SCHOOL AND MEDICAL INSPECTION OF CONTAGIOUS DISEASES.

CINCINNATI, February 5, 1907. EDITOR LANCET CLINIC:

In your issue of February 2 appears a communication from Dr. Allen, Health Officer, regarding your editorial and my article which appeared in THE LANCETCLINIC of January 19. Dr. Allen states that he read with considerable interest the editorial. From his reply it does not appear that he read carefully. He states that "there is not a word in Dr. Lewis' letter that has any bearing whatever on the subject. We are attempting to do none of the things about which Dr. Lewis complains." In my letter I asked why no provision was made for the inspection of private and sectarian schools, believing that those who attend such schools are entitled to the same protection from the Health Department as are those of the city schools. Does not this have some bearing on the subject? I believe it does, notwithstanding Dr. Allen's dogmatic assertion to the contrary. Dr. Allen fails to mention this question in his answer; upon this he is eloquently silent, as he is also in regard to the laboratory diagnosis of diphtheria, of which I spoke. Has this not some bearing on the subject? I think it has; Dr. Allen may think otherwise. The reader will form his own conclusions. Before forming your conclusions, however, read the editorial by Dr. Brown and the original article.

Dr. Allen goes somewhat into detail regarding the relation of the Inspector and the physician, and invites me to make the matter clear to him wherein

ing the Inspector continued his vigilance, what are the methods employed? Anything that the attending physician could and would not employ? In the message sent by the Inspector to the attending physician the following occurs: "It will be my duty to co-operate with you in maintaining the necessary isolation of the patient, and on notice from you of the termination of the disease to see the patient and certify the facts required by the Board of Health." From this statement it is evident that the Inspector is expected to co-operate with the attending physician, in not inaugurating alone, but in maintaining the necessary isolation. Co-operate means to act or operate jointly with another or others. From this one is not justified in inferring that the single primary visit of inspection by the Inspector would mean co-operation, or would enable the Inspector to "prevent the case becoming a source of danger to others." The Inspector says: "It will be my duty to co operate." etc. This is regarding the future; he has already made his official visit and is now ready to cooperate. Does this not imply in plain English that the physician is attending the case under supervision? I hope that the matter is made clear to Dr. Allen. If the Inspector disapproves the isolation he is to notify the physician in charge. From this the inference would be that the Inspector is the judge of the isolation. Does this not imply supervision? Reading Dr. Allen's article I find no mention of this, and I might suggest that he familiarize himself with the pamphlet before expounding its hidden meaning.

If the duty of the Inspector is as stated in Dr. Allen's article, why does the Inspector send to the physician in charge the message stating that "It will be my duty to co-operate with you in maintaining the necessary isolation of the patient," etc. Has this been done for years, as stated by Dr. Allen, by the sanitary officer instead of the medical inspector? This feature for some reason has not been referred to in Dr. Allen's article, and it is one against which I pro

the subject. Dr. Allen, for some reason or other, omits mention of this message of the Inspector to the attending physician. If the Inspector's duty is simply to obtain certain information as required by the Health Department, why does he send a message to the physician? "The department believes the information received will be a little more accurate and of more service if obtained by its credited Inspectors than if obtained by a sanitary officer." This is a left-handed compliment to the sanitary officers which they will no doubt appreciate.

Dr. Allen remarks further in this connection as follows: "Physicians, when they report cases, never give us this information." When, may I ask, have physicians been required to give this detailed information? The Health Department furnishes a blank postal-card, upon one end of which is printed a list of diseases which physicians are required to report, and on the body of the card partly filled lines which call for date, disease, name and residence. This, seemingly, is all the department wants. Then why should physicians volunteer further detail?

According to Dr. Allen, the department accepts the physician's diagnosis and statement as to the existence of a case of infectious or contagious disease, but when it comes to accepting this same physician's statement as to convalescence and freedom from danger of infection he is not credited; his statement is not accepted by the department, especially in diphtheria. The culture sent by the physician is regarded with suspicion, as the infallible Inspector now visits the patient, obtains a culture and waits for a laboratory report, and, if recovery is complete, certifies the fact to the Board of Health. Inspector is the judge as to whether recovery is complete, not the physician? Is this supervision or is it not?

