St. Louis Medical Review A MONTHLY JOURNAL OF MEDICINE AND THE YEARLY SUBSCRIPTION, $2.00. To Foreign Countries in the Universal Postal Union, $2.50. PUBLISHED BY THE ST. LOUIS MEDICAL REVIEW ASSOCIATION, ST. LOUIS, MO. Articles, letters, news items, etc., intended for publication in the editorial columns should be addressed to the "Editors of The St. Louis Medical Review," and should be accompanied by the name and address of the sender and postage to cover their return, if unsuitable. All communications relative to advertising or business of the REVIEW should be addressed to St. Louis Medical Review Association, Metropolitan Building, St. Louis, Mo. Entered at St. Louis Pos: Office as Second-Class Matter. ST. LOUIS, AUGUST, 1909. SKIN AND CANCER HOSPITAL. Among the many items of interest to the medical profession of St. Louis is the preparation for the construction of the new St. Louis Skin and Cancer Hospital, there being but one similar institution in the United States and that located in New York city. St. Louis may be proud to boast of an institution which, when completed, will be second to none in this country and from which many important contributions have emanated. About four years ago a number of promin ent specialists undertook the establishment of a skin and cancer hospital, much opposition was at first encountered, but persistence on the part of the projectors soon established a hospital. The growth was slow at first, but good service and attention to duty on the part of the visiting staff resulted in the rapid growth of the clinics. Energetic administration on the part of the board of directors and a munificent donation from one of St. Louis' prominent citizens, Geo. D. Barnard, resulted in the purchase of a centrally located lot upon which active preparations are now being made for the construction of a hospital which will be a model institution in every respect. Carefully prepared plans have been made, and much time and consideration on the part of the directors has been given to perfecting a modern hospital. The third annual report of the hospital is of interest, showing the growth of the institution and the broad-minded plan upon which the institution is carried on. It is the only strictly charitable hospital in the city outside of the Eleemosynary Institution. Extracts from the third annual report show several items of interest: "I wish to emphasize the fact that the hospital is a charitable institution pure and simple. Medical attention, drugs, etc., are all free, and the members of the medical staff and the associate members thereof, give their time and services gratuitously." "On the recommendation of the medical board, concurred in by the board of directors, post-graduate instructions will be given to physicians and surgeons in cancerous and skin disWe hope thereby to encourage interest and work in these diseases among the physicians at large. It is planned to give them such lectures and demonstrations as will add to their knowledge of pathology, and the treatment of cancerous and malignant diseases. There is no other institution in the country that especially limits the instructions along these lines, therefore it is to be hoped the pioneer work thus undertaken by us, and the stimulus given by these lecturers, will be of considerable value and benefit.” cases. "The rapid growth of the institution is shown in the report of the president of the medical staff: In 1906, 118 patients were admitted in the hospital and 74 operations performed. In 1907, 156 patients were admitted in the hospital and 105 operations performed. In 1908, 231 patients were admitted in the hospital and 151 operations performed. In 1906, total number of outside patients, 3,769. In 1907, total number of outside patients, 4,987. In 1908, total number of outside patients, 6,110. The remarkable progress of the institution can be explained only by the conscientious performing of duty on the part of the directors and the patience and skill of its visiting staff. St. Louis is fortunate in having such an institution, and the medical profession is to be congratulated that some of its members are capable of conducting a charitable hospital which is a credit to the profession. THE RAILWAYS AND PUBLIC HEALTH. Whilst the health authorities of cities are now engaged in combatting the spread of tuberculosis by regulations, the railroads seem to be criminally negligent. A recent experience will illustrate this statement. On a Pullman sleeper I lately counted three cases of pulmonary tuberculosis that were traveling to Asheville, North Carolina. In the same sleeper were young children. The distress of mind to the ordinary passengers caused by having the poor creatures coughing and expectorating the whole night through is surely enhanced by the contemplation of possible infection. Nor is it an appetising process to be forced to use the same drinking cups or to wash in basins used by those with active pulmonary tuberculosis. To be assured by tuberculosis experts that the danger of infection is greatly overrated is an assurance that falls short of contenting the average traveler who is forced to live in close contact in unventilated boxes called sleeping cars with tubercular fellow pas sengers for many hours. To sleep for twentyfour hours in a tubercular ward of a general hospital is not as repellant as is this enforced. imprisonment