necessary. Should this fail to aflord relief,
then the uterine cavity should be explored
to ascertain the cause, which may be re-
tained membrane or placental tissue.
To conclude. The systematic employ-
ment of the douche is uncalled for.
The physician should be acquainted with
the indications for douching, for upon his
knowledge of these and his judgment, de-
pend entirely when the douche should be
employed.
AH instruments, nozzles and syringe tips,
should be sterilized prior to their insertion
in the vagina or uterus.
The examining hand and fingers should
receive especial attention.
Always wash the vagina prior to the in-
troduction of an instrument into the uterus.
The instrumeut should be introduced by
sight.
If catheterization is indicated, the cathe-
ter should be sterilized each time, A glass
one is preferable.
Do not trust any one excepting a trained
nurse to give a vaginal douche, as puerperal
sepsis is often attributable to the dirty
nozzle on the "'family syringe" in the hands
of an inexperienced person.
Puerperal Infection.
By C. H. Long, M. D., Escanaba, Mich., Sur-
geon to Tracy Hospital and County Physi-
cian.
This is an infection occurring during the
first four weeks after labor or abortion.
An infection contiauing or arising after
this date is not puerperal, but an endomet-
ritis in a sub-involuted uterus. Abortion
takes place from any abrasion or wound of
the genital tract, the placental site alwa/s
affording a convenient opportunity for in-
fection. Infections after abortions are the
same as after labor, differing only in sever-
ity according to the advancement of preg-
nancy : e. g. infection after an abortion at
four weeks produces less septicaemia than
at three months or after labor because of
the smaller uterus and less active lympha-
tics. We can conveniently divide infec-
tion into two varieties : first, putrid, and
second, septic. Either variety may be local
or general. Putrid infection is due to the
THE CHARLOTTE MEDICAL JOURNAL.
Z31
chemical products of harmless bacteria
known as saprophytes.
As a rule, this infection commences from
the endometrium, a superficial area of
slough in which the saprophytes are situat-
ed, very often mixed with other germs.
Beneath this, there is an aggregation of
white blood corpuscles standing as sentry,
preventing the further advancement of the
invading foe, the poison-producing sapro-
phytes ; — the invaders overcoming the in-
vaded, according to strength of numbers,
and vice versa. If the saprophitic organ-
isms are able to overcome the corpuscular
sentry, their poisonous products, called
toxins, rapidly enter the general circula-
tion and cause a general putrid infection,
described by Prof. Duncan as sapraemia,
the effects of which correspond in intensity
to the dose of the poison. Retained clots
and placental fragments are the usual causes
of putrid infection.
In septic infection, the lesser degrees are
caused by staphylococci, and the more
virulent by streptococci. The cocci lie
anywhere along the mucuous surfaces of
the genital tract, and under favorable con-
ditions enter by the lymphatics and veins,
through the uterine walls, into the sur-
rounding tissues, and even to distant parts
of the body. As a rule, in the early stages
of this process, the condition is a local
septic endometritis, but later a general
septicaemic condition possesses the patient.
Adjacent to infected vessels, serum and
lymph are thrown out, and in a short time,
if th*^. patient survives, we may have sup-
puration and pus. The more virulent and
rapid the infection, the less are the local
manifestations. If recovery takes place
without our interference, many and varied
are the remaining effects : — e. g. fixation
of the pelvic organs, pus tubes, phlegmasia
dolens, injured heart valves, etc., the pro-
duction of these conditions having been
accompanied by a more or less severe type
of general septicaemia. To the theorist or
the inexperienced, the diagnosis can be
made and treatment applied with mathe-
matical exactness. But, alas! how differ-
ent the condition as it really exists : The
busy physician, ushered into the presence
of his patient at any stage of the septic
process, with nurses good bad and indiffer-
ent, with various surroundings, from the
mansion of the rich to the hut of the pauper,
feels his weakness. It is no easy task, and
often utterly impossible to diagnose and
treat according to bacteriological condi-
tions. I believe it would be a grand accom-
plishment if every physician were able to
make cultures from the inside of the uterus,
and in this way, endeavor to differentiate
the various causes and apply the proper
treatment in puerperal fever. Unfortunate-
ly, skilled bacteriologists are not always
able to agree because of the diversity of the
pathological changes. While such condi-
tions exist, the general practioner must
continue to rely largely upon the clinical
picture rather than waste valuable time in
determining the exact bacteria causing the
infection, He will endeavor to apply that
method of treatment which will do good in
all cases.
