Page images
PDF
EPUB

MEDICAL Record:

A Weekly Journal of Medicine and Surgery.

GEORGE F. SHRADY, A.M., M.D., Editor. THOMAS L STEDMAN, A.M., M.D., AssoCIATE EDITOR.

PUBLISHERS

WM. WOOD & CO., 51, FIFTH AVENUE.

New York, July 9, 1904.

AUTOINTOXICATION OF INTESTINAL

ORIGIN.

THE question of antointoxication is treated quite extensively by Dr. G. Lyon in the Gazette des Hôpitaux for May 14 last. The intestine is a permanent source of poisons, which under certain conditions cause grave alterations in the principal organs (notably the liver, kidneys, and skin) and functional troubles, among which those of the nervous system occupy a prominent place. Autointoxication may exist in connection with diseases involving diarrhoea, but it is above all associated with those causing constipation; it is, in short, a consequence of all intestinal affections.

To understand its genesis, we must at the outset recognize that digestion is a double process, an enzymic and a microbic one. Both enzymes and microbes transform starch into sugar, both emulsify fats, and both transform albuminoids into peptone. But the rôle of the microorganisms does not end here, for they may act to bring about further and putrefactive changes, with the formation of sulphuretted hydrogen, lactic and butyric acids, and from the albumins the ptomains and substances of the aromatic group. Against the poisons so produced, the normal organism manages to protect itself principally through the action of the intestinal epithelium and the liver which destroy the majority of the toxic products, while the excretory organs eliminate the remainder. Given certain conditions, however, and the toxic products can be generated in excess of the powers of the organism to dispose of them, or those powers may fail in point of efficiency. Of these two conditions, the former is the more frequent. Various influences may interfere with the normal course of digestion. Errors in diet, qualitative or quantitative, may form the starting-point, or the cause may lie in the organism organism itself. Thus gastric atony, whether combined (as is frequently the case) with dilatation or not, plays an important rôle. any one of several modifications of the gastric juice may initiate the series, by entailing delayed digestion which means fermentations and putrefactions. But gastric conditions are as nothing compared to intestinal, as gastric defects can be made up by intestinal over-exertion, while for intestinal deficiencies there is no compensation. Apart from organic obstructive conditions, intestinal atony plays a frequent and very deleterious part, the more serious the higher in the intestine the stasis occurs. For once stasis sets in, we are already in sight of autointoxication. Another expression Another expression

Or

of this motor insufficiency is the constipation so often present. As other pathological conditions underlying autointoxication are enteritis (acute or chronic), colitis with constipation, cancer of the intestines, etc., but especially chronic appendicitis, as its rôle is in a number of cases misconceived. The fetid diarrhoea, which is very frequent in the last disease, and which is very rebellious to treatment, ceases at once upon ablation of the appendix. Autointoxication may then be associated with any disease of the intestines, those associated with diarrhoea as well as those connected with constipation, but it is far more frequently associated with the latter class.

The diagnosis of chronic autointoxication is easily made; the yellowish tint of the face with the coated tongue, fetid breath, anorexia, nausea and sometimes vomiting, constipation, or diarrhoea with fetid stools, usually emaciation, sad aspect, with loss of energy and inaptitude for work, the whole gamut of nervous troubles (migraine, torpor, vertigo, insomnia, multiple pains), make up the picture.

As regards the degree of intoxication taking place, the severity of the clinical symptoms affords no accurate indication, and the same is true of the examination of the stools. Some patients have numerous very offensivę stools with few symptoms, while others with a few apparently normal stools show a profound intoxication. It is then important to recognize that we have in the condition of the urine (in which the majority of the toxic. products is excreted), a quite accurate index to the state of affairs. Besides the bodies produced by both enzyme and microbic action, the microorganisms of the intestinal tract are capable of giving rise to putrefactive products; bodies belonging to the fatty series (ammonium butyrate,caproate, valerianate; ptomains), and to the aromatic series (phenol, paracresol, indol, scatol, aromatic oxyacids). These appear in the urine as sulphocompounds, their toxicity having been attenuated by combination in the liver with sulphuric and glycuronic acids. The aromatics have not the toxicity of the ptomains but they are excreted parallel with them, and constitute, therefore, a rather exact index to the amount of the ptomains. A number of observations have now shown that putrefaction of the food in the prima viæ is the only source of the "ethereal sulphates" in the urine, and that they are never derived from any of the albuminoids of the organism itself. Thus, in animals with sterilized intestines, fed with sterile food, the urine shows no trace of phenol, indol, or scatol. More important, from the practical standpoint, is the fact determined by White, Poehl, Herschler, Winternitz, and Bernacki, that limitation to a hydrocarbonaceous diet, brings about a reduction of these substances in the urine to one-third of the previous amount. On the other hand constipation increases the amount of the ethereal sulphates in the urine, as does also all obstructive conditions of the intestines. The latter fact would naturally lead one to suppose that purgatives would bring about a decrease. But the action of these drugs is, in fact, not a uniform one, castor oil and the salines increasing the amount of the urinary ethereal sulphates, while calomel decreases them markedly.

