NEWS NOTES. NO NEW cases of typhoid fever have been reported at Canton, O., during the past few days.

DR. JAMES BROOKIN, of Anderson, Ind., was killed at Lafontaine this morning when the automobile in which he was riding was struck by a Union Traction

car..

THE Southeastern Ohio Homeopathic Medical Society met in Zanesville July 25. The meeting was attended by physicians from Columbus, Cambridge, Newark and Granville.

DR. MURRAY G. MOTTER, Chief Inspector and second Deputy Health Officer of the District of Columbia Government, has tendered his resignation to the Commissioners, to take effect at once.

DR. JAMES EDWIN RUSSELL, whose death July 21, in New York City, was declared by physicians to be due to Bright's disease, was positively declared by the coroner to have been the victim of stranglers.

DR. WILLIAM M. ENSLEN, a Ft. Wayne physician who has entered municipal politics because he believes medical men should do so on principle, and who was seriously ill with typhoid fever, is convales

cent.

THE Third International Sanitary Convention of American Republics will be held in the City of Mexico, December 2 to 7, 1907, under the presidency of Dr. E. Liceaga, President of the Superior Board of Health of Mexico.

THE Committee of Dallas, Texas, physicians appointed by the Dallas County Medical Society to make plans for the establishment of a Hall of Science, or club and library for the medical profession, is quietly making much progress.

SURGEONS throughout Texas, on July 18, organized the State Anatomical Board, under the new law, allowing medical colleges to take possession of unclaimed dead human bodies. The board appointed agents in the towns where are located the medical colleges in Texas.

THE editor of the Rising Sun (Ind.) Recorder thus doth show his envy: "A physician who called recently to attend a wealthy stockman who had a pain in his side, diagnosed the case as appendicitis, secured the patient's permission to operate next week and then went home and wrote to the nearest city for an automobile price list."

THE New Orleans Picayune says: "If the general public could only be made to understand that with the departure of the filthy habit of promiscuous spitting, consumption would be a thing of the past, they might forego the very questionable luxury. It has always been considered a breach of good manners to offend in this respect, but the time is rapidly approaching when it will be considered something more than that, and will be looked upon as a jail offense."

WM. E. HAWKINS, Assistant Attorney General of Texas, has given an opinion to Joseph Greer, of Alvin, local surgeon for the Santa Fe at that place, to the effect that he could not ride on his pass and at the same time hold the position of city health officer. The terms "officers and employees" both alike refer to those in regular and continual service. Within the ordinary acceptation of the terms one who is engaged to render service in a particular transaction is neither an officer nor an employee. They imply continuity of service and exclude those employed for a special and single transaction.

NATHAN STRAUS, a New York man of influence and weight in public affairs, said last week: "The agitation for pasteurized milk has spread to Buffalo, Boston and as far West as San Francisco. Besides this, Surgeon-General Wyman, of the Public Health Service, at the direction of President Roosevelt, has taken up the investigation of the whole milk subject, with the view of enactment by Congress of a puremilk law that will compel the eradication of tubercular cattle from the dairy herd and require the pasteurization of all milk that cannot be certified as free from germs of disease."

Dr.

THE Atlantic Coast Line Railway Surgeons' meeting in annual session at the Jamestown Exposition adjourned July 24, after electing the following officers: President, Dr. P. J. Thomas, of Wilmington, N. C.; First Vice-President, Dr. J. H. McIntosh, of Columbus, S. C.; Second Vice-President. J. H. Pittman, of Jacksonville, Fla.; Third-VicePresident, Dr. C. R. Oglesby, of Waycross, Ga.; Secretary and Treasurer, Dr. M. Moran, Pinner's Point, Va.; Executive Committee, Drs. J. P. Thomas, Chairman; H. B. Leigh, F. P. Nicholson, E. P. Clyman, R. S. Clay and R. L. Harris.

THE Augusta (Ga.) Medical Society is protesting against that particular clause of the proposed State prohibition bill, which, if passed, will prohibit practicing physicians from prescribing any spirits or alcoholic stimulants to their patients with the exception of pure alcohol. The doctors say the clause is ridiculous, inasmuch as nothing but the disordered intellect of a bush politician could possibly conceive of the use of "pure alcohol" as an internal remedy. They appointed a committee to draw up a memorial to the Legislature requesting that the clause referred to be so changed as not to interfere with the practice of medicine in Georgia.