with chance met tuberculosis. victims where air space is practically non-existent. The remedy for this evil is obvious. Sleepers with the sign for "Tuberculosis passengers only" should be attached to all trains that run to well-known resorts for the tubercular, or at least to reserve drawing rooms in sleepers for such passengers. Editorial Pith IMPROVEMENTS IN ANESTHESIA. There have been but two deaths from anesthesia reported to our county coroner this year, but as doctors are loth to report such cases we opine this small number represents but a modicum of the real facts in our mortality. "The general administration of anesthetics as performed today is the shame of modern surgery, a disgrace to a learned profession." The above assertion by Baldy, in his 1908 presidential address before the American Gynecological Society, led to the selection of four well known surgeons to prepare and present a symposium on the subject of administering anesthetics (Surgery, Gynecology and Obstetrics, May.) The report is of great import, contains some well founded, caustic criticisms on the present methods and abuses in the administration of anesthetics, not a little cock-sure pedantry born of unpleasant observations in the clinics of others less fortunate than some members of the committee, some jejune vampings and some advice which will prove valuable to the anesthetist of limited experience, he of sufficient experience to comprehend the advice and shun the shoals; but the report contains little grist for the hungry horde of medical students who must of necessity occupy in a few short years the places of those now giving anesthetics in such lamentable and reckless manner as to constitute our chief glory and our crowning shame. The way to a brighter and better day is pointed, and we earnestly recommend a careful perusal of this symposium to all now engaged in giving anesthetics, and more especially to those now hopelessly floundering about in the shoes of our illustrious dead who formerly taught materia medica and therapeutics. Webster spent six months on the continent, and after close observation at numerous clinics is convinced of the justness of Baldy's remarks as quoted above. He attributes our present defectiveness to lack of proper teaching in the medical schools and to the vaunted superiority of ether as compared with chloroform in the production of anesthesia and the singular postoperative freedom from morbidity and mortality where ether has been used. In order to escape undue risk, Webster has been using local anesthesia (Schleich) in all surgical cases in which a general anesthetic would increase the risk. He has in the past seven years successfully operated for gallstones, done nephrectomies, resection of bowel, vaginal and Cæsarean section and numerous other abdominal and pelvic procedures under local anesthesia. Nitrous oxide as is given preference for short operations if a general anesthetic is to be given, and gas is also given as a preliminary to ether for operations requiring longer time. The method of changing from gas to ether frequently during the course of the operation, as employed by him, will not be readily adopted by the profession. The plan, however, of giving gas for a time and then changing to ether, which is continued for two or three minutes, is proving highly satisfactory in his hands for prolonged operations. Quoting Hewit, he says "there is no form of anesthesia at present known which is so devoid of danger as that which results from nitrous cxide when administered with a sufficient percentage of oxygen to prevent all asphyxial complications." No deaths have been reported following this method: "1. Nitrous oxide and oxygen (2 per cent). "2. Ether until complete anesthesia is obtained. "3. Nitrous oxide and oxygen (2 per cent), alternating with occasional doses of ether. "4. Oxygen gas for twenty minutes in anemic or debilitated patients or after protracted operations." Gordon falls into the error (Webster) of considering ether the safest anesthetic in use, and very properly makes a strong plea for the proper preparation of both mind and body of the patient. He sometimes gives a hypodermic of morphia and atropia-time not stated-to quiet nervousness and prevent bronchorrhea. "So much depends on the ability of the anesthetizer to inspire confidence that one person very easily controls where another fails entirely." He would employ none but the experienced, prefers a screen and lays stress on the choice of an inhaler. He employes the Mayo frame and the drop method. Peterson points out that we have been busily engaged in developing operative technique to the, at times, criminal neglect of minor details, and says this especially pertains to the administration of anesthetics. He traces much, if not all, of this lamentable state of affairs to faulty teaching, or the absence of teaching, of the student while in college, fully recognizing that many students have attended the required number of obstetrical cases and only learned that the child should be delivered through the vagina. He insists that the proper place to begin is with the undergraduate, and while all may not become competent anesthetists, still the general standard will be greatly improved. Peterson has sketched the following admirable plan for the college curriculum: "It was thought that instruction in the practical giving of anesthetics