he had to re-establish a police force and a lighthouse system with harbor master, pilots, etc. Nothing can excell the directness of his own words: "There were a great many unburied dead in the houses, between 2,000 and 3,000 wounded and sick and a great horde of half-famished and sick people, nearly 20,000 in number, who had just returned from El Caney, where they had gone during the siege. The water-supply of the city had been cut off; there was no water to be obtained except from cisterns and a few wells, and the streets were full of dead animals and all sorts of filthy material. I had to start in from the bottom and repair the waterworks. Then came the removal of the dead. Some of these were burned, because the number was so great and decomposition had advanced to such an extent, that they could not be buried. Burning is not uncommonly practised here during the epidemic season. "We had yellow fever all around us and about twenty cases in the Spanish hospital. The civil hospital was full of dying people, and public buildings were being used as hospitals. I have a force of about 170 men constantly employed and at many times have had nearly double this force working day and night to remove the vast amount of indescribable filth which had accumulated in the outhouses and yards, as well as the streets of the city, which is reputed to be one of the most unhealthy and dirty in the world. The death rate has dropped steadily since we came in and is now about one-fourth of what it was in July. The water-system has been put in order and a great many repairs made to it and the supply, although insufficient, is utilized to the greatest advantage. "I have had to hire doctors for the hospitals, purchase medicine for them, and supply them with beds and bedding and food, in fact, re-establish and take entire charge of them. I have also established a strict system of house inspection and inspection of the streets and have a disinfecting department as well as a cleaning department. "As the courts are not yet running, I have the delightful experience each day of acting as police judge and clearing the docket of all sorts of odd cases. Of course the most serious cases, such as crime, are being held for trial, either by military commission or by the courts when they are established and in operation. Today I do not know of an authentic case of genuine yellow fever in Santiago De Cuba proper, and every day increases our chances of escape." A DIPLOMA MILL The following significant and disgraceful advertisement has just been. offered to the Journal. "JUSTICE TO SUCCESSFUL PRACTITIONERS AND STUDENTS Undergraduate practitioners furnishing sworn statements from county officers, certifying they have practiced medicine successfully for years, can have degree of M. D. lawfully conferred at home, without attendance (from legally chartered Medical College). Students attending, graduated when competent, independent of time. Graduation in Dentistry same basis. For particulars address, Comment is unnecessary except to say that the name and address of the parties are at the service of the proper legal authorities. The State Board of Illinois should promptly squelch this recurrent effort of Chicago quacks. Behring excuses himself from commercialism in patenting his antitoxin by writing that he has renounced the medical profession, and by sneering at American medical ethics. As Gould says in the Philadelphia Medical Journal, "This may help us to estimate his personal character more accurately." He has, of course, no excuse for his greatest sin of patenting for his own pecuniary profit the results of many other and more eminent men. Finally as Gould says: "It is a matter of profound regret that German science so readily becomes subservient both to political and financial control." SOME OBSERVATIONS ON BRAIN ANATOMY AND BRAIN TUMORS -ABSTRACT Dr William C. Krauss, of Buffalo, read a paper at the 92nd annual meeting of the Medical Society of the State of New York, Albany, January 25, 1898, with the above title. He called attention (1) to the difficulty in remembering the gross anatomy of the brain, and (2) to the almost universal presence of optic neuritis in cases of brain tumor. He attempted to overcome the difficulty in regard to the anatomy of the brain by formulating certain rules, which are somewhat unique and original, and at the same time easily remembered. Studying carefully 100 cases of brain tumor in which an ophthalmoscopic examination had been made for the presence or absence of choked disc (optic neuritis) Dr. Krauss announced the following conclusions: 1. Optic neuritis is present in about 90% of all cases of brain tumor. 2. It is more often present in cerebral than in cerebellar cases. 3. The location of the tumor exerts little influence over the appearance of the papillitis. 4. The size and nature of the tumor exert but little influence over the production of the papillitis. 5. Tumors of slow growth are less inclined to be accompanied with optic neuritis than those of rapid growth. 6. It is probable that unilateral choked disc is indicative of disease in the hemisphere corresponding to the eye involved. 7. It is doubtful whether increased intracranial pressure is solely and alone responsible for the production of optic neuritis in cases of brain tumor. -The Philadelphia Medical Journal. VOL. III Cleveland Journal NOVEMBER, 1898 No. 11 F ILEUS An Address before the Cleveland Medical Society, October 28, 1898 BY JOHN B. MURPHY, M. D., CHICAGO OR a number of years, indeed for a century, the question of intestinal obstruction has been a very animated one with the medical profession. The statements by the medical and surgical branches of the profession have differed very materially as to the results by the various modes of treatment; the one, the medical man, by the expectant treatment; the other, the surgeon, by the operative treatment. Only a short time ago I was reading an article written by a surgeon, in which it was claimed that the percentage of recoveries after operation for intestinal obstruction was 34%. A short time after that I was reading an article by a medical man and the percentage of recoveries after medical treatment was 70%. Again I was contrasting the statements of various celebrated surgeons as to their results with operative treatment of intestinal obstruction; but they differed almost as widely as did the medical and surgical branches of the profession. Why this discrepancy? How was it that the medical man could make a statement that 70% of the cases of intestinal obstruction