OBITUARY.

DR. W. L. AARON died near Jasper, Ala., July 22.

DR. CAMPBELL CRUTCHFIEED, of Gordonsville, Tenn., died July 18.

DR. J. E. HOWELL died at Ocilla, Ga., after an illness of about two weeks with typhoid fever.

DR. E. B. KERNER, of Kernersville, N. C., died July 22. He was eighty-one years of age and had been practicing his profession for fifty-five years.

DR. G. R. GWYNNE, aged sixty-four, Lebanon, Tenn., died suddenly, July 23, of a valvular lesion of the heart. He was a veteran of the Civil War.

DR. W. M. FARRIS died at Tullahoma, Tenn., Tuesday, after a long illness, caused from paralysis. The deceased was one of the oldest practicing physicians in Tennessee. He was seventy-four years of

age.

DR. JAMES TURPIN, probably the oldest physician in Indiana, died July 20, at Evansville, at the age of four score and two. He served in the Federal troops as a private during the Civil War, and was a member of the local division of the G. A. R.

DR. J. T. KILLEBREW, of Mobile, Ala., was ground to pieces under the wheels of a moving freight train July 24. Dr. Killebrew was President of the Mobile Medical Society, a lecturer on the diseases of women in the University of Alabama, and an assistant in the Inge-Bondurant Infirmary. He was born and reared at Nashville, Tenn.

Correspondence.

HABITUAL USERS OF PERUNA.

CINCINNATI, July 18, 1907.

EDITOR LANCET-CLINIC:

Within the past year I have had under observation two cases of alcoholism from the habitual use of Peruna. The second and last case, a middle-aged man, came to my office just recently to consult me about extreme nervousness and insomnia. The nervous condition had developed to such a degree that he had found great difficulty in carrying on his business correspondence, and sleep was out of the question. Within two or three months past he noticed his condition had grown much worse. I was satisfied of the nature of his trouble before putting the question to him directly. I said to him: "You have been using stimulants to excess for some time past, have you not?" He informed me that he had not, much to my surprise. He then asked me if there was anything in Peruna that could induce such a train of symptoms, admitting at the same time that he had been taking as high as five or six drinks a day during the waking hours for a period of more than two years. I impressed upon his mind the fact that it would have been far better had he gone into a saloon and ordered that number of drinks, the percentage of alcohol would have been less, and that in all probability the long-continued use of Peruna was the exciting cause of all of his trouble. He seemed greatly surprised at this statement; did not evidently realize that it contained enough alcohol to prove injurious. I informed him that until quite recently the percentage was about 40, but that Uncle Sam, in the interest of humanity, had compelled them to reduce it to about 18, and that he had also compelled them to incorporate a laxative to obviate its being used as a beverage.

In this connection I would say that it is exceedingly amusing to read their printed statement on the label. It reads something like this: "At the earnest solicitation of our friends and patrons we have decided to incorporate a laxative in Peruna." The interesting question is, who are their friends and patrons? Uncle Sam could answer that, perhaps, better, certainly more logically, than any one else. This very fact, the reduction

of alcohol, explained why he had been feeling recently so much worse. The withdrawal of the accustomed amount of stimulant had increased his nervousness and insomnia.

The explanation given seemed to be entirely satisfactory, and explained the cause of

the troublesome diarrhea that he had been having at intervals for several weeks. It had become so frequent and constant that he felt his strength was being undermined. From all I could glean, evidently he did not attribute any of his symptoms to Peruna. No doubt this is only one of hundreds of similar cases. I frankly said to him that Peruna and other preparations of its kind had been the cause of more intemperance and drunkenness than all the saloons in Cincinnati combined. How an individual or corporation can stoop to a traffic so demoralizing, so damaging to human health and happiness, is certainly beyond my comprehension. Conscience must be seared and soul obliterated. If the latter exists it must be so infinitesimally small that if reduced to a gaseous state and that gas expanded to its utmost capacity it could find ample room in the circulatory system of a gnat. Ten thousand such could dance on the point of a cambric needle and have as much room as a bull-frog in the Atlantic Ocean.

