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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:
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
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
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
Complete Series, Vol. XVI. ) beyond surgical prevention. We know milk, only two contain the Bacillus proteus. enough, however, not to make the mistake Moreover many cases of gastro-enteritis of blindly accusing innocent agencies-like are observed in breast-fed children. It catgut for instance—which we of our own seems probable, therefore, that it is not act can and should eliminate as a factor in cows' milk, but rather the persons who care any tetanus case that uncontrollable condi- for the infants who communicate the infections may thrust upon us.
tious agent to them. The Bacillus proteus
is very abundant in the dejections of aniCatgut Sterilization; What It Means
mals (the cow, dog, horse); it is probably to Practical Surgery.- Nussbaum is quoted
carried thence by Aies to various food
stuffs, such as raw meat, cheese, grapes, as having said that "catgut is without doubt Lister's greatest discovery." Other
salad, vegetables, etc., which, eaten without writers are equally appreciative of catgut being disinfected, carry the microbe into and it seems to be universally conceded that
the alimentary canal. The prolonged conabsorbable sutures, next to asepsis itself,
tact of infected persons with infants is sufare the most important feature of aseptic
fcient to contaminate the latter. To prosurgery. Certainly absorbable sutures and
tect infants from gastro-enteritis, therefore, ligatures have greatly extended surgical
it is not sufficient to sterilize the cows' milk technique and without their aid, it is ex
that is fed to them; it is necessary, also, tremely doubtful if surgery would occupy
that the hands and the breasts of the women anything like its present position.
who suckle them should be frequently
washed with soap, and that the persons Several factors have been involved in giving to catgut its special utility, but of
who care for the infants take precautions
not to become infected with the Bacillus all its qualifications the possibility of its perfect sterilization stands foremost.
proteus. To this end M. Metchnikoff recommends washing fruits and vegetables, es
pecially salad vegetables, with boiling The Infectious Nature of Infantile Di
water, and even singeing cheese crusts. arrheas. Some authors have disputed the bacteriologic origin of infantile diarrheas and have attributed it to alimentary intoxication or to external causes, such as ex
Conditions Simulating Appendicitis.cessive variations of temperature. M. Dr. Alexander B. Johnson of New York Metchnikoff, at the last session of the read a paper at the recent meeting of the Academy of Medicine, made an important
New York Medical Society and offered the communication which tends to show the in
following conclusions: (1) A very large fectious nature of infantile diarrhea. He
number of conditions might simulate apfinds that suckling rabbits often contract a
pendicitis. (2) Many of them when carefatal diarrhea after having absorbed a
fully studied, especially with regard to the small quantity of the dejections of infants
past history and present signs and sympaffected with acute gastro-enteritis. A
toms, would render a differential diagnosis young chimpanzee which had been given possible. (3) In acute cases, with an ima little of the green diarrheic injections of
perfect history and an inability to observe a baby of six months was abruptly seized
the patients during the earlier hours of the
disease, an accurate diagnosis might be poswith a severe diarrhea which lasted four weeks, and a second chimpanzee which was
sible. This would be especially true (a) of given some of the diarrheic matter of the
perforating lesions of the alimentary tract first chimpanzee also had diarrhea the next
other than appendicitis; (b) of some af
fections of a tube and ovary upon the right day. According to the researches of M.
side; (c) of cases of well developed puruMetchnikoff, the pathogenic microbe of gastro-enteritis is the Bacillus proteus.
lent peritonitis; (d) in the erythema group, Hence, it becomes difficult to hold cows'
Henoch's purpura, with abdominal sympmilk responsible for infantile diarrhea,
toms, might so exactly simulate acute apsince out of every ten samples of cows'
pendicitis that no differential diagnosis was
possible during the earlier hours of the disJour., A. M. A., Dec. 11, 1909.
