The Project Gutenberg eBook of The American Practitioner and News. Vol. XXV. No. 3. Feb. 1, 1898
    
This ebook is for the use of anyone anywhere in the United States and
most other parts of the world at no cost and with almost no restrictions
whatsoever. You may copy it, give it away or re-use it under the terms
of the Project Gutenberg License included with this ebook or online
at www.gutenberg.org. If you are not located in the United States,
you will have to check the laws of the country where you are located
before using this eBook.

Title: The American Practitioner and News. Vol. XXV. No. 3. Feb. 1, 1898

Author: Various

Editor: H. A. Cottell

Release date: October 17, 2019 [eBook #60511]

Language: English

Credits: Produced by Richard Tonsing and the Online Distributed
        Proofreading Team at http://www.pgdp.net (This file was
        produced from images generously made available by The
        Internet Archive)


*** START OF THE PROJECT GUTENBERG EBOOK THE AMERICAN PRACTITIONER AND NEWS. VOL. XXV. NO. 3. FEB. 1, 1898 ***




Produced by Richard Tonsing and the Online Distributed
Proofreading Team at http://www.pgdp.net (This file was
produced from images generously made available by The
Internet Archive)









                                  THE
                    AMERICAN PRACTITIONER AND NEWS.
                          “_NEC TENUI PENNÂ._”
     VOL. XXV.       LOUISVILLE, KY., FEBRUARY 1, 1898.       NO. 3


  Certainly it is excellent discipline for an author to feel that he
  must say all he has to say in the fewest possible words, or his
  reader is sure to skip them; and in the plainest possible words, or
  his reader will certainly misunderstand them. Generally, also, a
  downright fact may be told in a plain way; and we want downright
  facts at present more than any thing else.—RUSKIN.




                           Original Articles.


                 SOMETHING ON THE DISUSE OF PHLEBOTOMY.

                      BY RUFUS W. GRISWOLD, M. D.

When I began looking into medical books preparatory to practice, fifty
years ago, the standard authors given us to read were not backward in
recommending blood-letting in the acute diseases; and a little later,
when an attendant at lectures at the College of Physicians and Surgeons
at New York, the professors were not lacking with the like advice. But
there has come a change, and so much of a change that, in this section
of country at least, the lancet has mostly gone out of use. That the
frequent use to which it was put seventy-five or a hundred years ago was
not at all times wise is likely; but the extent to which it has been
given up is also not wise. Rather more to notice some of the reasons why
it has so largely been abandoned than to argue for a reintroduction of
that ready and efficient instrument is the purpose of this paper.

A prominent point in the consideration of this comparative abandonment
of the lancet is presented in the question: Has there been such a change
in the type of the acute inflammatory diseases from three or four
generations ago as to render the abstraction of blood less necessary and
less useful? There are plenty of sound, hard-headed old doctors who will
give a negative reply to this query; and occasionally we may notice some
of them putting themselves in print to that effect. A Baltimore
practitioner not so very long ago said: “The necessity for the use of
the lancet is as great at the present time as it ever was in the past;
the type of the disease has undergone no such changes as to render the
abstraction of blood unnecessary or improper in the successful
management of all cases attended with a full, tense, and quick pulse.”
Others speak the like; but the majority of opinion is not pronounced in
that direction, but rather adverse. Conversations during a forty-four
years’ practice with men who began their professional calling sixty
years ago, when the lancet was in often call, is to the import that
there _has been_ such a change in diseases as renders the frequent
resort to blood-letting less important than formerly; that there is less
of the sthenic type in even inflammatory fevers, a more general
disposition to take on what we call typhoid forms, and thus depletion,
either by the evacuation of blood or the exhibition of reducing drugs,
is not so beneficial in even the acute inflammatory diseases as
formerly. This is the view that has been entertained by a large part of
those who began practice half a century or more ago, and this view has
been sustained by a large amount of written authority; but it does not
go to the extent of justifying that degree of abandonment of bleeding
that has prevailed for the last forty years. The general opinion of
to-day is, that while positions like that taken in the quotation given
are too positive, on the other hand our _practice_ is quite too lax; for
while we still believe in blood-letting to some extent, we but seldom
make use of it. Now as to the _why_.

Perhaps the first reason why the lancet is less used than formerly is
found in the fact, or rather in the belief, of the change indicated. It
is largely accepted as true by the older men in the profession that
patients do not bear blood-letting as well as three generations ago.
Accepting this as correct, it rationally follows that we should bleed
less. But this is only one of the factors in the account, and not the
largest one. The opinion that the physicians of the early part of this
century used the lancet too often is beyond doubt correct. The doctrine
of the purely symptomatic nature of fever put prominently forward by
Brousais, and earnestly championed by active and pushing minds a century
ago, and which was generally received in Europe and in this country,
gave such an unfortunate impetus to the use of the lancet as finally led
to its abuse. Patients were bled for almost every thing; not only for
the fevers of acknowledged inflammatory type, such as acute pleurisy and
the like, were bled for, but also cases of typhus, typhoid, etc., upon
the ground that the fever in the case was only a symptom of the
inflammatory action and was to be subdued or lessened by antiphlogistic
remedies, chief of which was the abstraction of blood. The theory of the
essentiality of fever became lost sight of, and the doctor treated for
an inflammation rather than for a fever.

Without giving up the theory in which they had been educated, some
physicians began to see that in some epidemics of disease a larger
percentage of cases were lost among those where venesection had been
used than among those similarly sick who were not bled. The deduction
from this was that it would be better to bleed less. But a change was
not to be made without a struggle. Reference to the medical literature
of the first half of the century shows that there was a deal of warm
discussion between the blood-letters and the anti-blood-letters. Out of
the observations and discussions made there was cultivated a prejudice,
professional to a moderate extent but popular to a large one, against
bleeding _per se_, and without reference to the character of the disease
under treatment or to the differing conditions that might exist, which
helped to carry the usage from its former abuse at times to the opposite
extreme of general abandonment. It is a universal law in nature that the
farther the pendulum swings in one direction, the farther will it swing
in the opposite on its return. The pendulum of venesection had swung too
far forward for the best in the treatment of disease, and the return
carried it quite beyond the best in the backward reaction.

Beyond the reasons noted for the present comparative non-use of the
lancet, there has been added a pressure of an erroneous and illegitimate
nature that has aided to put bleeding under a general ban more
unfortunate for the sick than was the former rather indiscriminate use.
Somewhat contemporaneously with the warm discussion upon bleeding
carried on in the profession, and perhaps partly out of that discussion,
there started up in various parts of the country an illegitimate class
of practitioners, mostly illiterate and destitute of preliminary
culture, interchangeably known as Botanics, Thompsonians, Eclectics,
etc., whose chief stock in trade for public acceptance was denunciation,
without regard to the conditions that might be met in a case, of
leeching, bleeding, blistering, scarification, and other agents for
cures. This denunciation found ready public credit. Not only from the
mouths of the class named, but in various other ways, the prejudice they
sought to create was widely diffused. Outside of the libraries of the
profession you seldom see a medical book; anywhere else they have been
rarities. But in many sections of the country for the last sixty years a
canvass of the families would show an abundance of books, published for
family reading, emanating from irregular practitioners, all of them
saturated with lying abuse of the methods of treatment of the regular
physicians. These books were loaned from one family to another, much as
the weekly papers or the cheap novel; and they were read and believed
in. The result was that many who read were indoctrinated with the belief
that bleeding, no matter what the disease or the conditions, was not
only not necessary, but pernicious, and often the cause of death; and
there was little printed contradiction offered to disabuse the public
mind of this false accusation.

Co-ordinating with this means of false instruction has been and is the
public press. As respectable practitioners do not stoop to the quackery
of advertising, the pecuniary interest of the press, so far as means and
methods for the cure of diseases is concerned, is identical with the
pecuniary interests of advertising quacks. The public press sells itself
to the broad diffusion of the ways and means of medical quackery in all
its forms. The subsidies of impostors and patent medicine men fill up
one carotid artery for the support of the press; and the influence of
that press, however weak the intellect that bestrides its tripod, is
more potent than a hundred of the ablest men in the profession, for the
sufficient reason that the voice of the men in the profession seldom
strikes the public ear through the same broad and forceful channel.

The result of the false teaching of the class of books alluded to and of
the medical advertising, and of the bleating of the tramping lecturers
was that a large part of many communities came to believe that
blood-letting was a crime against health, and a hindrance to recovery
from disease, no matter what might be the conditions. The average
intelligence of even well-educated communities goes no further than to
accept the plausible teaching that is every day thrust upon its
tympanum; it does not stop to criticise the motives nor to analyze the
arguments of the advertiser, nor is it cultured in this direction to the
capacity of justly weighing them according to their true significance.
The average intelligence of even well-educated communities is not up to
that grasp of the science of medicine necessary to determine between
false and fallacious teaching and that which is rational and correct; it
does not differentiate between clap-trap and honesty; it does not
separate humbug from truth, and as an ocean of humbug passes the public
gullet easier than an ounce of truth, it is not strange that the
condition obtaining about bleeding is not so much that the physician has
discarded it as improper, or has lost sight of its value in many cases,
as that the community will not tolerate him in the abstraction of blood.
Public prejudice overrides professional opinion, unless the opinion runs
current with the prejudice. To bleed your patient and then have him die
is to be damned; if he dies without being bled, no matter whatever else
you may do or leave undone, the chances of being cursed are largely
lessened. Besides this, very little or nothing is gained against the
prejudice by recovery after bleeding, since the popular opinion will be
that the patient would have gotten well quicker and better without it—an
opinion that can seldom be disproved. Exactly in the same way in any
case where venesection has been practiced and the patient does not get
well, the opponents of the operation will assert that the bleeding
caused the death, and that, in the absence of it, the patient would have
got well; which also is difficult to disprove. The average mind proceeds
from supposed causes to effects with most unreasonable logic.

As a matter of fact, the whole art of the practice of medicine is
involved many times in many uncertainties as to the effects that are to
follow the administration of drugs or the institution of any procedure,
however simple, that it may puzzle the most sagacious to determine the
exact weight of any factor introduced, whether it be for good or for
ill. It should not therefore surprise us that to minds quite
unacquainted with the therapeutical effects of blood-letting in disease,
a death that follows a bleeding, however remote in point of time, should
be credited to the operation rather than to the disease for which the
operation was performed. An uncertain percentage of cases of many acute
inflammations will recover, whether bled or not; an uncertain percentage
of them will die, whether bled or not, and no matter how treated; and,
while it will sometimes happen that of two cases of the same disease the
one that is bled will get well and the one that is not bled will
succumb, it will the next week happen that of two other cases of the
same trouble the one that is bled will slip off and the one not bled
will hold on finely. And it is a notorious fact that in some
communities, if a patient is bled and then dies, nine out of every ten
persons in the neighborhood will say, and part of them will believe,
that the bleeding was an accessory if not the chief cause of the
untoward event; and it is usually quite impossible for the doctor to
show that the nine are not right in their view of the matter.

Under these circumstances it can hardly surprise us that the use of the
lancet has gone out of fashion. It is not so much that we have less
faith in its beneficence, rationally employed, as that our patients are
opposed to it. Whether in spite of the opposition we should employ it
oftener than we do is a question that every one must settle for himself.
It might be possible for a bold and determined man to work up that road
to confidence with his patients in it, but the path is so beset with
difficulties that a hundred will fall by the way where one succeeds. A
single death after phlebotomy will do more to impede the success of a
young man in the profession than a dozen deaths without it; it is wise
therefore to be cautious in the use of so potent a remedy, and to sin
less in commission than in omission of opening a vein. It may be said
that whether he succeeds or fails it is the duty of the physician to do
in all cases what he thinks will be the best for his patient. This
position may have its merits but it is a better thing to teach than to
act upon. There is no law of right that demands of the practitioner that
he shall assume the responsibility of the stupidity and ignorance of all
his patients, and, worse still, of all the irrational prejudice they
have allowed themselves to imbibe, and which no amount of logical facts
will dispossess them of.

The writer, in the nearly fifty years of his practice as student and
graduate, has had an average share, perhaps, of his patients die; but he
has never had one die of any sort of fever after he had been bled as an
aid in subduing that fever. On the other side, he has had patients die
of the acute inflammatory diseases when they have not been bled; and,
to-night, recalling those cases, he is of the opinion that some of them,
if they had been well tapped in the arm at the outset of the sickness,
they would have been saved.

 ROCKY HILL, CONN., December, 1897.


