NEW YORK STATE MEDICAL ASSOCIATION.

FIFTH DISTRICT BRANCH.

Nineteenth Annual Meeting, Held in New York City, May 19,

1903.

PARKER SYMS, M.D., PRESIDENT.

Symposium on Malaria: Morphology of the Anopheles Mosquito; Its Habits; Modes of Destruction.-Dr. W. N. BERKELEY opened the discussion with a paper having this title.

Three species of the anopheles were described, and attention was called to the fact that there were many enemies of the larvæ. He said there was no permanent remedy against anopheles except drainage, but there were several well-known methods of temporarily ridding a neighborhood of these pests.

Laboratory Diagnosis and Life Cycle of the Parasite of Malaria.-DR. W. T. KLEIN read this paper. He said that as the malarial plasmodium could not leave the body of itself, and was not found in the stools, it was natural to look for an agent of such transmission. This was found in the mosquito. Further study brought out the now well-known fact, that there were two cycles, viz.: (1) The endogenous cycle in the body of the human, and (2) the exogenous cycle in the body of the mosquito. The tertian organism being the commonest in this latitude, was taken for study. The parasite was seldom, if ever, found free in the plasma. Just after the chill it could be seen in the red cells as an unpigmented, spheroidal body which, in the unstained and fresh state, was actively amoeboid. In the next stage there was formed, usually within two hours after the chill, the characteristic ring. This gradually increased in size, and showed active amoeboid movements in the unstained specimen. As the ring increased in size a thickening of the protoplasm developed at one section, and the body assumed a more nearly spherical form, while the pigment granules became more numerous and the chromatin broke up. At the end of the first twenty-four hours the organism occupied about three-quarters of the invaded red cell. In the full-grown organism the nucleus broke up into a recticulum, which invaded the protoplasm and the chromatin granules continued to divide, becoming fewer in number and larger. The breaking up of the segmenting body and the liberation of the spores were synchronous with the rigor. The cycle was completed approximately in forty-eight hours. Almost from the very beginning the erythrocyte became swollen and soon exhibited a granular degeneration of its protoplasm, which was best demonstrated by the staining method of Goldhorn. The quartan ring resembled that of the tertian, but was slightly smaller and its pigment granules were smaller and more numerous. There were usually between six and twelve spores, and the cycle was completed in seventy-two hours.

The rings of the æstivo-autumnal form were distinctly smaller than those of the tertian, and the rings were more delicate and symmetrical. The full-grown and segmenting forms were seldom seen in the peripheral circulation. Two distinct types of æstivo-autumnal forms were recognized, one having a cycle of twenty-four hours, and the other having a cycle of forty-eight hours. The crescent body was an intracellular body of crescentic shape with the horns somewhat rounded. The full-grown body contained one or two centrally located chromatin groups surrounded by motionless pigment granules. The parasite was transferred to man by the bite of the mosquito, the disease usually developing in from eight to ten days after inoculation. All inoculations, however, were not successful, showing that certain conditions were necessary for the successful development of the endogenous cycle. Diagnosis. The blood suspected of containing the malarial parasite might be examined either dry or fresh, and the specimen should be taken, if possible, about eight hours after the chill. This was because there was a tendency for the organisms to retire to the internal organs just

before the chill. Ewing claimed that in an acute malarial fever, even though quinine had been administered, malarial parasites could always be found if the blood were carefully and patiently examined within eighteen hours of the chill. It was exceedingly important that the cover glass and slide used for the examination should be absolutely free from dirt, otherwise annoying errors were apt to arise. For this microscopical examination a one-twelfth-inch oil immersion lens was required. The polychrome methylene-blue stain colored the chromatin a bright red, which contrasted well with the light blue of the intracellular organism. Certain precautions must be observed in order to obtain reliable results. The speaker said that his personal experience as examiner of such blood for the New York Health Department had led him to prefer L. B. Goldhorn's staining method to all others. The entire fixing and staining process could usually be completed in one minute, and the results were eminently satisfactory. The chief feature of this method was the beautiful staining of the chromatin granules, thus greatly facilitating the diagnosis. The errors in diagnosis were usually made with the hyaline and unpigmented forms; hence the value of a stain which brought out well the chromatin granules. A marked diminution in the number of the red corpuscles was a constant occurrence, and the cells were extremely deficient in hæmoglobin. The absence of leucocytosis was also characteristic. A rapidly rising temperature without a marked increase of leucocytosis should lead one to suspect malarial infection; on the other hand, a marked leucocytosis should make one doubt the existence of an uncomplicated malarial infection. Pigmented leucocytes should always be looked for. In æstivo-autumnal fever the parasites were always most numerous during the apyrexial stage, but there were mild forms of the disease in which the parasites could only be found with difficulty In such cases, however, pigmented leucocytes were always present.

