The Condition of the President's Heart Once More.-Since the President's death we have had a surfeit of theorizing regarding its cause. Now that the poisoned bullet has been el minated we are presented with such fine-spun speculations as the possibility of injury to the solar plexus, a peculiar idiosyncrasy of the tissues preventing their healing, altho their vitality was otherwise unimpaired; or the injury of the pancreas producing a general gangrene of the impaired tissues. It is hardly worth while to talk about the solar plexus as the cause of death. Deaths ascribed to injury of this structure follow immediately upon the wound and are not long drawn out, as in the President's case. It is useless to attempt to discuss an idiosyncrasy of the tissues, when we did not know certainly that it existed at all, and the assumption that it did in this particular case is purely gratuitous. As for the pancreas, as far as we can discover from personal communication from the attending physicians, glycosuria or other symptom of pancreatic disease was never present.

On May of last year a discussion was held before the College of Physicians of Philadelphia upon the effect of anesthesia in heart disease. It was shown then that in valvular disease of the heart without muscular degeneration an anesthetic has little or no injurious effect (Finney). On the other hand, there is reason to believe that in myocardial disease the anesthesia may cause a fatal termination either by producing sudden heart failure (Mayo) or by causing a sudden exacerbation of the morbid condition (Stengel), and attention was particularly called to the fact that in these cases the patient might continue in apparently good health for several

days after the operation and then go into a state of sudden collapse exactly as in the case of the President.

We do not believe that enough attention has been paid clinically to myocardial disease. Whatthe actual cause of death there is no doubt, however, that the President's pulse was a just cause for anxiety from the very beginning of the case, and that the terminal manifestations of the case were collapse and heart failure. Whether these were produced by the anesthetic acting upon an already weakened heart, or whether the condition of the myocardium was such that the shock of the injury was capable of causing it ultimately to become insufficient, we do not know, but at least we shall await with keen interest the histological report upon the condition of the heart muscle.

The following two letters, from American Medicine for October 5, present two more thoughtful opinions:

THE CAUSE OF GANGRENE IN THE PRESIDENT'S CASE. To the Editor American Medicine:-The various attempts to explain the results of the bullet wound in the case of our late President, so far as I have seen, make no mention of the following theory: From the location of the wound the adrenal must have been wholly or in part destroyed. We know that adrenalin, in the general circulation, slows the heart, raises blood-pressure, and perhaps heightens general metabolism. Locally applied it contracts the small vessels more powerfully than any other known agent. Therefore, were one of the glands to be in large part destroyed, we should expect, from lack of its secretion in the general circulation, a fall of vascular tension, a weakening and rapidity of the heart, and perhaps a lowered rate of metabolism. Locally there would be a prolonged anemia of the parts bathed in the secretion of the injured gland, resulting in gangrene without inflammation. Could this case be better described? JOHN I. COCHRANE, M.D.

East Arlington, Vt.

THE ADVERSE CRITICISM OF PRESIDENT M'KINLEY'S
PHYSICIANS.

To the Editor of American Medicine:-I have been very much surprised at the unwarranted and severe criticism by the New York Medical Record, of the medical men who attended the late President. The only feature in this criticism which is just is that made with reference to the location of the ball by the x-rays, and this would be unjust if applied to any period during his life after the injury was received. On the morning of the day on which the postmortem examination was held I was at the house of my friend, Dr. Moore, of Westfield, N. Y., and in discussing the matter with him, I said that the bullet should be located in the President's body by the x-rays before the postmortem began. My experience in the Civil War as an assistant surgeon and as a chief surgeon in the Spanish-American War had taught me that small balls were sometimes hard to find in living or dead bodies. The man who criticizes such a case, and in such a manner as the writer in the Record has done, shows experienced readers that he has sought for few balls in the human body. To have pusht the operation bəyond the point to which Dr. Mann pusht it would have required almost complete evisceration, adding greatly to the risk of subsequent peritonitis and intestinal obstruction thru adhesions. The shock of the operation, added to that of the bullet, would not unlikely have terminated the President's life at an earlier date, and nothing would have been gained to offset these risks. I know personally that at no moment Dr. Mann's assurance went beyond a hope. late as Wednesday night prior to the death of the President he was in serious doubt of his recovery. To my mind, the best was done that could be done. The prior condition of the patient was unfavorable to the healing of any wound. The ball was small and the charge of powder behind it was light. The flight of the ball was short, its velocity slow and its momentum feeble. The result was a contused and lacerated wound in tissues in which the vitality was low. The wound was so located that the principles of surgery applying to it-namely, free incision and drainage-could not be practised. The wound was fatal from the start, and his surgeons are worthy of commendation, and not condemnation.

