may be absent and the fever may not be marked until after the patient has become overwhelmed with the septic ptomaines. The pulse, which at first is not much quickened, increases in rapidity and decreases in volume as the fever rises; the respirations are shallow and rapid; the urine shows an increasing amount of albumin, nausea and vomiting sets in, the patient has a very anxious expression of countenance, his face becomes pale, he grows very restless, delirium appears, and in short he has all the symptoms of acute virulent sepsis. Pain in the injured part is frequently not severe at first, but as the disease advances and the affected part becomes more and more edematous, it increases and becomes quite excruciating. Soon after receiving the injury a slight edema appears, and the skin changes its color to a dusky brown hue, somewhat the color of a rind of bacon, due to the extravasated hemoglobin, and there are streaks of a dark greenish yellow color extending up the limb. The rapidity with which these changes takes place is a marked characteristic of this disease; it travels hour by hour and within a day or two from its onset has involved the whole limb. The swelling increases rapidly and blebs or bullae filled with a dark straw colored fluid form beneath the epidermis, and the superficial veins of the limb, especially those on the inner side, stand out in bold relief, showing a very distinct and irregular smoky greenish color of the skin between them; gaseous emphysema emphysema caused by putrefactive bacteria appears and gives a crackling feeling to the tissues beneath the skin; putrefaction advances rapidly along the lymphatics, the tendon sheathes the connective tissue spaces and beneath the fasciae, and if not promptly arrested by high amputation these chemical poisons get into the patient's general circulation, and he soon dies from the invasion of the septic ptomaines. In this form of gangrene, nature seems to be utterly unable to cope with the invading poison, therefore no line of demarcation is perceivable, and to wait for its appearance is to invite death. The wound is usually of an ashen gray indolent appearance with no tendency to heal, and if the limb be cut into a greenish purulent serum, with no tendency to localization comes from every direction. It is a mistake to think that gangrenous parts do not bleed freely when incised. The diagnosis of this form of gangrene is usually not very hard to make, especially in its advanced stages. Some or all of the above symptoms outlined are easily recognized; the crackling of the skin on palpation, the dusky brown hue to the integument with no line of demarcation apparent, and the rapid advances of the disease are pathognomcnic. The early recognition of the disease is quite essential to its successful treatment. Death is the usual result in from 70 to 80 per cent of all patients so afflicted, and more than 90 per cent of those who do not die are compelled to undergo high amputation of the affected limbs to save life. Statistics on this form of the disease are scarce. C. P. Gildersleeve (Medical Record, March 4, 1899) reports a series of sixteen cases in which the bacillus aerogenes capsulatus was found; there were twelve deaths, a mortality of 75 per cent. This may be considered an average mortality in this frightful malady, even since the time of antiseptics, since which time the disease is not so frequent as formerly; therefore, prophylaxis by means of thorough surgical cleanliness is the first indication in treatment. All authors advise prompt and high amputations above the edematous zone as soon as the disease is recognized; the arm should be taken off at or near the shoulder joint and the lower extremity high up in the thigh. We should always go high enough, if possible, to avoid tissues that are swollen and filled with the greenish brown serum above alluded to. No sutures whatever should be put in the flaps, which are to be left wide open to be dressed at frequent intervals with hot antiseptic (preferably bichloride) solutions until the soft tis sues become healthy. It is needless to state that such operations should be done with dispatch, and everything done to sustain the patient already overwhelmed with septic ptomaines. Dr. Van Buren Knott (Jour. A. M. A., April 11, 1903) practices somewhat a novel procedure in these cases; he estimates as nearly as possible the line between the healthy and diseased tissues, and after thoroughly cleansing the limb and wrapping the gangrenous parts in sterile towels, amputates circulary all the soft tissues and bone at the same level, taking particular care to ligate every bleeding vessel without including any perivascular tissue in the bite of the forceps or ligature. The wound is left absolutely open-not using a single suture-and dressed with gauze saturated in hot saline