5. The Heavy Metal group of germicides includes mercury, silver, lead, copper and bismuth. The meal salts act on bacteria by combining with the proteid to form albuminates or similar compounds in much the same way that silver nitrate reacts on hydrochloric acid to form silver chlorid. At the same time that the metal albuminate is formed, acid is set free though not in all cases in a quantitative ratio. The most used germicide of this group is mercury. Mercury, such as mercuric chlorid, when acting as a germicide forms a precipitate which is absolutely fixed in the bacterium. In all cases, the bactericidal action of mercuric chlorid is due to the mercuric ion since after its action all the chlorid is set free. In fact, all members of this group owe their activity to the presence of the ions and not to the undissociated salt. The activity of calomel is due to its conversion to bichlorid of mercury. Sodium chlorid or potassium iodid enormously increase the conversion of calomel into soluble mercuric chlorid and thus cause mercury poisoning.11 Silver salts are of the same degree of activity as mercuric salts but have a restriction in that their germicidal action is neutralized by chlorids almost completely, whereas mercuric chlorid is only slightly restricted by chlorids. 6. The Physical Agents which exert bactericidal action are heat, sunlight, electrolysis, ultra violet rays and mechanical removal as by soap and water. Sunlight, heat and ultra violet rays in all probability act on bacteria by coagulation of the bacterial proteids. Soap and water act by the mechanical removal of the bacteria since it has been shown that soap in itself has practically no germicidal value.12 Electrolysis acts by the generation of molecular chlorin or similar oxidizing agent at the anode and caustic soda at the cathode. In view of the very wide variation in the chemical properties of antiseptics and disinfectants and the consequent variation in the mechanism of their action, it becomes necessary to use great precaution in adopting a method of testing for the efficiency of individual bacterial agents. The first real method which proved of value in recognizing the worth of disinfectants is the Rideal-Walker method, which has been in use for some time in England and Europe. On account of certain defects in this method, it was modified to become known as the Lancet method. Investigation by the Hygienic Laboratory established the liability of considerable error in the Lancet method and it has proposed a method based on 11. W. Ostwald, Principles of Inorganic Chem. (1902), p. 669. 12. Pilod, Seifen sieder Ztg., 39, 1389. the Lancet method but improved in many respects.13 In brief, the test is performed as follows: One-tenth c.c. of twenty-four-hour broth culture of the typhoid bacillus is added to 5 c.c. of the diluted germicide in a sterile test-tube and at a temperature of 20 C. At intervals of 22, 5, 72, 10, 121⁄2 and 15 minutes, a loopful (4 mm. loop) of the antiseptic, to which the bacteria were added, is transferred to 10 c.c. of standard broth and incubated at 37 C. for twenty-four hours. If growth takes place that particular dilution in the time exposed is not sufficient to kill the bacteria. If growth does not take place, the dilution kills. At the same time that the tube with the diluted germicide is tested, a test is made using carbolic acid under exactly the same conditions. The ratio of the killing power of the germicide to that of the carbolic acid is known as the phenol coefficient. This coefficient is arrived at by dividing the highest dilution of the germicide in question which will just kill the typhoid bacteria in 21⁄2 minutes by the highest dilution of carbolic acid. The same calculation is made for the 15-minute period and the average of the two is the "Hygienic Laboratory phenol coefficient." The following table will illustrate how this is accomplished. The objections to this method of determining the germicidal coefficient are as follows: (1) An insufficient number of dilutions are made for any single time period so that the error as may be seen in the above table can easily be 20 per cent. from that cause alone. Some of the time intervals may be sacrificed for additional dilutions. (2) The test is not a fair comparative test of some germicides because of the presence of excessive organic matter from the broth culture used. The peptone and meat extract in this broth culture would possibly consume some germicides without reacting in any way with 13. Anderson & McClintic, Hygienic Laboratory Bulletin No. 82. the others. In other words, a method which practically completely excludes organic matter except the bacterium used is desirable. To obviate this difficulty, a method has been commercially and successfully used, whereby instead of a broth culture of typhoid bacilli, a distilled water emulsion of a twenty-fourhour colony grown on an agar slant and standardized is used. (3) No provision is made for the proper mixing of the bacterial emulsion with the diluted germicide. The seeding tubes containing the diluted germicide may be provided with sterile stoppers so that the bacterial emulsion may be uniformly and thoroughly mixed with the germicide. (4) The test is too complicated for commercial purposes particularly in necessitating the employment of unnecessary time tests of 5, 72, 10 and 121⁄2 minutes. A complete test on an unknown germicide would require the use of at least 150 tubes and the technic is entirely too difficult under such conditions, and the time required too great. •(5) No advantage is to be gained by using more than one time period for exposure of the bacteria to the germicide inasmuch as any method must be largely