As regards successful treatment, the first indication is the retardation of the existing intestinal putrefaction. For this purpose sterilization of the intestine by means of drugs has been tried, but the practice is to-day discredited as an impracticable utopia. The effects of naphthol and its derivatives are, it must be said, much disputed and most disputable. Besides naphthol exercises. an irritation of the most active description on the stomach, and its prolonged use can cause glandular atrophy. Also the administration of hydrochloric acid is useless, at any rate as regards intestinal antisepsis, and it may be remarked that hyperchlorhydria does not include antisepsis in its symptomatology. The same is, however, not true of lactic acid, which diminishes markedly the urinary ethereal sulphates.

It is, however, by diet that the effect is to be produced. To start with, the albuminoids are to be reduced to a minimum, for it is their fermentation which yields the toxins. Combe recommends

"saturation" of the patient with hydrocarbonaceous articles of diet, the word "saturation" being taken in its most literal acceptation. This antiputrefactive diet of Combe yields the most excellent results. Also Poehl and Bernacki have proven that a milk diet diminishes the ethereal sulphates, and that on such à diet the stools contain no indol, scatol, or phenol, but only leucin and tyrosin. This resistance of milk to putrefaction is attributed by Winternitz to the contained lactose, which on fermentation produces lactic acid which in its turn inhibits putrefaction. Similarly, fresh cheese has been shown to possess antiputrefactive properties. As regards eating, meals should be alternately solid and liquid, the patient not eating when he is drinking, or vice versa. Rovighi and Schumann have shown that this course involves a diminution of the ethereal sulphates. After each solid meal the patient should lie down, without sleeping. Green vegetables and all fruits, cooked or raw, are to be excluded. After a variable time the milkfarinaceous diet is to be mitigated on trial with meat, the yolk of eggs, and green vegetables.

Enteroclysis has more value than as an enema. The water is absorbed, relieving thirst and assisting in the lavage of the blood. The tube should be introduced with the patient lying on the right side with the left leg flexed upon the abdomen, and very slowly with successive pauses, to allow of an unfolding of the rugæ in advance of it. The solution is best an isotonic one (7 parts of sodium chloride per 1,000) introduced at 38°, and under a low pressure (with an elevation of only 15 to 20 centimeters), to avoid spasm of the intestine. Purgatives and lavage should be alternated. The purgative of

election would seem to be calomel.

In certain cases with profound intoxication (as evidenced by nervous troubles, oliguria, subicterus, etc.) in which an immediate effect is urgently. demanded, subcutaneous injections of saline solutions are to be resorted to, as this is the only method which can be relied upon for a rapid deintoxication of the organism.

The immediate symptoms being relieved, in the further treatment recourse should be had to hydrotherapy, open-air life, exercise, subcutaneous injections of sodium cacodylate and of strychnine;

and gastrointestinal massage is one of the best means at our disposal for the correction of the stasis.

PARATYPHOID FEVER.

IN the Scottish Medical and Surgical Journal for May is a paper by Dr. R. D. Keith on paratyphoid fever. The first part of the article is devoted to a consideration of the disease chronologically, and states that the first case was described by Achard and Bensaude of Paris in 1896, who isolated a paratyphoid bacillus. Schottmüller of Hamburg was the first observer to take up the subject in Germany, who isolated the specific organism of the disease and gave to the fever the name paratyphoid on account of its close resemblance to typhoid fever. Schottmüller concluded, from the investigation of a large number of cases of clinical typhoid in the General Hospital of St. George in Hamburg, that the bacilli isolated were the cause of the disease, and that of six cases there were two groups, one of which contained two, and the other four bacilli. These two groups, subsequently described in the literature as type "A" and type "B," differ in degree both culturally and in their serum reactions. It was found that the serum reactions of the members of the first group corresponded with one another, but not with those of the second group, and that while the serum reactions of the members of the second group corresponded with one another they differed from those of the first. These conclusions in all

important details have been confirmed by the investigations of many observers, including several

Americans.