solution, which dressings are changed from two to four times a day. After a week or ten days if the wound is clean, and the patient's condition is good the flaps, already outlined, are dissected up, the remaining soft tissues cut, and the bone sawed off at the proper level. The advantages claimed for this procedure are that the gangrenous tissues are speedily removed from the enfeebled patient rapidly and with little shock, free drainage is provided, allowing an interval in which to build up the patient, and the limb is ampu tated at the lowest point consistent with safety. I have never tried this method, but it seems rational and worthy of consideration. In a few early cases in which the infection is limited free incisions of the afflicted part and afterwards keeping the limb in a continuous hot boric acid or saline, both may arrest the disease; but we should be always on the lookout and ready to amputate promptly. A few hours delay in this form of gangrene may mean the loss of a life. After operation, we should, of course, be very careful to stimulate the patient with alcohol and strychnine, provide good nourishment as soon as he is able to take it, and above all see that the stump of the limb is dressed often so as to keep it clean and provide as free drainage as possible. My two cases were are follows: CASE I.-W. P., male, age 35, foreman of a railroad construction gang, on March 29, 1904, dropped a pistol from his pocket, and the fall caused the weapon to explode, the ball entering the fleshy part of the calf of the right leg on the inner side four inches below the knee, passing through the limb behind the bones which were not injured, and coming out two inches higher on the outer surface. The patient, not believing that his injuries were dangerous, remanied in his car out on the road two days and continued to superintend the work from his bunk; at the end of that time he came to St. Vincent's Hospital and was admitted at 9 p.m., on March 31. His condition was fairly good with a tem. perature of 99 deg. and a pulse of 96. The wounds of entrance and exit looked healthy, the circulation in the part was good, there was very little swelling of the limb, but patient complained of great pain in the leg. His injuries were dressed antiseptically and patient put to bed with instructions to night nurse to give a quarter of a grain of morphine hypodermically to ease pain. He had a fairly good night, but next morning the limb was more swollen and circulation was not so good, pulse and temperature about same as evening before. Hot applications were applied and frequently changed for the next twenty-four hours, at the end of which time the pain had increased, pulse gone to 120 and temperature to 102 deg. F., and marked gangrene had made its appearance. I advised immediate amputation. Patient's mother declined this until her family physician, Dr. E. M. Robinson, saw him. It was three hours before the consultation was held, at the end of which the thigh was amputated rapidly at the junction of the middle and upper third; 1000 c. c. of hot saline solu tion was given intravenously just at the close of the operation; patient's condition was so bad he died at 6:00 p.m., just forty-five hours after his admission to the hospital, and six hours after operation. CASE II.-W. M. D., male, age 47, a railroad brakeman, fell from the top of a boxcar on June 30, 1904, about 11 o'clock p.m., and sustained a compound fracture of the left radius, near the wrist. He was admitted to St. Vincent's Hospital at 6 o'clock next morning, July 1st; put under chloroform, wound examined and as thoroughly cleansed as possible, and dressed antiseptiThe circulation in the cally on a splint. hand was good and he did very well until the fifth day, when evidences of sepsis set in about the hand, which was freely incised and dressed in hot bichloride gauze; on the morning of the sixth day the hand looked a little better, but during the next twenty-four hours his pulse ran up to 116 and the temperature to 104 deg. F. The skin on the arm now began to show the dusky brown color which was spreading rapidly toward the shoulder, crepitation in the cellular tissues could be felt, the patient was flighty, and gangrene was evident. I advised im. sired to wait until her family physician, Dr. mediate amputation, but patient's wife deJohn A. Moore, could see her husband. The consultation was held four hours later, during which time patient had grown rapidly worse, and at 1 p. m., July 7, 1904, I amputated the arm near the shoulder. Patient was under the ether just fifteen minutes and 1000 c.c. of hot normal salt solution was given subcutaneously during the operation. The stump was left wide open, and dressed with hot bichloride gauze, which was changed twice daily for ten days. His condition was very precarious for two or three About this time a days after which he began to show some signs of improvement. large pectoral abscess, caused from the salt solution, developed and complicated matters considerably, this was opened with cocaine anesthesia, and after a long and stormy convalescence he made a good recovery. 