Hans Martens, aged 29, a German and a book-keeper by occupation, came to my office on September 12, 1895, at 10 A.M. Two hours before, while at work, he sud ginal wall and from the surrounding tissues by a circular incision and freed from its pelvic attachments for a distance of three inches. It was found that the freed end, or rather two inches of it, consisted of greatly denly became blind in his right eye. Vision returned hypertrophied circular muscular fibres, which must have and after one hour he was able to see only the lower served the purposes of a sphincter. The freed rectum half of objects. was then drawn through the opening made through the depression and attached to its margins by means of interrupted silkworm gut sutures. The perineal wound was united by buried catgut sutures, and the skin by silkworm gut. The rectum united along the greater part of its periphery to the anus. Unfortunately the perineal wound became infected and a large gluteal abscess formed. It was drained and the patient made a good recovery. I saw her October 20, 1895; she has perfect control of her feces; is married and performs her marital duties perfectly. In the report of the Operative Surgery in the Service of Dr. W. T. Bull at the New York Hospital, published in the New York Medical Journal, September 14, 1895, is narrated the following almost identical case, the difference being only of the ages of the patients and in the method pursued to establish the proper relationship be tween the sphincter ani and the rectum: L. M., female; was born with an imperforate anus. The rectum terminated just behind the vagina, the two being separated only by the mucous membrane. At six months the rectal opening was enlarged. Function was normal, except when diarrhea was present; then there was an inability to retain the stools. At fourteen years of age, when the patient applied for operation, the uterus and vagina were normal, the rectal opening was as described, there was a well marked sphincter in its proper place, and in its center a dimpling of the skin represented the same. Dr. Bull dissected the rectum free from all its sur. roundings for an inch and a half, made an incision directly backward, splitting the perineum to the center of the sphincter, transplanted the rectum to this its normal position, stitched it to the skin, and closed the wound anteriorly with seven silver-wire stitches, as one closes a lacerated perineal wound. Recovery in appearance and in function was prompt and perfect. Upon interrogating him I found that he had worn lenses (-3. D) for fifteen years. Five years ago he had a severe attack of rheumatism involving many articulations and his chest. At the time of my examina. tion vision in the right eye was 15/100 and in the right eye 15/0. The ophthalmoscope showed nothing unusual in the left eye while the right fnndus presented an interesting picture. The lower external quadrant of the retina was bloodless, the line of demarcation between the normal and diseased retina being well marked. Close examination revealed the presence of a plug in the inferior temporal branch of the arteria centralis. Beyond the obstruction, for a distance equal to the diameter of one disc, was a piece of artery which was narrow and void of blood. Toward the peripheral portion of the vessel blood was present. The field of vision is shown in the accompanying diagram. The patient promised to return for treatment but did not do so. Twenty four days later I saw Mr. Martens. A Case of Embolism of a Branch of the Vision in the affected eye was 15/10 The ophthalmo Central Retinal Artery. BY JAMES MOORES BALL, M.D, Ophthalmic Surgeon to the Woman's Hospital and the St. Louis City Read before the St. Louis Medical Society, October 12, 1895. Instances of embolism of a branch of the arteria cen tralis retinæ are so rare that I feel justified in reporting the following case: scope showed that the retina in the affected area had regained its coior. The field of vision is the same as at the time of my first examination. The affected vessel is smaller in diameter than normal. Holden, of New York, after a study of five cases of embolism of the branches of the central retinal artery, concludes that this field of vision may be irregular on account of variation in arterial blood supply, and that in these cases an anastomotic circulation may be estab. lished. In view of the fact that the retinal arteries, like those of the brain, have been classed as terminal vessels, I think the latter statement is of importance. MEDICAL REVIEW. EDITORIALS L. T. RIESMEYER, M.D., EDITOR. DEPARTMENT EDITORS: DR. F. J. LUTZ, General Surgery. PUBLISHED UNDER THE AUSPICES OF THE of professional criticism. It is but natural that, if a YEARLY SUBSCRIPTION, $3.50. SINGLE COPIES, 10 Cents. minds of the laity by reading about medical matters is furnished by the innumerable quack advertisements with which the daily press abounds, and which allure some otherwise sensible people into making the rounds from one