As

It will be remembered that the temperature had advanced beyond the physiologic limit (100° F.) before the operation was undertaken, and continued to rise while the operation

was in progress. This was not due to peritonitis, nor to sepsis, for the reason that sufficient time had not elapst before the temperature rose. To what then was it due? Nobody has said, so far as I know. I venture to express my own thoughts upon the subject and to advance an explanation. The bullet in its course past thru the solar plexus of the sympathetic nerve, tearing, lacerating and bruising its filaments. Immediately following this the arterial vessels to the surrounding viscera were paralyzed and dilated. The blood-supply was increast, local irritation was exaggerated and the progress modified. The temperature was Increast from 50 to 100 in the parts affected, and the temperature of the whole body rose rapidly. This terrible injury to the solar plexus was to some extent spent upon the heart immediately after the injury, and later manifested itself fatally. The source of the gangrene may be rationally traced to the injury to the solar plexus, and the consequent great disturbance of nutrition. When we add this explanation to that of the reduced physical condition of the patient at the time of the injury, we may well cease to wonder at the result. R. STANSBURY SUTTON.

Pittsburg, Pa.

Later: In the full official report just given out by the surgeons (October 19), very little if anything new is given, but the following points are of interest: The failing light of a September afternoon was a disadvantage in the operation. Later, a movable electric light was used with advantage. We all know that when a serious and difficult operation can be arranged for deliberately, the strong light of midday is chosen. Other disadvantages were, "depth of the abdominal cavity" (thickness of the abdominal wall, due chiefly to fat), and lack of instruments to draw the edges of the wound apart during the sewing. Speaking of the search for the bullet during the operation the report says:

"The operation on the stomach now being finished, Dr. Mann introduced his arm so as to palpate carefully all the deep structures behind the stomach. No trace of the bullet, or of the further track of the bullet, could be found. As the introduction of the hand in this way seemed to have a bad influence on the President's

pulse, prolonged scarch for further injury done by the bullet, or for the bullet itself, was desisted from."

Examination of the heart muscle showed well markt fatty degeneration. An interesting fact is that "there was no leak

age of pancreatic fluid into the surrounding tissues." The wound to the kidney was found to be of no importance as contributing to the fatal result. The chief factors leading to the fatal result seem to have been the condition of the heart muscles, and "lowered vitality."

[As there are already signs of a recrudescence of the small pox epidemic of last winter, we placed in the hands of Dr. Benjamin Lee, the able and efficient secretary of the State Board of Health of Pennsylvania, the very full and free discussion of the subject in our pages last winter and spring, and askt him to read the same and then give our readers an "authoritativ word" on the subject as a preparation for a possible reappearance of the epidemic this winter. The most useful (and interesting) form of journalism is that which

first calls out the real state of mind of the profession on a given subject, and if wrong, to put it right. This is what makes THE WORLD so popular with the "rank and file" of the profession. We now take pleasure in presenting the following from Dr. Lee.-ED.]

The Small Pox Epidemic.

Editor MEDICAL WORLD:-I have read

with mingled interest, amusement and indignation, the protracted correspondence which ran thru so many members of your valuable journal on the diagnosis of small pox, last winter and spring. It has been interesting as showing how wide-spread the present epidemic of this disease has been. been. From north, east, west and south, from Canada to Mexico, from Philadelphia to San Francisco, have your busy contributors written, giving freely of their experience and of their opinions. But it has been still more interesting as demonstrating the fact that everywhere it has made its appearance, it has uniformly

presented the same mild type, so mild as to throw many practitioners, perhaps a majority of them, off their guard. In fact, the failure of the family physician to recognize his first cases has been responsible for the rapid and unusual extension of the infection. Mild epidemics of variola, or more properly speaking, epidemics of mild variola, are not only nothing new, but are mentioned in all systematic works on the practise of medicin. I have in my library a treatise on practise by the Court Physician of Austria, publisht a little more than a hundred years ago. About one-third of the entire work is devoted to small pox alone, showing the important position which this disease occupied in the mind of the average practitioner of that day. Just about such a form as we are now becoming familiar with is described in this book. This fact sufficiently refutes the theory that the amelioration of the type has been due to the vaccination of successiv generations. The more rational explanation, to my mind, is that this particular strain of variolous virus was imported from the West Indies during the recent war. Certainly the first cases observed in Pennsylvania possest this history. Heat, as is well known, destroys the vitality or impairs the activity of both the vaccine and the variolous contagions.

