to make a positive diagnosis. The patient here was much reduced and quite weak but made a recovery. Gersuny

Cholelithiasis becomes surgical according to Govery MEDICAL REVIEW.

-when there is danger of rupture of the gall bladder; when there is beginning sepsis; when there is intestinal obstruction; when the attacks of colic are frequent; when jaundice is persistent; and when pain is constant and disability results.

Erythema Nodosum of Syphilitic Origin Beurmann and Claude (Annales de Dermatologie et de Syphiligraphie) have observed a nodular erythematous eruption among syphilitics. One who has had occasion

L. T. RIESMEYER, M.D., EDITOR.

DEPARTMENT EDITORS:

DR. F. J. LUTZ, General Surgery.
DR. W. B. DORSETT, Gynecology and Obstetrics.
DR. E. C. RUNGE, General Medicine.

PUBLISHED UNDER THE AUSPICES OF THE
MEDICAL REVIEW ASSOCIATION

BY O. H. DREYER.

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to see a large number of syphilitics will meet with cases YEARLY SUBSCRIPTION, $3.50. SINGLE COPIES, 10 Cents. of this kind from time to time, and will be very much puzzled to decide whether this eruption constitutes a feature of the syphilis or is an intercurrent malady. Mauriac described such conditions and believed that they were of the same nature as early gumma. Bensnier, Duyon, Balzer, Barthelemy, Jullien, Vidal and Leloier, have also observed this, but do not regard them as syphilis. According to Beurmann and Claude this erythematous condition shows itself during the first months of the disease, but is also observed much later, concurrently with tertiary manifestations, or even with out any other manifestations of the disease. It is found especially among the aged and debilitated, and in preg nant women It consists of red or reddish nodules, usually situated upon the anterior surface of the lower limbs, sometimes on the upper, also upon the trunk, and rarely upon the face. They are usually rounded, some. times as large as the palm of a hand, and are not pain ful and do not itch. As a rule they form an appreciable projection beyond the skin; at times can only be de Entered at the St. Louis Postoffice as Second-Class Matter. tected by grasping the skin between the fingers. They are frequently multiple, but sometimes only a few are present. They usually last fifteen days, and slowly dis appear by resorption. These ndules are most often dis tinct, but sometimes confluent, and thus form large in durated plaques, the induration extending into the sub cutaneous cellular tissue. In appearance they are very A Proposed Change in the Management of much like the gumma, and they rarely ulcerate. The authors agree with Mauriac that all of these various popular, knotty, erythematous and subcutaneous eruptions of a gummatous nature are found together; but this lesion is always identical and differs only in the degree. Thus the erythema here spoken of is not an erythema nodosum on a syphilitic, but an erythematous condition which is part of the specific process. The authors also take into consideration the pathological and anatomical changes. It is not necessary to con sider all of these lesions as being of syphilitic origin. The nodules in non specific conditions are painful, while those in the syphilitic are not

The treatment of this form of specific erythema nodosum is by the internal adminstration of iodides and of mercury. The ordinary erythema nodosum disappears in a few days, while the variety present in the syphilitic will remain for some time even if under treatment.-Medicine

EDITORIALS

the St. Louis City Hospital.

Every large hospital should have its visiting staff of physicians by which all the various specialties in medi cine are represented. This is the rule in every well regulated hospital. Public hospitals should not be excluded in this respect. The deficiency of the St. Louis public hospitals with regard to this matter is a weak point in the management of the eleemosynary institu tions of this city which, when commented on by well educated physicians, is frequently styled a “disgrace to the city." Why the present system so long in vogue here has not been changed long ago, we are unable to say; it certainly appears strange that this condition of things seems to be allowed to go on indefinitely.

We are pleased, therefore, to read in the St. Louis Republic of April 17, that an effort is to be made on the part of representative physicians to bring about a

reform in at least one of the St. Louis public hospitals. tions, regarding the treatment of cases should be conIn the article referred to the opinion of two prominent scientiously carried out. We have been informed of surgeons are quoted and the situation is explained as instances where a consultant of the City Hospital follows: would give advice to a resident physician, who never"There is a quiet movement on foot among the physi-theless acted upon his own ideas of treatment, although cians to bring about a change in the system of manag- he had little or no experience in the specialty to which ing the City Hospital. It is contended that under the existing arrangement there is too much work for the Superintendent, and that there are so many cases under his care that it is a physical impossibility for all of them to be given proper care and attention.

such a case belonged, while the consultant was a specialist of national as well as international reputation. Although such an incident may be a great exception it nevertheless furnishes one illustration of some of the objectionable possibilities under the present system of management.

