CoHege of ^Ijpgiciang anb burgeons Hibrarp TROPICAL SURGERY AND DISEASES OF THE FAR EAST TROPICAL SURGERY AND DISEASES OF THE FAR EAST INCLUDING ANSWERS TO A QUESTIONNAIRE BY JOHN R. McDILL, M.D., F.A.C.S. Major, Medical Eeserve Corps, United States Army. Lecturer on Surgery, Rush Medical College, University of Chicago; Former Professor and Head of Department of Surgery, College of. Medicine and Surgery, University of the Philippines; Chief Surgeon, Philippine General Hospital, St. Paul's Hospital, and Cosmopolitan Hospital, Manila; Former Major of Volun- teers and Chief Operating Surgeon in the Field, Seventh Army Corps in Cuba, and to the First Reserve Hospital in Manila; Fellow Society of Tropical Medicine and Hygiene (London), Far Fastern Association of Tropical Medicine, Ameri- can Medical Association, etc. Approved for Publication by the Surgeon General of the United States Armv ST. LOUIS C. V. MOSBY COMPANY 1918 IV) 1^ Copyright, 1918, By C. \'. Mosey Compaxy Press of C. V. Mosby Company St. Louis Dedicated to My Dear Friend, Doctor Ariston Bautista y Lim of Manila, Professor of Clinical Medicine in the College of Medicine and Surgery, University of the Philippines, in Appreciation of His True Friendship and of His Unselfish Devotion TO the Advancement of His People. Digitized by the Internet Arciiive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/tropicalsurgerydOOmcdi FOREWORD The winning of the world war demands the assembling of all knowledge which may be of possible use. Surgical as well as medical diseases of the Tropics are already encountered in all armies, not only during their tropical service, but in that in Europe and America as well. The author having noted this fact during overseas sexvice in 1916-1917 has put together material which he has been collecting for years and has added abstracts of recent literature in the hoi:>e that such a compilation may be of some value during and after the war. Opportunities for observation were found in a prac- tically^ continuous life of fourteen years in the Tropics ; in our South, Cuba, the Philippines, and in frequent visits to China and Japan. Four years of this time were served as a volunteer surgeon in the United States Army, as chief operating surgeon to an army corps in the field in Cuba, in Luzon with troops in the field, and in base hospitals in Manila as operating surgeon. Ten A^ears were spent in jDrivate and public practice in Manila dur- ing which many medical institutions were organized. The clinical data in Part I are mostl}^ from the last five thousand carefully recorded surgical cases among Fil- ipinos. The material of Part II was derived from travel and personal contact with many of the medical men in China, Japan, Indo China, and the Straits Settlements, as well as from answers to a questionnaire sent to over two thousand medical men in the Tropics. The ground covered in Part II includes -the Philippines, JaiDan, China, Indo China, Ceylon, Straits Settlements, Guam, Samoa, Burma, India, and parts of Africa in all of which countries 7 8 FOREWORD the allied ti'oops arc already in the field. The medical men who contributed data are prominent in their fields, many have been living in Far Eastern countries the best part of their lives and are still there. The best reports were from United States Army Surgeons Chamberlain, Phalen, Vedder, Nichols, and Page and from surgeons of the United States Navy, especially Surgeons Cottle and Odell. The reports and published Avorks of the surgeons in the i^nglo-Indian medical service, which were kindly furnished by the Honorable Surgeon- General C. P. Lukis, of Calcutta, were splendid and con- tained important original work by such men as Sir Havelock Charles, Major Leonard Rogers, Sir Ronald Ross, and Austin Smith of Agra. Of great general in- terest are the descriptions by the medical missionaries, especially in China, among whom were Snell of Soochow, Plummer of Wenchau, and Margaret E. Philipps of Ping Yin; Ralph G. Mills of Seoul, Korea, and sixteen colleagues, practicing in Korea for an average of ten years each, made the questionnaire the subject of a symposium. Landsborough of Formosa, Turner of South Africa, Hollenbeck of AVest Africa, Castellani, de Silva and Faul of Ceylon, Castor of Burma, and many others have made valuable contributions both to literature and in personal communications concerning tropica! medi- cine and surgery. This information and my own experience bear out the truth that the broad principles of epidemiolog}^, prophy- laxis, pathology, and therapeutics are equally applicable everywhere, and that there is no foundation for the idea that diseases met with in other countries can be classed as special in type or differing, except in pathologic range, from the diseases of our own and European countries, although the anomalies and curiosities of a foreign med- ical experience have their interesting features. When the important diseases knoA^m as "tropical," which are FOREWORD ■ 9 now being discovered everywhere, appear, the question of their origin is invariably answered by pointing to the constantly improving means of comnmnication around the world and to the fact that diseases always follow the paths of commerce and the march of armies. J. R. M. June, 1918. CONTENTS PART I The Conditions Supposed to Modify Surgical Procedure in the Tropics, Surgical Diseases Earely Seen Elsewhere, Also Those Seen Mostly in Equatorial Lands but Transportable to Other Countries and Likely to Come Within the Experience of any Medical Man. CHAPTER I ^ Introduction Litioduction, 17. CHAPTER II Surgery -and Surgical Operations Surgery and Surgical Operations, 22. CHAPTER III Diseases of the Head, Neck and Thorax The Head and Neck, 25 ; Congenital Defects and Anomalies, 25 ; Injuries and Results of Injuries and Disease, 25; Cysts, Fistulas and Torticollis of Neck, Rare, 25 ; Ludwig 's Angina, 25 ; Tuberculosis and Hodgkin 's Dis- ease, etc., Neck, 26; Cancer, Cysts, and Osteomyelitis, 27; The Thorax, 29; Bronchomycosis and Bronchomoniliasis, 30. CHAPTER IV The Abdomen The Abdomen, 33; Hernia, 33; The Spleen, 34; Splenic Anemia and the Kala-azar, 34; The Colon, 37; Entamebic Dysentery, 37; History, Walker and Sellards, 37; Diagnosis, Treatment, and Prophylaxis, 39; Balantidial Dysentery, 63; Bacillary Dysentery, 66; General Intestinal Parasitism, 67; Influence on Surgical Prognosis, 67; Relation to Typhoid Hemorrhages, 68 ; The , Liver, 69 ; Entamebic Abscess, 69. CHAPTER V Gynecology and Obstetrics Gynecology and Obstetrics, 86; Pelvic Inflammatory Diseases, 86; Ob- stetric Customs, 86 ; Tumors, 89. 11 ILLUSTEATIONS FIG. PAGE 1. Encephaloeystocele ' . . 26 2. Enormous goiter with colloid and fatty degeneration 27 3. Cancer of the mouth and extension to the neck in a iDetel nut cliewer 28 4. Cancer of the cheek and face from primary cancer of buccal mucosa in a betel nut che\yer 29 5. Multiple areas of necrosis in acute entamebiasis 38 6. Multii)le ulcerations severe chronic entamebiasis 39 7. Typical examples of Ameba and Entameba 47 8. Colon of a man dead from Balantidium eoli infection .... 63 9. Section of large intestine of monkey, sho\ving three Bialantidium coli suis in the deeper part of the mucosa 64 10. Section of a mesenteric lymph gland of monkey, showing several Balantidium coli hominis in the edge of the glandular tissue 65 11. Section of large intestine of a man dead fr.om Balantidial dysen- tery 66 12. Liver. Upper surface showing minute multiple foci of secondary infection from entamebiasis of the colon 70 13. Liver. Cut surface of same spiecimen as Fig. 12 . . \ . . . 70 14. Liver. Section of right lobe with large multiple abscesses ... 71 15. Liver. Solitary superficial entamebie abscess on outer surface of right lobe 72 16. Curvilinear incision to expose 9th and 10th ribs 72 17. Resection of four inches of 10th rib; resulting gutter to be closed immediately by catgut suture 73 18. Cavity or gutter left liy rib resection, partly sutured .... 73 19. While incision into the peritoneal cavity is being made the mobilized chest wall is held firmly against the diaphragm by two fingers of an assistant ~'^ 20. Edges of chest wall and diaphiagm, which are to be united by suture, held apart '"^ 21. Suture of chest wall and diaphragm completed, showing exposure of liver "6 22. Mikulicz pack to procure adhesions after failure to find an aljscess 77 14 ILLI'STTIATFOXS 15 FIG. PAGE 2?,. Drain in place, gauze ring around tubo' to prevent soiling of peri- toneum and to form adhesions 78 24. Diagramniiitic sketch showing layers incised and digital method of temporarily preventing pneumothorax till diaidiragm and chest wall are sutured • 79 25. Combination drain and hemostat for liver abscess 81 26. Combination drain and hemostat intiated in a liver abscess specimen 82 27. Liver. Roundworm invasion through large common duct, showing small abscesses • 83 28. Liver. Roundworm invasion through large common duct, showing smair abscesses • 84 29. Ovarian cysts 87 30. A six months' abdominal lithopedion, carried seven years ... 88 31. Filaria nocturna 96 32. Head end of Filaria nocturna 96 33. Filaria nocturna 97 34. Beginning elephantiasis in an American in Manila 100 35. Chronic elephantiasis nostras streptogenes of scrotum and leg . 101 36. Neurofibromatosis resembling elephantiasis 102 37. Silk covered with memlirane at angle with parietal peritoneum shows ectropion 109 38. Instruments for inserting silk in peritoneal cavity 109 39. Silk for insertion in peritoneal cavity 109 40. Gangosa cases in Guam with nasopharyngeal involvement . . . 118 41. Group of gangosa cases in Guam 119 42. Group of gangosa cases showing marked disfigurement following nasopharyngeal lesions 120 43. Gangosa lesions 121 44. Extensive gangosa mutilation in a Filipina 122 45. Gangosa 1-3 46. Yaws in Samoa 126 47. Yaws 127 48. Yaws 1-8 49. Gristly healing of tiopical phagedenic ulceration 131 50. Syphilitic ulcerations in Filipino 132 51. "Tropical ulceration." Bone exposed 133 52. Early nodular leprosy 134 53. Advanced nodular leprosy 135 ILLUSTKATIONS FIG. PAGE 1. Encephaloeystoeele 26 2. Enormous goiter with colloid ami fatty degeneration 27 3. Cancer of the mouth and extension to the neck in a betel nut chewer 28 4. Cancer of the cheek and face from primary cancer of buccal mucosa in a betel nut chewer 29 5. Multiple areas of necrosis in acute entamebiasis 38 6. Multiple ulcerations severe chronic entamebiasis 39 7. Typical examples of Ameba and Entameba 47 8. Colon of a man dead from Balantidium eoli infection .... 63 9. Section of large intestine of monkey, showing three Balantidium coli suis in the deeper part of the mucosa 64 10. Section of a mesenteric lymph gland of monkey, showing several Balantidium coli homiuis in the edge of the glandular tissue 65 11. Section of large intestine of a man dead fr.om Balantidial dysen- tery 66 12. Liver. Upper surface showing minute multiple foci of secondary infection from entamebiasis of the colon 70 13. Liver. Cut surface of same specimen as Fig. 12 . . \ . . . 70 14. Liver. Section of right lobe with large multiple abscesses ... 71 15. Liver. Solitary superficial entamebie abscess on outer surface of right lolie 72 16. Curvilinear incision to expose 9th and 10th ribs 72 17. Eesection of four inches of 10th rib; resulting gutter to be closed immediately by catgut suture 73 18. Cavity or gutter left by rib resection, partly sutured .... 73 19. While incision into the peritoneal cavity is being made the mobilized chest wall is held firmly against the diaphragm In- two fingers of an assistant "^ 20. Edges of chest wall and diaphragm, which are to be united by suture, held apart '^5 21. Suture of chest wall and diaphragm completed, showing exposure of liver "6 22. Mikulicz pack to procure adhesions after failure to find an aliscess 77 14 ILLT'STRATIDXS 15 FIG. PAGE 23. Drain in place, gauze ring aiouml tulio to prevent soiling- of peri- toneum and to form aflliesions 78 24. Diagrammatic sketch showing layers incised ami digital method of temporarily preventing pneumothorax till diaphragm and chest wall are sutured • 79 25. Combination drain and hemostat for liver abscess SI 26. Combination drain and hemostat inilated in a liver abscess specimen 82 27. Liver. Roundworm invasion through large common duct, showing- small abscesses ■ 83 28. Liver. Roundworm invasion through large common duct, showing smair abscesses • 84 29. Ovarian cysts • 87 30. A six months' abdominal lithopedion, carried seven years ... 88 31. Filaria nocturna 96 32. Head end of Filaria nocturna 96 33. Filaria nocturna 97 34. Beginning elephantiasis in an American in Manila 100 35. Chronic elephantiasis nostras streptogeues of scrotum and leg . 101 36. Neurofibromatosis resembling elephantiasis 102 37. Silk covered with membrane at angle with parietal peritoneum shows ectropion 109 38. Instruments for inserting silk in peritoneal cavity 109 39. Silk for insertion in peritoneal cavity 109 40. Gangosa cases in Guam with nasopharyngeal involvement . . . 118 41. Group of gangosa cases in Guam 119 42. Group of gangosa cases showing marked disfigurement following nasopharyngeal lesions 120 43. Gangosa lesions 121 44. Extensive gangosa mutilation in a Filipina 122 45. Gangosa 1-3 46. Yaws in Samoa 126 47. Yaws 127 48. Yaws 1-8 49. Gristly healing of tiopical phagedenic ulceration 131 50. Syphilitic ulcerations in Filipino 132 51. "Tropical ulceration." Bone exposed 133 52. Early nodular leprosy 134 53. Advanced nodular lepros}- 135 16 ILLUSTRATIOXS FIG. PAGE 54. Pure nerve leprosy 1.36 55. Xerre leprosy. Infiltration of hand 1.37 56. Xerve leprosy. Plantar jiedis ulcer 138 57. Macular leprosy 139 58. Madura foot 149 59. Ainhum 151 GO. Female pregnant chigger 152 61. Male chigger 152 62. Goundou and leoutiasis 153 63. Pyogenic infection of hand 156 64. Pyogenic infection picture taken at a time when gangrene of the forefinger had set in 157 65. SjTnmetrical fibromata 180 66. S.^Tnmetrical fibromata on forearms and ankles 181 67. "Fuente, " showing ball of wax in ulcer for permanent counter- irritation against all diseases 182 68. The Bevan incision for splenectomy, method of using gauze pack for temporary hemostasis 291 69. Closure of sx:)lenic si^ace by snaking catgut suture ...... 295 TROPICAL SURGERY AND DISEASES OF THE FAR EAST PART I THE CONDITIONS SUPPOSED TO MODIFY SURGICAL PROCEDURE IN THE TROPICS, SURGICAL DISEASES RARELY SEEN ELSEWHERE, AND THOSE SEEN MOST- LY IN EQUATORIAL LANDS BUT TRANSPORTABLE TO OTHER COUNTRIES AND LIKELY TO COME WITHIN THE EXPERIENCE OF ANY MEDICAL MAN. CHAPTER I INTRODUCTION The sixty degrees of latitude of tlie earth's surface in the torrid and subtorrid zones, embracing forty-seven countries with a billion people, are the future treasure houses of the world, and it is the Western medical man who will make possilile the evolution of these undeveloped l)ut no longer far-off or mysterious lands by converting their waste places into suitable habitations, not only for tlieir own populations, but also for the exotic human transplant wlio will 1)e necessary for the initiation oP the change. The white man's dread of tropical disease and trop- ical sunlight has been proved unfounded. After a few slight physiologic irregularities, which soon adjust them- selves, he has little to fear from so-called tropical dis- eases, which are all infections, are usually avoidable, and 17 18 TROPrCAI. .SURGERY AXD DISEASES Avliose treatment is now so well nnderstood that the death rate of the white races in well-ordered trox)ical colonies is as low as in onr hest regnlated cities in Europe or America. Knowledge of the diseases of other parts of the world is as important to medical men, especially to medical officers of onr armies, as is information concerning their connnercial needs and resources to the business world liecanse all are being brought ever nearer to- gether by the world war and by constantly improving methods of communication. It was not so very long ago that the development of a few cases of a dreaded epi- demic disease, brought from some far off pestilential spot, struck terror from the coast to the interior and paralyzed our commerce to the extent of millions of dollars. The former panics, the blind and costly errors hastily made for protection, are unheard of now because scientific medicine has discovered the methods of the transmission of disease and promptly and quietly safe- guards human life and commercial interests with a min- imum of public alarm. The world's debt to experimental medicine can not be calculated. Vaughan has pointed out that the glory of ancient civilizations departed on account of disease and that the map of the earth has been changed far oftener by microbes than by wars. In China in the fourteenth century thirteen million died from the "Black Death" and in Europe from 1347 to 1350 twenty-five million per- ished from the same cause; in the eighteenth century, sixty million people died from smallpox in Europe alone. For centuries men have sought the causes of yellow fever, plague, malaria, and other diseases, and some of the guesses were near the mark. The Egyptians made the cat a sacred animal because where cats flourished there was no plague, but the relations between the cat and the rat did not suggest anvthing. Sir Henrv Blake saw a med- IXTltODrCTlOX 19 ieal l)()()k in C'cyloii, t'oiirtccii liuiidi-ed years old, wliifli charged the mosquito with eai'i'viiig inaUu-ia. But it was not until twenty years ago that the principle of insect- borne diseases was fully established. ]\Ianson, in 1883, proved the mosquito to be the intermediate host of fila- ria, while Sir Ronald Ross demonstrated the real truth of the principle of insect-borne diseases only seventeen years ago ; he little dreamed that it was to be but the be- ginning of a long series of related discoveries which would entirely end humanity's helplessness in the face of epidemic disease. To Koch we owe our knowledge of cholera, plague, and African tic fever. Reed, Carroll, and Lazear of the Medical Corps of the United States Army, proved, — Lazear at the cost of his life and Carroll al- most, — that the Stegomyia plays the same role with "Yel- low Jack" that the Anopheles does ^\T.th malaria. In a one thousand bed military held hospital full of typhoid, at Jacksomille, in 1898, Reed, Vaughan and Shakespeare, as a conmiission, demonstrated to us that millions of germs Avere on the feet of our millions of flies and that they carried the infection from the latrines direct to the mess tables. Amebic dysentery should soon be under control owing to the epochal work by AYalker (1914) and to the discovery of emetin by Rogers (1912). Thus the new creed of universal health bans the moscpiito breeder of malaria, filariasis, and dengue, the flea of bubonic plague, the lice of typhus, the tsetse fly of sleeping- sickness, and the tic of spotted fever; and man is not the only beneficiary, but his domestic animals as Avell. The prevalence of the epidemic diseases in the torrid zone has made it the great field for research and relief workers, and today millions of souls in and near the equatorial belt are freed, not only from the devastation of epidemic diseases, but also from that of the hookworm Avhich AVickliffe Rose has shown in his i-eport of 1911 has deprived them of two-thirds of their efficiency ; Africa is 20 TROPICAL SURGERY AXD DISEASES awakening- from the sleeping sickness which made it " Tlie Dark Continent," and preventive medicine is every- where writing new geography of habitable territory and commercial opportnnity. To the tropics, when cleaned up, we can look for the world's future supjDly of food, as our grazing areas are being rapidly encroached upon for farming purposes and the corn and wheat areas are dwindling in proportion to the increase of population. And the beauty of it all is that the economic value to the Avorld of scientific medical research is represented by only an insignificant fraction of its cost, while it makes pos- sible the development of any section of the earth, pro- vided the price of its sanitation is furnished. The work of Surgeon-General Gorgas, which will eventually be acknowledged as the greatest single achievement which made the success of the Panama Canal possible, Avas clone for five ]3er cent of the total expense. Any nation or any community at home or abroad can now fix its own death rate b}^ the amount of money it is willing to spend. It has become almost axiomatic that preventable ill health is a social crime and that the man or the community that suffers in consequence has only self to lilame. In writing on the surgery of these lands in its diag- nostic and therapeutic aspects it is not possible or desir- able to sharply separate the surgical from the medical and from the other general conditions; the subject needs to be treated as a whole or a wrong conception will be acquired of the snrgical problems encountered. Our greatest lesson from the combination of modern science and business in the treatment of disease an^^^vhere, is that there is absolutely no competition between the med- ical, the surgical and the other branches of our art, so that in remedial measures surgery is merely the mechan- ics of therapy. The general principles of pathology, therapeutics, and operative technic, common to all fields of surgery, apply INTHODUCTIOiSr 21 in all i^arts of the Avorkl. Strictly tropical diseases are few and unini})ortant and can be described in a few words. ' ' Tropical disease " is a term of convenience, but is liardly more accurate than would be the term ''arctic disease;" though frost bite may be as rare in the tropics as heat prostration is in the arctics, neither affection could be classified as a strictly climatic condition. Cer- tain surgical, as well as medical, diseases, whose causative agent is ubiquitous, flourish best in the warm countries, but their frequency and their control depend uiDon per- sonal hygienic and general sanitary measures whose prin- ciples are also as universally applicable as are those of surgery. Good surgery, like gold, is wherever one finds it and is not modified in any way by climate. So-called tropical surgery and tropical medicine are only medicine and surgery as they occur in the tropics. All diseases are cosmopolitan; their relative incidence and the general conditions under which they occur make the only differ- ence. CHAPTER II SURGERY AND SURGICAL OPERATIONS Correct clinical surgery does not vary anywhere in the world; the organization of a proper clinic in the tropics requires the assembling of exactly the same units and material as elsewhere ; untoward results of any oper- ation can always be traced to a defect in technic. The most serious condition facing a clinic in the Far East is the distance from bases of supply and the absence of a body of trained doctors and nurses from which to select and develop an operating personnel, because when an op- erating group is brought together, the vacations, sickness and vacancies, which are always occurring, are often hard to fill without sending to the homeland or Europe for substitutes. There is some discomfort in the operat- ing rooms during the warmer months, but with a mini- mum of clothing, masks, and gauze wristlets to take care of excess perspiration and with the normal ecpianimity of a surgeon, one gets along very nicely and can do nearly as much work as in other climes. Plenty. of clean air without draughts is obtainable l)y using double wire screens on large Avindows near the ceiling. The usual before and after technic also obtains and the average stay in hospital is the same as in Europe or xVmeriea. It seems characteristic of the native races wherever they may be that the surest way to their confidence is through efficient medical and surgical aid. Once the word goes out that diseases hitherto regarded by them as hope- less can be cured, patients apply for relief and accept without question any measures proposed, a mental atti- tude greatly to their advantage. When we first offered the Filipinos major surgery, they regarded the idea with 22 SITRGERV AND SURGICAL OrKRATIONS 23 horror until influenced by successful cases; then eighty- five thousand of them applied during the third year of the Philippine General Hospital which was opened in 1910. Surgically the Philippines are an nnseratclied, virgin field. From a superficial survey of five hundred thou- sand inhabitants living outside of Manila, I o1)tained data of over ten thousand surgical cases and all of the lesions reported were the visible tumors, swellings, and deformi- ties of the unclothed parts of the body. In this country and in Europe the laboratory is not always the essential feature in diagnosis to the extent that it is among a people where the finding of one definite cause of illness is hardly ever sufficient to account for a patient's condition. Since Oriental and other insanitary races have enjoyed a contact with Western civilization, and have begun dying out, it is not unusual to find a single individual wdth malaria, tuberculosis, syphilis, gonorrhea, a drug habit, filariasis, severe skin lesions, other sources of systemic disease, amebas and three or four other intestinal parasites in addition to his surgical atfection, and yet to find that he is not entirely disabled by any of them; there is also the ever-present possibility of an epidemic disease such as cholera, pox or plague, all of wdiich tends to develop the successful medical man into an Argus-eyed individual. Consequently, diagnosis and treatment, at their best, require, not only a far greater application and correlation of laboratory findings and bedside observations than in our climes, but all of the general and physical conditions of these peoples must be appreciated and taken into consideration as well. The fish and vegetable diet, nonindulgence in alcohol and the placid existence led by the majority of natives are to their advantage. They take anesthetics quietly and react fa- vorably after severe operations. The average pulse is lower, the blood pressure about the same as in the United States, and the temperature about one degree subnormal. 24 TROPICAL SURGERY AXD DISEASES The anesthetic in the Philippines is ether, given by the drop method. Miss Emma Ochsner, official anesthetist for a time in Manila, noted that it requires yjerhaps fifteen to twenty per cent more ether on account of the rapid evaiioration than in temperate zone clinics, also that on account of the dark skins of natives, j^allor or conges- tions were not readily recognized and that the hest index to the oxidation of the hlood during an anesthesia was its color in the operation wound. It is surprising to note the persistent emplopuent of chloroform throughout tlie Ori- ent. There is no excuse for offering a scanty experience of a few hundreds or even a few thousands of chloroform anesthesias without a death, as justification for using this dangerous, long since discarded drug. One thing to be always borne in mind concerning the postoperative treatment in dealing with the most igno- rant classes is, that the surgical dressings must be ap- plied so that they can not be removed; the patients are very apt to take them off if there is much pain or dis- comfort. CHAPTER III DISEASES OF THE HEAD, NECK, AND THORAX THE HEAD AND NECK Ilarelijj and cleft j^alate seem very common, probal)ly because these cases are never repaired. Incised wounds are very frequent on account of the universal use of the bolo and knife in settling disputes. Several cases were seen in which the lips and a piece of the tongue have been cut off as jDunishment for spying during military times. In two cases in which the mutilation resulted in a pencil-sized hole where the mouth had been, a useful and presentable mouth was made by plastic surgery. The anterior nares were found closed in a number of children by the scars of smallpox. The angiomas, cysts, and neu- ralgias are not common. A few cases of Recklinghau- sen's disease in young people were seen and removed. Impaired nutrition of the cranial bones from rickets is evidenced in the frequently noted cuboidal head. There is little tendency to the general or irregular bony over- growth conditions occasionally seen in other climes. The congenital anomalies, cephalocele, encephalocystocele, ex- ternal and internal hydrocephalus are rather common and some striking cases are encountered (Fig. 1). Xontrau- matic intracranial hemorrhages, tumors, infectious cere- brospinal fever and other affections of the envelopes of the brain itself, except traumatic and tuberculous men- ingitis and an occasional syphilis of the nervous system are infrequent. In the neck, cysts, fistulas and torticollis are rare. The principal infectious condition is Ludwig's angina which is often met with and is often fatal if neglected. Accord - 25 26 TROPICAL SURGERY AXD DISEASES iiig to the microbic infection, wliicli is usually a mixed one, the process in the lymph nodes is slow or rapid; it is always associated with carious teeth or some mucous membrane infection of the oral cavity. The treatment is early and free incision of the overlying skin and blunt tunneling of the induration to secure drainage. Tuberculous infection of the lymph nodes of the neck is one of the commonest conditions found and it is always associated with infected tonsils and bad teeth. Treat- ment for many years was by excision; later, immuniza- tion with Koch's lymph, the opening of abscesses as they Fig. 1. — Encephalocystocele. (Avithor's collection.) occur and instruction in antitul)erculosis hygiene were recommended. Of malignant growths, Hodgkin's disease is next in frequency to tuberculosis of the neck, and in the Philip- pines, splenic anemia, or Banti's disease, probably a splenic type of Hodgkin's disease, is also frequently- encountered. Xo treatment, except by x-rays, in a few cases, was found effective, and attempts at excision only aggravated the disease. Bunting and Yates '^ recent work holds out some promise of relief. Goiter in all its Med 'Bunting and Yates: The Rational Treatment of Hodgkin"s Disease. Tour. Am. d. Assn., 1915, Ixiv, No. 24. DISEASES OF THE HEAD AND NECK Z( varieties is very common in the Philippine Islands and its course and treatment does not differ from the disease in this conntry. As in all unoperated countries, some extraordinary cases are encountered (Fig, 2). Fig. 2. — Enormous goiter with colloid and fatty degeneration. (Autlior's collection.) A few cases of multilocular lymphatic cysts were seen, one of enormous size that extended far out from the side of the neck, overhanging the shoulder, and extending into the depths of the neck and into the axilla in a young 28 TROPICAL SURGERY AND DISEASES Cliinaman; excision of all of it was imiDracticable, but carbolic acid and tincture of iodine applied to the lining, wliicli section showed to be endothelial, resulted in a cure. Cancer is always secondary in the neck excej)t in tlie sali- vary glands in which mixed tumors are not infrequent. Lipomas, single and multiple, also are mostly found in the neck in the Far East. Nothing unusual was noted in Fig. 3. — Cancer of the mouth and extension to the neck in a betel nut chewer (1911). (Author's collection.) the diseases of the e^^e, ear, nose and throat, or the sinuses of the facial bones. In the mouth, tongue, teeth and jaws, pathology was very frequent and due to defective teeth and lack of oral asepsis. The most common site for can- cer is on the side of the buccal cavity where the betel nut cud is held (Figs. 3 and 4) ; this chew is made of a slice r)T:=;EASI':S OF TflK THORAX 29 of betel, a nut of the Boii^^a jjalm, a ijiiieli of tobacco and some lime, all wrapped in a piece of the acrid astrin- gent buyo leaf. The effect of this fiery bolus, which turns the teeth blood red and black, aided by lesions of the inner cheek, caused by the sharp edges of decaying teeth is to furnish plenty of local irritation for the develox^ment of a primary cancer. Osteomyelitis, fluid-containing cysts, ' % -^\: - j- i'<* Fig. 4. — Cancer of the cheek and face from primary cancer of buccal mucosa in a betel nut chewer (1911). (Author's collection.) and epulis of the lower jaw were more common than in this country. Gangosa is described under syphilis. THE THORAX Perhaps the only diseases of the lungs and the bronchi, very common in the Tropics and unusual or not recog- nized elsewhere, are those due to certain fungi. 30 TROPTCAL SI-Rf;ERY AXD DISEASES Bronchomycosis Castellani, years in Ceylon, now of the University of Naples, lias published many cases since 1905. He de- scribes a bronchomycosis due to a variety of fungi be- longing to the following genera: ''1, Monilia; 2, Xocar- dia; 3, Aspergillus, Sterigmatocystis penicillinm; -1, Mu- cor and Ehizomincor, Lichtheimia; 5, Sporotrichum; 6, Undetermined fungi. The symptoms are somewhat sim- ilar whatever fungus is the etiologic factor. In mild cases there are signs of slight bronchitis with mucopuru- lent expectoration, in which the fungi are found. In severe cases the patient presents all the symptoms of phthisis with hectic fever and hemorrhagic expectoration. Mild cases may become cured spontaneously; they are often benefited by potassium iodide." He describes in detail the form of bronchomycosis due to fungi of the genus Monilia; this type of bronchomycosis being ex- tremely common in Ceylon, it has been possible for him to investigate it more completely. Bronchomoniliasis Synonyms. — Broncho-oidiosis Cast; Bronchoendomy- cosis Cast. Definition. — An infection of the bronchial mucosa, due to fungi of the genus Monilia. Etiology. — In Ceylon, the malady is generally due to ]\Ioiiilia tropicalis; the same fungus is found in cases coming from Southern India and the Malay States, and a very similar one in a ease that apparently contracted the disease in Europe. It would appear that the fungus is the real cause of the disease, as no other etiologic agents, such as the tubercle bacillus, etc., are found. Moreover, when the patient gets better, the fungus be- comes very scanty or disappears completely. In some cases Castellani o])served and described thirteen other DISEASES OF TFTE TIIOIIAX species of Monilia but doubts wlictlici- all of tlieni are pathogenic. The infection niay take pU\ce from man to man, and also, most prol)al)ly by tlie fungi living sapro- phytically in natui'e. Moniliadike fungi are extremely connnon in Ceylon, in tea dust for instance, and it is Yerj probable that the so-called "tea-factory cough" is a type of moniliasis, as in such cases a nionilia is found in the sputum, and monilia-like fungi are constantly found in the tea dust of the factories. Moreover, guinea pigs, in the nostrils of which tea dust is regularly insufflated, de- velop after a time a moniliasis of the lungs. Symptomatology. — A mild and a severe type of the malady may be distinguished. In the mild type the general condition of the patient is fairly good, there is no fever, and he simply complains of cough. The expectora- tion is mucopurulent and very often scanty; no blood. The physical examination of the chest will reveal a few coarse moist rales or absolutely nothing. The condition may last several weeks or months, and may cure spon- taneously, or, continuing, may turn into the severe type. The severe type closely resembles phthisis; the patient becomes emaciated, there is hectic fever, mucopurulent and bloody expectoration. Occasionally, true hemoi^tysis occurs, a teaspoonful or more of bright blood being- spit up at a time. The physical examination of the chest shows patches of dullness, fine crepitations and pleural rubbing. This type is often fatal. Between these two ex- treme types there are cases of intermediate severity, with subcontinuous and continuous fever, more or less definite bronchial, and bronchoalveolar symptoms. Prognosis. — The cases of a mild type may recover spontaneously or under appropriate treatment. Those of the malignant type usually end fatally. Diagnosis. — The diagnosis of moniliasis is based on finding the fungus in the sputum. It is absolutel}" nec- essary that this should be collected in sterile Petri dishes 32 Tr.OPICAL SI'ROEr.Y AXD DISEASES and examined as soon as possible, as sputum exposed to the air becomes contaminated with all sorts of fungi in the tropics. In fresh preparations of the expectoration, spore-like, roundish or oval cells, 4 to 6 micra, are seen, and some mycelial particles. The fungus is Gram-posi- tive. To identify the fungus, cultural researches are necessary. DiFFEREXTiAL DiAGxosis. — Primary bronchomoniliasis as described in this chapter, should be distinguished from the secondary bronchomoniliasis occasionally met with in cachectic patients suffering from cancer, diabetes, tuber- culosis, etc. In such cases there is generally a thrush of the oral mucosa, and the thrush monilia spreads to the pharynx, larynx, and bronchial mucosa, while in primary bronchomoniliasis the oral mucosa is not, as a rule, af- fected. From pulmonary tuberculosis the condition is distinguished by the absence of the tubercle bacillus in the sputum and the negative animal inoculations. Cases of mixed infection, however, tuberculosis and moniliasis, are occasionally met with, the sputum containing both the tubercle bacillus and the monilia fungus. Moniliasis differs from bronchospirochetosis by the absence of spiro- chetes, from endemic hemoptysis by the absence of the ova of Paragonimus westermani kerbert. Treatment. — ]\li]d cases and those of moderate gravity respond quickly to potassium iodide (10 to 20 grains), given well diluted in water or milk, three times daily. When potassium iodide causes severe symptoms of iodism, sajodin in the same doses in cachets may be ad- ministered. In tlie cases of malignant tyj)e Castellani has seen no imj)rovement from the many different treatments tried. Potassium iodide, however, should always be tried in these cases as well as balsamics. The diet should be nourishing; hypophosphates and glycerophosphates, etc., may be tried to keep up the strength of the patient, as in phthisis. CHAPTER IV THE ABDOMEN Xothing- unusual was encountered in thirteen years' experience in the Philippines in the surgery of the abdo- men and its contents, except in the colon, liver, and spleen. Appendicitis, gall duct disease, gastric and duo- denal ulcer were not so frequent as in the United States and consequently s^Tiiptoms referred to the stomach were not so common. Cancer, however, in its usual favorite localities was frequenth^ observed. HERNIA In spite of the fact that the squatting posture of natives while defecating or sitting down, presses the abdominal rings firmly against the thighs, inguinal hernia is rather common among the laboring classes; it has no special points of interest unless it is that the occurrence of the sliding variety, which was encountered many times, is unusually frequent. The Ferguson-E. Wyllys Andrews type of operation was preferred. During military service in Manila during 1900-1901 I operated upon one hundred cases among American soldiers and noted an amount of fat in the cord which might lie described as lipomatous and which required removal in many cases, as at that time the Bassini operation was employed. In natives lit- tle fat was found, but the appendix was a content of the sac in about three per cent, and in three cases in 250, the l)ladder was found; femoral hernia was very rare. All patients were kept in bed tliree weelvs and were cau- tioned against heavy lifting or any overexertion for three months more. 33 34 TROPICAL SURGERY AXD DISEASES THE SPLEEN The patliolog}^ and surgery of the spleen have received special attention at the Mayo Clinic since 1912, and as splenic disease is very common in the Tropics and liith- erto neglected through lack of knowledge concerning it, as an aid to tropic workers, iDermission was secured to use their publications and several are herewith reprinted from ''Collected Papers of the Mayo Clinic," to which reference is suggested for fuller information. This mat- ter will be found in the appendix.. Splenic Anemia and the Kala-azar Splenic anemia, Banti's disease, or splenomegalia, was not uncommon and as a possible relation between this condition and Hodgkin's disease, which is so common in the Philippines, has been recently noted, these islands might be a good field for investigation. Operation was obtained in only a few cases and those were mostly un- suitable on account of extensive adhesions and liver cir- rhosis. Kala-azar, ("Kala-jwar," Indian for ''black disease"), splenic leishmaniosis and internal leishmaniosis, caused by the Leishman-Donovan protozoan, probably identical with the Herpetomonas, attacks especially tlie endothe- lial cells of the circulatory system. This disease is widely distributed in Asia. It is very chronic and in the later stages with the enlargement of the spleen and liver re- sembles chronic malaria in its s^anptoms of sweating, anemia, general pains, skin pigmentation, nose bleed and marasmu-s. It is usually fatal. A iDositive diagnosis is established by splenic or hepatic punctui-e which will usu- ally' reveal the Leishman-Donovan bodies in large num- bers. Recently Dr. Samuel Cochran of Hwai;^'uan, An- hwei, China, has demonstrated that the "bodies" may be found in abundance in any Ijanph node in the body and he TirE ABDOMEX 35 usually takes the most accessible cervical node for diag- nosis. It has been variously described under the names of infantile, Indian, Italian and Malta kala-azar and an enormous amount of investigation has been made. It is to be regarded as infectious and eases should be isolated ; all vermin about botli tlic sick and the well should be de- stroyed and dogs should be closely inspected, as they have a very similar disease. Xo specific has been discovered, and treatment by drugs, principally quinine and arsenic, has not been sat- isfactory. Di Cristina and Caronia^ (1915) have applied Vianna's tartar emetic method in ten cases of internal leishmaniosis, and report gratifying results. They gave it intravenously, injecting from 0.02 to 0.1 gram of a 1 per cent solution of the antimony and potassium tartrate on alternate days. Two_of the patients were moribund. Two others were children and they were much improved ; five others were completely cured and one died from acute nephritis; the dosage in this nephritis case was less than in the others, so that, if the medication w^as in any way responsible for the kidney disease, the kidneys must have been exceptionally susceptible. The total amount ranged from 0.06 to 0.84 gram, given in the course of ten to forty days. The children were between one and six years old; the affection was severe and of two to eight niontlis' standing. Mackie {BrltisJi Medical Jountal, Xov. 20, 1915, p. 7-45) had two prompt cures of kala-azar by injections of tar- tar emetic; one case of the lip and cheek and one case of the spleen and general: intravenous injections of 4 to 6 c.c. of a 1 per cent solution in normal saline every two or three days were used; there was some temper- ature after the first two injections ; the treatment lasted about two weeks ; cutaneous lesions which were slow in healing closed after a few applications of carbon diox- ^G. di Cristina and G. Caronia: Tartar Knietic in Internal I.eishniaiiiosis. Pedriatria, Naples, Feb., 1915, xxiii, Xo. 2, pp. 81-160 36 TRdPICAL SUKGEEY AK^D DISEASES ide sno^v. Two per cent antimony tartrate ointment lias also Ijf/en efficacious. Gaeliet, working in Persia, claims very good i-e suits Avith one or two intravenous in- jectious of arsenobenzol ; as a rule one injection is nec- essary, lie says, but sometimes two are required and tlii^ cure is complete in three to live weeks. Eoiiers (Tropical Disease Bull. y vol. 9, No. 5, March 15, 1917) reported additional eases of Kala-azar among Europeans making 18 successfully treated by intra- venous injections of tartar emetic. He states that of the 18 consecutive cases, 13 were cured; 2 greatly im- I)roved and still under treatment, 2 improved and dis- continued treatment and one died of phthisis. Cases were called cured when ''the fever has comiDletely ceased for two or more months, together with consider- able gain in weight and a restoration of the blood, and especially of the white corpuscles to the normal and de- cided dimiimtion in the size of the spleen.'' Rogers suggests that in view of his results, the use of tartar emetic appears to be worthy of further study in human trypanosuniiasis and sleeiDing sickness in Africa. The injections a\ ere continued two or three months after the fever had ceased and only stopped as a rule when the body weight had nnich increased, the spleen become con- siJeralily re(lnr(M.]. tlie l)lo':)d had approached or reached normal anil tlie parasites had. disap^Deared from the spleen. It is thought that the period of treatment may be reduced liy a more rapid increase of dosage. Treat- ment in adults is i)eoTm with -4 e.c. of the 2 per cent solu- tion, 6 c.c. are oivHH at the second injection and at each subsequent injection one c.c. is added, if no toxic satqi^- toms supervene, up to 8 or 10 c.c. See page 128 for CasteUani's treatment under Yaws. A great many cases of abscess of the spleen have been reported from China, several of which recovered after drainage, out no pathology was given. THE COLOX 6i THE COLON Entamebic Dysentery This disease competes witli malaria for the honor of being the most ubiquitous of endemic tropical diseases. Americans first became acquainted with entamebic dysen- tery in 1898 during tlieir subjugation of the Philii^pines and the respect soon acquired for it was such, that in the early days, although every man was greatly needed for the military operations, the discovery of a single ameba of any sort in the stools resulted in an immediate transfer of the patient to the r'nited States. The only literature then available recognized but one variety of ameba and gave but one prognosis, death within a short time or at the latest in two or three years (Osier). Prob- ably every man of our- entire expeditionary force of over 65,000 men suffered at one time or another from dysenteric boAvel trouble and it was the princi])al cause of disability. In recent years this disease is being found in almost every state in the Union. An enormous amount of investigation has been done by pathologists and pro- tozoologists notably by Schaudinn (1903), Musgrave and Clegg (1904), Craig' (1905), Vedder (1906), Darling (1912), and later by Walker and Sellards (1910-1913), to determine the pathogenicity of the various species and their eti<^logic relationship to endemic dysentery. The recent experiments by AValker and Sellards- conclusively established the etiology; they differ from those hitherto performed: "(1) in the number of comparative tests made of different species; (2) in that experiments have been more carefully controlled and especially in that the species of ameboid organisms fed to, and recovered from, the experimental animal in every case have been deter- mined; and (3) in the fact that the experiments have been -Walker, E. L., and Sellards, A. \\'. : Experimental Entamoeb'c Dysentery, Philip- pine Jour. Sc, Sec. B, Tropical Medical, August, 1913, viii. No. 4. do TROPICAL SURGERY AND DISEASES made, not upon the lower animals, but upon man. ' ' These experiments showed: that the cultivable amebas are non- pathogenic; that the Entameba coli is nonpathogenic; and that Entameba histolytica is the essential etiologic factor in endemic tropical dysentery and that ''Entameba - ■ - -^ ._.J Fig. S. — Colon. Multiple areas of necrosis in acute entamebiasis. (Author's collection.) tetragena Viereck" is identical with Entameba histoly- tica, and "tetragena" cysts are developed in the life cycle of Entameba histolytica; that it is a strict or obligatory parasite and can not be cultivated outside of the body and that the average incubation period of the dysentery THE COLOIiT 39 lias l)een 64.8 days. All of the experimental dysenteries were obtained after ingesting Entanieba histolytica from normal stools of '^carriers." Diagnosis Clinical Symptoms. — Physical weakness, loss of appetite and digestive disturbance with or with- ■--• •^> aum ■T^. Fig. 6. — Multiple ulcerations severe chronic entamebiasis. (Author's collection.) out diarrhea usually indicate the onset of parasitism of the colon by Entameba histolytica, but the relation to the local infection, in which abdominal pain and tenesmus may be entirely absent, is so often overlooked 40 TROPICAL SUEGEPvY AND DISEASES that many cases are treated for the reflex gastric s^onp- toms. The liver at times becomes congested, edematous, and swollen ; back pressure in the portal system aggra- vates the primary colonic disease (Figs. 5 and 6), and it in turn disturbs the liver f^till more and the patient has ^'tropical liver.'.' WliQii the flux is not marked^ and, as too often happens; a diagnosis is not made, these cases, when they die, afford examples of what Niemeyer calls '' mortifying postmortem disclosures." The majority of cases, however, have frequent, mucoid and bloody stools at the outset and vdien the disease is well established, their main characteristic is fluidity. Walker ^iid Sellards acquired information of the great- est value /for the diagnosis, treatment, and prophylaxis of entamebic dysentery as follows: "(1) It will be pos- sible to make an accurate laboratory diagnosis. (2) The distinction between the pathogenic and the harmless enta- meba having been established, there will no longer exist an excuse for the indiscriminate treatment of all persons who show entamebse in their stools. (3) The relatively long incubation period and the ability to diagnose latent infections make it possible to anticipate Avith treatment an attack of entamebic dysentery. (4) Since there is evidence that ipecac treatment, which is very efficient in relieving attacks of entamebic dysentery and causing the entamebee to disappear temporarily from the stools, does not always kill all of the entamebse in the intestine, treat- ment should always be controlled by stool examinations for Entamebse histolytica. By this precaution, relapses, so common in entamebic dj^sentery, can be forestalled. (5) The following data have been acquired upon which to base a rational prophylaxis of entamebic dysentery: (a) Entameba histolytica is the essential etiologic agent in the disease, (b) The specific entameba is an obligatory parasite, and can not propagate outside of the body of it-s host, (c) The motile forms of this entameba, which are THE COLON 41 passed in the l)l<)0(ly mucous stools in acute dysentery, quickly die and disintegrate and are probably, under natural conditions, incapable of withstanding passage through the human stomach, (d) In consequence of the relatively long incubation period of entamebic dysentery, the prevalence of chronic and latent infections, and the frequent failure of treatment to kill all of the entamebse in the intestine, carriers of Entameba histolytica are com- mon in endemic regions, (e) These carriers are con- stantly passing in their stools large numbers of the re- sistant, encysted stage of Entameba histolytica. (6) These facts make it probable that carriers of Entameba histolytica constitute the chief, if not the sole, agents in the dissemination of entamebic dysentery. (7) Prophy- lactic measures should, therefore, be directed toward car- riers of Entameba histolytica, and should include the fol- lowing: (a) The identification of carriers of Entameba histolytica by the microscopic examination of the stools of convalescents, household servants, and other suspects or persons whose employment or associations make them particularly dangerous to the public health, (b) The sanitary disposal of feces, (c) The treatment, controlled by microscopic examination of their stools, of all carriers of Entameba histolytica. (8) Since the incubation period of entamebic dysentery is usually long and latent infec- tions are common, the most efficient personal prophylac- tic measure is frequent stool examinations, as an index for treatment, of all persons residing in endemic regions, in order to distinguish the resting and encysted entameb^e of the chronic and latent infections, w^iich stage furnishes the most unequivocal characters for the differentiation of the pathogenic Entameba histolytica from the harmless Entameba coli." Upon the correct microscopic diagnosis of the specific organism depend the treatment and prophylaxis; as this identification has been subject to many errors 42 TROPICAL SURGERY A:ND DISEASES and tlie extensive practical experience gained by AValker has demonstrated that the microscopic diagnosis can be made with certainty, the subjects as treated by him fol- low in full. ''The material for the microscopic examination for En- tameba histolytica should be a stool obtained, contrary to the prevailing practice, without the previous admin- istration of a purgative. In stools obtained after a pur- gative, Entameba histolytica, if present in the fluid stools, is in a preencysted stage at which it most closely resem- bles the nonpathogenic species, Entameba coli; conse- queiith^, a differential diagnosis between the two species is difficult and often impossible. "It may be objected that Avithout a purgative, infec- tions Avith Entameba histolytica will frequently be over- looked. However, such is not the case. It has been my ex- perience in following many cases of entamebic infection with daily stool examinations, including cases doubly in- fected with Entameba histolytica and Entameba coli, that the entamebse are rarely absent from the normal stools several successive days and that Entameba histolytica is more constantly present, and usually present in larger numbers, in the stools of infected persons than is En- tameba coli. In 930 microscopic examinations made of stools, without the previous administration of a purga- tive, from men known to be parasitized with Entameba histolytica, and who were not undergoing treatment, the entameba) were found 664 times, or in 71.39 per cent; that is, in nearly 3 out of every 4 of such examinations. More- over, the negative results were based on the examination of a single coverslip which was often hurriedly made. The examination under similar conditions of 303 stools of men known to be parasitized with Entameba coli showed the entamebae in 171, or 56.44 per cent of the ex- aminations; in other words, in about 1 out of every 2 of such examinations. THE COLOiSr 4:d *'A further objection that may be raised to the examina- tion of formed stools, is the fact that in such stools usually only encysted entamebcP are to be found. It is an opinion generally held, and which is supported by the statement in all textbooks, that a positive diagnosis of entamebic infection should never be made unless motile entamebas are observed. It is of the greatest importance, however, for the diagnosis of clironic and latent infections that one should be able to distinguish resting and encysted en- tamebre from other bodies found in feces and to differ- entiate the cysts of Entameba histolytica from those of Entameba coli. This can be done with certainty by the experienced jorotozoologist. The majority of the 1,233 examinations mentioned in the preceding paragraph were made of formed stools containing nonmotile and encysted, chiefly encysted, entameb^e. Moreover, it is the encysted stage of the entameba that furnishes the most unequivo- cal characters for the differentiation of the pathogenic Entameba histolytica from the harmless Entameba coli. ''In the examination of liver abscess pus for Entameba histolytica, the pus first obtained after the operation usually does not contain entamebse; frequently they ap- pear in the pus from the drainage tube only after several days. The explanation of this is to be found in the fact that the entamebse are not found in the pus of the abscess, but only in the tissues of its walls. Consequently, it is only when the walls of the abscess begin to slough olf that the entamebse appear in the drainage from the abscess. Therefore a negative diagnosis of entamebic liver abscess should never be made except after negative examinations obtained for several successive days after operation. ''Dysenteric or diarrheal stools should be examined as soon as possible after they are passed, since the motile entameb?e present in such stools quickly die and disin- tegrate. On the other hand, in the formed stools of 44 TROPICAL SURGERY AND DISEASES chronic and latent infections, the encysted entamebse l^ersist unchanged for days, and consequently the exam- ination can be made at one's leisure. ' ' In making the examination, a small platinum loopf ul of the fluid or semifluid material should be placed on a microscope slide and the cover-glass dropped upon it. Slight pressure may be exerted, if necessary, upon the cover-glass with the forceps to cause the material to flow as a thin film between the cover-glass and slide. If the stools be more or less formed, a small drop of water should be placed upon the slide and a minute portion of the stool rubbed ui^ in it, forming a fairly thick suspen- sion of the feces in the water, upon which the cover-glass should be placed. A satisfactory preparation must be thin, but there should not be an excess of fluid which will permit the cover-glass to float about when the oil-immer- sion objective is applied to it. A warm stage is not neces- sary for making the examination. ''The ad^'antage of a preliminary examination of the preparation with low magnification (Leitz 3 to Zeiss AA objective) can not be overestimated. It enables the ex- aminer to make a rapid survey of the whole preparation and to pick out the individual entameb;© for ex- amination with the oil-immersion objective. When the entamebse are few in the preparation, they can be found with difficulty, if at all, with higher mag- nification. AVith a Leitz 3 or Zeiss AA objective and a 3 ocular, the entamebge appear as round, oval, or irregular, colorless, and refractive dots which with proper focusing stand out distinctly in the back- ground of the preparation. Practical experience will en- able the microscopist to distinguish them from certain other bodies that are met with in stools. By applying the oil-immersion objective — most conveniently used with the dry objective on a revolving nosepiece — to every body in the preparation that looks suspicious under low magni- THE COLON 45 fication, this oxpericnce will soon be attained. Indeed, it is not only possible for the experienced microscopist to identify an entameba with the low nui^'nification, but to distinguish a cyst of Entameba histolytica from one of Entameba coli with a considerable degree of certainty by the difference in its size and refractiveness. A suspected entameba, having been located in the preparation with the low power objective, should then be examined with the K2 oil-immersion objective. With this magnification the entamebffi present' certain morphologic characters that enable the experienced investigator to identify them, whether they be in the motile, resting, or encysted stage. The motile forms- will give little difficulty, even to the novice, since their movements are characteristic. ''The resting entameba is distinguished from other bodies found in the stool by its size, distinctness, regu- larity of contour, degree of refractiveness, and especially by its nuclear structure. The entamebse vary in size within considerable limits, but are usually from 20 to 30 microns in diameter. They are, therefore, larger than pus cells, or other protozoa, with the exception of Balan- tidium coli, that are found in the stools of man. They are also more refractive than pus, epithelial, or other cells found in the stools. The nuclear structure of tlie enta- mebse is particularly characteristic. The unencysted en- tamebse possess, unless in the process of division, only a single nucleus. This nucleus is round, or occasionally slightly oval or irregular, small with reference to the size of the cell, and appears not solid but as a refractive ring (Fig. 7 — 3, 5, 6, 7). This relatively small, ring- shaped nucleus appears to be absoluteh" diagnostic of an 'entameba. Only one other kind of cell observed in stools possesses a nucleus in any way resembling that of an entameba. This is an epitheloid cell, sometimes found in mucous stools, which has a ring-form nucleus relatively much larger than that of an entameba, occupying one- 46 TROPICAL SURGERY AISTD DISEASES Fig. 7. (From water-color drawiugs by Teodosio S. Espiuosa) The illustrations in Fig. 7 are all drawn from fixed and stained prepara- tions at the magnification of Zeiss 140 oil-immersion objective, ocular 3, and tube length of 160 millimeters, and with the aid of a camera lueida. 1. Motile form of a typical Ameia, cultivated from the Manila water supply. Note the small size, central arrangement of the chromatin in the nucleus, and the contractile vacuole. 2. Encysted form of the same species of Ameia. Note the small size and single nucleus with central arrangement of the chromatin. 3. Motile form of Entameba coli, from the stool of a healthy person. Note the dense, granular structure of the cytoplasm, the relatively large amount of chromatin and its peripheral arrangement in the nucleus. 4. Encysted form of Entameia coli, from the stool of a healthy person. Note the large size, the relatively thick cyst wall, the 8 ring-form nuclei, and the absence of ' ' chromidial bodies. ' '" 5. Motile form of Entameia liistolytica, from the stool of an acute case of entamebic dysentery. Note the reticulated structure of the cyto- plasm and the scanty chromatin in the ring-form nucleus. 