Treatment. — In considering the treat-
ment, and anticipating that retained mem-
branes or placenta have been removed with
curette or forceps, I will confine myself
mainly to cases already infected, omitting
prophylaxis and internal remedies generally
applied in strict accordance with the best
modern medical authorities. A thorough
disinfection of the operator's hands, instru-
ments and materials; also the patient's
external genitals and vagina. Now irrigate
the uterus, using a large glass, return-flow,
irrigating tube, attached to a fountain
syringe filled with a quart of Thiersch's
solution, followed by five or six quarts of
boric or normal salt solution. If the infec-
tion is of no more than twelve hours' dura-
tion, this is all that is required, with the
exception of perhaps repeating the opera-
tion. The length of time of the infection
guides our mode of procedure. If the
temperature is not normal in four hours,
irrigate again, and pack uterus and vagina
with io% iodoform gauze. Wait twenty-
four hours for a change. If the patient is
better, leave gauze for twenty-four hours
longer; if no improvement, remove the
gauze, curette the uterus and repack. Al-
low this to remain forty-eight hours. If
still no improvement, open the cul-de-sac,
thoroughly separating the pre-uterine tissue,
and fill the pelvis with strips of gauze, thus
outflanking the enemy, and turning pos-
sible victory into defeat. This gauze pack-
ing is changed according to conditions.
The quantity of the discharges vary, some-
times amounting to pints. Here we are
advised to give enemas of salt solutions,
thereby preserving the strength of our
patient. We presume that the proper
remedies have been administered, and
everything performed for the benefit of the
patient.
I feel safe in stating that if this treatment
has been fearlessly and methodically pur-
sued, we will save a class of puerperal
cases which would have proven fatal.
Certainly, if the germs have gotten beyond
our reach, it greatly reduces the usefuUness
of the operation. But even if our patient
dies, we have the satisfaction of consoling
338
THE CHARLOTTE MEDICAL JOURNAL.
ourselves with the thought that we did oui
duty, and our interference was not in
jurious.
Treatment of Tuberculosis Based Upon
Results form Previous Pathological
Examinations of Blood, Sputum
and Urine of Patients.
By L. H. Warner, M. D., formerly Bacteriol-
og-ist St. Catharine's Hospital, Brooklyn.
N. Y.
From observations of a series of cases of
tuberculosis which I have made, in cases
which had been treated by various physi-
cians according to their best ideas of "treat-
ment, cases which have been diagnosed by
physical examinations, and cases the treat-
ment of which was based upon results
obtained from a pathological examination
of the blood, sputum and urine of the
patient, I have come to be convinced that
the latter class of pathological examinations
if continued from time to time are the best
guide to help the physician and patient to
a successful termination of this dreaded
disease. There are many new remedies
used in tubercular diseases which tend to
prolong life amongst which we find phvsi-
ological and biological products derived
from the animal organism. The anti-
toxines, anti tubercular serums and nuclein
products belong amongst the latter class of
products. What effect these products have
upon the tubercle bacillus, or what tissue
repairing function they may possess, cannot
be demonstrated by experimentations upon
the lower animals alone, but su;h experi-
mentations must be reaffirmed by clinical
results obtained from their use upon the
tubercular patient. I will not dispute that
were we confronted by a patient with a
dry and irritable cough, profuse exectora-
tions, temperature of loi or more, pulse
no or more, emaciated, no appetite, ascul-
tation aud percussion revealing a tubercular
process, night sweats and hectic fever, we
would be correct in making our diagnosis
of tuberculosis, especially if the examina-
tion of the sputum revealed the presence of
bacillus tuberculosis. The majority of
practitioners if confronted with the above
conditions are satisfied to place their patient
on the various medications indicated in
tuberculosis consisting of hygenic sur-
roundings, special diet, tonics, cod liver
oil in many instances resort to anti-tuber-
cular serum. Their methods of treatment
are followed indefinitely to be changed
according to symptoms prevailing. Little,
if any, attention is paid to the pathological
study of the blood of the patient at the
beginning of treatment to note what effect,
if any, the treatment might have upon the
various blood cells, and whereby the physi-
cion might learn whether he might look for
a favorable or unfavorable prognosis of the
case. Why the examination of the blood
should be an important factor in the treat-
ment of tuberculosis may be learned if we