        TAKA-DIASTASE IN THE TREATMENT OF AMYLACEOUS DYSPEPSIA.

                       BY WALTER P. ELLIS, M. D.

Pepsina porci, the pepsin of the hog, was one among the first of the
animal products to be used in medicine, and many physicians, not well
versed in organic chemistry, supposed that in it they possessed a
sovereign remedy for indigestion in all its forms and stages, and the
confirmed dyspeptic had only to apply the specific to have his digestive
apparatus restored to its youthful health and vigor. Unfortunately for
this view and for the sufferers, the fact was overlooked, or not duly
appreciated, that pepsin is only one of several substances which Nature
employs in the complete digestion of food, and that the products or
secretions of several different glands have a part in the process, each
of which is essential to the proper preparation of food for the
nourishment of the human body.

It has been estimated by competent observers that as great a proportion
as seventy-five per cent of all the intractable cases of dyspepsia in
this country are caused primarily by faulty saccharification of the
starchy foods which constitute such a large portion of the diet of the
American people. This being the fact, is it any wonder that the
administration of pepsin alone should fail to give relief in many cases?
It fails because the fault lies, not in the stomach, but in the salivary
and other glands whose secretions possess the amylolytic property, and
the remedy is the administration of substances that will restore that
property to the secretions, or which possess it in and of themselves.

Until quite recently the practitioner was compelled to rely for this
purpose upon the various malt extracts upon the market, the diastatic
power of which was so feeble that the service they rendered was but
slight. What was needed, and for which many of the most patient
investigators were searching, was a diastase which would do for the
starchy elements of the food what pepsin does for the proteids. The
digestion of food in man has been the subject of much patient and
methodical study and investigation during the last two decades, notably
by Ewald, Kellogg, Hayem, and Winter, and others, resulting in the
placing of the therapeutics of disordered digestion upon an exact
scientific basis. It is not, however, necessary for the purposes of this
paper to go very deeply into the minutæ; a superficial survey will
suffice.

Digestion begins in the mouth with the act of mastication, the presence
of food in the mouth, or even the thought of it, acting upon the
salivary glands to produce a free flow of saliva, which, being
thoroughly incorporated with the food by the act of mastication, exerts
its peculiar influence upon the starchy constituents, converting them
into dextrose, maltose, etc. This amylolytic action lasts but a short
while, the ptyalin of the saliva being active only in neutral or
slightly alkaline media; consequently when the food reaches the stomach
and peptic digestion begins, its effect ceases.

The saccharification of the starchy elements of the food before reaching
the stomach serves to separate or disentangle them, as it were, from the
proteids, and deliver the latter to the stomach in the condition most
favorable to the action of the gastric ferment or pepsin.

The stomach, after a variable length of time, during which the peptic
ferments accomplish their allotted task more or less thoroughly and
completely, delivers the resultant mass over to the small intestine,
where the secretions from the pancreas, liver, and intestinal glands, by
finishing the transformation of the starch begun before the stomach was
reached, emulsifying the fatty constituents, etc., complete the complex
work of digestion.

It will be seen from the foregoing that the derangements of digestion
may, for ordinary clinical purposes, be divided into three classes, each
of which is distinct from either or both of the others, although they
shade into each other by imperceptible gradations, so that there are no
well-defined boundary lines separating them. The first class includes
all those cases which are characterized by a deficiency, in quality or
quantity, of the salivary secretion, and a consequent failure of or
interference with the digestion of the starchy elements of the
food—amylaceous dyspepsia. The second includes those in which there is
difficulty in the digestion of the proteids, due to a variety of
causes—gastric dyspepsia. In the third is placed those cases in which
the trouble is located below the stomach, and are caused by inability of
the pancreas and other glands to normally perform their
function—intestinal indigestion.

One constantly meets with cases belonging to each of these varieties,
and he must correctly diagnose each case if he would apply the treatment
necessary to produce the best results. For the present, however, we have
only to do with the first variety, as my object in the preparation of
this paper is to direct the attention of the profession to a new
diastatic ferment which acts with as much or even greater energy upon
the amylaceous foodstuffs as does pepsin upon the proteids.

Such a substance has long been a desideratum with those who treat many
dyspeptics, and who have been compelled to content themselves with malt
extracts with which the market is supplied. The substance referred to
was discovered by a Japanese chemist, Jokichi Takamine, not as the
result of accident but while working scientifically with that exact end
in view, and is now supplied to the profession by Parke, Davis & Co.
under the name of Taka-Diastase. The writer has had frequent occasion to
use it since it was first brought to his notice about a year and a half
ago, and in that time has not had a single case in which its
administration was not attended by the very best results. Notes of
several cases were kept, three of which will be presented here as the
most appropriate conclusion.

CASE 1. L. A., white male, age thirty-eight, a barber by occupation,
consulted me first in the fall of 1894. He was at that time, as he had
been for several years, the victim of a most obstinate and intractable
form of dyspepsia. He had been a coal miner until forced by ill health
to quit that for some lighter occupation. He, however, continued to grow
worse until, when coming under my care, he was very much emaciated,
weak, nervous, and irritable, his stomach unable to retain any thing
save the blandest articles of diet, and those only in small quantities.
Treatment was begun by regulating his habits, diet, etc., and putting
him on an emulsion of bismuth subnit. and pepsin pur. immediately after
eating, and tr. nux vom., hydrochloric acid, and tr. colomba before
eating. His condition improved somewhat under this treatment, but only
to a limited extent, and it became evident that more efficient measures
must be resorted to if we hoped to accomplish permanent good. It had
been noted that a meal, however scant, composed mainly of starchy
substances was always productive of an acute attack, and acting upon
this suggestion extract of malt was added to the remedies he was using,
and, to a certain degree, with good effect. He, however, did not go on
to complete recovery, but the improvement ceased at a certain point, and
in spite of continued treatment with the remedies mentioned his
condition remained about stationary. Unable to work, morose, cross, and
irritable, existence was a burden to himself as well as family and
friends. At this juncture my attention was attracted to Taka-Diastase
and a supply was at once procured. The patient was given a number of
capsules containing five grains each, with instructions to take one
capsule at the beginning of each meal, continuing the bismuth and pepsin
mixture as before, immediately after eating. In a very short time
improvement was discernable, and from that time was rapid and
continuous. The treatment was kept up, with the addition later on of
ferruginous and bitter tonics, until there could be no doubt of his
complete and permanent restoration to health. He has now been at regular
work in the shop for several months, and says that he “never felt better
in his life.”

CASE 2. Mrs. J. H., a white woman, aged forty-six, wife of a well-to-do
farmer. Until within the last year or two had enjoyed the best of
health, and was inclined to stoutness in consequence. Dyspeptic symptoms
had troubled her more or less during the time mentioned, and of late had
increased in severity so much that she asserted, at the time she
consulted me, that if she dared to eat any thing at all she suffered the
greatest agony in consequence. A neighboring physician had treated her
for some weeks previous to her visit to my office, and, as I afterward
learned, had given her the regulation treatment with pepsin, bismuth,
hydrochloric acid, etc., with results so discouraging that she had lost
all hope of receiving any benefit from “doctor’s medicine,” as she
called it, and it was only at the urgent solicitation of husband and
friends that she came to me for treatment, being careful to inform me
that she had no idea I could help her in the least.

Her case was diagnosed “amylaceous dyspepsia,” and she was given
Taka-Diastase in eight-grain doses, half of which was to be taken before
eating and the remainder during or after, with tr. nux vom. and
hydrochloric acid, in moderate doses, _ter in die_.

Despite her determination not to be benefited by “doctor’s medicine,”
the improvement was prompt and continuous, and so manifestly due to the
treatment that she soon forgot or overcame her antipathy, and with
characteristic inconsistency now asserts that it is impossible to get
along without it. She eats three meals regularly every day, and suffers
no inconvenience whatever in consequence.

CASE 3. W., a white male, aged forty, had never had any serious illness,
and digestion had been especially good until about four weeks before
consulting me. At that time he, in company with some friends, ate quite
heartily of watermelon. He had always eaten watermelon freely and with
impunity prior to that occasion. It did not agree with him so well that
time, and in a few hours he was seized with an acute gastralgia of the
most severe character, and from that time to the present he has had more
or less trouble of that kind, even a very small quantity of food,
especially if it be of a starchy nature, giving rise to the most
distressing symptoms.

The diagnosis of amylaceous dyspepsia was also made in this case, and he
was at once put upon the Taka-Diastase in doses of five grains given
with the meals, and temporarily excluding starchy foods from his diet as
much as possible without too great inconvenience. There was also great
torpidity of the liver, and for that he was given sod. phosphate in
teaspoonful doses every morning before breakfast, taken in a gobletful
of hot water. Under this treatment improvement was satisfactory and
rapid, and with the addition of bitter tonics later on he was ultimately
restored to complete health.

_Remarks._ Case 1 was an example of that class with which, prior to the
introduction of Taka-Diastase, the general practitioner was too often
compelled to acknowledge his inability to cope successfully. In them
there is difficulty in the digestion of both amylaceous and proteid
substances, and the remedies usually recommended were efficacious only
so far as digestion of the latter was concerned, and did not reach the
former at all. The cure was incomplete, and must have remained so until
the substance we have been considering, or something analogous to it,
was furnished the physician with which to complete it.

Cases 2 and 3 were examples of the first class mentioned above, viz.,
amylaceous dyspepsia, and while under treatment with pepsin, etc., they
were considered the most intractable of all; under Taka-Diastase they
yield rapidly, and are cured in a surprisingly short time.

 LIVERMORE, KY.




                         Reports of Societies.


               LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.[1]

 Stated Meeting, December 3, 1897, the President, F. C. Wilson, M. D., in
                                the chair.

Footnote 1:

  Stenographically reported for this journal by C. C. Mapes, Louisville,
  Ky.

_Uterine Fibroma._ Dr. L. S. McMurtry: I present this specimen of
uterine fibroma on account of two very interesting features of this
class of tumors which it illustrates. The first relates to the
morphology of these growths. The tumor is a very large one, and occupied
the entire pelvis and the abdomen to the superior limits of the
umbilical and lumbar regions. It is a multi-nodular tumor, and its
disposition in relation to the fundus of the uterus is unlike any
specimen that I have ever encountered. It will be observed that the
neoplasm springs from the lower segments of the uterus, and the fundus
is not involved in the growth at all.

The second feature of interest, and this is especially interesting from
a surgical point of view, is the relation of the bladder to the tumor.
It is very common for the bladder to be carried upward with the growth,
thus rendering it very liable to injury in operation. This feature is
exceptionally conspicuous in this tumor on account of the nodular
condition where the bladder was attached, forming a sulcus. In releasing
the bladder, after splitting the capsule, the uneven surface of the
tumor caused me to inflict an injury upon the coats of that viscus.
After dissecting off the bladder I found that I had made an opening in
it at this point. It was immediately closed with a double row of catgut
sutures. The operation was done six days ago, and the convalescence of
the patient has been most satisfactory indeed. The bladder injury has
not complicated the patient’s convalescence at all, its function being
carried on just the same as if it had not been involved. The
convalescence has been afebrile from the beginning, and recovery is
assured.

The method I observed in treating the pedicle was to amputate the cervix
very low down, leaving a very small rim of the cervix, and suturing the
peritoneum over it all the way across the pelvis, making the pedicle
extraperitoneal. The conformation of the growth and its relation to the
cervix uteri made this method of dealing with the pedicle especially
applicable in this particular instance. The patient is thirty-four years
of age, and the operation was urgent on account of persistent hemorrhage
and marked pressure symptoms.


_Discussion._ Dr. J. A. Larrabee: I would like to ask the reporter for
what length of time this tumor had been developing?

Dr. L. S. McMurtry: The woman was thirty-four years of age, and
according to the history obtained the tumor was first noticed three
years ago. The patient has made a beautiful convalescence. I present the
specimen on account of its morphology, and because of the difficulties
that might be encountered in performing an operation in such cases by
the bladder being impacted in the sulcus.


_Tubercular Testis._ Dr. W. O. Roberts: This patient is twenty-four
years of age; his father and mother are living; father sixty-four,
mother fifty-four; his grandfather on his father’s side died at the age
of sixty-four of what was supposed to be consumption; his father’s twin
brother died at the age of twenty, after an illness of eight months, of
consumption; his mother’s family history is good.