6. Tlie "tetragena" type of motile Entameba liistolytica, from a chronic case of entamebic dysentery. Note the structure of the nucleus. It contains a heavier peripheral ring of chromatin — a part of which is detached from the nuclear membrane — than in the tj-pical histo- lytica ; and there is a central karyosome, consisting of a central granule surrounded by a circle of chromatin granules. 7. The preencysted stage of Entameba histolytica, from a ''carrier" case. Note the small size, dense cytoplasm, and heavy peripheral ring of chromatin in the nucleus, which causes it to resemble a small Entameba coli. 8. Encysted form of Entameba histolytica, from a convalescent case of entamebic dysentery. Note the small size, the cyst wall, the 4 ring- form nuclei, and the ' ' chromidial body. ' ' THE COLON Fig. 7.— Typical examples of Ameba and Entameba. (Walker and Sellards: Entamebic Dysentery, Philippine Journal of Science, vol. vui, No. 4.) 48 TROPICAL SURGEEY AND DISEASES fourth to one-half of the cell. While an entameba may occasionally be observed with an abnormally large nu- cleus, probabl}^ preparatory^ to division, the nucleus never approaches the size of the nucleus of the epitheloid cell. The latter cells are also less refractive and granular than entameb^e. "Tlie encysted entameba is round or slightly oval, more refractive than the resting or motile stage, and is surrounded by a more or less distinct cyst wall. The nuclear structure here also is characteristic. The cyst contains several (from 2 to 8, depending upon the species of entameba and the stage of development of the cyst) ring-form nuclei usually smaller than, but of the same structure as, the nucleus of the motile entameba (Fig. 7-4,8): ' ' The technic and descriptions so far given refer to the examination of living entamebse in fresh stools. This method of stool examination of entamebas is the quickest and for general purposes of diagnosis the most satisfac- tory. The preparation of stained specimens takes more time and a more extensive technic, and certain distinctive characters of the entameba are lost in the fixed and stained preparation. On the other hand, staining some- times assists in bringing out the details of nuclear struc- ture, and is necessary for making permanent prepara- tions of entamebae, *'The technic of fixing and staining entameba which has given the most uniformly satisfactory results is as follows: A thin smear of the fresh feces or liver abscess pus is made on a cover-glass, fixed in sublimate-alcohol mixture or Zenker 's fluid for from five to fifteen minutes, thoroughly washed in distilled water, stained in aqueous alum hematoxylin from three to five minutes, washed in distilled, water, passed through successive grades of ab- solute alcohol, cleared- in xylol or oil origanum, and mounted in xylol balsam. All of the stages of this process TPTE COLOlSr 49 are most conveniently carried out by floating the cover- glass, preparation downward, upon the surface of the different liquids contained in watch glasses. The prep- arations should be fixed moist and should not be allowed to become dry throughout the process of staining and mounting. ''The sublimate-alcohol mixture consists of 2 parts of a saturated aqueous solution of mercuric chloride and 1 part of absolute alcohol. The sublimate solution should be saturated warm and should be kept in stock. The absolute alcohol should be added in proper proportion only at the time of using, because alcohol evaporates and the solution changes in standing. ''The aqueous alum hematoxjdin has the following composition: Hematoxylin crystals ■ 1 Saturated aqueous solution of ammonia alum 100 Distilled water 300 Thymol a crystal "The hematoxylin crystals are dissolved in the water by the aid of heat, and the other substances added to the solution. The stain should be ripened for from i\ week to ten days in a flask or bottle loosely plugged with cotton. It is then readj^ for use and should be kept in a tightly stoppered bottle away from the light. It Avill keep in good condition for several months. "Bodies that are liable to be mistaken for entamebiie in the stools include air bubbles, fat globules, starch or pro- tein grains, pus and epithelial cells of the host, and cer- tain unicellular vegetable organisms. Of tliese, air bub- bles, fat globules, and starch or protein granules of un- digested food, while possibly deceptive with low magni- fication, should from their structure cause no difficulty when examined with high magnification. Stools contain- ing mucus or pus often contain many cells which are confusing to the inexperienced microscopist. It will as- 50 TROPICAL SUEGEEY AND DISEASES sist the observer if he remembers that these pus and epithelial cells with few exceptions are distinctly smaller than entamebtTe. It will, therefore, be necessary only to take into consideration cells which, when viewed with the low magnification, are distinctly larger than the average. ''In feces containing pus there are sometimes present large round cells of uncertain identity which in size and general appearance closely resemble resting or encysted entamebse. The cells contain from one to several small, round or irregular, refractive, nucleus-like bodies that stain like chromatin. It is possible that they are cells showing degenerative changes with fragmentation of the nucleus. These cells are, however, readily distinguished with high magnification from entamebEe by the structure of the nucleus-like bodies, which are not ring-form, but solid chromatin masses. Motile forms of entameba also will be frequently found in such stools, which will aid in the diagnosis. "Certain unicellular vegetable organisms known as Blastoc3'tis hominis BrumiDt, which are believed to be allied to the yeasts, are found rather frequently in the stools of man in the Tropics. Smaller forms of these cells have been mistaken for the cysts of Trichomonas intesti- nalis, and the larger forms simulate the encysted enta- mebffi very closely in size and general appearance. They are, however, slightly less refractive than the cysts of Entameba, and can, therefore, be distinguished by the experienced observer, even with low magnification. Un- der high magnification tliej are seen to have a wholly different structure from the cysts of Entameba. They are round, oval, or slightly irregular, and possess a distinct wall. The protoplasm is restricted to several narrow seg- ments of the cell, and contains from one to several gran- ules staining like chromatin. The main body of the cell is filled with a homogeneous, hyaline, slightl}^ refractive, and often faintly yellow mass, the nature of which is THE COLOlSr 51 doubtful, but it probably represents reserve food sub- stance. "An examination of Figs, 3 to <5 in Fig. 7 Avill give a good idea of the general morphology of the entamebfe. Figs. 1 and 2 show the motile encysted stages of a typical nonparasitic ameba for comparison with the entameba. "The differentiation of Entameba histolytica from En- tameba coli depends upon certain morphologic characters of the two species which are very distinctive at certain stages, but less distinctive at other stages, of the develop- ment of the two species. These stages of the development of the parasites are correlated with the clinical manifes- tations of the infection and especially with the consistence of the stools of the host. Therefore, the comparative morphology of Entameba histolytica and Entameba coli are most conveniently discussed in relation to the nature of the stools in which they are found; nameh^, (1) in dysenteric stools, (2) in diarrheal stools and stools after a purgative, and (3) in formed stools. 1. Ix Dysexteeic Stools "Both Entameba histolytica and Entameba coli occur only in the motile stage in dysenteric stools; and, when double i)arasitization exists, Entameba histolytica is usually the more numerous in such stools. "Size. — The size of both histolytica and coli are sub- ject to wide variations, and little dependence can be placed on this characteristic for diagnostic purposes. In dj^senteric stools histolytica often appears larger than coli (Fig. 7 — 3 and 5). That this larger size of histolytica is only apparent, and not real, is probable from the fact that in the encysted stage (the onl.y stage in which reliable measurements can be made) histolytica is almost invari- ably smaller than coli (Fig. 7 — 4 and ^ v'- Fig. 10. — Section of a mesenteric lymph gland of monkey, showing several Balan- tidium coli hominis in the edge of the glandular tissue. (Walker: Experimental Balantidiasis, Philippine Journal of Science, \'III, B, No. 5.) that some of the inorganic salts of mercury or silver, given by mouth or hypodermically, might be efficient, as they are eliminated in part by the mucosa of the large intestine, but the local treatment is impracticable because they are precipitated by albumin and are relatively "Walker, E. L. : Quantitative Determination of the Balanticidal Activity of Certain Drugs and Chemicals as a Basis for Treatment of Infections with Balantidium Coli, Philippine Jour. Sc, 1914. 66 TROPICAL SURGERY AXD DISEASES toxic to man. The practical value of the organic com- pounds of silver which possess considerable balanticidal activity can be determined only by clinical experience. Bacillary Dysentery Bacillary dysentery, caused by groups of closely re- lated bacilli, is sporadic and prone to become epidemic. Fig. 11. — Section of the large intestine of a man dead from Balantidial dysentery- (Walker: Experimental Balantidiasis, Philippine Journal of Science, VIII, B, No. 5.) The accepted etiologic organisms are the Shiga bacillus and the Flexner bacillus associated with the Bacillus coli, which occur throughout the intestine but principally in the lower bowel. The onset may be sudden, although a premonitory period of gastrointestinal disturbance of one or two days is not uncommon; this is characterized by griping, tenesmus, fever, and diarrhea until blood and THE COLOX 67 mucus form the entire discharges with a continued desire to defecate. The most severe cases have resulted fatally, within four days, from gangrene of the colon ; mild forms often recover on the third or fourth day while still in the mucous stage. The surgical complications are few com- pared with entamebic dysentery. Allbutt and Eolleston mention arthritis of the large joints as a rather frequent sequel; general sepsis and even pyemia, with parotitis, diffuse abscess or peritonitis are also occasionally met with. Tlie liver in the majorit}^ of severe cases shows more or less evidence of hepatitis with congestion, but abscess formation is very rare. Paralysis of the loAver extremities, of the sphincter ani or of the bladder, hemor- rhoids, prolapsus ani, cystitis, nephritis, and especially gastroduodeno-hepaticoi3ancreatic disorders are most common. Under treatment by drugs the disease has a mortality of ten to thirty per cent. The antitoxic serum prepared by Shiga from the bacillus strain bearing his name is fol- lowed by remarkable results and a mortality of less than one per cent in cases infected by the bacillus; no serum against the Flexner bacillus or other acid strains seems to be effective as at present prepared. Vaccine treatment has not been successful. A description of other surgical diseases of the colon such as tuberculosis, carcinoma, dilatation, prolapse and infections, secondary to general diseases, would not differ materially from these conditions encountered elsewhere. General Intestinal Parasitism At least seven different parasites influence surgical prognosis and give rise to dysenteric symptoms; amebic, malarial, balantidial, kala-azar (not yet found in the Philippine Islands), schistosomal, bacillary and esoph- agostomal (not yet found in man in the Pliilippine Islands). bo TROPICAL SUEGEEY AXD DISEASES Many forms of verminous disturbance of the intestinal function remain to be described. Statistical studies of the evidence of intestinal worms among Filipinos, al- though so far based mostly on but one coverslip prepara- tion with no preliminary catharsis, nevertheless show that such intestinal parasites as ascaris, trichuris, hookworm, ox^niris, tenia, hymenleiDsis, and strongyloides are so com- mon that at least one hundred per cent of Filipinos har- bor one or more species of these intestinal worms; there are very few single infections per one hundred persons and 1.85 infections per person seems to be a fair estimate of intestinal helminthiasis among Filipinos. These esti- mates are based on the examinations of 19,302 natives from every part of the Islands. To this may be added the examinations of the stools of over 6,000 Filipinos in St. Paul's Hospital, Manila, from 1905 to 1910, which showed about 1.50 infections per person. Lartigau has shown that bowel parasites and their products and bowel bacteria are carried to the liver b}^ the portal system and that on their way back to the l30wel they not only excite disturbance of heioatic struc- ture and function, but cause various infections of the bile tract and mucosa; the gut again suffers by receiving the secretion of a damaged liver and a pathologic vicious circle is established. They also cause profound reflex disturbance of function in the gastroduodeno-hepatico- pancreatic physiologic system secondarily, by acting as irritants in the large bowel, just as a chronic appendix reflexly causes gastric and duodenal disturbances, which in turn interfere with the mechanism of secretion, storage, and outflow of digestive secretions and of bile, thereby producing conditions favorable both for bacterial infec- tion in the gall bladder and for systemic infections. The importance to the surgical patient of correcting these intestinal conditions is very great: for instance, nearly fifteen per cent of Philippine typhoids have hemorrhages. THE LIVER 69 THE LIVER Entamebic Abscess It is merely another tribute to the marvelous ability of the liver to dispose of the poisons and pathogenic or- ganisms which pass in contact with its cells, that abscess, secondary to a colon parasitized with entamebte, is not more frequent; because the parasites are usually to be found in the portal vessels together with the daily output of other septic and toxic substances from the diseased gut. Interpretation of clinical signs and symptoms and the treatment of liver infections demand consideration of the following: the extensive relationship of the organ to other derivatives of the i:)rimitive gut; its wonderful function; its fixed, for clinical purposes, position: its great friability; its great vascularity, especially during the portal obstruction and back pressure of an. acute hepatitis ; that its veins have no valves and lack contract- ible tissue ; that it has two vascular systems, the main trunks of each in one pedicle, which can be completely controlled by digital or f orci-pressure ; and finally the clinical importance of the accessory portal systems and the variations in their blood pressure. Diagnosis ai^b Treatmeis^t of Liver Abscess When the colonic infection is chronic, there often oc- curs an acute parenchymatous, cloudy swelling of the liver in which an ameba-laden embolus from a septic thrombophlebitis of the ulcerated colon finds both lodg- ment and the conditions favorable for developing an ab- scess. Enlargement of the liver and an exacerbation of the dysentery, rise of temperature, marked leukocytosis, sweating, pain between the ribs on pressure and in the shoulder, make the diagnosis easy; but some solitary abscesses are practically without symptoms until they become large and cause marked pain from tension, or 70 TROPICAL SUEGEEY AXD DISEASES until a dry grmiting cough indicates threatened perfora- tion into the king. Exploratory puncture is dangerous, unless one is prejDared to follow up a discovery of pus l)y immediate operation before withdrawing the needle. Fig. i: -L,iver. Upper surface shov/ing minute multiple foci of secondary infection from entamebiasis of the colon. (Author's collection.) Fluctuation can of course never be detected. When the diagnosis is difficult and the patient's condition is fair, one can often safely follow an expectant plan for a fortnight or longer. Fig. 13. — Liver. Cut surface of same specimen as Fig. 12. (Author's collection.) The proi^er way to examine a liver for pus is to expose sufficient of its surface to allow of thorough and re- peated hollow needle exploration from day to day; this is readily provided for by jDacking a wound widely open until adhesions have formed about an opening that is THE LIYEPv 71 floored l)y the liver, preferably on the outer surface of the right lobe. As emetin liypodermically will search out and destroy entaniebse Avherever they may be in the living tissues, entaniebie liver abscess, unless a mixed infection, is now very soon arrested, rendered sterile as to para- sites, and needs drainage for a short time only to effect a cure of the large solitary variety. Fig. 14. — Liver. Section of right lobe \vi;h large multiple abscesses, showing beginning coalescence of three central abscesses. (Author's collection.) It is possible that the hitherto hopeless form of mul- tiple, minute abscesses (Figs. 12 and 13), sprinkled throughout the entire liver substance, or even the larger kind (Fig. 1-1) will become arrested, and in time absorljed by natural processes after emetin has killed off the patho- genic parasites. In an experience of over one hundred cases of liver abscess which I operated upon betAveen 1900 and 1907, ninety-five per cent were in the right lobe and 72 TROPICAL SURGERY AND DISEASES Fig. 15. — lyiver. Solitary superficial entamebic abscess on outer surface of right lobe. (Author's collection.) Fig. 16. — Curvilinear incision to expose 9th and 10th ribs. of the so-called single variety (Fig. 15) ; ninety per cent of these recovered; one case of multiple abscesses in which two or more small abscesses, which may have been the only ones, were reached and opened, also recovered. Even THE LIVEK 16 after efficient use of emetin the old laAv, uhi pus ibi evacuo, will always prevail ; the method of attack must be decided upon according to the location of the pus. British sur- Fig. 17. — Resection of four inches of lOth rib; resulting gutter to be closed immediately by catgut suture. Fig. 18.— Cavity or gutter left by rib resection, partly sutured; dotted line below indicates the next incision which is close to the vipper border of the 11th rib and extends into the peritoneal cavity through all layers of chest wall and diaphragm. geons in the Tropics are partial to a quick and easy method by aspiration and syphonage and the instrument makers sell many sets of special instruments for this 74 TEOPICAL SCRGERY AXD DISEASES purpose devised by Mansoii and others. Like all opera- tions in which the operator can not see what he is doing, it has few terrors for the most timid. Such a procedure is unscientific and unsafe but has its uses and is to be commended to one untrained in surgerj^ when conditions are such that a surgeon is not available. The Abdominal Route.^ — When the liver dullness ex- Fig. 19. — While incision into the peritoneal cavity is being made the mobilized chest wall is held firmly against the diaphragm by two fingers of an assistant; this should prevent entrance of air into the pleural cavity until the cut edges of chest wall and diaphragm can be clamped together and then sutured, making air tight closure of the pleural cavity. tends well below the costal margins and especially when the organ bulges anteriorly as it sometimes does in neg- lected cases, the abdominal route, preferably through the right rectus muscle, if visceroparietal adhesions are en- countered, amounts to nothing more than a simple oncot- ^McDill, J. R. : Tropical Infections of the Derivatives of the Primitive Gut: Their Complications and Treatment, Surg., Gynec. and Obst., Nov., 1911, 523-558. THE LIVER 75 omy. If adliesioiis are limited and recent, or absent, the abscess cavity if accessible should l)e opened thvougii a ring of gauze packed between the liver and the abdom- inal wall, either immediately or after forty-eight hours, according to the two-stage principle. A transpleural operation to attack a liver abscess, before it has developed to an extreme stage or before the liver swelling is evident Fig. 20. — For demonstration only; the edges of chest wall and diaphragm, which are to be united by suture, are held apart. on inspection, gives the best access to the entire right lobe in which ninety-five per cent of abscesses are found. This exposure of the liver surface is not affected, except favorably, by the great reduction in size that occurs within twenty-four hours after needling a swollen liver; if pus is not found at the time of operation, the organ can be explored through the wound daily for weeks, if 76 TEOPICAL SUEGERY A^D DISEASES necessary, with tlie hollow needle, nnder cocaine anes- thesia. The following procedure avoids pneumothorax and empyema and has been quite satisfactory:' 1. Place the patient flat on the back or Avith the right shoulder and hip raised a little with the right arm at right angles to the body. 2. (Fig. 16) Curvilinear incision to expose ninth and tenth ribs. Reflect in one flap all of the tissues down to, but not including, the fascia overlying the muscles. 3. (Fig. 17) Sub]3eriosteal resection of 10 cm.. Fig. 21. — Suture of chest wall and diaphragm completed, showing exposure of liver. (4 inches) of the tenth rib; removal of the ninth rib also is sometimes indicated; great care is necessary to avoid wounding the periosteal bed composed of periosteum, en- dothoracic fascia and parietal pleura; close the resulting gutter inunediately with a running catgut suture through the entire thickness of the musculature. This results in a loose and movable section of the chest wall. 1. (Fig. 18) Cavity or gutter left by rib resection partially sutured. The dotted line below indicates the next incision which follows closely the upper border of the eleventh rib; it is coextensive with the rib resection and extends into THE LTVEIl 77 the peritoneal cavity dividing all laj^ers of the chest wall and the diaphragm. 5. (Fig. 19) While this incision is being made, the fingers of an assistant firmly press the loosened chest wall inwards and against the diaphragm to prcAT'nt pnenmothorax when the incision opens or crosses the pleural sac; as soon as the pleural cavity has been passed and the thickness of the diaphragm divided, the peritoneal cavity is opened; this should occur first about the center of the wound; the two upper, cut margins of mobilized chest wall and diaphragm, respectively, are "SR-iM^ill Fig. 22. — Mikulicz pack to procure adhesions, after failure to find an abscess; through the adhesions daily explorations, with cocaine, can be made, if necessary, until pus is found. tlien clamped together with two or three forceps, effectu- ally closing the pleural cavit}^ The oi^ening can now be extended right and left by first securely clamping the dia- phragm to the chest wall, and when a running catgut suture replaces the forceps, making air-tight closure of tlie pleural cavity, the liver is freely exposed and ready for even a manual exj)loration. Fig. 20 demonstrates the cut edges of chest Avail and diaphragm held apart; be- tween the flaps the pleural cavity is shown; below is the liver. Fig. 21 shows coaiDtation by suture of the edges (^ TROPICAL SURGEEY AND DISEASES of chest wall and diaphragm completed, shoAving extent of exposure of the surface of the right lobe of the liver. Fig. 22 shows a case in which pus is not found at the time of operation, showing gauze packed in a Mikulicz hag which extends beneath the wound margins covering an area of liver surface about 6.5 cm. (2^2 inches) in diam- eter. After adhesions form, the liver can be explored daily if necessary under local cocaine anesthesia. In one case Fig. 23. — Drain in place, gauze ring around tube to prevent soiling of peritoneum and to form adhesions. the abscess had not developed sufficiently to be located and drained until three weeks after the original opera- tion. Fig. 23 shows the tube in place surrounded by gauze pack; sutured margin held up showing parietal peritoneum on under side. Fig, 24 is a diagrammatic sketch showing the layers incised and the digital method of preventing pneumo- thorax until the diaphragm and the chest wall edges are united, Pneumothorax, all statements to the contrary THE LTVER 79 notwithstanding, is always a very serious accident even to a healthy man and should it occur during an operation, in spite of all precautions, the steps of the operation should be completed and the air and also any fluid en- countered in the pleural cavity should then be aspirated V Fig. 24. — Diagrammatic sketch showing layers incised and digital method of temporarily preventing pneumothorax till diaphragm and chest wall are sutured. by means of a Potain aspirator, using a medium-sized cannula with a blunt end. With the aid of a differential pressure apparatus the operation can be done very easily and rapidly and the pressure can be dispensed with as soon as the pleural cavity is closed. The usual enlarge- ment of the right lobe narrows or even temporarily 80 TEOPICAL SURGERY AXD DISEASES obliterates, in some cases, the angle of the pleural space which greatly facilitates the operation. The right lobe after this exposure can now be palpated upwards on the dome and on its posterior surface downwards and for- wards; the anterior surface and margin and sometimes, if not greatly enlarged, the under surface can be reached by the examining fingers. The liver, when acutely edem- atous, will bulge freely into the wound, is bluish in color, and soft and pulpy to touch. The indications to the exploring fingers of underlying abscesses are i)eritoneal adhesions and resistance or hardness due to pus tension. Before iiicising- an abscess or before exploring with the hollow needte' and syringe, pack off with a ring of gauze which may be fastened in jDlace by two or three Xo. 1 catgut stitches to the parietal peritoneum, although this is not often necessar^^; sewing to the liver surfaces is seldom satisfactory. If the operator prefers to wait for parietovisceral ad- hesions before oiDening an abscess, if the condition of the patient requires it, fasten the exploring needle in situ as the cavity may not be readily found again because an edematous liver invariably shrinks very rapidly after any operative handling. When an abscess near the sur- face has been opened and its cavity can be reached, its walls should be palpated for neighboring pus collec- tions, supplemented by the aspirating needle, and if the partition between cavities is not too thick, it can be broken down by a long forceps; if there seems too much intervening liver tissue, it can be more safely left to work its way towards the opening cavity in which the tension has been relieved, when it can be opened later if it does not open spontaneously by confluence. Open deep abscesses by a narrow stab incision, using the needle as a guide and enlarge the opening with forceps or the finger. As soon as the abscesses are opened, insert a large rubber tubular drain, stop, and put the patient to bed. Flush- THE LIVER 81 iiig, curetting, sponging out, etc., are all contraindicated. The causes of death in this class of cases are too often due to too much operating, too much anesthetic, too much loss of blood, and consequent shock. These operations can be suspended at any moment after the liver has been exposed and be completed later under local an- esthesia. Treatment of Hemorrhage from the Liver. — Normally the liver blood pressure is very low but in a considerable percentage of chronic dysentery cases some hepatic con- dition has developed which may cause enough obstruc- tion and consequent increase of intravenous portal blood pressure so that the back pressure will produce in liver Fig. 25. — Combination drain and hemostat for liver abscess. wounds of such organs the most furious type of venous hemorrhage ever encountered, and unless checked im- mediatel}^ it will exsanguinate the patient in a few mo- ments. To meet this emergencj^ a combination drain and hemostat was devised as follows: (See Fig. 25) A small, firm, red rubber catheter is passed through the wall of the large rubber drain from its lumen outward, leaving the end within the double thickness of condon which forms the bag. To avoid occlusion of the catheter from constriction by the puncture, it may be necessary to take away a bit of the rubber where punctured or to burn a hole that will be small enough to hold the catheter firmly without obstructing it and at the same time snugly 82 TROPICAL SURGERY Al^D DISEASES enough to prevent the escape of the air. This apparatus might also be used to advantage instead of gauze for wounds after excisions of a portion of the surface of the liver, after the idea of Kousnetzoff and Penski, who, Fig. 26. — Combination drain and hemostat inflated in a liver abscess specimen. For better view of improved apparatus, see Fig. 25. (Author's collection.) in 1894, recomiiiended a continuous suture over gauze packing for such wounds. Fig. 26 shows another but in- ferior type of apparatus distended in a liver abscess specimen. The advantages of this siiniDle and always available arrangement are that it acts at the same time THE LIVER ».:> as a drain and as a lieniostat; it can he inserted and in- flated in a few seconds; it produces efficient, uniform and equable pressure upon all parts of the irregular bleeding surfaces of any tunnel made through the liver substance either to open an abscess or for a trauma from any other cause. The pressure can be regulated as required, can be Fig. 27. — Liver. Roundworm invasion through large common duct, showing small abscesses. Case 1 of Dr. Vernon L,. Andrews, not reported. easily renewed in case of leakage of the air or another apparatus can be quickly substituted in case of rupture of the balloon. It is easily removed by traction on the drainage tube, after cutting the outside silk ligature which inverts the bag from within outward. In one case the Kelly i^roctoscope through which a long, wide, dou- 84 TROPICAL SURGERY AND DISEASES bled gauze bandage was T)acked, controlled an alarming hemorrhage. ''In the examination of liver abscess pus for Entameba histolytica, the pus first obtained after the operation usually does not contain entamebse; frequently they ap- pear in the pus from the drainage tube only after several dsijs. The explanation of this is to be found in the fact that the entamebse are not found in the pus of the abscess, ,,+ -,«■ «'V-5# Fig. 28. — L(iver. Roundworm invasion through large common duct, showing small abscesses. Case 2 of Dr. ^'ernon L. Andrews, not reported. but only in the tissues at the walls of the abscess. Con- sequently, it is only when the walls of the abscess begin to slough oif that the entamebag appear in the drainage from the abscess. Therefore, a negative diagnosis of eii- tamebic liver abscess should never be made except after negative examinations obtained for several successive days after operation." (Walker.) Occasionally round worms will find their way to the THE LlVEIl 50 liver when the common duct has become dilated; they have never been recognized during life, but have been discovered i)ostmortem in a few cases. (See Figs. 27 and 28.) Flukes of several species have also been found occasionally. For the most recent information on cosmopolitan hepatic conditions, reference is made to the article on ''The Liver and its Cirrhoses," hj Dr. William J. Mayo, in the Journal of the American Medical Association, May 11, 1918. CHAPTER V GYXECOLOGY AND OBSTETRICS About fifty per cent of all surgical cases encountered among the natives of the Philippines belong to so-called gynecology. The varieties of pathology found and the causes of diseases peculiar to native women do not differ materially from those in America, not excepting hygienic conditions, general and local, although civiliza- tion, education, and social conditions so often a factor are supposed to be greatly inferior to those in the United States. It has not yet occurred to the natives that limita- tion of offspring is a good thing sometimes and, being religiously opposed to criminal abortion, it also has not become established as custom or as fashion. The very unhygienic conditions under which childbirth takes place and the ignorant, brutal, and meddlesome midwifery make for numerous lacerations of the birth canal and enough infection to bring up the average of pelvic inflam- matory disease to perhaps more than that of their more civilized white sisters who are indebted to a greater ex- tent to the gonococcus for these troubles. When labor is not accelerated by violent means, traumatism is slight, as the babies' heads are small and infections are infrequent. A tight cord is often worn about the waist ''to keep the child small;" this almost cuts the body of the mother in two at times; a woman must work hard during pregnancy; the native midwife makes frequent examinations for five cents each and ''changes the baby around;" the super- stitions of the very ignorant are of the most terrifying nature ; the inother rareh' knows when the baby is coming and is seldom prepared for it ; during labor she is kneeled on, squeezed, and rammed by wooden or stone clubs which 86 GYNECOLOGY AND OBSTETRICS are sold for the purpose in tlic markets; (luring partui-ition a rope is looped around the hody aV)Ove the uterus "to keep the child from goini;- up" and the ends are pulled on Fig. 29.— Ovarian cysts. < I'lirjlograpli in' Dr. R. U. Castor, of Sweljo, Burma.) SO strongly by two men that, in one case I saw, the ribs on both sides were fractured; the placenta is pulled away by the cord, or if it does not come in about an hour, the 8s TROPICAL SURGERY AND DISEASES cord is cut short. The placenta when burned with paper and pen under the house assures an ''ilhistrious" child and a placental soup for the mother prevents all compli- cations. The tight rope about the body is kept snug during labor 'Ho prevent the breath and blood mixing together ; " a band is cinched up about the pelvis by strong men to keep her from falling apart; bleeding is encour- aged by making the patient sit up; she is stuffed with food and under no circumstances is she allowed to sleep for three days or she will become, "loca," (insane); the Fig. 30. — A six months' abdominal lithopedion, carried seven years: a second and smaller one was found in the pelvis. (Author's collection.) uterus is then ''put back" and smoked over an herb fire to dr}^ up its rawness and for three months she can not take a cool bath. The baby comes in for his share of attention also, as may be believed from the statistics which show a mortal- ity of 65 per cent in infants under one year of age. These were the obstetric customs in the province in which I was stationed in the early days of American occupation, but they are being rapidly changed through educated native medical men and nurses as the Filipinos are very quick to learn and to appreciate improvements. GYNECOLOGY AND OBSTETRICS 89 Tuberculosis and malignant affections, dermoid and every variety of ovarian cyst are common and as sur- gery in the provinces is not often resorted to, some ex- treme cases are seen (Fig. 29). Among tlie curiosities encountered was a double lithopedion in a woman tliirty- six years of age whicli was carried seven years; the abdominal specimen, a six months ' child, was swung high up in the omentum and draped about with many coils of small intestines (Fig. 30) ; the pelvic specimen in the right tube was 8 cm. (314 inches) long b}^ 3.5 cm. (IV2 inches) through; each was a firm stony mass except where some adipocere and mummification occurred. Fibroids are common in all parts of the uterus; probably over twenty per cent of native women have fibroids, but less than five per cent of these have symptoms or apply for treatment. The patients ,are very tractable and react from the most extensive operations very satisfactorily. CHAPTER VI GEXITOUEINARY In the Philippines, vesical and renal calculi were very common but prostatic hypertrophy was never observed. Venereal disease was not common, but cancer of the penis was rather frequent. I reported amebic infection of the urinary bladder, without rectovesical fistula, in 1904; the source of the infection was traced to the use of an un- clean catheter which was employed in irrigating the bowel of other patients for entamebic dysentery; when the pa- tient entered the hospital for pain in the lumbar region, the urine was normal ; after daily irrigations for ten days and one exploration for stone on the seventh day, lie com- plained of dysuria, hematuria and severe pain at the end of micturition; large motile amebas Avere found in his urine; amebas were positive for a month; there were no amebas in his stools; a daily irrigation with 1:500 up to 1 :100 solution of quinine, five to six ounces of which could be retained from two to five hours, cured the condition, Lynn of Costa Rica also reported a case (1914) infected by a syringe previously used in the rectum and -six cases were said to have occurred in the military base hospital in Manila (1900-1904) but the data could not be found of record. TROPICAL FISTULiE IN ANO Maxwell,^ of Formosa (1912), reports multiple deep fistulous tracks of the buttocks which are not common; two or three cases a year occurred in 8,000 cases. It commences as a fistulo-in-ano; as it is painless the cases are neglected and become very extensive; some are of ^Maxwell, J. L.: Trans. Soc. Trop. Med. and Hyg., 1912, vi, No. 2, p. 50. 90 - GENITOURINARY 91 five years' duration; incision and curettage do not help and excision is impracticable on account of the extent of the disease ; they were not tuberculous and no fungi could be detected, but large amebas were found in every case. Ulcers of the rectum, perirectal abscess and fistulas due to amebas were common in the Philippines in the early days but no such condition as Maxwell describes was ob- served. Kartulis described a similar condition in Egypt due to a blastomycosis of the gluteal region, later ob- served by Castellani in Ceylon, in which a saccaromyces- like organism was found; he claimed that the sinuses did not communicate with the intestines. In Maxwell's cases the amebas may have wandered in from the bowel. CHAPTER VII CATASTROPHE AND EMERGENCY SURGERY Emergency surgery included man}^ and extensive in- cised wounds due to tlie fiery temper of tlie native and his fondness for the bolo and dagger in settling disputes. The eruption of Taal volcano, forty miles south of Manila, on January 30, 1911, at half past two in the morning, furnished the most extensive experience in catastrophe work. since the American occupation of the Islands. Fifteen hundred people were killed and sev- eral hundred burned; about two hundred of the worst cases were brought to the hospital in Manila several days later. The burns were of every degree of the exposed parts of the body and nearly all were infected; the pain complained of was not excessive and slow recovery under picric acid dressings was the rule. Some of the patients at a distance from the volcano described their burns as due to a rain of mud that was not hot but seemed to con- tain some escharotic; others near the volcano attributed their burns to the force of a blast of hot wind filled with hot sand and ashes that lasted ten or fifteen minutes, followed by a shower of ashes, a deluge of hot mud and lava and later by a downfall of rain. Many other injuries besides burns occurred; one of the hospital cases seen was as follows : The house of Seuora Apolonia Solis, on the hanks of Taal Lake, was swept into the water and she, carrying a child at term, while swimming, was deejDly cut on the head and groin b}" a flying piece of metal roof; her baby was born that morning; her wounds healed nicely later and mother and child survived. Another wholesale jjrostration of people occurred one Sunday after the masses celebrating Saint John's day, 92 CATASTROPHE AND EMEllGP^NCY SURGERY 93 when it was the custom to bathe in the sea. The beach was crowded Avith natives writhing in agony from tlie effects of jelly fish poisoning. Some of them were para- lyzed by the poison and may have died; all suffered intensely; the superficial effects on the skin of some white persons whose feet and legs only came in contact with the jelly fish masses, were an intense burning and reddening; the general symptoms which were alarming were heart failure, a complete loss of strength, and nausea. Treat- ment was morj)hine, diffusible stimulants, soap and fresh water cleansing, and soothing applications to.ihe skin. Stitt called attention to the fact that these fish must pos- sess various degrees of venom and cited the case of a powerful American naval employee who dived overboard to refresh himself and was killed instantly. The other principal under-water danger to man is sharks. Some of the military surgery of which a great deal was handled during the campaigns of 1898-1902 was unusual and interesting on account of the native weapons, and might properly be classed as emergency surgery. Gas gangrene and tetanus were not uncommon either among soldiers or in civil life. Snake bites are not a feature of Philippine accidents, as the principal venomous varieties although represented are neither numerous nor active. The pythons which kill by constriction grow to over 30 feet in length, are terrifying to contemplate but are sluggish; this lethargy, however, is not always shared by beholders. I saw a squad of five soldiers do a half mile in two minutes flat over bad ground, immediately after having slid down a river bank almost on top of a monstrous old serpent coiled up in the sun in the dry bed of the stream, probably digesting his last . month 's meal ; as soon as they could overcome their momentum they went back and got him. Young pythons, six or seven feet long, 94 TROPICAIi SUEGERY AXD DISEASES used to be vended by native boys as ratters, for about five dollars Mexican; placed in the attic of a house which seems to be his town domicile of choice, he forages for himself and keeps the premises rat-free. The only evidence of his presence will be an occasional racket when in combat with an intruding cat or a wet spot which shows on the ceiling if of bamboo matting. When it is bad hunting indoors, he is apt to fare forth at night and rob the hen roost; he may even find an affinity and furnish unwelcome additions to the family, but the worst thing he does is to lie down and die between Avails and pollute the air most tremendously. House snakes were not popu- lar with Americans, especially not with women who had babies, and there was small demand for them. Their power of constriction is very great. In the early days of military occupation a small boy carrying a six foot snake wound around his body was exhibiting him to some offi- cers, in front of the Oriente Hotel in Manila. The offi- cers annoyed the reptile so much by prodding him with their sticks that he closed down on the lad and crushed him so severely that, it was said, he died later. Awakened one night during a typhoon by crashing glass and falling objects I arose and slew an eight foot specimen, glitter- ing and beautiful in a brand-new coat, in my bedroom, where he had lost his way on his reascent to the roof. There are no dangerous wild beasts except the wild carabao or water buffalo, which when hostile has no match for ferocity; one must either kill him or take to a tree, and that forthwith, or be killed, for, although Aveigliing about a ton, he is as quick as a tiger. Other- wise the country is a hunter's paradise, swarming with game of all sorts. Heat prostration in the Philippines is practically unknown. Leeches work through any foot- wear excejDt boots. The bleeding from their bites is very persistent and can be stopped only by continuous pres- sure. CHAPTER VIII FILARIASIS The filaria nematodes, excepting the malarial Plas- modia and amebas, are the most widely distributed para- sites of the torrid zone, and are also found occasionally in the United States and Europe. Certain mosquitos which act as the intermediate hosts for the filarial dis- eases of surgical importance were experimentally deter- mined by Manson, Bancroft, and others. The embryo nematodes of Filaria bancrofti in the blood of the human host are taken in by the various species of Culex and Anopheles, and undergo in these insects the changes necessary for reinoculating man during a subsequent feeding; consequently, it is of the greatest importance whenever a case is discovered to protect the mosquitos against infection by screening off the parasitized person. The innumerable embryos in the peripheral circulation are never the pathogenic agents of so-called filarial con- ditions. (Figs. 31, 32 and 33.) Captain Phalen and Lieut. Xichols^ of the United States Army Tropical Board in 1908-1909, made about 7,400 blood examinations in various localities of the Philip- pines to get an idea of the prevalence and distribution of filaria, and found it to represent two per cent of infec- tions for the islands; thirty-five cases had elephantoid disease. Protection from mosquitos is preventive but this is impracticable for a native population, hence when- ever a case is discovered among the native employees of foreigners, it should be discharged at once as the Culex fatigans Wied., which transmits the disease, is omni- present. ^Phalen, Jos. M., and Nichols, Henry T.: Philippine Tour. Sc., 1908, Sec. B, iii, 305; 1909, Sec. B, 127. 95 96 TROPICAL SURGERY AXD DISEASES Fig. 31. — Filaria nocturna, X about 390 (double exposure). Showing the general morphology and the viscus-like organ at the junction of the middle and posterior thirds cf the parasite (Wherry and ]\IcDill).* (Photomicrograph by Charles Martin, Manila, photographer, Bureau of Government lyaboratories.) Fig. 32. — Head end of Filaria nocturna, X about 880. The sheath, the three duct- like threads connecting the anterior end of the viscus-like organ with the head end of the embryo, and the transverse striations of the musculo-cutaneous layer may be seen (Wherry and i\IcDill).* (Photomicrograph by Charles Martin, Manila, photog- rapher. Bureau of Government I^aboratories.) ^Reprinted from Jour. Infect. Dis., June 24, 1905, vol. ii, Xo. pp. 412-420. FILARIASIS 97 A. — Represents a dead fil- aria, showing granular de- generation. B. — Drawn from a filaria just before granular degen^ eration set in. Proportions about correct as seen with the Zeiss 1/12 oil im., comp. oc. 8. Length, 0.330 mm.; breadth, 0.00765 mm. The distances between the anatom- ical markings were as fol- lows: A-B, 97.92 n; B-C, S3. 55 n; C-D, 61.20 11; D-E, 64.26 /*; E-F, 53.55 /i; total, 330.48 II, or 0.33 mm. C. — Head end of filaria, showing retracted lips and spicule. Fig. 33. — Filaria nocturna. (Wherry and McDill* — Figures redrawn by T. Espinosa from original drawings.) 'Reprinted from Jour. Infect. Dis., June 24, 1905, vol. ii, No. 3, pp. 412-420. 98 TROPICAL SURGERY AlSTD DISEASES Medical Treatment. — Many drugs have been employed empirically without success. The most promising inter- nal treatment, aimed at the death of the joarent worm, is the new arsenical antiluetic preparations, arsenoben- zol, ''606," and anilarsenate of sodium, "Atoxyl," of which 10 to 15 drops of a 10 per cent watery solution is given h^^odermically every day or every other day for six weeks. Failure of the embryos to reappear in the blood after one and two years, following such arsenical treatment, can be taken as presumptive evidence that the parent worm has been destroyed; if further experience shows this treatment to be effective, an early destruction of the parasites will prevent the development of the hojoe- less conditions now found in chronic cases. Clapier (Les loorteurs de Kystes filariens (Onchocerca volulus et de Xodosites Juxta-Articulaires en pays Toma (Region militaire de la Guinee), Bull. Soc. Path. Exot., February, 1917, vol. X, No. 2, pp. 150-157) describes a common subcutaneous cystic tumor in the Toma country which separates Liberia from the rest of French Guinea. They are of slow groT\i;h, vary in size from a shot to a small orange, very firm, rounded, generally multiple, not painful to pressure — or slightly, slight tendency to suppuration. These signs are conunon to both the juxta- articular and the volvulus cysts; the juxta-articular, however, are very firm or hard, neighboring tissues puffy, less regular in contour, i^refer to localize on bon}^ epiphyses, have a definite tendency to symmetry (see Figs. 65 and 66) and are often adherent to the perios- teum, whereas the volvulus cysts are elastic, regular in shape, neighboring tissues not puffy, not clearly con- nected with bones or joints but localized in inguinal fold, pubes, ribs and scapula. There is little tendency to s^mi- metry and they are generall}^ movable. Exploratory puncture A^dll confirm the diagnosis ; in the nodules there is no fluid, in the cysts is a thick viscous, grayish, yellow FILAEIASIS 99 or orange fluid rich in microfilariae; the cj^'st cavities are partly filled with tangled threads attached to the walls; these are the adult worms; the females are con- nected with the walls, the males are free. The nodules are white on section and fi.brous and there is no cavity. Juxta-articular nodules appear to have more than one origin, a nocarclia (Madagascar) and in Nyasaland, yaws. Elephantiasis The specific factors are perhaps rarel}' the parent worms of filaria, although five and six worms have been found blocking the l^rmphatics (Castellani) ; usually some undetermined microbial causes exciting an obliterative inflammation or secondary and frequent invasions of the deeper parts by the skin diplococcus and other patho- genic organisms are the actual causes of chronic obstruc- tion of the hanphatic and venous circulations of any blocked off area; these with the resulting characteristic fibromatosis changes in the hypoderm produce what we call elephantiasis. The following case is t}7)ical of so- called beginning cases and strongly suggests streptococ- cus infection. American, thirty-three years old, resident of the Philip- pines ten years, married to a native woman; in 1906 he began to have attacks of chills and ten day fever with pain every two or three months in the right lower ex- tremity beginning in the foot, which became swollen, hot and tender; this case suggested clinically nothing so much as a chronic submerged erysipelas, according to Sabouraud, Unna, and others. In 1911 the increasing size of the limb brought him to the hospital. Numerous attempts to find embryos in the blood at night or in the tissues of the swollen limb failed. After rest in bed and bandaging for two weeks the skin became elastic; long double Xo. 14 silk was looped subcutaneously from over 100 TROPICAL SURGERY AND DISEASES the instep in front to the inguinal and hypogastric re- gions above, and another loop was passed behind from Fig. 34. — Beginning elephantiasis in an American in Manila. (Author's collection.) just above the heel to the region of the buttocks into healthy subcutaneous spaces, according to Handley's" ^Handley, W. Sampson: Hunterian Lectures, Brit. Med. Jour., 1910. riLAPJASIS 101 method of lymphangioplasty. The improvement after six months was not so apparent as in the weeks imme- diately following the operation, but the patient claimed that he was much more comfortable (Fig. ?A). In the true clironic elephantiasic condition or elephantiasis nos- tras streptogenes there is no fever, the skin is hard and verrucose and the overgrowth in some cases is enormous (Fig. 35). Fig. 35. — Chronic elephantiasis nostras streptogenes of scrotum and leg. (Deschien's Atlas.) The prominent clinical feature is lymphatic and venous obstruction with lymphedema; numerous surgical proce- dures have been attempted for its relief. Limited excision has been unsatisfactory. Sir Havelock Charles removed the diseased tissue entire from the foot to knee and skin- grafted the surface with a good result. Castellani' claims good results in selected cases by complete three to six ^Castellani: Brit. Med. Jour., 1908, ii, 1361. 102 TROPICAL SURGERY AND DISEASES months' rest lying down, firm equable continuous pres- sure by very carefully applied bandages and daily injec- t£l^. / "'• i-mrnH^ Fig. 36. — A case of neurofibromatosis in a woman thirty j'ears old resembling elephantiasis. "Klephantiasis Nervorum." (Unpublished photo from Dr. R. H. Castor, of Swebo, Burma.) tions deep into the affected parts of 2 to 4 c.c, in water of ''fibrolysin" which is a mixture of thiosinamiii and riLARIASlS Wo salicylic acid. This treatment renders the skin clean, loose, and flexible, so that long strips can be resected aseptically. Elastic support must be worn to prevent relapse. When the parts attain enormous size, there is nothing to offer but amputation. Matas* (1913) in re- viewing the treatment of elephantiasis, reminds us of the failure of ligation of the main artery advocated by Car- nochan in 1851 and of the more recent multiple cuneiform excisions of skin and underlying fibromatous tissue by Kuznetzoff (1905) and others, with favorable results in a certain number of cases. Handley's silk-lymphangio- plasty has not given good results after extensive trial by many surgeons. Le Nourmant pointed out that no matter how ancient or aggravated elephantiasic states may be, the tissue lesions are limited by the derm and hypoderm and do not extend below the deep aponeurosis where the tissues retain their normal circulation and are capable of taking care of the stagnant lymph above the aponeurotic partition, provided an opening is established between them. Lanz^ of Amsterdam in 1906, improved on Handley's method by the formation of communications of subcuta- neous and deej) muscular and periosteal lymph channels to within the bone; he fenestrated the fascia lata, trephined the femur and passed flaps of the fascia down through the muscles and into the medullary canal, with excellent results. Oppel, of St. Petersburg, extended this method to the tibial and crural points without opening the bone. Rosanow,° of Moscow, shows by a case in which he ob- tained a good and an apparently lasting result, that deep triangular and rhomboid flaps of fascia tucked between underlying muscles may bring about a drainage and cure of elephantiasis; Kondeleon" (1912) removes large sec- ■*Matas, R. : Surgical Treatment of EJlepliantiasis, Am. Tour. Trop. Dis., July, 1913, 60. =Lanz, 0.: Zentralbl. f. Chir., Jan. 7, 1911, 3. "Rosanow: lyymphangioplasty in Elephantiasis, Arch. f. Clin. Chin, 1912, xcix. "Kondeleon: Miinchen. med. Wchnschr., Dec. 10, 1912, 26. 104 TROPICAL SURGERY AND DISEASES tions of the fascia lata in the thigh and leg, claiming that permanent new anastomotic channels are formed between the lymph spaces above and below the site of the re- moved aponeurosis and his six cases in Athens support his contention. Matas,^ and Gessner, each made a limited Kondeleon operation on one case with marked improve- ment. The possibilities of repeated injections of anti- streptococcal polj^valent serum which gave such satis- faction in one of Matas' cases should not be forgotten, nor the autogenous vaccines made from the mycotic in- vaders of the deeper tissues. Charles,^ in India, has suc- cessfully operated upon several hundred cases of scrotal elephantiasis by complete ablation of all diseased skin and tissue, carefully preserving the return circulation of the penis; he then covers the denuded parts and testicles to the base of the penis by sliding adjacent healthy skin; the penis is covered by Thiersch grafts. His mortality was one per cent. Chylous Ascites, Chylothorax, and Chylocele These are not common conditions, but are occasionally recognized by the presence within the peritoneal, pleural or tunica vaginalis testis sacs of a milky fluid, which, if chyle, rejDresents some injury to the large lymph vessels; if the chyliform fluid contains only degenerated epithe- lium fat and i^us cells, it is usually an exudate from a con- cealed cancer or tuberculosis. The surgical treatment of true chylous collections, if the lesion in the vessel does not close spontaneously under watchful waiting, is that of other effusions into these cavities; a chylocele can be overcome by any of the methods devised for the cure of hydrocele; a chylothorax, if persistent and due to loss of absorptive power of the pleura or failure of the lymph vessel lesion to close, will require some modi- sCharles. R. H. : Indian Med. Gaz., 1901, xxxvi. 84. FILAllIASIS 105 ficatioiis of Handley's and Kondeleon's operations. Ascites of the peritoneal sac when there is no pliysiologic objection to draining it bade into the general circulation, is often manageable by an epiplopexy devised by Talma, Drummond and Morrison (1896) or by several other procedures originated since, but the average death rate of these procedures has been about 20 per cent. Schiassi fixes the siDleen and omentum in a recess of the abdom- inal wall. Mayo places the omentum anterior to the pos- terior sheath of the rectus by burrowing between two incisions, one over the liver and one 10 cm. (4 inches) lower. Narath's method is very jDopular. Under local anes- thesia the fluid is let out through an incision above the umbilicus; a thumb sized, 10 cm. (4 inch) long piece of omentum is drawn out, avoiding tension on the colon; the peritoneum is sutured around the base of the piece of omentum and the rest of it is placed in a subcutaneous pocket to the left. There is nothing to prove the theory that the good results after these operations are from collateral circulations, while there is much to show that the fluid finds its way directly to the subcutaneous spaces alongside the herniated organs where they have produced a defect in the abdominal wall, which opens under pres- sure. Eck's fistula between the portal vein and the inferior vena cava is not only difficult but when accom- plished has been followed by alimentary intoxication and death. Gall bladder drainage is indicated in the obstruc- tive billiary type of toxic cirrhosis with ascites; this type has been produced experimentally many times. Wynter tried femoral canal drainage, operating- through a trocar wound after tapping, but it was diffi- cult and tedious, a general anesthetic was required, the opening was liable to be blocked at any time by omentum or intestine, or it would be sealed by reparative processes. Wynter also planted a flanged silver eyelet with a 7 mm. 106 TEOPICAL SURGERY AXD DISEASES (1/4 inch) Avide opening subcutaneously in the linea alba, but it and other devices of this tjj)e proved failures. Henschen,° after two efforts to provide drainage for ascites in a stomach cancer case, made a tunnel from an incision above the left spine of the ilium through the abdominal wall to a median incision opening into the peritoneal cavity; the mouth of an ordinary rubber con- dom Avas then sutured to the opening in the peritoneum, the condom was drawn through the tunnel and the blind end cut oif, leaving it projecting the width of a thumb above the plane of the externus aponeurosis; this end was then spread out into a ring and sutured to the aponeurosis, and the skin was closed. The immediate result was an extensive edema around to the middle of the back, the ascites was kept down, and the pressure dis- turbances of the heart and lungs subsided entirely. If the omentum is sutured out of the way, the drainage might persist in this operation but the hernia liability must be considerable. Dobbertin,^° under local anesthesia, ligates, divides, and turns up about 5 cm. (2 inches) of the saphenous vein below Poupart's ligament, passes it upward under the ligament and out through a second incision just above it; a cutf of joeritoneum is brought up between the external abdominal ring and the edge of the rectus and into it is sutured the end of the vein; the opening through the abdominal wall w^as made by splitting and is sutured open to prevent constriction of the vein. Dobbertin found that the blood from the vein did not escape into the perito- neum; he claims that the oj)eration is simple and harm- less, and adds that it may become necessary to repeat the operation on the other side later. Although this procedure returns to the blood by the most direct route, the fluid which originally came from the blood, there are sHenschen: Zentralbl. f. Chin, Jan. 11, 1913. ^'Dobbertin: Die directe Daurdrainage des chronischeii Ascites durch de ^'ena saphena in die Blutbahn, Arch. f. Clin. Chir., 1913, No. 4. FILARIASIS 107 secondary changes at times in the peritoneal fluid on ac- count of which It might be better to return it to the systemic circulation by an indirect path or through the lymphatics. De Lambotte^' (1905) of Antwerp was the first to use silk to drain the abdomen; he tied a large knot 6.5 cm. (2V2 inches) from one end of a thick silk thread 54 cm. (18 inches) long, put the knotted end in the peritoneal cavity and the rest of the silk under the skin of the thigh; marked edema appeared the fourth day in the thigh but soon ceased because the intraperitoneal end became embedded. Of the ascites cases reported by this method the most instructive and suggestive in many ways was one of Handley's. Until five to seven months after the operation no proof was evident of drainage along the silks in the thigh, when the edema appeared simulta- neously with a crop of gummata; no specific treatment was given until nine months after the operation. In 1913, by a series of experiments, V- attempted to show that the relief of ascites after operations which her- niate an abdominal organ, or which implant silks from the peritoneal cavit}^ to the subcutaneous spaces, is prob- ably not from collateral circulations in the one case, or from capillary drainage in the other, but is due to leak- age of the fluid through the space alongside the mar- supialized organ or the implanted silks, which are pre- vented from uniting to the surrounding tissues firmly enough to hold in water under pressure, not only by this pressure itself, but also by the normal and constant movements of the abdominal wall. The chronic ascites patient pays too dearly for relief by tapping off large quantities of fluid, rich in proteins, salts, and the char- acteristic constituents of the tissues and fluids of the "De Lambotte: Samaine med., 1905, 19. ^-McDill. J. R.: Chronic Ascites: Treatment and Drainage by Lym|iliangioplasty through a Trocar Wound under Local Anesthesia: An Experimental Studv, Surg., Gynec. and Obst., 1913, xvii, 523. 