arbitrary. Rapidity of germicidal action is not measure of ultimate germicidal action and a long but practical time of exposure should be chosen. Furthermore, the 22 minute period makes the technic more difficult. A thirty-minute period is about right for easy technic and economy of time. The method outlined below seeks to overcome the above named objections and makes the technic quite simple and within the reach of more laboratory workers. PROCEDURE Thirty tubes 5% inch by 5 inches and provided with tight stoppers are sterilized by steam or hot air and placed in a test-tube rack. The amount of 1 per cent. solution of germicide and of sterile water indicated by the table is run into the tubes from a standardized buret. The tubes are stoppered, shaken and allowed to stand over night. Thirty tubes of clear standard broth are prepared and numbered in accordance with table. A twenty-four-hour growth of Bacillus typhosus on a standard plain agar slant is removed to a sterile vial with sterile distilled water, thoroughly shaken and filtered through a sterile filter (or centrifuged) and diluted to standard of 1,000 million per cubic centimeter. Three-hundredths c.c. of this emulsion is added to each tube of diluted germicide in accordance with time schedule and the tube is is the phenol coefficient. In case the coefficient is greater than 2, a repetition of the test may be made for more accurate results with many dilutions in the region the coefficient is now known to be. A method of standardizing involving the determination of the percentage of bacteria killed by different dilutions of the germicide has been suggested and is worthy of consideration but can hardly be as satisfactory as the Hygienic Laboratory method or of one of its type.14, 15 1013 Grand Avenue. OTHER REFERENCES Reichel, Biochem. Z. 22, 149-231 (C. A. 4, 486). Ottolenghi, Disinfection 3, No. 2 (C. A. 4, 2344). Eisenberg & Okolska, Centr. Bakt. Parasitenk I Abt. 69, 312 (C. A. 7, 3140). Croner, Centr. Bakt. Parasitenk I Abt. 61, 75 (C. A. 7, 2591). Chick, 8th Int. Congress Appl. Chem., 26, 167. Hale, Am. J. Pub. Health, 3, 46 (C. A. 7, 1919). Jordan, British Medical Journal, Sept. 13, 11 No. 2750, pp. 641-712 (J. A. M. A., 61, 1406). The definition itself presupposes looseness. Both spleen and kidney have a normal degree of movability within certain limits. This is not implied when we say floating kidney or wandering spleen. When a spleen forms a pedicle of peritoneum around its blood-vessels which permits it to fall from under the ribs to the iliac fossa, or indeed to any other region in the abdominal cavity as often happens, according to the position assumed by the patient, it is abnormally loose and produces symptoms. The same 14. Druper & Lewis, Jour. of Industrial & Engr. Chem., 6, 198 (March, 1914). 15. E. B. Phelps, J. Infect. Dis., 8, 27. * Read before Southeast Missouri Medical Association, Oran, Mo., May 6, 1914. may be said of a movable kidney. In the case of the spleen, this abnormal condition is usually brought about by an abnormal increase in weight caused by different pathological conditions. In this climate a common source of enlargement is chronic malarial infection. Since we have discovered that the festive mosquito is the peddler and inoculator of malaria and have learned to protect ourselves against him and destroy his breeding places, medical men do not see one case of hypertrophied spleen where they formerly saw a score. The other forms of splenic disease are more rare. The movable kidney is caused by a different condition. It is much more common in women than men, and is due largely to certain types of physical conformation of the body; but tight lacing and tight belts, to which are suspended heavy, wearing apparel, supply the principal causative element. Active physical exercise under tight belts counts for an etiological factor in movable kidney in men. The dragging weight on the vessels and nerves and the twisting and kinking sometimes produced in the pedicle of a loose spleen or kidney are sources of distress when the patient is erect and active and sometimes of excruciating pain. To relieve this source of invalidism has taxed the ingenuity of the surgeon. One remedy for floating spleen is excision splenectomy; but this treatment has a mortality of perhaps 7 per cent. Nothing is so appalling to the surgeon as mortality. The spleen is not necessary to life nor health. This fact is settled to the satisfaction of physiologists, therapeutists and surgeons. Its function is not understood even in these days of boasted wisdom and scientific acumen. Several theories have been advanced and defended, but none of them are supported by satisfactory evidence. Some physiologists believe that the spleen serves an important function in manufacturing bloodcells. Others argue that its principal activity is the destruction of cast-off red cells; but the thing is proved satisfactorily and that is that a evidence they offer is not convincing. One degree of anemia follows extirpation of the spleen and attains its maximum in two weeks to two months, after which the blood state gradually returns to normal. Relative to the more satisfactory. kidneys our knowledge is These organs are necessary to health and life. Their function of excretion, of sewerage, is well understood. One kidney may be destroyed or removed and the other will take up its work and preserve health. I have patients from whom I have removed one kidney and they have been transferred from a state of invalidism to health. This operation which we call nephrectomy, while not extremely dangerous of itself, must be approached with caution. The other kidney may be absent or diseased or may become diseased or