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In cases of diphtheria the recovery of the patient is to be established by the universally conceded unreliable laboratory test. The weekly reports of the Board of Health for the week ending January 18, gives the following results regarding diphtheria: 2 positive; 12 negative; week ending January 25: 2 positive; 11 negative; week ending February 1: 3 positive, 16 negative. Comment is unnecessary, further than to call attention to this as the method by which recovery and

freedom from danger of infection is established.

We are told by Dr. Allen that the Inspector does not "examine a sick child, enters no sick chamber, but goes to see a well child." If the child is well-and we have Dr. Allen's statement that such is the case-what is the object in examining a well child? It is common knowledge that the bacilli of diphtheria are frequently found in the throats of persons who present no symptom whatever, either local or constitutional, of illness, who are in absolute health; and it is also known that the most painstaking and persistent effort of the bacteriologist fails to find the bacillus in but a small percentage of undoubted cases of diphtheria. Notwithstanding, however, as I stated in my first article, the Inspector plus the bacteriologist are the tribunal to whom recovery is referred. The physician's statement as to the existence of the disease is all right -not, however, as to the non existence. By what occult power is the Inspector to arrive at the conclusion that a patient who had suffered from scarlet fever and who has not desquamated-all do not necessarily desquamate-is free from the danger of infecting? How about measles, whooping-cough and other infectious diseases? It has been broadly intimated that physicians are negligent or careless in reporting infectious or contagious diseases. If such be true, the present method will hardly correct their carelessness.

The pamphlet and Dr. Allen's interpretation suggest the following vagrant fancies, though they may have no "bearing whatever on the subject." Why are sectarian and private schools, a large percentage of our school population, denied the protection of school inspection? Is it the province of the Board of Health to limit this protection to the city schools, as set forth in the pamphlet? Is the danger confined alone to the city schools? Are not the parents of children of sectarian and private schools tax-payers, and therefore entitled to the same consideration as parents of children of the city schools?

If inspection of isolation, approval or disapproval of the same, co-operating in maintaining the necessary isolation and at recovery of the patient, especially from diphtheria, obtaining a culture after the physician has reported the case well, by the Inspector is not supervision, what is

it? If the physician's word is good enough to be accepted as to the existence of a case of contagious or infectious disease, why is it discredited when he reports recovery? It is not accepted, as the Inspector takes a culture after the physician has reported

recovery.

Why is this unreliable laboratory test regarding diphtheria to be applied in deciding freedom from danger of infection? When were physicians ever asked to furnish detailed information regarding contagious or infectious diseases? How does the Health Department know that physicians would not give such information? Inference is not evidence.

I am gratified at the endorsement of the editor, and that of every physician with

whom I have spoken regarding the subject, which means a good many. No objection is offered to the object. Methods only are questioned. This article aims to refute the gratuitous statement of Dr. Allen that there is not a word in Dr. Lewis' letter that has any bearing whatever on the subject." Flippant remarks and bald-headed statements, like chickens, sometimes come home to roost. This is no "Comedy of Errors" or "Much Ado About Nothing"; rather "The Taming of the Shrew."

"Upon what meat doth this our Cæsar feed that he is grown so great?"

Mr. Editor, what have you to say in your defense? W. E. LEWIS.

Gynecologic Superstitions.

Dr. Lucy Waite, of Chicago (American Medicine), makes a plea for the uprooting of dogmatic theories and worn-out superstitions in gynecology, and calls attention to some of the prevalent erroneous doctrines which need recasting.

Foremost among these dogmas, and most difficult to dislodge, Dr. Waite cites the tenet which establishes the so-called normal position of the uterus. Once accepted that the normally placed uterus must be in anteversion, all gynecology has been attuned to this idea, and innumerable text-books, by scientific representations of the "normal" and "abnormal position of the uterus, have engraved this superstition on the eye, as well as upon the mind. So firmly has this idea become rooted that, in spite of the fact that German scientists have proved by actual demonstration and numerous clinical observations that the normal-sized non-metritic movable uterus may lie in any position in the pelvis without producing symptoms, women are still being tormented with pessaries, and abdomens are being opened by thousands to force this inoffensive organ to assume a position which shall correspond to the one photographed in the gynecologic brain.

