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AMERICAN MEDICAL ASSOCIATION, CHICAGO, JUNE 10-14.

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MEDICAL SOCIETY OF THE MISSOURI VALLEY, OMAHA, SEPTEMBER 19-20

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Artificial legs and arms with rubber feet and hands are the most durable, natural and noiseless when in use.

They are the easiest and most efficacious to wear,
These cuts, taken from life, prove that a person wear-

ing one or two artificial legs is capable of
performing any kind of labor. The farm-
er with an artificial leg ploughing in the
field, the miner with an artificial arm
working with his pick the blacksmith
shoeing horses, the ticket agent stamping

tickets with an artificial hand, the bagThere are over

gage master with two arti50.000 of Marks'

ficial legs handling heavy patent artificial

trunks, and the engineer legs and arms

with one artificial leg runwith rubber

bot

ning a locomotive, all of hands and feet

ATTITUUT

whom discharge their duin use, worn by

ties with the assistance of
men, women and children of
every occupation, in all parts
of the world.

The Government of the
United States and other coun-
tries endorse and purchase
them. By sending measurements as called
for on our measuring sheet, those inter-
ested can remain at home and obtain
properly fitting artificial legs and arms.
More than one-half of the artificial limbs
constructed by A, A. Marks are made from
measurements furnished as above without requiring
the presence of the wearer. We guarantee a perfectly
fitting limb. Received 49 highest awards.
A Manual of Artificial Limbs sent free; also measuring sheet.

A. A. MARKS
702 BROADWAY,

NEW YORK CITY ESTABLISHED 65 YEARS POSODO

ODOC

- P0DFODOC

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= Incorporating =
The Kansas City Medical Index-Lancet

An Independent Monthly Magazine

ol. XXXVII.

JUNE, 1818

No. 6

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Original Contributions

and the physician suggests removal of the tonsils, he points to little Willie next door who has tonsilitis every winter and yet never has had the

slightest touch of St. Vitus dance. [EXCLUSIVELY FOR THE MEDICAL HERALD.)

These objections which we are so constantly hearing and which are also constantly coming

up to our own minds are not weakening our IPORTANCE OF FOCAL INFECTION IN

conviction that arthritis and chorea are microbic DISEASES OF OBSCURE ETIOLOGY*

in origin. Nor do they lessen our strong susDR. RALPH H. MAJOR, Kansas City, Mo. picion that many other less obvious conditions

are probably caused in part at least by bacteria. The role played by bacteria in the production But to the careful student of the question they those diseases not generally regarded as of must indicate rather clearly that other phases crobic origin, is gaining increased attention. of the disease need thorough investigation. je past two decades in medicine have witnessed

In many individuals foci of infection lead to e transfer of many diseases from the group of

many diseases from the group of the production of disease in other organs, for exnstitutional diseases to that of specific in- ample the numerous cases of endocartitis and ctions. The physician of fifty years ago who arthritis which are so well known to every ould have regarded chorea as due to bacteria clinician. The striking results following the : would have insisted upon quarantining his removal of such foci are often very apparent. ises of infantile paralysis would have probably Equally interesting are the cases of septicaemia Ive been held in about the same esteem as a which are due to a focal infection. In many of lleague of today who should advocate the view these cases removal of the docus is followed at syphilis is due to a conjunction of the planets by a disappearance of the septicaemia and the 'that malaria is due to bad air.

complete recovery of the patient. In the medicine of today bacteria and their In other patients, however, there are foci of oducts have been assuming more and more a infection which are well marked and yet do not redominant place. This school of thought ably lead to disease in the more distant organs. Anrected by a large and increasing group of en- other group of very puzzling cases are those in husiastic bacteriologists, pathologists and clin which the original focus is hard to locate or in cians to which recently dentists have been added, fact impossible of demonstration and yet we as filled medical literature with observations have definite unmistakable clinical and pathologf great interest and undoubted value. The ical evidences of such a focus. udy of focal infections in the tonsils, nasal Since the chances of bacteria entering the ssues and teeth with their remote effects have blood stream through some focus of infection en so fascinating and dramatic that we often seem so excellent because of the great prevaar the layman complaining that all the doctors lence of bad teeth and tonsils to mention two lk about just now is infection.