As to the clinical characteristics of paratyphoid fever, observations of more than one hundred cases have been published, of which, however, only 46 are available for the purpose of a minute clinical analysis. Dr. Keith describes the disease-although, as he confesses, somewhat loosely-as an acute infectious process caused by a bacillus closely resembling in many particulars the typhoid bacillus, and the symptoms and course of the disease closely resembling those of typhoid fever. The onset is marked by headache, lassitude, loss of energy, and general weakness. Occasionally there is epistaxis, and in some cases vomiting and pain in the abdomen. By the time the patient comes under observation he is feverish and may feel chilly, but regularly marked rigors are hardly ever met with. As a rule, the temperature does not rise above a moderate height (102° F. or thereby), except in the more severe cases, nor does it remain for more than a few days at this height continuously.

Occasionally a critical fall is observed, and it has been observed by most investigators that even at its height the temperature has, as a rule, a remittent or intermittent character. The pulse is, as a rule, quite regular but somewhat small. Its frequency, according to some, is not increased at the commencement of fever.

A roseolar eruption resembling that of typhoid fever was present in thirty-two out of forty-six cases. It was described in some cases as occurring not only on the skin of the abdomen and chest but also on the back and limbs, and in one case even on the face. The tongue is generally covered with a moist white coating, but is occasionally dried and furred.

Diarrhoea is more prominent than constipation, and is sometimes present at the commencement of the disease. The abdomen is not, as a rule, markedly distended, nor is tenderness a prominent feature, but pain is in some cases present, and iliac gargling is an almost invariable accompaniment of the disease. The spleen is enlarged in the majority of cases, but so far as can be ascertained during life the liver is not affected. The urine during the course of the disease shows a deposit of lithates. Albuminuria, when present, is, as a rule, not marked and is found during the height of the fever. Hyaline and granular casts have been observed, and in one case blood was found to be present. In nineteen

out of forty-six cases the urine was found to give the diazo reaction, and in eight the test for indican was positive. The heart is practically always unaffected. With regard to the lungs, bronchitis is comparatively common, and emaciation is not so marked in this disease as in typhoid fever.

Of the complications observed, bronchitis is the most common. Pharyngitis is not uncommon, and next in frequency to it comes bronchopneumonia. Thrombosis of the femoral veins, pleurisy, phlebitis of the veins of the leg, endocarditis and cystitis have also been observed. Sequelæ have not definitely been known to occur.

Up to the present only three authentic fatal cases have been described. In all of these paratyphoid bacilli have been isolated from the organs after death, but in no case was any characteristic lesion found. The appearances were in most cases those of an acute general infection.

Studies undertaken to show the morphology, cultural characteristics, and behavior toward various media of the bacillus of paratyphoid fever bring out the characteristics distinctive of the paratyphoid bacilli "A" and "B." It is shown: (1) That there is a distinction between "A" and "B" paratyphoid bacilli. (2) That as regards the characteristics here alluded to paratyphoid "A" organisms are on the whole nearer bacillus coli than the "B" group. (3) That bacillus paratyphoid "B" is identical as regards its cultural characteristics with Gärtner's bacillus. (4) That "A" and "B" paratyphoid bacilli are distinct both from the bacillus coli communis and the bacillus typhosus.

Dr. Keith considers the serum reactions in cases of paratyphoid infections and their bearing on the serum. test in typhoid fever. The chapter in which this portion of the subject is dealt with is both too long and too technical to be adequately treated in an editorial. The value of immune sera is pointed out (1) As a means of identifying bacilli quickly. (2) As a means of showing the more exact relationship of bacilli to other members of a family or group.

The author gives the following résumé of the conclusions drawn from the investigations considered by him: (1) That there exists a disease which simulates the disease known as typhoid fever so closely that they can only be distinguished by bacteriological means. (2) That the disease is caused by an organism which exists in two varieties and which may be regarded as bacteriologically intermediate between the bacillus typhosus and the bacillus coli communis. (3) That the disease is on the whole mild and that the prognosis is good.

