the better, as a rule. Avoid close, stuffy rooms, and avoid dust as much as possible, especially that dust which comes from our dwelling places. A study of the distribution of tuberculosis, indicates that it is present as a rule in proportion to the housing of individuals. The Indians of the plains are not tubercular, but bring him into more civilized surroundings and he becomes consumptive like the white man. The scrawny, weatherbeaten cattle of the wild west are far less tubercular than the well housed and well nour

ished stock of our barn-yards. Never permit the dust in our homes to be stirred up. The feather duster should be abolished, and the broom should seldom be used in a house.

The dust may be removed from furniture by means of a piece of cloth slightly dampened with kerosene. Unvarnished wood-ware may be cleansed with a cloth moistened with water. If a broom must be used it should be sprinkled with some liquid as kerosene or covered with a piece of cloth which has been Women should not wear skirts moistened.

that sweep the sidewalk, thereby carrying into the house dirt and filth that may produce disease. Sunlight should enter wherever possible. It kills the germs of disease, and so renders the air more pure. And with the sunshine from the heavens let in also a little sunshine from the soul. Encourage the faltering; cheer the discouraged. The pleasant word, the smiling face, the kind act tells on all our lives.

c. Our food should be plain and wholesome; avoid overeating as well as starvation. Pastries, puddings and too many of the socalled dainties should seldom if ever be indulged in. 1 trust that no one here belongs to that class called vegetarians. Although it is true that most of us eat too much meat, yet such things as eggs, milk and butter with occasionally a piece of good beefsteak are among the best things we can use to strengthen our system. Nor do I believe that there are any here who fail to eat their breakfast. Eating three times a day, although enough, is not too much.

d. Our living quarters should not be too warm, 60 to 70 deg. F. is sufficient for any oue. Overheating causes us to become too delicate and very susceptible to taking colds. Our sleeping room should be more cool, although we should be well covered to keep thoroughly warm. So long as we avoid draughts there is not much danger of taking cold. Our clothing should be of such thick ness as to keep us comfortably warm. It must necessarily vary with the time of year. Wet clothing and wet or cold feet should not be tolerated.

e. Exercise, especially out of of doors in the open air, is stimulating and invigorating. It causes the blood to circulate more actively through every part of the body, and as it moves through the tissues it brings to them more nourishment and removes the waste products. It gives to the tissues more vigor and with it more resistance to withstand disease.

f. Avoid all excesses. Excesses may destroy in a few minutes what has been gained in years. Our sleep should be regular and of proper length. Eight hours a day is not too much for anyone. Intemperance in the use of alcoholic liquors should be carefully avoided. Few things reduce the vital resistance more rapidly.

People with a rather weak constitution, especially if descended from consumptive parents, should seek an out-door occupation. Stooped and cramped postures while sitting should never be indulged in.

If these rules of hygiene are carefully carried out the danger of contracting the disease become comparatively slight, and if once it has been contracted the chances for recovery are quite good. Encouraging, too, is that while all this is being done to fortify the system against tuberculosis, it fortifies it against disease of every kind, prepares it to more effectively discharge the duties of life and overcome the obstacles which more or less beset the path of every one.

These are good instructions you will say, but what about putting them into practice. Shakespeare in his "Merchant of Venice" causes Portia to say: "If to do were as easy as to know what were as good to do, chapels had been churches, and poor men's cottages princes' palaces. It is a good divine that follows his own instruction." This statement is probably as true now as it was in Shakespeare's time, but why should we not do our best?

Let us all remember that the cure of tuber

culosis in its early stages is comparatively easy, but once it has advanced to the latter stages, there is little hope for recovery. If you have consumption, follow the golden rule, "Do unto others as you would that they should do unto you." Let us see to it that we observe with great care, these rules of hygiene-proper food, proper clothing, proper sleep, proper exercise, and moderation in all things, whch are essential to our well being. Let us know that our homes and public buildings are properly heated, thoroughly ventilated and scrupulously cleansed. us ask ourselves to stop spitting and expectorating in our homes and in all public places. Let us ask our dairymen to keep only

Let

healthy cattle, and to use the utmost care to preserve the milk which he brings to our doors in its original purity and freshness. Let us ask our teachers to inform the pupils in our public schools concerning the essentials of such disease as tuberculosis while teaching them the principle of right living. Let us beseech our public press, to use their weapons to aid in the crusade against consumption. Let us request our public officials to pass ordinances and adopt rules aiming at the restriction of this disease process.

If all these things are done then the time will probably not be far distant when not only tuberculosis, but many other infectious diseases will be not only materially diminished in number, but entirely disappear. Pasteur has truly said, "It is in the power of man to cause all parasitic diseases to disappear from the face of the earth."

