operations and difficult cases has greatly increased, and the greater number of deaths among members has been in these nearly hopeless cases. At Missoula the work has also increased, and it has been necessary to fit up the basement in the new addition for the accommodation of the Japanese patients, by the purchase of additional equipment and making some slight alterations. The buildings have been kept in good repair and usual repairs made. The medical and surgical work of the members along the line has been carefully administered by the local surgeons and every attention given in the treatment of cases. The stretcher equipment located at all important stations has been kept in repair and an additional supply purchased for new locations. The accident emergency cases on passenger trains and the first-aid packages on freight trains have been maintained and kept in complete condition, renewals being made every time they are used. It has been necessary to purchase some additional emergency boxes to meet the increased demands for this equipment in the way of new locations and increased trains. the pancreas is recognized as the cause of the fatty necrosis the matter of indemnity will be considered in a different light, even in cases where the pancreatic lesion. alone would probably be insufficient to cause death.Medical Bulletin. THE SURGEON'S HANDS. The part which contact of the surgeon's hands plays in operative wound infection is so well recognized that every new procedure looking toward a perfected technique is assured of an unbiased trial. Sterilization of the hands is at best but a relatively asceptic process, and for this reason, whenever the operator's hands touch a wound surface, infection is possible. Since the awakening which began in the culmination of Lister's work the value of thorough mechanical cleansing with soap and water scrubbing is universally accepted, some surgeons placing so high a value upon this method as to constitute their only safeguard to the wound against their touch. In the early days of antisepsis the surrounding atmosphere being believed (centuries old belief) to be the source of ill The number of emergency cases at shops, given tempo- infection, strong carbolic spray across the field of oper rary immediate treatment, has been as follows: ation, hands and instruments coming in contact with the wound surface was in vogue. Later, learning of the innate power of the operator's hands to infect, the constant spraying gave place to strong carbolic and bichlorid. hand immersion solutions. The irritation to the in87 dividual's hands caused by these methods was sometimes 130 so violent as to force the physician from his chosen field, as in the case of Lorenz, who, first a general surgeon in Albert's clinic, was compelled to abandon open operative work. 1,751 M. Roosen-Runge raises the question concerning the influence of traumatism in producing fatty necrosis of the pancreas. He has particularly studied at the Hamburg Hospital four cases of fatty necrosis in which the autopsy showed an alteration of the pancreas. In the first the ball of a revolver had perforated the tail of the organ. In the second the pancreas formed the base of a cavity constituted by the stomach and transverse colon and covered by the omentum. The gland was friable, its contents of a blackish-brown color, interspersed with islets of lighter hue, and had entirely lost its histological structure. The pancreatic canal alone, with its vessels, was unchanged. The third patient presented an analogous lesion. The fourth patient exhibited a rupture of the gland and its canal. In the four cases the disease was consecutive to injury. The first was due to a pistol shot, the fourth to being run over by a wagon, and in the other two violence (kick in the abdomen, fall down staircase) had preceded by some weeks the development of the disease. These four cases, added to several others previously published, tend to demonstrate the importance of traumatism in the genesis of fatty necrosis. The question is of much practical interest in regard to the indemnity to be claimed in case of accident. If it be classed according to the older view as an independent primary disease the relation between the accident and the disease which caused death may be denied. If, on the contrary, the lesion of Furbinger's method of hot sublimate solution, I to 1,000, scrubbing, after a preliminary soap and water brushing, and rinsing the hands in fresh solutions of the same strength from time to time during the progress of the operation, is the most commonly followed out at present, though the use of Kelly's potassium permanganat wash, followed by decolorization by oxalic-acid solution, gains favor. The one objection to a general employment of the last-named method is that of irritation of the skin. Many surgeons cannot bear the action of these two drugs upon the cuticle more than two or three times a week, even by the addition of lime water, used subsequently; and