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bacilli do not cause pulmonary disease, and that they are more or less rigidly localized in the interior of the body-in the majority of cases in the lymphatic glands and the serous cavities. The inference is obvious that they do not enter the body by the respiratory tract. We have also stated that ulcerative tuberculous enteritis is the result of infection with human bacilli. We have, then, to discover by what pathway the bovine bacillus enters the body and by what agency.

As introductory to this discussion, the figures of Lewis quoted above are in point. Beside showing that the average age of his cases during which bovine infection is most frequent was half that of the average of human infection, Lewis states that cervical adenitis in patients over seventeen years is the result of human infection in four-fifths of the cases, which means that while in young adults human infection predominates, in children bovine infection is more frequent.

The most obvious connection between cattle and children is in the milk supply, and it is this foodstuff that has been most widely discussed as a medium for dissemination of tuberculosis. Hess has made a study of the milk in New York, and has found that 16 per cent. of the milk retailed in that city contained virulent tubercle bacilli (animal experiments), and that in all but one case the organisms were of the bovine type. He further found that a fourth of the children using this infected milk reacted to tuberculosis..

It has been shown by other workers, among them Ravenel, the tubercle bacilli may pass through the intestinal wall or through the tonsils without leaving any lesions to mark the course. That is to say, they pass through the mucous membrane of the villi and enter the lymph-stream and become localized in the lymphatic glands, and there produce characteristic changes, and that from these glands they are disseminated.

We have arrived now at the facts that human bacilli are the cause of pulmonary consumption and that bovine are the cause of lymphatic; that bovine infection is frequent in children, human in adults; that human infection is the result of inspiration (chiefly), and bovine of infected food, and that there is little or no relation between the two sorts of infection.

Suppose it be true that 90 per cent. of tuberculosis is due to infection from human beings (Hess); suppose it be true that bovine tuberculosis is as a rule not a serious menace to health; suppose it to be true that bovine tuberculosis is less a menace to others because of the difficulty of transmission from individual to individual-are these sufficient reasons for neglecting to protect ourselves from it?

Whether bovine tuberculosis does much damage or not, is not the question. It does some damage. It increases the doctors' bills, it weakens our children and decreases their resistance, and it kills some of them; and whenever a preventable disease ap

pears to do ever so little damage, it is our duty not to neglect it because it is so unimportant, but to stamp it out.

Anesthesia.

F. HOEFER M'MECHAN, A.M., M.D.,

Staff Anesthetist to the City and St. Mary's Hospital and the Polyclinic.

The Teter Apparatus.

Of all the apparatus so far devised for the nitrous oxide and oxygen technique of anesthesia, that perfected by Dr. Charles K. Teter, of Cleveland, O., is the simplest, safest, most economical and practical. It is the inventive development of over thirteen thousand personal administrations. Its efficiency has been endorsed by expert anesthetists in many of the leading surgical clinics of the United States.

The Teter apparatus was invented primarily as a nitrous oxide and oxygen device, but special attachments make it equally serviceable for the concomitant use of ether and chloroform. If nitrous oxide and oxygen are to be used throughout any operative procedure, this technique of narcosis may be pleasantly induced and absolutely safely maintained by this apparatus with a minimal consumption of the gases. If ether is the anesthetic of choice, the patient may be anesthetized by nitrous oxide and oxygen, and then gradually carried under the influence of the ether, and narcosis continued by the dropmethod of etherization in combination with a variable percentage admixture of oxygen. If the desired depth of surgical anesthesia or sufficient muscular relaxation cannot be obtained in certain operative procedures by the use of nitrous oxide and oxygen alone, by means of a special attachment definite percentage vapors of ether or chloroform may be used concomitantly. If oxygen is indicated with any of the anesthetic techniques or sequences, it may be given in percentages varying between 1 and 10, or it is at hand under such pressure as to make it instantaneously available for perflation of the lungs orally or through a tracheotomy tube. Aside from these exceptional and very desirable mechanical adjuncts of administrative technique, the Teter apparatus supplies all the anesthetics utilized as warmed vapors, now conceded to be the safest, most economical and most respirable form in which they can be delivered.