The Concurrence of Anopheles Mosquitos and Malaria.— Mr. HENRY CLAY WEEKS, Engineer in Economics, presented this paper. He said that the misfortune of being

ten years ahead of one's time was that one was put down as a crank, but in this instance the crank effected a revolution of ideas and was able to prove the possibility of exterminating mosquitos from a given region. He commended the quite exceptional and very progressive public spirit of the Board of Trade of Worcester, Mass., which had published an exhaustive report with regard to the existence of malaria in that place, and announced the intention of excluding it. He believed there was much yet to be learned about the mosquito, and it was sincerely to be hoped that people in many other places would not shrink from publishing the fact of the existence of malaria, and so take the first important step toward the banishment of this public disgrace. The speaker then read from various reports with regard to localities, which he was not at liberty to name, all tending to show the concurrence of malaria, with anopheles mosquitos. Attention was called to the fact that the larvæ of the anopheles were found much later in the season than those of the ordinary culex mosquito. He was now engaged in a systematic investigation with regard to malaria in the southern part of Brooklyn. He was glad to say that this movement against malaria was spreading, and he believed that in the near future the results would be remarkable and far reaching.

of the routine work of the hospital. We must realize that ordinarily from ten to twelve hours were required for the malarial paroxysm to pass through its complete cycle, whereas most other chills did not take so long. He had seen chills following sepsis from double ear disease which did take as long, and which, consequently, left the diagnosis in doubt until the blood examination had been made. Although there were types of malarial chills which only lasted from four to six hours, these were mild cases, and the temperature did not rise to 104° or 105° F., as in the ordinary malarial paroxysm. When the fever was 104° or over the pulse did not show a corresponding increase in frequency, being often below 100. This was not true of any other similar elevation of temperature with which he was acquainted. These observations were intended to apply only to the form of malaria commonly seen in this climate. Captain Delaney of Calcutta had recently published some interesting observations on that most puzzling form of malaria, the æstivo-autumnal type. He found that this type occurred in about 17 per cent. of the cases there on the first or a single examination, but that if the differential count of the leucocytes were made, in over 90 per cent. of the cases a justifiable diagnosis of malaria was possible. The polynuclear leucocytes were found to be undiminished, the small lymphocytes were increased, often as high as 60 per cent., and the large mononuclear leucocytes were also greatly increased. By these cells he meant all those mononuclear cells which were as large as the polynuclear ones. If they constituted over 12 per cent., he made a diagnosis of malaria. This position was supported by the reports of many cases. Only four cases appeared to be exceptions to this rule, and each one of these occurred in persons who had just developed malaria for the first time. In his cases there was usually a good proportion of hæmoglobin, and the color index was always over one. He found a very high leucocytosis only in those exceedingly severe cases of the æstivoautumnal variety in which the parasites were present in the circulation in large numbers. With regard to the differential diagnosis of malaria from tuberculosis, the speaker called attention to the different length of the cycle, and the fact that the temperature quickly fell to normal, whereas in the early stages of tuberculosis the temperature ran from the subnormal to the subfebrile, the temperature ranging from 97° to 100° F. In sepsis the chill, the rise of temperature and the sweating occupied a comparatively small period, and recurred irregularly. In cholelithiasis there was frequently a form of fever that had been designated "remittent." When the gallstone became impacted in the duct it was apt to cause such a fever, and this was usually associated with jaundice. Gradually the duct became dilated and the symptoms subsided, only to be followed by another impaction and other slow dilatation. This explained the remissions observed in such cases. In yellow fever, with a stationary or rising temperature there was a falling pulse; in malaria, the pulse did not continuously fall. It was often difficult to distinguish between æstivo-autumnal malaria and typhoid fever because one must accept the existence of double infections. A fever which rose in a step-like curve and did not rise suddenly and fall as suddenly, and which occurred in a case giving the history of malaise and the prodromal symptoms of typhoid, should be diagnosticated as typhoid, and not as malaria. Moreover in typhoid there would be the abdominal symptoms without much nausea or vomiting, whereas in malaria nausea and vomiting were common, and abdominal symptoms were rare. The enlargement of the spleen in typhoid did not occur as early as in malaria. The diazo-reaction in the urine was not so common in malaria as in typhoid, and the Widal reaction might be present to assist in the diagnosis. Unless the malarial parasites could be found in the blood after repeated examination, or unless the blood changes already described were not present, one