for some, their use is entirely interdicted from this cause. A modification of Kelly's method, in use by certain surgeons immune from the annoyance of skin reaction, is to allow the hands and arms to soak in the permanganat solution and to allow it to remain upon the skin surfaces until the end of the operation. For those able to employ this means it seems of greatest value in preventing wound infection from this direction. Seeking other methods upon the same lines, tincture of iodin has been employed. Coatings of sterile varnish solutions made from gum-resin bases are advocated, these last failing to reach perfection owing to their property of peeling during movements of the hands and fingers. Rubber gloves as infection protectors have many users, and the employment of talcum and salicylic dusting powders to prevent perspiration forming during wear, removes the objection of opposers to their use, who lay great stress upon the danger following punctures. However, the loss of sensibility in determining pathological conditions and in handling tissues and instruments is sufficient to inhibit their more general use. To best meet the conditions we at present rely strongly upon a thorough five to ten minute scrubbing with tincture of green soap and hot running water of both hands and arms, aided by a rubbing with a handful of washing soda or chlorid of lime, with many rinsings in running After softening, the nails are cleaned with a pointed skewer or orange-wood stick, then scrubbed with. soap and lime. After thorough rinsing in sterile, running water, the hands and arms are next dipped in a bichlorid solution of 1 to 1,000 strength and scrubbed lightly meanwhile. water. Attired in long-sleeved, sterile gowns, tied at the wrists, and handling tissues rather with instruments than naked fingers, we believe the surgeon will be enabled to keep below the balance of his patient's resisting power for germ infection during operations.-Med. Critic. THE MODERN THERAPY OF SEPTIC PUERPERAL AND SURGICAL INFECTIONS. BY ROSWELL PARK, M. D., LL.D., PROFESSOR OF SURGERY, UNIVERSITY OF BUFFALO. The most efficient measures for the treatment of surgical infections are the various silver preparations for whose introduction we are indebted to Credé of Dresden. We have been for decades looking in vain for an effective antiseptic which is devoid of marked toxic or irritating properties. Allotropic silver (Collargolum) seems to offer us the nearest approach thereto. Between this silver preparation which is so bland and the silver salts like nitrate of silver, there are the lactate and citrate of silver, also introduced by Credé, of which reasonably strong solutions can be used upon quite sensitive surfaces without producing much, if any, disturbance. Let us first take the aqueous solution of soluble metallic silver (Collargolum), which in the strength of 1 to 300 in distilled water makes a somewhat cloudy solution. In this strength it may be used by intravenous injection in cases of severe general or puerperal sepsis, rapidly spreading gangrene, acute articular rheumatism or other serious infections. In fact, solutions as strong as I to 100 may be employed; it being desirable to introduce .9 grains to 11⁄2 grains at least. If there be difficulty in injecting it into a vein it may even be given beneath the skin. Unpleasant effects will not be noticed, neither will any immediate relief follow, but the solution thus introduced coming into contact with the blood, which in these cases is swarming with germs, will promptly begin its bactericidal work, whose effects should be manifested after two or three hours by a fall of temperature and amelioration of septic symptoms. Silver used in this way has been of great service in cases of carbuncle and even of acute anthrax. Moreover, its administration may be repeated as often as may seem necessary. When metallic silver is made into a suitable ointment (Unguentum Credé), which, by the way, much resembles mercurial ointment, and is then applied to the skin, there is a rapid absorption of the silver itself with its dissemination into the blood stream and results like those just mentioned; it is simply somewhat slower. For many years I taught that the combination of resorcin, ichthyol and mercurial ointment, which I believe I introduced into surgical practice, was the most effective remedy for erysipelas and all similar septic infections. To-day I have found but one combination which I think superior for this purpose, and that is the silver ointment (Unguentum Credé). No matter what part of the body be anointed absorption. takes place readily and promptly, consequently any convenient surface may be medicated in this way. Cleanse the skin thoroughly, smear the ointment freely, cover with oiled silk, and put over this (if comforting to the patient) a warm application to promote absorption. If the surface be not tender the ointment may be rubbed in. In cases of puerperal sepsis if may be applied