examples, it is perhaps pertinent to inquire first Van Helmont, in the 17th century, disgusted just how often this occurs. ith the universal blood letting for all diseases In this connection the work of Nicholls and implained that "a bloody Moloch presides in of Ford is particularly interesting. Nicholls le chairs of medicine.” Many patients of today found bacteria in forty livers taken indiscrimem to be complaining that just now a sort of inately at autopsy and also in kidneys both from na infection has usurped Moloch's seat. And cases of nephritis and also in normal kidneys. hen he is told that his arthritis is probably due He also examined the mesentery of normal ani

bad teeth, he points out that his next door mals and found by microscopic methods that it eighbor, whose mouth is filled with old snags, contained large numbers of bacilli and cocci. He as never had so much as a twinge in any of his concluded from his investigations that bacteria Jints. And again if his child developes chorea are constantly pressing into the body through "Read at the meeting of he Medical and Surgical

its various epithelial and mucus surfaces into the internal organs. However, he pointed out that such bacterial invasion does not, as a rule, suspected. The work of Tarozzi and of Canfora cause infection. In health they tend to be de- is especially interesting. These observers have stroyed very soon after their reception. “The noted that animals can be injected intravenously evidence of this,” he states, “is now overwhelm- with tetanus spore, and show no untoward symp ing."

lub, March 21, 1918.

toms. If, however, the animal is subjected to Ford investigated the bacteriology of normal slight traumatism of skin sufficient to produce tissues and organs. He was able to cultivate a a blood clot or a small area of necrosis it die great variety of organisms from the livers and presently with the symptoms of a well developed spleens in 80 per cent of the rabbits, guinea pigs, tetanus. Here obviously the local injury allowed cats and dogs he examined. Adami, speaking the organisms: to settle in the part, proliferate of this work, states that “Ford in general ob- and elaborate their specific toxins which produce tained no growths within three days. Evidently the disease. the bacteria in the organs are attenuated so that As important as these physical traumata are, their growth is feeble and it is arrested until we must remember, however, that we may have the bactericidal substances of the organ have a chemical trauma as well. This phase of the become inert. These observations prove con- subject is not nearly so well understood, but clusively that bacteria are constantly entering when our ideas of chemical trauma have reached the organism. But the bacteria thus introduced the clearness of our ideas on physical trauma, we are very rapidly removed by the endothelial cells will at least have advanced far in our under lining the blood vessels, especially those of the standing of focal infections. spleen, kidneys and liver, so that while the tis- Much interest has been aroused of late, con sues of the healthy body are not of necessity free cerning the possible relationship between focal from microorganisms they are potentially infections and the development of gastric ulcers sterile.” It is also to be observed that this en- Letulle, who found a gastric ulcer in a man sul trance of bacteria, according to Adami, may fering from dysentery, isolated the dysentert take place not only through the alimentary tract, bacillus from the stools and found that when but through the respiratory system as well. pure cultures were injected into guinea pigs

These fundamental observations showing typical gastric ulcerations followed. Chante that pathogenic bacteria are so commonly pres- messe and Widal also produced typical gastrig ent in Organs without producing lesions empha- ulcers by introducing dysentery bacilli directly size strongly the old truism that for the produc into the stomach. Letulle also produced gastrig tion of disease two factors are necessary-bac- ulcers with cultures of staphlococcus, Bezanco teria and the patient. Just as the pneumococcus and Griffon wit

and Griffon with cultures of pneumococcus, ang grows on an agar slant but does not grow on

Enrique and Hallion with diphtheria toxin. More potato medium so the pneumococcus multiplies recently in this country Rosenow has describe in some individuals while in others it dies out. gastric ulcerations in animals which were injecte In many cases the different results depend upon with cultures of streptococcus. the patient's so called resistance and a complete These observations on the probable bacterial understanding of the process awaits the gradual origin of many gastric ulcers seems at first unraveling of the mysteries of immunity. In glance to conflict with the views advanced many other cases the factors are not so complex, and years ago by Virchow and since his time taught here the simpler observations of animal experi- by many pathologists. Virchow's idea of gastrit mentation together with the pictures of patho- ulcer was that it was commonly a process of logical anatomy assist our explanation.

embolism and thrombosis of the stomach ar The influence of trauma upon the localization teries with subsequent infarction and necrosis of bacterial infection is one of our best known ex- of the stomach wall. These views found addiamples in this connection. The pioneers in bac- tional support in the experiments of Cohnheim teriology emphasized with right, the influence who produced infarctions and ulcers of the of points of least resistance in the development stomach wall by injecting lead chromate into of disease and they have recorded an immense the gastric arteries. number of observations along these lines. We A microscopic study, however, of the ulcer all know that if we injure the joint of a rabbit produced by bacterial injection shows that 11 and then introduce pyogenic bacteria into his many cases there is a bacterial embolus presen circulation the animal will almost invariably in the process. Thus it has been proved thal develop a purulent arthritis, whereas a normal Virchow's ideas in many cases at least, wert control animal injected similarly has a chance fundamentally sound. of escaping without joint involvement.