should exclude malaria. In this latitude we should deal with fevers as other than malaria unless we could

prove them to be malarial. This would prevent many mistakes which had occurred in the past.

Treatment. Fortunately we had a specific for the treatment of malaria. The maximum quantity of quinine was found in the blood six hours after its ingestion into the stomach. The malarial parasite could only be acted upon before it had become mature. The chill occurred about the height of segmentation; hence he gave five grains of quinine every four hours, and continued it until the desired effect was obtained. After this he gave three grains three times a day for a week. In cases of severe malarial infection coming from the Philippines he had followed Manson's treatment, and had not yet seen a case in which it had not proved successful if the patient lived long enough for the quinine to be absorbed. According to Manson, five grains of quinine should be given every four hours until a decided effect was obtained and the temperature reached normal; then, three grains were given three times a day. After the temperature remained at the normal the patient was told to cut a lemon into small pieces, pulp, skin and seeds, place it in onè quart of cold water and boil it down to one pint. It was then strained through muslin after having been sweetened to suit the taste. This quantity should be drank every day for four or five months. After three weeks the patient should take a calomel purge, and then three grains of quinine three times a day for one week. At the end of a month he should repeat the calomel purge and the quinine for another week, and this should be repeated at intervals of a month for four or five months, all the while drinking the lemon-juice. It was well to remember that whereas the ordinary sulphate of quinine was almost insoluble and contained only 72 per cent. of the alkaloid, the hydrochlorate of quinine was exceedingly soluble, and contained 81 per cent. of the alkaloid.

DR. FRANCIS P. KINNICUTT said that a knowledge of the latent phase of the plasmodium was necessary for the intelligent treatment of malaria. Ross, than whom there was no higher authority, recommended first a saline purge, and then ten grains of quinine every two hours for the first fortnight, fifteen grains daily for the second fortnight, ten grains for the second month, five grains for the third month, with ten grains instead of five grains at first twice a week, and then once a week. This dosage was intended for a person weighing one hundred and fifty pounds, and should be greater or less in accordance with variations from this standard weight. In every case of infection with the malarial plasmodium quinine should be given regularly for four months, whether relapse occurred or not. This was a most important fact to be borne in mind. He did not think that clinical experience showed that Manson's treatment was as effective in destroying the parasite as the one given by Ross. The best method of administering quinine was in acid solution; the next best was in the form of powder shaken up in water. Dr. Lambert had very properly called attention to the great solubility and strength of the hydrochlorate and the bihydrochlorate of quinine. During the continuation of the fever little benefit could be expected from arsenic, and while methylene blue appeared to destroy the malarial parasites, it did so more slowly than quinine and often gave rise to certain unpleasant effects. As a preventive of infection, when necessarily exposed to it, he advised taking five grains of quinine daily, with ten grains twice a week.

DR. DAVID P. AUSTIN Said that the period of incubation was about one week, and there was a strong tendency for relapses to occur at intervals of a week up to the fourth week. After this period it was not likely to recur again the same season. As an initial dose he endeavored to give, some hours before the chill, fifteen grains of quinine, ten grains of calomel and five grains of capsicum. This was usually sufficient to interrupt the chill, so that the

next one might be looked for one week later, and should be forestalled by the administration of ten grains of quinine.

DR. W. I. COCKE of Port Washington, Long Island, spoke of some successful and permanent cures that he had obtained in a considerable number of cases from the administration of nuclein. The "Cuban Mixture," composed of sulphur, camphor and capsicum, had also proved useful in his hands.