A CASE OF TUBERCULAR STRICTURE OF THE ILEUM.

JOHN MCHALE DEAN, M. D.

WITH PATHOLOGICAL REPORT

H. P. WELLS, M. D.

A REVIEW of the literature on the subject of tubercular stricture of the bowel will convince surgeons that this subject has been definitely neglected and they will appreciate my incentive to report the following case from my practice, which is interesting in itself, but doubly so because it illustrates a class of cases of which but few are recorded.

The patient had only recently arrived in this country from Italy, and could, unfortunately, converse only in the Italian language. I was, therefore, compelled to arrive at a history through the mediation of an interpreter of limited ability. The patient, H. G., was twenty-one years of age; height five feet four inches; extremely emaciated and very anemic. Previous history showed merely the diseases of childhood-pertussis, measles, etc. Family history: Father and mother living and enjoying good health. No history of tuberculosis in her immediate family, except a younger sister at present suffering from a well-defined case of cervical tubercular adenitis. Patient being a daughter of poor parents, the hygienic surroundings in which she was compelled to live were extremely poor.

Present history: On entrance to the hospi. tal the patient complained of vomiting and colicky pains in the umbilical region. She called attention to the noises in the intes

tines, plainly audible at tines, plainly audible at a distance of twentyfive feet. Patient weighed ninety pounds. Through the interpreter I learned she had been ill for the past six months with periodical vomiting and adominal pains. In the last three months patient had been bedridden. She has had periodic attacks of diarrhea, while in the interval of same her stools are formed and apparently normal.

On the day of entrance the patient was given a saline cathartic that occasioned severe vomiting and a copious diarrhea. She presented the appearance of extreme shock by subnormal temperature; cold, clammy perspiration and thready, rapid pulse. Stimulants and morphia improved the condition and patient expressed herself as feeling well again, but that she was certain of a recurrence of above, since she had had similar attacks every three days. The vomiting was first stomach contents, later mucus, and finally a stercoraceous type. The stools measuring about two gallons collectively were a pale grayish yellow in color and composed of mucus and pus. No food or other solid particles were found in them, while the odor was very offensive. Microscopic examination showed mucus, pus cells and coli commun bacilli. During the above attack, the borborygmus was very pronounced as well as the undulatory action of the intestines.

Physical examination: Patient pale, emaciated, skin delicate and fine, the temporal and superficial veins are plainly visible through it, expression bright but anxious; hair flaxen and eyebrows long and curved. Bony prominences and tuberosities could be clearly studied as the adipose and muscular tissue were extremely wasted. No enlarged glands palpable except in the inguinal regions where a fine chain of small glands could be felt. Chest narrow, and the fifth left intercostal space shows the pulsation of heart in normal location. Lungs showed no abnormality either by auscultation, palpation or percussion. Respiratory sounds consequent to patient's debility were feeble. Heart rapid, no murmurs elicited and sounds clear and distinct. Percussion showed normal cardiac area. Respiration costo-abdominal. Pulse varied between 100 and 120, and temperature showed evening exacerbations from 99.4 to 100 deg. The spleen normal.

Blood diminshed red corpuscles and marked leucocytosis, hemoglobin 50 per cent (Gower). Urinalysis: Specific gravity 1012; acid; faint trace of albumen; no sugar; chlorides diminished; urea diminished; no bile; marked increase in indican.

Microscopic examination negative.

The abdomen presented an irregular out. line. Coils of intestines from left to right

stood out prominently. By palpation I could clearly outline a large dilated coil of intestine that appeared in the region of the transverse colon. By deep pressure the peristaltic action was set up, causing the patient some uneasiness and pain. The excited peristalsis showed a motion from left to right, and the noises caused were plainly audible at a considerable distance. The end of the peristaltic wave was marked by a blowing sound that almost possesed the type of a whistle. No abdominal tumor or enlarged glands could be detected by deep or superficial pressure. Stomach analysis showed trace of HCl, and absence of lactic acid. Inflation with air showed it to be of normal size and brought out nothing abnormal. Patient's appetite was poor, she taking merely liquid foods by compulsion. Distension of the colon was successfully accomplished by air and water, meeting no obstruction and showing the normal distended transverse colon was situated anterior to the obstruction.

Diagnosis of partial obstruction of the ileum due to a probable tubercular condition was made. Exploration was advised and

consented to.

