suppuration of one of the three spaces is estab-
lished, of the epitympanum of the aditus, or of
the antrum, be it that we have before us, caries,
granulous ostitis, cholesteatoma necrosis, or an
empyema, with more or less considerable dis-
eased walls."
In view of all we know now about
the suppurative affections of the midd'e
ear we are able to answer upon the ques-
tion why it is safer not to wait too long
before operating on the middle ear, that it
is easier to deal with a mastoid affection
which does not extend into the neck, into
the lateral sinus, into the cranial fossx.
Digitized by CjOOQIC
Dbcember, 1904. THE MASTOID AND THE MIDDLE EAR— AMBERG. 545
or into the meninges or the brain. Com-
plications of such nature require more
extended interference, and a more pro-
longed after-treatment, besides giving a
doubtful prognosis. The early incision
of the drum membrane is of paramount
importance. Koemer published the ex-
perience that the number of patients in
whom the drum membrane had been
opened early in a middle ear suppuration,
did not have to submit to mastoid opera-
tion so frequently as the number of pa-
tients in which an incision of the drum
membrane had been postponed. For the
general practitioner I should like to em-
phasize the necessity of an early incisioi\^
of the drum membrane in acute otitis,
media and the early recognition of a mas-
toiditis.
Furthermore, close attention should be
paid to the conditions of the nasopharynx
and the fauces. Affections of the nasal
passages hypertrophic and diseased ton-
sils, and especially adenoid vegetations
must be attended to, in order to prevent
and to successfully treat a middle ear sup-
puration.
If I should be asked what, in my mind,
is the reason that the mastoid and radical
operations are still looked upon with fear
by many I am obliged to answer that it is
the lack of good training in otology in the
medical schools, the absence of thorough
bedside experience, which is so important
in middle ear affections, and the fact that
there does not seem to exist sufficient ana-
tomical material to practice the technique
of the operations which is not easy. For
the shortsightedness in the latter instance
the community pays the penalty with the
death of many of its members. More
autopsies and more opportunity to per-
form operations mentioned on the dead
body will surely save many a life.
Endocarditis.— Conclusions.
1. Malignant endocarditis is a disease of bac-
terial origin; it differs from single acute endo-
carditis in the extent of endocardial inflammation
and tissue necrosis ; in the fact that the right heart
is more often attacked; in the more frequent
embolic processes which are septic in character.
Micro-organisms are found in the blood during
life, in the thrombi and in the heart valves after
death.
2. There is nothing in the clinical appearance
distinctive of any particular variety, of germ
causing it.
3. Primary cases are rare, though they do ex-
ist; most cases, however, accompany rheumatism,
septicaemia, the acute infectious diseases, or are
engrafted upon an old endocarditis.
4. Almost all are .fatal ; the ones due to severe
infection in a few days; the septic ones in a few
weeks. The first variety have a leucocytosis of
15,000 or over; the latter usually below that num-
ber, some being slight.
5. Emboli and haemorrhages are of frequent oc-
currence and may be fatal in their results.
6. The urine usually shows evidence of neph-
ritis ; it may tontain blood and pus from haemor-
rhage or infarct.
7. Infants and young children seem to be almost
exempt from the disease.
8. Treatment is usually unavailing, excepting
the serum therapy which is of uncertain value.—
(The American Journal of the Medical Sciences,
November, 1904. R. S. Morris.)
Abnormal Frequency of Urination Treated
with Epidural Injections. — Conclusions.
1. Epidural injections with decinormal salt so-
lution offer the most promising results in abnor-
malities of urination due to faulty vesical inner-
vation.
2. Incontinence of urine, enuresis, excessive
frequency of urination (unless due to other
pathological condition) can at least be amelior-
ated by epidural injections.
3. Cautiously performed, epidural injections
are in no wise dangerous to the patient
4. Epidural injections are no more painful than
any hypodermic injection with a mild solution.
5. Epidural injections can be performed by any
one who follows the technique outlined and is
alert to those anatomical variations which are so
frquent in the region.
6. The immediate effects of epidural injections
are very rarely even disagreeable. — (The Amer-
ican Journal of Urology, November, 1904.)
546
EDITORIAL.
Jour. M. S. M. S.
The Journal of the
Michigan State Medical Society
All communications relative to exchanges, books for review,
manuscripts, advertisiflg and subscriptions should be
addressed to Editor A. P. Biddle, 57 Fort Street West,
Detroit, Mich.