Officers Elected.-President, Dr. J. C. Bierwirth, Brooklyn; Vice-President, Dr. Milton C. Conner of Middletown; Secretary, Dr. E. V. Hubbard of New York City; Treasurer, Dr. Henry Dodin of New York City.

New Instruments.

OBSERVATIONS ON RETRACTION AND RETRACTORS IN ABDOMINAL SURGERY, WITH DEMONSTRATION OF AN AUTOMATIC CELIOTOMY RETRACTOR.*

BY ARTHUR STURMDORF, M.D,

NEW YORK.

ACCESSIBILITY of the surgical objective point to sight and touch dominates all operative prognosis.

In intraabdominal operations, such accessibility to sight and touch is obtained by distending the abdominal incision by means of retractors; by postural manipulations, and by partial or complete. evisceration. The first of these aids, namely, retraction, is invariably essential and indispensable; while postural manipulation and partial or complete evisceration may be called into play as complementary aids.

In uncomplicated abdominal conditions, with freedom from extensive adhesions, and in which the necessary operative procedures are of comparatively short duration, the enumerated means, as ordinarily employed, accomplish all that is essential. But it is otherwise in an abdomen presenting extensive and complicated agglutinations. Here we are dependent for accessibility solely upon the retractor, until by intraabdominal manipulations, sufficient visceral mobility is obtained so that postural and eviscerating aids may be utilized.

It is in these cases of necessarily prolonged retraction that the technical shortcomings of retractors in use at the present day become manifest.

Yet, while the immediate detriments from structural faults in retractors, during operation, have been fully recognized. as evidenced by the enormous variety of such instruments in vogue, there is one ultimate detriment of paramount importance, which to the present writing has received no emphasis. This ultimate detriment which distinguishes abdominal wound retraction from wound retraction in other regions, is the production of wound conditions inimical to firm union, thus favoring the development of visceral protrusions. The occurrence of post-operative hernia, while materially reduced in frequency by modern methods, is not entirely obviated by the same.

The most accurate layer-coaptation in suturing celiotomy wounds cannot secure an adequate union of wound edges, bruised and devitalized by longcontinued pressure and friction. I am convinced that this traumatic element also stands in causative relation to the cases of "late gaping" in cœliotomy wounds, which were reported recently by Collins, Lilienthal, Morris, Brewer, Morris, Brewer, Moschowitz, Blake, Walker, and Foote. In discussing these cases, Dr.

*Demonstrated before the Gynecological and Surgical Sections of the New York Academy of Medicine.

Erdman, reported one in which the wound opened on the ninth day, without apparent cause, and this, despite the fact that he had taken special pains in coaptating the parts at the time of operation. It is not necessary to demonstrate gross lesions in evidence. The baneful effects of antiseptics upon the healing process in clean wounds is fully recognized. Can continuous pressure by badly fitting, pronged, toothed, or fenestrated irons be less deleterious? Pressure and bruising devitalize wound surfaces and deprive them of the two functions essential for their primary and permanent union. The cytogenetic, necessary for the production of young, healthy connective tissue cells-and the bacteriolytic, essential for the annihilation of such bacterial presence, as the

Posterior view of retractor.

most scrupulous antiseptic endeavors cannot obviate. The attenuation of a post-operative hernial covering is not due primarily to a simple diastasis of the parietal strata, but to a more or less extensive atrophy of the involved layers. Note the uniform absence of adipose tissue in such an incompetent scar, and the fact that, most frequently, the visceral protrusions are more prominent in the immediate vicinity of and not through the scar itself. Note the influence on the occurrence of post-operative hernia, from the pressure of drainage tube and gauze strip.

Wound retraction is nevertheless indispensable and its detriments must be obviated or at least mitigated. A longitudinal abdominal incision, distended laterally, presents an opening more or less elliptical in shape. The points of greatest distensibility in this elastic ellipse are in the center of its lateral borders-in other words, through its widest diameter. This distensibility diminishes rapidly from these points toward the apices of the wound.

