The China medical Journal.
Voi,. XIJII. NOVEMBER, 1929 No. 11
TREATMENT OF KALA AZAR WITH REPORT OF 92 CASES FROM HOPE HOSPITAL, ANHWEI, CHINA
Tkedore M. Y ates, B, S. M., II. D.
Soon after opening Hope Hospital in Hwai Yuen, cases of visceral Leishmaniasis began coming in for treatment. The patient with this disease is truly a pitiful spectacle with ab domen distended from enormously enlarged spleen and liver, fever, ulcerated gums, general weakness and so often acutely ill from a superimposed pneumonia or dysentery infection. At that time, even though kala azar was a recognized disease, there had not been found any effective method of com bating it. Massive doses of quinine were administered but these and other methods of treatment rarely had any effect. Dr. Samuel Cochran did a number of splenectomies but frequent ly the condition of the patient was so poor that this method could not be considered. (Recently one of these splenectomized) patients paid us a visit bringing in another patient, so even this method has its successful cases. When the intravenous use of tartar emetic was introduced the whole aspect changed. From then on there was a weapon that could be used in resisting this disease and patients need no longer be sent home as incurable. Gradually as the news of the success of this treatment spread the number of cases in creased until at present there are at least fifty cases treated annually in our hospital. Hwai Yuen is about one hundred miles north west of Nan king in Anhwei Province. The cases usually come in for treat ment from districts eighty to two hundred and fifty miles away, drifting down the rivers from Honan or western Anhwei, com- Group oj nineteen kala-azar patients i n hospital at one time. 1054 The China Medical Journal mg by wheelbarrow or walking from regions not near the rivers, sometimes travelling several weeks before arriving at \he hospital. The condition of the patient who had undertaken such-a long journey can readily be imagined. . The majority of these cases are poor farmers. They bor row money on their crops, or land, and are severely put to it financially to bear the expense of the journey and of the stay in the hospital. The Twenty Dollar cost of a three month’s treatment is in many cases more than they can raise in any way. Many of them have never seen so much money at one time. At first tartar emetic, on account of its toxicity, when used intravenously, was used with so much timidity and care, that the course of treatment extended beyond six months, as the dosage was slowly increased, and even then relapses were noti unusual. Actually these relapses were failures to cure due to insufficient concentration of drug in patient. Later, as we became more familiar with the interavenous use of this drug, the treatment became more or less standardized anl less prolonged. However, each patient has his own toler ance point which must not be passed, or unfortunate results occur, so the necessary length of time for completion of treat ment varies with each individual. During the Fall of 1926, the routine treatment consisted of intravenous injections of 1% tartar emetic solution in doses of 3 c.c. progressively, but carefully, increased up to 12 to 14 c.c. but even 130 lb. men were not able to stand this maximum dosage any length of time. The patient lay down for two hours immediately following the intravenous medication, and if he had nausea, sharp raise of temperature or other reaction, the subsequent dose was de creased. Quite often a coughing spell occurred immediately after, which, in most cases, could be ignored. An average sized adult would receive about 280 c.c. in about three or four months time, before arrest of disease was fully secured. The injections were made three times a week and the duration of treatment, as shown in accompanying tables, still averaged 91.5 days, three months, Showing outline oj spleen before Showing decrease in area of treatment began, (broken line) and spleen after treatment of one month outline of sjjleen at end of one duration. month. Case 8074, duration three years, left hospital at end of ,70 days. White blood count increased from 1000 to 4200. Spleen outline: r/s above shown
Case 8679—Showing marked decrease in size of spleen. Caxc in hospital 40 days. The Treatment of Kola Azar 1055
During a large part of this time the patient was desperate ly ill. I shall not describe the symptoms, as they are so realisti cally described in Manson’s “Tropical Medicine” and by Brooke (in the American Journal of Tropical Medicine, VII, $1). The cases in China ranged in severity from those too ill to get oute of bed to others who would continually slip away from the nurses, and go out, and buy indigestible infected food from the street vendors. The mortality is due to intercurrent infections, pneumonia in winter and dysentery in summer. Due to their leucopenia, (note case tS711 has W.B.C. of 7001) their resistance is very poor and comparatively few recover from a severe respiratory attack. We found that to them pneumonia is very infectious, travelling from bed to bed. At one time we had three cases of pneumonia in one ward, all contracted during stay in hospital Strict and prompt isolation of all cases who developed coughs and fever cut down our pneumonia rate remarkably. Four of the seven treatment cases are labelled amoebic. These answered to emetin treatment much more slowly than do our usual amoebic dysentery cases. In some cases (see No. 8387) there seemed to be a direct connection between the dosage of tartar emetic and the severity of diarrhoeal symptoms. This patient, I feel sure, would have reacted favorably to our present treatment and possibly would have recovered. The treatment in each case is re-inforced by the clearing up of intestinal parasites. With simple ascaris infection we use santonin. With mixed infection, in all cases, we use oleum chenopodium and CC14, the dosage depending on the age, size and condition of the patient. Some cases have to have three or four treatments before the stool becomes negative for hook worm ova, although consistently negative for ascaris ova after the first treatment. A routine liver puncture is done in each case, with few exceptions and this is repeated until a smear positive for Leish- man-Donovan Bodies is obtained. However, on account of the seriousness of the illness, treatment is not delayed waiting for a positive finding, if the case is clinically kala azar. On account of the preliminary small dosage of tartar emetic the medication does not interfere with the chances of securing a smear pos itive for Leishman Donovan Bodies, 1056 The China Medical Journal
Because of the slowness of the tartar emetic treatment we were very pleased to hear that in India there had been developed an organic antimony compound, by the use of which one could get larger dosage with less toxic symptoms, thereby reducing danger to patient, not only from overdose, but also the danger from prolonging his illness and lengthening the period of his hypersusceptibility to intercurrent infection. We were encour aged by Dr. Struthers of the Shantung Christian University to use this type of preparation and the following are our observa tions :— The new antimony compounds were secured in Shanghai. One, von Heydn’s “471” a German preparation, is a urea salt of antimony. The other preparation used was B ur rough s- Wellcome “Stibamine Glucoside.” In efficiency we could find no difference between these two salts. By buying larger am pules of this medication from Burroughs-Wellcome we could bring the cost per patient down to below $5.00 each, so we gradually used more of their product and less of the German. Immediately before injection the contents of the ampule are emptied into enough sterile distilled water to make the con centration not more than 4%. The initial dose, in the case of an adult, was 0.05 Gram. This was doubled for the second dose, two days later if no reaction occurred. Then the maximum dose of 0.2 G. was quickly attained. (Very rarely did we go as high as 0.3 G. in the case of adults of over 130 lbs. body we ight) This dosage of 0.2 G. was maintained until about 2.0 G. or more were injected. During this time weekly liver punctures permitted a study of the effect of the drug and usually after the Leishman-Donovan bodies disappeared the treatment was stopped. This took about 47 days.
The results:—First of all, we had no toxic effects in any of our thirty-one cases. With tartar emetic about one injection in ten caused a severe reaction. This in spite of using very careful dosage and preparing solution immediately before use. The mortality rate decreased from 23% to less than 10%- Possibly this apparent decrease is due in part to the shorter time that patients are under observation, but we have heard nothing of deaths of patients after their rteturn home and when we were using tartar emetic we heard: frequently of their dying Case No. 8691— Two years duration, in hospital 71 days. Increase of XV.R.C. from 2/,(>0 to 8300. Gained 15 lbs. in w eight.
Case No. 8711— One year duration. W.B.C. on admission, 700, on discharge 2800. Gained six pounds during the 32 days period of treatment. Case No 8716—Duration 10 months. Length of treatment 36 dai/s Gained six pounds in weight during treatment.
Case No. 8717—Duration one year. Length of treatment 49 days. W.B.C. increased from 4000 to 6250. Gained eight pounds in weight. The Treatment of Kola Azar 1057
on the way home, after they had been discharged with the disease apparently arrested. The decrease in the size of the spleen is very rapid under tli-e new treatment. In most cases we expect it to decrease a third in the first ten to fourteen days. With the tartar emetic treatment the decrease in size in two weeks is not perceptible. Possibly it is because of the rapid decrease in size of this organ that th’e patients treated with the organic antimony compound showed such a slight gain in weight (average of one pound). However, the improvement in the patient’s appearance, gain in strength, subsidence of fever and increase in W.B.C. made us confident that if we kept these patients in the hospital an other two months, as under the tartar emetic treatment, ttrey would have shown a marked gain in weight. There were liver punctures made once a week in the second group of cases. The needle used is a very fine platinum iridium one and the amount of fluid removed (“liver juice”) is exceed ingly small. This really amounts to a fine spray, which is, forced out over the surface of a glass slide. This is stained according to the Wright method, using eosin-azur stain, and a surprisingly large number are positive on the first examination. A series of eight positive examinations, without a failure, is not unknown. — In some cases the patient would have as many as four in jections between examinations by liver puncture and therefore the amount of medicine necessary before liver puncture became negative would seem to run higher than is really the case. This is off set possibly by the fact that as the patient recovers the Leishman-Donovan bodies tend to become scarcer and therefore the chance of not finding a Leishman-Donovan body in the tiny drop of fluid examined becomes progressively greater. However, for the purpose of comparing the two methods of treatment the figures may still be used. They show an average of 0.043 G. of tartar emetic (0.012 G. antimony) per kilogram body weight to render liver puncture negative. (The lowest was 0.037 G. tartar emetic or 0.010 G. antimony) The new organic preparations of antimony sterilized the liver pulp after an aver age total dose of 0.046 G. compound (0.014 G. antimony) had been administered per Kgrm. body weight. (The lowest negative liver was encountered after a total dosage of 0.025 G. compound, 1058 The China Medical Journal
or 0.0077 G. antimony.) From these figures it appears to take about the same amount of the less toxic medication to render the liver sterile. According to the least dosage required the organic compound would seem to be 50% more efficient. In studying tolerance to large quantities we found our largest dose of tartar emetic per Kgrm. of body weight was 0*088 G. (0.024 G. antimony) With the new preparations our largest dose per kilogram body weight was 0.101 G. (0.0313 G. antimony) In neither case were toxic symptoms noted. Therefore it appears that the use of this new preparation in the treatment of kala azar has cut down the mortality rate from 23% to 10%, and shortened the hospital stay from 91 days to 47 days and at the same time its dosage can be, on account of its lower toxicity, much higher. Formerly the patient left the hospital after a stay of 91 days, with an average total of 0.0473 grams per Kgrm. tartar emetic (i.e. 0.0138 grams of antimony). Now the average patient leaves the hospital after a stay of forty-seven days with 0.0633 grams per Kgrm. body weight of organic antimony preparation (i.e. 0.0199 grams of antimony). Since the chances of a recurrence of this disease (really a noncure) depend in a reverse ratio on the quantity of antimony injected this would materially reduce our number of recurrences. The average duration of the disease in the first series of cases was 12.7 months. The average duration of illness of those treated with the new preparation, previous to admission to hospital, was 18.6 months. The intestinal parasites incidence in the .first group was 96% for hookworm, 59% for ascaris and 32% for whip worms. Of the second group 90% had hookworm, 53% round worm, 13% whipworm. Of the first group 25% showed a triple infection of hook, round and whipworms; 30% showed a double infection with hook and roundworm; 5y± showed a double infection with hook and whipworms. Of the second group (i.e. those treated with the new org anic compounds of antimony);—13% showed a triple infection with hook, round and whipworms; 33% showed a double in fection of hook and roundworms. The Treatment of Kala Azar 1059 TABLE JL 1060&
Ultra- Days ... . , , . Tartnr- >Uiíht W . U. (1. I,¡ver P u n e!. K uy’t- mony emetic. No«. Fiitent; Vri. Hasp. 1 Adm. nifikh. Adm l>lsch. Adm. DitftMi. Disrh. per per NaK.Uver liver l’anisiti's N< >{•<■ s ______• Hodies Kurin. Ki'nn. nffc.'r G. after <•;. i) •> 885-1 10 103.4 70 0) f)S (—) (-) ? 1 > i O < I .019 .058 II -R—W Pnemnon ia 8S58 25 1/2 105 185 122 135* 2440 5200 l’ost. ( ~ ) Po8. Pos. 1 inprov. .041 .011 .037 .010 11 -I I - ■ (Trypollav. 8374 20 1 104 04 104 so tf >> .037 .010 11 (2% 408 cc. 835)0 18 1/2 101.4 188 05 74 880') (-) Pos. ,, .015) ,00s ' 9 .008 .010 n — K—W Tryp, 148 cc. 8402 13 M /2 .103.4 52 75 os I >i(!< 1 ft .021 .OJO ii W Diarrhoea Journal Medical Ch ina The 8408 27 8 4 105 40 121 1 IS ,, .001 .001 II --R Pneunion ia 8405 20 1-1/4 10Í 120 mo 104 niprov. .055 .0)5 Li ver absce.cs 8400 8 1 2 11)2.4 U’ ! 48 54 J» .077 021 ii-— It 8407 18 1 2 10f> 107 87 5 >2 *' M it if .050 014 ii 8410 12 1-1 2 104 10) 55 Os •r (-) Í) .072 .020 .003 .018 ii -R—W Try;». 75 cc. 84 U 11 1 101.« 114 -11 52 f '8S 025 ii —R—W 8412 2 ) 1 2 95). 8 131 107 121 ’’ (-) Vi?. ,, .(’10 .018 W Tryp. 70 cc. 811?) 21 2 103 2 110 * * 104 123 ,1. ¡0 .018 ii 8428 18 1 105 152 07 72 - ’ ) i (-) fi ,07o .020 ,‘ Gl .017 ii —R—W--Scarlatina? 8427 19 2 [* 101. G n o 84 100 4150 ’ 5 .058 ,0 J 0 ii-- R — \V 84128 48 1 2 101.4 108 127 143 45)00 ,, .<¡42 .012 ii--R Tr.yp. 9 cc. 8431 s 1 105 50 120 58 (-) Pos. 07!» .022 .077 .022 ii--R S4S4 27 1 3 108.8 } ’ 107 112 124 .048 .013 ii 84 86 35 O 104.4 2G 120 184 ’ J (—) n lOiimp. .007 .0)2 ii AsciU'.s-NepliritiH 8441 8 1 ?2 103 S7 50 55 Pos. t i iin prow .(»52 .015 ii--R—W 8442 15 1 8 104 103 05 74 (-) Pos. ,, .050 .017 .059 .0] 7 ii -R 8504 15 2 o 102.0 117 64 68 * f (-) yy >> .070 .020 .000 .0.18 H 8505 28 i 104 103 115 113 (-) if , , .044 .012 .037 .010 II-R—W 850‘o 10 2 50 108.0 o7 0) Died .0 2 .008 Broncli . Pneumonia 8507 10 1 102.2 84 G) 55 ** (-) } » 1 tv. prov. .(■■OS .01!) .001 .017 It 850 S IS I 1«'5 20 122 D;ul .00 ¡.5 .0005 11 Diarrhoea 8510 17 101.4 9r 2 8 97 5S 77 (-) M Iinprov. .oco .019 .055 .0 !5 II — It 8516 11 103.8 8 ■’ 1/4 52 50 Dio 1 O.I20 Sudden Dys pnoea, I'eath 8528 17 ” ■ ’ 1/4 102.G 104 85 04 (-) I mprov. .058 .010 .041 .012 11-- R — W Amoebiasis 8529 IS ’’ 1/4 100.6 104 84 5*7.5 11200 ( —) IV«. , , .057 .010 .087 .010 II--R—W 8559 34 2 3 102.8 8) 135 132 ,, (-J ,, Died .085 .010 .020 .007 H-—It -(Diarrhoea (Died Suddenly Table III.
Dura Tnitar- (•;. Anti Noi? Liver Neg.Liver Days Wofffht Cond. No. Açtî til'M Teir.p. in W. B. <\ Livor ’uuet T e a t Oll emetu; mony niter O. after U Intest. NT„f»a Acini. I>¡f.c!i Adln. Piseli. Adln. Discli m. I>isch per Vra. Hosi>, DIscMi. per median. A ut i mon y Parasites Notea L D.IÎ-idieC( Ktirin. Kenn. Kt:. Kr.
8-101 14 2 3 1U4 101 54 50 2200 P< I mprov. .0; 5 .020 *>;> 11—R— M Tartar eir.et. 83 IG 13 2 102.2 46 48 .04(5 .013 Aim eOii: dysentery M öl 24 1 102 GS 98 Ilo (—) .072 1 !°2 .072 .022 11 GH 8-¿.3 4 13 1/2 105 51 63 .090 .028 II —R—W Azar Kala of Treatment The 8535 14 1 101 7 7 67 71 (— ) .085 .026 .081 .025 II ~ R W Ami eb.T. H. So* 8557 8 1 2 .102 3'» 44 44 .101 .031 .101 .021 H -H 11 5 ß 104 4 :-iö 8564 6) G 2 f ) Died .0-2 .016 11 liron.Pneumonia 2i 2. y 8577 100 3 ! N5 86 ) f (-) linprov, .074 .023 1 63 .01!» H — K— Jaundice 8588 10 1/2 100.6 39 5!/ GS 1 1 (-) .(’Gl .029 .101 .01!) II -R— 8590 18 i 103.x 42 90 92 64 00 (—) .( C>G . 020 .Of 5 .017 H - H - W £(.108 10 2 102 4 54 61 (50 10800 S0,0 (—) .077 . 24 .( 03 .020 R 8609 27 1-1/2 104 13 113 I) ed .003 .0009 II — K— Bron.Pneumonia 8612 ‘>4 (i 104 8909 51 108 111 36)0 (-) I mprov, .055 .017 .035 .011 R Diarrhoea 8G1G 15 i-M ; 101.4 70 ( —; 50 i •> 3400 6000 P
T a b l e IV (a) Under tartar emetic treatment ♦Average stay in hospital 91 days ♦Average Total dose/Kgrm. body weight .0473 G. *Average Total dose of antimony/Kgrm.. body weight .0138 G. Liver punct. Negative lowest dosage /Kgrm. .037 G. Largest amount injected/Kgrm. .088 G. Total antimony in above/Kgrm. .0246 G. Average total T.E. before liver negative .0543 G./Kgrm. A,verage total antimony before liver negative .0207 G./Kgrm. Average age 20.8 yrs. Average duration (before coming to hospital) 12.7 mo. Average highest temperature in hospital 103° F. ♦Average weight on admission 90 lbs. ♦Average weight on discharge 94.1 lbs. Improved 72.1% Unimproved 4.9% Died 23% Complications:—Diarrhoea (?) 3 Amoebiasis 5 Liver abscess 1 Sup. Otitis Media 1 Acute nephritis 1 Cancrum oris (Noma) 1 Pneumonia, Bronch. 4
T a b l e IV (b) Under treatment with organic salts of antimony
♦Average stay in hospital 47 days ♦Average total dose/Kgrm. body weight .0633 G. ♦Average total dose antimony/Kgrm. body weight .0199 G. Liver puncture negative lowest dosage .025 G./Kgrm. Largest amount injected/Kgrm . -101 G. Total antimony in above .03131 G. Average total medication before liver negative .046 G./Kgrm. Average total antimony before liver negative „ .0147 G. Average age 16.1 yrs. Average duration 18.6 mos. Average highest temperature in hospital 102.9 °F. ♦Average weight on admission 78 lbs. ♦Average weight on discharge 79 lbs.
♦Only cases in hospital 10 plus days included in these figures. The Treatment of Kala Azar 1063
Improved 90% Unimproved Died 10% Average W.B.C. Admission (15 cases) 3540 Average W.B.C. Discharge (15 cases) 5970 Average Increase in W.B.C. 2430 Highest W.B.C. on admission 10800 Lowest W.B.C. on admission 700 Complications :—Diarrhoea 1 Amoebasis 2 Pneumonia, Bron. 3 Pneumonia, Lobar 1 Herpes Zoster 1
S u m m a r y . 1. A comparison is made of 61 casts of kala azar treated with tartar emetic and 31 cases treated with the new organic salts of antimony (“Stibosan” and Neostam”). 2. By using1 the new preparations of antimony in place of tartar emetic we were able to reduce the mortality and decrease the hospitalization period. 3. A study is made of the quantity of antimony necessary to produce a liver puncture consistently negative for Leishman- Donovan bodies. 4. In the group of 61 cases nine showed negative liver punctures from admission, fourteen percent. In the group of 30 cases treated with organic salts of antimony who had liver punctures made one only was consistently negative. A notation of “ascites” was made, possibly explaining difficulty in making a successful puncture in this case. This case improved under treatment so it was probably true kala azar. 5. Tables accompanying show cases as follows:—I and II, Cases treated with tartar emetic. Ill Cases treated with organic salts of antimony. IV Comparison of results of treatment. We wish to thank Dr. H. E. Hsieh of Hope Hospital, who did all the liver punctures and examination of smears, and Dr. Paul Eaton of the School of Public Health, Univ. of Georgia, for his assistance and encouragement in the preparation of this paper. 1064 The China Medical Jóurnal
INTRACRANIAL COMPLICATIONS OF SUPPURATIVE MIDDLE EAR DISEASE A report of eight eases. Y. L. C h e n g , M.D. (From the Division of Neurology, Peking Union Medical College). Intracranial complications of suppurative processes in the middle ear in the form of meningitis, sinus-thrombosis, epidural or brain abscesses, are not as rare as generally supposed. Yerger, in an investigation of 1188 cases of meningitis observed in Cook County Hospital from 1911 to 1920, reported 63 cases of meningitis developed as a complication of an otitic infection. The total number of cases of suppurative middle ear disease observed there during the same period was 1254. From these figures he concluded that 5 per cent of all cases of meningitis have an otitic origin and that 5 per cent of cases of otitis media develop meningeal complications. Mygind in a paper on otogenic meningitis treated in the ear and throat department of the Copenhagen Commune Hospital from 1905 to 1922 reported 210 cases of middle ear disease complicated by intracranial conditions. Since there is no such record, as far as we are aware, in the Chinese medical literature, the following cases may be of interest. C a s e I. Acute hemolytic streptococcus mastoiditis. Sup purative non-hemolytic Streptococcus cerebro-spinal meningitis. Chronic suppurative otitis media. A Chinese, aged 39, came to the otolaryngological clinic on October 31, 1927 complaining of fever and pain in the right ear with discharge for 20 days. He was found to have sagging of the posterior wall of the auditory canal, purulent discharge coming under pressure from the middle ear through a per forated drum and slight tenderness over the mastoid tip. Operation was advised but the patient did not appear until November 21, 1927, when he was admitted to the hospital. On admission his temperature was 37,6°C. pulse 96, and respiration 20. The ear condition did not differ much from that observed on October 31. He was mentally clear and showed no sign of nieningeal irritation. A simple mastoidectomy was done, the tip of the mastoid was found perforated, the lateral sinus was exposed by the caries and two large places on the posterior wall of the mastoid cavity were noticed to be soft and slightly pulsat ing. Culture of the pus obtained from the mastoid cells showed Intracranial Complications of Middle Ear Disease 1065
streptococcus hemolyticus. There was good drainage and the patient seemed out of danger when suddenly nine days after the operation his temperature rose to 39 °C. then to 40 °C. without leucocytosis. Mentally he was slightly dull, he showed some rigidity of the neck and had slight headache. The tendon reflexes were increased and distinct ankle-clonus on both sides was found with positive Babinski’s sign. Spinal puncture the next day gave 1800 cells per cubic millimeter, chiefly poly morphonuclear, and 110 mgra. of protein per 100 cc. Culture showed streptococcus non-hemolyticus. 18 cc. of 1 per cent mercurochrome was given intravenously. Spinal puncture on the two following days showed negative culture and a steadily declining cell content and proportion of polymorphs. By the third day all symptoms cleared up. The patient was discharged on January 10, 1928 with some thin mucopurulent discharge from the middle ear still present and with the posterior mastoid wound still open. He was followed in the clinic until February 16, 1928 when the mastoid wound had entirely healed and there was only slight discharge from the middle ear. In this case presumably an inflammatory process had spread from the mastoid to the meninges, causing the change in the spinal fluid and in the circulation to the pyramidal tracts at the brain stem level. If the meninges were actually infected, the infection quickly disappeared. The efficacy of the mercurochrome in the sterilization is doubtful. The first culture of the spinal fluid may have been a contamination since later cultures were all negative. CASE II: Chronic suppurative otitis media. Acute mas toiditis. Hemolytic streptococcus cerebral meningitis. A Chinese, aged 23, was admitted to the hospital on May 7, 1927 for pain and discharge from the right ear. He had had discharging ears since childhood and his hearing was much impaired. He was first seen in the clinic on April 26, 1927, when he was treated with spiritus boroglycerini for bilateral chronic suppurative otitis media. He returned on May 5, 1927 with swelling of the right zygomatic region and of the upper part of the right mastoid region. On admission his temperature was 38,6°C. pulse 92, and respiration 24. The right external auditory canal was filled with thick pus, the ear drum was bulging and the swelling of the mastoid region was the same as noted before without tenderness. Leucocyte countin the blood 1066 The China Medical Journal was 5000. A simple mastoidectomy was performed under general anesthesia immediately after admission. The mastoid cells were found to be filled with pus and granulations, and profuse purulent discharge was evacuated under pressure. Culture of the pus gave a hemolytic streptococcus. No sinus or dura was exposed during the operation. The patient had a regular convalescence from the mastoid operation, the local wound was gradually healing, and he was allowed to walk around in the ward about two weeks after the operation. He seemed entirely well until May 27, when he began to complain of headache without nausea or vomiting. He was mentally clear and showed no signs of meningeal irritation. On May 30, however, the temperature suddenly went up to 40,7 °C. and the patient became very restless. Leueocytosis was then present, the count being 15850. There was rigidity of the neck, positive Kernig’s sign, and generalized muscular twitching but no cranial nerve palsy or paresis of any limb. Spinal puncture gave a cloudy fluid under normal pressure. Smear examination and culture of the fluid demonstrated the presence of hemolytic streptococcus. 20 cc. of 1 per cent mercurochrome was given intravenously the same day, and the dose was repeated the two following days. Later spinal punctures gave more purulent fluid under increased pressure. After May 31 the patient had incontinence of stools and retention of urine, he rapidly became worse and died on June 5, 1927. There was no necropsy.
Case III: Acute mastoiditis. Multiple abscesses. Arachnoid abscess. A Chinese, aged 24, admitted to the hospital on June 29, 1928, had had otorrhea from the left ear for about two years; he complained of headache on the left side for three weeks, and profuse purulent discharge from the left ear and swelling of the left mastoid region for two weeks. He was confined to bed for 4 or 5 days prior to admission with swelling of the left upper eyelid, some trouble in speech and weakness of the right limbs. He became unconscious on June 26. On admission he was semi comatous, his right arm and leg seemed paralyzed. The reflexes were present, and the right facial nerve was normal* He did not speak at all, and did not understand much of what was asked him. There was a large fluctuating swelling over the left temporal and parietal region of the scalp, and very profuse purulent discharge from the ear which seemed to be com Intracranial Complications of Middle Ear Disease 1067 municating with the large swelling of the scalp. There was no definite rigidity of the neck nor positive Kernig’s sign. The left eyelid was swollen, but the eye was not bulging. The function of the left abducens could not be examined. Leucocyte count was 24600. A simple mastoidectomy was done immediate ly. The antrum was found filled with thick yellow creamy pus, and the lateral sinus and dura were exposed by the disease. The petrous bone above the middle ear was very soft, but it was not removed. Spinal puncture done on the day after operation showed 1800 polymorphs, but no other cells per cc. No bacteria were found in the smear. Culture showed unidenti fied Gram-negative non-motile bacilli and Gram-positive bacilli. Puncture of the temporal lobe through the mastoid field was suggested but the patient was in too poor condition to stand any operation. He died on July 2, 1928. Necropsy was performed about 24 hours post mortem and an abscess cavity was found under the scalp, exposing the rough bone of the skull, occupying nearly the entire perietal bone, and extending in front over the orbital arch into the órbita. The temporal muscle was still attached to the bone, but was dis colored. After removal of the skull cap no definite epidural abscess was found, but there was some pus around the upper part of the middle cerebral artery which was probably connected with thrombosis in the sinus at this level, where pus was already present in the thrombus. The sinus in its more anterior and posterior parts contained only coagula (probably postmortem). No connection with the outside purulent process could be found. On opening the dura over the left hemisphere very thin watery, putrid pus, containing yellow fibrin coagula escaped, a culture of which gave unidentified organism of the bacillus alkaligenus group. The brain cortex was covered with this pus and coagula. This subdural pus extended over the entire convexity of the left hemisphere, went down along the temporal lobe but left its anterior median point free and also left the petrosal surface conspicuously free. The occipital pole and posterior cranial fossa were free from pus or typical inflammation. The roof of the petrous bone was red, very soft, and in places nearly perforated, but there was no discoloration of the dura where the inflammation could have directly passed from the ear to the meninges. The left hemisphere was larger than the right, the ventricle was closed, the convolutions were broadened and flattened. The cortex underlying the purulent arachnoid showed 1068 The GMna Medical Journal
greenish discoloration, but nowhere was the cortex macros- copically involved in the inflammatory -process, which also did not go into the fissures, as is -common in purulent meningitis. Microscopic examination of a section of the dura taken from the infected region showed areas of necrosis infiltrated by large numbers of polymorphonuclear leucocytes, most of which were disintegrated, and also small areas of hemorrhage. Both the outer and the inner surface of the dura were affected. A section of brain tissue taken from under the pus collection showed thickening of the pia by proliferation of fibrous tissue, some degree of edema with infiltration by polymorphonuclear leucocytes, and the blood vessels engorged with blood. The same process also extended into the fissures but was milder. The brain parenchyma underlying the infected pia, likewise, leucocytic infiltration, proliferation of blood vessels, and increase of glia cells. The deeper tissue was normal. Here we have, as a complication of the otitis, a localized abscess formation in the cerebral subarachnoid space with only a slight degree of invasion of the brain parencyma and of generalized meningeal irritation.