over the abdomen or to the inside of the thighs. In erysipelas it should be applied to the affected part. It makes very little difference what the exact nature of the infection is, one may rely upon it that the silver will be absorbed and will do good work. This is true, for instance, in such acute infections as endocarditis and meningitis. Advantage may also be taken of the properties of metallic silver by giving it internally as an intestinal or urinary antiseptic, for which purpose it should be given in pills or capsules. These are unirritating and extremely efficient and may be given where remedies like salol, benzosol, etc., are ordinarily exhibited. Lastly I would speak of the use of lactate and citrate of silver, not only for such purposes as the preparation of catgut, silk, gauze, etc., but in solutions of from 1 to 300 to 1 to 500 for the irrigation of septic cavities, and for such purposes as washing out the peritoneal cavity in cases of tuberculous peritonitis, for which I have repeatedly used it and always with benefit. I differ from the late Doctor Fenger of Chicago, who did not favorably regard washing out the abdominal cavity. In my own experience, flushing with a 1 to 500 solution has been of the greatest apparent benefit and has never occasioned any regret. Infected bladders, uterine cavities and vaginas may be advantageously, freely and frequently washed out with similar solutions. When using them one may have the feeling that he is using solutions of greater efficacy and of far less toxicity than any of the mercurial preparations would afford. Therein lies the beauty of these preparations, that in anything like equal strength they are more effective and much less toxic than the mercurial salts. This is a very brief epitome of my views regarding the value of the silver preparattions in surgery. I often state in my clinic that the good old-fashioned nitrate of silver is not used nearly so much as it should be and prove the strength of my conviction by its general use in 1 to 10 per cent solutions in pus cavities. Not only is a full germicidal effect obtained but also that stimulation to healthy granulation which the nitrate is well known to afford. All in all, if I could have but one source for antiseptic solutions and applications, I would rather look toward the preparations of silver than in any other direction.-Alpha Omega Delta Bulletin. ADRENALIN AS A STIMULANT IN SHOCK. BY M. S. MILES AND W. MUHLBERT. The writers have made an experimental research upon adrenalin as a stimulant in vasomotor depression. It is generally believed that the phenomena of surgical shock are dependent upon relaxed arterioles. A fatal termination is not due so much to heart failure, to which it is commonly ascribed, as to the inability of the heart to maintain vascular pressure when the arterioles of the body are relaxed. It is difficult to produce the phenomena of shock in animals, but an analogous condition is caused by excessive doses of ether. In these cases it was found that adrenalin was much more efficient in raising vascular pressure than was either strychnine, digitalin, or normal saline solution; hence, it was much better than these so-called heart stimulants. It was found to be much more efficient in cases in which the respiratory centers were not paralyzed. Their experimental work jus tifies the conclusion that adrenalin is indicated in vasomotor collapse following cocain or chloroform poisoning, and shock after operation. When used, it should be given subcutaneously, and the site of the injection should be slowly and deeply massaged until the adrenalin shows its characteristic effect on the pulse. Too great dilution with normal saline solution is not advisable, as absorption is slower, and the effect is less energetic.-Medicine. Among the manifold guises in which hysteria appears, some of the strangest and most unfortunate are those which affect the central nervous system and special senses. An interesting case is added to the list of these afflictions by Drs. Delamere and Conor, of the French army, who have published their observation in a leading periodical. It is recognized that muscular contracture is often the first symptom of hysteria and that it may be produced in consequence of an injury. The effect may be out of all proportion to the severity of the accident. The duration of the contracture is variable and it may be intermittent or permanent. Contracture of the orbicularis palpebrarum may easily be misinterpreted if one does not think of the possibility of hysteria and examine the patient from that point of view. Hysterical blepharospasm, which may be tonic, chronic, or pseudoparalytic, has long been known. Celsus mentions ocular manifestations which, in the opinion of Gilles de la Tourette, are of hysterical nature. Carré de Montgerrou reported in 1717 the case of a woman, 27 years of age, smitten with painful blepharospasm of the left side. Since that date cases have multiplied and been