It follows that, to obtain a maximum of distension with a minimum of force, the blades of the retractor should be so shaped as to exert the greatest traction on these points of greatest distensibility; namely, in the center of the lateral borders of the incision and neither above nor below these points.

Thus the disadvantage of the ordinary flat-bladed retractors becomes evident. The flat retracting surface being applied to the concave border of the distended incision, maximum traction is exerted by the lateral edges of the flat blade at points above and below the center of greatest distensibility; the wound becomes angulated, to the detriment of tissue and space. If we recall the direction of the vascular channels in the abdominal wall, such forcible angulation might throw some light on the etiology of thrombosis in the veins of the lower extremities, after cœliotomies running an otherwise uneventful course, as reported by Lennander, Coe, Meyer, and others.

The wider the retracting blade, the more prominently will this factor come into play. It follows that, to obtain the maximum of retraction with a minimum of injury, the shape of the retracting blade must conform to the lines of the distended wound and not to those of the relaxed incision.

Modelled on these lines, two semi-elliptical blades result, which, placed in situ, present a dilatable metallic ellipse fitting smoothly and snugly within the wound ellipse, thus obviating the injurious results of improper blade contour. . . . In addition to the disadvantages of improper shape the ordinary hand retractors necessitate the presence of additional assistance; an undesirable feature because additional assistance cannot always be had, and when had

entails additional sources of infection, with encumbrance of the operative field.

The instrument which I take the liberty to submit, possesses proper blade conformation and an automatic self-retaining mechanism, which enables the operator, unaided, to control any desirable amount of steady traction, in any diameter of the wound, for any length of time.

I claim but a small share of originality in the construction of this retractor. The blades are modified from Fritche's instrument, and the self-retaining mechanism was suggested by Kelly. Yet a glance will show very essential differences from both.

The instrument, as submitted, was used in a number of tedious and difficult abdominal operations, and proved itself eminently satisfactory. It enables me to carry through successfully, without any assistance whatsoever, in the presence of several of our members, a complicated gynecological extirpation, with the usual peritoneal plastic work. The instrument is simple in construction, easily disarticulated for sterilizing purposes, and free from inaccessible crevices and joints.

In applying it, it is only necessary to avoid insinuating the free edge of the blades into the preperitoneal space, preventing injury to or peeling of the peritoneum. It does not encumber the field of operation by projections of any kind. The blades rotate freely, thus enabling the operator to change the lines of traction from the transverse to the oblique or longitudinal diameter without extracting the instrument, by simply rotating it within the incision, as shown in the illustration. Owing to the shape of the blades they cannot slip either in or out of the wound. If found desirable, one blade can be easily detached during operation and the instrument used as an ordinary single-hand retractor.

It is supplied with several sizes of interchangeable blades, thus making it applicable to any length of incision. It is manufactured by the Kny-Scheerer

Co. of New York.

106 EAST SIXTY-SECOND STREET.

THE IGNITION VACUUM BOTTLE.

A CHEAP, CONVENIENT, POWERFUL ASPIRATOR. BY KARL CONNELL, M.D.,

NEW YORK.

HOUSE PHYSICIAN, NEW YORK HOSPITAL.

A STRONG clear glass bottle of medium or wide mouth is selected. For aspirating the chest an ordinary five-pint bottle of about one-inch mouth is a convenient size. This is fitted with a perforated stopper, rubber preferably, to which is attached a foot or two of firm rubber tubing clamped by a hæmostatic forceps or other device. Three drachms of 95-per-cent. alcohol is poured into the bottle, which is then turned until the entire inner surface is coated. The excess of alcohol is poured off. The bottle is then placed upright and ignited at the mouth before the film of alcohol has time to dry or settle. (Figure 1.) A sheet of flame descends into the bottle, varying in time for complete ignition from a fraction of a second to several seconds, depending on the strength of the alcohol and the temperature of the glass. As the flame touches the bottom, the bottle is quickly corked. On attaching the needle the aspirator is complete.

By this simple procedure, taking less than half a minute, one displaces regularly 75 to 85 per cent. of the air in the bottle, thereby securing an initial suction power sufficient to raise a 28-foot column of water.

The capacity is limited only by the size of the bottle. That described will aspirate 60 to 68 ounces, which in a personal experience of some two hundred tappings has been found to be the maximum amount