2218 7th avenue. TUBERCULOSIS, SOCIALLY AND FINANCIALLY.* C. A. BOICE, M. D. WASHINGTON, IA. WE are told the story of a gentleman who while traveling in Turkey, made inquiries of his guide concerning the population and industries of the various cities through which they passed. The guide informed him that it was difficult to answer his questions, and that the knowledge was useless any way. The proper study of the ravages of the great white plague necessitates very much. work in the collection of statistics. The work is difficult, but it is by no means useless. It is invaluable. During the past summer we have witnessed the general excitement which always prevails when a virulent epidemic visits our country. A few hundred cases of yellow fever occurred in a Southern state, with a few score deaths. The whole country was intensely interested, some men in official position lost much valuable time in jealous wrangling when they should have stood shoulder to shoulder against the "yellow peril. Yellow fever is but an occasional visitcr to our country, and its ravages extend over but a limited area; while consumption is present at all times and in all places. Consumption is carrying away to an untimely grave in this country every year 110,000 victims, 3,000 every twenty-four hours, two every minute, and no very great excitement prevails. Why? "Whilst meagre phthisis gives a silent blow, That we may know how and when to act, we must learn the social and financial importance of the captain of the men of death. The struggle with tuberculosis is intensely bound up with the solutions of the most complex economic problems, and no plans will be complete which do not have for their basis the material and moral improvement of the people. The struggle with tuberculosis demands the mobilization of the social forces. -public and private, ocial and voluntary; and the man behind the gun is the general practitioner who shall, lead and guide and direct in the universal campaign. Osler says that it is not necessary to awaken the public. The public is already awake and. sitting on the edge of the bed, awaiting further orders. An old heathen superstition, "That Read before the Henry County (Iowa) Medical Society, August 10, 1905. plagues and pestilences were expressions of a merciful provision on the part of Providence to lessen the burthen of the poor man's family, and that it was impious and profane to wrest from the hands of the Almighty these divine dispensations." There are some believers in that old superstition living yet. Lord Beaconsfield said that "the public health is the foundation upon which reposes the happiness of the people and the power of the state, and that the first duty of the statesman is the care of the public health." We are only sorry that our present day statesmen do not see their first duty in the proper light. Ten per cent of our total death-rate is due to tubercular diseases. "Consumption is the most feared, the most prevalent, the most fatal of diseases. Other diseases have caused more dismay, more panic and occasionally, for short periods, even more destruction, but consumption has been the most constant and the most pestilential of all, the worst scourge of mankind." Every community has many cases, rare is the family which is not directly interested. No age, nor race, no condition in life or lo cation of home is exempt. "The continued activity of the prevalence of this disease is a reflection on the civilization in which we live." Men show a greater mortality rate than do women, 10.7% of all deaths in men are due to tuberculosis, 10.3% in women. The greatest mortality among men occurs between the ages of twenty-five and thirty-four. Thirty-three per cent of all deaths in men between the ages of twenty and thirty are from preventa. ble diseases. Women show the greatest mortality rate between the ages of fifteen and twenty-four. Tuberculosis of bones and joints and of the glandular system occurs with greatest frequency in childhood during the milk period of life. The great prevalence of these forms of tuberculosis at this time of life calls for a more careful and thorough study of the disease as it occurs in the source of our meat and milk supply Tuberculosis is widespread among all the lower animals-cattle, hogs, horses, chicken, and all wild animals in captivity are affected. Of the domesticated animals, those which are the basis of our food supply show the greatest predisposition. In some countries (Denmark, Belgium, Germany, England) 2 or 3 per cent of the hogs, 25 to 33 per