Let

I would ask, is it not within the province of this great State of Ohio to legislate against this crying evil that is secretly undermining the morals and health of community? the legal ax fall swiftly and forcibly upon this hydra-headed monster-the sooner the better. Unfortunately, one of the most deplorable features of the situation is that the press of the country is aiding and abetting this unholy traffic. This is the most discouraging feature of the situation. In conclusion, I will venture the opinion that if there is such a thing as variation of temperature in the place we are all anxious to evade the men engaged in this traffic will be given the hottest place to crack brimstone, and I am not quite sure but some editors will be assigned positions as helpers in very close proximity.

W. H. DEWITT, M.D.

THE Shelby County (Tenn.) Medical Association is progressive and enterprising. Under its auspices, on July 12, Dr. George W. Whittaker, of the dairy division of the Agricultural Department, Washington, addressed a large audience upon the question of a pure milk supply. The gathering was representative not only of the city and State physicians, but also of ths dairymen of Shelby County, and a most interesting and profitable evening was enjoyed. Dr. Whittaker introduced his remarks by pointing out the necessity for a certain knowledge of bacteriology among the dairymen in so far as that science has to do with the production and delivery of pure milk. He showed that in handling milk the dairyman should exercise the same care with his utensils as does the surgeon with his instruments when preparing for an operation. He emphasized the importance of cleanliness and illustrated with stereopticon views the dire effects of carelessness upon the part of the dealers.

Malignant disease has ever held a prominent though somewhat vicarious place in medical and surgical literature. To-day we are hearing a great deal of favorable results from early radical operation on patients suffering of carcinoma, some surgeons claiming three-year cures in 80 per cent. of their cases; other writers are making scarcely less extravagant claims for treatment by various sera, while the old-time and honored practitioner who has seen a recurrence of the disease after the lapse of thirty years following operation, looks upon the young enthusiast and his "figgers" with a feeling akin to pity commingled with contempt.

In these high-pressure times the surgeon seems to have lost sight of the fact, so well known and dear to heart of the physician, viz., "all disease has a tendency to self-cure. Now comes Dr. Graham, of the Rush Laboratory (Surgery, Gynecology and Obstetrics, June, 1907), with an explanation of some 'cures," in an article on the latency of carcinoma. He describes a number of retrogressive changes which may and do take place in carcinoma; they include fatty, mucoid, colloid and calcareous degeneration, and instances are cited wherein the tumor and its clinical manifestations disappeared never to return during the lifetime of the patient. Distinct healing processes are described as having occurred in the periphery of carcinomatous tumors and some of the pearls were replaced by young connective tissue.

Wehr, in 1883, reported a case of spontaneous cure in an experimentally produced carcinoma. The late Dr. Daniel Young, of Cincinnati, related to the reviewer the case of his mother, who suffered of carcinoma of the breast for forty years; the tumor became atrophied, and finally the entire breast became completely detached at the age of eighty-four. Dr. Gross and a number of other prominent surgeons saw the case and confirmed the diagnosis of carcinoma.

The four cases of Gaylord and Clowes are quoted, and, although the clinical diagnosis was confirmed by microscopic findings, sufficient time had not elapsed in the cases of Senger, Crosbie and Gould to be convincing to the reader that cure had really resulted. One year, one month and six months, respectively, had intervened since the disappearance of the symptoms at the time the case was reported. In the fourth case no

mention is made of time. No recurrence followed in Richardson's case of carcinoma of the bladder, which disappeared spontaneously four years after the (microscopic) diagnosis was established.

Numerous other cases of spontaneous healing are included in the report, but the time element makes one doubt their claim of cure. The case quoted from Bryant, of a woman, aged thirty-three, suffering of ulcerating breast tumor with axillary involvement, which was found eight years later to be entirely replaced by scar tissue, is clearly a case of tuberculosis of the breast. This view has the advantage of further confirmation in that the patient succumbed later of "pulmonary trouble."

ers.

Subsidence of carcinoma of the breast is reported to have taken place after acute pulmonary tuberculosis by Paget, Sigg and othPerrin observed much suppuration in and disappearance of cancer after thyroidectomy, and Beatson noted retrograde changes in a breast carcinoma after oophorectomy. Subsidence of symptoms has also been noted after gastro-enterostomy by Stendel, Lindner and others.