This young man had gonorrhea seven years ago, with orchitis of both
sides as a complication, the left testicle swelling first, then the
right; the swelling lasted in each for about two weeks. Had gonorrhea
again in November, 1896, and says again in December of the same year. At
this time he noticed that his left testicle was getting hard in places
and was swollen, but there was never any pain. The inflammatory process
has never been very acute. However, he noticed after taking a horseback
or bicycle ride the testicle would be somewhat tender. Had another
attack of gonorrhea during the month of September of the present year,
which he says lasted only two weeks, and during this attack the testicle
was also affected.

He now has a swelling of the left testicle, and a hardness about it and
in the epididymis, which I would like for the members to examine,
expressing an opinion as to the nature of the trouble.


_Discussion._ Dr. J. M. Ray: I do not know that the ocular symptoms will
throw any light upon the case. I remember that this young man came to me
some time ago to have his eyes examined. He stated that he had been
under the care of a prominent oculist in the South, and had been fitted
with glasses. When I saw him he had some trouble in the use of his
glasses, and also complained of defective sight of one eye. Upon
examination I found a spot of atrophy of the choroid, showing the
location of a former acute choroidal disease, and there was considerable
diminution in acuteness of vision in that eye, with a defect in
refraction in the other eye. Under mydriatics I fitted him with glasses,
since which time he has been perfectly comfortable so far as his eyes
are concerned.

He states that he remembers I said something to him at that time about
tubercular disease, after looking into his eyes, but I have forgotten
the circumstance; I only remember that I found choroidal disease.

Dr. J. A. Larrabee: Of course we are all led somewhat by the diathetic
history of our cases. Chronic inflammations tend to take on the part of
the diathesis. I did not understand the reporter to say that any test
had been made, by withdrawal of some of the fluid or otherwise, to
determine the exact nature of the condition. I desire to say, however,
that if this were my testicle I would have it removed. I believe that
would be the safest plan. An absolutely positive diagnosis would be
difficult to make without a microscopical examination for the tubercle
bacillus, but I can not help feeling prejudiced in that direction.

Dr. J. L. Howard: I agree with Dr. Larrabee as to what should be done
with this testicle; it should come out. I, too, think it tubercular,
although in all probability the gonorrhea is a factor in the case in
stimulating the growth of the testicle. I do not know that a
microscopical examination would give us much light upon the subject; in
fact I would not wait for that, I would simply remove the testicle at
once.

Dr. Wm. Bailey: The question is not by any means settled as to the exact
nature of the disease in the case before us, whether the patient, having
had repeated attacks of gonorrhea, has not also been so unfortunate as
to have syphilis. With a tuberculous history of course a tuberculous
condition of the testicle seems plausible; but inasmuch as tuberculous
disease of the testicle may remain for a long time possibly without
great danger in affecting the patient otherwise, and knowing the changes
that take place in the testicle from repeated attacks of gonorrhea,
orchitis, etc., I believe if it were mine I would be disposed to keep it
for a while, particularly as the other testicle seems to be somewhat
atrophied, with this one of pretty good size. I think I would keep the
larger one.

Dr. T. S. Bullock: I am inclined very much to agree in the opinion
expressed by Dr. Bailey. I have frequently seen, after repeated attacks
of gonorrhea, a testicle that had become enlarged, without any pain. The
testicle in this case appears to be perfectly smooth, and in view of the
fact that tubercular disease of this organ may exist for a long time
without affecting the general system, I should certainly keep the
testicle until my general health began to show some evidence of
declination.

Dr. F. C. Wilson: The question is a very difficult one to decide. There
is one feature of the case that has not been sufficiently emphasized,
and that is the probable damage to the testicle itself by the repeated
attacks of gonorrhea. We know that the use of the testicle, so far as
any procreative uses may be concerned, has probably been abrogated by
these repeated attacks of gonorrhea, and with this view of the case the
question of removal of the testicle by surgical means would be
simplified; and it seems to me with the tuberculous history, if the
question could be decided even approximately, or even probably, that it
is tubercular, then it had better be removed. But it seems to me I would
first make every effort to solve the question, even aspirating or
removing a small part of the tissue so as to be able to make a
microscopical examination, and in that way possibly throw some light on
the subject.

Dr. W. O. Roberts: It strikes me that this is tubercular, although it
may have been, as Dr. Howard says, excited by gonorrhea. The condition
feels to me nodulated and not smooth, and the disease appears to be
located chiefly if not entirely in the epididymis, and I think the
testicle should be removed. Whether it is tuberculous or not the
usefulness of the organ is destroyed, and I think it ought to come out
if it is tuberculous, especially because the other testicle will become
involved. So far as the cosmetic appearance is concerned, if that is a
feature in the case, we could insert a celluloid testicle. I believe if
the affected testicle is not removed, granting the diagnosis of
tuberculosis to be correct, that the other testicle will surely become
involved.


Dr. Turner Anderson: It is seldom that we have obstetric matters
presented to this society. I have thought perhaps a case I recently
attended might be of some interest. We are aware that the umbilical cord
is frequently found encircling the neck of the child. I delivered a
child four days ago in which the cord was wrapped around the neck twice,
then branched off under the arm, encircling the arm again at its dorsal
surface, then across again, branching over the back. You may better
understand the condition when I say that the cord came up from its
attachment at the umbilicus, encircling the neck twice, branching over
and under the axilla, around the arm, thence to its attachment to the
placenta. The woman was a primipara. As soon as the head was delivered I
detected that the cord was wrapped around the neck. I made an effort to
find the part that led to the placenta. The cord was found pulseless,
and I was in some doubt as to whether it had been so long encircling the
neck as to have produced death of the child. Just as the body of the
child was being extruded the cord snapped, tearing off fortunately from
its placental attachment. The child was delivered and after a little
effort was easily resuscitated. The pressure was so great, the traction
upon the cord was so decided, as to leave a white line across the back
of the child. There was a white mark around the neck, across the
clavicle, around the arm and over the back of the child which did not
disappear for some time afterward.

The proper line of practice, I take it, in those cases where the cord is
around the neck of the child, is to first determine whether the cord is
still pulsating. If pulsating, we are justified in being a little more
tardy in our efforts to deliver the shoulders and release the child. If
possible we would of course draw down the cord and release it from the
neck of the child in this way; but in those cases where we are
confronted with the cord wrapped tightly around the neck of the child,
especially in the primipara, where the length of time which will be
consumed in delivery is uncertain, the line of practice I believe in
should be prompt delivery or division of the cord. As a rule when we are
confronted with a condition of this kind we can meet it satisfactorily
by a little delay and by holding the head of the child well up against
the vulva while the shoulders are being extruded. As the releasing pain
occurs and the shoulders and body are extruded, you can usually by
pressing the head well up prevent undue traction on the placenta and any
accident which might follow rapid delivery and undue traction upon the
cord. This was a case in which there was spontaneous rupture of the
cord; it tore away entirely by the uterine effort. This accident had no
influence upon delivery of the placenta; it came away promptly. It was
evidently not torn loose from its attachment, and there was no
hemorrhage.

_Discussion._ Dr. J. A. Larrabee: The case is not only interesting, but
also somewhat unique as far as I am aware. We are all familiar with the
double wrapped cord, but in this case the acrobatic movements of the
child must have been considerable, in utero, to have produced the
condition described by Dr. Anderson; the child had evidently been
engaged in jumping the rope for some time. When the cord is wrapped
around the neck of the child as described, I think the best plan is to
expedite delivery. Of course in the primipara we must not be in too
great a hurry, we must utilize melting or crowning pressure to prevent
injury, but the management of these cases I think is entirely that of
dystocia, and powerful external pressure upon the fundus of the uterus,
bringing it down as low as possible, is the proper plan of expedition.
In the case reported, however, no amount of external pressure would have
accomplished any thing; fortunately the snapping of the cord enabled the
doctor to deliver and resuscitate the child, which is about the only
thing that could have been done. In this case it would have been almost
impossible to have divided the cord. Aside from the anomaly of the case,
which is worthy of especial mention, I do not know of any proceeding
which would have been equal to that which was followed. It is a little
strange that the placental attachment did not give way; if this had been
true, if there had been a separation of the uterine attachment of the
placenta, then we would have expected the placenta to have been expelled
with the child instead of a rupture of the umbilical cord.

Dr. J. L. Howard: I would like to ask Dr. Anderson if usually, when the
cord is wrapped around the neck of the child, the cord is not an
abnormally long one? I have had this accident happen twice in my
experience, but no trouble resulted because of the abnormal length of
the cord in each instance.

Dr. J. G. Cecil: This is an accident which as we know happens
frequently, as well as many other anomalous things in connection with
the umbilical cord. I would have been disposed, if the labor had been
delayed in this case, that is, the final delivery of the child, more
than four or five minutes, to have severed the cord, fearing that it
might have had something to do with the delay. If there was no pulsation
in the cord, there would have been little risk in cutting and not tying
it; then there would have been no further delay to the delivery; there
would have been no danger from hemorrhage, from premature separation of
the placenta, or danger from inversion of the uterus. However, as the
case turned out so well under the management that was adopted, it does
not become us to criticise that management, because the successful issue
proves the wisdom of the plan followed.

I have once or twice encountered some delay in expulsion of the child by
reason of a short cord wound around the neck. I have never seen one so
displayed around the shoulder as in the case reported by Dr. Anderson. I
remember to have seen one case, however, in which there was a knot tied
in the cord, and tied so tightly that it shut off the circulation and
resulted in death of the child, and also complete atrophy of the cord
between the knot and the navel end. This was a very interesting case,
and was reported to the Louisville Clinical Society three or four years
ago by Dr. Peter Guntermann; it was one of the most interesting cases of
accidents to the cord that I have ever seen. How the knot was tied so
tightly in the cord can not well be explained; knots in the umbilical
cord are not very unusual, but it is unusual to see one tied so tightly
that the circulation is shut off thereby. It was thought, I believe, by
the reporter on that occasion that the accident was due to a fall which
the mother sustained just before the delivery, which was premature.

Dr. Wm. Bailey: Nothing in the management of the case reported by Dr.
Anderson can be criticised by me. I am inclined to think that under no
circumstances was pressure made on the cord sufficient to interrupt the
circulation until after the head of the child was delivered. Then it
became a question as to the proper management. I believe it would have
been better to have cut the cord, as it might have lessened the
difficulty of delivery, and that there would have been no harm done to
the child in this case, because there was no pulsation in the cord. The
doctor had all the time for this delivery that would have been allowed
him if he had a breech presentation with the head making pressure upon
the cord, and ordinarily he would deliver such a case in from five to
seven minutes, and that would give a chance for resuscitation of the
child just as in the case of drowning. The child can be deprived of
circulation through the cord, in an accident like this, as long a time
as a person can be submitted to water, or drowned, and be resuscitated.
I have seen but one case in which there was a rupture of the cord during
delivery. I saw one exceedingly short cord, in which delivery of the
child ruptured the cord; it was not around the neck, it was simply too
short for the child to be delivered without detaching the placenta; just
as the child was delivered the cord was spontaneously severed at the
umbilicus, simply allowing me a sufficient amount to be caught with the
fingers and held until a ligature could be applied. I do not remember
the exact length of the cord, but it was so short that it was not
possible to deliver the child without either breaking the cord or
detaching the placenta. The cord ruptured spontaneously, and there was
no further accident or trouble.

I believe if Dr. Anderson had to attend another case under exactly the
same circumstances he would prefer to cut the cord rather than to break
it off at the placental attachment. Inasmuch as he did not cut the cord
and the child was successfully delivered, and also as there was no
trouble in delivering the placenta, of course it makes no difference;
but I always like to have the cord attached to the placenta so that if
it becomes necessary to go after the placenta, in case of retention for
instance, I can have the cord as a guide. In Dr. Anderson’s case there
was no possible advantage in having the cord intact; as it was
pulseless, no injury could have been done the child by cutting the cord
before completing the delivery, and by cutting the cord as soon as it
was found that it encircled the neck, all possible difficulties as far
as the cord preventing delivery was concerned would have been removed.

Dr. T. S. Bullock: I am very much interested in this case; I have never
seen one exactly like it. The greatest danger in this particular
instance was that alluded to by Dr. Cecil, viz., producing inversion of
the uterus. I think Dr. Anderson managed the case in the proper manner,
and by his method of expression the only possible danger was inversion
of the uterus.

I have only seen one instance of dystocia from short cord; that was a
case in which the cord was the shortest I ever saw, and was wrapped
around the neck, where it was necessary in order to deliver the child to
cut the cord after tying it and then employ instruments, the cord being
so short that with each uterine action you could feel the cupping of the
uterus from tension on the cord.