(4)

That the treatment of the disease is similar to that of typhoid fever. (5) That the disease spreads in the same manner as typhoid fever,a nd that the same hygenic and general measures should be taken in cases of this disease as are adopted in typhoid fever. (6) That in suspected typhoid-like cases a bacteriological examination is of the greatest importance both for diagnosis and prognosis and should be made wherever it is possible. (7) That up to the present the disease must be regarded as acute general infection in which no definite local lesion has been shown to exist.

Paratyphoid fever is probably conveyed in the same manner as is typhoid fever. It is not markedly infectious. The incubation period is about fourteen days, the spots appearing from the twentieth to twenty-sixth day. Perhaps the most valuable deductions to be drawn from the investigations of paratyphoid fever is that experiments have tended to show that immune sera can be produced which have a protective power against lethal doses, not only of homologous organisms but also of organisms which are related, thereby indicating to some extent the possibility of a new line of treatment in cases of infectious diseases.

Wright, as is well known, is of the opinion that typhoid fever can be warded off completely in some cases and in others rendered less severe by injections of dead cultures. Dr. Keith suggests that the indications given by the results of the experiments on animals with protective sera in the case of bacillus typhosus and allied organisms is but the initial stage of a new curative method of treatment. This matter, however, requires further elucidation before any large definite statements can be made regarding it. regarding it. Nevertheless, it may be said that the prospect is hopeful.

TRACHOMA AS AN EPIDEMIC AND MARITIME DISEASE.

In the annual report of the Surgeon-General of the Public Health and Marine Hospital Service for the fiscal year 1903, recently issued, Passed Assistant Surgeon J. M. Eager has an article on the above subject. The writer points out that the trans missibility and relation to shipping of trachoma. are brought prominently before the observer in connection with the inspection of emigrant ships in Italy. In view of the contagiousness of trachoma, the Italian Government now refuses to allow the embarkment of cases of active ophthalmia on emigrant ships leaving Italy, either for South America, where there is no prohibition against the entrance of trachoma, or for the United States. The object of this ruling is to prevent the spread of the disease aboard ship.

Dr. Eager reviews the history of trachoma from an epidemiological standpoint, and says that while it may be considered as a disease which, though known in ancient times to be contagious, was not noted to take on an epidemic character until recent centuries. Hippocrates, Galen, Plutarch of Cheronca, and Rhases, the famous Arabian physician of the ninth century, mention ophthalmia as an eminently contagious malady. The Rabbi Moses, a great exponent of the doctrines of Galen, says in his aphorisms that to gaze steadily into the eyes of a trachomatous person is enough to make anyone's eyes water, and that continuous contact with sufferers from ophthalmia generally results in contracting the disease.

The name trachoma was given to the affection

through the writings of Prospero Alpino, an Italian, who visited Africa in the sixteenth century for the purpose of studying Egyptian medicine. It was through the campaigns of Napoleon that trachoma. became prevalent throughout Europe. All the armies engaged in those wars being more or less affected by the disease. In 1820 Guillé of Paris demonstrated the contagiousness of trachoma.

The only record found in literature of trachoma as a maritime disease is that given by Guillé (Bibliothèque ophthalmologique, Paris, 1820). The disease occurred on a slaveship, Le Rodeur, which on the voyage out was free from ophthalmia, but whose slaves when sixteen days from Guadeloupe exhibited signs of the malady, which soon spread in the most rapid manner.

At the present time trachoma is notably endemic in Arabia, Egypt, Italy, Spain, Western Russia, Poland, Ireland, and South America. Exact statistics as to the prevalence of trachoma in Italy are not available, but these are, in most instances, incomplete, and in others, owing to inherent disadvantages, entirely indecisive. However, enough is known to show that the disease is very prevalent in many ports of Italy. Dispensary reports establish the fact that trachoma is greatly on the increase in that country, while Professor Fortunato states that in some of the maritime places of Sicily and Sardinia, from all available means of observation, it may almost be said that the entire population is trachomatous.

Dr. Eager ends an instructive paper by saying that the statistics of the medical inspection made in Italy for the United States are of little value in estimating the prevalence of trachoma in Italy for the reason that the figures are distorted by the fact that often persons notably trachomatous do not attempt to take passage or are refused the same by the transportation companies prior to the day of sailing, and so do not appear at the regular medical visit... Then, too, many persons, some not trachomatous, but fearing they may fall under suspicion, and others really victims of the disease, practise a sort of universe malingery at the time of the inspection. Adrenalin with cocaine hydrochlorate is a favorite prescription for eyedrops. By its application, a blanching of the conjunctiva is brought about, a condition which, even in the absence of other evidence, is sufficient to put the person under observation until the disappearance of drug effects has rendered proper examination practicable.