SabKripCloa Price, Two Dollars per year. In Advance
DECEMBER, 1904
£t)ltorlaI
RULES GOVERNING MICHIGAN
UNIVERSITY HOSPITALS—
THE RICH TREATED
FREE.
Hospital management still presents
many mooted questions. Its relations to
medical teaching, the medical profession
and the people are not entirely satisfac-
tory. Hence, the official statement of the
Regents of Michigan University will be
read with interest. They have two hos-
pitals and two medical schools under their
control. Whether the Regents consulted
with their faculties or the profession at
large or even their own alumni does not
appear. We trust every physician in
Michigan will, carefully study these rules
and decide for himself whether, in his
judgment, they will promote the interests
of (1) the schools themselves, assisting
the faculties to' secure more and better
clinical material; (2) the University as a
whole; (3) the alumni of the medical
schools; (4) the medical profession of
the state; (5) the people of the State of
Michigan. The Michigan Alumnus,
October, 1904, gives the official state-
ment answering queries propounded by
Dr. Carrow thus:
*'l. The primary object for which the
University Hospitals were established
and maintained by the people of the state
is to furnish the medical faculty facilities
for giving instruction to medical students,
and all patients admitted to these hospi-
tals for medical or surgical treatment are
admitted upon the express conditions that
they shall receive such medical or surgical
treatment in the presence of medical stu-
dents for the purpose of giving medical
or surgical instruction. Hence, if the pa-
tient is valuable for the purposes of giv-
ing medical or surgical instruction, the
question whether he is rich or poor is not
one which the duty of any employee of the
University of Michigan requires him to
investigate, or to remark upon either to
the patient or in the presence of the stu-
dents.
*'2. In no case shall any patient com-
ing to the University hospitals for treat-
ment be subjected either directly or indi-
rectly to any influence, pressure, or in-
ducement on the part of physicians in
charge of the hospitals or their assistants,
or by any employee of the University, to
induce such patient to leave the hospital
and go to the private office, or private
hospital, of any of the hospital physicians
or elsewhere for treatment.
"3. Whenever a patient has been ad-
mitted into either of the hospitals "for ex-
amination and treatment and has been so
registered, no hospital physician or as-
sistant physician shall be allowed to treat
such patient as his private patient for the
relief of the ailment for which such pa-
tient has been admitted to the hospital un-
less such patient shall have signified in
writing to the superintendent of the hos-
pital his or her desire for such change.
"4. The superintendent, the hospital
physicians, the assistant physicians, the
internes, nurses, and all employees are
hereby required to give all patients proper
and prompt attention, and subject them to
as little delay as possible, to the end that
all persons coming tojhe^hc^^l^gjgie
Dkcbmber, 1904.
EDITORIAL.
547
University of Michigan for medical or
surgical treatment may do so with full
assurance and perfect confidence that they
will receive speedy and considerate atten-
tion.
"6. The University of Michigan and
not the physician shall furnish to patients"
in its hospitals any glasses, optical, surgi-
cal, or other appliances which may be
prescribed for their relief by the physician
in charge of the case.
"6. It shall be the duty of the superin-
tendent of the hospital under the direction
of the physician in charge of the case to
procure and furnish to the patient such
glasses, optical, surgical, or other appli-
ances so directed by the physician in
charge at a reasonable cost."
Two branches of the Michigan State
Medical Society — the Wayne (p. 659)
and Shiawassee (p. 656) Counties — ^have
unanimously protested against the action
of the University Regents in ordering the
free treatment at the State Hospitals of
the rich as well as poor. The Wayne
G)unty Medical Society has appointed a
committee to confer \yith the Regents on
the matter.
NATURE'S WAYS.
We are surrounded on all sides by a
great number and by a great variety of
micro-organisms, some virulent, others
non-virulent. Nature is indeed kind to
us all. How comparatively few of us
suffer from the presence of these hosts of
microbes. Roger* has most interestingly
described the defense of the organism
against infection.
When infection does take place one of
two things may happen. There may be
no struggle between the microbe and or-
♦Infectious Diseases by C H. Roger.
ganism because of the highly virulent na-
ture of the microbe or because of the low
resistance of the organism, or the invaded
organism may endeavor to arrest the in-
vader or to circumscribe the infection,
producing a local reaction. Unfortu-
nately this first defense is often insuffi-
cient and the microbe enters the circula-
tion.