recall to our memory the structure and
evolution of the tubercle. The bacillus
tuberculosis enters the tissue or organ and
strangulates or irritates the connective
tissue elements, causing proliferation of
round cells, resembling epithelial cells by
their abundance of protoplasm. Infiltra-
tion with leucocytes, mostly mononuclear,
from the surrounding blood vessels follows,
and this leucocytic infiltration represents
the reaction of the vascular system to the
tubercular irritation or infection. There is
no need to further follow this subject, but
in my belief, knowing the above facts, it is
of interest and a necessity to learn the
exact pathological condition of the leucocy-
tes in the blood of a tubercular patient. If
a leucocytosis is presented we must deter-
mine the percentage of the mononuclear
and polynuclear forms and of myelocytes
noting probable karyokinetic figures within
the neucleus. We must follow the results
thus obtained by an examination of the
urine to learn as what extent the leucocy-
tosis is destructive. This we learn by the
amount of xanthin leases and uric acid, and
we may also learn that protective substances
are liberated in the urine. In tuberclosis we
generally meet with hypoleucocytosis or
leakopcsnia or a deficiency in the number of
leucocytes caused by a disturbance in the
distribution of leucocytes. Whichever of
the above conditions confronts us, they
deserve due consideration and thought
prior to determining upon the treatment of
the case. Modern physiology teaches us
that whenever the first alarm of disease is
sounded in the organism, that the leucoocy-
tes at once rush in increased numbers to
resist any pathologic attack. Leucocytosis
is not a diseased condition, but on the con-
trary it is the rallying of physiological
units to the point of the attack, causing
protection to the organism. By their
phagocytic action the leucocytes devitalize
any foreign element introduced into the
organism. Ordinarily the leucocytes appear
as small roundish cells, but when stimulat-
ed to activity they change their form, they
elongate and force their way through the
smallest and narrowest of channels. At
times they break, their nuclein is absorbed
by the different cell tissues of the body or
THE CHARLOTTE MEDICAL JOURNAL,
they form into one or more new leucocytes.
This latter condition is a favorable one and
if produced on a large scale by means of
medication is of vital importance. The
creation of new and active leucocytes is
most desirable in the treatment not alone of
tuberculosis, but in all infectious diseases.
The leucocytes possess the power to wander
through the blood channels at will. They
will pass out of the vein channels through
the vein channels through the capillary
walls and will re-enter the veins. They
absorb all proteids and waste matter, they
attack, destroy and digest toxic germs.
They possess all the fundamental properties
of protoplasm, thus when they divide and
the protoplasm escape into the surrounding
tissue, it has the property of becoming a
part of that tissue. The leucocytes supply
the different cell tissues with fresh building
up material in the shape of neuclein, they
are the carriers and distributors of tissue
pabulum. The use of the microscope is
absolutely necessary along the lines of
investigation in tubercular diseases, to
determine as to the most efficacious medica-
tion to be employed in the treatment of this
dreaded disease. The casses which I cite
here were followed up by the semi-weekly
examinations of the blood, urine and sputum.
The treatment was regulated according to
results obtained from these examinations,
and lam satisfied the extra work and study
has been beneficial both to the patients and
myself. Good food, fresh air and other
favorable conditions must accompany all
treatment. If your patient feels stronger
and more vigorous in the poor, cold, thin
air of the mountains he should go there, if
his vitality is renewed by inhalation of
damp salt air he should select his abode
near the sea coast. The same climate will
not suit two individual tubercular patients.
The physician should endeavor to find out
from his patient, which surrounding seem
to give him the most energy and vitality,
and should direct his abode accordingly
Thus I find that some of my cases prospered
near the sea shore while other recuperated
aided by mountain air.
Case I. — First stage. Feb. 1899, Mifs
D. age 19. Farther and mother died of
phthisis, has been sick for the last few
months. Cough with slight expectoration,
loss of appetite. Normal weight 125 lbs.
now weighs 98 lbs. Night sweats, hectic
flushes.
BLOOD KXAMINATION :
Haemoglobin, 49 per cent.
Red Cells, 3,350,000
White Cells, 7200
a number of decrepit red corpuscles, small
sized and pale poor in albumin and haemog-
lobin. No nucleated red cells.
DIEFERENTIAL COUNT OF LEUCOCYTES:
Polymorphonuclear, 80 per cent.
