us much should quinine be administered.
By this time the temperature should be very



much modified in atypical malarial infec-
tions. The temperature in many cases of
typhoid in Eastern North Carolina will
rise quickly, run a high course for six or
eight days, then suddenly drop, even if no
quinine be given, one to three degrees, then
running an uneven course though gradually
diminishing until the normal is reached.
In many cases, unless carfully considered,
this sudden drop of the temperature on the
sixth or eighth day will prove misleading,
especially if quinine has been administered.
In all cases of simple typhoid infection the
temperature though often remittent is less
distinctly so than in malaria. In many cases
of typhoid fever seen in Eastern North
Carolina distinct paroxysms can often be
made out, thus resembling malarial fever.
There is more bronchitis in typhoid than
malaria fever, though it may be present or
absent in either. Nose bleed is very rare
in malaria, and when present, unless in one
predisposed to it, it should be regarded
with suspicion. It is a more important
symptom of typhoid fever than generally
admitted.

A study of the circulatory system is of
little value in the diagnosis of either infec-
tion. The expression may or may not be
dull and heavy, and the conjunctiva and
cheeks may or may not be flushed in either.
The tongue usually considered as indicating
much in fever is of little value in Eastern
Carolina except in certain cases. I have
seen it coated, large and flabby, with teeth
indentations in typhoid, and I have noticed
the red-edged sharp-pointed typhoid tongue
in malarial fever. There is a tremulousness
about it which is often present in typhoid
but seldom in malaria. Labial herpes is a
strong indication of malaria. One impor-
tant diagnostic sign is the early appearance
of anjemia with an icteroid hue in malarial
fever, while in typhoid fever the jaundice is
not seen at all and the anemia not before
the end of the second week. Severe gastric
symptoms are sometimes present from the
very beginning in typhoid fever of the Sea-
board section, though it is not so constant
as in malaria. This is probably due to the
tendency to visceral congestion so univer-
sally present in malarial sections. Intes-
tinal symptoms so marked in the mountain
region are of some value to us in the East,
though not of so very much importance. I
have seen malarial fever with as pro-
nounced abdominal tenderness and tympani-
tes as are usually found in typhoid, and ty-
phoid with as little abdominal symptoms
as are generally present in malarial fever.
Constipation is as frequently seen in typhoid
fever of the East as in malaria. The ty-
phoid eruption is of much aiagnostic value,



THE CHARLOTTE MEDICAL JOURNAL.



and though very often but few spots can
be found, yet I believe they are present
more or less in all cases. I have not been
able to derive much help from a study of
the liver and spleen in these cases. Nerv-
ous symptoms are more pronounced in ty-
phoid than in malarial infection. There is
no doubt that the mosquito transmits ma-
laria. In my opinion this is the only way
in which man is infected. The accurate
determination of the exposure or nun-
exposure of the patient to the ravages of
this insect, especially the anopheles cloriges
is a very important point in the differential
diagnosis.

Stupor, subsultus tendinum, muttering de-
Irium, sordes on the teeth, etc., when pres-
ent, are generally due to errors in diet.

While a close study of the patient, the
history of the case, the symptoms presented
along the lines indicated above will enable
the conscientious physician to arrive at a
satisfactory diagnosis, yet in spite of all
|this he may find himself in the dark. There
are three tests which if applied intelligent-
ly and considered collectively will make the
diagnosis positive sooner or later.

With the chemical test I have had no ex-
perience. I have never been in doubt after
trying the otlier two tests and have there-
fore never used it, but I see no reason why
the diazo-reaction should not be of service
in many instances. As to the therapeutic
test (the administration of quinine) I have
this to say, that while it is so often invalu-
able, yet we should not permit ourselves,
if possible to avoid it, to needlessly drug
our patients. If we must use quinine to
determine the character of every case of
fever may we not do much harm to our pa-
tients.? I am sure that a case of so-called
gastric fever would be much injured by it,
and I feel quite confident that it brings
about mischief in typhoid fever in many
ways needless to mention here. I believe
its diagnostic value is over-estimated. We
usually say that should the temperature be
markedly affected by it in three or four days
that it indica.tes malaria. So it does very
often, but sometimes not. For example :
on the sixth day of her illness I was called
to see little Miss M. She had typical ty-
phoid fever. On the eighth day of her ill-
ness her temperature dropped two degrees
and then ran the usual course. No quinine
was given. Suppose I had administered
large doses of the alkaloid the two days
previous using this test alone, I would have
declared at once that I was dealing with
malaria.