cent of the beef cattle and 50% of the milch cattle are tubercular. In the United States as a whole, the per cent of milch cows affected is about five (Minnesota 7%), but when left to itself, the disease increases so rapidly that it is not an unusual thing to find milch herds where from 50 to 90 per cent are tubercular. In the interval between 1895 and 1901, the Bureau of Animal Industry examined the carcasses of 30,000,000 beef cattle and of 120,000,000 hogs. In 1895 the condemnation of cattle carcasses for tuberculosis was 407.4 per million; in 1901 this had increased to 1285.6 per million, a gain of over 300%. In 1896 the condemnation of hog carcasses was 29.5 per million; in 1901 the number had arisen to 352.8 per million, an increase of over 1200%. Some portion of this increase is undoubtedly due to a more careful inspection, but the fact remains that tuberculosis among our domestic animals is on the increase, and at a very rapid rate. In 1901, at the Chicago stock yards, 4,000 hog carcasses were condemned; in 1904 the number was 14,000. Ninety per cent of these diseased hogs came from the dairy districts of Iowa, Minnesota and Wisconsin. These hogs were fattened on the buttermilk from the creameries. Iowa has 600 creameries. In Massachusetts, from 1856 to 1895, the deaths from tuberculosis (other than pulmonary) have increased 36%, while the general mortality from consumption has decreased 45%. This means that the disease is on the increase in those animals which serve as the basis of our food supply, and that unless more care is exercised in the selection and care of our dairy herds our boasted sanitary measures will come to naught. That it is possible to contract tuberculosis. from the milk and meat of diseased animals, there can be no doubt. Clinical evidence is overwhelming in support of the contention. In Michigan, where vital statistics are reliable, in children under five years of age there averaged from 1885 to 1897, 104.3 deaths from tuberculosis not affecting the lungs to every 100 deaths from the pulmonary form. In the period from 1898 to 1900 the ratio had increased to 263.3 to 100. Why this tremendous increase in the mortality from other forms of tuberculosis as compared with consumption at what has well been called the milk-drinking age of life? A recent epidemic of sickness among the students of the U. S. Naval Academy caused an investigation of the milk supply to be made, with the result that thirty-six out of the herd of sixty-two milch cows were found to be tubercular. One tubercular animal in a herd is like a rotten apple in a barrel of good ones-it is not long until the entire herd is diseased, then if some of the animals be sold, the infection is carried to other herds. Tuberculosis affects hogs almost exclusively through the intestinal tract- hogs are scavengers. Very rarely is the muscular tissue the seat of this disease. Cattle usually show the infection in the lungs, glandular system and udder; hence, the spreading of the disease through the meat and milk is inevitable. It is a question which deserves far greater attention than it is receiving. In 1900 the average age of all dying (except those under fifteen) was 52.8 years; of those dying from consumption the average age at death was 37.4 years. At this age the normal after-life time is thirty-two years, so that the real loss of life covered-measured in time-is represented by 3,520,000 years annually. Death is most common in young men and women at ages when they are just beginning to repay the commonwealth the expenses of education. Again, tuberculosis is more fatal among married people than single, seeming to bear out the statement of Robert Louis Stevenson, "that marriage is a field of battle and not a bed of roses." The mortality from tuberculosis is, therefore, a problem compared with which all other social problems of a medical character sink into insignificance; and it is safe to say that the possible prevention of a large portion of the mortality of this disease is justly deserving of the solicitude, the active personal interest and liberal pecuniary support of all who have the real welfare of the people at heart. Race. The influence of race on any social phenomenon is hopelessly obscured by the historical accidents of conquest and migration. We almost feel the truth of the saying, "we need not deny that blood tells, but we must not be prematurely certain that we can hear what it tells, or that we can distinguish the voice of the particular blood that speaks." The registration area of the United States includes 38% of the population, and the reports collected therefrom are a fair representation for the whole country. Statistics show that the colored races (Africans, Indians, Chinese and Japanese) have a general mortality rate of 70% in excess of that for the white race; while the tubercular mortality exceeds that of the whites by over 300%. These colored races show great tendencies to crowd together in dirty tenements. The ignorance and carelessness of such peoples provides an ever ready field for the infecting organisms. The death rate among white children (under fifteen years of age) is 31.8 per 100,000; among colored children the rate is 246 per 100,000. Total colored mortality rate (ages fifteen to forty-four) is 587.4 Occupation.