I think there would be less danger from premature separation of the
placenta than from inversion of the uterus. In the case Dr. Anderson has
reported the danger to the child from compression of the cord was
obviated by prompt delivery.

Dr. J. A. Larrabee: Will not Dr. Bullock tell us whether the case he
refers to, where he could feel a descending or cupping of the uterus by
the expulsive efforts, was a primipara?

Dr. T. S. Bullock: The woman was a primipara; the cord was very short,
it was tied and severed, then the delivery completed with forceps. I
would like to ask the gentleman whether, in those cases where they have
employed Crede’s method of delivering the placenta, they have noted a
cupping of the uterus from efforts to extrude the afterbirth?

Dr. J. A. Larrabee: I have occasionally noticed cupping of the uterus
under those circumstances.

Dr. F. C. Simpson: I remember a certain practitioner in this city
several years ago made the statement that he seldom tied the cord after
cutting it; that he did not see any necessity of tying the cord. If this
is true, then there would certainly be no danger in severing the cord in
cases such as Dr. Anderson has reported, and it would not even be
necessary to tie it until after the delivery had been completed.

Dr. Wm. Bailey: I want Dr. Anderson to speak to one point in particular
in closing the discussion, viz., would there not be great danger if the
placenta was separated at a time when the child was still partly in the
uterus?

Dr. F. C. Wilson: The only point I wish to bring out in connection with
the case is the possibility of detecting the fact that the cord is
around the neck of the child before delivery, and being on our guard for
it. Encircling of the cord around the neck of the child ought to give
rise to a funic bruit. You can hear very plainly a funic bruit, a bruit
which is synchronous with the fetal heart sounds. Where this can be
detected at a point where we know the neck of the child lies, it
indicates to us that the chord is around the neck.

There are certain other circumstances under which we may also detect a
bruit: For instance, the one mentioned by Dr. Cecil, where the cord was
tied into a hard knot. I have met with several such cases in my
practice, and a bruit can be produced in this way, but at a different
place from the location of the neck, and it is a permanent bruit; a
bruit that is heard all the time. Where that is the case, of course it
indicates that there is some permanent obstruction of the cord, and the
likelihood is that it is due to a knot tied in the cord. We know that
sometimes the cord slips over the neck, and then the child’s body slips
through the cord, thus making a perfect knot; it then may be drawn
tighter and tighter, finally producing considerable obstruction. If the
bruit that is heard is evanescent, heard sometimes when you are
listening and not at others, that indicates simply a temporary pressure
upon the cord which may produce a bruit that is fetal in its rhythm, at
the same time it is heard occasionally only. Where the cord encircles
the neck and is drawn tightly it is apt to give rise to a bruit that is
more or less permanent, and always heard at a point where we know from
other methods of examination that the neck of the child is located.
Where this occurs we ought to be on the lookout and prepared to find the
cord encircling the child’s neck, and ought to endeavor to release it in
the first place, and where we are unable to do that, then the question
of severing the cord will come up. The cord being pulseless in the case
reported by Dr. Anderson would have simplified that question very
materially. The cutting of a cord that is not pulsating is an easy thing
and not at all dangerous. Even where the cord is pulsating I have cut it
repeatedly without even attempting to tie it, simply holding one end—of
course you have to make a guess as to which end is attached to the
child. You can not always tell that, but you can easily see from the
continued bleeding or pulsating whether you have the proper end or not,
and by simply holding that between the fingers the delivery can be
expedited, and then the cord can be tied immediately afterward. Where
the cord is pulseless there would be no danger in severing it and
leaving it untied and even unheld. I have time and again, after delivery
of the child, cut the cord and not tied it, but always waiting till
pulsation had ceased. I think there is no danger in doing this. If a
cord is cut after it ceases to pulsate and does not bleed by the time
the child is washed and ready to be dressed, there will be no hemorrhage
from it afterward.

Dr. Turner Anderson: Referring to the point made by Dr. Howard, I
believe, whenever the umbilical cord presents anomalies as illustrated
by the case reported, that it is as a rule abnormally long. The cord in
this case was abnormally long.

Dr. Larrabee made a point to which considerable importance should be
attached, viz., that it would not have been an easy matter to have
divided the cord in this case. I think practically he presents the case
exactly right. When a cord encircles the child’s neck twice, then
branches off and goes under the arm, then branches off over the back, it
presses the neck so tightly and the conditions are such that it would be
a very difficult matter to get one’s finger beneath the cord at the neck
and divide it. It is not such an easy matter to sever a cord under these
circumstances as one might suppose. I believe the majority of
obstetricians content themselves, when they find the cord is encircling
the neck, by simply making an effort to stimulate uterine contraction,
and to deliver the child as rapidly as is consistent with safety to the
mother, and while so doing take the precaution to support the head, to
hold it up well against the vulva and prevent undue traction on the
placenta.

It is seldom that we fail to resuscitate a child born under these
circumstances. The cord as a rule is not encircling the child so tightly
so as to prevent our ability to resuscitate it.

Dr. Bailey has correctly stated that arrest of pulsation in the cord
does not occur until after delivery of the head, and we have a limited
time then to stimulate uterine action and to disengage the body of the
child and release the cord from the neck. Contraction and arrest of
pulsation of the cord do not occur prior to that time as a rule. I can
conceive it possible that it might do so, but as soon as the head is
delivered, contraction then is so great that unless the cord is very
long there is an arrest of pulsation and the danger commences.
Fortunately we have recourse to stimulating uterine action, and have a
chance to deliver the child in the manner I have suggested with
sufficient promptness.

I am satisfied Drs. Bailey and Bullock recognize all the dangers of
premature separation of the placenta in an uncontracting uterus. In the
primipara I can not believe that a slight cupping of the uterus, or the
premature separation of the afterbirth, would be a matter of any very
great moment. We are all agreed as to the dangers which may occur from
separation of the normally attached afterbirth prematurely in the
absence of uterine action.

In the primipara we know how very closely the perineum, unless it is
lacerated, hugs the neck of the child, and to isolate and cut the cord
under such circumstances is a very difficult matter. I do not attach
much importance to not cutting the cord, although if I could feel it
around the neck of the child and could sever it I would not hesitate to
do so.


_Protrusion of the Rectum._ Dr. W. O. Roberts: To-day at my clinic at
the University of Louisville a man presented himself complaining of
hemorrhoids. I put him on the table on his back, drew his legs up to
make an examination, and he strained slightly, had an action from the
bowel, and passed out about four inches of his rectum. After examining
it carefully to see whether or not there were any hemorrhoidal masses
about it, or a tumor of any kind, I started to get some vaseline to
assist in replacing his rectum, when he drew it back himself as though
he had a string fastened to it. He did not touch it, but simply drew it
back. I turned the table about so the class could see the prolapsed
rectum, and he shot the rectum out and drew it back four or five times.
It is a very peculiar and unique condition to me, and I would like to
inquire if the members have ever encountered a condition of the kind in
their practice.

_Discussion._ Dr. J. M. Williams: This is undoubtedly a case of prolapse
of the rectum with a lax condition of the connective tissue. It may be
from continually coming down, and I have no doubt that the bowel comes
down after each defecation; there is some kind of an action by which the
patient controls the rectum. It may be that contraction of the sphincter
muscle starts the rectum upward, and then it simply follows its course.
I can offer no other explanation of the condition. Certainly if the
bowel comes out four inches there would be considerable tension upon the
mesenteric attachment. It seems entirely possible that this phenomenon
could be influenced and controlled by the diaphragm and abdominal
muscles, and this may be the solution of this unique case. I have never
seen a case of this kind.

_Epileptiform Seizures in an Infant Aged Ten Months._ Dr. J. A.
Larrabee: I have been considerably interested and I may say annoyed by a
case that has been under my care recently. It is in a family which is
decidedly neurotic, and in which there is possibly, without history or
committal, a taint of specific disease. It is not very unusual to have
epileptic manifestations in children at an early age, but the case I
desire to report is, I think, somewhat anomalous. There have been, for a
period of fourteen days, eleven petit mal seizures in every twenty-four
hours in an infant ten months old. These seizures have not apparently
concerned or involved the integrity of the child in any respect. The
intellectual functions, so far as intelligence is written upon the face
of an infant, do not seem to have been affected. The infant is just as
well apparently as if it did not have every hour or so an epileptic
convulsion. The attacks present the usual phenomena of true epilepsy.
The duration of these attacks is from one to two minutes, accompanied by
the usual phenomena, flushing, unconsciousness which is perfect, the
attack then passes off and the infant is well again.

This condition of affairs having been going on for a period of fourteen
days in this case without any impairment in the general health of the
infant, or in its nutrition, certainly points, I think, to a specific
cause. I have often had cases, not quite so remarkable as this, where
the tendency has been neurotic or specific in character, which improved
under appropriate treatment; but this case has resisted all treatment,
even specific treatment by the inunction of mercurials and the
administration of the iodides.

The condition is still in progress, the infant having eleven seizures in
every twenty-four hours, not exceeding this number and not falling
short. I have witnessed several of them, and they are perfectly
characteristic of epilepsy. An older child in the family passed through
an ordeal of paroxysms, was unable to walk for three years, and this
child has been restored under treatment, and that treatment has been
antisyphilitic. One child in the family has been lost, and the history
is that it died from scorbutus. The family is decidedly neurotic, and I
suspect a specific taint.

The case has been exceedingly interesting and even annoying to me
because I have been unable to make the slightest impression upon it by
treatment in lessening the number or severity of the paroxysms. I am
pursuing the same line of treatment that I did in the case of the older
child which recovered, and believe I have sufficient ground for specific
treatment, but so far it has not been productive of relief.

The peculiarity about the case is that the occurrence of these paroxysms
has not so far interfered with the nutrition or the general health of
the infant. In this respect I think the case is somewhat remarkable.


_Discussion._ Dr. T. S. Bullock: I would like to ask if Dr. Larrabee
gave the bromides in the case he has reported.

Dr. T. H. Stucky: Have you tried the bromide of gold and arsenic?

Dr. J. M. Ray: In connection with Dr. Larrabee’s case I recall one that
I saw several months ago in a child a little older than his which gave a
peculiar history. The mother brought the child to me, the history being
that the child complained of having something the matter with its ear. I
examined the ear carefully. No inflammatory or other disease was present
about the structures of the ear; hearing was perfect, and the drum
membrane was intact. The child at this time was three years of age. The
history that the mother gave me was about as follows: The child had
never complained of earache; she had never noticed any defect in
hearing, but sometimes two or three times a day the child would
apparently be interested in her toys or in something about the room, and
all at once she would scream and run to her mother and say that the
house was turning over, that there was a bug in her ear, etc. This would
happen several times a day, and on several occasions the child had
fallen over apparently unconscious, or in a state of partial
unconsciousness.

After looking into the ear carefully and not finding any evidence of
disease, I referred the case to the family physician, and in talking the
matter over with him he suggested that these attacks were probably petit
mal. He put the child upon bromide of gold and arsenic, and a prompt
recovery resulted. The last I heard from the case the attacks were few
in number, occurring at long intervals and slight in character, although
at one time they occurred two or three times a day.

Dr. T. H. Stucky: I have seen several cases of epilepsy in children, but
never saw one in a child so young as that reported by Dr. Larrabee. I
have followed out the usual routine, giving bromides and other remedies
with varying results; and later, following the suggestion of Dr.
Buchman, of Fort Wayne, have tried combination mentioned by Dr. Ray,
viz., the bromide of gold and arsenic. I believe the latter to be
especially indicated and exceedingly serviceable where we have reason to
suspect a taint, as mentioned by Dr. Larrabee, getting as we do the
sedative influence of the bromide, the alterative influence of the gold,
and also the well-known effects of the mercury contained in the
combination.

I believe where anemia is very marked in these cases, and there is a
feeble heart action, and we are fearful of the depressing effects of the
bromides alone, that in the use of the bromide of strontium and gold we
gain a decided advantage, getting as we do the sedative as well as the
cardiac influence of the strontium salts. Dr. Marvin demonstrated this
conclusively before this society in a statement made by him in regard to
the action of strontium salts in digestive disturbances, especially
those conditions characterized by marked flatulency. If this be true,
and we have reason to believe it is, it appears to me that the bromide
of strontium and gold would be even better than the bromide of gold and
arsenic in cases such as Dr. Larrabee has reported.

Dr. J. A. Larrabee: The case is reported not to demonstrate any unusual
manifestation of epilepsy, but on account of the exact regularity and
periodicity of the seizures, and the age of the patient, coupled with
the fact that the treatment which seems to be indicated has not been
followed by relief. In looking up the literature of the subject I find
that cases of this character are usually attributed to a specific cause.