What are some of nature's defenses
against the various micro-organisms?
Lymphatic glands, great omentum, liver,
lungs, serous and mucous membranes and
skin all guard the living organism against
the pathogenic microbe. A micro-organ-
ism getting into the lymphatic vessels
reaches a lymphatic gland where, it has
been demonstrated by Manfredi, it looses
part at least of its virulence. Contrary to
what was once believed, the peritoneum
resists infection well. The great omen-
tum plays an important part in the pro-
tection of the peritoneum.
The intestine normally is full of bac-
teria. Some of these may and do at times
become virulent. The defenses against
bacteria endeavoring to invade the organ-
isms from the intestinal tract are as fol-
lows: (1) Intestinal epithelium; (2)
mesenteric glands; (3) liver, and (4)
peritoneum. .
Roger's study of the action of the liver
and lungs on the various organisms is of
much interest. He finds that the liver is
a protective organ against anthrax bacilli
and the staphylococcus aureus, while the
lungs have the same action on the strepto-
coccus. His researches show that the
liver is an excellent culture media for the
colon bacillus. The frequency and grav-
ity of hepatic infection of gastro-intestinal
origin is well explained by this fact. He
further found that fasting diminished the
protective function of (J^'^Uv^i against
548
EDITORIAL.
Jour. M. S. M. S.
the staphylococcus aureus, but quite
slowly. Ether and glu^cose taken in large
doses diminished also the protective power
of the liver. In small doses they in-
creased it.
Various microbic poisons are found
within the intestine. The interesting re-
searches of Queirolo, Denys and others
have established the protective roll of the
intestinal epithelium, which acts on both
vegetable alkaloids and certain microbic
toxins, especially those produced by the
colon bacillus. Some of these poisons
leave the intestinal canal through the lym-
phatics, only to be arrested and modified
by the glands. The greater part, however,
pass into the blood and reach the liver
through the portal vein.
The liver arrests vegetable alkaloids,
toxins, modified aromatic substances, ar-
rests and neutralizes ammonium salts (at
least those in which the base is united
with carbonic acid or some organic acid).
The lungs are able to attenuate at least
certain poisons. They* act on vegetable
alkaloids, ammonium carbonate and fatty
acids.
On entering the blood microbes prob-
ably undergo attenuation by oxidation or
by neutralization exercised through cer-
tain principles which the leucocytes dif-
fuse.
The kidneys serve for elimination of
toxins. The infectious poisons contained
in the organism are albuminoid sub-
stances. Those contained in the urine are
of alkaloidal nature. Roger suggests
that perhaps the primary complex mole-
cule is broken up in the kidney and leaves
this organ as an' alkaloidal radical.
The respiratory apparatus eliminates
volatile substances. The skin likewise
V eliminate toxins. The toxins in the
intestine may cause a diarrhoea, vomiting
or both, and by this means some of the
toxin is removed from the body.
THE CARDIAC AND VASCULAR
COMPLICATIONS AND SE-
QUELS OF TYPHOID
FEVER.
William Sydney Thayer* sums up our
knowledge concerning the subject in the
following conclusions:
1. Typhoid fever is a disease which
from a clinical standpoint, is often asso-
ciated with symptoms suggestive of a
grave weakening of the heart muscle.
These changes, whether due primarily to
direct action of the typhoid poison on the
heart or to impaired nourishment from
vaso-motor paralysis, result, in a consid-
erable proportion of cases, in a temporary
insufficiency of the mitral valve as indi-
cated by the appearance of apical systolic
murmurs which are, not infrequently,
transmitted to the axilla. These mur-
murs develop especially at the height of
the disease, during the latter part of the
first and in the second, third and fourth
weeks, and disappear usually with conval-
escence. Sometimes, however, they may
persist.
Twelve out of one hundred and eighty-
eight cases of typhoid fever who were
followed from three months to fourteen
years after convalescence, showed condi-
tions suggestive of organic cardiac lesion.
In the majority of these cases a systolic
apical murmur had been detected during
their illness. Over one-fifth of our old
typhoids in whom, during their illness, a
systolic apical murmur was heard, showed
* Johns Hopkins Hospital Bulletin, October,
1904.
Digitized by VjOOQIC
Decbmbbr, 1904.
EDITORIAL.