108 TROPICAL SURGERY AXD DISEASES body -wliicli are necessary to metabolism, if this transu- date can be restored to the circulation by a simple opera- tion. My experiments show that the ends of three strands of No. 20 silk, sewed together and slightly projecting into the lower levels of the peritoneal cavity, become a perma- nent silk-connective-tissue peg; that the breach it makes in the abdominal wall allows the escape of fluid, and that the hernia and adhesion liability is nil. In tliirty days the intraperitoneal end Avas found to have become con- verted into a connective tissue and silk peg covered with a dense membrane making it impossil)le as a capillary drain; around tliis jieg the peritoneum Avas puckered and everted (Fig. 37) and not strongly attached to the silk. The instruments can be made from old tools found in any doctor's office (Fig. 38). The Kelly tube with trocar and the Pean forceps are not essential; use any cannula that will take the "carrier" Avhen loaded with the silk. The technic consists in (1) paracentesis just above the pubis and 5 cm. (2 inches) from the median line; be sure the cannula is in, because on account of the recumbent position of the patient very little fluid will flow; (2) pass the silks (Fig. 39) through the cannula until about 2.5 cm. (1 inch) project beyond the parietal peritoneum; hold it exactly there, slip the cannula out over the ''carrier" and thrust each of the three ends which have been cut to the desired length, using the bodkin eye first, downward and in three directions into the subcutaneous fat; (3) re- move the ''carrier" and without disturbing the silk ends in the peritoneal cavity, tuck in the bends of the silks and suture the skin opening very snugly. When these special instruments are not available, the silk can be planted through a short incision under local anesthesia, with one stitch to anchor it to the deep fascia; also after an ex- 13loration, when it is indicated, the silk can be easily in- serted to one or both sides of the wound before closing the abdomen. FILARTASTS 109 Fig. 37. — The silk is covered with a dense membrane and at the angle with parietal peritoneum shows a marked ectropion of the peritoneum. (Author's collection.) Fig. 38. — A, Sim's uterine sound; B. same with handle removed, blunt end per- forated and probe pointed, making the "Bodkin;" C, 25-cm. (10-inch) Emmet's cotton carrier; D, No. 14 standard gauge catheter; E, the "silk carrier," made from C and D ; F, trocar for the Kelly endoscopic tube; G, used as cannula; H, Pean forceps. (Author's collection.) Fig. 39. — The three pieces of No. 20 silk with aljout 4 cm. (1^^ inches) of their ends stitched firmly together with fine silk, held in the silk carrier ready for insertion through the cannula. (Author's collection.) 110 tropical surgery and diseases Conclusions 1. Ascites patients have an impaired vital resistance, deficient powers of repair, and do not stand extensive operations well under a general anesthesia. 2. The operation is not much more serious than a simple paracentesis and other silks can be inserted at any subse- quent tapping until there is sufficient drainage; pressure by intraperitoneal fluid is desirable after this operation to weaken the line of union between the silk and the sur- rounding tissues, but if it becomes too distressing, a tapping may be necessary to give temporary relief, on which occasion more silks may be inserted: permanent drainage may not become established until two or three pionths. 3. The permanency of any improvement will depend upon the correction of an intestinal toxemia when pres- ent, rest in bed when indicated, total withdrawal of alco- hol, a bland and almost salt-free diet, and attention to any cardiovascularrenal disturbances. Several good results have been reported in favorable cases; that is, in those in which the eifusion was chronic and aseptic. Lymph Varix and Lymph Varicose Glands Although Ijmiph varix and lymph varicose glands may occur am'^vhere in the body, the varix is usually asso- ciated with chylocele and lymph scrotum and the vari- cose glands are found in tlie groins and both can occur in the same patient who may also show a chyluria. The beginnings of these conditions are usually painless and attention may be first called to them by their size or by an inflammatory attack ; to the superficial observer, the groin glands may resemble hernia; they are a tangle of varicose Ipiiphatics usuall}^ connected with pelvic and abdominal vessels; the hj^Dodermic needle will show the characteristic fluid which often contains filarial embryos. riLARIASIS 111 If they become very troublesome, removal can be recom- mended, but tlie patient should understand that a sepsis may be fatal, lymphorrhagia may follow or other neigh- boring areas may become implicated and cause an ele- phantiasis. Hematochyluria This condition is due to a rupture of a lymph varix into any part of the genitourinary tract. It is usually discovered accidentally, although pain in the back and groins may precede it. Often retention from blocking of the meatus internus by a coagulum is the first symptom. The diagnosis is unmistakable as soon as the milky or peach colored urine appears and the microscope reveals, in a large proportion of cases, the dead embryos of filaria. The chyluria comes and goes according to the patent or shut condition of the opening from the varix. It is very chronic and the patient becomes extremely anemic and debilitated. Treatment, except that directed at destruc- tion of the parent worms by arsenical preparations, noted above, is of no value. Wherry and McDill in Manila in 1904 treated a Japanese girl for this disease by x-rays after cinchonizing her with quinine ; the embryos disap- peared completely from the blood ; after recovering from a moderate x-ray burn, causing also a left pleurisy, she recovered and was in perfect health four years later. Wellman and Adelung^^ reported a success after this method but the condition relapsed later. Bilharzia Hematobia (Distomum Hematobium) This is another and frequent cause of hematuria prin- cipally among the natives of Egypt and seems limited to Africa; its most characteristic symptom is a variable amount of pure blood at the end of micturition caused by the presence of the parasite in the wall of the bladder; "Wellman and Adelung: Jour. Amer. Med. Assn., April 23, 1910, p. 1368, 112 TROPICAL SUEOEEY AXD DISEASES large numliers of tlie spined ova are always found in the urinary sediment. It is often complicated by filarial in- fection which may contribute chyle to the urine. The transactions of the German Urological Congress of 1912 cite records showing that the old Egyptians, 1200 B. C, wore a sort of condom to prevent the contraction of bil- harzia disease. According to all authors recovery is in- frequent and curative treatment is futile. Eobertsoii'- (19U) used Avliat he calls '•tlmno-benzol" for several months as a bilharzia toxin and reports that even in the worse cases all swmptoms and signs of the in- fection disappear, although an egg or two may be found after prolonged search in some cases which are appar- ently well. He noted that hemorrhage ceases, all ureteral, vesical and urethral jjaiii vanishes, and in two or three days after treatment the ova come away mostly stained black lint all dead, as none of them hatched out: the detritus of bilharzia also disappears and the exudate in the urine passes away almost entirely on boiling. Rob- ertson holds that the helminth toxins cause the head- ache, backache, sweating, frequent micturition, giddi- ness, pallor and emaciation and, that as the remedy re- moves them all, "th^Tiio-benzol" is toxic to the worms themselves. His prescription is three grains of th^^miol in ninety grains of benzol every four hours for three or four days and urotropin administered in the intervals. Ekins^^ tried this treatment on four cases in Alexan- dria; they were not benefited by the drug, on the con- trary, he feels that it may be harmful and he found that the intoxicating effect, which lasted several days, was a great nuisance as the patients had to be held in their beds. Further experimentation may show where the teclinic of these two men is at fault. "Robertson, William: Thymol-Benzol in Bilbarziasis. Tr. Soc. Trop. Med. and Myg., Xov., 1914, viii, Xo. 1. i^Ekins, C. M., Director. Alexandria Hospital, Eg>'pt: Tr. Soc. Trop. Med. and Hyg., June, 1915, viii. No. 7. FILARIASIS 11^3 Dracunculus Medinensis, Dracontiasis, Guinea Worm, or the Worm of Pharaoh, Etc. This is one of the most ancient and widespread of tropic diseases and is also occasionally found in the lower ani- mals. It is believed to have been ''the plague of fiery serpents" complained of by the Israelites in the Desert. The intermediate hosts according to the experiments of Feschenko, confirmed by Manson in Turkestan, are cer- tian fresh water cylops ; the embryo nematodes in water gain the interior of the body cavity of the cyclops by penetrating its integument and there undergo a meta- morphosis similar to F. nocturna in the mosquito. Leiper showed that very dilute hydrochloric acid on the infected cyclops releases the eml)ryos; this is probably what oc- curs in the gastric juice of the human stomach when in- fected water is drunk. The female worm alone is known in the pathologic process in the human host. The full grown worm is slender, yellowish and round, averaging about 76 cm. (30 inches) in length and about 1 mm. (%o inch) in diameter. The worm after she matures from an embryo in the connective tissues of the trunk or limbs bores her way usually to the leg below the knee, and pierces the skin by a more or less intense inflammatory process, culminating in a localized swelling surmounted by a blister which opens in a few days, revealing a small circular erosion with a small opening at its center. Some- times the head of the worm protrudes from the little hole. By douching the area with cold water a clear or milky fluid appears, or a fine translucent tube, supposed to be the uterus prolapsed through the mouth, protrudes for an inch or so, fills with an opaque material and rup- tures ; this fluid contains millions of embryo worms about Yso inch long and Kooo inch in diameter. If the bed of the worm becomes infected by pyogenic organisms, an ab- scess may result by which the worm is sloughed off; if 114 TROPICAL SURGERY AND DISEASES the process is aseptic, parturition progresses by the daily delivery of the contents of a couple of inches of the uterus, which section shrivels up so that in about a fortnight the worm emerges spontaneously or can be withdrawn readily and the canal heals. Sometimes the worm dies before maturity or if mature may fail to tunnel through the skin; in such events an abscess follows an infection or the worm becomes encysted as p, hard subcutaneous symptomless cord. Unskillful attempts at early removal often rupture the worm ; the escape of the young into the subcutaneous tis- sues usually results in a disastrous toxic inflammation which with sepsis added may cause extensive necrosis, may last for weeks and leave some serious disabilit}^ The best treatment is to keep the opening clean, douche the parts with cold water, and otherwise let it alone, espe- cially if it is near a joint; if readily accessible it can be excised. Emily^^ injected the body of the worm, Avhen it protruded, with 1 :1000 sublimate solution and found that twenty-four hours later extraction was usually easily ef- fected; when the worm is not accessible at the opening, he found that a few drops of the solution at several places as near it as possible would kill it; then it will be ab- sorbed or can be excised. Filaria Loa or "Calabar Swellings" This infection is most common in West Africa and is caused by filiform worms about 30 to 40 mm. (1% to 1% inch) long, the male being 25 per cent smaller; both sexes wander freely about in the subcutaneous tissues; when passing under thin skin and especially under the conjunc- tiva, they can be plainly seen. It is not yet known just what insect acts as the intermediate host. The F. diurna is suspected as the embryo of F. loa and as the disease i^Emily: Arch, de Med. Nav., June, 1874. FILARTASIS 115 seems to be acquired only in ''the bush" some form of biting flies will no doubt be found to be the intermediate host. The worm in its subcutaneous travels causes tran- sient swellings, the ' ' Calabar swellings, ' ' due to discharge of the embryos, which rarely call for treatment but when it traverses the subconjunctival tissues severe irritation may result; it can be removed through an incision. Emily's treatment by alcohol injections for the sub- cutaneous manifestations might be useful as in guinea worm. CHAPTER IX SURGICAL INFECTIONS A FOURTH STAGE OF SYPHILIS (GANGOSA, YAWS, AND CHRONIC ULCERATIONS) Gangosa Gangosa, a Spanish word meaning '^talking tlirougli the nose," most common among the natives of Guam, is a chronic destructive ulceration beginning in the fauces and extending to the hard palate, nose, and even to the face, neck, arms, and thorax. This disease, thought for a time to be peculiar to the Marianas, the Caroline and the Marshall Islands, is now being discovered through- out the Tropics generally. The physiognomy of some of the natives of the Philippines suggest the effects of the disease in a modified form. Kerr,^ Odell," and Garrison of the United States Navy, have told the first clear story of gangosa, a disease which has never been understoood and which has resisted treatment from earliest times to 1910. Senn referred to it as " the unknown disease. ' ' Julius Rosenbaum, of Berlin, and Halle, in his "Ge- schichte der Lustseuche im Alterthume," quotes Dio Chrysostom, of the second century, who scores the in- habitants of the City of Tarsus for a widespread afflic- tion which he attributed to their notorious sexual perver- sions and which seems to have been a disease similar to what we call gangosa. Referring to the ''snoring and snorting" of the people of Tarsus he says: "However, not primary affections of the posteriors were the punishment of the Cinaedus, but secondarv ones of the mouth and ^Kerr, W. M. : Gangosa. U. S. Nav. Med. Bull., April, 1913. -Odell, H. E., Surgeon, tj. S. Navy: Personal communication, Nov., 1911. 116 GANGOSA 117 throat. First and foremost was the hoarseness of the voice, to which ]\Iartial alludes, Avlien he makes the champion of the baths, the Cinaedus Charinus, speak with a weak, hoarse voice. It is surely worth mentioning and it is a thing no one can deny. I mean the noteworthy fact that a disease has attacked so man}^ in this city. I can not, by heaven, express myself more clearly with decency. The grossest ignominy is brought down upon their native city by these sleepers by day, the drunken, the overfed, and such as have lain ill, and they ought, I say, to have been expelled from your borders as has been their fate everywhere else. For it is not now and then, or here and there, they are met with, but at all times and in all places in the city occasion may be found to threaten, scorn and deride them for these signs and sounds of shamelessness and lewdness the most scandalous. If a man passes in front of a house in which he catches the sound, he says, ' Of a surety there is a 1)rot]iel there. ' Now what shall be said of a city in which nothing but this tone of voice prevails universally so that no exception can be made of time or place whatever! What if, further, all men walk in this city with skirts upraised as if wading in a quagmire ? Tell me what is the reason others nick- name you 'hawks?' Well then! suppose a stranger from a distance judges from your voices what kind of men you are, what it is you do? You are not fit, I tell you, to be neatherds or shepherds. I wonder anyone would take you for descendents of the Argives, as you profess to be, or indeed for Greeks at all, — you who outdo the Phoenicians in lubricity. At any rate I do think it would behoove a man of any morality in such a city to close his ears with wax, far more than if he were sailing past the Syrens' shore. There he would run the risk of death, but here of foulest licence, of violation, of the vilest seduc- tion. Once Ionic harmony was in vogue, or Doric, or yet the Phrygian and Lydian, now it is the music of Aradus 118 TROPICAL SURGERY AlTD DISEASES o GANGOSA 119 gz >'-/i 120 TROPICAL SURGERY AND DISEASES ?S GANGOSA 121 and the Phoenician modes that please yon. You love this rhythm par excellence as others do the Spondaic. AYas over a race of men that were good musicianers — through the nose? Know now tluit tlie gods in their ano-er have Fig. 43. — Gangosa lesions. Guam. Noguchi negative. Lesions closed under mi.xed treatment. (U. S. Navy Med. Bulletin.) played havoc with the noses of most of your fellow citi- zens, and that is why they have this voice of their own. But I sa}^ this thing is the mark of the most infamous lewdness, of the most infamous madness, of contempt for all decency and a proof of the fact that there is no more 122 TROPICAL SURGERY AND DISEASES any single thing held to be disgraceful. Their speech, their look, their gait proclaim it." Gangosa is not fatal; the ulcerations are of the naso- pharynx, derm and hypoderm; no visceral lesions are found; the upper lip is usually spared; the tongue and floor of the mouth are never affected. (Figs. 40, 41, and 42). The skin ulcerations which occur anywhere except Fig. 4-1. — Extensive gangosa mutilation in a Filipina. (U. S. Navy Med. Bulletin.) over the abdomen show two types; one, developing as a small nodule, or patch of nodules, softens and discharges at the apex through a small opening ; the second and most common tjj)e has a sharply defined, raised, cyanotic mar- gin with a necrotic base, a seropurulent discharge and may be very extensive, is not painful, heals very slowly, recurs often, and may be very disfiguring. The gumma- like lesions of bone, tendons, and subcutaneous tissues are GANGOSA Fig. 45. — Gangosa. Age 17. Frambesia when 5 years. Ulcerations ten years; healed under mixed treatment. Complement-fixation test (Fniery) positive. Noguchi positive. (Kerr: U. S. Navy Med. Bulletin.) 124 TEOPICAL SURGERY AXD DISEASES not so common and occur usually in tlie leg and leg bones. (Figs. 43, 44, and 45.) There is still considerable to be done on the pathology. Gangosa has always been a puzzling disease until cleared up through therapeutic and serologic tests by the medical officers of the United States Xavy. Early in 1910, Odell instituted the treatment which has eradicated the active manifestations of the disease and the secret of his suc- cess lay in enforcement by military order of antisjqohilitic therapy; 338 cases were found among a population of 11,000; under a mixed treatment all active signs of the lesions ceased in about eight months and the few relapses were found to have evaded taking the medicine; this therapy was persisted in for two years when it was sus- pended for six months to observe tendencies to relapse. Salvarsan was received about the middle of 1912 and its effect on the new cases was very striking; it is now the prime factor in controlling the disease although it must be supplemented by a prolonged course of mixed treat- ment. Xo laboratory technic has revealed the presence of a treponema of any description and no cases of syphilis have ever been found to originate in Guam. Garrison says there are no tabes, paresis, hydrocephalus or syphil- itic abortions in Guam and that in 150 autopsies he saw but two or three gummatous livers; but as the disease yields magically to antiluetic treatment, looks like noth- ing but syiohilis, nine cases out of ten being near relatives to other typical cases, and as the scars are characteristic, it is perhaps a fourth stage of syphilis. After one 3^ear of treatment, one hundred cases showed a positive Was- sermann test in 82 per cent, slightl}^ positive in 3 per cent and negative in 15 per cent. Eeactions on brothers and sisters were also positive although these blood relatives showed no gangosa; 83 |)er cent of 315 cases gave a posi- tive history of yaws prior to the first symptom of the gangosa. GANGOSA 125 Frambesia, or Yaws Frambesia or }' aws is found everywhere under various names throughout tlie tropical world. Although very, debilitating and rej)ulsive in appearance, the disease is seldom fatal and is regarded by the races among whom it is prevalent as an inevitable disease of childhood. It also appears in a late or tertiary form among adults, usually of the face, causing in some cases flattening of the nose; another very chronic form is found on the soles of the feet where it protrudes as a round flat painful growth through the thickened skin. In Guam after ex- aminations of 2429 normal natives it was found that 74 per cent had contracted the disease, generally during childhood. (Figs. 46, 47, and 48.) It has an incubation stage of two to twenty weeks ; the eruption is preceded by an initial fever of variable in- tensit}^ of about one week and during its decline the eruption appears, preceded by a patchy white desquama- tion, in which minute papules push up through the skin and acquire a cheesy, yellow summit ; the typical yaw may ■grow in two weeks to any size up to 3 cm. (I14 inches) in diameter, as a rounded excresence, capped and en- closed by the yellow material, which dries and becomes a firmly adherent, dark or black crust; it requires some force to remove the crust, when a smooth, rounded, red, painless swelling is seen extending % to % inch above the surface of the skin, somewhat resembling a rasp- berry from which it has its name ; the crust soon re-forms ; it remains stationary several weeks and then shrinks and falls off. Several yaws, especially about the mouth and anus, may coalesce, leaving an ulcerated and fissured base; according to the nature of the mixed infection, ul- cerations of various degrees occur and may persist for years; healing of these surfaces often leaves marked cicatricial deformity; recurrences are not uncommon. In 126 TROPICAL SUEGEEY AXD DISEASES r Fig. 46.— Yaws in Samoa. (U. S. Navy Med. Bulletin.) GANGOSA. 127 over 90 per cent the Treponema pertenue was demon- strated and all cases gave positive serum and Xoguchi reactions except in the late or tertiarj' cases. No syphilis has even been recorded as contracted either in Guam or Samoa. The treatment hj salvarsan, injected into the mus- Fig. 47. — Yaws in granddaughter. Taytay, Rizal Province, Luzon, P. I., May, 1909. (Philippine Journal of Science.) cles of the Imttoeks, was followed hy a cure in eight to ten days in all cases that could he controlled; the only delay in healing was due to mixed pyogenic infections; relapses occurred which also healed promptl}' after larger doses of salvarsan. 128 TROPICAL SURGERY AND DISEASES Dr. Knrien, of Ce^^lon, (Report to Colonial Office, Aug- ust 27, 1916) has treated over 3,000 cases of yaws by salvarsan, arsenobenzol and kliarsivan and found tliem almost equally effective in curing tlie disease in from three days to three weeks. The diseases of protozoal origin referred to by Cas- tellani, are yaws, kala-azar, oriental sore, and relapsing Fig. 48. -Yaws in grandfather. Taytay, Rizal Province, Ivuzon, P. I., 1909. (Philippine Journal of Science.) fever. In yaws, on Castellani's experience tartar emetic gives better results when combined with other drugs, es- pecially potassium iodide. Although salvarsan and neo- salvarsan are without doubt the specific drugs for yaws, it is often difficult to arrange for the administration of intravenous injections in out of the way districts and *The Treatment of Certain Diseases of Protozoal Origin by Tartar Emetic, Alone and in Combination, British Medical Journal, Oct. 21, 1916, pp. 552-553. GANGOSA 129 also many patients refnse to submit to any form of in- jection. For these and otlier reasons an internal treat- ment by easily obtainable drugs is much to be desired and Castellani gives a prescription which has given ex- cellent results in Ceylon. He devised his "yaws mixture" containing tartar emetic, salicylate of soda, potassium iodide and sodium bicarbonate. The sodium salicylate "seems to hasten the disappearance of the thick yellow crusts." The sodium bicarbonate decreases the emetic properties of the mixture. At the same time it makes it cloudy but, through the intervention of the editor of the British Medical Journal, successful attempts have been made to obviate this. The result is the modified formula given below : Tartar emetic gi'- .1 Sod. bicarb. gr. XV Sod. salicylate gr. X Potass, iodide dr. j Glycerine dr. ij Or syrup dr. j Or sod. tartarate gr. X Aquae ad. oz. j Castellani thinks that glycerine gives the clearest mix- ture. It is given diluted in water three times a da}^ ; half doses to Europeans. The mixture Avas given for ten to fifteen days, then five to ten days' rest;" then another course for another five or ten or fifteen days, and sat- isfactory results were obtained in fairly recent cases in which the disease had started three to twelve months previously. Castellani has recently treated four cases of infan- tile kala-azar in Corfu. Three cases recovered. They were treated by tartar emetic in intravenous injections (1 per cent tartar emetic in sterilized normal saline), in 130 TROPICAL SURGERY AKD DISEASES intramuscular injections, by the mouth, and by combi- nations of these methods. The intramuscular method is very convenient in children. To avoid the ]Dain carbolic acid is added according to the following formula : Tartar emetic gr. Tiij Ac. carbol. Til X Glycerine dr. iij Aq. dest. ad. oz. j Half to 1 c.c. every other day in the gluteal regions by intramuscular injection. The addition of gr. 1/3 sod. bicarb, makes the mixture slightly alkaline. Martindale's antimonium oxide preioaration is considered less good. The formula for oral administration is as follows : Tartar emetic gr. V Sod. bicarb. gr. XXX Glycerine oz. j Aq. chlorof. oz. j Aquse ad. oz. iij (dr. j to dr. jj in water t. d.) In adults the dose can be doubled. A case of oriental sore was rapidly cured Iw twelve intramuscular injections and the tartar emetic mixture. Tartar emetic has been used in 17 cases of relapsing fever in Macedonia and Corfu, Imt in this disease it is less effective than salvarsan; in a large percentage of cases it appears to prevent relapses. Intravenous in- jections give the best result. The conclusion is that tartar emetic can be considered a specific in esiDundia, granuloma inguinale, and leish- maniosis, that it is efficacious in yaws and seems to have a beneficial action also in relaiDsing fever. Chronic Ulcerations The etiology of these conditions, so common among the natives of the ecpiatorial belt, is gradually becoming better imderstood as laboratory methods are introduced. GANGOSA 131 The chronic ulcers in Guam and Samoa brought to light the fact that the majority of the cases like gangosa and fi-ambesia show positive reactions to the Wassermann and Noguchi tests, respond to salvarsan and other anti- luetic treatment and probably have the Treponema pal- lidum or pertenue as the etiologic factor. Figs. 49, 50, and 51.) Eggers'^ (1914), in a preliminary report, on the spirochetal infection of leg ulcers in China found 115 smears containing spirochetes out of 1,500 collected Fig. 49. — Gristly healing of tropical phagedenic ulceration. Wassermann positive. Filipino. (Butler: U. S. Navy Bulletin.) from all over China, and concluded that at least one of the six types of bacilli found is of clinical significance ; the others are doubtful and no constant relationship) can be shoAvn between the types of bacilli and the spiro- chetes. The central part of China seemed least involved, but 3,000 specimens are being collected for a future re- ^IJggers, H. E. : On the Spirochetal Infection of Ulcers in China, China Med. Jour., Nov., 1914. 132 TROPICAL SUEGEEY AXD DISEASES Fig. 50.— Syphilitic ulcerations in Filipino. (Butler: U. S. Navy Med. Bulletin.) GAXGOSA 133 Fig. 51. — "Tropical ulceration." Bone exposed. Positive Wassermann. Filipina. Probably gangosa. (Butler: U. S. Xavy Med. Bulletin.) port. Eeed, of Cliangslia, Cliina, ol)served little tertiary syphilis, but saw the primary and secondary forms often and suspects that the Treponema there must be of a dif- ferent strain from the usual. 134 TROPICAL SURGERY AND DISEASES LEPROSY In the absence of successful medical or specific treat- ment, the operative surgery of leprosy and its complica- tions has not received the attention in standard works tliat it should and, except in a few leper colonies, the '*-,'*«»• *. * .«-. #■ Fig. 52. — Early nodular leprosy. Infiltration of ear. (Unpublished photo from Hawaii — Courtesy of Moses Clegg.) radical methods of the surgeon which are the main agents in the treatment are not employed to the extent demanded by this class of sufferers. Leprosy was described in the Bible by Moses in 1500 B. C, and his instructions for segregation were of divine origin, but Egyptian records of leprosy antedate the LEPROSY 135 Bible thousands of years. In spite of all tliat has been done, the disease in some localities is spreading rapidly. Morrow^ states that ''In Basutoland, in 1895, the total number of lepers was 148, and at the close of 1912 there were 700." This increase is probably not entirely due Fig. S3. — Advanced nodular, leprosy. (Unpublished photo from Hawaii — Courtesy of Moses Clegg.) to new eases as our experience in the Philippines showed that the more efficient the inspection the more cases of leprosy were found. The last reports showed that there were about three million lepers in the world and of ^Morrow: South African Med. Rec, June 28, 1913. 136 TEOPICAL SURGERY AXD DISEASES these only 169 were of official record in the United States up to 1914; but there are twenty-five hundred lepers in the United States and no leprosarium. This chronic condition is due to an infection with the bacillus lepra? discovered by Hansen in 1871 and first Fig. 54. — Pure nerve leprosy. Atrophy and contraction of hands. (Unpublished photo from Hawaii — Courtesy of Moses Clegg.) successfully cultivated by Moses Clegg in Manila in 1909. The bacilli are found only in the nodular and mixed types; never in the anesthetic form. Although it can not be proved by present methods, the contagious- ness of leprosy is admitted by all observers. The field LEPROSY 137 In gon- for investigation of leprosy is still wide open, eral, animal inoculations with leprous material have been negative. The great majority of leprologists hold that leprosy has not been produced in laboratory ani- Fig. 55. — Nerve leprosy. Infiltrrilion of lianJ. Facial paralysis. (,1'npuljlislied photo from Hawaii — Courtesy of Moses Clegg.) mals ; over seventy unsuccessful attempts have been made to inoculate leprous material in man. The Barbadian leper might be an exceptional subject for study because their pigs, fed on old dressings, developed a peculiar dis- ease with skin lesions and at the same time the rodents 138 TROPICAL SUEGEEY AND DISEASES •developed tlie rat leprosy. (Figs. 52, 53, 54, 55, 56, and 57.) Forty per cent of the children of lepers die during their first 3"ear of life but only a small percentage of the sur- vivors develop the disease and then only after an ex- posure of three to fifteen years; the average exposure necessary is five years. Although an immense amount of work has been and is being done, serodiagnosis and Fig. 56. — Nerve leprosy. Plantar pedis ulcer. Small toe removed for necrosis. (Unpublished photo from Hawaii — Courtesy of Moses Clegg.) immunity tests are discouraging and so far are incon- clusive. Lepers are subject to all other ills of the flesh, but their sedentary life protects them from the usual amount of traumas and from the penalties of strenuous and high living. The Wassermann reaction is positive in a considerable number of cases and the syphilis which is at times confused with the leprotic state does not seem in any Avay to be modified by the leprosy and is readily LEPKOSY 139 cleared up by antiluetic treatment. Tuberculosis is an- other common complication of leprosy and in some colo- nies 50 per cent of the inmates are tuberculous. The Fig. 57. — Macular leprosy. Ringworm form of infection. (Unpublished photo from Hawaii — Courtesy of Moses Clegg.) incidence of cancer and all other affections, except eye lesions and ulcers, seems to be rather low. 140 TROPICAL SUEGERY AXD DISEASES The best general treatment is segregation on a fertile island situated in a warm and equable climate, in com- munities arranged with special regard to municipal and personal hygiene and to social Avelfare conditions. The nodular and anesthetic lepers should be separated to pre- vent the development of the mixed type which is rapidly fatal; the usual antituberculosis measures are also in- dicated. Of alleviating drugs the ancient Chinese remedy, chaulnioogra oil, is the only one that has retained an}' reputation. The most extensive modern application of this remedy has been made by Heiser^ whose experiments are very encouraging especially in arresting the disease. Heiser's formula is, chaulnioogra oil, 60 c.c; camphor- ated oil, 60 c.c, and resorcin, 4 gm., sterilized, filtered, and injected under the skin of the arms or legs. Injections were begun with one cubic centimeter weekly and after tliree weeks the weekly dose was gradually raised to 3 c.c, or more as tolerated. The reaction begins a few liours after injection and lasts till the next day; it follows the first injection only and consists of slight headache, malaise and some nausea. Weekly injections have been keijt up for nine months. AVithin four weeks all patients show marked improvement. The tuberculous forms seem to respond to the treatment l)etter than the anesthetic forms. The oil is used hypodermically and the prolonged hot baths as employed at the Louisiana Leper Home are made a part of the treatment. The Surgery of Leprosy Preoperative Care and Anesthesia. — Owing to the re- duced resistance and low nutrition of the skin and other tissues, strong antiseptics are particularly contraindi- cated. The skin around an ulcer is usually very unhealthy and harbors i3athogenic organisms in abundance. Dr. ^Heiser, Mctor G.: Am. Jour. Trop. Dis., Nov., 1914. LEPEOSY 141 Sandes,'' of Cape Town, South Africa, who has done splen- did work in the surgery of lepers, prepares for operation in the following manner which would be hard to improve upon. "The previous day the patient was bathed; the particu- lar site well, but gently, washed with soap and Avater, shaved and swabbed with alcohol. A one per cent alco- holic solution of iodine was then applied, and the part wrapped up in an aseptic cloth. On being placed on the table, the area was swathed with alcohol and a second application of the iodine solution. A large cup of bovril or beef tea one hour before operation seemed to have. an excellent and stimulating effect in tiding the patient over the subsequent period of stress and exposure." Anesthetics. — As a rule even no local anesthetic is nec- essary in the insensitive areas, so common in lepers, espe- cially if the confidence of the patient is secured and sur- gical violence is avoided; when pain is caused during an operation, novocaine is indicated. Special caution is re- quired during general anesthesia on account of the feeble heart and the general tissue saturation with waste prod- ucts, germs, and toxins. The drop method with ether is best but for all abdominal and work lower down Sa'ndes relies upon spinal anesthesia which he has found safer and preferable to ether. The following brief report by AY. J. Goodhue of 325 operations, x^erformed in 1913 at the Hawaii Settlement of 700 lepers at Molokai, is ample proof that surgery is the main factor at present in the therapy of leprosy. Leg- amputations 5 Arm amiiutations 3 Eesection of bone for osteomyelitic bone necrosis 120 Eadical surgical interference for cure of plantar-pedis ulcer. . 64 Excision of axillary glands for axillary adenitis 12 Excision of cervical glands for ceivical adenitis 4 "Sandes, T. Lindsay: South African Med. Rec, June 28, 1913. 142 TROPICAL SURGERY AND DISEASES Excision of inguinal glands for inguinal adenitis 8 Excision of femoral glands for femoral adenitis 2 Excision of mammary glands for mammary adenitis 2 Excision of submaxillary glands for submaxillary adenitis .... 3 Leproniatous infiltration ulnar nerve 8 Nerve stretching of ulnar for acute ulna-algia 3 Nerve stretching of ulnar for digital flexion 5 Plastic operation for labial stenosis 2 Plastic operation for inferior labial paralysis 1 Tracheotomy cases for laryngeal stenosis and imminent stran- gulation 12 Tracheotomy cases for relief of complete ajjlionia 3 Tonsillotomy 7 Uvulotomy 3 Operation for cure of pterygium of one or both eyes with Paquelin cautery 58 Total number of glandular cases 28 Total 325 Based on observations at this clinic, the great value of tracheotomy should be emphasized. Sandes does not put it any too strongly when he says: ''Tracheotomy under local anaesthesia through the upper four rings of the trachea gives instant relief. It is not a brief postpone- ment, but a satisfactory and permanent reprieve as far as the larynx is concerned. The lowering shadows of mors suhita are dissipated. In a day's time the smiling features of a refreshed and grateful patient tell their own tale." It is done by Goodhue mth or without an anesthetic. Often after a few weeks the tube may be removed, the lar^mgeal condition having subsided. Ulcers are the most common affliction of lepers; the majority of them are due to even the slightest of injuries, especially burns, and are not leprous in their pathology. They are treated as any other ulcer in a nonleprous pa- tient and the results are as gratifying; skin-grafting is very successful after the surface has been suitably pre- pared; a warning for the treatment of atrophic ulcer is that if the local circulation is embarrassed by even slight constriction or pressure it will never improve. SURGICAL TUBERCULOSIS 143 Osteomyelitis and necrosis particularly of the hands and feet furnish by far the largest number of operations in lepers and recurrences are frequent. In some cases all that was left of the fingers was a row of finger nails rest- ing on the metacarpal bones, the characteristic adactylate stump of leprosy. This bone destruction is due as much to trophic disturbances shown by decalcification and osteoporosis as to microbic causes which are often secondar}?- invaders. The treatment should be radical removal of an affected bone or its shaft to prevent recur- rences and sinus formation. Neurologic Operations for the results of deposits in nerve trunks causing contractures differ not at all from these procedures elsewhere. Interference with the con- tinuity of the nerve itself is followed by bad results. Nerve anastomosis to arrest changes has not been tried in suitable early cases, but on terminal cases Sandes claims it will restore a considerable amount of sensation, appre- ciation of pain, and tactile sense. The Eye Complications are a most serious feature of lepros}^; in the first decade 90 per cent are affected and the treatment has been so unsatisfactory that an ophthal- mologist should be stationed at every leper colony. Opacities from corneal ulceration following ectropion, due to paresis of the orbicularis, are very common. Chronic iridocyclitis is said to be the most serious lesion; with occluded pupil and secondary cataract it results in total blindness in many, and all become more or less blind. The retina and the optic nerve usually escape damage until very late and then it is not usually due to the lepra bacillus. SURGICAL TUBERCULOSIS In the Philippines, tuberculosis affects probably the entire population and about 2 per cent of the population have the disease in an advanced form; from reports it is 144 TROPICAL SURGERY AXD DISEASES probable that this rate also obtains in the crowded sec- tions of India and China. It is veiy rare in cattle; is practically unknown among the carabaos or water buffalo, pigs and goats; but surgical tuberculosis among the na- tives is not uncommon. In 10,000 surgical cases in Manila I found about 500 cases of bone, joint, and glandular tuberculosis, mostly glandular. There is nothing to dis- tinguish these cases clinically from those of temperate zones. DISEASES OF THE SKIN Dermal Leishmanioses (Oriental Sore, Aleppo Boil, Biskra Button, Delhi Sore, Fly Bite, Etc.) This condition has as mam^ names as districts in which it occurs. It is widely scattered throughout both tropic and sulitropic countries and elsewhere wherever labora- tories for medical research are established. Darling^ dis- covered two autochthonous cases of Oriental sore in the Canal Zone in 1910 and gives a complete history of the disease to date in his report. The pathogenic agent of Oriental sore, Oriental boil, Aleppo boil, Biskra button, Delhi sore, ''Fly bite," "Bess el temeur, " etc., is mor- phologically indistinguishable from the Leishman-Dono- van bodies found in fatal kala-azar and named by Eoss, "Leishmania donovani;" yet there are certain biologic differences between the parasites of kala-azar and Ori- ental sore, in that infections by the so-called Leishmania tropicum are limited to the skin, particularly those parts exposed to sunlight; even in its insect host, the mosquito or the fiy, it has the necessary light by translucence, whereas the Ijeishmania donovani of kala-azar requires darkness. It usually attacks children before the seventh year and one attack generally confers inununity. 'Darling, S. T. : Dermal Leishmaniasis in a Native Colombian, Proc. Canal Zone Med. Assn.. 1911, iv, part 1, 154, 177. DISKASKS Ol' THE SKIX 145 The sores first appear as ijai)ules on exposed parts of the body, but other parts are susceptible to autoinocula- tion. There is a nodular form which may be single or multiple and wliich may develop no further; a common t\-pe is the solitary ulcer. The incubation period is from three to twenty weeks and the sore ver}^ often has its origin in a definite fi}^ bite. The maximum size of single ulcers is 6 to 8 cm. (2 to 3 inches) which is attained by progressive ulceration in from six to eighteen months when it gradually diminishes and the ulcer heals. Tlie constitutional symptoms are not marked ; pain is unusual and it is not a very serious conditioii. A positive diagno- sis is made by finding the parasites in smears or sections of tissue ; the bodies are also easily cultivated from very young lesions on blood agar and typical ' ' buttons ' ' can be inoculated on either man, monkeys, or dogs. On monkeys and dogs tlie nose grows the "button" most successfully. The treatment will continue to be expectant until the exact mode of infection is discovered; early excision gives good results. The repulsive ulcerating granulomas of the pudenda, tropical sloughing phagedena, gangre- nous proctitis, etc., are clinically all severe mixed pj^ogenic infections usually in marantic subjects. The etiology of the leg ulcers so commonly met with and which fre- quently become cancerous will, when more care- fully studied by laboratory methods, undoubtedly be cleared up. (See page 128 under Yaws for Castellani's treatment.) Tropical Dermatomycosis This is a large sul\]ect and our only exact knowledge of it is due mostly to the researches of Castellani.® A recapitulation of his investigations must be limited to: Tinea cruris. Tinea capitis tropicalis, Tinea Flava et nigra. Intertrigo saccharomycetica and Tinea iml)ricata. sCastellani. Aldo: Tr. Soc. Trop. Med. and Hyg., 1913, vi, Nn. 3. i4(j TROPICAL SURGERY AND DISEASES ' ' Tinea cruris has been known to tropical practitioners under the name of 'dhobie itch.' For the fungus most commonly found in such cases, characterized by the pe- culiar 3"ellowish color of its colonies, he suggested the term 'Trichophyton cruris.' In 1907 Sabouraud investi- gated very completely the same condition in France which he called ' Tinea inguinalis. ' There can be no doubt that this is the dhobie itch of tropical authors, or Tinea cruris. Tinea cruris may be caused by several species of fungus, each of which gives rise to a slightly different variety of the disease. "Up to the present Castellani has observed the follow- ing organisms: Ep. cruris, Ep. perneti, Ep. rubrum, Tri- choph3^ton nodoformans. Epidermophj^ton cruris, Cas- tellani (1905); S3aion5ans: Ep. inguinalis, Sabouraud (1907); Tr. castellani, Brooke (1908) causes the common- est and best known type of the disease as described by all tropical authors, and in Europe by Sabouraud. The condition is characterized by large festooned patches with elevated margins on the scrotoperineal region and inner surface of the thighs; it is an error to consider Tinea cruris as always localized to the groin and armpits. In many cases it spreads to other parts of the body (except- ing only the scalp) ; it may start on the chest and arms and spread to the groin and armpits, or it may even not affect these regions at all. Epidermophyton rubrum, Castellani (1909), or Ep. purpureum. Bang (1911) is characterized b}^ the beautiful deep red pigmentation in Sabouraud and glucose agar. It induces a tjqDC of dhobie itch which has a great tendency to spread from the groins and axillae to other parts of the body. The eruption has often an eczematoid appearance. Trichophyton nodo- formans, Castellani (1911) is characterized by the pecu- liar brick-red color of the cultures on Sabouraud 's agar; this color is lost in subcultures. It induces a peculiar DISEASES OF THE SKIK 147 type of dhobie itch with deep nodules along the edge of the eruption.- ''Tinea capitis: This form is comparatively rare. All the cases were due to the same endoectothrix tricho- phyton; the scalp presented in all cases numerous white patches covered by an enormous number of pityriasis whitish squamag. The patches remain bald permanently. The fungus is a Trichophyton endoectothrix, practically identical with T. violaceum of Sabouraud. "Intertrige saccTiarmomycetica: The affection is ap- parently rare. It generally attacks the scrotocrural and axillary regions. The affected skin is red and there may be slight exudation. The borders of the eruption are fairly well marked, but never elevated. In most cases there is little itching and the condition may recover spontaneously. ''Tinea flava: This dermatomycosis is confused hj several authors with the pityriasis versicolor of temperate zones, but the researches of Jeanselme and Castellani tend to prove that it is a separate entity. The disease, which is extremely common in many countries, is characterized by the presence of bright yellow patches found on various parts of the body. It is very difficult to cure. The fungus is a Malassezia, M. tropica, Castellani (1905), which so far has not been grown. "Tinea nigra: This was first described in 1872 by Man- son in China, but his observations were forgotten, as they were not quoted by him in his subsequent publica- tions. It was redescribed in 1905 by Castellani in Ceylon. It is characterized by the presence of black patches due to a fungus Foxia mansonia, Castellani (1905). "Tinea imhricata: The etiology of this disease has been the subject of numerous controversies. In recent years the general opinion has been that aspergillus-like fungi are its real causes. From his investigations Castel- 148 TROPICAL suRCJERY a:n'd diseases lani considers that aspergilli and aspergillus-like fungi have nothing to do with the condition and that when they are present they are merely saprophytes- or contamina- tions; that they are not trichophytons; they resemble more the achorions. He produced the disease typically in man by inoculating j)nre cultures of two species of fungi which he isolated, the Endodermophyton concen- tricimi and End. inclicum. " Tricliomijcosis flava, rubra et nigra of the axiUarij regions: The affected hairs present nodular formations, plainly visible to the naked ej'-e, of rather soft consist- ency, and easily removable by scraping. The formations are either ^^ellow or black, or less frequently red; the}^ may be ver}^ abundant and form a yellow or black or red sheath round the hair. By the use of the microscope these nodules are seen to consist, in the yellow variety, of enormous numbers of bacillar^^-like bodies, embedded in an amorphous cementing substance; in the red and black varieties large groups of cocci are observed as well. The yellow variety is due to a Nocardia (N. tenuis), the mycelial segments of which, being very thin, have a bacillary appearance. The black variety is due to a symbiosis between the same Nocardia, and a black pig- ment-producing coccus, which Castellani described under the name of Micrococcus nigrescens. The red variety is caused by a symbiosis between the same Nocardia and a red ijigment-iDroducing coccus. Diagnosis: The condi- tion must be differentiated from the various forms of Trichosporosis (piedra, etc.), and from Leptothrix of temperate climates. It is easih^ distinguished from the former by the fact that Nocardia tenuis in contrast to the various species of Trichosporon is an extremely thin fun- gus; it differs from the latter by the nodules being soft, easily removed, and by the hairs not becoming brittle; moreover, it is easily curable. Treatment: A good method of treatment is dabbing the hair two or three times daily MVIUCTOMA, on JMADURA I'OOT !4!) Avitli a solution of formalin in spirit (oi to ovi) and apply- ing a snlpliur ointment (2 to 5 per cent) at nig'ht." In 1906, in a case of amebic dysenter}^ and suspected hepatic abscess, I found motile aniebas in a general pus- tular cutaneous eruption; in this same case Musgrave and Clegg found amebas in the circulating blood, Keng^ (1914) describes a dermatitis of small, hard, red, discrete papules, like beginning smallpox, which became vesicles, ruptured and scabbed over; in other cases it was a dif- fuse spreading erythema with pus in the subcutaneous tissues; each form seemed to spread from the region of the anus of amebic dysentery cases and Entameba his- tohiica was found in each lesion. Fig. 58. — Madura foot. (From a specimen in the Army Medical Museum, Washington.) MYCETOMA, OR * 'MADURA FOOT" Mycetoma, or Madura foot, is a fungus condition of th<^ foot, rarely of the hand or other parts of the body, and '•'Kcng: Jour. Trop. :\Ied., 1914, xvii, p. 193. 150 TROPICAL SURGERY AND DISEASES never of the internal organs. It is found in all warm countries ; is common in India ; runs a verj chronic course and, unless amputated, terminates in death after many years of exhaustion (Fig. 58). The foot becomes en- larged to two or three times the normal ; all of its tissues fuse by an oily degeneration into a cystic mass full of sinuses containing the mj^cotic collections which ooze from openings on the surface. It begins usually on the sole by slow formation as small painless swellings, per- haps half an inch in diameter, which rupture in about a month discharging a viscid, syrupy, synovial, and at times bloody fluid containing minute rounded particles of various colors, white or yellow, black or pink, from which the three clinical varieties derived their names ; in these granules are found the pathogenic fungi; pyogenic invasion is usually a complication. Besides the strepto- thrix m.ycetomi Laveran and the streptothrix madurse, Brumpt described six different fungi which can cause clinical mycetoma; four of them, provisionally, are among the mucedineae. AINHUM AND CHIGGERS The surgical curiosity called ainlium, a disease of flat- footed, barefooted peoples, commonest in Africa, which results in a cicatricial band amputation of toes, usually the little toe, according to Creighton Wellman" (1914), is probably caused b}^ chiggers. In West Africa he no- ticed, "that the chigger has, even in healthy feet, a pre- dilection for the under surface of the little toe, and espe- cially so if, as is often the case Avith barefooted peoples, the skin is cut or torn. It is well known to those who have studied the insect that it invades abraded or irri- tated surfaces oftener than sound skin. The fold under the proximal joint of the little toe corresponding to the ^"Wellman. Creighton: Forchheimer-nillings, Tlierapeusis of Internal Diseases, D. Appleton & Co., iv, 690. AINHUM AND CHIGGERS 151 web between the toes is the point where wounds are oftenest made by the sharp grasses, througli wliich the native walks and runs. A principal reason for this is that the little toe of barefooted blacks, especially, lies separate from the otliers at an angle due to anatomic reasons connected with flat-footedness. When wounds are made here the chiggers persistently invade them and Fifif. 59. — Ainhum. (From Manson.) must be removed constantly. So these insects seem to play a part, in many instances at least, in the continued irritation which, especially in blacks who have fibrogen- etic tendency, leads to the contracting fibroses resulting in ainhum." (Fig. 59.) THE CHIGGER, SARCOPSYLLA PENETRANS, EWUNDU, OR SAND FLEA The chigger plays a heavier role in the production of mutilation and disease than hitherto suspected. It is a common pest originally from South America which has 152 TROPICAL SURGERY AXD DISEASES traversed Africa, reached India, and seems to be on its Avay around the world. Welhnan says, "it usually pro- duces no serious lesions, yet I have seen shocking- deformi- ties, loss of limbs, gangrene, septicemia, and death re- sult, directly or indirectly, from its presence. Apropos i ^^ik A \ " "^^^ss* ^/7 Fig. 60. — Female pregnant chigger Fig. 61. — Male cliigger (Sarcopsylla (Sarcopsylla penetrans). Magnified. (Af- penetrans). Magnified. (After Well- ter Wellman.) man.) of its being the possible transmitter of specific micro- organisms, I may mention that I have found various bac- teria, including Bacillus lepr^ in chiggers but the insect has not been carefully studied to determine if it be a true carrier of such germs.'' (Figs. 60 and 61.) GOUNDOU, OR ANAKHRE This curious disease was first described in 1882 as "the horned men of Africa." It consists of synmietric bony growths of the nasal bones and of the nasal processes of the superior maxillary bones. It usually begins in childhood, and also affects monkeys. The growths ordi- narily attain half a hen's egg in size and impart a simian expression to the face. (Fig. 62.) The overlying skin is not involved; the nostrils are bulged inward and are partially obstructed, but no lesions of the mucosa have been observed in the mature cases. Its beginnings are characterized l)y severe headaches and a sanguinopuru- GorxDOT', on axaktiiie 153 lent discharge from tlie nose for six or eight months when, according to ]\lanson, the pain and discharge sub- side but the swellings increase painlessly and gradually and in extreme cases may, by their immense size, destroy the eyes l)y pressure. Xo careful histopathologic studies seem to have been made of the tumors, but the final result seems to be purely a bony growth. Maclaud (1895) is of the oijiiiioii that the disease originates from the larvae Fig. 62. — Goundou and leontiasis (Honduras). (U. S. Xavy IMedical Bulletin.; of some insect in tlie nostril and tliere is nnich to sustain this the(»r\-. It has long ht'vn known that several species of flies deposit their eggs in the nasal cavities where the larvaj develop rapidly and if the secondary microbic in- fections are severe enough, death has often resulted. The early s3anj)toms of goundou are plainly due to an active inflammatory process in the anterior nares and when the specific pathogenic agent is discovered, it will prob- ably be found to be a myiasis. The growths nrc easily removed by chiseling, and there is no tendency to recur. 154 TROPICAL SURGERY AND DISEASES Botreau-Eoiissel {Bull. Soc. Path. Exot. June, 1917, vol. X, pp. 480-483) saw 117 cases of gouiidon on the Ivory Coast and removed the paranasal tumors sub- periosteally 108 times, 107 times with success ; he groups them: 1. Paranasal tumors the only symptom, 48. 2. Paranasal tumors the most striking symptom, hut other hyperostoses present, 62. 3. No paranasal tumor present or, if present, secondary to other hyperostoses, 7. The bones most frequently affected were the tibia, 58 ; upper jaw, 14 ; lower jaw, 13 ; forearm and fibula, 4 each ; humerus, femur and clavicle, 2 each ; malar bone, 1. There Avas never any history of intranasal infection or discharge but always one of an eruptive disease called ''dobe" lasting from three to twelve months. The dobe was yaAvs and in the serum of the frambesial nodules Spirocheta castellani was demonstrated. BUBOES Buboes of the inguinal region in men, accompanied by a mild degree of fever and considerable pain, running an indolent course, with slight tendency to su]3puration, and nonvenereal so far as any evidence is concerned, are quite common in hot countries. The disease was often encountered in the Philippines, especially among white men during the military occupation. Many glands were involved and the tendency was to become chronic. Un- der expectant and local treatment a low grade inflamma- tion, with softening, occurred in the majority of cases in two or three weeks. Although no venereal disease was discoverable, habitual and even excessive venery was admitted by many of the patients. No evidence of rec- tal or pelvic disease was evident, and sections of the glands showed inflammatory changes only. The suspi- cion that the condition in Manila was due to surface ab- sorption of gonococci or other organisms during venereal excesses could not be substantiated bacteriologically; the TYOGEiS'lC lA^l-'ECTiONS 155 only organism discoverable by the incomplete methods employed was the streptococcus in the nodes that suj)- purated. Little benefit was apparent from local therapy and rest in bed; compk^te removal of the nodes, which often shelled out easily, was found to be the most satis- factory treatment. Some authors consider the condition due to a weak strain of plague bacilli, apestis minor, or to a malarial cause, etc. Castellani and Chalmers describe a subacute and chronic form of bubo, and Barlow," in Honduras, encountered an epidemic, nonsuppurating form which was limited to one gland; numerous punctures yielded only sterile juices; it had a sharp onset with pain, fever (102° F.) and redness which subsided in a Aveek or two. Salicylates, 40 grains or more daih^. Barlow claims are a specific and that if begun on the first or second day the patient may return to work in three days. TETANUS This infection deserves special mention only because it is too often a postoperative complication; it was in Manila, at least in the early days; and tropical surgical clinics should always be on their guard against it and prepared to combat it promptly. PYOGENIC INFECTIONS Pyogenic complications of Far Eastern surgery have little to distinguish them from those of other lands. In the warm and moist parts of the earth microorganisms of both the animal and the vegetable kingdom naturally flourish perennially and in profusion as do all tropical growths. Much has been written of the necessitj^ of doubling and trebling the antiseptic surgical iDrecautions in the Tropics on this account, but the onh^ permissible "Barlow, N.: Epidemic Climatic Bubo, Am. Jour. Trop. Dis., 1914, i, No. 11, 787. 