Of particular interest is the non-appearance of symptoms following operation in the case of Dr. McArthur. The patient, aged sixty-one, had her right breast removed June, 1897, and there had been no recurrence at the time of her death, November, 1903. The autopsy by Prof. Hektoen revealed the following points bearing on our topic:

Histological Examination." Lung sections. taken through the whitish puckered areas of the pleura show broken, irregular rows of cells lying in a considerable amount of stroma. There is evidently an attempt at tubule formation on the part of the tumor cells. Around the periphery of each mass are many congested capillaries, and a rather dense, small, round-celled infiltration. The growth is not sharply circumscribed and limited to the pleura, but in places it extends into the alveolar walls, which are thickened near the border of the lung. In sections of some of the whitish areas the amount of stroma is relatively greater in proportion to the number of cell cords, and in such instances there are nests of cells surrounded by a rather thick connective tissue wall. Well-formed bloodvessels are present in septa between the cellnests. The cells composing the tumor parenchyma are, for the most part, of irregular shape, but many are roughly cuboidal. The nuclei are large and granular and of irregular shape. No mitotic figures are evident on careful search in many sections. In one section there is an appearance of a fusion of

several cells having occurred resembling giantcelled formation. Other parts of the lungs show edema and passive hyperemia.'

The liver, pancreas, adrenals and kidney all contained small tumor formations similar in their histological conformation to those occurring in the lungs. Thus numerous metastatic foci were demonstrated in the various organs six years after the operation, and still the patient had been wholly free from any of the clinical manifestations of malignancy (cured) during this interval. The patient died of exhaustion following an attack of diabetes insipidus.

Of especial interest is that part of the report which describes the encapsulation of the older tumor formation and the new granulation tissue surrounding the more recent growths, showing conclusively that nature had made an heroic and successful effort to limit the spread of the disease to surrounding tissues.

The presence of scar tissue, atrophic and broken-down epithelial cells and the absence of mitotic figures are but confirmatory evidence of the tendency to "self-cure" in carcinoma.

Dr. Graham concludes his report with these significant remarks:

"That actual spontaneous healing does occur, or at least that carcinoma cells frequently are rendered inert in the human body, seems reasonable when the numerous cases of so-called 'cure' of carcinoma after surgical interference are considered. For in the majority of such operations, at least, it is not likely that every carcinoma cell is removed, and the remaining ones must subsequently be overcome by a natural protective process of the body.

,,

Stomach Surgery.

Much of the chaff is being winnowed out of the literature of stomach surgery, and in consequence thereof we are getting an occasional-all too rare-article from the pen of an experienced worker who has the wisdom to discriminate the indications for operation and the courage to report his failures.

Surgery of the stomach dates back for thirty years, whereas technical work, work based upon certain definite chemical, physical and symptomatic findings, covers little more than one-tenth that period. We do not wish to disparage the efforts of any of the host of earnest workers along this line, but to Moynihan in England and Mayo in our country, are we most indebted for that which is judicious and distinct in the stomach surgery of to-day. While the former name is more fre

quently associated with gall-bladder and duc surgery, still a careful reading of the history of his stomach work as tabulated in the June Surgery, Gynecology and Obstetrics, will reveal a clear, concise and fearless presentation of facts relative to operative procedures for non-malignant disease of the stomach. The analysis includes all cases operated upon by Mr. Moynihan up to September, 1906, embodying a report of perforating ulcer, recurrent hemorrhage, miscellaneous, and of hourglass stomach, making a total of 334 cases, of which 313 recovered, He maintains that perforation has invariably been preceded by an exacerbation of ulcer symptoms for a few days or much longer prior to the incident of rupture. When perforation occurs there is a sudden agonizing pain, a pain which almost reaches the limit of human endurance. This and the hypersensitiveness of the skin over the area constitute the early diagnostic signs of perforation when they occur in an ulcer subject, shock, collapse, rapid pulse and muscular rigidity being later manifestations, and their development should be obviated by early repair of the perforation.

66

The early diagnosis can be made from the history of ulcer, the sudden onset and the continuance of intolerable pain, restriction of thoracic movements, surface tenderness and abdominal rigidity, or restriction of the normally free abdominal movements." Infolding of the ulcer is the best method of closing a perforation and is all that will be necessary unless the perforation occurs near the pyloric orifice, in which case an enterostomy should be done before closing the abdomen. Drainage is requisite only in late operations, and should be of the suprapubic type, the patient being placed in a Fowler position.