C a s e IV: Chronic suppurative otitis media. Acute mastoiditis. Abscess of the cerebellum.
A Chinese, aged 17, was admitted on December 2, 1927 for intense headache of about a months duration. He had had chronic discharge from the left ear for two ears and sudden onset of left earache and severe headache on the left side a month prior to admission. About a week after the onset of the headache, he began to have a daily feverish and chilly sensation, and a week before admission frequent vomiting. On admission his temperature was 37,6°C. pulse 80 and respiration 26. líe was mentally clear but had slight retraction of the head and suggestive Kernig’s sign. There was weakness of conjoint parallel movements of the eyeballs to the left and coarse nystagmus as the eyes were directed to the left. Fundus findings were suggestive of an early optic neuritis. Otherwise the cranial nerves were all normal. /There was a difference in the power of the two upper limbs, the left being weaker. There was marked ataxia in left elbow and shoulder movements, and in finger-to-nose and pass-pointing tests on the left side, and higher tendon reflexes on the left side with ankle- clonus. and a suggestive Babinski reflex. The (left external Intracranial Complications of Middle Ear Disease 1069 auditory canal was red and swollen and the drum bulging and inflamed. X-ray examination showed mastoiditis on both sides with abscess formation on the left. Leueocytosis was present, the count being 10400 with 83 per cent polymorphs. Culture of the discharge from the ear showed streptococcus hemolyticus and staphylococcus aureus. Spinal puncture at 9 :30 a.m. on December 3 gave a clear and colorless fluid with increased cell (96 per cubic millimeter) and protein (56 mgm. per 100 cc.) content. Respiration suddenly ceased at 11:40 a.m. (2 hours and 10 minutes after the spinal puncture) and at the same time profuse thick yellow pussy discharge from the left ear was seen. The heart kept on beating until 3 :20 p.m. with the aid of oxygen inhalation, lung motor and artificial respiration. There was no necropsy. In this case the clinical symptoms and signs are sufficient to -make a diagnosis of a pathological process in the left side of the cerebellum. The mode of death rather suggests a medullary death, perhaps from rupture of a cerebellar abscess as a result of disturbance of pressure balance produced by the spinal puncture.
C a s e V : Acute otitis media. Acute staphylococcus aureus mastoiditis. Suppurative staphylococcus aureus cerebro-spinal meningitis. Brain abscess. A Chinese, aged 17, came to the clinic on October 8, 1928, complaining of occipital headache, pain in the left side of the neck and some deafness in the left ear for 10 days and of fever for 4 days. His temperature was 38,4°C. and he had a bulging, inflamed, left ear drum, which was incised and the auditory canal was packed with carbolic glycerine gauze. On October 13, he returned and was admitted to the hospital for occipital headache, fever, stiff neck, lumbar pain and vomiting which had developed just after the first visit to the clinic. On admission his temperature was 39,2°C. pulse 76, and respiration 24. He was mentally clear but showed stiffness of the neck, positive Kernig’s sign, and paresis of the left facial nerve of the peripheral type, in addition to the otorrhea on the left side. Leucocyte count in the blood was 9850 with 75 per cent polymorphs. Spinal fluid was cloudy, came out under increased pressure (267 mm. of w ater), and gave 965 cells per cubic millimeter, chiefly polymorphs. Culture of the fluid was positive for staphylococcus aureus, and this was confirmed by culture of the fluid obtained on later punctures. On October 15, 1070 The China Medical Journal
the temperature was still high, 39.8 °C. The patient’s condition remained about the same. Mastoidectomy was performed since it was conjectured that the meningitis might be a serious reaction to a mastoiditis although there was no sign of such a condition (the result of the culture of the spinal fluid was then not yet known). There was pus in the mastoid antrum, which was curetted. No dura or sinus was exposed. Culture of the pus gave staphylococcus aureus. Temperature dropped to 36.8°C. the day after operation but rose again on October 17. The patient was mentally clear and showed no sign of sinus thrombosis or of brain abscess. An epidural abscess was suspected and an exploratory operation was performed, which, however, revealed no inflammation of the dura. On October 19 a combined cistern and lumbar puncture was done and the spinal subarachnoid space thoroughly washed with 50 cc. of normal saline. The temperature continued high and fluctuated between 37°C. and over 40°C. and the pulse rate stayed around 70 and 80. Repeated lumbar punctures were done but no further lavage as the patient had shown a bad reaction to the first. Gradually the temperature settled down to a lower level (below 37°C.), the spinal fluid became clear with declining cell content, and the culture of the spinal fluid became negative; but the leucocyte count remained between 11000 and 13000. The patient appeared to be well when on November 4 he had a chill, a sudden rise of temperature to 39 °C. with vomiting. On November 5 he was mentally dull, felt worse, and showed slight weakness of the right lower facial nerve, but without increase in the signs of meningeal irritation. Spinal puncture again gave a turbid fluid with 2040 cells, 75 per cent poly morphs. Rupture into the subarachnoid space of an isolated pus pocket was suspected, but the fluid gave no growth. On November 6 although the temperature dropped, the patient became more drowsy, at times restless, and had a slow pulse rate varying between 50 and 60. There was, however, no localizing sign for a brain abscess aside from the very slight weakness of the right lower facial nerve. Eye ground examina tion on November 8 revealed only hyperaemia of the disk. The patient grew steadily worse and died on November 10, 1928 without any further objective finding. Postmortem aspiration of the left temporal lobe through the operation wound gave 50 cc. of greenish pus, There was no necropsy, Intracranial Complications of Middle Ear Disease 1071
C a se V I : Chronic Otitis Media Brain abscess. A Chinese, aged 24, was first seen in the otolaryngological clinic on November 28, 1928 for pain in the left ear with otorrhea and severe headache of about a month’s duration. He had had otorrhea for years. Examination showed an inflamed left ear drum with a small perforation, through which pus escaped. Paracentesis was advised but the patient refused and went home with carbolic glycerine gauze packing. He wras admitted to the hospital on December 3, 1928, however, for increasing severity of the headache and for fever of two days duration. He had vcmited once. On admission his temperature was 39°C. pulse 88 and respiration 21. The ear condition had remained practically the same, without definite sign of mastoiditis, but the patient was very restless and looked very sick. There was no rigidity of the neck or Kernig’s sign but spinal puncture gave a cloudy fluid containing 10260 cells per cubic millimeter, chiefly polymorphs. Smear examination and later culture of the fluid showed no organism. A simple mastoidectomy was immediately performed. The mastoid cells were found large and full of clear fluid. The lateral sinus which was very superficial and much further upward and forward than usual, was exposed in an area about half a centimeter in diameter. As soon as the antrum was opened, creamy pus came out from the middle ear under pressure. Culture of the pus gave no growth but culture of the pus from the external ear gave staphylococcus aureus. Combined cistern and lumbar puncture was done and the spinal subarchnoid space washed with normal saline solution on two successive days, with the idea that the process might be a developing purulent meningitis. The spinal fluid, however, never showed any organism either on smear examination or by culture, and cleared up rather rapidly. The temperature came down and fluctuated between 37° and 38°C. but the patient was never entirely free from headache and was very irritable. He showed progressive slowing of the pulse rate but no definite localizing sign until Dec. 14, 1928, when amnestic aphasia, weakness of the right lower facial nerve and of the right upper limb with Oppenheim’s sign on the right side, and slight hyperaemia of the optic disks occurred. These signs progressed so rapidly, that exploratory craniotomy was done on the same day. A small opening was made over the left temporal region of the skull, the dura was slit and a ventricular needle introduced. The abscess cavity was promptly located 1072 The China Medical Journal % and thin yellowish fluid, later brownish pus under considerable pressure exuded. A rubber tube was inserted into the cavity for drainage. Culture of the pus gave streptococcus hemoly- ticus. The patient seemed to improve a little the first few days after operation. On December 18, however, he again became drowsy and later, on December 21, he showed progressive choked disk. The drainage tube slipped out of the wound on December 21, a ventricular needle was reintroduced, and the tube replaced. The patient did very poorly, and so he was operated on again on December 24 as drainage was evidently not efficient. The abscess cavity was reached and a drainage tube again inserted. The patient was discharged against advice on December 28, 1928, and died at home soon afterwards. Case V II: Chronic, suppurative otitis media. Chronic mastoiditis. Mastoid fistula. Cerebrospinal meningitis. Throm bosis of cavernous sinus. A Chinese boy, aged 17, was seen for the first time in the otolaryngological clinic on September 18, 1926 for fetid pussy discharge from the left ear with much pain for 5 days. He had had discharge from the left ear at intervals for ten years. Examination revealed a swelling behind the left auricle with tenderness over the mastoid process, and a swollen and furun- culous external auditory canal with purulent discharge from the middle ear. Mastoidectomy was advised but the patient refused. The furuncles were incised. On September 27, 1926, he was admitted for mastoid operation. On admission his temperature was 37°C. pulse 80, and respiration 20. His mentality was clear, cranial nerves were normal and there was no rigidity or retraction of the neck. The swelling of the external auditory canal had subsided, but there was fluctuating swelling behind the left auricle and two abscesses over the mastoid, and thick, foul pus and cholesteatomatous mass in the middle ear. Leucocyte count was 11400 with 82 per cent polymorphs. A simple mastoidectomy was performed on the day of admission. About 30 cc. of thick fetid pus was evacuated under pressure. The mastoid was found destroyed by cholestea tomatous granulations and a fistula was followed extending from the lesion to the skin. An area of the lateral sinus was exposed by the disease just below the fistula. The mastoid cavity was curetted and the sloughing tissue removed. Culture of the pus iSkPTOf B, proteus. The patient progressed fairly well except Intracranial Complications of Middle Ear Disease 1073 that the wound did not clear up. A radical mastoidectomy was performed on October 13, 1926, fifteen days after the first operation. No dura or sinus was exposed, and the previously exposed lateral sinus was fairly well covered with granulations. The patient had a sudden twitching of the left side of the face during operation. The next day he complained of headacho and dizziness, and vomited twice. Spontaneous nystagmus to the right was noted when the eyes looked to the right, but no other pathological signs were detected. His temperature at this time began to rise and on October 19 reached 40°C. The next day he showed stiffness of the neck and positive Kernig’s sign but no localizing signs of cerebellar or temporal- abscess, and he was mentally clear. Leucocyte count was 19050 with 94 per cent polymorphs. On spinal puncture, the fluid came out under normal pressure, was cloudy and gave a cellcount of 21800. Culture of the fluid was negative. 22 cc. of 1 per cent mercurochrome solution was given intravenously on October 21 and on October 23 18 cc. At 8:00 p.m. on October 23 the patient became unconscious and there was protrusion of the right eye. On October 24 he was still unconscious, the pro trusion of the right eye became more marked, there was flaccid paralysis of the left upper and lower limbs with exaggerated tendon reflexes and ankle-clonus, and also bilateral Babinski’s sign. At times there was slight involuntary jerking of the right limbs. Combined cistern and lumbar puncture was made and the spinal subarachnoid space thoroughly washed with 70 cc. of normal saline. Patient died on October 25. There was no necropsy. Case VIII: Chronic otitis media. Subacute hemolytic streptococcus mastoiditis. Thrombosis of the lateral sinus. Hemolytic streptococcus bacteraemia. A Chinese girl, aged 24, admitted to the hospital on December 29, 1928, had had otorrhea from the right ear for two years, profuse purulent discharge from the right ear with swelling and tenderness of the mastoid region for two months, and headache for a few days. On admission her temperature was 37.4°C. pulse 80, and respiration 16. The right external auditory canal was filled with purulent discharge, the tympanic membrane was inflammed, swollen, and bulging, and was per forated inferioriy. The right mastoid region was swollen and tender. She had a severe headache and some dizziness but 1074 The China Medical Journal
was mentally clear and showed no sign of meningeal irritation. A simple mastoidectomy was performed. The mastoid cells were found to be filled with pus, a culture of which gave streptococcus hemolyticus and nonhemolyticus. Blood leucocyte count was 20720 per cubic millimeter. On December 31, the headache became more intense and the temperature went up to 40.6°C. She was irritable but showed no rigidity of the neck or Kernig’s sign. The fluid obtained from a spinal puncture was essentially normal and gave no growth on culture. On January 4, 1929 the temperature dropped to subnormal and rose again after a severe chill. Spinal puncture was repeated and now showed definite evidence of block in the venous system of the dura mater on the right side, although the fluid was normal (no rise of spinal pressure on compressing the right jugular vein, which had been present during the first puncture). On January 5, she was again operated on, an abscess cavity was found in the soft tissues below the lower end of the wound, and another isolated mastoid cell was found to be full of pus. The dura of the middle cranial fossa wras exposed and appeared normal. After the second operation she seemed a little better but her temperature was still high and irregular with frequent chills. On January 8, the blood taken for culture on January 2 showed growth of hemolytic streptococcus, and 20 ce. of 1 per cent mercurcchrome was injected intravenously. The tem perature dropped the next morning, but blood culture taken on January 7 was again positive for hemolytic streptococcus. On January 11 exploration of the lateral sinUs was decided upon and was performed. A fairly big piece of firm clot was removed from the lateral sinus and at the same time the right jugular vein was ligated in the neck region. Culture of the clot gave non-hemolytic streptococcus. There was no evidence of purulent softening in the clot. The lateral sinus was packed with iodoform gauze. The temperature still remained high and the patient looked exhausted, so a blood transfusion of 400 cc. whole blood was given on January 13. Blood taken on January 15 for culture gave no growth. The temperature dropped on January 16, and the patient became free from headache and able to sit up on January 21. She had an unevent ful convalescence. Intracranial Complications of Middle Ear Disease 1075
Discussion. , Seven of the eight cases here reported were observed in the two years 1927 and 1928, during which period 94 cases of otitis media (41 acute and 53 chronic cases) were admitted to this hospital: i.e. 7.4% of the patients suffering from otitis meria did develop one of these intracranial complications. From the fact that out of the seven cases observed in 1927 to 1928, five occurred during an acute attack in the chronic stage of the disease and only one in the acute stage (no history was obtained from case V.), we may conclude that these complications usually follow an acute exacerbation of a chronic process. In other words 2.4% of our acute cases and 9.4% of our chronic cases of otitis media did develop intracranial complications. We have in this series almost all the intracranial com plications of middle ear disease: meningitis in cases I and II, arachnoidal abscess in case III, brain abscess in cases IV, V and VI, and sinus thrombosis in cases VII and VIII. It is interesting to study the clinical picture of these conditions in regard to differential diagnosis. In all these intracranial complications headache is almost always present and is usually the first symptom of which the patient complains. The headache is probably more severe and persistent in meningitis cases, but in the early stage of brain abscess formation, if there is an affection of the meninges, it may also be the only prominent symptom. Nausea and. vomiting may accompany any of these conditions, so they are only of value in directing the attention to the possibility of a developing intracranial complication. Other focal symptoms are cranial nerve palsies in basal meningitis; amnestic aphasia, hemiparesis or hemianopsia in abscess of the left tem- porosphenoidal lobe; hemianopsia and hemiparesis in abscess of the right temporal lobe; and vertigo and incoordination of muscular movements in abscess of the cerebellum. Of the signs we may mention mental status, fever, pulse rate* leucocytosis and spinal fluid findings. It may generally be said that in meningitis and sinus thrombosis there is a comparatively higher fever than in brain abscess, in which the temperature is high only in the early stage when meningitis is predominating. This may be easily explained by the rich vascular supply of the meninges which affects a rapid and 1076 The China Medical Journal
continuous absorption of toxin. Another difference between meningitis and sinus thrombosis is that meningitis gives a high and continuous fever while sinus thrombosis gives a high and irregularly intermittent fever with accompanying chills. From the composite charts here given, we at once notice the slow pulse rate in cases of brain abscess. The pulse rate in cases of meningitis and sinus thrombosis were all above 80 per minute, whereas in all three cases of brain abscess the pulse, rate was hardly ever above 80 even when the temperature was about 40°C. and when all symptoms and signs pointed only to a meningitic process. Whether this is one of the evidences of general increased intracranial pressure is difficult to say, as in all our three cases no slowing of the respiratory rate, no elevation of blood pressure, and no choking of the optic disks was noted except in case VI where the choked disk developed after the diagnosis had been well established and confirmed by operation. In eases of meningitis and sinus thrombosis choked disk was not observed, but hyperaemia of the optic disks was demon strated in both our cases of sinus thrombosis. As regard the mental state, it is generally believed that meningitis patients present a picture of activity, irritability and alertness and that brain abscess patients present one of drowsiness and dullness. But in the two cases of brain abscess which we were able to observe from early in the course of the disease, irritability seemed more marked than in cases of meningitis. Drowsiness was only observed when the abscess had reached a fair size. ,The spinal fluid findingfs are of particular interest. Of tha two cases of meningitis, case I was probably only a serous or sympathetic meningitis, a reaction of the meninges to a neigh bouring infection. The rapid subsidence of the fever, the normal spinal fluid pressure, the rapid decrease of the spinal fluid cell content and the negative culture (the first culture might have been a contamination as it did not give the same organism as from the ear pus), all speak in favour of this. In case II we found hemolytic streptococcus cerebrospinal meningitis. Although the spinal fluid cellular content was not very high and showed no increase, there was a steady increase of the pressure, which wap very high. The increasing high pressure and .the repeated cultures marked the positive findings of the spinal "fluid in the cases of purulent meningitis. Case V was probably northing but a localized leptomeningitis resulting in abscess fornition, Intracranial Complications of Middle Ear Disease 1077 and'the spinal fluid was only a late generalized reaction of the meninges as in serous meningitis. This form of localized leptomeningitis is not a rare condition and should be kept in mind for differentiation from brain abscess. Of our three cases of brain abscess two were observed from an early stage of the disease, and in each a primary diagnosis of purulent meningitis was made on account of the high cell content of the spinal fluid, (10,260), and in our case III on account of the repeated posi tive cultures of the spinal fluid. The fluid, however, readily cleared up, even where organisms were present, without any special treatment other than mere drainage by repeated lumbar and cistern punctures. We must assume that in these two cases an initial meningitis preceded the formation of the brain abscess. It is doubtful if this is true in all cases of brain abscess even when every thing points to a simple meningitis. In the meningitic stage of brain abscess, if we may call it so, we find, however, that the fever is not very high or continous and that the pulse rate is slow in contrast to that in purulent meningitis. In thrombosis of the sinuses lumbar puncture is useful for the evidence of block in the venous system of the head. On compressing the jugular vein the pressure of the spinal fluid promptly rises, and when this pressure is released it as promptly drops. Ordinarily the rise of spinal fluid pre- sure on separately compressing the two jugular veins may not be identical and is of no diagnostic significance; but when one finds absence of rise in compressing one jugular vein or a slow, graduated rise which stays up on releasing the pressure, one may be reasonably ¡’sure of a block in the venous return from the head, usually by lateral sinus complication. This together with the septic temperature and the positive blood cultures helped us to make the diagnosis of sinus thrombosis in case VIII. Leucocytosis was present in all our eight cases. In case VIII the count was as high as 32000. In the course of the dise ase it may vary from time to time without any apparent re lation to the progress of the disease, and the actual figure is therefore not of much importance. Treatment of all such cases is difficult and uncertain. Only two of our eight cases recovered. In serous meningitis recovery can be expected after a prompt removal of the primary focus. In purulent meningitis Sterilization of the subarachnoid space 1078 The China Medical Journal
should be tried. Different kinds of chemicals such as mer- curochrome, gentian violet, neutral acriflavine, and flavine dyes have been tried by intramuscular, intravenous, or intraspinal injections, but the consensus of opinion is that they are of little, if any value, and that they are even dangerous when applied in- traspinally. Drainage with lavage of the subarachnoid space is, probably, the best treatment available. Sinus thrombosis may be treated either by leaving the con dition alone or by operation. If brain abscess is suspected operation should be done at once: a small opening on the skull is preferrable as it prevents to a great extent herniation and fungation of the brain. Prognosis in any of these conditions is poor. The treatment should therefore, be directed towards prevention, by doing simple mastoidectomy before brain sympt oms occur.
C o n c l u s io n s F rom O u r O bservations . (1) 7.4% of cases of otitis media develop intracranial complications, usually following an acute exacerbation of a chronic process. (2) Headache is the first symptom. It is more severe and persistent in affections of the pia and dura than in affections of the brain. (3) Meningitis gives a high and continous fever, sinus thrombosis a high but remittent fever, and brain abscess is not characterized by fever. (4) Pulse rate is slow in brain abscess even in the early stage. Elevation of blood pressure, slowing of respiratory rate and choked disk are not usually found in brain abscess. (5) Patients with brain abscess are very irritable in the early stage of the disease and later become drowsy. (6) Purulent meningitis may not have a very high cellular content in the spinal fluid, but brain abscess may have a very high cell count, and also a high polymorphonuclear count, in the fluid in the early meningitic stage. (7) Sinus thrombosis may be suspected on finding a block in the venous return of the head as evidenced by absence of pressure change in spinal fluid oji jugular compression. Intracranial Complications of Middle Ear Disease 1079
(8) Leucocytosis in the blood is present in all these con ditions. (9) Treatment of these conditions has been unsatisfactory- Their prognosis is uncertain. I wish to use this opportunity to thank the Department of Otolaryngology for their kindness in letting me have the use of their histories.
B ibliography .
Mygind H. “Benign forms of otogenic meningitis” abstract in Brit. Med. Journ. 1922 vol. 2 p.465.
Yerger C.F. “Meningitis of otitis origin” J.A.M.A. 1922 vol. 79 p.1924.
Symonds C.P. “Some points in the diagnosis and localisation of brain abscess” Journ. Laryn. and Otol. 1927 vol. 42 p.440.
Semmes R.E. “A review of the intracranial complication of ear, nose and throat infection from the neuro-surgical standpoint.” Trans. Am. Laryn. Rhin. and Otol. Soc. 1927 vol. 33 p.517.
Eagleton W.P. “Intradural complications of aural and nasal origin” Archiv. of Otolaryngology 1926 vol. 4 p.69.
Swift G.W. “The differential diagnosis between septic meningitis, hrain abscess and lateral sinus thrombosis complicating mastoiditis” Ann. of Otol. Rhin. Laryn. 1927 vol. 36 p.669.
Shuster B.H. “Intracranial complications of otitic origin with reference to diagnosis and management” Laryngoscope 1927 vol. 37 p.897.
Tawse H.B. “Suppurative middle ear disease and temporal lobe abscess with recovery” Journ. Laryn. and Otol. 1927 vol. 42 p.532.
Mvgind H. “The operative treatment of otitic meningitis” J.A.M.A. 1910 vol. 55 p.759.
Rainey and Alford “The treatment of septic meningitis by continuous drainage” J.A.M.A. 1923 vol. 81 p.1516.
deVries “Mercurochrome given by intraspinal injection” China Med. Journ. 1928 vol. 42 p.(>92.
Kolmer “The chemotherapy and serum therapy of pneumococcus and streptococcus meningitis” Archiv. Neur. and Psych. 1927 vol. 17 p.249.