It seems rational therefore to anticipate that the subjection of either of them to a sub-tropical temperature for centuries would diminish its virulence. It will be remembered that when small pox was first introduced among the aborigines of the New World it carried them off by thousands. At the present time, or more strictly until the United States occupation in Porto Rico and Cuba, while the disease was excessivly prevalent on those islands, the death-rate resulting was comparativly slight. In Porto Rico the disease has now been almost entirely eradicated, the entire population of 800,000 having been vaccinated under the supervision of Major George G. Groff, Brigade Surgeon United States Volunteers, a former president of the State Board of Health of Pennsylvania.

I have been amused at the readiness and cocksureness with which men who have never seen a case of small pox will make a diagnosis of a disease which has puzzled able diagnosticians; but I have been filled with indignation when I have found men of this caliber, after experts of long and aried experience have definitly decided

the affection to be true small pox, and after state boards of health, having given the subject mature consideration, have affirmed it to be so, still presuming to set up their little inconsequential opinions in opposition, and pronouncing it to be chicken pox, impetigo contagiosa, or "Cuban Itch." And the trouble is that each of these ignoramuses has his following, and unsettles the minds of a considerable number of persons in his immediate neighborhood, thus preventing the adoption of the necessary precautions.

As was sagaciously predicted by Dr. William M. Welch, in his report to the State Board of Health on the outbreak in Allegheny County, Pa., it is not to be expected that in our climate the virus will preserve its mild characteristics. Already in the city of Philadelphia the death rate has during the past month reacht over 14 per cent of the cases reported, while during the early part of the epidemic thruout the state it was less than 1 per cent. Owing to the intelligent appreciation of the situation by the general public, and the energetic and wise measures adopted by the Board of Health of Philadelphia, I do not apprehend any great increase in the number of cases, but the probability is that, as the infection is fairly well distributed over the city, we shall have it present with us to some extent all winter. The inclosed circulars will indicate what steps the State Board of Health has been taking to suppress the outbreak. You may find something in them that will interest your readers.

Philadelphia.

BENJAMIN LEE, M.D.

The following, from the Board of Health circulars inclosed by Dr. Lee, will prove helpful:

THE DIAGNOSIS of SMALL POX.

Owing to the great infrequency of small pox at the present day resulting from the general adoption of vaccination, comparatively few physicians have had an opportunity of becoming familiar with its symptoms. The careful quarantine of the disease by the vigilant health-authorities in all our cities still further diminishes the chance of a medical student ever seeing a case. In former days the family physician was also the preceptor of students and took them with him in his daily round of visits. In this way they were frequently enabled to study infectious diseases at the bedside. Now all this is changed. Clinical teaching is given only at the general hospitals, and from them such diseases are very properly excluded. Hence, it has come about that on the first appearance of small pox in a country village it is almost invariably mistaken for some other less dangerous disease, and many persons become infected before its true nature is recognized. This Board, therefore, deems it important to call the attention of physicians to the salient points which distinguish this disease from all others.

In the first place, let it be borne in mind that the mildness or severity of the attack has little or no value as a diagnostic indication. Because the patient is able to be up and about, even well enuf to work or to play, is not a sufficient reason to conclude that he is not suffering from small fox. Nor is the absence of or failure

to perceive the characteristic odor of small pox ground for deciding against the presence of that disease. The same may be said of the secondary or suppurative fever.

The disease with which it is most easily confounded during the first few hours of the eruption is measles, and if there has been no small pox in the neighborhood this mistake may be readily made. The appearance of vesicles or papules, however, will soon clear up this question, and the diagnosis will then be between chicken pox and small pox. If the disease be small pox, on passing the finger over the surface the papules will feel firm and hard under the skin, like small peas or shot, while no such impression will be given in the case of chicken pox. If it be the latter disease, pressure made with the thumb and finger on either side of the papule in such a way as to stretch the skin tightly over it will almost entirely efface it, while no such effect will be produced in the case of the small pox papule, owing to the fact that it is formed in the deep layer of the skin.

