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180.

I 20.

Salix Nigra in Oophoralgia, 87; ( Ulcers, Frogskin Grafts in, 45; | Etheridge, J. H., Chicago, 78, Sexual Sedative Action of, 87. Pepsin in, 20.

103. Salol: in Bladder Catarrh, 178; as a Uutoward Effects, 16, 48, 52, 116, Dressing, 88; in Syphilis, 52. 122, 128, 186.

Fenger, C., Chicago, 1. Santonin in Eye Disease, 87. Uræmia and Perineorraphy, 12.

Field, M. D., New York, 34. Saundby's Bright's Disease (Rev.), Ural. 89.

Flintermann, J., Detroit, Mich., 41. 95. Urethan in Tetany, 186.

Fox, G. H., New York, 47. Saw Palmetto in Amenorrhoea, 88; | Urethra Discharge, 9; Injury, 156; French, P., Mexico, Miss., 75. in Impotence, 88; in Prostatitis,

Stricture, 5. 88. Urinary Calculi, 56.

Galbraith, T. S., Indianapolis, 145 Scarlatina, Acetanilid in, 155; Uterine Asthma, 124; Epithelioma, Goelet, A. H., New York, 34. Mercury Iodide in, 16.

185; Cough, 91: Fibroids, 179; Goodell, W., Philadelphia, 71. Sclerotic Cuts, 94; Rupture, 57. Myoma, 102.

Gray, J. L., Chicago, Ill. Secondary Infection (Ed.), 84. Uvula and Morning Sickness, 94. Gray, L. C., New York, 32, 192. Seminal Emissions, 57; Testicle Inflammation, 20.

Vaccination Ointment, 186. Hanks, H. T., New York, 34. Senn's Bacteriology (Rev.), 96; Vagina, Foreign Bodies in, 190. Heuff, 0. N., Chicago, 104. Gas Test, 129.

Vagino-Vulvitis in Brides, 189. Hoag, J. C., Chicago, 105. Sexual Starvation (Ed.), 118.

Varioloid, 68. Shakespere's Son-in-Law,

Dr. Varioloform Rash from Mercury, Ingals, E. F., Chicago, 140. Hall (Ed.), 184.

158. Skull Injuries, 156.

Venereal, Induration, Non Specific, Jackson, W., New York, 40. Societies and Colleges, 24. 61, 95,

9; Warts, Chromic Acid in, 19. Jacobi, M. P., New York, 34. 127, 159, 195.

Venesection in Puerperal Eclamp- Jaggard, W. W., Chicago, 105 Sod. Chloride for Children, 149;

sia, 54. Dithiosalicylate, 186; Ethylate Veratrum Vir. in Pneumonia, 52. in Moles, 144; Sulphite in Vertebral Exsection, 130.

Keyes, E. L., New York, 5. Thrush; 170.

Vesico-Vaginal Fistulæ, 158. Kiernan, J. G. Chicago, 76. Somnal, 155.

Viburnum Prunifolium, 16. Sozoidolates, 53.

Vulvo-Vaginitis in Brides, 189. Lange, C., Pittsburg, 112. Spermine, 120.

Larrabee, J. A., Louisville, 147, Spinal Concussion, 185.

Wardner, Dr., Resignation of 167.

(Ed.), 157. Spirits Minindrerii in Coryza, 186.

Lewis, Bransford, St. Louis, 145. Wax in Ear, 187. Spleen, Laceration of, 159. State Items, 30, 64, 97, 130, 163, Weekly Medical Review (Ed.), McKone, J. J., Tacoma, Wash195.

ington, 7. Sterility in Prinipara, 18.

Whitechapel Murders, 192. Mansfelde, von, A. S., Omaha,
Stricture. Urethral, 5.
Wild Yam, 106.

Neb., 75.
World's Fair (Ed.), 153.
Strychnine in Constipation, 173.

Maxwell, A., Indianapolis, 138.
Styrone, 86.
Worms, 15; 190, 191.