Large lymphocytes (large and transitional)
8 per cent.
Lymphocytes (small) 9 per cent.
Eosinophiles o per cent.
Myelocytes 3 per cent.
EXAMINATION OF SPUTUM :
Pus cells
Bacillus tuberculosis (exceedingly numer-
ous)
EXAMINATION OF URINE :
Color ; milky
React ; slightly acid
Space Grav, 1014
Albumin traces
Sugar, none
Diazo Reaction ; positive.
MICROSCOPICALLY :
Ephithelial cells, pus cells, few leuco-
cytes and red cells, free fat drops, few uric
acid crystals, bacteria and few tubercle
bacillus.
Patient was ordered four Protonuclein
tablets two hours before meals and before
retiring. This treatment was continued
for 8 weeks during which time I saw the
patient twice a week for the purpose of
following up my blood, sputum and urine
examination. The former reveals a daily
increase in young and active leucocytes, a
gradual increase in red cells. The amount
of tubercle bacillus decreases daily and
within three weeks of beginning of treat-
ment no more bacillus is found. The
urine is apparently normal. On the first
week of April 1899, patient weighs 119
pounds a gain of 21 pounds, in 8 weeks
cough has entirely ceased, no abnormal
sounds can be heard on auscultation and
percussion. Since that time, up to this
day, I have seen the patient repeatedly,
feels entirely well, no return of any pre-
vious symptoms.
Case IL — Second stage, Feb. 1S99, Mrs.
L. age 39. Parents both died of phthisis.
Patient has been sick for about a year and
has fairly lived on Cod Liver Oil and
tonics. Appetite poor, tubercular cachexia
Severe cough and profuse expectoration.
Loss of appetite, pulse 98 — no, tempera-
ture always — i to 3 degrees above normal
in the evening. Hectic flushes. Normal
weight 173 lbs., now weighs, 131 lbs.
Tubercular deposit located in upper lobe of
right lung, small cavity.
BLOOD EXAMINATION :
Heamoglobin ; 42 per cent.
340
THE.. CHARLOTTE MEDICAL JOURNAL.
Red cells; 2,600,000
White cells; ^3A^o
crenated and decrepit red corpuscles, poor
in heamoglobin, no nucleated red cells.
DIFFERENTIAL COUNT OF LEUCOCYTES :
Polymorphonuclear; 81 per ccunt.
Large Lymphocytes ; 9 per cent.
Lymphocytes (small) 9 per cent.
Eosinophiles o per cent.
Myelocytes; i per cent.
EXAMINATION OF SPUTUM :
Pus cells
Bacillus Tuberculosis.
EXAMINANION OF URINE.
Color ; Pale straw
Reaction ; acid
Sp. Grav ; 1012
Albumin ; traces
Sugar ; none
Diazo-reaction Positive.
MICROSCOPICALLY :
Epithelial, cells, pus cells, in clusters,
leucocytes, and a few red cells, uric acid
crystals micrococci streptococcus, pyogenes,
smegma bacillus and bacillus tubercu-
losis.
Patient was ordered four tablets of proto-
nuclein before meals and before retiring.
Within the first week I noticed that this
patient did not show the improvement as
in case I. The second and third examina-
tion of the blood also showed no such
changes as were noted in case 1. It then
occurred to me that Protonuclein exerts its
physiological action directly upon the cel-
lular element of the blood and further more
that immediately before, during or after a
meal there occur profound pathological
changes in the blood, and that possibly the
latter condition deterred the action of Pro-
tonuclein and I at once decided to direc*-
the patient to take the Protonuclein two
hours before meals and before retiring.