In answer to Dr. Bullock’s inquiry: I have used the bromides in this
case without any effect whatever. Of course epilepsy in the child is
nothing new, but this case presents some peculiarities. There is a
decided neurotic tendency in the family, which may have some bearing
upon the case. The child is going along having the number of seizures
stated each day without any evidence of disturbance of nutrition or
impairment of general health, which is rather remarkable. Some of the
attacks are almost grand mal, most of them petit mal, and I am convinced
that the trouble is due to specific taint.

The next move I make will be to put the child upon the bromide of gold
and arsenic.

                                JOHN MASON WILLIAMS, M. D., _Secretary_.




                       Abstracts and Selections.


THE INFLUENCE OF THE ORGANISM UPON TOXINS.—Metchnikoff (_Ann. de
l’Instit. Pasteur_, November 25, 1897,) has applied the method of
comparative pathology to the question of the mechanism by which the
animal organism prepares antitoxins, and the laws which regulate their
production. By growing bacteria and lowly fungi upon culture media
containing toxines he was enabled to show that the virulence of the
latter was in most cases diminished and sometimes destroyed. In any case
these microbes have no influence in the production of antitoxins, and
the idea of preparing them by this means must be abandoned. The animal
organism alone being capable of producing antitoxins, the next point was
to find out whether this was a property common to all animals, or
limited to the superior. Metchnikoff found that the injection of large
quantities of tetanus toxin into scorpions and the larvæ of other
arthropods produced no antitoxin. The toxin remained for months in the
blood or tissues without losing its properties; similar results were
obtained when it was taken into the alimentary canal of the leech. It
was hence shown that even those invertebrates in which antimicrobic
phagocytosis is most marked are utterly incapable of producing
antitoxins. Coming next to vertebrates, no power of producing antitoxin
is possessed by fish or amphibia; it first appears in reptiles, but not
in all kinds. Thus tortoises, like invertebrates, can retain tetanus
toxin in the blood for a lengthened period without forming antitoxins;
it is in reptiles that the production of the latter is first observed,
but in them only when they are kept at a temperature higher than 30° C.
If the temperature is 20° C. the results are just the same as in
tortoises and invertebrates. The establishment of the antitoxic property
in these cold-blooded animals is not attended with any rise of
temperature, and the same is true in warm-blooded animals such as fowls.
With regard to the last-named animals, whose power of producing tetanus
antitoxin was first demonstrated by Vaillard, Metchnikoff has some new
and important observations. He finds that practically all the toxin
injected into the peritoneum passes into and remains in the blood, none
of the organs being toxic after their blood has been washed out. To this
an exception is found in the case of the genital organs, ovaries, and
testicles, which possess the power of fixing some of the circulating
toxin. This they share with the leucocytes, to the toxicity of which
that of the blood is due. After a while the toxic power of the blood
diminishes, and after passing through a neutral period it becomes
antitoxic. It is now found that with the exception of the generative
organs, none of the organs when freed from blood possess any antitoxic
power. The genital glands are found to be markedly antitoxic, but the
author brings evidence to show that the antitoxin is not manufactured by
them, but is absorbed from the blood, so that in the fowl the antitoxic
property resides solely in the blood. Metchnikoff concludes that it is
not possible to accept the idea that natural immunity depends on
antitoxic power, and he further points out that the latter is evolved in
the history of the animal kingdom at a much later date than the
phenomena of phagocytosis.—_British Medical Journal._


THE TREATMENT OF TUBERCULOSIS WITH TUBERCULIN R.—Dauriac (_Progrès
Médical_, December 4 and 11, 1897,) reports the results of the
employment of Koch’s tuberculin R. in various cases of tuberculosis;
fourteen of these presented local affections, such as suppuration over
the sternum, enlarged cervical glands, ulceration of the skin, etc. All
of the patients were satisfactorily cured. In a second paper he
describes the results in fifteen cases of pulmonary tuberculosis in
various stages of the disease; all were greatly improved, and many are
described as cured. One of the cases was insufficiently nourished and
clad, had no fixed residence, and, when the treatment was commenced,
large cavities were found at the apices of both lungs. A case is also
described in which, in addition to pulmonary tuberculosis, lesions were
present in the kidneys and the bladder. This patient also made a
complete recovery. The treatment, in spite of these brilliant results,
is supposed to be most applicable to the earliest stages of the disease,
and it is suggested that it would be advisable to detect the presence of
tuberculosis by injections of minute doses of the original form of
tuberculin. The treatment is usually commenced with a dose of 1/500 mg.
This should be increased daily until a dose of 10/500 mg. is reached;
this then should be increased 1/50 mg. daily until ⅕ mg. is reached, and
this increased ⅕ mg. daily until 1 mg. is given. This can then be
further increased if considered desirable, the maximum dose being about
20 mg. The immediate effects of the injections are usually _nil_. With
doses in excess of ⅗ mg. a slight elevation of temperature is
occasionally observed. Local reaction is extremely rare. The subsequent
effects consist in reduction of fever, cessation of sweats, increase in
appetite, and disappearance of tuberculous lesions. As none of the
patients reported in this paper was admitted to the hospital, but simply
came three times or less frequently a week to the dispensary for
injections, improvement could not possibly have been due to any
alteration in their hygienic surroundings.—_The Philadelphia Medical
Journal._


CESAREAN SECTION BY TRANSVERSE INCISION OF FUNDUS.—Braun (_Centralbl. f.
Gynak._, No. 45,) has had experience of Fritsch’s cesarean section, the
operation being the second of its kind ever recorded. Fritsch bases his
practice on the course of the secondary branches of the uterine arteries
which run horizontally, so that a longitudinal incision down the front
of the gravid uterus can not fail to cause free hemorrhage. He is
accustomed to extirpate diseased fallopian tubes completely, snipping a
wedge-shaped piece out of the uterine cornu. Bleeding is always free,
but the tying of a suture passed antero-posteriorly under the bleeding
vessel stops it at once. The ligature lies at right angles to the
vessel, the most favorable position. Hence Fritsch conceived the idea of
making an incision straight along the fundus from cornu to cornu, in
order to extract the fetus in a cesarean section. Braun publishes full
notes of his own case. The patient was a rachitic primipara with a
universally and irregularly contracted pelvis. The conjugata vera was
two and three-quarter inches. Labor pains had set in. Care was taken to
antevert the gravid uterus sufficiently, the upper part of the wound
being held together with forceps during delivery of the child. Then the
transverse incision was made. Braun found that it bled as much as the
longitudinal incision in cesarean sections where he had operated during
labor at term or in relatively early pregnancy. The placental site did
not lie near the fundus. The delivery of the fetus, which was living and
weighed six pounds, was neither harder nor easier than through a
vertical incision. The wound in the fundus was under four inches long
after the fetus had been extracted. The sutures had to be placed close
together, fifteen deep and eight superficial being applied. Ergot was
given after the abdominal wound was closed, as there was hemorrhage. The
patient made a good recovery.—_British Medical Journal._


LABOR IN MATURE PRIMIPARÆ.—De Koninck (_Revue Medicale_, Louvain,
October 30, 1897,) has compiled an instructive memoir on labor in
primiparæ married for some years and relatively mature (twenty-eight
years Bidd and Pourtad, thirty-two Ahlfeld). De Koninck gives thirty as
the earliest year coming under “maturity,” the “_primipares agees_” of
French authorities. He sets aside as curiosities certain cases of
primiparæ almost “aged” in the English sense of the term, such as
Cohnstein’s two women aged fifty and Steinmann’s woman aged fifty-two.
It appears that in a genuine uncomplicated case of delayed impregnation
the advent of the catamenia is always found to have occurred late in
youth. Out of 401 such cases menstruation was retarded till twenty in
39, till twenty-four in 4, and till twenty-six in 1. As to the retarded
first pregnancy, abortion, ectopic gestation, twins, and special renal
mischief are relatively frequent. Above all, lingering labor is
specially common, statistics even exceeding guesses and _a priori_
reasoning in this respect. In 12 out of 17 noted by De Koninck labor
lasted from forty to fifty hours, the remaining labors being yet longer;
1 exceeded ninety hours. Feebleness of uterine contraction is absolute
from first to last, and independent of any obstetrical combination. They
also cause far more physical and mental exhaustion than the vigorous
contractions of a young uterus, and at the same time are more painful.
There are discrepancies in the “pains” seen in mature primiparæ of the
same age, probably homologous with the great variations in the age of
menopause observed in otherwise normal women. The uterus may be older in
one woman aged thirty-five than in another of the same age. The forceps
and other obstetrical operations are often required in the mature. Most
of the above facts are easily explained. The excess of male infants
borne by mature primiparæ (thirty per cent) is a less explicable
phenomenon. Hecker considers the predominance of male infants as a
speciality of all primiparæ, but Rumpe turns attention to the fact that
in a family of children the predominance of males is commoner the
further the mother is from her first menstrual period.—_Ibid._


KINESITHERAPY IN HEART DISEASE.—Colombo (_Gazz. Med. di Torino_, 48, N.
39, 40, 1897,) pleads for a more general use of kinetic treatment in
heart disease. Even in advanced cases he seems to think such treatment
is very advantageous. Milder forms of treatment, for example, the
Swedish method of gymnastic exercise, should be started at first, and
afterwards more active methods, for example Oertel’s, can be tried. The
action of the Swedish method is most marked upon the peripheral vessels,
while Oertel’s system acts more directly upon the heart itself, so that
dividing heart disease into disease of central or cardiac, and that of
peripheral or vascular origin, the different methods could be applied
accordingly. The Swedish method, moreover, has this advantage, that it
can be applied in severe cases which can not leave their beds. Barie
(_Sem. Med._, November 12, 1897,) advocates the treatment of heart
disease by Swedish gymnastics. The aim of the exercises is to facilitate
the work of the heart by increasing its contractile power and by
lessening the peripheral resistance. The exercises are a series of
regulated, combined, or alternating movements of resistance or
opposition. The movements employed fall under the main groups: (1)
Kneading, rubbing, or stroking of the muscular masses in the limbs and
abdomen; (2) movements of circumduction which facilitate the circulation
in the main venous trunks; (3) movements which favor respiration. The
exercises are very varied, and accomplished by means of passive and
active movements, numerous different manipulations, and by special
apparatus. The average duration of the treatment ought not to be less
than an hour a day during three months of each year. The treatment is
suitable for cases of dilatation, hypertrophy, fatty degeneration,
chronic myocarditis, and various neuroses and functional affections of
the heart. Such symptoms as shortness of breath, palpitation, insomnia,
cephalalgia, giddiness, gastric phenomena, edema, ecchymosis, cyanosis,
improve or disappear under treatment. The pulse-rate is lowered, but
rises again as soon as treatment is interrupted. Rational application of
the treatment does not exclude internal treatment by ordinary medical
means, and the two methods may often be employed simultaneously with the
best results.—_Ibid._


LIVE FROGS AS AN ANTITHERMIC.—An English practitioner of Constanta,
Roumania, writes: On the evening of October 19th I was called to visit a
Roumanian boy, six years old, suffering from typhoid fever. I found him
_in extremis_, almost pulseless. The child’s head was completely wrapped
over with a large white sheet, and as I looked at it this enormous white
envelope seemed to be on the move, and while I was surveying this
covering there crept from under it a small frog, which quietly sat over
the child’s left arm. It seemed quite content. I immediately called the
mother’s attention to it and requested her to take the animal away,
thinking it had crept there as an intruder. “Oh, no!” said the old lady,
“a doctor recommended that a lot of them should be kept to the head to
keep it cool.” Seeing the head covering still on the move, I raised it
for curiosity, and in a second out jumped about twenty other frogs and
hopped away in all directions. I have often heard the expression “as
cold as a frog,” but this was the first time I had seen a frog applied
as a head-cooler.—_London Lancet._


TREATMENT OF ENDOMETRITIS IN BROMINE VAPOR.—Nitot (_La Gynecologie_,
October 15, 1897,) maintains that the correct prophylactic treatment of
parenchymatous metritis and chronic salpingitis consists in rapid cure
of recent endometritis, which is the starting point of those troublesome
diseases. To insure cure a remedy is needed which can penetrate to the
deepest recesses of the muscosa, and even the tubes, without dangerous
effects. Caustics and fluid preparations do not possess such properties.
A gas is required, and it must be freely diffusible, antiseptic, and
capable of acting on the epithelium so as to modify without destroying
them (“anticatarrhal action”). Bromine emits gas with the necessary
qualities; a saturated aqueous solution should therefore be placed in a
bottle with double tubing like an ether spray or the chloroform bottle
in a Junker’s inhaler. A hollow sound, connected with one tube, is
passed into the uterus, while the solution is made to bubble by pressure
on a ball connected with the second tube. Thus vapor is propelled into
the uterus. Nitot claims the best results, and notes that the advantages
of gaseous diffusion over intra-uterine injections or other medication
are self-evident.—_British Medical Journal._




                  THE AMERICAN PRACTITIONER AND NEWS.


