pain was great 
and paroxysmal, the temperature remained 
low and the pulse high. Late Thursday af- 
ternoon the vomited matter became fecal. I 
saw himi at midnight. His extremities were 


cold, his abdomen distended, his pulse al- 
most indistinguishable; he vomited at in- 
tervals ; his intellect was clear, and he direct- 
ed his own affairs knowing that he was in a 


dying condition. An area of dullness filled 
the upper left side of the abdomen and ex- 
tended as low as the pelvis. His little flat 
was only a few blocks from the hospital, and 
he was carried there on a stretcher, where he 
arrived at 1 a.m. He had not vomited dur- 
ing the transportation, but on placing him 
on the operating table he vomited again and 
died in five minutes. 


A necropsy made at once showed an ac- 
cumulation of bile-stained fluid in the upper 
or cephalic peritoneal cavity, extending 
downward in the left retrocolic space as far 
as the sigmoid, amounting to at least three 
or four pints. The gallbladder, which con- 
tained a large clove-shaped stone, had a ne- 
crotic, ragged perforation in its cervical por- 
tion apparently directly over the stone. Its 
external surface was covered with gray-green 
fibrin, and clots of greenish fibrin floated in 
the effusion. There was no general periton- 


itis and no perforation in the stomach or evi- 
dence of other disease. 

In the case of a celebrated business man of 
Chicago, rupture occurred, after nearly thir 
ty years of recurring attacks of acute cholecy- 
stitis, less than two hours after the beginning 
of the fatal colic. 

A long respite from colic is no indicatio: 
that the disease has disappeared or that th 
next attack may not be attended by disaster 

The influence of traumatism in precipitat 
ing a rupture of the gallbladder is very we! 
recognized in cases where the rupture occur: 
at once as the result of a blow, a fall, or th 
lifting of a heavy weight. When the abdo 
men is run over by a heavy cart or crushe:! 
between car couplers, the rupture of the gal- 
bladder is frequently a grave complication of 
other injuries. When the bile is free from 
infection, the peritonitis is self-limited an‘ 
repairative ; the absorption of the bile by the 
extensive peritoneal surfaces produces jaun- 
dice, which may complicate the diagnosis 

In cases of cholecystitis even a slight in- 
jury, a jolt, a blow, a sudden muscular action 
may produce impaction of the stone in the 
cystic duct and the initiation of a biliar) 
colic. This colic may go on with distention 
of the gallbladder until the viscus ruptures. 
A traumatism may initiate a deformity in 
the duct or result in a hemorrhage into the 
gallbladder which is the starting point of a 
calculus and the means of localizing infec- 
tion in the gallbladder. Thus, in one case at 
least in my own observation a blow over the 
epigastrium| was followed by severe reaction, 
the symptoms of hemorrhage, and ten years 
later, during an attack of biliary colic, a sin- 
gle gallstone, 1 c.m. in diameter, was dis- 
covered, in the nucleus of which was the evi- 
dence of an old hemorrhage. Kehr, Miinch- 
ner Medicinische Wochenschrift, 189%. 
page 1201, suggests that in certain cases 
cholecystitis is an occupational disease. Ther 
is no doubt that certain injuries, attitude: 
and habits tend to deform the duct and in- 
jure the gallbladder and otherwise precip'- 
tate infection; but no particular class 0! 
people and no particular occupation seems 
more liable than others to cholecystitis. 


tion ¢ 


gall] 
tively 


he 





t 


CHOLECYSTITIS—HOLMES. 


Rupture of the gallbladder into an at- 
tached hollow viscus is one of the most hoped 
for terminations of the expectant treatment. 
It is a fact that in many cases of cholecystitis 
the eystie peritoneum over the stone becomes 
inflamed and attaches itself to the duo- 
denum, the stomach, the colon, the abdom- 
inal wall, the round ligament of the liver, 
the perirenal peritoneum, the pelvis of the 
kidney, or the ureter, or a small intestine, 
and the stone and the content of the gall- 
bladder produce pressure atrophy in the 
adjacent tissues with the ultimate discharge 
of the stone and pus into these neighboring 
parts. The duodenum is the most intimately 
connected with the cystic duct and the neck 
of the gallbladder, against which it naturally 
lies. It is probable that stones perforate 
the duodenum oftener than the other viscera. 
Sometimes more than one channel is made by 
the perforating infection, and more than one 
sinus is found at the necropsy. When con- 
nective tissue spaces, such as the round liga- 
ment of the liver, receives the infection and 
the stone, the discharge of these pathologic 
elements may be found at great distances 
from the gallbladder. They appear at the 
navel; they descend the urachus into the 
urinary bladder; they perforate the dia- 
phragm and produce an accumulation of pus 
in the pleura, the pericardium, or enter the 
bronchus of an attached lung. They dissect 
down the rectus, and the gallstones are dis- 
covered in an abscess in the groin, or fhey 
are removed in a perirectal abscess, or a pel- 
vic abscess in females. They may even be 
found in a hernial sac, or may be coughed up 
or vomited from the trachea or esophagus. 
The pathology of a rupture into an adjoin- 
ing viseus is practically the same in all cases, 
and the danger of awaiting such an event is 
emphasized by the danger of a peritonitis, 
the natural complications of the event in it- 
self, and the unknown deformities which may 
resu!t should a spontaneous recovery follow. 


Pressure and partial or complete obstruc- 
tion of an adjoining passage by the distended 
gallbladder or cystic duct is an event of rela- 
tively common occurrence, which is diagnos- 
tie at times and at other times confusing to 


327 


the observer. The duodenum is naturally 
most often interfered with by the pressure of 
the stone in the cystic duct or by the general 
distention of the neck of the gallbladder, and 
this obstruction initiates a circle of symp- 
toms and reactions which often end in vomit- 
ing and, if we consider the longer course, in 
ectasia of the stomach. This must be looked 
upon as almost a natural consequence rather 
than as a complication of cholecystitis, and 
it gives rise to one series of most unfailing 
diagnostic symptoms. 


Pressure upon the hepatic or upon the com- 
mon duct by a stone in the cystic duct, by 
the distended neck of the gallbladder, by a 
lymphadenitis of the lymph glands, or by a 
phlegmonous infiltration of the tissues about 
the cystic duct, produces an obstruction to 
the exit of, bile from the liver, and gives 
rise to jaundice, enlargement of the liver, 
and cholemia, which may confuse the diag- 
nosis and complicate the treatment In some 
cases even this is so gradual in its onset, so 
unvarying in its course, and accompanied by 
such emaciation, loss of strength and conco- 
mitant symptoms, as to deceive the most crit- 
ical into a diagnosis of carcinoma. Such a 
case was reported before the Chicago Sur- 

gical Society by Dr. L. L. McArthur.* It 
most perfectly illustrates the difficulties of 
diagnosis and the complications of treatment. 

In July, 1901, he had occasion to make 
as a last resort an operation upon a patient 
in the practice of Dr. Henry Favill. This 
patient had been seen by von Jaksch, in 
Prague, who had made a diagnosis of malig- 
nant disease and sent him home immediately 
to die, without thought of operation. When 
the patient reached Chicago he was seen by 
Dr. Christian Fenger. The diagnosis of 
malignant disease was confirmed, and “hands 
off” was the verdict. This patient was in 
that terrible condition which obtains after 
six months’ persistent jaundice. In addition 
to an enlarged and hardened liver he had ex- 
treme ascites. On reviewing the history with 
Dr. Frank Billings and Dr. Favill, they sug- 
gested that as a last resort an exploratory 
incision at least be made, and, if a stone be 
*Annals of Surgery, May 1902, page 666. 





328 


found, the patient be given some relief by a 
cholecystectomy or cholecystenterostomy. In 
the face of an otherwise fatal issue, and 
recognizing the danger of hemorrhage, the 
patient requested the operation. A quick ex- 
ploration of the gallbladder was made. It 
was found packed with stones, with one large 
barrel-shaped stone plugged in the cystic 
duct. The patient died on the third day 
after the operation. A partial postmortem 
examination revealed on the margin of the 
liver, at a point close to the gallbladder, a 
small tumor the size of a hazelnut, which 
was removed for examination and pronounced 
an adenoma. But no malignant disease of 
the liver, the duodenum, the stomach or the 
pancreas was seen. This is not an exception- 
al observation. Before the same Society, Dr. 
James E. Moore, of Minneapolis, reported a 
similar case, and Dr. McArthur himself had 
seen ascites associated with stone in the 
cystic duct. 


It will be noticed that in this case, which 
was easily remediable in the early chronic 
stage of the disease, during which without 
doubt the diagnosis of cholecystitis had fre- 
quently been made, there was no obliteration 
of the portal vein by thrombosis, but simple 
obstruction, giving rise to ascites. The bar- 
rel-shaped stone not only obstructed the por- 
tal vein, but it partially obstructed the com- 
mon duct, and produced dilatation of the 
biliary tracts in the liver, with all those 
changes which accompany biliary stasis and 
cholemia. The study of the anatomic rela- 
tions between the cystic duct, especially the 
cystic duct distended and filled with the 
stone and crowded out of its normal position 
by an hypertrophied and congested liver, and 
the immovable vertebral column, and the in- 
tervening portal vein, common duct, hepatic 
artery, and pancreas, makes the mechanical 
ascites and mechanical jaundice perfectly in- 
telligible. The reason that the hepatic artery 
or the duodenal branch of the hepatic is not 
obstructed so as to give symptoms depends 
upon its rigidity and the free anastomosis 
with the gastric and the duodenal branch of 
the superior mesenteric. 


Pressure of a stone in the. cystic duct or 


CHOLECYSTI TIS—HOLMES. 


upon the portal vein, or an extension of a1 
inflammation from the neck of the gall-blad 
der into the tissues about the portal vein, ma) 
give rise to mechanical obstruction or 1 
thrombosis of this channel, with the serious 
consequences of this accident, namely, ascite: 
and gangrene of the ileum. It is a condition, 
however, which is perhaps more common); 
attendant upon or coincident with a choledo- 
chitis. It can scarcely be looked upon as 
remediable, either by internal medication or 
surgical operation. The symptoms of t 
condition are not prognostic of the terrib 
calamity, and little or no warning is given 
to arouse either the patient or the physician 
to the likelihood of this dire event. Rixf 
reports the following case: 


A man 53 years old, and weighing 225 
pounds, had suffered more or less from ab- 
dominal trouble for eight years. Three years 
ago he had a severe attack of biliary colic, 
in which he is said to have passed a number 
of stones. Since that time he has had more 
or less continuous pain in the abdomen just 
One morning 


below the point of the stone. 
he had a sudden pain just below the umbil- 
icus, so severe as to lead him to take a large 


dose of morphine. He had no chill, but he 
vomited after taking the morphine, and his 
pulse that day was 90 and his temperature 
99. The next day his pulse was 100 and his 
temperature 100. There was spasm of the 
abdominal muscles, especially in the region 
of the appendix, and great local tenderness. 
The third day his pulse was 120, and his tem- 
perature 100. By night the pulse had risen 
to 128 and the temperature to 100.5. On 
the morning of the fourth day his pulse was 
144, his temperature 100; there was gre 
tenderness over the lower half of the ab- 
domen, mostly upon the right side; t! 
were 11,409 leucocytes; some jaundice 
present; the peritonitis seemed to be « 
tered about the appendix ; there was comp! 
obstruction of the bowels, with no passag 
of feces or gas for three days, and the pa- 
tient had the Hippocratic look. Under gen- 
eral anesthesia the abdomen bulged notic 
ably upon the right side, and a tumor cou 
be felt in this region. An incision on ‘the 





CHOLECYSTITIS—HOLMES. 


xternal border of the right rectus showed a 
loop of small intestine twelve inches long 
pletely gangrenous and an equal blue and 
mgested portion on each side of it. This 
ndition of the bowel was not due to hernia, 
torsion or volvulus. The incision was ex- 
tended upward, and the gallbladder found to 
mtain a number of calculi. In order to re- 
ove the piece of intestine the mesentery 
as incised. It did not bleed. Throrabosis 
f the superior mesenteric artery or one of 
its branches was diagnosticated. Instead of 
ypical resection of the bowel the gangren- 
us portion was removed, and the congested 
portions left outside the abdominal wound. 
This course was chosen in preference to a 
resection because the patient was in poor con- 
dition to endure a protracted operation, and 
there was no line of demarcation between tlte 
sound and the diseased gut. The- patient 
died the next day, and the necropsy showed 
a thrombosis of the principal tributary of thie 
portal vein. 


The intimate relations between the neck 
of the gallbladder, the cystic duct, the com- 
mon duct and the portal vein are well recog- 
nized. Just how this partial obliteration of 
the portal vein and the congestion necrosis 
of the intestine took place the necropsy failed 
to show. 


Pressure upon the hepatic artery, produc- 
ing anemia of the liver or aneurysm of the 
artery, is a rarer complication. The pressure 
acts rarely alone, but usually is attended by 
infection, with coincident involvement of the 
common duct or portal vein. Obstruction of 
the mesenteric artery, the pancreatic duct, 
the receptaculum chyli, and the vena cava 
are each of them parts of an epigastric hurri- 
cane, in which a single lesion is apt to be 
overlooked. Only as a residual lesion can 
any of these mishaps come to surgical treat- 
ment. 


Attachment of a gallbladder or cystic duct 
to adjacent viscera by old adhesions is pro- 
duetive of grave maladies and painful lesions 
diffieult to diagnose and amenable only to ex- 
ploratory incision and surgical repair. When 
« gallbladder has discharged itself of its con- 


329 


tent into the stomach, the duodenum, or the 
colon, the condition of the patient may be 
no better, and even worse, than before the 
fortuitous cataclasm. Even adhesions which 
occur in the process of a relatively mild chol- 
ecystitis and pericholecystitis may be deform- 
ing to the stomach or duodenum, to the 
common duct or the vascular apparatus, and 
either produce ectasia of the stomach, hour- 
glass contraction of the stomach, insufficiency 
of the muscular wall of the duodenum, tor- 
sion or aneurysmal dilatation of the blood 
vessels, or obstruction of the lymph chan- 
nels. The diagnostician must always bear 
in mind that these adhesions give rise to 
pain, to obstruction, to the secondary mani- 
festations of cholelithiasis, producing a pic- 
ture which is almost indistinguishable from 
that of a true progressive disease of the gall- 
bladder. 