Dowman E. “Treatment of brain abscess” Archiv. of Surg. 1923 vol. 6 p.747. 1080- The China Medical Journal i¥ K Case I—Acute hcmolyilc streptococcus mastoiditis. Suppurative non-heomhjik streptococcus cercbro-spinal meningitis, Chronic suppurative otitis media. Intracranial Complications of, Middle Ear Disease 1081 Case II— Chronic suppurative otitis media, Acute mastoiditis, Hemolytic y streptococcus cerebral meningitis. ' 1082 1 The China Mtdlenì Journal Case III—Acute mastoiditis, Multiple abscesses, Arachnoid abscess. W Case IV—Chronic suppurative otitis mediaé Arnie mastnidilif;, Abscess of the cerebellum. Intraci an ¡at Complications of Middle Ear Disease 1083 Case V—Acute otitis media, Acute slajthylococcus aureus mastoiditis, Suppurative staphylococcus aureus cerebro-sphial meningitis, Brain abscess. 1084 The China Medicai Journal Case VI—Chronic otitis media, Brain abscess. 28, 2« 90 Case Case Intracranial Complications of,-Middle Ear Disease Ear of,-Middle Complications Intracranial I—hoi spuaie tts mda Crnc astoiditis, m Chronic 'media. otitis suppurative VII—Chronic sod itl, eer-pnl meningitis, Cerebro-spinal fistula, astoid M hobss f h cvros sinus. cavernous the of Thrombosis > 1085 1086 The China Medical Journal Case VIII—Chronic otitis media, Subacute hemolytic streptococcus mastoiditis, Thrombosis of the lateral sinus, Hemolytic streptococcus bacteraemia. Gastric and Duodenal Ulcer in Manchuria 1087 GASTRIC AND DUODENAL ULCER IN MANCHURIA* D. S. R o b e r t so n , M.A., M.D., M.C. Moukden Medical College, Moukden. All doctors who have practised in both China and Western countries are agreed that the incidence of disease generally shows great differences in these regions, but very little inves tigation has been made of these differences, although such investigations might prove of very great practical importance. Any marked discrepancy in incidence in different regions may throw light on the etiology of diseases, the causes of which are still a mystery. There must be a cause for such difference in incidence and if we can find such cause, we have gone a long way towards elucidating the etiology of the condition. But first we must be sure of our facts as to incidence. The present paper is a preliminary contribution to the study of gastric and duodenal ulceration in Manchuria. On looking through the literature one finds that statistical records of these conditions in China and especially in North China are rare. Gibson in Hongkong reported that no sign of Gastric Ulcer was seen in 815 autopsies, though it is not stated whether this condition was actually searched for in every case. Elliot (1) in Szechuan reported 10 cases of Gastric or Duodenal Ulcer in one year out of 500—600 cases—about 2%. Later Elliot (2) reported 40 cases operated on in 2*4 years, and probably as many seen but not operated on. He considers the condition “very colmmon” in Szechuan. Snell (3) at Soochow diagnosed more than 20 in a few months, and considers the condition ‘'very common.” J. L. Maxwell (4) says that Gastric and Duodenal Ulcers are “not specially rare among the Chinese in Formosa.” On the other hand out of 2589 patients admitted to the P.U.M.C. in 1923 (5) there were 17 cases of Gastric Ulcer—6%, and out of 3528 admitted to the Canton Hospital during 1923 there was only 1 case of Gastric Ulcer—.03%. (6) Out of 4669 patients in 1927-28, the P.U.M.C. (7) reported 4 cases of Gastric Ulcer and 18 of Duodenal Ulcer, and 7 of pyloric stenosis. If we assume 4 of these cases of stenosis to be due to ulceration, we get a total for the two conditions of 26—.56%. ^Presented at the 17th Annual Conference of the Manchuria Medical Association, May, 1929. 1088 The China Medical Journal Our statistics : During- the years 1927 and 1928* 30 cases were diagnosed as either gastric or duodenal ulcer out of a total of 3087 admissions—a percentage of 0.97 Diagnosis in the great majority of these cases was based on history, clinical examination, gastric analysis by the fractional method, tests for, occult faecal blood and X-Ray examination. In a small proportion of cases diagnosis was confirmed at operation. The small number of cases operated on is due to two factors— (1) the excellent results obtained from purely medical treatment, and (2) the reluctance of many Chinese patients to agree to operation even when necessary. There is thus a very considerable difference in incidence of ulcér in thèse widely separated regions, or at least let us say a difference in frequency of diagnosis, for as we shall see later this is a condition which does not always diagnose itself, but must be looke'd for. Comparing these figures with those from the only Western Hospital available at the time of writing—the Western Infirmary Glasgow (8), we find that in the Medical Wards of this Institution there were 46 Duodenal and 51 Gastric Ulcers out of a total of 2217 medical cases, while 88 cases were operated on in the Surgical Wards out of total of 5225—a percentage all over of 2.5. Some of these cases may be reported on both sides of the hospital, but even if so the figures are still much higher than anything reported in China. Analysis of 30 Cases : Pain was present in 29 cases. In 18 it was slight, in 6 moderate and in 5 severe. . Duration of Symptoms:— M a x im u m ...... 24 years Minimum .. .. 9 days is , . Average . - ...... 5 years Age of Patient:— M a x im u m ...... 54 Minimum ...... 18 Average ...... 34 ...... The paiji was described as epigastric in 19, as abdominal 6, as general in 4, Gastric and Duodenal Ulcer in Manchuria Time of Pain:— Within 2 hours of a meal ...... 9 cases Later—especially at n i g h t ...... 11 „ No relation to food ...... 9 „ It is often very difficult to elicit a history of periodicity of pain from Chinese patients, but careful enquiry will often succeed in this when a casual question brings forth a blank denial. Vomiting was present in 20 cases:—Haeinatemesis in 5—4 of these were very slight and 1 moderate. In np case was the haematemesis sufficiently severe to produce anaemia of marked degree. Gastric Analysis:— Hyperchi or hydria in 20 cases. Normal acidity in 4 cases. Hypo-acidity in 3 cases. ^ No report in 3 cases. Blood in gastric contents—26 cases. Faecal blood (usually occult)—14 cases. Signs and symptoms of pyloric stenosis in 11 cases. X-Ray Examination: . i - r„s Ulcer reported as Gastric in 4 cases. Ulcer reported as Duodenal in 4 cases. Ulcer reported as Pyloric in 11 cases. X-Ray appearance negative in 4 cases. No report in 7 cases, 'jo . ' In one case signs of ulcer were seen in both the body of the stomach and at the pylorus. This was confirmed at operation. Only rarely was a definite niche seeii by radioscopy. ‘ For part of the period under survey our regular radiographer was absent on furlough, otherwise the dis tinction between Gastric and Duodenal might have’ been more definite. Deductions from this Analysis: Four things .stand out prominently:— • • < a:-) (1) Pain was severe in only 1/3 of the cases. f f:j 1090 The China Medical Journal (2) Haematemesis occurred in only 1/6, and in no ease' was it excessive. Compare this with the figures of the Glasgow Western Infirmary where 27 cases were admitted in 1925, with haematemesis as the principal symptom—2 of which cases died. (3) In none of the 30 cases did perforation occur. In one case which came to operation the surgeon (Dr. C. F. Simpson) reported the ulcer as nearly perforating. Compare again with Glasgow Western Infirmary where 76 cases of perforated ulcer were operated on in 1925 out of 9743 admissions. Osier (10) states that per- formation occurs in 6Vo% of gastric ulcers. From our experience in Moukden Hospital perforated Gastric or Duodenal Ulcer is a very rare condition. I have been able to find records of only one case (9) and so far as I can find they are equally rare elsewhere in North China—e.g. out of 4669 in-patients in P.U.M.C. 1927-28—no case reported. (4) X-Ray examination rarely shows a deep niche. How are we to explain these facts? To my mind the only explanation is that while Gastric and Duodenal Ulceration is not an uncommon condition in Manchuria, though probably not so common as in Scotland, yet the ulceration is usually super ficial, and not of the deeply eroded type so often met with in the West. How otherwise are we to account for the rarity of severe haematemesis and the extreme rarity of perforation? There is one other point calling for notice. If this be true, that ulceration is usually only superficial, how are we to account for the very frequent occurrence of pyloric stenosis? 11 out of our 30 cases gave clinical or X-Ray evidence of this condi tion. There are at least these possibilities: (1) That even a superficial ulceration of long standing may produce a great degree of fibrosis and consequent stenosis. This is, I believe, quite possible. (2) That many of these cases of stenosis are due to some other pathological conditions—e.g. adhesions due to Chronic peritonitis (chiefly tubercular), or to other pathological conditions outside the alimentary canal. (3) Many of the cases of stenosis are due to spasm and improve very considerably on treatment. Gastric and Duodenal Ulcer in Manchuria 1091 Treatment: I shall mention treatment only in so far as it influences the above mentioned conclusions. We treat our cases:— (1) By carefully regulated progressive diet. (2) By 2 hourly administration of alkaline powders, in an attempt to neutralise or at least to diminish the acidity of the Gastric fluid. I shall not go into details as all are doubtless familiar with this treatment. In the great majority of cases the results so far as one can see, are excellent, and in a few weeks the patient seems normal —to all methods of examination. Unfortunately follow-up of most cases is difficult so I am not too dogmatic as to end results. The chief point here is that it is difficult to conceive of a deep indurated ulcer improving so rapidly as these cases seem to do. To give any adequate reason for these racial or geographical differences in the incidence and severity of Gastric Ulcers would involve an investigation far outside the scope of the present paper. The causation of Gastric Ulcers is still in doubt. There are many theories—e.g. trauma, infection, diet, deficiency of vitamines, nervous influences, tobacco, etc., or a combination of several of these factors. Is Gastric Ulcer in Manchuria due to a different cause or causes than in the West? Or is it due to the same cause acting to a lesser degree? Or is there a measure of immunity to Gastric Ulcer in Chinese Subjects? These and kindred questions call for further investigation, but it is hoped that this paper will call forth expressions of opinions from members of this Congress, and perhaps stimulate some to a more detailed study of this very fascinating problem. R e f e r e n c e s 1. Elliot, C. C.: Duodenal and Chronic Gastric Ulcers in China. C.M.J. 1917. XXXI. 15. 2. Elliot, C. C.: Duodenal and Gastric Ulcers. C.M.J. 1918. XXXII. 413. 3. Snell, J. A.: Diagnosis of Chronic Gastric and Duldenal Ulcers. C.M.J. 1918. XXXII. 307. 4. Maxwell, J. L. C.M.J, 1924. XXXVIII. 835. 5. Report of P.U.M.C. Hospital, 1923. 6. C. M. J. 1924. XXXVIII. 835. 7. Report of P.U.M.C. Hospital, 1927-28. 8. Report of Western Infirmary of Glasgow, 1925. 9. Mole, R. H.: C.M.J. 1923. XXXVII. 140. 10. Osier. Principles and Practice of Medicine. (6th Ed.) 475. Í09Ú The China, Medical Journal- THE DIAGNOSIS AND TREATMENT OF ACTINOMYCOSIS With a Report of 9 Cases M. M. ZlNNINGEE, A.B., M.D. Peking, China. Actinomycosis has been of marked interest to m2 ever since, some years ago, I completely failed to recognize it in a patient in whom the diagnosis was perfectly evident. This experience is doubtless not unique, and unquestionably many cases of act inomycosis are overlooked, not so much thru ignorance as from failure to consider the possibility. In those clinics where it is thought of and looked for, the incidence is relatively high, in others the diagnosis is 'practically never made. For example in 1923, New and Figi {10) reported 107 cases of actinomycosis of the face and neck treated at the Mayo Clinic, only 7 of which had been recognized before they came there for examination. 7 The disease is due to a fungus of the streptothrix group, which grows in filamentous form in the diseased tissues. These filaments are gram positive in staining reaction. At irregular intervals and under special conditions little yellowish granules appear in the tissués and in the pus. These are firm bodies, spherical or ovoid in shape, and about 1 mm. in diameter, and have been called “sulphur granules.” Microscopically they are made up of short filaments arranged in a radiate fashion, each tip bulbous or club-shaped and covered with refraetile material. The. radiate arrangement has Hed to the use of the name “ray- fungus” which is sometimes given to the organism. In sections of,the tissue stained with haematoxylin-eosin or with Gram’s stain, titese sulphur granules show as very definite and charact eristic structures. Two. general varieties of actinomyces have been recognized, the first by Bostroem who described an aerobic stréptothrix which he found on the heads of Various straws and grasses in marshy lands. Some time later Wolff and Israel pointed out that the diseáse in man is caused by an anaerobic streptothrix which grows only at body temperature. There is also a so-called actino-bacillus described by Ligniere and Spitze, a bacillus which gives rise to granules, but this may be d is re g a rd ed for practical considerations. However, the theories of tran smission are dependent to some extent on the nature of the organism. It is generally believed that the disease is acquired by a traumatization of a mucous membrane surface by a blade of grass, a bit of straw, a seed, or some such vegetable matter Actinomycosis 1093 -which carries the organism described by Bostroem, and instances have been reported where such objects have been found in thè tissues in the center of small areas of actinomycotic infection. Wolff and Israel, however, felt that the disease was due to an anaerobic organism which grew only at body temperature, and they felt that this was a more or less normal inhabitant of the mouth and air passages, and became pathogenic only after traumata which allowed it to penetrate into the sub-mucous tissues. (15) Regardless of the particular characteristics of the organism, the clinical manifestations of the disease are quite well known. The ¡presence of the organism in the tissues leads to a local necrosis, and this is accompanied by a marked leucocytic re action with liquifaction and pus formation but without much redness, oedema, pain or indeed any sign of acute inflammation. Surrounding the area of necrosis there is generally an intense fibrous tissue reaction which may form a dense, indurated, tumor-like mass. Often there are multiple small sinuses open ing from this indurated tissue, from which there flows abundant pus, in which the sulphur granules can be found. The infection travels along fascial planes like other infections, but also may progress thru bone and muscle, so that disease of the intestine frequently extends thru the abdominal wall, and pulmonary lesions come thru the chest wall. The disease is much more frequent in men than in women, about 80% of all reported cases being males. It occurs at any age but the greatest incidence is in young adults 20-30 years old. About 90% of all the lesions occur in one of three regions—face and neck, lung or intestine. In the group of 670 cases collected by Sanford and Voelker, (11) the location was as follows : Head and neck 60%, abdominal 18%, thoracic 14%, the remaining 8% being divided between the extremities, bone, skin, etc. The condition may be either acute, sub-acute or chronic, but is usually the latter. It is frequently mistaken for tuber culosis, and for this reason is often overlooked. In the early stages it may be difficult or impossible to recognize. The diag nosis can be established only by finding the organisms in the pus or sputum, or in sections of tissue removed for examination. In the pus or sputum they will be overlooked unless proper ex amination is made, for ordinary stained smears and .cultures 1094 The China Medical Journal will fail to show them. The pus must be inspected minutely for the sulphur granules, and if one is seen it must be fished out, crushed on a slide under a cover slip and examined with the microscope, when the typical ray-fungus can be seen. Sever al tricks have been described to make the finding of the granules easier. One consists of shaking some of the pus in a test-tube with distilled water. This breaks up any bits of necrotic tissue which may resemble the granule superficially, but the granule itself remains intact and sinks to the bottom. A variation of this is to add a few drops of blood to the distilled water, and the greenish-yellow granules show more plainly against the red background. The granules may not be present in the pus at all times, and it may take weeks of intensive study before the diagnosis can be established, just as it is sometimes necessary to make repeated examinations of sputum before tubercle bacilli can be identified. The symptoms depend on the region of the body which is attacked. Lesions of the mouth, face, and neck appear first an firm swellings with little or no pain. These either are incised or open spontaneously to discharge pus thru small sinuses, open ing from a firm fibrous mass. Lesions of the lungs give the symptoms of pulmonary tuberculosis with fever, cough, sputum and often pulmonary hemorrhage. It differs from tuberculosis in that the lesion is frequently in the lower lobes of the lung, and the leucocyte count is generally high just as would be ex pected from the leucocytic reaction in the tissue described above. As the infection progresses it extends thru the chest wall like an empyema necessitatis, and sinuses develop, again surrounded by firm indurated tissues. Abdominal actinomycosis is most frequent in the caecum, ’appendix and sigmoid. It often sim ulates tuberculous peritonitis or tuberculosis of the caecum. Occasionally it is the etiologic factor of, or is associated with, acute appendicitis, several cases of this kind having been re ported. I wish to emphasize again the important clinical features Actinomycosis is a subacute or chronic disease, strikingly similar to tuberculosis in its manifestations, associated with moderate fever, generally with leucocytosis, characterized by marked local necrosis of tissue, surrounded by indurated fibrous- reaction, spreading slowly but progressively along and thru fascia, muscle and bone. Actinomycosis 1095 The treatment is unsatisfactory. The suggested forms of therapy are multitudinous, and each method has its exponents. Practically all writers agree however that free incision and drainage is one of the most important if not the most important factor in treatment. (3) Of drugs, iodine in some form has the most adherents: Potassium iodide has been the time honored remedy and in modern literature about half the authors regard it as specific, and the other half as valueless. Doses as high as 800 grains a day have been given. In 1926—Chitty (4) reported 4 consecutive cases of actinomycosis cured by giving them by mouth, tincture of iodine in milk. The dose is started at 7 drops of the 7% tincture in a half glass of milk 3 times a day, and may be increased up to 25-30 drops. The assumption is that there is formed a colloidal solution rich in non-irritant but easily absorbed iodine. The mixture must be made fresh at each dose. Hiinermann (8) reports two cases cured by giving Yatren intravenously. A 4% solution was used, giving daily injections, beginning with 0.5 cc and gradually increasing up to 5 cc a day. Various iodine containing solutions have been used to irrigate the wounds and as moist compresses. Copper sulphate has been advocated by mouth and as a parenchymatous injection of 1%—3% by Baragz, (1,2) but apparently no one else has tried this therapy. He also has used silver nitrate as a parenchymatous injection. Thymol by mouth has been advocated but I have been unable to find any published reports of its use. Its toxic action on the kidneys would re quire care in its dosage. The use of X-ray and radium in lesions of the face and neck forms a pleasant contrast to the poor results obtained by other methods. Lesions of the thorax and abdomen however do not seem to respond well to these agents. Tempsky (13) re ports 45 cases of actinomycosis treated by X-ray. Of these, 36 were of the face and neck, and apparently all except 2 were cured. Surgical drainage and potassium iodide internally were also used in all the cases. Wakely (14) reports 9 cases of the disease treated by X-ray, surgical drainage and potassium 1096 The China Medical Journal iodide, the majority of which were cured. The most striking report is that of Heyerdahl (6,7) who reports 21 cases of actinomycosis of the face and neck treated by radium, all of whom were cured. All cases were proven by microscopic examination of tissues removed for section, and all except the last 2 or 3 were followed for a period of 1-13 years. Heyerdahl is apparently the only advocate of radiant therapy who uses, nothing except that treatment. He gives his patients no drugs and prefers no surgical drainage. Finally, vaccines made of fragments of killed actinomyces have been used, and Colebrook (5) reports 25 cases so treated in conjunction with surgical drainage, but his figures are not convincing. At the Mayo clinic the following plan of treatment has been used for actinomycosis of the face and neck: all pockets are opened and drained, packed, with iodoform gauze and swabbed daily with tincture of iodine. Radium is used in all cases. Potassium iodide is given by mouth beginning with 10 drops of the saturated solution three .times a day and increasing to 200 drops three times a day. 70% of 85 cases treated this way were apparently cured. (10) All the reports show that the lesions of the face and neck: offer the best prognosis, and apparently radium and X-ray are the best agents for treating the infection in that location. Abdominal and thoracic actinomycosis is usually fatal and there is no unanimity of opinion as to the best way of treating the infection here. In general it may be stated that radical surgical drainage is one of the best means we have of curing the disease. This must be done in a thorough and painstaking way, and must be repeated again and again as new areas of infection are detected. Patients must be examined repeatedly to deter mine whether new abscesses are forming, or whether the infection is spreading. There is no agreement as to the value of iodides, though those who feel they are of value insist that the dosage must be very high, not less than 600 grains (40 gins.) a day. During the past six months, two cases of actinomycosis were recognized at the P.U.M.C. Hospital, and there are records of 2 other cases seen in previous years. I have also had the opportunity iof observing 5 cases at the Cincinnati General Ho Actinomycosis 1097 spital during the past five years. These 5 cases have been pre viously reported, (6 ) but I will briefly review them here. The individual case records show you more clearly than I could otherwise describe it, the difficulty in establishing the diagnosis, and the course of the disease. Case 1. L. M. H. Chinese, female, 25 years of age admitted to P.U.M.C. Hospital July 30, 1928 complaining of a swelling of the left jaw which had started two months before. For 1 month she had had difficulty in opening her mouth. So far as she knew she had had no fever or chills. The examination revealed a swelling over the angle of the left mandible, about 5 cm. in diameter, which was firm and irregular, and faded imperceptibly into the surrounding tissues. The X-Ray of the jaw was negative. A diseased tooth was removed with no effect on the tumor. There was slight fever but the loucocyte count was only 6,100. No definite diagnosis was made. On August 10 the entire tumor was removed. It wTas found to be a mass of fibrous and fatty tissue, adherent to the skin, the parotid and submaxillary glands, and to the mandible. In freeing it from the mandible a single drop of pus was seen, smear and culture of which were both negative. The wound was closed without drainage and healed per primam. The patient was discharged from the hospital with a tentative diag nosis of tuberculosis. The microscopic sections showed actinomycosis in a corner of one section, establishing the true diagnosis. She was brought back to the hospital and was given 2160 milligram hours of radium. She was last seen Oct. 10, 1928.' and was apparently cured at that time. C a s e 2. H. Y. C. Chinese, Merchant, male, age 38 was admitted Oct. 23, 1928, complaining of cough and pain in the left chest of five months duration. On May 30, after attending a feast the patient was awaken ed from his afternoon nap by a severe, stabbing pain in the left, axilla. He went immediately to a Chinese physician who 1098 The China Medical Journal gave him opium to smoke. The pain lasted a week or more during which time his appetite was very poor and he was very much constipated. So far as he remembers there was no chill or fever at this time, though irregular fever started after the pain ceased. A week or more after the onset of the pain, the patient began to raise large quantities of muco-purulent sputum—as much as several cup-iuls a day. Sept. 7, he noted that the sputum was blood tinged and it was blood streaked on a number of subsequent occasions but there was never a frank hemoptysis. Associated with the illness there had been profuse night sweats, and the patient had felt weak and unable to work. On Sept. 12, he was admitted to the Taylor Memorial Ho spital. At that time he showed dullness over the left lower chest with diminished expansion, of the chest and marked dim inution in the breath sound. He was raising a large amount of sputum repeated examinations of which failed to reveal tuber cle bacilli. His temperature was very irregular—ranging from 100-103°F. (37.7-39.5°C) His W.B.C. count was 14,000. His blood Wasserman and Widal were negative. The X-ray of the chest showed marked infiltration througout the lower part of the left lung. Repeated thoracentesis was done but nothing was obtained except a few drops of thick whitish mucous, cultures and smears of which were negative. During his stay in the hospital his appetite was good, and his sputum dininished, but he remained weak and continued to run a fever. He was admitted to the P.U.M.C. on the medical service Oct. 28, 1928. At that time his examination showed contraction of the left chest with fullness in the intercostal spaces, dimini shed respiratory movements and diminished tactile and vocal fremitus. There was some dull reddish discoloration over the chest wall with marked tenderness on pressure. This was thought to represent infection of the chest wall. The general appearance was very good, except for moderate anaemia. There was well marked clubbing of the fingers. The blood examina tion showed r.b.c. 4,210,000 Hb 47i/2, W.B.C. 66,200 with 93% polymorpho-nuclear leucocytes and 2% lymphocytes. The temperature was 39.2°C. the pulse 100. Thoracentesis recover ed 15-20 cc of thick greenish pus which showed many leucocytes but no organisms in smear. The patient was transferred to the Surgical Service for drainage of empyema. On account of the failure to find org Actinomycosis 1099 anisms in the smear of the pus, we postponed surgical drainage until the report of the culture was obtained. To our surprise there was no growth at the end of 24 hours. A thoracentesis was then done in an attempt to get more pus for examination, but three attempts all resulted in dry taps. At this stage we should have suspected actinomycosis be cause of the long duration of a chronic suppurative lesion of the lower lung, associated with high fever, marked leucocytosis, and penetration of the chest wall. The reddened, tender area over the lower left chest was ex plored and when this was done an osteomyelitis of the rib was discovered. The diseased rib was removed but no communica tion with the pleural cavity was demonstrated. Several days later another abscess of the chest wall developed anteriorly and above the wound already made. When this was discovered the possibility of actinomycosis was suggested. When the abscess was opened there was found to be little pus, but very extensive necrosis of several ribs with an opening- extending into the pleural cavity. Drainage was established. The appearance of the large wound now present, was that of a tuberculous infection of the pleura with extension to the chest wall. The pus was examined several times for actinomy cotic granules but none were found. On Nov. 27, the pathologic department reported the finding of actinomycosis in the tissue removed at the last operation. Two days later a new abscess was discovered posterior to the large wound and in the pus discharging from this, small greenish granules were obtained which microscopic examination showed to be actinomyces. He was then given 7 drops of tincture of iodine in milk three times a day, the dose being increased daily. His temperature was very irregular ranging from 36°-39rC, and the operative procedures had little effect on his temperature. The pulse was constantly rapid. The appetite remained good, and there was little loss of weight, but the red cell count and hemaglobin declined steadily. The white count was always high varying from 11,500 to 27,000. His sputum was moderate in amount, and contained no “sulphur granules.” On Dec. 2nd and Dec. 6th, he was given heavy radium applications to the wound, 6680 mgm. hours altogether. New abscesses developed and were incised, I1/* Yatren irrigations and compresses were 1100 The China Medical Journo! used to dress the wounds. The patient finally died on December 8th. . For the few days preceding1 death, the pulse became weaker and more rapid, dyspnoea and orthopnoea developed. Just be fore death he became very cyanotic and dyspnoeic with much mucous in the throat. No autopsy was obtained. Case 3. H. S. a Chinese medical student, 24 years of age, was ad mitted to the P.U.M.C. hospital Dec. 12, 192-5 with an acute perforation of a gastric ulcer. A pyloroplasty with excision of the ulcer was done and the patient was discharged well Jan, 1, 1926. He was readmitted Feb. 20, 1926 because of dull aching pain in the epigastrium which had been present for some days. His temperature ranged from 37°-38.2eC and the white blood count from 11,000 to 18,000. A subdiaphragmatic abscess was suspected but this diagnosis could not be confirmed. March 2, 1926 a localized intra-abdominal abscess was opened thru the old incision. Culture of the pus showed no growth. Another abscess developed near the left costal margin and was opened on April 6. The culture of this pus was also negative. The fever remained low but the leucocytes remained high—13,000-20,000. The patient seemed to improve, and was allowed up in a chair, but a new abscess over the chest wall just above the costal margin appeared and was opened May 3. Act inomycosis was suspected by this time, and microscopic sections of tissue showed the fungus, though no sulphur granules had yet been found in the*pus. The patient was given potassium iodide. On May 13 during irrigation of the abscess cavity the patient had a coughing spell. He was given X-ray therapy for 3 days beginning May 14. On May 17, sulphur granules were first found in the pus. He then began having blood tinged sputum and by July 9, there was definite evidence roentgenologi- cally of involvement of the lung. Other abscesses developed and were opened Sept. 8 and 23, and Nov. 8. The patient grew pro gressively worse and died Dec. 22, 1926. The autopsy showed extensive actinomycosis of the liver, lungs and wall of the stomach, apparently the lesions in the liver being the oldest. The perforated ulcer removed at the first operation was care fully sectioned but no actinomyces were found. Actinomycosis 1101 In addition to large doses of potassium iodide and 3 X-ray treatments, the patient received tincture of iodine in milk up to 30 drops 3 times a day. He also received thymol up to 1 gm. 3 times a week near the end of his illness. He received in all 6 blood transfusions. The fever was very variable thruout the entire course of the illness. The white count was almost always high most of the counts being between 15,000-28,000. Sulphur granules were never found in the sputum. Case 4. H. M. S. Chinese, female of 40 was admitted June 4, 1923 complaining of a sinus in the right inguinal region of 2 years duration. According to the history a mass had gradually appeared, had ruptured spontaneously, and had continued to drain. Examination revealed a large, smooth, rounded mass the size of a grape-fruit occupying the right lower quadrant, fixed to the posterior abdominal wall, but adherent to the anterior abdomen only where the sinus opened just above Po- upart’s ligament. The tentative diagnosis was either a chronic appendiceal abscess or a retro-peritoneal abscess. The sinus was injected with bismuth paste, but the X-Ray examination showed that the paste entered only a short distance. The spine, sacro-iliac joints, pelvis and hip joints were normal roeng- tonologically. An incision was made, but only a little pus was obtained. Tissue was removed for diagnosis and actinomy cosis was found. The patient was given potassium iodide up to 2 cc. of the saturated solution 4 times a day—or 480 grains a day. The temperature ranged from (37.0 to 38.2°C). The white count remained constantly low (6,000-8,000). The patient was dis charged from the hospital July 17, 1923 with a clean, granulat ing wound, but was readmitted 2 weeks later because of profuse discharge of pus. Her temperature was about the same, white blood count 4,200. She complained of pain in the buttocks running down into the thigh. She was given large doses of potassium iodide and improved and left the hospital again Aug ust 10, 1923. In October she was seen in the out-patient de partment with her wound almost healed. In Feb. 1924 in reply to a letter, her daughter wrote that the wound had closed and re-opened twice since she left the hospital, but that she was getting weak, had a bad cough and much pain in her loins. (The following cases were seen at the Cincinnati General Hospital) 1102 The China Medical Journal Case 5. White, male, age 53 years. Admitted Sept. 12, 1924. Complaint: chest and left foot sore and swollen. The swelling of the left ankle appeared spontaneously 15 months before ad mission. The swelling gradually increased, an ulcer appeared and pus drained. Eight months before admission he noted a large, red swelling over the front of the chest. This became gradually larger, tender on pressure, and finally ulcerated at several points and discharged thick creamy pus. He had had a cough for about one year, with no expectoration until about the time the swelling of the chest wall appeared, when expectoration of thick, mucoid pus began. He had lost 20 pounds in weight in a year. The chest examination on admission showed signs supposed to be due to a moderately advanced pulmonary tuberculosis, and it was thought that the chest lesion, the pulmonary lesion, and the lesion on the left ankle, were all tuberculous. The temperat ure ranged from normal to 101 degrees, (37-38.3°C) W.B.C. 10 000. The X-ray of the tibia showed periosteal thickening. The X-ray of the chest showed a shadow in the superior medias tinum. Smears and cultures of the pus showed staphylococci and gramnegative bacilli. Tissue excised for diagnosis, showed chronic inflammation but no evidence of tuberculosis or actinomycosis. Repeated examination for actinomyces were negative until October 9, when granules were discovered in large numbers. They could be recovered at will, from that time till the patient was discharged. He was given potassium iodide in large doses, and was sent to the heliotherapy ward.