549
on subsequent examination evidence of or-
ganic disease. The average systolic blood
pressure (Riva Rocci) was higher in
every decade among our old typhoids than
in healthy individuals who had never had
the disease. The radial arteries were pal-
pable with strikingly greater frequency in
our old typhoids than in healthy indivi-
duals of the same age who had never had
typhoid fever.
2. Endocarditis, while not a common
complication of typhoid, is probably more
frequent than generally supposed. It was
present without being suspected in 3 out
of 95 cases coming to necropsy at the
Johns Hopkins Hospital, while in 3 fur-
ther cases out of the remaining 1,363 the
clinical symptoms suggested its presence.
It is not impossible that endocarditis is
more frequent than indicated by these fig-
ures.
3. Pericarditis is an unusual and un-
important complication of typhoid fever.
Three instances only were noted in our
1,468 cases.
4. Phlebitis and venous thrombosis is
a frequent complication of typhoid fever,
occurring in over 2.6 per cent, of our
cases. The onset occurs usually in the third
week or later and is in most cases associ-
ated with fever, leucocytosis and local
pain. The phlebitis is, in the great ma-
jority of cases, localized in vessels of the
lower extremity, especially the left side,
and is particularly frequent in the femoral
veins (about one-half of our cases).
Thrombosis of the iliac and femoral veins
is always a serious complication, although
the immediate dangers (gangrene, exten-
sion of the thrombus, pulmonary embo-
lism) are not great, the after- results are
often grave. In thrombosis of the fe-
moral or iliac vein, the affected extremity
is always considerably and permanently
enlarged, and there is usually more or less
persisting disability (extensive varicosi-
ties often resulting in ulceration, marked
weakness of the limb, and frequent
cramps in the muscles, especially at night
and after over-exertion).
5. Arteritis and arterial thrombosis is
a more frequent complication of typhoid
fever than is generally recognized. This
complication appears to be especially com-
mon in the cerebral vessels, although it
may occur in the extremities. The onset
is most common in the third week or later
and the attack is often ushered in by fever
and leucocytosis. In the extremities ar-
terial thrombosis is commonly followed
by gangrene; in the central vessels by
hemiplegia. Arteritis in the extremities
may be associated with partial parietal
thrombosis from which nearly complete
recovery may occur.
6. A survey of our pathological ma-
terial would suggest that typhoid fever
may be a not infrequent cause of great
arterio-sclerotic changes.
7. While the deleterious influence of
typhoid fever upon the cardio-vascular
systems is not as g^eat as that of acute
rheumatism, yet through the unfortunate
frequency of the disease in this country it
is probable that post-typhoid cardio-vas-
cular defects are not uncommon.
ACCESSORY THYROID ON THE
TONGUE.
Dr. Randolph Winlow, of Baltimore,
concludes that "a moderate sized,
rounded, elastic tumor, situated at the
base of the tongue, and covered by
smooth, normal or congested mucous
membrane, not painful, with no metas-
tasis, growing slowly and occurring usu-
Digitized by VjOOQIC
550
EDITORIAL.
Jour. M.S. M.S.
ally in young women, is almost certainly a
neoplasm consisting of thyroid tissues.
These growths do not usually present any
alarming symptoms, but should be re-
moved when they give rise to discom-
fort or cause difficulty in deglutition or
respiration."
Various methods have been used for
their removal. The McBurney'*' method
is from below, the incision extending
from the hyoid bone to the chin in the
medium line. The mylohyoid muscle is
cut and geniohyoid and geniohyoglossus
muscles on each side are pushed apart. In
this manner the tumor is reached and
enucleated through the incision. The mu-
cous membrane covering the growth is re-
moved with scissors through the wound.
Catgut is used in closing the wound and
in bringing the muscle together.
The method used by Oliver C. Smith, f
of Hartford, was much more simple. He
operated through the mouth, which in his
case was entirely feasible.
Curtiss and Gaudier'sJ method is to
draw the tongue out as far as possible
and circle the neoplasm with a suture.
This is drawn tight, incised and then the
suture is tied.
DIFFICULTIES IN EXTERMINAT-
ING QUACKS.
It is often asked why the Michigan
State Board of Examiners do not root
out those guilty of illegal practice. Those
convicted of offense against the law are
certainly few. Many actual quacks ob-
tained licenses under the old laws or no
* American Medicine, December, 1902.
tiV. y. Medical Journal, October 29, 1904.
tRez'ue hebdomadaire de Laryngologie, d'oto-
logie et de rhinologic, April 12. 1902.
law period. These retain their rights.