If a careful daily record of the tempera-
ture of typhoid fever seen in Eastern Caro-
lina be kept, very many similar cases would



be found. Again, suppose we have a low
remittent malarial infection engrafted upon
a subject whose excretory organs were
functionating much below normal, so low as
to be barely able to throw off the poisons
naturally produced by the economy, should
we not expect to find the fever actually
continued if not increased by quinine? I
think so. This alkaloid throws extra work
on these already over-burdened organs, and
makes it practically impossible for them to
rid the system of the toxins produced by
the disease. So that in a case like this we
would say that it was typhoid should we
depend upon the therapeutic test alone.
There is no doubt that quinine is one of the
most badly abused of all drugs ; and its in-
discriminate use in therapeutic diagnosis
should be severely condemned.

A careful microscopic examination of the
blood will demonstrate practically to a cer-
tainty the presence or absence of malarial
organisms. Just here let me say that some-
times the administration of a large dose of
ergot two or three hours before the exami-
nation will bring out an otherwise hidden
organism. If the malarial plasmodii are
found we should then satisfy ourselves that
there is not also a typhoid infection. To
do this we have a test which in careful
hands will prove a most valuable one, and
that is the Widal reaction. I shall not dis-
cuss it here. I believe it to be thorough-
ly reliable when properly done. This much
I will say, that the stock cultures should be
transferred from agar to agar every three
or four days and kept at room temperature.
This test should be made with bouillon cul-
ture from lo to i8 hours old at normal tem-
perature, and the serum mixed in the pro-
portion of 1-40 with one hr. time limit.
This in my experience has proven itself to
be the best method. There are several ob-
jections to this test, however, from a diag-
nostic point of view, chief among these be-
ing the lateness in the course of the disease
when it is demonstrable, and the fact that
one must be more or less of an expert in its
application. This last objection can be
urged against the microscopical test for
malaria with equal force.

Sometimes we see in North Carolina a
fever which has a tendency to be continued
which does not show the malarial organ-
isms and does not respond positively to the
Widal reaction. Those cases which I have
seen were no doubt due to intestinal bac-
terial infection. I do not consider this fever
as a continued fever, hence shall not discuss
it. This type of fever is of much impor-
tance, however, and this much should .be
noted when discussing continued fevers,
that the lack of proper medical attention



560



THE CHARLOTTE MEDICAL JOURNAL.



will sometimes permit it to run a longer
course than it should. For instance, if the
stomach be very irritable, as it often is in
these fevers, the persistent use of quinia
with the idea that it is malariii. and a re-
fusal on the part of the physician to admin-
ister a purgative, fearing if it siiould be ty-
phoid that it might produce an uncontrola-
ble diarrhea, (and I have seen a physician
manifest such a ridiculous fear) this fever
will last much longer than usual, and will
be of a continued nature.

As to the continued fevers of North
Carolina I have nothing especially to offer.
The proper management of the case after
the diagnosis has been made is an impor
tant and serious question. The course out
lined in any up-to-date text-book for the
typical cases of malarial or typhoid fevers
apply with equal force to these atypical
forms which we have been discussing.

My own experience, and my observation
of the practice of others, have taught me
that probably the three most important
things for North Carolina doctors to guard
against in the treatment of these as well a
other fevers are : first, the reckless use of
quinine ; second, the over-dosing of typhoid
fever patients, and third, the lack of
thoroughness in reference to the diet.



Abortion.*



By E. T. Dickinson, B. S., M. D., Smith-
field, N. c:

This paper shall be an effort at brevity
embodying points not beyond discussion,
and yet the properly recognized and well-
tried teachings and methods which should
be remembered in the management of every
case of abortion coming under our profes-
sional observation.