« A mixed vaccine was prepared and a few injections were given. He refused to take the sun treat ments as prescribed and was discharged at his own request, unimproved, Nov. 10, 1924. The patient was not traced. Case 6. White, male, aged 30, who had an interesting pathologic history. In 1916 he had a shrapnel wound of the neck. In 1919 he had an appendectomy. In March 1922 a n abscess developed in the right lower abdominal quadrant, just above P o u p a rt’s ligament, which ruptured, and drained thick, creamy pus, in which staphylococci were found. In April, 1922, an abscess developed in the scar of the shrapnel wound ot the neck, Actinomycosis 1103 This was opened and drained. In June, 1922, he had a tonsillectomy. In Oct. 1922, he had a suppurative pericarditis drained on Surgical Service. In Jan. 1923, ,he was admitted for pain in the back, over, the lumber spine. It was of sudden onset, two weeks before admission. X-ray of the spine was negative. The patient was kept in bed for several weeks, and was discharged Jan. 26, 1923. He was re-admitted March 2, 1923, with the pain in his back much worse. The wound in his neck had healed but the sinus in the right groin drained profusely. A kyphus was present at the level of the twelfth dorsal and first lumbar vertebrae. X-ray of the spine showed wedging and loss of bone structure in the body of the first lumbar vertebra and some involvement of the second lumbar. A tube in the sinus in the right groin was shown by X-ray to pass upwards and posteriorly toward the spine. The temperature ranged from normal to 101 degress, (37-38.3°C) white blood count 17.500, Hb. 75 percent. He was transferred to the orthopedic service with a diagnosis of pul monary tuberculosis, and tuberculosis of the lumbar spine with psoas abscess. The diagnosis was evidently not entirely certain, for some tissue was removed for section. This revealed chronic infection in granulation tissue, but no tuberculosis or actinomy cosis. On March 13, 1923, he had a severe pulmonary hemorrh age. March 16, a plaster jacket was applied. March 26, he was transferred to the Branch Hospital for treatment of his pulmonary tuberculosis. It is interesting to note that no tuber cle bacilli had been demonstrated in his sputum. April 8, 1923, he was sent back to the General Hospital, because it was found on removing his cast, that there was a large abscess over the entire lower half of his back. On opening this abscess, Dr. Reid discovered “sulphur granules” and micros copic examination showed that the ray fungus was present. Portions of granulation tissue from the wall of the abscess also showed actinomyces. The patient was given large doses potas sium iodide. His general condition, however, was extremely bad. He died three days after operation. Autopsy was refused. Case 7. Colored, male, age 32, admitted February 5, 1927, com plaining of an abscess. In June, 1926, the patient had an attack of acute abdominal pain, cramp-like in character, but 1104 The China Medical Journal not associated with vomiting or constipation. In September 1926, he noticed a lump in the right lower abdomen. In December 1926, this lump was opened in a Detroit hospital, a large abscess being drained. He was in the hospital 17 days and was discharged with several draining sinuses. He remained fairly well till about the first of February, when he again had abdominal cramps and the drainage from his sinuses became more profuse. On admission the temperature was 99.4, (37.2°C) pulse 22, W.B.C. 13,000 R.B.C. 3,840,000. There was a large abscess of the anterior abdominal wall the tissues surrounding it being very much indurated. There were several draining sinuses, 8 in the old scar in the right lower quadrant and one at the umbilicus. The abscess was opened the day of admission, but less pus was obtained than was expected. The abscess was found to consist of a series of sinuses burrowing through dense scar tissue. Two days later, at staff ward rounds, Dr. Reid suggested, on account of the extreme induration, that it might be an actinomycotic infection, and he demonstrated the sulphur granules. Culture of the pus had shown staphylococci. Barium enema showed a slight filling defect in the tip of the caecum. The patient was given tincture of iodine 10 minims in milk, three times a day. A vaccine was prepared. He improved greatly and was discharged May 10, 1927, with the sinuses still draining a little. He returned to the hospital October 12, 1927, complaining of a sharp pain in the right lower chest, which he had first noted about a week before. It was a constant aching pain made worse by deep breathing.- There had been no cough or ex pectoration. There had been no jaundice or chills, but a few night sweats. The temperature was 100.5, (38 °C) pulse 100, W. B. C. 14,900. The abdominal wound looked about the same as at the time of discharge. The physical examination of the chest was essentially negative, except for some splinting of the right chest and point tenderness on pressure over the seventh interspace and the eighth rib in the anterior axillary line. X-ray of the chest showed the lung fields to be clear, but the diaphragm slightly elevated on the right. On account of the fever which went up to 102-103 degrees (39-39.5° C), the abdominal wounds were reopened. They were f o l l o w e d into the peritoneal cavity through tissue, apparently the omentum, Actinomycosis liOö honey-combed with pus-filled sinuses leading to a mass in the region of the sigmoid. Drains were placed, and the patient’s temperature became lower. He soon died however, and the autopsy showed an actinomycotic abscess of the liver in addition to the extensive disease of the bowel, peritoneum, and anterior abdominal wall. Ca s e 8 . Colored, male, age 21, admitted first on October 8, 1926, complaining of vomiting, and of swelling and pain in the abdomen. Ou September 7, 1926, the patient was crushed between a bank of earth and the bucket of a steam shovel, the latter hitting him in the abdomen. He was not immediately disabled, but worked for several hours. The following day, however, he had to go to bed, and had remained there almost continuously since. Five days before admission his abdomen swelled up, he had sharp abdominal pains, vomiting and slight diarrhoea. At the time of admission he looked quite ill. His temperature was 102. (39°C), pulse 100, W.B.C. 7,850. There was a mass the size of a large orange in the right lower abdomen and signs of fluid in the flanks. He vomited persistently for several days and then gradually improved. On October 14, his abdomen was explored under local anesthesia, the preoperative diagnosis being tuberculous peritonitis with partial obstruction. There was found a marked plastic exudate holding adjacent loops of bowel together, with much free turbid, odorless fluid. The bowel was slightly distended. The omentum was thick, pale and translucent. No tubercles were seen. The mass in the right lower quadrant seemed to be made up of matted loops of bowel and was adherent to the anterior abdominal wall over an area three inches in diameter. Smears of the fluid in the peritoneum showed leucocytes, but no organisms. Culture reported later showed B. Coli. It w^as felt that we were dealing with a chronic peritonitis, probably tuberculous. The incision became infected but healed readily. The patient im proved, and was discharged on December 21, 1926. He was readmitted February 1, 1927. on the medical service with ci history of nausea and vomiting associated with severe abdominal pain,—of three days duration. He rapidly improved and was discharged February 9, 1927, with a diagnosis of acute gastroenteritis. A gastro-intestinal X-ray series made at this 1106 The China Mcdical Journal time was reported negative. The temperature was normal. W.B.C. 12,000. He was readmitted on Surgery, April 3, 1927, with two draining abscesses of the anterior abdominal wall, which had appeared about two weeks before, and had opened spontaneous ly. The abscesses were indolent looking, with dusky, purplish, exuberant granulation tissue protruding through a number of openings. The centers were soft, but the surrounding tissues were extrordinarily indurated and leathery. This immediately suggested actinomycosis and the ray fungus was easily demon strated. The temperature was normal. W.B.C. 13,600 R.B.C. 4,300,000. The abscesses were opened and the granulation tissue curetted out. The patient was given iodine in milk. He improved and was discharged June 10, 1927. He returned again September 6, 1927, this time with an aetinomycotie abscess of the left thigh. The lesions of the abdominal wall had improved. The abscess of the thigh was opened, treated with Dakins solution, and closed partially by suture, and was almost healed when the patient was discharged October 8, 1927. Case 9. White, male, 32 years of age, admitted September 25, 1927. On July 7, 1927, the patient was operated on for acute appen dicitis. The appendix lay retrocecal and upon delivering it the tip was found to be gangrenous. No abnormality was noted in the caecum. The wound was closed and it healed, and the patient was sent home. Three weeks after operation the patient began having pain in the right lower quadrant, associated with fever. A mass developed. August 31, 1927, an intra-abdominal abscess was opened through the old incision. In the pus, “granules” were found which proved to be actinomyces. He was given iodine in milk but did not tolerate it-well. X-ray treatments had to be discontinued because of fever and nausea. On September 25, 1927, he was admitted to the .heliotherapy ward of the General Hospital for radiation with the arc lamp, On admission his temperature was 102 (39°C), W.B.C. 16,000 Hb 66% R.B.C. 4,760,000. He had a very stormy Actinomycosis 1107 time. He continued to vomit, the abscess drained profusely, and the fever continued high. He died early in November, 1927. The appendix has been carefully sectioned, serial sections being taken from different areas. Over 40 sections have been studied, but no actinomyces have been seen. 1. von Bra?z, (Roman). Die Behandlung der Aktinomykose mit Kupfer sul fat u.s.w. Zentralbl. f. Chir. 49; 634, 1922. 2. idem: Ann. Surg. 37; 336, 1903. 3. Brickner, (M.M.), Pelvic actinomycosis. 5 cases successfully treated by operation. Ann. Surg. 81; 343, 1925. 4. Chitty, (H), Actinomycosis successfully treated by iodine in milk. Brit. Med. Journ 1; 418, 1926. 5. Colebrook, (L), A report upon 25 cases of actinomycosis with especial reference to vaccine therapy. Lancet 1 ; 893, 1921. 6. Heyerdahl, (S.A.), Actinomycosis of the face and neck treated with radium. Brit. Journ. Radiol. 31; 1, 1926. 7. idem. Uber die Radium behandlung der Aktinomykose des Gesichts und des Halses. Strahlentherapie 25; 679, 1927. 8. Hünermann, (Th.), Behandlung der Aktinomykose des Halses mit Yatren. Deutsch, med. Wchnschr. 53; 801, 1927. 9. Judd, (W.R.), Vaccine therapy in a case of actinomycosis, etc. Brit. Med. Journ. 2; 886, 1926. 10. New, (Gordon B.), and Figi, (F.A.), Actinomycosis of the head and neck. Surg. Gynec. and Obst. 37; 617, 1923. 11. Sanford, (A.H.), and Voelker, (M). Actinomycosis in the United States. Arch. Surg. 11; 809, 1925. 12. Simpson, (W) and McIntosh, (C.A.) Actinomycosis of the vertebrae. Arch. Surg. 14; 1166, 1927. 13. Tempsky, (Art). Resultate der Röntgentherapie bei der Strahlen pilzerkrankung. Beitr. z. klin. Chir. 139; 207, 1927. 14. Wakeley, (C.P.G.) The treatment of actinomycosis by X-Ray, with a report of 9 cases. Arch. Radiol, and Electroth. 28; 129, 1923. 15. Warwick, (W.T.) A clinical contribution to the aetiology of actinomy cosis. Lancet 2; 497, 1923. 16. Zinninger, (M.M.) Report of 5 cases of actinomycosis. Journ. Med. 9; 71, 1928. 1108 The China Medical journal THE TREATMENT OF WOUNDS P h i l i p B . P r ic e , M .D . From the Department of Surgery, Shantung Christian University, Tsinan, Shantung. P a rt II. Recent Gains in the understanding and treatment of Infected Wounds. Following the development of aseptic technic in the operating room, new operations were developed by the score, classical operations were performed with almost certain success, and surgical wards became filled with “clean” cases. It was inevitable that the less satisfactory treatment of infected wounds should suffer eclipse, both in the interest of the surgeon, and in he curriculum of the medical student. So it was that at the beginning of the World War, when the medical corps was suddenly called upon to handle huge numbers of wounds, practically all of which were innoculated with virulent organisms, it was found unprepared, and not altogether equal to the task. Many methods were tried, and each had its advocates and critics. But whatever the method, or whoever the surgeon, the battle against septicemia and suppuration was won slowly, if at all, and the precentage of the permanently disabled was high. However, this state cf affairs, which prevailed generally during the first year of the war, seemed so unsatisfactory to a certain group of scientists, that they turned their energies and technical training to a solution of this age-old problem. Their work was scientific in the best sense of the word. Chemistry, bacteriology, pathology, and surgery worked in cooperation, laboratory experimentation preceded clinical application, and every step was tested critically with controls. Two members of this group will be remembered longest in the History of Surgery— Henry D. Dakin and Alexis Carrel—and the following resume of recent gains in the understanding and treatment of wounds* is largely a report of their work. F irst, In The Pathology of Wounds: A wound is a local, and should he, therefore, a controllable infection. During the first six to twelve h o u rs the b acteria remain localized a b o u t th e dirt a n d o th e r foreign bodies carried into th e tissues, but they multiply with Unbelievable rapidity. Then, when secretions begin to be poured out, the germs are carried abroad, and by the end of twenty four hours, every The Treatment of Wounds 1109 part of the wound is infected. The bacterial flora gradually changes: first it is large, and one finds many large rods, anaerobes, and other less familiar forms; at the end of twenty four hours, if the wound be deep or irregular, the streptococcus begins to predominate; after some days the staphylococcus is usually the chief organism. So in wound pathology one must recognize three stages: 1. A pre-infiammatory period, the first few hours, even as long as one day, when the tissues look normal, and are not very painful, and when there is little or no secretion. 2. The inflammatory stage, in which the tissues are phlegmonous or gangrenous, and discharge a thin, serous, or bloody fluid, and in which the part is very painful, and there is more or less general reaction of fever, toxicity, etc. 3. The period of suppuration, in which there is a gradual subsiding of acute symptoms and signs, both local and general, and the discharge becomes thick, white, “laudable” pus. Most important of all, a negligible number of germs are found in the living walls of a wound: they are all on the surface, about foreign bodies and necrotic tissue, or imprisoned in scar tissue. S e c o n d , I n T h e M e c h a n ic a l C l e a n s in g of W o u n d s : This has been practiced, of course, from time immemorial, and in recent decades with increasing success. As early as 1891, Halsted was closing without drainage all wounds that entered his wards, whether fresh or long standing, and he obtained primary healing in practically all of them. But in less careful and skillful hands there wTere many failures. Carrel and his co-workers, however, have put mechanical cleans ing on a rational basis, and their advice is sound and scientific: 1. In the Pre-inflammatory stage, under general anes thesia, practice total excision, or at least wide incision of the wound, splitting, or even cutting muscles freely, carefully removing with sharp dissection all foreign bodies, all bruised or necrotic tissues, and all clotted blood. Be very conservative about removing small bony fragments. Secure perfect hemostasis. I lio The China Medical Jo n u m i 2. In the Inflammatory stage, whether gangrenous or phlegmonous, be conservative, content with removing superficial dirt or other foreign bodies; if necessary, and only if necessary, enlarge the mouths of the wounds to insure drainage; work tubes gently into the depths of the wound, irrigate with Dakin’s solution, and await the stage of suppuration.' 3. In the Suppurative stage, when the temperature and swelling are down, and the pain is alleviated somewhat, treat the wound like a fresh one, with wide incisions, surgical cleansing, and preparation for Dakinization, T h ir d , I n T h e C h e m ic a l S terilization of W o u n d s : This was Lister's original contribution. He used carbolic acid for the most part. Halsted was even more successful with dilute solutions of Mercuric chloride. But, alas! most surgeons lack an “infinite capacity for detail,” and have only a passing acquaintance with the bacteriological laboratory, and consequent ly the opinion became—and still is—quite current that a badly infected wound cannot be sterilized by chemical means. The work of Dakin and Carrel has re-established this principle, and put it on a scientific basis. The sterilization of a wound is accomplished, not, as is generally thought, by th e single application of a strong antiseptic, but by long-continued contact with an efficient, but relatively weak antiseptic that will not injure the tissue cells. Antiseptics act very differently in aqueous suspensions of bacteria, and in the presence of serum or body proteins. Thus Tinct. Iodine is reduced to 1/100 its germicidal power, Bichloride of Mercury to* 1; 200, Silver Nitrate to 1/100, and Carbolic Acid to such a degree that a 2% solution is ineffective in wounds. After extensive experimentation with over two hundred chemical antiseptics, Dakin recommended neutral Hypochlorite of Soda, in the strength of 0.45% to 0.5%, because of its remarkable combination of properties: it is non-toxic, non- irritating, an efficient antiseptic, it destroys bacterial toxins as well as bacteria, and slowly dissolves devitalized tissue's. Any antiseptic is rapidly diluted by wound secretions as; to be rendered ineffective as a germicide. So Dakin’s solution is to be renewed at least every two hours, day and night. The Treatment of Wounds 1111 Any wound whose entire surface can be put in contact with Dakin’s solution can be sterilized in a relatively short time. The rapidity of sterilization depends, not upon its size or depth, but upon whether all foreign bodies and necrotic tissues have been removed, and the efficiency with which the solution is brought in contact with every part of the wound surface. Thus a large, deep wound, without pockets, often may be sterilized in 24 hours, whereas a small, irregular one, containing a bit of sloughing tendon or fascia, may require weeks. As for associated fractures, experience has shown that while the femur, tibia, humerus, and lower jaw are slower, compound fractures of the other bones can be as rapidly sterilized and prepared for closure as the soft tissues. Gaps in bone can be successfully filled with grafts or Beck’s paste, if the wound is surgically sterile. In all this, the microscope is as necessary as the scalpel or irrigating tube. F o u r t h , I n T h e S e c o n d a r y Cl o su r e of W o u n d s : After a wound is rendered surgically sterile (one bacterium to 20 or more high power fields), it can be closed confidently without drainage. Secondary suture can be done as perfectly as primary, and without the latter's inevitable risk. Wounds united before the eighth day contain no scar tissue, and, there fore, there is no resultant abnormality of function. Cicatriza tion, if unhindered by infection, progresses at a definite rate, the curve of which has been expressed in algebraic terms by Lecomte du Nouy. It is Nature’s method of repair, or attempted repair, usually at the expense of function. It can be avoided by early secondary closure of wounds, which have become surgically sterile. As for the results of these principles actually put into practice, I quote from Dr. Keen’s book on “War Wounds:”* “The two most important witnesses are unquestionably Professor Wm, H. Welch and Professor Depage. “The testimony of Professor Wm. H. Welch, of Johns Hopkins,! is most valuable because of his eminence as a pathologist and as a broad-minded philosophic observer. :“Thc Treatment of War Wounds” by W. W. Keen, M.D., L.L.D.; W. B. Saunders Company, Philadelphia; 1D1S. ! “Dr. Welch's Testimony.—After a visit to Compiegne,—not a casual visit, blit one during which he studied the method and the smears “day by day”,—Welch says: “ ‘There can be no question that Carrel deserves the credit— and a very considerable credit this is—of recalling the attention of surgeons to the possibility of the sterilization of infected wounds by chemical means. The idea is, of course, not new, but the original Listerian one. That the Carrel-Dakin pro cedure actually accomplishes such sterilization sufficiently for surgical purposes is quite conclusively demonstrated, and what ever changes be made in his technic as the result of further experiences, he will deserve the credit of reapplying a great surgical principle of wound treatment, which had been practical ly abandoned.’ . . . . “ Tt was fascinating to wfatch (by the microscope) the reduction, often astonishingly rapid, at other times slower, of these bacteria under irrigation by the Dakin fluid. It was a quite novel thing to find the bacteriologist occupying this relation to the surgeon and telling , him when the wound could be safely closed. The cicatrization after closure under this bacterial control was amazingly rapid.’ . . . . “ ‘I see no conflict with the teachings of surgical pathology in Carrel’s w ork. . . . Experience with the Carrel method proves conclusively that the destruction of these surface bacteria, without injury to the body tissues, is of primary importance. So many who discuss this question seem to lose sight of the fact that a great principle is really involved, viz., that of the sterilization of wounds by chemical methods without damage to cells, and the influence of such sterilization on the repair of wounds. Carrel’s work is fundamental on this point .. ..The actual results are quite unequalled, as Almroth Wright himself told me, and as so many have testified.’ ” “ . . . .Describing what Dr. C. L. Gibson, of New York,* saw at La Panne, Belgium, where the method is strictly and efficiently carried out: “ ‘Dr. Depage greeted me by saying that he had 80 com pound fractures all grouped in one ward and that not one was suppurating. He kindly devoted a whole forenoon to their * General Bulletin, Society of the New York Hospital, March 27, !})-<• The Treatment of Wounds 1113 demonstration, and I had the opportunity to see every one of these 80 cases, even to the smallest details. None of the dressings were touched till I had the opportunity to see them and estimate the amount and nature of the discharge contained on them. I had an opportunity also to see the bacterial chart of every one of these cases, see a number of these cases ‘closed,’ and in some cases observe their condition and final healing. I was able not only to corroborate Dr. Depage’s statement that not one of these compound fractures was suppurating, but could affirm, in addition, that I failed to see a single drop of pus in any one of these cases. When one remembers that these wounds offer the maximum possibilities, particularly the shell wounds, with terrific mangling of the tissues, extensive splin tering of bone, harboring many and diverse forms of projectiles and foreign bodies, necessarily all primarily infected,—in other words, the worst possible imaginable wounds,—the result is something one must know for oneself to appreciate. “ ‘These wounds heal in a manner that is simply indescrib able. One has to see the behavior of these sutured wounds oneself to realize what happens. They heal with no more reaction from their appearance and manifestations than would be given by a wound which has been sutured on a cadaver— total absence of reaction, pain, swelling, redness, and even of infiltration around the wound edges. Dr. Dehelly, of Havre, tells me that he has closed 400 of these wounds with only six failures to obtain perfect primary union. Of these six mishaps, none was of any importance, and in some of these Dehelly said the fault was probably due to his failure to await complete sterilization, as evidenced by the bacterial count.”. But the closing words of Carrel and Dehelly in their book, “Infected Wounds,”* .should be emphasized. “Since our methods have been employed with success under the ordinary conditions of ‘ambulances’ and hospitals, the steril ization of both fresh and suppurating wounds ought to be practiced almost everywhere. But surgeons should not forget that all the details of the method have been studied experimen tally and established in a certain way to produce a certain result. Neither the preparation of Dakin’s solution may be ’ “The Treatment of Infected Wounds” by A. Carrel and G. Dehelly. translated by Herbert Child; Paul B. Hoeber Company, New York City, 191?. 1114 The China Medical Journal modified, not the processes for mechanical and chemical cleansing of wounds. It is indispensible to learn the method before attempting to apply it, and this apprenticeship demands several weeks, even from an experienced surgeon. But we can be quite sure that, applied in their entirety, the methods just described will prodace the desired results. Admitted, their use exacts more precision and more care than the old methods, for any approach towards technical perfection requires more elaborate apparatus and a more specialized staff. But efforts of no great magnitude on the part of doctors and nurses will most certainly yield an immense improvement in results.” In conclusion, I wish to speak of our own experience in the treatment of infected wounds, and especially compound frac tures, of wThich we have had a great many. The Carrel-Dakin method has been used here for only tiiree months. Its institution has not been without difficulties. Those who had never seen it used, did not welcome the extra care and time and apparatus required. Doctors and nurses have had to be taught, one by one, something of the principles and technic. It was only after some weeks that our Dakin’s solution was found to be too weak, because the titrating agent was impure. Of necessity the dressings have to be done in large part by internes, who (unfortunately- rotate every three weeks, and scarcely have time to gain any proficiency ere they are moved to another service. Nevertheless, the improvement brought about by this method, still so imperfectly applied, has been remarkable. Within the past few days five compound fractures have been discharged, three of whom were treated by the older methods, and two—our first two-—by the Carrel-Dakin method. (1) F 5117. Male. Age 56. Admitted,Aug. 10, 1928. Traumatic simple fracture of right lower leg, which developed pus and ruptured spontaneously 5 days later. Admitted 20 days after injury. Fracture of tibia about 3 inches above ankle. Foul pus being discharged from a sinus. Temp. 101°, pulse 120, resp. 30. 1st day: Ether anesthesia. Incision. Resection of about 1 inch from each fragment. Vaselin gauze packing, and plaster cast (Orr’s method). Following this daily fever, pulse over 100. 24th day; Fever rising. Pain, Cast opened and wound dressed. The Treatment of Wounds 1115 44th day: Fever rising again. Spinal anesthesia. In cision and drainage. Considerable reaction for several days. 52nd day: Incision. Resection of ends of tibia, and fresh ends of fragments put in apposition. Plaster cast. General reaction for several days. Temp. 102 + °. Pulse 120+• Edema of foot. 77th day: Window cut in cast to dress wounds. Large amount of foul pus. Occasional vaselin gauze dressings there after. 107th day: Under local anesthesia incision for better drainage. Reaction—temp. 104.2°, dropping to normal in 4 days. 120th day: Under novocain incisions on either side for drainage. Vaselin gauze pack and plaster cast. Temp, rose to 101.6°, dropping in 6 days. Later rose again gradually. 141st day: Spinal anesthesia. Excision of sinuses. Thorough curetting of all necrotic tissue. Temp, rose to 100.4°, falling in 2 days. Daily dressings. Foot dark and edematous. Gradual improvement. Wounds fairly clean. No fever. 181st day: Cast removed. No union. X-ray shows no callus, and Fibula greatly atrophied. Still some pus discharged from sinuses that run deep into the scar tissue and to bone. Hanging the foot down is very painful, no active motion of ankle or toes. Circulation of foot poor. 190th day: General anesthesia. Amputation of lower leg at middle third. Pathological examination of amputated leg- showed extensive scar tissue formation and infection, no callus, weak fibrous union of widely separated fragments. Following operation, primary union. Good stump. Massage. Gradual regaining of health and strength. Up on crutches. Finally a plaster pylon made. 279th day: Discharged (2) F 5551. Farmer. Age 80. Admitted Nov. 26, 1928. Shot in leg by bandit; also wounds about the head. Ad mitted 3 days later. Moderate shock. Temp. 101.4°. Pulse 100. Resp. 21. Compound fracture of both bones about 3 inches above ankle. Circulation of foot good. R.b.c.. 4,500,000. W.b.c. 16,600. Hb. W#ss + + . Urine neg. N. E, other- Wise neg. 1116 The China Medical Journal 1st day: Spinal anesthesia. Excision of sloughing tissue. Counter incision for through and through drainage. Irrigated with large quantities of weak bichloride solution. Large per forated rubber tube through and through for drainage. No bone removed. Thomas splint. Stirrup traction. Following operation fever rose to 102° for 5 days, then dropped to daily maximum of 100°. Swelling and pain gradually subsided. Traction until full length regained, and ends of bones in contact. General condition improved. But pus continued to be dis charged, and there was edema to the knee. At the daily dressings wound irrigated with eusol. 61st day: (Interne’s note) “Position of leg good. No union. 2 small sequestra removed from lower end of tibia/' 74th day: Incision and drainage of abscess extending from the wound half way up the lateral aspect of the lower leg. 98th day: Large piece of dead bone, 1 x 2 inches, removed from the wound. Smaller pieces removed each day during the following week. Sinuses irrigated with Dakin’s solution every two hours. 114th day. Stirrup removed, and traction discontinued. Wounds almost healed. Still a little discharge. No bony union. X-ray shows no callus. V-> inch separation of fragments. 133rd day: Thomas splint removed. Plaster cast applied, not hoping for union, but for gradual sterilization, so that bone graft can be attempted later. 139th day: Discharged walking on the cast. (3) F 5564. Male. Age. 32. Admitted Nov. 29, 1928. Gunshot wound left upper arm near elbow, received 5 days before admission. Bullet entered posteriorly and emerged anteriorly. Arm greatly swollen. Compound T-fracture, involving joint. Temp. 100°. Pulse 110. Resp. 22. W.B.C. 9100. Hb. 80%. Wass. neg. 1st day: Incision and drainage. Removal of bone frag ments, the largest 1 inch in length. 1:500 bichloride solution irrigation. Rubber tube drainage. After operation temp, rose to 103°. Much pain and swelling. Thomas arm splint. No traction. Daily dressings, with eusol irrigations. Continued to have a little pus, and the swelling would not subside. The Treatment of Wounds 1-117 41st day: Ëther anesthesia. Old wounds reopened. Scar tissue cut out. Small pieces of bone removed. Part of wound curetted. Drained. Jones splint, with arm flexed. Post operative temperature 102°, dropping to normal in 6 days. Some days later wounds irrigated every 2 hours with Dakin’s solution. Syringed out with eusol at daily dressings. Swelling and discharge continued, although wounds looked clean. 57th day: Ether anesthesia. Wounds reopened. Com munication established between the anterior and posterior wounds. Cavity curetted. Lateral incision added for better drainage. Washed with hot 1:500 bichloride solution. Rubber tube drainage. 2 small sequestra removed. Very little callus encountered. Thinking that the previous edema of the entire arm and hand were due to pressure of the ring of the Jones’ splint in the axilla, elbow extended again, and.the arm put in a Thomas splint, abducted, and elevated. Very little post operative reaction. But swelling, pain, and discharge continued. Temperature gradually rose as wounds closed in. 90th day : Ether anesthesia. Anterior and posterior wounds opened widely, so that they communicated. Pus pocket evacuated. Bony union found. Irrigation tubes put in for Dakinization. 106th day: Jones’ splint reapplied. Elbow flexed. Wounds closing. Temperature normal. Firm swelling of arm and hand. 127th day: Wounds practically healed, and arm painless. Splint removed, and arm put in sling. No motion, active or passive, in elbow, wrist, or hand. Massage begun. 135th day : Discharged. Fixation of elbow, but the patient cannot let the arm hang without support. Swelling of arm and hand much improved. Shoulder muscles very weak, and passive motion much limited in all directions. Forearm cannot be pronated. No motion at wrist. About 25% motion regained in fingers. Onlythe fore-finger can meet the thumb. Upper arm shows 2 inches shortening. X-ray shows upper fragment against the olecranon, with the condyles on either side. Now these are familiar cases. Every general surgeon in bandit-ridden parts of China has met them often, and dreaded them, They seem to mock the surgeon, however skillful or 1118 The China Medical Journal conscientious he may be. It is for just such cases that the Carrd-Dakin method offers new hope and promise. (4) F 5783. Farmer. Age 37. Admitted Feb. 8, 1929. Gunshot wound by bandit 10 days before admission. Com pound, comminuted fractures of middle third of left humerus. Small ragged wounds on lateral and medial sides of arm, dis charging thin bloody fluid. Arm much swollen, hot, and painful, iiooked toxic. Temp. 100.4°. After 3 days general symptoms subsided somewhat, but the local condition had not changed. Operation under ether. Thorough mechanical cleansing through a long incision on the lateral side. Medial wound merely excised. Bone fragments not disturbed. Put in a Jones’ splint, and irrigation started immediately. (The operation was done too soon, however, for the temperature rose to 103°, and the pulse to 120; but fell in two days to normal.) The bacterial count the first day after operation was over 700 per h.p. field. 9th day: no pain or fever. Very little swelling of the arm. Bacterial count 100. 19th dayT1 No fever. Patient sitting up. Bacterial count 20. Active movements of hand and wrist begun. 27th day: Bacterial count 3. Wounds look healthy, and are closing in so ‘fast it is hard to irrigate efficiently the deepest parts. Dressings'painless.. 37th day: The Bacterial count did not fall below Vt, but the irrigations had to be stopped, because the wounds had filled, except for a small superficial area on the lateral surface. Bony union quite firm, but with anterior bowing of about 10°, due perhaps to the pressure of the ring of the splint. Splint removed, and arm put in a sling. 45th day,, Massage begun, and active and passive motion of the elbow. 53rd day : (7 weeks after operation) : discharged. W ounds healed; Almost perfect motion regained already. No shorten ing. ' - ■ The Treatment of Wounds in a (5) F 5871. Soldier. Age 44. Admitted March 4, 1929. Admitted 15 hours after gunshot wound of left arm. Bullet entered posteriorly, and emerged anteriorly. Compound, badly comminuted fracture of lower third of humerus. Not much bleeding. Arm slightly swollen, but showed no inflammation or discharge. Numbness of forearm and hand. Temp. 97.8°. Pulse 100. Resp. 22. Hb. 90%. W.B.C. 9800. Rales heard in left apex. Operation as soon as operating room could be made ready. Brachial plexus block. Careful mechanical cleansing. Biceps and triceps widely split. No bony fragments removed. Jones5' splint applied. Dakinization begun immediately. 2nd day. Temp. 100.6°. Bacterial count, 2. Very little pain. 3rd day. Temp, normal. Active movements of hand and wrist encouraged. 7th day. Temp, normal. No inflammation or pain. No pus. Bacterial count, i-i* Rotation of forearm encouraged. Persistent efforts to get the bacterial count low enough to suture the wound failed, due perhaps to the lack of the glass distributing tubes, so that bacteria were injected from the unsterile ends of the tubes at each irrigation. 30th day. Bones covered with granulation tissue. No pus. Patient up. Bacterial count still ranging from 1U> to */£. There seems to be bony union. Numbness (radial) improving. 36th day. Wounds so shallow, irrigation stopped. 42nd day. Splint removed. Bony union quite firm. Sling. 51st day. Left the hospital, although he was urged to stay a few days longer. Wounds healed. Slight tenderness over the external condyle, and daily rise in temperature to 99' or 99.2' (Tbc?) X-ray showed no osteomyelitis, but firm bony union. No angulation or shortening. Some binding of biceps and triceps by scar tissue, which was improving daily with massage and use. Motion of elbow at discharge, 170° to 45°; also im proving daily. The contrast of results in these cases is even more clearly shown by an attempt at a score or grading (in which each of five characteristics is estimated on the basis of 20.) 