cian-the Prince of Peace-when He said unto them

"LOVE YE ONE ANOTHER." Room 209 Savings Bank Bldg., Marquette, Michigan.

THE FIELD OF LOCAL ANESTHESIA IN A WAR HOSPITAL.

LOUIS J. HIRSCHMAN, Major M.C., U.S.A. DETROIT, MICHIGAN.

Among the many interesting surgical methods revived and elaborated through the stress of military needs, the employment of local anesthesia has been of great value in the surgery performed in a military hospital.

Base Hospital 17, Harper Hospital unit of Detroit, was located in a city of 130,000 inhabitants. This city was a great railroad center and was on the direct line traversed by many of the American Expeditionary Forces in going to and from the front. Many thousand troops were encamped in the vicinity of this hospital, and among those freshly arrived from the U. S. A., it was not at all infrequent to find cases of hernia, rectal diseases, abscesses and other conditions met with in civil practice. The prevalence of coughs, colds and pulmonary diseases in France, and the susceptibility of the freshly arrived American troops to the same, made the employment of general anesthesia impossible in many cases requiring surgical measures for their relief.

For years the writer has been employing local anesthesia in the treatment of diseases of the rectum and anus, as well as in the radical treatment of hernia. On account of its many manifest advantages over general anesthesia, it had been used in suitable cases as the anesthetic of choice in civil practice. In a war hospital where expedition in the handling of surgical cases, minimized hospital confinement, and early return to duty were of prime importance, anything which would hasten the desired ends, was of distinct benefit. Added to this was the prevention of the great danger of post-anesthetic complications, involving the lungs and kidneys, as well as the fact that on account of the absence of post operative vomiting, the patient's nutrition could be built up so much sooner. Another important advantage is the fact that the anesthetist can be dispensed with. This releases a medical officer for other more important duties. An operation under local anesthesia can be performed more rapidly than in the time allowed for the

administering of a general anesthetic and of performing an operation together. This meant more surgical operations could be performed in the same length of time.

In addition to the surgical procedures mentioned above, many operations on the scalp and skull, rib resections, amputations of fingers, and secondary suture of wounds of considerable extent, excision of infected wounds, operations for phimosis, varicocele and bubo were performed readily under local anesthesia.

In the author's surgical service, the average time required for an operation for inguinal hernia was seldom over twenty-five minutes. Five or six rectal operations were performed in one hour and the average secondary suture same time. Rib rerequired about the sections were completed in fifteen minutes and colostomies and the operation for appendicular abscess were performed in fifteen minutes.

The employment of a hypnotic before operations under local anesthesia is of prime importance. The administration of twenty grains of chloretone one hour before operating, or of a quarter or third of a grain of morphine onehalf hour before operating was the author's usual practice.

The patient would come to the operating room in a quiet tranquil frame of mind. His ears were muffled with cotton and a towel placed over his eyes and all unnecessary noises and conversation eliminated. If however, a patient wishes to converse with the operator, he was allowed to do so, and oftentimes the operation took on more of the character of a social visit, than that of a surgical procedure. Patients would leave the operating room smoking cigarettes and would go back to their wards cheering up the patients who were to follow.

The absence of after-pain was a very pleasant feature of the employment of local anesthesia. The solution used was one quarter of one per cent. novocain to each ounce of which was added six drops of solution of adrenalin chloride. It is of the greatest importance to use sufficient solution to secure pressure anesthesia and important nerves such as the ilioinguinal in hernia should be well blocked by perineural infiltration.

Any of the operative measures used under general anesthesia in the treatment of hernia can be just as well employed under local. The average time required for the hospitalization of a hernia case where local anesthesia was employed in its cure was reduced one week. The value of this saving of time in military life is

of great importance and in civil life, it should be equally so.

Sepsis was practically unheard of, in fact did not occur as often as in cases operated under general anesthetic, which the author believes is due to the fact that there is less handling of the tissues under local than under general anesthesia.

In rectal surgery, it is unnecessary to dilate the sphincter. The employment of local anesthesia by its relaxation of the sphincter allows a better field for operative measures than the divulsed and damaged sphincter of the old regime.

Moreover the patient in most of the cases is allowed to be up and about after the first twenty-four hours. Convalescence and an early return to military duty is hastened. Patients after most operations performed under local anesthesia, seem to vie with one another in the speed with which they could be returned to duty.

In the surgical treatment of war casualties, the removal of foreign bodies, such as machinegun bullets and shell fragments was very easily accomplished. The most suitable cases were those in which localization by the X-ray demonstrated the presence of foreign bodies in the soft structures and not embedded in bone.