156 TROPICAL SUEGERY AXD DISEASES teclinic for sterilizing everything that comes in contact with a Avonnd, Avherever an operation is to be performed, is the one that can not be improved upon; namely, the one that is standard and that is in use wherever the best surgery is done; climate, amount and ubiquity of germ life have nothing to do with it. If there is any peculiarity about microbic wound infection in the Tropics, it is jDrob- ably in that the streptococcus is so rarely encountered Fig. 63. — Dr. W.'s hand. The photograph was taken at a time when retro- gressive changes had set in. At the tip of the forefinger some remains of the cauli- flower-like granulations may still be seen. ill wounds compared to its prevalence in temperate zones. The results of pyogenic infections among natives are very frequent and often serious, but this is due to their un- hygienic lives and ignorance of asepsis or antisepsis. Two cases of a peculiar form of hand infection, one in a hospital surgeon and one in a nurse, due to an organism resembling the Koch- Weeks bacillus were reported by rvo(ii':N ic" IX I'ECTroxs 157 McDill and Wherry.' ' The surgeon had been treating- cases of acute suppurating conjunctivitis and a small painful papule appeared on the tip of the right index finger; four days later it was incised but no pus was found; two days after this the nurse lanced it and pricked the pulp of the index finger of her left hand during the operation; the wound secretion Avas scant and clear and tlie wound became a eauliilower-like mass (Fig- 63) ; by Fig. 64. — A photograjih of ^Nliss B.'s hand, taken al a time when gangrene of the forefinger had set in. the end of the second week the pain was intense and the wound was thoroughly curetted; by the end of the third week it was worse and greatly swollen and a little pus was found on the twenty-eighth day; temperature Avas never over 102' F.; the ])ain was intense, there was great ^^McDill and Wherry: A Report on Two Cases of a Peculiar Form of Hand Infec- tion, Jour. Infect. Dis., 1904, i, No. 1, 58-71. 158 TROPICAL SURGERY AND DISEASES mental depression and complete loss of appetite; treat- ment had no apparent effect. In another month complete resolution occurred with good function. The nurse sterilized her wound at once with bichloride solution and applied 95 per cent alcohol com- presses, but in three days a painful vesicle formed; continuous packs of a very cold saturated solution of acetate of aluminum were employed ; no discharge ap- peared in the incision; incessant stabbing pains per- sisted; the digital arteries pulsated ^^ith a wirelike tension; only twice the temperature reached 102° F.; pro- nounced mental and plwsical prostration, vigilance, sleep- lessness and vomiting uninfluenced but little, even by morphine, characterized the condition for three weeks. Twice the soft tissues of the wound were curetted to the exposed bone with relief for only thirty-six hours ; the whole hand was swollen at the end of twenty days when the infected area was again cleaned out and the tendon sheaths drained toward the palm. Gangrene of the end of the finger became apparent (Fig. 6-±) and five weeks after the onset the finger was amputated when three inches of necrotic long flexor tendon pulled away easily. Dr. Wherry's bacteriologic examinations and inocula- tion experiments on rabbits, guinea pigs and monkeys led him to consider the organism as identical with or as a closely related type of the Koch-Weeks bacillus. THE ARTHRITIDES Both rapid and chronic invasion of the joints from localized infection foci anywhere, from gonorrhea, and from syphilis, with local and general symptoms, are not infrequent in the Tropics, and they further closely re- semble these conditions elsewhere by being called "rheu- matism. ' ' The generally reduced bodily resistance of the poorer classes is a tangible factor and the injurj^ to which THE AETHIUTIDES 159 the disease is usually traced as the proximate cause is almost always a slight trauma or a chilling of the part by exposure. Probably three-fourths of the cases are due to the organisms of lues and gonorrhea, especially in the seaboard centers of population. These cases of venereal origin, when correcth^ diagnosed, usually yield readily to vigorous specific treatment combined with attention to the general metabolic disease. PART II OBSERVATIONS ON CHINA, JAPAN, AND THE PHIL- IPPINES, AND COLLATED ANSWERS TO A QUESTION- NAIRE OF FIFTY-THREE INQUIRIES SENT TO COUN- TRIES IN AND ABOUT THE TROPIC ZONE IN 1911* CHAPTER X OBSERYATIOXS OX CHINA, JAPAN, AND THE PHILIPPINES CHINA China with her four-thousand-year-old ideals and tra- ditions and the tremendous inertia of her four hundred million people, devoid of public sentiment, real patriotism and a national consciousness, presents to the medical man and sanitarian an almost unapproachable problem. The enthusiastic Occidental who longs to help China clean house and who is baffled at times by her indifference to, or utter rejection of, his well-meant and really beneficent plans for her welfare, must not forget how deep and long- she has drunk of the drug of self-sulficiency and com- placency. For the past twenty years we have heard much of "awakened China" and yet today among those who have worked hard for her regeneration there is cause for profound discouragement if it is not realized that she is * Author's Note: I am assured by surgeons recently from China that the answers to this questionnaire do not in some respects represent knowledge concerning medical conditions today; that there has been a very decided improvement since the ^lanchus were banished and that a survey now would reveal statistics of real value and that there has been a very great advance made in surgerv since 1910 and especially since 1912. 161 162 TROPICAL SURGERY AXD DISEASES yet dazed and stupefied from the effects of her age-long- narcotic dreams. It has taken all of the successive blows dealt at her ''universal sovereignty" fetish, her defeat by Japan in 1894, by the allied powers in 1900, the treat- ment of her as a negligible quantity in the Eusso-Japa- nese war fought on her soil in 1904-, the encroachments of all the European nations, and lastly, the startling- demands of Japan to bring home to at least her ruling- powers that the reason for her humiliation is, as a for- mer President once admitted, her weakness. It would seem that now is a fitting- time to call to the attention of those who are responsible for China's future that this weakness has its origin largel}^ in the lack of appreciation of the value to the state of healthy able- bodied citizens, and of the fact that it is impossible to kindle the fires of patriotism and to create an adequate force for national development and protection in sick bodies. Convince the Chinese that the efficiency and energy of their country is reduced over seventy per cent by the chronic curable diseases of tuberculosis, malaria, syphilis, and intestinal parasites, including five million cases of eye diseases, and that these conditions can be remedied, and they will at least tolerate the modern medi- cal man and sanitarian as tliey already do the foreign po- litical adviser, engineer, and railway builder, jDarticularly under the condition that native controlled institutions and a body of Chinese medical men will be developed. The sine qua non in China is government cooperation; no headway can be made in the treatment of a whole people totally ignorant of medical matters without the initiative of their rulers in the establishment of medical institutions and the enforcement of the immediately urgent therapy by official power. So far, efforts to remedy the physical ills of the Chinese people have been made only in connection with the teach- ing-^ of religion and have scarcely ruffled a small part of OBSERVATIONS OX CIITXA 163 tlie surface of the problem. For over one hundred years the medical missionaries of all countries have done their best. There are at present ninety-three Protestant mis- sionary societies at work in various parts of China, There are about four thousand Protestant missionaries, includ- ing wives and unmarried women Avho constitute half their number, and of these nearly five hundred are medical men and women. There are close to twelve hundred foreign and six hundred Chinese Catholic T)riests also in the field. Hundreds of the missionaries and their con- verts have suffered martyrdom and time and again they have been driven out and all of their property destroA^ed. Their greatest service has been in the favorable impres- sion they have made on the Chinese and the proofs they have given of the genuine disinterestedness of their mo- tives. With the Oriental, with whom self-interest is paramount and who has heretofore not been able to con- ceive of others being without it, this has not been easy of achievement and in sjDite of all the depreciating stories circulated about the missionaries, their work has been of incalculable value and has become the basis of much mutual understanding in place of suspicion and distrust. The struggles against incredible odds and with meager support of the mission medical men and women to better conditions is a great story of devotion and unselfishness. It is through their work principally that the evangelistic members have been able to reach the Chinese. They have founded about one hundred hospitals and eleven medical schools, skeletal organizations mostly, but to which can be added the vital elements necessary to develop them to great usefulness. So far the schools have turned out less than two hundred poorly trained Chinese physicians, while tens of thousands of first-class men are needed, and the hospitals, through lack of staff and equipment, are not fulfilling the real functions of hospitals to the communities in which they exist. The number of foreign 164 TROPICAL SURGERY AND DISEASES trained native doctors is small; they have taken lucrative positions and their influence on the general health situa- tion is very slight. The medical members of the various missions have wisely formed a union for the purpose of organized effort in colleges, societies and publications, and are doing splendid work. There are men in this association who only need backing to go to the top of their profession. It is to be hoped that the ruling powers of China will take up the problems of health and sanitation without delay, and that they will do so ^^ith a long look ahead, will commit themselves to a fixed program covering at least two decades, and be guided by those foreign advis- ers whose disinterestedness, wisdom and abilit}^ are un- questioned. With the exjperience of all nations and the willing cooperation of the best men of friendly powers at her disposal, China has an opportunity, unique in the world's history, to acquire the strongest educational sys- tem of any, because her field has not 3"et been invaded to any appreciable extent by the unfit and the untrained. Medical science, long centralized in Europe, is shifting- westward to America in many respects. Japan, still fur- ther west, is already attracting attention to her ability to take and hold a leading place, and in another century or less it is not unreasonable to expect that if China will drink deep from the fount of pure science onl}^, she can become the actual ''middle kingdom" of the world of medicine and science. If China 's little, nation-disturbing neighbor, Japan, can accomplish such wonders in med- icine and military surgery in thirty years that the rest of the world must govern itself accordingly, China's colos- sal ]oride should at least impel her to make a sustained effort to demonstrate her ability to not only do likewise but to do so on a far grander scale. Even though the psychologic period is apparently present and even though the proposition is to us so plainly OBSERVATIONS ON CHINA 165 beneficent and it is so obvious that great and certain power follows real knowledge, in order to receive con- sideration, the idea must be presented to the Chinese with due regard to their peculiar state of mind and habits of thought or tliere is always danger of it being received with impenetrable apathy. It must be remembered that the obvious and essential to the Occidental mind may be an uninteresting triviality to the Oriental, that much of our enthusiasm and zeal is inexplicable to him and that there is a great necessity to proceed slowly and with calmness in presenting any problem. ''A Chinaman will not hear patiently in a month what a Frenchman can say in an hour. ' ' But there is one opening in his armor of phlegmatic calm through which he may be reached. He is intensely appreciative of success. Once he is shown that a thing really works and accomplishes its object, his sympathy and admiration are enlisted because success to him means, not only so much in dollars and cents, but to his superstitious mind it spells the favor of his gods as well. Although every disease is prevalent in China, the epi- demic diseases devastating at times and leprosy not seg- regated and although the Chinese generally use cooked food and drink, the answers to my questionnaire of 1911 from all parts of China showed that the predominating diseases were tuberculosis, syphilis, and intestinal para- sites. When statistics are available, malaria will prob- ably also be found in this group. Surgery, except for the most obvious and pressing conditions which can be handled by ordinary skill and equipment, is as yet un- developed in China except in university centers. Medicine as Practiced by the Chinese* Since the opening of the Canton Hospital in 1838, the advance of Western medicine in China has been .gradual but continuous. Of recent *By William W. Cadbury, M.D., Physician to the Canton Christian College, Canton, China. Reprinted from Med. Rec., New York, Aug. 26, 1916. Published by permission of Dr. Cadbury. 166 TROPICAL SURGERY AXD DISEASES years the medical profession of the United States has shown consider- able interest in the hospitals and medical schools established by mission- aries, and this interest has been greatly intensified by the recent an- nouncements of the China Medical Board of the Rockefeller Foundation that it is their intention to assist and carry on the institutions already established at Peking and Shanghai. It is the purpose of the Board to make the schools equal to or even better than any now existing in the United States. In view of this greater interest of the medical profession of our coun- try, there is doubtless more or le^s speculation as to what is the status of Chinese medicine as it has existed and still exists among the people of this vast empire. The notes here submitted are partly the result of personal observation in the city of Canton, and partly of conversations with a Chinese doctor of the old style. I have also referred largely to the articles noted below under references. Medicine in China may be considered under two divisions — the purely superstitious, which depends on charms and magie and is largely fos- tered by the Taoist priests, and the art of medicine as practiced by the Chinese doctor. These two phases of treatment of the sick are closely interwoven with one another so that it is sometimes impossible to draw the line between them. Let us first consider the sux^erstitious practices and beliefs. In the city of Canton may be found temples dedicated to the "Spirit of Med- icine," or healing. .The ignorant people, especially women, believe that the deity presiding in these temples can restore health upon the pay- ment of small sums of money to the priest and the performance of cer- tain rites. Chinese medicine, like philosophy, rests on a dualistic basis. At the bottom of all the laws of the universe are two principles, the "yang" and the "yin. " They are generally represented by a circle divided into two x^ai'ts, each of which is a comma-shaped object resembling a serpent. One is white and the other black, or one is green and the other red. The circle represents the great absolute and the two divisions within it the "yaug" and the "yin." Again the "yang" or male element or force is represented by straight lines, and the "yin" or female element by broken lines. Thus the pantagram was devised by a Chinese emperor about the year 2900 B. C. This is made up of com- binations of straight and broken lines surrounding the circle and its two divisions, making a perfect emblem of the balancing of the forces of the universe. Over many a doorway in China this sign is disj)layed to warn off evil spirits. The principle of duality typified by the "yang" and "yin" is more comi^rehensive than "male" and "female." They stand for positive and negative, the sun and the moon, light and dark, acid and base, heaven and earth, and they correspond to Ohrmuzd and Ahriman of the Zoroastrians, Osiris and Isis of the Egyptians, the even and the odd of Pythagoras. The universe with its dual forces is a macrocosm. Man is the micro- OUSEltVATIOXS ON THIXA !()< fosiii. Thus ^\■c read that as heaven has its orders of stars, and earth its currents of water, so man has his pulse. As earth has its water courses, called lakes, springs, etc., so man lias his courses in the pulse — the three "yang" and the three "yin." The priests explain these forces of the universe by personifications in the form of evil spirits, or devils, and the people are kept in constant fear of these demons of tlie air whicli they believe arc constantly bent on bringing disease or death. Hence the many superstitious practices resorted to for deceiving or warding off the evil spirits. The priests recite incantations, paper money is burned, and the pantagram is hung over the doorway. The demons are especially fond of marring beautiful children, hence the parents invent disgusting names for their offspring in the hope of misleading these tormentors. Boys are especially liable to injury at the devils' hands. Hence a guest never inquires into the sex of a newborn child, and a boy is often dressed as a girl and called by a female name. The Chinese physician is quite a different individual from the Taoist priest, although magic and astrology are inextricably bound in with his theories of the human organism. The first authority on medicine in China was the Emperor Chen Long, who lived about 27.37 B. C, and made a classification of some hundred medicinal plants. A later emperor wrote up medical science so far as it had progressed in 2637 B. C. In the earlier ages there was some jjrogress in anatomy, but for the last one thousand years at least, there has been practically no advance. The profound respect for the dead has interfered with dissectintj and the performing of autopsies. Again there is no cooperation between doctors and no medical organization. The so- called Imperial Academy of Medicine at Peking has no jurisdiction over physicians in other parts of the country. It is composed of the phy- sicians to the emperor. They give instruction to the younger members in the medical classics. Generally speaking the practice of medicine is unlicensed. Most doctors receive their library from a father or rela- tive who also imparts the secret remedies on which his reputation was established. During his apprenticeship the young doctor diligently studies the classical books and practices palpation of the pulse. The doctor is called upon only for more serious maladies. For the simpler complaints home remedies and the formulas of old women are used. In times of war the Chinese soldiers attend to their own wounds. Adver- tisement is quite ethical and the office of a doctor may be recognized by the tablets displayed about the entrance, on which the skill of the physician is testified to in high-sounding phrases. These testimonials are usually signed and presented to the doctor by grateful patients. The name of the doctor is of great importance, thus one hears of Dr. "Eoot- of -Strength, " Dr. "Khubarb" and Dr. "Salts of Hartshorne." As one would suspect from the absence of dissection and the experi- mental methods, the Chinese conception of physiology and anatomy is fanciful to the extreme. The bodv is said to be divided into three 168 TEOPICAL SURGERY AND DISEASES parts: (1) tlie upper or lieadj (2) the middle or chest; and (3) the lowe'f part, or abdomen, and lower extremities. Life depends on the equilibri- um of the "yang" and the "yin. " It is but one manifestation of the universal life. The body is the microcosm, the universe the macrocosm. The "yang" is the warm principle, actively flowing. The "yin" is the moist principle passively flowing. As the whole order of the uni- verse results from the perfect equilibrium of these two forces, so the health of man depends upon their equilibrium in the body. If the "yang" or active principle predominates, there is excitation; if the "yin" or passive principle predominates, there is depression of the organism. The action of these two forces manifests itself through eleven organs: the heart, liver, lungs, spleen, left kidney, large and small intes- tines, stomach, gall bladder, urinary bladder, and right kidney. The lungs are divided into four large and two small lobes. The larynx passes directly into the heart, which is the organ of thought, together with the spleen. The liver has seven distinct divisions. The gall bladder is the seat of courage. The urine p'asses directly from the small intes- tines into the urinary bladder through the ileocecal valve. The brain and spinal marrow produce the semen which passes directly into the testicles. There are said to be three hundred and sixty-five bones in the body. Functionally the viscera are divided into two groups known as the six viscera in which the "yang" resides, and the five viscera in which the "yin" resides. The first group is composed of the gall bladder, stomach, small intestine, large intestine, bladder, and left kidney, with its three heat centers the three lumbar sympathetic ganglia. The five viscera are the heart, liver, lungs, spleen, and right kidney. The dia- phragm is placed beneath the heart and luags, and covers over the intestines, spine, and stomach. It is an impervious membrane and covers over the foul gases, not allowing them to rise into the heart and lungs. The stomach, spleen, and small intestines are the digestive organs. They prepare the blood which is received by the heart and set in motion by the lungs. The liver and gall bladder filter out the various humors. The lungs expel the foul gases. The kidneys filter the blood, while coarser material is evacuated by the large intestines. The "yang" which is of subtle nature has a constant tendency to rise. The "yin" which occupies the brain and vertebral column, as well as the five viscera, tends to descend. Each of the organs has a canal whereby it communicates with other organs. Thus the liver, kidney, and spleen are connected with the heart by special vessels and the vas deferens arises from the kidney. Some of these communicating channels end in the hands and some in the feet. One of the vessels in the little finger is used to determine the nature of infantile diseases. Six of these vessels carry the "yang" and six carry the "yin. " These two forces are disseminated through the whole organism by means of the gases and the blood. The former act upon the latter as the wind upon the sea. The interaction of these two OBSERVATIONS ON CHINA 169 as they circulate in the vessels produces the pulse. The blood makes a complete circulation of the body about fifty times in twenty-four hours. In these fifty revolutions the blood passes twenty-five times through the male channels or those of the active principle and twenty-five times through the female channels or those of the negative principle. The blood is said to return to its starting place once in every half hour, instead of once in twenty-five seconds, according to modern physiolo,gists, having traversed a course of some fifty-four meters. Each organ is related to an element: fire rules the heart, metal the lungs, etc. There is likewise a close relationship to the planets, to season, color, and taste. This interrelationship is well illustrated by the following table: — Organ Planet Element Color Taste Stomach Saturn Earth Yellow • Sweet Liver Jupiter Wood Green Sour Heart Mars Fire Red Bitter Lungs Venus Metal White Sharp Kidney Mercury Water Black Salt Auscultation and percussion are wholly unknown as diagnostic aids to the Chinese physician. Entire reliance is placed on palpation of the pulse and the general facies of the patient in making the diagnosis. The taking of the pulse is almost like a solemn rite. The pulse may be palpated at eleven different points, as follows: — Radial, cubital, temporal, posterior, auricular, pedal, posterior tibial, ex- ternal plantar, precordial, and in three places over the aorta. Usually, however, the physician is satisfied with the palpation of the pulse of the right and left wrist. With the right hand he feels the left pulse and with the left hand the right pulse. He applies three fingers, — the ring, middle and index finger over the pulse and the thumb underneath the wrist. Then he palpates the pulse with each finger successively. Under the ring finger the pulse of the right hand reveals the condition of the lung, middle of chest, and large intestines, while in the left hand the ring finger determines the state of the heart and the small intestines. The pulse under the middle finger corresponds on the right to the condi- tion of the stomach and spleen, on the left to the state of the liver and gall bladder. The index finger placed over the pulse of the right radial shows the condition of the bladder and the lower portion of the body, over the left radial it reveals the state of the kidneys and ureters. For each of these six pulses the physician must practice weak, moderate, and strong pressure, to determine whether the pulse be superficial, mod- erate, or deep. This must be done during nine complete inspirations. If the pulse be rapid the "yang" principle is predominant, if slow, the "yin" is predominant. There are twenty-four main varieties of pulse. The Chinese physician must be trained to palpate the pulse so skillfully that by this single means the nature of diseases and even the months of gestation in a pregnant woman may be determined. Ten or more minutes must be spent in the palpation of the pulses. Sometimes a Chinese physician will consider other factors. For ex- 170 TROPICAL SURGERY AiSTD DISEASES ample, it is said that by cxaraination of the tongue thirty-six symptoms may be diagnosed according as tlie tongue is white, yellow, blue, red, or black, and depending on the extent of the coating. From the general appearance of the face and nose the state of the lungs may be discovered. Examination of the eyes, orbits, and eyebrows shows the condition of the liver. The cheeks and tongue vary with the state of the heart, the end of the nose with the stoma cli. The ears suggest the conditions of the kidneys; the mouth and lii^s the state of the spleen and stomach. The color and figure of the patient also count in a diagnosis. Diseases are spoken of as internal and external. External cases are those apparent on the surface, such as all skin affectations, tumors grow- ing on the surface and of late all surgery has been classified as the practice of external diseases. Internal diseases include all fevers and diseases of the heart, Iniigs, and abdominal organs. More specifically diseases are classified under nine heads as follows: (1) Affections of the great blood vessels, including smallisox; (2) diseases of the lesser blood vessels; (3) fevers; (4) female complaints; (5) cutaneous dis- eases; (6) conditions requiring acupuncture; (7) diseases of the throat, mouth, and teeth; (8) diseases of the bones; (9) affections of the eye. Diseases are said to be produced by internal and external agents. Among the external diseases are: (I) wind, which causes headache or apoplexy, dizzin'ess, chapping of face, diseases of the eye, ear, nose, tongue, teeth, etc.; (2) cold may cause cough, cholera, heart pains, rheumatism, and abdominal pains; (3) heat causes chills and diai'rhea ; from dampness comes constipation, distention of abdomen, watery diarrhea, gonorrhea, nausea, pain in kidneys, jaundice, anasarca, pain in small intestines, and pain in the feet; (5) from dryness come thirst and constii^ation; (6) Fire causes pain in the sides, diabetes, etc. The diseases of internal origin are classified as disorders of the gases, blood, sputum, and depressed spirits. The treatment of disease by the Chinese doctor consists chiefly in the administration of drugs. Surgery has been an unknown art. Re- cently two charitable institutions have been established in Canton for the treatment of the sick according to native methods of practice. At one of these so-called hospitals I was informed that bullets were re- moved by placing a kind of plaster at the wound of entrance. The ingre- dients of the plaster have a remarkable magnetic power over the embedded bullet and gradually draw it out through the same opening by which it entered. My informant had never seen this line of treatment actually carried out, however. Perhaj)s in no line does the native j)ractitioner show his ignorance more than in the treatment of fractures. Xo attempt is made to reduce the parts. A special clay is placed in a wooden bowl. The heads of several chickens are cut off, while incantations are repeated and the blood is allowed to flow on the clay in the bowl. Blood and clay -are now mixed together and applied to the fractured extremity. Bandages are used to bind on thin strips of bamboo. When the last turn of the OBSERVATIONS ON CHINA 171 bandage is being wound on, the blood of another chicken is poured on. The only real oiieration performed by the Chinese is the castration of tlic eunuch, and castration as a penalty for adultery. With one sweep of a sharp knife the genital organs are completely removed on a level wjtli the skin of the ]iubis. A metal plug is inserted in the urethral opening and a cloth wrung out of cold water is a])]died to the bleeding surface and firmly bound on. The patient is allowed to drink no water for three days when the dressing is removed, the plug withdrawn and the i)atient allowed to urinate. Coming now to the real field of the Chinese doctor we find that the number and variety of remedies recommended by the Chinese Materia Medica can only be compared to our own National Pharmacopeia. The great Materia Medica compiled in the 16th century is composed of 52 books and contains 1892 remedies. Kipling's verse applies to,_the Chinese as to the British people for whom he wrote it: "Alexanders and Marigold, Eyebright, Orris, and Elecampane, Basil, Eocket, Valerain, Eue, (Almost singing themselves they run) Vervain, Dittany, Call-me-to-you, Cowslip, Melilot, Eose of the Sun, Anything green that grew out of the mould. Was an excellent herb to our fathers of old. ' ' The drugs and other medicaments are weighed out according to a decimal system as follows: 1 tael or leung ec^uals 40.00 gm. 1 tsin " 4.00 gm. 1 fan ' ' .4 gm. 1 lei " .04 gm. 1 ho " .004 gm. Often a prescription is given because of the resemblance of the drug to the organ affected. Thus for renal diseases, haricot or kidney beans are given. Minerals are administered as salts. Plants are used in the form of roots, stems, leaves, flowers, and dried fruits. The bones of a tiger are frequently ground up and given to a debilitated person. The grasshopper is dried and used as a medicine and the shells of the cicada are collected from the bark of trees and mixed with other ingredients. Tinctures and extracts are prepared from rice wine. Pills are often made with a thick shell of paraffine which is broken off and the contents chewed up. Various forms of pilasters and blisters may be applied to the skin. The actual cautery is often used as a revulsive. Among the pills the best are the "Wai Shaang Uen" or life-preserv- ing pills costing about a dollar apiece. They are comi)Osed of Man- churian ginseng, deer's horns, and other drugs. Among other common remedies may be named dried, powdered rattlesnake skins, the bile of 172 TROPICAL SURGERY AND DISEASES the ox and dog for jaundice, dried shrimps, etc. Quicksilver is often poured into gunshot wounds in order to dissolve the bullet. In some drug shops two signs are hung at the entrance; on one are written the names of venereal diseases, on the other such diseases as hemorrhoids, wounds, ulcers, etc. The patient explains in which class his disease belongs and is promptly given the appropriate remedy. Among the most used drugs are some that are found in the western pharmacopeias; viz., ginseng, rhubarb, sulphur, pomegranate root, aconite, opium, arsenic, and mercury. Diseases of the liver and eyes, which are sympathetic organs, are cured by giving pork's liver. In Kwangtung Province human blood is considered an excellent remedy and at executions people may be seen collecting the blood in little vials. It is then cooked and eaten. A genuine prescription written by a physician to be used as a laxative was composed of rumex hydrolepathium, quercus glauca, sodium sulphate, and magnolia hypoleuca. The parts from these plants are boiled with the sodium sulphate and the "tea" is drunk by the patient. A remedy which I have not infrequently seen applied to a patient in extremis is as follows: A rooster is killed and the body is cut in half, longitudinally, and the bleeding half is quickly applied to the skin of the patient 's abdomen. If there is any possibility of cure this is supposed to be infallible. The use of the acupuncture needle seems to be seldom resorted to in the neighborhood of Canton. The theory on which it is based is that if one punctures the blood vessels connecting different organs the disease will be aborted. Three hundred and eighty-eight points suitable for acupuncture are described. There is a manikin at Peking pierced with holes at all the points suitable for acupuncture. Paper is pasted over it and students learn to find the proper holes through the paper. The needles vary from 1% to 28 cm. in length and are made of gold, silver, or steel. During the operation the patient coughs and the errant humors are directed back into their normal courses. Such in brief is medicine as it is practiced by the Chinese doctor of today. One is reminded of the old humoral theory of Europe in the Middle Ages. But modern education in China has brought a new light to the people and in all the large cities and many of the small ones, Western medicine is slowly but surely winning its way. JAPAN Medical education in Japan was founded by German teachers about thirty-five years ago. The official language for medicine and allied sciences was German, which is used to a considerable extent today. About twelve years ago the last of the foreign teachers were replaced by Japanese. OBSERVATIONS OX JAPAN 173 The place Japanese medical scientists have taken in the world needs no comment except perhaps to call atten- tion to the brief period in which it has been attained as an evidence of the immense value of a definite prear- ranged plan, carried out to the letter. This shows in all phases of their national development and in medicine even as early as 1900 when the Japanese medical corps in the army at Pekin was superior to that of any other nation. Their victory over Russia in 1904-1905 was a victory of the extreme scientific efficiency of a small army over enormous odds in men and money in an army in which such methods were wanting; the medical corps of the Japanese army b}^ prearrangement guaranteed against the loss of men by disease and was the main factor in the success of their arms. The influence of modern medicine, applied entirely by Japanese, on the national health and welfare is one of the chief sources of her strength and is her guarantee against decadence. In these respects she is far ahead of other nations, some with centuries of history behind them, and Japan, after less than forty years development from a chaotic condition, is held up as a model they must follow or suffer the consequences. The weak point in her med- ical educational system is her second grade medical schools whose preliminary educational requirements are those of the middle public schools which have three years less work than the higher schools from which one can enter the university medical school. Admission to the second grade medical school is by competitive examina- tion which is rather strict, but Chinese are admitted with no condition other than that of being able to speak Japanese. The Surgery of Japan Several years ago Professors Scriba (German), Sato, and Kundo, surgeons of the Imperial University of Tokyo, 174 TROPICAL SURGERY AXD DISEASES informed me that the immber of leg and foot ulcers was very large but no cases of Madura foot had been seen; that in former years there was a great deal of syphilis in Japan and also considerable venereal disease; that beri- beri is common among the young, strong, and healthy; that cancer, except of the skin, is common; that surgical tuberculosis and other chronic surgery occurs in about the same percentage as in Europe and that their general results are good. The only surgical condition they con- sidered peculiar to Japan they called "Kakke" and had made it the subject of special researches. It is an acute suppurating myositis, ushered in by fever, followed in three or four days by deep and superficial furunculosis which later developed into large intramuscular abscesses. Under drainage these abscesses heal and the loatients usually recover completely in uncomplicated cases. The result of the investigations into the specific microbic cause and source of infection had not been determined. THE PHILIPPINES The natives of the Philippine archipelago belong to the Malay race, and while there are very few pure Malays among the leaders, the stock has been improved by the admixture of other blood especially that of the Chinese. They are the most enlightened and vigorous branch of the Malays, have been Christians for centuries, and are near- est akin to Europeans in tliought and aspirations of any alien race. They are eager to learn all that can be im- parted, and have evinced such intelligent capacity that their rapid progress in the art of self-government and their universal desire for education should appeal strongly to American sympathy. As in other Oriental countries, the efficiency of the natives is enormously decreased by chronic curable dis- ease, but their salvation in this respect can not be assured OBSEHVATJONS ON THE PJilLlPPlNES 175 until a competent body of native medical men is devel- oped. There are two medical schools; one a government and one a church school. Premedical and medical educa- tion is now well established in the government school only; the students are earnest, studious, intelligent, and hard working. The Filipino women hold a very high posi- tion of influence for good, and their force, dignity, and strength of character are striking. The aptitude of the younger women for nursing and the medical profession will be of enormous value to their race in solving its physical problems. The principal diseases are due to malaria, tuberculosis, and intestinal parasites. The epi- demics of cholera, plague, and smallpox have been brought under control for a time at least by the splendid work of the American Department of Health, but so far no impression has been made on the more important tu- berculosis, malarial, or intestinal diseases, and none will be until education in health matters is further advanced and a large body of trained native medical men is created. There are less than 500 doctors for the population of eight million, one to each 20,000 of the population or one to each 420 square miles of territory, and of these over 250 are in the city of Manila. Although next to police and fire protection, the health of the people was the most crjdng need of the Philippines, it was eight years after the Americans took over the gov- ernment of the Islands before they recognized the desira- bility of public medical institutions or medical education in any but an academic way. The only medical organiza- tion supported by public funds during this period, outside of board of health work, was one to care for high officials, their families and those dependent upon them; this was later extended to include all employees of the govern- ment and their families. Medical education is making poor progress in the Philippines and will not improve until a new start is made. 176 TROPICAL SURGERY AND DISEASES The government must formally recognize its health prob- lems and commit itself to a program that will ultimately solve them. Several thousand competent native medical men are needed. The profession of medicine and public health must be made attractive to students by the found- ing of numerous scholarships and the creation of a de- partment of public health in which there is a future for ambitious men. The present organization of the govern- ment university medical school and hospitals is ideal only so far as its plan on paper is concerned. It has broken down through lack of direction which could or- ganize the independent and discordant elements into a harmonious whole. There is no real cooperative clinical, teaching, and hospital organization, no true spirit founded on the correct and practical philosophy and psychology which should saturate from above downwards each worker, unit, institution, and student, without which adequate public support and pride in the institutions can not be expected. Foreign medical men selected with great care as teachers, who from the ordinary standpoint were the best trained and equipped men available, are too often failures because no attention is paid to prepar- ing them to accept things as they find them, to lay aside their prejudices and to cultivate a real sympathy, under- standing, and aptitude for the native problems. The church medical school has a far lower standard than ordinary minimum educational requirements demand. This school graduates more men and perpetuates a double standard medical hodj which will be fatal to true prog- ress. The teaching is entirely in Spanish with no bilin- gual requirements, which is a mistake, even though all medical literature is readily translatable into the Spanish idiom. It will take a longer time to teach in English, but the best results for the Filipino people and their fu- ture medical xorofession will be attained in the end. A subject for consideration for Filipino complacency OBSERVATIONS ON THE PHILIPPINES 177 is that if they expect to progress and retain what has been accomplished for them, they can do so only by following the example of Japan in her university medical education and never replace a foreign teacher with a native until the native has proved his ability to fill the position by some- thing more than political influence enough to get the job. Japan's secondary medical school system, however, is something to be avoided. Since the Philippine govern- ment medical school ojDened in 1907, about one hun- dred degrees in medicine have been granted and at a cost of over $150,000 a year. There has been a lack of real apjDreciation of the imperative needs for modernly edu- cated native medical men so far as any efficient practical method to meet these needs is concerned, such as the stimulating of students to enter the profession. At least one hundred graduates a year from the university school alone should have been going out by the end of 1917, and the standard of the Spanish school could have been raised, had the forces and influences at the command of the gov- ernment been put in motion to this end. As at present conducted, it would be far better and more economic to send the government school students to the United States for the last two years of the five year course ; this would give them the best methods of clinical teaching, the high ideals of modern institutional work and a use of the English language Avhich they are not getting now; something that they could take home and apply in the continuation of their education in their home hospitals to the great advantage of those institutions as well as to the cause of medical education. In addition, there should be established "a material betterment" fund to send abroad at stated intervals deserving young men, teachers and institutional men for the i3urposes of observation and study. There is no reason why the Filipinos should not take high place in the medical world in less than thirty 178 TROPICAL SUJIGERY AXD DISEASES years, but everything depends upon adherence to a wise and comiDrehensive general plan. As a si3ecific example of general conditions in the Philippines, note the following abstract: A Medical Survey of a Typical Filipino Country Town of 6000 Inhabitants In 1909 a body of medical school, health department, and laboratory men spent three months on a medical sur- vey of Taytay, a town of 60(30 persons, that had suf- fered severely from epidemics in the past and was known to be an average insanitary country town. The survey was under the direction of Dr. P. E. Garrison, United States Xavy, who suggested the idea, and the scheme might furnish a working model for other tropical coun- tries. The work was done by volunteers during the sum- mer vacation and at very small expense. The water supply from wells was found to be about as undesirable as possible for community health, but the ground was promising for drilling, and an artesian flow has since been secured. The bacteriologic analysis of the drinking water, made by Clegg, showed from 500 to 12,030 bacteria per cubic centimeter, also bacillus communis, vibrios, amebas and flagellata, while the chemical analysis showed high chlorine figures with an excess of nitrogen in all its forms. The principal food supplies used were almost entirely local. Eice was the basis of the meal and fish, both fresh and dried, was the second most common food. Pork, the only meat, was for sale on market days; chickens and ducks were abundant and eggs both fresh and incubated (bolut) were somewhat used by the well-to-do classes; various prepared foods were on sale consisting mostly of rice and sugar; also Chinese foods of seaweeds, a spaghetti and mongo beans; wheat, milk, butter and OLiSEItVATIOXS ON Till-; IM 1 llJiTKXES 179 cheese had no ])lacc in ilic dietary; t^vellty-five fresh fruits were to be had l)iil only the bananas, mang'oes, and pine- apjDles are first-chiss from an edible standi)oint; over twenty vegetables were available but were very inferior and most of them Avere in limited quantities; of pot herbs and condiments they had six to eight varieties of each. Aron investigated their food from a physiologic stand- point; the daily average amount of rice per person was found to be 700 grams, equaling 50 grams of protein and 2000 calories; fish to 4-0 grams of protein and 200 calories, and vegetables equaling 500 calories or a to-tal of 2700 calories for an average person, all for an average cost of 121/2 centavos a day or 6 cents in U. S. currency. In a provincial town an average native can live very com- fortably on this amount, but a hard working man needs at least 25 per cent more food and they are in much bet- ter condition with more meat. Mosquitoes and other insects found by Banks were, 18 species of flies ; bedbugs, not common ; head lice, which are abhorred by all Filipinos, were universal; fleas made all of the dogs miserable and occasionally annoyed the na- tives; dog tics occurred, also caraboa lice which seldom bother men. Ten varieties of mosquitoes were detected. The vital statistics and the general sanitary conditions were carefully worked out by Clements and are very interesting; the death rate was from twenty-seven to forty-five per thousand. Garrison examined 17 per cent of tlie ])opulation for intestinal parasites and found ascaris, trichui'is, liook- Avorms, strongyloides, oxyuris, ameba, ciliates, flagel- lates, and encysted protozoa; total infection per thousand, 182; intestinal worms alone, 172.G. Dr. Bean investigated the racial anatomy and made anthropometric studies. Of 789 physical examinations made, 558 comiDlained of some disease; disease of the nervous svstem was found 180 TROPICAL St^RGERY AXD DISEASES in 32; of the genitourinary system, 37; tnmors, 20; general, 20; alimentary system, 165; respiratory, 135. Malaria parasites were found sixteen times in 742 indi- viduals in fresh hlood smears; no relapsing fever spiro- Fig. 65. — Symmetrical fibromata (1909). (Philippine Journal of Science.) chetes were found in any of the fever patients examined. Filariasis searched for at night Avas found once in 400 people; about 1 per cent of 800 people examined had tuberculosis; 4 cases of typhoid were found; 11 cases of goiter, all in women; no beriberi, due to the use of un- milled rice; venereal disease and syphilis were rare. OBSERVATIONS OX TPIE PJIILIPIMXES 181 Fig. 66. — Symmetrical fibromata on forearms (Philippine Journal of Science.) id ankles. Luzon, P. I., 1909. 182 TROPICAL SURGERY AXD DISEASES Symmetric siil)cutaneous fibromata were found in about 3 per cent of women over 30 years of age, either on one or both ankles and elbows ; sections showed them to be pure fibromata and some were calcified. (Figs. 65 and 66.) Fig. 67. — "Fuente," showing ball of wax in ulcer for permanent counterirritation against all diseases, 1909. (Philippine Journal of Science.) Twenty-one cases of yaws were found after a careful search; several "Fuente" cases were found. (Fig. 67.) Many maps, illustrations, and disease tables were made and a census Avas taken. For the complete report, see the Philippine Jounial of Science, 1901, iv, No. 4. CHAPTER XI ANSWERS TO A QUESTIONNAIRE OF FIFTY- THREE INQUIRIES SENT TO COUNTRIES IN AND ABOUT THE TROPIC ZONE The purely medical responses to the circular request are omitted, but nmch of the surgical and borderline in- formation acquired, fragmentary as it is, Avas considered of sufficient value to edit somewhat and present without apologies. Some of this material Avas published just as it was received, in a Manila medical bulletin which has since ceased publication. Over two thousand copies of this questionnaire mailed to medical workers in and near the tropic zone in 1911 brought a four per cent response. This Avould have been highly satisfactory to any commercial advertiser be- cause second and third ''follow-up" communications would have increased this percentage considerably ; simi- lar improvement could have been expected had this ques- tionnaire been systematically pressed. The most of the answers, however, show that the average of medical men and women in and near the equatorial belt are no bet- ter and no worse than their brethren in other parts of the world; that about 90 per cent of practitioners of medicine everywhere, including those in cities, do not record their observations, do not examine their j)atients in any but the most superficial way, have no proper work- ing library of books and current literatui-e, or do not make their observations and their reading availal)h' to themselves or to the world l)y a simple system ol' in- dexing. One man who lias ])een higldy honored by his country and profession as a tropical authority since re- 183 184 TROPICAL SUEGEEY AND DISEASES turning home, replied, regretting his inability to answer the questions, that although he had resided in the Trop- ics for six years, he had not kept any notes. The few good reports are so perfect that they can well serve as models to those tropical workers ambitious to be of real service to the world and to medical science. Those readers whom these reports will interest, Avill find much to reflect on, as to the presence of certain dis- eases in one place and their entire absence or infre- quency in another, on the ditferences in type and severity in countries on the same lines of travel and on the evi- dent fact that diseases kno^\m to be due to certain mi- crobic organisms vary greatly in different parts of the Avorld. In a disease, for instance, which is clinically chronic syphilis, gives the specific serologic reaction and ^delds promptly to antiluetic therapy, no treponema of any sort is discoverable and no primary syphilis de- velops amoiig the natives or foreigners ; the same dis- ease with a treponema in another country manifests it- self very rarely in the late forms, but is frequently seen in its primary and secondary stages. Enough was gained by this effort perhaps to warrant a more system- atic and sustained attempt to acquire such data. Such an endeavor to be successful should be undertaken by the American Societ}^ of TroiDical Medicine, as the older tropical organizations, it seems, can not be interested in problems outside of their own colonies. Races, Physical Conditions, Food and Habits American Samoa (Cottle.^) — American Samoa is situ- ated 14° South of the equator. The temperature is very equable, there being a difference of only two or three de- grees between day and night and of only eight or ten de- grees between summer and winter. The rainfall is often more than 275 inches in tlie year, yet the degree of humid- ity is seldom high enough to affect the health. The na- ANSWERS TO QUESTlONNAlPtE 185 tives are of the same race as the Maori of New Zealand and the HaAvaiian of the Sandwich Islands. Abont 7000 natives, and 100 Europeans live so isolated from the world— three da^^s of steaming from their nearest neigh- bors — so unaffected even by temporary contact with other races, that they are remarkably free from the com- mon contagious and infectious diseases that exist in most places in the world. The iiative eats the cocoanut, ba- nana, bread fruit, and taro, a vegetarian diet, yet one which gives him health and strength and endurance Avell above the average. Fish, pork, and salt meats are the occasional luxuries added in times of feasting. An amount of physical labor equivalent to about five hours a week will bring the individual practically all his personal necessities, but his hospitable tastes, further fostered by elaborate marriage, birth, and death customs force the easy-going leisure loving Samoan to hard work and these demands on his energy keep him vigorous, robust, and well-developed. He can row forty to sixty miles a day without fatigue. He can travel miles with a very heavy burden on his back. He can show a surpris- ing energy and muscular endurance in his native dance and can accomplish a great deal of work in the fields. A poor laborer for a wage, he is an excellent worker when getting ready for a celebration. Isolation from contact with the other races, government protection from com- mercial exploitation, an abundance of good food carefully prepared and well cooked, a good water supply, an agri- cultural life, well-built houses, an equable warm climate, cleanly personal habits, and a very normal type of sexual life are conditions all of which combine to make the Samoan a healthy animaL Were it not for the presence of a few parasitic and infectious diseases which atfect large numbers of the population — one individul often har- boring two or more infections — sickness would be almost unknown among them. 186 TllOPICAL SURGERY AND DISEASES GrUAM. — Odell,- service during 1909-1911. The natives are Chamorros ; j)opulation ahont 12,000; American sail- ors, marines, civil emploj^ees and civilians who are per- manent residents of the island, number about 250; Jap- anese, Spaniards, and others number about 100. The American x)opulation as to their physical condition, food and habits do not differ to any degree from what they would be in the United States. The native xjopulation had been so changed by the admixture of Filipino blood during Spanish possession of the Island that there is great doubt if there now is a pure blood Chamorro left. Today the Chamorro resembles the Filipino. Rice is the main food of the native, though yams, corn, cocoanut, the few fruits native to the island, and the nuts from cer- tain varieties of palm are. used to a considerable extent. Fish forms a smaller part of the diet than is conunon in most tropic islands, owing to the abseiice of shoals where fish can be taken, and beef is used to a greater ex- tent. Agra, Iis^^dia." — Hindus of various castes, Mohammed- ans, and Christians have been admitted in the hospital for surgical and medical treatment. The general physi- cal condition of about 30 per cent is fair, but that of about 70 per cent is indifferent. The majority enter in advanced stages of disease. A large number of Hindus are vegetarians, but those who eat meat generally take it as an accessory diet. Bread and rice form their chief foods. Among Mohammedans, although all of them are meat eaters, the meat dish forms only an accessory part of the diet, their chief foods also being bread and rice. Indians use a large amount of chilies in their food. They make their food palatalile l)y the addition of condiments, cloves, cardamoms, cinnamon, caraway, asafetida, and a powder made from dried mangoes. The better class In- dians use a lot of ghee (liquid butter) and milk witli their food. The majority of people, especially among AXSWEItS T<> (a'KSTIOXXAlltH J8< the poor, take only one princiijal meal daily about 2 p.m. For breakfast tliey take a small quantity of pai-eliecl grain, etc. The better class Indians take two principal meals daily with light refreshment in the morning and afternoon. Hindus and Mohammedans are practically all total abstainers as regards alcohol, though some of the lowest castes drink native distilled liquors in excess. Zameoanga, p. 1.'"^ — Tlie general physical condition of Moros is apparently good, but when taken sick they show slight resistance. The Filipino is more resistant to dis- ease, lives better, and is, as a rule, fairly well off. The principal food of all classes is rice and fish. The Moros eat less meat than do the Filipinos. The habits of the Moros are indescribal)ly unsanitary. They bathe occa- sionally and have no household hygiene. Moros always defecate in water and wash after .defecation, using the left hand. The left hand is thus dishonored and is not used in the ''chow" pot. As this is their only hygienic practice it does little good, except that the ground around Moro dwellings is not full of hookworm, but the streams are polluted with typhoid, cholera, and dys- entery. South Africa. ^'^ — Turner-^ dealt ])rincipally with the natives from Portuguese East Africa, that is, boys re- cruited for the mines between Delagoa Bay and Mozam- l)ique. These natives may be roughly divided into those coming from south of latitude 22° S., and those from north of that latitude. The former are looked upon as nontropicals, the later as tropicals. The nontropicals consist of four or five well marked tribes ; viz., Hangaan, Mtyopi, Inlambane boys, and Delagoa Bay natives, principally Tongas. The tropical natives are a very mixed lot, as may be judged from tlic wide area over Avhich tlicy are recruited; they vai'y from Swahili and .good class central African Aiigoui and Jao natives to some verv low class trilx's on the Zamliezi. 188 TROPICAL SURGERY AND DISEASES West Afeica.® — Hollenbeck® finds the natives of good pliysique but wholly insanitary ; they live on corn meal, beans, meat, fruit and vegetables. Colombo, Ceylox.' — Two thirds of the population are Singhalese, 2,230,897. The rest is composed of Tamils, 951,740; Moors, 228,034; Burghers, 23,482; Malays, 11,- 902; Europeans, 6,300; other races including Afghans, Kaffirs, Chinese, Japanese, etc., 9,718; Veddahs, 3,971. Of these the Singhalese are of Aryan stock, but mixed with Dravidian stock. The Tamils are Dra^ddians. The Moors are mostly Dravidians who have been converted to Mohammedanism, Avhile a few claim an Arabian de- scent. The Malays are Mongolian, the Burghers are descendants of the Portuguese and Dutch settlers. A good number of them, however, are of mixed stock. The merchant, trading and professional classes have a ten- dency to obesity and a good proportion develop diabetes. The laboring classes are generally thin, but well de- veloped, strong and cajDable of substantial work. The Singhalese as a rule are inclined to be lazy and will not work unless necessity compels them. The Tamils are more active and industrious. The Moors are generally traders. The Burghers belong mostly to the profes- sional or clerical ser^-ices, while a good many of them are mechanics. The indigenous population subsists chiefly on rice and curr3\ The large majority of the Singhalese and Tamils are vegetarians, while those who are in large toA^^ls take a mixed diet. Alcohol is consumed largely by residents of to^^iis. The majority of the population practices total abstinence. Opium is very little used, and only by persons Avho are subject to some chronic mal- ady. Tobacco smoking is very common. Shoka, Formosa.® — Poj)ulation, 3,000,000 Chinese; 70,- 000 Japanese; 100,000 aborigines. The Chinese are mostly rice farmers, living among the rice swamps ; some of the civilized aborigines come as patients but none of AXSWERS TO QL'E.STIOXXAIRE 189 the wild savages. Many are of Malay stock. The food of the Chinese and civilized aborigines is rice with veg- etables, fish and sometimes, though rarely, pork. KoREA.