As a result of cholecystitis the gallbladder 

may be found in any part of the abdomen. 
It was approached by no less a clinician than 
Lawson Tait in the expectation of finding an 
ovarian tumor. It has been found to fill the 
whole right side of the abdomen and thus 
mistaken for a cyst of the right kidney. It 
is sometimes completely buried in adhesions 
and drawn by their contraction from its 
legitimate position to the left side of the ab- 
domen. It may be found under instead ‘of 
over the transverse colon, thus making the 
distention of the colon a sign of no diagnostic 
value. It may be contracted to a parchment- 
like mass covering a stone in the cystic duct, 
or it may be distended in one direction or 
another, or in two or three directions, in sueh 
a manner as to produce diverticula which 
resemble accessory gallbladders. 
_. With the symptoms of a cholecystitis a 
lymphadenitis appears in the lymph glands 
to which the gallbladder is tributary, and this 
infection may go on to suppuration. The 
secondary lymphadenitis remains after ‘the 
subsidence of the primary disease, and) has 
occasionally been erin geet and successfully 
treated. 


Carcinoma appears in the diseased gall- 
bladder, the eystie duct, or their adnexa, with 
a frequency which is so high that it has been 





330 


suggested as an additional indication for 
cholecystectomy. It is likely that carcinoma 
of the gallbladder is preceded in every case 
by cholecystitis and the irritation of gall- 
stones. In 80 to 90 per cent of necropsies 
upon such patients the evidence of a preced- 
ing cholecystitis has been discovered, either 
in the presence of stone or in fistula or de- 
forming adhesions indicative of a primary 
disease. In two cases at least were chole- 
cystostomy has been performed carcinoma 
has subsequently been discovered, and these 
events have been used as arguments for 
cholecystectomy as against cholecystostomy 
in disease of the gallbladder. The fact that 
the early diagnosis of carcinoma of the gall- 
bladder is impossible, and that there is usu- 
ally a decade or two of cholecystitis before 
carcinoma arises, relieves the surgeon from 
any responsibility for the absolute impotency 
of his art. 


We are not so much interested in the ab- 
solute frequency of these complications as 
we are with their inevitable sequence and the 
special disasters which threaten the patient. 
Thus, of all the hopes for relief which the 
luck-trusting physician depends upon none 
is so rare as the perforation of the gallblad- 
der into an adjoining colon and the discharge 
of the stone with the feces. The possibility 
of this rupture, however, any time in the 
course of a violent biliary colic is one of the 
most patent indications for cholecystectomy 
or cholecystostomy. Without the slightest 
warning, and in the course of a biliary colic 
more insignificant than usual, a perforation 
of an infected gallbladder is likely to occur. 
While this is a relatively rare accident, it is 
of no small importance, and the fact that it 
appeals very strongly to the mind of the pa- 
tient and physician leads me to present it 
first in my list of complications and as a 
part of the natural course of the disease. 


A most common event in the course of 
cholecystitis is the advance of the stone into 
the common duct. This event initiates a 
disease of such gravity and with such com- 
plicated and pronounced symptoms, that it is 


CHOLECYSTITIS—HOLMES. 


necessary to treat it in an article by itsel 

Here we shall only refer to the general faci 

most prominent and suggestive. As soon a 
the stone escapes through the last curve o 
the cystic duct, it comes into elastic tissu: 

which make up the wall of the common duct 
and generally finds for itself a roomy cana 

in which it advances from day to day or we: 

to week until it meets some natural or art 

ficial obstruction. The first strait throug 

which it passes is the muscular wall of thi 
duodenum . This gut is perforated on it: 
dorsal side by a longitudinal slit throug!) 
the muscular fibers, and admits the commo: 
bile duct and the larger pancreatic duct a 
the same place. This muscular buttonhol 
offers more or less obstruction to the stone. 
but it eventually, through the distention o 
the duct with the bile behind: the stone, gives 
way and allows the stone to fall beyond th: 
valve, which separates the pancreatic from 
the common duct, into the pouch now pro- 
duced in the mucosa of the duodenum known 
as the Ampulla of Vater. Here the ston 
frequently lies until by the production o! 
connective tissue in the wall of the duct, o1 
through the edemb and atrophy of the mu 
cosa, it completely obstructs the outlet and 
symptoms are initiated. This simple recita 
tion hardly gives any idea of the anguish, 
dangers and catastrophes which threaten the 
patient at every stage of its progress. Thi 
stone passes the outlet of the pancreati: 
duct and obstructs the flow of the pancreati: 
secretion. Worse than this, it drives itsel! 
forward until the pancreatic duct is opene:! 
to the pressure of the bile behind, which ma\ 
or may not be infected with the residue from 
the infected gallbladder. These secretion= 
are driven into the dilated pancreatic duct 
and a pancreatitis of one form or another is 
initiated. At any point in the course of this 
stone through the stormy two and a hal! 
inches it may produce an atrophic necrosis 
of the wall of the duct, or a pericholangitis 
which may terminate in a general peritonitis 
or in such adhesions to the pylorus, the duo- 
denum or the stomach as to cause obstruction 
and initiate this terminal cataclysm. 





G@he Bllinsis Mediial Journal. 


The Official Organ of the State Medical Society. 











OCTOBER, 1905. 








NEXT ANNUAL SESSION, SPRINGFIELD, MAY 17, 18, 19, 1906. 





OFFICERS: 


PRESIDENT—H.C. MITCHELL, Carbondale. 


First VICE PRESIDENT—W. K. NEWCOMB. Champaign. 
SECOND VICE PRESIDENT,—M S. MARCY, Peoria. 
Sacastrany—EDMUND W. WEIS, Ottawa, Ex-officio clerk of council. 
TREASURER—EVERETT J. BROWN, Decatur. 


Eprtror—GEORGE N. KREIDER, Springfield 


ASSISTANT EDITOR AND BUSINESS MANAGER—F. R. GREEN, 68rd and Lexington Ave., Chicago. 


SECTION ONE. 


Practice of Medicine, Medicai 
Specialities, Materia Medica, 


Therapeutics, Etlology, Path- 
cology, Hygiene, State Medi- 
cine and Medical Juris- 
prudence. 

J. Stowell Chairman 
Rd... Memorial Building. 
Chicago. 


H. H. Whitten 
Peoria. 


SECTION TWO. 


Surgery, Surgical Specialties, 
and Obstetrics. 


J. H. Stowel. 
J. R. Christie. 
The Pres. and 


Committee on Prevention of 
Tuberculosis. 


J. W. Pettit, Ottawa. 


Cc. L. Mix, Chicago. 
J. F. Percy, Galesburg. 


Committee on Public Policy and 
Legislation. 


Frank Billings, Chicago. (4) 
Carl E. Black, Jacksonville. 
J. W. Pettit, Ottawa. 

The Pres. and Sec’y. Ex-Officio. 


Committee on Scientific Work. 


Sec’y. Ex-Officio. (9) 


The figures refer to the Coun- 
cilor Districts. 


The Council. 


(1) J. H. Stealy, Freeport. 

«@) W. O. Ensign, Rutland, 
Chairman. 

(3) M. L. Harris, Chicago. 

oO. B. Will, Peoria. 

(6) J. Whitefield Smith, Bloom- 
ington. 

(6) G. E. Black, Jacksonville, 
Clerk. 

(7) E. E. Fyke, Centralia. 

(8) C Barlow, Robinson. 

J. T. McAnally, Carbondale. 








BANQUET TO DR. SENN. 

We understand that early in November 
at the suggestion of the profession of Chi- 
cago the entire country will unite in tender- 
ing a banquet to Dr. Nicholas Senn as a 
token of appreciation of the valuable ser- 
Senn has rendered to medical 
science in the past 38 years. The propriety 
of thus honoring its distinguished members 
which was inaugurated some five years ago 
by the Chicago Society when a banquet was 
given to Christian Fenger will be conceded 
by everyone. The exact details of this func- 
tion which will take place early in November 


vices Dr. 


will be given in our next issue. 


1S THE AUTOMOBILE ADAPTED TO THE 
WORK OF A PHYSICIAN? 

The autocar has evidently come to stay 
and especially during the season now com- 
ing to a close has been used by a large 
number of our readers. Some of them 
report favorably concerning the machine and 
we are desirous of hearing from a great many 
giving the first cost, the cost of maintenance, 
the type of machine used and its adaptability 
to the work. This month we print items 
concerning two machines. May we not hear 


from at least a dozen within the next ten 





332 


days. Give your brethren the result of your 
experience. 





A NEW JOURNAL IN CHICAGO. 

We have received from the Publisher, 
Frank S. Betz of Hammond, Ind., a copy of 
the Journal of -Physical Therapy, edited by 
Dr. Gustavus M. Blech of Chicago. The 
avowed purpose of this publication is to dif- 
fuse knowledge concerning such physical 
agents as the faradic, galvanic and static cur- 
rents, the Roentgen Rays, the ultra violet 
rays, the physicians hands or special machines 
for the administration of massage, vibration 
and gymnastic exercises, apparatus for the 
production of active and passive hyperaemia, 
etc. We welcome the Journal and hope it 
will have a wide influence for good. 





INSPECTION OF PROVISIONS AT THE 
CHICAGO STOCK YARDS UNDER 
GRAVE SUSPICION. 


The Chicago health department bulletin 
in its issue of September 23d makes the 
following statements regarding the inspec- 
tion of provisions in that city. That part 


of it relating to the government inspection 
is remarkable and disgraceful. 
ous President should bring his big stick 


Our strenu- 


with him and look into this matter. It is 
just now more important than digging the 
Panama ditch. 


Early in his administration the present 
commissioner directed his attention to the food 
inspection work of the Laboratory. Effort was 
first concentrated, with all available resources, 
upon the food supplies of the “Ghetto” district 
—its meat, fish, vegetables and fruit; and then 
upon the South Water street commission houses. 
The results have already been given to the 
public in the Bulletin and in the columns of the 
daily press. 


More recently the Union Stock Yards and 
neighboring slaughter and packing houses have 
received attention. 

During the last two weeks the two inspectors 
at the stock yards—the entire available force 
for this work—have condemned and destroyed 
242 cattle, 503 hogs, 31 sheep, and 9 calves, 


EDITORIAL. 


being a total of 202,901. pounds of meat unr: 
for human food, but ready to be offered for sa! 
to the citizens of Chicago. 

The principal causes of condemnation an 
destruction were such diseases as tuberculos 
pneumonia, “lumpy jaw,” Texas fever, jaundi: 
necrosis, cholera, pleurisy, uremia and anemi,. 
and other causes were emaciation, asphyxiatix 
bruises, killed by trampling (“downers”), etc. 


Among these animals were six cattle that 
had been passed by the government inspectors. 
Two cattle were found last week by the depart- 
ment inspectors that had been passed by the 
government inspectors, after the evidences of 
tuberculosis had been trimmed out. The city 
inspectors destroyed these cattle. 

The government inspectors refused to allow 
the city meat inspectors to remove glands, and 
other organs suspected of being diseased, for 
the purpose of microscopic examination by the 
laboratory bacteriologists. 

Following is a comparative statement of the 
work done by the laboratory inspectors during 


,the. week, and during the corresponding weck 


of last year: 


Dressed meat, pounds 

Peaches, baskets 

Fruit, crates 

Markets inspected 

Complaints adjusted 

Total pounds of meat condemned..2,002 173,769 
Two important facts stand out prominently 

in the foregoing statements: 


First.. The absolute necessity of continuing 
and extending food inspections if Chicago is 
to make any further betterment of a health 
record of which every citizen may be justly 
proud. The improvement of the milk supply 
and of the water supply is creditable. But the 
above figures show the quality of the food 
supplies generally to be not only discreditable, 
but positively dangerous. 

It is notorious that death rates are highest 
among the poor and especially among the 
children of the poor. It is equally notorious 
that it is the poor who are the most: numerous 
purchasers of cheap foods, and such foods as 
would be condemned on inspection are, of 
course, sold at cheap rates if allowed to be put 
on the market. 

The purchaser is the sufferer at both ends 
pocket and stomach. He is defrauded in tlie 
nutritive value of the flesh of emaciated, anem 
asphyxiated animals, and he is exposed 
health and life by eating the flesh of disease: 
animals, tainted fish, stale vegetables a: 
rotting fruit. Evén if not actually made sick, 
his vitality is lessened and his, working for « 
impaired. 

it is not the-rich and well-to-do who nec 
this protection, but the poor and those 
moderate means. 





EDITORIAL. 


The second fact is almost too obvious to 
need stating. An increase of the food inspection 
force of the health department is imperatively 
necessary. 





IMPORTANT CHANGES IN THE U. S. PHAR- 
MACOPOEIA, EFFECTIVE SEP- 
TEMBER 1, 1905. 

Preseribers should specify “U. S. P., 8th 
Revision,” or “U..8, P., 1890,” as the case 
may be, in writing prescriptions containing 
Pharmacopeeial substances, thereby prevent- 
ing a possible error on the part of either pre- 
scriber or dispenser. 

Particular attention is directed to the fol- 
lowing changes : 





| New average 
dose. 





Lig/Ferri et Ammonii anh. 
Masham s Mixture) 


Tinct. Cantharidis. 

Tinct. Capsici....... 

Tinct. Strophanthi. § 
TUNES We eens. cb snkcee anes 


The following Preparations have been IN- 
CREASED in strength: 





Revision. 


x me ct. ct, Opt, avrg avrge dove 
tt om Tersel ~ 


I eesat Bachem’ s) 

Tinct. pene —_ (Sweet Or- 
ange 

Tinct. Calumbe .. : 

_ Cantharidis, avrge dose, 5 min. 


wy -- avrge dose, 8 to 10 min. 
ns t damomi 


SOROS, CE 0 ans cate checente 
BUNCE IED .« £ndy 0d Su uvcnee ee dene 
Tinct. Rhei.. 

ntariz.. 