Expulsion of the ovum before the period
of viability will be understood as abortion ;
that occurring after the child is viable to
within a few weeks before the normal ter-
mination of pregnancy as premature labor.
The period of abortion extends to the
twenty-eighth week of pregnancy, and on
account of improved incubation is growing
shorter. Premature labor includes the period
of the twenty-eighth to the thirty-eighth
week of gestation, and for the same reason
is growing correspondingly longer.

Abortion is of frequent occurrence and
serious nature ; frequent to the extent of at
least once in every motherhood. Judging
from Whitehead's statement that thirty-
seven out of every one hundred mothers



*Read before Ihe North Carol:
Tarboro. N, C, May, IHOIJ.



la Medical Society at



abort before they reach the age of thirty,
serious to the extent approaching consump-
tion in that sex, when considered as the
starting point, when neglected, of various
diseases of the uterus, as sub-involution,
chronic metritis and endometritis leading to
invalidism as well as the numerous deaths
by sepsis and pelvic peritonitis.

The causes of abortion are inconceivably
infinite, may appear infinitely small, ob-
scure and inevitable, or infinitely gross, bold
and despicable. They may be grouped
into paternal, maternal, ovular, therapeutic
and criminal. The last two are induced
abortion. It occurs most frequently be-
tween the ninth and sixteenth weeks of
pregnancy, and at the time corresponding
to the natural monthly period. It should
ever be remembered that in most cases the
diagnosis is a simple affair, but the practi-
tioner will meet with no condition which
at times will puzzle him to the same degree
to answer these questions :

1. Has the woman been pregnant?

2. Has she aborted?

3. Is the abortion complete or incomplete ?

4. Is it criminal?

These must be decided before intelligent
prognosis and treatment can be decided
upon.

If the woman is found pregnant and abor-
tion threatens, it is very important to know
whether or not it is unavoidable, as tiie ano-
dyne treatment of merely threatened abor-
tion renders the inevitable type the more
slow, incomplete and complicated. If there
has been not much hemorrhage nor contin-
uous uterine contraction it is safe to con-
sider the abortion as merely threatening.
The patient must be put at once at complete
rest and placed as soon as possible under
the influence of drugs that will diminish
nervous sensibility and weaken muscular
action, the anodyne method; opium in the
form of suppository being perhaps best and
is more generally used in this country. If
the abortion can be prevented the uterine
contraction will soon cease, the bleeding
stopped and the patient usually will drop
to sleep.

If this result should not follow the treat-
ment within a few hours, hope of delaying
abortion should be abandoned and measures
should be taken to secure complete and
early expulsion of the ovum. Two dangers
threaten the mother, hemorrhage and septic
infection. These dangers are best guarded
against and at the same time complete ex-
pulsion of the ovum secured by the proper
use of the antiseptic tampon. After sev-
eral hours when the tampon is removed,
and if necessary renewed, the ovum will
often be found adhering to it. Adminis-



THE CHARLOTTE MEDICAL JOURNAL.



561



tration of ergot will aid in the early com-
pletion of the process of expulsion. If the
abortion is surely complete, the after treat-
ment will be simple and period of recovery
uneventful. If it is found incomplete, as
will most often be in the early months of
gestation, the large mass of the deciduous
membrane being almost certainly retained
in the uterine cavity, and later the placenta
being frequently left behind, the treatment
will not be so simple and prognosis so satis-
factory. Here it is that there is so much
difference of opinion as to the proper course
to pursue — whether the conservative or the
active course of removing at once the sub-
stances in the uterus which may give rise to
future complications. The proper course,
undoubtedly, is the one corresponding to
the inclination of the physician in charge.
If we were all accustomed to the proper use
of the curette, the future safety of the wo-
man in every case would demand that the
secundines be at once removed after the
expulsion of the f(rtus in every case in which
such removals can be made without force
sufficient to injure the woman. But it must
be remembered that in the hands of general
practitioners, unaccustomed to gynecologi-
cal manoeuvers and aseptic measures the
curette in the puerperal uterus will often
prove a dangerous instrument. If this ac-
tive treatment be adopted the aftercare will
be very simple, for the lochial discharge
will be very slight and involution of the
uterus rapid. But whatever course we pur-
sue until this latter condition is perfected,
the woman should be confined to bed.