could best be combined with practical therapeutics, a subject which has sadly fallen by the wayside in the past twenty years in medical teaching. The idea is to make such an instructor a connecting link between the scientific branches of the first two years and the clinical branches of the last two years. He should be a well trained phar macologist, yet at the same time one who is well versed and has a liking for practical therapeutics and such a practical subject as the administration of anesthetics. He could arrange his courses in the latter subject so as to teach them both theoretically and practically. The student could be shown why, for example, the drop method of giving ether is safer and pleasanter for the patient. He could be taught variations of pulse and respiration under the anesthetic, the manner of resuscitation in case the patient collapses, and many other things which one must of necessity know if he is to be a good anesthetist. Some of the instruction would necessarily be class work, lectures or demonstrations before small classes. A good part of the work, however, would have to be individual teaching by an instructor and his assistants. In any medical school worthy of the name there would be an abundance of material for such a course. In a teaching hospital it need not interfere with the employment of a trained and paid anesthetist. In fact, it would be easier to secure the services of such a person because the position of anesthetist would almost immediately be placed on a far higher plane than exists today." Robb, in speaking of the trained or untrained anesthetist, says if he were going to be operated upon he would make three stipulations: (1) The best possible hospital facilities; (2) a skilled operator; (3) a skilled anesthetist," and very fairly asks why we should demand these conditions for ourselves and withhold them from our patients. He dwells at length upon the moral responsibility and the absolute necessity of a well trained anesthetist in dealing with surgical emergencies; of the criminally reckless practice of permitting a fledging to give ether to a patient who has met with an injury soon after taking a full meal, or to a patient with a damaged heart or faulty kidneys; and sketches a plan similar to the one quoted in the text of this abstract for the betterment of our present condition. Unfortunately, but few persons can acquire the art of giving a safe, sane anesthetic, and this regardless of teaching or experience. Like unto all highly specialized arts, it is a gift, not an acquirement. First, he must be able to concentrate his mind on a pin-point; second, he must be able to inspire absolute confidence; third, he must be a man of broad mental training, one who sees and comprehends quickly the general condition and fully recognizes the influence the drug he is giving is producing upon the patient from the time the first drop is inhaled to the tying of the last suture. He schould be an observing enthusiast who has sat at the elbow of a competent anesthetist during the etherizing of twenty or thirty patients before essaying the important task himself. He should work in conjunction with the surgeon, but never under him. He should aim to develop the best that is in him by discarding for all time rectal and other bizarre forms of anesthesia, and selecting one method-the dropin which to become as highly proficient as his mentality, surroundings and experience will permit.-Lancet Clinic. FLIES AND MOSQUITOS AS CARRIERS OF DISEASE. We are glad to note that the laity, as well as the profession, are commencing to realize the fact that flies and mosquitoes are not only exceedingly unpleasant companions, but each is also a serious menace to health. One of our Toronto papers, the Mail and Empire, recently published an article on the house fly, and stated (quite correctly) that an outbreak of typhoid fever in Trenton, N. J., was attributed to house flies. It has been known to the profession for some time that the fly carries typhoid germs, tubercle germs and other infectious bacteria, and distributes them over our food. We are told that one investigator found 100,000 bacteria on the legs of one fly. We are told by Dr. Lindley, in an address delivered by him before the National Conference of Charities and Correction at Richmond, Va., that Dr. Daniel D. Jackson says the common house fly causes 7,000 deaths annually in New York City. Our careful housekeepers have been in the habit for many years of fighting the fly in various ways. The old-fashioned fly paper is found to be of very little use. They depend largely now on the use of screens, and keeping their rooms as dark as possible. If the room is kept dark and small apertures are left the flies will leave the darker room for lighter quarters. We fight the mosquito in various was, but chiefly by screens, nets, smoke (smudge) and anointing our faces and hands with some oil preparation, but generally speaking, the mos quito beats us in the long run. It is somewhat remarkable that in a city like Toronto they are increasing rapidly, and we have no doubt that during last year our citizens, but especially young children, suffered more from this pest than for many long years before. The menace to delicate young children is very serious, and the poison from the mosquito sometimes causes death. We hope that the laity will soon learn that the important method of fighting these serious pests is the adoption of methods of prevention. The flies come from accumulations of filth, and the mosquitoes from foul, stagnant waters. Ordinary cleanliness about our premises and or dinary drainage of all ordinary pools will abolish house flies and mosquitoes.