333 


The following Preparations have been DE- 
CRBEASED in strength: 





| Revision. 








g 


Liq. Ferri Chloridi . 
. Ferri avrge “dose, 15 min. 
“deaaitt a average dose, 10 min. 

at. Seen. Policrnm, average dose,| 
Dicidveds Ganthied -b<cdenu 

Tinct. Benzoina Comp 

Tinct. Cannabis Ind 

Tinct. Colchici Sem., average ey 

30 min 4 ‘oi 
. Digitalis, average dose, 15 min. 
Tinct. Gambir Compositi (Cate- 
chu Comp.).. 
5 ave! 

Tinct. Hyoscyam 

Tinct. K 

Tinct. Lobelia 


Tinct. Wacis Venice, average ¢ a dese, 
10 min. 


ze dose, 8 min. 


BReek ke FRE Se 


0.15s 1% 
| Strychn’e | Strychn’e 
Tinct, Opt... co.cc. ce ccce.cceseee d | Rete as fE-B Oo Bas 


Tinct. Opii Deod 


Tinct. Physostigmatis. . 

Tinct. — ebse 

Tinct. Scil 

Tinct. Stramonii . ‘ 
Tinct. Veratri, average dose, 15 min. 
gaa. Sulp! h. on 
Via. tolehicl, average dose, ‘30 min. 
Vin. Ergot . od 








HEALTH AND PLEASURE 
THE WEST. 

Southern California by which we mean 
all that part of the State lying south of San 
Francisco has long posed as a sort of Ameri- 
Italy 
the appellation. 


RESORTS OF 


can and for many reasons deserves 
Certainly the enterprising 
and progressive citizens of this part of the 
Pacific slope have created some beautiful 
centers and the surroundings and climate 
annually draw many thousands of delighted 
tourists from all over the world. 

Before speaking of the south it might be 
well to mention San Francisco and to warn 
invalids away from it especially in the sum- 
mer months which we were told were the 


One 


most disagreeable of the entire year. 





334 


week in last July was remarkable and 
unusual because of the torrid heat and the 
following weeks were no less disagreeable 
for visitors because of arctic cold which 
prevailed making it necessary to wear furs 
and overcoats out of doors and to turn on 
the steam in the radiators of the hotels. The 
fog which was all but constant during our 
visit made us think of London which is 
renowned the world over for having the most 
disagreeable climate on the foot-stool. 

Los Angeles is probably the greatest 
tourist and health center in the State. This 
city which had a great boom beginning 
about 1885 and collapsing in 1889 is again 
afflicted with an epidemic of insanity regard- 
ing land values which of course must sooner 
or later be succeeded by a relapse to reason 
and the ruin of the dreamers who are now 
tempting fate. Were it not that this mania 
seems to strike the weak and the strong, the 
“lunger” and the robust alike we would not 
mention it but after learning that a young 
lady of Zanesville, Ohio, who went there for 
pulmonary tuberculosis had become a real 
estate speculator and was rapidly becoming 
independent from her investments at the 
rush sales, we feel that silence on this subject 
would be wrong. Fancy the effect on the 
tissue changes that would be wrought in a 
delicate subject by attending one of the 
sales. The enthusiasm of some of the 
“angels” about their city is something re- 
markable and we are tempted to relate a 
story about this city of 125,000 that accord- 
ing to bill boards is going to have “250,000 
inhabitants in 1910 on which date property 
will be certain to be worth three times what 
The 
particular person of whom we write had 
lived in Los Angeles as much as a week, 
having gone there to recruit a damaged lung 
and as everybody else seemed to do had be- 


it can be purchased for at this time.” 


EDITORIAL. 


come fascinated with the place. “I sup- 
pose,” said I to him “you expect to live 

see this city have 500,000 people, do you 
not?” “TI don’t know about that” said 

“but I am perfectly certain it will have 

million in less than ten years.” They we 
issuing a new directory when we were there 
which showed we believe something like 6\\ 
physicians and 1,200 real estate agents resi- 
dent in Los Angeles. How they all mana, 
to live no one was able to explain to | 

But what about the consumptive? We must 
not forget him in our praise or criticism of 
American Italy. The more we saw the more 
we are inclined to say to our Illinois physi- 
cians. “Keep your tuberculous patients and 
treat them yourself along modern scientitic 
lines as exemplified at the Ottawa colony.” 
A small per centage may be benefited by 
residence in California. A large per centage 
will not be benefited by a trip there and 
therefore according to the law of general 


averages none should go. 


~ 


Correspondence. 
im me. P 





RARPOPDDDP SD 


~ 
wel 





A QUESTION OF ETHICS. 
August 14, 1905. 
Editor Illinois Medical Journal, 

My Dear Doctor: I beg to ask your opin- 
ion on the ethical aspect of the enclosed |ct- 
ter. It explains my situation quite well. | 
recently came here and wish my presence and 
line of work known to the public of t 
county. In your opinion, would the letier, 
if printed and sent to the teachers violate +! 
ethics of the state society. 

The little charts mentioned are small co} 
of Snellen’s Test Type or similar ones w 
my professional card on back thereof. 
trust I am not imposing on you and beg 
thank you for an opinion. 


My Dear Sir: I have located in this cit) 
follow my profession and shall pay especial 





CORRESPONDENCE. 


tention to defects of the eye, particularly to the 
fitting of glasses. 

In order to get my business before the public 
I beg to call your attention to the following 
offer which I am making to the teachers of 
this county: 

Should you be able to send me a patient to 
be fitted with glasses I will make you a present 
of a first class botany glass, such as usually 
sells for 50 cents. This present is due you as 
soon as the patient is properly fitted and has 
paid his bill. Should you send more than ene 
you may select from my catalog goods to the 
amount of the several credits or apply on work 
fer yourself. 

In sending a patient you should notify me at 
the time, otherwise I would not know you were 
entitled to any credit or others might claim it. 


Are you safe in sending work to me? 


I know I am a stranger to you and all I 
need say is, that I came here to make my home 
and build a practice. Only honorable treat- 
ment and good work will do it. 


At the institute here I gave a neat eye chart 
to each teacher for his school room. If you have 
not one I shall be pleased to send it for the 
asking. Your superintendent, Miss —————, 
recommended them as did the instructors. 


I shall have smaller test cards which you 
may distribute to each family and thus get 
several credits without any undue effort. 


This communication was referred to Dr. W. 
0. Ensign, Chairman of the Council, who sent 
the following reply: 

THE QUESTION ANSWERED. 
Geo. N. Kreider, M. D., Editor, 
Springfield, Ill. 
Dear Doctor: 

Yours of the 25th inst. at hand this morn- 
ing and mentions that ethical question again, 
which other matters had delayed at this end 
of the line. 

| herewith return the documents sent and 
a reply, but the wisdom of publishing the 
inquiry and circular letter of Dr. , or 
the enclosed reply, or any part of it, I must 
leave wholly to your judgment. In such re- 
ply I do not speak by the authority of the 
Council, hence omit Chairman to the sig- 
nature. 

[f published it would be proper to omit 
the name of Miss in the circular 
letter. 

Very truly yours, 
Wn. 0. Ensign. 
E \itor Journal : 

Of the above communication referred for 

reply, it may be said: 


335 


The foregoing inquiry and proposed cir- 
cular letter constitutes a fair sample of a 
class of communications not unfrequently 
presented to the attention of members of the 
Council during each year. A very consider- 
able proportion of such inquiries bear evi- 
dence of candor and a sincere desire to be- 
come correctly informed on the subject in 
question, while not a few appear to betray 
indications of a brief professional experience 
on the part of their authors. 


The inquiry: “In your opinion would the 
letter if printed and sent to the teachers, 
violate the ethics of the State Society ?” con- 
stitutes a candid question and is entitled to 
a like response, and may here and at once 
be given a distinctly affirmative answer. 


The motives and purpose of the inquirer 
are made quite clear in— 


ist. His expressed wish to make his “pres- 
ence and line of work known to the public of 
this County.” 


2nd. “In order fo get my business before 
the public.” 


3rd. “To make a home and build up a 
practice.” 


Objects by no means reprehensible or un- 
worthy, and he reasonably concludes as to 
the latter that “only honorable treatment and 
good work will do it.” 


But what of the methods and conditions 
suggested to that end, in the proposed cir- 
cular letter to the teachers. “Should you be 
able to send me a patient to be fitted with 
glasses, I will make you a present of a first 
class botany glass.” This is a thoroughly 
commercial proposition, and is fortified by 
most exact conditions as to its fulfillment. 
“This present is due you as soon as the 
patient is properly fitted and has paid his 
bill,” thus requiring of the teacher that he 
not only secure the patient but that he be- 
come an interested party to the successful 
fitting of the glasses as well as to the pay- 
ment of the patient’s bill. 


If parties who are tempted to seek undue 
methods of calling the attention of the public 





336 


to themselves and their branch of the pro- 
fession would stop for a single moment to 
consider that such means, if proper for them- 
selves, must be equally so for every other phy- 
sician in the same locality, they would doubt- 
less many times hesitate before adopting or 
employing anything of the kind. As an il- 
lustration ; there are about fifteen other regis- 
tered physicians in the city, or fifty-five in the 
county, from which the above inquiry eman- 
ates. Each of the number at the same time 
following along similarly proposed lines, in 
an-effort to secure the attention and patron- 
age of the public, must create such conditions 
of pernicious activity in that community, as 
could not result otherwise than in bringing 
discredit and disgrace upon the entire med- 
ical profession, and the complete loss of the 
respect and confidence of the people in the 
locality in which they reside. 

Passing over at this time the fact of the 
injustice of such questionable methods on the 
part of the few toward the equally intelligent, 
capable and deserving physician, who wins 
his way to a creditable place in his profession 
and the respect and confidence of the public 
by commendable means only, it might be well 
to here present a few extracts from the 
“Principles of ethics of the American Med- 
idal Association,” of which body the Illinois 
State Medical Society constitutes a compon- 
ent part. 

Chapter 1. Art. 1.. Sec. 1. “Every one 
entering the profession, and thereby becom- 
ing entitled to full professional fellowship, 
incurs an obligation to uphold its dignity and 
honor, to exalt its standing and to extend 
the bounds of its usefullness.” 

‘Sec. 3. “Every physician-should identify 
himself with the organized body of his pro- 
fession as represented in the community in 
which he resides.” 

" See. “It is incompatible with honorable 
standing in thé profession to resort to public 
advertisements or private cards inviting the 
attention. of persons affected with particular 
diseases.” 

auAtt. VI. Sec, 4. “It is derogatory to 
professional character for physicians to pay 
.or offer to pay commissions to any person 


CORRESPONDENCE. 


whatsoever who may recommend to them 
patients requiring special or general treat- 
ment or surgical operations.” 

The foregoing quotations serve sufficient! 
to make it clear that such circular letter to 
the public, or any part of it, as the inquirer 
presents, would be a violation of the ethics 
of the medical profession and not calculated 
to uphold such profession’s dignity or honor. 

Incidentally it is further shown to be the 
duty of every physician to identify himself 
with at least the local professional organiza- 
tion of the vicinity in which he resides, which 
organization is usually the county medical 
society. 

In connection with this latter fact, it 
might be suggested that to such all propo- 
sitions of similar character might be wisely 
submitted with the assurance that if they 
should there meet with the approval of the 
better portion of the local profession, as is 
usually to be found in such organizations, 
they would be very likely to bear the test 
of due propriety and professional justifica- 
tion and would then doubtless be deemed 
to be neither unworthy, unjust or not ethical 
in the estimation of the general medical pro- 
fession. 

Very truly yours, 
Wm. O. Ensign. 


CASS COUNTY MEDICAL SOCIETY MORIBUND. 
VirerntA, It1., Sept. 5, 1905. 
Editor Illinois Medical Journal, 
Springfield, Ill. 

Dear Doctor: In reply to yours of the 
2d inst. will say. It was intended that the 
County Medical Society should have charze 
of the afternoon exercises in the teacher's 
institute, but at the last moment the Physi- 
cians, with the exception of two failed tc 
appear, so it was not a society meeting, on!y 
two were heard. I was in hopes we coud 
report an excellent meeting but can not. 
much fear we, as a. society, are dead. 
seems impossible to get anyone to take any 
interest in it. We cannot get them to 
tend. 

Yours respectfully, 
J. A. MoGer, Secretary. 





CORRESPONDENCE. 


‘ue Auto as A BusINEss PROPOSITION FOR 
THE Doctor. 


| have found my Auto a great convenience 
my practice, enabling me to answer calls 
re promptly than should I have driven a 
I can also save a great deal of time 

making calls, which allows one more time 

r office work. 

My running expenses and repairs will 
a.nount to about one hundred and fifty dol- 
lars ($150.) A great deal of my expense ac- 
count was unnecessary, which fact I have 
wily learned after becoming better acquainted 

th the ear. 


rse. 


[ shall continue to use the Auto in my 
yractice. 

For doing country work alone, in this part 

the country, I hardly consider the Auto 
racticable. 

The Auto as a business proposition (pro- 
ssional) is not at present satisfactory or 
munerative; but to consider the business 
side and enjoyment of operating a car, the 
combination is a pleasure I would not be de- 
prived of. 

Respectfully, 
F. E. Nortu. 
laylorville, Ill. 





Tue Law DiscriMinates AGAINsT Puyst- 
CIANS. 
YORKVILLE, ILL., Sept. 18, 1905. 
Editor Ill. State Med. Journal, 
Springfield, Ill. 

Dear Sir: No doubt your attention has 
been called to the following injustice, but 
it has very forcibly been brought to my 
notice recently. 

\ servant sickens with acute pneumonic 

ereulosis and dies, in a county under 

wnship care of the poor. When taken sick 
sends for a physician who objects to tak- 
charge of the case on account of poor 
The employer makes the statement that 
young man has property amounting to 
The physician accepts the case and 

« boy dies. The employer is appointed ad- 
mnistrator. The undertaker furnishes a 
ca ket which does not cost him to exceed $20. 