described by many writers. The case published by the authors whom we follow was that of a young soldier. His parents, brothers and sisters were healthy, but his father was of the nervous type. The patient had during childhood suffered from nocturnal terrors. He had generally enjoyed good health. He had never been subject to vertigo. Rather more than a year previously he had been in the military hospital for pneumonia. Four months later he was attacked by bronchitis. During convalescence he worked in the garden, where he received a slight blow from a branch upon the left eye. There was some pain, followed by a mild conjunctivitis and blepharospasm upon that side. He was given an eight days' furlough, during which period the contracture disappeared. In returning to his regiment by rail some coal dust was blown into the left eye. The ticles were removed by the surgeon and he was sent to the infirmary for conjunctivitis. The eye gradually closed. The blepharospasm had returned. He again entered the hospital, from which he had been discharged after recovering from the pneumonia. This was about six months prior to the date of publication. par The man was of robust build and had no appearance of nervousness. The left eye was constantly and completely covered by the upper lid. In attempting to raise the lid one was met with a strong resistance, which, however, could be overcome. A rather curious phenomenon was then observed. In proportion as the left lid was raised the right fell. The pupillary reflex of the left eye was preserved, but the corneal reflex was notably diminished and there was anesthesia of the conjunctiva. Nothing of importance was revealed by ophthalmic examination of the eyeground. The right eye was normal and possessed a visual acuity of 0.7, while that of the left eye was 1.20. The visual field was almost nil upon the left side; upon the right it was reduced one-half. The eyebrow was decidedly lowered upon the left side. Pressure over the supra-orbital and infra-orbital neither increased nor diminished the spasm of the orbicularis. As regards sensibility, the pharyngeal reflex was lost. Numerous anesthetic zones existed upon the body, especially upon the left side. There was hemianesthesia upon the left side of the face, breast, abdomen, and back, including the buttocks. Both upper limbs were insensitive to pricking. The left legs were anesthetic as high as the knee. The patellar reflexes were exaggerated. There was no epileptoid tremor. There was no disorder of motility. All the signs pointed undoubtedly to hysteria. The blepharospasm was of the tonic and permanent variety. The authors compare their case to that of Lasègue, in which a young girl, fourteen years of age, without neuropathic antecedents, had some grains of sand blown into her right eye. There was a little conjunctivitis and lacrymation, which lasted, however, but a few hours. The next morning the girl was attacked by a contracture which absolutely prevented opening of the lids of the right eye. The spasm persisted for about four months and then disappeared overnight. Other hysterical manifestations then followed. These two cases demonstrate that the hysterical effects may be of astonishing magnitude compared to the accident by which they were excited. The want of proportion should arouse suspicion and lead us to search for other evidences by which to establish the hysterical nature of the affection.-Medical Bulletin. Remember that no foreign body in the ear, except living insects or vegetable substances, can do harm. Syringe gently, unless the foreign body is likely to swell.Fenwick. A CONTRIBUTION TO THE TREATMENT OF BURNS. In Feldscher Dr. Th. S. Wassiljew records a case of extensive burns which is of interest in various ways. In the first place it seems to disprove the generally accepted view that such cases are hopeless when one-third of the surface of the body is affected; secondly, a brilliant cure was achieved in this case; and thirdly, the case, though tragic, gives a vivid picture of Russian peasant life. The patient is a shepherd, aged 32, of small stature and. normal strength, humpbacked and mentally weak. While herding his flock one day a pregnant and littering sheep went astray. The owner's wife upbraided him and vociferously insisted that he must find the lost sheep under all circumstances. The poor fellow wandered around in vain all day and continued his search during the night, at last succeeding in finding it with four newly-born lambs. The prroprietress rewarded him with a bottle of whiskey. As he was thoroughly chilled by his ramblings, he built himself a fire and laid down alongside to dry his clothes. and warm his stiffened limbs. The whiskey took effect and he was soon in a deep slumber. In the morning he was aroused by the flames which licked up his trousers legs and were beginning to roast him. In horrible agonies he tore off his clothes, assisted by a peasant who happened to notice the disaster. When brought