must be submitted to him for identification, enabling him to proceed from simple to complex cases, until he is able to determine the composition of the most difficult mixtures.

Quantitative.-1. To analyze substances of known composition, such as crystallized salts, that the accuracy of his work may be tested by a comparison of his results with the true percentages.

2.Required to make analyses of materials occurring in commerce or in the applications of technical and sani tary chemistry, etc., as fertilizers, fuel, water; etc. The object being to instruct in analytical methods.

board, or laboratory, the senior officers thereof shall appoint, as they may deem advisable, the medical officers under them as instructors in the special work, assigning to each such subjects as may be agreed upon by consul. tation, care being taken that the system of instruction will necessitate everything in writing. The student must carefully prepare all reports on the subjects assigned to him before presenting them to the instructor for inspection and remarks. When papers are completed they shall be delivered by the instructor to the senior officer of the hospital, examining board, or laboratory, as the case may be, who will retain them until all papers prepared by the student during his term of instruction are received, when they. shall be forwarded to Director of Naval Laboratory and Department of Instruction, in accordance with prescribed form.

Organic. The laboratory work to consist of: Ulti mate analyses, including determination of carbon, hydrogen, nitrogen, sulphur, and haloid elements in organic substances; determination of vapor densities, molecular weights, specific gravities, melting and boil- VIII.-Medical officers, when assigned as instructors, ing points, and calculations of formulæ. Analysis must whether attached to laboratory, hospital, or examining be made on material supplied or authorized beforehand board, shall keep accurate record in book form of all by the instructor at the laboratory, and he will require work required of assistant surgeons undergoing inof the student, whenever practicable, reports in writing struction. These record books, when completed, shall on completion of the work.

be delivered to the Director of the Naval Laboratory MICROSCOPY AND MICROBIOLOGY: Practical acquaint- and Department of Instruction to be placed on file. ance with the handling of the microscope, its con They will also see that assistant surgeons are provided struction, use, care, and choice; simple lens, optical with everything necessary to prosecute their work in an principle, construction, and use; compound lens, low-intelligent manner; use of apparatus for qualitative, power objectives, use and care; accessory apparatus, quantitative, and organic analysis, for microscopy, and general method of work, illumination, effect of different for bacteriology and chemical reagents for practical media; the eyes, peculiarities, use, and protection; work in laboratory or elsewhere, use of surgical instrumounting, dry, in liquid, and in cells; section cutting ments and appliances for hospital work, free access to soft and hard tissues, crystals, rock sections and grains; library, and use of modern text-books on every subject staining; high power objectives, use and care, cover taught. connections, and immersion fluids; adulteration of foods, IX.-Assistant surgeons will be held responsible for drugs, etc., detection of fibers, paper, and handwriting. the proper care and safe return of instruments, books, Microbiology-Laboratory examination of unicellular microscopes, apparatus of all kinds, etc., placed in their forms of life, yeasts, protococcus, ameba, the molds, charge during course of instruction. alge, and fungi of fresh waters; fauna of potable

waters.

X.-When the professional record of an assistant surGeneral Bacteriology.-Isolation, preparation of cul- geon is completed, and all papers prepared by him on ture media, mounting and study and identification of subjects assigned at hospital, examining board, and species, bacteria of potable waters, sewage bacteria, laboratory have been received by the Director in charge of the Laboratory and Department of Instruction, he typhoid bacillus, biological examination of Croton water, Brooklyn aqueduct water, etc., bacteria of the ted to the Bureau of Medicine and Surgery, in accordshall see that they are properly compiled and transmitatmosphere, biological analysis of air of hospital wards, ance with the prescribed form. class rooms, etc, disinfectants and filters, bacteriological tests.

VI.—Application, whenever necessary, will be made to the Commandment of the Naval Station, New York, for authority for the medical officer assigned to the duty, in company with the assistant surgeons undergo ing instruction, to visit receiving ship, and all modern 8 ommssion, ships undergoing construction and nearing completion, that may be at the navy yard, for the purpose of inspection of every part of the vessel, and gaining information relating to general arrange ment of sick and other quarters, system of ventilation and heating, air space, etc.

XI. The assistant surgeon's professional record will be kept on file in the Bureau of Medicine and Surgery until he becomes eligible for examination for promotion, when it will be transmitted to the Naval Medical Examining Board for inspection, to be returned to the bureau on completion of his examination. This record, together with examination papers of both first and sec. cond examination, will then be bound in book form and kept for future reference, as a guide in assignment to duty, according to professional and other qualifications.

Now is the time to subscribe for the MEDICAL

VII-When assistant surgeons are assigned for instruction in specified branches to hospital, examining REVIEW.