His bill is something like $75 and it being 
considered first class in the eyes of the law 
is paid in full. So on down the list to the 
so called third class of claims which consists 
of the expense of the last illness “not includ- 
ing the physicians charge.” A bill for care 
during the last illness is filed by the em- 
ployer-administrator and is paid in full. Ab- 
solutely nothing is left the physician and he 
is left without any resource for collecting 
his bill. 

Now why are the undertaker’s services 
more important than the physician? Why 
the discriminating clause in the third class 
“not including the physician’s charge?” 
Could not our committee on legislation who 
are doing such good work and of whom we 
are proud, take steps to have this rank dis- 
crimination effaced from the law and give 
the physician at least an equal chance with 
the undertaker ? 

Fraternally, 
F. R. Frazier, M. D. 

Pres. Kendall Co. Med. Society. 





WHY BIRTHS ARE NOT REGISTERED. 
Dr. G. N. Kreider, Editor, 

My Dear Sir: I enclose a letter that will 
go a long way to explain non-registration of 
births. 

I have been a physician in this county 
(Cook) and State for eleven years and never 
have received one cent for reporting births. 
Do you think for a moment that a physician 
is going to give time and expense from his 
own pocket? I have tried several times to 
obtain what the law says a physician should 
have, but never a cent have I received. I 
remember very distinctly one trip I made to 
the County building. I was directed to a 
certain room. There were three persons in 
the enclosure (paid of course, by the county) 
apparently not on hand te do. They looked 
over my reports and said I would have to 
call in about a week or ten days. At the end 
of the stated time I called again. No, there 
wasn’t anything for me, I would have to call 
again. I replied, “I don’t propose to be 
running here. for nothing. Can’t you. send 





338 CORRESPONDENCE. 


it—” O, no, you will have to call in person. 

Any doctor is a fool to pay any attention 
to any such laws or requirements. 

I have also received a letter from County 
Clerk Olsen which I will ask you to print 
(see below.) 

Yours very truly, 
La Grange, Ill. W. F. Dean, M. D. 


Chicago, October 12, 1903. 
Dr. W. F. Dean, 
129 Harris Avenue, 
La Grange, Ill. 

Dear Sir: Replying to your communication 
of recent date regarding fees due you for re- 
porting births, will state that I am informed 
by the County Treasurer, that he cannot, at 
this time, honor warrants upon him for such 
for the reasdn that he has no money in his 
possession available for that purpose. 

As an appropriation should be made by the 
Board of Commissioners of Cook County to pro- 
vide for the payment of such claims as yours, 
and as said body have failed to take such action, 
its attention will be called to the matter. 

Very respectfully yours, 
Peter B. Olsen, 
County Clerk. 





Complaint From Chicago Physician That He Is 

Not Paid His Fee for Reporting Births. 

Chicago, Sept. 8, 1905. 
Editor Illinois Medical Journal: 

Have read Mr. Hugo S. Graiser’s statement 
relative to the report of births. Let me state 
that I have never succeeded in securing one 
cent for any birth I have ever reported. I 
have taken the reports personally in bunches 
in the hope of securing the fee, but usually 
since then mail them immediately. Let me 
state frankly that I believe the graft which 
appropriates the 25 cent recording fee and 
beats the doctor is the chief sinner. I would 
like to know of anyone who ever received a fee. 

I dare you to publish this. It is bad enougn 
to be defrauded by the parents out of our con- 
finement fee as we often are here in Chicago 
without talking about the “outrage.” Let the 
officials tend to their own skirts and keep them 
clean. Dr. Newhall, 

1127 Racine Ave. 

P. S.—Make the fee a $1.00, so it will be 
worth while to fight the grafters, I begin to 
suspect there is a nigger in the field some- 
where if it is true as stated. 





THE BEST TENT. 
To the Editor of the Illinois Medical Journal. 


Sir—I write a few lines apropos of “The 
Use of the Tent‘in the Treatment of Tuber- 


culosis.” After some years experience in 


camping, perhaps a word on the subject « 
choice of tents will not be amiss. 

For shape, the Portean tent, made by 
citizen of Evanston is nearly ideal. It 
about the only type of tent where ventilati: 
in warm weather is possible. It requires bi 
one pole. It will not “blow down.” 

The question of material is another matter. 
Duck, from eight (8) ounce to twelve (12 
is commonly used in the belief that heavy 
weight material keeps out the rain. A fi 
sometimes does the business, but closely 
woven cotton almost as light as sheeting 
treated with a preparation of one part para- 
fine in three of turpentine or the famous 
“Waterproof Silk” as it is called is the finest 
thing the writer ever used. Its weight is al- 
most nominal. 

Last summer he used a tent of such ma- 
terial so treated. It rained twenty-one nights 
and not a drop of rain got in the tent. Rub- 
bing against the roof or walls does not affect 
its water shedding properties. 

Respectfully, 
C. H. Keogh. 





Book Norices. 

Diagnostics of Internal Medicine. A Clin- 
ical Treatise upon the Recognized princip!:s 
of Medical Diagnosis. Prepared for the use 
of students and’ practitioners of medicine, | 
Glentworth Reeve Butler, Sc. D., M. D., 
Chief of second medical division of t 
Methodist Episcopal Hospital, Brooklyn, \. 
Y., with five colored plates and 280 illustra- 
tions and charts. Second revised edition. 
Appleton & Co., New York. Cloth, $6.00. 

This classical work which has had su 
remarkable popularity during the past fo 
years that fifty thousand copies have been s 
has reached a second edition and althou; 
100 pages and 40 additional illustrati: 
have been added, the price remains the san 
Dr. Butler has grasped the valuable idea 
illustrating the diagnosis of diseases and | 
work is receiving well merited considerati 
by the profession. We know of no work « 
diagnosis that can be so heartily recon 
mended to medical students as Butler’s Dia 
nostics. It is almost invaluable. 





mec 
reac 
repr 
liter 
knov 
qual 
mot 1 
pref: 
ten 
man 
work 
Johr 
very 
jean 
ured 
icun 


NEWS ITEMS 


he Principles and Practice of Medicine, 
designed for the use of practitioners and 
stulents of medicine by Wm. Osler, M. D., 
Fel'ow of the Royal Society; Regius Profes- 
sor of Medicine, Oxford University, etc. 
Sixth edition, thoroughly revised from new 
plaics. D. Appleton & Co., 1905. Cloth, 
$6.00. 
(Qsler’s classical work has been copyrighted 
eight times in the past 13 years; has gained 
a greater circulation than any practice of 
medicines ever secured in America; has now 
reached its sixth edition and undoubtedly 
represents the high water mark of medical 
literature in the English speaking world. To 
know Osler’s practice thoroughly is to be ac- 
quainted with the best exemplification of 
modern medicine. As Dr. Osler says in his 
preface, “So many sections have been rewrit- 
ten and so many alterations made that in 
many respects this is a new book.” This 


work embodying the results of his labor at 
Johns Hopkins University and Hospital, is 
very properly Osler’s valedictory to his Amer- 


ican colleagues and as such should be treas- 
ured and appreciated by them. It should be 
fcund in the hands of all our readers. 





CARBONIC ACID IN MEDICINE. © 
By Achilles Rose, M. D. 

12mo, cloth, 268 pages, Price $1.00, net. 

Funk & Wagnalls Company, 44-60 E. 23d St., 
New York City. 

This book aims to set forth the fullest facts 
about the healing qualities of carbonic acid gas. 
These beneficial properties were known cen- 
turies ago but they strangely passed into disuse 
until they have now become unjustly forgotten. 








ews tems. | 
u a = 





) 
) 

Dr. Jethro Davis, of Sciota, has removed to 
Raritan. 


Dr. J. W. Veatch has removed from Cornell 
to LaSalle. 

Dr. C. W. Talbott has removed from Secor 
to El Paso, Ill. 

Dr. W. B. Gardner of Loami has returned 
from Portland, Ore. 

Dr. Milton R. Walter of Baltimore, Md., has 
removed to Chicago. 

Dr. Van Horne of Jerseyville, has sold his 
apple crop for $2,000. 


A. RRPRPPP 


339 


Dr. W. Y. Herrick 
located at Dixon, Il. 

Dr. B. F. Forrest has removed from Forrest 
to Eagle Lake, Texas. 

Dr. Hill of Athens is erecting a new resi- 
dence on the main street. 

Dr. Perey Taylor of Springfield and family 
has returned from Colorado. 

Dr. C. A. Stokes, of Edinburg, 
Nebraska during September. 

Drs. C. M. Bowcock and Walter Ryan have 
been visiting in Rochester, Minn. 


Dr. C. F. Voyles of Murdock, Douglas Co. 
has removed to Rochester, Minn. 


The residence of the late Dr. G. W. Fringer 
at Pana was sold recently for $5,000. 


Dr. J. R. Trigg, formerly of Farmersville, 
is practicing in Oklahoma Territory. 

Dr. Pierce, of Iuka, formerly of Cornland, has 
located at Buffalo, Sangamon county. 


Dr. Eberspacher of Pana, has returned from 
a two months tour through the western states. 

Dr. La Vern Boyd formerly of Springfield, 
recently of Baltimore, Md., has located in 
Edinburg. 

Dr. E. 8S. Spindel, of Springfield, visited the 
Colorado Health and Pleasure resorts during 
September. 


A Children’s Home in Peoria conducted by 
Mrs. Flynn, is under investigation by the county 
authorities. 


Dr. F. B. Morgan, formerly of Fort Collins, 
Col, has located at Cornell, having secured the 
location and practice of Dr. Veatch. 


Dr. M. M. Bradley, of Waverly, has pur- 
chased property in Chatham and will return to 
his former location. 

Dr. C. C. Webb of Charleston has been spend- 
ing the summer in Joplin, Mo., looking after his 
interests in the mines and a drug store. 


Dr. E. A. Knodle of Beardstown, sold his 
practice to A. E. Soule, of Fort Byron. Dr. 
Knodle has gone to the West for a six months’ 
visit. 


Dr. Wilson Stuve, formerly a resident of 
Springfield, where he was born and raised, died 
suddenly at Oklahoma City, Oklahoma, Sep- 
tember 1, 1905. 


Dr. and Mrs. Frank Coppel, of Havana, have 
removed to California. They were tendered a 
banquet by the Eastern Star Lodge prior to 
their departure. 

Dr. W. H. Watterson formerly of Chicago, 
later of Edgewater, Colorado, where he went 
for his health, has recovered and located in 
Fox Lake, Wisconsin. 


The new consumptive hosp¥al at Dunning, 
which is considered a model of its kind, is re- 
sponsible for a marked decrease in the death 
rate of tuberculous patients. 

Supt. Podstata in his report recommends 
that a small separate ward be constructed for 
the care of the patients who are hopelessly 
afflicted with consumption. 


of Lytton, Iowa, has 


visited in 





340 


During March, April, May, June, July, and 
August of last year the death rate of tubercu- 
losis patients was 42.52. For the corresponding 
months this year the death rate was 27.21. 

Mrs. J. C. Corbus, wife of Superintendent of 
the Illinois Eastern Hospital, was striken with 
heart disease, August 25, while getting a glass 
of water for a sick son, and died almost instant- 
ly. 

Dr. and Mrs. Arthur P. Wakefield of Spring- 
field have been appointed missionaries to China 
by the Foreign Mission Board of the Christian 
Church. They will leave for China in Septem- 
ber, 1906. 

The mortality rate of the city of Springfield 
for August, 1905, was remarkably low, being 
40 in an estimated population of 40,000. As 
there are undoubtedly nearly 45,000 inhabitants 
in the city the death rate is nearer 9 per thou- 
sand than the 10 per thousand given in the 
report. The only cases of contagious disease 
were some cases of scarlet fever, none fatal. 





Screen All Tanks. 


Every tank in town must be screened ac- 
cording to law. This will include a number of 
more or less prominent citizens—New Orleans 
Times-Democrat. 





Canton to Have a Hospital. 

The Misses Graham, former residents of 
Canton, recently agreed to erect a hospital, 
provided the citizens raised an endowment 
fund of $20,000. The business men and resi- 
dents were canvassed and it was found impossi- 
ble to raise the money. The Misses Graham 
were accordingly notified. They have now 
agreed to purchase the site and erect a hospital 
at a cost of $15,000, accepting the amount sub- 
scribed as an endowment instead of the $20,000 
originally asked. Construction work will be 
commenced this fall. 





4 


Chicago Btems. 


 meamenapeteemenrenenenemnens 





li 


Dr. 


~~ a ~~ _-* _wsT* 





and Mrs. Henry P. Newman have re- 
turned to Chicago from Wallon Lake, Mich. 


Dr. and Mrs. James I. Stone of 128 Rush 
St., Chicago, have returned after a prolonged 
stay in the Adirondacks. 

Dr. and Mrs. R. H- Babcock of Chicago,-have 
returned from Green Lake, Wis., and taken 
apartments at the Virginia. 

H. Wolff, of Chicago, was recently prose- 
cuted for violating the medical practice act by 
practicing without a license, and fined $200 and 
costs. e 

Dr. Arthur R. Reynolds until recently health 
commissioner of Chicago has accepted the posi- 
tion of medical director of the French Lick 
Springs Hotel Company of Indiana. 

The engagement of Dr. William N. Senn, of 
Chicago, son of Dr. Nicholas Senn, to Miss Mar- 
jorie Lynch of 556 Dearborn Ave., was. recently 


NEWS ITEMS. 


made by Mr. and Mrs. Thomas F. Mulla: 
brother-in-law and sister of the bride. 

Dr. Arthur R. Edwards, of Chicago, will © e- in: 
liver the address on medicine at the next meet 
of the Mississippi Valley Medical Society, to 
held in Indianapolis, Oct. 10, 11, and 12. 
subject is “Certain Phases of Uremia, T 
Diagnosis and Treatment.” 