Monroe, G. J., Louisville, 192. Substitution (Ed.), 84.

Moyer, H. N., Chicago, 71.
Yeast and Impacted Fæces, 52.
Sulphonal, III, 121, and Diges-

Munn, Dr., Pittsburg. 36. tion, 155; in Night Sweats, 16;

Murdock, J. B,, Pittsburg, 74.

CONTRIBUTORS. Untoward Effects, 52.

Murray, R. A., New York, 9, 175. Sulphur as an Alterative (Ed.), 85. Adams, G., Poplar Bluff, Mo., Pantzer, H. O., Indianapolis, 108. Superfætation, 111.

143. Suppositories Glycerine, 22. Alexander. Harriet C. B., Chi Poe, A. C., Cleveland, O., 132.

Peaslee, A.W., Telluride, Col., 126. Suppuration without Microbes, 190.

cago, 42, 171. Surface Temperature, 125. Arnold, G. D., San Francisco, 82. Reed, R. H., Mansfield, O., 75. Surgical Dressings, 56.

Axford, W. L., Chicago, 8. Suspension in Spinal Cord Disease,

Richardson, W. H., Boston, 129. Baldy, J. M.,

Mass., 7.

Philadelphia, 71,Sycosis, 22.

Rochester, D., Buffalo, 172.
Syphils, 9, 52, 138, 155, 181. Beates, Jr., H., Philadelphia, 70. Rodman, J. J., Owensburg, Ky.,
Syringomyelia, 38.
Bertrand, J. H., De Forest, Wis.,

176.
171.
Bishop, S. S., Chicago, 145.

Scott, W.A., Pleasantville, Ia., 76.
Tapeworm, 89.
Blanchard, Wallace, Chicago, 135. Shoemaker, J.V., Philadelphia, 106.

Shaw, A. B , St. Louis, 191. Tendons, Bodies in, 20.

Boldt, H. J., New York, 34.
Tetanus, 155, 190.
Brill, N. E., New York, 137.

Smythe, G.C.,Greencastle, Ind.,101. Tetany, 161, 186, 192.

Burnham, A. F., Ashland, Ill., 4. Thorn, S. S., Toledo, O., 75. Tetronal, 121.

Burnett, E. C., St. Louis, 9. Thymol in Diarrhæa, 52.

Tuttle, J. H., New York, 8. Burr, C. B., Pontiac, Mich., 177. Thrush, 168. Thyroid Cartilage Fracture, 132. Church, A., Chicago, 38.

Ullman, G. A., Albany, N. Y., 17. Toenail Ingrowing, 123.

Clevenger, S. V., Chicago, 13.
Tonsilitis, Chronic, 140.
Coe, H. C., New York, 9.

Van de Warker, Ely, Syracuse, N.
Tonsilitomy, 141.
Currier, A. F., New York, 9.

Y., 179. Toxic Antagonism, 89.

Vernon, G. W., Indianapolis, 139. Trachelorraphy, 145.

DaCosta, J. A., Philadelphia, 170 Trephining, 156; in Psoitis, 19. Dalton, H. C., St. Louis, 10. Watkins, T. J., Chicago, 81. Trional, 121.

Dana, C. L., New York, 33. Wells, E.F., Shelbyville, Ind., 174. Tuberculosis, 128; Meningeal, 136; Davis, T. D., Pittsburg, 37. White, J. W., Philadelphia, 9. or Typhoid, 176.

DeArmond, J. A., LeClair, Ia., 35. Williams, A, M., Hot Springs, Turpentine in After Pains, 188; in Doering, E. J., Chicago, 40.

Ark., 138. Croup, 123.

Dudley, A. P., New York, 9. Woods, J. T., Toledo, O., 72. Typhoid fever, 94, 101, 122, 125, Dudley, E. C., Chicago, 102. Wright, B.P., Syracuse, N. Y.,141. 176.

Duffield, S. P., Detroit, Mich., 68. Wylie, W. G., New York, 33,

II2.

