it may be very important, for instance, in
cnteroanastomosis or in obstruction of the
bowels to know whether a loop is near the
duodenum or close to the ileo-cecal valve.
George H. Monks (Annals of Surgery, Oc-
tober, 1903) gives a very valuable contribu-
tion to this question, entitled "Intestinal
Localization." He found that an approximate
localization of a part of the small intestine
is possible through a small adbominal sec-
tion by observing certain characteristics, as
its position in the abdominal cavity, its size,
color and thickness, the presence or absenca
of valvulse conniventes, the thickness and
translucency of the mesentery and especially
the distribution of the blood-vessels in the
mesentery, etc. Taking the average length of
the small intestine at 21 feet, there are the
first seven feet usually located in the left
hypochondrium, the middle third in the middle
section of the abdomen and the lower third
in the pelvis and in the right iliac region. The
color of the first 14 feet is bright pink, the
color of the last seven feet yellowish-gray.
The size and thickness of the intestine de-
creases from the duodenum downward. Val-
vulae conniventes are large and numerous in
the first third, absent after a distance of 14
feet from the duodenum. The mesentery is
thin and translucent in the upper third, thick
and opaque near the colon, tabs of fat on the
intestinal attachment of the mesentery com-
mence at about the fourteenth foot of the
small intestine. The vessels of the mesentery
form only one loop in the first four feet.
Digitized by VjOOQIC
6o
PROGRESS OF MEDICAL SCIENCE. Jour. M. S. M. S.
further down two loops and are entirely ir-
regular in the lower part of the ileum. The
observation of these and other characteris-
tics enabled Monk to locate correctly with
only small errors at least on the cadaver any
loop of small intestine withdrawn through a
small abdominal section.
GYNECOLOGY AND OBSTETRICS. '..
Under the charge of
B. R. SCHENCK.
Urinary Hyperacidity.— T. R. Brown ^gain
calls attention to the cases simulating cystitis,
in which the symptoms are due, not to an in-
fection of the bladder, with true inflammation,
but to an irritation of the mucous membrane,
caused by an abnormally high acidity of the
urine. From repeated examinations, Brown
' believes that the normal acidity is 25, i. e. —
100 c. cm. of urine are neutralized by 25
c. cm. of deci-normal sodium hydrate solution.
In the cases under consideration it was found
to be from 2 to 5 times this amount. If this
condition is not recognized by carefully ex-
cluding, by means of cultures, a true cystitis,
unnecessary local treatment may aggravate
the symptoms and finally cause infection and
inflammation. The condition is usually of
neuropathic origin.
During the past two years the writer has
met with ten cases, the histories of two of
which are given. With one exception all were
in neurasthenics. Most of them had been
diagnosed as cystitis. Brown believes that
this condition occurs frequently, and that it
is often misinterpreted and erroneously
treated.
The treatment consists in the administra-
tion of potassium citrate in x to xxx gr. doses
every four hours, until the acidity is reduced
to, or below, normal, and then in sufficient
doses to maintain this. Sodium bicarbonate
may also be used. Large quantities of any
pure water should be taken. Irrigations and
local treatments are absolutely contraindicated.
— (N. F. Med. Jour., Nov, 14, 1903; Phil. Med.
Jour., March 2, 1901.)
Sphygnomanomctcr. — Graves describes a
modification of the Riva-Rocci sphygnomano-
mctcr, for use in the operating room which
obviates the inconvenience attending the use
of the mercury instrument. An ordinary
aneroia manometer is used as an indicator.
the lever controlling the needle being bent
backward so that the excursion of the latter
will be greater and the graduations on the
dial farther apart. The scale on the face is
etched to correspond to millimeters of mer-
cury. Such an instrument is simple and has
been found to give very satisfactory results
at the Free Hospital for Women in Boston. —
(The Bulletin of the Free Hospital for Women,
Boston, Vol. 1, No. 2.)
The Treatment of Puerperal Sepsis.— Mont-
gomery speaks of the decrease of the disease
during the past 30 years, and of the
tendency to hide the true condition by diag-
nosis of la grippe, malaria, typhoid fever,
,etc. Much difference of opinion as to the
proper treatment exists and many procedures
are advocated. Montgomery deprecates the
use of the serum, hysterectomy, and the in-
fusions of formalin. After trying the latter,
he believes that it is no more efficacious than
normal saline. The patients must be kept
clean, vaginal douches of sublimate (i to 2000)
or formalino (i to 1500) given, and the condi-
tion of the bowels and the kidneys watched.