Annie Hill, a Chicago palmist was fined +3) 
and ordered out of Sheboygan, Wis., beca ise 
she charged a Mrs. Joanna Vandyke $100 f 
mysterious powder which she was told to bin 
in the cellar to enable her to find $100,000 
a bag of diamonds that the palmist dec!: 
were hidden there forty years ago by s 
wrecked sailors. 


The corner stone of the new Washingt 
Park hospital, Chicago, was laid Sept. ; 
members of the Sophia Aid Society. The struc- 
ture is being erected in Sixtieth street, 
tween Vernon and Vincennes avenues. 
principal address was made by Prof. Jules 
Mauritzon of Augustana college, Rock Island, 
Ill. The society is a Swedish charitable org:ani- 
zation, and the exercises were the celebratio 
of the first anniversary of its organization. The 
society now occupies temporary quarters at 
6010 Vincennes avenue. The new building wil! 
be a three story brick structure and will accom- 
modate 105 patients. 


for 


be- 


The 


>) 


r 


incre’ 


tl 


parent 
Avenu 
Herbe 


Jat 





bot! 
Serious Ailment and His a 


Physician. 

T. P. Quinn has diagnosed the case of Mayor 
Dunne and finds the patient to be suffering 
from a total lack of backbone. Dr. Quinn 
though not regularly in charge of the case, 
will try to stiffen the patient by giving him 
absent treatments.—Chicago Tribune. 


Mayor Dunne’s 


the 





, 


Ma 
minist 
s 
noon, 
Wager 

Joh 


Grace 


Chi 


The Illinois Charitable Eye and Ear In- 
firmary has acquired 100 feet additional front- 
age on Peoria street, just north of Adcarts 
street, Chicago, for $20,000, on which it wil! 
build a modern fireproof addition to its present 
building. The recent state legislature appro- 
priated $75,000 for the acquirement of the land 
and construction of the building. A _ deed 
covering fifty feet on Peoria street from the 
Lewis institute was filed for record recently 
From Amy F. Bond twenty-five feet was pur- 
chased and twenty-five from Maj. Blo:'gett, 


Miss 


aged 


Chi 
to Mis 
ber 12 


Wn 
Chicag 
Rot 
in Gri 


both at the rate of $200 a front foot. Ww. 
Greent 





STRENUOUS LIFE OF CHICAGO. 


Chicago's streets were like a “bloody 
field” during the first six months of the 
according to the figures of the city statist 


Statistics for the six months ending 
June show that 643 persons in Chicag« 
unnatural deaths and 4,093 were in 
Accidents caused the death of 352 persom 
injury of 3,716, the casualties being mor« 
six times the number for the correspo 
period last year, when the killed numbe: 
and the injured 553. 


ittle 
ear, 
lan 
with 
met 
red 

and 





Her 
son in 


layor 
ering 
uinn 
ase 
him 


NEWS ITEMS. 


Sighty-one persons met death and 995 were 
red through personal violence. This is an 
rease of 50 per cent over last year’s figures 
the same cause, which were 45 killed and 
injured. The increase of casualties from 
onal violence is attributed to strikes. 


‘here were 5,802 charges of violence, as 
aginst 5,434 last year, 337 persons being 
charged with assault with deadly weapons. In 
adc tion to the deaths by personal violence and 
acc dent, 210 persons killed themselves. 


f Marriages and Deaths. 4 
AONPORMIARCODDODL 
MARRIAGES. 


Vm. B. Caldwell, M. D., Monticello to Miss 
Anna Olentine of Paxton, Sept. 20. 

Ross L. Motler, Browns to Miss Grace Jones 
of Princeton, Ind.; Sept. 13. 

Married at the residence of the brides 
parents, Mr. and Mrs. C. W. Northup, 231 Waiola 
Avenue, LaGrange, September 27, 1905, Dr. 
Herbert C. Dewey and Miss Abbie L. Northup. 


James G. Ross, M. D., to Miss Lillian Henak, 
both of Chicago, August 23. 











Married at the residence of the officiating 
minister, the Rev. Rufus A. Finnell, pastor of 
the Stuart Christian church, Thursday after- 
noon, September 28, 1905, Dr. H. Strohl of 
Waggoner and Miss Eva Grace GiH of Girard. 


John Steele Sweeney, M D., Chicago, to Miss 
Grace Hamilton of Two Rivers, Wis., August 16. 


Charles F. Voyles, M. D., Murdock, Ill, to 
Miss Hazel Wagner of Newman, IIl., August 16. 


Charles Martin Wood, M. D., Decatur, IIL, 
to Miss Edith Loose of Illiopolis, Ill., Septem- 
ber 12. 


DEATHS. 
Wm. M. Brown, M. D., died at his home in 
Chicago, Sept. 14, aged 48. 
Robert Hugh Cook, M. D., died at his home 
in Grayville, August 6, after a long illness, 
aged 73. 


W. 8S. Duncan, M. D., died at his home in 
Greenup, Ill., August 2, aged 80. 


Henry Utley, M. D., died at the home of his 
son in Sterling, April 27, aged 82. 


Ferdinand S. Overfield, M. D., died at his 
home in Brookville, Ill, August 16, aged 76. 


Wm. R. Owen, M. D., shot and killed him- 
self in a church in Minneapolis, August 27, 
age about 60. His home was in Sublette, Ill. 


Luther E. Stowell, M. D., died in Peoria, 
August 26, after a long illness, aged 30. 


l ittleton Thompson, M. D., died at his home 
in Utica, Ill, August 19, after an iliness of four 
Weexs, aged 55. 





Mew Bucorporations. 











New corporations were licensed by the Secre- 
tary of State at Springfield as follows: 

Barton Chemical company, Chicago; capital, 
$1¢,000; manufacture medicines, appliances; in- 
corporators, Charles M. Foell, Marvin E. Barn- 
hardt and John R. Perry. 

Northwestern Neurological college, Chicago; 
not for profit; educational; incorporators, 
Charles L. McDonnell, William Gayle, F. C. 
Hammond. 


Rumo Remedy company, Chicago; capital, 
$10,000; manufacture medicines; incorporators, 
Oscar H. Olsen, William Huber, and Stanislaus 
Lewandowski. 

European Health Institute, Chicago; capital 
$25,000; sanitarium; incorporators, Josep Poray 
Kaczorowski, J. J. Golembiowski, and Edward 
Mucho. 

Conklin Salve Company, Chicago; capital, 
$1,000; manufacture medicine; incorporators, B. 
F. Moffat, R. C. Galusha, Fred W. Bentley. 

International Society of Advanced Thera- 
peutics, Chicago; hygienic; incorporators, 
George Rickard, E. P. Marko, Allan A. Wilson. 





Looking on the Bright Side. 

The doctor had been injured so severely in 
a street car collision that the surgeons were 
compelled to amputate his right hand. 

“Upon the whole,” he said, “it’s a. lucky 
accident. Do you know that in the palm of 
the ordinary unwashed hand there are over 
80,000,000 microbes to the square inch? A man 
in my profession has to meet all sorts of people. 
I shall get an artificial hand, and hereafter I 
shall be able to shake hands with anybody 
with perfect safety.”—Chicago Tribune. 





Nosology. 
“Dector,” asked the caller, “what would you 
recommend for a disordered liver?” 
“My friend,” said the old doctor, noting the 
color of his nose, “I should recommend that he 
live a more orderly life.” 


Good Location for Young Medical Men. 

“Charles Van Newport's new automobile will 
seat forty people.” 

“Great Scott! Did you say forty?” 

“Sure. Fifteen doctors, fifteen surgeons, six 
machinists, two fine settlers, the chauffeur, and 
Charlie.”—Columbus Dispatch. 





Another Lie Nailed. 

Hamlet was listening to the ghost. 

“What a blooming lie it is,” he muttered, 
“that ‘dead men tell no tales’! ” 

Encouraging the ghost to proceed with the 
grewsome narrative, he struck a Sir Henry 
Irving attitude and signed to the orchestra’ 
leader to turn on thé slow music.—Chicago 
Tribune. 





Chicago Medical Society. 


The Medical Society of Cook County, Regular meetings are held every 
Wednesday evening from October to June at the Chicago Public 
Library Building, Randolph Street Entrance in the large hail 
on the ground floor toward West end of the Building. 


OFFICERS: 


Cc. S. BACON, 426 Center Street . 


FRANK X. WALLS, 4307 Ellis Avenue .. 
A. E. HALSTEAD, 2937 Indiana Avenue.... 


W. A. EVANS, 103 State Street 
WM. HARSHA, 103 State Street 





President 
Secretary 
‘Treasurer 
Chairman Medicolegal Committee 


-.+-.+.-.Chairman Membership Committee 











ABSTRACT OF PAPER READ BEFORE THE 
CHICAGO MEDICAL SOCIETY JUNE 14, 
1905, BY DR. JOSEPH M. PATTON. 


Report of a Case of So-called Musical Heart, 
With Specimen and Photographs. 


The case reported was of unusual interest 
because of the fact that for fifteen years the 
patient had been observed and examined by 
probably more medical men than any other in- 
dividual of which we have record. He was 
known as “The Man with the Musical Heart.” 
A Russian by birth, 38 years old. An attack of 
inflammatory rheumatism about 15 years ago 
left him with the unique cardiac murmur which 
since that time offered him means of making 
a living by exhibiting hmself. For this attack 
he was treated in Bellevue Hospital, New York 
City. 

The patient had many written and somewhat 
fanciful diagnoses presupposing all manner of 
lesions of either side of the heart. The patient 
claimed that the murmur was due to a sword 
thrust, but the scar from the wound was entire- 
ly superficial and in no way connected with 
the heart. 

The patient first came under Dr. Patton’s ob- 
servation about 12 years ago, presenting the 
usual signs of double aortic and double mitral 
lesions, and in addition a distinctly musical, 
systolic murmur heard over the precordial area. 
The diagnosis of that time was in accordance 
with these findings, the musical murmur being 
attributed to some abnormal condition of the 
chordae tendineae in the left ventricle. 


The patient was under observation as a 
clinic, hospital or office patient at various times, 
and constantly for two months previous to 
death. The musical murmur disappeared en- 
tirely about six weeks previous to death 
*Cardiac failure was progressive from the time 
of the disappearance of the murmur. Death 
occurred on the night of May 30th. 


The post mortem (including the heart only) 
was made immediately after death by Dr. John 
Fisher. The heart was examined a few hours 
later by Dr. Fisher and Dr. Patton, and showed 
the usual changes of double aortic and mitra! 
disease with no unusual measurements. Theré 
was a communication between the base of the 
left ventricle and the right auricle, closed by a 
papilla at its auricular end, but which could 
have had nothing to do with the production of 
the musical sound. There were also chord 
attachments for the corners of the base of the 
arterial surface of the aortic valves to the 
aortic wall. These could not have produced the 
murmur in question. 


Two chordae tendineae attached to the tip of 
the papillary’ muscle at the apex of the left 
ventricle and’ to the tip of the anterior cusp 
of the mitral valve, which was much thickened 
and elongated were broken off at their valvular 
attachment and lay loose in the ventricle. They 
were much thickened and covered with fine 
vegetations. 


The sudden disappearance of the mur 
before the heart showed serious signs of fail’ 
can only be explained by the breaking of thes 
cords, for whether we accept the views of 
rigan, Chauveau, or of Heyncius in relatio: 
the physics of the production of murmurs, | 
evident that we cannot apply to this case | 
basic principle governing the production 
ordinary murmurs—that they are prima: 
vibrations of the blood stream, because of 
pitch and harmonic element. Musical murn 
as a rule, are of more serious import than 
dinary blowing murmurs. The author has 
served their appearance in several fatal « 
of endocarditis shortly before death. 


An important deduction to be drawn f 
this case is that musical murmurs of 
character indicate a more extensive de 
of involvement of the tissues of the heart | 
is necessary for the production of the ordi: 
blowing murmurs, 





only) 
John 
hours 
10 wed 
nitral 
There 
of the 
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could 
ion of 
chord 
of the 
D the 
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tip of 
e left 
cusp 
kened 
Ivular 
They 
» fine 


urmur 


COUNTY SOCIETIES. 





County and District Societies. 











ADAMS COUNTY MEDICAL SOCIETY. 
Regular meetings held in Quincy the second Mon- 
day of each month at 2 p. m. Membership 70. 
Officers. 
resident ...Jno. A. Koch, Quincy 
‘irst Vice Pres....... J. M. Grimes, Camp Poiat 
second Vice Pres H. Hart, Quincy 

Geo. E. Rosenthal, Quincy 

R. J. Christie, Quincy 

ensors—Jos. Robbins, L. B. Ashton, E. B. Mont- 
gomery, Quincy. 

Delegate to the State Society, L. H. A. Nick- 
erson, Quincy. 

Alternate to the State Society, R. J. Christie, 
Jr., Quincy. 

The regular meeting of the Adams County 
Medical Society was held in Quincy, August 
14th, 

Those present were Drs. Ashton, Burch, 
Christie, Gilliland, Hart, Justice, Nichols, H. J., 
Nickerson, Rice, Rosenthal, Williams, W. W.., 
and Fletcher. 

Dr. Gilliland presented a case of a male, age 
56, who showed a fungating lesion on the dorsal 
aspect of the left hand and an ulcerative lesion 
of the tip of the nose, the former of some five 
years duration and the latter of two years. 
The nasal lesion was a rather deep ulcer with 
clean cut edges, discharging a thin white watery 
material and presenting some slight evidences of 
scarring at the margin. On discussion it was 
brought out that the diagnosis lay between 
lupus and rodent ulcer and that the microscope 
would be necessary to establish a diagnosis. 
X-ray or Finsen light treatment was recom- 
mended after the pathologists opinion was ren- 
dered. 

Dr. Hart presented the following paper on 

Pelvic Abscess. 