If it be found that the case is one of that
class in which the physician himself, for
the safety of the mother, finds it necessary
to bring about the premature discharge of
the contents of the pregnant uterus, to de-
monstrate absolutely the absence of crim-
inal intent should be his first thought. It
is of some importance to know whether we
are dealing with a viable or a nonviable
child in order that the proper method be
employed. If the twenty-eighth week is
approaching and it is possible to wait until
the period of possible viability of the child
arrives, such should be done ; and this done,
the induction should be postponed as long
into the viable period as it is reasonable to
venture, and thus compromise between the
interests of mother and child, but always
giving the mother the advantage of any
doubt.

In bringing about the expulsion of the
foetus by artificial methods we should, as
ntarly as possible, imitate nature, by secur-
ing clonic contractions of the uterus and
the consequent evacuation of that organ.
The process is a reflex act induced by the



application of a stimulus, the impulse of
which is sent along the peripheral nerves
and causes the uterus to contract. This re-
flex act may be brought about in various
ways, but many are unreliable while others
are complicated and unsafe. The reputa-
tion of emmenagogues in unsafe doses is
largely based on erroneous diagnosis. The
use of all drugs for this purpose is unscien-
tific, unreliable, unsafe and, indeed, super-
fluous, as if the woman is pregnant, she
will lose her life before the child is destroy-
ed ; if she is not pregnant, they are unnec-
cessary. Only the ignorant laity use them.
The most reliable, safest and most generally
employed method is that adopted by Sir
James Simpson of introducing, under asep-
tic precautions, a soft rubber bougie into
the uterus and retaining it there by a vaginal
tampon until uterine contraction are excited
sufficient to expel the ovum. The dangers
are sepsis, inflammation and hemorrhage.
The first two must be avoided by observing
strict asepsis of the external genitals and
vagina and of the hands of the operator.
vShould there be much hemorrhage, the
placental site has probably been invaded
and the bougie should be withdrawn and
reinserted in another direction. If after
this the hemorrhage becomes alarming a
firm vaginal tampon may be placed. This
method after the first few months of gesta-
tion usually acts promptly and efficiently.
If, however, the abortion is to be induced
in the first eight or twelve weeks of preg-
nancy, cervical dilatation and thorough
aseptic curettment is to be preferred.

If the abortion be found criminal the in-
dications are to guard against sepsis and
hemorrhage. It is imperative for the wo-
man's future usefulness and well-being that
all cases be kept quiet in bed until complete
involution of the uterus is certain. In the
interest of the profession and the common
community as well, when even slight sus-
picion of criminal interference exists, the
physician should exercise great care in ex-
amining his patient and make complete
notes of any history he may obtain from the
patient and others present, and also keep
complete notes of his physical examination,
and the clots and portions of the embryo
should be kept for inspection. If there is
positive evidence of criminal abortion pro-
duced by a second party the case should at
once be reported to the proper authorities
and all evidence possible should be placed
at their disposal. In this way much can be
done toward the prevention of criminal
abortion.

A recent question, worthy of serious dis-
cussion, arises when a woman has commit-
ted abortion upon herself. Morally it seems



562



THE CHARLOTT EMEDICAL JOURNAL.



right that the physician should report the
case in the capacity of a citizen. But, pro-
fessionally it would be the part of reason-
able policy if not morally right, to save life if
possible and to keep the offender secret, this
as much in the interest of future unfortun-
ates as for the solution of the present dilem-
ma ; and, too, it seems the surest means of
discouraging the development of an increase
in number of professional abortionists, who
have neither the interest of the future com-
munity at heart nor the safety of the wo-
man.

As to the propriety and demand for larger
liberty in the induction of abortion in un-
fortunate young unmarried women the time
has probably not arrived for its discussion,
but it has been urged that there should be
a recognized difference between abortion
for convenience in the married and in an
unfortunate single woman, whose shame
would be agonizing to herself, her kinsmen
and the branded child she bore. One plain-
ly feels the need of this difference after
turning away one of these unfortunates.
But while each of us with a heart, with a
sense of justice, and with an active and
right conscience keenly feels the need of
this legal difference under similar circum-
stances, we must not persuade ourselves nor
allow ourselves to be over-persuaded that
induction of abortion, except for the life of
the woman, is and must always be highly
criminal against both morality and the most
conservative law, and we must look for re-
lief only in the establishment of some insti-
tution for the protection of both mother and
offspring, and thus to allow them both the
greatest opportunity of becoming useful
citizens of the community.