The complete Teter apparatus for general anesthesia consists of a folding stand, which, by means of set-screws, may be regulated to any desired height. Upon this is mounted a mixing chamber, from which run T-shaped supports, on the long arms of which are interposed the regulating valves and netted bags. for receiving the gases from the tanks, which are hung from double-cylinder yokes. A double-acting valve is placed in the cylinder yokes between the two tan'; to permit the removal of empty and the plac

ing of full tanks without interrupting the conduct of narcosis. The drop ether or chloroform attachment is slip-jointed to the rear of the mixing chamber when in use; the vapor ether or chloroform attachment is slip-jointed to the warmer, which screws directly on to the front of the mixing chamber. A spiral wire-reinforced, cloth-covered hose runs from the warmer to the mask, which is made of transparent celluloid and is capped by an inspiratory gas-air regulator, controllable by the thumb and a set screw, and also an expiratory valve. The face-piece has an inflatable rubber rim to provide for absolutely air-tight adaptation to any face. A rubber tube from the vapor attachment to the facepiece provides for the admixture of ether or chloroform when used concomitantly to secure a more profound anesthesia or an increased flaccidity of the musculature.

TECHNIQUE OF NITROUS OXIDE AND OXYGEN NARCOSIS WHEN FACE INHALER IS USED.

The nitrous oxide bag is filled about two-thirds full, and the oxygen bag so that it is distended under a light pressure. Just before placing the inhaler over the patient's face, open the valve from the nitrous oxide bag. In placing the face-inhaler in position such coaptation must be secured as will exclude all air. Now start the nitrous oxide to flowing from the cylinder into the bag, so regulating the flow by means of the key on the cylinder valve that the bag is full all the time. After the patient has been breathing the pure gas for from ten to fifteen seconds the oxygen valve should be opened to the second notch (indicated by the ratchet catching into the marked grooves of the regulating valve), increasing the percentage one notch at a time after three or four inhalations until the fifth or sixth notch has been reached. The occurrence of asphyxia calls for a higher percentage of oxygen, otherwise from 5 to 6 per cent. will meet the usual requirements of routine narcoses. It will be necessary to start the oxygen flowing from the cylinder into the bag after the patient has been breathing the mixture about forty seconds. To insure the indicated percentage of oxygen, the bag must be kept well distended, and to accomplish this the oxygen should be allowed to flow very slowly from the cylinder, so that it can scarcely be heard escaping. If the patient does not go under the anesthetic in about forty seconds, he is inhaling too much oxygen or there is an admixture of air. Correct the latter by adjusting the face inhaler and its inflated. rubber rim; the former by turning the oxygen valve back a notch or two for a few seconds, or else decrease the flow of oxygen from the cylinder. While patients may be anesthetized by this technique in thirty seconds, it is more discreet not to attempt too much haste in the induction of any narcosis. By giving the system a little more time to accustom itself to the interchange of the gaseous composition of the blood, the induction and maintenance of narcosis will be rendered much safer.

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of the patient, this gauze need be changed but infrequently. Air enters through two openings above the cone and gauze, and, taking up the anesthetic, passes from the volatilizing to the mixing chamber, where oxygen may be admitted in any desired percentage; thence through the warmer to the face inhaler.

While narcosis may be induced from the beginning with ether, it is preferable to use nitrous oxide and oxygen as a preliminary anesthetic. When the patient has passed into the surgical state of narcosis, the nitrous oxide is gradually discontinued, the oxygen percentage is decreased to about 1 per cent., ether is allowed to flow in a stream until the gauze is well saturated, then the dropper is automatically regulated to supply the desired amount necessary for the individual case or the phase of surgical procedure. The rapidity of the drop is governed by the condition of the patient and the required depth of narcosis, just as the drop method of etherization with other masks. If the patient shows any tendency to come out before the ether takes full effect, the nitrous oxide should be discontinued very gradually.

tion of the patient and the required depth of narcosis, just as the drop method of etherization with other masks. If the patient shows any tendency to come out before the ether takes full effect, the nitrous oxide should be discontinued very gradually.

An oxygen percentage varying between 4 and 7 will overcome any tendency to cyanosis without interfering with the anesthetic effect of the ether.

The same technique is used in administering chloroform, except that a much less amount is allowed to flow on the gauze, and it must be dropped very slowly. The concomitant use of oxygen makes chloroform narcosis almost as safe as ether and air.

TECHNIQUE OF ADMINISTRATION WITH THE VAPOR ATTACHMENT.