In both diseases the papules soon begin to form blisters (vesicles) on the summit, and in both these are filled with a clear or cloudy fluid. In the case of chicken pox this characteristic is maintained until the vesicles dry up, but in small pox the fluid rapidiy becomes yellowish and opaque, indicating the formation of pus, and we have the true small pox pustule. The vesicles of chicken pox develop much more rapidly than those of small pox. The small pox pustules are surrounded by a distinct red areola which is not found in chicken pox. In severe cases of small pox the pustules often run together, constituting confluent small pox. This does not occur in chicken pox.

Another striking distinction between the vesicle of chicken pox and the pustule of small pox is that on or about the sixth day of the eruption the center of the small pox pustule begins to sink in, producing a little cup-shaped depression. This is known to physi cians as umbilication, and is a sign of great value. The scab which forms as the pustule of small pox dries up, is dark-colored, firm and strongly adherent, while that of chicken pox is lighter in color, less compact, and fals off earlier.

Both of the diseases under discussion are self limiting, that is to say, run a definit course and have a definit duration. They are ushered in by chilliness, followed by fever, accompanied by headache, backache, loss of appetite and often vomiting, but in the case of small pox the eruption does not make its appearance until the end of the third or the beginning of the fourth day, while in chicken pox it appears on the second day of the illness. In small pox the backache is usually a very prominent feature. The eruption begins as a rule on head and face, often on the upper lip, and then spreads to the body and limbs. In small pox it is more apt to appear abundantly on exposed surfaces, such as the face and hands, while in chicken pox it prefers surfaces covered by the clothing. The marks of small pox, aside from pitting, persist for many weeks, usually producing a brown pigmentation of the skin, The develop. ment of pustules on the palms of the hands, the soles of the feet, the ball of the eye and the inside of the mouth are all strong evidence of the presence of small pox.

With the development of the eruption all of the feverish symptoms disappear, and in mi'd cases do not return.

A third dis-ase, however, for which small pox has recently been mistaken in this State, does not present a self-limited and definit course. I refer to the superficial cutaneous affection known as impetigo contagiosa. In this disease, if there be an initial fever it is usually very slight. A child will go to bed at night feeling as well as usual, and may wake in the morning with reddish spots on the skin, which soon become blisters, or blebs. These, instead of being round and prominent like those of small pox, are usually flat, irregular in shape and of variable size, and tend to run together, forming crusted patches. As they dry in the center, they continue moist at the edge, and in this way spread, and may last for several weeks. The crust which they form is yellow, bulky, superficial and easily detached, seeming as if stuck on. This disease, simple in nature, is more apt to be confounded with chicken pox than with small pox. It often attacks several members of a family one after another.

PRECAUTIONS IN THE SICK ROOM.

1. The patient should be placed in one of the upper rooms of the house, the farthest removed from the rest of the family, where is to be had the most complete ventilation and isolation. The room should be instantly cleared of all curtains, carpets, woolen gaods and all unnecessary furniture. The rooms should be kept constantly well ventilated, by means of open windows, and of fires, if necessary. The utmost cleanliness should be observed both with regard to the patient and the room.

2. A basin containing chlorid of lime or quick lime in solution, or some other convenient disinfectant, should be kept constantly on the bed for the patient to spit in. Change the clothing of the patient as often as needful, but do not carry it while dry thru the house. A large vessel (a tub) containing a disinfectant solution should always stand in the room, for the reception of all bed and body linens immediately on removal from the person or contact with the patient. Pocket handkerchiefs should not be used, but small pieces of rag should be employed instead for wiping the mouth and nose; and each piece after being once used should be immediately burned. Two basins, one containing water impregnated with a disinfectant solution and the other containing plain water, and a good supply of towels, must always be ready and corvenient, so that the hands of the nurse may be at once washt after

they have been soiled by contact with the patient. All glasses, cups and other vessels used by or about the patient should be scrupulously cleansed before being used by others. The discharges from the bowels and kidneys are to be received, on their very issue from the body, into vessels containing a disinfectant, and immediately removed.