1120 The China Medical Journal Above Cases ' 1 2 3 4 5 Nutrition (distal to injury) 0 18 10* 20 20 Sensation ( „ „ „ ) 0 20 20 00 20 Deformity 0 0 46 19 20 Motion (considering all the joints) 0 o 2* 16 18* Power 0 0 1* 15» 17* Total Result 0 42 47* 90* 95* Now these cases in themselves prove nothing, but they are backed by a long series of more or less unsatisfactory cases in this hospital, and a small but encouraging group now under going the new treatment in the wards, and, what is a great deal more significant, they are backed by the uniform experience of all who have adopted the method of Carrel and Dakin in its entirety. It seems to me that we have here an opportunity to make a special contribution to China at this time. Our graduates go out, for the most part, into “inland” hospitals, where a large percentage of in-patients will have infected wounds. In the smaller hospitals there are relatively few “clean” surgical cases. If our graduates can learn how to eliminate pus, and most of the pain of inflammation, from the hospitals to which they go, how to undertake infected cases confidently and scientifically, and how to promote relatively rapid and almost certain healing of infected wounds, they will make to their country a contribution difficult to overestimate. PREGNANCY AFTER LIGATURE OF THE FALLOPIAN TUBES OR PERSISTING AFTER CURETTAGE J. Pbeston M axwell, M.D., P.R.C.S. Professor of Obstetrics & Gynecology Peking Union Medical College It is sometimes assumed' that the prevention of pregnancy and its arrest after commencement is an easy task, but such is by no means always the case. I am not speaking of the uncertainty of all mechanical and chemical anticonceptive (*Thosé giving promise of improving.) ' 1 Failure to Prevent Pregnancy 1121 appliances, but of cases where the prevention of, or arrest of, conception has been deliberately planned, and carried out by means which under ordinary circumstances should have proved successful. Zangemeister, for instance, reports the case of a woman where both tubes and one ovary had been removed for repeated tubal gestation, and where a year after the last opera tion she became pregnant in the uterus. It has long been known that tying of the tubes in continuity is a method which, whilst it usually succeeds, has been known to fail more than once, and' Kustner has reported two cases where uterine pregnancy follow ed wedge excision of both tubes for the purpose of sterilization. Two cases of this kind have come under my care during the last year and both of them are instructive cases. Mi-s. Chen Shou Shih, aet 21, a married Chinese woman, Hosp. No. 19762, was admitted to the Peking Union Medical College Hospital on March 12th, 1928. Two years ago a Caesarean section was performed in Tien tsin for pelvic contraction (rickety fiat pelvis). She left the hospital well after 3 weeks, but on entering her house she kicked at a dog and was immediately seized' with p On March 15th, 1928 an operation was performed. The patient and her husband asked that if pregnant it should be terminated, and' future pregnancies prevented, as she refused to face a third abdominal operation. The abdomen was opened by a median subumbilical incision to the left of the old scar. The pregnant uterus ( 3 months) presented with a firm omental adhesion on the right side in front. It lay, so to speak, in a cradle caused by a cyst which was adherent to the back and right side of the uterus, passed over to the left, and ran down to the bottom of Douglas’ pouch. The cyst was the size of a foetal head, and was tied down in the pouch by several strong bands and by light adhesions of recent formation. When these were separated and the cyst freed, it was found to be an ovarian cyst, twisted clockwise a full turn, but not intensely strangulated. There was no good ovarian tissue visible on this side. The tube looked normal and' two silk sutures were still in position. On the left the tube had been tied twice, the inner suture was present, the outer appeared to have cut its way out and was not seen. The ovary was normal, contained a corpus luteum of pregnancy and was left alone. The uterus was removed. With it was removed the right tube and the inner two thirds of the left tube, leaving the sutures in situ on or around the tube. There was a little oozing from Douglas’ pouch, but this was stopped by hot compresses. The appendix was long and succulent. It was removed in the usual way, to avoid' the possibility of a further abdominal operation for this cause. Carbolic Acid and alcohol were used for the stump, which was buried. The abdomen was closed with a continuous catgut suture for the peritoneum, continuous chromic gut for, the fascia, one silkworm gut stay suture, and a continuous fine black silk suture for the skin. The operation lasted about an hour, and the patient left the table in good condition. Patient made an uninterrupted recovery and left the hospital well. The examination of the specimen was done by the Pathological Department whose report is as f o l l o w s Path. No. S-12291. Illustration 1 Section of Left Fallopian Tube at site of ligature showing constricted tube, and remains of ligature above and to the left, x GO. Illustration II Section oj flight Fallopian Tube at site oj ligature showing constricted tube and remains of ligature above. X GO. Failure to Prevent Pregnancy 1123 Gross Exa mination: The specimen consists of a large cyst measuring 16x9X8 cm. Its external surface is nodular, well encapsulated and greyish white and pinkish in color. In places it shows dark red areas. The consistency is soft. On section the cut surface shows that the wall varies in thickness measuring 1-15 mm. The lumen is filled with light yellow soft material and a large amount of black hair. Attached to this cyst is a Fallopian tube measuring 10 cm. in length, 0.5 cm. in diameter. Two black dots are evident, one about 2 cm. from the cornu and another 5 cm. from the cornu. These black dots form elevations in the free surface of the tube but are wholly covered by peritoneum. On section the cut surface of the tube is not remarkable in gross. The left tube measures 5 cm. in length, 2-5 mm. in diameter. About 2 cm. from the cornu a black dot is visible, elevated and covered with peritoneum as on the right side. About 3.5 cm- from the cornu there is a depression on the free surface of the tube which looks as if there had been a small mass there .which had come away. The area is quite sound and covered with peritoneum. On section the cut surface of the tube is not remarkable in gross. The uterus was pregnant. There was no sign of disease grossly and no sign of the old Caesarean Section scar save for an omental adhesion rather towards the right side of the middle line in front. It contained a months pregnancy and had been removed at the supravaginal junction. Microscopic Examination: Sections of the wall of the large cyst show that it is' com posed of stratified squamous epithelium between which, in one section, large cells of different sizes containing dark brown pigment (melanin) are present. The underlying tissue shows many sebaceous and sweat glands, hair follicles, muscle, fat, fibrous and nerve tissue with moderate leucocytic infiltration. In the fat tissue there is an area of newly formed bone tissue surrounded by fibrous tissue.. Many sections from the left Fallopian tube \tere made and examined. The lumen of the tube is everywhere patent but is .seriously const rick'd at the places where the ligatures have been present. At the narrowc-st place there are a few papillary pro The China Medimi Journal jections, the epithelium covering these appears to be in perfect condition and lying over the tube and slightly on one side is the remains of the silk knot and probably the ligature which had been put around the tube. The ligature around the tube has entirely disappeared, and search through a number of sec tions has failed to reveal any of it on the broad ligament side of the tube. In another section from the right Fallopian tube the tube appears to be a little dilated the papillae having dis appeared and the tube being lined by what appears to be healthy epithelium. In the lumen of this portion there are a few blood cells, leucocytes and phagocytic cells. The muscularis of the tube is not remarkable. The cross section of the remains of the silk knot shows the presence of foreign body giant cells and here again the ligature round the tube has completely disappeared. A section of a portion of the right Fallopian tube away from the suture area shows that the lumen is filled with villi and the tube appears to be perfectly normal. Diagnosis:—Dermoid cyst of right ovary. Atrophy of both Fallopian tubes at the sites of ligature, silk knots still pre sent and foreign body giant cells reaction. Normal Fallopian tubes in other portions. The lumen of the ligatured tubes is not completely occluded. Dr. C. H. Hu’s opinion is that the ligature cut through the tube which healed behind it, and that the black silk remains represent both knot and ligature. I agree with him in this opinion. It is doubtful whether this cutting through the tube was not a matter of time and a gradual process. The second case is that of an American lady, aet 38, (Hosp. No. 2081). After the birth'of her second child in 1920 she was troubled by prolapse and an old rupture of the perineum. Dr. Dudley of Chicago, who happened to be in the East, operated in 1922 and brought the uterus into position by a Baldy Webster operation, and at the same time did an extensive perineorrhaphy. After about a year she became pregnant and owing to tl^e scarring of the vagina and to the fact that she de veloped a mass of varicose veins the size of an orange in the left labium, I thought it better to do a Caesarean Section. Both her husband and herself asked in writing for the tubes to be tied. There were a good many adhesions and the tubes were not well identified but were tied in continuity with a single Illustration Hi Section of Right Fallopian Tube away from the ligatured area. X 25. Failure to Prevent Pregnancy 1125 ligature of linen thread on each side, and there is no doubt whatever of their inclusion. She made a good recovery and remained well till May, 1928 when she aborted at 2 ^ months. The tiny foetus was recovered and seemed to be perfectly norm al. One of her three children had been killed during the period subsequent to the Caesarean section, and she was delighted at the possibility of having another child, even if it meant a fur ther Caesarean section. But evidently the tube had not been permanently blocked. And this is further proved by the fact that she is again pregnant. So that it is clear that to ensure permanent sterilization the tube should not merely be tied but cut, and means taken either by burying one end or otherwise to secure an efficient closure of the lumen. What about the chances of the persistence of pregnancy after a curettage. One would on the face of it regard them as nil, but the matter is by no means as simple as that. On Dec. 10th, 1926 an old patient of mine, an American (Hosp. No. 6149) came to the Peking Union Medical College Hospital feel ing very wretched. She had had two children, the last one in Dec. 1923, and after the last confinement she got an acute streptococcic inflammation of the right and left breasts. The right one had to be removed, the left recovered after multiple incisions, but was left scarred and useless. In April 1926 she was admitted for Acute Rheumatic fever with mitral stenosis, and recovered with a damaged heart. She was now pregnant and the last monthly period had begun on Oct. 8th, 1926. After consultation it was decided that it was very inadvis able that the pregnancy should continue, and I was asked to terminate it by a curettage. She was placed under gas and oxygen, the canal dilated to No. 10 Hegar and the cavity syste matically scraped and then packed for 12 hours. She recovered at once, lost her nausea, and thought no more about the matter till four months later when, on her way home to the States, she consulted a doctor because her abdomen was enlarging, and he found a pregnancy corresponding to the proper date. She went to term and had a normal child without difficulty on July 12th, 1927. I had noticed that sections of the material scraped out showed only decidua, but thought that the portion contain ing. chorionic villi had been lost. 1126 The China Medical Journal Bearing this case in mind when another case came into my hands, I was specially careful about the matter. The patient was a Chinese lady, (Hosp. No. 194S4) a mul tipara with four children, sent to me because of incipient active tuberculosis of one apex with a request from her physician that the pregnancy should be terminated. The last monthly period had been on November 24th, 1927 and she was admitted to the Peking Union Medical College Hospital on Feb. 8th, 1928. Here I dilated the uterine canal to No. 14 Hegar and after removal of part of the conception with forceps, scraped out very thoroughly with a sharp flushing curette, and packed the uterus with gauze for 24 hours. Nausea at once stopped but being only able to find decidua in the sections, I kept her under strict observation. On April 14th, 1928 or roughly 4'» j months from the last monthly period it was clear that the pregnancy was progressing, so I again dilated to 24 Hegar and delivered a normal conception from below, having some little difficulty with the head of the foetus. The foetus appeared to be about 2 V2 months old, so that the pregnancy at the time of the first curettage must have been about six weeks old. In the first case the pregnancy was probably about the same age. Why were these conceptions missed by the curette? In neither case was there any suspicion of the existence of a double uterus and it is remarkable, to say the least, for an ovum to stand an attempt to remove it with a sharp flushing curette and a firm packing of the uterus for 24 hours. Is it possible that the ovum was detached and then settled dowtl a g a in -or was it tucked away somewhere in the cornu of the uterus and missed altogether? In these early conceptions it is not always easy to find the ovum or to get microscopical evidence of chorionic villi. In another case in which anticonceptive appliances had been em ployed under medical advice and failed, I terminated the pre gnancy about the sixth week in exactly the same way as I had done in the second of these two cases. The procedure in this case was quite effective, but in ho section of the material re moved was I able to find anything but decidua. It is well known that a sound may be passed into a pre gnant uterus without disturbing the pregnancy and myomec Failure to Prevent Pregnancy 1127 tomy has been performed with the same satisfactory result. It is generally believed, however, that extensive operations on the cervix are apt not merely to terminate a pregnancy but to predispose to abortion. This is not always the case. A Korean woman, aet 32, (Hosp. No. 9699) was admitted to the Peking Union Medical College Hospital on Dec. 17th, 1924 for profuse, intractable leucorrhoea of ten months duration. She spoke Chinese very poorly and had had four full term deli veries. The last monthly period had been on or about Nov. 21st, 1924. She had a hypertrophied nodular cervix with much endocervicitis. On Dec. 27th, 1924 a Sturmdorf operation was done by Dr. N. J. Eastman, the cervix being dilated to No. 19 Hegar a Hegar dilator No. 5 being passed into the uterus at the close of the operation, and a uterine probe passed during the post operative examination on January 12th, 1925. On Aug. 28th, 1925 she came to hospital in labour with a full term pregnancy. The cervix dilated badly and as the lower uterine segment was thinning out, the husband was sent for in order to get permission for a Caesarean section. Less than an hour later she suddenly ruptured her uterus. Coeliotomy was done, followed by a supravaginal hysterectomy and she made a good recovery. So that in this case passing a No. 5 Hegar and a uterine probe into the uterus combined with the sturmdorf operation, failed to arrest a pregnancy which must have been about three weeks old at the time of operation. The lesson of these cases is that one should not be too posi tive in asserting the impossibility of pregnancy after a double salpingectomy; keep in mind the possibility of a curettage fail ing to arrest a pregnancy; and bury or otherwise secure the sealing of the uterine end of a cut tube where permanent steriliz ation is desired. BIBLIOGRAPHY Kustnyr, 0. “Zur Indikation und Methodik der Sterilisation der Grau.” Monatsschrift f. Geb. u. Gyn. 1905. Bd. XXI. S. 280. McMillan, W.A. & l?unn, R.H. Abdominal pregnancy following hysterec tomy. S.G.O. Vol. XXXIII. No. 2 (1921) page 199. Zangemeister, W. ‘‘Intrauterine Gmviditat nach beiderseitig operierter Tttbargrayidiat.” Zentralblatt fur Gynak, Fbr. 18th, 1928, Nr. 7. 441. *the China Medical Journal HEALTH SURVEY OF NANKING P. Z. King, M.D., €.P.H., Y. Y. Y ing, M.D. and Y. T. Yao, M.D. I. Introduction. The dim past of the history of Nanking can be traced back to the latter part of the Chow Dynasty about 2500 years ago. The city had its glorious time during the Six Dynasties (300- 500 A.D.) and the Great Ming Administration (1368 A.D.). The successive political changes that took place during the said periods and the disastrous effect of the Taiping war had literally reduced it to a mere skeleton. The strategic importance of the city has again made it a victim of the civil wars since the birth of the Republic, thus rendering retrogressive phenomena an inevitable consequence. All of a sudden, as bolt in the clear sky, Nanking is again exalted above all and becomes the me tropolis of the nation. Inconvenience in the various spheres of life is keenly felt. However plans of reconstruction are being painstakingly drawn up by the Government and we have every reason to hold great hopes for the future. In regard to the Public Health situation in the city, the problem is a serious one to tackle. Pending the inauguration of a definite working scheme, we have been studying the actual existing condition of the city, using whatever data which may seem to us reasonably reliable. It is not disgraceful to show our own shortage as only by doing so can we come to a better understanding. Moveover it is simply a sincere desire in an attempt to uplift the physical welfare of the community—the main function of our profession. The following is an abstract of $he essentials of the report. The minute details will be found in the Chinese text. II. The City Nanking (Lat. 32°, 03’ N. Lang. 118°47') is situated on the southern bank of the Yangtse River, being 375 miles east of Hankow and 193 miles west of Shanghai and occupies an area of 205 sq. li. The main part of the city wall was built during the Ming Dynasty an<3 it is about 66 li (22 miles) in circ u m fe r ence. It is still within the sub-tropical zone, w h i c h extends 20°—35° N. and S. o f the equator, and is situated on the sam e latitude as San Diego, Cal. or Jerusalem, Asia Minor. The topography around Nanking is varied. On the western side a Health Survey of Nanking 1129 low range of barren hills, 100—200 ft. in height, intervened between city and the River. The Purple Mountain, a range of hills just outside of the N-E corner of the wall with its crest 1450 feet about ground, dominates the city. A small col lateral stream from the Yangtse River comes in on the north, winding around the west and south of the city. Several canals run through the city which are navigable only at a few stretches. III. Meteorology. A. Pressure. According to observations which were made during the period 1905-1915, the following data were obtained': January . . 771.4 February .. .. 700.0 March . . 767.4 April .. 763.1 May . , 759.7 June 755.2 July . 754.1 August 755.1 September . . . . 76L0 October . . 766.1 November . . . . 770.0 December .. 771.9 Annual mean: 763.7 From the above you will see that the pressure is quite high in winter and low In summer. B. Temperature. Having no high mountains in its vicinity, Nanking is exposed to polar airs in the winter and invaded by hot and humid airs in summer, thus rendering the climate somewhat colder and hotter during their respective seasons than other places along the same latitude. January July Year Nanking ...... 2.7°C. 27.4°C. 1 5 .2 C . Average for Lat. 32 5' 11.8°C. 2(5.7 C. 18.9°C. A low temperature of 12.5°C (9 F) wras recorded on the early morning of Jan. 4, 1917 and a hot wave of 40.2 C (104 F) registered in July 1914. Temperatures below 10°C were also observed in 1915, 1922 and 1923. Such low temperatures are in the opinion of the Meterologist rare in other parts of the sub tropical belt near the sea level. The minimum temperature usually fell in January and the maximum in July. The chanuv tcok place rather sluggishly during the summer and winter and was rather precipitous during spring and autumn. It may be of some epidemiological significance. C. Rainfall. The mean annual rainfall has been 1100 mm. (44 ’), being heaviest during the month of June and July. 1130 The China Medical Journal D. Relative Humidity. The mean monthly and annual relative humidity reads as follows:— January .. 77.9 February . . 77.8 March .. 77.6 April . . 77.8 May 77.7 July 83.0 June .. 81.1 August .. 81.0 September .. .. 81.0 October .. 78.0 November .. 78.0 December .. 76.0 Year 79.0 The relative humidity bears a close relationship with the amount of rainfall. In Nanking it reaches its maximum in July and after that it declines until the minimum is reached in December. E. Wind. The information on wind in Nanking is very meagre. Usually the North-east wind predominates between August and April and south-east wind between June and August, the month of May being the transitional period. IV. Population The latest census was completed in September of 1928. It is summarized as follows: A. Total Population 497,526 Males 309,621 Females 187,905 B. Residences 89,123 Av. no. of people per residence 5.05 C. No. of people who can read 133,732 (26.88# of total population) This percentage of literate population can by no means be correct, as the census was incomplete and failed to show the number of children of pre-school age. D. No. of people who have children 148,881 Male 70,242 Female 78,639 Health Survey of Nanking 1131 E. Population by age (according to original classification) 1. School Children (6-12) 51,364 10.32% 2. Adult, male (20-40) 126,391 25.40% 3. Adult and young (not included in 1. & 2.) 319,771 64.27% F. Crippled 1,661 G. People with occupations 228,344 Males 209,434 (67.6% of total males) Females 18,910 (10% of total females) H. Population by'Section: Section Area (sq. li) No. of No. of Density per Residence Population sq. li 1. East 48,160 11,472 72,184 1500 2. South 23,264 22,079 120,154 5164 3. West 44,288 20,114 108,023 2439 4. North 78,666 9,905 57,370 729 5. Central 13,920 14,218 85,001 6106 6. Hsia-kwan 28,720 11,322 54,674 1903 7. Pa-kwa-tsio 188,448 13 120 0.6 421,466 89,123 497,526 Grand average— 1180 per sq. li. Sections 6 & 7 are outside the walled city, but is under the control of the Nanking Municipal Government. I. Foreign Populations:— British ...... = 33 American ...... • 49 Japanese <•...... I . •• 43 French ...... 3 Turkish ...... • • 1 Russian ...... •. 84 Norwegian ...... : .. • • • - • • 1 Indian ...... 6 Total ...... 220 The population was less than 300,000 about 10 years ago. There has been a tremendous influx of people from various parts of the country during last two years. Consequently the problem of residential accommodations has been extremely urgent. 11S2 The China Medical Journal V. Social ami Financial Standing of the Peoçde Of all the living- quarters, there are 74,131 civil residences, 9,163 stores, 1198 miscellaneous buildings and 4,631 huts.— (about one in 20). So there are at least 23,0Q0very poor people in the Capital. They are to be seriously considered, if one ex pects satisfactory results from a publichealth campaign. Silk constitutes the major trade in Nanking and tanning has gradual ly come into importance just recently. VI. Educational Standing The number of schools and students is tabulated as follows : Type of School No. Students 1. Public Free Schools 45 23,961 2. Primary- Schools ...... 24 6,085 3. Middle Schools ...... , 17 3,327 4. University and College .. 3 3,000 89 36,373 The Public Free Schools are opened for the illiterate and each course lasts about three months. Of the Universities and Colleges the Central University naturally plays an important role. The University of Nanking and the Ginling College for Women are valuable educational assets for which we owe a great deal to the well-wishing missionary circles. VII. The Public Health Department The local Public Health Department is under the direct control of the Municipal. Government of the City of Nanking, but is subject to the supervision of the Ministry of Health. The budget amounts to $269,796 (per annum) which is 6.1% °f the total budget of the Municipal Government, but the full amount is not provided- , What the Department actually receives only amounts to two-thirds of the budget. The staff of the Depart ment is composed of a Commissioner, a graduate of the Chekiang Provincial Medical School* who studied bacteriology and hygiene in Germany fo r a few years, and: 3 Division Chiefs. Two of the latter were graduates from the above mentioned Medical School and the third graduated from the Pharmacy Department of the same institution* Health Survey of Nanking 1183 VIII. Vital Statistics. A. Registration of Death. The death rate is recorded from the number of burial permits issued by the Department of Public Safety during the month. This is checked by data obtained by the Sanitary Inspectors. The monthly death rate of the year 1928 is tabulated as follows: Month Male Female Total January 152 137 289 February 182 127 309 March 136 130 266 April 170 135 305 May 163 126 289 June 185 149 334 July 195 178 383 August 248 205 453 September 282 227 509 October 281 185 466 November 242 180 422 December 249 155 404 2,485 1,934 4,419 From the above records the following data are obtained: 1. Death rate per 1000 population...... 8.86 2. Death rate per 1000 males (43.83r/< of the M. & F. rates combined) ...... 8.03 3. Death rate per 1000 Females (56.17^ of the M. & F. rates com bined...... 10.29 No definite explanation of this marked difference between the death rates of males and females is available. The death rate of only 8.86 per 1,000 can not be correct if compare with that of other countries where sanitary conditions are undoubtedly better than Nanking at present. The following is quoted from the Year-book of the League of Nations 1926. Nations Death Rate per 1000 Norway ...... 10.64 Denmark ...... 11.30 (1924) England & Wales ...... 11.60 Germany ...... 11.70 Sweden ...... 11.70 U. S. A...... 11.80 A u s t r i a ...... 14.72 F in la n d ...... 16.00 Hungary ...... 16.50 Poland ...... 18.70 Spain ,...... 19.00 Japan ...... • • ...... 20.27 1134 The China Medical Journal The death rate of the Chinese Population in the Shanghai International Settlement in 1926 was 15.3 while that of the foreign population was 20.1 per 1,000 according to the, report of the Public Health Department of the Shanghai Municipal Council. It is much more reasonable than the Nanking record which was taken under the crippled circumstances. B. Registration of Births. The registration of births is even more difficult under the present circumstances. On account of lack of understanding among the people, the pre dominance of the old-fashioned untrained midwives, the lack of free prenatal and obstetrical service and all the rest of it, the registration data must be fallacious. The following is the record obtained in the year 1928. Month No. of Births J a n u a r y ...... 58 February ...... 70 March ...... 75 April ...... 64 May ...... 50 June ...... 39 July ...... 66 August ...... 135 September ...... 155 O c t o b e r ...... 162 November ...... 159 December ...... 150 (?) Total ...... 1183 The birth rate was 2.2 per 1,000. This figure is obviously incorrect if we bring into review the records of other countries: Nations Birth Rate per 1,000 (1926) Sweden ...... 16.9 England & W a l e s ...... 17.8 France ...... 18.8 Germany ...... 19.5 Norway ...... 19.7 Austria ...... 20.0 Denmark .. .. 21.9 (1924) U. S. A ...... 22.6 Hungary ...... 23.0 S pain ...... 29.97 ...... ,, ,, ,, 3g.68 Health Survey of Nanking 1135 IX. Control of Communicable Diseases. Efforts to control communicable diseases in Nanking are hopelessly lacking. We cannot expect to start everything simultaneously, especially since there is such financial difficulty. Last year a small Summer Disease Hospital was opened during the Cholera Season. The Health Department is now giving free vaccination against smallpox to the people as a starting point in the control of communicable diseases, and is soliciting the cooperation of the practising physicians in reporting dis eases of communicable nature. X. Water Supply. The water supply in Nanking is another serious problem. The lack of a water plant has fundamentally hindered all other sanitary reforms according to the modern scientific standards. Hitherto the water supply of the city has been furnished from three sources, viz. wells, ponds and river. A. Wells. There are altogether 1642 wells of the surface water type distributed as follows: Section Public Well* Private Wells Total East t O 92 165 South 155 586 741 West 139 63 202 North 123 196 319 Central 138 63 201 Hsia-kwan 5 9 14 Total 633 1009 1642 They are not protected in any sense and many of them are undoubtedly very badly polluted. B. Ponds. There are 694 ponds of various sizes, and are distributed as follows'. Seection Public Ponds Private Ponds Total East 10 75 85 South 11 22 33 West 5 70 75 North 28 361 389 Central 6 93 9{J Hsia-lavan 4 9 13 Total 64 630 694 1136 The China Medical Journal A certain number of them are probably favorite breeding places of mosquitoes which constitute such an awful pest in the hot seasons. But in view of the fact that proper drainage system is lacking, those ponds are said to serves the purpose of reservoir and have saved the streets from being flooded during the rainy seasons. How much truth there is in the presumption, we are not in a position to state definitely, but it deserves some consideration when it comes to filling in of the ponds while the drainage accommodation is still lacking. C. River and Canals. As already mentioned, the Yangtse sends off a small collateral stream entering in the North and winding around the Western and southern outskirt and a num ber of canals traverse the heart of the city. Owing to the relative softness and better palatibility, people usually prefer river and canal water. You will see in certain sections of the city, especially in the morning, a procession of water carriers, dragging along the dusty and treacherous road, and towing laboriously the crude and clumsy water wagons. It is said that sometimes well water is adulterated with a suitable quantity of yellow dirt and sold as river water at a good price. D. The drilling of 8 artesian wells has recently been con templated. One of them is almost completed. XI. Public Latrines. The present public latrines, mostly owned by individuals as private establishments are nothing but excreta reservoirs and fly-breeding places. As 25-40% of the Excess Mortality in China is due to gastro-intestinal diseases for which the flies serve as efficient carriers, the building of sanitary latrines is certainly a matter of prime importance. There are 382 latrines, not including kongs and pits, and distributed as follows: Section Priva te owned Public ovmed Total East 36 5 41 South 59 2 61 West 73 6 79 North 75 4 79 Central 63 6 69 Hsia-kwan 36 17 53 Total 342 40 m "Health Survey of Nanking XII. Street Cleaning and Disposal of Refuse. For the 1900 streets there are 400 scavengers and roughly 300 bottomless and coverless wooden refuse receptacle though- out the city. There were 1800 of the latter in 1922 but were found to be less than a hundred in the early part of 1928. The spontaneous wearing out of these boxes is not sufficient to account for their rapid disappearance. They might have been used as fuel during recent political disturbances in the city. A small proportion of the refuse is used for filling in ponds to abolish stagnant water while the major part is disposed on vacant lots. There are at least 120 heaps and piles in the city, with a roughly estimated quantity of at least 20,000 tons. The Health Department has only two motor trucks which are too few for speedy and efficient transport of the refuse to the out side of the city. The use of wheelbarrows constitutes the important part of the present mode of conveyance. The final disposal of the refuse has therefore come in as a sanitary problem. XIII. Sanitary Inspection. The Municipal Health Department has under training. 30 Sanitary inspectors or “Sanitary Police” as they are called here. They are given a short course with 1 hr. class work daily, lasting for a month. Their usefulness is yet to be seen. There is no Public Health Laboratory in Nanking at present. The plan for a small one has been contemplated just recently. XIV. Food Control. Provision for food control is still lacking. There is one abattoir for beef and mutton under direct control of the City Health Department. Pigs are not admitted on account of the strong prejudice of the Mohammedans. Milk gradually is coming into importance as more people are using it. No efforts are made to control the trade. An effort has been made to screen all food and confectionary which are put out for sale. XV. School Hygiene. Entrance physical examination is required in middle schools and colleges. Students of the primary schools are badly neglected. The teaching of Health Habits in primary schools in accordance with recommendation of the World Federation of Education Association has not yt t been instituted. The City 1138 The China Mediml Journal Health Department is now encouraging vaccination in the schools and a few hundred of the young students have already been vaccinated. Proper primary school compounds are very few in Nanking so that the desirable standards can very hardly be kept up. XVI. Curative Medicine. A. Registration of Physicians, Midwives, dentists and nurses has not yet been rigidly carried out. Information in regard to the actual number of the various types of practitioners is still too meagre to be dependable. About a year ago under the administration of the previous Health Commissioner, 61 regular modern physicians were recorded, (about 1:8123 population). As quite a number of new practitioners have come to Nanking during last year, 1:5000 is a reasonable estimate. In addition, there are at least two hundred native practitioners of the old school. B. Midwifery and Infant Care. There are at present only a few regul&r modern midwives in Nanking. Their service can, only be obtained by the well-to-do class and is therefore too aristocratic to be of any advantage to the general public most of the mothers have to call in the old “Grandma” who claim to have, inherited special genius from their ancestors and have therefore the right to give “the first spank.” The consequences can hardly be appreciated. The age classification of these old midwives is rather interesting: A ge. No. f'/r 20-30 1 l.i 31-40 5 8.8 41-50 9 15.8 51-60 22 38.6 61-70 17 29.8 71-80 3 5.3 Total 57 100.0 Prenatal clinics and infant welfare activities have not yet been instituted. There is no record of infant mortality. The rate in Peping is roughly 250 per 1,000 births according to the latest figures. It is probably not much lower here in Nanking. If we again quote the figures of other nations, our infant mortality appears frightful. Health Survey of Nanking 1139 Nations Infant mortality (per 1000 under ly r . 1926) Norway ...... 50.0 England & Wales .. .. 70.0 Sweden ...... 71.5 U. S. A...... 71.6 Denmark ...... 79.0 G e r m a n y ...... 105.0 (1925) S p a i n ...... 123.0 Japan .. 142.0 C. Hospitals. There are six general hospitals with a total capacity of 304 beds, 200 of which are in the Drum Tower Hospital of the University of Nanking. Here again we owe a great deal to the Christian Missionary members of our pro fession. The other 100 beds are distributed among 5 private hospitals (the latter term being loosely applied). So there is only one bed for every 1636 persons. There are only two dispensaries, one supported by a mission ary organization and the other by the City Health Department. No accommodation for infectious diseases is available just now. XVII. Special Health Activities In this are included Port Hygiene, Industrial Hygiene, and special measures for the prevention or eradication of special diseases. Very little is being done along these lines. We have still in our memory the splendid result of the anti-fly and anti-mosquito campaign in 1922, conducted by the cooperative effort of the Kiangsu Entomology Bureau and the Police De partment. Similar activities were instituted in Soochow and Shanghai in that same year with equally gratifying result. This can certainly be repeated with advantage. XVIII. Conclusions and Recommendations In conclusion, we have to confess frankly that there is nothing in the nature of Public Health that the city of Nanking can be proud of. According to the Appraisal Form as adopted by the National Medical Association of China, Nanking can be given only 1/10 of the total credits. As the difficulties are 1140 The China Medical journal numorous and every thing in the nature of construction is still on the way, it would seem unjustifiable to blame any one in dividual or any group of individuals. However, Nanking has to make haste and cannot afford to lose time. It is all very well to recommend that Nanking should immediately institute a perfectly up-to-date Public Health program for a modern metropolis. It certainly sounds pleasant but would appear like an ephemeral castle in the air if one tries to do too much at once. After due consideration, we venture to make the follow ing recommendations which Nanking should consider adopting immediately. I. Measures for the Prevention of Communicable Diseases of Gastrointestinal Type. A. Anti-fly measures 1. Reinforcement cf street-cleaning facilities and improving the administration. 2. Sanitary latrines. 3. Control and abolishment of “kongs" and pits. 4. Larvicidal measures (using sodium cyanide or boiling water as recommended by the Kiangsu Entomology Bureau in 1922). B. Improvement of water supply. 1. Construction of a water plant. 2. Artesian wells. 3. Control and protection of the drinking wells. C. Sanitary Control of Food, 1. Sanitary inspection. Enforcement of screening. 3. Prohibition of sales of cut fruit and other un wholesome food). II. Anti-mosquito Measures. 1. Attention to breeding places. 2. Anti-larvae measures. 3. Study of the local mosquitoes and their relation to malarial fevers. Health Survey of Nanking 1-141 III. 'Maternity Care. 1. Midwifery training school. 2. Training class for the old type midwives. 3. Registration and control of midwives. IV. Vaccination against Smallpox. 1. Training of vaccination. 2. Enforcing group vaccination. 3. Enforcing public vaccination. 4. Prohibition of smallpox innoculation. R e f e r e n c e s : 1. Health Survey of 86 Cities 1925 by Am. Child Health Assoc. 2. Public Health Bulletin No. 136, 1923 II. S. Public Health Service. 3. Appraisal Form for Rural Health Work 1927 Am. Public Health Assoc. 4. Appraisal Form for City Health Work 1927 Am. Public Health Assoc. 5. Tentative Appraisal Form for Health Work in Large Cities in China 1928 by John B. Grant & P.Z. King. 6. International Health Year-book 1926 League of Nations. 7. Mosquitoes & Flies 1922 by Kiangsu Entomology Bureau 8. Reports of the Nanking Municipal Government. 