If, however, a corps of consultants is in the future to be appointed to the City Hospital, who is to be the judge of their qualifications? Among the representa. tives of the numerous regular schools, the homeopathic and the eclectic school there may be many who aspire to the honor and duties of a consultant. Nor are there few, in all probability, among those who do not belong to any of the faculties who would consider themselves equally or even more eligible than many of the faculty members.

"The idea of a number of the leading physicians and surgeons who were seen by a reporter of The Republic is to relieve the Superintendent of the responsibility of the care of the patients and devote his time to the executive duties of his office entirely, leaving the cure of the patients to a corps of physicians, each of whom shall be responsible for certain cases intrusted to his care. It is not the intention or desire of the physicians who favor this plan of management to interfere in any way with the duties of the Superintendent, but merely to relieve him of the immense amount of work and a portion of the vast amount of responsibility resting up. However this matter may be finally settled we sinon him. They believe that a corps of resident assist cerely hope that the future visiting or consulting staff ants will be required, the same as under the present of the City Hospital be made up of men who have the plan, but that they will derive greater benefits from necessary time to devote to the duties of a visiting seeing every kind of cases handled by specialists in that particular branch of disease than they could possibly derive from witnessing treatment by one who is not particularly interested in the case.

"It is intended, too, that every superintendent of the hospital in recent years has made a hobby of the treat ment of certain cases. With all of the recent heads of the institution that hobby has been surgery, and it is claimed that as a result cases in other lines have not received the attention they should. The appointment of a visiting corps of physicians, it is held, will remedy this fault and raise the St. Louis Hospital to the stand ard of similar institutions in New York, Philadelphia, Brooklyn and other large cities."

The sentence in the article of which the above is an extract, suggesting a restriction of the Superintendent's duties to the executive part of his present work, we can indorse only in case that the present work of the Su perintendent be divided among a physician or surgeonin chief, or, better (regarding appropriateness of nomenclature), senior physician, and a lay superintendent with executive duties exclusively. That a physician should act simply as an executive officer of a hospital would be tantamount to degradation, and such a suggestion on ths part of brother physicians might be interpreted as an unqualified insult. When such matters are discussed in the secular press, it would therefore be ad visable to explain more explicitly and unequivocally the exact nature of the suggested change as regards its ef fect upon the highest medical officer of the City Hospital. We are quite in harmony with the view that there should be a staff of visiting, respectively consulting physicians and surgeons, and that the latter's sugges

physician and consultant and that these be not selected
from men who are already visiting physicians of other
hospitals, but that other equally worthy members of the
profession receive proper recognition. At present one
member of the profession may be a consulting physi-
cian or surgeon to a number of different hospitals and
institutions, while many others, equally worthy and
experienced, remain unrecognized.
We would suggest
that if there is to be a visiting staff of physicians and
surgeons to the City Hospital, that the latter class be
abundantly represented and that their colleagues who
already have more of such positions than they can
properly attend to personally and not "by proxy" be
not chosen as members of the contemplated visiting or
consulting staff. That, however, such a staff should be
created, no intelligent physician can doubt; the only
question can be, how and by whom its members are to
be chosen. We agree with the gentlemen who were
interviewed by the reporter of the Republic that the
selection of medical officers of public hospitals should
not depend upon politics, but upon the necessary prac
tical training and experience in the various branches of
medicine; but it may be a difficult matter, under exist.
ing conditions, to form an unbiased judgment with re-
gard to the standard of such requirements.

In a reply to the above suggestions of prominent physicians the Superintendent of the City Hospital, Dr. Sutter, makes the statement that practically the proposed plan is in vogue at present. "Specialists are constantly prac. ticing in the hospital, in consultation with the Superin. tendent and staff. There is not a day that specialists are not in attendance upon the respective cases in which they are interested. Any specialist of known standing

is welcome at all times to work in conjunction with the Superintendent and his staff, and if, as I understand the proposed plan, the idea is to enable specialists to prac tice in the Hospital, I can only say that I regard it as rather superfluous."

the medical organizations of the State, they certainly should do so without further delay.

We would like to have on our roll of membership the names of all who are worthy and are laboring to lift the profession and people upon a higher plane of medical education.