ABSTRACTS

Visceral Philebotomy.-Harley (Jour. of the Amer. Med. Ass.) claims great success in the treatment of hepatic inflammation by withdrawing blood directly from the congested liver. His method consists in piercing the viscus with a long trocar about seven milli metres in diameter, so as to "wound one or more bloodvessels of sufficient caliber to yield a free stream of blood." After sufficient blood is withdrawn the finger is held over the mouth of the trocar till the stream of blood has clotted back into the viscus. The trocar is then withdrawn and the wound closed by adhesive plas ter and a bandage applied.

He reports successful treatment by this means of several cases of chronic and acute hepatitis, and has seen it applied to pulmonary congestion. He seems to have met with no cases of subsequent internal hemorrhage, a danger not to be disregarded, for his only reference to this occurrence is indirect. He says, that on withdrawing the instrument it is important to get the clot in the canula to break off from that in the canal so as to leave the latter behind, in order that by its presence there it may prevent any oozing of blood from the organ. This is best done by giving a slight twist to the canula at the moment it is felt to leave the organ. The external puncture is closed by adhesive plaster and a flannel bandage bound firmly over it to bring the internal surface of the parietes against the wounded or gan, to prevent the possibility of accidental internal hemorrhage.

It is hardly probable that the recommendation to extend this procedure to all the viscera, as the spleen and kidneys, will meet with a wide acceptance.

acid employed be free from nitrous acid, and if the cultures be pure, the cholera-red (indol) reaction will take place. A good ten per cent gelatin culture-medium is inoculated and kept at a temperature of 22° C. At the end of from fifteen to twenty hours characteristic appearances will have developed. If upon primary microscopic examination cholera bacilli have not been found, agar plates are cast in addition to the inoculation of the peptone solution and the gelatin plates. Six hours after the inoculation of the peptone solution curved bacilli are from time to time looked for; and as soon as found agar plates are cast. The material to be examined is preferably not mixed with liquefied agar; but the sterile agar is permitted to harden in covered dishes and placed for a few days in the thermostat to permit the expressed water to evaporate. The surface of the agar is then inoculated with the suspected material or from the peptone solution and kept at a temperature of 37° for eight or ten hours. If cholera bacilli be preser.t they form colonies of light yellow, transparent appear ance. If few cholera bacilli have been found in the peptone solution and few or no colonies on the gelatin plates, suspicious or doubtful colonies upon the agar plates must be transferred to other agar plates, to pep. tone solution, and to gelatin plates, so that sufficient material may be obtained for the purposes of the indol reaction and of experiment upon animals. For this last purpose, cultures from the surface of agar plates are to be preferred. With a platinum loop, about 1.5 mg. of the culture are taken and mixed with 1 c.cm. of steril. ized bouillon and injected into the peritoneal cavity of a guinea-pig. This is lethal for a pig weighing from 300 to 350 grammes. The peptone solution may also be employed for the detection of cholera bacilli in water. To about 100 c.cm. or the suspected water are added one per cent each of peptone and sodium chloride and the mixture is kept at a temperature of 37°. In ten, fifteen, and twenty hours agar plates are to be inocu. lated with this solution. The resulting colonies are further cultivated upon peptone, glycerin, and agar studied for the indol reaction, and injected into lower animals.

The Results of Treatment by Tracheotomy and Intubation in Six Hundred and

The Bacteriologic Diagnosis of Cholera. -The following is the mode of procedure carried out at the Institute for Infectious Diseases at Berlin, in a bac teriologic study of a suspected case of cholera (Zeitschrift f. Hygiene u. Infectionskrankh.; Deutsche medi cin. Wochenschrift; Amer. Jour. Med. Scienc). Coverglass preparations are first made (the flakes of mucus that are often present in the dejecta being selected) and stained with a dilute carbolized fuchsin solution. If Ninety Cases of Diphtheria.-In an exhaustive comma bacilli be found, peptone cultures and gelatin plate-cultures are made. The peptone medium consists of a sterilized one per cent watery solution of peptone and of sodium chloride, to which sufficient soda is added to impart a decided alkaline reaction. This is kept at a temperature of 37° C. If cholera bacilli are present in large number, a pure culture will be found on the surface of the peptone solution at the end of six hours; if present in smaller number, the culture will develop more slowly and there will be an admixture of other bacteria. It is best to look for the bacilli in from six to twelve hours after inoculation. If the peptone contain a certain proportion of nitrates, if the sulphuric

