hope that in the near future the prophylaxis of this dread disease will be an assured fact.

Already some very important work has been done, and many new facts have been obtained that seem to have a very important bearing on the etiology of this mysterious disease. For instance, the ubiquity of tetanus germs and their spores has been shown, and they have been found in all soil and dirt, especially soil that has been fertilized or mixed with horse manure. All fruits or vegetables are liable to contamination from this dust, and the tetanus organism has been found repeatedly on such articles of diet. Furthermore, numerous observers have found the tetanus germs and their spores in the intestines, so the direct relation between certain food stuffs and the more or less constant presence of tetanus germs in the body is established. Kamen has advanced the opinion that the tetanus organism can and does multiply in the intestinal tract of man, just as it probably does in the horse. If this is so, it is easy to understand that absorption or entrance to the blood stream is of frequent occurrence. The question naturally arises, why then does tetanus develop so seldom?

This brings us up to another phase of the question. The tetanus organism is an obligate germ and must have favorable conditions present before it or its spores can develop and become pathogenic. As previously stated, probably a good many people have tetanus germs in their intestines and even in their blood more or less all the time. They are harmless, however, for conditions favorable to their lodgment in tissue and subsequent growth do not exist. The studies of Vaillard, Vincent and Rouget have a direct significance in this direction, for they have shown that when tetanus spores are introduced ordinarily into the tissues they are promptly destroyed by the leucocytes. But let a small portion of the tetanus toxin be introduced simultaneously, and the spores develop at once with all the characteristic symptoms of the disease. Similar results follow coincidental injection of putrefactive material, or simple chemical agents like lactic acid. In other words, it would seem that the tetanus spores are latent until

activated by special conditions. While as yet these activating conditions are not well recognized there is abundant reason to believe that they exist in certain isolated tissue injuries, particularly those attended by tissue necrosis and putrefactive processes. Mixed infections have also been shown to exert a considerable influence in the development of tetanus.

From the foregoing necessarily cursory consideration of the subject one prominent fact presents itself, and that is that the development of tetanus in any given case calls for the existence of a fairly definite equation, the factors of which are:

1st. The tetanus germs, or their spores. (a) These may be carried directly into a wound in the ordinary manner of infection (in which case if the wound is closed, development is rather rapid), although as a rule ordinary aseptic procedures offer effective protection. (b) The germs may exist in the intestinal tract and blood stream but remain innocuous until a nidus occurs that presents the exact conditions essential to their lodgment and growth with development of the fatal toxins. This nidus may result from accidental injury, or it may be presented by any closed surgical wound, no matter how careful aseptic technique has been followed. The existence of a wound with its necessary tissue changes is the one essential detail.

2nd. The blood or lymph channels. These are factors in those cases which might be termed autogenetic, in that the infective organism is carried by the blood vessels to the place or point in the anatomy where it becomes pathogenic.

3rd. The nidus. This has been already previously referred to and is obviously important, since it provides the soil and certain mechanical conditions essential to the growth of the tetanus germs.

4th. The activating principle. In some respects this, next to the germ itself, is the allimportant factor in the actual development of tetanus. It is an unknown factor to a large extent, but there is every reason to believe that on its presence or absence the occurrence or non-occurence of tetanus is largely if not entirely dependent.

In conclusion, it must be apparent that a vast field of investigation is still before us, since the whole tetanus question is still conjectural. But enough is already known of this fearful disease to show conclusively that its etiology is so complex that, for the present at least, the occasional case is quite

beyond surgical prevention. We know enough, however, not to make the mistake of blindly accusing innocent agencies-like catgut for instance-which we of our own act can and should eliminate as a factor in any tetanus case that uncontrollable conditions may thrust upon us.

Catgut Sterilization; What It Means to Practical Surgery.-Nussbaum is quoted as having said that "catgut is without doubt Lister's greatest discovery." Other writers are equally appreciative of catgut and it seems to be universally conceded that absorbable sutures, next to asepsis itself, are the most important feature of aseptic surgery. Certainly absorbable sutures and ligatures have greatly extended surgical technique and without their aid, it is extremely doubtful if surgery would occupy anything like its present position.