There still remains, however, another factol More recent work along these lines has also to be explained, by certain patients who are con brought out rather unexpectedly as it were, the stantly swallowing pathogenic bacteria, or havi fact that trauma may play a more important bacteria circulating in their blood stream ane role in certain diseases than has hitherto been presumably in their gastric arteries, fail to de :lop gastric ulcers. Here the answer suggested them on one side of their plate, making mean7 Bolton's work upon ulcer of the stomach. while a sagacious remark about an ounce of pre

Bolton injected animals repeatedly with ex- vention. acts of gastric mucosa and in that way pro- That appendicitis may result from bacteria iced what might be termed a gastro-toxic passing out from the lumen into the wall of the rum. The serum when injected intraperiton- appendix seems fairly definitely established. lly into normal animals produced typical gas- And in such cases microscopic examination of the ic ulcers. He found, however, that if the appendix shows erosion and necrosis of the muomach contents were neutralized with sodium cous membrane with a gradual extension of the carbonate at the time of the injection no ulcers process outwards. In these cases if we do find veloped. Conversely he showed that if the fecal concretions or foreign bodies in the apidity of the gastric juice was increased by the pendix we have an excellent example of bacterial Iministration of acids, injection of the gastro- infection combined with a mechanical trauma. xic serum produced more severe ulcers than in Very often, however, our friend who carefully le controls.

deposited his grape seeds on the side of his Bolton's conclusions as the result of his ex- plate comes down much to his amazement with eriments and the microscopic study of the tis- an attack of acute appendicitis. At operation a ie, were that the gastrotoxic serum produced large inflamed appendix is removed which, hownecrosis of the gastric cells which allowed the ever, on being opened shows no fecal concretion istric juice to digest an area in the stomach nor even a grape seed. And then some surgeons all. If we substitute for the sero toxic necrosis are puzzled as was the patient. bacterial necrosis, we have an excellent ex- A careful microscopic examination of this apnple of pathological lesion produced by a com- pendix shows that the mucosa is intact, nearly nation of bacterial infection with a chemical normal, and that practically all of the pathoauma. This suggestion does not, of course, logical changes are in the wall and increase in peal so strongly in the uncommon cases of gas- intensity as we pass outwards to the serosa and ic ulcer with anacidity, but it would seem to meso appendix. In this case the infection has ply in the vast majority of cases where there is been obviously from without, through the bloodill an acidity present either increased, normal stream—in other words an embolic prociks. diminished in amount.

This idea that many cases of appendicitis are The relationship between bacteria and appen- embolic in origin is constantly gaining ground citis seems to be as definitely established as

definitely established as among pathologists and surgeons. And in this most any fact in medicine. We have all been group we look for and frequently find foci of imiliar since the classic paper of Fitz with bac- infection elsewhere. In our own limited experirial infection of the appendix, the acute in- ence several cases can be recalled in which this ammation followed by pus formation and rup type of pathological picture was associated with ire with a local or general peritonitis. Just foci of infection in the teeth and tonsils. Many thy, however, this process occurs in some in- surgeons of large experience doubtless recal! lividuals and not in others is a question which is many instances. One observer particularly, till a subject of lively debate.

Kretz, has emphasized this point of view and We are all familiar with the long-taught idea has even gone so far as to record his opinion hat in some way the lumen of the organ becomes that most cases of appendicitis are due to inccluded and that the bacteria which are in the fected tonsils. abit of wandering at will in and out of the ap- Recent bacteriological studies would seem to endix become enraged as it were, at this in- lend additional support to this idea. Aschoff ingement of their personal liberty and begin and his students find gram positive diplococci ) viciously attack the appendiceal mucous mem- and gram positive bacilli as the etiological fac. rane. Expressed scientifically we read that tors. The oft repeated statement handed down :clusion of the lumen with retention of the from text-book to text-book that the colon 5aIntents lead to a multiplication of the bacteria cillus is the most commonly found organism ith an increase in their virulence.

need not disturb us, since it might be remarkeri In many cases fecal concretions or foreign that any bacteriologist failing to grow a colon odies seem to produce the occulsion of the bacillus from a diseased or even normal appenImen. Many undoubted instances of occlusion dix, must be working with an exceptionally poor De to intestinal worms are reported and we have lot of culture media. cently seen an appendix removed at operation In these cases of embolic appendicitis, many hich contained an ascaris worm. This idea of factors may aid the bacteria in localizing in the le role played in appendicitis by foreign bodies appendix. The fecal concretions may produce as been so dramatically described by the press an erosion which allows an initiation of the prolat we often meet individuals who in eating cess, or kinks in the bowel may interfere so rapes carefully pick out all the seeds and put much with the circulation as to aid in this local

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