This attachment consists of a Y-connection to which a glass jar is attached. On both arms of the Y are stop-cocks to regulate the desired amount of anesthetic vapor, which is further controlled by a long and short tube attached to the top of the jar. The appliance is slip-jointed to the apparatus and connected with the face inhaler by a rubber tube. At times it is desirable to administer ether or chloroform concomitantly with the nitrous oxide and oxygen to secure more profound anesthesia or greater relaxation of the musculature. If ether is used, the. glass jar is filled so that the long tube will reach almost to the surface of the ether. If chloroform is used, the long tube is unscrewed and about half an ounce of the anesthetic put in the jar.

When the patient is fully anesthetized but not fully relaxed, and with the nitrous oxide and oxygen flowing as in the ordinary technique, the cock on the face inhaler is opened, as is also the cock on the long arm which descends to the ether. It will be noticed that nitrous oxide and oxygen are passing

over the surface of the ether and taking up from 6 to 8 per cent. of vapor. This percentage is decreased to 4 by opening the cock on the other arm. This percentage can be further reduced by closing the cock on the long arm, in which instance the current of gases passes over and not into the jar.

In using chloroform, the long tube is unscrewed, and instead of getting an 8 per cent. of vapor when the cock is open on the long arm, a vapor per cent. of between 2 and 3 is procurable. When both cocks are open the percentage is 2, and when the cock on the short arm only is open about 1 per cent, or less of chloroform vapor is obtainable.

This attachment is also used in conjunction with the mouth tube when it is necessary to maintain narcosis by the oral method for operations on the face and eyes, in or about the nasal cavities, for cleftpalate, hare-lip or carcinoma of the tongue.

The jar is charged with chloroform or ether in the quantities previously mentioned. The mouthtube is connected with the inhaler end of the rubber tubing. Both cocks on the attachment are closed. The face inhaler is applied and the patient anesthetized in the usual way. Upon the advent of surgical narcosis the face inhaler is removed and the mouth prop inserted. The mouth tube is hooked onto the cheek and used as a retractor. The cock on the long arm of the attachment is now opened, and the nitrous oxide and oxygen passing through the jar will carry the vapor of chloroform and ether into the throat of the patient. The force of this vapor current is governed by the flow of the nitrous oxide from the cylinder, the percentage of the vapor by the regulation of the cocks on the attachment. Narcosis may be maintained by this technique in the most difficult cases without hindrance to the operating surgeon.

TECHNIQUE OF ADMINISTRATION WITH THE TETER

NASAL INHALER.

The apparatus is arranged as for the ordinary administration, except that the nasal inhaler and smaller hose replace the face inhaler. The valve from the nitrous oxide bag is opened, and the nasal inhaler adjusted so that the lower edges of the rubber cap do not press upon the alæ of the nose. Rigid air exclusion must be secured. Having adjusted the inhaler, the patient is instructed to breathe through the nose. To facilitate nasal breathing, a quarter section of a rubber ball may be held over the mouth. The nitrous oxide is allowed to flow continuously so as to keep the bag full. After the first few inhalations of nasal breathing the oxygen valve is turned to the second notch and the percentage then gradually increased to 5 or 6, according to the necessity. After half a minute, start the oxygen to flowing very slowly into the bag, so as to keep it under slight pressure.

After inducing the required depth of narcosis, remove the quarter section of rubber from the mouth. If the patient is inclined to breathe through the

mouth, release the plunger in the inhaler and it will descend upon the expiratory disk. This is accomplished by releasing the set-screw which holds this plunger in position. With the nasal inhaler held firmly in position, the nitrous oxide is turned on more strongly, so that although the patient may be breathing through the mouth, the pressure of the gas will compel the inhalation of the nitrous oxide with whatever percentage of oxygen is needed.

This technique of narcosis does not give as tranquil an anesthesia as when all air can be excluded, but it renders the patient sufficiently quiet and analgesic so that the operations mentioned may be painlessly and expeditiously performed.

Finally, should any danger symptoms arise during the conduct of narcosis, all anesthetics are to be shut off immediately. The oxygen valve is opened to its full extent, and the bag inflated with considerable pressure. If respiration has ceased, the perflation of the lungs with the face inhaler in position will in the majority of cases re-establish breathing. If necessary artificial respiration may be utilized with the face inhaler in position and the oxygen stream perflating the lungs. When respiration has been re-established, the narcosis may be continued.

Abuse of Hypodermic Medication During Operation.