to the hospital, some distance away, the chest and abdomen, penis and scrotum, and the fingers of both hands were burnt. The patient suffered fearfully, temperature varied between 102 degrees and 104 degrees F. At least one-third the surface of the body was burnt, so his life seemed in grave danger. Treatment consisted in soothing inflammation and pain with cold compresses of solution of subacetate of lead. Xeroform powder was then applied. It possesses great desiccant and deodorizing powers, inhibits pus formation and stimulates granulation. In this case it was used as a 5 per cent vaselin salve, applied on large pieces of gauze and renewed daily. The patient began to feel well and pain ceased. At first suppuration continued, so that the compresses were soaked with pus, and patches of burnt skin adhered when they were removed. Soon the epidermis and parts of the corium detached; the burnt surfaces became raw and bleeding, being in spots obscured by particles of corium. After about two months everything was clean, suppuration had disappeared and healing progressed rapidly, though places which had been most exposed to the flames, of course, cicatrized more slowly. The strength was therefore raised to 10 per cent, which noticeably hastened the process. After about four months almost all the wounds had healed. The beneficial action of the xeroform is chiefly due to its great desiccant and antiseptic properties, which lessen the secretion, cleanse the burnt surface and promote growth of the epithelium. Bleeding was noticeably less than in cases in which other salves were used. In scalds, in which the corium had not been injured, marvelously rapid effects can be obtained with a ten per cent xeroform ointment, healing being complete in a few days. Med. Woche. Notices and Reviews. "The Practical Application of the Röntgen Rays in Thera- When we recall the fact that it is less than eight years since the discovery of the X-rays by Prof. Röntgen, we are filled with wonderment that so much experience has been gained to justify the publication of such a volume. upon the generation and value of these subtle rays. In Part I Prof. Caldwell has presented those features of the scientific nature of the rays, and the principles of the generating mechanisms, together with such indications as to their practical use to enable the average physician to utilize this epoch-making discovery. After a brief historical sketch the following subjects are considered: The essentials of an X-ray equipment, in which the various sources of the electrical energy are described; X-ray tubes (comprising over 30 pages on the various kinds of tubes and indicating their comparative value); induction coils; interrupters and their management, in which these mechanisms are clearly described and their respective uses and merits pointed out; static machines and their management; fluoroscopy, discussing the principles, apparatus and value of this wonderful adjunct to X-ray investigation; radiography, in which the mechanical and practical features of X-ray photography are gone into in minute detail. This part is closed with an excellent chapter on the choice of an X-ray outfit. Prof. Caldwell as a scientist has given us a succinct statement of facts about these wonderful rays and a lucid description of the apparatus for their generation and the details of the methods of usage to secure the most satisfactory results. It is a broad-minded yet conservative statement of the present status of what is known about the rays by the scientific world, which is enriched by what the author believes concerning many of the unsettled data. Dr. Pusey has handled his part of the work in the thorough manner and progressive spirit characteristic of the man. Being throughly posted in electric physics, he early appreciated the possible value of this new therapeutic measure. To those who have heard his modest and conservative, yet clear and positive, reports upon the progress of his X-ray work, this work will serve as a more complete and satisfactory record of not only what he himself has done, but also of what others have done in the same field. All that is essential and of practical value to the physician can, therefore, be said to be here presented in a compact and predigested form, ready for assimilation. His first chapters are devoted to a presentation of such general facts as experience has warranted. The effects, both gross and histologic, as well as immediate and remote, are fully discussed, as are also the causes which operate in producing such changes. The historical data and the logical deductions are so deftly worded that these chapters would be enjoyed and appreciated even by lay men. The technic of various operators is presented and discussed, as are also the effects of the various elements of the generating mechanism. The practical utility of and indication for the use of the X-rays is presented under nine headings: Affections of the appendages of the skin; inflammatory