recovered, and the surgeon said 34% only recovered with operation? The difference was because the medical man included in his cases of intestinal obstruction an entirely different class of cases from the surgeon. If the surgeon and the medical man had included the same class of cases, that is the class of cases in which there existed a natural mechanic obstruction to the intestinal canal, their percentages would have been the same. Then the question comes up: are we able to make a differential diagnosis between true mechanic obstructions and an interference with the innervation? In order to clear that subject up, after giving it much consideration, I concluded that we should not treat the subject as intestinal obstruction at all; that we should include under some head all of the cases that produce the train of symptoms which we recognize as most pronounced in true mechanic obstruction of the intestine, and for that purpose we have used the term Ileus. By the term ileus we do not mean any definite pathologic entity. We merely include in that a train of symptoms, and that train of symptoms consists of pain in the abdomen, nausea and vomiting, and inability to produce bowel-movement. Then let us subsequently separate and classify our lesions into the varieties; those that are caused by mechanic obstruction, and those produced by other conditions than mechanic interference to the passage of the contents of the ailmentary canal. In order to get the subject plainly before us let us first picture the intestinal tract as a long muscular tube, some thirty-odd feet in length, having flexures, contractions and valves. Then consider that the intestine has in addition to its physiologic function of excretion and absorption the power of propelling its contents. The part in which the surgeon is interested is the propulsion of the contents. How is the contents propelled? It is propelled by a regular rythmic contraction and expansion of its walls. Anything that interferes with the regular action interferes with the passage of the contents of the intestine. The first subject then that should attract our attention is that it receives its motor power from its nerve-centers. If there is an interference with the nerves that disturbs the regular contraction of the muscular wall of the intestine there is a manifestation of intestinal obstruction. Let us take the division of the cases as I have arranged them here on this chart. We may have an interference with the passage of the contents of the intestine; first, by an atonic or adynamic condition; by a condition. in which the bowel does not contract and propel its contents. Again, we may have an interference produced by an excessive contraction of the intestine, as we have in lead-poisoning. Again, we may have interference by some mechanic interference to the passage of the contents. If, now, the surgeon and the medical man will include under the term ileus all of these conditions, we can readily agree in opinion as to what cases should be treated surgically, and what medically. If we include under the head of adynamic all of the disturbances that interfere with the nervesupply of the intestine, then we can separate these from the surgical class of disease, or from the class that requires operation. The conditions which produce a paralysis of the intestine, or an inactivity, may be central; that is, we may have it from a central nervous lesion. As you know, in tabes we have crises in which all of the symptoms of intestinal obstruction last for five, six or seven days. And, indeed, some of the best surgeons of the world have performed laparotomies on patients of this class for the true mechanic obstruction, when the lesion was a nervous disturbance in the spine. Then we may have paralysis of the intestine from operations on the mesentery excised for tumor. Every general practician has seen cases of fracture of the spine high up in the dorsal region with intestinal obstruction for five or six days after the fracture, so that the distention of the abdomen becomes so great as to impair respiration, and protrusion of the rectum results from the intraabdominal pressure. Again, interference with the sympathetic produces paralysis of the intestine, and in that way we have the symptoms of ileus produced. The innervation of the intestine is often very materially interfered with from reflex causes; and a large percentage of the cases of so-called intestinal obstruction, true ileus, that recover without operation are due to reflex causes. The most common of the reflex causes is hepatic calculus. You will find a patient suffering from an impaction of an hepatic calculus in the cystic duct or in the common duct. With pain in the abdomen, nausea and vomiting, local tenderness, it is impossible to produce a bowel-movement; and that continues as long as the calculus keeps in transit. When the calculus becomes stationary in any part of the duct, and you have it dilated and a diverticulum formed, the reflex action ceases, the intense pain subsides and active peristalsis is restored. While the calculus is in transit the pain is so intense that you have a reflex ileus as a result. The same is true in the passage of renal calculi, with no interference whatever with the intestinal tract from a mechanic standpoint. In ovarian compression, and in twisted pedicle it is not an uncommon thing to have the surgeon summoned to operate for intestinal obstruction. The pain in the abdomen comes on suddenly; it is associated with nausea and vomiting; it is many times not accompanied by a rise of temperature; it is followed by tympany on account of the paralysis of the intestinal wall; and the surgeon is called to operate for intestinal obstruction. He makes his examination and he detects in the pelvis a tumor. If it be a fibroid he may find when he dislocates it that he has relieved the ovary from compression, the pain subsides and the patient recovers. If, on the other hand, it is a twisted pedicle no amount of manipulation relieves the pain; and if he performs a laparotomy he will find the pain has not been produced by an intestinal obstruction. The inability to move the bowels was not the result of obstruction of the intestinal tract, but was due to reflex causes. And that, I believe, is not an uncommon cause of the ileus, or inability to move the bowels, after amputation of a tumor. The next variety is pleurisy. How can a pleurisy produce the symptoms of ileus, with pain in the abdomen, nausea and vomiting, tympany, inability to move the bowels? Diaphragmatic pleurisy can do that, and not |