doctor's office to another. How serious a matter this question is, in reality, has been most perfectly illustrated by the innumerable victims of tuberculin. It is above all the daily press which is responsible for the many premature deaths in consequence of exaggerated statements regarding the healing power of this remedy which, in the hands of skillful and discriminating practitioners who have carefully studied and made themselves thoroughly familiar with its indications and contraindications, appears to Members of the profession who send us information of matters of general interest to our readers will be considered as doing them and us a favor, and we shall take pleasure in inserting the substance of such communications. Communications, Medical Books for review, and all letters containing business communications or referring to the pub-answer all the purposes which have first been pointed lication, subscription, or advertising department of the REVIEW, must be addressed to O. H. DREYER, Publisher 112 N. 4th Street, St. Louis. out by Koch. The overwhelmingly sad experience with a remedy which eventually has been destined to lead the way to the most important medical discovery of modern times, should never be lost sight of as a warn Entered at the St. Louis Postoffice as Second-Class Matter. ing example as to the harmful consequences of prema What the Public Should Know of Medical Proceedings. Since the exclusion of the reporters from the meetings of the St. Louis Medical Society we are ever and anon asked by laymen, who used to look up the proceedings of the St. Louis Medical Society in the daily papers, why the public should not be informed of medical dis cussions. We have good reason to believe that the same question has been asked most of the members of the Society. While there is no reason whatever why the public should not be enlightened with the established facts in the art and science of medicine and with gener ally accepted truths and proven theories, it is, as a rule, exceedingly detrimental to the welfare of patients to be prematurely and indiscriminately made acquainted with a new method of treatment or a new invention, before such new discoveries have stood the crucial test turely informing the public of the results of medical investigations. What has occurred on a large scale in the injudicious and undiscriminating glorification of tuberculin, must necessarily repeat itself, with respectively greater or less harmful consequences, whenever this or that method of treatment is advocated by the different speakers at a medical meeting. Even if the daily paper would, in each individual case, furnish absolutely correct reports to the public, the confidence of the latter in the profes sion would not be augmented by the often diametrically opposite views of the speakers. To physicians it is often plain that what appear to be opposite views do not, upon close scrutiny and investigation, differ very materially after all, whereas, to a reporter, or the laity in general, they might be looked upon as absolutely incompatible. As a rule, it may be accepted as an axiom that wherever a decided controversy obtains between wellinformed and well-balanced minds, it is about a question which has not been definitely settled. It is the unset- Virchow recognized, as he expressed himself, the tled medical question whose discussion should not be great confusion which existed among students as well public, but should remain within circles that are able to as practitioners regarding the relative bearing of these discriminate as to the nature of difference in opinion. two terms and which had come about by the difference In order to illustrate the inordinate importance that in some of the clinical and the pathologic-anatomic manimight be placed upon such antagonistic views we might festations of affections designated as diphtheria and mention the discussion of diphtheria-antitoxin at the croup. The importance Virchow places in his lectures upmeeting of the St. Louis Medical Society of November on elucidating the subject of diphtheria and croup, evi8, when the conviction of the specific healing action of denced by the frequency with which he returned to the this new remedy was, practically, unanimous, but when subject, has indelibly impressed itself upon our mind the disagreement between several members as to the and we have often had occasion to notice the difference identity, respectively unidentity, of croup and diphtheria of opinion manifested in medical discussions of these (see the following editorial) would have caused a great affections showing the wisdom of Virchow's frequent deal of confusion in the non medical intellect and would recurrence to the subject. He laid the principal blame infallibly have the effect of perplexing and mystifying for creating this confnsion at Rokitanski's door, who the average reporter to such a degree that his opinion had called inflammatory affections of the mucosa uteri, regarding the possibility of differentially