Suturing of lacerated wounds, particularly of the scalp was a very favorable operation under local anesthesia. Debridement, or the excision of devitalized tissue in a wound, could be done surprisingly well, provided the wound was not too extensive or involved too much muscle. Secondary suture of superficial wounds was an ideal procedure under local anesthesia.

To recapitulate, any operative procedure which can be done just as thoroughly under local anesthesia as under general anesthesia, should be performed for the following reasons: 1. It is safer.

It can be performed more rapidly. 3. Shock is absent.

4. Fewer assistants are required.

5. After-pain is absent.

6. Patients can take nourishment immediately.

7. Recovery is hastened.

local than general anesthesia, which materially assists in his convalescence, and in a ward is reflected on his fellow patients.

12. Post anesthetic complications are ab

sent.

1016 Kresge Building.

A CASE OF CONGENITAL PTOSIS. H. L. Begle, M.D.

DETROIT, MICHIGAN.

Malformations and failures in development are frequently observed in a clinic or hospital for children. While they are always of interest, it is unfortunate that we can not do more to remedy them. Dr. La Ferte has spoken of the various forms of spina bifida that he has encountered at the Children's Free Hospital. I wish to present a little patient who exhibits a failure of development in that she is unable to elevate the upper eye-lids sufficiently. The lids droop and she has a sleepy expression. Vision. is interfered with, for while the pupil lies in the palpebral space when she looks downward it is covered by the lid when she looks upward.

The condition is designated congenital ptosis and results from lack of development of the levator muscles. Unlike acquired ptosis, resulting from paralysis of the third nerve, both eyes are usually affected. Sometimes a few fibers of the levator muscles are apparently present for the eye-lids can be partially raised by them but in this case I have not been able to demonstrate any action by the muscles.

Very early in life children with congenital ptosis learn to use the frontalis muscle to partially open the eyes. By contraction of this muscle the eye-brows are raised and with them to a varying extent the lids. Therefore one observes skin-folds on the foreheads of these patients. Moreover if the head is tipped backward while the patient looks downward the pupil is not covered by the lid and relatively high objects can be seen.

I have performed the so-called Hess operation on the right upper lid in this case. An incision was made along the entire length of the eye-brow. The skin of the upper lid was dissected loose to the lid-margin. Three doubled-needled sutures were then introduced through the lid near the lid-margin and were brought out through the skin of the forehead a few centimeters above the brow where they were tied over gauze rolls. The original in

cision was then closed. The sutures were left in place for two weeks. The aim of the operation is to cause a growth of connective tissue along the threads and form tendinous outshoots from the frontalis to the skin of the lid thus reinforcing the action of that muscle. Moreover the lid may be slightly folded and shortened.

In this case I have not been successful in

Jerusalem (By Mail)-How American Red Cross physicians engaged in relief work here are accomplishing worth while results in the face of great difficulties and what they are up against, is shown in a report just received here from W. S. Dodd, A.R.C. doctor, working at Mejdel in this section.

With two capable English trained nurses, and three native helpers, more or less useful Dr. Dodd, his "hospital" housed under tents, performed 252 operations in seven weeks, besides giving medical examinations, treatment and counsel to hundreds of the destitute inhabitants and refugees.

His report says in part: "The work of the Hospital was of the plainest sort, it might be called primitive. About twenty-five tents comprised the Hospital proper, with a Dispensary tent, and tents for the living quarters of the staff.

The soil was all the purest sea-sand with thistles and scant grass; going barefoot was the universal custom, and in our own quarters we of the staff used to follow that custom with great pleasure. * * * "The professional side of the work was of the greatest interest to me and every day was a pleasure. The clinics numbered sixty to a hundred a day. Of course we had all classes of cases in medicine and general surgery, but by far the larger proportion of our patients were eye-cases.

"Of the 252 operations that I did in less than seven weeks, 222 were for the eyes. This is the number of persons operated on, most of them having more than one operation, perhaps on all four lids, so that I really operated on 408 eyes.

"There were some cataracts, not more than would be seen in the same number of cases elsewhere, but Trachoma and its consequences accounts for almost all of the eye troubles in this land. I set out to treat cases radically and secured fine results when I could keep the patients long enough for a reasonable after-treatment. But even so, the number of eyes that can be saved from partial and total blindness is large and the economic value of each eye thus saved is enough to make the prosecution of this line of work of the greatest importance for the redemption of the land.