The mortality in the twenty-seven cases of perforation of the stomach or duodenum was 33.3 per cent. Perforation of the stomach occurred three times in males and fourteen times in females, whose ages ranged from seventeen to forty-four years. The site was anterior wall fifteen times and posterior wall two. The "kissing ulcer" was encountered once, and failure to detect and close the perforation in the posterior wall of the stomach resulted in the death of the patient. Duodenal perforation on the eleventh day after closing a stomach ulcer resulted disastrously to the sufferer, although the stomach perforation was found to be soundly healed postmortem. Two perforations one and a half inches from each other were found in the anterior wall, and a perforation in another case occurred in the centre of an hour-glass

stomach, the latter case necessitating a gastroplasty in addition to closing the ulcer. In the duodenal cases, of which there were ten, perforation took place nine times in the first portion and once in the second portion of the bowel. Primary gastro-enterostomy was performed in six of the series, all but one recovering; and secondary gastro-enterostomy was required in two cases for persistent ulcer symptoms. "The present condition of all the patients in this series is perfectly satisfactory."

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Hemorrhage may occur at any time in the course of gastric or duodenal ulcer. It is characterized by spontaneity, abruptness of onset, the rapid loss of a large quantity of blood, the marked tendency to spontaneous cessation, the infrequency of a repetition in anything but trivial quantity, and the transiency of the resulting anemia.'

Four types of hemorrhage are described as occurring in chronic ulcer:

"1. The hemorrage is latent or concealed, is always trivial and often inconspicuous.

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

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

"4. The hemorrhage is instant, overwhelming and lethal."

Hemorrhage from acute ulceration never demands operation for relief, but the recurrence of hemorrhage in the chronic ulcer, with considerable time intervening between attacks and an ever-increasing loss of blood, constitutes an imperative demand for surgical intervention.

Here, as elsewhere in attempts at controlling hemorrhage, one should not rest content until the bleeding vessel is securely ligated; however desirable this may be as a working basis, it is not always possible to live up to it in dealing with hemorrhage from the stomach, and here, as in perforation, infolding of the ulcer will best subserve our purpose.

In hemorrhage from duodenal ulcer enterostomy is done in addition to infolding. Thirty-three cases are tabulated which were operated upon for severe recurrent hemorrhage; in sixteen cases the stomach alone and in eleven cases the duodenum was the

site of the lesion, while in four cases hemorrhage from both stomach and duodenum was going on. The mortality (18 per cent.) was due in one case in which no ulcer was found to cirrhosis of the liver, one died of a pneumonia and others of exhaustion, and one with very low percentage of hemoglobin (27 per cent.) at the time of operation died of shock. Bleeding did not recur in any of the cases after operation.

In twenty-one cases of this series gastrojejunostomy constituted the sole treatment; there were but two of these cases died. Excision of the ulcer was combined with gastroenterostomy in two cases, one of which succumbed. Infolding of the ulcer and gastroenterostomy were performed on eight cases, followed by two deaths. Gastro-jejunostomy with obliteration of the pyloric lumen was done in one case, the patient recovering. The after-results in this list are satisfactory; but one patient suffers a little from painless vomiting of bile," but her digestion is good and she is gaining in weight.

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In the short consideration given to chronic gastric and duodenal ulcer the Rodman operation (excision of the ulcer-bearing area) with gastro-enterostomy is wholly satisfactory. This implies multiple ulcers, but excision of single ulcer is commended before providing suitable drainage. Although mere infolding has been done in a number of cases, the best results have been attained by removal of the ulcer or ulcers, combined with good stomach drainage. Special stress is laid upon excision of the ulcer if it is situated in the lesser curvature and if there is but one ulcer. This method will effect a cure in all cases, pyloric insufficiency excepted.

Commenting on the difficulties of accurate diagnosis of stomach lesions in the recent past, he says: "Now, after we have been able, in a large number of cases, to set side by side the details of the clinical history and the disclosures of the operating-table, the difficulties are very considerably lessened. For example, duodenal ulcer, in a very great proportion of cases, can be diagnosed without any physical examination of the patient. The story he tells in his anamnesis might often be learned by heart from a written description, so exactly are the details, even the hours of the onset of pain, recited. But in all cases accurate observations should be made as to the length of stay of food in the stomach; the chemical reactions, the bacterial flora, the digestion, leukocytosis, should all be investigated. Repeated stasis of food for over twelve hours means organic disease; it is not found apart from organic disease. I place a high