had taken the turn of recrimination of the physician against the surgeon. We know that the gentleman indicated is a skillful, conscientious surgeon, and Dr. Adams felt sure that if the surgeon would not operate upon Dr. Lochboehler's patient at home, conditions were such that he would not have operated at a hospital. As regards the diagnosis in this case, subsequent hemorrhage did not by any means indicate perforation. As for himself, if one of his patients showed signs of perforation and recovered without operation, he would conclude that no perforation had occurred. Dr. Lochboehler was unfortunate in not hearing Dr. Vaughan's paper on perforation with operation, with a very creditable proportion of recoveries. The surgeon who had been mentioned should be present to reply to this probably unintentional criticism. Dr. Adams believes that the Washington surgeons are always ready to operate when and where they believe it to be their duty to operate.

Dr. Vaughan wished to congratulate Dr. White upon his successful case. Some might doubt the diagnosis in this instance; he did not. The first successful case of laparotomy for typhoid perforation was that of the late lamented von Mikulicz, and it was very similar to that reported by Dr. White—an ambulant case. The patient was up and about, had just eaten a hearty meal when he was taken ill; von Mikulicz watched him for 72 hours, then on opening the abdomen, the perforation was found and closed. The patient got well. A paper by Hart and Ashhurst in Transactions of the American Surgical Association for 1903 gives a table of 362 cases with a mortality of 75 per cent. He felt somewhat chagrined that after all the trouble he had taken to report his cases Dr. Lochboehler had never heard of his ten cases with four recoveries, all in this city.

Dr. White, in closing the discussion, said that at least one case of typhoid perforation has recovered spontaneously; it was discovered after death from some other disease; the omentum had become adherent over the perforation, and had saved the patient's life. The value of surgical intervention is indicated by the fact that a very large percentage of the typhoid mortality is due to perforation if from 30 per cent. to 40 per cent. of these may be saved by laparotomy, the total typhoid death rate will be very materially reduced.

A PARTIAL REVIEW OF INTERNAL MEDICINE.*

BY C. NORMAN HOWARD, M. D.,

Washington, D. C.

When the field of internal medicine is so alive with facts, when they are coming upon us from all parts of the world, when each investigator is throwing his quota into the arena and going back for more, it is indeed a complex mass from which the physician is to choose in the actual treatment of the sick.

There will be no attempt to even itemize this wealth of material in a short paper, for it would at best degenerate into simply not only an index but an incomplete index.

It is more important that there may be brought before the Society for discussion the trend of medicine along certain lines.

The first of these to be noted is the changing attitude of the profession toward germ diseases. It will be remembered that micro-organisms were first noticed in 1632, their probable relation to disease pointed out in 1762, and the theory subsequently enlarged upon by many men for many years. Finally, a physicist, a biologist and a physician (working each in his chosen sphere) made the germ theory of disease so plain that the medical profession has adopted it almost without question and been guided by it for the last twenty-five years.

The desire to indiscriminately kill the germs gradually subsided as increasing knowledge showed the fruitlessness of such attempts, and still broader knowledge proved that the vast majority of them are not our enemies; while a multitude even render service to us, the most striking being that of reducing organic matter to carbonic acid, ammonia and water. They are thus at the same time rendering even a greater blessing to the vegetable kingdom. Whether this dead organic matter lies sprawling on the face of the earth or is borne up by the waters of the river, sea or pool, or floats as effluvia in the air, these saprophytes do their work as the scavengers of the world.

With the above knowledge we more calmly now face the fact that our body is covered with germs-the staphylococcus epidermidis albus being, for instance, practically a constant inhabitant. There are so many germs and so well lodged that it is claimed by

*Read before the Medical Society, November 21, 1906.

many that the hands can never be made absolutely sterile. When we further consider that there are on the average about 2,400,000 openings, each one many times the size of a micro-organism, leading down from the surface of the body into the sweat glands (not to mention the sebaceous ducts), it is perhaps not unreasonable to suppose that these minute bodies can gain entrance to the blood. In addition to these are the ones accompanying the food. Milk alone, for example, is considered pure if it has but 10,000 bacteria to the cubic centimeter. When we take a glass of good, pure, wholesome milk we get about 3,000,ooo germs, and if it is not procured with strict cleanliness we get about ten times as many. When they are well into the body they find other germs there, such as the colon bacillus, with a squatter's claim to the intestines. There are an abundance of micro-organisms in the mouths of the healthy. In fact the total number is so great and at least one of the varieties so constant that the finding of the streptococcus brevis1 is considered almost as delicate a test for saliva as the finding of the colon bacillus is for the presence of fecal matter.