-A list has been compiled of fifty-three different occupations. Marble and stone-cutters head the list with a rate of 540.5 per 100,000 engaged in that work. Tobacco workers hold second place, physicians and surgeons rank fortieth, with a rate of 168.8; clergymen rank fiftieth and bankers fifty-third-the healthiest of all42.8 per 100,000. Condition in Iowa.-Iowa is essentially an agricultural or rural community. We have only one city with a population in excess of 50,000. Only 16.8% of our people live in cities of over 8,000 inhabitants. Men constitute 51.8% of the city population. We have no crowded tenements; no filthy breeding places of epidemics. Our population is 2,231,853, and we have tuberculosis-lots of it. The Board of Control, from fairly reliable statistics, credits the state with 10,000 cases of tuberculosis and a yearly mortality of about 2,000. Iowa's mortality rate from this one disease is 7.05% of all deaths. Fortythree of the states exceed us, and we exceed five-Idaho, Wyoming, Indian Territory, New Mexico and Utah. California leads the Union with a rate of 15.46%. The average length of life after the onset of the disease is two and one-half years. We certainly have cause for congratulating ourselves, not for anything which we have done, but for our natural advantanges, but we have room for improvement. Pasteur said that "It is in the power of man to cause all parasitic diseases to disappear from the world." In New York City very reliable statistics have been kept since 1885. At that time the annual tuberculosis mortality was 8,000. The mortality remains the same while the population has doubled in the past twenty years. Preventive measures are saving for that city 8,000 lives yearly, still the city is losing $23,000,000 annually on account of the plague. Mortality from consumption decreased 46% from 1800 to 1900. "We must care for the consumptive in the right place, in the right way, and at the right time until he is cured; instead of as now, in the wrong place, in the wrong way, and at the wrong time until he is dead.” The following facts must be told again and again: 1. Tuberculosis is infectious. 2 Tuberculosis is preventable. 3. Tuberculosis is curable in from 80 to 90% of the cases when diagnosed early and treated correctly. The treatment of tuberculosis has for its basic principle, rest, food and fresh air, all other lines of treatment are but supplementary to these. Financial Importance.-Maryland statisticians estimate the average individual loss for every wage earning male dying with tuberculosis at $741.64; and the potential loss to the community for such death at $8512.52. Dr. Homer Thomas, of Chicago, has estimated as follows for Illinois: Money loss in education of those who die before the age of twenty, $1,187,800; loss from inability to perform manual labor on the part of those sick, $30,000,000; loss in savings of those who die before the end of the producing age, $5,139,000; and cost of sickness, $225,000, a total for the state of $36,551,000 a year. Illinois has about 7,000 deaths in a population of almost 5,000,000. Iowa's death rate of 2,000 is two-sevenths that of Illinois. At the same ratio, our annual loss for this leader of the preventable, and therefore unnecessary, diseases is $10,443, 142. For the United States in the same proportion, the average yearly contribution to ignorance and slothfulness totals the enormous sum of $574,385,420; nearly $8.00 for every man, woman and child; more than one-half the value of the entire corn crop, $952, 868,000. Signs of Progress.-Massachusetts, New York, Pennsylvania, Indiana, Illinois, New Hampshire and Iowa have State Societies for the Study and Prevention of Tuberculosis. These societies will accomplish great good in the systematic study of the disease as it is, and in the scientific presentation of the learned facts. The working rule of the average statesman would seem to have been, "millions for tribute, but not one cent for defense," but with the information gathered by these societies we have no doubt but that Daniel Webster's famous remark will find a more widespread application. Masaschusetts and Pennsylvania now have State sanatoria, and without doubt Iowa and Illinois will soon be in line. These states have found that the money expended for sanatoria has been returned many fold, in increased health and happiness of the people. |