paper, in which the indications for and comparative results of these methods are minutely studied, comprising six hundred and ninety cases of diphtheria occurring between 1874 and 1891, in the Children's hospital, in Zurich, Baer (Deutsche Zeitsch. fur Chir.) concludes that the better average results obtained by the method of intubation are not due to the earlier operation, but cateris paribus, are found in the operation itself, and especially in the youngest patients. There is apparently no distinction to be made in sex, either as regards prognosis or the course of the disease after operation. The mortality in the six hundred and ninety cases was forty three and eight-tenths per cent. Or, according to

the tracheotomy and intubation periods, forty-five and stomach, as in acute and chronic gastric catarrh and three-tenths per cent, and thirty nine per cent res-in gastric ulcer. Nausea, due to disease of other abpectively. Since, in the latter period, there was a dominal or pelvic viscera, as the liver, kidneys, uterus greater number of operations in the pharyngo-laryngeal and ovaries, is likewise relieved by the administration cases, in which the mortality is always very high, the of this remedy. It allays the gastric irritabiliry which actual mortality during the intubation period was eight accompanies tabes-mesenterica and marasmus. Vomitper cent better than during tracheotomy. ing produced by over indulgence in liquor has been subThe author does not, however, believe that the intu- dued by its powers. It has been found of advantage in bation operation is a rival of tracheotomy, but rather a cases of sea sickness, and in the relief of the gastric means to be used before and in conjunction with it, irritability of bottle-fed babes. Its peculiar province, tracheotomy being reserved for cases in which intuba- however, is alleviation of the vomiting of pregnancy, tion fails. He gives the following as his indications in which it approaches the character of a specific. As and contra indications for performing intubation. These every one knows, this difficulty is frequently very inare not as many as have formerly been insisted upon, tractable, and one approved remedy after another may and he believes that the spread of the diphtheritic be used without avail. To those who have witnessed process into the trachea is not a contra-indication, as is repeated failures of medication, ingluvin can be recom. shown by many cases reported. Feeble children should have intubation, since the wound complications make their chances much less. Cases which are brought sub finem vitae need intubation with short tubes, or trache otomy. When superior tracheotomy cannot be per formed, intubation, on account of its shorter duration, is indicated. Indications for a secondary tracheotomy following after intubation are:

1. Where masses of membrane or free portions pre. vent laryngeal respiration, even after aspiration. This is, however, seldom observed.

mended as one of the most efficient remedies which we possess for the relief of this distressing symptom. In gluvin is likewise beneficial in dyspepsia, when produced by functional inactivity. It is able to promptly check the diarrhea which is caused by indigestion. By reason of its influence upon the stomach and bowels, ingluvin is capable of marked service in cases of cholera infantum and cholera morbus. From the preceding ac count it will be seen that ingluvin possesses an exceedingly important sphere of usefulness.

Ten grains I found generally a sufficient dose. In

2. When laryngeal and tracheal stenosis persist after some instances 20 grains were required, while in the intubation has been performed.

3. Where it is impossible to insert the tube on ac count of its being coughed up, and where there is threatened asphyxia.

The indications for a primary tracheotomy and contra-indications of intubation are:

1. Complete closure of the nasopharyngeal space through swelling and membranous deposit on the mucous membrane of the pharynx and tonsils.

2. Intense edema of the glottis.

3. A retro-pharyngeal abscess as a complication.

4. In cases where the short tube cannot be used.

He also recommends intubation in all forms of chronic stenosis, and reports two new cases.--American Jour nal of the Medical Sciences.

The Clinical Application of Ingluvin.Ingluvin is the name given to a preparation made from the gizzard of the domestic fowl (John V. Shoemaker, Medical Bulletin). It is a yellowish, gray powder of a faint odor, and almost devoid of taste, It is insoluble in water Ingluvin is put up by its manufacturers, (Messrs. William R. Warner & Co., of Philadelphia) in 5 grain tablets. Ingluvin is compatible with alkalies. Its virtues reside in a peculiar-bitter principle which en ters into its composition. It is prescribed in the same doses and combinations as pepsin. Ingluvin was introduced to the notice of the medical profession about 18 years ago. It is of special benefit in the relief of sick stomach. This substance may be given with success when vomiting depends upon organic affection of the

milder forms of indigestion a 5 grain tablet, after each meal, accomplished the desired purpose. To infants I gave the remedy in doses of 1 or 2 grains.

A series of cases occurring during the past few years in which Ingluvin was administered with benefit has been selected as affording a typical example of the effi cacy of Ingluvin. The total number amounted to 49 and a brief history is given of each case. They were classified as follows:-4 cases of cholera morbus; 8 of infantile diarrhea; 9 of diarrhea in the adult; 2 of dysenteric diarrhea; 1 of acute indigestion; 3 of dys pepsia; 2 of dyspepsia with reflex symptoms; 1 of dyspepsia from uterine disease; 2 of flatulent dyspepsia; 1 of nervous dyspepsia; 2 of gastralgia; 2 of colic; 4 of gastric and gastro-intestinal catarrh; 1 of gastric ulcer; 1 of vomiting caused by alcoholism; 6 of vomiting of pregnancy.

