September.

ARMY AND NAVY MEDICAL ASSOCIATION. Springfield, Ill., September 27. E. P. BARTLETT. Secretary, Springfield, Ill.

AMERICAN ELECTRO-THERAPEUTIC ASSOCI ATION. Buffalo, N. Y., September 13-15. JOHN GERIN, Secretary, Auburn, N. Y. MISSOURI VALLEY MEDICAL SOCIETY. Council Bluffs, Iowa, September 15. DONALD MACRAE, JR., Secretary, Council Bluffs, Iowa. AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNECOLOGISTS. Pittsburg, Pa.. September 20-22. W. W. POTTER, Secretary. Buf falo, N. Y.

MEDICAL SOCIETY OF VIRGINIA. Annual meeting at Virginia Beach, August 30. LANDON B. EDWARDS, M.D., Richmond, Va., Secretary.

September.

IDAHO STATE MEDICAL SOCIETY. Moscow. Idaho. September . EDW. E. MAXEY, Secre tary. Caldwell.

(Continued on page xvi.)

Vol. XXXIX. No. 13.

Original Articles.

HEALTH DEPARTMENT

DISINFECTION.

By William T. Watson, M.D.,

Baltimore, Md.

READ BEFORE THE CLINICAL SOCIETY OF MARYLAND AT THE MEETING HELD APRIL 1, 1898.

WHAT I have to say tonight is a criticism upon our Health Department. I do not, however, wish to be understood as in the position of judging the department by its faults alone, so take this occasion to say that I believe it is now more efficient than ever before in its history, and that its new chemical and bacteriological laboratories are doing most ex-, cellent work in protecting the health of the community. I am confident that the bacteriological department, by aiding physicians to an early diagnosis of diphtheria, thereby securing prompt treatment and prompt isolation of the patients, has been the means of saving the lives of many children during the past two years.

I also wish to say that only by means of the culture media placed at the disposal of physicians by the Health Department have I been able to make the tests to which I shall allude.

The criticism that I have to make of that department is that its inspectors sometimes do not inspect, and its disinfectors never disinfect.

As an illustration of my first criticism I will cite a recent instance in my practice. On February 15 I was called to see a girl, aged about ten, who had diphtheria. On March 2 the child had been perfectly well for a week, but still had diphtheria bacilli in her throat.

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I told the parents to keep the child isolated and send for a Health Department inspector, who would let them know when the child was free from germs and could mingle with others, and would give her a certificate to go to school.

In a few days an inspector called, looked in her throat, pronounced her all right and said she might leave the room. He said he would have the room disinfected that day. This was on Saturday. The parents asked to have the disinfection deferred until Monday. I was then called upon to explain why the inspector could pronounce the child free from germs by simply looking in the throat, whereas I could only tell by means of a culture. I, of course, told them that the inspector had not done his duty. I made a culture myself the next day (Sunday), and found the bacilli abundant. When the disinfector arrived on Monday he was not allowed to proceed, and the child. was kept isolated till the germs disappeared.

In this house was a little boy of four or five years, whose parents were very anxious to protect him from the disease, and yet this guardian of the public health gave permission for this infected girl to associate with him.

Now to turn to the other subject, that of disinfection.

While working with Dr. Reik upon the disinfection of instruments with formaldehyde gas, I became very much impressed with its germicidal properties.

We worked with an airtight chamber of a cubic foot capacity. We infected knives with great quantities of sporebearing authrax bacilli and killed them all in ten minutes. We put such large quantities of the yellow staphylococcus

upon the instruments that they looked as if they had been dipped in mustard, and yet they were all killed in ten minutes.

Being in possession of a formalin lamp, and my patrons complaining that the Health Department disinfectors were slow in coming, I undertook to disinfect

some rooms.

I followed the directions given by Schering and Glatz, and used the gas generated from one paraform pastille to sixty cubic feet of air. I exposed in these rooms swabs infected with diphtheria bacilli, some moist, some dry, but always could get a growth from the swab.

I then doubled and trebled the quantity of gas per cubic foot recommended by Schering and Glatz, but always with the same results-the bacilli still lived.

I then came to the conclusion that I had better let the Health Department do the work with their larger equipment.

I continued my tests in the rooms disinfected by the department. I placed upon the mantelpiece a platinum wire which had been infected with bacilli from a culture, care being taken not to get any of the culture media upon it.

I have made six such tests, and in every case the diphtheria bacilli grew abundantly.

In one instance the disinfector, aware of my test, used seven and a-half times the usual amount of formaldehyde, or one gramme of paraform to four cubic feet. of air, but the result was the same-an abundant growth of bacilli.