Coal tar products should not be used, but high
temperatures combated with cold sponges.
Frequent enemata of salt .solution are useful.
Local inflammation in the pelvis is to be
treated by the application of ice, and pus,
should it form, be promptly evacuated by
vaginal incision. When the infection is pro-
found, without local manifestations, saline in-
fusions offer the best hope of recovery. Not
over 750 c. cm. should be given at one time.
—{Amer. Med., Vol. VI., p. 735, Nov. 7, 1903.)
Eclampsia. — Tschernomordik gives some
valuable statistics on this disease from the
Charite in Berlin. During the ten years pre-
vious to 1899 there were 322 cases, or 1.83%
of all births. It occurred more frequently in
primiparae than multiparas, and was oftenest
observed only during the confinement. Next
in frequency was during the puerperium, dur-
ing labor and the puerperium, and lastly dur-
ing the pregnancy alone. The maternal mor-
tality was 23.9%. There were 12 cases of
twins, and 103 still births. Albumen occurred
in the urine in all but 6 cases.
The treatment consisted in the administra-
tion of morphia and chloral and the speedy
termination of the pregnancy. The fatal cases
were studied with a view of determining the
cause of eclampsia, but nothing new was dem-
onstrated.— ((7^«, /. Gyn., 1903, No. 41, Oct. 10.)
Digitized by
Google
The Journal of the
Michigan State Medical Society
PUBLISHED UNDBR THB DIRECTION OP THE COUNCIL
Vol. in
DETROIT, MICHIGAN, FEBRUARY, 1904
No. 2
Original Brticlea
THE RELATION OF SURGICAL PATHOLOGY
TO SURGICAL DIAGNOSIS.*
JOSEPH C. BLOODGOOD.
(Associate Professor of Surgery, Johns Hop-
kins University, Baltimore.)
It cannot be denied that surgical tech-
nique is far in advance of surgical diagno-
sis. In the great majority of instances the
failure to cure is due, not to the fault of
the operative procedure, but to the fact
that the operative intervention has been
instituted at too late a stage of the disease.
This fault is due to three factors : — (x),
which we may call the period of latency of
the disease, i.e., the time during which the
lesion has not attracted the attention of
the host; (a), the period during which the
patient delays before seeking the advice
of the physician; (b), the time spent by
the physician in coming to some conclu-
sion in regard to treatment.
To shorten the period (x), the latent
stage, is beyond our power, but fortunate-
ly but very few surgical diseases become
incurable during this period.
Before attempting to shorten the second
stage, (a), that is the time during which
the patient waits, we should attempt to
correct our own shortcomings.
*A portion of paper presented before the
Wayne County Medical Society January 7,
1904.
Without much doubt the far better re-
sults of the earlier operative intervention
will soon reach the public and shorten the
third stage of the delay.
The paramount object of surgical diag-
nosis is to recognize a lesion in that stage
in which operative interference wilj not
only give the best chances of a permanent
cure, but will accomplish a cure with the
least danger to life, and mutilation of the
individual.
The hope of future surgery lies, there-
fore, with the general practitioner. It is
he who should be impressed by the undis-
puted fact, based upon the accumulated
experience of careful records from large
clinics, that permanent results depend most
uix)n early, the very earliest possible, op-
erative interference.
To shorten the period (b), during
which time the physician delays, we should
seek to instruct ourselves to be content
with less positive symptoms. We must
base our clinical diagnosis, not on a symp-
tom complex which enforces delay, but on
the symptoms present at the first examina-
tion. In a majority of instances a careful
Digitized by
Google
62
SURGICAL PATHOLOGY— BLOODGOOD. Jour. M. S. M. S.
study of the clinical history and a pains-
taking examination will allow one to de-
cide whether delay is justifiable.
It is unnecessary and dangerous to de-
lay treatment for exact diagnosis; the
question is, not what is the exact nature of
the surgical disease, but, rather, is it, or is
it not, a lesion which will allow delay.