^ — Mills and sixteen colleagues. Population, Koreans, 12,000,000; Japanese, 200,000; Chinese, 25,000; Foreigners (Americans, British, etc.,) 400. Classes of patients : Patients treated by us are almost entirely Ko- reans, the Japanese being treated by their own physi- cians and druggists. Hospital and dispensary patients are largely from the middle and loAver classes, although the aristocrats are frequently reached; women come quite freely to the male physicians for treatment in most stations, especially in the Xorth. Koreans physically are fairly well developed. A recent army examination covering some thousands of men gave a range in height of from 4 feet 11 inches to 6 feet 3 inches. The weight would probably be less than exx)ected from the height. The ordinary coolie often is fairly muscular and larger than the Japanese, but averages less than the Manchu- rian Chinese. The middle classes, chiefly merchants and shop keei)ers, are not so well developed and their more sedentary habits have not made them fleshy. The ' ' Yang ])ans," or aristocrats, are so averse to manual labor and indulge their appeties to such an extent that weak bodies, indigestion, sexual neurasthenia and impotence at an early age are very common. A fat Korean is a rarity although the women are inclined to be a little more plump. General dietary: Rice and millet are the staples; "kim chee," a kind of sauerkraut composed of native cabbage and turnips with salt, red pepper and other in- gredients "to taste" is also widely eaten. AVheat and buckwheat are chiefly used in ''cook soo" a boiled vermi- celli, Avhile oats and barley are less important. Corn is chiefly eaten off the cob when the "milk stage" is nearly past, and when matured is used only for animals. Beans 190 TROPICAL SURGERY AXD DISEASES are used in a variety of ways and to a considerable ex- tent. Broomcorn is chiefly g'ro^\T[i for the seed from Avhich Avhiskey is made. Dried fish in the interior and fresh ones near the coast are much nsed, Avhile chickens and eggs are eaten by the better classes. Pork and dog meat enter into the menus of feasts to a considerable extent, and beef, often from worn-ont or diseased ani- mals is eaten. AVhile the dietary is perhaps sufficient for the native under his normal conditions, it does not seem sufficient to meet the demands of a more intense life. In the game districts the Koreans eat a great deal of fresh good beef, hare, deer, pheasant, duck, geese and at times horse, donkey, and even leopard. Koreans will not eat XDigeon because of an old superstition that there can be but one boy and girl born in the family if they do so. General Resistance of Patients to Surreal Measures — Shock — Anesthetic Used — Infection of Operation Wounds — Percentage of Aseptic Results in Clean Cases BuEMA." — General resistance to surgical measures is good in natives of a hot climate, but not so good as in Eu- roi)eans. Chloroform is used, AVound infection seldom occurs and is probably in one respect less likely to oc- cur from hands in this damp, warm climate than in a cool European climate, because constant perspiration makes it easier for the operator to cleanse his hands. Agea, IjStdia." — The general resistance of the hospital patients is good and, being mostly vegetarians, their wounds heal well. Shock in ordinary operations is sel- dom observed, but they do not stand the more severe operations, particularly on the abdominal cavity, so well as "Western races. Chloroform is almost always used. Infection of operation wounds is rarely noticed, and the AXSWKItS TO (il"i;s'l'l()X.\Ali;R 11)1 ])('!•('(' 1 1 ta,i;T' of aseptic results in clean cases is prac- tically 99 per cent. Zamboaxga, p. I.^"' — Moros resist surgical wounds bet- ter than Filipinos, Init they do not resist medical diseases so well. The Moro is more of a fatalist than the Filipino and, AA'hen sick, gives up and dies, Moros Avith simple diseases will refuse to eat so as to hurry up the end that they are sure is near. The small meat ration of the Moro also nndouhtedly affects his resistance unfavora- bly. Xatives are almost immmie to pus infection. Have never seen shock in a native during, operation. Shock has been seen after severe injuries and in these cases the reaction was satisfactory even though death afterwards resulted. Anesthetic ^^I'^f^i'i'^cl is ether, drop method. Aseptic results are the rule in clean cases. Hoi^GKOXG." — Europeans unaffected by the subtrop- ical climate. Chinese are ver^' susceptible to sliock but stand operations under local anesthesia which in the for- mer would necessitate a general anesthetic ; sensilnlity in the Chinese seems not so highly developed as in AYest- erners. Chloroform is the general anesthetic. SoocHOw,^ PixG Yix,^- AND AVexchow,^^ Chixa. — The general resistance of the people to surgical treatment is the same as in American hospitals. Percentage of deaths following operation is high, but this is due to coming in a very poor condition to withstand surgical interference. Shock usually is slight. Chloroform is used. Infection is I'are in a clean case; iodine solution is used to ])re]")are skin. vSouTH^* AXD AVest'"' Africa. — General resistance of na- tive patients to surgical measui-e is good; good asepsis in clean cases. Colombo, Ceylox.' — As a rule patients stand opera- tive measures well. The laboring classes make better recoveries than others ; shock is not marked except in very prolonged operations or in women and cliildren of 192 TROPICAL SURGERY AXD DISEASES a neurotic type. Cliloroforni is universally used. In Aveakly individuals A.C.E. mixture is used. Strepto- coccic infection is very uncommon, and staphylococcic in- fection sometimes occurs; ninety per cent of tlie clean cases run an ase]3tic course. Shoka, Formosa.^ — Stand operations Avell. Do not readily suffer from shock: chloroform as general anes- thetic, and cocaine as local: do not use drop method. Operative wounds are rarely infected. Samoa. ^ — Surgical patients do very well. Prolonged anesthesia and severe operations seem to be as well re- covered from as in the white races in temperate climate ; shock is less to be feared than in the white races. Chlo- roform has been used almost exclusively for the past five years in major cases and ethyl chloride general anes- thesia in minor ones without a single untoward effect in the last 500 cases of general anesthesia. Wound infec- tions in clean operations, except of the scrotum, are as rare as in temperate climates. Guam.- — The Japanese bear surgical operations well. The Chamorros' resistance is somewhat less. Shock is greater than with our j)eoiDle, and seems abnormally so in operations upon the intestines and pelvic organs. This was attributed to the anemia from hookworm in- fection wliich is almost universally present in some de- gree. A rather poor diet was no doubt also a contribut- ing factor. Ether by the dro]D method was the anes- thetic employed, but chloroform had been formerly used to a considerable extent; no deaths had occurred from its use. No infection of operative wounds occurred; cases doing as well in this respect as those operated in the United States. The patients were very tractable when they were in the hospital, being better in this mat- ter than our ovvm people. KoREA.^ — General resistance very good. Shock seldom seen. Anesthetic chiefly chloroform, although ether has ANSWERS TO QX'ESTIONNAIRE ll)6 been more used in Seoul. Operative Avonnds, generally clean. Iodine nmch nsed in preparation. The Most Common and Frequent Surgical Diseases Ceylon." — Inguinal hernia ; hydrocele ; appendicitis ; hemorrhoids. Formosa.® — Malaria and its sequelae, enlarged spleen, anemia; round worms, ankylostomiasis, dysentery. Korea." — The most common and frequent diseases are : tuberculosis, syphilis, malaria, chronic gastritis, otitis media, indigestion, bronchitis, and diarrhea. Climate: Influence on Foreigners and on Natives BuRMA.^'' — Enervating on both foreigners and on na- tives. Agra,^ India. — The climate is very hot and dr}'- in the summer, and cold and dry in the winter, and it is gen- erally a healthy one. Natives stand the climate well and are usually well nourished and healthy; foreigners also, provided they get their periods of change. Hongkong. ^^ — Foreigners age more rapidly, especially those addicted to alcohol and sexual excess; presbyopia commences at least three 3^ears earlier, ciliary exhaus- tion and cramp are commoner than in temperate zones among young hypermetropics. AVenchow^^ and Ping Yin,^- China. — Climate has an enervating effect on all foreigners and to a less extent on the Chinese. Ceylon.^— Foreigners generally lose the power of sus- tained effort and are easily tired after a i)eriod of three years. The skin becomes bronzed. Some of those Eu- ropeans who have adopted the Cejdonese diet of rice and curry, abstained from much meat eating and either ab- stained from alcohol or used it moderately, have acclima- tized themselves, and lived to good old ages, without visiting Europe. 194 TROPICAL SURGERY AlifD DISEASES Formosa." — Climate very enervating to Europeans, in summer especially; moist hot climate. Natives are ac- customed to it and stand it better. Samoa.^ — Climate alone seems to exert but little effect upon the foreigner. The continued even warm tempera- ture will, after a year or so, cause him to feel slight changes in temperature, which in a more temperate zone he would not notice. For the native the climate seems to be practically perfect. Guam,- — Climate, the best in the Tropics in that lati- tude. Daily temperature at noon not high, evenings al- ways cool so that light cover is agreeable. The Euro- pean who stays tAvo or three years in this part of the world and who protects himself against the fly and the mosquito to a reasonable degree, can work, either men- tally or physically, at the same pressure and during the same hours as in a temperate zone. A longer stay, five years or more, will subject him to a real risk of con- tracting filariasis. The native population seems to suf- fer more from epidemic asthma during the seasons of greatest rain, July to October. KoREA.^ — Climate generally bracing all over Korea. In the winter a little snoAv and ice in the South with cold winds and gradual changes of temperature. In the North the Avinds are not severe, the ice on the river reaching a thickness of two and one-half feet. Spring and fall are delightful everywhere. The rainy season is very debilitating in the southern and central portions. Electrical demonstrations in connection with storms are infrequent and accidents of any kind from lightning are rare. Effects upon foreigners : Menstrual irregularities or suppression common; nerve tire; sleepiness during first year common; debility and headaches in the rainy season. As to the latter condition no such marked cases are seen as those commonly denoted "Japan head" so frequent among women in Japan. Diarrhea during first ANSWERS TO QT^ESTIONXAIRE 195 summer; increased nervousness ; some danger of heat ex- haustion; rainy season very depressing, the rest of the year exhilarating. Hard Avork in this beautiful and brac- ing climate seldom hurts any one. Etf ect upon natives : Koreans in the North are observed to be taller and of a sturdier, more reliable character than those in the South. The colder the climate, the more the people crowd to- gether in small houses with all the evils arising from such conditions. Exposure to the cold and rain with in- sufficient clothing leaves its impression. It is said that tuberculosis is more prevalent in the South where the climate is more mild and exposure not so great. Europeans: Habits, Exercise, Periods of Service, Preva- lence Among Them of Diseases of Hot Regions Burma." — Climate, temperate arid regular; active ex- ercise the rule. Leave of one year should be given every three years. After a stay of three years in the climate of Burma, resistance to tropical diseases is much lower and their prevalence becomes marked. Manila.^^ — Habits and exercise should be adjusted for the good of each individual and no hard and fast rules can be laid do-v\m. The enlisted men and most line offi- cers take considerable exercise and benefit thereby. American women almost universally take practically no exercise in the Philippines and this, combined with a too strenuous social life for many who live in Manila, is, we believe, the cause of a large number of cases of tropical neurasthenia. The main habit to be avoided is an undue use of alcohol, the effects of which are the same here as elsewhere. For various reasons there is a tendency to use more alcohol here than at home. There is also a ten- dency to avoid taking a sufficient amount of exercise be- cause of the heat. The prevalence of ' ' tropical diseases ' ' depends upon the habits of life and hygienic surround- ings. With proper care they may all be avoided in most 196 TROPICAL SUllGERY AXD DISEASES instances. The tour of duty at present in force for the arni}^ is two years. This ^ye believe to be a suitable one when all factors are considered. Agra, Ixdia.^ — Euroi3eans live very abstemious lives nowadays, take little or no alcohol in the hot weather, and live sparingly. All the year round exercise is taken daily, and Europeans find it necessary to have the re- laxation, especially those whose work is continuous and hard. Exercise takes the form of riding, e. g., polo all the year round, pig sticking in the hot weather, tennis, racquets, and golf all the year round, cricket in the cold weather, football and hockey also the year round. The usual full period of service for pension is thirty years, but pensions can be taken after twenty and twenty-five years. Government servants are forcibly retired at 55 unless above a certain rank which only a small percent- age attain. The period of leave of absence to England is usually one year in five, but the average amount of leave taken is not so much as this; usually about eight months leave home in five ^^ears. At the x>resent time with the healthier conditions of life in India *' tropical" diseases are very much less coimnon than they used to be. Cholera and liver abscesses are rare among Euro- peans ; dysentery is seen, but is chiefly of a mild type and malaria is far less common than it used to be. HoxGKOX-G, Chixa.^^ — 111 at least 50 per cent there is tendency to drink more alcohol than is good for the hu- man body mthout going so far as to term this alcoholic excess. Exercise: Every variety of game is indulged in. As a rule five years of service is required by the majority of firms and then one year's leave. SoocHOw, Chixa." — Out of doors a great deal. About a seven-year service and one-year furlough. Malaria is very common, tertian and subtertiaii. The usual intes- tinal parasites are very common. Ceylox." — Europeans, as a rule, go in a good deal for ANSWEIJS TO QUKSTIONXAIRE 1*J7 horse riding, cycling, golf, tennis and cricket, hut nn- fortmiately a good nnmber of them take whiskey in ex- cess, particularly after exercise. Generally they go on leave for a period of six months to a year after every five years. Enteric fever, dysentery, diarrhea, and sprue are some of the common tropical diseases to which they are subject. FoEMOSA.® — Europeans vary much in regard to exer- cise and habits. The tendency is to live too well and take too little exercise. Missionaries serve from five to seven years and then take a furlough for a 3"ear or more. Europeans suffer from malaria and dysentery, not so much from malaria now that their houses are mosquito j)roofed. Guam.- — Europeans exercise less, and consume more alcoholic beverage than they would' at home. The period of military service is about two years, and during that time the enlisted personnel and officers have one or two trij)s to Japan or China for change. Civil employees and residents do not go away as a rule. Some of the permanent residents have been there for years mthout any bad effects. Dengue, furunculosis, dysentery, and tinea are seen. ^Vlien an epidemic occurs, practically all of the people who have not had dengue have the disease. Tinea is not so prevalent as it Avas in the foreign popu- lation in the Philippines ten years ago, but is frecpently seen. Furunculosis is fairly connnon. Dysentery is not very common owing to the care exercised in diet and the general use of distilled or boiled water. The American population is more free from the ailments common among the natives because of the care taken with diet and a better hygienic life. Xo case of epidemic asthma (guha) was seen in the American population. KoKEA.^ — Effects on foreigners: Menstrual irregu- larities or suppression: sleepiness during the first year. Foreigners are chiefly Americans.' Habits not specially 198 TROPICAL SUEGERY AND DISEASES different from at home. Furlough periods for mission- aries are every six to eight years. Troj)ical diseases among foreigners are found only in the South. Sprue: several cases ; diagnosis complicated by a similar symp- tom-complex in nursing mothers that clears up on wean- ing the child. Dysentery: a number of cases, folloAved by liver abscess after a few. Malaria : very common in former times, less so now, but still fairly common in more southern parts. Relapsing fever: several cases, especially among physicians. Typhus fever: no cases for several years. Wounds: Infections, Pathogenic Causes, by Streptococcus, by Staphylococcus, by Tetanus, Etc., Native Treatment of Wounds Burma." — AVound infections are not marked. Chief infection by staphylococcus. That by streptococcus rare. Tetanus practically nil, since routine use of an- titetanic serum in all dirty wounds ; but in dirty wounds treated in native houses this infection is common, much more so than under somewhat similar surroundings in Europe. Agra, India." — Infections of wounds by streptococcus, staphylococcus or tetanus are frequently seen in the out- patient room; especially in compound fractures. These cases are dressed Avith mud, cow dung or any filthy rag and after some days brought to hospital. It is always necessary in large Indian hospitals to have separate sep- tic wards for such cases and amputation of limbs is very frequent. AVenchow^^ and Ping Yin,^- China. — Wound infections by tetanus and other pyogenic bacteria are common. Ceylon.^ — Knife wounds are fairly common. Blows with clubs and fists are few in proportion. Staphylococ- cic infections are more common than streptococcic in- fections. Tetanus occurs in association with lacerated ANSWERS TO QUESTIONNAIRE 199 wounds, compound fractures, and sometimes in cases of small wounds caused by the mid-rib of a cocoanut leaf. Formosa.^ — ^Wound infections by both staphylococcus and streptococcus are verj^ common. Tetanus is not un- common. Tobacco is a favorite ap]3lication to wounds. Native Treatment of Wounds and Diseases Burma." — Native treatment of wounds and diseases crude; largely by charms, actual cautery, and leaves of sacred trees. Ping Yin,^- China. — Native treatment of wounds is by application of flour, ashes, earth, etc. Boils, abscesses and all swellings and painful areas are treated by appli- cation of adhesive plaster. Acupuncture most frecpent method of treatment. Other methods of treatment are pinching, bruising, thumping and the cautery. Ceylon.® — There are three systems of native treat- ment; viz., the Singhalese, the Tamil, and the Moham- medan. Some of these native practitioners have ac- quired local fame in the treatment of particular diseases. The native treatment of Avounds, fractures, and sprains appears to have given satisfaction; from personal e:j^ aminations of some of the medical cases treated by na- tive practitioners, I must admit that the results have been satisfactory. They generally use medicinal herbs and pastes made of leaves, but the composition of their oils and pastes is kept rigidly secret and is handed doA\Ti from father to son. In the treatment of d^^sentery both acute and chronic they are very successful. Hysterical disorders are also successfully treated by them and there are a few who have a reputation for the cure of snake bite. Samoa.^ — Wound infection is the rule unless the wounds are cared for surgically; staphylococcus aureus being the most common ; streptococcus rare. Tetanus has been observed but is verv rare. The natives treat a wound 200 TROPICAL SUEGEEY AXD DISEASES hy neglect until infection occurs and then by bathing it in the sea. At a later stage Avhen healing has begun, the wonnd is sealed ^^ith leaves to keejD out flies and dirt. The native treatment of other diseases is largely contuied to M'hat they call "Innii lumi, " a well-developed form of general massage, at times gently used so as to give relief to the patient, at other times administered with sufficient force to do harm. Xot infrequently abortions are brouglit on in this way. Gua:\i.- — "Wound infections were fairly frequent among the natives o^\ing to the filthy dressings applied at the time of injury and the time necessary to convey the pa- tient to the doctor, as the injuries generally took place on the ranches some miles from Agaiia where the hos- pital is located. It was surprising how frequently clean results were obtained in serious wounds, gores from bulls and the like, that were fairly common and where the wound had every opportunity for infection. Streptococ- cus infections were not conunon ; stai3hylococcus was the common infecting agent and pyocyaneus infection Avas more frecpient as an accomi^anying infection than in any ether place that I have observed. Tetanus was fairly frequent in punctured wounds and tetanus neonatorum was conunon in Agaiia until the first of 1912 when the old system of midwives was abolished. Natives have no treatment for womids different from that among our oavu people. Korea. ^ — Native treatment of Avounds and diseases: Cover with hard dressings, hot dressing, chicken split open, soot, pitch plaster, dog manure, occlusive dress- ings. oil-i3aper, mud, cow manure to cervical adenitis and cuts, fresh dog skin, tobacco leaves, lime, salt, boiling oil, bird dung for eczema; some use starch j)aste or cob- Avebs in early stages and later, leaf poultices or black Avax; kerosene has been used lately. Urine serves as an eA'e Avash and for Avounds on horses ; Avounds A^uth hem- Aj^swers to questionnaire 201 orrhage are bandaged with leaves or sometimes a plaster of pitch ; a constriction bandage is used for snake bite ; contusions are treated with mud or occasionally Avith clnng; splints for fractures are bound with excessive tightness. Cauterization of sacral region is done for malaria, of the anterior fontanelle for comoilsions in children, of the protruding parts for uterine iirolapse; inoxa is also used; acupuncture is done for rheumatism, neuralgia, joint affections, and all sorts of pain. Mer- cury vapor inhalations are used for syphilis, often re- sulting in salivation. Hot sweat baths, counterirrita- tion and blood-letting, (short needles repeatedly applied) and suli3hur baths for scabies are some of their treat- ments. Among the variety of internal medicines are ginseng, deer's horns, tigers' bones and teeth, urine of a baby, dog meat soup, and one case is reported of the menstrual blood of a virgin being prescribed for a sick young man. Santonin and quinine are coining into com- mon use. All medicines are taken in great quantities and very largely diluted. Many cases of ordinary sore throat, tonsillitis and enlarged tonsils are thought to be specific and great harm results from the aiDplication of the yellow oxide of mercury locally and in the nose, as well as the inhalation and the insufflation of other com- pounds. The iDractice of medicine in Korea is largely borrowed from China although a great manj^ of the medicinal plants are gathered on the hills. The treatment is chiefly symptomatic and the ''shot gun" prescription is found at its Avorst. To say that all such medication is inefficient or harmful Avould be carrying the matter too far. Acute gastritis and the malnutrition of infants react A^ery un- f aA^orably under this treatment Avhile ' ' indigestion ' ' does as Avell on such decoctions as on any other line of treat- ment so long as the patient himself Avill not or can not remove the cause. Acupuncture A^itll the long needle has 202 TROPICAL SURGERY AK^D DISEASES resulted very disastrously in manj?^ bone and abdominal cases and the absence of such results in thousands of other cases must be due to the special dispensation of a kindly Providence and an acquired immunity to ordi- nary pus infections. Dr. Stryker of Pyeng Yang* adds the folloAmig: after injury from a fall, the Koreans drink dog's dung mixed in water; to prevent poisoning, drink their o^^^l urine; for inguinal adenitis, apply nicotine from pipe, scratch with dry snake tail, apply hot rice poultice; iistula-in- ano, apply hot iron; sore eyes, apply nicotine, snakes' gall or small piece of gold to eyelid ; boils, oral suction, soot, bear's grease; hemorrhages, hot candle grease, hot ashes, dyes; dysentery, rice powder and water, acorns powdered with honey, yelloAv pine tree fioAvers powdered and mixed with honey and soot; diarrhea, dried vermi- celli and thick A^ine, red bean candy boiled in Avine ; indi- gestion, strong salt AA^ater, bean sauce; during rainy sea- son, water dripping from an old straw roof; bronchitis, vinegar, raAv pear Avith pepper (cook and eat hot), honey and pork; dropsy, fresh bull skin and lie in it on hot floor, pig's grease applied to body; tyi)hus feA^er, eat bar- ley gruel, Avhite dog's dung soaked in Avater and used as a drink, virgin's menstrual blood soaked in Avater and used as drink; malaria, make x^atient Avalk during chill or face sun and bleed from nose Avitli needle, or scare patient Avhile in chill by means of snake, etc. ; tapcAvorms, eat acorn nuts one handful; round worms, diink boiled castor oil; stomatitis in children, AA'hite dog's dung poAV- dered and put in mouth, also hot dog grease ; pulmonary tuberculosis, drink human blood, eat raAv placenta ; gon- orrhea, vermicelli Avater, SAvalloAv dung mixed in Avater, hot steam locally ; syphilis, inhalations of poAvdered mer- cury; tuberculous glands of the neck, musk poAATler; ec- zema, man's hair, oil, and dust from a high shelf mixed and applied; to prcA^ent abortion, take a piece of Avood ANSWERS TO QUESTIONNAIRE UUd from handle of a Avell bucket, burn and dissolve ashes in water and drink. The Most Common and Frequent Diseases Burma/" — Tuberculosis. Agra, India. ^ — The disease for which during the whole year there is the largest hospital attendance is malaria, otherwise there is no specially prominent disease. South Africa.^* — The most common disease varies ac- cording to the locality. On the Transvaal Gold Mines pneumonia causes more trouble among natives than any other disease. Cerebrospinal meningitis occasionally oc- curs in epidemic form among natives. Spirillum fever, the result of the bite of Arnithodoran Montata, is preva- lent in places ; malaria is universal in the low ground and causes invalidism among natives during childhood and early youth. HoNGKONG,^^ Wenchow,^^ China, — Europeaus : gonor- rhea and abdominal complaints. Chinese : trachoma, syphilis, tuberculosis, intestinal parasites, malaria, dys- entery. Ceylon.'^ — The most common and frequent surgical diseases are inguinal hernia, hydrocele, appendicitis, hemorrhoids. Formosa.® — Malaria and its sequelae; enlarged spleen and anemia, round worms, ankylostomiasis, dysentery. Samoa,^ — There are several very common and frequent diseases which are given below Avith a rough, but accu- rate, estimate of their frequency in the population. 1. Nematode infections : ascariasis, about 80 per cent of native children ; uncinariasis, about 90 per cent of adults ; trichuriasis, about 70 per cent of adults ; filariasis, about 50 per cent of adults over thirty years. 2. Treponema infections : f rambesia, yaws, all native children have it, have had it, or Avill contract it. 3. Eye infections: (a) acute diplococcic conjunctivitis, affects Avhole villages if 204 TROPICAL SURGERY AXD DISEASES not controlled; (b) clironic granular conjunctivitis, 30 to 60 per cent of children are affected. 4. Skin infec- tions: tricliopylitosis corporis, about 40 per cent of adults; cliromophytosis, about 40 per cent of adults. 5. Common surgical conditions : deep abscesses, large ul- cers, and elephantiasis. Guam.- — Americans : dengue, dysentery and furuncu- losis. Chamorros : worm infections, hookworms, ascaris and whipworms : dysentery and intestinal infections of children, tuberculosis, epidemic asthma ( guha), syphilis (gangosa), pneumonia, and leprosy. Malaria Malaria is possibly the most important disease of the world in general, and Ross'" statistics show that it is the most important disease of the Tropics. As a rule about one-third of the population of malarious countries suffer from attacks every year, even 100 per cent of the children of very malarious regions may show either par- asites or splenic enlargement. AVhile the case mortality is only about 0.5 per cent, the total mortality runs from 10 to 15 per 1.000 : in India it is estimated that malaria is responsible for about 1,300,000 deaths each year. Again, malaria so comiDlicates other diseases that, espe- cially in surgical cases, one must be prepared for the possibility of an explosion of latent malaria follo^\ing the trauma of an operation, as is also the case at times in chronic alcoholism and syphilis. Ten years after the discovery of the cause of malaria by Laveran (1880), we were in the dark as to the method of transmission of the parasite and it was not until 1899 that Sir Eonald Ross proved the mosquito transmission for man, Avhich was subsequent to the Italian experiments in 1898. Ross ob- serves that although fifteen years have elapsed since the knowledge of the mode of transmission of malaria was obtained, yet not more than one-tenth of the im- AXSWEPri TO QUESTIOXXAIEE 205 provement of health has heen effected which Avas pos- silDle of accomplislnnent had mankind put its heart into tlie iDrohlem of malaria eradication. Malaria: Prevalence as Shown by Blood Examinations; Fever Due to Malaria Following Operations Agea, Ixdia." — Malaria is the most prevalent disease in India and has for the whole population a heav^' death rate either directly or indirectly' as complicating other diseases. It is most prevalent in the months of July, August, September, October, and Xoveml^er, that is, in the months of the rains or just following the rains. The amount differs from year to year. Given good ^Drodue- tive years ^yit}l cheap food and the general population in healthy condition and normal rains, there is not usually an excessive amount of malaria ; but given bad years, foodstuffs scarce, famine and jDoor nutrition, and hea^-A^ rains on the top of this, malaria is usually excessive and has a high death rate. OAAdng to the measures being- taken all over India in combating malaria, it is being gradually reduced and with improved sanitation, better drainage, the i^roiDhylactic issue of quinine and the edu- cation of the masses it is hoiDed to greatly lessen the amount of malaria year by year. AVe do not find ma- larial fever as a rule complicating operations very much. In our Agra experience it is rare. HoxGKOXG, Chixa."- — Extremely prevalent ; chiefly be- nign. However, malignant tertian forms are not uncom- mon after operations and after confinement. Africa.*'' ^'* — Have no European patients. Tlie adult native who has been reared in a fever district apj)ears to have acquired a certain inununity to malaria and is but rarel}' troubled with it, a native from a nonf ever dis- trict, however, is just as susceptible to fever as a Eu- ropean if exposed. Ceylox.' — Malaria is uncommon in Colombo. It is 206 TEOPICAL SI'RGERY AXD DISEASES very common in outlying districts : have very seldom seen malaria after operations, FoEMOSA.^ — Very prevalent. Estivoantunnial, tertian, quartan, all common. Parasites easily found in the blood: no doubt the fever that occurs after operations sometimes is due to malaria. KoREA.^ — Malaria very frequent (microscopic diag- nosis) : in about -iO per cent of the children, microscopic diagnosis in doubtful cases : none seen, clinical or other- wise in Kangkai Avhich is in the extreme North among the mountains. The widesxDread use of quinine has re- sulted in a great decrease in the prevalence and severity of the disease. Samoa.^ — Malaria does not exist in Samoa nor has careful search revealed the presence of any species of the family Anophelina?. Guam.- — Xo malaria exists on the island. Prevalence of Opium or Other Drug Habits and Alcoholism BuEMA.^"— Opium eating is i3revalent among the lower class Burmans and Chinese in the larger toA^ms. The cocaine habit is becoming so among the same classes. Al- coholism is not iDrevalent. Morphine is largely adminis- tered by injection. Opium and cocaine by the mouth. IxDiA." — After the age of forty a small percentage of the people become addicted to taking opium. They gener- ally start the habit for the cure of certain diseases such as chronic diarrhea, asthma, bronchial catarrh and diabetes. Opium is frequently given to children to quiet them. The tobacco liabit is general. Bhang is generally used by higher castes especially Brahmans. Alcoholism: Peo- ple generally are sober. Among the lower castes the habit is more general. Among the educated Indians the habit is increasino'. ANSWERS TO QUE.STIOXXAIBE 207 HoxGKOxG." — Opium ]ia1)it distinctly on tlie decline among Chinese ; alcohol on the increase. SoocHOw,-^ PixG Yix,^- Chixa. — Opium habit is the curse of the people but no worse than in any other place in China. It is easy to break the average smoker by sub- stitution of another form and gradually reducing. We have over thirty of this class in our wards all the time now. Alcoholism is quite common. Afkica.^* — Cannabis Indica, native name ''Dacha," is smoked by many tribes ; no reports of opium being used. Ceylox.^ — Opium hal3it is not very common and only occurs among people who are suffering from some in- curable chronic maladies such as inoperable cancer, dia- betes, etc. A certain i^roportion of people suffering from gallstones, and stones in the kidney, who refuse opera- tive treatment also take to it. Alcoholism is common among the laboring classes and chiefly in large towns. It is also common among the well-to-do classes. For:viosa.^ — Opium smoking is very connnon. Also some morphine ^^ctims who use the hypodermic syringe. Alcoholism is not very common among the Chinese. The Japanese and also the aborigines are fond of the bottle. KoEEA.^ — The Korean medical association called atten- tion to the prevalence of the opium habit in Korea and that, contrary to laAv, there was knoAvn to be a good deal of traffic in this drug carried on by druggists of various nationalities. This was officially i)resented to the gov- ernment in Chosen and was favorably received. For- merly very rare, recently fairly common. Alcoholism generally stated as moderately connnon, excessive drink- ing is not the rule. Reid adds and several confirm that drinking is more prevalent among the farmer class; he probably means "plain drunks" on the street. Curell estimates that 60 per cent of men drink to some extent and adds that liver complications are rather common; others report liver cases. 208 TROPICAL SURGERY AXD DISEASES Samoa.^ — Alcoholism among the natives is practically miknown. A law of the land prohil)its the sale or giving of alcohol to the native and it has been well enforced. Drug habits are practically nnkno^^^l in this little com- mnnity because of a law which forbids the importation of drugs or patent medicines except by express written permission of the medical government; a law which is capable of great good in any community. Gtuam.- — There is no opium or other drug habit in the native population, and the importation of drugs is under the supervision of the health officer of the island. The natives drink "tuba," the sap from the buds of the cocoa- nut tree; this is generallj^ allowed to ferment, but at times is taken before fermentation takes place. The use of ''tuba" is common. There is also a certain amount of distilling of the fermented "tuba" going on, but this is prohibited by the government and those engaged in the manufacture are punished when detected. The use of this spirit is not very general. There is some use of beer, Avhisk^^, and gin, but the amount is not great and the native can be called a temperate individual. Surgical Tuberculosis: Pulmonary, of Bones, Joints, Tendons, Peritoneum, Skin, Genitourinary Organs and Intestines; Frequency of Pott's Disease; Public Antituberculosis Measures Burma" axd Agra,^ Ixdia. — Tuberculosis of all tissues except the skin is not uncoimnonly met with. Pott's dis- ease is rare. Lupus is practically unknown. Tubercu- losis of the testes is rare. Tuberculous diseases of the intestine are probably much more common in natives than in adults of European countries and appear to be on the increase. Pulmonary tuberculosis is common and is certainty on the increase. Tuberculosis of bones and joint's also is very coimnon and roughly accounts for about 20 iDer cent of the admissions on the surgical side. ANSWERS TO QUESTIONNAIRE 209 Tuberculosis of the g-enitourinary organs forms about 1 per cent of the admissions in the hospitals. SoocHOW^ AND Ping Yin^- and Wenchow/'^ China. — Tuberculosis is the most common of all diseases and the curse of the country; there is no form but what is met with. Patients respond well to modern treatment, but this can not be given to every patient. Africa.^"-" — Pulmonary tuberculosis common among natives living in proximity to Europeans. Whether Pott's disease is common or not is doubtful. It is prob- able that a deformed child would be destroyed, if living in outside districts. Ceylon.^ — Pulmonar}^ tuberculosis is common among the poorer classes in towns. Tuberculosis of the bones, joints, tendons, peritoneum, skin, genitourinary organs, and intestines is very uncommon ; not more than two or three cases of each are seen during the year. Formosa.® — Tuberculosis very common, especially pul- monary. Tuberculous cervical glands very common. Not very much tuberculosis of bone and joints nor of tendons. Lupus not seen. Tuberculosis of the cecum is not infrequent; is often associated with chronic intus- susception which is operated upon. Pott's disease is very common. Tuberculosis of the testes, epididymis, vas deferens, prostate, and bladder occasionally met with. Korea.'' — Surgical tuberculosis: tuberculosis of all kinds is quite common, especially of bones. Many of the cases had sequestra. Joints: no definite pathologic studies have been made, and, while tumor albus is fairly common, the later stages are masked by the secondary infection incident to acupuncture. Tendons: no report. Peritoneum: many cases seen. Skin: some cases recog- nized and probably a good many overlooked. Pott's dis- ease: quite frequent. Cervical and axillary adenitis: abundant; many of these patients have large tonsils. Samoa.^ — Pulmonary tuberculosis exists in American 210 TROPIOAL SURGERY AND DISEASES Samoa, about twelve cases having been diagnosed in the past 3'ear when about three thousand cases of disease were seen. No bone tuberculosis was observed during this period ; two healed joint cases were seen ; five tendon sheaths, probably tuberculous, were operated on. Tuber- culosis of the genitourinary organs and of the intestines, was not recognized. Pott's disease is present, about tw^enty old cases being scattered through the population. Tuberculous glands of the neck are quite common ; there were six operations for this in the last 500 operations performed. GuAM.^ — Pulmonary tuberculosis is very common and fatal. Knee-joint involvement is frequent in children; no cases were seen in adults. The treatment by rest, hyperemia and good food gave excellent results in the hospital. Tuberculous involvement of the vertebrae and of other bones and joints was remarkably infrequent; no new cases were seen and there were but few old cases seen on the island. Peritoneal tuberculosis was not com- mon. Intestinal tuberculosis was frequent in children and there were great numbers of cases of involvement of the mesenteric glands. Cervical glandular disease was common in young adults and children. Kala-azar • Burma." — Kala-azar is practically unknoA^^l. It is met with from time to time, but no properly investigated case occurring in a native of Burma has yet been re- ported. All the cases seen here have probably been im- ported cases from India or Assam. PiiS^G YiisT, China.^^ — Infantile type of kala-azar is ex- tremely common. Have not looked for the Leishman- Donovan bodies, but the cases agree closely in all their clinical features A\ith those described by one mission doc- tor in Peking, Dr. Graham Aspland, by whom they have been isolated. (See China Medical Journal, May, 1911.) ANSWERS TO QITERTIONNATEE 211 Samoa/ — Kala-azar ivS not found. Guam.- — Kala-azar does not exist. Syphilis: Results with Ehrlich's "606" Treatment BuRMA.^°— Syphilis very prevalent. Ehrlich's "606" has been tried on a small scale with no ver^^ gratif3dng- results, as regards establishing immunity from the later effects of syphilis. Agra, India. ^ — S^^philis is fairly common and forms about 20 per cent of the admissions to the hospitals. The majority of cases come during the second stage and third stage of the disease; with Ehrlich's "606" treatment th,e sores heal more rapidly; the Wassermann reaction is sometimes negative after one injection, but always nega- tive after two. We combine the treatment with mercury internally. We have seen no ill results from it. Hongkong" and Ping Yin,^^ China. — Syphilis is very prevalent; 606 treatment a great help, but not absolutely curative. Colombo, Ceylon.^ — Syphilis fairly common among the to^^m population; used 606 in thirty cases, with very gratifying results. Treatment with mercury has been continued; the results have been particularly satisfac- tory in phagedenic ulcerations, bone pains in joints, and on secondary eruptions. Samoa.^ — Syphilis is not present. A few cases came to the port three years ago, but were deported before caus- ing any spread of the infection. A few cases of late and of hereditary syphilis have been seen, but these were in cases where the original infection could be traced to some other island. Korea. ^ — Many cases of s;fphilis are seen. Guam,- — No primary syphilis was seen and none exists on the island. There is an old syphilitic infection which is very common, "gangosa." Treatment with salvarsan was started in June and had not been carried far enough to make a report. 212 TROPICAL SUEGEPvY A^'^D DISEASES Typhoid: Complications, Percentag-e of Perforations, Peritonitis, Osteomyelitis, Parotitis, Operations Made Eaxgoox, Burma. ^- — Typlioid fairly common among Europeans and natives of India and Burma. Mental af- fections have been noted as a not infrequent complica- tion in natives. Percentage of perforations is higher among natives than Europeans owing to former seeking medical aid late. Osteomyelitis and parotitis uncom- mon. If perforation is recognized early enough, laparot- omy is performed ; successful cases practically nil. Maxila.^^ — For some years after the American occu- pation it was thought that typhoid was unusual in the Philippines. It has been recognized, however, by army surgeons in 23ractically every island in the archipelago. This board has been Avorking on the subject of typhoid for two and a half years and has come to the conclusion that typhoid is common and ever present among both Americans and natives and is prol^ably more prevalent than it is in the United States. "We have investigated man}^ ej)idemics, A great many cases of typhoid in the Phili]Dpines, both among natives and whites, are mild and atypical and can not be recognized except by lab- oratory methods. The mortality, of late years, when good facilities are available, is no higher than in the United States, or about 7 p)er cent. Our experience ^^dth paratyphoid is limited to two cases in which we isolated the organism from the blood. About 15 per cent of Phil- ippine tyiDhoids have hemorrhages, probably due to in- testinal parasites. Agra, Ixdia.^ — Typhoid is common among Europeans in India, but rare among adult natives. It is becoming less common among Euroj)eans as more precautions are taken. Antityphoid inoculation and the isolation of "carriers" have done much to lessen its frequency. Among comiDlications, perforation, peritonitis, osteomy- elitis, and parotitis are rarely seen. Hemorrhage is ANSWERS TO QLIESTlOiXNAHlE 213 more common, and so arc tliroml)osis and periostitis. Hongkong, China." — Cholecystitis, gallstone and bil- iary sand not iinconmion after typhoid. However, this disease is not very connnon in Hongkong unless im- ported, and is mild in type. Colombo, Ceylon.'^ — During 1912 two cases of typhoid perforation were operated on and recovered; no statis- tics of the general prevalence of typhoid fever and its complications available. Shoka, Formosa.® — Typhoid is fairly connnon. Have seen severe hemorrhage from the bowel ; one case of per- foration operated on unsuccessfully. Samoa.^ — Typhoid is not present. Guam.- — There is no typhoid on the island. Dysentery: Amebic, Bacillary, Perforation of Intestine, Peritonitis; Hemorrhage from the Bowel. Appendi- citis: Operations for, Results. Appendicostomy: Is Dysentery Becoming Less Frequent and Less Serious Under Modern Conditions? Relative Percentage Among Natives and Europeans Rangoon, Burma."' — Dysentery is one of our common- est diseases and has a prominent place in all death statis- tics of Burma. Both amebic and bacillary dysentery are met with, the former being the more common. Under the head of bacillary dysentery it is almost certain that more than one disease is included at the present time. Among the cases described as dysentery are many cases of ulcerative colitis which are probably neither amebic nor bacillary dj^sentery; such cases are very frequently returned as "chronic diarrhea," owing to their pro- longed course and slight clinical evidence of ulceration of the large bowel. At autopsy, the ulcerations found are usually very shallow and are very minute though numerous. Agra, India." — Dysentery is common in India, Init nn- 214 TPtOPiaU. SURGERY AXD DISEASES der modern conditions we do not see as many serious cases as formerly. In the mild cases the saline treatment (magnesia sulphate) is the most satisfactory, and the ipecac treatment in the more serious cases. Have not seen appendicitis as a complication and have i^erformed appendicostomy. It is more common among natives than Europeans, but it is much less common than formerly among native troops and prisoners owing to the im- proved sanitary conditions. It is rare to see a severe case among the better class of Europeans. HoifGKOXG."- — In private practice at least 90 per cent of the dysentery seen is amebic. The routine treatment is salines by mouth and quinine, nitrate of silver, and boric acid injections per rectum given in the genupec- toral position. In relapsing cases of amebic dysentery salines often fail and ipecac is then given. Appendicitis is connnon after any affection of the colon ; have had no cases suitable for appendicostomy. Weistchow^^ axd Pixg Yix,^- Chixa. — Dysentery exceed- ingly common, endemic most of the year and epidemic each summer and autumn. AAliole villages often carried off by an epidemic. Diet, albumin water. Ipecac gives the best therapeutic results when properly administered. Rectal injections of quinine also valuable. Perforation, peritonitis, or severe hemorrhage in dysentery not seen. Colombo, CEVLOiSr.'' — One case of appendicostomy in a very severe type of bacillary dysentery where antidysen- teric serum had been tried without benefit. Although the patient was relieved of the more urgent s^inptoms, he died from s^Tinptoms of septicemia on the third day. In three cases of chronic colitis appendicostomy was done A^ith good results. Have never seen perforation dysen- tery, nor appendicitis following dysentery. Dysentery is more connnon during the dry seasons following wet weather. It is more common among natives, but Euro-, peans have a more severe type. ANSWERS TO (^TESTION XAIUE 215 Shoka, Formosa.^ — Dysentery very eominoii ; hoth ame- bic and bacillary; treatment ])y salines preferred to ipecac or calomel; few of the complications except stric- ture of the rectum in one child ; appendicostomy not tried. With our new Avater supply dysentery is becoming much less frequent; next to malaria it is perhax)s the com- monest disease. Samoa.^ — Dysentery is common; type bacillary, exact organism not determined. Amebas have not been found. Predisposing causes seem to be mainly ingestion of de- caying food or too great an amount of food during times of feasting. Two clinical types : iirst, semiacute, ten stools a day, slight amount of blood, well in a feAv days after simple catharsis and starvation, by far the usual type; second or blood type, twent}'^ stools a day, pain, tenesmus, blood, pus, mucus, sometimes almost pure blood in considerable quantities, prostration moderate. These cases get well two to three weeks after administra- tion of ipecac in large doses. The European is careful of his diet and practically never contracts either form of dysentery. The European who lives with the native is liable to the same forms. Death from this cause alone is very rare in cases treated, but in cases left to the native doctors death is common, for they insist upon feeding their patients. They believe that frequent stools demand frequent feeding. KoREA,^ — Amebic dysenter^^ is not uncommon and diar- rhea of other kinds is very common in the summer time. Weir has made definite search for the amebas and has found them in a" few cases. Hospital practice in Seoul shows quite a number of liver abscess cases ; other com- plications infrequent; appendicitis rare. Guam.- — No bacillary dysentery on the island. Ameinc dysentery is common. The number of cases of amelnasis having dysenteric s^anptoms is not relatively very great. The incidence of dvsenterv is nraeli reduced since the 216 TROPICAL SURGERY AND DISEASES introduction of a Avat^r supjily and the closing of the okl surface avcIIs. Tln^ infection is not of a severe type and seems to be growing milder. The ordinary ipecac and opium treatment was the routine and the results generally were good; in some of the more severe cases irrigations with quinine also were given, and cures gen- erally resulted. Eight appendicostomies were made ^^-ith 13erfect results in six cases; one was improving when last seen; one case died, as the disease was too far ad- vanced to expect any other result. AiDXDendicostomy or cecostomy as the operator may desire is of the greatest value and amebic dysentery in certain cases becomes a surgical rather than medical disease. After a patient has had medical treatment for a reasonable length of time without good results, appendicostomy should be made and s(H)n enough to previ^iit tlie develoi)ment of ulcerative conditions that are sure to produce permanent injury to the bowel; several cases in the service in which the ordinary medical treatment was of no apparent value and where the symptoms suggested liver abscess cleared up perfectly after appendicostomy was performed. Xo cases of perforation of the intestine were seen. Hemor- rhage from the bowel Avas at times fairly severe but in no case dangerous. No peritonitis or appendicitis was seen that was due to ameba. The disease is very much more frec[uent among natives tlian Americans OAving to the precautions taken by the latter. It is difficult to state percentages, but relatively not one case occurs in the American to ten in the natiA'e. Intestinal Parasites and Intestinal Worms: Have Sys- tematic Examinations of the Stools of the Natives in Large Numbers and in Different Places in the Country Been Made? Raxgoox, Bur^ia."^" — Intestinal A\'orms are A'ery fre- quent. Xo systematic examinations have been made. ANSWERS TO QUESTIONNAIRE 217 Round worms in fair iiuiiiIxTs are almost always present in Burmese; one or two cases of intestinal ol)struction caused by large masses of these worms have been met Avith. Ankylostoma infection "of a minor degree is very connnon. Tenia inf(^ctions are rare. SwEBO, Burma/* — These observations were made on prisoners and also from those attending in the liospitals. They are all male adults. Out of 2000 cases examined parasites were found in 1048 of them, giving a percentage of 52. Of these 257 were ankylostoma duodenale, 253 ascaris lumbricoides ; 243 trichocephalus dispar; 170 rhabdonema intestinale; 89 ameba coli; 29 oxyuris ver- niicularis ; 5 tenia saginata and 2 were tenia solium. Re- sults with santonin on 100 new admissions into jail: Each prisoner who was in good health when he was admitted into the jail was given santonin, 5 grains, followed by a saline purge. Of these 82 per cent had worms, 51 of them passed 2 worms each, 12, 1 worm, 11, 3 worms, and 8 passed 4 worms. The longest of these worms was 14 inches, and the shortest was 6 inches. The average was 9 inches. Results with 100 old admissions in the jail : AVith another 100 prisoners already in jail and selected from a healthy set of men, I obtained the folloA\ing in- formation. Of these 89 passed worms, 30 of them j)assed 1 worm each; 26, 2; 18, 4; and 15 passed 3 worms. The longest of the worms measured 15 inches (female) and the shortest 4 inches (male). The average, 7 inches. Re- sults Avith 500 prisoners : Fifty prisoners were selected from time to time from the different sections in the jail. The observations extended over a year and the results were as follows: 109 passed worms, 38 of them 1; 27, 2; 22, 3 ; 6, 4 ; 6, 5 ; 5, 6 ; 3, 9 : 1, 7 ; and one passed 8 worms. Remarks : These observations show that ankylostoma duodenale was the most prevalent, then ascaris lumbri- coides, then trichocephalus dispar and then rhabdonema intestinalis. The large number of ankylostoma passed 218 TROPICAL SURGERY AND DISEASES was due chiefly to the climate, which was exceedingly damp throughout the year, but especially during the rains. The prevalence of ascaris lumbricoides and tricho- cephalus dispar requires no comment as they are very common in the Tropics. Rhabdonema intestinalis is not uncommonly found in the Tropics : these parasites w^ere most prevalent at the end of the rains, September and October, and then during the rains, July and August. Shoka, Formosa.® — ^Intestinal parasites and worms ex- ceedingly common. Amebic, malarial, and bacillary dys- enteries are all very common. Ascaris, trichuris, hook- worm, oxyuris are common; only one case of tapeworm. Samoa.^ — ^Intestinal parasites : very common ; ascaris, uncinaria, trichuris, oxyuris vermicularis. It is prob- able that every native child carries the ascaris, that every adult carries the hookworm and most of them the trich- uris. A very few children have the ox^airis vermicularis. An examination of seventy men, picked for their good hygienic surroundings, all of them being members of the native guard who live in barracks, showed that all of them carried hookworm ; that nearly all had, in addition, the AvhipAvorm and that a few had the ascaris. About five hundred examinations of the general adult popula- tion scattered throughout the island shoAved practically the same proportion. It was a matter for comment when the stool of a child failed to show eggs of ascaris. While large numbers thus carry one or more intestinal para- sites, only a small percentage, say 10 per cent of the adult population, show marked effects from this cause, probably because of the abundance of food and small amount of hard work, conditions which make up for the loss occasioned by the parasites. However, practically every case of illness as a routine measure Avas treated for intestinal parasites in order to facilitate recovery to convalescence. Neglect of this measure would at times ANSWERS TO QUESTIONNAIUli 219 delay tlie effect of treatment for otlier medical or sur- gical conditions. Korea. ° — Ninety-nine per cent of Koreans have intes- tinal worms ; cliiefi}^ ascaris. No systematic examination of stools. GuAM.-^ — Ascaris, whipworms, and hookworms, both varieties, were found in almost 100 per cent of the na- tives. In 1910 the school children of Agat were brought to Agaiia for examination and treatment. Of 121 chil- dren, 119 were positive to hookworms upon first exam- ination and the whole number upon the second examina- tion. The other worms were about the same. In this year all of the school children of the island were taken into the hospital between January 1 and July 1 for worm treatment, and observation gave practically the same results. Systematic stool examinations have been made and recorded for some years. All patients entering the hospital had stool examinations made as a matter of routine. Salines were given as a rule and the stool ex- aminations were made a few minutes after a movement was obtained. There was no rule about the number of smears examined, but if one was negative the examina- tion Avas generally carried to three or four slides be- fore the case was considered negative. In the negative cases the examinations were made on two or more daj^s. This work was very carefully done. Balantidium was found to be fairly common. This was worked up dur- ing the past year and the infection found to be more fre- quent than had been anticipated. One case of death was attributed to this cause as no other factor could be found at autopsy. No tape worms were encountered in the time under consideration. ''Tropical Liver" and Liver Abscess Rangoon, Burma." — Liver abscess is of moderate fre- quency; until the last two years the usual treatment had 220 TROPICAL SURGERY AND DISEASES been to open freely and drain in the ordinary way ; many quite early cases died as the result of secondary septic infection. In the early small abscesses the pus is sterile so far as the usual pyogenic organisms are concerned; amebas can generally be found if a proper selection of pus be made. In the older abscesses bacteria are gen- erally present together with amebas ; the bacteria found are coli, staphylococcus, and pneumococcus. Consider- ing the relative proportions in the community of natives and Europeans, there is no doubt but that the large single tropical abscess of the liver is much more common among the latter. Ulceration of the appendix is found in a few cases of dysentery examined postmortem, but it does not give rise to symptoms during life. Intes- tinal hemorrhage is common to a slight degree in most cases of true dysentery; in a few cases of very acute bacillary dysentery hemorrhage has been very severe, and at postmortem the ulceration was insignificant. Pro- fuse hemorrhage does not occur from the large gan- grenous ulcers so common in amebic d^^sentery; the ves- sels are probably thrombosed long before they become ulcerated. Agra, India.' — During 1909, 1910, and 1911, forty-three cases of liver abscess have been treated in the Agra hos- pitals. Twenty were operated on b)^ the open method; i. e., incision, resection of rib if necessary, and drain- age ; of these, ten died ; many come in with huge abscesses and in a very bad condition indeed, some almost in ex- tremis. Thirteen cases Avere treated by aspiration and the injection of hydrochloride of quinine; of these, two died. The cases A\^ere all large single abscesses. We rarely see them before a bulging of the side or in front is visible, but the diagnosis is usually established by a leukocyte count. In all the cases the histor}^^ of dysentery was invariably present. From our statistics liver abscess is much more common among natives ; that ANSWERS TO QUESTIONNAIRE 221 is because, for the most part, our Agra hospitals are for the admission of natives, hut it is commoner among natives probal^ty because of neglect of early treatment. No cases of appendicitis associated with dysentery and no cases of intestinal hemorrhage associated with liver abscess were seen. Colombo, Ceylon." — Liver abscess is not common al- though dysentery is very prevalent. It is more com- mon among Europeans than among natives. Last year twelve cases were operated on with one death; of these only two cases occurred among natives. Where marked symptoms are present, indicating the location of the ab- scess, operation is a simple matter ; the abscess is opened after excising a portion of the rib and shutting off the pleural cavity by stitches. Where no local tenderness or bulging existed, laparotomy was done and the liver palpated with the hand inside the abdomen. An ab- scess located by this method was opened by resection of a rib at a subsequent operation. In all cases drainage tubes were inserted and the cavity freely drained. In deep-seated abscesses where the opening had to be made through a considerable thickness of normal liver tissue, bleeding was found to be profuse, and had to be checked by gauze which, was removed later and the tubes in- serted. In ten cases the abscesses were solitarj^; in two cases multiple. Irregular fever, sweating and localized tenderness over the region of the liver, with increase of liver dullness are the chief signs. Wenchow, China.^^ — Liver abscess fairly common. Six cases operated on, all recovered; swelling visible in each case. All had previously had dysentery. Shoka, Formosa.^ — ''Tropical liver" occurs in for- eigners who live too well. Twelve al^scess cases in Chi- nese. "Where the exploring needle shows pus, incise; and if the liver is not adherent to the abdominal wall, stitch it to the peritoneum before opening. Recoveries 222 TROPICAL SURGERY AND DISEASES about 70 per cent. The abscess is generally solitary and the pus sterile; amebas not found. Cases generally do not come until there is a sv/elling. In niaii}^ cases no antecedent history of dysentery. Guam.- — Liver abscess and tropical liver are not very common considering the number of cases of amebic dys- entery seen. KoREA.