THE MEDICAL STANDARD.

CHICAGO:
G. P. ENGELHARD & CO

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177

VOLUME VI.

APR84, 18809. NUMBER 1.

EXTIRRA TIPA OFA SEE RECTUM.

BY CHRISTIAN PENOER, M, D., CHICAGO.* The removal of the rectum is an important be seen, there is a ring-shaped carcinomatous subject, as it is one of the achievements of tumor two and a half inches long occupying modern surgery. Extirpation of the rectum is a the entire circumference of the gut, ulcerated child of modern surgery, inasmuch as it was not on the nodular surface, making a constriction until iodoform gauze was used for packing and which hardly permits the passage of the little drainage that it became devoid of its dangers. finger. At the upper and lower part of this In former times it had such an appalling mor- ring is three-quarters of an inch of healthy tality that colotomy was preferred by the wall of the rectum transversely divided, thus English surgeons, and the removal of the rectum · showing that the anus with the sphincter has regarded as an almost not permissible operation. been left.

Volkmann made the first step toward utiliz- As to the method of operating, I want to dising antiseptic principles and reduced the tinguish between the operation for low and high death rate, but his method of drainage with carcinoma. Low carcinoma includes the anus permanent irrigation was cumbersome, compli. and will seldom if ever go up so high that there cated, and often, in cases where the peritoneal will be necessity for any more preparatory opcavity had to be opened, dangerous. I have erating than to remove the coccyx; very rarely, seen in such a case the abdominal cavity filled with a view of getting more operating room it with more than two gallons of carbolic acid may be necessary to resort to the next step in solution; thus it was not until the advent of the higher operation, namely, livision of the iodoform gauze that a radical change came left sacro-sciatic ligament, which gives a good about. I have paid a good deal of attention to deal more room. these operations, inasmuch as I have extirpated In the operation of high carcinoma the next the rectum sixteen times, eleven times for step in getting access to the rectum is to recarcinoma and five times for inflammatory move the left half of the sacrum, as proposed stricture. As far as carcinomas are concerned by Kraske, or even to remove it entire transI will in this connection present two specimens, versely on the line of the third foramen, with the one illustrating a low carcinoma, as I prefer subsequent replacement in situ.

This latter to call it, a carcinoma that involves the way of getting operating space I have tried once sphincter; and one a high carcinoma, that is a and found satisfactory; the patient survived the carcinoma that has left the sphincter and a operation and died six weeks later from causes couple of inches of the rectum intact. The first independent of it, after everything around the specimen is a low carcinoma, consequently the rectum had healed satisfactorily. anus is there. The carcinoma, as may be seen, The two operations, of which the one for low takes in the anus and about three inches of the carcinoma might be termed extirpation or ampurectum, and behind it there is a mass of adipose tation (Holmen), the one for the high operation, tissue from the concavity of the sacrum, in resection (Volkmann), are of course entirely which we see a tumor the size of a walnut, different, inasmuch as the former commences which is a carcinomatous para-rectal lymph- at the anus, extending from there upward, and gland. It is always advisable to remove this the other commences above and behind the tissue just the same as to remove the axillary anus and is really a posterior operation in the glands when a carcinoma of the mamma is sacral region. The reason for distinguishing operated upon, or the submaxillary glands when between the two operations, besides the entirely operating for carcinoma of the lips, because this different technique, is also the difference in is the place where the carcinoma first extends gravity of the operation. This means a differoutside of the rectum to the lymph glands in ent gravity of the disease, namely, that a high the surrounding tissues.

carcinoma is much more serious than a low The other specimen is what we might term carcinoma. Statistics which I got together a high carcinoma, inasmuch as the anus and year ago in this respect showed eighteen high lower portion of the rectum are left. As will carcinomas with a mortality of fifty per cent., *Read before the Chicago Medical Society, May 20, 1889.

while a series of two hundred and seventy-two

operations for mixed high and low carcinomas showed a mortality of twenty-two per cent. In most of the statistics we meet with now no distinction is made between high and low carcinoma in the sense in which I wish to express it; that is the reason why the older mortality does not enable us to judge about a single case, inasmuch as it is too low for high carcinoma and too high for low carcinoma. Old statistics of Billroth showed a mortality of thirty-nine per cent.; more recent statistics of König showed a mortality of twenty four per cent. Quite recently Bramann published twenty-seven of Von Bergmann's cases with twenty-six recoveries and one death, that is 3.6 per cent. mortality.