During my service as gynecologist, at St. 
Mary’s Hospital, this city, covering a period of 
several years, the prevalence of the above men- 
tioned disease, with its far reaching effect on 
the reproductive functions of our women, has 
appealed to me, as a disease to which too little 
attention is given by the general practitioner, 
and while I do not promise anything especially 
hew or startling on the subject, if you will bear 
with me I will present today, a short paper 
bearing on this topic. To cover all the ground 
implied by our heading in one paper, would be 
taxing your patience too severely; therefore, I 
will confine myself to that form of pelvic ab- 
scess, which we find encapsulated in the fallo- 
pian tubes, namely pyosalpinx, touching inci- 
dentally perhaps, on the other forms of pelvic 
infection, 


Causes.—Gonorrhea, of which ‘tis truly said, 
“No other disease has caused so much indirect 
mortality, mutilation and suffering,” is undoubt- 
edly the principle causative factor in pyosal- 
pinx, as well as all other pelvic inflammations. 


To the question*, “What is the proportion of 
cases of pelvic inflammation, coming under 
your care, which are attributable to gonorrheal 
infection?” sent to many leading gynecologists 
of this country and Europe, Humiston replied, 
that ninety per cent of his cases were attribut- 
able to this cause. Price answered, that in 
over one thousand abdominal sections for pelvic 
inflammation ninety-five per cent were attribut- 
able to gonorrhea, and that in ninety-five per 
cent of these cases, the history was reliable and 
clear. Pozzi and Frederick stated their experi- 
ence at seventy-five per cent. The statement 
often made that, “Half the abdominal operations 
performed in the world today, are required on 
account of the infections, adhesions, and pus 
collections, due to gonorrhea,” is said by Hum- 
iston and Price to be an under-statement, they 
placing it at ninety to ninety-five per cent. 
Mann says that just about all of his pus-tube 
operations are required on account of gonor- 
rheal infections. No one, not connected with a 
public institution treating this class of cases, 
can have a correct conception of the prevalence 
of this disease; and, it is by no means all found 
in prostitutes, or women of loose morals, but 
very frequently in wives of unquestioned virtue, 
who have been innocently innoculated by hus- 
bands, who are unaware of the fact, that, they 
are the immunized habitance of myriads of 
germs, which only await their transplantation to 
a virgin soil, to bud and blossom like the pro- 
verbial rose. I can recall a number of Quincy's 
fairest daughters, who were so unfortunate, as 
to have been the recipient of a dose of clap for 
a wedding present, which, resulting in pus- 
tubes, condemns them to a probable childless 
existence, and the social aim of matrimony thus 
irretrievevably defeated. 


In a small minority of cases, streptococcus 
infection is the causative factor, the germs 
gaining an ingress during an improperly con- 
ducted puerperium, after an abortion, or intro- 
duced into the uterus by unclean instruments. 


Although I have always tried to exercise due 
care in properly sterilizing my instruments, in 
all intra-uterine manipulations, a case occurred 
a few years ago, which, I will relate, wherein, I 
am not sure, I was not responsible for the con- 
dition, which necessitated a serious surgical 
operation, and of course caused much suffering, 
to say nothing of the danger and expenses en- 
tailed; I had treated the patient at different 
times, for a slight endometritis, for a period of 
some two years, had not seen her for probably 
a year, when I was called to see her. I found 
her confined to her bed, having been under a 
physician’s care for some weeks. She was car- 
rying a mild degree of fever, suffering consider- 
able pain in the lower abdomen, radiating down 
into the thighs, and complaining of a sero- 
sanguinous vaginal discharge. 


*Journal A. M. A. March 11, 1905. Joseph Tebea Johnson 





344 COUNTY SOCIETIES. 


Digital examination revealed large double 
pus-tubes, which were subsequently success- 
fully removed, the woman making a somewhat 
tedious, but complete and permanent recovery. 
Her husband emphatically denied ever having 
had any venereal disease; she had had no mis- 
carriage and her virtue was above suspicion, 
and while I am wont to believe, the trouble de- 
veloped from the slight endometritis, for which 
I, as well as other physicians, had previously 
treated her, I have never been able to eliminate 
entirely the possibility of my responsibility. 

Streptococci ranks second as a causative 
factor, and usually gains entrance by the same 
route as gonoccocci; but are said to sometimes 
penetrate the uterine walls, setting up a metri- 
tis, and then a parametritis, by continuity of 
tissue, or follow the lymphatics, usually termin- 
ating in cellular abscess, 

Staphylococcus, Colon Bacillus and Tuber- 
cular Bacilli, may be mentioned, also, as occa- 
sional factors. 

Course.—The micro-organism gonococci be- 
ing deposited in the vagina, finds its way along 
the mucous membrane, first involving the uter- 
ine mucosa, and then, that of the fallopian tube 
where, if the infection be of a mild type, nature, 
through its hordes of leucocytes summons to 
repel the attack, may be to arrest its progress, 
and destroy its virility, the tube in some cases 
becoming pervious, and capable of again per- 
forming its function. (These cases with 
their damaged ciliary membrane interfering 
with the proper descent of the ovum, are said 
to be sometiems responsible for tubal preg- 
nancy.) 

When the infection is more virulent, nature 
failing in her effort to destroy the germs, pro- 
ceeds to circumscribe, or wall off the offending 
material, by throwing out inflammatory lymph, 
causing co-aptation of the walls of the tube, 
both at the fibriated and uterine ends; the tubes 
becoming edematous and heavy fall back toward 
the pelvic floor, where from contiguity of tissue, 
they become adherent to the adjacent organs. 


Thus fixed in their new position, the germs 
in some cases seem to loose their virility before 
the pus sack attains any considerable size, the 
contents become inspissated, and the damage 
wrought, and disability caused, is comparatively 
small, being limited to the malposition of the 
organs, and, the adhesions holding them in their 
unnatural position. The more usual course, 
however, is a continued enlargement, by reason 
of the pyogenic lining membrane, until a tumor 
of considerable size is formed, which, if spon- 
taneous evacuation does not take place, may at- 
tain enormous proportions. I recall seeing a 
case some years ago, from -which nearly two 
gallon was removed from the two tubes enu- 
cleated. 

Symptoms.—The surgeon seldom sees these 
eases in the acute stage of the disease, when 
seen however, they are, if of gonorrheal origin, 
preceded by more or less acute inflammation of 
the urethra, vulva and vagina, followed by pains 
in the pelvis, accompanied by painful micturi- 
tion and a varying degree of temperature. 

In streptococcus infection the symptoms are 


more acute and grave, usually ushered in wit! 
a chill. The fever soon becoming alarming! 
high, with corresponding pulse; after a perio 
of from six to fifteen days, if from gonorrhea 
and from three to twelve weeks, if from strept 
occus, the acute symptoms subside, but the p: 
tient is far from well, she has pelvic pain 
painful and frequent menstruation, more or le: 
sero-sanguineous vaginal discharge, painf 
micturition and defecation, from adhesions a: 
pressure, bearing down pains and backache, a: 
usually, though not always, an evening tempe: 
ature. 

Diagnosis.—The diagnosis is not usually diff 
cult. The history of an attack of gonorrh: 
septic labor, or miscarriage, can usually but n: 
always be elicited; when such information s 
forthcoming it is of diagnostic importance, f: 
quently the history of an initial attack is wan'- 
ing, the patient says she began to have pain- 
ful menstruation, tenderness of lower abdom: 
lack of animation, etc. The general appearan:e« 
of the patient as sallow complexion, stooping 
and careful gait, etc., will indicate suffering 
more or less constant and acute. Digital exam- 
ination reveals an immovable pelvic floor, in- 
durated masses can sometimes be detected on 
one, or both sides of the vaginal vault, or per- 
haps in Douglas’ cul-de-sac, tender and perha)s 
slightly fluctuating, if of large size, a tumur 
may be felt above the pelvic brim. 

Treatment.—Preventative treatment is of 
paramount importance; the best means of pro- 
tecting the innocent from the latent gonococcus, 
is commanding the attention of our societies 
today, which, presages a better understanding 
of the subject by the profession. 

The general practitioner, who usually sees 
these cases, must be impressed with the seri- 
ousness of this disease, which he too often 
treats with levity. The laity must also be edu- 
cated; must be instructed as to the fearful dan- 
ger lurking in the slight and apparently harm- 
less gleety discharge, and the direful results 
following woman's inoculation. This knowledge 
can probably, best be disseminated through the 
agency of our state board of health, to whom 
is entrusted the general supervision of the in- 
terests of the health and life of the people. 


After infection has gained ingress into | 
fallopian tube of woman, if seen in the initi. 
tory stage, the treatment should be paliative: 
for surgical interference at this time is v: 
dangerous, you have no well defined absx 
cavity to attack, the adjacent peritoneal co\ 
ings have not, as yet, become immunized, 4 
any disturbing of the lightly agglutinated s'- 
faces, would cause a rapid spreading of the 
fection, and probably, an early fatal termi: 
tion; instead give frequent and copious vagi''' 
douches of hot water, use ice applications 
abdomen, and opium when necessity seems ‘ 
require. 

After the subsidence of the acute sympto 
is the time of election for surgical interferer 
an operation slight in character, but with m 
promise of a permanent cure, without mut 
tion, is now indicated, namely vaginal incis 
and drainage, which, if performed early, wi 


nooecten oss 





COUNTY SOCIETIES. 


elieve, cure a large majority of these cases; if 
ferred however, until the lining wall of the 
sscess cavity becomes pyogenic the probability 
a cure by this method, are small indeed, for 
ything short of a total destruction of all the 
ogenic lining membrane, by curette, caustics 
otherwise, will result in a permanent fistu- 
is tract, or recurrence of the abscess. 


Vaginal drainage is usually performed in the 

lowing manner; after thoroughly cleansing 

e parts, the vaginal wall is pressed up 
azainst the point selected for puncture, with the 
ndex finger, which, also serves as a guide for a 

ir of scissors, or sharp pointed clamps, which 
ace plunged into the abscess cavity, upon their 
\ithdrawal, the scissors or clamps should be 

ened, thus making an opening large enough to 
rmit of the introduction of a gauze pack, after 
ie cavity has been thoroughly explored, cur- 
ted and irrigated. Very little hemorrhage will 
encountered, in this procedure, if care is 
uken to avoid the uterine artery. Other dan- 
rs of this operation, is the possible wounding 
of the ureters, bladder or rectum, and the more 
common accident, of transfixing a loop of the 
ilium., That these dangers may be lessened I 
have conceived, and carried into execution with 
gratifying results, in a number of cases, the idea 
of an extra-peritoneal drainage, which I will 
describe. 

An incision posterior to, and slightly to one 
side of the cervix, is made, cutting down to the 
peritoneum, which is then followed by dissec- 
tion, with the finger upward, close to the uterus 
separating the anterior and posterior folds of 
the broad ligament, until the tube is reached, 
afer which it is punctured and treated, as in 
ordinary vaginal drainage. If the case be a 
double pyosalpinx, the incision should extend 
in a semi-circle, across the entire vaginal vault; 
the dissection, after reaching the uterine body, 
being carried to either side of that organ, until 
the fluctuating mass is encountered. This 
method, in addition to lessening the danger of 
the accidents mentioned, entirely obviates the 
possibilities of the purulent abscess contents, 
flowing or leaking into the pelvic cavity, and 
setting up a general or localized peritonitis. Af- 
ter vaginal drainage the pack should be left in 
two or three days, after which, the cavity 
should be thoroughly irrigated daily with boric 
acid solution, and re-packed until by granula- 
tions and contraction it is entirely obliterated, 
which, in adaptable cases, will occur in from 
two to four weeks. Unfortunately cases of 
pyosalpinx are usually referred to the surgeon 
at a later period than the one just described; 
the improvement after the initiatory symp- 
toms have subsided, encourage the patient, 
as well as her physician, to think that 
she is going to make a spontaneous re- 
covery, and it is only after months, aye per- 
hips years, of varying degree of ill health, that 
the surgeon’s services are solicited; then a very 
d ferent operation is required, that of enuclea- 
tion, Some very eminent surgeons, among them 
Pryor, of New. York, enucleate through the va- 
£.na, with excellent results, but for the less fre- 
quent, and less skilled operator, the abdominal 


345 


route should be chosen, whereby his tactile 
sense, may be aided in the difficult dissectiogs 
and manipulations, by the sense of sight. 

The opening having been made, the omental 
adhesions properly dealt with by ligation, if any 
interfere with the examination, the patient 
should be placed in the Trendelenburg position, 
and the free abdominal cavity walled off by the 
use of hot moist pads, the fundus located, the 
finger can usually be worked down to Douglas’ 
cul-de-sac, and from this point the adhesions 
around the tubes carefully broken up; some- 
times however, the better point of ingress will 
be found, out on the dorsal wall of the pelvis, 
where, after getting the fingers down behind the 
tube, by a rolling motion, the entire mass is dis- 
sected up retaining its normal attachments to 
the uterine body. 

At this point the question of a pan-hyster- 
ectomy must be considered, for many excellent 
surgeons, among them Mann, of Buffalo, ad- 
vocate a complete hysterectomy, whenever it is 
necessary to enucleate a fallopian tube by rea- 
son of its infectious contents. 

To remove the pyosalpinx and leave an in- 
fected uterus, will only partly alleviate the pa- 
tient’s symptoms, if at all, and the results will 
be unsatisfactory, in the extreme; the patient 
continue to drag out a miserable existence, for a 
time, and finally return, or more likely, seek the 
services of another surgeon, who will be called 
upon to operate for the condition you have 
failed to relieve; this question requires ‘serious 
thought, and close discrimination, if the pa- 
tient be young, the pyosalpinx single, the other 
tube and uterus healthy, the purulent mass 
should be removed, after ligation at the cornu, 
and an effort made to save the apparently 
healthy viscus;if an endometritis exists, the 
uterus should be carefully curetted, and packed 
with iodoform gauze, a small drain of the same 
material being drawn through an opening in the 
cul-de-sac, if any question exists as to the 
sterility of the field. 