                          “_NEC TENUI PENNÂ._”

 ══════════════════════════════════════════════════════════════════════
 Vol. 25.                  FEBRUARY 1, 1898.                     No. 3.
 ══════════════════════════════════════════════════════════════════════

                     H. A. COTTELL, M. D., Editor.

                  *       *       *       *       *

 A Journal of Medicine and Surgery, published on the first and fifteenth
             of each month. Price, $2 per year, postage paid.

                  *       *       *       *       *

  This journal is devoted solely to the advancement of medical science
  and the promotion of the interests of the whole profession. Essays,
  reports of cases, and correspondence upon subjects of professional
  interest are solicited. The editor is not responsible for the views
  of contributors.

                  *       *       *       *       *

  Books for review, and all communications relating to the columns of
  the journal, should be addressed to the Editor of THE AMERICAN
  PRACTITIONER AND NEWS, Louisville, Ky.

                  *       *       *       *       *

  Subscriptions and advertisements received, specimen copies and bound
  volumes for sale by the undersigned, to whom remittances may be sent
  by postal money order, bank check, or registered letter. Address

                             JOHN P. MORTON & COMPANY, Louisville, Ky.

                  *       *       *       *       *




                     THE ART OF NEGLECTING WOUNDS.


The New York Post-Graduate Clinical Society[2] was recently treated to a
moving discourse on the novel subject of “The Art of Neglecting Wounds,”
by Dr. Robert T. Morris, one of the instructors in surgery in the
Post-Graduate School.

Footnote 2:

  The Post-Graduate, Vol. XIII, No. 13, January, 1898.

The author confined his remarks to wounds made by the surgeon when
operating, and hints pretty strongly, though he does not say so, that
their subsequent treatment even by the surgeon himself might not
inappropriately be called “meddlesome surgery.”

For instance: In incised wounds (the margins of which have not been
quite approximated) the capillaries begin to develop granulation tissue
in the coagulated lymph deposited upon the surface in a few hours if the
trophic nerves have not been much injured. This granulation tissue is
extremely delicate and will not bear handling. When such a wound is
suppurating freely the strong temptation to wipe away the pus with
sponge or gauze should be resisted for two reasons, first, “Granulation
tissue suffers traumatism whenever it is touched, no matter how lightly,
and, as a result of such traumatism, there will be developed exuberant
granulation tissue, which will be poorly supplied with blood-vessels. We
have in weak granulations, so to speak, what might be called ‘watered
stock.’ It is a very common result of our well-intentioned but
ill-directed efforts at keeping the wound clean.”

Gauze upon the granulations will injure the tissue still more, since its
filaments entangle the granulations, which on removal of the dressing
are broken off in small fragments. The device which prevents this injury
is a covering of very soft gutta-percha tissue or Lister’s protective
silk. But the surgeon who practices this let-alone method, though backed
by sound pathological knowledge and therapeutic principles, will not
escape the censure of the family or the nurse, and too often allows his
sense of neatness to take precedence of his more sober sense founded
upon pathological knowledge.

This “neglect” is particularly desirable when epithelium is shooting
across the wound. These hyaline cells are so extremely delicate that the
slightest touch will damage or remove them to the detriment of the
healing process. The dressing on a suppurating wound should be allowed
to remain five or six days. Though the ignorant may find fault with the
surgeon for such temporizing, he must insist upon it for the patient’s
well-being.

Another illustration is drawn from the operation for appendicitis, in
which we have adhesions, pus, and wide infection. Here new pathological
factors are met with. The peritoneum throngs with polynuclear leucocytes
which are engaged in destroying the bacteria. If time be given these
faithful guards to mass themselves in the peritoneal lymph channels,
they will prevent the extension of the peritonitis from this point. The
surgeon, having evacuated the pus, removed the appendix, and inserted
the drainage apparatus, is tempted, because of its bad smell, to wash
out the wound. Such a measure would not only give the patient
detrimental annoyance, but would inflict a new traumatism upon the
tissues. “This traumatism calls out an unnecessary number of leucocytes,
and an unnecessary degree of reactive inflammation ensues. If, on the
other hand, the colon bacilli are allowed to increase, they will at
first produce a very foul odor to the discharge, but in three or four
days we will usually find streptococci abundant, and perhaps displacing
all other bacteria.” In such cases, leave the drainage apparatus in
place and “neglect” the wound. “Repair and destruction of bacteria will
go on much better if we leave the wound alone, after having removed the
principal mass—the contents of the abscess cavity.”

Another illustration is found in burns of the second degree. Here large
blisters have formed and broken, and much skin is denuded of its
cuticle. In such a case the author administers an anesthetic, opens the
blebs, removes the detached skin, scrubs the parts with an antiseptic
solution, covers the denuded surface with strips of gutta-percha tissue,
and leaves the case to nature. When a change is made, it should be of
the outer dressings only. And the reasons for this treatment are that in
such burns “the serum which is thrown out is germicidal, and is
destroying all the bacteria upon the skin very rapidly. This germicidal
action will go on so long as the serous exudation is free, but when the
coagulation of lymph begins on the surface, this action becomes very
much diminished, and the bacteria are then liable to liquefy the lymph
and grow very rapidly, as new portions of serum are thrown out. This
leads to sepsis and sometimes to the formation of thrombi, with necrosis
of the duodenum and perforating ulcer. The patient’s friends complain if
the dressings are left long in place, and yet I know of no wounds which
do so well when ‘neglected’ as burns.”

In the discussion that followed, the author, being asked what he would
do with suppurating sinuses, said “he knew of sinuses that had been kept
open week after week and month after month, and had proved veritable
gold lodes to the surgeons. If the surgeon had been compelled to go away
for a time, these sinuses would have healed long before they did. This
might seem like a joke, but it was a fact with which he was brought face
to face all the time. His rule was to leave sinuses alone, in the belief
that the poorly fed granulations lining them would in time cause
approximation of the walls, and healing would occur. It was true that
exceptions would have to be made for some sinuses, but that did not
affect the rule as given.”

Such considerations give accentuation to the dictum of Velpeau, that
“nature is a good physician but a bad surgeon,” and dignify the _bon
mot_ of Holmes, who, seeing the smoothly healed and finely cushioned
stump which resulted in time after an amputation, exclaimed:

               “There’s a divinity that shapes our ends,
               Rough hew them how we will!”

For the surgeon’s far more than the physician’s successes depend upon
the _vis medicatrix naturæ_, and he who is best versed in physiological
and pathological processes, and administers the surgical art
accordingly, will secure the best results.

They who neglect their surgical cases from ignorance, carelessness, or a
wanton disregard of the great pathological dicta of the day, can find no
justification in these teachings, for the truth, as embodied in the
author’s closing words, puts all such to shame and confusion: “A good
deal of skill is required in order to neglect wounds well. This
‘neglect’ of course implies a proper understanding of the processes with
which one is dealing.”




                               Obituary.


                         DR. J. Q. A. STEWART.

On the 25th ultimo this accomplished physician and estimable gentleman
died at his home in Farmdale, Ky. He had been in failing health for
something more than a year. His ailment was Bright’s disease, and the
end was precipitated by uremia.

Dr. Stewart was born near Louisville, Ky., in 1829. In 1849, having
secured a good common school education, and graduating in law, he went
to the gold fields of California, where he sojourned for seven or eight
years. Returning to his native State, he entered upon the study of
medicine, and graduated from the Kentucky School of Medicine in 1859. He
began practice in Daviess County, Ky., but after a few years moved to
Owensboro, where a larger field of usefulness and fuller success awaited
him.

In 1878 Dr. Stewart was called by Governor John B. McCreary to the
position of Medical Superintendent of the Kentucky Institution for the
Training of Feeble-Minded Children. It was here that the chief work of
his life was done. And it was here that he served humanity and the State
with honor, with ability, with fidelity, and with an earnest,
self-sacrificing devotion to the welfare of these rejected waifs of
humanity which entitles him to place and rank among the higher
philanthropists of our philanthropic profession.

In the care of the feeble-minded Dr. Stewart added to his executive work
the habits of a careful student, and became one of the best known
alienists of the land. His address as retiring President of the Kentucky
State Medical Society in 1894 was an able and scholarly treatise upon
the management of the feeble-minded. It was received with great favor by
the Fellows, and has since been the subject of high encomiums from
doctors, lawyers, and political economists.

After sixteen years of State service Dr. Stewart purchased the old
Kentucky Military Institute near Frankfort, where he established the
“Stewart Home for the Feeble-Minded.” The venture was successful beyond
expectation, and here in the bosom of his family he passed serenely and
blissfully the closing years of his gentle, useful, and beautiful life.

[Illustration: DR. J. Q. A. STEWART.]




                           Notes and Queries.


THE SURGERY OF THE THYROID FROM A NEUROLOGIC STANDPOINT.—In a
suggestively written paper in the January number of the American Journal
of the Medical Sciences, Dr. J. J. Putnam uses the following words: “We
are rather in the habit of assuming that the removal of large portions
of the thyroid does no harm, provided it does not cause myxedema. But
the probability is that we shall learn to recognize affections which lie
between myxedema and health, as well as peculiarities of development and
disorders of nutrition for which the thyroid is more or less
responsible.” ... That this is a statement of fact will hardly be
disputed by any neurologist, but that it expresses a truth that has as
yet been insufficiently impressed on the profession generally is another
fact the importance of which is not likely to be overestimated. It is
only within a comparatively brief period that we have learned that the
thyroid had any definite function and our knowledge of its physiology is
still very far from being exhaustive. The dangers also of interference
with it are as yet also only partially known, but it is certain that
they are not confined to the operation itself. The cases of sudden fatal
dyspnea occurring hours after an apparently prosperous operation in
Graves’ disease, recently reported by Debove and others, are in evidence
of this, and Dr. Putnam adduces other important facts and arguments
against any too venturesome surgery of the thyroid gland. Among these
are the experiments of Halsted, showing that excision of the gland in
dogs had a serious and very evident disturbing effect upon their
offspring, and that even very slight operative interference produced
hypertrophic changes and apparent increase of secretion in the gland
itself; and the observations of Kocher of goiter and cretinism inherited
from parents with no disease other than impaired thyroid function are
also cases in point. Still another fact brought forward by Putnam is the
one that removal or atrophy of the thyroid in infancy checks the growth
and function of the reproductive organs, and gives rise to the various
disturbances of development that follow the suppression of this very
important function. The close relations of the various internally
secreting glands, the thyroid, the testicles and ovaries, the suprarenal
glands, and the pituitary body, for this it seems probable must be
included in this category, are revealed in many pathologic conditions,
and the thyroid as the largest, and presumably the most important, has
apparently a larger part in the disturbances than any of the others. It
seems to be involved to some extent in many cases of acromegaly; its
relations with the genital development have already been mentioned, and
its implication in many pathologic conditions of organs is probable and
is strongly suggested by the clinical history in certain cases of
Graves’ disease. Seeligmann has indeed recently reported a case of this
affection apparently closely associated with genital disorder in which
he obtained decided benefit from the administration of ovarian extract,
thus adding another suggestion to the therapeutics of the disorder.

When any organ is removed, as Putnam says, two factors are set in
operation which may have more or less important effects upon the system
generally. One of these is the action of toxins, the other is the effort
of the organism to adapt itself to the new and changed conditions. The
first of these is important enough in the case of removal of the thyroid
gland, but the other, from what we are beginning to know of its
physiology, must be even more important. Because the function of the
organ is already deranged, it does not necessarily follow that matters
will be remedied by its removal. The operation may only make a bad
matter worse. The mortality of thyroidectomy, according to Poncet, is
from fifteen to thirty per cent, which is alone enough to induce
caution. When the facts brought forward by Dr. Putnam are also
considered, the known and the possible and hinted though yet unknown
effects of thyroid ablation, there is still more reason for prudence and
hesitancy in this operation.