For example, given a patient exhibiting
symptoms pointing to some acute abdomi-
nal trouble, the question of importance to
decide is not so much what the exact lesion
is, but are there sufficient symptoms to in-
dicate an immediate laparotomy. In many
acute abdominal lesions a delay of even a
few hours is fatal. A mistake in the local-
ity of the incision which would compel a
second opening is trifling as compared
with the delay of an hour in order to be
more positive in regard to the locality of
the lesion. In gastric, duodenal and ty-
phoid perforations, a decision must be
made at once in order to save the life of
the patient. It is unnecessary to mention
the danger of delay in intestinal obstruc-
tion. Yet to recognize this lesion in an
early stage, in which the chances of recov-
ery are greatest, one must be content with
fewer and less positive symptoms than
have been considered in the past, and a
new sign, a rise in the number of the leu-
cocytes, has been found to be one of the
most important aids. Delay in appendi-
citis in many instances means death or an
abscess formation, which demands drain-
age. It is far rtiore difficult to diagnosti-
cate appendicitis in the proper stage for
operative intervention, than to perform the
operation. It is much easier to instruct
students in the operative technique of ap-
pendectomy than to teach them the timely
recognition of the lesion. Place a recent
graduate in a large surgical clinic, and he
will become an efficient operator long be-
fore he becomes an expert diagnostician.
To illustrate the importance of an ear-
lier working diagnosis, I shall confine my
remarks this evening chiefly to the diag-
nosis of tumors, and later further illus-
trate by a lantern slide demonstration on
diseases of the breast and bone.
The records of a large surgical clinic are
pathetic in regard to malignant tmnors.
Fortunately there is more than sufficient
evidence to indicate that a malignant
tumor in its early stages is a local disease.
This fact should be impressed upon the
laity and upon ourselves. As long as can-
cer and sarcoma are confined to the locality
of their birth, they are curable. In addi-
tion, many cases of carcinoma are curable,
even wBere metastasis has taken place to
the neighboring lymphatic glands. Ac-
cumulated experience demonstrates that in
the period (x), during which a tumor
does not give sufficient evidence of itself
to attract the attention of its host, the dis-
ease seldom becomes incurable.
The stage (a), due to the delay of the
individual, unfortunately in many cases is
fatal. But when we come to study the
clinical histories with care, we are cha-
grined to find that the incurability of the
lesion can be attributed just as often to the
physician's procrastination as to the indi-
vidual's ignorance or timidity.
A decision in regard to a tumor should
be made at once. The terms "innocent"
and "malignant," employed by Bland Sut-
ton in his excellent text book on tumors,
are most appropriate, and we can use them
in formulating a law in regard to the
treatment of tumors directly opposite to
the almost universal law applicable in the
trial of individuals accused of crime,
namely, a tumor should be considered
malignant until every means has been ex-
hausted to demonstrate that it is innocent ;
Digitized by
Google
February, 1904. SURGICAL PATHOLOGY— BLOODGOOD.
63
also in regard to tumors in contrast to the
treatment of individuals, "Lynch law" is
by far the better procedure than "due pro-
cess," so frequently followed in waiting
for developments.
The responsibility of the physician,
whose advice is sought by an individual
in regard to some tumor formation, is
great, if he advises delay, and if during
this period the tumor becomes inoperable
locally, or destroys the possibility of a per-
manent cure by internal metastasis, the
odium should fall upon him, and not upon
the later surgical intervention.
In a clinical diagnosis of tumors, we
may divide them into three groups: — be-
nign, doubtful and malignant.
If a patient first comes under observa-
tion when the tumor is undoubtedly malig-
nant, there is no question in regard to im-
mediate operation, and should the opera-
tion fail to cure permanently, the fault
lies with the patient.
A clinical diagnosis of a benign tumor
should only be made in those cases in
which there is no possibility of mistake.
This is possible in many instances, and an
operation need not be advised. All tumors
which are not benign or malignant, belong
to the second group. In such tumors de-
lay is never justifiable. Immediate surgi-
cal intervention should be not only ad-
vised but urged.