On the other hand, if the patient is ap- 
proaching the menopause, the other tube under 
suspicion, or the uterine tissue boggy and fri- 
able, a complete removal of the organs, includ- 
ing the cervix, should be made, provided, of 
course, the physical condition of the patient 
does not contra-indicate this major operation, 
by reason of the additional shock entailed. Af- 
ter pan-hysterectomy, performed, in the usual 
way, and iodoform gauze plug should be drawn 
down through the opened vault of the vagina, 
leaving the upper end a little above the cut 
edges of the vaginal walls. The after treatment 
is very simple; after the removal of the gauze 
plug, which, should be left for from two to four 
days, the vagina should be washed out daily 
with warm boric acid solution. 





BOONE COUNTY MEDICAL SOCIETY. 
Dr. G. N. Kreider, Springfield, Il. 

Dear Doctor:—In compliance with your re- 
quest I will give you an account of what we 
have done in this county. 

Dr. J. H. Stealy, of Freeport, acting for the 
Illinois State Medical Society called a meeting 





346 


of the physicians of Boone County for July 
14th at the Julien House, Belvidere, Ill. Four- 
teen physicians attended this meeting and after 
a talk by Dr. Stealy and a full discussion or- 
ganized the Boone County Medical Society. 
No factional lines were drawn. The following 
officers were unanimously elected: President, 
R. W. McInnes, Secretary, R. B. Andrews, Vice 
President, D. E. Foote, Treasurer, J. B. Lietzell, 
Censors 1 year, Chas. Scott, 2 years, A. W. 
Swift, 3 years Robt. Hutchinson. The president 
appointed Drs. Mitchell, Marriett and De- 
lavergne a committee on constitution and by- 
laws. 

The meeting then adjourned. 

The first regular meeting of the Boone 
County Medical Society was held Friday, Sept: 
1st. in G. A. R. hall. There was a large attend- 
ance twenty-five physicians being present and 
much interest manifested. Dr. J. B. Murphy 
addressed the meeting, his subject being Gas- 
tric Ulcer. In his usual clear and concise way 
Dr. Murphy treated the subject and held the 
undivided attention of those present. 

This first meeting was considered auspicious 
for the future of the society and by the time 
of the next meeting the first of December we 
expect to have nearly if not all the profession 
in this county, members of this society. 

Your very truly, 
R. B. Andrews, Secretary. 





CRAWFORD COUNTY MEDICAL SOCIETY. 
Regular meetings are held bi-monthly on the sec- 
ond Thursday. Membership 24. 

Officers. 

Dr. Frank Dunham 

Dr. L. R. Illyes 

Secretary Dr. H. N. Rafferty 

Treasurer Dr. C. Barlow 

Board of Censors: Dr. G. W. Fuller, Dr. C. H. 

Voorheis. 

Committee on Arrangements: Dr. I. L. Fire- 

baugh, Dr. C. Barlow, Dr. H. N. Rafferty. 


The Crawford County Medical Society held 
its regular bi-monthly meeting at the office of 
Dr. A. G. Meserve, Thursday, Sept. 14, 1905. 

The meeting was called to order by Dr. L. 


R. Illyes, Vice-President, in the absence of 
President Dunham, with the following members 
present, viz.:. Barlow, Birch, Firebaugh, Illyes, 
Kirk, Meserve, Midget, Mitchell, Price, T. N. 
Rafferty, H. N. Rafferty, Smith and Voorheis. 

The minutes of the previous meeting were 
read and approved, after which Drs. A. G. 
Meserve and J. E. Midgett were nominated to 
fill existing vacancies on the Board of Censors. 
On motion, the rules were suspended and the 
secretary was instructed to cast the unanimous 
ballot of the society for these gentlerhen. 

Dr. L. R. Illyes read an able paper on “Acute 
Intestinal Obstruction,” which was freely dis- 
cussed by all present. 

Dr. T. N. Rafferty’s paper on “The County 
Society” was timely, owing to the sluggish 
condition of our society at present, and was 
well received. 

The discussion was mainly concerning the 


COUNTY SOCIETIES.. 


subject of consultation with irregulars, an 
their admission to our ranks. 

After a lengthy and profitable discussion « 
all the phases of these propositions, the Societ 
adjourned, to meet in November, at which tin 
an unusually interesting program is promised. 





DECATUR MEDICAL SOCIETY. 
Regular meetings are held in the Decatur Ch 
Rooms the fourth Tuesday of each month 
Membership 62. 


Officers. 
President, Everett J. Brown 
Vice-President, Ellen F. Grimes 
Secretary-Treasurer, Benjamin Bachrach 


Board of Censors: S. E. McClelland, Lynn } 
Barnes, Cass Chenoweth. 

The regular monthly meeting of the socie' 
was held in the Decatur Club rooms, Tuesd 
evening, August 22, 1905, and the president being 
absent, the vice president, Ellen F. Grimes, pr: 
sided. 

Dr. J. Stebbins King read a very interest! 
paper on Some Personal Experiences with Ye'- 
low Fever. It was greatly appreciated by the 
society, for the doctor had had considerable ex- 
perience with the disease, while army surgeo: 


‘both in this country and in Cuba. 


Dr. Will C. Wood reported several interest- 
ing cases, which was welcomed by the society. 

The two amendments to the by-laws were 
adopted. 





JERSEY COUNTY MEDICAL SOCIETY. 

Society met at the Court House, Aug. 2nd 
1905, at 2. p. m. 

Dr. Waggoner in the Chair. 

Members present: Drs. Waggoner, Barnett, 
Flautt, Bohanan and Van Horne. 

Minutes of the June meeting were read anid 
approved. , 

Dr. O. O. Giberson of Delhi was elected to 
membership. 

Dr. A. A. Barnett read an interesting pape: 
on summer complaint of children. 

The treatment should be upon hygienic prin- 
ciples. Cleanliness and antiseptics being 
much value. Small doses of Calomel and Bis- 
muth are advised. To relieve nausea spiced 
plasters are of much utility. 

Many other useful remedies were embodied 
in Dr. Barnett’s paper. 

The paper was discussed by Drs. Fiau' 
Bohanan, Waggoner and Van Horne. 

Dr. Van Horne continued his paper on Hyd: 
Therapy. 

Dr. Van Horne offered the following resol: 
tion which was adopted: 

Resolved, That a legislative committee be a) 
pointed to confer with other medical societi 
with a view of securing the passage of a! 
propriate laws pertaining to the manageme!'' 
and control of patent and proprietary med 
cines. 

In support of the resolution he said: “Our 
legislators have started such laws but have nm 
felt the backing and support of the medical pro- 
fession, who after having the subject intr 





COUNTY 


duced into the legislature would retire to their 
homes, trusting all would be well, while the 
enormous monied interests of the proprietary 
and quagk medicines were always on the alert 
and on hand with boodle and with paid attor- 
neys to defeat legislation that would be inimical 
to the enormous fortunes that they wrung from 
the people.” 

he resolution was adopted. The legislative 
committee to be appointed at the September 
meeting. 

On motion society adjourned to first Wed- 
nesday in September. 

September 6, 1905, society met at the Court 
House. 

The President, Dr. Williams, in the Chair. 

Members present: Drs. Williams, Barnett, 
Gledhill, Bohanan and Van Horne. 

Dr. Joseph Enos and Dr. Geo. B. Smith were 
elected to membership. 

The legislative committee appointed by 
President Williams was as follows: A. K. Van 
Horn, Chairman; H. R. Gledhill, R. Bohanan 
and Joe Enos. 

Typhoid fever was before the society for 
discussion. 

Dr. Gledhill gave an interesting talk on ty- 
phoid fever and reported two cases recently 
treated by him; they were of unusual interest. 

A general discussion of typhoid fever was 
entered into by the members present. 

Dr. Joseph Ends, Dr. J. S. Williams and Dr. 
Barnett each gave interesting facts in the man- 
agement and treatment of the disease. 

The board of censors decided to continue the 
subject of typhoid fever for the October meeting. 

On motion the society adjourned to the first 
Wednesday in October. 





SANGAMON COUNTY MEDICAL SOCIETY. 
Regular meetings are held at the Lincoln 
Memorial Library in Springfield the second 
Monday of each month at 8 p. m. 
Membership 80. 

Officers. 

President W. O. Langdon, Springfield 
Vice President R. D. Berry, Springfield 
Secretary-Treasurer....C. R. Spicer, Springfield 
Directors, B. B. Griffith, E. E. Hagler, A. D. 

Taylor. 

The Sangamon County Medical Society held 
its regular meeting in the Lincoln Library 
Sept. il, 1905. Fourteen members and four 
visitors were in attendance. : 

Drs. Bell, James and Graser were elected to 
membership. The applications of Dr. J. W. 
Mays, of Illiopolis and Drs. F. C. Fink, P. W. 
Monroe, Stanley Castle and C. L. Patton were 
received and referred to the board of censors. 

Dr. Griffith was elected to fill the vacancy in 
the board of censors caused by the absence of 
Dr. Hopkins. The invitation extended to the 
State Medical Society at its last meeting to 
hold its next meeting in Springfield was dis- 
ussed. All seemed agreed that the convenience, 
comfort and general interests of the State So- 
ciety would be best conserved by making 
Springfield the permanent place of meeting. 


SOCIETIES. 


Dr. Munson was the essayist of the evening 
and presented an interesting paper on “Our Milk 
Supply.” 

Among the many strong points presented 
were the following: The cost of furnishing 
good milk in necessarily greater than where no 
special care of the herd nor proper handling of 
the milk are observed. That the consumer 
erroneously considers the price rather than 
the quality of milk and patronizes the producer 
of cheap rather than good milk. Special atten- 
tion was called to the care of the containers 
for the milk and the fact noted that cold storage 
pateurization nor any other process would make 
milk wholesome which had been contaminated 
by any means during transit to the consumer. 


The sanitary regulations of other cities were 
referred to—especially Rochester and New York 
City. Also the fact that the laws of New York 
had been so amended that at present it is 
necessary to have a license to sell milk and to 
procure the same the dealer must conform to 
strict regulations. Mention was made of the 
incident which led to the recent investigation 
of our local milk supply and the flagrant abuses 
and pernicious practices in vogue in the adul- 
teration of milk offered for sale. It was the 
author’s opinion that much of the faulty 
management of the milk complained of was 
a matter of ignorance on the part of the 
dairyman and dealer rather than a malicious 
intent and that the effects of the preservatives 
used were not appreciated. 


The paper was well received and called 
forth a general discussion. Dr. Arthur Prince 
‘noted the passing of an effort on the part of a 
dairyman who endeavored to conduct a sani- 
tary dairy. The project failed partly because 
the public failed to appreciate the efforts of the 
dairyman and the necessary added cost of 
milk; but more especially because in separating 
the fat from the milk by a powerful centrifugal 
separator the mucin was removed from the 
milk and though the fat was again added to the 
milk it produced constipation. Dr. Dixon raised 
the question as to whether formaldehyde, in 
such amounts as would be necessary to preserve 
the milk, was really injurious and if so, how? 


Several replied to the question to the effect 
that when used continuously the formaldehyde 
acted as an irritant to the delicate mucus mem- 
branes of the stomach—especially in children. 

The following resolution offered by Dr. 
Kreider was adopted: 

Resolved, By The Sangamon County Medi- 
cal Society; 

ist. That events of the past few weeks have 
shown that municipal control of the milk supply 
of the city of Springfield is absolutely necessary 
to preserve the life and health of all citizens, 
more especially children and invalids. 

2d. That a committee be appointed to visit 
those dairies claiming to furnish clean milk 
and report at the next meeting of our Society. 

3d. That the municipal control should be 
along modern scientific lines and that we urge 
the authorities to take immediate action in this 
important matter. The committee appointed by 





348 


the chair as provided for by the resolution were 
Drs. Kreider, L. C. Taylor and S. E. Munson. 
The meeting closed in order. 





VERMILION COUNTY MEDICAL SOCIETY. 

Regular meetings are held at the Council 
Chamber, Danville, Illinois, the second Monday 
in each month at 8 P. M. 


President 

Vice President 

Secretary-Treasurer 

Board of Censors—H. F. Becker, Joseph Fair- 
hall and Benj. Gleeson. 

Public Health and Legislation—Joseph Fairhall, 
E. E. Clark, T. E. Walton. 

Program—F. N. Cloyd, E. B. Coolley, C. P. Hoff- 
man. 


PROGRAM 1905-6. 
October 9, 1905. 
Summer Diarrhoea in Children, E. B. Coolley. 
Discussion led by R. A. Cloyd and R. A. Brown. 
Treatment of Typhoid Fever, Clark Leavitt. 
Discussion led by B. Taylor and S. M. Black. 
Report of Cases. 
November 13, 1905. 
Symposium Tuberculosis. 
Diagnosis, F. M. Mason. 
Discussion led by Leroy Jones. 
Treatment (non-surgical) J. B. Morton. 
Discussion led by F. N. Cloyd. 
Surgical Treatment, S. C. Glidden. 
Discussion led by C. E. Wilkinson. 
Report of Cases. 
December 11, 1905. 
Social Session. 
Committees to be appointed by the chair. 
Election of Officers. 
January 8, 1906. 
Rheumatism, A. J. Leitzbach. 
Discussion led by G. M. French and 8S. L. 
Landauer. 
Legal Medicine, Joseph Fairhall. 
Discussion led by E. E. Clark and J. A. Chaffee. 
Report of Cases. 
February 12, 1906. 
Hepatic Insufficiency, Theo. Regan. 
Discussion led by J. B. Hundley and J. W. 
O’ Haver. 
Auto-intoxication, J. H. M. Clinch. 
Discussion led by A. Merrill Miller and J. G. 
Fisher. 
Report of Cases. 
March 12, 1906. 
Emergency Therapeutics, F. E. Saunders. 
Discussion led by O. W. Michael and Solomon 
Jones. 
Emergency Surgery, P. H. Fithian. 
Discussion led by W. A. Lottmann and T. E. 
Walton. 
Report of Cases. 
; April 9, 1906. 
Opthaimia Neonatorum, C. P. Hoffman. 
Discussion led by Benj. Gleeson and E. E. 
Clark. 
Asthenopia, B. I. Poland. 
Discussion led by I. E. Huston and E. M. 
Smith. 
Report of Cases. 