This caused an immediate change for the
better, and subsequent experience has
taught me that Protonuclein proves most
efficacious if administered half ways be-
tween meals. The patient continued on
this treatment for three months. After
the first weeks treatment a decided change
for the better was noted, not alone by phy-
sical examination, but the latter was cor-
roborated by pathological examinations of
the blood, sputum and urine. Repeated
blood examinations revealed the fact that
Protonuclein increased the number of white
corpuscles. It is necessary to state here
that the precipitated leucocytosis differed
in all respects from leucocytosis as general-
ly found. Using the hot stage for blood
examination and extending my examina-
tions and investigations in each instance
for one hour or more. I found within one
hour after taking Protonuclein, that the
Polynuclear leucocytes and leucocytes with
karyokinetic nuclei became very active,
they appeared to distend and the nuclear
forms divided into three or more distinct
nuclei. In due time each one of the nuclei
surrounded themselves with a blastema
and assumed the role, so as to say, of a
rejuvenated leucocyte with full phagocytic
properties. If we recall the fact that the
functions of the phagocytes tends to attack
and destroy bactefia, it appears very reason-
able to assume that in tuberculosis they
attack the tubercle bacillus. The devas
tated surfaces previously inhibited by the
bacillus are rebuilt by the nuclein of the
leucocytes. Thus by administering medi-
cation in the tuberculosis I believe we get
absolute results by selecting organic pro-
ducts which tend to supply the leucocyte
with an abundance of nuclein, more tnan
they can ordinarily obtain from the diges-
tive channels.
Returning to Case II. — Previously re-
ported, it remains to be said, that the
patient appeared in perfect health four
months after beginning of treatment.
Weight 162 pounds menses had returned,
patient sleeps, and eats well, and is able to
follow her daily occupation. I have seen
the patient repeatedly during the winter,
and although she had several attacks of
slight colds, there is no indication of any
tubercular disease. The above cited cases
are but two out of a series of 37 cases,
clinical reports of which show the value of
Protonuclein in the treatment of tubercular
disease. I must admit that previous short
experiments with this organic product
rather left me in doubt as to its theraputic
value, but I have learned that the proper
administration of this remedy depends upon
a close physical study of the patient as well
as upon a pathological examination of the
blood, sputum, urine etc. At times an
examination of the stomach contents is of
great value, especially if general malaise
nausea, indigestion accompanys diagnosis
of tuberculosis.
The Financial Side of the Practice of Medi-
cine.*
By W. J. Weaver, M. D., Marshall, N. C.
Residing in a small town and practicing
in it and its surrounding country, I have
*Read before Buncombe County Medical So-
ciety.
THE CHARLOTTE MEDICAL JOURNAL.
341
not been able to discover any great medi-
cal truth with which I might startle you
tonight. I am very sorry I cannot do so
for nothing would give me more pleasure
than announcing a specific for some of our
greater maladies. I might have announced
my subject as the treatment or diagnosis of
some of our commoner diseases and by ran-
sacking the various text books and maga-
zines have bored you to the very end of en-
durance without giving you anything new
whatever. Having therefore, discovered
that my experience and opportunities have
not been of sufficient importance to occupy
your time, I have decided to say a few
words to you from a financial stand point,
and if what I have to say will hasten the
day of our union in this matter, even the
slightest bit it will not have been said in
vain.
Believing therefore, that this subject al-
though not medical in nature, will be of in-
terest to the society I will make no fuither
apology for its presentation.
The object of this paper is to lament the
unnatural rivalry and discord existing in
the medical profession. Particularly is it
lamentable when we consider the age of the
profession and the customs of the country.
It is a condition that serves no member of
the profession, and yet costs each one much
of his hard earned money.
In the first place, this is an age of organi-
zation, of combination, of trusts, and the
medical profession, although one of the old-
est and most honored of all professions
stands alone in its unorganized state and
allows itself to be swindled out of much of
its dues.
Now whose fault is this? It is surely not
the patients' for we could hardly expect
them to organize and compel themselves to
day their doctor bills. It can be no ones
fault but the physicians' and this fault is
due to the lack of organization, and lack of
business principle. A physician's knowl-
edge is his capital and he should demand
recompense for it, just as much as the mer-
chant or lawyer does, for it is certainly just
as essential to human existence as either
law or merchandise. Man enters and leaves
this world under the care of a physician,
and from time to time during his stay here
he is compelled to seek his advice and guid-
ance
This being so, why is it that so large a
per cent, of physicians' bills are left unpaid ?
It is not because the man is too poor, for he
is able to pay the merchant and lawyer.
It is simply because there is a lack of busi-
ness principle among physicians, more than
in any other profession or trade.
For example : A man calls at your of-
fice, who was never known to pay a doc-
tor's bill, and asks you to treat him or his
family. If you treat him he will never pay
you, and if you refuse him he will find some
one who is not so strict, or who doesn't
know him so well, who will treat him, and
this doctor, whoever he may be, is the man
who is at fault. Perhaps he does not know
the fellow is a professional dead-beat, in
which case it is not so much his fault as the
fault of the whole profession for not hav-