FOOD PRESERVATIVES.

A committee has recently been sitting, taking evidence as to adulterations and the use of preservatives in food. It has been especially considering the question of the use of preservatives in food. According to the New York Times, Dr. Frear, in discussing this contention, said that the testimony of the manufacturers had pretty generally been that such goods could not be packed without preservatives without a certain percentage of loss, but we must remember that the housewife who puts up her own catsup and preserves also suffers a percentage of loss. "The best opinion," Dr. Frear says, "seems to be against the use of preservatives as a general proposition as injurious, but, on the other hand, it is argued that the quantity used is so small as to be harmless in the products in which they are most necessary. The manufacturers seem to believe that it ought to be enough if all goods containing preservatives were plainly labeled, so that the consumer could see for himself, and take the responsibility for what he is taking into his stomach."

The

It is expected that the Secretary of Agriculture will be able in a few months to draw up a set of standards which will define what is meant by purity in foods, and what constitute adulterations. MEDICAL RECORD has always taken the view that preservatives should, as far as is possible be absent from foodstuffs. In fact, there is little doubt that in the large majority of cases articles of food require no preservatives. By allowing the use of foreign matter in food, the thin edge of the wedge for all kinds of deception is allowed to enter. Undoubtedly, if the use of preservatives is permitted at all, food so treated should be plainly labeled. The question of pure food is a momentous matter, and one which directly affects the whole community. Ignorant persons must be protected against themselves, and the manufacturers must remember that it is not only their interests which are at stake but the welfare, to a greater or lesser extent. of the entire population of the country. Selfish interests cannot be allowed to prevail over the good of the many, and legislation should be strictly enforced which clearly defines the relative position of manufacturers and the general public with regard to food preservatives.

THE MEDICAL LIBRARY MOVEMENT IN THE UNITED STATES.

Standard books on medicine and surgery, and the latest works on these subjects, together with the most recent medical literature, are considered to be essential to the physician of the present to these the up-to-date day. Without access

medical man feels to some extent lost, for he recognizes that it is necessary for him to keep abreast with the times and to know something of everything that is going on in the medical world everywhere. Thus the medical library has become an absolute need, and the main provider of medical and scientific pabulum to the practitioner. As a factor in medical education the library is of inestimable value, in this respect equalling if not transcending any other means.

Dr. Albert T. Huntington of Brooklyn, in the Medical Library and Historical Journal, for April. 1904, writes on the medical library movement in the United States. The first one in this country was founded in 1760, but it is only within the past

forty years that the great medical libraries ci to-day have been built up, and only within the last decade that the medical library movement has become active and widespread.

Dr. Huntington gives a list of the various medica libraries in the country, the date of their foundations, and the number of volumes contained in each. There are in the United States 215 of such institutions, while the number of volumes in these is estimated at 1,023,295.

The author points out that if we should assume that all the libraries in the list compiled by him are in an active state of existence and their resources readily available to the profession, two striking facts are very evident: First, that certain centers are oversupplied with medical libraries, and that the fusing of several distinct collections into one great library whose resources should be free to the whole profession could not be other than advantageous to the best interests of all concerned, Second, that there are certain large sections of the country which are utterly barren of adequate medical library resources.

Dr. Huntington is of the opinion that there are two requisites for the establishment and perma nent success of a medical library: First, a desire on the part of the local profession to have a library;

second, the control of that library, wherever the books are housed, by the medical profession. Therefore, it is best, whenever practicable, that the library should be separate, and under the auspices of some general medical organization. The foregoing is undoubtedly good advice and should be followed as far as is possible.

The medical library movement has evidently taken firm root in the United States, and from all apprearances will flourish in the future to a greater extent than at present.

News of the Week.