Several factors have been involved in giving to catgut its special utility, but of all its qualifications the possibility of its perfect sterilization stands foremost.

A

The Infectious Nature of Infantile Diarrheas. Some authors have disputed the bacteriologic origin of infantile diarrheas and have attributed it to alimentary intoxication or to external causes, such as excessive variations of temperature. M. Metchnikoff, at the last session of the Academy of Medicine, made an important communication which tends to show the infectious nature of infantile diarrhea. He finds that suckling rabbits often contract a fatal diarrhea after having absorbed a small quantity of the dejections of infants. affected with acute gastro-enteritis. young chimpanzee which had been given a little of the green diarrheic injections of a baby of six months was abruptly seized with a severe diarrhea which lasted four weeks, and a second chimpanzee which was given some of the diarrheic matter of the first chimpanzee also had diarrhea the next day. According to the researches of M. Metchnikoff, the pathogenic microbe of gastro-enteritis is the Bacillus proteus. Hence, it becomes difficult to hold cows' milk responsible for infantile diarrhea, since out of every ten samples of cows'

1 Jour., A. M. A., Dec. 11, 1909.

milk, only two contain the Bacillus proteus. Moreover many cases of gastro-enteritis are observed in breast-fed children. seems probable, therefore, that it is not cows' milk, but rather the persons who care for the infants who communicate the infectious agent to them. The Bacillus proteus is very abundant in the dejections of animals (the cow, dog, horse); it is probably carried thence by flies to various foodstuffs, such as raw meat, cheese, grapes, salad, vegetables, etc., which, eaten without being disinfected, carry the microbe into the alimentary canal. The prolonged contact of infected persons with infants is sufficient to contaminate the latter. To protect infants from gastro-enteritis, therefore, it is not sufficient to sterilize the cows' milk that is fed to them; it is necessary, also, that the hands and the breasts of the women who suckle them should be frequently washed with soap, and that the persons who care for the infants take precautions not to become infected with the Bacillus proteus. To this end M. Metchnikoff recommends washing fruits and vegetables, especially salad vegetables, with boiling water, and even singeing cheese crusts.

Conditions Simulating Appendicitis.

Dr. Alexander B. Johnson of New York read a paper at the recent meeting of the New York Medical Society and offered the following conclusions: (1) A very large number of conditions might simulate appendicitis. (2) Many of them when carefully studied, especially with regard to the past history and present signs and symptoms, would render a differential diagnosis possible. (3) In acute cases, with an imperfect history and an inability to observe the patients during the earlier hours of the disease, an accurate diagnosis might be possible. This would be especially true (a) of perforating lesions of the alimentary tract other than appendicitis; (b) of some aifections of a tube and ovary upon the right side; (c) of cases of well developed purulent peritonitis; (d) in the erythema group, Henoch's purpura, with abdominal symptoms, might so exactly simulate acute appendicitis that no differential diagnosis was possible during the earlier hours of the dis

ease.

TREATMENT.

Post Partum Hemorrhage; Two Effective Ways of Controlling It.1-Stewart's conclusions are the following: I. This term should only apply to the loss of 1000 c.c. of blood after delivery with blanching of lips, air hunger, and pronounced pulse symptoms. 2. A good preventive is to allow the mother to rest undisturbed fortyfive minutes after delivery of the child. 3. Hemorrhage several hours after delivery may be checked by the administration of an ounce of vinegar by mouth. this be ineffective an hypodermic injection of a similar quantity into the uterine wall will be indicated. 4. A Rose bandage will prevent recurrence of bleeding after it has once been checked. 5. Threatening or existing hemorrhage at the completion of labor may be forestalled or checked by the application of chloroform to the interior of the uterus. This is far superior to any of the preparations of iron.