9. The Climate of Nanking during the Period 1905-1921 by Coching Chu. 10 Quarterly Meteorological Bulletin Vol. No. 1, 1928 by Institute of Meteorology, National Research Institute.. The China Medical Journal THE LEPER KING OF ANGKOR Lee S. Huizenga M.D., Dr. P. H. (Yale) In many lands strange and yet beautiful legends have gathered about lepers. Traditions, painting, sculpture and literature have sought to preserve these legends. In that mys terious city of Angkor in the jungle vastnesses of Cambodia, are ruins hid under the debris of centuries that are surprising the world. The builders of these wonderful architectural mo numents, the Khmers, have long disappeared. Their ruins re main to tell the story. Chiselled in stone bas-relief is the history of their religion. Among these ruins the leprologist also finds interesting remains. It is the stone representation of the once leper king of Angkor and his two faithful wives. The legend tell us that one of the kings of Cambodia centuries ago lived in great luxury. According to the age old custom of the court, he called for dancing girls from every part of his dominion to make sport for him. A beautiful daughter of a leprous mother was also called to the king’s court. She had been the support of her mother and the mother was greatly grieved at the thought of having her daughter leave her and go to make sport for the king and finally land in his harem. Consequently she sought revenge. The leprous mother, still able to cover her leprosy was a beautiful woman, as was her daughter. She powdered herself, adorned herself with jewels and beautiful clothing and appeared before the king. So taken was the king with her that he ordered her into his presence The woman eagerly took this opportunity to maliciously seek the king’s harm for carrying away her daughter. She flung herself about the king’s neck and embraced him so long and so affectively that she was certain he had contracted leprosy from her. Yet her devillish intention remained undiscovered. This still is a traditional way in the countries about South China of ridding oneself of leprosy and forcing it upon another. After a lapse of . years the king developed leprosy. His people recognizing his condition separated him from society, built a palace for him, and compelled him to live all alone in segregation on a hill overlooking the capitol. None but his servants wwe allowed in his • presence. •, For months he lived alone. Clinical Notes 1143 Two of his favorite wives wished to stay with him and their devotion for their husband king was exemplified by them in secretly tunnelling a passage through the mountain from the old palace to the isolation home of the king. Without being detected in their quiet work the wives, finally, broke through in the presence of the king and although the king had developed leprosy in the advanced stages, by this time, they ministered unto his needs unto his death. In real oriental coloring the story magnifies loyal woman hood rather than royal womanhood. The commemorate the loy alty of women to their husbands many a stone archway is found in China. In Angkor one finds today carved in stone and bear ing marks of the ravages of time the stone figures of the Ang kor Leper King transformed into a Buddha and his two faithful wives immortalized in stone, one at each side of him. The transformation that takes place in the lives of some, lepers today, both physical and spiritual is little short of mira culous and is actually taking plase in most of our leper asylums today. Clinical Dotes CONJUNCTIVAL POLYP ARISING FROM GRASS SEED H e n r y R . O ’B r ie n M .D . McCormick Hospital, Chiengmai Siam While working in the rice harvest in northern Siam a Lao man of 21 felt a part of a head of grass slip into his left eye. This was removed with some difficulty, but there was not bleed ing. Following this the eye smarted and was reddened all the time. He felt that there some kind of growth in the eye and finally came to the hospital. The eye was found to be injected in the lateral acanthus and in both lids. Attached laterally was a leaf of granulation tissue, a thin polypoid mass sliding between the ocular and palebral eonjunctivae. At the operating table the polyp was removed with snare and -scissors. A grass seed, of the variety known here as “Yakon,” was found within. It was approximately 8x6x1 mm in dimensions. The eye healed promptly. 1144 The China Medical Journal ASCARIS IN THE APPENDIX H e n r y E. O ’B e i k n M.D., McCormick Hospital, Cliieugiuai, Siam Late in December, 1928 a Lao girl of 18 began to have frequent pain in the abdomen, usually in the right lower quad rant, coming on after breakfast and after supper. The pain was sometimes very severe, but she had no nausea, vomiting, or fever. Her bowels moved regularly, and her appetite was good. Dr. E. C. Cort of this hospital found her on a visit to a country church, and urged her to come in. Examination at the hospital showed some deep tenderness over McBirney’s point, with some right sided tenderness on pelvic examination. Temperature was normal. Her blood showed 11,250 leucocytes, Hookworm and round worm eggs were found in the stool. With such slight findings she was given chenopodium 0.67 cc on January 11th. The next day an appendectomy was performed. The ap pendix was found to be stiff and distended with an ascaris, half of which was palpable in the caecum. There was some move ment, but no great activity. Attempts to milk the ascaris down into the caecum were unsuccessful, but while the appendix was being opened at the tip, the worm made its escape. A routine appendectomy was performed, and the patient proceeded to get well. The question arises whether the round worm was in the appendix all along, so that its presence was responsible for the girl's previous pain, or whether it took refuge in the appendix only after the administration of the chenopodium. The latter seems more probable, as a prolonged residence in the appendix should have set up more peritoneal reaction than was observed at the time of operation. Hospital Technology Section 1145 Hospital Technology Section MURPHY DRIP The following or fide ov some of the fiver points in the technique of the Murphy drip seems to be of more than passing interest to most of 7f« in China. It is taken from the “Indian Medial Gazette” of Jan. 1919, and is by Dr. A. H. Proctor, M.S., F.R.C.S. E. Twenty years ago J. B. Murphy wrote regarding appendic itis, “We have treated on this plan forty-seven consecutive cases of peritonitis, of the direct perforative type, with two deaths, one, the sixteenth case, of a double pneumonia six days after the operation, long after all the peritoneal symptoms had subsided, the other, the forty fifth case, died on the fourth day from intestinal obstruction due to the twisting of the ileum around the omentum, which was adherent to the old hernial opening (Keen’s Surgery, Vol. IV, p. 789). To-day at two of the leading hospitals in England, these cases have a mortality of 20 per cent, and 29 per cent, against Murphy's 4.25 per :ent. (Recent advances in Surgery, p. 291). Assuming Murphy’s figures to be correct, the only possible ex planation is some radical difference in treatment. Now the essential factor in the Murphy treatment was prolonged ad ministration of normal saline and calcium chloride solution per rectum. Every surgeon will be prepared to swear that he also uses continuous saline per rectum in these cases. It would pro bably be nearer the truth if he said he prescribed it. Hew often does the nurse report that the saline was stopped, because the patient starts to reject it after three or four pints had been given? In one large hospital, I am told, they have given up rectal saline in favour of subcutaneous saline, a route with obvious limitations. A reference to the standard text-books on nursing, would lead any one to suppose that the details Murphy insists on, are not essential, and with both surgeons and nurses there has been a general failure to grasp his principle^. These principles are two, namely;— 1146 The China Medical Journal I. That the saline shall be administered at the rate of absorption, so that at no time is the rectum distended with fluid. II. That there shall be, at all times, a free outlet for flatus. The object is the same, to avoid distension of the rectum. Distension is the normal stimulus to the rectum to empty itself, and if the flatus has not a free outlet, it will be forced by the side of the rectal tube into the bed. In its passage it is accompanied by the fluid contents of the rectum, and further administration is stopped, because the patient is considered to be rejecting the saline. If the flatus cannot escape past the rectal tube it passes back up the colon and disturbs the quies cence of the bowel, which is so essential for recovery. At the same time it causes pain and discomfort which is attributed to the proctoclysis, and provides another excuse for stopping the saline. Murphy’s technique naturally observed these principles, but it was always difficult for nurses to manage satisfactorily. Either the can was placed too low and the patient received an intermittent supply, or it was placed too high and the bed flooded. Murphy’s description indeed is open to the criticism that it fixed an arbitary position for the reservoir, and a varying head of fluid depending on whether the reservoir was full or nearly empty. The temptation- to regulate the flow by droppers, clamps, or by altering the position of the reservoir was irresis tible. i' Certain modifications of Murphy’s technique, which do not violate his principles, have overcome the difficulties. Two simple experiments will enable the essential points to be grasped by the nurse in charge, Experiment I Take the barrels of two four-ounce glass syringes and con nect them up with a length a rubber tubing about four feet in length. Call one “A” and let it represent the rectum. The other “B” represents the supply funnel. Holding them on the same level fill them with water until they are half full. Now keeping “A” fixed move ‘-B” up and down. It will be noted that as “B” rpoves up the level of the water in relation to the top of the Hospital Technology Section 1147 funnel moves down, and vice versa. The level of the fluid in fact remains stationary, depending on the level of the fluid in “A”, which represents the rectum in actual life. In other words all that we need to do, to determine the level of a pool of fluid in the rectum, is to connect it by a tube to a funnel, and fix the funnel so that the level of the fluid shows in the funnel. Experiment II Bring “A” and “B” close together, letting the tube hang down in a loop. Blow down “A” and estimate the effort re quired to blow air out through “B”. Then straighten the loop by separating the funnels to the maximum without kinks, arid try again. Repeat the experiment after introducing a dropper or a clamp as is commonly done to regulate the flow. It is at once obvious that loops, clamps, droppers, etc., are adequate obstacles to the return of flatus. The practical ap plications of these observations is as follows A cylindrical funnel, such as the glass funnel of an army pattern salvarsan apparatus or the barrel of a four-ounce syr inge, is connected up with the rectal nozzle. The whole ap paratus is now filled with saline solution so that when the rectal nozzle 'in held level with the middle of the funnel the solution is just bubbling over the tip of the nozzle. The funnel is now lowered in relation to the nozzle, and the latter inserted into the rectum. The funnel is raised and four to six ounces more fluid run into the rectum. The funnel is now carefully raised and lowered until we ascertain the position where the fluid just half fills the funnel. It is fixed at this point, and any loops and kinks straightened out. The level of the fluid is now exactly the same as the level of the'pool in the rectum, and if correctly adjusted rises and falls with respira tion. Now above the funnel we suspend a heated reservoir or vacuum flask containing the bulk of the saline solution. Leading from it is a tube and a dropper, by means of which the solution can be dropped at the required rate into the open mouth of the funnel. The rate of flow is accurately determined by measuring the quantity into an ounce measure, and taking the time. At present the supply funnel is being kept warm by means of a hot water bag wrapped round it. A more satisfactory arrangement is to have an electrically heated section of piping « 4 8 The China Medical Journal between the piping and rectal nozzle. This section of pipe, however, must be straight and not in the form of a spiral as is usual in such apparatus. Attention may profitably be called to other points that were insisted upon by Murphy. The nozzle should be a vaginal hard rubber or glass tip. flexed at an obtuse angle two inches from the tip, and having numerous openings. It should be inserted so that the angle fits plosely to the sphincter and the tube is then bound firmly to the thigh with adhesive plaster so that it may not expelled. Many books recommend a rubber catheter and that it be passed as far as passible into the rectum. This is wrong. Murphy insisted on numerous openings and that it be passed only as far as the obtuse angle, that is, for two inches. The rate of flow should be such that it requires not less than forty nor more than sixty minutes for a pint and a half of the solution to percolate into the rectum. The protoclysis should usually be continued for three days, rarely as long as five or six. The solution he used was normal saline with one drachm to the pint of calcium chloride. Murphy recommended the administration of a pint and a half every two hours. At the same time he advocated a rate of flow of a pint and a half in one hour. It is presumed, therefore, that he gave his patients alternate hours of rest, except in the severer cases, for he quotes the cases of a child of eleven absorbing thirty pints in twenty four hours. From personal* experience I am satisfied that a strict adherence to Murphy’s methods produces better results that those quoted from “Recent advances on Surgery” at the beginning, of this note. N.B.—Murphy’s technique has been given above. In pra ctice at the Presidency General Hospital we use isotonic saline and glucose solution and a somewhat slower rate of flow ap proximately % to 1 pint per hour. EdîtoriaiR 1149 Editorials CANCER RESEARCH At the XIXth Biennial Conference held in Shanghai in February 1929 a special session under the charge of the Surgical Section was assigned to the subject of “Cancer in China” and a full report of the papers appeared in the May issue of the Journal. At the conclusion of the session it was decided to accept Dr. Englaender’s suggestion that the League of Nations be approached with a view to the formation of a special Com mission, with the result that the following resolution was passed by the Conference :— “Cancer in China The Conference of the Cbina Medical Association assembled in Shanghai in February 1929 having con^ sidered the question of Cancer in its broad aspects, and being aware of the great differences in the incidence of this disease in different parts of the East, and the variations of this incidence as compared with Cancer in the West, resolved as follows:— 1. To draw the attention of the Health Committee of the League of nations to this matter, and suggest to it that a Commission should be established to enquire into the relation if any of the manner of living or diet to the difference in the East of the frequency of the incidence of Cancer in the various parts of the body. 2. To instruct the Executive Committee to take steps to carry out the above resolution.” The resolution having been considered by the Executive Committee, the Chairman of the Research Council was instructed to communicate with the League of Nations. The correspondence which we publish below will we feel sure prove of interest to all members of the C. M. A. Dr. Rajchman at the conclusion of his letter refers to the recent literature of the League. It would appear from Sir George Buchanan’s report that investigations are proceeding in regard 1150 The China Medical Journal to heredity, occupation and race, but that the preliminary nature of the returns does not yet w arrant any definite conclusions. It will also be noted that after having made a preliminary study of cancer mortality in Japan the League is of the opinion that “the necessary data for the extension of this study in the East are either lacking or unreliable and that the credits for the purpose in the League’s budget are not sufficient.” We would therefore urge on all hospitals throughout China the necessity of accurate records with regard to this matter and plead for an extension of the work which has already been carried out by Dr. Maxwell and Dr. Ludlow. On another page of the Journal will be found a review of the report of the Sub-commission on the Radiotherapy of Cancer. Attention is called in this report to the necessity of reaching agreement regarding the standard classification of the stages of uterine cancer and of using a standard form of case record. The report also urges the necessity of further inter national co-operation in the radiological treatment of cancer. In view of the interest already taken by the C. M. A. in this subject, this report should receive its careful consideration in order that some means may be devised to apply its recom mendations to the cancer problem in China. It will be time enough when the data have been collected to invite the expert opinion of the League, but in the meantime there is an opportunity for those working in China to make a contribution to the solution of a world problem. 18th. July, 1929. The Secretary, Health Section, League of Nations. Dear Sir, At a conference of the China Medical Association recently held in Shanghai, a session was devoted to papers on the incidence of Cancer, and considerable interest was aroused on the question of differences in the regional distribution of cancer, as between China and the West. Fig ure« were brought forward by Dr. Maxwell to show a difference in dist ribution in China as compared with that accepted; for Western co u n tr ies. On the other hand Dr. Ludlow exhibited figures whjeh show a similar in cidence and distribution in Korea as in the West. In view of the fact that the Health Organisation of the League of Nations includes a Cancer Commission which has already carried out Investigation? on the anthropology of cancer, the Conference considered Editorials 1151 that it was desirable to call the attention of the League of Nations Health Organisation to the opportunities presented in China and neighbouring countries for a study of the question of regional distribution and its possible relation to racial differences in diet and general manner of living. As Chairman of the Research Council of the C.M.A. I was directed to communicate with you on this matter, and I should be grateful for any help and advice which the Health Section of the League might be willing to give in regard to this investigation. With kind regards, Yours sincerely, (Signed) H. G. E a r l e . Chairman, Research Council China Medical Association. P. S.—I am sending under separate cover a copy of the China Medical Journal, which gives the papers contributed to the Conference. LEAGUE OP NATIONS Health Section SOCIETE DES NATIONS Section d’Hygiène. Dear Sir, I thank you for your letter of July 18th, enclosing extracts from the XlXth biennial Conference of the China Medical Association, in which the attention of the Health Organisation of the League was drawn to the opportunities presented in China and neighbouring countries for a study of the question of regional distribution of cancer and its possible relation to racial differences in diet and general manner of living. The Cancer Commission of the League of Nations has already been struck, just as was your Conference, by the great regional differences in the incidence of this disease. These differences which were noticeable in various parts of Europe, America and Australia existed not only between the various countries, but also between the geographical units of the same country. For this purpose, the Cancer Commission established, as a basis for the investigation, a geographical distribution of cancer mort ality in various countries. It has, however, been found that practically in no country are these data reliable, the geographical units with low cancer incidence being those which show a high percentage of deaths attributed either to senility or to unknown or ill-defined causes of death. For this very reason the correlation which the Cancer Commission has established between the differences in cancer mortality in different re gions and between anthropometric differences in different geographical units could not lead to any definite statement. . The Cancer Commission was from its very beginning aware of the very important relationship which might exist between cancel' and diet. 1152 The China Medicai Journal It seemed, however, impossible, as in the anthropometric enquiry, to undertake this investigation with the scanty data at present available. As regards the variation in the East in the incidence of cancer of various organs, as compared with that of the West, the Health Section has been studying the cancer mortality in Japan, as compared with that of some European countries. It has been found (Dr. Hiroshi Kusama, in “Statistical Study of Cancer Mortality in Japan,” Gann, the Japanese Journal of Cancer Research, Vol. XXII, No. 3, 1928) that Cancer of the breast appears to be surprisingly less frequent than in European countries, cancer of the digestive tract, though common in Japan, to be less frequent than in England and Wales, the Netherlands and Switzerland, but to be more frequent than in New Zealand and Italy. , Cancer of the female reproductive organs was found to be somewhat more frequent in Japan than elsewhere, though the death rate ascribed to this form of the disease was found to exceed only slightly that recorded in England and Wales. As to the question of regional distribution and its possible relation to differences in the diet and general manner of living, you may be in terested to know that in the Japanese study a relatively high mortality rate attributed to cancer of the stomach and liver was found in the following four areas:— 1) Nara, Shiga and adjacent prefectures. 2) Chiba and Saitama prefectures. 3) An area of which Niigata prefecture is the centre. 4) A smaller area including Tottori prefecture. An investigation in these four areas, as compared with four other? in which the mortality rate attributed to cancer of stomach and liver is the lowest, might possibly elucidate the question of the relationship bet ween cancer mortality of the digestive system and diet, providing the data are reliable. I fear that, on the whole, it would be difficult to go any further with the Health Organisation’s Cancer study in the East for various reasons, the most important of which are that the necessary data are lacking or unreliable and that the credits for the purpose in our budget are not suff icient. Nevertheless I greatly appreciate the action of the China Medical Association and hope they will communicate to the Health Organisation the results of any work they may undertake along this line. I take this opportunity to forward to you some documents of the .Cancer Commission of the League of Nations. With kind regards, Yours very sincerely, (Signed) Ludvik Rajchman. Medical Director. To the Chairman of the Research Council of the China Medical Association, 2 Canton Road* SHANGHAI. Editorials 1158 MEDICAL EDUCATION The annual publication of educational numbers by leading medical journals affords opportunity for a review of the tend encies of medical education. During recent years the educa tional number of the British Medical Journal has been enlivered by the publication of original articles in regard to the place occupied by certain fundamental subjects in the medical cur riculum. These articles remind us that medical education in order to be effective must be alive to the constant changes which medical research makes in regard to the content of the subjects to be taught and in regard to their relative importance in the curriculum. The current number published on August 31st. is particul arly interesting in this respect. In the first place the history and present position of medical education in the U. S. A. is re viewed by Sir Norman Walker, while Professor Fraser con tributes an article on “The place of Human Physiology in the Training of the Medical Student.” The importance of phy siology in the medical curriculum has always been recognised: in the Scottish Universities the subject used to be known as the “institutes of medicine.” There has, however been a good deal of change since then, and it is probably true that the im portance of carefully controlled experiments has concentrated the attention of physiologists on animals rather than on man. Since the Great War however there has been a renewed attack on the problems of human physiology. During the war the need for research in human physiology became very ap parent. As Professor Fraser points out, before we were able to deal with such problems as shock and collapse, normal me chanisms had to be investigated, while the changes consequent on “gassing” found medical men and physiologists alike in a similar condition of ignorance. The difficulties inherent in the teaching of human physiology depend on the fact that whereas the physiologist works in the laboratory, it is in the wards an^ out-patient department that the material for teaching human physiology really exists. As Dr. Haldane has always contend- ed, physiology is a subject s-ui generis and cannot be investigated and taught merely as an application of chemistry and physics, l’t is true that the behaviour of the body cannot be understood without a knowledge of chemistry and physics, but this know-* 1 1 5 4 The Chi?m Medical Journal ledge alone will never explain the behaviour of the body. In this respect there is very little human physiology in the average text-book, it is little more than an interesting catalogue of chemical and physical facts which have been observed in the tissues and organs of living organisms. And that brings us to another criticism. Books on physiology still suffer from what used to be called the cell theory. It is perhaps time that more attention should be turned to the individual, and in the case of the medical student what he needs is a physiology of the human individual. The experimentalists severely criticised their predecessors for jumping to conclusions which were not warranted by the observed facts, but a student of medicine pre paring to deal with patients must be given some conception of the individual as a whole and cannot wait until the analytical physiology of tissues and organs has produced sufficient facts for a scientific synthesis. The point of view of the practitioner of medicine should be the individual rather than his organs and tissues. Having diagnosed the cause of a patient’s symptoms and perhaps located it in a single organ, he must also proceed to estimate how the other organs of the body are reacting and treat not only the diseased organ but the whole individual. The medical student must be given some conception of how health is successfully maintained by a normal individual in a constantly changing environment, open it may be to all the attacks of micro-organisms and other agencies to which less fortunate members of the community succumb. In other words, the medical student needs a physiology of health as well as a pathology of disease. He will then understand better what really constitutes disease and how the body may be assisted in the struggle to preserve its normality. Thus will be laid the foundation of a rational therapeusis. Professor Fraser discusses in some detail how to overcome1 the difficulties inherent in the teaching of such a physiology. It is clear from what he says that there must be mutual co operation between the departments of physiology and medicine. Both are needed for the proper understanding of human phy siology. But whatever be the solution of the problem it is also clear, to quote the words of Professor Haldane, that: “Medicine needs a new physiology which will teach what health really means and how it maintains itself under the ordinarily varying conditions of the environment.” Announcements 1155 flnnouncímtnts POSTGRADUATE COURSE IN OPHTHALMOLOGY An intensive postgraduate course in ophthalmology will be given in the Peiping Union Medical College for the month on March 1930. The course will be a full-time course given in Chinese. The mornings will be devoted to ward rounds, operations, refraction, and laboratory work; the afternoons to lectures, lantern slide demonstrations and clinical work with special study of interest ing cases in the dark and refraction rooms. Instruction will be given in the new building of the eye clinic where the facilities for teaching are excellent. It is the intention of the instructors to make the course of practical value to physicians who have had some experience in the treatment of eye diseases and who are obliged to devote all or practically all of their time to clinical work. Enrollment will be limited to twelve students, and all accre dited doctors are eligible for admission. The tuition fee for the course is $50. Applications for registration or fellowships should be directed to the Registrar of the Peiping Union Me dical College, Peiping. Current medical Literature THE FUNCTION OF THE PRACTITIONER IN THE MODERN MEDICAL SCHOOL R u s s e l l L. C e c il, M.D. New York During the past thirty years a remarkable transforma tion has taken place in the character and pedagogic methods of American medical schools. A generation ago our medical colleges were poorly equipped and practically without endow ment. At that time clinical teaching was carried on exclusively practitioners, and in many institutions even the fundamental medical sciences were taught largely by physicians who were giving part of their time to practice. The China Medical Journal Today the situation is entirely changed. Many of our lead ing schools of medicine have endowments that rival in size the entire financial assets of smaller universities. With this in crease in wealth it hap been possible for the medical schools to have the fundamental sciences taught entirely by professional teachers. In more recent years this movement toward full-time teaching has been extended to the clinical branches, and now a number of the leading schools have placed the departments of medicine, surgery and pediatrics under the control of full time teachers. This elevation of medicine and surgery to thi; rank of true university departments has been of enormous value in establishing clinical medicine as an independent science, and the development of research laboratories in connection with the medical and surgical wards has added greatly to the opport unities for clinical investigation. With the appointment of full-time teachers and with a greatly improved laboratory equip ment, the character of medical teaching in the United States has made great strides forward, so much so that it is safe to. say that at the present time American medical schools are equal and perhaps superior to any in the world. The placing of these large trust funds in the hands of me dical schools has made the conduct of the modern medical college much more exacting. It is fitting and proper that a medical department, for example, with a budget of fifty to a hundred thousand dollars a year should -he directed and supervised by a teacher who is devoting his entire time to the dispensation of such a huge sum. This trend toward ‘full-time teaching is not confined to medical schools alone. Other professional coll eges, such as law, engineering, architecture and theology, are conducted almost entirely by f ull-time teachers. It is inevitable that the modern medical school should follow their example. There are, however, better reasons than these for the establishment of full-time teachers in medicine. Medicine is becoming an independent science and, if medical students are to have the proper scientific background, it is necessary that their teaching .should rest largely in the hands of men who have the scientific point of view. G. Canby Robinson has ex pressed this idea clearly in a recent address: The life of the successful physician is usually full of activity and in the majority of instances, especially away from the centers of medical progress, practice soon falls into a routine Current Medical Literature 1157 which is not often seriously disturbed by any innovation Many succumb to the force of example and precept of their older colleagues. They soon learn to do without the scientific basis that had been given them more or less thoroughly. In crder to prepare students of medicine to resist in future life the forces of empiricism and tradition, scientific habits of mind _;iust be firmly driven in. Zinsser makes the same point when he says: The medical student who intends to become a practitioner devotes four short years to learning the premises from which all his future reasoning must take its departure. The last two of these are spent in clinics which bridge for him the transition from the principles to their application. All the rest of his life is passed in practice, where it is easy for him to perfect himself in the exercise of his skill and ingenuity but excessively difficult for him to follow, even in his own specialty, advances in the basic sciences which may, in the turning of a hand, antiquate his accepted practice or put in his grasp new and powerful we apons to increase his usefulness. The future practitioner of medicine must be in a posi tion to understand and apply the advances of science in his daily practice. In order to do this, he must be rooted and grounded in the principles of science and in scientific methods of thinking. Only teachers who are themselves in the closest touch with medical science can impart these scientific habits of mind and provide him with a foundation on which he can build in after years. The modern teacher of medicine believes that the “art” of medicine is something which the student must learn from practical experience. The “science” of medicine must be drilled into him during his four years of medical school. If modern medical education is definitely committed to the teaching of medicine by professional teachers, we may well ask the question: “Is the practitioner of medicine any longer need ed in present-day organizations, and, if so, in what capacity?- Must the practitioner with academic yearnings be content in the future to. do his teaching in postgraudate schools and his re search work in extra-university hospitals, or is there still a place for his services in university medicine? I am of the opinion that the practitioner will still be a necessary part of the modem university organization and will now briefly pre sent my reasons for this belief. 1158 The Chimi Medical Journal , The first and perhaps most important function of the practitioner in the modern medical school is that of liaison officer, or middleman, between the university professors on the one hand and the general practitioners and the general public on the other. Without some such connecting link, there is danger of a loss of sympathy and understanding between these groups. With respect to professors and practitioners it is true, of course, that both groups are composed of doctors of medicine and both are referred to as physicians; but their professional aims and interests are radically different. The professor of medicine is physician-in-chief to the university hospital, and as such is naturally interested in the handling of patients; but his larger interest is in disease itself and the teaching of disease to students; the average practitioner is absorbed chiefly in taking care of sick patients and building up a practice. The professor is the scholar; the practitioner, the man of affairs. Professors of medicine, for example, are not particularly in terested in county, state or even national medical organizations. Their multifarious duties in the medical school and hospital make it almost impossible for them to take an active part in these organizations. The practitioner gives his active support to these various medical societies for both social and professional reasons. Practitioners who spend a part of every day in the university clinic can report to the medical societies from time to time on the advances that are being made in research. The important advances in medical science must be taken up by the professors and instructors in clinical medicine and carried to the man in the street. New diagnostic measures, new remedies of all kinds, are first tried out in large hospitals. The prac titioner who is in constant attendance at one of these hospitals keeps up with the scientific “gossfip” and carries it outside to his colleagues who have no contact with the clinic. Just as the practitioner with university affiliations acts as a middleman between the professor and the family physician, so he may also be the means of keeping public-spirited laymen and philanth ropists in sympathy with the hospitals and medical schools. It is only by stimulating this interest that the endowments so necessary to full-time medicine are obtained. Another important field for the practitioner in the modern medical school is in the outpatient department. Here the practi Current Medical Literature 1159 tioner finds himself in his natural element. The type of patient that comes in to an outpatient clinic is the same type that makes up the bulk of the physician’s office practice. For some reason the full-time professor usually finds it difficult to become interest ed in the outpatient department. The vague symptoms and signs which these patients so often present do not lend them selves to vivid demonstrations or to dogmatic teaching. The young practitioner is particularly interested in outpatient work because it fills the gap between his internship and the day when he receives an appointment on the visiting staff of a hospital. There will always be a few practitioners who have a talent for research work, and if they have such a talent, every opport unity should be given them by the university clinic to carry out *» their ideas. It is really surprising how many of the important contributions of the last two decades have come from men who have been engaged in active practice. One need only mention Banting and diabetes, Minot and pernicious anemia; but many others could be cited. The practitioner will always approach a problem in medicine at a somewhat different angle from that of his colleague in full-time medicine. The practicitioner is in tensely interested in the practical application of science to his profession. His problems therefore are usually concerned with some diagnostic measure or some new therapeutic agent. No one will deny, however, that these problems are just as im portant as the more fundamental problems usually attacked by research fellows or university professors. There is danger,, of course, that the practitioners research will take on a superficial quality. Some of the research now being done by men in pra ctice shows a lack of adequate training in the fundamental branches of science. This is particularly true of much of the work that is being carried out in the field of bacteriology but applies to a less extent in the fields of physiology and chemistry. A .meat deal of money and time is being wasted on half-baked research work which, because of its inaccuracy, leads other workers astray, at least for a short time, and fills up medical literature with a mass of useless data which might better have never seen daylight. Research is a form of intellectual endeavor which, if not done well, is best left undone. .Much of this in accuracy in clinical research is involuntary; some, unfortunately, is purposeful, with an eye to its beneficent effect. 