destroyed by injury. We cannot give up the function of both and remain in this world. Normally, the spleen is located under the lower ribs, from the eighth to the eleventh, on the left side, between the stomach and diaphragm. The kidney begins near the point where the spleen ends and extends downward from the level of the spinous process of the eleventh dorsal vertebra to that of the third lumbar and about two inches from the vertebral column. The kidneys rest opposite the psoas muscles. When of normal size and location they cannot be felt by the examining physician. The following case has been of unusual interest to me, and I believe will be interesting and instructive to you. The patient has kindly consented to come before you at this meeting to show the results of treatment. She first consulted me in August, 1907, nearly seven years ago. My record shows a diagnosis of a lacerated perineum with a prolapse of uterus to within two inches of vulva. She had endometritis. She had cystocele; also a floating spleen. She was sent to the hospital where I did a curettage and an Emmett's anterior colporrhaphy for the relief of her cystocele and a colpo-perineorrhaphy for the restoration of her perineum. On discharging her, she was advised to place a pad of folded towel under the spleen before rising in the morning and hold it in position with a muslin binder. The spleen was abnormally large and heavy from chronic malarial poisoning. She had suffered repeated attacks of chills and fever during the past few years. When in the erect position, this big spleen settled into her left iliac fossa and no doubt contributed to the descent of the uterus which pushed her bladder out of her pelvis. Her health and comfort were greatly improved by the above treatment. She returned six years later, September, 1913, in a neurasthenic condition, and complained of dragging pain in her abdomen when on her feet and especially if she took much exercise. Physical examination revealed a tumerous mass in each iliac region when she sat erect but were easily pushed up under the short ribs when she reclined to the dorsal decubitus. With one hand below the twelfth rib over the lumbar region, the other over abdomen, in front, these masses were easily outlined through the thin parietes and were diagnosed movable kidneys. They were about the same size and had about the same range of mobility. A movable left kidney is commonly associated with movable spleen. She was advised to apply pads and binder to support the kidneys. A prescription for a tonic and digestion promotor was made; also a laxative was ordered and she was sent home. She was advised to be content with this treatment if she was fairly comfortable. If she could not proceed with her daily duties and enjoy a fair degree of comfort, I would undertake to anchor these tramp kidneys so that they would stay where they belonged. I did not hear from her again for six or seven months when she wrote to say that she was very miserable and wanted to know what more she could do. The pads and the binder were unsatisfactory. I advised her to go into hospital for operation, which she promptly did. Her preparation was started immediately on admission and she was operated the following morning. She was laid on her face on the operating table with a pillow under her abdomen to produce convexity of the loin. The right side of loin was opened first by the oblique incision. The kidney was exposed and drawn out of the body. The fatty capsule was all cut away from the inner side and half of it from the outer or front side. The capsula propria was incised from pole to pole, stripped up from kidney for an inch on both sides of the incision and folded forward. The folds of the proper capsule were united to the parieties on either side of the incision by mattress sutures of twenty-day catgut and the operation wound closed without drainage. On the other side there is a different story to tell. A similar incision was made but when the floating mass was brought out of the body it came out of the peritoneal cavity, had a long pedicle which protruded several inches beyond the skin surface and proved to be the spleen. The left kidney was then searched for and readily felt in its normal location. The spleen was of normal size. All the old malarial hypertrophy had departed but the long pedicle remained. The question at once pressed on us, What shall we do with it? What is the best for the patient? Nothing could be easier than to amputate it and drop the pedicle back into the abdomen; but the patient was already anemic and, as above stated, anemia follows splenectomy for two weeks to two months. Moreover, the patient had just had a nephropexy on the right side which made some demand on her endurance. Was it wise to add the burden of a splenectomy? Conservatism counseled "safety first." Splenopexy was chosen. Conditions were favorable because the morbid hypertrophy, with its enormous bulk and weight, had vanished. Splenopexy is a comparatively recent operation, but its results are encouraging. Like nephropexy, most of them are curative. The most approved methods are those of Rydygier and Bardenheur. The former anchors the spleen in a pocket made by dissecting up the peritoneum from a transverse incision under the ribs opposite the tenth. The latter does practically the same thing, but makes a different incision and adds a suspension suture which is passed through the lower end of the spleen and over the tenth rib, thereby hanging it to the rib. To go into the details of the technic of these operations would be out of place in a paper like this. Those of you who are interested can find these in your later books on operative surgery. In my case the