children a double Thomas is the proper
thing to put on; but in older children, who Post Partum Hemorrhage; Two Effec- can get about on the sound limb with tive Ways of Controlling It. Stewart's crutches, put on a single Thomas. Then conclusions are the following:
I. This comes the question of how long a child term should only apply to the loss of 1000
should wear a Thomas splint. He should c.c. of blood after delivery with blanching certainly wear it for some weeks after all of lips, air hunger, and pronounced pulse signs of acute suppuration have subsided. symptoms. 2. A good preventive is to al- If the splint is taken off too soon and the low the mother to rest undisturbed forty- child begins to get about and use his leg, five minutes after delivery of the child. there will be a recrudescence of the mis3. Hemorrhage several hours after delivery chief, and very likely the recrudescence will may be checked by the administration of be in a more virulent form than the original an ounce of vinegar by mouth. Should
disease. Mr. Stonham generally makes this be ineffective an hypodermic injection children who have had undoubted evidence of a similar quantity into the uterine wall of hip disease wear a Thomas's splint for will be indicated. 4. A Rose bandage will a year. But there may be another thing prevent recurrence of bleeding after it has which may influence the duration of the once been checked. 5. Threatening or ex
wearing of the splint, and that is if the disisting hemorrhage at the completion of
ease tends to progress. So long as the labor may be forestalled or checked by the
child is not getting worse, so long as he is application of chloroform to the interior improving, let him wear a splint by all of the uterus. This is far superior to any
means. Directly there is evidence that supof the preparations of iron.
puration is taking place in the joint, that there is increasing pain on slight move
ment, a Thomas's is of no use; it is necesTreatment of Tuberculous Hip.2 — In the first stage of the disease when there
sary to carry out some surgical procedure. is erosion of the acetabulum, before the ligaments are softened and before there is any question of suppuration, complete rest
GENERAL TOPICS. is the best thing. Then comes the question of how that complete rest shall be secured.
Medical Missionaries in China. When Mr. Stonham's teaching puts the whole
all the annals are written, telling of the unmatter very clearly; the first thing to do
selfish devotion and sacrifices of those who is to rectify any deformity that may be present. In order to do that, a weight ex
have taken up medicine as a life work, tension is put on, and one tries, by gradu- high on the scroll of efficient service ally increasing the weight, to coax the
will appear the history of the med
ical missionaries to China. A recent issue limb into its proper place; it may be done in a week or ten days, but it may take
of Yen-jin (the Dust of Peking), published
in the Chinese capital, contains an interestlonger. The weight chosen should be such that the child can bear it without any in
ing article on the "medical mission” in convenience and without pain. If a child China, contributed by a Japanese physician with hip disease has a weight extension
attached to the Mikado's legation at Peapparatus on and the child is fretful, trouble
king. At the outset the writer says that some, and crying, take some of the weight
his inquiries into the actual conditions of off; it is too much. In the course of two
the hospitals and medical schools mainor three days after that the weight will be
tained by Cristian missions were made in able to be increased, and when the limbs
Northern China, in the Yangtsu valley, are parallel the splint can be put on. With
and in Manchuria. While he does not ignore regard to the kind of splint to use, there
the work of the Catholic missions, his atis nothing like a Thomas. For quite young
tention seems to have been devoted particu
larly to that of the Protestant missions, *D. H. Stewart, M. D., Amer. Jour. of Obstet., representing 64 boards. He says: January, 1910.
· The London Practitioner, January, 1910. 1 Review of Reviews February, 1910.
In China to-day there is not a church which
at 5,000. There are some 250 mission hoshas not a medical practitioner or a hospital attached to it, while more important churches
pitals throughout the country, and the even maintain a medical school. Some of such yearly total of patients received by these practitioners and institutions are out of date, hospitals is said to be 2,000,000. One of but most of those hospitals and schools which the most commendable features of the have lately been instituted are modern in every
medical mission in China is a spirit of corespect, being equipped with well-trained physicians and instruments of the latest type. Fore
operation existing among the different most of such well-equipped institutions stands schools and hospitals. the Union Medical College or the Lockhart Besides maintaining hospitals and schools Medical College at Peking, which maintains a
the missionaries in China are disseminahospital known as the Peking Hospital. This college is identified with four Protestant mis
ting medical knowledge among the native sions of England and the United States. The students by the publication of books transPeking Hospital was inaugurated in the spring lated from Western languages. They also of 1907. The cost of the buildings and ma- publish a monthly magazine called the China terial equipment alone is estimated at $150,000.