1160 The China Medical Journal fa the field of teaching, I believe that there is still a distinct need of the practitioner in medical education. The time may come, twenty or thirty years hence, when the entire train ing of undergraduate medical students will be taken over by full-time professors and instructors. At the present time, how ever, the practitioner still fills an indispensable place , on the teaching staff of the medical school. In the wards he approa ches, the sick patient from a practitioner's standpoint; the pro fessor of medicine approaches, the patient with an enormous interest in his disease. The students are entitled to both points of view. The practitioner is likely to have at his command certain facts in the practical application of therapeutics which will be of special interest to the •students. Furthermore, the special branches of internal medicine, such as gastroenterology, neurology and the diseases of allergy, are still largely in the hands of practitioners, and students should have the benefit of their knowledge and experience. The practitioner will be parti cularly valuable as a teacher in the outpatient department. Functional diseases, which constitute such a large part of the practice of medicine, receive very little attention in the wards. If the student is to become familiar with this very important group of diseases, he will have to receive his instruction con cerning them in the outpatient department. The practitioner, who is only too well acquainted with this type of patient, is best qualified to give instruction concerning it. Our students at Cornell have always shown a particular interest in minor surgery. I believe they would be just as deeply interested in a course in “minor medicine/' a course that would deal exclusively with the rather insignificant ailments to which humanity is so prone. A word should be said here about teaching the so-called art of medical practice. This is something which neither the full-time professor nor the practitioner can impart to the student, but is that intangible something which physicians either possess naturally or pick up from experience. A considerable part of the “art” of medicine is compassed by good breeding; the remainder is the skill which the physician acquires in prac ticing his profession. The practitioner who proposes to teach modern medicine must vie with his fulltime colleague in keep ing abreast of hi.s subject. He must find time in his busy life to keep up with the current literature and visit other clinics. Current Medical Literature 1161 Some of the older school of practitioners developed a method of teaching which was full of human interest and oratory but rather dilute in respect to rational medicine. How much time should the part-time teacher devote to his university and hospital -work?-- We must assume, of course, that he is interested in academic medicine and will give to it all the time that he can spare from his other duties. During his thirties and forties he should be able to give from one half to one third of his day to college affairs. After 50, the burdens imposed by practice, medical societies and other activities may make it impossible for him to devote half time to the school. After 60, his value to the medical school, both as a teacher and as an investigator, will depend entirely on the individual. How shall the practitioner be rewarded for his services to the medical school? If it is true that men who are successful in outside practice have something very definite and important to contribute to medical teaching, they should have proper com pensation in titles, salaries and clinical opportunities. The men who prove themselves most valuable to the school should eventually become professors of clinical medicine. The size of their salaries will naturally depend on the amount of time devoted to university work. In times past, when medical schools had little or no endowment, many of the clinical teachers gladly gave their time for nothing. Even at the present time pra ctitioners with large incomes, whether derived from practice or from private fortunes, are willing to work in the medical schools for practically no remuneration because of the prestige associated with such positions. In the richly endowed schools, however, it would seem hardly fair for the medical colleges to accept a considerable part of a practitioner’s time without mak ing some compensation for it. As for clinical opportunities, there is a tendency in several leading schools now to turn over the ward patients and bedside teaching to full-time teachers, and to limit the practitioners* activities to the outpatient de partment. I am convinced that such a policy is not desirable and, if persisted in, will eventually alienate the interest of the better practitioners from university work. This address was almost spoiled in the making by a con versation which I recently had with a distinguished colleague >vho is now engaged in full-time medicine. When I spoke to 1162 The China Medicai Journal him of the problem which I had in mind, he remarked that there was nothing which the practitioner had to give to the modern medical school which could not be supplied as well by the full time professor, provided he were the right type of ynwi. Any physician who combines the broad human sympathies with the spirit of scientific medicine will be a valuable asset to the me dical school, whether he is in practice or not. Francis Peabody, in his remarkable letter on the Soul of the Clinic, remarked that he had become as tired of discussions on full-time teaching as he was of discussions on the Eighteenth Amendment. After pointing out that a complete full-time system would be impos sible from an economic point of view, even if it were desirable, he concludes with the following: In the last analysis, the whole problem resolves itself into what kind of men you select for the hospital staff What we want is less of the system and law that kills and more of the spirit that gives life. The most valuable asset to any university is the inspired teacher, the man possessed with that indefinable something which arouses the interest and enthusiasm of the student. Such men are rare in all colleges and all medical schools. How few teachers have the power of making what they say stick in the memory! And how such teachers are prized by the student! We cannot afford to exclude a man of this type from the medical school because he happens to enjoy practicing me dicine as well as teaching it, American universities will make a great mistake if they allow gifted and talented physicians to lose their interest in medical education. There are many practitioners who still have a profound interest in medical teaching; and, if this interest is fostered by proper recognition from the universities, these men will continue to fill a useful place in the modern medical school. The closer association of practitioner and professor in both didactics and clinical work will make the practitioner a better professor ^ncj the professor a better practitioner. J, A, M, A, Aug, 17, 1929, Current Medical Literature 1163 HYDATID DISEASE AS A CLINICAL PROBLEM D. W. C arm alt-Jones, M.D., F.R.C.P., Professor of Systematic Medicine, University of Otágo, N.Z. Clinically few signs are to be depended upon in the diag nosis of hydatid disease. Cysts of the liver generally produce deformities of the upper surface, and there may be surprisingly little downward displacement of the lower edge. There are no symptoms unless there is some disturbance of function in an organ from pressure or irritation, so that the patient comes complaining of symptoms suggesting cholecystitis, pleurisy, hydronephrosis, or peritonitis, and there is little to call hydatid disease to mind. “Hydatid thrill,” when present, is unmistak able, but it is very rare. Barnett has described it very carefully; he has only found it seven times in the examination of over 300 cases; in one of these he was good enough to demonstrate it to me. He distinguishes it from the fluid thrill occasionally obtained in any thin-walled cyst close to the abdominal parietes. He calls the true thrill an “exquisite spring-like vibration, which is quite distinctly prolonged beyond the moment of percusión, and which is associated writh a remarkable drum-like resonance heard on auscultatory percussion.” He has found it only under the following conditions. “ (1) The mother cyst has been close under the parietes. (2) Its walls have shown signs of de generation leading to a slackening of the high normal tension that exists within the usual hydatid cyst. (3) Some large daughter cysts have been present, not closely packed, but having room to vibrate in contaet with the wall of the parent cyst.” As mentioned above, laboratory tests have been introduced and improved of late years, but they are by no means infallible; those generally used are the white blood count, for excess of eosinophil leucocytes, the complement fixation test, the Casoni skin test, skiagraphy, and the macroscopic or microscopic de tection of hydatid material evacuated from the body by any means and out of any site. Eosinophilia may be present, but is by no means constant. Barnett’s “colossal” case which contained about eleven gallons of hydated material only showed 4 per cent, of eosinophil leuco cytes,. and Hercus states from the department of bacteriology of Otago University that only about 35 per cent, of cases show eosinophilia of more than 5 per cent. Eosinophilia when pre 1164 The China Medical Journal sent is suggestive, and has led to the correction of other diag noses in many instances, but it only occurs in one case in three; eosinophilia in sputum has before this led to the diagnosis of hydatid of the lung. The complement fixation test was first applied to hydatid disease by Ghedini in Italy in 1907, and has since been ex tensively used in many parts of the world. In Australia its application was worked out by N. H. Fairley, and in New Zealand, independently, by Hereus. Like most tests of the kind it is conclusive when positive, but a negative result does not exclude the possibility of hydatid disease. It is an immune re action, and depends on the stimulation of the tissues by the pre sence of hydatid material. But, as has been mentioned, the tissues of the host form a fibrous capsule round the cyst which may effectually prevent the escape of its contents into th^ tissues, in which case the complement fixation test is likely to be negative. It has also been mentioned that daughter cysts occur if the endocyst is injured, which promotes leakage; conse quently in cases of cysts containing daughter cysts this test is generally positive, whereas in unilocular cysts it is often negative. It happens that cysts of the liver often contain daughter cysts, whereas cysts of the lung are often single. In cases of dead cysts the reaction is negative. The Casoni skin test is done in the same way as the skin tests for sensitization to pollens and foodstuffs and the like, but it produces both a “superficial” and a “deep” reaction, of which the latter, the more important, is delayed for some hours. The Casoni test is more persistent than the complement fixation test, beeause, once sensitized, the tissues retain their power to react to the direct stimulus of the antigen for very long periods, whereas if the cyst dies the serum soon ceases to contain antibodies demonstrable by the complement fixation test. The skin test, of course, is made in search of an “anaphylactic reaction” ; it may be negative in unilocular unleaking cysts, and the reaction may be abolished if the tissues are flooded with excess of hydatid material, as in the case of rupture of a cyst. It will be understood that, with a patient’s tissues sensitized, the rupture of a cyst, or even its exploratory puncture, may induce anaphylactic shock of any degree of severity, and death has undoubtedly been caused by it. Symptoms occur in the systems usually affected by anaphylaxis; cutaneous, gastro Current Medical Literature 1165 intestinal, respiratory, cardio-vascular, and nervous (Dew). In the majority of cases of leakage, however, they are not very severe, and may easily be missed. As Freeman has stated of toxic idiopathies in general, the reactions vary “from a shock producing coma to a scarcely perceptible malaise.” Skiagraphy.—My colleague Dr. C. C. Anderson has recently discussed the radiological diagnosis of hydatid infection, with emphasis on the following; é points. Such diagnosis is easy in sites where there is sufficient contrast in permeability to X-rays between the cyst and surrounding tissues, as in bone and lung. The typical shadow thrown by a cyst is ovoid, but it is liable to distortion; it is normally a uniform shadow due only to the fluid, so that if the fluid becomes inspissated in a dead cyst the shadow cast is indefinite, but the adventitia around a dead cyst may be calcified, with a typical shadow. Suppuration may greatly obscure the picture. In the liver the chief indication of a cyst is irregularity in the upper border of the organ ; in the lung the ovoid shadow is generally unmistakable; diagnosis of a cyst within the peritoneal cavity is difficult. Clinical examination, blood counts, serum and skin reactions, and X-ray examinations are all seen to be fallible, but thé diagnosis of the disease can be rendered absolutely certain by the demonstration of hydatid material derived from the patient, when this can be obtained. One hooklet or one fragment of laminated ectocyst is pathognomonic, and their discovery in material evacuated by a patient is of the same diagnostic value as is the demonstration of tubercle bacilli in the sputum from a case of suspected phthisis. Hydatid cysts may be passed from most of the orifices of the body; not infrequently a “thing like a grape skin” is coughed up from the lung. Hydatid material, possibly bile-stained, is sometimes passed per rectum, and cysts have been passed per urethram and from the uterus. Scolices or hooklets may be recovered from sputum, urine, discharge from sinuses, or from fluid obtained by exploratory puncture. The fluid obtained by puncture of a healthy cyst, without suppuration, is water-clear, like cerebrospinal fluid. If it contains broken-down material it resembles dirty water, not serous fluid. Sometimes a quantity of clear saltish fluid is coughed up if a cyst ruptures in the lung. It is very undesirable to puhcture a hydatid cyst, and it should never be done if thé condition is suspected and a diagnosis can 1166 The China Medicai Journal be arrived at by any other means. The risks are those of anaphylactic sho;k and secondary echinococcosis. It is evident that the diagnosis of a very serious disease, to which the inhabitants of a sheep-raising country are peculiarly liable, may present great difficulties, but that if the risk is constantly kept in mind, a study of family and personal history, physical examination, skiagraphy, blood and skin reactions, and pathological investigations will generally discover the presence of hydatid, though any single investigation may be misleading. The treatment is evidently surgical, and it is important that cysts, if present, should be removed. B. M. J. July 6, 1029. THE CHEMICAL OBLITERATION OF VARICOSE VEINS A Clinical and Experimental Study H o w ard M. K e r n , M.D. and L e w is W. A n g l e , M.D. Fellow in Plastic Surgery Baltimore S o l u t io n s There are five solutions being used rather extensively in Europe and in this country, namely, sodium chloride, 15 to 30 per cent; sodium salicylate, 20 to 60 per cent; dextrose, 50 per cent, the mixture of Meisen; sodium chloride, 10 per cent; sodium salicylate, 25 per cent, and quinine and urea (0.5 Gm. of quinine and 0.25 Gm. of ethylurethane in 2 cc. of water). There are valid objections to all of these solutions. In the case of the sodium chloride and, sodium salicylate, the cramp follow ing the injection is severe and there is at times a very marked perivenitis after injection, with infiltration, redness and tenderness of the skin and subcutaneous tissue surrounding the vein. This may persist for a week or ten days in spite of hot applications, and the patients are extremely uncom fortable. Then, too, faulty injections result in local gangrene with a very slowly healing wound, which of course is not dangerous but is most disagreeable and painful to the patient. Occasionally, patients have an idiosyncrasy for sodium salicy late and develop stupor, tinnitus and headache. However, the veins are easily and well obliterated with these solutions. The Meisen mixture gives about the same results as either solution alone. Fifty per cent dextrose is innocuous; it gives a very Current Medical Lit-erature 1167 slight cramp, and it does not cause any slough when injected outside the vein, though there is considerably pain; however, it is effectual (in our hands) in only a small number of cases, and this seems to be the opinion of other investigators. We have not had any experience with quinine and urea, but other inves tigators report that it causes intense pain and minor tenderness which lasts for weeks. Following its use there have been reports of intense cramps, accentuation of menstruation, searlatiniform erythemas, and severe symptoms in cases of idiosyncrasy. There are also reports of slough when it is injected outside the vein. After giving the first four solutions a fair trial, we soon began to seek a solution that would be effective in the majority of cases, would not cause a slough, and would produce a minimum amount of reaction. After considerable experiment ing we found that equal parts of dextrose, 50 per cent, and sodium chloride, 30 per cent, when used as a mixture, made an ideal solution. When injected into the abdominal wall of a dog, intradermally (in not too large amounts), subc-utaneously or intramuscularly, no slough resulted. There was only slight local reaction, and the formation of a hard mass that slowly absorbed. Experimentally and clinically it causes an endophle- 1 litis equal to that of the salt solution alone, and the resulting thrombus is exceedingly firm. Either solution alone will cause a destruction of the endothelial lining of the vein, but why the mixture should cause a destruction of the intima when injected into the vein and not a destruction of the cells outside the vein is difficult to explain on any basis other than a mechanical one. Clinically, if the solution escapes while an injection is being done, the patient complains of burning which is moderate ly severe and leaves an area which becomes painful, red and very tender to the touch but has never sloughed. If hot com presses are applied, all pain and inflammation will disappear in from forty-eight to seventy-two hours. However, at times a hard mass remains which is slowly absorbed. If a faulty injection is made, the area should be actively massaged for a minute so as to distribute the solution throughout the tissues and prevent the formation of the inflammatory mass. D osage We havo used this mixture exclusively during the past four months in from 2 to 10 ee. doses and it has proved satisfactory 1168 The CKina Medical Journal in 95 per cent of the cases. Only in dispensary practiee in very large dilated and sacculated veins above the knee have we had to resort to 30 per cent sodium chloride alone and in some instances results were obtained only after three or four injec tions. In private practice the mixture has also worked in this type of case, as the patients have rested from twenty to thirty minutes following injections, a procedure that is difficult to carry out in the outpatient department. The 30 per cent sodium chloride and 50 per cent dextrose may conveniently be hermetically sealed in 10 cc. ampules and then mixed at the time of injection. The salt solution should be colored slightly with methylene blue so that the ampules may be readily distinguished. The ampules have been kept for months in a refrigerator and there has been no change in the respective solutions, nor have the patients suffered any toxic symptoms. If the dextrose is of a good grade and the solution carefully -made, it is unnecessary to add a preservative. T e c h n ic In order to obtain the desired results in a short time and with the least discomfort to the patient, the proper technic of injecting irritating solutions is a most important factor. 1. Syringe and Needles.—The ordinary 5 or 10 cc. Luer syringe and 24 or 26 gage needles are used, depending on the size of the varix to be injected. We cannot overemphasize the fact that a successful vena puncture depends, to a great extent, on the sharpness of the needle. 2. Site of Injectionj—In the usual cases in which th e varicosities are limited to the leg, injection is usually begun in the most prominent protrusion of the most distal varix. In those cases in which the varices are not only present below the knee b u t involve the internal saphenous vein for some dis tance u p the thigh, injection is best begun just below the knee so as to block the main channel. After this is accomplished the varices distally located respond quickly to the treatment. In fact, we h a v e found repeated injections in the lower b ra n c h e s to fail until this was done. We have not hesitated to inject varicosities in the upper third of the thigh arid have caused thrombosis within 2 inches of the fossa ovalis, In three cases in our series there was an Current Medical Literature 1169 ascending chemical phlebitis involving the entire internal saphenous vein after the injection of 30 per cent salt solution. Outside of causing some discomfort to the patient for two weeks, nothing untoward happened. It is our feeling that if the saphenous vein is dilated and tortuous above the knee and there are varices present below the knee, the entire affected venous tree must be obliterated or there will be a recurrence of varices on the leg, because of the great downward pressure of the heavy column of blood. 3. Position of Patient During Injection.— (a) Standing is perhaps the most unsatisfactory position of all, both to the patient and to the operator. However, in some cases in which certain varices are prominent enough to be injected only when the patient is standing, it is the method of choice. For this position we have devised a simple stand w7ith a rail which has been a great help. The side of the stand without the rail is placed next to the ordinary examining table. The varices are readily accessible to the operator from the sides, and the patient has arm support in every direction that he faces. As soon as the injection is completed, the patient easily assumes the lying or sitting position on the table. (b) The sitting position is perhaps more comfortable to the patient but less satisfactory to the operator. As the leg hangs, the varix to be entered is distended. It is entered by the needle and the leg brought to a position of 90 degrees by the assistant, so as to empty the veins partially. During this shift in position, however, the vein is often ruptured, the needle is pushed through the posterior wall of the vein or pulled out of the lumen, and an unsuccessful puncture or injection is made. (c) The horizontal is the most satisfactory position of all but, unfortunately, cannot be maintained in all cases. The patient is asked to stand, and while the varices are well dis tended a tourniquet is applied proximal to the site of injection. The patient then lies down, the varix is entered easily, and the tourniquet is released. The vein quickly empties and the injection is then made. The solution is not diluted with blood but comes into intimate contact with the vein wall, which insures thorough destruction of the intima. This is the position we always use if possible. In some very large varices we have found it necessary to block off 3 to 4 inch segments of the vein below and above witl] 1170 The China Medical journal tourniquets and inject within this limited area before thrombosis can be obtained. In cases complicated by ulcer or eczema, an attempt is made to inject the varix that is keeping this area engorged with venous blood. The varices in such cases are often hidden by the thickened tissues and are at times most difficult to locate. If the leg is raised and the vessels emptied of blood, the varix may be palpated as a deep channel between the scar tissue walls. Injection should be made well distal to the infected ulcer in order to avoid a septic thrombus. The healing of the ulcer or eczema will depend on the ability of the operator to find and inject the offending varix. 4. Amount of Solution.—The mixture of dextrose solution, 50 per cent, and of salt solution, 30 per cent, is used in doses of from 2 to 10 cc., depending on the size and length of the varix to be injected. We never inject more than 10 cc. into one varix and not more than 20 cc. at one sitting. 5. Injectwn.—The skin overlying the varix is cleaned with tincture of iodine, followed by alcohol. Several minims of blood is aspirated after the varix has been entered and the injection is slowly begun, with alternate aspirations of blood and injections of solution, so that one may be sure that the needle is always within the lumen of the vein. After the injection is completed, the needle is quickly with drawn and pressure applied with a gauze sponge until the puncture is closed. The patient is then asked to keep the leg elevated for fully fifteen minutes and often the vein can be felt as definitely thrombosed before the patient leaves the table. If the injection has been made with the patient the prone position, thrombosis will oscur proximal to the point of injection; how ever, if the patient was standing it will be distal to this point. A firm pressure bandage taking in the entire leg and foot is applied and worn continuously during treatment and for three weeks after the last injection in order to support the veins until complete organization of the thrombi has taken place. Injections are repeated every other day or twice a week, depending on the patient. The number of injections required to obliterate individual varicosities varies too widely to permit a definite statement. Many times the larger thick-walled tortuous veins respond more quickly than those with thin walls. Current Medical Literature 1171 6. Clinical Effect of the Injection.—When the patient returns forty-eight hours after treatment, he may or may not complain of discomfort in the legs. The majority of patients arc unaware that anything has happened to their veins until palpation reveals slight tenderness along the course of injection. The vein can be palpated as a firm cord about one-third its former size. The skin over the vein is discolored slightly, having a light brown cast, which is thought by some to be due to the destruction of the sympathetic fibers accompanying the vein. We feel that it is due to the inflammatory process involving the vein and deeper layers of the skin. C o n c l u s io n s 1. We are convinced that the injection treatment is the method of choice as opposed to operative treatment, both from the standpoint of danger and also from the standpoint of time lost. 2. There are four contraindications to this treatment: (a) active or ia'ieni, phlebitis; (b) obstruction to the deep veins; (c) arterial disease of the extremities (Raynaud’s disease and thiombo-angiitis), and (d) cardiac disease. Pregnancy, in itself, is not a contraindication, but as the varices are greatly improved after delivery, we believe it is best to wait. 3. A mixture of 50 per cent dextrose and 30 per cent sodium chloride is an ideal solution to use for obliterating the veins. 4. Injections should be made in the horizontal position, if possible. 5. If the internal saphenous vein is varicosed above the knee as well as below, it should be obliterated as high as is necessary to insure a cure of the varices of the leg. 6. There is little or no danger in the treatment if it is dene by careful operators with a thorough understanding of vascular conditions. N o t e .— Since this 'paper w a s submitted for publication w e have added fifty cases to our series and have had no untoward results. Experiment a l l y we have injected a mixture of 4 ce. of 30 per cent sodium chloride a n d 2 cc. of 50 per cent dextrose solution in a single area under the skin of the ubdominal wall of a dog. A marked inflammatory reaction resulted but there was no necrosis. J. A. M. ;1. Arni. lOiJi1. 1172 The China Medical Journal HOW LONG SHOULD LEPROSY TREATMENT BE CONTINUED? E r n e s t M u ir , M .D ., F.R.C.S., Leprosy Research Worker, School of Tropical Medicine and Hygiene, Calcutta Ten years’ experience of the treatment of leprosy has made the writer of this paper cautious in his presentation of the answer to this question. The treatment of leprosy is in a state of flux. Year by year improvements are being made, and what holds good for this year may not be true for the next year. Yet there are certain general principles which may be laid down for guidance. 1. It must be evident to all who have treated cases of leprosy that: (1) Some cases get better much more quickly than others. (2) The disease may linger on in the body long after all active signs have disappeared. (3) In order to get the patient rid of active signs, and to keep him from developing these signs again, it is necessary that his general health should be maintained for an indefinite period. 2. This leads to a consideration of what are the ‘activ e signs of leprosy.’ These may be classified as follows: (1) A positive bacteriological finding. The skin, nasal mucosa and lymph nodes must all be examined. Repeated examination of the skin must be made. If ’ ' the ears are found positive during treatment, they must be examined again till repeated smears are found negative. The; clip-smear method is recommended as most reliable when few mycobacteria are present. Any other portion of the skin which has been found positive before should likewise be re-examined. The nasal septum, if positive to begin with, should from time to time be scraped, and smears made till negative. (2) No patient should be declared bacteriologically n eg ativ e until he h a s had repeated maximum doses of potassium iodide administered (240 grains in an adult), w ith o u t signs of reaction. Current Medical Literature 1173 (3) A raised or erythematous macule in leprosy is a sign of active disease. (4) The increase in size of a macule or of an anaesthetic area indicates active disease. (5) The diminution of such an area also shows active disease. Only the living can die, and the infection must still be alive as long as it continues to get less. Active lesions must be distinguished from permanent lesions. Where fingers and toes have been lost we cannot expect them to grow on again; and, likewise, where nerve fibres have been destroyed we cannot expect them to be renewed. Permanent anaethesia should, therefore, be expected, both in the sites of old macules and in the sites of acroteric (glove-stocking) lesions. The above five points will serve to distinguish active from permanent lesions. Nerve trunk thickening or tenderness must also be counted as an active sign. Iodides will often light up tenderness in nerve trunks as wrell as swelling and congestion in the skin, lymph nodes and such organs as the testicles, long after bacteriological and clinical signs of activity have failed to be elicited by other means. The iodide-sedimentation test is also a delicate criterion which, when carefully interpreted, is of distinct value. 