Chronic Endometritis, Its Varieties, Pa-
thology and Symptoms, with
Special Reference to Treatment.*

By B. Ray Browning, M.D., Littleton, N. C.

I desire to express my appreciation of the
honor conferred upon me as Chairman of
the Section on Gynaecology to prepare a
paper for your consideration at this meet-
ing. In the selection of my subject I have
not had in view the presentation of any-
thing new or startling, but shall content
myself in the short time at my disposal to
touch upon some of the essential and in-
teresting features of the subject chosen.
Endometritis is an inflammation of the
lining of the uterus. It is a disease of men-



*Read before the North Carolina Medical So-
ciety, atTarboro, N. C, May, 1900.



strual life, and while I have not observed
it before puberty, yet it exists according to
good authority, constituting the virginal
form ; it also extends beyond the menopause
in the well-known form of Senile Endo-
metritis. I shall content myself, however,
with considering those varieties occurring
during the child-bearing period. There are
two distinct varieties of endometritis, viz :
(a) Glandular, and (b) Interstitial, with
probably a third or uncertain variety, the
fungoid or villous form. There is also a
variety of endometritis occuring in the puer-
peral state, which, while it does not come
distinctly within the scope of this paper,
will be touched upon at a later period.

Without necessarily admitting the broad
statement that all inflammatory processes
are due to microbes as taught by Senn, Roy
and other surgical writers, it may be claimed
that the position is strengthened by the in-
vestigations made to determine the patho-
genesis of endometritis. It is a well es-
tablished fact that in the healthy uterine
cavity there are no microbes. Winter has
proven this by examinations of a large num-
ber of uteri removed from the body.

Strauss and Doderlein have found the
lochia in non-febrile puerperal cases free
from bacteria. It 's a singular, though
wonderful fact, that the uterine cavity
should remain free from germs when it has
been clearly shown by Winter and many
others, that in all, or nearly all women, the
vaginal and cervical canal contain large
numbers of microbes. The absence of
uterine secretion, as suggested by some,
may have some bearing upon this subject.
It is quite important to remember that the
microbes found in the vagina and cervix
have usually lost most of their virulence.
This is true of both the staphylococcus and
streptococcus. The unbroken epithelial
membrane of the endometrium is probably
in no danger from them after they have im-
dergone the change produced by a residence
in the vaginal and cervix canals, and the
menstrual decidua, instead of forming a
nidus, is also toxic to them. All cases of
endometritis post-partum, or post-abortum,
are probably of microbic origin. Endo-
metritis originating in other conditions, as
from the introduction of sounds and tents,
specific vaginitis, etc., is probably due to
the same cause.

Bacteriological investigations during the
last few years tends to confirm this. The
recent report of Brandt, working in Slav-
janskys clinic, who examined 25 cases of
chronic endometritis, and found bacteria in
22, streptococci were present in 2 cases;
staphytococci in 7 ; gonococci in 3, and non-
pathogenic bacteria in the other ten. Pos-



THE CHARLOTTE MEDICAL JOURNAL.



itive information as to the tissues inhabited
by the bacteria, their mode of growth and
the way in which they produce their patho-
logical effects in chronic endometritis, has
not yet been obtained. It is probable that
the connective tissue spaces of the stroma
are the chief habitat of the germs in all
cases ; their presence in the epithelial cells,
on the surface of the mucous membrane
and in the glands is not doubted. The
epithelial layer, although consisting of only
a single row of cells, is a protection to the
underlying stroma. Brandt believes that
the different forms of endometritis are
caused by the different bacteria located in
the different habitats. Thus, in catarrhal
endometritis, endometritis interstitialis, he
finds short thick bacilli in the hemorrhagic
extravasations. In septic endometritis,
endometritis decidualis acuta, the dilated
glands are filled with cocci, while in gonor-
rheal endometritis, the gonococci are in the