^- — Liver abscess is fairh^ common; tropical liver, reported only by Weir. Samoa. ^ — ^^Five cases of enormous chronic enlargement of the liver without splenic enlargement have been seen just before death. One of these cases was explored with needle in several directions without obtaining pus. No autoi^sies were possible. Liver abscess has not been found. Cancer EA]srG00]sr, Burma. ^" — Carcinoma is considerably less frequent thou in England. Breast, penis, and uterus are the parts most frequently affected. Xo precancerous stage observed. Ejoithelioma of the cheek is not uncom- mon and is probably excited by betel-chewing. Epithe- lioma of the penis is common among Chinamen. Car- cinoma of the breast is not so common among natives as among women of Europ)ean countries. Epithelioma of the tongue is exceedingly rare among natives ; two cases seen during six years of hospital experience. On the other hand primary carcinoma of the liver appears to be very much more common among natives both Indian and Burman than among Europeans. This cancerous growth of the liver may be mistaken for liver abscess, as it gives rise to fever and i^ain. Carcinoma of the rectum is practically unknown. Agra, Ixdia.' — Carcinoma is common in India and more cases are seen now than formerly because the vil- lage people resort to hospitals more frequently. Can- cer occurs in all organs and parts of the body in about ANSWERS TO QUESTIONXAIRE 22.^ the same proportion here as in Europe. Epithelioma of the penis and tongue is excessively prevalent. Ping Yin,^- Soochow,^ and AVenchow,^'' China. — Car- cinoma fairly common ; regions chiefly affected are breast, rectum, lips, cheek, uterus, penis, skin of back and esoph- agus. In many cases the cancer has been preceded by a small pimple, papule, or sebaceous cyst often of many 3^ears' duration. Johannesburg," Africa. — Malignant disease does not appear to be so common among natives as among Eu- ropeans. Colombo, Ceylon.^ — In males carcinoma of the cheek, upper and lower, jaws is common. Next in frequency is carcinoma of the penis, then carcinoma of the tongue. In females cancer of the uterus and cancer of the breast. A precancerous stage has often been noted in connection with cancer of the cheek in the form of leukoplakial patches. Shoka, Formosa.^— Carcinoma is common in the mam- ma, cervix uteri, upper jaw, penis, sometimes in old scars, and lip. Guam.-— Carcinoma of the uterus Avas seen in one woman, and it was not found at any of the postmortem examinations. Eangoon, Burma.^° — Sarcoma not frequently met with, abdominal sarcoma springing from the pelvis has been most often observed. Sarcoma occurs in all regions of the bod}", but it is most common in the cervical region. Agra, India." — ^AVe see many cases of sarcoma, mainly of the long bones, jaws, nose, orbit and also of all parts of the body where such tumors usually occur. SoocHOw"" AND AYenchow,^"' China. — Sarcouia is very frequent, involving upper jaw, long l)ones, eye, foot, tes- ticle, parotid. CoLo:\iBO, Ceylon.'^ — Sarcoma is uncommon. It usually occurs in connection witli the upper jaw. 224 TROPICAL SURGERY AXD DISEASES Shoka, Formosa.® — Sarcoma, fairly common, particu- larly so in the neck, also at lower end of the femnr, and npper end of hnmerns. KoREA.^ — Cancer and sarcoma, fairly common, bnt not so prevalent as in the United States. The rarity of can- cer of the lip in a race where pipe smoking is almost miiversal among men and not uncommon among women is rather noticeal^le. The frequency of breast cancer among women whose breasts are so exposed to the sun and various irritants is easy to understand. Ovarian cysts are quite common. Every one reports fibroids as connnon and in addition several have had cases of car- cinoma of both the cer\ux and the body of the uterus. A number Avith experience elsewhere state it as their opinion that the frequency of this condition is about as in Europe and America. Samoa. — Sarcoma not observed. Guam. — No cases of sarcoma were seen. Diseases of Women Among- Natives: Ovarian and Uterine Tumors; Puerperal Injuries; Native Method of Accouchement Raxgoox, Buema.^'' — Ovarian and uterine tumors are of moderate frequency. Genital and pelvic diseases of women are frequent, chiefly the result of venereal infec- tion or sepsis following childbirth or abortion. Results of puerperal injuries are common in the district. Native methods of accouchement are primitive and barbarous. Agra, Ixdia.^ — In the special hospitals for Avomen in Agra Ave see a large number of cases of oA^arian tumors; tAA^enty to thirty cases are operated on annually. They are usually A^ery large tumors of the oA^ary or the broad ligament and frequently AAith many adhesions ; the cases almost alAA'ays do Avell. Uterine tumors are less common, but many cases of small and large fibroids are seen. Genital and peh^ic diseases are A^ery common among na- AiS^SWERS TO QUESTIOXXAIRE 225 tive women and there is a large ont-patient and in-patient department here under three English qualified women physicians, as many of the cases are "purdah nashin" ladies. As regards the native method of accouchement, no cleanliness whatever is observed during and before labor; the woman is made to strain almost from the on- set of the lal^or pains. The usual posture is the sitting one, and the placenta is in most cases extracted by the ignorant midwife directly after the birth of the child. Endeavors are now being made to educate these ' ' Dhais ' ' or native midwives in antiseptic and modern midwifery, and excellent work is being accomplished in attaining this end. Cesarean section is performed from ten to twelve times a year in the maternity hospital here, al- ways for cases of contracted pelvis, usually due to osteo- malacia or pronoimced rickets. HoifGKo:N'G." — Ovarian and uterine tumors common. Ping YiiSr, Chijsta.^- — Uterine tumors are chiefly cancer of the cervix. Genital and pelvic diseases of women mainly syphilitic. Puerperal fever common and often fatal. Tetanus infection the result of puerperal injuries. Native method of accouchement, squatting position, labor rapid, often precipitate. First stage is very short and rather painless. Colombo, CEYLOisr.^ — Ovarian uterine tumors, extra- uterine gestation, and pelvic cellulitis following puerperal injuries are very conunon. The native method of ac- couchement is purely expectant in tj^e; no attenipt is made to find out the presentation; no antiseptics are used but an oil, expressed from the seeds of the mayosa tree and said to i)ossess antiseptic projDerties, which is freely applied over the abdomen and is also taken in- ternally. Shoka, Formosa.^ — Ovarian tumors, cysts, dermoids, and polypi fairly common. Displacements and prolapse of the uterus very conunon. Ovaritis and pelvic cellulitis. 226 TROPICAL SURGERY A^B DISEASES puerperal or gonorrheal, and endometritis common. Puerperal injuries often lead to sloughing, cicatrization and stenosis of the vagina and to vesicovaginal and recto- vaginal fistulas ; fibroids of uterus not uncommon. Samoa. ^ — Chronic pelvic disease among the native women is practically unkno^^m. Puerperal sepsis, how- ever, is quite common ; five cases presented for treatment in a 3^ear in which about two hundred births were re- corded. Gonorrhea is almost unknown. The few cases which have been seen can nearly all be traced to cases that were imported about two years ago. When pres- ent, the disease is very mild in its course. The prevail- ing and common use of the drink called "kava" is said by some to lessen the liability to infection from this dis- ease, but the infrequency of this disease is probably due to isolation from lines of travel, and the practical absence of a prostitute class. KoREA.^ — Genital and pelvic disease in women is com- mon from displacements caused by unrepaired lacera- tions, short puerperium and general enteroptosis, of which dilated stomach is an important factor, due to constant nursing in infancy, irregular eating in child- hood, and gluttonous eating in adult life. Complete pro- lapse not uncommon ; native treatment is to burn off the presenting part with strong nitric acid, oil, or the actual cautery. The result is functionally good, but if preg- nancy folloAvs, then the case is serious. The treatment always is folloAved by cervical stenosis and often by vag- inal stenosis. Endometritis, quite conunon, due to un- cleanly hygienic habits, sexual indulgence and venereal insults. Salpingitis is surprisingly uncommon. Fistula, vesicovaginal and rectovaginal is not uncommon, and often is extensive. Lacerations, very common. Ac- couchement : Position, sitting, and on hands and knees, A\nien labor is delayed, it is believed that kneeling on a bear's skin will cause the baby to come quickh'. Foil- ■ aintswers to questionnaire 227 well speaks of the custom of placing the beans and stalks of the castor oil plant at the foot of the patient. Ap- parently the danger of leaving an adherent or retained placenta in the uterus for several days is not sufficiently recognized. Accidents and nialpresentations follow ap- plication of traction on the presenting part and the pushing and kneading of the al^domen. For difficult labor some natives use hot mud poultice, the mud taken from a rat hole and applied to the vagina, or a fresh split rooster applied to the vagina. Guam." — Ovarian and uterine tumors are not frequent. Three cases of ovarian cyst were operated upon and tAvo of fibroid tumor of the uterus. Many examinations of the pelvic organs Avere made and these were the only cases found. Three cases of pyosalpinx were operated upon. Lacerations from childbirth Avere common, but seemed to cause little trouble. Under the old system of midAvives, puerperal infections Avere common. The method of accouchement Avas the same as our oAvn, due, no doubt, to the instructions given b}^ tlie physicians Avho began obstetric work among the natives in 1900. The Avomen liaA^e a habit of tying a band or cord around the waist above the uterus for some time before labor for the XDurpose of keeping doAvn the pain. This Avas the only peculiarity seen. Genitourinary Diseases Among- Men Rangoon, Burma.^° — Venereal affections of the blad- der, penis, and testicles are very common. Hypertrophy of prostate is rare, but has been seen. The numl)er of men liAdng o\^er the age of sixty years is small in Ran- goon. Agra, India.^ — Genitourinary diseases among men are common in India and about 7 iDer cent of our admissions are for stricture, perineal abscess, extraA^asation of urine, cystitis, etc. Enlargement of the prostate seems from 228 TROPICAL SURGERY AXD DISEASES what ^ve see here to be common among old men. We never see the cases nntil they come for cystitis and reten- tion of urine and are usually in a very bad condition. If prostatectomy is performed in such cases as these, they hardly ever recover. We have performed quite a number of prostatectomies, but in more favorable cases and about 50 per cent have recovered and done well. Hoxgkoxg"^^ axd "Wexchow,^^ Chixa. — Genitourinary diseases and their complications are common in men. Enlarged prostate is not common chiefly by reason of the fact that Europeans rarely stay out long enough in the East and this complaint has not been found among Chinese. Colombo, Ceylox.'^ — Gonorrhea is fairly common; a large proportion of these cases suffer later on from stric- ture. Hypertrophy of prostate has been observed in a large number of cases, but only a few submit to operative treatment. Shoka, Formosa,^ — Genitourinary diseases are exceed- ingly common ; e. g., chancres, buboes, gonorrhea, venereal condylomata and warts, stricture of the urethra, orchitis, spermatorrhea and impotence. Have not seen-hyper- troxDhy of the prostate in old men. Guam.- — Xo cases of genitourinary disease were found on the island. Gonorrhea is not very coimnon among the men as they marry cpiite young. It is becoming more frequent, however, as there are more men being enlisted on the station ship which goes to Japan or China about twice a year. Primary syphilis and chancroid were not seen at all and no primary syiDhilis exists on the island. I believe that there is a certain immunity to the disease OA^dng to the hereditary syphilis (gangosa) now on the island. Only two cases of hypertrophy of the prostate were seen. One of these was in as pure-blooded a Cha- morro as there was on the island. Samoa/ — Hyx)ertrophy of the prostate was observed ANSWP:RS to QUESTIOXISrAIRE 229 in an American negro resident here, but no case has been found in the native though its clinical symptoms often have been sought. Rectal digital examinations have not been made in a series of cases. KoEEA.^ — Genitourinary diseases are not materially different from other countries ; bubo, not very common ; stricture, common; urethritis, nonspecific, in which no gonococci are found. Senile prostate rare. No one seems to have made any special search for the condition and cases to which attention was called b}^ s^anptoms were rare indeed. Hypertrophy from gonorrheal infec- tions is common enough. Appendicitis: Rule for and Method of Operating-; Treat- ment of General Peritonitis RANGOoiir, BuRMA.^° — Appendicitis occurs frequently. Operation in acute stage is performed at the earliest opportunity. Results are excellent. For general peri- tonitis following perforation, the Fowler-Murphy treat- ment with free abdominal drainage is carried out. The results have been very gratifying. Agea^ Ixdia.^ — Ai^ioendicitis is not connnon among na- tives of India. The cases we see are almost always in the European hosj)ital, we always operate at favorable periods of quiescence and the results are very satisfac- tory indeed. SoocHOw, Chiista.^ — I presume that I have seen as many as ten cases, but they refuse operation. I consider it much more rare than in the United States. Piis^G Yi2^, Chixa.^^ — Appendicitis unknoA'STi. Wei^chow, Chixa.^' — Appendicitis ver}^ rare. Have only seen one or two cases in Chinese which I have diag- nosed as appendicitis. Chronic abdominal abscesses generally discharge worms, making the diagnosis of the original trouble difficult. Shoka, Formosa.® — Generally see appendicitis at the 230 TROPICAL SURGERY AXD DISEASES abscess stage, Avhen tlie treatment consists of making a hole and pntting in a drainage tube. These cases do well. Samoa.^ — Ap]3endieitis is quite rare. Only one case has been found in 1000 surgical conditions operated upon. Gastric Symptoms Caused by Gallstones, Ulcer, Appendi- citis and Cancer Rangoon, Bur:ma." — Several cases of gastric sym]D- toms due to gallstones have been met with. Gastric and duodenal ulcers are on the whole rare, but occur from time to time. Cancer of stomach is not of frecjuent oc- currence. Gastric s^anptoms due to appendicitis have only rarely been noted. Agra, India.^ — Gallstone disease, gastric, and duodenal ulcer and appendicitis are not common among the na- tives in this part. ' They are rarely seen in our hospitals except a few cases in women. Hongkong." — Gallstones and biliary sand are very common. Duodenal ulcer is not uncommon : appendicitis is very common ; cancer of the bowel not common. Shoka, Formosa.^ — Gastric s^anptoms common, due to too much food. Operated on a few cases of gallstones and several cases of pyloric stenosis due to cicatrization. Appendicitis is generally seen at the abscess stage. Guam.^ — Appendicitis from ordinary causes is very rare. There were only four cases in the native popula- tion during two years stay in Guam. All persons dying ill Agana and immediate vicinity in Avhich the cause of death had not been accurately determined Avere subjects of postmortem examination. No cases Avere found. The population of the area Avas about 8000. The cases of ap- pendicitis that occurred Avere all seen rather late Avith one exception and all recovered after operation; the course of the disease being about as it Avould in our 0A^^l people. No cases of gallstones. There Avere no cases of fi'astric or duodenal ulcer. ANSWERS TO QUESTIONiS^AHlE 231 Samoa/ — Gastric symptoms due to indiscretion in diet are not unknown, but are rare. KoREA.° — Gastric symptoms are very common; many times they are hard to distinguish from general intes- tinal symptoms, and those from actual disease are often lost sight of or at least cojifused with those resulting from adhesions after "needling." This makes the diag- nosis of reflex gastric symptoms doubly hard. Cancer has been definitely located in a number of cases. Gall- stones have been suspected in a few cases, but their ex- istence has not been proved : several undoubted gallstone cases have been observed in fat Avomen in most of whom jaundice was present. Catarrhal jaundice without pain or other evidence of complication is quite common. Di- lated stomach and associated gastritis are prolific causes of distress and lead to the oft-repeated statement that the "food doesn't go down well." Dr. H. C. Clark (1914) critically examinmed several hundred native laborers of the Canal Zone in regard to reflex gastric disturbance and concluded that reflex gas- tric symptoms due to causes from the gastro-duodeno- hepatico-pancreatic system awere not uncommon. Leprosy: Leper Colonies and Segregation; Surgery for Leprosy Rangooist, Burma.^"- — Leprosy is common and Major Rost, I.M.S., has reported successful cases of injection by his vaccine. The cases are segregated in asylums un- der medical supervision. No leper colonies. Agra, India.^ — Leprosy is uncommon in this part of India. All the cases are so far as possible segregated into leper asylums. The asylum is visited by health of- ficers periodically. SoocHOw,^ PiifG YiiiT^- AjStd Wexchow,^" Chixa. — Lep- rosy of the anesthetic type is in this region though not 232 TROPICAL SURGERY AND DISEASES abundant. The ''lion face" is common. There is no segregation. The people have slight fear of it. Johannesburg, Africa.^* — Leprosy very common among many South African tribes. Shoka, Formosa.^ — Leprosy fairly common. Have tried nastin in vain. Not segregated. GrUAM.- — There are twenty-five cases on the island. Salvarsan was being tried in the treatment of the disease, but no improvement was noted in any patient. Segrega- tion has been practiced since 1902 and there was some attempt at segregation by the Spaniards. The disease does not seem to be increasing and the type does not seem to be very virulent. Samoa.^ — Leprosy has not been observed in American Samoa; however, a small colony of lepers is present in German Samoa. KoREA.^ — Leprosy is found only in the southern half of Korea. Li Seoul the average is one case a month and they all came from farther south. Not segregated. There exists only one asylum for their care. Yaws GuAM.^ — Fairly common, but did not seem so much so as it was at first and the disease is certainly not so frequent as it is in Samoa. The lesions are not so numerous or "wet" as they are there. Salvarsan had not been tried. Samoa.^ — Every Samoan child contracts yaws, as a rule about the age of three to five years. The mother is willing to expose her child to the infection because she believes it is better for the child to have it in early life. Before the use of "606" the open lesions persisted from. six months to a year or more in spite of treatment mth potassium iodide. Since the use of "606" the open lesions are healed in a week or ten days. Too few cases have been treated in this manner, to date, to give even ANSWERS TO QUESTIONNAIRE 233 an index as to the permanency of this method of treat- ment. KoREA.^ — Yaws not observed. Tropical Ulcers and Granulomas of Skin Kangoon, Burm:a.^°— Tropical nlcers of the phagedenic type have been snccessfully treated by peroxide of hy- drogen. Johannesburg, Africa.^'* — Ulcers of various kinds prevalent on the legs, especially among mine boys work- ing under ground. Wenchow, China." — Tropical ulcers and granulomas of skin common. KoREA.^ — Tropical ulcers not found. Samoa.^ — A common form of nicer as a rule affects the legs, varies in size from the area of the palm of the hand to an ulcer involving one-fourth of the surface of the lower leg; commonly seen on the calf instead of on the anterior tibial region. Other sites are the outer lat- eral-tibial and flexor aspects of forearm, generally more than one and seldom more than four. These ulcers dis- charge a stinking, watery fluid, small in amount, and have a yellowish granulomatous base flush with the epidermis which can be easil}^ curetted to a depth of one-fourth of an inch, when an oozing, bright red, clear base can lie obtained with a sharply limited ragged skin edge. Cu- rettage followed by large doses of potassium iodide and combined with surgical cleanliness have resulted in a healing ulcer in most cases. When healed a thin, broad, parchment-like epidermal scar is left, not unlike the scar of syphilitic ulceration. It is believed that these ulcers are a late manifestation of the ''^^aws" though the be- lief has not been backed up, as yet, by an}^ specific tests such as the Noguchi or Wassermann. Of late salvarsan has been used in a few cases in addition to the other 234 TROPICAL, SURGERY AND DISEASES treatment with the result that healing has apparently been more rapid. Guam.- — "Tropical ulcers" have all disappeared with the use of mercury and iodide of iDotash, as applied to gangosa (syphilis). Filariasis RANGOOi!^^ Burma." — Xo experience. Infections are not common in Burma. - FiLARiA IjST the PHILIPPINES. — Captain Phalen and Lieutenant Nichols of the United States Army in 1908 and 1909 made about 7,400 blood examinations in va- rious localities to get an idea of its prevalence and dis- tribution and found the disease to represent 2 per cent of infections for the islands; 35 cases had eleiDhantoid dis- ease. Protection from mosquitoes is preventive but this is impracticable for a native population, hence, when- ever a case is discovered, among the native employees, it should be discharged at once as the Culex fatigans AVied., which transmits the disease is onini|)resent. SoocHOw,^ HoNGKONG,^^ China. — Filaria nocturna has been found in a feAV cases, two of elephantiasis and one in a severe case of cMduria. Four other cases of elephantiasis have been examined and the filaria not found. Johannesburg, Africa.^* — Filaria nocturna present in some areas. Shoka, Formosa.® — Have seen a few cases of filaria nocturna. Generally associated Avith orchitis. Samoa.^ — Filariasis. Salvarsan tried in ten cases without benefit. Complications : localized elephantoid swellings treated successfully b}^ surgical removal; dif- fuse elephantoid swellings not treated with success sur- gically. Korea.® — Filariasis not found. ANSWERS TO QUESTIOXXAIKE 235 Guam' — Tliirteen cases have been found. No symp- toms, no treatment, no hematofhylnria. Ainhum and Goundou Manila." — The board has seen one case of ainhum in the person of a Jamaica negro; not seen in Buema^" or Formosa^ but in Johaxxesburg/* Africa,^ the disease is fairly common. Goundou not diagnosed. Samoa^ Korea, axd Guam.- — Ainlnim and Goundou not seen. Tumors: Benign and Malignant Samoa.^ — Tumors, libromas, and lipomas most often seen; malignant tumors rare. Kokea.^ — Keloid of moderate degree quite common; lipomas, frequently seen; osteomas, few; angioma and uterine fibroids few cases; papilloma, common. Guam.- — LiiDomas and a feAv sebaceous cysts only were seen. Any part of the body seemed likely to 1)e the site. Urinary Calculi Rangoon, Burma." — Urinary calculi are very much less frequent than in India. Litholapaxy is the selected operation for stone in the bladder. Eesults only mod- erately good, chiefly owing to want of experience. Agra, India.' — Calculi in the bladder are common in India, especially in children, and are mostly composed of either uric acid or oxalates. The chief operation is litholapaxy in about 90 per cent of the cases. The re- sults are very successful, hardly any cases are lost. If litholapaxy can not be performed because the stone is too large or the urethra too small for the passage of instruments, then suprapubic cystotomy is performed; and the bladder drained. Hongkoxg,^^ Soochow,^ China, and Formosa. — Gravel more common than stone in Europeans; bladder stone common in Chinese; kidney stone not diagnosed. 236 TEOPICAL SUEGERY A:N'D DISEASES Samoa/ — Urinary calculi of bladder and kidney not observed clinically. Antopsies difficult to obtain. KoEEA.^ — Urinary calculi of bladder and kidney ; all re- ports indicate that these conditions are rare. T\Tiether there is any connection with the water supply or not, it might be noted that the geology of Korea is essen- tially granite and that limestone and marl^le occur but in very limited quantities. GuAM.^ — Urinary or renal calculi not seen. Hodgkin's Disease Eangoox, Buema," Agea, Ixdia," Soochow, Chiista.^ — Hodgkin's disease very rare, only one case has been def- initely diagnosed; the patient was a European; a few cases in Hongkong, and in Ping Yin/- China ; in Africa^'* prevalent among natives. Samoa/ — Hodgkin's disease not seen, though enlarge- ments of glands are connnon from other causes. KoEEA.^ — Hodgkin's disease not seen. GuAM.^ — No cases seen. Diabetes Rangoon, Buema.^° — Diabetes connnon among natives of India. Eare among Burmans. Treatment is difficult because natives of India will not diet themselves. Gan- grene is not very prevalent. Agea, Iistdia."- — Diabetes is very common in India, espe- cially among the better classes. It occurs chiefly among the native Hindus. Gangrene is rare among diabetics, but carbuncle is very common in these cases and is fre- quently seen in the hospitals. HoisTGKOxG.^^ — Glycosuria common in Chinese ; true dia- betes not so common; treatment, high frequency auto- condensation will cure glycosuria, but not true diabetes. It is infrecpient in Foemosa^ and Weistchow,^^ and in Afeica^* diabetes is not found. Samoa.^ — Diabetes seen ANSWERS TO QUESTIONNAIRE 237 onty in one instance and in a European. Koeea.° — Dia- betes rare. Guam.- — Xot seen. Paralysis Agitans Agra, India,^ Bue,ma^° and Africa.^* — Paralysis agitans is rare among the natives. Samoa, Guam, Korea. — Xo eases observed. Infantile Paralysis •WENCH0^^', Ping Yin, and Formosa. — Infantile jDaraly- sis is common. Korea.^ — Infantile paralysis cases seen long after acnte sj^nptoms had passed. Samoa.^ — Not observed, neither acnte nor terminal ef- fects. Guam.- — No new cases. There had evidentl}^ been an epidemic some eight years ago as several yonng people had the resulting paralysis; these cases were fonnd to have had the disease about the same time. Hernia Rangoon, Buema,^° Agra, India.' — Hernia is of moder- ate frequency among the working classes. The cause is probably due to muscular exertion. It is not so com- mon as among Europeans and one reason may be the position a native assumes in the act of defecation; i.e., sitting on his feet with the inguinal rings well protected by the thighs ; nor do natives work as hard as Europeans. Is much more frequent among the hard working Chinese in China, also in Formosa and in Africa.^'* Samoa.^ — Hernia is rarely seen, probably because they do not jDresent with it ; tAvo cases of strangulated variety seen in five hundred operations, one inguinal, one fem- oral. Guam.- — Hernia is quite frequent in men, and strangu- 238 TROPICAL SURGERY AXD DISEASES lation was common. There were no cases seen in the fe- male. All cases Avere oblique inguinal and aside from congenital defects, the only cause seemed to be the gen- eral anemic condition resulting from hookworms and the heavy labor incident to obtaining saw logs. Korea. ^ — Hernia is stated by every one to be quite common in children and adults ; most cases are operated, few trusses being used. ^& Tropical Abscess Samoa.^- — Abscess is the most frequent surgical condi- tion met with. These abscesses are deep-seated, as rule, close to or surrounding a large artery, very little indura- tion, very similar to the abscesses seen in low grade sep- ticemias ; generally single ; common sites ; brachial artery just above elbow, femoral artery Scarpa's triangle, iliac artery pointing at anterior superior spine of the ilium; little or no constitutional reaction; common organism a staphylococcus of low virulence ; ra]3id recovery by drain- age through small opening. KoREA^ ai^d Guam.^ — Tropical abscesses not seen. Congenital Defects RAiiTGOOi;^, Burma." — Congenital defects are on the whole somewhat rare, except imperforate anus which is not uncommon. Agra, Ixdia," axd Formosa.^ — All the congenital defects are fairly common except squint. In Ixdia accessory fingers are very commonly seen, but natives will never have the accessor}' finger amputated as it is considered a sign of bad luck. Guam.- — The natives of Guam seem remarkably free from congenital defects ; very few cases of talipes, squint, harelip, and but one of cleft palate and clubbed feet and hands. Samoa.^ — Harelij), cleft iDalate, club-foot, one of each ANSWERS TO QUESTIOXXAIRE 239 ease has been seen in last six thousand eases treated; squint seems to be rare. Korea. ° — Squint not unconnnon ; treatment was not de- sired. Harelip, quite common and it is the experience of everyone that onee you begin to treat these eases your "fame" immediately spreads and patients eome until the condition seems more common than it really is. All stages of the deformity are found to exist from a mere notch to a generally ''open countenance." Cleft palate, clubbed feet and hands, polydactylism, imperforate anus, hermaphroditism, undescended testicle, imperforate va- gina, exstroph}^ of the bladder, hypospadias, atresia of the vagina and absence of uterus, one ease each. Varicose Veins Raxgoox, Burma;" Agra, Ixdia;^ Philippines. — Vari- cose veins seldom require operation. Hydrocele ex- tremely common among natives of India, not so common among Burmans who do not wear tight fitting "loin" cloth ; varicose veins are common among the coolie class in China. Samoa. ^ — Varicose veins observed in natives but once. Korea.® — Rather uncommon. Guam. 2 — Xo cases of sufficient magnitude to attract at- tention were seen. Hemorrhoids and Fistula India,' Burma," China and Formosa. — Hemorrhoids and fistula are of moderate frequency. More frequent among those following a sedentary occupation. Samoa. — Hemorrhoids and fistula not seen. KoREA.^ — Hemorrhoids : Everyone states that the con- dition in a mild form is quite common and that severe cases are not often seen. The continued sitting posture is a reason advanced for the presence of the affection since constipation is so uncommon. It is worthy of note 240 TROPICAL SURGERY A^iTD DISEASES that altliougli this affection of the rectal blood vessels is less common than in America, that of infection, as represented by abscess formation and tistula, is mnch more prevalent. Fistula : All agree npon the frequency of this affection in mild and aggravated forms. Patients in Kangkai have rei^eatedly told the writer that pin- worms cause these fistulas and that their exit has been frequently seen. The treatment by repeated needling and lancing of the anus in certain cases of chronic gas- troenteritis of children and 3"oung adults and in other abdominal conditions, with as yet undifferentiated symp- tomatolog}^, on the assumx)tion that they Avere suffering from "rectal disease," probably is a cause. The lack of an}^ or sufficient cleansmg after defecation in a large proportion of the population must be an important pre- disposing cause. The warm floor is also believed to have a causal influence. Treatment: Cut and scrape, some use bismuth paste. Two hundred cases were treated with excellent results in nearly all except tuberculous patients. Guam,- — Hemorrhoids were not common, a few ceases only and only one case necessitating a Whitehead opera- tion. Fistula rare. Actinomycosis, Glanders, Echinococcus Burma." — No actinomycosis as an indigenous disease; a few cases of "Madura foot" are seen, but they were al- ways imported from India. Glanders is exceedingly com- mon among the ponies of the iDublic conveyances in Ean- goon. Cases of acute glanders in man were met mtli three times last year, but they are probably commoner than is supposed, for in the house from which one of last year 'si cases came, three people died of "abscesses" during two years. Bacteriologic examinations are not carried out save among the comparatively few patients who come to the hospital. There is a disease which re- sembles glanders very closely and Avhicli is fairly com- AXSWERS TO QUESTIOXXAIKE 241 mon among- the natives of Rangoon. So far as we are aware tliis disease lias not been hitherto described; a full description of this disease will l)e pnljlished as soon as our bacteriologic work has been confirmed. Echino- coc-cus infection has been reported among the natives of Burma, but every case examined in the laboratory or in the mortuary has proved to be a mistaken diagnosis. Agea, Ixdia;^ Foemosa; South axd AVest Afeica. — Xo cases of these diseases. Samoa.^ — Actinomycosis, glanders, and echinococcus not seen. KoEEA.'' — ^^Veir rejoorts one bone case of actinomycosis. No cases of glanders reported. Dr. Oh, of Kunsan, Korea, in a personal communication stated that he had had one liver case of echinococcus. Several cases of an- thrax rei^orted. Tonsils and Adenoids in Children BuEMA," IxDiA,' South axd West Afeica." — Tonsils and adenoids are not so common among native children as among Europeans. Xative children live an open air and free life. Xasopharyngeal diseases are very fre- quent in Hoxgkoxg" and other crowded Chinese cities. Xearly every child one examines has a hypertrophied Luschka's tonsil; ptosterior rhinoscopy shows hyioer- troj)hic swelling of the orifices of the eustachian tubes and some swelling of the posterior ends of the inferior turbinate bones. All Chinese patients have some post- nasal catarrh accompanied by an excessive secretion of mucus, due to their extremely crowded and unhygienic mode of life ; also their excessive ingestion of farinaceous food leads to an increased production of mucus not only in the alimentary canal, but from all the mucous tracts. Samoa.^ — Adenoids in pure-blooded natives sought and not found. Adenoids common in young half-castes, white and Samoan. 242 TEOPICAL SURGERY AXD DISEASES Korea.® — Adenoids in children. This subject seems not to have attracted the attention of the various phy- sicians to any great extent. Mouth-hreathing as an af- fection of sufficient importance to modify the facial ex- pression is at least not common; doubtless many of the prevalent "running ears" and sore throats would dis- appear if one could remove the adenoids. Guam'^ — Adenoids and mouth-breathers, very rare. Infectious Diseases of Children Burma." — Diphtheria and scarlatina very infrecpient. Mumps common among natives of India from the hill dis- tricts and less common among natives of Burma from the hills. Among the natives of Burma who live in the plains, noma is very rare. Manila.^'^ — Diiohtheria a few years ago was considered ver}^ rare in the Philippines. Whether unrecognized be- fore or more recently introduced, it is now found not in- frecjuently. In one case virulent bacilli were present in the throat ninety days after the onset of the disease and disappeared promptly on spraying the throat with a cul- ture of staphylococcus pyogenes aureus. In another case in which were found virulent bacilli, after twenty-one days similar prompt disappearance occurred after using the staphylococci. Agra, Ixdia.^ — Diphtheria is not common, but it is seen occasionally among native children ; never in an epidemic form. Scarlatina never seen among European children in schools. Measles is very common both among Euro- pean and native children. Noma never seen in this part of India. HONGKOXG^^ AKD ChIXESE CiTIES''' ^', FoRMOSA,- AXD IX SouTH^* AXD AVest*^ Africa. — Scarlatina is practically un- known. Cases that have been reported have been of doubtful diagnosis or have been imported. Diphtheria is not common; pseudodij)htheria more so and a mem- ANSWERS TO QUESTIOXXATRE 243 l)raiions affection of the tlii'oat due to streptococcus pyo- genes still more coiiiiiiou. Postdiphtheritic paralysis is not a common sequence. MumjDS is very common, espe- cially among the Chinese. Mucus disease is an exces- sively eonnnon complaint among the European childi-en horn or resident in the East, due in the main, to native servants acting without maternal supervision and over- feeding the children of ahout seven years of age; cer- tainly it is more frequent in cliildi-en of this age than in younger children. This disease is very amenable to treatment, a rectified diet and small doses of arsenic and occasionally minute doses of opium to control the lienteric diarrhea which is very prone to result therefrom. Samoa, ^ — Diseases of children occur only when intro- duced from other islands. Chicken-x)ox has been endemic for some years. An epidemic of measles occurred during the past year attacking practically every person under the age of nineteen, killing about 8 per cent. Dysentery occurring during convalescence was the cause of death. Korea." — Diphtheria is not often seen by the for- eigners. It is increasing in frequency. Perhaps this is apparent only because of a more widespread use of the dispensar}' by the common people for the treatment of minor affections. It is possible that the concentrated tobacco smoke of the Korean house operating contin- uously day and night may decrease the frecpiency of in- fection; the degree of contagiousness is very evidently much beloAv that found in America. Scarlatina reported as having been seen by only three men and they say it is rare. Hirst believes it is increasing in frequency some- what. Parotitis is uncommon in some regions, common in others. Every doctor, except one, reports cases of noma and most speak of it as being fairl}^ common. All these cases were fatal except one, and all were seen sev- eral days after the onset. Most of the cases Avere seen during epidemics of measles. One case of diphtheria was 244 TEOPICAL SURGERY AND DISEASES reported in which antitoxin was used. Mumps : epidemic in 1910 ; 53 cases. Measles epidemic in 1909. Whooping- cough eiDidemic, 59 cases. Ophthahnia is common. Many cases of syphilis seen. Guam. ^— No di]Dhtheria, scarlet fever, mumps, small- pox or noma. Had about fifty cases of chicken-iDox and a good many cases of yaws; epidemic conjunctivitis was common in the late part of 1909 and early part of 1910. There also is a conjunctivitis more common in children and young adults though by no means uncommon in adults, which resembles trachoma but which yielded quite readil^T" to % per cent zinc sulphate solution. There is a disease known locall^^ as ''guha" and which has been described under the name of "epidemic asthma," which is more prevalent during the periods of greatest rain- fall, Jul}^ to October. It is quite fatal in young children and occurs occasionally in adults. There is a fever of moderate severit}^, no glandular involvement, and the postmortem picture resembles a capillary bronchitis. Guha has not been seen in a foreigner. Ludwig's Angina Burma." — Ludwig's angina not frequent. India,^ Formosa,® West*' and South^* Africa. — Lud- wig's angina is never seen. Samoa.^ — Not observed. Korea. ^ — Rare. Elephantiasis Burma." — Elephantiasis of moderate frequency. Much less so than in Southern India. The vast majority of cases are imported from India. Agra, India.^ — Elei)hantiasis is not found in these parts, we occasionally see a case that has come from Lower Bengal or the South of India where it is common. Ping Yin, China.^- — Elephantiasis rare ; in Wenchow, China,^' is common; none in Formosa,® but in South AXSWElt.S TO Qt'ESTIO^'XAIIlE 245 Afeica,^* elepliantiasis very common; in some parts of the East Coast, also in some localities in West Afeica.'' Guam. — There was but one case of elepliantiasis on the island. Samoa."^ — Perhaps one in every hundred adults has some form of elephantiasis : legs most common ; scrotum next, penis next, breast next, arms next. ExiDerience here seems to i)oint to the truth of the surgical princi- ple, that a localized elephantoid swelling which is com- pletely removed by surgery is not liable to return, but a diffuse elephantoid swelling attacked and partly re- moved surgically, will probably be aggravated by the surgical interference and in a year or two become of greater size that it would have become if no operation had been performed. The native believes that the scar left by an infected wound in elephantoid tissue Avill check the growth of the SAvellings and he j)ractices this method of treatment Avith some show of success. Koeea'^ axd Philippines. ^-^^ — Not frequent. Skin Diseases Burma. ^" — Yaws common in the Chindwiii District of Upper Burma; rare elsewhere. Skin diseases have not been investigated with any thoroughness at this hospital. IManila.^'^^A member of the United States Army Board has conducted a clinic on skin disease for several years in the Philippine Cleneral Hospital. The 532 cases that have been observed and treated during that time are tabulated as follows : Dermatomy coses. — Blastomycosis, 11, 2.07% ; tinea cir- cinata, 171, 32.14%; tinea versicolor, 14, 2.63%; tinea nigra, 2, 2.63% ; tinea s^'cosis, 2, .38% ; tinea tonsurans, 1, .19%; tinea favus, 4, .75%; tinea imbricata, 4, .75%; un- determined, 11, 2.97%. Infections, Prohably Bacterial. — Impetigo simplex, 20, 3.76% ; acne vulgaris, 14, 2.63% ; iin]3etigo contagiosa, 10, 246 TROPICAL SURGERY AXD DISEASES 1.88%; dermatitis, 46, 8.65%; dermatitis, vesicular, 3, .56% ; dermatitis papular, 8, 1.5% ; cellulitis, 1, .19% ; in- fected Avound, 1, .19% ; furunculosis, 3, .56% ; folliculitis, pustular, 4, .75% ; leprosy, 1, .19%. Diseases Due to Protozoa and Animal Parasites. — Ground itch, 1, .19% ; syphilis, secondary, 10, 1.88% ; syphilis, tertiary, 1, .19% ; mites, unclassified, 3, .56% ; scabies, 25, 4.7% ; yaws, 11, 2.07%. General Skin Diseases. — Pemphigus, 4, .75% ; pom- pholyx, 11, 2.07%; psoriasis, 6, 1.13%; herpes, 5, .94%: herpes zoster, 7, 1.32% ; lichen, 1, .19% ; seborrhea, 3, .56% ; dermatitis venenata, 2, .38% ; gangrene, moist, 11, .19% ; eczema exfoliatum, 1, 3.2% ; eczema sclerosum, 24, 4.51%; eczema erythematosum, 3, .56%; eczema papulo- sum, 3, .56% ; urticaria, 1, .19% ; vitiligo, 1, .19% ; pru- rigo, 3, .56% ; blisters, 1, .19% ; alopecia areata, 1, .19% ; hyperkeratosis, 10, 1.88%; undetermined, 46, 8.65%; grand total, 532 cases. Blastomycosis of the skin has been studied extensively by the Board. (See the Philippine Journal of Science, iii. No. 5, p. 395, Section B, November, 1908.) Blastomy- cosis of the lungs has also been found. In Chixa ais^d Formosa® skin diseases of every variety exist. Samoa.^ — The common skin diseases are : chromophy- tosis, trichophytosis, a pustular disease of extremities, a scabies-like disease. KoREA.^ — Psoriasis, fairly common, except in the north, where a dozen a year out of two thousand skin cases were seen. Scabies, very prevalent. Lacquer derma- titis and poisoning, occasional, sometimes fatal, espe- cially among hat makers and occasionally the Avearers. Ichthyosis, fairly common. Eczema and dermatitis, uni- A^ersal. Acne vulgaris, not very common, chiefly among better classes. Acne rubra, rare. Acne indurata, few cases. Alopecia, rare. Dermatitis calorica, common. Dermatitis exfoliativa or iDityriasis rubra, tAvo cases, ANSWERS TO QUESTIOXXAlllE 247 both died. Dermatitis medicamentosa, two cases due to iodoform; one in Japanese. Dermatitis venenata, occa- sionally. Erysipelas, few cases each year. Herpes, rare. Hyperidrosis, few cases. Leucoderma, common, ne^ois, feAv cases. Pediculosis, common. Urticaria, feAV cases. Guam.- — Skin diseases are not eonnnon in Guam; "ground itch" is frequentl}^ seen, and tinea eircinata is fairly common. Ichthyosis Avas more common than in any other tropical country in Avhich I have had duty. Trichophyton Skin Infections — "Prickly Heat" Agea/'^ Raxgoox"' axd Formosa,^ Ixdta. — Very common indeed among all natives of the lower classes. Treat- ment consists of mercurial and chrysophanic ointments, iodine, and x-rays. Prickly heat, although often extensive and troublesome in hot weather and rainy season, is not a disability. It is treated with lotio hydrarg. perchlor. (1 :1000) and drying powders of boric acid, oxide of zinc, and starch. KoREA.^ — Trichophyton skin infections are found, ring- worms of the general surface, genitocrural region and of the scalp are seen occasionally. Treatment consists in plenty of green soap and water washings, iodine, and sulphur ointment. Samoa. ^ — Trichophyton infections are very common. It is difficult to find a native without one of its forms. Treatment used is tincture of iodine locally with excel- lent results. Only one case of tinea eircinata has been seen, and that in a man Avho belonged to an island (Tokelau) where the disease is endemic. Prickly heat is far more severe than the type seen in more temperate regions. No satisfactory treatment has l)een evolved. Sea bathing seems to aggravate the condition in Samoa rather than relieve it, j)robably because of the numerous 248 TEOPICAL SURGERY AND DISEASES forms of phosphorescent animalcules in the sea water. Treatment most satisfactory from a palliative stand- IDoint is a wash of aluminum acetate with one per cent carbolic acicl. Guam.- — Tinea circinata is fairly common, though not so much so as it was in the Philippines in 1900-1902 ; treatment, 15 per cent salicylic acid in alcohol. Heat rashes were rare and caused no disability. Furunculosis Agra,^ Eangoon," India. — Furunculosis is seen in the hot weather and rainy season, and it is fairl}'' common especially among Europeans. Our procedure is to take a culture from an unopened boil, prepare a vaccine, and give regular doses. The cases alwa^^^s do well under vac- cine treatment; staphylococcus albus is generally found. Hongkong," Ping Yin^- and Formosa,^ China. — Furun- culosis very common in the hot months, best treated mth autogenous vaccines ; no failures yet from this method of treatment; tincture iodine applied in out cases. Samoa.^ — Furunculosis is rarel}^ seen in the native ; is frequently seen in the white race, about the same as in temperate climate. Best treatment, autogenous vaccina- tion. Korea. ^ — Furunculosis is seen eveiywhere. The cus- tom of pasting little pieces of oiled paper over any sore prevents the healing and creates a tendency to spread. Cases are treated by cleansing incision where necessary, and a 70 per cent alcohol dressing has proved effective. Guam.- — Furunculosis is common among Americans. Treatment: incision, carbolic acid, alcohol applications, and the use of Bier's cups. A few cases necessitated the use of vaccines and the results were good. The condi- tion did not seem at all common among the natives. ANSWERS TO QUESTlONNAMtE 249 Pemphigus Contagiosum Manila.^' — Tho treatment of pemphigus contagiosum lias been very simple. We have had very good success using equal parts of pure camphor and carbolic acid. The skin of the bleb is torn away and the denuded area well swabbed with this mixture. If all vesicles are so treated before they rupture and spread the infection, the disease may be cured in a few days. Tincture of iodine is also very efficient used in this way. Hongkong." — Pemphigus contagiosum very common ; treatment by biniodide of mercury 1 :2,000 and a dusting powder of equal parts of talc, boric, and salicylic acids. Samoa.^ — Pemphigus contagiosum not present. Korea. ^ — One case in a girl. Treatment ; wash of lime- Avater and dusting powder of boric acid and starch. Guam.^ — A few cases among children. Treatment: cleanliness and Fowler's solution. Lesions of Lower Extremities in Barefoot Natives . Rangoon, Burma." — A curious melanotic sarcoma of the heel has been seen upon one or two occasions. Agra, India.^ — Few cases of any trouble of the feet in natives. Occasionally they get fissures from the hard skin. Cancer of the skin of the feet among natives has not been observed. Hongkong." — A pemphigoid eczema occurs on the skin of the feet which is of an exceedingly contagious na- ture. It is characterized by, at the first, intense itching, generally between the toes, tlieii on the soles of the feet; later, a vesicle forms, the contents of which spread the affection to other parts of the body; the final condition being a purulent one. No organism discovered, Formosa,^ Ping Yin,^- and Wenchow,^'^ China. — Car- cinoma has been observed on the sole of the foot fol- lowing cut, plus infection and Chinese treatment by ir- ritating plasters. 250 TROPICAL SURGERY AXD DISEASES Korea.'' — Lesions of skin of lower extremities not found. Guam." — Skin trouJjles of the loAver extremities con- fined largely to the ''ground itch" jDrobably caused by the hookworm. Samoa.^ — Lesions of skin of lower extremities in bare- foot natives exceedingly common. There are three t^^pes : First, in young children, multiple small punched- out sores called "poi," look not unlike pustular eczema; begin as a successive crop of pustules beneath a super- ficial layer of epidermis, commonly on soles of feet, palms of hands, legs up to knees, rarely on arms and body, and are chronic ; weeks to recover ; little or no con- stitutional reaction; recovery under cleanliness and ap- plication of mild parasiticides such as balsam of Peru; commonly found to be a precursor of yaws, though in all probability an independent condition. Second type: in adults as a rule; scabies-like involvement of skin mainly on the legs and bodies ; no parasite demonstrated ; seems to affect whole families ; slow chronic course ag- gravated by salt-water bathing ; thickening of epidermis, dry, scaly itching lesions believed to be due to a parasite living in the sleeping-mats. Third type: large ulcers in adults. GANGOSA Chixa,^-' ^^ KoREA,° Formosa,^ Burma," Samoa/ axd Africa.'" " — Gangosa was not observed. Guam.- — AVe are satisfied that the disease is inherited syphilis transmitted for several generations, the exact date of its introduction into the island being unkno^^ii. Clinically the lesions are those of syphilis. AVasser- mann, positive in about 85 per cent of the cases tested, and also present in practically all of the cases in which the blood relatives (brothers and sisters) were tested. There is a marked family stain, evident as soon as a ANSWERS TO QUESTIONNAIRE 251 card index of those affected was prepared. The use of mercury and iodide of potash caused the lesions to at once improve and the disease has now been brought to such a state that there are no open lesions in any of the inhabitants except in the new cases that continue to de- velop from time to time and in those who neglect their treatment. The number of these cases is very few, as all those who are known to have the disease are under supervision and treatment, and any neglecting to take their treatment are punished. The disease is a very in- teresting chapter in syphilis. The common evidences of inherited syphilis, Hutchinson's teeth, snuffles, and the like are not seen at all. The Avomen are not subject to miscarriage any more than those known not to have syphilis. The average age at the onset of the disease is 25.7 years. There is no record of a primary syphilitic sore having been seen in a Chamorro, to my knowledge, and no member of the enlisted force of the navy or marine corps has received syphilitic infection from a na- tive of Guam. The evidences of syphilis, excepting iritis (primary) and certain of the affections of the brain and nervous system (dementia and tabes), have all been seen. Keratitis is fairly common, but yields readily to treatment ; bone involvement is common and early para- Ij^tic l)rain conditions were seen ; involvement of the liver and spleen and other organs was seen, and ^delded promptly to mixed treatment. Though many attempts were made to demonstrate the presence of treponema none were successful. Salvarsan arrived in May, 1911, but at the time of my departure the older cases in which it had been tried, had not given any results. No history of syphilis could be obtained from any of the natives or from the Spaniards remaining on the island. AYe were satisfied that the original infection had taken place some generations ago. The evidences of involve- ment of the circulatory system were negative, only one 252 TROPICAL SUEGERY AXD DISEASES case of aneurysm was kno^\'Ti to exist, and this was in a woman of about sixty years of age. It is not known whether a Wassermann was made in her case. The Was- sermann was made in one hundred cases, not selected, and maiw of them had taken mixed treatment for about one year. At the time of my leaving we had 339 cases who had had the disease; one case was a leper and the gangosa lesions healed promptly under the use of mixed treatment. No lesions Avere found that differed from those seen in syiDliilis except that the disease presented none of the secondary skin eruptions and its course was not so severe as in untreated cases in our o^Ml x^eople. A Comparison o| Certain Diseases Among Natives and in the Observer's Homeland KoREA.^ — Intestinal diseases are less virulent, while throat diseases, measles, and scarlatina are more so. Lung diseases are more rapid in their progress. Em- pyema, more prevalent. Skin affections are more prev- alent than in the United States.' Syphilis usually of a milder form, chiefly manifest in nasal and palatal de- struction, but rather uncommon elsewhere. Measles are common and severe ; ear and intestinal comj)lications oc- cur frequentl}". General spinal and peripheral nerve lesions, more uncommon than in United States. Tabes has as yet not been observed. Simple cases of goiter are generally reported as uncommon and those with exoph- thalmic symptoms have not l3een ol^served. In Kangkai and that section of Korea simple goiter is cpiite common in various stages of development. The Koreans have a saying that anyone who drinks the water that drains from the decaying roots of the edil^le pine will develop the disease. Typhus is very coimnon at Taiku and in the South generally, and it is apparently as common now as previously. Although the s^miptoms are not so se- rious as among foreigners, the Koreans are very much ANSWERS TO QUESTIONNAIRE 253 afraid of it and recognize its contagions nature. Cases of rabies occur from time to time in most every section of Korea. For a number of years the Severance Hos- pital was kept in readiness to treat with virus any case that might be sent in. Recently the government hospi- tal laboratories have instituted tliis department so that private institutions need not continue this work. Aii}^- one now can obtain a full treatment for $3.75 gold. Gan- grene of the fingers and toes was noticed in several cases of snake bite. One patient with a large patch of anes- thesia on the leg attributed this to a snake bite some years before. Bites from centipedes only cause a swelling with urticaria-like spots and the pain goes away rapidly after the use of ammonia solution. There was no siorue seen in natives. Relapsing fever is fairly common about Taiku, Intestinal diseases, diseases of the bron- chi, and skin diseases are more common here than in the United States. Endemic hemoptysis very common in the most northern province and now that we are making a systematic daily sputum examination the cases are in- creasing. Smallpox cases are seen every winter, Samoa.^ — There are five diseases which are commonly met with; namely, granular conjunct;ivitis (trachoma), Samoan conjunctivitis (diplococci), meningitis, several forms, otitis media, purulent, and fish poisoning. Gran- ular conjunctivitis presents all the complications and se- quelae of trachoma though clinically its features are a little less severe and its course a little less rapid than is usual in trachoma. Nevertheless, the two diseases are practically^ the same. The school children were ex- amined by eversion of the lids and the different schools showed 30 per cent to 60 per cent of the children suf- fering from this disease. Over five hundred examinations were made. Blindness partial and complete is very common in Samoa and much of it has been thought to be due to this condition. Acute Samoan conjunctivitis 254 Tropical surgery and diseases is a highly contagions endemic disease of the conjunc- tivae ocnlar and palpebra; an acute purulent conjuncti- vitis. It affects whole families and villages and will recur mau}^ times unless controlled. Silver salts will cure even very severe cases in a few da3^s. The con- dition closety simulates gonorrheal ophthalmia, but is less severe. It is caused by a diplococcus differing only slightly from the gonococcus but said to have different cultural reactions. (See article by Dr. P. S. Rossiter, U.S.N., U. S. Naval Medical Bulletin, 1909.) Meningitis is one of the common causes of death in young children. More than six deaths occurred in one 3^ear out of a total of less than three hundred from this cause alone. Two of these cases were shown to have a turbid spinal fluid with many leukoc^^tes and an intracel- lular diplococcus. They, hoAvever, failed to respond to an injection of Flexner's antimeningococcic serum. Three of these cases showed a clear fluid Avith a few mononuclear leukoc^^tes and no bacteria. They were be- lieved to be tuberculous. The others were of unlviiown origin. CouAmlsions general and prolonged were a prominent symptom. All children were well nourished and died a few hours after onset. It was with the great- est difficulty that the superstitious natives could be per- suaded to let the doctor see these cases. They con- sidered them hopeless from the onset. Otitis media is only moderately common among the natives and gives rise to very few complications and responds fairly well to treatment. Most of the cases are apparently caused by the native habit of cleaning the ears with a quill. Fungus infections of the external canal have not been observed. Fish poisoning: A mollusk called "Matamalu" is used by the native as a food, when cooked. Occasionally a child Avill eat this before cooking. Symptoms of acute gastrointestinal irritation ensue followed by a peculiar ANSWERS TO QUESTIONNAIRE 255 state of stupor and marked dyspnea not milike a very severe attack of bronchial asthma. Death ma}^ ensue in a few hours. Recovery is the rule. Guam." — Hypertrophy of the prostate is very rare. Varix of all kinds extremely rare. Pneumonia not very common, but when it occurs has a greater number of cases of empyema than is common with our people. For the nuinl)er of cases of tuberculosis of the lungs that exist, the percentage of cases of involvement of the bones, peri- toneum, meninges and skin is very small. Abdominal tumors are rare and the general surgical clinic Avas smaller than I have ever seen in a 12,000 poi^ulation. Accident work was very rare and we had almost as many accidents among the few Japanese on the island as we had with all of the natives. BIBLIOGRAPHY iCottle, George F., Surgeon, U. S. Navv : Personal communication, Novem- ber, 1911. 20clell, H. E., Surgeon, U. S. Navv: Personal communication, November, 1911. sSmith, H. Austin, Major, I. M. S., Principal of the Medical School, Agra, India: Personal communication November, 1911. 4Page, Henrv, Major, U. S. Army Medical Corps: Personal communica- tion, 1911. sSnell, John A., Soochow Hospital, Soochow, China : Personal communica- tion, 1911. eHoUenbeck, H. S., Angola, Portuguese West Africa : Personal communi- cation, December, 1914. "Paul, S. C, Senior Surgeon, General Hosi^ital, Colombo, Ceylon: Per- sonal communication, 1911. sLandsborough, David, Mission Hospital, Shoka, Formosa : Personal com- munication, 1911. f'Rej^ort on Diseases in Korea, edited by Dr. Ralph G. Mills of Seoul, Korea. A symposium by physicians practicing in Korea for an average of nine years each. This personal communication is based upon the statements of sixteen physicians who were assembled in the annual meeting iii Seoul, September 30 to October 2, 1911. The names of the contributors with station and years of experience in medical work in Korea are as follows: Oliver R. Avison, IS years, and J. W. Hirst, 7 years, Seoul ; Hugh Currcl, 9 years, Chinju ; E. Douglass Follwell, 16 years, and Rosetta S. Hall, 21 years, J. Hunter Wells, 16 years, and E. de M. Stryker, 7 years, Pyeng Yang ; W. O. Johnson, 14 years, Taiku ; I. M. Miller, 1 year, Yeng Byen ; Ralph G. Mills, 3 years, Kangkai ; A. H. Norton, 3 years, Haiju ; W. C. Purviance, 3 years, Chongju ; W. T. Reid, 4 years. Song Do ; J. B. Ross, 7 years, Wonsau ; J. D. Van Buskirk, 2 years, Kongju ; Hugh W. Weir, 7 years, Chemulpo. 256 TROPICAL SURGERY AXD DISEASES loBarry, C, Major, I. M. S., Superintendent, Civil General Hospital, Ran- goon, Burma : Personal communication, 1911. iiHarstou, G. Montague, Oplithalmic Surgeon, Tung Wa Hospital, Hong- kong, China: Personal communication, 1911. isphillips, E. Margaret, Saint Agatha Hospital, Ping Yin, Shantung, China: Personal communication, 1911. isPlummer, W. E., Wenchow, Chekiang, China: Personal communication, 1911. i^Turner, C. A., Medical Officer, Witwatersrand Native Labor Association Limited, Johannesburg, South Africa : Personal communication, 1911. 15U. S. Army Board for the Study of Tropical Diseases, Manila, P. I., com- posed of Major Weston P. Chamberlain, Capt. Edward B. Vedder, First Lieut. John E. Barber : Personal communication, 1911. leRoss, R. : Malaria and the Transmission of Diseases, The Huxley Lec- ture, Lancet, London, Xovember 7, 1914. I'Ochsner, Emma J.: Bull. Manila Meet. Soc, Feb., 1913. isCastor, R. H., Swebo, Burma: Personal communication, 1911. isDeSilva, A. M., General Hospital, Colombo, Ceylon: Personal communica- tion, 1911. 