Of course when a goiter has become a dangerous mechanical
embarrassment to important functions, or when a tumor exists in the
thyroid that by its growth and situation has become a threatening
danger, the case is clear, and operation may not only be justifiable
but necessary. It is in such affections as Graves’ disease, in which
thyroid operations are still somewhat popular, that we are likely to
have not only useless but dangerous surgery, and the time seems to
have come to emphasize the cautions implied in Dr. Putnam’s paper. The
theory of hyperthyroidization in this disease, though it has
apparently much in its favor, is not yet sufficiently demonstrated,
and even were it so, would not form a justification for any
indiscriminate or frequent practice of operative interference. Graves’
disease is not by any means a hopeless disorder under medical
treatment, even in its advanced stages; it is therefore impossible to
say when surgery is indicated as a last resort. When the facts of its
absolute inefficiency in perhaps the larger proportion of instances in
which it has been tried, the immediate dangers of the operation which
are not slight, and the remote ones pointed out by Dr. Putnam, are all
taken into consideration, it would seem that it ought to be relegated
to innocuous desuetude.—_Journal of the American Medical Association._


THE TREATMENT AND PROGNOSIS IN GRAVES’ DISEASE.—This short article is
prepared solely with the view of eliciting from medical men who have met
with cases of exophthalmic goiter in their practice, the results of
their observations regarding many points of interest in connection with
this curious disease. I do not intend to give a systematic description
of the affection in question. This can be found in any good modern
text-book. Described many years ago by Parry, Basedow, and by others
more recently, it is much better understood and more widely known than
formerly.

Opinions differ radically as to its real nature. The best modern
authorities regard it as a pure neurosis, and functional only in
character, although organic changes often develop during its course in
the heart, thyroid gland, and elsewhere. Some still speak of it as due
to changes in the medulla oblongata; others again look upon functional
and structural changes in the thyroid gland as the real cause of the
malady. My own experience inclines me to view it as a neurosis pure and
simple, although marked and characteristic structural changes supervene
during its course, and may become permanent. Probably in the near future
we shall learn more as to its exact nature. Already it is satisfactory
to note that cases are far earlier and more frequently recognized, and
that their treatment is more successful.

From their first appearance its special features attract attention.
These are few in number, and easily borne in mind: 1. An unusual and
more or less constant rapidity of the heart’s action; 2. The early
presence of more or less protrusion of the eyeballs; 3. A marked
enlargement of the thyroid gland; a tendency to tremors or tremblings
under very little, and sometimes no excitement, although this always
increases it. It is not surprising that these indications of
exophthalmic goiter which develop more or less rapidly and become often
most distressingly marked, should cause much anxiety to the patients and
their friends, as well as to their medical attendants.

With regard to the duration of ordinary chronic cases (for acute ones
are seldom met with), what has been the experience of those who may read
this article? I have never met with an acute case, but have seen months
and one or two years pass before there was more than a partial
improvement.

One case, a very bad one, in which the patient’s circumstances were so
poor that she worked on during her illness, when she should have had
care and rest, recovered completely. But so serious was this case, that
the sight of both eyes was entirely lost from the excessive protrusion
of the eyeballs during the disease. When I first saw her, which was
years after her recovery, the story of her case was intensely
interesting, but most sad.

Then as to the frequency with which relapses occur in this disease, it
would be interesting to get the experience of good men. Many speak of
relapses being frequent, even after apparently complete recovery has
taken place. Others think them not of so common occurrence.

There are also many points of great interest in connection with the
prognosis. One of these is the probability of the recovery being
perfect. My own experience has been that the lighter or milder the case
the greater the probability of a perfect cure.

Another matter of interest is in connection with cases in which the
symptoms greatly abate, the health indeed appearing to be perfectly
restored, but in which the exophthalmos and thyroid enlargement continue
noticeable; whether in such patients very slight causes may not lead to
a return of the disease. From what I have seen, the conclusion appears
correct, that provided the heart’s action is normal as to frequency, and
not too easily disturbed, these cases are not specially likely to have a
second attack, which is tantamount to saying that, provided the heart’s
action has become normal, any other relic of the illness is
comparatively unimportant.

I have observed, too, more or less scleroderma present when the attack
has not been by any means of a serious character, and when afterward the
general health became all but perfectly restored. This is an interesting
concomitant. It would be desirable to have others give their experience
as to its occurrence in cases they may have attended.

Then as to the effects of pregnancy during the course of the disease;
some high authorities speak very strongly as to its great danger. Others
remark that the affection has improved during gestation. This is another
matter on which fuller information would be most useful.

As to the percentage of fatal cases, this is hardly as yet to be
determined so as to be useful to the practitioner. My own cases have led
me to the conclusion that every particular case has to be regarded _per
se_, that is, if the symptoms are light and comparatively trifling, and
show signs of abating, the prognosis is favorable, while under an
opposite state of things it is the reverse.

As to treatment, what has succeeded best in my hands has been enjoining
upon patients the necessity of a great deal of physical rest, at least
ten or twelve hours a day if possible, and the avoidance of all mental
worry. On this, great stress should be laid. These patients require
abundant nourishment. Galvanism in my hands has been found most useful;
employed twice a day and so applying the poles that the current may go
from the back of the neck through the thyroid gland, and the heart, and
even (the current being made very weak) through the eyeballs. This
current has been continued for months, and in some cases for a year and
a half, with good effects. Sometimes tincture of digitalis has been
useful in moderate doses, ten or twelve minims three times in
twenty-four hours, in some cases, and useless in others. Iron has been
found of great value and persisted in for a long time. As a nerve-tonic,
strychnine in small doses has been exceedingly beneficial. Quinine, if
used, should, unless malaria complicates the case, be used in small
doses only, such as 1½ grains three times a day, with the iron and
strychnine.

I know that many of the matters I have mooted in this paper have been
quite recently discussed by Drs. Ord and McKenzie, of London, in an
excellent article on exophthalmic goiter in the fourth volume of the new
System of Medicine edited by Allbutt, but a still wider discussion on
the matters alluded to, and on many others, by practitioners who have
met with and treated such cases, will do much good, and tend to make the
care of such cases more pleasant and the results of treatment more
satisfactory. _Walter B. Geikie, M. D., C. M., D. C. L., in Philadelphia
Medical Journal._


DANGERS OF THE NASAL DOUCHE.—Lichtwitz (_Sem. Med._, November 26, 1897,)
deprecates the routine prescription of the nasal douche in all cases of
hypersecretion of the nasal mucous membrane. Irrigation is called for
only when the nasal fossæ require clearing of pus and crusts, for
instance in idiopathic ozena. This affection is mainly limited to the
nasal fossæ properly so called, and irrigation is in such a case the
most fitting form of procedure. An ordinary syringe or enema syringe
with suitable nozzle should be used. In all other nasal affections
irrigation is inadequate or useless; it is even dangerous. Repeated
flooding of the mucous membrane may give rise to olfactory lesions.
Antiseptics are highly injurious and pure water is badly borne; the
physiological solutions of sodium chloride, sod. bicarb. or sod. sulph.
are the only harmless liquids. In numerous cases irrigation has caused
the sense of smell to be temporarily or permanently diminished or lost.
Distressing frontal or occipital headache may result owing to the liquid
passing into the sinuses. The injection of irritating liquids may even
set up inflammation of these cavities. The most skilful and careful
irrigation is insufficient in many cases to prevent the resulting
headache. A very grave complication is the penetration of the liquid
into the middle ear, suppurating otitis media occasionally supervening.
In acute coryza, especially in children, douching should never be
practiced. In one such case known to the author mastoiditis followed
irrigation of the nasal cavities. The predisposition to otitis is
increased after retro-nasal operations, in particular after ablation of
adenoid vegetations. For eight years the author has given up all
irrigation after pharyngo-tonsillotomy, and during that period has met
with no case of post-operative complication.—_British Medical Journal._


ANTIPYRIN.—In July of this year the antipyrin patent, held by the Hochst
color-works, will expire by limitation, it having run its course of
fifteen years—the span of life allowed to a German patent. During these
fifteen years the monopolists have sold the drug at about $12.50 a
pound, but it will, of course, fall considerably in price the moment the
manufacture and sale are permitted competitors. It is anticipated that
it will shortly fall to at least half its present price, when the usual
convention of the principal competitors will be called and the
inevitable trust formed, leading to a consequent rise in price. It is
rumored that a number of chemical works are busy with the manufacture of
antipyrin, so as to be prepared with it immediately upon the expiration
of the patent.—_Philadelphia Medical Journal._


PROFESSOR ROBERT KOCH has been invited by the Indian Government to make
another stay in India for the purpose of studying the epidemic and
endemic diseases of man and beast so prevalent there. Koch is now
engaged on work that will keep him in German East Africa for some time,
probably about a year, and does not think of leaving until he has
concluded it.




                            Special Notices.


RHEUMATOID ARTHRITIS.—Rheumatoid arthritis is a chronic progressive
disease with an almost hopeless prognosis as regards a complete cure.
The most that can be hoped for is to arrest its progress for a longer or
shorter time, and to render the patient’s life more tolerable by
improving his health and relieving the pains in the affected
articulations. Galvanism, massage, baths, and an invigorating diet have
been found of more or less value, as well as the administration of
cod-liver oil, ferruginous preparations, and the iodides. A
comparatively new remedy that seems to have a promising future before it
in the treatment of this disease is Lycetol. Judging from the
observations thus far published its use in rheumatoid arthritis is
capable of effecting considerable improvement. One of its distinct
advantages is that, owing to its pleasant taste and freedom from
irritating effects, its administration can be kept up for a long time, a
point of great importance in the treatment of chronic affections, in
which remedies must be given for a prolonged period before beneficial
results can be expected. In two cases recently reported by Dr. Paul
Norwood (Times and Register, November 6, 1897), one being a very bad one
of chronic rheumatoid arthritis, the results were very encouraging. A
slow but steady improvement occurred in the second case, while in the
first the patient provoked a recurrence by discontinuing the treatment.
In view of the obstinate character of the affection and its resistance
to the remedies heretofore in use, Lycetol should be certainly
considered an eligible remedy in these cases.


MEETING OF AMERICAN MEDICAL PUBLISHERS’ ASSOCIATION.—The Fifth Annual
Meeting of the American Medical Publishers’ Association will be held in
Denver, on Monday, June 6, 1898 (the day preceding the meeting of the
American Medical Association).

Editors and publishers, as well as every one interested in Medical
Journalism, cordially invited to attend and participate in the
deliberations. Several very excellent papers are already assured, but
more are desired. In order to secure a place on the program,
contributors should send titles of their papers at once to the
Secretary.

                                     CHAS. WOOD FASSETT, St. Joseph, Mo.


OBSTINATE CONSTIPATION.—I used Chionia, a teaspoonful three times a day
and at bed times, in a case of long standing obstinate constipation. The
first three nights I directed a hot water enema to be given every night.
This treatment brought about regular and spontaneous evacuations, and
resulted in a complete cure.

                                                 E. T. BAINBRIDGE, M. D.

 Lickton, Tenn.


THE phosphates of iron, soda, lime, and potash, dissolved in an excess
of phosphoric acid, is a valuable combination to prescribe in nervous
exhaustion, general debility, etc. Robinson’s Phosphoric Elixir is an
elegant solution of these chemicals. (See advertisement.)


=LABOR SAVING=: The American Medical Publishers’ Association is prepared
to furnish carefully revised lists, set by the Mergenthaler Linotype
Machine, as follows:

=List No. 1= contains the name and address of all reputable advertisers
in the United States who use medical and pharmaceutical publications,
including many new customers just entering the field. In book form, 50
cents.

=List No. 2= contains the address of all publications devoted to
Medicine, Surgery, Pharmacy, Microscopy, and allied sciences, throughout
the United States and Canada, revised and corrected to date. Price,
$1.25 per dozen gummed sheets.

List No. 2 is furnished in gummed sheets, for use on your mailer, and
will be found a great convenience in sending out reprints and exchanges.
If you do not use a mailing machine, these lists can readily be cut
apart and applied as quickly as postage stamps, insuring accuracy in
delivery and saving your office help valuable time.

These lists are furnished free of charge to members of the Association.
Address CHARLES WOOD FASSETT, Secretary, cor. Sixth and Charles streets,
St. Joseph, Mo.

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




                          TRANSCRIBER’S NOTES


 1. Silently corrected typographical errors and variations in spelling.
 2. Anachronistic, non-standard, and uncertain spellings retained as
      printed.
 3. Footnotes have been re-indexed using numbers.
 4. Enclosed italics font in _underscores_.
 5. Enclosed bold font in =equals=.