logical procedure appeared to be to pocket the organ behind the peritoneum and between the latter and the lumbar fascia. This would place it external to the ureter and behind the descending colon. I found it easy to strip up the peritoneum and I soon had the spleen snugly tucked away behind it, outside the peritoneal cavity. I then sewed up my incision in the peritoneum leaving just enough room for the pedicle without constricting it; then sutured the fascia and muscles and finally the skin. I secured union on both sides by first intension, not a drop of pus appeared on either, and I got her out of bed on the eighteenth day, and sent her home on the twenty-first. She appeared to be in good condition in every way except a despondent mental state. This had been observed by her physician before admission to hospital. She says she feels that her old discomfort will return and that her kidneys will be loose as before. We hope to see this mental cloud disappear, with her invalidism, as her convalescence advances and that the bright side of the picture of life may be turned to her psychical perspective to inspire good cheer and comfort. PELLAGRA IN CITY HOSPITAL* A. H. FORTNER, M.D. ST. LOUIS In order not to consume any more time than is absolutely necessary, I shall present, in a sort of tabulated form, only the data which have a direct bearing on the diseases under consideration. I find that there are only 10 cases of pellagra recorded in the hospital, 1 entering in 1910, 2 in 1912 and 7 in 1913. There is hardly any doubt as to the correctness of the diagnosis in the majority of the cases, as most of them were agreed upon by the various specialists on the staff. There is, however, one case included in which there is doubt. This case had other symptoms of the disease and the diagnosis was thought justified by the senior and junior interns, who discovered characteristic skin lesions on the dorsi of the hands three days before death. In considering the geographical origin of the cases, the data are probably not as accurate as they might be, but so far as can be ascertained from the histories the patients had spent most of their lives in the following states: five had always lived in Missouri; one in Indiana and Missouri, St. Louis six years; one in Kentucky and Missouri, St. Louis two months; one in Iowa and Missouri, St. Louis two years; one born in Texas, in Alabama forty-five years and Missouri two months; one came from Georgia to St. Louis thirty years ago. ETIOLOGY But few inquiries were made regarding this. Three stated that they had always eaten a great deal of cornbread. One was unable to give history, but the mother said that so far as she knew the patient had never eaten corn or corn products. One lived near a running stream in a sandy soil where there were sand flies. Predisposing Causes.-The ages ranged form 34 to 60 years. Five were between 34 and 40, and 5 older. Four were females and 6 males. Seven white and 3 negroes. The 4 women did housework; 4 of the men were laborers, 1 was Read before the Medical Society of City Hospital Alumni, March 5, 1914. a porter and 1 a barber. Previous depressing conditions were present in 6; 4 drank alcoholics to excess, 1 had always had general ill-health and 1 had had a chancre thirty years prior to entrance. SYMPTOMATOLOGY Gastro-Intestinal.-All had diarrhea and loss of appetite; one, nausea and vomiting; one complained of sore mouth and throat; one was jaundiced. Neurologic Findings.-Three showed mental symptoms with general exaggeration of reflexes. Three had marked mental symptoms and sluggish reflexes. One had no mental symptoms and marked exaggeration of the reflexes in general. One had mental symptoms and reflexes apparently normal. One had mental symptoms and no mention made of reflexes. One had no mental symptoms and all reflexes sluggish. One of the cases that showed no mental symptoms had positive Babinski, Chaddock's ankle and Oppenheim's signs; she also complained of a creepy, cold, numb sensation which would come over her and last about thirty minutes. This was the only case that had sensory disturbances. The mental disturbance was slight in many of the cases, varying from marked depression to melancholia and slight dementia. One had attacks of delirium, was disoriented and had delusions. General Symptoms.-All the patients were emaciated and weak on entrance to hospital, except one. This one lost rapidly in weight and was among the ones who died. The temperature was not high in any. One ran an irregular daily temperature of from 99 F. to 101.5 F., having 106.5 F. the day of death. Three had evening rises to 100 F. and 101 F. One ran normal up to death, when it rose to 102.6 F. Five ran a normal temperature throughout. In all cases, the temperature was taken per rectum. There was nothing characteristic about the pulse. The rate increased in direct ratio to the temperature, and became weaker and increased in rate as the disease progressed. Two of the women had menstrual disturbance; one had become irregular and one ceased menstruating at the age of 33. Skin. There were a few of the patients who gave a history of recurrent skin eruptions. One who had noticed that he always sunburned easily had an eruption, which he said started rather suddenly as a diffuse redness and infiltration. Vesicles soon occurred over the areas and these were replaced by crusts. There was a sharp line of demarcation and much brown pigmentation at the borders. The lesion was first noticed on the hands and arms, but later a similar one occurred on face, ears and back of neck. They were all bilateral and symmetry was perfect. He complained of an itching and burning sensation at the site of the lesions. |