Medical Journal, boasting of twenty-two Its grounds are extensive enough to permit of the addition of more buildings as the institu- years of existence. A committee of spetion grows larger. All the buildings are sup- cialists has been at work with a view to plied with steam heat and electric light. Be
selecting the most appropriate Chinese sides numerous class-rooms, there are spacious lecture halls. Every student is furnished with
words for technical terms in medical scia microscope for his exclusive use. At pres
ence. Its labors have resulted in the coment there is no class higher than the third pilation of a medical dictionary containing year, or junior class. The expenses of the
some 15,000 words. While some translaschool and hospital as well as those of the students are defrayed by the four mission
tions are made from antiquated books, boards. The students are enlisted from among
these are gradually being replaced by transthe graduates of middle schools and colleges lations from the latest publications in Engunder the auspices of various missions. Al- land and America. though they invariably understand English, lectures are given in Chinese, as the foreign instructors are well versed in the native lan
SURGICAL SUGGESTIONS. guage. I was told by several students that it was far easier for them to learn their lessons when lectures are delivered in their own lan- Ligation of the cystic artery at the beguage than when they are given in any for
ginning of a cholecystectomy often makes eign tongue. As the student is required to pay only 100 taels (about $55) for tuition,
the removal of the gall-bladder a bloodless board, and the use of instruments, the mission procedure. boards have to render him a considerable financial assistance. When the institution was A short drainage tube, and its early postinaugurated, the late Empress Dowager donated 100,000 taels. Besides, this, various depart
operative removal, are perhaps the best ments of the government have also contrib- safeguards against the formation of an uted small sums from time to time. To meet empyema sinus. its growing expenses the institution requested the Chinese Government to grant an annual subsidy, but the government has so far come
By frequent feeding every two hours, an to no decision about the matter. The rooms
obstinate biliary fistula may spontaneously in the hospital are divided into three classes. close. The rates for the rooms are 4 to 6 Mexican dollars per day first-class, 3 Mexican dollars sec
Unilateral deafness without known cause, ond-class, and 30 sen third-class. The thirdclass rooms are for those who need charity,
associated with facial palsy on the same side, but in addition to these there are rooms pro- should suggest a lesion in the posterior cerevided to receive patients absolutely free of bral fossa. charge. The hospital has twenty foreign physicians, who are also instructors in the college.
Meltzer's sign-pain on active flexion of
the hip, with the knee extended, while the According to this writer the entire force examiner presses firmly down over McBurof medical missionaries of the various ney's point-is a most valuable corroboraProtestant missions numbers no less than tive evidence of appendicitis. It is not in300, while the number of Chinese physicians tended for cases in which abscess is paltrained by these missionaries is estimated pably present.-Am. Jour, of Surgery.
H. EDWIN LEWIS, M. D., Managing Editor.
Copyrighted by the American Medical Publishing Co., 1910.
Complete Series, Vol. XVI. No. 3.
New Series, Vol. V., No. 3.
The fee question is always a serious The preceding remarks have been sugone to the medical profession, especially to gested by the reports of a recent decision the general practitioner. Why is it that in a Georgia court of law. A physician in the psychic make-up of the average hu- in that state, which like many another memman being, there is such an aversion to ber of the Union, has been undergoing paying a doctor's bill? Probably there are more or less legislative upheaval for some several reasons for the widespread exist- time, sued a father for services rendered ence of this reluctance to pay for medi- to his child of tender years. Unfortunatecal services; certainly it is a transitory af- ly the child died. The court held, therefection, for every physician knows how fore, that in consequence of this fact, it willing most patients are to reimburse the was apparent the physician's services were doctor when in pain or in need of his min- unsuccessful, and the father was under istrations. No one who has ever heard a no obligations to pay for same! husband or father urging a physician to Judicial asininity is not unknown. It make all possible haste to attend a suffer- is too much to expect that a kind and benefing wife, or a sick child, can question the
icent Providence will not lapse as often sincerity of the promises to pay, prompt- when selecting men for judgeships as for ly and generously. The promiser means any other calling. In view of the high order what he says—when he says it. But when of intelligence, to say nothing of the other the danger is over, it is strange how the qualifications required to make a judge of perspective changes. Services that in pros- even ordinary usefulness on the bench, it pect seem invaluable, in retrospect become is truly remarkable that the Power that valueless. The perspective sense is, there- watches over us does not make more misfore, at fault in this matter, and respon- takes, and place us more often at the sible for the antipathies that suddenly de- mercy of some judicial pin head. Lucky velop when a physician asks his wage. All indeed are the American people that the this constitutes one of the darkest and ideals of their courts—from the lowest to most unpleasant features of medical prac- the highest-have done so much to detice, and many a medical man has learned velop a judiciary of exceptional intelli-usually too late—that the pay-as-you-go gence, unimpeachable integrity and above plan is the only way a doctor can get a all, of sound common
It is the fair return for his hard conscientious rock on which our whole social organizawork. In other words, the time to collect tion has been built, and it must constitute is when a patient realizes his needs, not our refuge whenever our personal, political when the doctor needs to realize.
or social rights are assailed, or menaced.