As to the carcinomas I have operated on, in four high carcinomas, two men and two women, there were two deaths as the immediate consequence of the operation, and two recoveries from the operation, of which one died six weeks afterward, after everything around the anus had been healed. The second, the patient from whom this specimen was taken, is well, has gained twenty pounds in a few weeks, and is much improved by the operation.

For low carcinoma I have operated seven times, on six men and one woman, with four recoveries and three deaths, two of which were in immediate consequence of the operation. The third died from arterial hæmorrhage after four weeks.

A new field for extirpation of the rectum, or the low operation, was proposed by Israel in 1883, namely, to operate in this way for nonmalignant inflammatory strictures, whether due to syphilis or the gonococcus. This form of disease of the rectum will sometimes resist all other local measures, dilatation, division, etc., but will form peri-rectal abscesses and fistulæ, make life unbearable, and finally terminate in amyloid nephritis and death. In so intractable a case I have reason to believe that extirpation of the rectum is a decided success. I have done five extirpations for inflammatory stricture, on four women and one man, with no deaths.

In sixteen cases of this nature, reported by Israel, Busch, Riegner, Bardenheuer and myself, there were fifteen recoveries and one death, a mortality of about six per cent. The possibility of extirpation of the rectum for nonmalignant stricture of course depends upon the extent of the latter. It must be possible to reach reasonably healthy rectum above and draw it down. In the case of limited stricture, when the operation has been applied, all the authors agree that the patients have been decidedly benefited.

The advantage of the removal of such a strict

ure, if it is possible to get good healthy wall of the intestine, is that the disease is done away with at once. There are always foci of pus in the wall and the tissues surrounding such a rectum, and finally, around a stricture of this kind most irregular pus cavities form enormous pockets, which are of course done away with by the extirpation of the stricture when possible. When the stricture is above a certain point,then extirpation becomes impossible.

To return to the subject of discussion for tonight, the carcinomas: There are some points of importance in the operations which I shall now call attention to for instance, in operating for high carcinomas it is sometimes very difficult to bring the upper portion of the bowel down because the meso-rectum or lower portion of the mesentery of the sigmoid flexure may be unusually immovable. The mesentery must, of course, be divided until the bowel comes down. A good deal of dissecting may have to be done before the bowel can be brought down. In this respect I believe it is often possible to know beforehand about this difficulty, inasmuch as I think that the longer the stricture has existed, the easier the operation will be, because the efforts at defecation will make the upper portion more movable, and thus make the operation easier. It has often seemed to me also, when I came to a certain point in dissection, that then the upper bowel has come down easier; at the same time I have met with one case where it was almost impossible to get the upper intestine down. When united to the anus or lower portion of the rectum there must be no tension at all, inasmuch as the sutures can seldom be kept aseptic, and thus are liable to tear through. The danger of tension is shown in a number of Kraske's cases, where in the same night of the operation the sutures gave way, the end of the upper bowel turned upward in an effort at defecation, which took place right into the peritoneal cavity. Kraske believes that preparatory treatment of such a patient to the extent of having the bowels entirely emptied might guard against such an accident, but I consider it rather doubtful whether any preparatory treatment can always guard against such a fatal defecation when rupture of the sutures takes place. I do not see how this can be absolutely guarded against, but the more movable the bowel and the more freely it is brought down, the less tension there is, and of course the less liability to this accident.