-Canadian Practitioner. PURE MILK. Sanitary instruction to the lay public has developed into one of the important duties of physicians, and especially of city and state health officers. Preventative medicine affords excellent opportunities for modern medicine to demonstrate the advantage scientific work has over such sects as Osteopaths, Christian Scientists, etc. The recent "Milk Show," held in Cincinnati, was a remarkable demonstration of the importance of good, clean milk, and of the methods of obtaining it free from dangerous contamination. Evans, in the Journal of the American Medical Association, June 5th, 1909, discusses in detail this exhibit, which was given under the auspices of the Milk Commission of the Academy of Medicine of Cincinnati, and may well be taken as a guide for other societies, and especially ours in Atlanta, in arous ing an interest in this matter. Although this commission is now entering only its third year of activity, it has just brought to a successful conclusion one of the most comprehensive edu cational attempts of this kind ever made by an American city in the crusade for the betterment of its milk supply. The civic organizations gave the committee hearty support from the start and twenty thousand people are said to have visited the exhibit in five days. Hundreds of dairymen also attended the sessions of the dairy institute, where addresses were made by many well-known authorities. "The underlying principle was the education of the consumer, as well as the producer, and that a better understanding between the two would make for an earlier solution of the problem of a clean milk supply." The committee provided a complete laboratory for bacteriological and chemical examination of milk, and made thorough examinations of the samples of milk submitted. As an object lesson to farmers' miniature dairy buildings were reproduced with every detail of construction. An annual national certified milk contest was encouraged by the Cincinnati milk show, and silver cups are offered by the American Association of Medical Milk Commissioners and by the Certified Milk Producers' Association of America. Implement manufacturers were allowed to exhibit modern dairy equipment which assists in making their business more profitable and their product more acceptable. "A better mutual understanding of the conditions between the producer, dealer and consumer, was the natural result. To those consumers who heard these discussions and to the far larger number who read about them in the newspaper reports of the meeting, was brought home the conviction that his inquiry should be, not 'How Cheap,' but 'How Good Is the Milk I Buy?"-Journal Record of Medicine. BETTER SALARIES FOR OFFICERS OF THE PUBLIC HEALTH AND MARINE HOSPITAL SERVICE. For several years the American Medical Association has advocated the establishment of a National Department of Public Health, and recently this movement has taken a more con crete form through the united efforts of that Association, the American Public Health Association and the Committee of One Hundred of the American Association for the Advancement of Science. No one who has given the subject serious thought doubts the necessity for such a department, but the problem is tremendously complicated by the lack of constitutional authority for federal interference with the health powers of the various states. There is at present a Bureau of Public Health which has proved its merit and ability in many a hard-fought battle with pestilential disease, notably in the New Orleans yellow fever epidemic of 1905 and the bubonic plague campaign which is now drawing to such a successful close in San Francisco. Until such time as the establishment of a great public health department can be brought about, these functions must be discharged by that Bureau, and it is, therefore, imperative that it be strengthened and assisted in every way if its efficiency is to be maintained at the standard which the preservation of the public health demands. The last session of congress closed without enacting a bill which had already passed the senate, placing the salaries of the officers of the United States Public Health and MarineHospital Service on a parity with those of the Army and Navy. Common justice to one hundred and thirty medical men demands the passage of this law. The founding of a national Department of Health is an affair of the future; this is a crying necessity of the present and should be placed before every congressman and his aid asked to the end that the men who are conducting the federal health work may receive what is their just due. If the medical profession will act collectively and individually, this may be secured.-Boston Medical & Surgical Journal. THE AFTER EFFECTS OF ANESTHETICS. There is no measure more important in its place than anesthesia, nor one that has been used so generally, and with both good and evil results. It is rapidly becoming the common belief that the administration of anesthetics should only be conducted by experts; by those who realize the constant danger in every case, |