As a result of this arbitrary establish.

ment of the position of the uterus, a second dogmatic assertion has taken almost an equal stronghold on the profession, and is very closely allied to the first, namely, that retrodeviations of the uterus are a cause of constipation. No effort has ever been made to prove this proposition, and still it has been most generally accepted. Indeed, it seems almost a pity to be obliged to give up this particular superstition, because it appears so plausible and is always so satisfactory to the patient. The writer's attention was first called to this matter in dissections on the abdomen and pelvis. In over twenty bodies Dr. Waite experimented by packing the rectum and sigmoid with cotton, and found that these organs could be enormously distended without crowding the uterus, and that it rode upward and forward obedient to the increasing size of the rectum without making the slightest anatomic protest. Practically the same result followed the distension of the bladder with air. uterus assumed a retroposition and became gradully more elevated as the size of the bladder increased without any anatomic hindrance, the roomy pelvis accommodating, without any apparent inconvenience, the full rectum and distended bladder with the elevated and retroplaced uterus between them. The writer therefore concluded that if the uterus was in any way

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responsible for constipation in women, it was not on account of direct pressure due to any particular position which it might happen to assume.

The theory so long accepted that flexions and the pinhole os were a cause of dysmenorrhea has given rise to a most harmful superstition. The ancient gynecologist considered marriage and childbearing as practically the only remedy for the dysmenorrhea of young girls, and many a one has been condemned to lifelong menstrual pain because she has not been able to follow out the only advice given her by her physician. This advice was based partly on the accepted etiology of dysmenorrhea, that it was in the majority of cases mechanical, due either to a flexion or to a stenosis of the os, both of which conditions were supposed to be corrected by pregnancy, and partly on account of the prejudice which has always existed. against putting a young girl under local treatment. She has been made to feel that uterine or ovarian disease was somehow a disgrace, and especially when it was a penalty of her unmarried state. While it may be assumed that the majority of the profession is too enlightened to-day to hold these views, one hears not infrequently of physicians giving out these opinions, and the laity, even the more intelligent, is still under the impression that a young girl's menstrual pains will disappear after her first pregnancy, and do not realize that they are doing her a great injustice in leaving her to suffer until that time arrives.-Medical Standard.

Chorea Gravidarum.

French and Hicks (Practitioner), in a series of twenty-nine cases of chorea gravidarum, observed that rheumatism or chorea occurred previously in nineteen cases. They are convinced that chorea gravidarum and infantile chorea have the same pathology. The ages of these patients ran from nineteen to thirty-one; the majority were about twenty; eighteen, were primiparæ, five were in their second pregnancy, four in their third, and one each in the fourth and fifth. The tendency to recurrence was distinctly shown in four cases. Chorea may be absent during the first pregnancy yet occur in a later one; it may come on at any time, but is distinctly less likely to occur during

the latter months. When chorea recurs in successive pregnancies it is prone to begin on the same month each time. The mortality in this series was 10 per cent. The writers draw attention to the significance of pyrexia in the prognosis. On the other hand, a normal temperature would justify a good prognosis, as far as immediate results were concerned, regardless of the severity of the choreic movements. The majority of cases do well when treated in exactly the same way as non-pregnant cases. The induction of labor is seldom the line of treatment to be adopted. It is unwise to induce labor simply because the movements are severe, and after pyrexia has set in it is too late.

Injuries to the Child's Head During
Labor.

Sachs warns the obstetrician that, other things being equal and, above all, the life of the mother not being in danger, it is wise to curtail the period of labor as much as possible,, and not necessarily to wait until the child's heart action becomes feeble. Many children might have escaped epilepsy, idiocy and paralysis, if the period of labor had been properly managed. He is firmly convinced that protracted labor is the most powerful factor in producing epilepsy, idiocy, or paralysis in the new-born; one or often all of them are developed, and may be due to conditions present at the time of birth. further says that the medical men in attendance at confinements have for years followed a policy of indifference toward the welfare of the child, and have allowed too many children to be born into the world after labor unnecessarily prolonged, and in conditions that are a distinct disadvantage to society and to the individuals for the entire period of their natural lives.— Journal A. M. A.