*** END OF THE PROJECT GUTENBERG EBOOK THE AMERICAN PRACTITIONER AND NEWS. VOL. XXV. NO. 3. FEB. 1, 1898 ***


    

Updated editions will replace the previous one—the old editions will
be renamed.

Creating the works from print editions not protected by U.S. copyright
law means that no one owns a United States copyright in these works,
so the Foundation (and you!) can copy and distribute it in the United
States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part
of this license, apply to copying and distributing Project
Gutenberg™ electronic works to protect the PROJECT GUTENBERG™
concept and trademark. Project Gutenberg is a registered trademark,
and may not be used if you charge for an eBook, except by following
the terms of the trademark license, including paying royalties for use
of the Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is very
easy. You may use this eBook for nearly any purpose such as creation
of derivative works, reports, performances and research. Project
Gutenberg eBooks may be modified and printed and given away—you may
do practically ANYTHING in the United States with eBooks not protected
by U.S. copyright law. Redistribution is subject to the trademark
license, especially commercial redistribution.


START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE

PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free
distribution of electronic works, by using or distributing this work
(or any other work associated in any way with the phrase “Project
Gutenberg”), you agree to comply with all the terms of the Full
Project Gutenberg™ License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and Redistributing Project Gutenberg™
electronic works

1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand, agree to
and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg™ electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg™ electronic work and you do not agree to be bound
by the terms of this agreement, you may obtain a refund from the person
or entity to whom you paid the fee as set forth in paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be
used on or associated in any way with an electronic work by people who
agree to be bound by the terms of this agreement. There are a few
things that you can do with most Project Gutenberg™ electronic works
even without complying with the full terms of this agreement. See
paragraph 1.C below. There are a lot of things you can do with Project
Gutenberg™ electronic works if you follow the terms of this
agreement and help preserve free future access to Project Gutenberg™
electronic works. See paragraph 1.E below.

1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the collection
of Project Gutenberg™ electronic works. Nearly all the individual
works in the collection are in the public domain in the United
States. If an individual work is unprotected by copyright law in the
United States and you are located in the United States, we do not
claim a right to prevent you from copying, distributing, performing,
displaying or creating derivative works based on the work as long as
all references to Project Gutenberg are removed. Of course, we hope
that you will support the Project Gutenberg™ mission of promoting
free access to electronic works by freely sharing Project Gutenberg™
works in compliance with the terms of this agreement for keeping the
Project Gutenberg™ name associated with the work. You can easily
comply with the terms of this agreement by keeping this work in the
same format with its attached full Project Gutenberg™ License when
you share it without charge with others.

1.D. The copyright laws of the place where you are located also govern
what you can do with this work. Copyright laws in most countries are
in a constant state of change. If you are outside the United States,
check the laws of your country in addition to the terms of this
agreement before downloading, copying, displaying, performing,
distributing or creating derivative works based on this work or any
other Project Gutenberg™ work. The Foundation makes no
representations concerning the copyright status of any work in any
country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other
immediate access to, the full Project Gutenberg™ License must appear
prominently whenever any copy of a Project Gutenberg™ work (any work
on which the phrase “Project Gutenberg” appears, or with which the
phrase “Project Gutenberg” is associated) is accessed, displayed,
performed, viewed, copied or distributed:

    This eBook is for the use of anyone anywhere in the United States and most
    other parts of the world at no cost and with almost no restrictions
    whatsoever. You may copy it, give it away or re-use it under the terms
    of the Project Gutenberg License included with this eBook or online
    at www.gutenberg.org. If you
    are not located in the United States, you will have to check the laws
    of the country where you are located before using this eBook.
  
1.E.2. If an individual Project Gutenberg™ electronic work is
derived from texts not protected by U.S. copyright law (does not
contain a notice indicating that it is posted with permission of the
copyright holder), the work can be copied and distributed to anyone in
the United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase “Project
Gutenberg” associated with or appearing on the work, you must comply
either with the requirements of paragraphs 1.E.1 through 1.E.7 or
obtain permission for the use of the work and the Project Gutenberg™
trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted
with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg™ License for all works
posted with the permission of the copyright holder found at the
beginning of this work.

1.E.4. Do not unlink or detach or remove the full Project Gutenberg™
License terms from this work, or any files containing a part of this
work or any other work associated with Project Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this
electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg™ License.

1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form, including
any word processing or hypertext form. However, if you provide access
to or distribute copies of a Project Gutenberg™ work in a format
other than “Plain Vanilla ASCII” or other format used in the official
version posted on the official Project Gutenberg™ website
(www.gutenberg.org), you must, at no additional cost, fee or expense
to the user, provide a copy, a means of exporting a copy, or a means
of obtaining a copy upon request, of the work in its original “Plain
Vanilla ASCII” or other form. Any alternate format must include the
full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,
performing, copying or distributing any Project Gutenberg™ works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing
access to or distributing Project Gutenberg™ electronic works
provided that:

    • You pay a royalty fee of 20% of the gross profits you derive from
        the use of Project Gutenberg™ works calculated using the method
        you already use to calculate your applicable taxes. The fee is owed
        to the owner of the Project Gutenberg™ trademark, but he has
        agreed to donate royalties under this paragraph to the Project
        Gutenberg Literary Archive Foundation. Royalty payments must be paid
        within 60 days following each date on which you prepare (or are
        legally required to prepare) your periodic tax returns. Royalty
        payments should be clearly marked as such and sent to the Project
        Gutenberg Literary Archive Foundation at the address specified in
        Section 4, “Information about donations to the Project Gutenberg
        Literary Archive Foundation.”
    
    • You provide a full refund of any money paid by a user who notifies
        you in writing (or by e-mail) within 30 days of receipt that s/he
        does not agree to the terms of the full Project Gutenberg™
        License. You must require such a user to return or destroy all
        copies of the works possessed in a physical medium and discontinue
        all use of and all access to other copies of Project Gutenberg™
        works.
    
    • You provide, in accordance with paragraph 1.F.3, a full refund of
        any money paid for a work or a replacement copy, if a defect in the
        electronic work is discovered and reported to you within 90 days of
        receipt of the work.
    
    • You comply with all other terms of this agreement for free
        distribution of Project Gutenberg™ works.
    

1.E.9. If you wish to charge a fee or distribute a Project
Gutenberg™ electronic work or group of works on different terms than
are set forth in this agreement, you must obtain permission in writing
from the Project Gutenberg Literary Archive Foundation, the manager of
the Project Gutenberg™ trademark. Contact the Foundation as set
forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend considerable
effort to identify, do copyright research on, transcribe and proofread
works not protected by U.S. copyright law in creating the Project
Gutenberg™ collection. Despite these efforts, Project Gutenberg™
electronic works, and the medium on which they may be stored, may
contain “Defects,” such as, but not limited to, incomplete, inaccurate
or corrupt data, transcription errors, a copyright or other
intellectual property infringement, a defective or damaged disk or
other medium, a computer virus, or computer codes that damage or
cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except for the “Right
of Replacement or Refund” described in paragraph 1.F.3, the Project
Gutenberg Literary Archive Foundation, the owner of the Project
Gutenberg™ trademark, and any other party distributing a Project
Gutenberg™ electronic work under this agreement, disclaim all
liability to you for damages, costs and expenses, including legal
fees. YOU AGREE THAT YOU HAVE NO REMEDIES FOR NEGLIGENCE, STRICT
LIABILITY, BREACH OF WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE FOUNDATION, THE
TRADEMARK OWNER, AND ANY DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE
LIABLE TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL, PUNITIVE OR
INCIDENTAL DAMAGES EVEN IF YOU GIVE NOTICE OF THE POSSIBILITY OF SUCH
DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you discover a
defect in this electronic work within 90 days of receiving it, you can
receive a refund of the money (if any) you paid for it by sending a
written explanation to the person you received the work from. If you
received the work on a physical medium, you must return the medium
with your written explanation. The person or entity that provided you
with the defective work may elect to provide a replacement copy in
lieu of a refund. If you received the work electronically, the person
or entity providing it to you may choose to give you a second
opportunity to receive the work electronically in lieu of a refund. If
the second copy is also defective, you may demand a refund in writing
without further opportunities to fix the problem.

1.F.4. Except for the limited right of replacement or refund set forth
in paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO
OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT
LIMITED TO WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied
warranties or the exclusion or limitation of certain types of
damages. If any disclaimer or limitation set forth in this agreement
violates the law of the state applicable to this agreement, the
agreement shall be interpreted to make the maximum disclaimer or
limitation permitted by the applicable state law. The invalidity or
unenforceability of any provision of this agreement shall not void the
remaining provisions.

1.F.6. INDEMNITY - You agree to indemnify and hold the Foundation, the
trademark owner, any agent or employee of the Foundation, anyone
providing copies of Project Gutenberg™ electronic works in
accordance with this agreement, and any volunteers associated with the
production, promotion and distribution of Project Gutenberg™
electronic works, harmless from all liability, costs and expenses,
including legal fees, that arise directly or indirectly from any of
the following which you do or cause to occur: (a) distribution of this
or any Project Gutenberg™ work, (b) alteration, modification, or
additions or deletions to any Project Gutenberg™ work, and (c) any
Defect you cause.

Section 2. Information about the Mission of Project Gutenberg™

Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers. It
exists because of the efforts of hundreds of volunteers and donations
from people in all walks of life.

Volunteers and financial support to provide volunteers with the
assistance they need are critical to reaching Project Gutenberg™’s
goals and ensuring that the Project Gutenberg™ collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a secure
and permanent future for Project Gutenberg™ and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help, see
Sections 3 and 4 and the Foundation information page at www.gutenberg.org.

Section 3. Information about the Project Gutenberg Literary Archive Foundation

The Project Gutenberg Literary Archive Foundation is a non-profit
501(c)(3) educational corporation organized under the laws of the
state of Mississippi and granted tax exempt status by the Internal
Revenue Service. The Foundation’s EIN or federal tax identification
number is 64-6221541. Contributions to the Project Gutenberg Literary
Archive Foundation are tax deductible to the full extent permitted by
U.S. federal laws and your state’s laws.

The Foundation’s business office is located at 809 North 1500 West,
Salt Lake City, UT 84116, (801) 596-1887. Email contact links and up
to date contact information can be found at the Foundation’s website
and official page at www.gutenberg.org/contact

Section 4. Information about Donations to the Project Gutenberg
Literary Archive Foundation

Project Gutenberg™ depends upon and cannot survive without widespread
public support and donations to carry out its mission of
increasing the number of public domain and licensed works that can be
freely distributed in machine-readable form accessible by the widest
array of equipment including outdated equipment. Many small donations
($1 to $5,000) are particularly important to maintaining tax exempt
status with the IRS.

The Foundation is committed to complying with the laws regulating
charities and charitable donations in all 50 states of the United
States. Compliance requirements are not uniform and it takes a
considerable effort, much paperwork and many fees to meet and keep up
with these requirements. We do not solicit donations in locations
where we have not received written confirmation of compliance. To SEND
DONATIONS or determine the status of compliance for any particular state
visit www.gutenberg.org/donate.

While we cannot and do not solicit contributions from states where we
have not met the solicitation requirements, we know of no prohibition
against accepting unsolicited donations from donors in such states who
approach us with offers to donate.

International donations are gratefully accepted, but we cannot make
any statements concerning tax treatment of donations received from
outside the United States. U.S. laws alone swamp our small staff.

Please check the Project Gutenberg web pages for current donation
methods and addresses. Donations are accepted in a number of other
ways including checks, online payments and credit card donations. To
donate, please visit: www.gutenberg.org/donate.

Section 5. General Information About Project Gutenberg™ electronic works

Professor Michael S. Hart was the originator of the Project
Gutenberg™ concept of a library of electronic works that could be
freely shared with anyone. For forty years, he produced and
distributed Project Gutenberg™ eBooks with only a loose network of
volunteer support.

Project Gutenberg™ eBooks are often created from several printed
editions, all of which are confirmed as not protected by copyright in
the U.S. unless a copyright notice is included. Thus, we do not
necessarily keep eBooks in compliance with any particular paper
edition.

Most people start at our website which has the main PG search
facility: www.gutenberg.org.

This website includes information about Project Gutenberg™,
including how to make donations to the Project Gutenberg Literary
Archive Foundation, how to help produce our new eBooks, and how to
subscribe to our email newsletter to hear about new eBooks.