But there are plenty others, which with
impunity ply their trade. No doubt the
fundamental difficulty lies in the fact that
the people want just such service as these
lawbreakers supply.
In New York City the Medical Society
of the County of New York has convicted
only about five hundred charlatans during
the past five years. In explanation of this
small number out of the existing thou-
sands the society gives the following :
First — Lack of funds. There are two
thousand members of the medical profes-^
sion in the New York County Society. In
order to make our work as effective as
possible, the scientific features of our so-
ciety have been curtailed in order to de-
vote our funds to the suppression of the
dangerous quack. For the last five years
we have expended every available dollar
for this purpose.
Second — Inherent difficulties in the na-
ture of prosecutions. In rarely one case
out of one hundred will the real victim of
the charlatan consent to give evidence.
They report their cases to the society, on
condition that they be not called as wit-
nesses. This is to avoid the exposure,
humiliation and disgrace which in many
instances would follow publicity. This
necessitates the society procuring its own
evidence, at great expense, against every
charlatan it prosecuted.
Third — Radical defects in the medical
law. We have no definition in this state
as to what constitutes the practice of med-
icine. Until the legislature gives us a sat-
isfactory definition, great uncertainty will
exist. We have repeatedly asked the leg-
islature for such a definition, and have
been as often refused.
Fourth — Failure of the newspapers to
co-operate. The modern charlatan could
Digitized by
Google
DkchmbeRi 1904.
COUNTY SOCIETIES.
551
not exist without publicity given his ad-
vertisements by the press. If our New
York papers would refuse advertisements
for the sale of drugs for a criminal pur-
pose, illegal lying-in establishments and
the distressing advertisements of the so-
called specialists for diseases of men only,
and the '^consumption cure" frauds, it
would not be difficult for the medical so-
ciety, even with its present lack of funds,
to rid the community of the chief offen-
ders. These vicious advertising charla-
tans draw their recruits from innocent
victims attracted by the advertisements
unblushingly received by many New York
newspapers.
DEATH OF D. W. C. WADE.
Dr. Wade died at the Flint Hospital,
Friday, November 4th, aged sixty-nine.
Several weeks previous he had been oper-
ated on for appendicitis, but complica-
tions prevented recovery.
Since 1863 he has practiced medicine
at Holly and was the oldest physician in
that region. He came into notice early
•in his professional life by his advocacy of
hydrobromic acid and a working formula
for its preparation. He loved surgery,
and for a time maintained a private hos-
pital for the convenience of his patients.
He loved office practice rather than the
typical rides of the country practitioner.
He was a forceful writer and many pa-
pers from his pen may be found in past
volumes of the transactions of the Michi-
gan State Medical Society, and in the
medical journals. Of these it must be
said that he always had something to say,
said it and stopped. As a result many
of his papers were abstracted by other
medical journals, and so reached large
audiences.
He loved his local society and presided
at its meeting in Pontiac last September.
The older members of the profession will
recall his frequent attendance at the meet-
ings of the Michigan State Medical So-
ciety and the American Medical Associa-
tion, and his eager interest in all that
promoted their prosperity. Through these
associations he had a wide acquaintance
among the best physicians, not only in his
county but throughout Michigan and be-
yond its borders. His work as a physi-
cian and surgeon was typical of the best
work done in small cities — honest, thor-
ough, up-to-date.
All who knew him lament the loss of a
true friend, a helpful co-worker in the bet-
terment of mankind. Especially has the
State Society lost the support of a strong
and able advocate.
Counti? Society? fle\x>0.
GENESEE COUNTY.
The annual meeting of the Genesee County
Medical Society was held October 25, 1904, at
Flint. Officers were elected as follows:
President, A. S. Wheelock, Goodrich.
Vice-president, G. V. Chamberlain, Flint.
Secretary-Treasurer, H. R. Niles, Flint.
Directors — For fve years, J. C. Willson,
Flint; for four years, Bela Cogshall, Flint;
for three years, Annie Stevens Rundell, Flint;
for two years, W. C. Kelly, Flifit; for one year,
Abram Goodfellow^ Clio.
. Three applicants were elected to membership
as follows: Edmund Bachman, Fenton; Ed-
ward C. Rumer, Davison; H. C. Switzer,
Gaines.
In accordance with the recommendation of