"The accident cases are always interesting. I had the last end of treatment of some cases of bombed hands, of which there had been quite a number in the earlier days. These were largely in children, and were due to their picking up unexploded Turkish bombs that were lying in the fields

producing a fold but you will note that the patient when she tries, is able to open the right eye much wider than the left. I am told by her sister that she no longer tips her head backward when looking at objects but is able to see them through the increased frontalis action. The operation has therefore helped matters and one can feel encouraged to try the same procedure on the other side.

from the time of the British advance in the Gaza region. Many fingers and even hands were lost from this cause.

"Vermin was the great enemy we had to fight. Fleas were hardly counted as a problem because we could do nothing against them, they were everywhere and inevitable, and so far as we know at present not being the carriers of any special disease, did not come within the hostility of a medical conscience.

""Lice and maggots were a daily terror. How many wounds and injuries came to us filled with maggots I can not tell. A favorite dressing for a wound is a piece of raw meat, a breeding place for maggots, and they can hardly be blamed for invading the adjoining premises.

Many a child had to be put under chloroform in order to search out and pull from their hiding places deep in the middle ear a half dozen wriggling maggots whose every motion was causing torture to the innocent victim.

"A woman came to the clinic complaining of headache. A single sore on her face lead to questioning, and when she rather unwillingly undid her turban we found an exaggerated case of impetigo, and every separate sore was as if the whole thickness of the scalp down to the bone had been punched out, and every sore was a nest of maggots. I removed 60 at the first seance, and at the first dressing next day the nurse had more to do. The headache was cured without further treatment. And these are not the most loathsome cases that we saw. "Another great difficulty with which we had to contend was the filthy habits of the people. In spite of providing proper sanitary facilities, we were compelled to have a scavenger go around every morning and clean up the filth from around the tents of the patients. The women were as bad offenders as the men. We made it a rule that anyone known to have violated these simple sanitary regulations must go without their dinner next day, and this was quite an effective punishment."

During November the following articles have been accepted by the Council on Pharmacy and Chemistry 'for inclusion with New and Nonofficial Remedies: National Pathological Laboratories: Rabies Vaccine (Harris).

Schering and Glatz: Creosote Carbonate, S. and G. Guaiacol Carbonate, S. and G.

A NOTE CONCERNING THE EPIDEMI

OLOGY

AND TREATMENT OF

AMEBIC DYSENTERY WITH
A REPORT OF TWO CASES.
GEORGE R. HERRMANN, B.S., M.D.

ANN ARBOR, MICHIGAN. (From the Medical Clinic, University Hospital, Ann Arbor, Michigan.)

Amebic dysentery has in the past been reported and discussed in this Clinic because of the apparent rarity of the condition in these latitudes. At present such is no longer the conception, but conditions abroad, which will sooner or later be brought home to us, warrant a review and make a discussion distinctly worth while just at this time.

The troops from the tropics are carrying their flora of animal parasites with them to the lines in France, and the spread of the infections is especially favored by the intimate relations and exigencies of camp and trench life. England has already reported the inevitable effects; great numbers of British soldiers have become infected, consequently incapacitated and sent home for convalescence. At this point the problem has begun to assume a position of unusual importance, for the ordinary limits of the geographical distribution of the tropical diseases are being widely extended and not only the military, but the civilian population as well, is being threatened. Amebic dysentery is undoubtedly the most important, the most dangerous, and the most resistant to cure of the tropical parasitic conditions to which our soldiers will be exposed. It is of especial interest to us because of its, by no means infrequent, troublesome presence in our midst in the north. temperate zone even under the ordinary conditions, in times of peace.

The recent occurrence of two cases of amebic

dysentery in this Clinic, brings up two questions of vital importance along the lines of public health for the future. The questions are, first, is the disease transmitted by carriers; and second, are there sporadic cases arising in the north temperate zones?

Extensive investigations by eminent parasitologists such as Craig (1) of the U. S. Army. Fantham (2) of the British Army and others have recently added many new and important ideas to our knowledge of the life history of the entameba histolytica and the mode of spread of the parasitic infection. The vitally important question of carriers of amebic dysentery was worked out conclusively by Walker (3), who found that by feeding the encysted forms of entameba histolytica to twenty men, he was successful in infecting eighteen, four of whom developed the typical dysentery, and the other fourteen became the so-called "contact carriers" of the organism. The amebae appeared in the stools on the average about six days after the ingestion. The term, "contact carriers," has thus been applied to those carriers who have never been affected with the disease, while the term "convalescent carriers.". is applied to those who have recovered from the disease but continue to expell the cysts.