2oPhalen, Jos. M., and Nichols, Henry J. : Journal of Science, 1908, Sec. B., iii, p. 305; 1909, Sec. B., p. 127. APPENDIX SURGEEY OF THE SPLEEX The Relation of the Spleen to Certain Anemias* (William J. Mayo). — Eeceiitly, as a result of the study of the pathology of the living, largely from material obtained at the operating table, more accurate knowledge of the function of the spleen has been gained although in this we are still woefully lacking as compared to our knowledge of the other organs of the body. The Eelatiox of the Spleex to the Liver axd Digestive Tract. — Tlie spleen and liver are closely associated in function. The liver is es- sential to life, the spleen is not. The liver acts as a gigantic means of defense against poisons, both parasitic and chemical, which would other- wise reach the general circulation from the gastrointestinal tract through the radicals of the portal vein. This is well shown in cancer of the rectum and intestine, which through the portal circulation, often de- velops embolic processes in the liver though seldom in the lung. Can- cer of the stomach, on the other hand, by reason of direct commu- nications with the general circulation through the diaphragm as well as through the portal vein frequently develops secondary cancer in the lungs as well as in the liver. The splenic artery arises from the celiac axis, the same source which supplies the pyloric end of the stomach and upper duodenum, the liver and pancreas, all of which are derivatives of the foregut, and all or- gans concerned in the proper preparation of food products for diges- tion and absorption, as in them also the venous return of the spleen becomes part of the portal circulation. The vascular system of the spleen is large and is curiously arranged, inasmuch as the walls of the blood vessels, except the endothelial lining, are absent and the blood comes in direct contact with the splenic pulp. The spleen contains a considerable amount of noustriated muscle fiber and elastic tissue, but only a very scanty supply of nerve tissue, and that largely from the sympathetic. Every organ of important in- ternal secretion is very closely, if not organically associated with sympathetic nerve tissue. Xote the adrenals and hyj)ophysis, part glan- dular and part sympathetic ganglia. This close relationship of the glandular secretion with the sympathetic nervous system enables wide- spread effect, so that the internal secretions may be said to play on the sympathetic nervous system as the fingers play on a piano. The scanty nerve supply of the spleen shows that it does not produce an important internal secretion. Its function must be closely associated *Jour. Indiana Med. Assn., Nov. 15, 1915, viii. 499-504. Abstracted from Collected Papers, Mayo Clinic, 1916. 257 258 TROPICAL, SURGERY AND DISEASES with metabolism, shown by enlargement during the digestive period and contraction following digestion. That these physical changes are brought about through the blood stream seems assured since epinephrin solution in the circulation will cause the sx^leen to contract one-third in size, as noted by Elliott and Kanavel.i The idea that the spleen is an obsolete organ of little function is not tenable, as Eccless has pointed out. The outstanding fact in a retrogressing organ is the reduced blood supply. The tonsils, for ex- ample, were at one time supposed to be retrogressive, but the fact that the tonsil has five sources of blood supply shows that it is not obsoles- cent, yet it is not essential to life and when diseased has great poten- tiality for harm. This is quite analogous to the spleen. It would appear that the spleen removes from the circulation not only cellular elements of definite food value, but also, when unable to properly care for these products, sends them to the liver for elabo- ration into energy-producing substances, on the one hand, and de- struction of various toxic agents on the other, that nothing of value may be eliminated and that dangerous products, wherever produced, may be rendered harmless. The relation of all animal life to food supply is of first importance. It is a trite saying that nature abhors waste. The amount of energy nature can produce in the living with a limited amount of food has no imitators in man 's handiwork. One must confess that whatever his mental and moral deficiencies, and they are certainly great, as a machine, man has no equal. The degenerated cellular elements from the blood and even the food values of ingested parasites are conserved. It has been shown that the phagocytes of the body depend, to a con- siderable extent, on ingested bacteria for their nutrition (Hisss), Stohrs and Adami have shown that the leukocytes of the body pass out on the free surface of the intestine and return loaded with bacteria and particles of fat, and that the pigmented areas of the liver are de- rived from the coloring matter of slaughtered bacteria. In the same manner the fluids of the intestinal tract are redistilled in the proximal colon after being used mechanically to float the food products down the small intestine and, that nothing may be wasted, bring them in contact with the valvulae conniventes, which are to man what roots are to a tree. The close association of cirrhosis of the liver with enlargements of the spleen has long been noted. In primary cirrhosis of the liver the spleen is enlar,ged and in splenic anemia with splenomegalia the ter- minal stage shows cirrhosis of the liver. In some cases, much diffi- culty is experienced in determining whether the hepatic cirrhosis is primary and the splenomegalia secondary, or the contrary. Nearly thirty years ago Gregory* rather picturesquely stated that nature had three ways of protecting the organism against noxious agents: First, by absorption, destruction and elimination through natural processes; second, by encapsulation of such harmful substances as it was unable completely to destroy or eliminate, of which the encysted bullet is a APPEXDIX 259 gross example; and third, by extrusion, as in the spontaneous opening and discharge of infective organisms in phlegmons. It would seem probable that in cirrhosis of the liver the second of these methods was in operation. It has been suggested that in chronic alcoholism, for example, the liver, finally unable to destroy and eliminate, at- tempts to encapsulate a diffuse poison and that the contraction of this scar tissue produces the cirrhosis. But cirrhosis of the liver is by no means confined to alcoholics. It is often seen in comparatively young people and those who have never used alcohol. It probably would not be far wrong to say that certain toxic substances circulating in the blood may be gathered into the spleen and sent thence to the liver for destruction, and that chronic hepatic insufficiency might even- tually lead to the production of cirrhosis of the liver, on one hand, and on the other, show its effect on the spleen, as, a splenomegaly with resulting anemia, as, no matter what the cause of the splenic hypertrophy may be, an increased capacity for destruction of the red cells seems liable to develop. Syphilitic cirrhosis of the liver with splenomegalia is an example of the nonalcoholic type of disease and splenectomy in these cases promptly relieves the anemia, although the spleen itself, on pathologic examination, may show no evidence of spiro- chetal action. Certain it is that the removal of the spleen has been of very great benefit in some cases of cirrhosis of the liver, especially of the Hanot type. These experiences, however, have been too recent to enable any conclusion to be drawn, but among the group of splenic anemias in which a greatly enlarged spleen has been removed and cirrhosis of the liver was present with ascites, etc., patients have been apj)arently cured, and the cures have now lasted long enough to enable us to say that at least the cause of a progressive and heretofore fatal malady has been removed. We could not expect a cirrhosed liver to return to normal, but the prog- ress of the cirrhotic process has been interrupted and the remaining he- patic tissue has been sufficient to carry on function. Of the important organs of the body, the liver is one of the few which has the power of regeneration. If half of the liver of a dog be removed, it will be re- stored in a few months. In the kidney regeneration does not take place. It is rather a hypertrophy of the original tissue of the kidney than a tnie reproduction of lost tissue from existing tissue which occurs under similar experimentation. If we accept the idea that the spleen removes from the blood nox- ious agents, are we to conclude that all the circulatory blood must go through the spleen for this purpose; or is there an attraction between organs and the arterial supply of the body, that is, do certain organs definitely attract substances circulating in the blood? Eosenows has shown, for example, that the streptococci cultured in the gall bladder are definitely attracted to the gall bladders of experimental animals when injected into the circulation. This is also equally true of other oigans — the appendix, the stomach, etc., so that he has been able to 260 TROPICAL SURGERY AND DISEASES produce definite infections of organs with injections of bacteria properly- cultured. The Relation of the Spleen to the Blood. — The spleen i& found in all red-blooded animals. The ancestral blood corpuscle, from which both red and white have their origin, is probably the mesenchyme cell, a form of lymphocyte which appears first in the fetal blood. The most primitive blood is, therefore, white blood. This is found in the fetus before the red blood appears. All animals that have only one kind of blood have white blood. As the scale of animal life ascends, red blood begins to appear and nearly all the conditions of the blood of the different anemias is the normal blood of some of the lower animals. In fetal life all of the lymphoid and adenoid structures of the body, the bone marrow, the spleen and in its early stage, probably also the liver, are blood-forming organs. The liver loses this function long be- fore birth. In leukemia, all of these primitive organs, including the spleen and liver, for some unknown reason, begin to produce embryonic white blood, just as in cancer there is an unlimited production of em- bryonic epithelial cells and in sarcoma of embryonic connective-tissue cells. After birth, the spleen continues to produce a certain number of leukocytes, as shown by the fact that the splenic vein contains a higher percentage of leukocytes than the other veins of the body, but does not produce erythrocytes. Oslers states that after severe hemor- rhages the spleen may temporarily produce red cells. It has also been definitely shown that worn out red corpuscles are strained out in the spleen and destroyed; thus the splenic vein eon- tains a higher percentage of hematin than other veins of the body. In disease we may surmise that excess of s^ilenie function destroys red corpuscles which are not worn out and the condition becomes one which we speak of as si)lenic anemia or hypersplenism, and that the exceed- ingly rare condition of excess of red cells in the blood called polycy- themia may be due to deficiency of function of the spleen and associated organs — a hyposplenism.7 This explanation, however, is undoubtedly too simple and does not take into account the possibility of the spleen interfering in some unknown manner with the production of red cells in the bone marrow. It is more probable, however, that in certain conditions of disease red cells are sensitized in other tissues, as shown by the increased fragility of the red cells (Chauffards and Widals), and are then destroyed in the spleen. Since, when the spleen is re- moved in cases of primary anemia, pernicious anemia and in hemolytic jaundice, it is found crowded with disorganized erythrocytes, this hy- pothesis seems the more logical. Of great significance is the knowledge that the spleen and possibly other organs, of themselves not necessary to life, may be tlie link easily broken in an otherwise fatal chain. From the fact that the spleen is not necessary to life and yet that its remo-^'al may definitely check certain hopelessly progressive blood dyscrasias, one must conclude that the spleen is not the cause but rather the agent of destruction, as in APPENDIX 261 liemolytic jaundice, and that when the spleen is removed the noxious substances are rendered innocuous elsewhere under niore favorable con- ditions, although what becomes of these toxic agents after the spleen is removed we have no means of knowing. Be this as it may, clinical ex- perience has definitely shown that many of those anemias associated primarily with an enlarged spleen and secondarily with cirrhosis of the liver are definitely cured by removal of the spleen. Anemias of Possible Splenic Origin. — In grouping these anemias much ditficulty is experienced and the accepted terms of designation concern, to a great extent, syndromes. Splenic Anemia. — The group called the splenic anemias shows rather a definite clinical picture, for example, secondary anemia, leukopenia, enlarged spleen, hemorrhage from the stomach and, in the late stages, the characteristics described by Banti,io cirrhosis of the liver, ascites, etc., a disease most common in young adults. Children, however, are not infrequently subject to the disease of the adult type and it is possible that the "pseudoleukemic anemia" of infants or von Jaksch's disease is also a manifestation of the same condition (Giffinii). In von Jaksch's disease there is a leukocytosis which is chiefly a lympho- cytosis together with a diminution of erythrocytes, a large spleen and cachexia. In this condition infants, for physiologic reasons, usually show an excess of leukocytes up to 30,000 or more, older children more often developing the condition seen in adults with leukopenia, but even in adults the leukocytes may be in excess in otherwise typical cases of splenic anemia. In our clinic to Sept. 20, 1915, seventy-one splenectomies have been performed w^ith six deaths. Twenty-nine were in cases of definite splenic anemia. All the patients recovering from the operation, with five ex- ceptions, have remained quite well in spite of the fact that some were in the late stages of the disease, that is, markedly advanced h.epatic cirrhosis, ascites, and jaundice (Gifiinlis). Gaucher 's Disease. — Gaucher 's disease or large-cell splenomegalia is closely associated with, splenic anemia and early removal of the spleen will probably cure the condition. Gaucher 's disease is characterized by a slowly growing spleen, which eventually becomes of great size, with secondary anemia and, in the terminal stages, the characteristic endothelial growths appear in the liver, lymph nodes and bone marrow. According to Brill and Mandelbaum,i3 it always begins before the thir- teenth year and averages twenty years before a fatal termination, usually a terminal complication. Semolytie Jaundice. — That hemolytic jaundice, in the great majority of cases, is due to hypersplenism may now be accepted. Whether the spleen is acting on its own initiative or through stimulation of the blood in destroying the red cells we have at present no definite knowledge. Five patients with hemolytic jaundice have been operated on in our clinic. None of these cases was of the familial type, though all had beigun in childhood. In this condition there is an enlarged spleen and 262 TEOPICAL SUEGERY AXD DISEASES constant moderate jaundice of the acholuric type, that is, there is bile in the stool, absence of itching of the skin and freedom from all symp- toms of obstructive jaundice. Usually there is increased fragility of the red cells and an excess of urobilin and urobilinogen in the urine but no bilirubin. Exacerbations are often preceded by typical crises somewhat resembling gallstone colic, with increased temperature, malaise, headache, loss of appetite and an increase of the jaundice. During the crisis the spleen is enlarged and tender. In three of our patients, two under 20 years of age, gallstones were present. Improvement after splenectomy in our cases was a most remarkable phenomenon. The jaundice began to clear within twenty-four hours following the splenec- tomy and in four days had completely disappeared, with complete res- toration of well-being.14 There have been attempts, more or less successful, to demonstrate essential differences between the familial hemolytic jaundice of Min- kowskiio and the acquired disease of Hayemie and Widal.s Chauffards says that in the congenital type the disease shows itself more or less distinctly from birth, and the patients are "more icteric than sick," while the acquired type begins in adolescence and the patient is "more sick than icteric." The congenital type may last for a life- time with the patient in fair health; the acquired type is progres- sive and leads to death through anemia and its complications. There is a remarkable similarity between cirrhosis of the liver with enlargement of the spleen and splenomegalia with cirrhosis of the liver. Just so are we impressed by the similarity between acquired hemolytic jaundice and Hanot's cirrhosis of the liver. Both are more common in young adults and are more or less chronic in their course, the patients with hemolytic jaundice frequently living out a life ex- pectancy, and those with Hanot 's cirrhosis lasting from four to ten years. Both have enlarged spleens accompanied by jaundice, often slight, but with exacerbations, both may have crises marked by pain in the region of the liver, and in both ascites is usually absent. It is very evident that there is some connection between hemolytic jaun- dice and Hanot's cirrhosis. That hemolytic jaundice is definitely cured by splenectomy can be stated as a fact, and growing experience leads to the conclusion that improvement and sometimes definite cure in Hanot's type of cirrhosis of the liver may be effected by splenectomy, although in confusing types of the disease with hemophilic tendencies one must be guarded in advising surgical treatment. Pernicious Anemia. — It has been kno^^ii for many years that pernicious anemia is often accompanied by a large spleen. Ejii^ingeri" first pointed out that after the spleen was removed, in pernicious anemia an extraordinary improvement in the condition of the blood was usu- ally noted, and experience has borne out Eppinger's observations. Cabotjis in discussing six splenectomies for pernicious anemia, said he had never seen such great improvement produced by any medicinal agent as had followed splenectomy; that no medicament with which APPENDIX 263 he was acquainted -would Ijring up and hold the red cells above four million. Four of his patients had been incapacitated for two years or more and within a few months following splenectomy they were able to go back to work. He points out that sufficient time has not elapsed to show that these patients are cured, but even as a means of producing a prolonged interval of well-being the splenecto- mies have been worth while. It is true that the spinal cord changes in pernicious anemia have not been benefited by splenectomy and they have even progressed after splenectomy in spite of the general improvement of the patient. Also the blood in the splenectomized patients so far observed did not en- tirely lose the characteristic pernicious cells nor could we expect it to do so. We can not expect the operation to overcome structural changes in organs which have been permanently damaged, and up to the present time the only cases which have been subjected to operation have been largely those in advanced stages of the disease. Experience shows that splenectomy should be resorted to early and in these cases cure may at least be hoped for. The spleen has been removed in twelve of our cases of pernicious anemia (Sept. 20, 1915). The im- proA'ement in some of these cases has been remarkable, but not enough time has yet elapsed to warrant any definite statements being made. In reviewing the basic facts of splenic anemia, hemolytic jaundice and pernicious anemia, the one fact that stands out is that there is a destruction of the red blood cells and that this hemolytic change is accompanied by physical changes in the spleen. It is interesting in this connection that in sixteen of the seventy-one cases of splenec- tomy in our clinic gallstones were found, and all were in the groups of anemias (forty-seven cases). In addition to these rather definite groups of eases, enlargement of the spleen is found under conditions for which through lack of knowledge we have no ready classification, as in certain diseases with hemoph-iliac and purpuric tendencies, and it may eventually be shown that the spleen is associated with, these conditions of the blood. Pa- tients with anemia associated with splenomegalia and having high tem- perature, such as are seen in the pregnant state, require further study. I shall not discuss infections of the spleen, bacterial and protozoal, which give rise to surgical conditions, nor those anomalies and tumors, of which we have observed some remarkable examples. I have pur- posely omitted reference to the pathology of the spleen itself, because this study is not as yet sufficiently advanced to be more than sug- gestive. Wilsoni9 is now studying our cases and is able to show that there is a true microscopic pathology in these diseases which it is hoped will prove to be characteristic. Our knowledge of splenic disease, like most of our knowledge of organs in concealed situations, has been the result of study of living pathology under surgical conditions. Postmortem examinations, which were once looked on as the final word on disease processes, have too 264 TROPICAL SURGERY AISB DISEASES often not shown the chronic diseases from which people suffered during life, but only the disease from which they died. Experimentation on animals, like the postmortem, has been of enormous A-alue in laying a foundation for medicine, but as the animals themselves were not diseased, the conditions favorable to exact knowledge were not pres- ent, and experimentation is now seen in its i^roper light as an aid to understanding but not as the final solution of jDroblems of the living. But the living pathology brought forth by the surgeon has in this field, as in others, enabled medical research to produce most valuable material for study and has within the last few years advanced our knowledge of the physiology, pathology, and therapeutics of diseased conditions of the spleen more than all else that has been done since the beginning of time. BIBLIOGRAPHY ^Elliott, C. A., and Kanavel, A. B.: Splenectomy for Hemolytic Icterus, Surg., Gynec. and Obst., 1915, xxi, 21. -Eccles, R. G. : The Tonsils and the Struggle for Existence, Med. Rec, Xew York, 1915, Ixxxviii, 47. ^Iliss, P. H.: Some Problems in Immunity and tbe Treatment of Infectious Diseases, Arch. Int. Med., July, 1909, 32. ^Gregory, E. H.: Cell Antagonism, Jour. Am. Med. Assn., June 11, 1887, 645. ^Rosenow, E. C. : Bacteriology of Cholecystitis and Its Production by Injection of Streptococci, Jour. Am. Med. Assn., Nov. 26, 1914, 1835. ^Osler, W. : The Principles and Practice of Medicine, New York, D. Appleton & Co., 1912. 'Hemolytic Jaundice and Splenectomy, Editorial, Jour. Am. Med. Assn., June 17, 1915,. 255. ^Chauffard, A. : Pathogenie de I'ictere congenital de I'adults, Semaine Med., 1907, No. 3, 25; Les icteres hemolytiques, ibid., January, 1908; Cholelithiase pigmentaire dans un cas d'ictere congenital hemolytique; analyse chemique des calculs. Bull. et mem. Soc. med. de Hop., 1912, xxxiv, 80. Cited by Elliott and Kanavel, Note 1. ^Widal, A., and Brule: Differenciation de plusieurs types d'icterse hemolytiques, Presse med., 1907, Ixxxi, 641. Cited by Elliott and Kanavel, Note 1. lOBanti, G. : Arch. d. Scuola d'Anat. patol., 1883, ii, 53; Cited by Eyon, I. P., Dis- eases of the Spleen, Osier's Modern Medicine, 1908, iv, 759. "Gififin, H. Z. : Clinical Notes on Splenectomy, Ann. Surg., 1915, Ixii, 166. ^-Gififin, H. Z.: Clinical Notes on Splenectomy, Ann. Surg., 1915, Ixii, 166; Clinical Observations Concerning Twenty-seven Cases of Splenectomy, Am. Jour. Med. Sc, 1913, cxlv, 781. I'Brill, N. E., and Mandelbaum, F .S. : Large-Cell Splenomegaly (Gaucher's Disease), Am. Jour. Med. be, 1913, cxlvi, 863. "Those interested in hematogenous jaundice should read the recent contribution by Elliott and Kanavel, Note 1. ^^Minkowski, O. : Ueber eine hereditare, unter dem Bilde eines chronischen Icterus mit Urobilinurie, Splenomegalie und Nierensiderosis verlaufenden Affection, Ver- Ivandl. d. Kong. f. inn. Med., 1900, xviii, 316. ^'Hayem, G. : Sur un variete particuliere d'ictere chronique, ictere infectieux chronique spleno megalique, Presse med., 1898, i, 121. Nouvelle contribution a I'etude de I'ictere infectieux chronique spleno-megalique. Bull, et mem. Soc. med. d. hop. de Paris, 1908, Series 3, xxv, 122. "Eppinger, H. : Zur Pathologie der Milzfunction, Berl. klin. Wchnschr., 1913, 1, 1509, 1572, 2409. '■''Cabot, R. : Discussion on Blood and Blood Diseases, Jour. Am. Med. Assn., June 26, 1915, 2164. '"Wilson, L. B. : Pathology of Spleens Removed for Certain Abnormal Conditions of the Blood, Ann. Surg., 1915, Ixii, 158. The Spleen. — Its Association avith the Liver and its Eelatiox to Certain Conditions of the Blood (William J. Mayo) ." — For many years when doing abdominal operations, if it could be done without risk to the patient, it has been my practice to make a careful manual ex- *Abstracted from Jour. Am. Med. Assn., March 4, 1916, Ixvi, 716-721. APPENDIX 265 amination of the contents of the abdomen. Thus I have been im- pressed with the fact that the spleen shows enlargements and other physical changes ratlier regularly in connection with diseases of the liver and of the blood. In papers on this subject written at various times, attention has been called to the fallacy of the physical ex- amination of the spleen, and it may be said that unless the spleen is sufficiently enlarged to be felt beyond the free, border of the costal margin, the enlargement would probably not be recognized. At times careful physical examination by percussion, for instance, has ap- parently revealed the area of splenic dullness, but on the opening of the abdomen the fact showed how fallacious percussion had been. Faith in these methods has been due to the fact that in certain dis- eases, like typhoid, which often end in death, the spleen is generally enlarged, and w^ith this knowledge at hand a diagnosis by percussion has been made and proved correct at necropsy. By means of the roentgen ray, the possibilities of accurately examining the spleen for such enlargements are developing. The roentgenologist has been able to outline the kidneys, the liver, etc., as well as the digestive and thoracic organs, with a marvelous degree of accuracy, and we may expect that he will accomplish the same for the spleen in the near future. The humiliating mistakes made by surgeons, of which we have made our share, of diagnosing as splenic enlargement a cancer of the stomach or colon or tumor of the kidney, are now avoidable by careful roentgenographic exclusion of these organs. The function of defense of the liver is shown by Adami,i who points out that the leukocytes of the living body pass out on the free mucous surface of the duodenum and upper jejunum, and pick up bac- teria which they usually destroy, but should they fail to destroy them, the liver becomes the agent of destruction, and the pigmented areas in the liver are derived from such slaughtered bacteria. Eesearch. has shown that the phagocytes of the body are developed in direct response to bacterial invasion. As Vaughans has pointed out, the period of incubation of a disease is the time which is necessary to develox? or train leukocytes to bodily defense. He shows that the reaction we call typhoid fever is a defense manifestation, and that preventive serums, such, as vaccination for smallpox, typhoid, etc., act to educate the cells of the body to resistance against certain organisms and to change the proteins of the body so that they no longer act as food for these bacteria. Vaughan advances the theory that bacteria are not vegeta- ble organisms but parasitic growths in a distinct class by themselves. Eccless suggests that the phagocytes of the body live on bacteria, and that the food values of the bacteria are thus conserved. He looks on the tonsils and other lymphoid structures, such as the appendix, as what may be called chronic vaccinators, since through the tonsils are constantly permitted to pass a certain number of bacteria which stimu- late the development of phagocytes. This shows that a moderate re- 26(3 TROPICAL SURGERY AXD DISEASES action in tlie tonsil may not always be the cause of an impending gen- eralized infection, but rather an early defense manifestation. It is interesting to note liow the spleen is controlled in its function. Stimulation and control is exerted over the voluntary parts of the body by the cerebrospinal nervous system, over the involuntary or vege- tative part of the body by the sympathetic ganglion acted on the in- ternal secretions. In addition, there is the essential rhythm of non- striated muscle. The vegetative part of the body was well developed before the organism had reached the stage of a cerebrospinal nervous system, a comparatively late development. The sympathetic nervous system, probably mesoblastic in origin and now closely associated with the cerebrospinal nervous system, acts in association with the internal secretion, and all organs of important internal secretion, such as the suprarenals and the hypophysis, in which gland and sympathetic ganglia are present, are so closely associated as to form a single organ. That the spleen does not have an important internal secretion is shown by the fact that its removal does not deprive the body of any important constituent; and that it is not under the complete control of the nervous system is shown by its extremely scanty supply from Auerbaeh's plexus. But the spleen does have a considerable amount of nonstriated muscle fiber, and it is altogether probable that this mus- cle has an important function and possibly is responsible for the di- gestive rhythmic change in the size of the spleen. To go further into the interesting phase of a subject to which Keith has called attention would lead us far afield. Suffice to say that the rhythmic waves are automatically checked by sphincters, and in failure of rhythmic intestinal movement and sphincter control may lie the se- cret of so-called intestinal intoxication and neurasthenias of intestinal origin. The presence of nonstriated muscle in the spleen gives im- portant evidence of the primary' relationship of the spleen to the di- gestive system. Enlargements of the Spleex. — These may be divided into four groups : (1) new growths, (2) infections, (3) enlargements associated with he- patic disease, and (4) those associated with the blood. 1. Neiv Growths. — The first will not be considered at this time. I shall very brietiy take up the results of splenectomy in some of the dis- eases in the latter three groups. 2. Infections. — In so-called primary tuberculosis of the spleen the removal of the organ has cured a few patients. It is quite likely, how- ever, that tuberculosis is practically never, in reality, primary in the spleen, and that this diagnosis is the result of insufficient clinical study. Our one patient of this type died from general miliary tuberculosis af- ter a temporary improvement of several months. In three instances we have removed greatly hypertrophied spleens from patients suffering with chronic syphilis and marked anemia. In one of these, specific treatment had been carried out for two years, in another for six months, without satisfactory improvement in the general condition or' APPENDIX 267 the anemia. Following splenectomy, there was marvelous improvement of the anemia in all of them. Marked enlargement of the spleen is quite frequently present in pa- tients with a history of chronic recurring septic conditions. These spleens are usually smaller than those of splenic anemia, although oc- casionally we have seen a very large spleen filled with infarcts. We have removed the spleen from seven patients with 'histories of chronic recurring sepsis. Patients of this type usually have a lowered resis- tance, and cardiorenal insufficiency is most likely to influence the ulti- mate i)rognosis unfavorably. 3. Splenic Enlargements Associated with Hepatic Disease. — Primary cirrhosis of the liver accompanied by enlargement of the spleen is re- markably similar to primary enlargement of the spleen with secondary cirrhosis of the liver, and in the late stages of either disease it is very difficult to determine in a given case whether the process was primary in the liver or in the spleen. In the same way it is difficult to differentiate between hypertrophic biliary cirrhosis of the liver of the Hanot type in which there is jaundice, and hematogenous jaun- dice, which has its origin in the spleen. Primary biliary cirrhosis of the Hanot type is doubtless a rare disease. It may last for from six to ten years, and the spleen as well as the liver is always enlarged. It is a disease of young adult life. As in hemolytic jaundice, there are crises marked by tenderness in the region of the liver and spleen with a temporary increase of jaundice. In a small number of instances in which Hanot 's cirrhosis has been diagnosed, the spleen has been re- moved with undoubted benefit, and possible cure. We have seen one such ease. Hemolytic jaundice can usually be differentiated by the fact that the fragility of the red cells in the peripheral circulation is de- creased, whereas in cirrhosis of the liver the resistance of the red cells is usually increased. In hemolytic jaundice urobilin, but not bile, is present in the urine, and the jaundice is not associated with itching. Yet to what extent these cases of biliary cirrhosis have been confused with those of hematogenous jaundice of splenic origin, and to what extent the SA-ndrome' which has been called Hanot 's cirrhosis of the liver actually exists, further investigation must decide. In four instances we have removed a greatly enlarged spleen in pa- tients suffering from portal cirrhosis of the liver. It is too early to know whether or not the end-results will justify the operation. Three of our patients, however, have markedly improved, and the ascites and anemia have disappeared. It must be evident to all that the spleen is only one avenue by which noxious agents may reach the liver and cause a cirrhosis. It is proba- ble that a large number of cirrhoses have their origin in the gastro- intestinal tract, but, no matter what the portal of entry may be, there is usually a concomitant enlargement of the spleen. In general, the common forms of cirrhosis of the liver may be di- vided into three classes: first, portal cirrhosis, in which the toxic ma- 268 TROPICAL SURGERY A^^^-D DISEASES terial obtains entrance through the portal system and the connective tissue proliferation advances from the portal spaces and in which the symptoms are those of portal obstruction; second, biliary cirrhosis, in which the infectious agent may be either ascending from the biliary tract or hematogenous, and in which the most pronounced clinical sign is chronic jaundice, while portal obstruction comes on late; third, mixed types, which are undoubtedly not rare and in which a preopera- tive diagTiosis is often impossible. is 4. The Blood. — Splenic Anemia : Patients with anemias associated with enlargements of the spleen are cured or greatly benefited by splenec- tomy. The syndrome called splenic anemia, the terminal stage, of which is known as Banti's disease, may be cured by removal of the spleen in a high percentage of cases. Clinically, splenic anemia is an entity. The spleen is large; there is a definite anemia showing a reduction of reds and a low hemoglobin, and the disease is progressive, ending in death. The process may be exceedingly slow and at times comi^letely interrupted in its clinical symptoms for several years; but all enlargements of the spleen that can not be shown to have some other definite cause must be looked on as incipient splenic anemia. The future history of such cases will finally prove the large majority of them to be of this character. Hem- orrhage from the stomach at times is one of the early symptoms, even before the spleen is much enlarged. These cases of gastric hemorrhage in which no other origin can be found should be carefully examined for evidence of splenic anemia. In the later stages, after ascites has de- veloped, and the liver has become cirrhosed, but little may be expected from the removal of the spleen, and yet several of our patients in this terminal condition have been cured by splenectomy (Fig. 4). Splenic anemia with adult characteristics is not infrec[uently seen in childhood, and is promptly relieved by splenectomy. It is Cjuite probable that the pseudoleukemic anemia of von Jaksch is merely the infantile type of splenic anemia, the increased leukocytes (30,000 or more) being merely a difference in the reaction of the blood due to infancy (Giffin). It may be said in this connection that while leuko- penia is usually present in splenic anemia, there are a number of instances in which patients having a moderate leukocytosis (20.000 or more) have been operated on at various ages and remained well after- ward. Several such patients operated on by us were previously diag- nosed as having true leukemia, and were treated for it. Preliminary to splenectomy and, in some cases, following it, trans- fusion of blood may be necessary. The blood of the donor should al- ways be tested in connection with the recipient for agglutination and hemolysis. BIBLIOCtEAPHY lAdami, J. G. : On Latent Infection and Subinfection and on the Etiology of Hema- chromatosis and Pernicious Anemia, Jour. Am. Med. Assn., Dec. 16, 1899, 1509; Dec. 23, 1899, 1572. APPENDIX 269 "Vaughaii, V. C: Infection and Immunity, Commemoration Volume, Chicago, Ameri- can Medical Association, 1915, p. 1. 'Eccles, R. G. : The Tonsils and the Struggle for Kxistence, Med. Rec, New York, 1915, Ixxxviii, 47. ■'Rosenow, E. C. : Elective L,ocalization of Streptococci, Jour. Am. Med. Assn., Nov. 13, 1915, 1687. ''Keith, A.: A New Theory of the Causation of Enterostasis, Cavendish Lecture, Lancet, London, 1915, ii, 371. "Cannon. W. B.: The Importance of Tonus for the Movements of the Alimentary Canal, Arch. Int. Med., October, 1911, 417. ^Alvarez. W. C. : Functional Variations in Contractions of Different Parts of the ^mall Intestine. Am. Tour. Phvsiol., 1914. xxxv, 177; Further Studies on Intestinal Rhythm. Am. Jour. Physiol., 1915, xxxvii, 266. *Ochsner, A. J.: Constriction of the Duodenum below the Entrance of the Common Duct, and Its Relation to Disease, Tr. Am. Surg. Assn., 1905, xxiii, 314. ^Lane, W. A.: The Kink of the Ileum in Chronic Intestinal Stasis, London, Nisbet, 1910; The First and Last Kink in Chronic Intestinal Stasis, Lancet, London, 1911, ii, 1540; A Clinical Lecture on Chronic Intestinal Stasis, Brit. Med. Jour., 1912, i, 989. MHertz, A. F. : The Ileo-Caecal Sphincter, Jour. Physiol, 1913, xlvii, 54. Hertz, A. F., and Newton, A.: The Normal Movements of the Colon in Man, Jour. Physiol., 1913, xlviii, 57. "Bayliss, W. M., and Starling, E. H.: The Movements and Inne'-vation of the Small Intestine, Jour. Physiol., 1900-1901, xxvi, 127. *^Mall, F.: A Study of the Intestinal Contraction, Johns Hopkins Hosp. Rep., 1896, i, 37. _ ^'Osler. W. : Principles and Practice of Medicine, New York, D. Appleton & Co., 1912. "Chauffard, A.: Pathogenie de I'ictere congenital de I'adulte, Sem. med., 1907, No. 3, 25; Les icteres hemolytiques, ibid., January, 1908; Cholelithiase pigmentaire dans un cas d'ictere congenital hemolytique; analyse chemique des calculs. Bull. et mem. Soc. med. d. hop. de Paris, 1912, x.xxiv, 80, cited by Elliott and Kanavel: Surg.. Gynec. and Obst., 1915, xxi. 21. "Widal, A., and Brule: Differenciation de plusieurs types d'icteres hemolytiques, Presse med., 1907, 641, cited by Elliott and Kanavel.^* *"Sappey, cited by Piersol, G. A. : Human Anatomv, Philadelphia, J. B. Lippincott Company, 1913, 1781. ^'Eppinger, H.: Zur Pathologie der Milzfunktion, Berl. klin. Wchnschr., 1913, 1, 1509, 1572, 2409. i^Wilson, L. B. : The Pathology of Splenomegaly, Surg., Gynec. and Obst., 1913, xvi, 240; Pathology of Spleens Removed for Certain Abnormal Conditions of the Blood, Ann. Surg., 1915, Ixii, 158. i*Giffin has been very much interested in hepatic cirrhosis in connection with splenic enlargement. I am indebted to him for the clear statement of the present view of these conditions. Gififin, H. Z. : Splenectomy for Splenic Anemia in Child- hood and the Splenic Anemia of Infancy, Ann. Surg., 1915, Ixii, 679; Splenectomy in the Treatment of Splenomegalia, Associated with Syphilis, Am. Jour. Med. Sc, to be published. ^oBrill, IST. E., and Mandelbaum, F. S. : Large-Cell Splenomegaly (Gaucher's Disease): A Clinical and Pathological Study, Am. Jour. Med. Sc, 1913, cxlvi, 863. ^'Minkowski, O. : L'eber eine Hereditare, unter dem Bilde eines chronischen Icterus • mit Urobilinurie, Splenomegalie und Nierensiderosis verlaufenden Affection, Ver- handl. d. Kong. i. inn. Med.. 1900, xviii. 316. ^^Hayem, G. : Sur tin variete particuliere d'ictere chronique. ictere infectieux chron- ique spleno-megalique, Presse med., 1898, i, 121; Nouvelle contribution a I'etude de I'ictere infectieux chronique spleno-megalique. Bull, et mem. Soc. med. d. hop. de Paris, 1908, Series 3, xxv, 122. ^Cabot, R. C. : Discussion on Blood and Blood Diseases, abstr.. Tour. Am. !Med. Assn., June 26, 1915. 2164. The following" is from an article on ''The Liver and Its Cirrhoses" by William J. Mayo, published in the Jour- nal of file American Medical Association, May 11, 1918. "In fifty-one cases of splenic anemia, in ^vhiell ^Ye have removed the greatly enlarged spleen, the relief to the portal circulation has been im- mediate. In those eases in which cirrhosis was present, the ascites has now disappeared and several patients have lived for years, one for more than seven, in excellent health. The evidence here points to the fact that the original poison was carried to the liver from the spleen and theoretically 2(0 TROPICAL SrEGEEY AXD DISEASES is i^robably a protein derivative, filtered from the blood. But in five cases of portal cirrhosis ^vith ascites, in which I removed the enlarged spleen, the four patients who recovered were greatly improved both as to their general condition and as to the relief of the ascites. On first thought, it seemed probable that in the removal of such a spleen I had checked the source of poisoning. Ou further consideration, another explanation appears possible or even probable. With the removal of the spleen, all the blood from the general circulation, which otherwise would have lieen sent to the liver through the sj)lenic vein, was prevented from going there, and in this man- ner suificient blood had been diverted from the liver to relieve the jjortal circulation. Possibly both views are more or less correct. The results in these cases should encourage us to splenectomize in suitable cases of portal cirrhosis in the future, esj)ecially when the spleen is enlarged. ' ' Giffin, in 1912, commenting on twenty-seven cases of splenectomy, divided them into three groups: (1) splenic anemia, (2) infections splenomegaly, and (3) such as wandering siDleen, tuberculosis, cirrhosis of the liver, and pernicious anemia. Clinical Observations Concerning Twenty-seven Cases of Splenec- tomy (H. Z. Giffin, Mayo Clinic).* — The association of enlarged spleen with anemia occurs in so many diseases and in such a variety of abdom- inal conditions that a fuller knowledge will be necessary before one can arrive at a correct classification of splenomegaly. The results of medical, surgical, pathological, and experimental experience must be reported abundantly before a correct grouping can be even attempted. That a certain picture conforming to splenic anemia as it is clin- ically described presents itself there is, of course, no doubt. How- ever, the many factors that are discussed by writers on the etiology of this condition at once make one question the ad^-isability of stamp- ing a given ease with a certain stencil. Syphilis, malaria, passive congestion as a result of portal obstruction, thrombosis of the splenic or portal veins, the occurrence of Leisehmann-Donovan bodies, the ac- tion of extraneous toxins, the occurrence of hemolysis, the existence of an undemonstrated infectious agent — these have all been considered as factors in the causation of certain cases. And there must be added to this list, after a consideration of the cases herewith reviewed, what appears to be more than an accidental association of disease of the gall bladder, with cases that can properly be diagnosticated clinically as splenic anemia. Moreover, at one extreme, there are many histories of short duration or those without the typical symptomatology and cases with, atypical blood count, while at the other extreme there are instances in which cirrhosis of the liver seems to form a slightly more prominent part of the picture than the changes in the spleen. And "Abstracted from Am. Jour. Med. Sc, June, 1913, cxlv, Xo. 6, 781. APPENDIX 271 apart from the clinical and etiological aspects there is confusion on the pathological side. The examination of spleens removed from pa- tients regarded from the clinical standpoint as cases of typical splenic anemia reveals no constant histologic picture. Connective tissue in- crease is the common finding, but endothelial or lymphocytic hyper- plasia may predominate to such a degree that the picture may even simulate a true tumor. Clinical Notes on Splenectomy (H. Z. Giffin, Mayo Clinic).* — Many types of splenomegaly are necessarily represented in this series and any classification of the cases is, of course, open to discussion and criticism. On the basis of their clinical and pathologic characteristics, they will be presented in groups as follows: Splenectomy, April 6, 1904-June 9, 1915 1. Splenic anemia (pathologically diffuse fibrosis) 27 cases 2. Gaucher's disease (endothelioid hyperplasia) 3 casesf 3. Pernicious anemia 7 cases 4. Hemolytic anemia (marked splenomegaly) 2 cases 5. Secondary infectious or septic splenomegaly 5 cases 6. L,ues (marked splenomegaly ) 2 cases 7. Acquired hemolytic (hematohepatogenous) jaundice. 2 cases 8. Cirrhosis of liver 1 case 9. Myelocytic leukemia 1 case 10. Lymphoma or lymphosarcoma 3 cases ] 1. Tuberculosis of spleen 1 case 12. Wandering spleen 2 cases 13. Acute febrile nonseptic? splenomegaly 1 case 14. Splenomegaly with marked eosinophilia 1 case Total 58 cases Splenic Anemia. — In this group have been "placed the 27 patients in whom the enlargement of the spleen was very great and in whom splenomeg- aly seemed to be the primary condition. The development of a severe type of anemia with low color index and the absence of leukocytosis were regarded as essential. Hematemesis occurred in a majority of the cases. Pathologically all the spleens showed an increase of con- nective tissue. There were 3 operative deaths in the group, while the total number of deaths was 8 in ten years. Hemorrhage was the cause of death in 2 instances, in 1 case occurring one year after operation and in the other, five and one-half years. In 3 other instances hemor- rhage occurred 2 and 3 times at different periods after operation, but the patients are at present in good health. It is, therefore, evident that the patients in this group had a low operative risk and an ex- cellent prospect of cure. Gaucher's Disease. — Our 3 cases in which the spleen showed evidence of endothelioid hyperplasia occurred early in the series. We have been unable to obtain a history of familial tendency in any of them. One of these patients is in excellent health seven years following operation. In 2 patients the spleen had probably been enlarged since adolescence. Pernicious Anemia. — Seven patients with pernicious anemia have been operated on in our clinic since August, 1914, with one operative death. *Abstracted from Ann. Surg., Aug.. 1915. tTwo of these cases have been questioned. A more detailed report will be published later. 272 TROPICAL SURGERY AND DISEASES A second patient died two months after operation with severe anemia. The third patient, two and one-half months after operation, is in very- good health with hemoglobin at 70 per cent. In the fourth patient the condition of the blood rapidly improved after the operation and the hemoglobin was 75 per cent in three months. The fifth patient, nine months after operation, has gained 23 pounds, the hemoglobin is 70 per cent and the red blood count 3,026,000. The last 2 patients are at present in the hospital. It is, therefore, seen that in our small series of splenectomies for pernicious anemia there was 1 operative death, 1 death at two months, while 3 of the patients showed marked tem- porary improvement. Many patients with pernicious anemia have presented themselves for diagnosis, but we have hesitated to advise surgical treatment. Hemolytic Anemia with Very Much Enlarged Spleen. — There were two cases of an unusual type in which the anemia was severe in character but in which the typical count of true pernicious anemia was not pres- ent and in which the spleen was very much larger than that ordi- narily seen in pernicious anemia. The first patient (A-7040) was op- erated on February 10, 1910. The blood count showed a rather high color index, not, however, above 1, and there were a few normoblasts and megaloblasts in the smears. The spleen was very large, weigh- ing 1640 grams. After operation showers of normoblasts occurred, a finding which is quite unusual in other types of splenomegaly save that of pernicious anemia. The second patient was operated on Jan- uary 23, 1915. The spleen was enlarged early in the history of the disease, apparently before the development of anemia, the blood find- ings were similar to those of the first patient and the spleen was large, weighing 1120 grams. It is true that these 2 cases may in reality be pernicious anemia, but the great size of the spleen, the fact that at no time was the blood typical of pernicious anemia, and the further observation that the en- largement of the spleen occurred early in the disease, would rather lead to the conclusion that they belong to a separate group in the produc- tion of which a disturbance of splenic function may have been primary and in which the reaction of the bone marrow was different from that in splenic anemia. Secondary Infections or Septic Splenomegaly. — Under this heading have been placed 5 cases in which the enlargement of the spleen was not marked, in which the splenomegaly did not seem to be a primary factor in the production of anemia and in which there was evidence of preceding abdominal or systemic sepsis. One of these f)atients is in good health five years following operation. Lues ivith Splenomegaly. — There were two instances in which large non- gummatous spleens together with secondary types of anemia were pres- ent in patients with strong positive Wassermann reactions. In one of these the liver was smooth and specific treatment had been given elsewhere without benefit. Splenectomy was followed by marked im- ; ' APPEXDTX 273 provoniifiit. In the oflicr inslance; larfjo palpable guiiiniata wore pres- ent in the liver. These ^vere.very mucli reduced by specific treat- ment before operation but the size of the spleen and the degree of anemia were not affected. In this case improvement has also been marked since splenectomy. Acquired Tlemolytic' (nenmtohepatogenaus) Jaundice.^ — Two cases have been- classified as hemolytic jaundice. It is possible that both of them might also be regarded as advanced forms of cholangitis with cirrhosis of the liver. The chronic jaundice, however, was prominent in these patients and the anemia was marked. Cirrhosis of tJie Liver. — One case has been regarded as cirrhosis of the liver. In this patient neither was the spleen large, nor the anemia marked. Advanced cirrhosis, of the liver was found at operation. Myelocytic Leuhemia.—r'A patient classified in -our report of 191.3 as a case of splenic anemia and so regarded by careful observers in other clinics, but of whom it wa^ noted at the timp.that the blood picture was not entirely satisfactory for this grouping, continued to be in fairly good health for five and one-half years, after which the leukocyte count become increased to 64,000 with 14 per cent of myelocytes. Lymphoma or Lymphosarcoma. — Our series includes 2 cases of lympho- sarcoma of the spleen. One of the patients remained -n^ell for sevdral years, but finally died with generalized sarcomatosis nine years after operation. The second patient was operated on July 3, 1914, at which time there was no evidence of metastases. After operation, however, general glandular enlargement rapidly occurred and death supervened five months latei*. A third patient presenting a decided lymphocytic hyperplasia pathologically but no definite evidence of malignancy is well eight years after operation. This case may Be benign. Tuieroulosis of the Spleen. — In 1904, a large spleen which proved to be tuberculous was removed from a patient who at the time of operation gave no definite evidence of tuberculosis elsewhere in the body. Wandering Spleen. — Two cases of this type were operated on because of pain resulting from twisted iJedicle. These patients are both alive and well three and seven years following operation. Acute Feirile Nonseptic Splenomegahj. — Several of the eases in this series were very unusual in their clinical manifestations and in the com- bination of conditions present. One of them was analogous in many ways to those cases occurring in Egypt and reported as Egyptian spleno- megaly and deserves detailed description. The patient was a man, aged thirty years, who gave a history in which there was no record of previous disease. He had seemed to be toxic and somewhat stupid for 6 or 8 weeks, while a remit- tent fever reaching l03° had been present. There had been ab- dominal enlargement for only 2 weeks, but no history of hema- temesis, while ascites was present at the time of examination and the spleen could be felt on ballottemenf. AVassermann test, Widal 274 TROPICAL SURGERY AND DISEASES reaction, blood cultures, etc., were negative. In spite of the his- tory of fever and the acute course of the disease, there was no leukocytosis but a definite leukoj)enia with a relative increase of lymphocytes and an anemia of the secondary type with hemoglobin at 70 per cent. The patient remained under observation for 3 months, the condition became less acute in character, and sple- nectomy was finally decided on. The spleen was very large, weighing 1940 grams, and the liver was somewhat cirrhotic. (The patient remained weak after operation, had 3 hemorrhages from the bowels, and finally died 5 months following operation.) The acute course, the presence of high fever, the rapid develop- ment of a very large spleen and ascites, the absence of leuko- cytosis and other evidence of sepsis and the absence of jaundice formulate the picture of a most unusual type of splenomegaly. Splenomegaly with MarTced EosinopMlia. — As far as we have been able to determine there is no case of this type to be found in the literature. This patient was a man, aged thirty-one years. He was first seen in our Clinic in March, 1913. He had had a continued fever which was diagnosed as typhoid eight years previous, and had complained of weakness since that time. Transitory edema had been present for ten months and had become extreme within ten days. At the time of his first visit there was a general anasarca, on account of which he was j^laced on milk diet, and the edema disappeared in ten days. The blood count at the time showed a secondary type of anemia with hemoglobin at 69 per cent and a leukocyte count of 15,400, while the most remarkable feature was the presence of a 66 per cent eosinophilia. The patient was under observation for three months, during which time many blood counts were made and verified by experienced hematologists and the eosinophiles varied from 58 to 77 per cent. Wassermann tests were negative; stools were negative; and the examination of muscle for trichinae was also negative, although not entirely satisfactory. The great enlargement of the spleen persisted and operation was finally decided on and performed in July, 1914. The spleen weighed 2110 grams. The patient has done well since the operation; his leukocyte count, however, has risen to 138,000, of which from 75 to 80 per cent are eosinophiles. There is very little basis for speculation at to the possible etiology of this unique case. Eesume. — Our series of 58 cases includes 27 of splenic anemia, 3 of the Gaucher type of splenic anemia, 7 of pernicious anemia, 2 of hemolytic jaundice, 5 of secondary infectious or septic splenomegaly, 2 of an unclassified type of hemolytic anemia with marked splenomegaly, 2 of lues, 3 of sarcoma or lymphoma, 2 wandering spleens and 1 each of myelocytic leukemia, cirrhosis of the liver and tuberculosis of the spleen. In addition, it includes 1 case of acute febrile nonseptie splenomegaly APPENDIX 275 which, is analogous in its clinical course to Egyptian splenomegaly, and 1 case in which splenomegaly was associated with an extremely high eosinophilic count. Splenic anemia is, in our experience, most favor- able for surgical treatment. The operative risk is relatively low and the prospect for a return to normal health excellent. Three of the 7 patients with pernicious anemia have shown temporary improvement up to 9 months after splenectomy. Eemoval of the spleen in non- gummatous splenomegaly associated with syphilis has been attended with excellent results in two instances. Pathology of Spleens Removed for Certain Abnormal Conditions of the Blood (Louis B. Wilson, Mayo Clinic)." — This study is a continuation of a previous report^ which covered the pathologic examination of 26 spleens removed at operation or autopsy in the Mayo Clinic, between No- vember 14, 1905, and November 1, 1912, from patients -on 18 of whom a more or less positive clinical diagnosis of splenic anemia had been made, and of two "wandering spleens" removed at operation within the same period, and of 31 more spleens removed at operation, between December 3, 1912, and June 9, 1915. Giffiu's^ grouiDing is observed in the fol- lowing pathologic protocols: Summary of Protocols of Group 1 — Splenic Anemia. — It will be seen from the above proctocols that the average age of the patients with a blood picture of splenic anemia at the time of operation was thirty- six years. The average duration of symptoms was 32 months. The average weight of the spleen was 1130 grams. This is a little higher than the average weight (10-40 grams) of the spleens from our positive splenic anemia (revised clinical classification) cases reported in 1913. The average of the two groups is 1093 grams. Few of the specimens equal the weights given by Lyon,3 who states that the average weight is 62 ounces (1860 grams). This discrepancy is probably due to the fact that Lyon's figures are drawn largely from autopsy reports, while ours are from operative material, the spleen continuing to enlarge until death. In general the change in the shape of the si^leen is not so marked as the change in size. In other words, the hypertrophy is evenly diffuse except in those cases in which infarcts have occurred. The maintenance of the notch is important from the standpoint of clinical diagnosis. Histologically, the most constant features are the marked reduction of the pulp and lymphoid tissue with the great increase of reticulum and the almost constant presence of amyloid degeneration and arterio- sclerosis. Whether the diffuse hypertrophic fibrosis is the result of inflammatory changes has not been accurately determined. I see no reason at present, however, to change from the commonly accepted theory that the process is one of low grade chronic inflammation. In this connection it may be noted that Bunting has isolated a diphtheroid organism in pure culture in four out of twelve tubes shown from the spleen in our Case XII. *Abstracted from Ann. Surg., Aug., 1915. 276 TEOPICAL SURGEr.Y AND DISEASES Summary of Protocols of Group 2 — Acquired Pernicious Anemia. — The average age of patients with pernicious anemia was forty-four years at the time of operation. The average duration of symptoms was 27 months. The average weight of the spleens removed was 463 grams. Only one was less than normal (195 grams). 