The last test which I made was in a room of only 950 cubic feet capicity-but little larger than a good-sized closetbut even here the germs survived.

Thinking that it might be objected that the test did not conform exactly to the conditions usually found in an infected bed room, I determined to make the conditions absolutely natural, so I obtained a piece of pseudo-membrane from the throat of a child having laryngeal diphtheria. This piece, about the size of a nickel, I transfixed with a platinum. needle and allowed to dry for three days, when it was exposed on the mantelpiece of a room about to be disinfected. The disinfector did not arrive when expected,

so the householder undertook to disinfect the room by burning a pound of sulphur. The capacity of the room was 1200 cubic feet. Two days later the disinfector arrived and went through his usual routine. The next day I took my piece of membrane, now dried for six days and shrunk to one-twentieth of its original size, and made a culture from it. In seven hours' time the culture media was covered with a growth of diphtheria bacilli and a few cocci. The sulphur used by the householder and the formaldehyde used by the city disinfector, if they had any influence upon the germs at all, it was that of a tonic, for they grew most profusely.

Why do the inspectors not inspect? It is doubtless due to the fact that the inspectors are practicing physicians, who have the city's work and their own to attend to at the same time, and, quite naturally, let the city's work come second.

If fewer inspectors were employed, with larger salaries and a guarantee of retention in office during good behavior, and were required to devote their whole time to the city's work, the work would be better and more economically done.

Why do the disinfectors not disinfect? I believe the reason is that as yet the department has not determined the amount of formaldehyde gas necessary for each cubic foot of space. When this is determined its disinfectors will have to be instructed how to make the room to be disinfected airtight.

The germicide used is doubtless the best, but the method of using it is sadly at fault. Means must be devised for converting leaky rooms into perfectly airtight spaces, and I believe by the liberal use of rubber adhesive plaster for cracks, keyholes, registers, etc., and felt strips for windows and doors, this could easily be done.

It would be better for a disinfector to spend a day or a week in each room, and then disinfect it, than to go through the form of disinfecting maybe a dozen rooms in the same time.

I am sure that our Health Department will work out this problem. Considering the importance of the subject, it seems to me that it should do so without delay.

AN EXHIBITION OF SKIN CASES.

By T. C. Gilchrist, M.R.C.S., L.S.A.,

Clinical Professor of Dermatology, Johns Hopkins University; Dermatologist to the Johns Hopkins Hospital; Clinical Professor of Dermatology, University of Maryland.

READ BEFORE THE CLINICAL SOCIETY OF MARYLAND AT THE MEETING HELD APRIL 1, 1898.

I HAVE the opportunity of presenting two very rare cases of cutaneous diseases. Case 1. Herpes Iris, a variety of Erythema Multiforme.-This patient, who is now nine years of age, came to the Hopkins Dispensary in December last presenting the characteristic features of herpes iris. The character of this affection is that of a severe type of multiform erythema. The name herpes iris was given to it in 1807 by Bateman on account of its multiform colors. The distribution of the lesions is on the hands, feet, forearms and legs. The mild cases are usually macular or maculo-popular, about the size of a split pea, and even then present the characteristic colors.

The distribution in this case at the commencement was on the backs of the hands and forearms, the feet and legs. Three days after her first appearance the lesions were very typical, especially on the back of the right hand, where there appeared a large bulla, which was completely encircled by a ring of small vesicles. This arrangement only occurs in one disease, and so our first diagnosis was then confirmed. Other vesicular and bullous lesions appeared later on the arms and legs. Two or three days ago, three months after the eruption first appeared, a relapse occurred, and the lesions were again seen particularly well marked on the left arm. The patient now presents these typical lesions scattered over both forearms, but they are not quite as well marked as when she came first under treatment.

This word herpes is now used in the sense of a group of vesicles, or to express the creeping propensities of a vesicular eruption. We have seen about twelve or fifteen cases in the series of over 13,000 dermatological cases observed at the Johns Hopkins Hospital, but this exam

ple is the most typical one of all. The mother did not care to send her to the hospital, and so the patient, on account of her wretched surroundings, has been undergoing a number of relapses while under treatment, which was not therefore very satisfactory. The patient has since been admitted into the hospital, and the skin is now quite healthy.