It is in this group of tumors in which a
clinical diagnosis sufficiently positive can-
not be made, that the relation of surgical
pathology to diagnosis becomes of para-
mount importance, because our inability •
to make a clinical diagnosis demands an
exploration of the tumor, and at this ex-
ploration we should be prepared to recog-
nize the lesion by the gross appearance of
the disease exposed by the knife. The ob-
ject therefore of surgical pathology is to
instruct in the positive recognition of sur-
gical lesions by their naked-eye appear-
ances. The study of surgical pathology
demonstrates that such a gross pathologi-
cal diagnosis is possible in the great ma-
jority of instances. The thorough investi-
gation of what we may call the clinical
history and picture, the gross pathological
appearances confirmed by microscopic
study, and the ultimate result after opera-
tive interference demonstrate that
1. A certain number of tumors can be
recognized from the clinical history and
picture as benign; in some of these cases
operative removal is not necessary, in oth-
ers in this group operation is indicated on
account of the size or discomfort of the
tumor, or because experience demonstrates
that these tumors have a tendency to be-
come malignant, and of course there can
be no dispute that it is far better to remove
them in the benign period;
2. In other tumors it is absolutely im-
possible to make a positive diagnosis; for
this reason an exploratory operation is im-
perative. The nature and extent will de-
pend upon the character of the surgical
disease exposed by the knife. A naked
eye diagnosis is possible in the majority of
cases ;
3. Unfortunately, a large majority of
tumors come to the surgical clinic at a
stage when there is no doubt in regard to
their malignancy. Operation, of course,
is indicated, if operable, but the study of
the ultimate results demonstrates that
when a malignant tumor has reached the
stage in which there is no difficulty in
making a clinical diagnosis, the possibili-
ties of a cure are greatly decreased, and in
many instances they have become incura-
ble because of local infiltration or internal
metastasis. In other words, if we wish to
improve the results in the permanent cures
Digitized by
Google
^4
CEREBRAI. AND MENTAL DISEASE— WBIGHT. Jour. M. S. M. S.
of malignant tumors, we must instruct
the public that they must seek the advice
of a physician the moment their attention
is attracted to a tumor formation. And
the practitioner must never delay in advis-
ing and urging these patients to submit to
immediate operation, except in those cases
in which there is absolutely no doubt of
the benign character of the tumor. And
not only this, but also that the benign
tumor in question has no tendency to later
become malignant.
Th« rarlicr the Tfidwiiittal sedcs the ad-
vice of the physician, and the earlier the
tumor comes to the surgeon, the more will
the importance and the necessity of the
naked-eye recognition of the surgical les-
ion be demanded by exploratory incision.
4. The study of surgical pathology
demonstrates that malignant tumors vary-
enormously in their malignancy.
Note. — All of the points in this introduction
were amply illustrated by excellent illustra-
tions taken from the cases at the Johns Hop-
kins Hospital, and thrown upon the screen by
the stereopticon.
THE ESSENTIAL POINTS OF DISTINCTION BETWEEN
CEREBRAL AND MENTAL DISEASE.*
HIRAM A. WRIGHT,
Detroit.
An essay having this title would be un-
called for were it not for the fact that too
many medical men entertain the idea that
when a person becomes insane, some area
in the brain cortex is the seat of the diffi-
culty. If it were true that insanity is al-
ways, or even occasionally, dependent
upon some cortical change, then it would
be proper to consider insanity as a symp-
tom, or complex of symptoms, dependent
upon the cerebral lesion which induces it.
Were this a true premise, then we should
logically conclude therefrom that the va-
rious types of mental disease, such as mel-
ancholia, mania, stupor or paranoia, should
be considered a3 types of cerebral disease,
not mental disease.
The question would naturally arise
then, what kind of a lesion of the cortex
will induce melancholia in one patient,
♦Read before the Section on General Medicine
at the annual meeting of the Michigan State Med-
ical Society at Detroit, June ir, 1903, and ap-
proved for publication by the Committee on Pub-
lication of the Council.
mania in another, and paranoia in a third ?
If insanity were dependent upon lesion of
the cortex, this question ought to be satis-
factorily answered by those who claim
that cerebral lesion is necessary to induce
' insanity. But it is offered as a reply that
in many cases there is no organic lesion
demonstrable in the brain of one who was
manifestly insane during life. In such a
case we are asked by some to accept the
theory, now being ardently advanced by-
many neurologists, that defective meta-
bolism, toxaemia, or auto-intoxication, is
responsible for the insanity observed. No
doubt in some cases these phenomena
(toxaemia or auto-intoxication) are asso-
ciated with insanity, but is it not more
reasonable to believe them results of, or
concomitants with the insanity, rather
than the causes thereof? Particularly so
in cases of melancholia or stupor, where
the patient, being despondent, and inactive
physically, indulges in little or no exer-
cise, frequently has constipation and di-
gestive disturbance. In such cases we
Digitized by
Google
February, 1904. CEREBRAL AND MENTAL DISEASE— WRIGHT.