4 The increase in weight is out of harmony with our conception of the atrophy usually found in the spleen in cases of pernicious anemia.s Here again the dis- crepancy is probably accounted for by the fact that in the last stages of pernicious anemia the spleen becomes atrophic, while our figures, based on operative cases, show an increased weight of the organ. Cytologically the increase is mostly in the lymphoid tissue, though it is worthy of note that in one case (Case III) there was a well marked fibrosis, this spleen weighing almost twice the average weight of the glands in the series. The almost entire absence of pigment in these relatively early sta,ge cases is again in contradiction to the usually accepted statement that in cases of pernicious anemia the spleen is pig- mented. General Summary of the Last Seven Groups. — The cases of hemolytic anemia, lues, and hemolytic jaundice resemble pathologically the cases of splenic anemia. The cases of secondary infection, lymphosarcoma, acute febrile nonseptic sj^lenomegaly, and splenomegaly with eosinophilia have little pathologic relationship to either splenic anemia or pernicious anemia. The lymphosarcoma case is a typical lymphoma whose malig- nancy was shown clinically. The other three cases give the general picture of an intense acute or subacute infection, causing hypertrophy and hyperplasia of all the parenchymal elements of the spleen without material increase in the reticulum. Our knowledge of the pathology of splenomegaly associated with chronic changes in the blood has made slow progress, largely because — • except in rare instances — ^we have been unable to study spleens from such cases until the later or terminal stage of the diseases has Ijeen reached. Now that splenectomies are becoming more common, it is fair to assume that clinicians will be on the lookout for large spleens in all cases of pathologic conditions of the blood and that we may hope for opportunity to study early pathologic changes in the glands removed at operation. If any progress is to be made, however, we must sharply differentiate the relative changes in the various histologic elements of the spleen and these changes must be studied in coiTelation with accu- rately observed clinical phenomena. At present the clinical diagnoses of splenic anemia, pernicious anemia, secondary infectious anemia, hemolytic jaundice, Gaucher 's disease, etc., are all lacking in clearness, a condition which must be materially improved upon before an instruc- tive parallel may be shown — if, indeed, any exist — between the several clinical syndromes in their various stages and the pathologic picture present in the spleen. APPENDIX 277 BIBLIOGRAPHY ^Wilson, L,. B. : The Pathology of Splenomegaly, Surg., Gynec, Obst., 1913, xvi, 240- 252. -Giffin, H. Z.: Clinical Notes on Splenectomy, Ann. Surg., Ixii, August, 1915. 'I^yon, I. P.: Diseases of the Spleen, Osier and McCrae Modern Medicine, 1915, iv, 957. ■■Piersol, George A.: Practical Anatomy, ii, 1871. ^Cabot, Richard C. : Pernicious and Secondary Anemia, etc.. Osier and McCrae Mod- ern Medicine, 1915, iv, 626. Discussion of Splenectomy for Splenic Anemia in Childhood (H. Z. Giffin, Mayo Clinic). — An excellent conception of the varied types of dis- ea.se in which anemia is associated with chronic enlargement of the spleen in children and infants can be obtained from the several papers by Went- worth, in which are given excellent reviews of reported cases. Wentworth concludes that the splenic anemia of infancy is a secondary anemia and in no way related to leukemia. He also infers that the adult form of splenic anemia may be a prototype of the splenic anemia of infants. Hutchison collected 22 cases of the splenic anemia of in- fancy in patients from 9 months to 21^ years of age. Ostrowsky re- ports 10 cases of his own, varying in age from 7 months to 2 years with leukocyte counts of from 8,000 to 25,000. Carpenter in a review of 348 patients with splenomegaly, under 12 years of age, places rickets first and syphilis second in the etiological role. Ashby concludes that the toxin causing rickets may also cause the splenic anemia of in- fancy and that the reported cases vary' from those with marked bone changes and small spleen to those with slight bone changes and a very large spleen. Carr draws attention, however, to the following facts: First, that in a majority of rickety children there is no splenic enlargement; second, that there is no connection between the severity of the rickets and the size of the spleen or the degree of the anemia; third, that in certain cases of the splenic anemia of infancy there is no evidence, whatever, of rickets. The general experience seems to indicate that, granted the frequent association of rickets, there are yet certain cases which, on account of their marked splenomegaly and their severe anemia, their evidences of extensive blood destruction, and a reversion to the fetal type of hemopoiesis should^ for the present at least, be grouped together as a separate disease entity. Reports of cases of the adult form of splenic anemia occurring in children under 2 years of age are very difficult to find, while the splenic anemia of infancy seems practically never to be present in patients over the age of 2J/4 years. This observation is in itself suggestive of the possibility that some relationship may exist between the two dis- eases. The chief clinical distinctions between the adult form of splenic anemia and the splenic anemia of infancy are in the blood picture, and chiefly the characteristics of the leukocyte count. In the splenic ane- mia of infancy there is more evidence of blood destruction than in the splenic anemia of adults; the red cell count is likely to be lower and the color index consequently higher, and normoblasts and megaloblasts 278 TEOPICAL SUEGEEY AXD DISEASES are present in tlie blood smears. In the adult form of splenic anemia there is an absence of leukocytosis while in the splenic anemia of infancy there is a notable leukocytosis, which is, however, in. reality a lymphocytosis. Our knowledge concerning the normal blood of in- fants and the reaction of the infant's blood to various toxic agents would lead us to regard these differences as less surprising. And espe- cially does the biological fact that infancy is a transition period, in which there may be reversions to the fetal type of hemoj)oiesis, have a bearing upon the variations in the infantile type of splenic anemia. In addition to the above characteristics, we now have also the knowledge that splenectomy has been followed by excellent results in both con- ditions. These facts would suggest the possibility that the splenic anemia of infancy may be a similar condition to the splenic anemia of adults and that the differences may be largely due to the peculiar reac- tion of the infants' hemopoietic system to the etiologic factor in the dis- ease. For the present, and until our knowledge is much fuller, a sharp distinction should be drawn between the two conditions. SUIIMAEY 1. The normal lymphocytosis of the infants' blood and its decided reaction to various toxic agents is always to be taken into account in consideration of any ease of infantile anemia. Infancy is a transition period during which a reversion to the fetal type of hemopoiesis is likely to occur. 2. The adult form of splenic anemia as it occurs in children and the splenic anemia of infancy have many characteristics in common, and also certain distinctive differences. 3. There is sufficient evidence to indicate a close relationship between the adult form of splenic anemia as it occurs in childhood and the splenic anemia of infancy. Until our knowledge is fuller, however, a shai-p dis- tinction should be drawn between the two diseases. 4. Splenectomy has been performed in only a few instances of the adult form of splenic anemia occurring in the first decade of life. One case of this character is reported herewith. There is a doubt as to the exact diagnosis in some of the seven cases collected from the literature. 5. A review of the literature of the splenic anemia of infancy (anemia pseudoleukemica of von Jaksch) shows that splenectomy has been per- formed in 4 instances of severe types of the disease, with marked im- mediate improvement. The Diagnosis of Diseases Associated with Enlargement of the Spleen (H. Z. Giffin, Mayo Clinic). — Exannuation uf the liver and spleen at the time of operation lias stimulated the interest of the surgeon in diseases which have been hitherto regarded as entirely medical. This interest will result in additions to our knowledge of the relative functions of the organs of the upper abdomen and will eventually assist in making the classifi- cation of hepatic and splenic diseases more nearly definite. That one may be in the receptive mood it is necessary to become as familiar as is possible with the diagnosis of diseases associated with si^lenomegaly. APPEXDIX 279 The exact degree of enlargement of the spleen is usually not fleter- mined until an edge is palpable belovr the costal margin. The fact that the outline of the spleen by percussion is uncertain because of its^ sit- uation is not an excuse, however, for the more or less general careless- ness exhibited in examining for the size of the spleen as a matter of routine. The spleen may lie high and be enlarged transversely, and in this event a definite splenomegaly may be overlooked. Perisplenitis, is a frequent surgical and x>athologic finding, and it is quite likely that clinical evidence of this condition is not obtained as often as it should be. If a patient Tvith a palpable enlargement in the region of the spleen presents himself for examination, it is of course first essential to de- termine positively whether or not the organ be spleen. And tMs dis- tinction is not always easy. The question will usually lie between spleen and kidney. If one can feel edge and notch, there is no difficulty, but it is sometimes impossible to demonstrate the characteristic contour. The edge of the spleen, like the edge of the liver, may at times be revealed by pressing the mass forward and toward the median line at the same time everting the anterior portion. Similarly, the organ may be pressed into the loin and its edge everted. Often the Mdney may be demonstrated as a separate mass lying posteriorly. By these means a difficult diagnosis may be made simple. At times, however, the only certain method of arri\-ing at a conclusion is by means of eystoscopic and pyelographic examination. The development of pyelography assures reasonably accurate information as to the existence of a tumor of the kidney, and pyonepkrosis, hypemephromaj, and cystic kidney have so resembled the spleen as to make a diagnosis impossible without this procedure, and perfectly definite with it. Tke position of the kidney as demonstrated by the injection of colloidal silver may be compared with the position of the tumor at the time of exposure, taking into consideration the focus used in making the radiogram. MovaMe and wandenng spleens are occasionally seen and, upon super- ficial examination, may be diagnosed as movable kidney. The spleen may descend as low as the pelvis. If, however, the occurrence of wan- dering spleen be kept in mind, the organ usually can be recognized by its contour. Two cases of wandering spleen have been operated on at St. Mary's Hospital. Another patient had been operated on elsewhere for movable kidney apparently as the result of a mistaken diagnosis. The Iddney had been stitched up, but the tumor, which, upon palpation, showed all the characteristics of spleen, remained as movable as before. Upon first consideration it would appear that tumors, of the stomach and intestine could not be confusing in the diagnosis of splenomegaly. During the last year, however, the writer has observed two cases in which a large carcinomatous mass could not be differentiated from en- largement of the spleen before operation. The absence of a history of gastric symptoms, negative findings on gastric analysis, the demonstration of an edge, and the location of the tumor led us to regard the tumor 280 TROPICAL SURGERY A2^D DISEASES as most likelv spleen, altliougiL tlie coutour was not typical enough, to warrant a positive diagnosis. One of these cases had been diagnosed previously as splenic anemia by an internist of great experience. An intestinal tumor will more often simulate the kidney than the spleen. The left lobe of the liver may be enlarged in such a way that its edge descends at the left costal border and is thus confusing. Omental tumors must be differentiated from movable spleen. If the splenic dull- ness can be definitely outlined by percussion, a diagnosis may be made by exclusion. The spleen may be moderately enlarged for years without apparent injury to health. Osleri reports having seen a group of such cases in women without anemia and from no evident cause. On several occasions we have observed in Greeks a moderate enlargement of the spleen without complaint or indicative findings. Some of these doubtless had had malaria. Cabofs has noted tliat other peojjles from Southern. Europe present the same condition. While a slight enlargement of the spleen seems to occur without harm, it must also be remembered that splenic enlargement sometimes precedes the development of anemia by several years' splenic anemia, and the spleen must be looked upon as a possible source of future trouble, especially if it be of considerable size. Its removal may then be considered. The spleen may be temporarily enlarged in many of the acute infections of childhood, also in rickets and other forms of malnutrition in babes. The enlargement of the spleen which occurs with typhoid fever, generalised tu- berculosis, and malaria, need only be mentioned. In connection with tuber- culosis it must not be forgotten that a marked tuberculous enlargement of tlie spleen inay occur without evidence of tuberculosis elsewhere. In some of the reported spleens, however, the tuberculous process seems to be less prominent than the general hyperplasia. One patient of this type was operated upon at St. Mary's Hospital in 1904 and made a good recovery, but died four months later. Franke3 has collected ten such operative cases. It is not likely that this type of splenomegaly will be differentiated from splenic anemia unless tuberculosis can be demonstrated elsewhere in the body. The spleen of malaria has been removed when other treatment has failed to prevent the return of at- tacks. The diagnosis is usually made easily; in fact, there is a temp- tation to ascribe splenic hypertroj)hy to inalaria when it may have no etiologic relationship. Syphilid of the spleen should always be considered as a possibility in every patient with splenomegaly, and a "Wassermann reaction can not be neglected in any questionable case. The frequency of syphilis seems to be quite generally appreciated at the present' time so that this error is less likely to occur today than it was ten years ago. Syphilitic cirrhosis of the liver v.ith splenomegaly is of comparatively frequent occurrence, and the difficulty of obtaining a history of infection is notorious. Congenital syphilis of the spleen is not -rare, in children. APPENDIX 281 There is, however, a nonluetic cirrhosis of the liver, which oer-urs in children; ascites and moderate enlargement of the spleen are present. Frimary sarcoma of the spleen is rare; the growth of the organ is rapid. Twenty-five cases have been reported and are reviewed in a paper by Bush.4 Eleven of the 25 were discovered at autopsy, while in 14 sple- nectomy w^as done with four operative deaths. Two remained well for several years. Pathologists agree that a positive diagnosis of sar- coma of the spleen is often hazardoiis, and when recurrence does not follow there is a possibility that the tumor was in reality a benign lymphoma. (Tiirk;5 Sternberg.e) One patient on whom splenectomy was done at the Mayo Clinic for what was morphologically lymphosar- coma has remained well for seven years. In another case a diagnosis of lymphoma was made, and the patient has remained well for a year and one-half. Clinically these two cases presented the syndrome of splenic anemia. The Gaucher type of endothelioma of the spleen is regarded by some ob- servers as a true tumor. Clinically, however, these cases may not be differentiated from splenic anemia, although Brill7 has suggested cer- tain points which may be of assistance in diagnosis. Three spleens of this type have been removed at St. Mary's Hospital. The clinical his- tories were those of splenic anemia. Cystic spleen may be difficult to differentiate from cystic kidney and cyst of the pancreas. Cyst of an aberrant duct of the liver in the left triangular ligament has been reported. Cysts occur in the spleen in about there per cent of patients with hydatid disease. Of nonparasitic cases, 42 instances have been reported (Mussers). Fiiroma of the spleen is rare. Carcinom,a of the spleen is secondary and uncommon in occur- rence. Infarcts in arterial disease and abscess in infectious diseases may cause splenic enlargement. Pernicious anemi-a may be associated with enlargement of the spleen, and, if the blood findings be not typical at the time of examination, a diagnosis may have to be deferred. The spleen is usually not lar,ge, and in this there is a contrast with splenic anemia and Banti's disease. Occasionally the coexistence of a very large spleen and an atypical blood-count leads to a questionable diagnosis. Lymphatic and myelogen&us leulcemia need only lie mentioned as the blood pictures are pathognomonic. Care, .however, must be taken if leukemia be seen in the aleukemic stage. It must not be forgotten that an enlarged spleen accompanies polycytliemia. The term psendoJeitl:emia is indefinite and should probably be reserved for that condition in which lympho- cytic infiltration of the viscera occurs without the characteristic blood changes of lymphatic leukemia. There is a low leukocyte count with lymphocytic increase, enlargement of the liver and spleen, and slight enlargement of the lymjihatic glands. Tlie nn.30 "rams. *Weslev M. Caroenter Lecture, New York Academv of ^Medicine, New York City, Oct. 18, 1917. 284 TROPICAL SURGERY AND DISEASES There has been no definite relation between the size of the spleen and the seriousness of the disease, nor was there any direct relationship between the result of the splenectomy and the size of the spleen removed. This of itself is a suspicious circumstance. The benefit derived from splenectomy, generally speaking, has followed the removal of a definitely enlarged spleen. The failure to establish such relationship in pernicious anemia, or to connect with the disease such gross and microscopic changes as are to be found in the removed spleens, would lead us to expect only limited benefit rather than cure of pernicious anemia through si^lenectomy. There was temporary improvement in every case, but following splenectomy we had some cases in which the cord changes progressed in spite of a great improvement in the anemia. We have not had a patient who lias been cured, but all in all, in about 75 per cent of the cases the benefit might be said to be suflBLcient to justify the operation. In the total number of operations three patients in our early experience died from the oj)eration ; the hemoglobin was under 30 per cent, the red cells were under a million. These patients should have been transfused before operation. Since practicing transfusion in advance of splenectomy, when the blood has been seriously deteriorated, we have had no deaths. There were no operative deaths in the last 32 cases. In many cases after initial improvement by transfusion and splenectomy, relapse has taken place, followed again by improvement after transfusion. We have carried some of these patients along for months in fair health by repeated transfusions ; as many as thirty have been given to a single patient. Fol- lowing each transfusion there would be marked benefit, with gradual de- preciation, until transfusion again became necessary. It has been believed that the introduction of new blood stimulates the hematopoietic organs, and this is probably the true hypothesis in patients whose bone marrow is not too severely damaged. Yet it should be noted that immediately after the transfusion, in certain cases, the anemia is relieved, the hemoglobin brought up from 10 to 30 points, and the red cells advanced api^reciably, only to be followed by a gradual decline. These are the predominately myelotoxic tyi^es. It is an interesting conjecture whether or not the patient may live on the work of transfused blood as well as be stimulated to the formation of new blood. A probable explanation is that the life of the red corpuscles is much longer than we have thought, and that the anemia returns in pro- portion as this fresh aid is used up. The sigiiificant blood changes in perni- cious anemia that differentiate it from secondary anemias are the changes in the number and type of the red corpuscles and in the blast cells found in the blood. The blast cells are the mothers of the erythrocytes, and each blast cell thrown into the blood represents a permanent loss of blood-making power. Therefore, neither stimulation nor treatment can reproduce that which has been lost. The difficulty with the whole subject of pernicious anemia concerns the fact that we do not recognize the disease until such vital and permanent changes as are indicated in the actual loss of these blast cells have taken place. It is even possible that jseruicious anemia, in its beginning, is not a definite entity, but that it is a terminal change of sev- eral conditions which we have not recognized until they have reached the APPENDIX Z85 final stage. Clinically, Imwcv.'r, it is a very (l(,'fiiiilo 'liscase wlicn Lotli liis- toiy and blodil ]iictuic aic (l('\c'l(i|icil. I'cinicious anoniia may be called a cancer of the n'l] '•,.ils, vccouinycii in iIk- hopeless stage. "When the early histories of patients with ])einicious anemia are studied the symptomatology seems fairly clear; yet many patients arc seen with anemias which are sus- pected to Le pernicious but which never develop the true characteristics of the disease. If pernicious anemia is to be cured it must be done l^efore permanent damage to the hematopoietic organs has taken place. It is pos- sible that certain types may be cured; yet so firmly fixed is our belief con- cerning the incurability of the disease that should we have patients cured by splenectomy we would be inclined to lift them out of the category of pernicious anemia and to group them with either hemolytic icterus or splenic anemia. To sum up, splenectomy has a field of usefulness in- selected cases of pernicious anemia, especially in those showing a marked hemolysis by the Schneider duodenal test and evidence of slight bone marrow damage. The operation of removal of the spleen for pernicious anemia is not, as a rule, ditficult. The spleen is only of moderate size, and not very adherent. Leiilcemia. — If there has been any one condition believed to be non-sur- gical and incurable, it is splenomyelogenous leukemia. The theory has been that 95 per cent at least of such patients operated on would die as a result of the operation, and that the 5 per cent who lived would not be benefited. Yet we have long known therapeutic agents (benzol, x-ray, etc.) which would reduce the size of the spleen and would also improve the condition of the blood; and as the size of the spleen became reduced such improvement might be expected. With the use of radium, which could be readily applied over the area of the spleen, a vast change came about in the therapeusis of splenomyelogenous leukemia. I do not know of any clinical experience that is more striking than the result which follows the application of radium over a huge leukemic spleen. Many times the spleen shrinks so greatly as to disappear below the left costal margin, the white blood corpuscles drop from hundreds of thousands to under 10,000. I have seen a leukopenia pro- duced, the white cells dropping from 600,000 to 3,700 in five weeks. Ac- companying this extraordinary leduction m the size of the spleen and reduc- tion in the number of white cells an equally extraordinary improvement in the anemia takes place, and the patient is marvelously benefited. As the spleen gradually increases again in size the white cells increase, the red cells decrease, and the patient loses ground. It is well to eliminate all of our presumptions concerning this disease and pause for a moment in perspective. Reduce the size of the leukemic spleen, and synchronously the white cells go down, the red cells come up, and the patient improves. As the spleen en- larges, the whites come up, the reds come down, and the patient goes down. Have we in this, as iu so many other instances, allowed tradition to hamper progress ? My fii'st experience in splenectomy for myelogenous leukemia was with a patient who came to the clinic with a greatly enlarged spleen, a white count of between 200,000 and 300,000, and who gave a history of having 286 TROPICAL SURGERY AISTD DISEASES had the disease for two years. There had been very great improvement under x-ray therapy; at one time the white cells were reduced by it to a point under 50,000, but, as regularly happens, the x-ray had finally lost its effect, and her condition when examined was worse than it had been at any former time. The patient herself was greatly impressed with the definite comrection between the size of the spleen and her condition, and was anxious to have it removed. I removed the organ, and the patient made an excellent surgical recovery. Within ten days the white cell count had dropped to less than 50,000 and the patient is greatly improved now, more than one year following the splenectomy. Based on this experience, wt have in a number of instances reduced the size of the spleen with radium until the blood count approximated the nor- mal, and then removed the spleen. We have found it inadvisable to force an extreme reduction of the leucocytes before splenectomy. If the general condition of the patient is good, a leucocyte count of 30,000 or less is satis- factory. All the patients, save two, have been markedly relieved. In the 19 cases there were no operative deaths. That these patients are cured I cannot believe, but the experience has been interesting and suggestive. Here again we find ourselves in difficulties not dissimilar to those in con- nection with the etiology and clinical course of pernicious anemia. One pa- tient in our earlier experience, I remember well, had been treated for leu- kemia during a period of five mouths in a large and well-known hospital, and in another for three months. We diagnosed the condition as splenic anemia. The spleen was removed, the patient promptly recovered, and has remained well now for more than five years. It is possible that we recog- nize leukemia as a disease only after it has reached the ho^jeless stage, a terminal condition of a much more common though unrecognized malady. It is questionable whether all the cases of splenomyelogenous leukemia ad- vance to the point where they are recognized as leukemia. These are inter- esting problems which can not now be answered. Leukemia may be called a cancer of the white blood, recognized in the hopeless stage. The leukemic spleen is not adherent, as a rule, and after reduction in size by radium is readily removed. Hemolytic Icterus. — We have performed splenectomy 19 times for hemo- lytic icterus. The results have been astonishingly good. I do not know of an operation giving more gratifying results. The jaundice which the patient has had for perhaps years will be perceptibly less in forty-eight hours, and within four days will have ciuite disappeared. Sixty per cent of these patients have complicating gallstones, apparently due to the greatly thick- ened bile, the result of pigments derived from the disintegrated erythrocytes. There are two types of hemolytic icterus, the familial or congenital type of Minkowski and the acquired type of Hayem and Widal. In the familial type several members of the same family may be affected, and possibly it may be found through several generations. As a rule, it is less serious than the acquired variety. Although never robust, many times those affected with familial hemolytic icterus will live out a normal life expectancy. The APPENDIX 287 acquired type is imicli more serious, and ends, as a rule, in death from some intercurrent malady after years of chronic semi-invalidism. The outstanding features of hemolytic icterus are the enlarged spleen, more or less enlarged liver, and chronic recurring jaundice, without gross oljstiTiction in the bile ducts. Biie is always to be fouTid in the stool. Inasmuch as a high percentage of these patients have complicating gall- stones, they may have an increase of jaundice due to a secondary infection from gallstones, varying the syndrome and introducing diagnostic difficulties. These patients all show marked anemia, and usually crises more or less serious develop in which there is pain over the region of the liver and spleen, with malaise, some increase of temperature, and an increase of jaundice. Chauffard and Widal have pointed out the diagnostic phenomena of increased fragility of the erythrocyte, which is practically constant. Splenectomy, as a rule, is not difficult in these cases, for although the spleen may be quite large it is seldom adherent to a marked degree. There was but one opera- tive death in our series. This patient was operated on during a crisis, and death probably would not have occurred had the operation been performed in the interval between crises. Biliary Cirrhosis. — Hemolytic jaundice is often confused with eertaia tA-pes of non-infective biliary cirrhosis, and especially with the so-called Hanoi's cirrhosis. We have removed the spleen four times for biliary cir- rhosis, which could not be properly classified as hemolytic jaundice. All the patients were above .30 years of age. Were it not for the age, the cases could be called Hanot's cirrhosis. The results in three were very satisfac- tory. The jaundice disappeared to a large extent, and the patients were able to return to work ; but in all the liver remained large. The operation of splenectomy for biliary cirrhosis is somewhat troublesome and difficult, more so than in hemolytic icterus. In our cases the spleen was large and there were many adhesions. In two the liver was sufficiently large to inter- fere mechanically with the operation. Splenic Anemia. — Osier was one of the first to describe splenic anemia, and his classical contributions, coming as they did at an early time, created a great and lasting interest in the condition. Splenic anemia is at least a clinical entity, but has been confused with many varieties of spleno- megalias, syphilitic, septic, malarial, hemolytic, jaundice, pernicious anemia, etc. Little by little an irreducible minimum is being reached and a definite type established. The patients having large spleens develop a progressive anemia and cirrhosis of the liver as a terminal condition to which Banti 's name has been given. The course of splenic anemia is chronic. There may be intervals of years in which the patieat enjoys a fair degree of health, but eventually it leads to a fatal issue, the debilitated patients succumbing to intercurrent disease. Hemorrhages from the stomach are of frequent occurrence in splenic anemia and sometimes hemorrhage is the first symptom that may be noted. The hemorrhages are probably gastrotoxic in origin and while, as a rule, fatal hemorrhage does not result, frequent, recurring hemorrhages cause great debility. The gastric hemorrhage of splenic anemia is a symptom well 288 TROPICAL SUEGERY AND DISEASES worthy of attention. It is not different from that which occurs in connec- tion with hepatic cirrhosis and it is altogether probable that many of the unexplained hemorrhages from the stomach in which no local lesion of the gastric mucosa is to be found, are a result of the toxic condition wliieh pre- cedes, accompanies, or is caused by splenic anemia and cirrhosis of the liver. Balfour, iii a paper on the causes of gastric hemorrhage, calls special atten- tion to the relationship of the spleen and liver to the bleeding. In gastric hemorrhage we must think of the spleen and the liver as causative factors just as in the differentiation of the causes of jaundice the spleen must be thought of as well as the liver. Warthin and others have found that many cases of splenic anemia show thrombosis of the splenic vein after death and they believe that the thrombosis is the cause of the splenic condition. In one of our patients who died the cause of death was found to be due to long-standing splenic and portal thrombosis. The final catastrophe was brought about by thrombosis of the superior mesenteric vein. It may be contended that splenomegaly associated with splenic, portal, or mesenteric thrombosis (one or all) would be better grouped with infectious spleno- megaly (probably streptococcal) rather than with true splenic anemia. The pseudoleukemia of infants described by von Jaksch is closely as- sociated, if not identical with splenic anemia, but because of the hema- topoietic variability of infancy is often accompanied by a high white cell count. Such cases are usually to be relieved by dietetic management, but the spleen has been removed with prompt and striking improvement. Bal- four splenectomized a two and a half year old child presenting the com- plete picture of splenic anemia. Splenic anemia is cured by splenectomy in a high percentage of cases and it should be performed before portal cirrhosis or thrombosis of the splenic vein occurs. The spleen is usually large and, as a rule, extremely adherent and the operation is more ditficult and dangerous than in any of the various other diseases for which splenectomy is indicated. In 43 splenectomies for splenic anemia we have lost 4 patients. Clinically, patients with enlargements of the spleen are to be seen in whom the enlargement is apparently not producing symptoms, but these cases should be looked on as incipient splenic anemia. Such causeless spleno- megalias as I have had opportunity to observe have eventually led to marked secondary anemia, although perhaps for years showing little effect on the patient's health. I have seen no good and much harm come from chronic splenomegalia, and other things l^eing equal, such spleens should be removed on general principles. Portal Cirrhosis. — The portal . cirrhosis of the liver which so frequently accompanies the later stages of splenic anemia have led us to remove the spleen in 5 cases of primary portal cirrhosis in which there was enlarge- ment of the spleen. The results on the whole have been gratifying, al- though one patient died following the operation. The remaining four are in satisfactory condition. For those portal cirrhoses with enlarged spleen which occur especially in young adults without alcoholic history, splenectomy would appear to be indicated. As a matter of fact in cases of this descrip- APPENDIX 289 tion Jo we not classify as priiiiarv jjnital ciriliosis those in wliicli tiie liver L'oudition is discovered first? If the splenic enlargement is first oliserved we call it splenic anemia with portal cirrhosis. The technique of splenectomy I will not dwell on. For those who are interested, I would refer to the article by Balfour, "The Technique of Splenectomy. ' ' BIBLIOGRAPHY ^Balfour, D. C. : Splenectomy for Repeated Gastrointestinal HemorrliaKes, Ann. Siir?., 1917, Ixv, 89-94. The Technique of Splenectomy, Surg., Gynec. and Oljst., 1916, xxiii, 1-6. =Chauffard, A.: Pathogenic de i'ictere congenital de I'adulte, Sem. med., 1907, xxvii. 25-29; Les icteres hemolyliques, ibid., 1908, .xxviii, 49-52; Cholelithiase pigmentaire dans un cas d'ictere congenital hemolytique; analyse chemique des calculs, I'.ull. et mem. Soc. med. d. hop. de Paris, 1912, xx.xiv, 80. ^'Cushny, A. R. : The Secretion of Urine, Lond., X. Y., Longmans, 1917, 241 p. ■'Eccles, R. G. : The Tonsils and the Struggle for Existence, Med. Rec, 1915, Ixxxviii, 47-56. •'Elliott, C. A., and Kanavel, A. B. : Splenectomy for Hemolytic Icterus, Surg., Gynec. and Obst., 1915, xxi, 21-37. "Giffin, IT. Z.: Splenectomy for Splenic Anemia in Childhood and for the Splenic Anemia of Infancy, Ann. Surg., 1915, Ixii, 679-687. The Treatment by Splenectomy of Splenomegaly with Anemia Associated with Syph- ilis, Am. Jour. Med. Sc, 1916, clii, 5-16. A Report on the Treatment of Pernicious Anem^ia bv Transfusion and Splenectomy, Jour. Am. Med. Assn., 1917, Ixviii, 429-432. Hemolytic Jaundice: A Review of Seventeen Cases, Surg., Gynec. and Obst., 1917, XXV, 152-161. Observations on the Treatment of Myelocytic Leukemia by Radium, Boston !Med. and Surg. Jour., 1917 (in press). 'Hanot, v.: Etude sur une forme de cirrhose hypertrophique du foie (cirrhose hypertrophique avec ictere chronique), Paris, 1875, 155 p. ^Hayem, G.: Variete particuliere d'ictere infeciieux chronique splenomegalique, Presse med., 1898, i, 121-125. Nouvelle contribution a I'ictere infectieux chronique splenomegalique, Bull, et mem. Soc. med. d. hop. de Par., 1908, xxv, 122. Quoted by Krumbhaar, E. B.: A Classification and Analysis of Clinical Types of Splenomegaly Accompanied by Anemia, Am. Jour. Med. Sc, 1915, cli, 227-245. '■'Jonnesco, T. : Splenectomie pour hypertrophie malarique. Bull, et mem. Soc. de chir. de Bucarest, 1901-1902, iv, 58. ^"Keith, A.: A New Theory of the Causation of Enterostasis, Lancet, 1915, ii, 371-375. "Krumbhaar, E. B., Alusser, J. H., Jr., and Peet, M. M. : Changes in the Blood Following Diversion of the Splenic Blood from the Liver, a. Control Study of the Effects of Splenectomy, Jour. Exper. Med., 1916, xxiii, 87-95. ^-Mall, F.: A Study of Intestinal Contraction, Johns Hopkins Hosp. Repts., 1896, i, 37-75. ^^Minkowski: L^eber einem hereditarischen, unter dem Bilde eines chronischen Icterus mit Urobilinurie, Splenomegalie, und Nierensiderosis verlaufende Affection, \'er- handl. d. deut. Cong. f. inn. Med., 1900, xviii, 316. "Osier, W.: On Splenic Anemia, Am. Jour. Med. Sc, 1900, cxix, 54-73. ^"Powers, C. A. : Non-parasitic Cysts of the Spleen, Ann. Surg., 1906, xliii, 48-60. i^Rosenow, E. C. : Elective Localization of Streptococci, Jour. Am. Med. Assn., 1915, Ixv, 1687-1691. Elective Localization of Bacteria in Diseases of the Nervous System, Jour. Am. !Med. Assn., 1916, Ixvii, 662-665. '■Rous, Peyton, and Robertson, O. IT.: The Normal Fate of Ervthrocvtes, Jour. Ex- pen Med., 1917, xxv, 651-663; 664-673. '^Vaughan, V. C. : Infection and Immunity, Jour. Am. Med. Assn., 1915, p. 164. '"Warthin, A. S.: The Changes Produced in the Hemolymph Glands of the Sheep and Goat bv Splenectomy, Contrib. Med. Research (\aughan), Ann Arbor, 1903, 216-236. -"Whipple, G. IT., and Ilojiper, C. W. : P.ile Piement Metabolism, Am. Tour. T'hvsiol., 1916, xl, 332, 348; 349-359; 1917, xlii, 256^263; 264-279; 544-557. -'Widal, F., Abrami, P., and Brule, jM. : Differenciation de plusieurs types d'icteres hemolytiques, Presse med., 1907, xv, 641-644. Quoted by Elliott and Kanavel, loc. cit. 290 TROPICAL SURGERY AXD DISEASES Splenectomy Balfour developed the present splenectomy teclmic of the Mayo Clinic which consists hrietly of leaving tlie spleen in situ to hold back the abdominal organs while it is being shelled out by the fingers, packing carefully behind until freed and brought out of the abdomen. When adherent it is found that after ten or fifteen minutes the gauze packing will have controlled the oozing completely. The stomach is then carefully freed, the tail of the j^ancreas avoided, and the vesse]s become readily manageable by clamps. The following is reprinted here from an article that appeared in Annals of Surgery, August, 1915: Surgical Considerations of Splenectomy (WiHiam J. Mayo). — Splen- ectomyr — The safety of spleuectomy depeuds on careful separation of tlie attackmeuts of tte spleen and its delivery with-Out injury to the vascular pedicle. Therefore much depends on the size and movability of the spleen and the amount and vascularity of its adhesions as well as on the thickness of the abdominal wall. Incision. — Bevani in 1897 described a most satisfactory incision for opera- tions on the gall bladder and biliary passages which, has been modified by various surgeons. A longitudinal incision is made through the upper rectus muscle extending obliquely along the costal margin^ about an inch and a half from it and up toward the ensiform cartilage. The longitudinal part of the incision may be carried down to any desired length permitting careful abdominal exploration. In this respect its value in operations on the biliary tract is very marked, as an appendix may be removed or any necessary operation may be performed on the pyloric end of the stomach or duodenum. The incision made on the left side is equally advantageous in gaining access to the spleen. In working in the biliary region the longitudinal part of the incision is best made in the inner half of the rectus muscle, for splenectomy it is best made in the outer half. If the incision across the rectus muscle is kept an inch or more from the costal margin, this little flap, when caught with a catspaw, makes an excellent retractor. Adhesions. — In most cases in which splenectomy is necessary, the spleen is enlarged and adherent to the parietal peritoneum and diaphragm especially over the upper pole. These adhesions differ greatly in their vascularity, being occasionally purely vascular, composed of a small artery and one or more varicose veins. Since these vessels cannot be seen and controlled until the spleen is loosened from its bed and drawn *The Collected Papers, !Mayo Clinic, 1916. APPENDIX 291 down, it is usually best to separate them with the fingers as close to the spleen as possible, trusting the control of any. hemorrhage to a large gauze pack until the spleen can be delivered and removed (Fig. 68). Fig. 68. — The Bevan incision for splenectomy, shown in v.pper figure. Lower figure — method of using gauze pack for temporary hemostasia to control bleeding of separated adhesions. (Courtesy of Dr. William J. Mayo.) At times the spleen is firmly fixed in position by adhesions so stroug they must be di%'ided by a cutting instrument. By making an opening 292 TROPICAL SURGERY AND DISEASES in tlie adhesions close to tlie splenic capsule and loosening the spleen as far as possible by a combination of enucleation and division, a very- adherent spleen may safely be removed. A subscapular splenectomy, in the sense one speaks of a subscapular nephrectomy, is not possible. The capsule of the spleen is closely as- sociated with the splenic pulp which is lacerated in the attempt to re- move it from within the capsule, causing great loss of blood. With a little care, however, the spleen can be separated immediately at the capsule, leaving the attachments in a condition so there will be com- paratively little bleeding. In this way the spleen can be quickly delivered and the pedicle temporarily controlled by fingers or an elastic rubber-covered pedicle clamp,^. The main thing to be accomplished is to leave the separated attachments in" such condition that a igauze tampon will temporarily larevent bleeding. In two cases in my earlier experience the spleen was so firmly fixed with vascular adhesions, I did not deem it wise to undertake sijlenectomy. Separation of the Splenic Ligaments. — Much may he learned eoueoniiug the normal relations of the spleen by operative work on the cadaver. The most serious vascular attachments are the vasa brevia in the gastrosplenic ligament which pass to the stomach. However, the bulk of these attachments can be delivered with the spleen, since the stomach can be drawn from the abdomen to a very considerable extent before separating the gastrosplenic ligament. Unfortunately, in a large ad- herent spleen there may be vascular connections in the deeper portion of the gastrosplenic ligament which pass inward and backward to anas- tomose with vessels along the spine and the crux of the diaphragm. Since these must be separated before the spleen can be eviscerated, early care- ful adjustment of an adequate gauze tampon, for temporary control of hemorrhage, may be essential. The lienorenal ligament has no great vascularity and can be readily divided. After the delivery of the spleen, the remainder of the gastrosplenic ligament and a leash of vessels passing to the inferior border of the spleen which connect it with the splenic flexure of the colon are tied in sections. This completes the peritoneal and omental attachments about the hilum, and, by dividing a few adhesions here and there, the spleen can be lifted up so that the vascular pedicle lies completely exposed for at least two inches. Pancreas. — The splenic pedicle should be sea-iched for the tail of the pancreas which, if present, will lie in the pancreatic notch of the spleen, behind the hilum. It can usually be readily separated, a few ligatures applied to bleeding points, and then dropped back into the abdomen. In three splenectomies, I2 tied off a portion of the tail of the pancreas with the splenic pedicle, in one case removing as much as an inch and a half, without any" harm resulting. The spleen was bleeding so freely from lacerations that time could not be spared for separation. In the third case, in whicn the splenic vessels were atheromatous and would not hold a ligature, I tied the splenic vessels together with the body of the pancreas about three and one-half inches from its tip with two APPEXDIX 293 ligatures of catgut, three-fourths of an inch apart. The patient re- covered ■ivithout serious STmptoms. The pancreas has five independent sources of blood supply which protect its circulation. The pancreatic ducts have been shown clinically and experimentally to have great powers of regeneration. Fat necrosis as the result of escaping pancreatic secretion from injury to the pan- creas in this situation, apparently is not to be greatly feared, probably because its secretions are not activated by duodenal secretion. Vascular Fedi-cle. — In the average case, the vascular pedicle can lie so thoroughly cleared that it may be easily ligated in sections. The artery should be tied first, but all vessels should be tied before any portion of the pedicle is cut. In spite of this precaution the spleen sometimes tears from the pedicle before it can be ligated. This accident happened in one of my cases — a fleshy patient. The spleen had a. short pedicle which retracted deeply, but I was able to grasp the vessels in my fingers and hold them until forceps could be applied. In this type of case it is better to grasp the entire pedicle with elastic rubber-covered clampss which will temporarily compress without damage any attached viscus, such as the wall of the stomach, until the splenic vessels can safely be controlled. In two instances I have iajured the stomach because of its close attachment to the splenic pedicle, in one case ligating a portion of the wall of the stomach, in the pedicle. Fortunately there was no escape of gastric contents and I was able to repair the damage. The patient recovered. In the second case I was less fortunate. There were large varicose veins in the gastrosplenic ligament and. in making a thorough exposure of the pedicle, one of the veins in the waU of the stomach was torn. Unfortunately, tooth-forceps were used to grasp . the vessel and the fragile gastric waU was lacerated. There was an escape of gastric contents into the bed from which, the spleen had been enucleated and the patient died a few days later from sepsis. When the vascular pedicle has been carefully exposed but is too short for accurate ligation of the vessels, the two-forceps method will be found very satisfactory. In this procedure, two forceps are placed three fourths of an inch apart on the pedicle and the spleen cut away Avithout regard to back bleeding. A catgnit ligature is thrown around the pedicle, below the proximal forceps, which is then loosened and the liga- ture tied in the compressed area, while the distal pair of forceps steadies the pedicle and prevents retraction. A second ligature makes the pedicle secure. There are undoubtedly some eases in which splenectomy is indicated but iu which the condition of the patient or the attachments of the spleen make the operation inadvisable. Two years ago Is suggested the possibility of ligating part of the vessels, believing that 'it would have an effect comparable to the liga- tion of the thyroid vessels in hyperthyroidism. I have not had an op- portunity to carry out this suggestion and am not at all sure that it could 294 TROPICAL SUEGERY AXD DISEASES be done "witli any degree of accuracy unless tlie delivery of the spleen "n"ere accomplislied and in tliat event splenectomy would be equally easy and more effectual. John Gerster* has suggested ligation of the splenic artery at the celiac axis as a preliminai-y step in splenectomy, or in some cases as a method of producing atrophy of the spleen when it would not be practicable to remove it. He has mentioned the ease with which the celiac axis can be reached through the gastrohepatic omentum. The splenic artery certainly could be conveniently tied at the celiac axis, or just where it lies at the sui^erior border of the pancreas. Experimental ligation of the splenic artery demonstrates that the normal spleen will not become necrotic, but that it will undergo atrophy. The lilood supply from the splenic artery to the pancreas and stomach which would be cut off by lig^ation is not important and would be well taken care of from the numerous anastomotic branches of other sources. Closure, of the Splenic Space. — This procedure is exceedingly important. Compression with the large temporary tampon will enable the smal- ler vessels to become sealed in a few minutes, but in the deeper re- cesses of the wound, there will probably be vessels requiring other treatment. With catgut on a small curved needle, the raw space, be- ginning at the tied splenic vessels, is closed as well as possible. The margin of the lienorenal ligament, on the outer side, is sufS.ciently firm to hold a suture, but on the inner side such bits of tissue must be caught here and there, as can be done safely until the bleeding vessels are com- pressed. The last sutures come well down on the diaphragm and had best be applied during cardiac diastole and during expiration. In some cases the splenic space will be dry when the tampon is removed and suturing is not necessary. To be able to leave the wound dry is a great satisfaction and well worth the little extra time taken to accomplish it. One of my patients died of so-called secondary shock, due to failure to control hemorrhage at a deep point, and in two of my earlier eases, before I understood the value of the snaking catgut suture, I was com- pelled to leave a large tampon to control the oozing (Fig. 69"). Drainage is not needed unless there has been injury to some viscus. The after care is quite the same as that following any abdominal operation. Mortality of Splenectomy. — The mortality of splenectomy depends more on the type of case accepted for operation than on the technical difficulty of the operation itself. If the patient is in good general condition, a small, movable spleen can be removed with a death rate so low as to be almost accidental. If the spleen is enlarged but has considerable latitude of motion, splenectomy may be performed with almost no mortality beyond the possible accidents of a serious operation. But if the spleen is enlarged and adherent and the patient is suffering from a high grade of anemia with myocardial and renal changes, marked by edema of the lower extremities, or is suffering APPENDIX 295 from ascites, jaundice, high temperature, etc, the mortality will neces- sarilv be hioh. Even under these conditions, surprisingly few patients die directl/ as the result of the operation. In 14 of our patients Fig.69.-Closure of splenic space by snaking catgut suture to control oozing of blood from deep-seated areas. (Courtesy of Dr. \\ illiam J. Ma>o.) edema of the lower extremities was marked. Seventeen had ascites with coincident mvocardial and renal changes, 7 were jaundiced, and o were suffering from high temperature at the time of the operation. 29G TROPICAL SURGERY A:N'D DISEASES There were many combinations of these conditions, all in connection with high grades of anemia, yet there were but 5 deaths in the hospital from all causes, in the 58 eases operated on. As shown by the post- mortem, 2 of the 5 deaths wore from preventable causes (hemorrhage and sepsis). In conclusion, I desire to express my early indebtedness to J. Collins WarrenS for his splendid x^aper, "Suz'gery of the Spleen," stiinulating interest in the subject. REFERENCES 'Bevan, A. D. : A Xew Incision for the Surgery of the Bile Tracts, Tour. Am. Med. Assn., 1S97, xxviii, 1225-1227. -Mayo, W. J.: The Surgery of the Pancreas, Ann. Surg., 1913, Iviii, 145-150 . ^Mayo, W. J.: Surgery of the Spleen, Surg., Gynec. and Obst., 1913, xvi, 233-339. ''Gerster, John: Personal communication. =Warren, J. Collins: The Surgery of the Spleen, Ann. Surg., 1901, xxxiii, 513-543. GENERAL INDEX Abscess of the spleen, 36 Abscess, tropical, 238 Actinomycosis, 240 Adenoids and tonsils, 241 Ainluini, 150, 235 Alcoholism, 20(3 Aleppo boil, 144 Amebiasis, 37 Amebic dermatitis, 149 Amebic ulcers, rectum, 91 Anakhre, 152 Anesthetics, 23 Appendicitis, 213, 229 Appendicostomy, 213 Arthritides, 158 Bacillary dysentery, 66 Balautidial dysentery, 63 Banti's disease, 26 Bess el Temeur, 144 Betel cliewers' cancer, 28 Bilharzia hematobia. 111 Biskra button, 144 Blastomycosis, gluteal region, 91 Blood i)ressure, 23 Bronchomoniliasis, 30 Broncliomycosis, 30 Buboes, 154 C Calabar swellings, 114 Calculi, urinarv, 235 Cancer, 222 Cancer, neck and mouth, 28 Carcinoma, 222 Catastrophe surgery, 92 Cerebrospinal meningitis, 203 Chiggers, 150 Children, infectious diseases in, 242 China, observations on, 161 Chinese medicine. 165 Chronic iilcerations, 130 Chvloeele, 104 Chylothorax, 104 Chvlous ascites, 104 Cleft palate, 25 Climate, influence, 193 Clinical organizations, 22 Colon, diseases of, 37 Commonest suigical diseases, 193 Congenital anomalies of head, 25 Congenital defects, 238 Cosmopolitan diseases, 21 D Delhi sore, 144 Dermal leishmauiosis, 144 Dermatomycosis, tropical, 145 Diabetes, 236 Diseases of the skin, 245 Diseases of women, 224 Distomum Hematobium, 111 Dracontiasis, 113 Dracunculus medinensis, 113 Drug habits, 206 Dysentery, bacillary, 213 Dysentery, entamebic, 37 E Ecliinococcus, 240 Elephantiasis, 99, 24-1 Elephantiasis nervorimi, 1(J2 Emergency surgery, 92 Entamebic dysentery, 37 Epidemics of fomier times, 18 Europeans, habits, diseases, etc., 195 Ewundu, 151 Fibromata, symmetrical, 180, 181 Filaria Loa, 114 Filaria, prevalence of, 95 Filariasis, 95, 234 Filariasis, cysts, 9R Fistula in ano, 239 tropical, 90 Fly bite, 144 Foot diseases and lesions, 249 Frambesia fvaws), 125 Fuente, 182 " Furunculosis, 248 297 298 GENERAL, INDEX G Game, 94 Gaugosa, 116, 250 Gastric symptoms, 230 Genitouiinarv diseases, 90 GeuitoiTiiuary diseases iu men, 227 Glanders, 240 Goiter, 27 Gondou, 152, 235 Guinea worm, 113 Gynceologv and diseases of women, 224 Gynecology and obstetrics, 86 Harelijj, 25 Head, diseases of, 25 Heat prostration, 94 Hematochyluria, 111 Hemorrhage from the liver, 72 Hemorrhage in typhoid fever, 68 Hemorrhoids, 239 Hepatic abscess, 69 Hernia, 33, 237 Hodgkin's disease, 26, 236 Hookworm belt, 19 Infantile paralysis, 237 Infectious, cause of disease, IS pyogenic, 155 Insect borne diseases, 18, 19 lutertrige saceharmomycetica, 147 Intestinal parasites, 216 Intestinal parasitism, 67 Intestinal Avorms, 216 Japan, observations on, 172 Japan, surgery in, 173 Jelly fish poisoning, 93 K Kala-azar, 34, 144, 210 Laboratory methods iu diagnosis, 23 Leeches, 94 Leishmania donovaui, 144 Leoutiasis, 153, 232 Leprosy, 134, 231 surgery of, 140 Liver abscess, 69, 219 Liver, entamebic abscess, 69 Ludwig's angina, 25, 244 "Lumi-lumi," 200 LATuph varicose glands, 110 Lymph varix, 110 Lymphatic cysts, 27 M Madura foot, 149, 240 Malaria, 203, 204, 205 Multiplicity of diseases, 23 Mutilations, military, 25 Mycetoma, 149 N JSTative and home diseases, 252 Native treatment of wounds, 199 Neck, diseases of, 25 Neurofibromatosis, 102 Nodules, juxta-articular, 99 O Obstetrics and gynecology, 86 Obstetrics, native, 225 Operating room technic, 22 Operation for liver abscess, 72 Oriental sore, 144 Osteomyelitis, typhiod, 212 Paralysis agitans, 237 Parasitism, intestinal, 67 Parotitis tyi^hoid, 212 Pemphigus contagiosum, 249 Pliilippines, medical surveys, 178 observations on, 174 Plague of fiery serpents, 113 Plagues of Middle Ages, 18 "Prickly heat," 247 Pulse, 23 Pyogenic infections, 155 Questionnaire, answers to, 183 races, physical conditions, food and habits, 184 K Recklinghausen's disease, 25 Rectum, ulcers, amebic, 91 Resistance to surgery, shock and infection. Aseptic results, 190 Rickets, 25 GENERAL INDEX 299 s .Sand flea, 151 (Sarcoma, 222 .Sarcopsylla penetrans, 151 Skin, diseases of, 144 Skin diseases, 245 Skin granulomas, 233 Snakes and snake bites, 93 Spirillum fever, 203 Spleen, 257 (see Appendix) abscess of, 36 diseases of, 34 (see Appendix) Splenic anemia, 34 (see Appendix) Sunlight, cause of disease, 17 Surgical material, 23 Surgical tuberculosis, 208 Syphilis, 130, 211 fourth stage of, 116 T Tartar emetic in kala-azar, 35 Temperature, 23 Tetanus, 155 Tetanus neonatorum, 200 Thorax, diseases of, 25 Tinea capitis, 147 cruris, 146 flava, 147 imbricata, 147 nigra, 147 Tonsils and adenoids, 241 Trichomycosis flava, et nigra, 148 Tiicliophyton skin infections, 247 Tropical abscess, 238 Tro|)ical dermatomycosis, 145, 245 'J'ro[)ical diseases in white races, 17 Tropical liver, 40, 219 Tropical ulcer, 233 Tulierculous nodes, neck, 26 Tulierculosis, surgical, 143, 20S Typhoid complications, 212 Ulcers, tropical, 233 Ulcers, rectum, amel^ic, 91 Urinary calculi, 235 V A^'alue of medical research, 20 Varicose veins, 239 Volcanic burns, 92 W Women's diseases, 222 Worm of Pharaoh, 113 Wounds, infections, treatment, 198 Yaws, 116, 232 Castellani 's treatment of, 129 IXDEX OF GEOOEAPHICAL REGIOXS A ArracA, 36, 111, 150, 152, 205, 209 Agra, Ixdia, 186, 190, 193, 196, 198, 208 Asia, 34 B Barbados. 137 Basutolaxd, 135 BUR2JA, 190, 193. 195, 198, 199, 203, 206, 208, 210 Caxal Zoxe, 144 Cape Towx, S. A.. 141 Carolixe Islands, 116 Ceylox, 30, 31, 91, 128. 188, 193, 196. 198, 199. 203, 207. 209 Ch-VXGSHa, Chixa, 133 Chixa. 36, 131, 144, 161, 203, 205, 209. 210 Colombo, Ceylox. 188. 191, 205 Corfu, 129, 130 E Egypt, 91, 111 F Formosa. 90, 188. 192. 193, 194. 197, 199. 203, 206, 207, 209 G Guam. n6. 124. 131. 1S6, 192. 197. 200, 204, 206, 210 GuiXEA. Frex'CH, 98 H Hatyah, 134 Honduras. 155 HOXGKOXG. 191. 193, 196, 203, 207 Hwatyuax, Axiiatei, Chixa, 34 Ix-DLV, 104, 144. 150. 186. 190, 193. 196, 198. 203, 205, 206, 208 Ivor;Y Coast, 154 Japan, 172 Johaxxesburg, Africa, 232, 233, 234, 235 K Korea, 189, 193, 194, 197, 200, 206, 207, 209 Liberia, 98 L M MACEDOx^A, 130 Madagascar, 99 ]!ilALAY States, 30 Manila, 195, 212, 234, 235, 242 245, 249 Mariaxas, 116 Marshall Islaxds, 116 MOLOELU. Hattaii. 141 X ^.YASALAXT), 99 Persia. 36 PiXG Yix, 191, 193, 198, 199 Portuguese East Africa, 187 Eaxgoox', 212 Ba:moa, 131. 186, 192, 194, 199, 203, 206, 208, 209 SoocHOTY, 191, 196 South Africa, 187, 191. 203, 241 South Amepjca, 152 SOUTHERX IXTilA, 80 Styedex", 63 T Tarsus. 116 ToMA, 98 Titikestax. 112 W West Africa, 114, 150, ISS, 191, 207, 241 Wexcuow, 191, 193, 198 Z Zamboaxga. p. I. IS 7-191 300 IXDEX OF AUTHOES Adeluxg, 111 ailbutt axd eollestox, 67 AXDEEWS, 33 ASl'LAXD, 210 Avisox, 188, 255 Baetjer, 57 Baxks, 179 Baebee, 256 Barlow, 155 Baury, 256 Beax, 179 Blake, Sir Henry, IS BOTREAr-KOUSSEL, 154 BowiiAX", 63 BRUilPT, 150 BuxTiXG AXD Yates, 26 C CadblTvY, 165 Carxochax, 103 Caroxia, 35 ClEROLL, 19 Castellaxi, 30, 91, 99, 101, 128, 145 155 Castor, 256 Chalmers, 155 Chambeklaix', 256 Charles, Sir Havelock, 101, 104 Clapier, 98 Cl-\ek, 231 Clegg, 37, 136, 149, 178 COCHEAX, 34 Cottle, 184, 255 Craig, 37 Ceeightox, 152 CUEEEL, 188, 207, 255 D D.^JEOiiNG, 37, 144 DeLambotte, 107 BeSilva, 256 Di Cheistixa AXD Caroxia, 35 Dig Chrysostom, 116 dobbeetix, 106 Drumjioxd, 105 EcK, 105 Eggers, 131 Elkixs, 112 Ejiily, 114, 115 Eaieich, 61 F Faul, 255 Ferguson, 33 Feschexko, 113 Fola\-ell, 188, 255 G Cachet, 36 Gaeeisox, 116, 124, 178 Gessxee, 104 GiFFix, (see Appendix) Goodhue, 141, 142 GORGAS, 20 Hail, 188, 255 Haxdley, 100, 103, 105, 107 Haxsex, 136 Haestox, 256 Heisee, 140 Hexschex", 106 Hiest, 188, 255, 243 Hollexbeck, 188, 255 Jeaxselme, 147 JOHXSOX, 188, 255 K Kaetulis, 91 Kexg, 149 Kerr, 116, 123 Koch, 19 Koxdeleox, 103, 105 KuRiEX, 128 KUZXETZOFF, 103 Laxdsborougii, 255 Laxz, 103 301 302 I5TDEX OF AUTHORS Laetigau, 6S L AVER AX, 204 Lazear, 19 Leiper, 113 LEISHilAX-DOXOVAN, 34 LeXouemaxt, 103 Lyxx, 90 M Mackie, 35 Maclaud, 153 Maxsox, 19, 95, 113, 153 Matas, 103, 104 ]\'Iaxwell, 90 Mayo, 34, 105, 257 McDiLL, 74, 96, 97, 107, 157 McDiLL and Wherry, 157 Miller, 188, 255 Mills, 189, 255 morrisox, 105 Morrow, 135 Moses, 134 Musgrave, 37, 149 Xarath, 105 XiCHOLS, 95, 234, 256 XOETOX, 188, 255 O OcnsxER, 24, 256 Odell, 116, 124, 186, 255 Oh. 241 Oppel, 103 Osler, 37 Page, 255 Phalex, 95, 234, 256 Philippixe Jourxal OF Sciexce, 182 Phillips, 256 Plummer, 256 Pi"RViAXCE, 188, 255 E E,EED, 19, 133 Eeid, 188, 255 Robertson, 112 Rogers, 19, 36, 59 ROSAXOW, 103 Rose, 19 rosexbaum, 116 Ross, 188, 255 Ross, Sir Roxald, 19, 144, 204, 256 ROSSITER, 254 RosT, 231 S Sabouralt), 99, 146 Saxdes, 141, 142 Schiassi, 105 Sellarus, 37, 57 Sexx, 116 Shakespeare, 19 Shiga, 67 Smith, 255 Sxell, 255 Stitt, 93 Stryker, 202, 188 T Talaia, 105 Turner, 187, 256 IT Urological Coxgress of 1912, Germax, 112 UxxA, 99 V VAX BusKiRK, 188, 255 Vaughax, 18 Vedder, 37, 59, 256 W Walker, 19, 37, 64, 65 Weir, 188, 222, 241, 255 Wellmax, 111, 150 Wells, 188, 255 Wherry, 96, 111 Wherry and McDill, 157 Wyxter, 105 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the 1 expiration of a definite period after the date of borrowing, as 1 provided by the library rules or by special arrangement with the Librarian in charge. □ ATE BORROWED DATE DUE DATE BORROWED DATE DUE * C28(842)MSO RC961 UU