The etiology of the disease is at present under discussion, some considering it an angio-neurosis, others believing that it is due to some micro-organism. Dr. Pardee, who is at present investigating this case, has allowed me to refer to some of his findings. His observations show that the vesicle was formed entirely beneath the epidermis. At the very commencement of the lesion the upper third of the papilla was displaced by the presence of fibrin, coagulated serum and fragmented nuclei. At a later stage the whole papillary space became filled with a mass of fragmented nuclei, fibrin, coagulated serum and a few lymphoid cells. This apparently points to some poison or micro-organism which makes its appearance directly beneath the epidermis, and which kills the polynuclear leucocytes as soon as they arrive on the scene. A number of cultures have been made from numerous vesicles, but all were found sterile. Examinations of the contents of the vesicles did not reveal the presence of organisms. So it occurs to one that probably it may be a toxine or some organism that cannot be stained by the usual and ordinary methods, which is set free in this region, which may be the cause of the lesion. I think these histological pictures do away entirely with the angio-neurotic theory.

In the treatment attention to the diet is the most important factor. The severe constipation that accompanies it leads one to expect that the toxine may come from the intestines. The prognosis is good.

Case 2. Prurigo. This patient appeared at the Johns Hopkins Dispensary three days ago, and has a disease which is very rare in this country. At the Hopkins we have only seen two out of our 13,000 cases of cutaneous diseases. She is now twenty-nine years old, and has had

the disease ever since her third year. There have always been lesions on the external surfaces of the legs and arms, accompanied by intense itching. The character of the lesions on the face and extremities is that of small excoriated papules about the size of a pin's head. There are numerous pigmented scars and pigmentations, especially on the extremities. Hebra was the first to describe the disease, and it is usually designated as Hebra's disease. It commences like urticaria in early childhood, and the typical papules are at first more perceptible to the touch than to the eye. It is the most itching of all the cutaneous diseases, and is said to be found just as frequently among the rich as among the poor. Dr. Robert B. Morison, of this city, investigated this disease while in Prague.

This patient shows well the discrete violently scratched papules scattered over her arms and legs, chiefly on the exterior surfaces, as well as on the face. One can see on the right cheek and right arm two papules which are hardly visible, and yet are distinctly perceptible to the touch. She has, at my request, refrained from scratching them, so that you could examine these primary lesions. The other excoriated and haemorrhagic papules are well marked. The patient says her health has always been good, and she appears now to be in good general condition. This case might be classed as one of a medium variety, and does not exemplify the severe type to which Hebra first drew special attention. There is no family history here which has any special etiological relation to the disease.

The cause of prurigo is yet unknown. The prognosis in this case is fairly good. The treatment would consist of strict attention to diet, daily baths and application of some mildly stimulating ointment.

NASAL DISEASES AND INSANITY.-The relationship of nasal diseases to insanity is elaborated by Dr. C. Ziem in the American Journal of the Medical Sciences, and consists largely of the subject as manifested in his own person, with a summary of observations of others, and general remarks, historical, physiological and pathological.

HERNIA OF THE OVARY, WITH A REPORT OF TWO CASES CURED BY LAPAROTOMY.

By B. Bernard Browne, M.D., Professor of Gynecology in the Woman's Medical College of Baltimore, Gynecologist to the Good Samaritan Hospital, etc.

READ BEFORE THE AMERICAN GYNECOLOGICAL SOCIETY, AT BOSTON, MAY 24, 1898. (Continued.)

In January, 1881, Dr. Edward Swa

37

sey reported a case in the American Journal of Obstetrics of a woman, aged forty-six, who had the appearance of a female, but who had never menstruated, and had no uterus or ovaries, and only a short cul-de-sac for a vagina. She had two tumors in the inguinal region, which were of uncertain character. Dr. P. F. Mundé thought they were undescended. testicles. Dr. T. Gaillard Thomas thought they were herniated ovaries. Leopold reported a similar case in the Archiv für Gynecologie, Vol. XIII, 1875. In neither of these cases were the tumors removed.

In January, 1882, Dr. Robert Barnes read a paper before the Royal Medical and Chirurgical Society of London on hernia of the ovary and observations on the physiological relations of the ovary. He reported two cases of his own, one of which, an acquired left inguinal hernia in a single woman aged forty-one, who had menstruated regularly, was operated upon and the ovary removed.

He

In 1882 John Langton, in St. Bartholomew's Hospital Reports, Vol. XVIII, has an article on hernia of the ovary. states that during eight years there were 589 cases of inguinal hernia in female infants that came under his personal observation at the City of London Truss Society, which were for the first time discovered either at birth or within the first year. Of these, 317 inguinal hernia on right side, 208 inguinal hernia on left side and sixty-four inguinal hernia on both sides.

Of these there were forty-three cases in which the ovaries could be distinguished, sixteen on the right side, twenty