Furthermore, it is sometimes impossible in high carcinoma by any method of examination before the operation to tell the exact extension of the carcinoma to neighboring organs. My

THE COOK COUNTY INSANE ASYLUM.

3

attention was called to this in one case, a cribed as following operation for high carcinowoman I operated upon two years ago in Mil- ma, are possible. The mortality suggested of waukee. I found that the carcinoma extended twenty-eight per cent. makes this operation á to the wall of the uterus from the anterior wall justifiable and a useful one. of the rectum, so much so that it was impossi- One word as to the final results. In my limble to get all the carcinomatous tissue out, and ited experience there is only one case of carcifurther, it was impossible to unite the peritone- noma in which I can say that the cure is probum. The patient died from acute septic peri- ably radical, inasmuch as more than two years tonitis in a few days.

have passed without a relapse. Of the rest of To what extent the difference in prognosis them, there are two who are now alive without will be between the high and low carcinomas I a relapse, but they are so recent that nothing do not know that it is possible to tell, because can be said about their future. this distinction has not been made sharply Freedom from relapse may to some extent enough. Thus there is nothing to judge by depend upon the form of carcinoma. The from the older statistics; it is only possible to more glandular or typical cylindrical celled guess about the high carcinomas.

carcinoma is more benign; the more mixed It is a great gratification to modern surgery glandular or small celled carcinoma is more to see that such results as have been des- malignant.

THE COOK COUNTY INSANE ASYLUM-AN OPEN LETTER.

BY S. V. CLEVENGER, M. D., CHICAGO.

[Concluded ] The incessant complaints against the Cook and poorhouse, to and from which trooped the County Asylum have given it a justly malodo- attendants, day and night, in various stages of rous reputation, and as far back as 1856 Dr. Ed- intoxication, and some of these places had the mund Andrews of Chicago, who was Demon- reputation of being “fence houses” for the disstrator of Anatomy at Rush Medical College, posal of stolen county property. Almost everysays that the corpses procured from the asylum thing seemed to have“a job” in it for some one,big at that time were so covered with vermin and or little. The Commissioners claimed the lion's filth as to necessitate scorching before students share of the stealages,and winked at the smaller could dissect them. There has been repeated thefts of underlings. Even the cheap keys testimony that lice abounded in the wards, and which were purchased at dear prices would Dr. Koller, an assistant physician, found mag- break in the locks at most inopportune times. gots in the wounds of neglected patients in 1884. The warden was an acknowledged stealing Bedbugs would torture patients under their agent for the "gang,” and among other methods strait-jackets and rats would mutilate the bodies of robbing not brought out on the “boodle trial" of those who had died unattended during the was the placing of fictitious names on the pay night. Male attendants were usually appointed rolls. Many such rolls will be found signed by by the Commissioners for their fighting abilities the same hand in receipting for employes' pay, at the polls, in fraudulently carrying eiections Provisions of all kinds for the insane were below and seemed to want to keep in practice at the grade, and less in quantity than charged for; expense of the insane.

They often openly de- the milk was skimmed, and often too sour to fied the superintendent, and when threatened use for long periods at a time, even when there with dismissal reminded that official that he had were no thunder showers. not sufficient political influence. The majority There were stealages in the clothing in variof the attendants being of this low character ous ways, and even the rags and bones were the efforts of those who were well disposed were sold for the benefit of the one who had control discouraged.

of such offal. Brawls, drunkenness, oaths, slamming of The County Board financial reports were faldoors, incessant alarms, blackmailing, bluster,

sified and confused in a variety of ways, often pistol shooting, intrigues, immorality, stealing, the expression "general expenses" would cover neglect of duty on part of subordinates, exerted a thousand dollars or more of unaccounted for a very depressing influence upon the decent of- bills, and at one time some fifty thousand dolficials there and caused them to waste much of lars were included in a lump in some such item their energies in keeping out of rows.