COUNTY .SOCIETIES. 


May 14, 1906. 
Perinephritic Abscess, H. W. Morehouse. 
Discussion led by W. A. Cochran and J. M. 
Guy. 
Alkaloidal Therapy, W. H. Paul. 
Discussion led by Effie Current and Samuel 
Moore. 
Report of Cases. 
June 11, 1906. 
Lesions of the Stomach, Robt. McCaughey. 
Discussion led by M. Sahud and H. F. Becker 
Orthopedic Surgery, G. L. Williamson. 
Discussion led by T. P. French and D. V. Ray 
Report of Cases. 


Membership of the V. C. M. S. for 1905, that 
Have Paid Dues. 

Babcock, H. S., Danville. 
Barton, F. W., Danville. 
Becker, H. F., Danville. 
Black, S. M., Georgetown. 
Brown, R. A., Humrick. 
Chaffee, J. A., Danville. 
Clark, E. E., Danville. 
Clinch, J. H. M., Danville. 
Cloyd, F. N., Westville. 
Cloud, R. A., Catlin. 
Colyers, J. R., Catlin. 
Cooley, E. B., Danville. 
Cossairt, W. S., Potomac. 
Current, Effie, Danville. 
Fairhall, Joseph, Danville. 
Fithian, P. H., Fithian. 
French, G. M., Danville. 
French, T. P., Danville. 
tleeson, Benj., Danville. 
Glidden, S. C., Danville. 
Hughes, G. W., Armstrong. 
Hundley, J. B., Danville. 
Huston, IL. E., Danville. 
Hoffman, C. P., Danville. 
Johnson, A. C.,- Sidell. 
Jones, Solomon, Danville. 
Jones, Leroy, Hoopeston. 
Kingsley, V. C. T., Danville. 
Landauer, S. L., Danville. 
Leavitt, Clark, Danville. 
Leitzbach, A. J., Fairmount. 
Lottmann, W. A., Danville. 
Mason, F. M., Rossville. 
Michael, O. W., Muncie. 
Miller, A. M., Danville. 
Moore, Samuel, Danville. 
Morton, J. B., Ridgefarm. 
O’Haver, J. W., Danville. 
Paul, W. H., Danville. 
Poland, B. L, Danville. 
Ray, D. V., Jamesburg. 
Sahud, M., Danville. 
Smith, E. M., Georgetown. 
Taylor, B., Westville. 
Walton, T. E., Danville. 
Wilkins, J. M., Fairmount. 
Wilkinson, C. E., Danville. 
Williamson, G. L., Danville. 
Worthington, R. R., Indianola. 
The above names have been reported to Secre 

tary Weis, and have paid dues for the yea: 

1905. Charles E. Wilkinson, 

Secretary. 














THE USE OF CYSTOGEN 


_ Cystitis 2 Pyelitis 


has become the recognized treatment of a large proportion 
of the American Genito-Urinary Specialists. It impregnates 
the urine with formaldehyde; washes the Genito-Urinary 
tract from the glomerulus of the kidney to the meatus uri- 
narius with this germicidal solution. Its influence will be 
seen in the rapidity with which it neutralizes ammonia, 
destroys putridity, and clears the urine of the tenacious 
mucus so prevalent in bladder troubles of the aged. 


Samples on application to 


CYSTOGEN CHEMICAL COMPANY 
ST. LOUIS, MO. 


COMMERCIAL Forms: 
Cystogen—Crystalline Powder. Cystogen-Lithia (Effervescent Tablets). 
Cystogen—S-grain Tablets. Cystogen Aperient (Granular Effervescent Salt) 
with Sodizm Phosphate.) 


























How to 


Feed the Baby 


Is often a perplexing question when mother’s milk is insufficient, either in 
quantity or quality. Pure cow’s milk is not always available, and most of the 
proprietary substitute foods are deficient in fat. Even cow’s milk, although 
containing the requisite fat, is somewhat deficient in carbohydrates.. But Win- 
ters says: ‘‘Children get over slight chemical differences in cow’s milk much 
more readily than they do physical differences—those due to contamination.” 
And Jacobi states: ‘Clean milk is far more important than any amount of 
modification.” 


Highland Brand Evaporated Cream 


Which is simply good cow’s milk reduced two and one-half times by 
evaporation and sterilized, overcomes all danger of contamination. Fur- 
ther than that it is more readily digestible than either raw, pasteurized or 
boiled milk. In short, it is far preferable to ordinary cow’s milk from 
every standpoint. It is the simplest, most uniform and satisfactory sub- 
stitute food. Trial quantity on request. 





HELVETIA MILK CONDENSING CO., Highland, Illinois. 








Please mention the Journal when writing to advertisers. xXI 





PUBLISHER’S NOTES. 


@he Allinsis Medical Journal. 


; EDITORIAL OFFICE, 522 CAPITOL AVENUE, SPRINGFIELD, 
Copy for advertisements must reach the editor’s office by the:20th of the month in order to secure insertion. 


PUBLISHER’S NOTES. 


The Journal is not responsible for any medical or therapeutical views expressed in 
this department. 








The Morning Dose of Saline. 


Physicians should emphasize the importance, 
to the majority of people past middle life, and 
especially to those who suffer from fermentive 
indigestion, particularly of the lower bowels, 
as so many do, of the morning toilet, or rather 
flushing of the bowel, with a well-diluted, non- 
irritating saline. Its action is first to unload the 
conjested capillaries of the mucosa, and then 
to sweep out the accumulated debris, leaving 
the bowel fresh for the duties of the day. 


To accomplish this a saline should be taken 
the first thing in the morning, a heaping tea- 
spoonful, more or less as needed, of a good 
preparation, dissolved in a half-glass of cool 
water: Taken in this way one-half hour before 
breakfast it should act within two hours after 
breakfast, getting entirely out of the stomach 
before it receives food, thus flushing the entire 
canal for the digestive work of the day. 


The best of all salines for this purpose is 
Abbott’s Saline Laxative (granular effervescent 
magnesium sulphate, c. p.). Just enough should 
be taken to produce the desired effect—one good 
free, satisfying, gratifying evacuation of a semi- 
solid consistency. Taking enough, and just 
enough, and taking it regularly under the condi- 
tions as outlined, no habit is established and the 
dose will not have to be increased. If irritating 
preparations are used, or if it is taken in any 
other way than suggested, this will not be the 
case. It is astonishing how much can be ac- 
complished in the maintenance of health by the 
regular use of this preparation as outlined. 
Here is a pointer not only for many, many pa- 
tients, but for the doctor himself as well. 





Cystitis.—The treatment of cystitis should 
be direct and indirect; whether it be due to gon- 
orrhea, obstruction, or any other cause, the man- 
agement is essentially the same. Here, rest is 
of first importance; such a condition of quiet 
is, at times, necessary that on the surface of the 
urine in the bladder there is not a wave or 
ripple. 

The hips should be raised and the urine kept 


from the bladder neck; the general health 
should be cared for, and the use of such de- 


mulcent diurectics as will flush out the blad- 
der with minimum discomfort. For the ac- 
complishment of this purpose, the following 
is of service when the urine is alkaline and 
much decomposed: 


Rx. Cystogen tablets, aa, 5 gr. No. XXV. 
Sig—One in a glass of water after each 
meal. 


Progress in Fracture Treatment. Progress 
is the order of the day and in no department of 
surgery is this better exemplified than in the 
treatment of fractured limbs. The advent of 
the Ambulatory Pneumatic Splint has enabled 
the giving of patients such superior treatment 
that shortening or deformity have been prac- 
tically eliminated. These splints may be ap- 
plied without an anesthetic or the causing of 
pain to patient and it at once allows the pa- 
tient to move in bed, sit up or walk about, a 
little more each day until well, as directed. 
Good bone union is invariably secured and treat- 
ment with it, makes patients stronger, enables 
them to enjoy the benefits of fresh air, sun 
and light, eat and sleep better and to recover 
from their injury much sooner than would 
other be possible. Extension, counter-exten- 
sion and immobilization are easily applied and 
maintained whether patient is in bed or walk- 
ing with this modern splint. Co-aptation 
splint, adhesive strap traction or any form of 
dressing indicated may be used with it. Its 
use assures free circulation, inspection, ventil- 
ation, bathing, dressings, massage, etc., besides 
gradual daily extension until subsidence of in- 
flammatory exudate is complete and satisfactory 
continuity and bone union has been secured 
This splint is adjustable to the right or left 
limb of any adult patient, for any fracture 
from the neck to the femur to the ankle and be- 
ing thoroughly well made and adjustable, may 
be renovated and used any number of times. 
We heartily commend its use to our readers. 
It is made by the Ambulatory Pneumatic Splint 
Mfg. Co., Chicago, who guarantee it to give 
satisfaction. 





FOR RENT—A beautiful suite of rooms in 
genteel neighborhood, near Lincoln park, suit- 
able for physician or couple. All modern con- 
venience. Address Mrs. J. J. Gorman, 547 
Dearborn Ave., Chicago, Ill. 





nOoOPerrteadae we 


_ oo = rs 


TONSILLITIS. 

Inflammation in any form attacking the ton- 
sillar region gives rise to symptoms of most dis- 
tressing character and at the same time pro- 
vides a most favorable soil for the entry into 
the system of other infections. It is well to 
remember that at first this disease is only a 
local disturbance affecting the capillary system 
and glandular structure, and if promptly and 
efficiently treated will remain local. The con- 
stitutional symptoms such as fever, headache, 
etc. Only develop when there is considerable 
infection taken up. 

In treatment, the first indication is to in- 
crease local capillary circulation. A local 
remedy must fill two requirements, i. e., a deter- 
gent antiseptic and a degree of permanency in 
effect. Many of the remedies which have been 
advocated for the varied forms of Tonsillitis are 
antiseptic, but they are not sufficiently exosmo- 
tic in their action to increase the circulation or 
else their effect is too transient. Glyco-Thy- 
moline frequently applied in a 50% strength with 
a hand atomizer produces a rapid depletion of 
the congested area through its well defined 
exosmotic property, reestablishing normial pas- 
sage of fluids through the tissues, promptly re- 
lieving the dry condition of the membrane and 
giving an immediate and lasting anodyne effect. 
As a gargle, a 25% solution hot, may be effec- 
tively used, providing the process does not cause 
undue pain. The external application of cloths 
dipped in hot water and Glyco-Thymoline in 
25% solution greatly increases the venous circu- 
lation. 





In a treatise “On Exodin as a Purgative for 
Puerperal Women,” Dr. Otto Schmechel records 
an extensive experience with exodin in the 
clinie of Privy Councillor von Winckel at 
Munich. It was given to 100 subjects, mostly 
young and healthy puerpera whose confinements 
had been normal, but who had no passage for 
three days after delivery. They all took it 
without any trouble whatever; there was no 
difficulty in swallowing the tasteless suspension. 
Never was there disgust or nausea. 

The results were in accord with those of 
Prof. Ebstein and Dr. Stauder; passages were 
procured without any trouble whatever. The 
dose of 22% grains, however, which they found 
to be always sufficient, gave some failures, and 
to assure certainty of effect in these puerperal 
cases it was necessary to give a dose of 30 
grains. Once the drug caused some tenesmus 
and a thin evacuation, but no other case of 
diarrhoea was observed. The stools were some- 
times formed, but usually mushy and brownish. 
They never contained mucus or any other indi- 
cation of intestinal irritation. ; 


PUBLISHER'S NOTES. 


351 


Often there was another stool on the same 
or following day. The interval between ad- 
ministration and defecation were somewhat 
lengthy. The earliest passage noted was Ip 
hours later, and this was only occasionally. 
Usually it took 18 to 20 and even 24 hours. 


As certain drugs, like rhubarb, are excreted 
in the milk of nursing women, the infants were 
carefully observed. It was never noted that a 
nursling got diarrhoea or was in any way in- 
fluenced when exodin was given to the mother. 
The urine of the patients was dark as a rule, 
but there was never albumin or any other 
pathological substance present. There was no 
staining of linen, as occurs with purgatin. 


Exodin thus proved to be a readily ad- 
ministered laxative which does not affect the 
stomach, is entirely non-irritant, and has no 
deleterious influence on the progress of the 
puerperium. The requisite dose appears to be 
39 grains, if certainty of effect is to be 
guaranteed. 





A NEW LIQUID ANTISEPTIC. 
Parke, Davis & Co., have recently intro- 
duced a new liquid antiseptic of considerable 
power, called Cresylone. It contains 50 per 


cent of Cresylic Acid and forms clear solutions 
with water in all proportions. 

A two per cent solution of Cresylone is not 
only an excellent disinfectant for instruments 
and hands, but a valuable detergent and lubri- 


cant, too. It is said not to injure metallic or 
rubber instruments, though celluloid articles are 
apt to become friable under its action. 


In the treatment of wounds a one per cent 
solution is usually employed, and a two per cent 
solution may be used in profoundly septic cases 
when more vigorous measures are indicated. 

Cresylone completely arrests the develop- 
ment of pus organisms and is, therefore, indi- 
cated in the various suppurations with which 
the general practitioner has to contend. In 
the treatment of otorrhea, irrigation with a % 
per cent solution is said to be of benefit. A 
solution of the same strength is of value in the 
treatment of ozena. 


As it removes odor, it may prove of service 
in gangrene. In cancer of the cervix uteri 
the application of gauze saturated with a solu- 
tion of Cresylone will remove the odor that 
accompanies this disease. For disinfecting 
sputa and stools Cresylone commends itself in 
the sick room, hospital ward, schools, prisons, 
etc. 


Therapeutically, the use of Cresylone has 
been suggested in various pathologic conditions, 
notably in the treatment of gonorrhea, lupus, 
tonsillitis, eczema, and cystitis of the female. 





CHICAGO, 
ST. LOUIS 


AND 





ny Ooet PORTE TN ged, 3: ere 


CRN ROIs a wa rab 








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