diseases of the skin; tuberculosis; cutaneous carcinoma, in which some most surprising results are noted and illustrated; carcinoma of breast; deep-seated carcinoma; sarcoma; the prophylactic use after operations for malignant diseases, and pseudo-leukemia, and various other affections. To the thorough presentation of these subjects is added a chapter of special interest to all X-ray operators-on general conclusions-in which the author's opinions on the various phases of X-ray treatments are clearly set forth. The value of the work is enhanced by a very complete index. All in all, this is the most complete and satisfactory work upon this subject with which we are acquainted. The publisher's work is of the characteristic standard. A. I. B. "A Text-Book of Obstetrics." By J. Clarence Webster, M. D. (Edin.), F. R. C. P. E., F. R. S. E., Professor of Obstetrics and Gynecology, Rush Medical College, Obstetrician and Gynecologist to the Presbyterian Hospital, Chicago, etc. Octavo of 767 pages, with 383 illustrations, 23 in colors. Philadelphia, New York, London: W. B. Saunders & Co.; Chicago: W. T. Keener & Co.; 1903. Cloth, $5 net; sheep or half morocco, $6 net. low forceps, and uses the Milne-Murray axistraction instrument in all cases. The volume would not be unduly lengthened, and would be gratifying to a student who met such a case, if special attention had been given to diagnosis and treatment of deep transverse positions of the head. Puerperal infection is well taken care of, and Webster's treatment consists in the application of glycerinated formalin gauze to the endometriun, to be removed in twelve hours if necessary. No statistics are given. The total abandonment of the intrauterine douche and indiscriminate curettage as here advocated will be a distinct advance in obstetrics. To many the chapter on eclampsia would be more satisfactory if the author had given his own experience and opinions on veratrum viride, and on the desirability of immediately terminating the pregnancy during the attack. Another part that stands out among the many exceliencies of the book is the subject of ectopic pregnancy, and it is noted that Webster is reluctantly yielding his views on the location of the egg in Müllerian tissue only before the evidence of the Van Tussenbrock and Thomp The fourth edition of Hirst's textbook contains about fifty pages more than the first, and shows evidence in many chapters of a thorough revision. As the author says in his preface, many of the old illustrations have been replaced by new ones, and on almost every page some alteration has been made. Especial attention has been paid in the revision to diseases of the genital organs The general revival of interest in scientific obstetrics. has been marked in the last two years by the appearance of six new authors between covers. To these are now added almost simultaneously the works of Edgar and associated with or following child-birth. Since the ap Webster. In view of the patient investigations by the author on the human placenta, it is not surprising that the chapter on placentation and fetal physiology should be unusually good. This part of his work is easily the most satisfactory and authoritative study that has yet appeared, and it shows the author at his best. Throughout the chapter on mechanism, and, indeed, frequently in the book, the original work done on the frozen sections of the well-known second stage case by Barbour and Webster is referred to, and the important bearing of this case on our obstetrical knowledge is well emphasized. Another subject which is constantly attracting more attention in the obstetrical world is the effect reciprocally produced between disease and pregnancy and labor. These relations are becoming more generally understood every year and are concisely brought up to date in Webster's book. pearance of the first edition in 1898 the work has been favorite on account of its practical character, its wellchosen and well executed illustrations, and the clear and pleasant style in which it is written. The present work shows that the author has taken pains to remove many of the faults which he and his critics found in the previous editions, and has thus brought the work up to date, and made it still more valuable. The most serious criticism of former editions referred to the directions for securing asepsis and antisepsis. Most of these "slips" have been corrected. One remains on page 777, where, in describing the preparation for forceps operation, he says that the instruments should be immersed for ten to fifteen minutes in a pitcherful of boiling water. On the other hand the directions given to close up a stationary washstand in the lying-in chamber and to close with strips the door of an adjoining bathroom for fear of contaminating the atmosphere are unnecessary and absurd in a house where there is good It is interesting to note that the author discards the plumbing. So also the use of boiled and filtered water |