to the perfect satisfaction of the Commissioners. Dram shops were convenient to the asylum, Whosoever arrayed himself against this state of things was marked for persecution, and there not principles, are the attractions, and at the is reason to believe that frequent political bottom of the entire matter. murders have taken place from such causes. A Unfortunately throughout the United States favorite method of entrapping an enemy was to most state asylums and nearly all the county fasten upon him some worked-up scheme, such asylums are thus badly managed and for idenas enticing him into questionable relations with

tical reasons. At Danvers, Mass., a palace females, and having witnesses in hiding.

asylum was built for show and spoils, while the To add to the turmoil, while the perfectly insane were being starved in the poorhouse. new boilers were being destroyed in the engine At Utica, N. Y., corruption was rife and simi room to enable more stealings, and the patients lar horrors occurred there, and we hear from were suffering for want of heat, the Commis- New Orleans and other places in the South, sioners would interfere with the classification of especially Kentucky, of even so bad a state of the insane by ordering violent cases, in which things as the insane being shot at by the officials. they happened to have an interest, to be placed The State management is better than the upon the wards assigned to quiet and conva- county or municipal, because the Legislature is lescing patients and otherwise interfere with the not so constantly in session and the medical proper treatment of the insane. Everything was men are more free to work reforms in the in. done to make an apparent showing of external terim, and the control is placed in the hands of cleanliness, but the whitewashing and the a board of local trustees who usually do no flowers and the well-kept lawn constituted it worse than to make the asylum and its funds but a whited sepulcher.

the occasion of booming their particular town, Among other things which alienists abomi- The overcrowding at our county asylum is nate, but which is rise in every political asylum, not the only cause of the brutalities there, and is the keeping and training of "show patients," the cry of overcrowding has always been made such as, by some peculiarity of manner, either by the county commissioners as justification for clownish or otherwise, could pander to the more contract jobbery. The "boodlers" started curiosity of visitors, and particularly such insane that cry during 1885 and placarded the walls of as were adroit enough to sing the praises of the the city with appeals for a million dollars with administration, through encouragement by ex- which to build a suitable asylum, and described tra favors for such services.

the horrors that would occur in case of a fire at Advances in the care of the insane are made the institution. in direct proportion to the growth of intelligence Rather than build additions to the present among the people, and the publicity given to miserable structure it would be better by far to public affairs.

abandon the county farm entire to the poorTo properly understand the causes of public house management and furnish the State with charity abuses we must not only look at imme- funds to build elsewhere, remote from saloons diate but remote factors. Like causes produce and the present location, two separate asylums like effects, and we can turn to the annual re- for males and females. ports of the Illinois State Board of Charities, The unrestricted pauper immigration to this. wherein are detailed precisely similar, if not country is a direct cause of this overcrowding. worse, brutalities existing in nearly every county March 1, 1884, a careful enumeration showed insane asylum in the State, and then refer to that at the county asylum there were 464 forthe September 8th, last, accounts in the Indian- eign born to 146 native born insane, in a total apolis papers, headed “Ill treating the insane. of 610, giving a proportion of 12 native to 88. Shocking disclosures affecting the management foreign born insane, which is certainly not the of the Indiana State Asylum. Ward strikers percentage of our sane population, the differkick and whip the unfortunate inmates in a bru- ences between which exhibit the fact that Eutal manner. Putrid meat, rancid butter, and rope is unloading her pauper insane directly wormy flour bought and used. Democratic cor- upon this country. There is a prospect of the ruption.” Some other States account for these city limits becoming coextensive with those of things as Republican corruption. In our own the county boundaries, as is the case with New county our “boodle gang" was chosen impartial- York and St. Louis. In this event the County ly from both parties, so we may well question Board will cease to exist, and our charities will whether one party is a particle better than the be dispensed by Aldermen. The change will other, and as some of these miscreants have not be for the better. Neither county commisbeen known to change from one party to the sioners nor aldermen, who are of the same other as often as five times in ten years to keep stock, and elected in the same way, should be on the winning side, it shows that spoils, and allowed to control public charities. The Tweed.

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