Should

Treatment of Tuberculous Hip.2In the first stage of the disease when there is erosion of the acetabulum, before the ligaments are softened and before there is any question of suppuration, complete rest. is the best thing. Then comes the question of how that complete rest shall be secured. Mr. Stonham's teaching puts the whole matter very clearly; the first thing to do is to rectify any deformity that may be present. In order to do that, a weight extension is put on, and one tries, by gradually increasing the weight, to coax the limb into its proper place; it may be done in a week or ten days, but it may take longer. The weight chosen should be such that the child can bear it without any inconvenience and without pain. If a child with hip disease has a weight extension apparatus on and the child is fretful, trouble

some, and crying, take some of the weight

off; it is too much. In the course of two or three days after that the weight will be able to be increased, and when the limbs. are parallel the splint can be put on. With regard to the kind of splint to use, there is nothing like a Thomas. For quite young

'D. H. Stewart, M. D., Amer. Jour. of Obstet., January, 1910.

2

The London Practitioner, January, 1910.

children a double Thomas is the proper thing to put on; but in older children, who can get about on the sound limb with crutches, put on a single Thomas. Then comes the question of how long a child should wear a Thomas splint. He should certainly wear it for some weeks after all signs of acute suppuration have subsided. If the splint is taken off too soon and the child begins to get about and use his leg, there will be a recrudescence of the mischief, and very likely the recrudescence will be in a more virulent form than the original disease. Mr. Stonham generally makes children who have had undoubted evidence of hip disease wear a Thomas's splint for a year. But there may be another thing which may influence the duration of the wearing of the splint, and that is if the disease tends to progress. So long as the child is not getting worse, so long as he is improving, let him wear a splint by all means. Directly there is evidence that suppuration is taking place in the joint, that there is increasing pain on slight movement, a Thomas's is of no use; it is necessary to carry out some surgical procedure.

GENERAL TOPICS.

Medical Missionaries in China.1- When all the annals are written, telling of the unselfish devotion and sacrifices of those who have taken up medicine as a life work, high on the scroll of efficient service will appear the history of the medical missionaries to China. A recent issue of Yen-jin (the Dust of Peking), published in the Chinese capital, contains an interesting article on the "medical mission" in China, contributed by a Japanese physician attached to the Mikado's legation at Peking. At the outset the writer says that the hospitals and medical schools mainhis inquiries into the actual conditions of tained by Christian missions were made in Northern China, in the Yangtsu valley, and in Manchuria. While he does not ignore the work of the Catholic missions, his atlarly to that of the Protestant missions, tention seems to have been devoted particurepresenting 64 boards. He says:

1 Review of Reviews, February, 1910.

Series

In China to-day there is not a church which has not a medical practitioner or a hospital attached to it, while more important churches even maintain a medical school. Some of such practitioners and institutions are out of date, but most of those hospitals and schools which have lately been instituted are modern in every respect, being equipped with well-trained physicians and instruments of the latest type. Foremost of such well-equipped institutions stands the Union Medical College or the Lockhart Medical College at Peking, which maintains a hospital known as the Peking Hospital. This college is identified with four Protestant missions of England and the United States. The Peking Hospital was inaugurated in the spring of 1907. The cost of the buildings and material equipment alone is estimated at $150,000. Its grounds are extensive enough to permit of the addition of more buildings as the institution grows larger. All the buildings are supplied with steam heat and electric light. Besides numerous class-rooms, there. are spacious lecture halls. Every student is furnished with a microscope for his exclusive use. At present there is no class higher than the third year, or junior class. The expenses of the school and hospital as well as those of the students are defrayed by the four mission boards. The students are enlisted from among the graduates of middle schools and colleges under the auspices of various missions. Although they invariably understand English, lectures are given in Chinese, as the foreign instructors are well versed in the native language. I was told by several students that it was far easier for them to learn their lessons when lectures are delivered in their own language than when they are given in any foreign tongue. As the student is required to pay only 100 taels (about $55) for tuition, board, and the use of instruments, the mission boards have to render him a considerable financial assistance. When the institution was inaugurated, the late Empress Dowager donated 100,000 taels. Besides, this, various departments of the government have also contributed small sums from time to time. To meet its growing expenses the institution requested the Chinese Government to grant an annual subsidy, but the government has so far come to no decision about the matter. The rooms in the hospital are divided into three classes. The rates for the rooms are 4 to 6 Mexican dollars per day first-class, 3 Mexican dollars second-class, and 30 sen third-class. The thirdclass rooms are for those who need charity, but in addition to these there are rooms provided to receive patients absolutely free of charge. The hospital has twenty foreign physicians, who are also instructors in the college.