diagnosing accompanied by the formation of membranous (croupdiphtheria and croup would be of a very "nihilistic," ous) exudations, as croup of the uterus or, if they oc or, at least, sceptical nature, and his idea as to the ex- curred in the bowel, as croup of the bowel, etc. act knowledge in medicine might be ventilated accordingly in his report of the proceedings. This is so well known as having occurred on many former occasions in the highest conceivable "superlative" degree, not to mention the many grotesque voluntary or involuntary fabrications and inventions on the part of some re porters, that it would be carrying coal to Newcastle to further expatiate on this question. By this nomenclature the clinical aspect of such affections was entirely ignored, it having reference only to the pathologic anatomic, local condition. The word croup implies difficulty in breathing. The selection of the word croup for local pathologic-anatomic conditions has been an exceedingly unfortunate one and would have been avoided, if it could have been foreseen, at the time of its introduction in medical nomenclature, that a number of other factors co-operated in making the inWe have on many occasions expressed our views with terpretation of the relation of croup to diphtheria a regard to the reporter question and are greatly pleased complicated and apparently confusing one. Das to record the fact that for many meetings they have ist der Fluch der ösen That, dass sie fortzeugend been successfully excluded by the watchful eye of Böses muss get ären. (That is the curse of the President Mooney. ** * We are also pleased to note that some highly respected stay aways are reappearing at the meetings and we have good reason to believe that as soon as the successful exclusion of the reporters becomes generally known, many others will follow suit and help to increase the usefulness of the Society. wrong act that, continuing in procreation, it is forced to generate evil). The second confusing circumstance is due to the fact that the "pathologic anatomic" diphtheritic process may be due to great variety of etiological factors. Bichloride of mercury, phosphorus, arsenic, turpentine and other poisons, taken internally, as well as strong acids, alkalies and corrosives in gen. eral, locally applied, may produce exactly the same anatomical lesions as those caused by diphtheria bacilli The Relation of Membranous Croup to and their ptomaines. These anatomical lesions are Diphtheria. In the discussion of the St. Louis Medical Society of croup and diphtheria, alluded to in the foregoing editorial, much diversity of opinion seemed to prevail. The chaos which appears to exist with reference to the rela tion of these terms to each other is by no means cleared up, when we resort to the various text-books for infor mation. The only satisfactory explanation which must make the relation of croup to diphtheria distinct and plain we have often heard Virchow explain to his labo ratory classes. Even at that time, over eleven years ago, it had been shown that the clinical picture of membran ous croup is, in the majority of cases, due to an infection with the Klebs Loeffler bacillus and it was claimed that, therefore, it was no longer justifiable to make a clinical distinction besween these two diseases. known under the name of diphtheritic necrosis and its consequence is the "go-called" diphtheritic membrane. Every surgeon has, in pre aseptic times, seen diphtheritic wound deposits (it is customary to speak of diphtheritic necrosis as a "deposit" and a "membrane"; both designations are misleading and would better be discarded from medical nomenclature) which were caused by the application of antiseptics or by various kinds of infections. Identical anatomical lesions may thus be caused by a multiplicity of etiological factors. The result of a croupous inflammation, the croupous membrane (in a pathologic anatomic sense), is also formed by a variety of causes, among others, by an infection with the Klebs-Loeffler bacillus and its chemical product, the diphtheria toxin. The anatomic features of and distinctions between the diphtheritic in flammatory process and the croupous inflammation, although we accept the diphtheria bacillus as the priirrespective of the etiology of either, we will leave un- mary exciting cause of what used to be called "membraconsidered as it is generally known or may readily be nous croup" this may sometimes be due to other factors, looked up in any work on pathological anatomy. which are capable of producing a local inflammation of mucous membranes characterized by the formation of a (in an anatomical sense) croupous membrane and caus croup, "so called." The question of the etiological identity or unidentity of croup and diphtheria is not a settled one in all cases, hence the difference of opinion in medical discussione. By due consideration of these facts it becomes plain that, in speaking of croup and diphtheria, great care should be exercised, when the