3. No person should be allowed to enter the room except those who are attending upon the sick. A sheet moistened with a strong disinfectant solution and suspended outside the door of the room or across the passageway leading to it is necessary to complete the isolation of the patient.

4. Boiling is the surest way of disinfecting all contaminated clothing. A disinfectant should first be added to the water. Any material which cannot be washt without injury should be exposed to a dry heat of abcut 240° F., or fumigated in a closed chamber, as directed below. A hot-air disinfecting chamber should be provided near all cities where beds, woolen goods, etc., may be disinfected under the direction of officers appointed by the Board of Health. All articles which can possibly be spared should be destroyed by fire.

5. Small por is most contagious during convalescence; therefore, strictly observe that the patient does not mingle with the family until all the scabs are entirely off, and only after a thoro purification by bathing, with a disinfectant in the water, and entire change of clothing.

6. In case of death, wrap the corpse in a sheet saturated with the strongest disinfecting solution, without previous was bing; if the means are at hand inject the cavities of the chest and abdomen with a solution of chlorid of zinc or other antiseptic fluid; and bury it in a deep grave, within 20 hours, and without a public funeral.

STANDARD DISINFECTING SOLUTIONS RECOMMENDED BY THE STATE BOARD OF HEALTH

1. Standard Solution No. 1.-Dissolv chlorid of lime or bleach. ing powder of the best quality (containing at least 25 per cent, of available chlorin) in soft water in the proportion of 6 ounces to the gallon.

2. Standard Solution No. 2.-Dissolv corrosiv sublimate ard permanganate of potash in soft water in the proportion of 2 drams of each salt to the gallon.

(NOTE.-1. This solution is highly poisonous. 2. It requires a contact of 1 hour to be efficient. 3. It destroys lead pipes. 4. It is without odor.)

3. Standard Solution No. 3.-To one pint of Labarraque's Solution of hypochlorite of soda (liquor soda chloratæ.-U. S. P.), add five parts of soft water.

4. Standard Solution No. 4-Dissolv corrosiv sublimate in water in the proportion of four ounces to the gallen, and add one dram of permanganate of potash to give color to the solution as a precaution against poisoning. One fluid ounce of this solution to the gallon of water is sufficiently strong. Articles should be left in it for two hours.

(NOTE.-Corrosiv sublimate solutions should be kept in wooden or crockery vessels.)

TO DISINFECT DISCHARGES FROM THE PATIENT.

Use standard solutions Nos. 1, 2 or 3, keeping a pint of the solution used constantly in vessel ready for any emergency. Let the discharges be past directly into the solution, and then let a pint more of it be added and allow the whole to stand for some time before being thrown into the sewer, or being buried. Milk of lime (ordinary white-wash) is also a very good disinfectant for this purpose.

TO DISINFECT CLOTHING, TOWELS, NAPKINS, BFDding and SUCH TEXTIL FABRICS AS CAN BE WASHT.

Use standard solution No. 4, one ounce to the gallcn of water, or use one gallon of solution No. 1, in nine gallons of water. Let the goods soak in the solution for at least three hours- better four hours before they leave the room. Stir them up so that the solution may get all thru them. After disinfection, boil the goods thoroly.

FOR THE DISINFECTION OF WATER CLOSETS, URINALS, SINKS AND CESS-POOLS.

5. Carbolic Acid Solution.-Mix one pint of carbolic acid with two and a half gallons of water

Standard solution No. 4, diluted with three parts of water may also be used in the proportion of one gallon (cf the solution) to every four (estimated) of the contents of the vault, Standard solution No. 1, would require to be used gallon for gallon of the material to be disinfected. Dry chlorid of lime may be sprinkled over the contents of a privy, or star dard solution, No. 2, may be made by the the barrel, and four or five gallons be applied daily during the epidemic.

TO DISINFECT THE SICK ROOM AFTER IT IS VACATED. Let the room be thrown wide open for several days, for a thoro airing. If papered, let the paper be all removed with care. Then let all the walls, the floors and the woodwork of the room, as well as the furnitnre. be washt with standard solution No. 4, 1 pint to 4 gallons of water, or, of solution No. 1, a quarter of a pint to a gallon of water. Let this work be done most carefully, getting the solution into all the crevices. If any dust be present in the corners