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Diagnostic Significance of Decidual Tissue.

W. P. Graves (Boston Med. and Surg. Journal) states that the passage of decidual membrane in a patient with symp. toms of pregnancy and with a mass on one side, together with a history of flow. ing, is extremely significant of an extrauterine pregnancy, but cases do occur where this seemingly conclusive chain of evidence is not proof of an extra-uterine

gestation. An ordinary miscarriage may be preceded by an exfoliation of a part or the whole of the decidua vera. The pathologist who receives a specimen of decidual tissue should make his report with extreme reservation, to avoid the commisssion of a serious surgical blunder. It may be impossible to differentiate even with great microscopical care, between an exfoliated dysmenorrheic membrane and the decidua of an extra-uterine pregnancy.

Menstruation as a Source of
Auto-Intoxication.

Riebold (Deutsche med. Wochenschrift) makes a special study of various morbid manifestations liable to accompany men. struation. He regards it as extremely important in the pathogenesis of numerous febrile affections, and thinks that there is no doubt that the menstruating uterus may occasionally prove the source of infection for actual septic affections. Fever accompanying menstruation is by no means uncommon, and is the result of absorption of bacterial toxins or of products of decomposition through the menstruating genitalia. The action of toxins is also evident in the numerous affections of the skin and nerves which may be ob. served accompanying menstruation, such as erythema, urticaria, herpes zoster and neuralgia. Still more important is the fact that infection or intoxication from the menstruating genital organs is liable to induce various forms of rheumatic affections, including actual polyarthritis and cardiac affections of a rheumatic nature.

The course of the acute menstrual articular rheumatism does not differ in any respect from the classic type except, possibly, in its unusual mildness in some cases. In eight of the fifteen cases observed only the joints of the feet were swollen and painful, and the rise in temperature was slight and transient. The heart was not perfectly sound in any of these fifteen girls; in all a valvular defect was apparent, quite serious in some. The changes in the heart were severe, out of all proportion to the mildness of the rheumatic involvement of the joints.

The experiences related, the author thinks, establish the fact that menstrual infection or intoxication of a rheumatic nature may be the insidious and unrecognized origin of a valvular affection. Some

typical examples of this febrile menstrual rheumatoid affection and of septic menstrual fever are related in detail. The only source for the staphylococci found in the blood in one case reported must have been the menstruating uterus. As menstruation ceased the symptoms subsided. In such cases there was none of the usual leucocytosis during menstruation. These septic cases are rare, but undoubtedly exist, and may explain certain cases of "cryptogenic sepsis." Patients who have had two, three or more recurrences of the menstrual rheumatoid affection have been free from them in his experience when the vagina was regularly rinsed twice a day at least with some antiseptic fluid. This is especially necessary when an odor suggests a putrefactive process. Frequent careful cleansing of the external genitals is important in prophylaxis of all these morbid menstrual phenomena.

A New Axis-Traction Apparatus.

Jacobson (Medical Record) describes his device as follows: The apparatus is composed of clamp, which attaches to the edge of a table; an outer case enclosing a worm and gear (which multiply the power); two rods, the lower one telescoping, joined to the clamp by universal joints; a crank-handle for operating the power-producing mechanism; a handwheel at the outer end of the telescoping rod for controlling the transit of the outer end of the apparatus through the orbit which it must describe, when in operation, around the universal joints as pivotal points; a steel tape, which may be replaced by another if kinked without taking things apart, and which winds up on a drum upon which it is held and around which it is guided by a metal case containing an aperture into which the tape passes and which does not itself revolve; a small axle upon which the gear revolves, and a dynamometer, one of the needles of which is pushed along as an index by the needle proper, remaining at the maximum point reached during the operation for later reference. The apparatus is made chiefly of an aluminum composition, and weighs about five pounds. This instrument enables the accoucheur to employ measured, steady and precise axis-traction, with a minimum of force and no expen