customary nomenclature ing clinical symptoms characteristic of membranous is made use of, to plainly discriminate between the interpretation of these designations in their etiological, clinical and pathologic anatomic bearings. It is the mixing up of these etiologic, clinical and anatomic features of croup and diphtheria and the confusing imper fect nomenclature which is at the bottom of all the apparent disagreements in the discussions of croup and diphtheria. From a purely clinical standpoint we would, with the present light on the subject of croup and diphtheria, formulate our views to the effect that, whereas in the great majority of those cases which used to be classed as ordinary "membranous croup" in contradistinction to "diphtheritic croup," the diphtheria-bacillus has been demonstrated in the local lesions, these should now be classed as cases of diphtheria whenever that bacillus has been shown to be present. In a very small percentage of cases, however, the diphtheria-bacillus can not be demonstrated and these "may," therefore, be due to other etiological factors. Taking into consideration that in some severe cases of diphtheria the diphtheria bacillus may escape detection on account of a mixed infection, in which it is located deeply in the tissues of the in flammatory foci, it would appear that the cases of what used to be called "membranous croup" in which the etiology is doubtful, are exceedingly few. The Necessity and Prospects of a New For many years doctors have been wondering why a great and prosperous city like St. Louis has public institutions that are away in the rear with regard to modern hospital equipments and it is surprising, indeed, that the many medical societies of this city who are do ing good work have not taken up this question for dis cussion long ago. We are, therefore, agreeably sur prised to glean from the daily papers the welcome news that at a recent meeting of the City Health Board, the President of the City Council, Hon. Chas. Nagel, expressed himself in strong language on the total unfitness of the present City Hospital for use as an institution of such character, and said it was a wonder to him that steps were not long ago taken toward procuring a new building. The present structure he condemns as one more fitted to a fourth class village than to a large, prosperous city like St. Louis. He is in favor of erect. There is, however, one clinical circumstance which ap- ing a new City Hospital, and believes a good location pears to us as speaking in favor of a distinct form of mem- for one would be in the southwestern part of town, in branous croup, independent of an infection with the the vicinity of the Insane Asylum, and other public indiphtheria bacillus, namely, that it appears to have been stitutions. The building of the new street railroad the experience of surgeons in pre-bacteriological times, which is proposed for that section would render the that tracheotomies in ordinary "membranous croup" building easy of access, and he thinks the city would furnished a favorable prognosis while in diphtheritic be largely benefited by grouping her public institutions. croup the prognosis of tracheotomy was unfavorable. If all cases of what was formerly known as membranous croup are due to an infection with diphtheria bacilli, this phenomenon could, of course, be explained by a milder infection. The opinion of the majority of au thors is drifting in the direction of accepting the diphtheria bacillus as the etiological factor of nearly all cases of "membranous croup" as well as "diphtheritic croup." Although we would hesitate in accepting this view as absolutely conclusive and final, it appears that the cases of "membranous croup" not primarily due to an infection with the Klebs-Loeffler bacillus are exceed ingly few and that the difference in the clinical picture of diphtheria and membranous croup, so-called, must be looked for in factors which are unknown at the pres ent time, possibly in a variation of biologic characteristics of the diphtheria bacillus or of predisposing ele ments. As a logical deduction from these facts it is plain that, I To obtain means to build a new hospital Mr. Nagel sug. gests that a small sum of money be annually appropri ated by the Municipal Assembly, and a sinking fund established in that way. By doing this taxes would not be materially increased, and in the course of a few years St. Louis could boast of another handsome public building, large and modern. All other officials of the Health Department were heartily in accord with Mr. Nagel's ideas. Chief Sanitary Officer Francis thinks that the city could prevail upon the United States Government to deed over the grounds and building of the Marine Hospital, at the foot of Marine avenue, providing the city would agree to attend the few patients there. If this could be arranged, Mr. Francis says, there are a number of buildings already constructed on the grounds which could be utilized in caring for the sick, and others could be