It has gradually dawned upon the profession that there is decidedly something more necessary than the mere presence of the germs in order that they shall produce disease. It is con

clusively shown that this must be the case when we find the germs of specific diseases such as the diphtheria bacillus, the bacillus of influenza and the pneumococcus in the mouths of healthy persons.

War against the disease-producing germs has not subsided, but of late we have laid more stress on strengthening the fortress than on attacking the enemy.

Sixteen years ago Behring wrote of serum therapy. We know now how through the application of this principle the mortality from diphtheria has been cut at least in half. The same principle has been applied in the treatment of tetanus, hay fever, pneumonia, scarlet fever, streptococcic infection, tuberculosis, typhoid fever and poisoning from snakes. The underlying theory, as we all know, is to give specific reinforcements to the antitoxins of our own blood.

None other of the sera has attained the high efficiency of that used in diphtheria.

Antitetanic serum seems to be now regarded as of decided value in prophylactic treatment.

The treatment of hay fever by the Dunbar "Pollantin" has been only partially successful.

The serum for pneumonia has not made many friends, although some few men have advised it.

The Germans have been using a serum for scarlet fever, but with indifferent results.

Erysipelas has been beneficially treated by injections of antistreptococcus serum; and favorable reports have been made upon the giving of this serum early in the treatment when a general streptococcic infection is feared.

Tuberculosis sera are being praised in some quarters, but there has been no general adoption of them.

Antityphoid serum has not received very much attention in this country; but in Paris, Chantemesse has had fairly good success with it, keeping his mortality down to 4 per cent. in a series of 765 cases, while the lowest typhoid mortality at other Parisian hospitals during the same time was 12.8 per cent.

Calmette has produced a serum which is of value in the treatment of cobra poisoning.

Noguchi has brought forward an experimental anticrotalus serum which has remarkably good effects when given to animals poisoned by rattlesnakes. Crotalus, it might be mentioned in passing, is the name given to a genus of poisonous snakes, including the rattlesnakes.

All the sera are seen to the best advantage when given so early that they practically act as prophylactics.

The entire object of the sera is to give aid to our natural forces-not as a shotgun tonic, not as a heart stimulant, but by actually supplying that which is needed.

A further step in the same direction has lately been advocated by Sir Almroth E. Wright, in which the blood is induced, through vaccines, to produce an increased quantity of antitoxic substances with which to combat infection. Dr. Wright has recently told us of his interesting work in some detail. By this method we become self-creative of the things we need, instead of borrowing from animals.

It would seem, then, that the production of antitoxic substances within our own body was a most happy and rational outlook along the lines of treatment of bacterial diseases.

However, because means have been devised for strengthening

the fortress, that does not mean an invitation to the germs of disease to increase without hindrance, for we have still the same obligations to fulfill in keeping down, as far as possible, through private and health-office methods, the spread and growth of the enemy.

In organotherapy we see again the effort to supply the body with its own essential elements; an effort to give directly the things which are lacking, the lack of which has brought normal tissues into the realm of pathology.

Claude Bernard, poet and French physiologist, first advanced the idea of internal secretions. His contemporary, Brown-Séquard, who outlived Bernard by sixteen years, dying but twelve years ago, forced the theory upon the medical mind through his work upon the extract of the testes. Brown-Séquard believed that these organs have an internal secretion which acts as a physiological tonic. Further experiments have partially but not definitely established his belief beyond question.

Since he began his work other organs have been under experimentation, with the result that to-day the thyroid gland is considered a specific in the treatment of myxedema and cretinism.

The use of the suprarenal bodies in Addison's disease has not met with the same success. It has a greater reputation through its internal secretion being able to locally constrict blood vessels, and, when given systemically, to raise blood pressure.

There is believed to be an internal secretion of the kidney itself with a vaso-motor function.

The enzymes in the external secretion of the pancreas have been administered for some time as an aid to digestion-another instance of supplying an actual bodily deficiency. Lately, however, an extract has been made of the entire organ, with a view to giving in medication not only its enzymes, but also utilizing an internal secretion, which was first brought to the attention of the medical world in 1889 by von Mehring and Minkowski; its function is the regulation of the consumption of sugar in the body. The internal secretion of the pituitary body is in some respects similar to that of the suprarenal bodies.

Those who have seen the distressing mental and physical symptoms which have come upon the women who have sustained a double oophorectomy, must surely have wondered whether in