65
might naturally expect to find some defec-
tive metabiolism, or a genn-laden intes-
tinal tract infested by both pathogenic and
non-pathogenic organisms.
Those who assert that such bacterial, or
toxic agents are etiologic factors in the
production of insanity have not observed
them until after the patient became insane,
not before the insanity became manifest.
If a bacteriologist should make an ex-
amination of the blood, or intestinal con-
tents of a person regarded as sane, and
should find certain toxic or bacterial prod-
ucts, would he dare make the prediction
that because of his findings, the person is
therefore liable to become insane? No!
but yet many alienists have been free to
assert that in some cases these toxins are
causes of insanity, rather than concommi-
tant or coincidental phenomena.
There can be no doubt but what tox-
aemia and bacterial infection of intestinal
contents are both quite frequently ob-
served among the insane, perhaps propor-
tionately more frequently than among
sane; but this does not by any means es-
tablish the truth of the claims put forth
that such physical states are causes of in-
sanity; far from it.
What more is the little "bug" going to
be accused of? He is responsible for a
great many physical diseases which a few
years ago were ascribed entirely to other
causes; let us not make him responsible
for that which in the nature of things he
cannot be, if we properly comprehend
what mental disease means.
We have dwelt somewhat at length
upon this phase of the subject, because it
is the latest theory advanced by some rec-
ognized alienists and neurologists as a
feasible explanation of the cause of some
cases of insanity; not because we accept it
as true, for we reject it entirely as unten-
able and wildly speculative.
Toxic blood states at best can but pro-
duce delirium. Delirium, however, is not
insanity, some writers to the contrary not-
withstanding. To consider a little fur-
ther the subject of organic lesions of the
brain in this connection, it must be re-
membered that about 80 per cent, of all
cases of insanity are classified as inor-
ganic psychoses. By this it is meant, no
change in the brain is found post-mortem
in patients suffering from these types of
mental disease, and since we find a con-
siderable proportion of patients suffering
from organic diseases of the brain, who
during life show no signs of mental de-
rangement, why should we adhere to the
opinion that mental disease is therefore
dependent upon brain change, organic or
otherwise ?
Sometimes, it is true, we find in the
brain of those who during life were mani-
festly insane pronounced pathological
changes, but this does not prove that the
insanity was dependent upon the lesion
found in the brain, since that many insane
patients manifest very similar symptoms
and yet display no evidence of organic
brain disease whatsoever upon postmor-
tem examination.
The brain of the insane patient is liable
to organic disease just as is the brain of
the sane. A person suffering from brain
disease is liable sometimes to become in-
sane, just as the person who is free from
brain disease. We know these facts
to be true, they are not mere trumped-
up theories.
As we have said above, more than 80 per
cent of all cases of insanity show no brain
disease on post-mortem examination. This
being true, what, then, is mental disease?
The question can only be answered intel-
ligently by one who has first studied what
the normal mind is. Just as the medical
student, in order to comprehend the full
Digitized by VjOOQIC
66
CEREBRAL AND MENTAL DISEASE— WRIGHT. Jour. M. S. M. S.
significance of certain pathological condi-
tions of the body, is first required to fa-
miliarize himself with the normal condi-
tion of the several organs of the body, so
Ave deem it proper that in order that a
student or a medical man may compre-
hend what mental disease is, he should
first form some definite conception as to
what normal mind is.
"The brain is the organ of the mind,"
is a familiar sentence used by many neu-
rologists to explain the unknown depend-
ence of mind upon brain, but what does
the sentence mean? Do we ever hear
anyone attempt to explain what they mean
by saying "The brain is the organ of the
mind?" They surely do not wish us to
believe that it is the organ of the mind
in the same sense that we believe the
iiver to be the organ which secretes bile.
We choose to explain the relationship be-
tween mind and brain by saying the brain
is the physical organ, by which intellectual
processes are made manifest.
There is a w'ide distinction between the
idea of intellectual processes being de-
pendent upon cortical integrity, and be-
lieving that intellectual processes are made
manifest by means of nervous activity.
Students of medicine who have never
studied psychology are accustomed to ac-
count for consciousness and intellectual
processes incident thereto on physiological