Relations of Dyspepsia to Pulmonary Tuberculosis.-At a recent French Congress for the Study of Tuberculosis recently held in Paris, one of the subjects discussed was that of the relationship of dyspepsia to pulmonary tuberculosis (Boston Med. and Surg. Jour.).

Marfan has maintained in his thesis that the digestive disturbances of the phthisical bear the relation not of cause but of effect; in other words, they are but one of the manifestations of the tuberculosis. Often the dyspepsia masks the tuberculosis. Marfand believes the initial dyspepsia to be caused by a "humoral state."

According to Hayem, whose paper attracted much notice, the gastritis of the phthisical is a common gastritis due to the ordinary causes of stomach inflamma. tions. It is generally accompanied with retardation in the evacuation of the stomach and consequently with dilatation. It sometimes precedes for several years the appearance of the tuberculosis, and is only exaggerated at the onset of the phthisis in patients who take excitant drugs or who adopt a regimen not adapted to the state of their stomachs.

The causes of the gastric affections of the phthisical are those of ordinary gastric affections, to wit, the abuse of tobacco and alcohol, errors in diet, etc. It is a mixed gastritis, parenchymatous and interstitial.

In one case, Hayem found, at the autopsy, a general amyloid condition of the entire mucosa; in another, a necrosis due to a thrombosis; exceptionally, he has met

THE EXTREMITIES DURING THE WAR OF THE REBELLION AND
THE PERIOD 1866-1891, WITH PERCENTAGES OF MORTALITY.

struck by these missiles a large portion will require to TABLE SHOWING THE NUMBER OF AMPUTATIONS AND EXCISIONS OF be promptly removed from the field of action, for a smaller proportion will be killed outright.

Under these circumstances it is evident that our or ganization for the purpose of rendering first aid to the wounded and transporting them to the field hospitals must be carefully considered, and that the most efficient. service will require a corps of assistants especially trained for this duty.

This matter has already received the careful attention of medical officers in the United States army, and we have now an organization designed to perform these duties, with the assistance of "company bearers" who also receive special training with reference to first aid, litter drill, etc. In time of peace our enlisted men of the "hospital corps" perform the duties of nurses, cooks and attendants in post hospitals, and they are regularly drilled in the most approved methods of handling wounded men and removing them from the field of battle.

A manual of drill for the hospital corps has been prepared by a board of medical officers and approved by the Secretary of War. It will shortly be published "for the information and government of the army and for the observance of the militia of the United States." A demonstration of the litter and ambulance drills, as directed by this manual, will be made by Major Hoff of the medical department of the army, English speaking secretary of this Section, who was one of the medical officers to whom the duty of preparing the manual was intrusted. After this demonstration I hope we may have a free discussion of the merits of the system, as compared with the older, haphazard way of caring for wounded men which prevailed during our civil war.

There are many present whose experience upon the field of battle will enable them to judge of the advan tages which are likely to result from system and previous training in handling wounded men; and also of the practicability of carrying out, upon the firing line, the methods which have been adopted.

Hip....

Thigh

Knee.

3,485

LOWER EXTREMITY.

SINCE THE WAR.

52

DURING THE WAR.

Number

of

Cases.

Percentage
of
Mortality.

Number
of
Cases.

Percentage

of Mortality.

Ankle.
Partial, of foot...

Leg

The results obtained by our military surgeons during the late war are summarized in the accompanying table, which has been prepared, at my request, by Maj. Chas. Smart, Surgeon U. S. A., from the data on file in the Surgeon General's office. The table also shows the number of amputations and excisions made by medical officers of the army since the war and the percentage of mortality from the same. It will be seen that the mortality rate has been considerably reduced. This is no doubt partly due to improved methods of treatment, and especially to antiseptic surgery, although a considerable proportion of the operations made since the war EXCISIONS:were made before the general adoption of antiseptic methods, or under circumstances which did not admit of the strict application of these methods.

For the purpose of showing the enormous responsibility of the medical department of the army in time of war the following figures are given, showing the to tal number of cases treated in the armies of the United States during the late war, as given in the "Medical and Surgical History of the War of the Rebellion." The figures relate to white troops only, and are for the period from May 1, 1861 to June 30, 1866:

རྩ་ཆོབོ❁

364

Hip......
Femur

66

175

Knee....
Bones of leg.

57

81.4