3. The next point to consider is how long treatment should be continued after all active signs have disappeared. This will obviously vary with the case. If all active signs disappear within two or three months, one or two months' treatment may suffice. If an obvious predisposing cause is found antj.,removed, its removal being followed by rapid disappearance ,of leprosy without the use of any special anti-leprosy remedies, then prolonged treatment is unnecessary, provided the predisposing cause is permanently removed. This is often the case with such a disease as syphilis. In an A1 case all signs of leprosy may disappear by the time a single course of one of the ordinary arsenical anti-sphilitic drugs has been administered. Likewise, a change in diet may cause healing of leprosy without any other remedy. u n The China Medical Journal . But in eaues which hav This is especially so where no predisposing cause has been discovered, or when the predisposing cause cannot be removed: as when a patient is forced to live in a malarious climate and continues to have attacks of malaria, or when he is suffering from post-dysenteric scars of .the bowel. We may, therefore, say that treatment should be continued for six to twenty-four months after we fail to find acid-fast bacilli or other evidence of their presence in the body. Even after treatment has been stopped it is important to keep in touch with the patient. He should report to the doctor every three months for the first year, and then every six months for the next two years. His reporting to the doctor will have the effect of insuring that he continues to keep up his general health to a high standard, and that no recurrence has intervened. If during these three post-treatment years the patient suffers from any debilitating disease or is subjected to other circumstances adverse to his health, the possibility of recurrence ci leprosy must be kept in mind, and special means taken to prevent it and to restore him to gobd health again as soon as possible. -The question of testing by iodide administration of the young children of leprous parents, or children that have been subjected to infection, naturally arises in this connection. Experiments that have been carried out at Purulia lead us to consider it probable that most of such children are infected; and that with good food, with the absence of predisposing causes, and with good hygienic conditions they are unlikely to develop the disease, and will generally, lose the infection before they reach the dangerous age of puberty. It is, therefore, unwise to light up latent disease in such children by giyiiui iodide. Indian Journal of Medicine, June 1929. Current Medical Literature 1175 CANCER AND THE GENERAL PRACTITIONER* Ceci,l Rowntree, F.R.G.S., Surgeon to the Cancer Hospital, London. Many of the papers on the subject of cancer might lead the casual reader to imagine that early diagnosis of this condition is never effected except by the writers of the papers in question, and that practitioners as a body fail signally in their duty to the community. It is often forgotten that the early diagnosis of a case of cancer demands the co-operation of an intelligent and alert patient, ready to seek immediate advice, with a doctor competent to appreciate minor departures from the normal and ready to give immediate advice. The patient, however, may be unobservant; or he may not bother, until it is far too late, about a condition which seems to him—usually because it is not painful—of little or no importance. Conversely, the doctor sometimes lets the patient down by making avoidable mistakes. Generally, I think, mistakes arise from one of two causes: The first is imperfect examination, which may be the fault of the patient or the doctor. The patient, for various reasons, may refuse to be thoroughly examined, or the doctor may continue to prescribe for his patient without attempting any real examina tion. He may, for instance, give treatment for “piles” without examining the rectum, or give medicine for abdominal pain without inspecting the abdomen. The other fruitful source of error is want of thought—failure to attain, by a careful sum ming-up of symptoms, the clear perspective which would lead to an immediate diagnosis. Unfortunately there is no royal road to a diagnosis of cancer—no short cut, as there is in the case of syphilis. But we have many valuable aids to diagnosis, both bedside and laboratory. In the former category are such instruments as the proctoscope, the sigmoidoscope, and the cystoscope, which are used far too rarely by practitioners, though in many cases they are easy to use, easy to maintain, and most invaluable in the information they give. In the latter category are tests for occult blood in the stools, or for free acid in the stomach. But it is most important to remember that these are only aids; they must never be con- ♦Abstyact of a lecture given at Leeds under the auspices of the Yorkshire Council of the British Empire Campaign. Ì176 The China Medical Jourmd sidered apart from their context—the patient. We must guard ourselves against the danger of getting lost in a laboratory maze; above all, we must not attach undue importance to negative findings, especially to those of the X-ray examination. One often finds that both patient and doctor are lulled into a feeling of security by a radiologist’s report that there is nothing abnormal 'jo be seen, which is wrongly taken to mean that nothing abnormal is present. The subject of early diagnosis embraces a consideration of the preventive treatment of cancer by the early detection and prompt treatment of conditions that we know to be precan- cerous. I still often see patients with warts of the lip and tongue, papillomas of the bladder, small rodent ulcers of the face, or small tumours of the breast, who have been told that they need not bother about them unless they become trouble some. By the time such things become troublesome they are troublesome indeed. P eriodical M edical E x a m in a t io n . I will refer briefly to the controversial topic of periodical medical examinations, although why it should be controversial I cannot imagine. We all go to the dentist at regular intervals; we are all examined for life insurance from time to time; some of us have our drains inspected periodically; others have their J electric wiring tested. It does not seem to me unreasonable, therefore, to carry this established principle to its logical con clusion and to undergo periodical medical inspection. I should like also to see much more intelligent and sustained instruction of our youth in the elements of physiology, f6r there can be no question that a more perfect knowledge on tfie^part of the public of normal physiology would result in a quicker appreciation of any departure from the normal standard, and greater readiness to seek advice. At present people know far more of the anatomy and physiology of their cars than of their own bodies. They Tcnow whether or not the car is missing, or heating up, or knocking, and that such defects require immediate inves tigation and treatment; but to similar premonitory symptoms in their own bodies they attach no importance, and often fail to undergo an overhaul until complete breakdown has developed. It is still beiieved by most surgeons that c a n c e r is a strictly local disease in its early stages, and that if the growth can be Current Medical Literature 1177 completely removed or destroyed a good permanent result will be achieved. What are the local methods of treatment at our disposal? They are only two—operative removal and radium; and it is the anxious and by no means easy task of the practitioner to make or influence a final decision when the alternatives have been put before the patient. R ad iu m T h e r a py . The therapeutic action of radium and its mode of use depend upon the fact that it emits two kinds of rays which produce effects upon the cells and tissues of the body— beta rays, which are caustic and indiscriminate in their action, equally affecting every kind of tissue, and gamma rays, which are selective in their action, and affect cancer cells more easily than the normal tissues. The caustic, indiscriminate, and, incidentally, the very superficial action of beta rays renders them unsuitable for therapeutic purposes, and as they are unable to pass through a thin sheet of platinum it is quite easy to cut them off entirely by enclosing the radium in a shell of platinum 0.5 mm. thick. The more powerful and selective gamma rays easily penetrate this amount of platinum, and as it is only these rays that we make use of, it is gamma-ray therapy that we really mean when we speak of radium therapy. A fundamental feature of the gamma ray is its short radius of effective action; it is therefore necessary to place the radium in intimate contact with the part it is proposed to treat, and so has come about the use of the buried radium needle. Radium needles are hollow, provided with an eye, and vary in length and thickness according to the purpose for which they are to be used and the amount of radium it is proposed to put inside them. Suitably filled, they are threaded with silk or similar material, and embedded in and around the growth, which under goes destruction, leaving the normal tissues unaffected. But this does not happen all at once, and we know now that there is an important time factor in radium treatment, the effects pro duced by a large quantity of radium acting for a short time being quite; different from those produced by a relatively small quantity acting for a long time. The explanation would appear to be that in the main the gamma ray exercises its selective faction upon cancer cells in the act of division. Not all the 1178 The China Médical Journal of a growth are undergoing this change at the same time; one cell may divide to-day and be destroyed in the process, while its next-door neighbour, which may not be due to divide for three or four days, will escape injury if the radium is not still in position. There has thus come about the gradual development of a technique involving the use of buried needles each contain ing no more than two or three milligrams of radium, but remaining in the tissues for a week or so at a time. There is another important practical point in treatment that results from the selective action of radium upon the dividing— that is, the growing—cell. The main mass of a new growth is composed largely of adult cells which have lived their life, and will, in any event, ultimately die a more or less harmless death. It is at the growing edge of cancer that all the actively dividing cells are situated, and it is therefore the periphery, and not the centre, that matters. If we can control the periphery, the centre will often look after itself. Surround the growing edge with a barrage of radium needles and the whole growth melts away. There are, furthermore, wide variations in the reaction exhibited by different kinds of cancer, but we are beginning to recognize and understand them, and by examina tion of the tissue are able to form some sort of estimate as to its probable reaction to treatment. Radium therapy has, however, very definite limitations, chiefly arising from the fact that the action of radium is strictly local. We are all sometimes pressed to give radium treatment in cases with metastases when we know full well that the course of the disease cannot be influenced in any .degree whatever. It is our duty to do what we can for our patients, not only physical ly, but mentally; but we also owe a duty to our own reputation, to our profession, and to the development of radium therapy. It would be the greatest disaster to the cause of radium surgery if the results following upon its reckless and uninstructed use were allowed to obscure the good results obtained in properly selected cases. Ca n c e r of t h e Cervix. Radium scored its first regular and consistent successes in the treatment of cancer of the uterine cervix. At the Cancer Hospital many patients who have come into hospital on an ambulance—weak, emaciated, septic, and bleeding—with a Current Medical Literature 1179 growth of the cervix long past the stage of operation, have been enabled, after treatment by radium alone, to walk home, well and strong./ The results of irradiation in cancer of the cervix are, in my judgment, such that radium can now complete on equal terms with surgery in the treatment of early and operable cases of this disease, and I believe that it is perfectly fair and proper to offer patients the choice of operative or radium treatment. Operation, even in the ablest hands, carries a fair mortality, and always involves removal of the ovaries and most of the vagina, but gives a good prospect of permanent freedom. Radium treatment, on the other hand, carries prac tically no mortality, involves no injury to ovaries or vagina, and gives a prospect of permanent freedom not quite so good perhaps as operation, but at any rate so good that the actual figures over a five-year period afford material for legitimate controversy between the protagonists of the two methods. Ca n c er of t h e B uccal Ca v ity . About the next site I want to consider there is no con troversy at all. It is the tongue, and buccal cavity generally, and here, with epithelium which closely resembles that of the cervix uteri, the results are similar. All surgeons will agree that operations for cancer of the tongue are about the most disappointing they are called upon to perform. It is true that we have all had occasional successes, but my own were so few and far between that I came to dread the admission of these cases to my wards. You will understand, therefore, with what interest we watched the work of Regaud in Paris and Evans and Cade in this country, and how gladly we relinquished operative surgery and whole-heartedly adopted the radium needle technique for the treatment of these depressing cases. We have a long way to go yet, and much to learn, particularly in dealing with the secondary glands, but we have certainly reachèd à point where it may be said that the treatment of choice for cancer of the tongue, floor of mouth, cheeks, pillars of fauces, tonsil, pharynx, and larynx is radium. Can c er of t h e B r ea st . Tht* radium treatment of breast cancer is still in the expérimental stage. The operative treatment of early cancer of the breast gives excellent results, for the mortality is negligible, the mutilation is not important, and the ultimate U 8° The Chino, Medimi Journal results are good. What can radium offer in similar cases? The immediate results in many cases are apparently as good as those obtained by surgery; the primary growth shrivels up, the glands (disappear, and, of course, the breast is not sacrificed. But we do not know yet how long this will last ; the systematic treatment of early breast cancer by radium has not been practised long enough to enable us to form a clear opinion as to whether the primary growth or glands return, or whether distant metastases are more or less likely than after surgical operation. My own practice, therefore, is to operate upon early arid suitable cases, but to use radium when the patients are old and feeble, when tjhere is any intercurrent disease, or w hen- owing to extensive glandular involvement—there appears to be no good prospect pf obtaining permanent cure by operation. Ca n c e r op t h e R e c t u m . In think the position with regard to the rectum is very similar to that of the breast. I have seen a few very good results from radium treatment—that is to say, destruction of the growth without the disadvantage of a permanent colostomy. But these cases are so few in number, and the results of surgery in early cases are so good, that I still think it our duty to recom mend surgical removal in suitable early cases, reserving radium for the more advanced cases, for the old and feeble, and for the very young; for I know of no case of cancer of the rectum under 30 years of age where operation has had any permanent success. These examples exhaust the common kinds of cancer in which radium has had a real test, but it has been tried, and is being tried, in many other situations. Cancer of the stomach, cancer of the colon, and cancer of the head of the pancreas are examples that suggest themselves as suitable, and I have embedded radium in all these situations. The numbers are too few, however, and the time too short, to form any t definite con clusion about results. T h e R esponsibility of t h e S u rg eo n. Cases of this latter class lead to a consideration of the question as to who is to decide when radium should be applied, and who is to apply it. There is no possible doubt as to the answer; it must be the surgeon; for who else is competent to perform an exploratory laparotomy, tpjdiagnose the nature, and Current Medical Literature 1181 estimate the extent and connexions of the growth, and embed radium needles suitably and effectively in such a way that they will do their work and then permit of safe withdrawal ? In the past in this country radium has been chiefly entrusted to the care of roentgenologists, who from the very nature of their training and daily avocation have few opportunities of acquiring extended clinical experience or of familiarizing themselves with surgical technique. But nowr that the position of radium has been established in surgery many hospital authorities have put their stock of radium in charge of the surgical departments. In my view this is the right procedure, and surgeons who wish to keep in touch with modern developments must learn the principles and practice of radium therapy in exactly the same way as they would learn the use of a new instrument or any other new method of treatment of proved value. There is no need even to discuss the suggestion that a new* class of specialist should be evolved—primarily a physicist—who must learn enough surgery to enable him to devise means of approach to growths in the less accessible situations. The “surgery of access” is everyday surgery, and the view that the use of radium should be confined to a special class is just as unreasonable as the suggestion that the use of potassium iodide should be con fined to pharmacologists. T r e a t m e n t of A dvanced Ca s e s . In discussion the treatment of advanced cases of cancer— cases which, for various reasons, do not lend themselves to radical operation or to radium treatment—I would first refer to the role of palliative operations—operations, that is to say, which merely aim at increasing comfort and prolonging life. There is a whole range of such operations—gastrostomy, jejunostomy, colostomy, and cystostomy—all most valuable in their way, but all cariying grave drawbacks in their train, chief of which is the fact that they must be performed upon patients already doomed to die of their disease, and so have come to be associated in people's minds with a hopeless outlook. I find that this pessimism is not confined to the general public, but that practitioners as a whole share the common opinion, and, indeed, often add the weight of their influence in dissuading their patients from undergoing them. 1182 The China Medical Journal I find' it easy to understand this, for no one practitioner sees very many cases of the kind, and it is difficult enough for him to form a just estimate when he daily sees his case going steadily downhill. He is inclined to forget how much unhappier the patient would be without it, and how much, on the average, such an operation does towards prolonging life and increasing comfort. One only sees the value of these operations in pers pective when they are done for non-malignant conditions. For example, a gastrostomy done for simple stricture of the oesop hagus is fully compatible with an active busy life. Similarly, jejunostomy performed for the treatment of chronic simple ulcers of the stomach too extensive for removal is an operation which has given brilliant results—so good, in fact, that I have lately tried the experiment of treating the smaller ulcers of the stomach by jejunostomy in preference to partial gastrectomy. I invariably perform it in all cases of cancer of the stomach too advanced for excision or for gastro-enterostomy. Pain is at once relieved, vomiting ceases, and nutrition is easily main tained by four-hourly feeds through the jejunostomy tube. What other means are at our disposal for helping the later stages of cancer, and delaying its almost inevitable termination ? I am afraid we must reluctantly admit that there is nothing ac present which is likely to prove a universal cancer cure. Wc are therefore reduced to treating symptoms, and I would like to refer to a few points which are brought home to us by our experience in the incurable wards of the Cancer Hospital. Unquestionably our most important duty is to relieve pain, and to this end there is nothing that takes the place of morphine. Very large doses will often be necessary, but it is worth remem bering that cocaine and hyoscine are useful variants in cases where morphine has distressing after-effects, or is ineffective. Many painful conditions are much relieved by exposure to X-rays. There is no doubt a psychic element as well, but our patients at the Cancer Hospital certainly get great help and comfort from their periodical visits to the X-ray department. Surgical opportunities of dealing with severe pain are few and far between, but when they come the results may be dramatic. For instance, the division of the lingual nerve in cancer of the tongue, or, better still, the destruction of the third Current Medical Literature 1183 division of the trigeminal nerve by alcohol injection, give immediate relief. Bolder measures involving such major surgical procedures as the division of the posterior spinal roots, or even a portion of the cord itself, have a smaller application than might be expected owing to the poor general condition of the patient by the time that they are indicated. The aspiration of fluid from the pleura or the abdomen is an obvious method of giving help, but I am not sure that it is generally done soon enough or repeated often enough. Attempts to control discharge from sloughing surfaces afford scope for ingenuity in the use of antiseptics, but the value of any antiseptic is greatly increased if it can be applied in the form of a power-driven spray. The mouth sprays used by dentists and operated by compressed air are most useful for this purpose and thoroughly cleanse every crack and crevice on a sloughing surface. I should like to see compressed air laid on at every bed in a cancer ward. If discharge is largely derived from excessive mucus secretion, the value of belladonna should be remembered. It gives special help in pharyngeal cases where the presence of much frothy mucus is such a troublesome feature. The question of deodorants must also claim attention, for however careful we may be in maintaining adequate ventilation, something of the kind is often necessary. In my experience the most valuable has proved to be essential oil of peppermint, which should be sprinkled on the dressings or the blankets. It is true that it only hides one unpleasant smell by a more power ful one, but at least it is recognized and understood, whereas the undisguised smell of advanced uterine or rectal cancer, of which happily the patient is often quite unconscious, brings the greatest misery and suffering to the relatives and friends. In thinking of symptoms and their relief we must not forget the patient. Sunshine, real or artificial, and fresh air, are of just as much importance in cancer as in other wasting diseases, and I look forward to the time when such hospitals as my own will have branches in the country where the incurable cases may spend their last remaining months of life on sunny balconies in the open air, rather than in the confined wards of a London hospital. B. M. J . May 4, 1929. 1184 The Chinar Medical Journal TOBACCO SMOKING W in g a t e M. J o h n s o n , M.D. 1. In a series of 150 adult male smokers, the systolic blood pressure was 128.23, the diastolic 78.87. In the same number of nonsmokers, the average systolic pressure was 129.64, the diastolic 79.23. The average age was practically the same, 42.63 years for the smokers, 42.41 for the nonsmokers. The weight of the smokers was 164.44, of the nonsmokers 161.08. The height was the same. 2. Of sixty fatal cases of angina pectoris in males, forty- two, or 70 per cent, were in smokers; eighteen, or 30 per cent, in nonsmokers. As a control, of 1,000 adult males taken from telephone directories in five cities, 81.8 per cent were smokers. 3. In a series of twenty individuals tested, the blood pressure after smoking showed no change in five but dropped in fifteen. The average fall in blood pressure after smoking for the whole group was 4.9 systolic, 3.4 diastolic. C o n c l u sio n s 1. Tobacco smoking apparently has no permanent effect on the blood pressure. 2. There is no foundation for the popular belief that smoking decreases the weight of an individual. 3. It is doubtful whether tobacco plays a major part in the etiology of angina pectoris. 4. The act of smoking, if it affects blood pressure at all, reduces it temporarily. 5. The effect of tobacco smoking is chiefly local, exerted principally on the pharynx. J. A. M. A. Aug. Si, 1929. Current Medical Literature 1185 LESIONS OF LATENT SYPHILIS Aldred Scott W arthin, Ph.D., M.D., LL.D., M.A.C.P. S u m m a r y . It will be seen that the lesion of latent syphilis repeats the essential pathology of the hard chancre and of the secondary and tertiary lesions of the active stage of syphilis, in that it is predominantly vascular and perivascular, and that the infiltra tions are derived from the proliferation of cells in situ. Each localization of the spirochaete leads to the production of what is essentially a miniature chancre. The presence of plasma cells and lymphocytes in the tissues in the form of localized perivas cular infiltrations may be taken as the criterion for the presence of Spirochacta pallida. The organisms, therefore, persist in the tissues, producing slight lesions leading eventually to fibrosis and atrophy of the parenchyma. Clinical symptoms will arise only when this atrophy and fibrosis reaches such a degree that functional disturbance results. In the average case in the male this functional inadequacy appears first usually in the cardio vascular system, and death from latent syphilis is most frequent ly due to cardiac insufficiency. There are, however, especial organ susceptibilities to the localization of the spirochaete: in one individual the central nervous system, in another the liver, in a third the adrenals, etc., may bear the brunt of the latent infection, so that the clinical picture and the manner of death may vary greatly, according to the organ or tissue chiefly involved. I have never seen at necropsy a case of perfectly healed syphilis. Search, often prolonged, always reveals active latent lesions in aorta, heart, or other organ. This is as true of cases treated in the modern manner as it is of cases treated with the old mercurial method. If any difference results in the two methods of treatment it would appear to be in the more frequent occurrence of chronic hepatitis in cases treated by the arsenial method. What the treatment accomplishes in either case is the more rapid reduction of the average active case to a stage of latency. There is no evidence pathologically that the case of syphilis ever becomes wholly free from spirochetes. The latency of the infection may last throughout the individual’s life: or at any time exacerbations may take place, and the disease arise above, the clinical horizon. What determines these renewals of 1186 The China Medical Journal virulence on the part of the spirochaete, whether it be due to a changed quality on the part of the organism or to changes in the resistance of the body, we do not know. The possibility of such a clinical renewal of activity on the part of the spirochaete is always a possibility hanging over the head of the individual who once acquires this infection. Even if the disease never again produces a clinical outbreak, the relatively immune spyhilitic will nevertheless develop various functional inade quacies as the price of the latency of his infection. These minute local infiltrations of plasma cells and lymphocytes represent the processes of a local tissue immunity. With time this immunity mechanism in itself becomes dangerous to the individual through the functional inadequacies which it may eventually produce. Whether a consistent five-year period of treatment would finally rid the body entirely of spirochaetes I cannot say, for in my material there have been no cases that have been under continuous treatment for that period of time. The fact remains, however, that in syphilitics accorded what has been regarded by the clinician as thoroughly satisfactory treatment, with complete clinical cure, latent lesions of syphilis still present themselves on microscopical examination of the necropsy material derived from such cases. B. M. J. Aug. 10, m u . . Book Review* THE PRINCIPLES OF APPLIED ZOOLOGY. Robert A. Wakdle. M.Sc. Professor of Zoology, University of Manitoba. Longmans, Green & Co. 2 1 /- Net. The publication of this book is a sign of the times. Hitherto books by zoologists have been written mainly from the academic point of view with such general principles as heredity, variation, natural selection and evolution as a background. It has been left to Kpecialists to deal with the different aspects of what is now termed Applied Zoology. In this book however an attempt ljas been made to deal with the applications of Zoology as a whole, a task which the author compares with “the difficulties experienced by the fisherman of Bagdad, in persuad: ing a'djmn to retire into the limited confines of a brass bottle.” It must be admitted that,'while the book perhaps suffers from its comprehensive Book Reviews 1187 ness, the author has succeeded remarkably well in giving a survey of the subject 'which will be of value not only to specialists but which can be read by the general reader interested in “his food supply, clothing and health,” with a considerable degree of profit. The book should prove of special value to the student of “tropical” medicine and will enable him to take a more intelligent view of the relation of animals not only to the causation and spread of disease in man but in relation to the environment as a whole. Finally the bibliography with which the volume concludes considerably extends its usefulness and makes it valuable as a work of inference. H. G. E. THE TREATMENT OF FRACTURES. Lorenz Bohler M.D. Trans lated by M. E. Steinberg, M.S., M.D. Published by Wilhelm Mandrich, Vienna. G.$5.00. Dr. Bohler as the head of a two hundred bed hospital for fractures during the war and now as Chief Surgeon of the Vienna Accident Hospital, has had exceptional opportunities for the study and development of the treatment of fractures. His book is divided into two parts. The first deals with general principles, including methods of producing analgesia, the treatment of pseudarthrosis, fresh compound fractures, infected fractures, etc.: while the seco n d indicates the special treatment required in the particular fracture described. I)r. Bohler has invented various pieces of apparatus for the reduction of displacement and the retaining of the fragments in position, but he recognises that the success of the treatment does not only depend on the surgeon’s skill with apparatus but also on ths organization of team work and therefore he outlines a suggested routine for the treatment of fracture cases. The two chief planks in his platform are the efficient reduction by extension and the proper use of plaster. This is altogether an excellent book, giving plenty of food for thought. H. G. T. OSTEOMYELITIS AND COMPOUND FRACTURES. H. W innett Orr. M.D., F.A.C.S. C. V. Mosby Co., St. Louis. Price G.$5.00. Dr. Orr has written this book to emphasize the necessity in cases of acute or Chronic osteomyelitis which may be associated with a compound fracture of the two cardinal principles—drainage and rest.' The techni que used he calls the Orr method and summarises it as follows:— 1 (!) Make a fairly large incision over the infected area, spread apart ■the skin, muscles, fasciae and periosteum just farenough to afford access to the diseased area and no farther. 1188 The China Medical Journal (2) Chisel a window into the infected bone area large enough so that all diseased and necrotic (but not infected) bone may be removed, all pus-pockets reached and no overhanging edges of bone remain in the diseased area. (3) Clean out the diseased area gently with a curette or gouge, being careful to damage tissues undergoing repair as little as possible. (4) Dry the cavity and wipe out with 10'} tinct. of iodine followed by 95 rr alcohol. (5) Pack, suture wound wide open but not tightly with a sterile vaseline gauze pack, cover with a dry sterile pad and bandage. (6) X ow perform any reasonable forcible manipulation necessary to place the parts in their correct anatomic position for. splinting. (7) Apply a Plaster of Paris cast if possible, otherwise a suitable splint so that the parts are thoroughly immobilized in comfortable and correct position. (8) The east is not to be split nor are windows cut until the wound dressings are necessary. And wound dressing is not necessary for some weeks. The wound is not to be dressed at all except for a rise of temperat ure or other signs of acute sepsis. Good readable type, good illustrations and good paper, the three characteristics of the C.V. Mosby publications are not lacking in this book. H. G. T. SELECTED READINGS IN PATHOLOGY, from Hippocrates to V irch o w ; Edited by E s m o n d R. L o n g , Professor of Pathology, University of Chicago. Published by Charles C. Thomas. Price G.$ 4.00. The Editor of this interesting book has selected 36 authors of medical works which bear to a greater or lesser extent on human pathology. Each section is headed with notes upon the author in question, autobiog raphical or critical. This is followed by translated selections from his writings. Portraits of 14 of the authors are given, and also several illustrations from the works quoted. The Editor’s avowed purpose is to make it possible for students and physicians to familiarise themselves with the actual thoughts of the more prominent pathologists of the ages, who to most are but names. In this he is remarkably successful. Even with the inevitable scrappiness of his material, Professor Long has managed to make one realise what vast pains have been necessary to build up today’s knowledge of human pathology. T h e s e extracts and the helpful introductory notes bring to us no s e n s e of superiority or amusement, but rather a feeling of rev er en ce for these masters of old who in the midst of difficulties and preconcep tions, the deadening effect of which we can scarcely comprehend, yet made step after step forward in the understanding of disease. Boole Reviews 118S The book is eminently readable, and well worth study. Those who do- read it w ill turn from it with a warm vote of thanks to Professor- Long for his painstaking work. Printing and Binding are alike excellent. J. L. H. P. THE MEDICAL MUSEUM. Based on a New System of Visual Teaching by S. H. Daukes, Director, The Wellcome Museum of Medical Science, Size 10" x 7". Pages 172. (The Wellcome Foundation Ltd. Endsleigh Court, 33, Gordon Street, London, W.C.I.) This book is not merely a theoretical contribution to the improvement of museums in general and medical museums in particular, but a descrip tion of practical achievement based upon theory and vision. The author is precise, clear and has obviously devoted much study, skill and care to a subject on which this book stamps him as an expert. Having in the first chapter discussed the functions of a medical museum and made a plea for reform and for a wider outlook, Dr. Daukes pro ceeds in subsequent chapters to describe and discuss the details of the new system of visual teaching or which the ideal medical museum is based. This is followed by appendices dealing with the application and development of the system, with typ^s of buildings, walls, screens, cases, labels, illustrations and technical details of preserving and mounting specimens. In conclusion there is a very valuable and complete bibliog raphy of technical museum publications and 45 whole-page illustrations of screens, sections and specimens which are most helpful as providings practical evidence of the soundness and practicability of this new system visual teaching. Everyone interested in museums, whether in regard to construction, development, control or use, should read and study this book. Having” done so there will Lj a natural desire to see its methods developed in actual practice, which, fortunately, is possible for all those who can visit Thte Wellcome Museum of Medical Science, 33, Gordon Street, London, of which Dr. Daukes is Director. LEAGUE OF NATIONS—CANCER COMMISSION. Reports Submitted by the Radiological Sub-Commission. These reports occupy 82 pages, and are divided into six chapters, each of which deals with some aspect of cancer of the utei'us. Chapter 1 reviews the work of the Sub-Commission on radiotherapjr of uterine cancer. It was decided in the first instance to confine the in vestigation to the Radiological Institutes of Stockholm and Paris, and the Frauenklinik of Munich University. 1190 The China Medical Journal Chapter 2 is a report based on preliminary proposals put forward by an executive committee. It indicates the methods to be used for obtaining full and comparable statistics, and for the data relating to the technique of treatment. A chart with anatomical diagrams is appended for standard comparisons in diagnosis, history, and treatment. Chapter 3 is a report on the technique and results of treatment of cancer of the cervix uteri at Radiumhemmet, Stockholm. This report is illustrated with a number of diagrams and tables of figures. The figures for the period 1914-1923 shew that of all cases treated by radiotherapy over \22 per cent were alive and free from symptoms after five years, and that of the operable cases treated by radiotherapy over 40 per cent were alive and free from symptoms at the end of five years. In Professor Forssell’s earlier work he used relatively small quantities of radium, -applied many times, but now that larger quantities are available the tendency is to apply larger quantities and to give not more than two or. three doses within a short period. Chapter 4 is a report on the technique and results of thie radio- therapeutic treatment of cancer of the cervix uteri at Munich. This report is admirably illustrated with fourteen photographs and diagrams o f the methods useG. Since 1913 no case of cancer of the uterus has been treated by opera tion. From 1913 to 1918 radio-active substances only were used, but since 1918 combined treatment by radio-active substances and X-rays has been commencec. As a rule only two series of treatment are given, with an interval of eight weeks. A striking fea,tux*e of this work is application of d^eep x-ray therapy to the pituitary body in all cases, in order to sensitise the cancer. Injections of dextrocide have been given for sensitising pur poses to all patients in the last two years, while diathermy and cataphor- •esis have been used as adjuvants in certain cases. The statistics *for various stages of the disease shew a higher per centage of cures where X rays have been used in addition to radioactive substances. Chapter 5 is a report on radiotherapy in the treatment of epithe- liomata of the cervix uteri at the Radium Institute in Paris. (It should be remembered that the French term “epithelioma” commonly means a malignant tumour of epithelial origin, and that the term “epitheliomas pavimenteux” corresponds to the English “epitheliomata.”) This rep o rt is also illustrated by diagrams and a photograph of treatment by “radium at distance.” The majority of the patients appear to have been treated by inter nal Curietherapy alone, but the writer of the report (Dr. D. A. Lacassagne) now considers that combined radio-therapy is the best method. Chapter 6, written by Prof. Claude Regaud is a memorandum on the organisation of, and the conditions required for, an effective campaign against cancer of the uterus. Correspondence 1191 Prof. Regaud’s recommendations may be summarised as follows:— 1. Public propaganda to facilitate early diagnosis. 2. Numerous centres for examination. 3. A close liaison between examining practitioners and a good pathological laboratory. 4. A few well equipped treatment centres. 5. That the treatment should be in line with medical progress, and that workers with radium should be adequately trained. S. D. S. Correspondence Oct., 23, 1929. ages, aprons, etc., and would The Editor, write direct to me, stating clearly China Medical Journal. their needs, and at the same time enclosing or arranging for pay Dear Sir, ment of transit of parcel and stat As newly-elected President of ing how it shall be sent, we shall the Hospital Aid Department of be very glad to do our best to our British Women’s Social Ser furnish the required articles, free vice Board, in Shanghai, may I of charge. be allowed, through the columns j I am, of your magazine, to say that if Yours truly, any hospitals in the interior should (Mrs.) Evan Morgan. be in need of roller or other band 3 Darroch Rd., Shanghai. WANTED Doctor to be head of depart- j For particulars app'ly ment of Eye, Ear, Nose and j Dr g g Throat and Chinese Doctor to be I . assistant in Medicine, both pos- ! Superintenden , itions vacant from November 1st. ! Soochow Hospital., NEW MEMBERS PROPOSED ALLEN, A Stewart M. D., C. M. (McGill) U.C.C. Chungking, Sze. Proposers: Dr. H. Gordon Thompson, Dr. J. H. L. Paterson. 1192 The China Medical Journal ROSE, Gerliard }f.D. (Breslau) Hangchow, Che. Proposers: Dr. S. D. S : urton, Dr. I’. Haddow. ,',en Ting Kwei. M.D. (Changsha) M.E.W. Red Cross Hospital, Shanghai. Proposers: Dr. J. R. B. Branch, Dr. H. Gordon Thompson. NEW MEMBER ELECTED Dr. 1. E . A. ReveJle, U. C. C. Chungking, Sze.