H. G. Wetherill, Denver (Journal A. M. A., May 7), condemns the practice of hypodermic stimulation during and after operations, and states that anesthetists and surgeons who have had the largest experience seldom use it. The best results and the lowest mortality of the busiest surgeons of to-day are attained by the simplest methods. Careful diagnosis and accurate estimates of the ability of the patient to undergi the operation are made. He is prepared with care, the anesthetic is wisely chosen and skilfully given, he is operated on without avoidable exposure,

(Continued from page 637.)

with me, but I have long since cast all authorities in medicine to the winds. When a man's practice is so large that his reading is limited to the sporting page of the daily newspaper, he becomes an authority in medicine and then "I am Sir Oracle and when I ope my mouth let no dog bark."

It is hardly necessary to say in the columns of a medical journal that the size of a man's income is by no means an index of his attainments. Generally it is just the other way.

Disgruntled Abernethy's wail is echoed in the columns of the newspapers of to-day. The practice of medicine is overcrowded just as is every other walk of life. Ambulance chasing attorneys; notoriety seeking, sensation mongering publico maniacs in the pulpit; the literateur, who looks like a poodle and writes like a d-d fool, and the biologist who discovers the elixir of life, are quite in the same class with the belly-cutting imbecile who operates on every provocation and often without one. And if the latter indicates the decadence of medicine, the former suggest the same of their respective callings.

Dismal failure and conspicuously brilliant success. are the exceptions and not the rule. The overwhelming majority of mankind travel the road of the mediocre, mentally, morally, physically and commercially.

The status of medicine as a science is quite on a par with that of geology, astronomy, or chemistry. Osteopathy, with its fantastic pathology and nonsensical therapeutics; the mummery, the flummery and the humbuggery of Christian Science, and other cults no less imbecile, bear the same relation to medicine as do barnacles to a battle ship. They

delays or hemorrhage, he is returned to a warm bed, impede but do not stop the progress of medicine.

placed in a favorable position, watched by a competent nurse and let alone. If he is very restless and really suffering from shock or severe pain as he emerges from the anesthetic he may be given a moderate dose of morphine and atropine, but, notwithstanding its stimulating and soothing effect, he is ordinarily better off if it can be omitted. No strychnine, no spartein, no digitalin, no nitroglycerine-no whip and spur for a tired and jaded and played out or overworked heart, if such he has—no piling up of new poisons to impose additional burdens on the organs of elimination. Let him alone. Keep him warm and very quiet. Give him all the water he can absorb by the avenue of choice; mouth, rectum, under the skin, or within the peritoneal cavity, and as few drugs as possible.

Consul General T. St. John Gaffney says that the Intenational Hygiene Exhibition, to be held in Dresden in 1911, will be the most extensive presentation of hygiene ever attempted. An exhibit from the United States is particularly desirable in a grand friendly competition in one of the most important problems known to mankind, the care of the health.

THE initial number of the American Journal of Physiologic Therapeutics is excellent, save in the length of name. Why is it that a brief name cannot be found for a journal devoted to physiologic medicine?

The American Institute of Homeopathy will meet at Los Angeles, July 17 next.

Medical science, in common with many other sciences, is gradually tending toward its own annihilation, although the multiplication of research institutes may postpone its total extinction until the resurrection day.

I feel as if I I think I had better close here. could write all night long on this topic. My purpose in writing to you was to make it clear that medicine as a science and a business stands on the same plane of the evolutionary process with all other phases of human activity. It has its deficiencies, it is not fully developed, but in these respects it is not different from anything else on this mundane sphere. H. SCHROER, M.D.

OPTOMETRISTS AND THE MEDICAL PROFESSION.

SIDNEY, O., June 13, 1910.

EDITOR LANCET-Clinic:

An episode of some interest to the profession recently occurred in connection with the joint meetings of the Miami and Shelby County Medical Societies, held at Troy, O., June 2, 1910. The membership thought it right to address a letter of

commendation to Governor Harmon in regard to the veto of the optometry bill. This letter found its way into a Piqua paper which published it without comment. This was, of course, quite offensive to the opticians, and one of them replied with a rehash of their stock arguments for the bill, which are always the same and always setting forth their anxious desire for a higher education, which the optometry bill demands. With the public this if, of course, conclusive evidence of the justice of their contention, Under the circumstances manifestly there was nothing to do but to put the matter in its true relations to the medical profession, and set forth the absurdity of the claims of the optometrists. This was done in the letter which follows:

As a member of the medical societies concerned in the letter of commendation of the veto of Governor Harmon of the optometry bill, I regard it as a privilege to reply to the communication of Mr. E. S. Scott recently published by you.