Operation.-A median incision about six inches in length was made in the umbilical and hypogastric regions. The abdominal cavity showed no fluid. A large distended loop of intestine was encountered and on following it to the right a tumor about the size of a lemon was found. The mesenteric glands were enlarged in the region of the mass, and enlarged tortuous lymph vessels leading from the mass to the glands could be seen and felt. The tumor involved the entire lumen of the intestines. The intestine encountered was the ileum and the tumor was about eighteen inches from the cecum; it was not adher. ent and could be readily delivered outside of the abdomen. The large distended intestine was proximal to the tumor while the intestine distally was of a normal appearance. After the usual protective measures were instituted, the abdominal cavity being walled off by 'gauze compresses suitably placed, resection was performed. A portion of intestines, about six to eight inches in length, was removed, together with the mesentery and its enlarged glands. In cutting through the proximal distended loop of intestines the coats, especially the muscular, were so hypertrophied that the wall resembled that of the stomach. The enlarged loop's end was entirely closed by silk and catgut and with distal or small end a lateral anastomosis was made in the side of the closed proximal loop by means of a large size Murphy button, fortified by linen Lem bert sutures in the usual way. The abdomen was cleansed, the mesentery su

tured by cat-gut and the anastomoses dropped back in the abdomen, at the same time carefully covering the site with a fold of omentum. The abdomen was closed in three layers with catgut.

The recovery was rapid and uneventful; the patient sat up on the sixth day, and left her bed on the tenth day. Abdominal wound healing per primam. The vomiting, pain and borborygmus entirely disappeared. Appetite became ravenous. Stools well formed and move without medication.

In three weeks patient had gained five pounds and left the hospital. Six months later patient called on me at my office, having gained about forty pounds, and admitted that the week previously she had entered the hymeneal ranks. Her general appearance was splendid, appetite almost insatiable, and bowels moved normally.

In arriving at a diagnosis of the site of obstruction, the writer considered the periodic-formed stool of great importance. to the nature it was surmised to be tubercular, because stricture of the ileum is most frequently tubercular.

I append the pathological report made by Dr. H. P. Wells, to whom I am indebted for valuable assistance in developing the pathological features of the case.

PATHOLOGIC REPORT.

Examination of the gross specimen shows a much constricted lumen which might be due to one or more of several conditions, viz., cicatrization of healed ulcers with their long axis in the transverse direction of the gut; thickening of the mucosa and submucosa from infiltration with inflammatory products; associated or not with ulceration; a diffuse infiltration of all the tunics of the gut wall, either by the specific inflammatory products of tuberculosis, or syphilis, or by some other chronic process with hyperplastic or hypertrophic increase of tissue.

Although the specimen came to my hand in a hardened state, it is judged that the lumen of the gut at the site of the lesion was so constricted to at times become impassable.

Proximally to the lesion the ileum ballooned out into quite a sac, measuring from 8 to 10 cm. in diameter in the fixed state.

The surface of the mucosa at the site of the lesion shows signs of ulceration for a space of about 6 cm. in the long axis of the gut and extending over its entire circumference. Proximally to the ulcerated area the surface of the mucosa presents a granular appearance, which was found to be due to the exfoliation of small patches of surface epithelium. This condition of the mucosa was not seen on the distal side of the ulceration.

Cut longitudinally and spread out the specimen has the appearance of a palm leaf fan; the strictured or distal portion forming the handle, and the dilated or proximal portion forming the leaf of the fan.

In the orientation of this specimen it is observed macroscopically that the section of gut removed probably goes well into normal tissue, at least as far as the specific inflammatory process is concerned. This observation was confirmed subsequently by sections which were removed from the extremes of the specimen, proximally and distally. Other sections for microscopic study were removed from the center of the obstructing mass, and included the entire thickness of the gut wall. Another was taken from the mesenterio side, including the full width of the mesentery from the gut to the cut margin, where it was separated at operation.

The sections removed from the upper and lower extremes of the specimen presented the following points of interest: the surface epithelium was stripped off from the mucosa in places, or rather was only found in places, the most of it being absent; the mucous and submucous coats were slightly infiltrated with round cells, with occasional eosinophiles, and occasional collections of masses of round cells; the latter being neither lymph nodes nor incipient tubercles, as was shown by the absence of epitheliod cells and the presence of eosinophiles. The serosa was normal in this location as far as could be judged from these sections.

There was marked hypertrophy of the muscular tunic, as could be easily seen macroscopically this hypertrophy being slightly more marked in the proximal than in the distal portion. The section removed from the center of the obstructing mass, and including the entire thickness of the gut wall from its lumen to the serosa, presented the typical signs microscopically of tuberculosis.

Instead of a mucosa and subumcosa were found an immensely thickened mass of round cell infiltrated new formed tissue, with here and there caseated areas, and remnants only, of a gland structure.