Dobell (4), Dale (5), Fantham (6), Imrie (7), Inman (8), Waddell (9), and others definitely demonstrated that carriers were responsible for the continuance of diarrhea among many of the soldiers for a long time after they had returned to England. The cysts were found in the stools of the convalescents as well as in the dysentery patients. Thus it stands a settled question with substantiating proof that there are "carriers" of amebic dysentery.

Low (10) reported very completely a case of amebic abscess of the liver in a patient who had

had no symptoms since his original attack twenty years before. Libman's cases also give long quiescent periods in their histories between the original attack and the liver abscess formation. Such evidence substantiates the supposition of long latent or quiescent periods in the diseases.

In collecting cases from the north temperate zone, we find Sanford (11) of the Mayo Clinic heading the list with 819 cases, 284 of which were due to entameba coli. These, together with Dock's (12) case and those of Walsh, Libman, Tuttle (13), Patterson (14), Rosenberger (15), total about 1,038 cases, 512 of

which were due to entameba coli.

Thus 500 cases with three from our own Clinic, (12), (16), (17). (18), (19), of patients residing north of 40° latitude (Philadelphia), who had never been any further south and who had never consciously been exposed, are known to have had entameba histolytica dysentery. This is proof enough that amebic dysentery is not confined to the tropics but that sporadic cases are by no means uncommon in the north. In fact Axtell reported a case of amebic dysentery contracted in the arctics of Alaska. He had a patient who had been a mate on a government boat on the Tanana and Yukon river. In this case the man is supposed to have contracted amebic dysentery by drinking swamp or surface water in the spring of the year. The patient asserted, according to Axtell, that he knew of thirteen or fourteen others with the same trouble. Careful examination with the proctoscope showed amebic ulcerations in which entameba coli were found.

To reiterate and recapitulate, we know that there are carriers of amebic dysentery, that the infection can remain latent for long periods of time and that the disease arises indigenous in the north temperate zone. May it not be possible that the entameba histolytica is an obligative parasite rather than facultative or a saprophyte? That is, the carrier, the living animal body, is the factor in the epidemiology, and that the frequent repollution of the source, whatever it may be, is necessary for the spread of the disease. Along with this is the question of how long the infection can remain in a community after the departure of the animal carrier source.

Our present cases might fall in any one of these groups. The facts in the histories are such that they can not be clearly classified, assigned or fixed epidemiologically. But one of the classes must cover them. It makes but little difference under what head we place them.

No matter what the grouping, they are of importance to us now and may be more so in the future. If carriers with a latent infection, they are of especial interest, and if they are sporadic, indigenous cases, they are of just as great importance.

The present cases are the first that have been in the Clinic in two years and they entered within fourteen days of one another. They are both typical entameba histolytica dysentery cases and present many points of similarity. Both have been in Michigan for a considerable time, as I will definitely state presently. Both had been in the tropics at some time in their lives. Each had his present trouble or exacerbation begin in 1914, that is, four years ago, when in each case overwork, worry and nervousness precipitated the attacks, which have continued somewhat intermittently ever since. Both showed entamebae histolytica and trichemonas intestinalis in their stools of blood and mucus; and the blood pictures showed an eosinophilia.

The one had been in the U. S. Army for three years in the Black Mountain Expedition through New Mexico, Arizona and Utah in July and August, 1908, and then in Honolulu, Hawaii, ending in 1910, when he returned to Chicago and then to Michigan, where he has been ever since 1910. He had no intestinal disturbance while in the southern states or in Honolulu, nor did he have any until 1914 when his diarrhea suddenly came on. The question is, did he act as his own "carrier" retaining the latent cyst in his bowel for four years, or did he acquire his infection in Michigan; the former seems more rational.

The other, a Greek, had had the original attack of dysentery in Palestine in 1900. He recuperated after five months, went back to Greece and then came to this country. In 1908 he moved to Detroit where he has been for the last ten years. He had no intestinal disturbance after his original attack in 1900 until 1914 when his bloody diarrhea began. Here again the question is, did he act as his own "carrier" with the encysted organism in his bowel for fourteen years, or did he acquire his reinfection in Michigan. Here again the former seems the more rational, more so than in the first case.

The evidence is by no means conclusive, but there is quite a considerable pointing toward the long latent carrier idea in these cases. Two cases are not sufficient grounds from which to draw any conclusion. We can merely say