From this statement of the Superintendent it appears that he does not differentiate between a volunteer staff Doctor, the medical profession needs your co-operaof consultants or one who has definite and distinct tive services. Are you ready and willing to do your duties to perform for which its members can be person- full share of the work necessary to secure and maintain ally held responsible. Now the volunteer consultant a united profession. If so, our arms are open to receive may direct the treatment of a patient and it may be you. It would, indeed, be most happy could we have carried out not according to his directions, but accord- the presence of an undivided profession. ing to the views of whoever of the resident staff of physicians may wait upon the case. The consultant is powerless to effectually remonstrate and whether this serves the best interest of the patient we leave to the judgment of experienced physicians.

Southern Illinois Medical Association.

As will be seen from a correspondence appearing in another place of this issue the next semi-annual meet ing of the Southern Illinois Medical Association will be held at Mt. Vernon, Ill., May 13 and 14. The Associa tion needs no introduction to our readers; they are well acquainted, by this time, with the excellent work and management of the Southern Illinois Medical Association.

The Illinois State Medical Society will hold its an. nual session in East St. Louis the week following our meeting. Every eligible physician of the State should be a member of the State Medical Society; but every one should remember that no one can be eligible to memberseip in that Society until he is first identified with his local society.

Entreating you to give us your undivided support in this great work, and confidently hoping to have the honor of your presence at the sessions of this meeting, we remain, dear doctor, fraternally yours, JAMES I. HALE,

President.

J. OSBORNE DECOURCY,
Secretary.

TRANSLATIONS.

BY EDGAR THOMPSON, M.D.

CORRESPONDENCE

Southern Illinois Medical Association.

TO THE MEDICAL PROFESSION:

The twenty-third annual meeting of the Southern Illinois Medical Association will be held in the city of Mount Vernon, Thursday and Friday, May 13 and 14,

1897.

Especial efforts are being made by the officers and members of this Association to make the programme of unusual interest and to make this a "banner" meeting in every particular. We urge the members everywhere to come and take an active part in the sessions.

If each member will do his full duty, we can easily make this the greatest medical meeting ever held in the southern half of this State.

Aseptic Traumatic Fever.-Dr. Pillon (La Press Med.) gives the following definition of a traumatic, non septic fever. A hyperthermia, most often light and of short duration, consecutive to accidental traumatisms or operations on healthy, non diathetic individuals, and which is not determined by endogenous or exoge nous parasitic infection. An exception must be made to the fever which is caused by a mechanical lesion of the spinal cord. This hyperthermia is caused by a special disturbance of the thermic centers.

The fever has, as a rule, a very ephemeral durationtwo to three days, but it may be prolonged many days. The amount of fever rarely passes 39°C. Finally, the fever may begin immediately after the injury or, as is more frequently the case, it will not appear for several days.

The classifications of the fever are various. A clas. We extend a cordial invitation to the medical profes. sification based on the height of the temperature is sion generally to attend our meeting.

To the medical profession of the southern half of the State we extend a pressing invitation to attend; as well as to the officers and members of each of the other medical societies of the State.

purely arbitrary. An etiological classification, based on the mode of action of the mechanical agent, is more admissible; but there is not always a direct relation between the extent of tissue injured and the extent of the fever resulting therefrom. Sometimes a violent contu. If there are any practicing physicians within our bor- sion will provoke a very light fever; sometimes an injury ders who are eligible to membership in their local of minimum importance will engender a high and prosocieties, and who have not identified themselves with longed fever. A pathological classification, based on

the nature of the injured tissue, is probably the most togenic substances which are elaborated in the dead scientific. tissues; the temperature will, consequently, return to. ward the normal point. When the sphacelus fall away the fever will entirely disappear.

The author's clinical experience has developed the fever of from 1.5 to 2.5°. The same amount of fever following conclusions: follows traumatic hydarthroses.

11. The diagnosis of aseptic traumatic fever is based upon the following: (a) upon the recognition of the exact cause-this includes the point of application and 4. Contusions of the third degree, followed by par mode of action of the violence, etc.; but it must be tial sphaceli, produce frequently a peculiar hyperther- noted that there is not always a direct relation between mie; this peculiar thermic curve is due to the production the degree of fever and the extent of local lesion; (b) of the sphaceli; the fever persists until the formation upon the study of the temperature; (c) upon the absence of the line of separation between the living and the of general symptoms; (d) upon the asepsis which is dead tissues. When this occurs the obliteration of the demonstrated by bacteriological examinations of the vascular connection prevents the absorption of the pyre effusions at the site of injury, and of the blood in the

general circulation period; (e) upon the absence of intercurrent affection; (ƒ) upon the observations of local signs.