The submucosa was entirely obliterated and the inner or circular layer of muscle was so thickly infiltrated with round cells that the higher power objective was required to make out the proper structure of muscle at all.

Between the outer or longitudinal layer of muscle and the very much thickened serosa typical tubercles were found in abundance. An interesting reference made by von Bergmann, Warren, and I believe one or two other authorities, to the muscle wall of the intestine as a barrier against the progress of

wall. The giant cell is beautifully shown in both these pictures, with the deeply staining and numerous nuclei piled up in one pole of the large mass of protoplasm of the cell.

The lighter areas of caseous degeneration are seen in the tubercle shown in photo No. 1, this being due to the failure of the degenerated cell to take up the nuclear stains.

The tubercles found in this section were, as above mentioned, principally in the greatly increased serous connective tissue, and in these distinct tubercle formations the epitheloid cell was plentiful, but the greatest infil. tration was in the mucous side of the wall. The epitheloid cell was also present in this densely infiltrated area, but more difficult to distinguish because of the great preponderance of round cells and leucocytes.

It is noteworthy with respect to the statement of von Bergmann and others given above regarding the resistance of the muscular tunic, that in the section just described the outer longitudinal layer of the muscle was intact throughout excepting at the points shown in the micrographs, where the tubercies have invaded. By saying intact I do not mean normal, as there was extensive cellular infiltration throughout, but not of a specific character.

The site of greatest frequency of tubercular lesions of the intestinal tract seems to be the region of the ileocecal junction.

This fact may be explained by the mechanical conditions here existent, viz., the acute angle at which the ileum joins the colon, and the consequent tendency to stagnation at this Another expoint in the fecal circulation. planation forwarded is that the acid reaction. of the upper part of the intestinal tract serves to inhibit the activity of the tubercle bacillus which finds its way into the bowel through swallowed tuberculous sputum, or infected food or drink, but as it travels on to the lower bowel and the reaction of the sections become alkaline, this inhibiting influence is removed and infection may occur. This ingenious theory is somewhat disturbed by the well-known acid resisting properties of the tubercle bacillus, but whether this quality of the germ obtains in a biologic sense as it does in the more mechanical sense as applied to its staining qualities, is of importance in this connection.

Tubercular ulcerations of the intestine, it would seem, are by far more common than is popularly supposed, as seventy per cent of cases of phthisis that come to autopsy are found to have intestinal lesions of tubercular character. Whether it is ever a primary disease or not seems doubtful from the evidence of statistics compiled on this subject. Eisenhardt, who made a thousand autopsies on pa

tients who had died of some sort of tuberculosis, found that out of this number 563 had intestinal tuberculosis, and in every one of these 563 subjects, pulmonary tuberculosis also existed..

As to the frequency of stricture in tubercular lesions of the intestines, Eisenhardt calculates that it occurs in about 25% of all cases. Hofmeister in 1896 collected 100 cases of tubercular stricture of the intestine in its various portions. The general types of intestinal tuberculosis are the following: the disseminated form, without tendency to recovery; the localized form with tendency to cicatrize, and tubercular lesion of the ileocecal region with the formation of a distinct tumor. The latter may be again divided into the mucous and submucous, and into the serous and subserous varieties, according as the source of infection is from within the intestine or from the mesenteric glands by extension from a tubercular processes elsewhere. This latter subdivision subdivision is mentioned principally by those who call attention to the resistance of the muscular tunic against the progress and extension of the tubercular process from one to the other side of the gut wall.

Some recent research along the line of source and route of infection has endeavored to show that instead of the bowel becoming infected as a secondary process from a primary lung infection, the matter stands just the other way, and that the intestine is first involved, the lung becoming secondarily affected through the lymphatic circulation. 2313 Washington Ave.

SUCCEEDS NOTHNAGEL.-Nothnagel's chair in the University of Vienna is to be filled by von Noorden of Frankfort-on-Main.

FOR PURE FOOD.-The legislature of Iowa has roeently passed a law providing for the annual appropriation of $10,000 to go to the support of a pure-food laboratory.

MISSOURI VALLEY SPECIAL TO BOSTON. Arrangements have been perfected for a superb special train to Boston, to attend the meeting of the American Medical Association, June 5 to 8. Route: Grand Trunk, via Niagara Falls, Toronto, Montreal, Thousand Islands, daylight ride down the St. Lawrence One fare, plus $1, iver, returning by rail. This train will run special for round trip. through from Chicago, and will be made up of Pullman palace sleepers, dining cars, buffetFor reservalibrary and observation cars.

tions and itinerary address Dr. Chas. Wood Fassett, Secretary, Medical Society of the Missouri Valley, St. Joseph, Mo.