According to this writer the entire force of medical missionaries of the various Protestant missions numbers no less than 300, while the number of Chinese physicians trained by these missionaries is estimated

, 1910

, Vol. V., No.

at 5,000. There are some 250 mission hospitals throughout the country, and the yearly total of patients received by these hospitals is said to be 2,000,000. One of

the most commendable features of the medical mission in China is a spirit of cooperation existing among the different schools and hospitals.

Besides maintaining hospitals and schools the missionaries in China are disseminating medical knowledge among the native students by the publication of books translated from Western languages. They also publish a monthly magazine called the China Medical Journal, boasting of twenty-two years of existence. A committee of specialists has been at work with a view to selecting the most appropriate Chinese words for technical terms in medical science. Its labors have resulted in the compilation of a medical dictionary containing some 15,000 words. While some translations are made from antiquated books, these are gradually being replaced by translations from the latest publications in England and America.

SURGICAL SUGGESTIONS.

Ligation of the cystic artery at the beginning of a cholecystectomy often makes the removal of the gall-bladder a bloodless procedure.

A short drainage tube, and its early postoperative removal, are perhaps the best safeguards against the formation of an empyema sinus.

By frequent feeding every two hours, an obstinate biliary fistula may spontaneously close.

Unilateral deafness without known cause, associated with facial palsy on the same side, should suggest a lesion in the posterior cerebral fossa.

Meltzer's sign-pain on active flexion of the hip, with the knee extended, while the examiner presses firmly down over McBurney's point-is a most valuable corroborative evidence of appendicitis. It is not intended for cases in which abscess is palpably present.-Am. Jour. of Surgery.

Complete Series, Vol. XVI. No. 83. New Series, Vol. V., No. 3.

The fee question is always a serious. one to the medical profession, especially to the general practitioner. Why is it that in the psychic make-up of the average human being, there is such an aversion to paying a doctor's bill? Probably there are several reasons for the widespread existence of this reluctance to pay for medical services; certainly it is a transitory affection, for every physician knows how willing most patients are to reimburse the doctor when in pain or in need of his ministrations. No one who has ever heard a husband or father urging a physician to make all possible haste to attend a suffering wife, or a sick child, can question the sincerity of the promises to pay, promptly and generously. The promiser means what he says-when he says it. But when the danger is over, it is strange how the perspective changes. Services that in prospect seem invaluable, in retrospect become valueless. The perspective sense is, therefore, at fault in this matter, and responsible for the antipathies that suddenly develop when a physician asks his wage. All this constitutes one of the darkest and most unpleasant features of medical practice, and many a medical man has learned -usually too late that the pay-as-you-go plan is the only way a doctor can get a fair return for his hard conscientious work. In other words, the time to collect is when a patient realizes his needs, not when the doctor needs to realize.

The preceding remarks have been suggested by the reports of a recent decision in a Georgia court of law. A physician in that state, which like many another member of the Union, has been undergoing more or less legislative upheaval for some time, sued a father for services rendered to his child of tender years. Unfortunately the child died. The court held, therefore, that in consequence of this fact, it was apparent the physician's services were unsuccessful, and the father was under no obligations to pay for same!

Judicial asininity is not unknown. It is too much to expect that a kind and beneficent Providence will not lapse as often when selecting men for judgeships as for any other calling. In view of the high order of intelligence, to say nothing of the other qualifications required to make a judge of even ordinary usefulness on the bench, it is truly remarkable that the Power that watches over us does not make more mistakes, and place us more often at the mercy of some judicial pin head. Lucky indeed are the American people that the ideals of their courts-from the lowest to the highest-have done so much to develop a judiciary of exceptional intelligence, unimpeachable integrity and above all, of sound common sense. It is the rock on which our whole social organization has been built, and it must constitute our refuge whenever our personal, political or social rights are assailed, or menaced.