Change in the Examination for the Army Medical Service. The examination of applicants for commission in the Medical Corps of the Army was materially modified on July 1. Immediate appointment of applicants after successful physical and professional examination—the latter embracing all subjects of a medical education-will be discontinued, and hereafter applicants will be subjected to a preliminary examination and a final or qualifying examination, with a course of instruction at the Army Medical School in Washington intervening. The preliminary examination will consist of a rigid inquiry into the physical qualifications of applicarts and written examination in mathematics (arithmetic, algebra, and plane geometry); geography; history (especially of the United States); Latin grammar, and reading of easy Latin prose; English grammar, orthography, composition; anatomy; physiology; chemistry and physics; materia medica and therapeutics; normal histology. The subjects in general education above mentioned are an essential part of the examination and cannot under any circumstances be waived. The preliminary examination will be conducted concurrently throughout the United States by boards of medical officers at most convenient points; the questions submitted to all applicants will be identical, thus assuring a thoroughly competitive feature, and all papers will be criticised and graded by an Army Medical Board in Washington. Applicants who attain a general average of 80 per cent. and upward in this examination will be employed as contract surgeons and ordered to the Army Medical School for instruction as candidates for admission to the Medical Corps of the Army; if, however, a greater number of applicants attain the required average than can be accommodated at the school the requisite number will be selected according to relative standing in the examination.

The course of instruction at the Army Medical School will consist of lectures and practical work in subjects peculiarly appropriate to the duties which a medical officer is called upon to perform. While at this school the students will be held under military discipline, and character, habits, and general deportment will be closely observed. The final or qualifying examination will be held at the close of the school term, and will comprise the subjects taught in the school, together with the following professior al subjects not included in the preliminary examiration: Surgery, practice of medicine; diseases of women and children; obstetrics; hygiene; bacteriology, and pathology; general aptitude will be marked from observation during the school term. A general average of 80 per cent. in this examination will be required as qualifying for appointment, and candidates attaining the highest percentages will be selected for commission to the extent of the existing vacancies in the Medical Department. Candidates who attain the requisite general average who fail to receive commissions will be given certificates of grad

uation at the school and will be preferred for appointment as medical officers of volunteers or for employment as contract surgeons; they will also be given. opportunity to take the qualifying examination with the next succeeding class.

It is not thought that, for the present at least, the number successfully passing the preliminary examination will be greater than can be accommodated at the Army Medical School, nor that the number qualifying for appointment will exceed the number of vacancies. If, however, the class of candidates qualifying should be larger than is now thought, the young physicians who fail to receive commissions will not have wasted their time, as the course of instruction at the school, while in a large measure specialized to Army needs, is such as will better fit them for other professional pursuits, and furthermore they will have received a fair compensation while under instruction.

Admission to the preliminary examination car be had only upon invitation from the Surgeon-General of the Army, issued after formal application to the Secretary of War for permission to appear for examination. No applicant whose age exceeds thirty years will be permitted to take the examination; this limit of age will be rigidly adhered to. Hospital training and practical experience are essential requisites, and an applicant will be expected to present evidence of one year's hospital experience or its equivalent (two years) in practice. The first preliminary examination under the amended regulations above referred to will be held about August 1, 1904; those desiring to enter the same should at once communicate with the Surgeon-General of the Army, Washington, D. C., who will furnish all possible information in regard thereto.

New York State Hospital for Incipient Tuberculosis. This institution was opened on July 1, at Ray Brook, Essex County, under the superintendence of Dr. John H. Pryor. The following information concerning the admission and maintenance of patients is from the act establishing a State Hospital in the Adirondacks for the treatment of incipient pulmonary tuberculosis.

The

Free Patients.-The trustees of the hospital are hereby given power and authority to receive therein patients who have no ability to pay, but no person shall be admitted to the hospital who has not been a citizen of this State for at least one year preceding the date of application. Every person desiring free treatment in the hospital shall apply to the local authorities of his or her town, city, or county having charge of the relief of the poor, who shall thereupon issue a written request to the superintendent of said hospital for the admission and treatment of such person. This request must state in writing whether the person is able to pay for care and treatment while at the hospital. requests will be filed by the superintendent in a book kept for that purpose in the order of their receipt by him. When the hospital is completed and ready for the treatment of patients, or whenever thereafter there are vacancies caused by death or removal, the superintendent shall issue a request to an examining physician, in the same city or county, or, if there is no such examining physician in the city or county, then the nearest examining physician, for the examination by him of said patient. Upon the request of the superintendent the examining physician shall examine all persons applying for free admission and treatment in the institution, and determine whether such are suffering from incipient pulmonary tuberculosis. No person shall be admitted as a patient in the institution without the certificate of one of

« PreviousContinue »