Here it must be noted that the surgeon should not forget the influence of menstruation and constipation as causes of post-operative fever, and he must not con. found true aseptic traumatic fever with the sympathetic fevers-in hysteria, chlorosis, etc

MEDICAL SOCIETIES

PROCEEDINGS OF THE ST. LOUIS
MEDICAL SOCIETY.

Stated Meeting of Saturday Evening, March 13, 1897;

12. The theories of the pathology of aseptic trau. matic fever are five in number: (a) the theory of atten- the President, W. J. LANGAN, M.D., in the chair. uated septicemia; (b) theory of epitraumatic fever; (c) theory of physiological local reaction; (d) theory of reflex fever; (e) theory of the absorption of pyretogenic substances.

The last two are only to be considered. The theory of reflex fever has some truth. The researches of Ansonman have demonstrated that in this aseptic fever a part of the elevation of temperature is due to nervous sensitiveness.

The last theory explains the fever by the absorption of thermogenous substances contained in the tissues al tered by trauma, or which are abnormally secreted by the tissues whose nutrition and functions are disturbed by the shock.

DR. LUTZ presented a specimen illustrating

Resection of the Bowel for the Cure of a Fecal Fistula Following a Stran gulated Inguinal Hernia.

The patient from whom this specimen was taken is a farmer twenty years old who, concerning this trouble, gives the following history:

When one year of age he had a right inguinal hernia which was reduced and did not trouble him again until December, 1896, when a tumor re-appeared on the same side followed by an attack of vomiting. His physician What, then, are the thermogenous substances? The did not succeed in reducing the tumor and his bowels author's experiments show that fever is liable to be pro did not move for ten days. About the 20th of Decem duced by the absorption of a simple traumatic bloodeffusion without any contusion of tissue being present. ber, some ten days after the initial attack, an incision was made in the lower portion of the right scrotal sac The degree of the fever depends on: (a) the composi which was followed by the discharge of a large quan tion of the extravasated blood-whether or no it con tity of pus. A few days later a second incision was tains pyretogenic substances; (b) the rapidity of the re absorption of the extravasation; (c) the degree and made over the tumor in the inguinal region from which mode of irritation of the peripheral nerve-fibres. But a large quantity of fecal matter escaped, and through the absorption of extravasated blood is not the sole this incision the patient has been passing his feces ever since. This was the history as taken on the 6th of cause of the fever. It is very probable that the peneMarch. tration into the systemic circulation of the substances set at liberty by the death of the cells has an hyperthermic action. Thus, generally, the more extensive the contusion of the cells just so much greater will be the

febrile reaction.

The experiments of Gangolphe and Courmont have demonstrated that tissues whose blood-supply has been cut off by a vascular obliteration, secretes pyretogenic

bodies without microbic intervention.

The alteration produced in the cellular elements by a traumatism-contusion-is, in a certain measure, of the same nature as aseptic gangrene consecutive to vascular obliteration. In both cases the aseptic traumatic fever is due to the absorption of pyretogenic substances se creted by the anatomical elements whose vitality is dis turbed.

The author presented in 1896 to the Biological Society many notes relative to two clinical observations, the one hemathrosis of the knee-joint, the other acute hy darthrosis, in which a very marked elevation of temperature coincided with the presence in the effused liquids of an enormous number of white blood corpus cles with very active ameboid movements. The author, therefore, thinks that these migrating cells can play a a role in the genesis of aseptic hyperthermie.

On examination, the right testicle is found to have sloughed out, and the opening in the scrotum communi. cates by a fistulous tract with a second opening about an inch below the inguinal ring; the fistulous tract follow. ing the course of the spermatic cord. Over the ingui nal ring is a tit like projection of mucous membrane projecting three-quarters of an inch above the surface of the skin. An instrument passed through this open. ing leads in an upward and backward direction toward the caput coli. The upper circumference of this projection is firmly adherent to the tissues. Its lower half can be elevated and underneath it is the opening of the bowel from which fecal matter escapes.

The operation consisted in laying open first of all the fistulous tract, beginning at the scrotal opening and ex. tending to the inguinal canal. The tract was thoroughly curetted. An incision was then made extending above the projecting intestine, as for the operation of hernis, laying open the peritoneal cavity to such an extent as enabled us to freely minipulate the portions of intestine involved. After liberating the intestines from their at tachment to the abdominal wall, it was found that the portion of intestine which projected above the skin was a portion of the ileum about four inches from the ileo