erected from time to time at a slight expense. We wish to congratulate the Board of Health upon taking up this question and can assure the members of exceedingly instructive and well-written article, the disthe Board that they will have the support of all truly eases of the pericardium take about sixty, and the disprogressive physicians in the city. esases of the heart itself, with the endocardium, the Mr. Nagel has on many occasions shown his good balance. One of the most interesting and instructive judgment in municipal affairs and we are glad that he is taking the initiative in the attempt at a much needed reform in some of our public charitable institutions St. Louis is rapidly becoming a metropolis and can not afford to bear the stigma of being behind any other city in point of modern equipment and improvements of its public hospitals. sections is that on neuroses of the heart, to which the author has devoted some seventy pages. The section on valvular diseases of the heart have also received the most careful attention of the author. Immediately following this article comes one on Diseases of the Blood-Vessels by Dr. A. Ernest Sansom, of London, who is well known as an autherity on these af. We hope and confidently expect that the importance fections. This paper, of about one hundred pages, is of this question will be realized by all local medical followed by one on Diseases of the Lymphatic Vessels societies and that united efforts will be made to en- by Dr. Bertrand Dawson, also of London. courage the proposition of Mr. Nagel. With men who The closing article, and one of special contemporanepossess the energy of Health Commissioner Starkloff ous interous, is by Dr. George Murray, of Newcastle. and his associates of the Health Board and the support on Tyne, on Diseases of the Thyroid Gland, including of the whole medical profession and best elements Myxedema, Cretinism, Exophthalmic Goitre, and Goiamong the citizens in general we can not fail in having tre, as well as Inflammation and Neoplasms. our most ardent hopes realized in a question which directly or indirectly involves the happiness and satisfaction of every well meaning citizen. In conclusion, we wish to congratulate in particular the highly esteemed President of the City Council, Hon. Chas. Nagel, for taking the initiative in this all-important and urgent matter by broaching the subject at the most appropriate, because official, place, the St. Louis Board of Health. BOOK REVIEWS Books reviewed in this column may be obtained, post-paid, by addressing the publisher of this journal, and remitting the quoted price. Twentieth Century Practice. An Interna- It is Dr. Murray's merit of introducing the thyroid. gland treatment which has been so successful in myxe. ted to write upon this subject. The author enters fully dema and cretinism, and he is, therefore, especially fit. roid treatment, developing the successive steps by which into the history and method of application of the thy this treatment has become a valuable addition to mod. ern therapeutics. It deserves special mention that this is the first time that this important subject has been presented in systematic form, outside of the journal articles by the originator of the method. Some of the illustrations in this article, reproduced from photographs, are very useful and instructive by showing the results of treatment in a practical and striking manner. The other illustrations also of the volume add to the usefulness of the work whose general excellence is, in every respect, the equal of the preceding volumes of this great series of works. Iatrol in Chronic Endometritis.-C. S. Parkhill, M.D., reports very favorable results obtained from the use of Iatrol in chronic endometritis of the os with granulations, attended with bleeding on touch, end albuminous discharge. His treatment is as follows: First, wiped out with absorbent cotton until hemor The "Twentieth Century Practice" has become by rhage ceased, and albuminous discharge removed; I this time a highly appreciated and popular work among then applied Iatrol with powder blower, directed the all members of the medical profession. The fourth use of a hot douche, night and morning, and a tampon volume contains some of the most important treatises of equal parts, boroglyceride (C. P. Co.), and glycerine in the practice of medicine. The first article treats of the important subject of Diseases of the Heart and Pericardium. The author, Dr. James T. Whittaker, of Cincinnati, is well-known to the profession as being eminently fitted for the task of writing upon these sub jects. each morning. Tampon was removed each morning and nothing used during the day. This treatment was followed twice a week and resulted in a surprisingly quick cure. I have also used Iatrol in indolent ulcers on leg with much success. I have found Iatrol superior in its results to aristol and consider it the best antiseptic Of the four hundred and fifty pages, devoted to this dressing I have ever used. |