I will assume that the letter was written in good faith and with a genuine desire to have the query answered. To refuse to do this might be construed to mean that our good friends, the jewelers, have the best of a proposition, which is utterly absurd.

To make this statement plain, that is, as to the absurdity of their contention, I have only to quote from his letter a sentence or two, which follows: "It has only been twenty years since the medical practice act was placed on the statutes of Ohio. Prior to that time, any man, regardless of qualifications, was permitted to experiment upon suffering humanity. The compulsory educational requirements of the medical practice act has resulted in the graduates of our medical schools being men of broad educational as well as technical preparation.”

This statement is true in every particular, and we will add that the act was passed for the express purpose of preventing just such charlatanry as is contemplated in the passage of the optometry bill. It was meant to prevent experimenting upon suffering humanity by persons who had not complied with its every requirement.

What are these provisions? A preliminary education equal to that of a high school graduate, and then a course of three or four years in a medical college of recognized standing. After that an examination by the State Board. When our friends of the jewelry and optical trade shall comply with these requirements, they can practice medicine in whole or in part as they shall choose. They may call themselves optometrists, if they please to do so, and use the methods of that half-educated cult if they desire.

The State will at least have done its duty in protecting the people.

It will be seen by the above statement of facts that the anxiety of our friend for a higher educative qualification is a mere pretense. What he really seeks is the sanction of law to practice medicine on a limited license.

If a man calls himself a physician, and he chooses to treat eyes, he must comply with the medical practice act. If he calls himself a jeweler or an optician and treats eyes he works under the protection of the optometry bill. In the former case he must have a thorough traning, in the latter a mere smattering of rudimentary knowledge.

It is a well-known fact that few men take up this specialty until they have had, in addition to their student training, that which comes by years of general practice. The responsibility is too great to permit a conscientious man to do work of this kind without thorough preparation. But here come a lot of tradesmen, mechanics, and offer their services, free of charge, to suffering humanity. Now, for the benefit of these benevolent persons, let us enquire what this free offer really means. The State medical practice act, which is so highly commended, specifically says, that without compliance with its provisions no man

shall prescribe a drug nor make an appliance for the sick or for any infirmity, for a fee.

In short, to circumvent the law, these otherwise good citizens engage to give their services without charge.

Is this done in good faith? Is it true benevolence? Or is it subterfuge and chicanery?

Other men who give services which are worth anything ask a price for them. The natural inference is that the service is either worthless or the fee is covered up in the mercantile transaction. Our friend is welcome to a seat on either horn of this dilemma.

But now he comes up and says that he just longs, yea hungers and thirsts, for a higher and better training, not quite so good as that which the regularly trained physisians have, but just a little better than that of a jeweler, not enough to hurt in its acquirement.

The answer is that the doors of all the high schools and the medical colleges are open, and all are welcome to take the course prescribed by low for the protection of the people.

But this course does not suit their convenience and so they want another, or supplementary medical practice act, to enable them to charge a fee without subterfuge and without infraction of the law. This is the whole case in a nutshell. It is one of deceit and utter selfishness.

Let it never be forgotten that examination of the eyes or of any other organ of the body is a medical act, to do which there must be compliance with the law which was designed for the protection of the people.

No one not having the full training of the physician has any legal or moral right to take upon himself the responsibility of prescribing for the infirmities of the human body, by drug, appliance or otherwise. To do so renders one liable to the charge of fraud and charlatanry. This is the answer to the gentleman from Piqua and it is hoped he will be satisfied.

It is enough to do such work under cover, but to give it the sanction of the law is too much. Governor Harmon could not be hoodwinked nor deceived.

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It is generally conceded that I have not been given a square deal by the President of the University, and a statement of my connection with the Medical Department of the Cincinnati University through the columns of your journal is due the profession and myself.

When I was consulted regarding the chair of anatomy the necessity of my devoting all my time. to the work was discussed. I told Dr. Dabney that without some assurance of permanency and a commensurate salary I could not do so. I explained to Dr. Dabney that inasmuch as the work in anatomy was to be divided among former teachers of the Ohio and Miami Medical Colleges, whom I was asked to assign to positions in the new faculty similar to the ones held by them in the former schools, there would be no necessity of my devoting all my time. I assured Dr. Dabney that we would cover the field of anatomy as prescribed by the American Medical College Association which would meet the standards of the State Boards as well. This was

acceptable to Dr. Dabney. I asked Dr. Dabney his intentions as to the future regarding the department of anatomy. Did he intend at some future time to

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